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73,886	114,190	53898	Discharge summary	report	Admission Date: [2116-3-29] Discharge Date: [2116-4-8] Date of Birth: [2048-5-25] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Bactrim Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Nausea vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Patient is poor historian at baseline, unable to get story from patient. . 67M ho Dm2, HTN, autism and dementia (baseline: A+Ox1) who presened to ED for abdominal pain and emesis and unsteady gait (usualy wheelchair bound). He has a poor baseline mental status secondary to dementia (A+O to self and place only). As of last night, had abdominal pain and emesis so was brought to [Hospital1 ]. Mental status did not change from baseline. No fevers. Was given rectal compazine by EMS and then vomited twice more 6 hrs later. . [Hospital3 ]: T 98.3, HR 96, RR 21, 99/73, 96%RA He was supposedly hypotensive at [Hospital1 ]. Lactate 1.7, Na 136, Cl 99, BUN 36, K 4.3, HCO3 27, Cr 1.2, Ca [14]. WBC 21, Hb 17, HCT 51.8. UA suggestive of cystitis (cathed urine that was bloody). Trop I 1.66, EKG with inverted T waves. CT Abd A+P showed bilateral perinephric stranding findings (although this is not seen in the final report) and question R lower pulmonary artery defect although artifact in final read. ? CXR RLL infiltrate. He was given: Zosyn and vanco for infiltrate and urine, insulin for glucose 420, zofran, 2L NS, aspirin 325mg, started in heparin gtt at 1530 and tranfered to [Hospital1 18]. . In the [Hospital1 18] ED, initial VS were: 97.6 74 116/71 (lowest BP 90/58 when sleeping) 16 96% 4L -giving 3rd L NS, heparin running at 1530. EKG showed NSR @ 79, LAD, long QTC, deep T waves in V2-V5, poor r-wave progression. Guiac neg. Access: two 20 g IVs Transfer vitals: HR 74, RR 21, O2 sat 98% on 3L NC, BP 94/59 Pt transfered to MICU for ?ACS, complicated cystitis, RLL pna . On arrival to the MICU, pt is lethargic, mildly diapharetic, arrousable, answers yes/no questions. Denies any chest pain. States he has some abdominal pain. When asked if he is drinking at eating at home he says no. Past Medical History: ([First Name8 (NamePattern2) ] [Hospital1 ] records, pt unable to give a history) dementia psychosis autism BPH urinary incontinence HTN HLD DM2 Communicating hydrocephalus Chronic abdominal pain Depression (of note, no history of cardiac disease, no prior MIs) Social History: Lives in [Hospital 16662] nursing home, [Location (un) 6409]. A+O x2 at baseline. Gradually worse over the years. Currently wheelchair bound. Initialy from [Country 4754]. No drugs. Family History: Unknown Physical Exam: ADMISSION EXAM: Vitals: T 98.1, HR 78, BP 107/71, RR 12, 98% RA General: lethargic, diapharetic, moist mucus membranes, good capillary refil HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated (JVP at clavicle when upright), no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: crackles in bases bilaterally Abdomen: right upper quadrant discomfort in deep palpation, no flank pain GU: foley with dark urine and bloody urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A+O x1, lethargic Stage 2 ulcers on coccyx, left heel . DISCHARGE EXAM: VS: 97.3 147/77 59 18 100% RA General: NAD, lying in bed, short appropriate verbal responses to questioning HEENT: NC/AT, sclerae anicteric, PERRL, EOMI, OP clear, MMM CV: RRR, nl S1 S2, no MRG Resp: breathing comfortably on RA without accessory muscle use, slight rales b/l, no wheezes or ronchi Abd: soft, non-tender, non-distended. GU: Foley present with slight evidence of bleeding at meatus. UOP the color of fruit punch wihtout irrigation. Ext: warm, well perfused, no cyanosis, clubbing or edema. Neuro: A&O x1, lethargic Stage 2 ulcers on coccyx, left heel. Waffle boots in place on feet, coccyx with Mepilex in place Pertinent Results: ADMISSION LABS [2116-3-29] 05:37AM GLUCOSE-324* UREA N-30* CREAT-0.9 SODIUM-138 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17 [2116-3-29] 05:37AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-2.2 [2116-3-29] 05:37AM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-81 TOT BILI-0.6 [2116-3-29] 05:37AM LIPASE-16 [2116-3-29] 05:37AM WBC-17.0* RBC-5.40 HGB-15.9 HCT-49.5 MCV-92 MCH-29.4 MCHC-32.1 RDW-12.8 [2116-3-29] 05:37AM NEUTS-87.7* LYMPHS-7.6* MONOS-3.5 EOS-0.4 BASOS-0.8 [2116-3-29] 05:37AM PLT COUNT-296 [2116-3-29] 05:37AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-300 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2116-3-29] 05:37AM URINE RBC->182* WBC-34* BACTERIA-FEW YEAST-NONE EPI-0 [2116-3-29] 05:40AM LACTATE-1.9 . CARDIAC ENZYMES [2116-3-29] 05:37AM BLOOD cTropnT-0.33* [2116-3-29] 09:30AM BLOOD CK-MB-5 cTropnT-0.34* [2116-3-29] 02:42PM BLOOD CK-MB-5 cTropnT-0.28* [2116-3-30] 11:38AM BLOOD CK-MB-4 cTropnT-0.18* . ABG [2116-3-29] 07:22AM BLOOD Type-ART pO2-74* pCO2-42 pH-7.43 calTCO2-29 Base XS-2 [2116-3-31] 04:50PM BLOOD Type-ART Temp-36.7 pO2-67* pCO2-35 pH-7.47* calTCO2-26 Base XS-1 Intubat-NOT INTUBA . [Hospital3 ]: [2116-3-29] 05:37AM BLOOD TSH-1.9 [2116-3-29] 05:40AM BLOOD Lactate-1.9 [2116-3-29] 07:22AM BLOOD Lactate-1.6 [2116-3-30] 12:08AM BLOOD Vanco-11.8 [2116-4-1] 06:37AM BLOOD Vanco-19.8 [2116-4-6] 08:00AM BLOOD Vanco-38.9* [2116-3-29] 05:37AM BLOOD Lipase-16 [2116-3-29] 05:37AM BLOOD ALT-13 AST-22 AlkPhos-81 TotBili-0.6 . Discharge Labs: [2116-4-8] 05:32AM BLOOD WBC-10.6 RBC-3.46* Hgb-10.1* Hct-31.1* MCV-90 MCH-29.2 MCHC-32.5 RDW-14.3 Plt Ct-344 [2116-4-8] 05:32AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-137 K-4.0 Cl-103 HCO3-26 AnGap-12 [2116-4-8] 05:32AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0 . EKG [3-29] Baseline artifact. Sinus rhythm. Probable underlying inferior Q wave myocardial infarction. Extensive inferior and anterolateral T wave inversions raise strong consideration of ischemia. Q-T interval prolongation is also noted along with left axis deviation. No previous tracing available for comparison. Clinical correlation is suggested. . EKG [3-31]: Sinus rhythm. Compared to tracing #1 deep T wave inversions persist but are improving. Clinical correlation is suggested. . EKG [4-3]: Sinus bradycardia with a single ventricular premature beat or aberrantly conducted atrial premature beat. Prior inferior wall myocardial infarction. Minor right ventricular conduction delay. Left axis deviation. Q-T interval prolongation (484). Inferior and anterolateral T wave inversions may be due to ischemia, etc. Early R wave transition. Compared to the previous tracing of [2116-3-31] no diagnostic change. . ECHO [3-29]: Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with near akinesis of the distal septum and distal inferior wall and severe hypokinesis of the apex which is mildly aneurysmal. There is moderate hypokinesis of the remaining segments (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Right ventricular cavity size is growwly normal. Free wall motion is not well seen. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen The mitral leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with extensive regional and global systolic dysfunction. Normal right ventricular cavity size. No definite pathologic valvular flow identified. . CT HEAD [3-29]: FINDINGS: There are no prior studies for comparison. There is moderate prominence of ventricles and sulci. The ventricular enlargement is not out of proportion for sulci nor there is significant dilatation of the temporal horns beyond the dilatation of the lateral ventricles. These findings indicate atrophy. The CT appearances are not typical for normal pressure hydrocephalus. Mild-to-moderate changes of small vessel disease seen. There is no midline shift seen. No acute hemorrhage identified. No large area of loss of [Doctor Last Name 352]-white matter differentiation seen. IMPRESSION: No acute abnormalities. Brain atrophy. . CXR [3-30]: FINDINGS: In comparison with the study of [3-29], the areas of opacification at the bases are less prominent. The right lower lobe lung mass is less well seen than on the CT examination. Cardiac silhouette is less prominent and the pulmonary vascular congestion has decreased. . KUB [3-31]: FINDINGS: A single supine frontal view of the abdomen shows a nonspecific bowel gas pattern with gas in the small and large bowel. No free air is detected on this supine film. A moderate amount of fecal material is noted in the right colon. No dilated loops of bowel are seen. Air is noted within the bladder which is likely due to recent instrumentation. IMPRESSION: 1. Nonspecific bowel gas pattern with moderate fecal material in the right colon. No bowel obstruction or ileus. 2. Air within the bladder is likely due to recent instrumentation. Brief Hospital Course: 67 M with history of autism and dementia (A+O x 1 at baseline), HTN, DM2, HLD who presents to ED with emesis and abdominal pain, found to have positive troponin and TWI on EKG in anterior/lateral leads concerning for possible ACS event, UA suggestive of cystitis, and RLL infiltrate. . # NSTEMI of uncertain chronicity: Troponins were elevated at the [Hospital 99401] hospital and on presentation here to 0.3, although in the context of CHF exacerbation. His EKG demonstrated diffuse TWI in anterior, inferior leads concerning for NSTEMI. He was started on heparin and aspirin. He underwent an ECHO which showed regional wall motion abnormalities and EF 25-30%. Cardiology recommended catheterization however prior to the procedure he developed frank hematuria believed to be from traumatic foley insertion in setting of heparin so anticoagulation was held and catheterization was deferred. EKG continued to show TWI, although slightly impoved in V1 and V3. Some of this may be [2-6] cerebral T-waves, and chronicity is unclear, particularly given the patient's lack of chest pain or dyspnea. It was determined that medical management would be appropriate given this uncertain timing. We cannot be certain that this is NSTEMI, as the changes may be chronic or due to his known cerebral injury. Heparin gtt was stopped [4-6] to allow hematuria to resolve, low risk of acute clot. Discharged on aspirin 325, statin, lisinopril and metoprolol. . # Global hypokinesis and apical aneurysm: Chronic systolic HF with EF 25-30%. Given global hypokinesis and LV apex aneurysm, we initially wished to continue anti-coagulation to lower clotting risk. However, given continued hematuria the risk of this treatment is higher than the limited benefit. The risk of thrombus with a chronic LV aneurysm is low, and anti-coagulation is not necessary unless other risk factors are present. Given his persistent hematuria and associated reduction in functional status, the risk-benefit of stopping heparin was clear. Focus on improving his functional status and maintaining cardiac function. No long-term anti-coagulation is necessary given low risk of clotting. . # Health Care Associated Pneumonia: He presented with cough, elevated WBC count and CXR with RLL infiltrate. He was started on vancomycin, cefepime, and levofloxacin for HCAP. He was noted to have a long QT so his levofloxacin was switched to azithromycin. Urine legionella antigen was negative and blood cultures were unrevealing. He was treated with azithromycin for 5 days and a 7 day course of vancomycin/cefepime for possible aspiration or HCAP. Noted to be MRSA positive from nasal swab. . # Dementia/autism: He presented with lethargy. Per report his baseline is A+Ox1. He normally takes Zyprexa 2.5mg at 9am, 5mg at 9pm, Ativan 0.5mg [Hospital1 ] standing and 1mg PRN. In setting of lethargy and concern for prolonged QT, his home meds were held. At time of transfer out of MICU his mental status improved back to his baseline. On the floor he triggered [3-31] for somnolence, but vital signs were stable, ABG showed mild hypoxia, and he became rousable without intervention. Continued to hold Zyprexa and Ativan with good result, no agitation. We suggest using these only PRN to avoid QT prolongation. . # Pyuria: His inital UA was suggestive of UTI. OSH CT report did not show perinephric stranding or signs of pyelonephritis. He was started on broad spectrum antibiotics for his pneumonia as above. His urine culture did not grow any organisms. . # Hematuria: Believed to be from traumatic foley insertion in setting of BPH and heparin. Urology was consulted and felt that continuous bladder irrigation could help heal any prostatic injury. He was also started on finasteride to improve prostate healing. This was continued for several days with success. Hct trend 46.0 on [3-31] --> 39.7 [4-1] --> 38.4 [4-2] --> 38.7 [4-3] --> 37.9 [4-4] --> 34.9 [4-5] --> 34.9 [4-6] --> 31.0 [4-7] --> 31.1 [4-8]. [4-6] patient began to complain of pain at Foley site, blood clot and minor bleeding visible at meatus. Heparin gtt stopped [4-6] (as per above), hematuria then began slowly clearing. Continuous bladder irrigation stopped [4-7], patient was monitored for clotting of Foley causing retention, however has not had problem in 24 hours with urine output. Urology follow-up as an outpatient was scheduled to ensure resolution of these symptoms.Please maintain Foley until urology appointment on [2116-4-15], at this point they will reassess. . . # Pressure ulcers: Patient observed to have pressure ulcers on heel and sacrum. These were present on transfer to our care, may be related to his relative inactivity at the facility and recent hospitalization. Managed with wound care, waffle boots. . Chronic Issues: # DM2: Continued home lantus and ISS. . Transitional Issues: - Outpatient follow up of pulmonary nodule found on CT scan - Outpatient follow up of hematuria with Urology. Please maintain Foley until urology appointment on [2116-4-15], at this point they will reassess. . Monitor UOP, if < 200cc in 4 hours please bladder scan. If bladder scan > 400 cc, hand irrigate Foley to remove any clot. Continue finasteride until hematuria resolves or Urology appointment. - Patient has two pressure ulcers; left heel, sacrum. Please continue wound care - Please check weight, provide additional diuresis (Lasix 20mg PO) for weight gain > 3 lbs - The patient's sister, [Name (NI) ], called the hospital for an update. She was not known to the patient's guardian, it is not clear what level of information she can have access to from our facility. Phone number: [Telephone/Fax (1) 110562] Medications on Admission: per Millenium pharmacy from [2116-3-4] Asa 81mg daily ativan 0.5mg [Hospital1 ] ativan 1mg prn anxiety colace 100 [Hospital1 ] compazine 10mg [Hospital1 ] standing humalog ISS Lantus 39 qhs nitro patch 0.2mg/hr from 9pm-9am zyprexa 2.5mg at 9am, 5mg at 9pm bisacodyl 10mg supp prn fleet enema prn loperamide 2mg q4hr prn diarrhea maalox prn MOM prn tylenol 500mg prn Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety: Please only use as needed due to QT prolongation. 4. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for agitation: Please only use as needed due to QT prolongation. . 5. Lantus 100 unit/mL Solution Sig: Thirty Nine (39) units Subcutaneous at bedtime. 6. Humalog 100 unit/mL Solution Sig: Two (2) units Subcutaneous four times a day as needed for FSBS > 150: per sliding scale. 7. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a day as needed for constipation. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation: if not relieved by senna, bisacodyl. 10. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension Sig: Fifteen (15) ml PO three times a day as needed for heartburn. 11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Fifteen (15) ml PO twice a day as needed for indigestion. 12. loperamide 2 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for loose stools. 13. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: no more than 4g/day. 14. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 16. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: or until resolution of hematuria. 17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 18. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 16662] Rehab and Nursing Discharge Diagnosis: pneumonia urinary tract infection evidence cardiac ischemia of unknown chronicity, possibly NSTEMI hematuria [2-6] prostatic injury Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 827]. You were transferred to this hospital with pneumonia and a urinary tract infection. You were treated with antibiotics and these infections resolved. You were found to have signs of heart damage, however it was not clear if this was old or new. We found that there was no evolution of this damage, so we managed this with anti-clotting medicine and other medications to help your heart work more effectively. A Foley catheter was placed while you were in the ICU, but unfortunately this caused injury to your prostate. You were on an anti-clotting medication, so you experienced ongoing blood in the urine for several days. Once the anti-clotting medication was stopped this began to resolve. Although your blood count dropped, it did not reach a dangerously low level and you were not transfused. The blood in the urine should continue to improve, although it may take 1-2 weeks to go away entirely. We made the following changes to your medications: - CHANGE Ativan and Zyprexa to PRN, as he was stable without anxiety or agitation without these medications and has QT prolongation per EKG - INCREASE aspirin to 325 daily - STOP compazine due to QT prolongation - STOP nitro patch - START Senna for constipation (in addition to bisacodyl, Fleet enema PRN) - START atorvastatin - START metoprolol and lisinopril for hypertension and cardiac ischemia - START finasteride until hematuria resolves or per Urology - START Nystatin swish and swallow PRN thrush - START multivitamin daily for nutritional support Please follow-up with a Cardiologist and Urologist as listed below. Weigh yourself every morning, adjust diuretics if weight goes up more than 3 lbs. Suggest Lasix 20mg PO daily. Followup Instructions: Department: SURGICAL SPECIALTIES/UROLOGY When: WEDNESDAY [2116-4-15] at 2:00 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: CARDIAC SERVICES When: WEDNESDAY [2116-4-22] at 11:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "707.07", "428.22", "272.4", "250.00", "788.30", "294.20", "707.03", "428.0", "791.9", "486", "410.71", "867.0", "600.01", "V46.3", "299.00", "E928.9", "401.9", "707.20", "599.70" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	17454, 17519	9293, 14140	325, 331	17699, 17699	4034, 5622	19659, 20267	2706, 2716		15487, 17431		17540, 17678		15079, 15464			17876, 18869			5638, 9270						2731, 3358					3374, 4015											14217, 15053	18898, 19636				269, 287							359, 2184										17714, 17852			14156, 14196		2206, 2478	2494, 2690
58,508	109,313	5543	Discharge summary	report	Admission Date: [2180-11-11] Discharge Date: [2180-11-17] Date of Birth: [2117-10-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4393] Chief Complaint: GIB Major Surgical or Invasive Procedure: Endoscopy Colonoscopy Paracentesis Liver biopsy History of Present Illness: 63 year old male with past medical history of alcoholic cirrhosis complicated by ascites and variceal bleeding, duodenal ulcer, pancreatic mass, hepatic metastases, CAD, afib on coumadin who started his clinical decompesation in [2180-3-26] with inguinal hernia. He presented in [2180-7-27] with lower extremity edema and ascites which was attributed to his liver failure vs chronic systolic heart failure. . He had screening EGD done on [2180-11-7] which showed nonbleeding esophageal varices. He presented to [Hospital ] clinic on [2180-11-8] where he had MRCP that showed cirrhosis, splenomegaly, pancreatic mass and hepatic metastases. A plan was formed to further evaluate this condition. Labs were drawn and were most notable for a HCT of 41, Ca19-9 of 461. . He had large volume paracentesis of 8L done on [2180-11-10]. He presented to OSH this morning after having episode of hematemesis and BRBPR. He was noted to have SBP of 77, HCT 20 and INR 2.3 (of note has been off coumadin for past 10 days). His BUN/CR was 50/1.3. He was given 3 units of PrBC with bump in his HCT to 27. He continued to be hypotensive requiring norepi gtt. He underwent endoscopy which showed gastric varices vs GEJ varix with clot in upper stomach which could be dislodged. He was continued on octreotide and protonix gtt and transferred to [Hospital1 18]. . On arrival to the MICU, he reports feeling better. GI scoped him as he continued to have BRBPR x 3 with increase in levo gtt. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: cirrhosis decompensated with ascites and variceal bleed pancreatic mass with metastases and elevated Ca19-9 diverticulitis with a colovesical fistula, which closed spontaneously. CAD Duodenal ulcer afib, on coumadin (not for last ten days) history of CHF Social History: No Alcohol, Tobacco or drugs Family History: Not contributory to current presentation Physical Exam: 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: non-tender, distended but soft, 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 Pertinent Results: MICU Labs: [2180-11-14] 04:03AM BLOOD WBC-8.7 RBC-3.63* Hgb-11.5* Hct-34.3* MCV-95 MCH-31.6 MCHC-33.4 RDW-20.2* Plt Ct-131* [2180-11-13] 03:55AM BLOOD WBC-12.0* RBC-3.74* Hgb-11.7* Hct-34.4* MCV-92 MCH-31.2 MCHC-33.9 RDW-19.7* Plt Ct-149* [2180-11-12] 04:52AM BLOOD WBC-17.8* RBC-3.47* Hgb-10.9* Hct-32.7* MCV-94 MCH-31.5 MCHC-33.4 RDW-19.3* Plt Ct-237 [2180-11-11] 11:29PM BLOOD WBC-14.6# RBC-3.02 Hgb-10.0# Hct-29.2# MCV-97# MCH-33.0* MCHC-34.1 RDW-18.6* Plt Ct-217 [2180-11-14] 04:03AM BLOOD PT-16.1* PTT-36.4 INR(PT)-1.5* [2180-11-12] 06:14PM BLOOD PT-15.8* INR(PT)-1.5* [2180-11-12] 12:47PM BLOOD PT-16.6* PTT-31.1 INR(PT)-1.6* [2180-11-11] 11:29PM BLOOD PT-19.3* INR(PT)-1.8* [2180-11-14] 04:03AM BLOOD Glucose-106* UreaN-29* Creat-0.9 Na-144 K-3.8 Cl-119* HCO3-20* AnGap-9 [2180-11-13] 03:55AM BLOOD Glucose-128* UreaN-39* Creat-0.9 Na-149* K-3.2* Cl-119* HCO3-24 AnGap-9 [2180-11-12] 05:05PM BLOOD Glucose-139* UreaN-48* Creat-0.9 Na-146* K-3.3 Cl-116* HCO3-25 AnGap-8 [2180-11-12] 04:52AM BLOOD Glucose-134* UreaN-59* Creat-1.0 Na-144 K-4.5 Cl-115* HCO3-21* AnGap-13 [2180-11-11] 11:29PM BLOOD Glucose-139* UreaN-61* Creat-1.2 Na-142 K-4.1 Cl-110* HCO3-26 AnGap-10 [2180-11-14] 04:03AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.9 [2180-11-13] 08:14PM BLOOD Calcium-8.4 Phos-2.3* Mg-2.1 [2180-11-13] 03:55AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0 [2180-11-12] 05:05PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0 # CT abd/pelvis 1. No evidence of an actively extravasating GI bleed. 2. Pancreatic tail lesion with multiple hepatic lesions, concerning for a primary pancreatic malignancy, possibly a neuroendocrine tumor, with hepatic metastases. No evidence of portal or splenic vein thrombosis. The tumor appears well defined and peripherally enhancing which is uncommonly seen in pancreatic ductal adenocarcinoma. 3. Cirrhotic liver and large amount of simple ascites; at the time of this study, a diagnostic paracentesis has been already performed. 4. Sigmoid diverticulosis. # Tagged RBC scan No evidence of active GI bleeding during 90 minutes of imaging. RUQ US IMPRESSION: Multiple hepatic lesions which are visualized on ultrasound and are amenable for ultrasound-guided liver biopsy. Findings were discussed with referring physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], on [2180-11-14] with nurse practitioner, [Doctor Last Name 636] Ghanem, and an ultrasound-guided liver biopsy has been scheduled for [2180-11-15]. Hepatic biopsy Path: 1. Adenocarcinoma, moderately to poorly differentiated, morphologically suggestive of a pancreaticobiliary primary; see note. 2. Scant adjacent non-neoplastic hepatic parenchyma with advanced fibrosis and rare nodule formation (confirmed by trichrome stain), moderate cholestasis and rare associated neutrophils; see note. 3. Iron stain is negative for significant iron deposition. Paracentesis: [2180-11-15] 03:54PM ASCITES WBC-190* RBC-225* Polys-6* Lymphs-55* Monos-0 Mesothe-4* Macroph-35* [2180-11-15] 03:54PM ASCITES Glucose-107 LD(LDH)-45 Albumin-<1.0 Negative for malignant cells Discharge Labs: * Brief Hospital Course: 63 with decompensated cirrhosis and metastatic cancer presents with episode of hematemesis and BRBPR. # GIB: The patient initially went to OSH for hematemesis and BRBPR. The patient was hypotensive and required phenylepherine while in the unit. An EGD was done in the MICU and no active source of bleeding was noted. There were grade 1 varices found in the lower third of esophagus, which were not bleeding, and with no stigmata of recent bleed. A Dileufoy's lesion was seen in the stomach that was also not actively bleeding, but 2 clips were still successfully placed. Both CTA and tagged RBC scan were negative for any bleeding source, Colonoscopy showed external hemorrhoids, and portal enteropathy, non bleeding AVMs. The patient was treated with Protonix [Hospital1 ] and ceftriaxone for SBP ppx. In total, he was transfused 7U PRBC, 2 FFP, and one unit platelets. Patient was transferred to hepatorenal service with improved hemodynamics and with stable crit, he had no further GIBs. # Cirrhosis - Presumably alcoholic. Radiography and SAAG were consistent with cirrhosis and portal hypertension. Patient had paracentesis which removed 15L of fluid, was negative for SBP so Ceftriaxone reduce from 2mg to 1mg daily for ppx against GNR sepsis in setting of GIB. Hepatic biopsy was performed which showed adenocarcinoma. Patient was seen by palliative care services and will go home with VNA and plan for outpatient home hospice care in the near future. He will see outpatient Palliative care with Atrius. . # Atrial Fibrillation: The patient was on beta blockers and digoxin for rate his atrial fibrillation; both were held while in the unit. The patient's coumadin was also held in context of his bleeding. Only Digoxin restarted on medicine floor. . # CAD: While in the unit, the patient's aspirin, beta blocker were held in setting of GI bleed. Simvastatin and fenofibrate also held. . # Pancreatic mass with liver mets: Unclear etiology, Hepatic biopsy performed which showed adenocarcinoma consistent with pancreatic metastasis. A family meeting was held to discuss these results and to inform the patient of the grim prognosis. Given his rapidly accumulating ascites and pancreatis metastasis his prognosis is poor and he is beginning to transition to palliative care. # Glaucoma complicated by retinal detachment: The patient was continued on his home prednisolone and atropine eye drops. TRANSITIONAL ISSUES: - Patient going home with VNA services and plan to transition to home hospice care - Patient discharged without long term mortality medications to limit his medication intake and to improve quality of life. Only medications discharged with included medications to keep him without symptoms. - Patient requires twice weekly paracentesis for comfort Medications on Admission: ALLOPURINOL 200 mg daily ATENOLOL 50 mg Tablet daily ATROPINE 1% drops to left eye once a day DIGOXIN 250 mcg daily FENOFIBRATE 200 mg po qdaily Potassium chloride 20 meq po qdaily FUROSEMIDE 40 mg daily PREDNISOLONE 1% right eye three times a day SIMVASTATIN 40 mg daily WARFARIN 2.5 mg po qdaily (not taken in past 10 day) ASPIRIN 81 mg daily MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM] Fluticasone inhalation 1 puff [Hospital1 *] sometimes Discharge Medications: 1. atropine 1 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s)* Refills:0 5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for itching. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: GI Bleed End Stage Liver Disease 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 pleasire treatomg ypi diromg this hospitalization. You were admitted to [Hospital3 ] [Hospital ] Medical center after you had a significant GI bleed which required you to be in the MICU and receive many units of blood products. After you were stabilized you were admitted to the medicine service for further management. You had a paracentesis which removed 13L of fluid so that a liver biopsy could be completed. Biopsy showed adenocarcinoma which was most likely from your pancreas. Your post-procedure course was uncomplicated and you had no further bleeds. The following changes to your medicatoins were made: - START Ursodiol Three times per day - START Hydroxyzine every 6 hours as needed for itchiness - STOP Coumadin - STOP Atenolol - STOP Aspirin - STOP Statin - STOP Fibrate - CONTINUE Digoxin Followup Instructions: You have a follow up appointment with your [University/College ] Vangard Heme/Onc physician [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 4407]	[ "303.90", "428.0", "197.7", "V45.82", "458.9", "572.8", "V58.61", "789.59", "428.22", "157.2", "285.1", "V66.7", "571.2", "537.84", "427.31", "572.3", "305.1", "456.21" ]	icd9cm	[ [ [] ] ]	[ "44.43", "50.11", "54.91", "45.23" ]	icd9pcs	[ [ [] ] ]	10677, 10735	6563, 8984	310, 360	10812, 10812	3333, 6519	11836, 12043	2702, 2744		9848, 10654		10756, 10791		9380, 9825			10963, 11813			6535, 6540						2759, 3314																9005, 9354		1913, 2361			267, 272							388, 1894										10827, 10939					2383, 2640	2656, 2686
44,807	151,424	42358	Discharge summary	report	Admission Date: [2119-10-1] Discharge Date: [2119-10-17] Date of Birth: [2082-4-23] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 896] Chief Complaint: s/p PEA arrest Major Surgical or Invasive Procedure: Endotracheal intubation Triple lumen catheter - internal jugular vein Triple lumen catheter - femoral vein Femoral arterial line Radial arterial line History of Present Illness: 37 yo M with bipolar and polysubstance abuse history presented from OSH after being found unresponsive, intubated, complicated by cardiac arrest transferred to [Hospital1 18] for further management. Per patient's family, he was at his usual state of health, ate dinner with sister [Name (NI) 6303], had a bottle of beer. He picked up his prescription medication, moprhine and clonazepam. [First Name8 (NamePattern2) ] [Doctor First Name 6303], his morphine dose is usually 60 mg. The patient apparently stated that he took 7 of his pills (unclear which). He went to bed and this was found to be drenched in sweat and unresponsive at 2PM on the day of arrival. He was sent to the OSH. Family did not notice any episodes of apnea. OSH ([Hospital6 12112]) record is incomplete at this time. Patient had multiple PEA arrest, recorded at 1746, 1750, 1755, 1810 and 1815; VT at 1800. Underwent CPR and received multiple doses of epinephrine, 1x atropine, multiple amiodarone, 1x vasopressin, propofol, dopamine, heparin gtt, integralin, and other medications. Apparently, the tox screen there showed + amphetamine, opiates, benzodiazepine, and ethanol. ABG at 1533 was 7.20/47/379/18 on FiO2 of 100, RR 14, CMV. In the ED, patient was initially thought to be hypotensive. He was on multiple pressors intiially- levophed, dopamine, dobutamine, phenylephrine. He received a femoral A line and femoral central line. He was found to be hyperkalemia with initial K up to 8, received insulin, calcium gluconate, and sodium bicarb. He was given vancomycin and zosyn given severe leukocytosis. Patient was then transferred to get CT imaging prior to transfer, on only levophed. On the floor, patient was intubated Review of systems: Unable to assess Past Medical History: - depression - h/o suicidal attempts - h/o overdose - back pain - h/o penetrating eye injury - blindness in 1 eye - HTN - MRSA - bipolar - hyperlipidemia - h/o H. pylori - h/o seizure Social History: - Tobacco: 2 ppd per family, for at least 15 years - Alcohol: daily, per family Family History: - non-contributory Physical Exam: ADMISSION: Vitals: T:38.7 BP: 118/67 P: 101 R: 16 O2: 100% on ventilator General: intubated HEENT: Sclera anicteric, mucous membrane dry, intubated Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, + ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds diminished, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE: VS - 97.5, 128/62, 75, 18, 96%RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, LUNGS - Course breath sounds throughout, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, mild TTP, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no cyanosis or clubbing, DP 2+ b/l, 2+ edema of all 4 extremities, +necrotic lesion on right thumb (unchanged). Mass appreciated in left groin, ~7x4 cm, TTP, firm, nonpulsatile. Left antecubital fossa: erythematous, non tender; improving. SKIN - no rashes or lesions NEURO - awake, A&Ox3, muscle strength 5/5, sensation grossly intact throughout, persistent flat affect with limited expression in his voice. Pertinent Results: ADMISSION: [2119-10-1] 07:55PM BLOOD WBC-36.9* RBC-5.11 Hgb-16.4 Hct-50.2 MCV-98 MCH-32.0 MCHC-32.6 RDW-12.4 Plt Ct-335 [2119-10-2] 02:05AM BLOOD Neuts-84* Bands-1 Lymphs-12* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2119-10-1] 07:55PM BLOOD PT-15.6* PTT-63.1* INR(PT)-1.4* [2119-10-1] 07:55PM BLOOD Fibrino-236 [2119-10-1] 11:00PM BLOOD Glucose-178* UreaN-33* Creat-4.2* Na-138 K-5.4* Cl-104 HCO3-18* AnGap-21* [2119-10-1] 07:55PM BLOOD ALT-1329* AST-1181* LD(LDH)-2620* CK(CPK)-[Numeric Identifier 91746]* AlkPhos-95 TotBili-0.7 [2119-10-1] 07:55PM BLOOD Lipase-421* [2119-10-1] 07:55PM BLOOD CK-MB-66* MB Indx-0.2 cTropnT-0.82* [2119-10-1] 11:00PM BLOOD Calcium-7.5* Phos-7.3* Mg-1.9 [2119-10-1] 07:55PM BLOOD Osmolal-309 [2119-10-1] 07:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2119-10-1] 09:02PM BLOOD Type-ART Temp-39.3 Rates-/16 Tidal V-600 FiO2-100 pO2-250* pCO2-39 pH-7.26* calTCO2-18* Base XS--8 AADO2-431 REQ O2-74 -ASSIST/CON Intubat-INTUBATED [2119-10-1] 08:03PM BLOOD Glucose-127* Lactate-8.7* Na-138 K-8.0* Cl-103 calHCO3-14* [2119-10-1] 09:02PM BLOOD Hgb-14.2 calcHCT-43 O2 Sat-97 COHgb-2 MetHgb-1 [2119-10-1] 09:02PM BLOOD freeCa-1.07* DISCHARGE: [2119-10-17] 06:45AM BLOOD WBC-10.3 RBC-2.99* Hgb-9.5* Hct-27.6* MCV-92 MCH-31.6 MCHC-34.3 RDW-14.0 Plt Ct-529* [2119-10-17] 06:45AM BLOOD PT-14.9* PTT-33.8 INR(PT)-1.3* [2119-10-17] 06:45AM BLOOD Glucose-92 UreaN-15 Creat-1.7* Na-138 K-4.2 Cl-106 HCO3-23 AnGap-13 [2119-10-15] 06:40AM BLOOD ALT-45* AST-26 LD(LDH)-279* AlkPhos-100 TotBili-0.4 [2119-10-17] 06:45AM BLOOD Calcium-8.6 Phos-5.2* Mg-1.8 URINE: [2119-10-1] 07:55PM URINE Color-Red Appear-Hazy Sp [Last Name (un) ]-1.011 [2119-10-1] 07:55PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2119-10-1] 07:55PM URINE RBC-35* WBC-25* Bacteri-MOD Yeast-NONE Epi-1 TransE-<1 [2119-10-1] 07:55PM URINE CastHy-5* [2119-10-1] 07:55PM URINE AmorphX-RARE [2119-10-1] 07:55PM URINE Mucous-RARE [2119-10-1] 07:55PM URINE Osmolal-346 [2119-10-1] 07:55PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG OTHER PERTINENT LABS: Neuron specific enolase: PENDING AT DISCHARGE Heparin dependent Ab: POSITIVE Serotonin release assay: NEGATIVE MICROBIOLOGY: [2119-10-14] Blood Culture, Routine-PENDING-No growth to date [2119-10-14] Blood Culture, Routine-PENDING-No growth to date [2119-10-9] Blood Culture, Routine-FINAL-Negative [2119-10-9] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL-Negative [2119-10-9] Blood Culture, Routine-FINAL-Negative [2119-10-9] URINE CULTURE-FINAL-Negative [2119-10-9] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL-Negative [2119-10-7] SPUTUM GRAM STAIN-FINAL-Negative; RESPIRATORY CULTURE-FINAL {YEAST} [2119-10-7] CATHETER TIP-IV WOUND CULTURE-FINAL-Negative [2119-10-7] Blood Culture, Routine-FINAL-Negative [2119-10-6] Blood Culture, Routine-FINAL-Negative [2119-10-6] URINE CULTURE-FINAL-Negative [2119-10-6] Blood Culture, Routine-FINAL-Negative [2119-10-4] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL-Negative; Respiratory Viral Antigen Screen-FINAL-Negative [2119-10-4] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL-Negative; RESPIRATORY CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-FINAL-Negative [2119-10-4] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [2119-10-3] URINE CULTURE-FINAL-Negative [2119-10-3] Blood Culture, Routine-FINAL-Negative [2119-10-3] Blood Culture, Routine-FINAL-Negative [2119-10-2] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STREPTOCOCCUS PNEUMONIAE}; LEGIONELLA CULTURE-FINAL-Negative [2119-10-2] Legionella Urinary Antigen-FINAL-Negative [2119-10-1] Blood Culture, Routine-FINAL-Negative [2119-10-1] URINE CULTURE-FINAL-Negative [2119-10-1] MRSA SCREEN-FINAL-Negative [2119-10-1] Blood Culture, Routine-FINAL-Negative [2119-10-1] Blood Culture, Routine-FINAL-Negative [2119-10-1] Blood Culture, Routine-FINAL-Negative STUDIES: [2119-10-1] ECHO: Very poor image quality. LV systolic function appears depressed. There is no ventricular septal defect. RV with depressed free wall contractility. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [2119-10-1] CXR: 1. Endotracheal tube in appropriate position. 2. Nasogastric tube courses below the level of the diaphragm, inferior aspect not included on the image. 3. Low lung volumes and possible mild pulmonary vascular congestion. 4. Non-displaced fracture of the posterior right 8th rib. [2119-10-1] CT torso: Left upper lobe aspiration or pneumonia. No pulmonary embolism upto the lobar and segmental branches. No abscess. Diffusely hypodense liver with a enlarged portocaval lymph node but no splenomegaly. This is likely related to hepatitis. [2119-10-4] NCHCT: 1. Evidence of diffuse cerebral edema without focal abnormality. 2. No acute intracranial hemorrhage. 3. Likely right intra-ocular hemorrhage that may be secondary to reported history of "penetrating trauma" (according to a note on OMR). [2119-10-5] ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. No gross vegetations seen. IMPRESSION: Suboptimal image quality. No obvious vegetations. Endocarditis cannot be excluded on the basis of this study. [2119-10-5] MRI Head: 1. Acute ischemic foci in the bilateral globi pallidi as well as the left parietal and temporal lobe. Given the involvement of the bilateral lentiform nuclei, an etiology of hypoxia should be considered. 2. No evidence of cerebral edema or hemorrhage. [2119-10-7] B/l LENIs: No evidence of DVT in either lower extremity. [2119-10-8] B/l UENIs: Thrombus in the right cephalic vein. Left cephalic vein not seen. No evidence of DVT otherwise noted. [2119-10-12] CT Abd/pelvis: 1. Small left groin hematoma without extension into the retroperitoneum or thigh. 2. Stranding about several loops of small bowel in the right lower quadrant. This could reflect infectious or ischemic episode. Less likely would be small hematoma. Further evaluation if desired can be obtained by contrast-enhanced CT with oral contrast. [2119-10-12] Femoral Vascular Ultrasound: Small left groin hematoma with no pseudoaneurysm identified. [2119-10-13] Left UENI: Nonocclusive thrombus within the distal left cephalic vein. Brief Hospital Course: 37 yo male with bipolar and history of polysubstance abuse found unresponsive, transferred from OSH intubated s/p PEA arrest and CPR on pressors. # Cardiopulmonary arrest: As per report, the patient was estimated to have had approximately 45 minutes of down time in the field and at the OSH with 5 PEA arrests and one episode of ventricular tachycardia. On arrival, the patient was cooled, reaching target of 33 C at 8am [10-2]. This was maintained for 24hrs and the patient paralyzed with cisatracurium. Re-warming was complicated by patient being persistently febrile, so that excessively cooling from pads was causing skin changes. Eventually pads were taken off at 4pm [10-4], after which patient was febrile to 101. By [10-5], patient opening eyes to voice and intermittently following commands. MRI brain shows multiple small infarcts suggestive of hypoxia. He was extubated on [10-9] and had complete neurologic recovery. The neurology team continued to follow him and did not find any subtle residual deficits from the small infarcts. # Encephalopathy: Most likely initially due to a drug overdose. His OSH tox screen was positive for amphetamine, benzo, opiate, and EtOH. He was also has severe leukocytosis on arrival, most likely result of cardiac arrest +/- infectious etiology. During the hospitalization, MS was also likely worsened by infection and sedating meds. He was initially treated with broad spectrum abx, then narrowed to treat strep pneumo (culture proven) pneumonia which was continued for an 8 day course. Flagyl was given out of concern for aspiration PNA. Pt was given thiamine, folate and multivitamin as well. # Septic shock. There was initial concerned for cardiogenic vs septic shock. He required pressors upon arrival, however these were discontinued after a few days as he began to recover. A TTE showed normal cardiac function, ruling out a cardiogenic etiology. He was treated with antibiotics and fluid resuscitation with pressors and his condition improved. His blood pressures remained stable throughout the remainder of his hospital course. # Respiratory failure. Most likely hypoxic hypercarbic respiratory failure in the setting of OD. Intubated on arrival and extubated on day 8 of the admission with no further difficulty breathing. # Anemia in setting of acute blood loss Pt with dark aspirate from OG tube and guaiac/gastroccult positive. [Hospital1 ] PPI initiated. Patient is to follow up with GI as an outpatient for possible EGD. Patient remained hemodynamically stable during this time period. Following transfer out of the ICU, the patient was noted to have a hematoma in his left groin (6x5cm). A CT scan did not show additional RP bleed and vascular ultrasound revealed normal blood flow through the vessel. # Thrombocytopenia / possible HIT Concerned for HIT with 4t score of 6 and cephalic vein clot, therefore heparin was held and pt was started on argatroban. Heme was consulted and felt that his likely [Doctor Last Name ] of HIT was low, however anticoagulation should be given as long as it outweighed the bleeding risks pending the confirmatory serotonin release assay. SRA was sent and was negative. The argatroban gtt was stopped and the patient was given fondaparinux for DVT ppx to avoid reintroducing unfractionated heparin. # Superficial thrombophlebitis Patient was noted to have an erythematous, warm region near his antecubital fossa on the left. It occasionally was noted to be weeping clear-whitish fluids. A nonocclusive clot was noted in the left cephalic vein. He was given approximately 48 hours of antibiotics, however given the overall appearance and history, it was decided that this was most likely due to superficial thrombophlebitis and was treated with hot packs and arm elevation. Although not entirely, the region improved significantly prior to discharge. # Acute renal failure / Acute tubular necrosis: This was thought to be due to rhabdomyolysis and ATN due to shock and poor renal perfusion. Improved throughout the admission with supportive care only. His Cr on discharge was 1.7. # Diarrhea On the general medical floor, the patient c/o once daily BM consisting of loose liquidy stools. Patient was noted to be Cdiff negative and his volume status was closely monitored. # Hyponatremia: Associated with free water deficit. Improved with free water repletion # Transaminitis. Most likely [1-4] shock, LFTs downtrending during the admission. Upon discharge, only ALT remains above the upper limit of normal. # Rhabdomyolysis. The patient had no compartment syndrome on exam. Likely from being altered and down for several hours. Improved with fluid resuscitation. # Hypertension: Occurred after patient recovered from sepsis. Hypertension was treated with clonidine given that there was also concern for withdrawal. Home antihypertensives were slowly restarted as renal function improved. Lisinopril continued to be held at discharge as Cr remained elevated. ==================================== TRANSITIONS OF CARE ==================================== -Dropping hematocrit with guaiac positive stools, patient is to see GI as an outpatient -Pain regimen was altered to MS contin 30 mg q8h and roxicet. -Lisinopril was held at discharge due to increased Cr. Pending Labs: -Neuro endolase -Blood cultures x2 from [2119-10-14] Medications on Admission: - roxicet 5-325 mg, 1-2 tabs q6hr prn for pain - atropine 1% eye drop to the right eye 4 times daily - clonazepam 2 mg, 1 tab, [Hospital1 ] - cyclobenzaprine 10 mg, TID prn - doxepin 150 mg qHS - HCTX 25 mg daily - ibuprofen 800 mg TID prn - lisinopril 20 mg QD - morphine MS Contin 60 mg TID for chronic pain - omeprazole 20 mg daily - prednisolone acetate 1 % ophthalmic suspension 1 drop to the right eye 4 times a day - simvastatin 20 mg qHS Discharge Medications: 1. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). 2. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop to right eye Ophthalmic four times a day. 3. atropine 1 % Drops Sig: One (1) drop to right eye Ophthalmic four times a day. 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Roxicet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 11. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 12. clonazepam 2 mg Tablet Sig: Two (2) Tablet PO twice a day. 13. doxepin 150 mg Capsule Sig: One (1) Capsule PO at bedtime. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Primary: PEA arrest due to overdose, substance unknown. Secondary: Acute renal failure Thrombocytopenia Superficial thrombophelbitis Hypertension Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [Known lastname 3142], It was a pleasure taking part in your care. You were transferred to our hospital after you were found to have overdosed on medications. You had a cardiopulmonary arrest that required CPR and mechanical intubation for breathing. You underwent a cooling protocol in the Intensive Care Unit and required multiple medications for your blood pressure. You began to recover and were able to have the breathing tube removed and were transferred out of the ICU. We found that you had developed a pneumonia for which you received antibiotics. We also noted that noticed your platelets had decreased and we were concerned that this was due to a reaction to a blood thinning medication known as heparin. You were started on a different blood thinning medication and more lab tests were sent. These lab tests were negative and the blood thinning medication was stopped. You also sustained a degree of kidney injury. This is improving, but it is not quite healed yet. It will be some time before we know if this is permanent. We also found that a hematoma had developed on the left side of your groin. This was likely due to a large IV that was used during your arrest. We did a CT scan which revealed that the bleed was isolated to this location and a ultrasound showed normal flow through the underlying vessel. We also noted that two small clots, one in both your left and right arm, had formed. These were likely due to smaller IVs that were used through out the course of your hospitalization. The clot on the left appears to have a mild infection. You do not need antibiotics for this unless it were to worsen. For now, this should be treated with warm packs and arm elevation. We found that your red blood cells, the cells that carry oxygen to your tissues decreased throughout the course of this hospitalization. We found that there is microscopic amounts of blood in your stool. This could be caused by many things and we recommended you follow up with a gastroenterologist. It is natural to feel weak after an arrest such as yours. You were evaluated by our physical therapist who feel you need additional, more intensive physical therapy at a rehabilitation center. You declined our offer and requested that you be discharged home. We recommend that someone be with you as often as possible while you are at home, ideally 24hrs a day. We strongly urge you to not use drugs in the future. Please understand that this was actually a FATAL OVERDOSE- you are VERY lucky to have been revived back to life. We are very happy that you were able to be resuscitated. Another overdose might leave you with more permanent damage. Please make the following changes to your medications: -HOLD: lisinopril as your kidney's recover until you doctor recommends otherwise. -Please avoid taking ibuprofen/advil/motrin, as these medications can be damaging for your kidney and cause bleeding -Please also avoid taking acetaminophen/tylenol, as this medication can be harmful to your liver. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 275] J. Location: [Hospital1 ] FAMILY HEALTH/ INTERNAL MEDICINE Address: [Location (un) ], [Hospital1 ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 31553] When: Monday, [2119-10-23]:00 AM Department: GASTROENTEROLOGY When: MONDAY [2119-10-30] at 11:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2837], MD [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "728.88", "965.00", "969.72", "451.82", "434.91", "578.9", "401.9", "577.0", "323.9", "288.60", "980.0", "570", "276.3", "E850.2", "276.7", "348.1", "038.9", "E853.2", "305.90", "507.0", "289.84", "785.52", "276.1", "E854.2", "041.2", "584.5", "348.39", "305.01", "969.4", "453.81", "707.8", "348.5", "285.1", "427.5", "518.81", "V12.04", "729.92", "682.3", "995.92" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "38.97", "33.24", "96.72" ]	icd9pcs	[ [ [] ] ]	18514, 18597	11407, 16808	290, 442	18798, 18798	3952, 6215	22036, 22618	2567, 2587		17308, 18491		18618, 18777		16834, 17285			18981, 21686									2602, 3933																	21715, 22013	2228, 2246			236, 252							470, 2209								6237, 11384		18813, 18957					2268, 2453	2469, 2551
32,425	121,264	28167	Discharge summary	report	Admission Date: [2160-7-2] Discharge Date: [2160-7-11] Date of Birth: [2109-1-23] Sex: F Service: MEDICINE Allergies: Shellfish / Flexeril / Tricyclic Compounds Attending:[First Name3 (LF) 12174] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 51 YO F w ESLD [1-8] HCV and septic hip who presented to an outpatient appt for reclast at which time she was noted to have a BP in the 70s. The patient was feeling well until the night prior to presentation when she had several loose bowel movements without blood. She slept last night and awoke this am feeling nauseous. She ate 1 bite of breakfast and vomited nonbloody gastric contents. She denied any fever, chills, or shortness of breath. She was scheduled for an outpatient Reclast infusion so was picked up by an ambulance for transport at which time EMTs noted her SBP to be in the 70s. The patient insisted on going to her appt rather than the ED. At her appt she was again noted to have SBPs in the 70s so was transported to the ED. . In the ED, patient was triggered for an initial BP of 73/43. She was given 2L NS without effect. A femoral CVL was placed and she was given vanc, zosyn, hydrocort, and norepi with improvement in her SBPs to the 100s-120s. Her labs returned notable for WBCs 7.8 with 23% bands, creat 1.5, K 6.6 and lactate 3.7. U/A was negative for evidence of UTI. Blood and urine cultures were drawn. EKG revealed peaked T waves so she was given insulin, dextrose, bicarb, and Ca gluconate. K went from 6.6 to 5.5. She is was noted to be very sleepy but arousable and able to protect her airway. CXR was c/w a retrocardiac opacity. VS prior to transfer were: 101/65 85-90 16 93% RA. . On the floor, the patient reports feeling better. She does complain of bilateral lower abdominal pain. Her mother says she is still not at her baseline but is much improved since arriving at the ED; most specifically, she is much less lethargic. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. HCV Cirrhosis, diagnosed [2151], nonresponder to interferon / ribavirin, s/p TIPS [11-8] for ascites. Course has been complicated by encephalopathy, thrombocytopenia, ascites, and hydrothorax. Was on [Month/Year (2) ] list but inactivated due to recurrent infections. 2. Hyponatremia baseline 128-133 3. Secondary adrenal insufficiency 4. Asthma 5. Diabetes mellitus 6. GERD 7. Anxiety 8. History of urinary tract infections 9. s/p hip fracture and ORIF in [11/2157], which was complicated by polymicrobial septic hip (E. Coli, enterococcus, coag neg Staph, Klebisiella) s/p washout [6-/2158], hardware removal [9-/2158], with wound vac in place at home. 10. History of LE Cellulitis 11. Possible prolactinoma suggestion of microadenoma [5-12] 12. Hypercalcemia thought due to aggressive vitamin D repletion Social History: Lives with her mother. [Name (NI) ] 1 daughter and a granddaughter. Stopped smoking in [2154], previously smoked [12-8] ppd for several years, unclear how long. Sober since [2148], drank an unclear amount of drinks per day before that. H/o IV heroin, stopped in [2148]. No other drugs used. No sick contacts or recent travel. Family History: Father - COPD, alcohol cirrhosis Mother - diabetes, HTN, HL Daughter - congenital heart dz Physical Exam: On admission: Vitals: 85, 101/65, 16, 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ON ADMISSION ([2160-7-2]): WBC-7.8 RBC-3.15* Hgb-9.9* Hct-30.3* MCV-96 MCH-31.4 MCHC-32.6 RDW-18.2* Plt Ct-61* Neuts-66 Bands-23* Lymphs-7* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+ PT-17.8* PTT-36.2* INR(PT)-1.6* Glucose-93 UreaN-48* Creat-1.5* Na-121* K-6.6* Cl-91* HCO3-22 AnGap-15 ALT-22 AST-50* AlkPhos-273* cTropnT-0.06* Calcium-8.2* Phos-5.1# Mg-2.0 Lactate-3.7 . UPON DISCHARGE ([2160-7-10]): WBC-8.8 RBC-2.45* Hgb-7.5* Hct-23.1* MCV-94 MCH-30.4 MCHC-32.2 RDW-20.1* Plt Ct-62* PT-21.8* PTT-38.3* INR(PT)-2.0* Glucose-166* UreaN-35* Creat-0.6 Na-137 K-4.1 Cl-107 HCO3-23 AnGap-11 ALT-27 AST-37 AlkPhos-204* TotBili-2.4* Albumin-2.8* Calcium-8.4 Phos-2.4* Mg-1.7 . MICRO: Blood Cx ([7-2]): Pseudomonas aeurginosa Urine Cx ([7-2]): no growth Stool Cx ([7-2]): no C. diff, Salmonella, Shigella, or Campylobacter Blood Cx ([7-4], [7-5], [7-6], [7-7]): no growth Stool Cx ([7-6]): no C. diff CMV viral load ([7-8]): not detected Stool Cx ([7-8]): no C. diff, Cryptosporidium, or Giardia . IMAGING: Portable CXR ([7-2]): 1. LLL consolidation, worrisome for PNA with possible superimposed atelectasis. 2. Right pleural effusion and increased interstitial markings reflecting mild pulmonary edema. . Abdominal U/S ([7-3]): Minimal amount of intra-abdominal ascites. The amount of fluid within the abdominal quadrants would be a high-risk procedure even for a diagnostic aspiration and we would recommend deferral of attempting sampling at this time. . PA&LAT CXR ([7-3]): Chronic bilateral pleural effusions and bibasilar opacities/atelectasis, possibly due to chronic aspiration. Increased left retrocardiac consolidation is again worrisome for pneumonia. . RUQ U/S ([7-3]): 1. Unchanged cirrhotic-appearing liver, without suspicious hepatic lesion or intrahepatic fluid collection to suggest abscess. 2. Contracted gallbladder related to recent meal. Biliary sludge and stable cholelithiasis but no findings of acute cholecystitis. . CT abdomen/pelvis w/ contrast ([7-4]): 1. Patchy opacity in the right lung base may represent aspiration or infection. 2. Small bilateral pleural effusions with associated compressive atelectasis, underlying infection not excluded. 3. Findings compatible with cirrhosis and portal HTN. 4. Wall edema in the distal rectum suggestive of proctitis. . Mandible XR ([7-9]): Patchy osteopenia of the mandible. Multiple erosions. Brief Hospital Course: 51 year old woman with HCV cirrhosis s/p TIPS in [2153], which has been c/b encephalopathy, thrombocytopenia, ascites, hydrothorax, and multiple infections, and septic right hip who presented to an outpatient appointment for reclast at which time she was was noted to be hypotensive and confused, and was sent to the ED. Please see admission note for further details. Brief hospital course by problem: . # Sepsis: The pt presented with vomiting, hypotension, and altered mental status and was found to have 7.8 WBCs with 23% bands. U/A was negative and urine culutures showed no growth. A CXR revealed a LLL consolidation suspicious for PNA, however the pt denied respiratory symptoms and was not hypoxic. An abdominal U/S revealed an unchanged cirrhotic-appearing liver, w/o evidence of abscess or ascites. An abdominal CT revealed wall edema in the distal rectum suggestive of proctitis. She was empirically treated for SBP with vanco, zosyn, and ciprofloxacin and received albumin. Blood cultures came back positive for Pseudomonas aeruginosa, however no source was identified. Antibiotics were narrowed to cefepime to cover Pseudomonas and flagyl for potential GI source considering proctitis seen on CT. A PICC line was placed. The patient's mental status improved with lactulose, rifaximin, and antibiotics and her vitals remained stable. Several repeat blood cultures were all negative. The pt was discharged home with VNA to help with antibiotic administration and PICC care. Cefepime was continued for a 14-day course. . # ARF: On admission the pt was noted to have a Cr of 1.5 which was felt to be prerenal secondary to hypotension. She was treated with fluids and her creatinine normalized. Cr was 0.6 upon discharge. . # [Year (4 digits) ]: On admission the pt was noted to have a K of 6.6. An EKG revealed peaked T waves so she was given insulin, dextrose, bicarb, and calcium gluconate and her potassium normalized. . # Diarrhea: Pt reported several loose BMs prior to admission and experienced several days of watery diarrhea during this admission. A flexiseal was placed. Stool cultures were negative for C. diff, Salmonella, Shigella, Campylobacter, Cryptosporidium, or Giardia, and CMV viral load was undetectable. An abdominal CT revealed wall edema in the distal rectum suggestive of proctitis, however this was felt to be unlikely to explain her watery diarrhea. Unclear etiology. Flagyl 500 mg q8 was continued for a 14-day course. . # Poor dentition: There was concern that her dentition may be a source of infection so dental x-rays were done and dentistry was consulted. There are two teeth that will need to be extracted so an OP appt was made with oral surgery on [7-17]. . # HCV cirrhosis: S/p TIPS in [2153], has been c/b encephalopathy, thrombocytopenia, ascites, hydrothorax, and multiple infections. LFTs were stable during this admission. Continued home meds plus increased lasix to 120mg QD and increased spironolactone to 150mg QD. . # S/p hip fracture and ORIF in [11-11], c/b polymicrobial septic hip s/p washout [6-/2158], hardware removal [9-12], with wound vac in place at home. A wound care consult was placed and . # Secondary adrenal insufficiency: Stable. Continued prednisone 5mg daily. . # Diabetes: Stable. Continued home meds. . # Asthma: Stable. Continued home meds. . # GERD: Stable. Medications on Admission: Albuterol Sulfate 90 mcg 2 PUFFS [Hospital1 ] Amoxicillin 2g PRN Dental work Calcitriol 0.25 mcg Capsule QOD Clotrimazole 10 mg Troche QID Doxycycline Hyclate 100mg PO BID Effexor 75mg PO BID Ergocalciferol (Vitamin D2) [Vitamin D] 50,000 units QMWF Fluticasone-Salmeterol 250 mcg-50 mcg/Dose INH [Hospital1 ] Folic Acid 1 mg PO daily Furosemide [Lasix] 80mg PO BID Gabapentin 100mg PO BID Insulin Glargine [Lantus] 22 units QPM Insulin Lispro [Humalog] Sliding Scale Ipratropium Bromide [Atrovent HFA] 1-2puff [Hospital1 ] PRN Ketoconazole 2% Cream [Hospital1 ] Lactulose 45mL TID ([2-7] BM/Day) Montelukast [Singulair] 10mg PO daily Oxycodone 5mg [12-8] PO Daily Oxycodone [OxyContin] 10mg PO BID Prednisone 5mg PO daily Rifaximin [Xifaxan] 500mg PO BID Spironolactone 100mg PO daily Calcium Carbonate 1g PO TID Magnesium Oxide 400mg PO BID/TID Multivitamin 1 tab Daily Sodium Chloride 0.65 % Nasal [12-8] PRN Discharge Medications: 1. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H (every 12 hours) for 8 days. Disp:32 gram Refills:0 2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 3. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection every eight (8) hours: For duration of PICC line. Disp:30 Refills:0 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 6. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO every Mon/Wed/Fri. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 11. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:0 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 13. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous every evening. 14. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 15. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation [Hospital1 ] (2 times a day) as needed for wheezing. 16. Ketoconazole 2 % Cream Sig: One (1) Topical twice a day. 17. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO three times a day: Titrate to [2-7] bowel movements daily. 18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for pain. 20. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 23. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 24. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 25. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-8] Nasal as needed. 27. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 28. Clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. 29. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 8 days. Disp:24 Tablet(s) Refills:0 30. Outpatient Lab Work On Monday [2160-7-14] and weekly thereafter: CBC, Chem7, LFTs, with results to be faxed to [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] ([Last Name (NamePattern1) 1326] Coordinator), [Hospital1 18] Liver Center at [Telephone/Fax (1) 697] Discharge Disposition: Home With Service Facility: [Location (un) 86] Home Care Services Discharge Diagnosis: Primary: - Sepsis secondary to pseudomonas infection . Secondary: - HCV cirrhosis - Adrenal insufficiency - Diabetes - Acute renal failure - Right hip wound 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: Ms. [Known lastname 68459], You were admitted to the hospital because you had vomiting with low blood pressure. You were found to have an infection in your blood which we are treating with antibiotics. Your kidneys were sick, but have gotten better. You were seen by a dentist, who recommended to see an oral surgeon to discuss teeth extraction. . Please continue to take your home medications. We have made the following changes: - STARTED cefepime 2g IV twice daily, last doses on [7-18] - STARTED metronidazole 500 mg orally every eight hours, last doses on [7-18] - INCREASED lasix to 120mg by mouth daily - INCREASED spironolactone to 150mg by mouth daily - HOLDING amoxicillin while you are taking cefepime. Please talk to the oral surgeons about this when you see them next week. . Please keep your appointments and take your medications as directed below. Followup Instructions: ORAL SURGERY CLINIC at [Hospital6 ]. [Location (un) 68462], [Location (un) ] Yawkey Ambulatory Center. Date/Time:[2160-7-17] 2:00 pm. Phone: [Telephone/Fax (1) 68463]. Your oral surgeon will be requesting further information about how long you have been taking Reclast. . [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2160-7-30] 10:50 . [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern1) 6751], MD Phone:[Telephone/Fax (1) 6742] Date/Time:[2160-8-1] 1:30 . [Month/Day/Year ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2160-8-6] 9:00 . [Month/Day/Year ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2160-8-21] 9:20 Completed by:[2160-7-17]	[ "493.90", "569.49", "571.5", "995.92", "584.9", "276.7", "287.5", "300.00", "038.43", "250.00", "998.83", "786.3", "785.52", "286.9", "E878.8", "276.1", "070.44", "789.59", "255.41", "787.91", "530.81" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	14213, 14285	6798, 10161	315, 336	14486, 14486	4241, 6775	15569, 16403	3602, 3695		11151, 14190		14306, 14465		10187, 11128			14669, 15546									3710, 3710																					264, 277				2050, 2356			364, 2032									3724, 4222	14501, 14645					2378, 3222	3238, 3586
24,995	142,614	46139	Discharge summary	report	Admission Date: [2173-11-13] Discharge Date: [2173-11-26] Date of Birth: [2107-9-11] Sex: F Service: MEDICINE Allergies: Gantrisin / Lactose Attending:[First Name3 (LF) 30] Chief Complaint: seizure Major Surgical or Invasive Procedure: R Femoral Line placement and removal. L PICC placement. History of Present Illness: HPI: 65 yo F with long histoy of type I DM, nephropathy (needing HD), peripheral neuropathy, and retinopathy, who presented with 4 episodes of GTC seizure activity after 2 hrs at HD on the day of admission. The patient was [3-21] through HD when she had the spontaneous onset of GTC seizure. Responded to 1mg Ativan. EMS was called - found her unresponsive on arrival, thought to be post-ictal. Had 2 additional seizures at HD that responded to Ativan 2mg x2. She did not appear to regain MS [First Name (Titles) ] [Last Name (Titles) 5348] prior to addt'l seizures. Had addt'l seizure in route to [Hospital1 18] ED. On arrival to [Hospital1 18] ED remained with poor MS. Was given propofol/rocuronium and intubated at [Hospital1 18] ED after decision for imaging was made. The patient had no previous hx of seizures in past. FS 139 was in field. . Of note, her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 3029] had been treating her for 3 days with cefpodoxime for a citrobacter UTI (resis to cipro/bactrim). Treatment appears to have begun [11-10]. . In the ED, initial VS were: 100.8, HR 124, BP 196/94, RR 18, 100% on vent. She was loaded with 1gm of Dilantin, she had a head CT and CXR which were negative, neurology evaluated her, and she was admitted to the MICU for further w/u. Of note, a Foley was placed that drained frankly cloudy urine. Past Medical History: 1. DM type 1 x 35 years. Previous admissions for DKA and hypoglycemic episodes. Her DM is complicated by peripheral neuropathy, proliferative retinopathy (left eye blindness), and nephropathy. Followed at [Last Name (un) ]. 2. Chronic renal failure: Appears [2-19] to DM and Cr has been 5 over past few months. On hemodialysis. 3. CAD - NSTEMI [10-23] in the setting of hospitalization for DKA, Nuclear stress test [8-23]: P-MIBI, without fixed or reversible defects, normal wall motion. EF 72%. 4. Hypertension 5. History of osteomyelitis, status post left transmetatarsal amputation. 6. History of herpes zoster of left chest in [2163]. 7. Bezoar, disclosed on UGI series [7-/2166]. 8. Achalasia 9. Carpal Tunnel Syndrome Social History: She lives at home with her son, who is mentally retarded. Past history of EtOH use. Ex-smoker, quit in [2154]. Previously smoked for 8yrs. No history of illicit drug use. Family History: Mother - DM Sister - breast ca, DM Brother - HTN [Name (NI) 2957] - SLE, d. renal failure Physical Exam: MICU PE VS: Temp:97.0 BP: 105/59 HR:90 RR:19 O2sat: 100% on vent GEN: NAD, Intubated/sedated. Spontaneously, arousable to voice HEENT: L eye minimally reactive, R eye blind/glaucomatous. +ETT in place RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 [Name (NI) 19109], no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. diminshed pulses throughout. +icythosis bilaterally. +trans-metatarsal amputation of R foot, amputated toes on L foot. NEURO: Intubated, moves all ext spontaneously. Grimaces to pain. . Medicine Wards PE VS: Temp:96.7 BP: 160/90 HR:92 RR:16 O2sat: 100% on RA GEN: Elderly AA woman in NAD. Resting with eyes closed, arousable to voice. HEENT: L eye round, reactive, R eye blind/glaucomatous. OP: tongue with slight white exudate, otherwise no lesions. No teeth. No cervical [Doctor First Name ]. + gag reflex. RESP: CTA b/l with good air movement throughout. RSC Hickman cath in place, c/d/i. CV: RR, S1 and S2 [Doctor First Name 19109], no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. diminshed pulses throughout. +icythosis bilaterally. +trans-metatarsal amputation of R foot, amputated toes on L foot. R femoral line in place, some dried blood around site of insertion, no mass/hematoma, palpable pulse, no pus. NEURO: Somnolent but oriented to place, own name, my profession (doctor). Thinks it is [2165]. Responds "[2165]" to question about month. Mild dysarthria. No teeth. Moves extremities spontaneously and follows simple commands (squeezed my hand with each hand ([5-22]), lifted b/l legs ([5-22] hip flexor strength), tracked my finger with her eye, smiled, raised eyebrows). Pertinent Results: [2173-11-13] 05:30PM WBC-6.7 RBC-4.52 HGB-12.4 HCT-41.4 MCV-92# MCH-27.3 MCHC-29.8* RDW-17.5* [2173-11-13] 05:30PM NEUTS-64.9 LYMPHS-29.6 MONOS-4.6 EOS-0.7 BASOS-0.2 [2173-11-13] 05:30PM PLT COUNT-200# [2173-11-13] 05:30PM PT-19.2* PTT->150* INR(PT)-1.8* [2173-11-13] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2173-11-13] 05:30PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-116 AMYLASE-122* TOT BILI-0.4 [2173-11-13] 05:30PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-116 AMYLASE-122* TOT BILI-0.4 [2173-11-13] 05:30PM LIPASE-12 [2173-11-13] 05:30PM ALBUMIN-3.4 CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-1.8 [2173-11-13] 05:30PM GLUCOSE-170* UREA N-6 CREAT-2.3# SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [2173-11-13] 09:33PM LACTATE-1.5 [2173-11-13] 11:08PM freeCa-1.08 [2173-11-13] 11:08PM TYPE-ART TEMP-37 RATES-18/0 TIDAL VOL-400 PEEP-5 O2-60 PO2-211* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [2173-11-20] 09:19AM BLOOD WBC-3.4* RBC-4.26 Hgb-11.5* Hct-37.9 MCV-89 MCH-27.1 MCHC-30.5* RDW-17.5* Plt Ct-271 [2173-11-21] 05:38AM BLOOD WBC-4.0 RBC-4.33 Hgb-11.7* Hct-38.9 MCV-90 MCH-27.0 MCHC-30.0* RDW-17.6* Plt Ct-296 [2173-11-22] 06:38AM BLOOD WBC-4.9 RBC-4.62 Hgb-12.8 Hct-41.6 MCV-90 MCH-27.6 MCHC-30.7* RDW-17.6* Plt Ct-287 [2173-11-25] 05:35AM WBC 6.1 Hgb 10.6* HCT 35.4* Plt 279 . [2173-11-21] 05:38AM BLOOD Glucose-48* UreaN-3* Creat-2.2* Na-141 K-3.8 Cl-103 HCO3-35* AnGap-7* [2173-11-22] 06:38AM BLOOD Glucose-136* UreaN-6 Creat-2.9* Na-138 K-4.7 Cl-101 HCO3-28 AnGap-14 [2173-11-22] 06:38AM BLOOD Calcium-10.1 Phos-2.2* Mg-1.8 [2173-11-26] Blood Na 142 K 4.1 Cl 104 Bicarb 29 BUN 3 Cr 2.4 Plt 239 Ca 9.0 Mg 1.7 Phos 1.4* , [2173-11-23*] 05:16PM BLOOD VitB12-1045 [2173-11-23] 05:22AM BLOOD TSH-1.7 . URINE [2173-11-13] 07:15PM URINE RBC-[3-22]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [2173-11-13] 07:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2173-11-13] 07:15PM URINE COLOR-Straw APPEAR-Cloudy SP [Last Name (un) 155]-1.008 [2173-11-13] 07:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . MICROBIOLOGY [2173-11-13] 7:15 pm URINE Site: CATHETERFINAL REPORT [2173-11-15] URINE CULTURE (Final [2173-11-15]): CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [2173-11-13] BLOOD CULTURE AEROBIC BOTTLE-FINAL NO GROWTH; ANAEROBIC BOTTLE-FINAL INPATIENT NO GROWTH [2173-11-13] BLOOD CULTURE AEROBIC BOTTLE-FINAL NO GROWTH; ANAEROBIC BOTTLE-FINAL NO GROWTH . [2173-11-16] 5:23 pm CATHETER TIP-IV Source: right femoral central line. FINAL REPORT [2173-11-18] WOUND CULTURE (Final [2173-11-18]): No significant growth. . [2173-11-18] 2:14 pm STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2173-11-19] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2173-11-19]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2173-11-19] Blood- pelim- NGTD*********** [2173-11-23] 5:16 pm SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST (Final [2173-11-24]): NONREACTIVE. [2173-11-25] 9:20 pm STOOL CONSISTENCY: SOFT Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2173-11-26]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [2173-11-26] stool- c.diff toxin pending . STUDIES [2173-11-13] NON-CONTRAST HEAD CT: No hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. The [Doctor Last Name 352]-white matter differentiation is preserved. No major vascular territorial infarct is apparent. Hypoattenuating foci are seen within the periventricular white matter consistent with chronic microvascular ischemic disease. Note is made of left phthisis bulbi. There is mild mucosal thickening involing the ethmiod sinuus. Ther remainder of the visualized paranasal sinuses and mastoid air cells are normally aerated. IMPRESSION: No hemorrhage. Mild ethnoid sinus mucosal disease. . [11-13] CXR FINDINGS: There has been interval replacement of previous tunneled dialysis catheter with a new catheter now from a right subclavian approach in standard placement. The patient has been intubated and the distal tip of the endotracheal tube is approximately 1.3 cm from the carina. A nasogastric tube has also been placed with the distal side hole within the gastric fundus. Lung volumes are mildly diminished. There is atelectasis in the right upper lobe. No definite consolidation or superimposed edema is seen. There is atherosclerotic disease of the aorta. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is seen.IMPRESSION:1. Right upper lobe atelectasis. 2. #[5-18] be due to low lying endotracheal tube at least partially obstructing the right upper lobe bronchus. Retract endotracheal tube by at least 2 cm for more optimal placement. . [11-15] CXR FINDINGS: In comparison with the study of [11-14], the area of increased opacification at the left base is somewhat less prominent on the current study, though there is some blunting of the left costophrenic angle consistent with pleural fluid. Brief Hospital Course: 66 year old female with Dm1, ESRD on HD admitted from dialysis status post status epilepticus with multple GTC seizures, thought to be secondary to urinary tract infection, without return of mental status to [Date Range 5348]. Course complicate by poor glucose control and blood pressure control. Brief hospital course by problem: . 1. Status epilepticus, new onset seizure in a 66 y/o F patient while on HD. The patient had 4 events in dialysis and 1 en route to the ED. They were likely generalized tonic clonic by description, and began after 1 hour of HD. The patient was unresponsive between events and after events. She received 4 mg total of ativan and she was intubated for airway protection and admitted to the MICU. She was subsequently extubated without complication. On initial exam by neurology, the patient had intact brainstem reflexes, but was not withdrawing to painful stimuli. Etiology of new onset seizure was thought to be either hemodialysis dysequilibration syndrome secondary to fluid shifts/electrolyte shifts in setting of hemodialysis or infectious etiologies given her functional immunosuppression with longstanding DM. Of note the patient had a low grade fever and had been treated with 3 days of antibiotics for UTI and had urine with frank pus. Vascular etiology for her seizure was thought to be less likely given her gradually increasing symptoms. Renal was consulted and felt the seizures were unlikely to have been caused by HD. Head CT was negative for bleed, toxic-metabolic work-up revealed that LFTs were normal, lactate was normal, glucose was normal, tox screen was negative, and U/A suggested UTI with urine cultures growing citrobacter. Neurology determined that the most likely etiology for seizure was urinary tract infection. The patient was transferred to the floor on [11-15] after being seizure free for>24 hrs. The patient was initially treated for 4 days with ceftriaxone, then received 1 dose meropenem 10/31 per sensitivity results of urine culture (see culture results), but given that meropenem may reduce the seizure threshold she was switched to tobramycin, which was dosed with HD (completed 7 day course of appropriate coverage on [2173-11-23]). The patient had no further seizures during the hospitalization, however her mental status remained below [Date Range 5348] and she was oriented x1-2, able to follow simple commands but generally unable to answer complex questions, with waxing and [Doctor Last Name 688] ability to talk in full sentences. She did appear to be more interactive and alert over the last few days of hospitalization and appeared motivated and cooperative during physical therapy. No focal neurological deficits were found and she was believed to have a toxic metabolic encephalopathy as below. 2. Delerium- toxic metabolic encephalopathy. The patient's delerium was likely multifactorial in etiology- a combination of infection, being post-ictal, poor glucose control and poor blood pressure control. Although her MS has been waxing and [Doctor Last Name 688], she has never been at her [Doctor Last Name 5348] MS after the seizure. The duration of symptoms were felt too long to be merely post-ictal. The patient was treated for UTI as above, though her symptoms persisted. In addition to the toxic-metabolic work up described above, Vit B12, RPR and TSH were all checked and were [Doctor Last Name 19109]. Her blood sugars have varied widely and she had one episode where she was briefly unresponsive due to hypoglycemia. This likely also contributed to her delerium. Her MS may was sometimes observed to improve after HD, suggesting her symptoms could be related to toxic build up from renal failure. Per the neurology consult, it may take a while for her to return to [Doctor Last Name 5348] from all of these insults. They recommended stimulating her with PT and having her recover in rehab as we have addressed all the underlying medical etiologies for her encephalopathy. She is scheduled to follow up with neurology as an outpatient to assess her recovery. . 3.DM1 -poor glucose control- The patient has DM complicated by triopathy. She had low BS in the MICU due to poor po intake and was put on a D5W gtt until tube feeds were started [11-15] and she was given 3u lantus daily. On the floor, the patient self- d/c'd her NG tube on [11-16]. Subsequently she was able to take pos with supervision. Speech and swallow evaluated her and recommended a pureed diet with nectar-prethickened liquids (diabetic and lactose-free). On [11-18] the patient was hyperglycemic, which was likely due to increased po intake. She received 12 u reg insulin at 11am for FS>400. She was given 8 units humalog 4 hrs later for FS persistenly in the 400s. But overnight she was persistently hypoglycemic (low 35), requiring 1 amp d50 and a d50 drip@100cc/hrx5hrs. It is unclear why the patient was persistently hypoglycemic as she received all of her insulin before HD. It was thought that perhaps the insulin remained in her system due to renal failure. Josin was consulted and lantus was started at 8units qhs. Due to continued issues with hypoglycemia this was changed to 3u qhs. On [11-22] she "triggered" for unresponsiveness with a FS of 34. She responded immediately to 1 amp d50. This was likely due to a series of medication errors as she received 3 u lantus both the night of [11-21] and the am of [11-22] (medication error by crosscovering intern), and also the RN gave insulin that day based on a scale for a FS of 273 instead of the actual FS value of 235). The ISS was lowered, the patient was covered just with ISS for the next day and then was started on 3NPH in the am of [11-24]. FS creeped up to 200s [11-24] and then were [Telephone/Fax (3) 98144]95 170 189 on [11-25]. [Last Name (un) ] recommended increasing NPH to 5units with breakfast. The patient is scheduled to follow up with [Last Name (un) ] on Monday [11-29]. . 4. ESRD on HD - Pt was kept on T, Th, Sat HD scheduled and was followed by the renal team. Her HCTZ was discontinued and renagel was changed to phoslo given changed diet requirements (pureed). Tobramycin was dosed after HD (completed a 7 day course) and she was given epo per renal recommendations. On [11-25] we discontinued her calcium acetate as her phosphate was low (see labs), renal also recommended changing her to a non-renal, diabetic diet in order to bring her phosphate back up. . 4. CAD The patient was continued on ASA, statin, BB. No active signs of ischemia, no chest pain were noted. . 5. HTN - The patient's HCTZ was discontinued and her metoprolol was gradually titrated up to 75mg [Hospital1 ] as she was persistently hypertensive to SBPs in 170s, occasionally requiring IV hydralizine. (She triggered once for a SBP of 210/120 and 1x emesis once on the floors on a morning before dialysis). Her BP has been stable over the past several days, ranging from 92-100/54-82 over [2173-11-25]. She is scheduled for follow up appointment with her PCP where her BP medications should be reviewed and titrated as necessary. . 6. PVD- The patient has several amputations and a stable necrotic 3rd toe on the R foot. Her family says it is darker than had been in past. [Month/Day/Year ] was consulted (have seen her in clinic in past but the last time was in [2170]). No active surgical issues were identified, but they recommended to follow up in clinic. An appointment with [Year (4 digits) ] was arranged for her. . 7. Diarrhea- over the last 4 days of hospitalization the patient developed diarrhea. Initially this was thought because she was mistakenly given some food with lactose in it. The diet was corrected and the diarrhea resolved but then on [11-25] she had 8 loose bowel movements. She was afebrile, had [Male First Name (un) ] leukocytosis and test for c. diff toxin was negative. This was not felt to be infectious in etiology. Banana flakes were added to her diet and she had only 1 loose bowel movement in the morning of [11-26]. . 8. Guaiac + stools. During her last week if hospitalization she had a few documented guaiac + stools without frank blood or change in color (brown) of her stool. Her abdominal exam remained unremarkable. Her HCT was monitored and remained stable and she remained hemodynamically stable during this time. On [11-25] her stool was guaiac negative. It is recommended that her PCP monitor this and determine whether further work up with a colonoscopy is warranted at her follow up visit . FEN: As above, tube feeds were started on [11-15] for poor po intake. The patient self-d/c'd the NG tube and has been taking pos since. Speech and swallow recommended pureed diet, nectar pre-thickened liquids and pudding supplements. It was determined that she is lactose-intolerant so her diet was diabetic, renal, lactose-free. It is recommended that once her MS improves she have a repeat speech and swallow evaluation as she may be able to be advanced further with increased alertness and attention. For the meantime it is recommended she have a diabetic, lactose-free diet. Please consult the nephrologist at her hemodialysis regarding need to re-institue a renal diet. She is not on a renal diet right now due to low phosphate levels. She is getting banana flakes to add bulk to her stools as she has had some loose stools. . Access: R femoral line was inserted on admission and d/c'd on [11-16] (inserted in ED). A left brachial PICC was placed on [11-16] and removed [11-26], she has a RSC Hickman cath for HD. PPx: Hep SQ, ppi Comm: [Name (NI) ] [Name (NI) ] (son) [Telephone/Fax (1) 97825] Code: Full Code Dispo: to rehab with PT/OT. The patient need hemodialysis and is currently on a T, Th, Sat schedule. Medications on Admission: Novolin SS Lipitor 80 Lisinopril 20 Lopressor/HCTZ 50/25 qD Folate Nephrocap Renagel 1600 tid Epo Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 650 mg Suppository Sig: [1-19] Suppositorys Rectal Q6H (every 6 hours) as needed for fever. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. insulin NPH 5 units q breakfast Humalog sliding scale: Breakfast- 0-60 [1-19] amp D50, 61-150 0 (zero) units, 151-200 1 unit, 201-300 2 units, 301-350 3 units, 351-400 4 units. >400 notify MD Lunch- 0-60 [1-19] amp D50, 61-150 0 (zero) units, 151-200 1 unit, 201-300 2 units, 301-350 3 units, 351-400 4 units. >400 notify MD Dinner- 0-60 [1-19] amp D50, 61-150 0 (zero) units, 151-200 2 units, 201-300 3 units, 301-350 4 units, 351-400 5 units. >400 notify MD Bedtime- 0-60 [1-19] amp D50, 61-250 0 (zero) units, 251-300 1 unit, 301-400 2 units, >400 notify MD Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1. Citrobacter urinary tract infection. 2. Generalized Tonic Clonic Seizures 3. Delerium. Secondary: 1. Diabetes type I 2. Peripheral vascular disease (dry gangrene of Right 3rd toe). 3. Chronic Kidney Disease Stage V on hemodialysis. 4. Hypertension 5. Coronary artery disase Discharge Condition: Fair. Confused mental status, often oriented to person only, sometimes to place, much decreased from [Hospital1 5348]. Afebrile, seizure-free since day of admission. Had some diarrhea yesterday, appears to be resolving today with banana flakes. C. diff negative. Discharge Instructions: You were admitted to the hospital because you had several seizures while at your hemodialysis center. You initially went to the medical ICU and were intubated to protect your airway during some of these seizures. You were successfully extubated and were transferred to the general floors. You were evaluated by neurologists who felt your seizures were due to a urinary tract infection. We treated your urinary tract infection with 7 days of antibiotics. You remained quite confused during your hospitalization and this was felt by the neurologists to be due to your multiple medical problems, including infection, poor blood sugar control, and problems with your blood pressure. They felt you would benefit from increased stimulation and rehabilitation. Please go to your follow up appointment with the neurologist to assess your progress. . For your diabetes and blood sugar management we consulted endocrinologists from [Last Name (un) ] Diabetes center, who made changes to your insulin regimen. During the course of hospitalization you had several episodes of hypoglycemia that was thought to be exacerbated by your poor diet intake but once you were eating better your blood sugars stabilized. Please go to your follow up appointment at [Last Name (un) ] to ensure close monitoring of your blood sugar control. . Several times during your stay you were hypertensive. We made changes to your hypertension medications and also managed your blood pressure with dialysis, which brought your blood pressure under better control. Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 3029] at the scheduled appointment to monitor your blood pressure. . You were also evaluated by a podiatrist for a gangrenous toe during your stay. Please go to your follow up appointment with [Last Name (STitle) ]. . During your stay you had evidence of blood in your stools (guaiac positive). Subsequent tests were negative for blood. Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 3029], as she may suggest further studies to evaluate this. . Please take all the medications as prescribed. Please go to all your follow up appointments as scheduled. . Please call your doctor or come to the hospital if you lose consciousness, have a seizure, feel light-headed, chest pain, shortness of breath, develop a fever, or develop any other concerning symptoms. Followup Instructions: - Neurologist [Name6 (MD) ] [Name8 (MD) ], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 1690] Date/Time:[2173-12-1] 1:30, [Hospital Ward Name 860] building - Primary Care Provider: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Date/Time:[2173-12-3] 11:10 - RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2173-12-3] 1:15 - [Last Name (un) ] Diabetes, Dr. [Last Name (STitle) ]/[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] NP: [Telephone/Fax (1) 2378]: [2173-11-29] 1:30pm - [Month/Day/Year ]: Dr. [First Name (STitle) 3209] [2173-12-7] 8:30 am [Telephone/Fax (1) 543] - please continue HD on T, Th, Sat schedule. Completed by:[2173-11-26**]	[ "345.3", "414.01", "V45.1", "349.82", "041.85", "250.53", "440.24", "250.43", "585.6", "403.91", "357.2", "250.63", "362.01", "599.0", "787.91" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "96.71", "96.04", "39.95" ]	icd9pcs	[ [ [] ] ]	22262, 22341	11112, 20945	288, 345	22672, 22941	4596, 9318	25417, 26219	2750, 2845		21094, 22239		22362, 22651		20971, 21071			22965, 25394									2860, 4577																					241, 250							373, 1770				9327, 11089											1792, 2542	2558, 2734
31,077	131,589	34001	Discharge summary	report	Admission Date: [2130-6-15] Discharge Date: [2130-6-21] Date of Birth: [2049-4-20] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Pneumovax 23 / Tetracycline Analogues Attending:[First Name3 (LF) 922] Chief Complaint: chest pain, worsening DOE Major Surgical or Invasive Procedure: [2130-6-15] AVR (pericardial)/CABG x 1/Modified MAZE History of Present Illness: 81 yo F with history of aortic stenosis and positive stress echo referred for cardiac catheterization. Cardiac catheterization showed 1 vessel CAD and aortic stenosis and she was referred for surgery. Past Medical History: PMH: HTN, AS, PAF, Lumbar disc Dz, Appy, Hyst, B knee replacements, Vaginal cyst removal, L Vein stripping, Tonsillectomy, cataract [Doctor First Name ], Sinus [Doctor First Name ] Social History: quit tobacco 30 years ago social etoh Family History: daughter with aortic valve surgery at age 16 Physical Exam: HR 60 RR 18 BP 155/65 NAD Lungs CTAB Heart RRR, HSM t/o Abdomen benign varicosities Pertinent Results: CHEST (PA & LAT) [2130-6-18] 10:08 AM CHEST (PA & LAT) Reason: interval change [Hospital 93] MEDICAL CONDITION: 81 year old woman with POD 3 AVR pericardial REASON FOR THIS EXAMINATION: interval change PA AND LATERAL CHEST ON [2130-6-18] AT 1020 INDICATION: Postop. COMPARISON: [2130-6-16]. FINDINGS: Compared to the prior study, the right CVL remains in place with tip in the SVC and no PTX. Stable bilateral effusions are seen layering out less than prior, but positioning differences might contribute. Upper lungs remain clear, and pulmonary vasculature is not significantly distended. No new consolidations. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 5647], [Known firstname ] [Hospital1 18] [Numeric Identifier 78494] (Complete) Done [2130-6-15] at 10:07:27 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2049-4-20] Age (years): 81 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Atrial fibrillation. Chest pain. Hypertension. Mitral valve disease. Shortness of breath. ICD-9 Codes: 402.90, 427.31, 786.05, 440.0, 424.1, 424.0 Test Information Date/Time: [2130-6-15] at 10:07 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) 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 #: 2008AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Aortic Valve - Peak Velocity: 4.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 77 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 46 mm Hg Aortic Valve - Valve Area: 0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. Focal calcifications in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. No masses or vegetations on aortic valve. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe mitral annular calcification. No MS. Moderate (2+) MR. TRICUSPID VALVE: Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. 2. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. No masses or vegetations are seen on the aortic valve. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The aortic annulus measures 2.1 cm. 7. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. 8. Moderate [2+] tricuspid regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results. POST-CPB: On infusion of phenylephrine. Well-seated bioprosthetic valve in the aortic position. No AI. Gradient of 17 mmHg mean with CO= 4.4 L/min. MR is now 1+. Preserved lv systolic function. Brief Hospital Course: She was taken to the operating room on [6-15] where she underwent a CABG x 1, AVR and modified MAZE/PVI. She was extubated post op. She was started on coumadin for history of afib. She was transferred to the floor on POD #1. She was transfused for HCT 23. Wires and chest tubes were dc'd without incident. She was noted to have ?melena and stool was guaiac positive. She was started on protonix [Hospital1 ], coumadin wsa held, and she was followed by serial HCTs and was seen by GI. Endoscopy on [6-20] showed two non-bleeding ulcers in the GE junction, mucosa suggestive of Barrett's esophagus, esophagitis and a small hiatal hernia. She will need follow up endoscopy to monitor the ulcer, as well as colonoscopy for further anemia evalution in 3 months or sooner if evidence of further bleeding. Coumadin was restarted and She remained in the hospital for serial hematacrit evalutions. She was ready for discharge home on [6-21]. Spoke with Dr. [Last Name (STitle) 68638] office who confirmed that they will follow coumadin as well as HCT. Medications on Admission: Coumadin 7.5(5x/wk)10((2x/wk), HCTZ 25', Calcium 600', Centrum 1 tab', Feosol 1 tab' 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Check INR [6-23] with results to Dr. [Last Name (STitle) 4469]. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Aortic stenosis Coronary Artery Disease Paroxysmal atrial fibrillion on coumadin Hypertension, Lumbar Disc Disease Esophageal ulcers Discharge Condition: stable Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily washing incision, pat dry: no tub bathing or swimming Report any weight gain greater than 2 pounds in 24 hours or 5 pounds in 1 week No creams, powder or lotion on incisions No driving for 1 month No lifting > 10 pounds for 10 weeks Followup Instructions: Dr. [Last Name (STitle) 914] 4 weeks Dr. [Last Name (STitle) 4469] 1 weeks with repeat hematacrit Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 2473]/Dr. [First Name (STitle) 2643] in [Hospital ] clinic in 3 months for repeat endoscopy/colonoscopy. Completed by:[2130-6-21]	[ "424.1", "530.10", "530.20", "285.9", "414.01", "V58.61", "427.31", "788.5", "276.6", "530.85", "458.29", "578.9" ]	icd9cm	[ [ [] ] ]	[ "37.33", "45.13", "39.61", "99.04", "36.11", "35.21" ]	icd9pcs	[ [ [] ] ]	8886, 8937	6174, 7238	343, 402	9114, 9123	1083, 1170	9536, 9852	917, 963		7373, 8863	1207, 1252	8958, 9093		7264, 7350			9147, 9513								4691, 6151	978, 1064																					278, 305	1281, 4642						430, 632															654, 845	861, 901
11,043	138,702	1715	Discharge summary	report	Admission Date: [2154-5-30] Discharge Date: [2154-6-4] Date of Birth: [2091-4-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9824] Chief Complaint: Fever/Chills Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 63 year old male with PMH significant for end-stage ischemic cardiomyopathy (EF 15-20%), on home milrinone (0.6 mcg/kg/hr) via chronic indwelling PICC (placed [9-13]), CAD s/p CABG, s/p BiV/ICD, DMII, and CRI who presents c/o diarrhea, fever/chills, and nausea vomiting. His PICC line has been in for approximately one year without issues, except one port is clotted. Patient reports onset of diarrhea approximately 5 days PTA, which resolved after one day. Reports 6-7 episodes of non-bloody, loose stools. Then, on the day prior to admission, patient experienced N/V x 2 episodes. Later that night had subjective fever, and shaking chills. Denies any abdominal pain. Also c/o cough productive of white sputum, which began last night as well. Patient denies sick contacts, or recent travel. This morning, patient had another 2 episodes of N/V. Called PCP's office who recommended patient come to ER. On presentation to ER, patient was febrile w/ temp 102.5, tachy w/ HR 112, and normotensive w/ BP 113/61. While in ER, SBP dropped to 80's. Patient was given 2000cc NS, and started on Vanco/levo/flagyl. He was maintained on his outpatient dose of milrinone. CCU fellow was called who recommended admission to MICU. He was admitted to MICU for further management. ROS: Denies dysuria, lightheadedness, dizziness, CP/SOB, LE edema, HA, Blurry vision, or neck pain. Past Medical History: 1) Ischemic Cardiomyopathy (EF15-20%) s/p [Hospital1 ]-V Pacer/ICD ([11-12]) 2) CAD/CABG [2135] (SVG-LAD, SVG-LCX) 3) DMII 4) CRI (Cr 1.3-1.8) 5) Anemia of Chronic Disease 6) HTN 7) Lichen Simplex Chronicus 8) S/p INH repair in [2151]. Social History: Lives with wife and daughter. [Name (NI) ] five children and two grandchildren. Born in [Country 9819] - has lived in USA for ten years. Previous leather goods importer/exporter. Never smoked cigs, drank ETOH or used recreational drugs. Family History: Brother had MI at 48. Mother had DM, CHF and MI and unknown age. Father had CAD, but no MI. Physical Exam: VS: T: 100.0; HR: 82; BP: 102/52; RR: 20; O2: 99% RA (500cc UOP) GEN: elderly man, lying in bed, NAD HEENT: PERRL bilat, EOMI bilat, dry MM, OP clear NECK: JVP @ 6 cm; no LAD CV: RRR, NL S1S2, [2-15] HSM at apex, no S3/S4 CHEST: CTA bilat, no w/r/r ABD: NABS, soft, NT, ND, no masses or HSM RECTAL: guaiac negative brown stool. no masses. EXT: No LE edema, warm; 2+ DP/PT pulses NEURO: A&O x 3, CN 2-12 intact, motor exam intact Pertinent Results: [2154-5-30] 12:30PM GLUCOSE-145* UREA N-42* CREAT-2.0* SODIUM-136 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19 [2154-5-30] 12:30PM ALT(SGPT)-27 AST(SGOT)-31 ALK PHOS-114 AMYLASE-66 TOT BILI-1.1 [2154-5-30] 12:30PM LIPASE-18 [2154-5-30] 12:30PM WBC-9.3# RBC-4.62 HGB-14.1 HCT-41.4 MCV-90 MCH-30.5 MCHC-34.1 RDW-14.5 [2154-5-30] 12:30PM NEUTS-92.9* BANDS-0 LYMPHS-4.3* MONOS-2.5 EOS-0.1 BASOS-0.1 [2154-5-30] 12:30PM PLT SMR-LOW PLT COUNT-119* [2154-5-30] 12:35PM LACTATE-2.5* Brief Hospital Course: #) FEVER: Blood cultures from [5-30] grew out 4/4 bottles Serratia, pan sensitive. DDx considered for fever included infectious gastroenteritis, pneumonia, or line infection. Initially he was placed on Vanco/Levo/Flagyl for broad spectrum abx coverage, but this was decreased to Levofloxacin monotherapy after sensitivities returned. The PICC line was d/c'd on [5-31] and a temporary central line was placed. A TTE was negative for vegetations. Given concern for seeding of his lines and pacer leads, an ID consult was obtained to assess the need for TEE to more definitively rule out endocarditis and course of Abx treatment. Because of his rapid response to therapy and insufficient evidence to definitively suggest a line infection, a two-week course of antibiotics was recommended and the pacemaker was not removed. His last two sets of blood cultures on [6-1] were still negative for growth on the day of discharge. . #) HYPOTENSION: The patient had SBPs in the 80's with low UOP in the ER. This was most likely due to distributive shock given GNRs in blood. UOP and BP improved w/ NS. Lactate was 2.5 on admission and improved to 1.4 within 24 hours. His sepsis was treated as above. . #) CV: --> PUMP: The patient has severe CHF on chronic milrinone drip at home which was continued at the prior dose. Bumex and coreg were held, and lisinopril and digoxin were continued. His home medications were resumed on discharge. --> CAD: The pt has a h/o CAD s/p CABG; he had no signs of ischemia on admission. ASA/plavix/statin were continued --> RHYTHM: has BiV/ICD; paced . #) ACUTE ON CHRONIC RENAL FAILURE: The patient had ARF on admission to ER w/ Cr=2.0. This was likely prerenal as it improved w/ IVF, and he was discharged with a baseline Cr of 1.5. . #) DM2: Prandin was held until the pt was taking PO's; it was restarted on [6-1]. He was maintained on a RISS. . Medications on Admission: Aspirin 325 mg PO daily Bumetanide 1 mg QAM, 0.5 mg PO QPM Coreg 12.5mg PO BID Digoxin 0.125 mg PO daily Epogen 10,000 SC QMWF Imdur 15 mg PO QHS Lipitor 20 mg PO QHS Lisinopril 2.5 mg PO QHS Protonix 40 mg PO daily Plavix 75 mg PO daily Prandin 2mg PO TID Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO qam. 3. Bumetanide 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Epogen 10,000 unit/mL Solution Sig: 10,000 Units Injection every Monday, Wednseday, Friday. 7. Imdur 30 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR PO at bedtime. 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Milrinone in D5W 200 mcg/mL Piggyback Sig: Thirty Two (32) mcg/min Intravenous INFUSION (continuous infusion). Disp:1 month supply Refills:2 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 14. Prandin 2 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:180 Tablet(s) Refills:2 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: PHYSICIAN'S HOME CARE Discharge Diagnosis: Primary: Serratia bacteremia Secondary: end-stage ischemic cardiomyopathy, coronary artery disease, diabetes mellitus Type II, chronic renal insufficiency Discharge Condition: good, stable, afebrile, tolerating POs, ambulating independently, no chest pain, edema, PND Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet If you have recurrence of fever, chills, lightheadedness, episodes of loss of consciousness, chest pain, nausea/vomiting, or redness/pain around your PICC line site, call your doctor or seek medical attention immediately. Followup Instructions: Please follow up with your primary care physician (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968]) on Thursday [6-13] at 8am. You may call his office at [Telephone/Fax (1) 250] to confirm this appointment. Please follow up with your cardiologist (Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437], [Telephone/Fax (1) 3512] ) on [6-24] at 2:30pm. Following this appointment, you are scheduled to be seen in the device clinic ([Telephone/Fax (1) 59]) at 3:30pm. Your doctor may in the future consider replacing your PICC line with a Hickman catheter which may have a lower rate of infection. He will discuss this with you if appropriate in the context of your milrinone drip requirements.	[ "584.9", "V45.81", "414.8", "V45.02", "038.44", "996.62", "250.00", "995.92", "785.52", "428.0", "585.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	7006, 7058	3435, 5331	327, 349	7257, 7351	2885, 3412	7722, 8487	2321, 2414		5639, 6983		7079, 7236		5357, 5616			7375, 7699									2429, 2866																					275, 289							377, 1765															1787, 2042	2058, 2305
31,916	146,431	21031	Discharge summary	report	Admission Date: [2112-2-22] Discharge Date: [2112-2-28] Date of Birth: [2051-4-12] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 3556] Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: NG tube placement endotracheal intubation History of Present Illness: Ms. [Known lastname 55865] is a 60 yo F w/PMHx sx for metastatic RCC (liver, brain, lungs) on Avastin, on 3L home oxygen who presents to the ED with two days of nausea and vomiting of brownish, feculent material, with no BMs. She had also noted increasing abdominal distension, but without significant pain. Per patient's daughter, she has been otherwise doing well. She denies BRBPR, melena, dysuria, hematuria, chest pain, SOB, fevers, chills. She has been tolerating the Avastin without any significant side effects and last received a dose on Wednesday. . In the ED, her vitals were T97.3 P 99 BP 147/110 O2sat 92% on 3L. She underwent a CT abdomen that showed SBO with transition point in distal jejunum/proximal ileum. NGT placed -- 2800cc feculant material drained. She was treated with levofloxacin 750mg IV and cultures were sent. She was seen by the surgical service but they declined surgical intervention. She was subsequently noted to have lower pO2 on repeat ABG and was intubated for hypoxemia. . She is admitted to the MICU for medical management of her SBO. Past Medical History: * Metastatic renal cell carcinoma, dx [2106] -s/p right nephrectomy [12/2106] with path showing grade 2 clear cell carcinoma; post-op course c/b colovesical fistula s/p LAR, drainage of peritoneal abscess, ventral hernia repair -known mets to lungs, adrenals, brain -is on home O2 3L/min thought [2-13] to pulm mets -s/p cyberknife tx to brain mets [3-/2110] and [12/2110] -s/p 2 weeks IL2 [12/2109] c/b neurotoxicity -s/p tx with sorafenib, sunitinib, and most recently avastin * h/o DVT [11/2110] on coumadin * PUD * s/p ccy * Anxiety Social History: Lives with husband. Denies [Name2 (NI) ]/EtOH/drug use. Family History: n/c Physical Exam: General: Intubated and sedated. HEENT: MMM. No scleral icterus. Neck: Supple. JVD flat. Pulm: Fine crackles at bases anteriorly. CV: RRR. No MRG. Abd: Obese, distended. Minimal bowel sounds. NGT in place draining feculent material. Extrem: Cool. 1+pulses. Neuro: Intubated and sedated. Derm: No skin lesions seen. Pertinent Results: [2112-2-21] 06:00PM WBC-5.2 RBC-4.20 HGB-11.7* HCT-37.8 MCV-90 MCH-27.8 MCHC-30.9* RDW-18.5* [2112-2-21] 06:00PM PLT SMR-NORMAL PLT COUNT-275 [2112-2-21] 06:00PM NEUTS-83* BANDS-2 LYMPHS-10* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2112-2-21] 06:00PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [2112-2-21] 06:00PM PT-34.8* PTT-35.4* INR(PT)-3.7* [2112-2-21] 06:00PM ALBUMIN-3.8 [2112-2-21] 06:00PM LIPASE-24 [2112-2-21] 06:00PM ALT(SGPT)-10 AST(SGOT)-22 ALK PHOS-200* AMYLASE-28 TOT BILI-0.8 [2112-2-21] 06:00PM GLUCOSE-137* UREA N-19 CREAT-0.9 SODIUM-141 POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-31 ANION GAP-19 [2112-2-21] 08:55PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.037* [2112-2-21] 08:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [2112-2-21] 08:55PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [2112-2-21] 10:44PM LACTATE-2.7* . Micro [2-21] urine cx negative [2-21] blood cx negative [2-22] sputum gram 1+ GNRs, 1+ GPC in pairs, 1+ budding yeast; culture with >3 colony types including MSSA, GNRs, beta strep, oral flora, yeast . Imaging [2-21] CT abd/pelvis IMPRESSION: 1. Findings consistent with a small-bowel obstruction with transition point in the distal jejunum/proximal ileum. 2. New centrilobular and patchy opacities in the lower lobes bilaterally. This raises the question of aspiration. Stable soft tissue density in the left hilum, incompletely evaluated and may represent lymphadenopathy. 3. Stable pneumobilia and mild intrahepatic biliary ductal dilation. 4. Central hernia containing small bowel as well as transverse colon. 5. Stable bilateral adrenal masses consistent with metastatic disease. . [2-27] CXR Moderate cardiomegaly and marked pulmonary, hilar, and mediastinal vascular engorgement are all unchanged. There is suggestion of mild interstitial edema on today's study. Left lower lobe consolidation is longstanding, probably atelectasis. ET tube, left subclavian line, and nasogastric tube are in standard placements respectively. Pleural effusion is presumed, small on the left. No pneumothorax. . [2-24] Renal U/S FINDINGS: The left kidney measures 11.6 cm. There is preservation of corticomedullary differentiation. There are no perinephric fluid collections. There is no hydronephrosis. No renal masses or stones are present. A Foley balloon is present within a collapsed bladder which is grossly unremarkable. Evaluation of the right renal fossa is unremarkable. IMPRESSION: No evidence of left renal hydronephrosis. . Brief Hospital Course: 1. Small bowel obstruction: The patient's abdominal imaging showed a SBO. She was evaluated in the emergency room by the surgery team, who felt that she did not initially require urgent intervention in the operating room. Her family preferred that surgery be avoided if possibile. She was initially medically managed with placement of a nasogastric tube. She was started on levofloxacin and flagyl empirically to cover possible intrabdominal infection. Her NG tube continued to put out large volumes of feculent material during her admission. After discussion with her family, she was made CMO. Ms. [Known lastname 55865] [Last Name (Titles) ] on [2112-2-28] at 2:35 am. 2. Respiratory distress: Ms. [Known lastname 55865] developed increasing dyspnea and hypoxemia in the emergency department, and was therefore intubated. Her respiratory distress was thought to be secondary to increased abdominal distension in addition to possible aspiration pneumonia. Of note, she required O2 at home thought secondary to pulmonary metastases. She was extubated following decision to change code status to CMO. 3. Oliguria The patient's urine output remained poor during her hospitalization, and responded only marginally to volume resuscitation. Renal ultrasound showed no evidence of obstruction, and measurement of bladder pressures showed no evidence of abdominal compartment syndrome. Medications on Admission: Tylenol prn Albuterol 1-2 puffs q4-6h prn Atenolol 50 mg qd Ativan 0.5 mg q6h prn VBenzonatate 100 mg tid Compazine 10 mg q6h prn Coumadin Effexor 187.5 mg qd Gabapentin 100 -300 mg qhs Lisinopril 10 mg qd Ondansetron 8 mg q6h prn Oxycodone prn Oxycontin 80 mg tid Zolpidem 5 mg qhs Discharge Medications: n/a Discharge Disposition: [Known lastname ] Discharge Diagnosis: Primary: 1. Small bowel obstruction 2. Aspiration pneumonia, suspected 3. Renal cell carcinoma Discharge Condition: [Known lastname ] Discharge Instructions: n/a Followup Instructions: n/a [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560]	[ "300.00", "V58.61", "198.3", "584.9", "552.20", "511.9", "197.0", "338.29", "V45.89", "724.2", "782.3", "V12.71", "338.19", "518.81", "198.7", "276.50", "V10.52", "V66.7", "V12.51", "276.52", "507.0" ]	icd9cm	[ [ [] ] ]	[ "96.07", "38.93", "96.72", "96.04" ]	icd9pcs	[ [ [] ] ]	6988, 7011	5229, 6627	292, 335	7150, 7174	2480, 5206	7226, 7362	2126, 2131		6960, 6965		7032, 7129		6653, 6937			7198, 7203									2146, 2461																					233, 254							363, 1444															1466, 2032	2048, 2110
43,693	110,248	25832	Discharge summary	report	Admission Date: [2109-7-5] Discharge Date: [2109-7-8] Date of Birth: [2056-5-20] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 759] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: 1. NG lavage [2109-7-5] 2. Colonoscopy [2109-7-8] History of Present Illness: This is a 53 female with a medical history of [Last Name (un) 865] esophagus who had an upper endoscopy for [Last Name (un) 15532]'s on [2109-7-2] with 8 bxs sent, who developed abdominal cramping BRBPR on day of admit. She was in her usual state of health after her EGD, but on day of admit developed abdominal pain and at 9pm had 3 small bloody bowel movements. She called her GI doc who instructed her to go to the ED. Of note, a few days before her EGC she did note that she had mild diarrhea ([3-21] bowel movements per day) and a low grade temp of 99 on Monday prior to admission. Patient did not have any black or bloody bowel movements. Pt did have occasional nausea over past few days, but no hematemesis, vomiting, abdominal pain. She has not been taking any NSAIDs or aspirin. In the ED initial vitals were: 98.9 123 162/111 16 100%. Patient was typed and crossed for 4 units of PRBC. Labs were notable for a hct of 36. Patient was given zofran for nausea and ativan for ???. Two large bore IVs were placed. An NG lavage was negative. While in the ED she had two bowel movements with an estimated 1.5L of blood loss. 1 units of PRBC was transfused. On transfer vitals were: 102, 146/84, 16, 97% ra. . On the floor, patient is comfortable. She denies abdominal pain, nausea, vomiting, further bowel movements. No lightheadedness, chestpain, dyspnea. . Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -[Month/Day (3) 15532]'s Esophagus -Plantar fasciitis -Rosacea -Dry eye -Fibroid embolization ~[2101] -Fibroid removal [2090] Social History: - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Lives with husband. Retired, lives in [State 108] for winter. Family History: Father - stomach cancer Physical Exam: Admission exam: Vitals: T: 97.6 BP: 160/93 P: 87 R: 14 O2: 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, trace lower extremity edema Discharge exam: Vitals: 98.4 97.1 118/82 118-132/72-92 100 82-100 18 100%RA 8H 775/BRP + BM's clear 24H 1360/2625 +loose marroon/tarry stools x3 General: sleeping, awakens to voice, pleasant female, appears comfortable HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, Abdomen: +NABS, soft, non-tender, non-distended, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no edema Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities, no focal deficits, gait deferred Pertinent Results: Admission labs: [2109-7-5] 11:00PM BLOOD WBC-9.5 RBC-4.09* Hgb-12.9 Hct-36.5 MCV-89 MCH-31.7 MCHC-35.5* RDW-12.3 Plt Ct-335 [2109-7-5] 11:00PM BLOOD Neuts-57.9 Lymphs-32.9 Monos-4.1 Eos-3.3 Baso-1.8 [2109-7-5] 11:00PM BLOOD PT-12.4 PTT-21.6* INR(PT)-1.0 [2109-7-5] 11:00PM BLOOD Glucose-146* UreaN-13 Creat-1.0 Na-140 K-3.5 Cl-103 HCO3-24 AnGap-17 [2109-7-6] 04:28AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 [2109-7-6] 12:23AM BLOOD Lactate-1.9 DISCHARGE LABS: [2109-7-8] 10:45AM BLOOD WBC-8.3 RBC-3.59* Hgb-11.1* Hct-32.0* MCV-89 MCH-31.0 MCHC-34.8 RDW-12.7 Plt Ct-297 [2109-7-8] 10:45AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-140 K-3.4 Cl-108 HCO3-23 AnGap-12 STUDIES: CTAP [2109-7-5]: IMPRESSION: 1. Diverticula, with no site of [Month/Day/Year ] within the colon identified. 2. Inferior right liver lobe lesion which is suggestive but not diagnostic of hemangioma. This should be further evaluated with MRI on a non-emergent basis. 3. Fibroid uterus. COLONOSCOPY [2109-7-8]: Findings: Flat Lesions A single medium localized angioectasia that was not [Month/Day/Year ] was seen in the ascending colon. An Argon-Plasma Coagulator was applied for tissue destruction successfully. Protruding Lesions Small non-[Month/Day/Year ] grade 1 internal hemorrhoids were noted. Excavated Lesions Multiple non-[Month/Day/Year ] diverticula with mixed openings were seen in the sigmoid colon, descending colon and ascending colon. Diverticulosis appeared to be of moderate severity. Impression: Grade 1 internal hemorrhoids Diverticulosis of the sigmoid colon, descending colon and ascending colon Angioectasia in the ascending colon (thermal therapy) Otherwise normal colonoscopy to cecum and terminal ileum Recommendations: The findings may account for the blood in the stool. Her GI [Month/Day/Year ] is most likely secondary to diverticular disease . Additional notes: The procedure was performed by the fellow and the attending. The attending was present for the entire procedure. The patient's reconciled home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology MICRO: STOOL CX [2109-7-6]: [2109-7-7] 7:10 am STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE (Preliminary): CAMPYLOBACTER CULTURE (Preliminary): FECAL CULTURE - R/O YERSINIA (Preliminary): FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2109-7-8]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2109-7-8]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: Ms. [Known lastname 9381] is a 53 year old female with history of [Known lastname 15532]'s esophagus who developed bright red blood per rectum four days after EGD with biopsies. Pt had NGL in the ED with no evidence of [Known lastname ]. She was transfused 1 unit PRBC's, 1LNS and monitored in the ICU overnight. GI was consulted and recommended colonoscopy. She was transferred to the medicine floors where her hematocrit remained stable. She had a colonoscopy which showed no active [Known lastname ], but diverticulosis, thought to be the most likely etiology of the bleed. She was discharged to home with PCP [Last Name (NamePattern4) 702]. # BRBPR: Most likely lower GIB. Pt had recent biopsies with EGD, but unlikely to be source as [Last Name (NamePattern4) ] was bright red rather than melanotic. NG lavage in ED was negative for bleed. Lower GI source more commonly presents with BRBPR with of possible differentials including angiodysplasia, diverticular bleed, AVM, hemmorhoidal, or infectious etiology. Patient had CTA in ED which showed diverticuli, but did not localize bleed. She was transfused 1 unit of PRBC and 1L NS prior to transfer to the ICU. Her HCT initially trended down but subsequently remained stable. She was initially placed on IV PPI [Hospital1 ] in the ICU. She remained hemodynamically stable in ICU and was transferred to the floor. On the medicine floor, orthostatics were checked and negative. She had one more bloody-melanotic bleed on HOD#3, thought to be old blood in lower GI tract. She remained HD stable and Hct was stable. She was taken for colonoscopy, which showed grade 1 internal hemorrhoids, diverticuli, angioectasia (thermal ablation performed), but no active signs of [Hospital1 ]. Stool cultures were sent and were negative for C. diff but with final stool cultures pending at the time of discharge. She was advised to follow-up with her PCP. [Name10 (NameIs) ] she rebleeds, then she would need follow-up with GI. # [Doctor Last Name 15532]??????s Esophagus: Patient with recent biopsies showing focal active esophagitis, gastric type mucosa with focal mild acute and chronic inflammation and and rare intestinal type goblet cell suggestive of [Doctor Last Name 15532]??????s, no dysplasia. Patient was started on IV PPI on admission. On the medicine floor, this was switched to po PPI. She was discharged on her home dose of Omeprazole 20mg daily. # Right hepatic lesion: Seen on CT, suggestive of hemangioma. Pt should follow-up with PCP for further management. TRANSITIONAL CARE: 1. CODE: FULL 2. FOLLOW-UP: - PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] - GI as needed, otherwise for [Last Name (NamePattern1) 15532]'s as previously scheduled 3. MEDICAL MANAGEMENT: no change, continue Omeprazole 20mg daily - f/u of hepatic lesion seen on CT 4. Outstanding tasks: - Will need outpatient follow-up for right hepatic lesion see on CT - Stool cultures pending Medications on Admission: Omeprazole 20 mg daily Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Outpatient Lab Work Please check potassium level in [3-21] days, check Chem 7. Please fax results to Dr.[Name (NI) 64316] office at [Telephone/Fax (1) 64317]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Lower gastrointestinal bleed 2. Diverticulosis Secondary Diagnoses: 1. [Telephone/Fax (1) 15532]'s Esophagus Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [Known lastname 9381], It was a pleasure taking care of you during this admission. You were admitted for bright red blood from the rectum. You were transfused one unit of blood and monitored closely in the intensive care unit. You did well, and were transferred to the medicine floors. You had a colonoscopy, which showed diverticuli (small outpouchings), internal hemorrhoids, and a small abnormal blood vessel that they ablated. The GI doctors think the [Name5 (PTitle) ] was from the diverticuli. You will need to adhere to a diet to help with this (see handout provided). You will not need to follow-up with the GI doctors after this [Name5 (PTitle) 648], except with your regular GI doctor [First Name (Titles) ] [Last Name (Titles) 15532]'s. If you do have more [Last Name (Titles) ], then you will need to see the GI doctors [Name5 (PTitle) 46451]. Your potassium level was slightly low. This is probably from the GI prep and loose stools. Have your blood drawn in [3-21] days and have the results faxed to Dr.[Name (NI) 64316] office. No medications were changed during this admission. Please continue to take the Omeprazole 20mg by mouth daily for the [Name (NI) 15532]'s Esophagus. Again, please see the handout we provided to help with dietary changes for the diverticulosis. Followup Instructions: Please follow-up with the following appointments: Name:[First Name11 (Name Pattern1) 539] [Last Name (NamePattern4) 64318], MD Specialty: Primary Care [Street Address(2) 64319], [Location (un) 10059], [Numeric Identifier 64320] Phone: [Telephone/Fax (1) 64321] When: Wednesday, [7-17] at 1:40pm Completed by:[2109-7-8]	[ "V16.0", "455.0", "573.8", "728.71", "790.29", "427.89", "569.85", "530.85", "695.3", "285.1", "562.12" ]	icd9cm	[ [ [] ] ]	[ "45.43" ]	icd9pcs	[ [ [] ] ]	9886, 9892	6474, 9504	307, 367	10071, 10071	3729, 3729	11585, 11939	2517, 2542		9577, 9863		9913, 9982		9530, 9554			10222, 11562			4209, 6451						2557, 3090	10003, 10050				3106, 3710													1803, 2198			262, 269							395, 1784					3746, 4193					10086, 10198					2220, 2360	2376, 2501
12,567	137,106	3874	Discharge summary	report	Admission Date: [2206-4-8] Discharge Date: [2206-4-12] Date of Birth: [2143-6-19] Sex: F Service: MEDICINE Allergies: Tetracyclines Attending:[First Name3 (LF) 15519] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms [Known lastname 17327] is a 62 year old female with h/o severe COPD who presents with worsened shortness of breath, and productive cough x 1 week. The cough is productive with green sputum. She denies baseline cough or sputum. She was recently admitted for a COPD exacerbation 3 weeks ago. Patient finished her antibiotics course on [3-19] and has been off the steroids for two weeks. She admits to recent sick contacts, as her grandchildren who she lives with have had URIs. In the ED, she was tachycardic to 140 She received zosyn, solumedrol 125 mg IV, and combivent x 3 prior to being transferred to the floor. On arrival to the floor patient became increasingly dyspneic and tachypneic. She was transferred to the ICU where she continued on IV solumedrol, levaquin, and scheduled nebs. She did well overnight and was transferred back to the the floor the following morning on home oxygen requirement (2L NC). On arrival to the floor, patient reports feeling better but is frustrated that she is back in the hospital. Denies any chest pain, fever, chills, abdominal pain, diarrhea, nausea, rash, or dysuria overnight. Patient admits to chronic constipation and shortness of breath. Past Medical History: - COPD, last PFTs [8-4] with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% predicted respectively); intubated several times in the past. on 2L home O2. - IgA deficiency, was on IV gamma globulin with Dr. [Last Name (STitle) 2148]. - CAD s/p MIs in [2186] (flu symptoms), [2192] (jaw pain), NSTEMI in [2197] (chest pain with left arm discomfort). Cath in [2197] with PTCA/stent to LCx. Cath in [4-/2202] with stent placement to RCA and LCx. - Hypertension - Hyperlipidemia - Gastritis, on PPI - Osteoporosis, with history of multiple compression and rib fractures from coughing - History of thrush/[Female First Name (un) ] esophagitis [12-30] steroid therapy - Depression - Tremor Social History: She lives with her daughter, [Name (NI) 6177], son-in-law and 3 grand-children. She is a widow. She is an ex-smoker, with about a 30-pack-year smoking history, quit in [2200]. No EtOH. Uses a cane and walker to ambulate Family History: Mother with DM, father with pancreatic cancer. Physical Exam: VS - 98.7, 140/82, 110, 32, 96% 4L GENERAL - Cachectic female, mildly SOB w/ speaking but able to speak in full sentences. Mildly tachypneic. + productive cough. HEENT - MMM, OP clear LUNGS - Barrel chest, diffuse expiratory wheezing, poor air movement HEART - very distant heart sounds, tachycardic ABDOMEN - scaphoid, soft, nt/nd/nabs EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions AOx3 Pertinent Results: ADMISSION LABS: [2206-4-8] 04:35PM WBC-12.3* RBC-4.80 HGB-12.9 HCT-42.4 MCV-88 MCH-26.9* MCHC-30.4* RDW-14.6 [2206-4-8] 04:35PM NEUTS-64.4 LYMPHS-19.1 MONOS-4.8 EOS-11.0* BASOS-0.7 [2206-4-8] 04:35PM GLUCOSE-113* UREA N-27* CREAT-0.8 SODIUM-143 POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-41* ANION GAP-10 [2206-4-8] 04:35PM CALCIUM-10.8* PHOSPHATE-4.8* MAGNESIUM-1.9 [2206-4-8] 04:44PM LACTATE-2.1* CXR ([2206-4-8]: No acute cardiopulmonary abnormality. Brief Hospital Course: 1. Dyspnea: Likely from COPD exacerbation as has had many in the past requiring hospitalization. Initially required ICU stay (<24 hours) though did not require NIV or intubation. Started on steroids and levofloxacin, along with nebulizers, singulair, advair. Patient was transferred to the floor where her symptoms continued to improve. She was discharged on her home regimen with the addition of levaquin 500mg daily x 3 days and prednisone 40 mg po daily. Plan to follow up with primary care provider [Last Name (NamePattern4) ]. [First Name (STitle) ] the following week. At this time prednisone course will be addressed. 2. Weight loss: Patient reports significant weight loss in recent months. She appears cachectic and malnourished. She denies any dysphagia, diarrhea, abdominal pain, or loss of appetite, limited access to food that would be contributing to her symptoms. She believes her weight loss is primary due to her being "too picky". She also states that her recent dyspnea has prevented her from eating. She refuses all supplemental shakes. Nutrition was consulted. Patient was counseled on stategies to maintain a high calorie diet. As patient's respiratory status improved her caloric intake increased. Recommend regular weight check and possibly outpatient nutrition counseling. 3. Gastritis: History of prior ulcer (EGD [2206-2-5]); started on PPI while on steroids. 4. CAD: Continued statin/plavix. 5. Code: Full (confirmed w/ patient) although would not want a trach Medications on Admission: 1. Prednisone 20 mg Tablet [Month/Day/Year ]: Three (3) Tablet PO DAILY (Daily): take 60mg for 2 days, then take 40mg for for 3 days, then 20mg for 2 days, then 10mg for 2 days. Disp:13 Tablet(s) Refills:0 2. Ipratropium Bromide 0.02 % Solution [Month/Day/Year ]: One (1) Inhalation Q6H (every 6 hours). 3. Clopidogrel 75 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol [Month/Day/Year ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Simvastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 6. Salmeterol 50 mcg/Dose Disk with Device [Hospital1 ]: One (1) Disk with Device Inhalation Q12H (every 12 hours). 7. Fentanyl 25 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Montelukast 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Paroxetine HCl 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 10. Oxycodone-Acetaminophen 5-325 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Levofloxacin 750 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:3 Tablet(s) Refills:0 12. Docusate Sodium 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO BID (2 times a day). 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: One (1) Inhalation every four (4) hours. 14. Vitamin D 50,000 unit Capsule [Hospital1 ]: One (1) Capsule PO qwed and sat. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation every four (4) hours. 16. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Medications: 1. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Montelukast 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 6. Nortriptyline 25 mg Capsule [Hospital1 ]: One (1) Capsule PO HS (at bedtime). 7. Docusate Sodium 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Fluticasone 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Salmeterol 50 mcg/Dose Disk with Device [Hospital1 ]: One (1) Disk with Device Inhalation Q12H (every 12 hours). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation q2-4h as needed for sob/ wheeze. 12. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [Hospital1 ]: One (1) Capsule PO 2X/WEEK ([Doctor First Name ],WE). 14. Calcium Carbonate 500 mg Tablet, Chewable [Doctor First Name ]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Oxycodone-Acetaminophen 5-325 mg Tablet [Doctor First Name ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 16. Multivitamin Tablet [Doctor First Name ]: One (1) Tablet PO DAILY (Daily). 17. Senna 8.6 mg Tablet [Doctor First Name ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 18. Levofloxacin 500 mg Tablet [Doctor First Name ]: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 19. Prednisone 20 mg Tablet [Doctor First Name ]: Two (2) Tablet PO once a day: Please continue on 40mg until appt with Dr. [First Name (STitle) ]. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: COPD exacerbation Secondary Diagnosis: Coronary Artery Disease Malnutrition Discharge Condition: Hemodynamically stable, breathing comfortably on home oxygen requirement (2L NC), able to ambulate with walker. Discharge Instructions: You were admitted to the hospital for progressive shortness of breath. You were found to have a COPD exacerbation. You were treated with steroids and antibiotics and your symptoms improved. The following changes were made to your home medications: 1) START Levofloxacin (Levaquin)500mg by mouth for three days. 2) START Prednisone 40mg daily until you see Dr. [First Name (STitle) ]. 3) START Senna 8.6 mg twice a day as needed for constipation . Please continue all other home medications as previously directed. . Please notify your physician or return to the hosptial if you experience fever, chills, increased shortness of breath, dizziness, loss of consciousness, chest pain, or any other symptom that is concerning to you. Followup Instructions: Please keep your previously scheduled appointments as listed below: Provider: [Name Initial (NameIs) 703] (H3) GENERAL 2 RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2206-4-15] 10:30 . Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2206-4-15] 12:00	[ "401.9", "V45.82", "311", "279.01", "733.00", "414.01", "535.50", "491.21", "412", "518.83", "263.9", "272.4", "416.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9133, 9191	3551, 5074	282, 288	9331, 9445	3042, 3042	10229, 10610	2522, 2570		6902, 9110		9212, 9212		5100, 6879			9469, 9702									2585, 3023			9720, 10206																		235, 244							316, 1517			9271, 9310		3059, 3528		9231, 9250								1539, 2260	2276, 2506
74,674	160,180	12815	Discharge summary	report	Admission Date: [2176-10-21] Discharge Date: [2176-10-29] Date of Birth: [2098-7-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2880] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: his is a 78 year old male who was recently discharged [10-11] for Vtach with pacer/ICD placement, NSTEMI with PMH of CHF with EF=30-40%, afib on Coumadin HTN, Aortic Stenosis ([Location (un) 109] 1.07, mean Grad 21 mmHg), CAD with 3VD s/p several PCIs with stenting, dyslipidemia, presenting with a 1 day history of dyspnea. He had his usual anginal chest pain which responded to nitro last night in addition to shortness of breath when laying down. He usually has 2 pillow orthopnea and paroxysmal nocturnal dyspnea, but he had increased shortness of breath than usual last night. He has also notice more swelling in his legs than usual. He was seen in clinic today and referred for evaluation for his bibasilar crackles and LE edema. In the ED his trop 0.07, BNP is [Numeric Identifier 39474], and mild hyponatremia. Lasix 20 mg IV x 1; ECG: no change from prior. CXR: effusion, edema. Initial vitals: 98.2, 64, 128/63, 18, 100%. . 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. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -> CAD: NSTEMI [2172] PCI- DES of the r-PLV and LCx/OM, [10-29] PCI- BMS to LAD; [2174]- PCI ([Hospital1 3278]) [Name Prefix (Prefixes) ]-[Last Name (Prefixes) ] for possible ISR -> Aortic Stenosis ([Location (un) 109] 1.07, mean Grad 21 mmHg), EF 50% on ETT [2172] -> Atrial Fibrillation -> Ventricular tachycardia s/p ICD placement [10-2] -> 3 vessel disease 3. OTHER PAST MEDICAL HISTORY: [2172]- CVA with residual speech difficulties Anemia GIB Anxiety Appendectomy Right Inguinal hernia Social History: Married with 1 adult son. [Name (NI) ] is retired. Prior to retiring he was a construction worker. Quit smoking 30 years ago. Prior to quitting he smoked <1ppd for approximately 20-25 years. Denies drinking alcoholic beverages or recreational drug use. Family History: Father died of a myocardial infarction in his early 70's. His sister underwent a CABG and died from a CVA at the age of 78. His brother died of a myocardial infarction at the age of 39. Physical Exam: VS: T=97.9, BP=120/65, HR=78, RR=22, O2 sat=98% RA GENERAL: Pleasant elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI, MMM. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no LAD. JVP of 12 cm. Normal carotid upstroke without bruits. CARDIAC: irregularly irregular. 3/6 SEM heard at RUSB. LUNGS: Resp were unlabored, no accessory muscle use. Crackles at bases bilaterally, no wheezes or rhonchi. ABDOMEN: Soft, NT, ND. No HSM, BS+. EXTREMITIES: Trace edema bilaterally. No clubbing, cyanosis. PULSES: Right: Carotid 2+ DP/PT 1+ Left: Carotid 2+ DP/PT 1+ Pertinent Results: [2176-10-21] 03:45PM WBC-10.1 RBC-3.69* HGB-11.1* HCT-33.4* MCV-91 MCH-30.2 MCHC-33.3 RDW-15.0 [2176-10-21] 03:45PM NEUTS-71.3* LYMPHS-21.3 MONOS-6.0 EOS-0.9 BASOS-0.5 [2176-10-21] 03:45PM PLT COUNT-236# [2176-10-21] 01:29PM UREA N-32* CREAT-1.1 SODIUM-131* POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-28 ANION GAP-12 [2176-10-21] 01:29PM PT-31.2* INR(PT)-3.1* CXR 9/28 per my read increased pulmonary [Month/Day/Year 1106] markings with bat-winging bilaterally . EKG: [10-21]- Afib at HR=67, LAD, LVH, ST depressions in V5-V6, some PVCs . 2D-ECHOCARDIOGRAM: [2176-10-5] The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) secondary to akinesis of the basal septum and hypokinesis of the rest of the left ventricle. There is considerable beat-tobeat variability of the left ventricular ejection fraction due to an irregular rhythm. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-26]+) mitral regurgitation is seen. . CARDIAC CATH: [2176-10-7] 1. Coronary angiography in this right dominant system revealed diffuse calcified coronary artery disease. The LMCA had mild disease. The LAD had widely patent stents, and total occlusion of a moderate sized diagonal seen on prior catheterization from [2173-11-11]. The distal 70% stenosis of the LAD was unchanged versus prior. The LCX had a widely patent stent, and mild luminal irregularities. The RCA was a large vessel, with moderate calcification and serial 40-50% stenoses. There was a large RPL that had a 60% stenosis in the mid-vessel, which was unchanged compared with prior. 2. Resting hemodynamics revealed moderate-to-severe aortic stenosis with mean gradient of 18 mmHg and estimated aortic valve area of 1.0 cm2. There were elevated left and right-sided filling pressures with mean RA pressure of 15, mean PCWP of 35 mmHg, and LVEDP of 29 mmHg. Cardiac output was mildly depressed at 4.0 L/min. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Elevated left- and right-sided filling pressures. Brief Hospital Course: This is a 78 year old male who was recently discharged [10-11] for Vtach with pacer/ICD placement, NSTEMI with PMH of CHF with EF=30-40%, afib on Coumadin HTN, Aortic Stenosis ([Location (un) 109] 1.07, mean Grad 21 mmHg), CAD with 3VD s/p several PCIs with stenting, who presented with acute on chronic systolic CHF exacerbation and subsequently developed sub-ICD firing threshold slow monomorphic ventricular tachycardia. . # Rhythm. The patient developed sub-ICD threshold rate monomorphic ventricular tachycardia, the first episode of which was asymptomatic and required overdrive pacing to terminate as well as a trip to the CCU for closer monitoring and IV amiodarone loading. He will continue his loading regimen with amiodarone 400mg PO BID until [10-31], amiodarone 400mg QD until [11-7], and then amiodarone 200mg QD. His VT focus is likely from prior scar from past MIs. Sotalol was discontinued after this first VT episode. He also had a second 3 minute run of symptomatic ventricular tachycardia with chest pain and shortness of breath a few days into his amiodarone loading. EPS with ablation of the VT focus was planned following this second episode of VT on amiodarone, but the patient and his wife felt that the risks of the procedure outweighed the benefits. The patient was discharged in his baseline rhythm of atrial fibrillation and was continued on Coumadin at his home dose to maintain an INR of [2-27]. He will be discharged on metoprolol succinate 50mg daily for rate control of his afib. This metoprolol dose limits his tachycardia to only brief bursts to the 130s on telemetry. Further increases in beta blocker dose was not tolerated by the patient's low blood pressure. . # Acute on chronic systolic CHF exacerbation: The patient has known chronic systolic heart failure with an EF=30-40% on an ECHO [10-5]. He presented with a BNP=16,250 and a CXR with increased pulmonary vasculature c/w CHF. The etiology for his acute presentation includes prolonged episodes of sub-ICD threshold VT at home as well as the patient being taken off of home Lasix dosing after a previous admission. He diuresed well with IV Lasix and was then transitioned to Lasix 20mg PO daily. His low dose ACE inhibitor and beta blocker were continued. . # CORONARIES: The patient has known 3VD and no intervention was made on cardiac cath [10-7]. This most recent cath showed 3VD with total occlusion of a moderate sized diagonal. He has undergone past PCIs and has several stents. He continued to develop chest pain at rest or while using the bathroom on almost a nightly basis this admission that was associated with significant ST depressions in II, V3-V6. His pain is relieved by nitro and his EKG subsequently returns to baseline. He is not a CABG candidate and will therefore require maximal medical management for his angina. His home ASA 81mg, Plavix 75mg, and simvastatin 80mg were continued. His home Imdur dose was increased from 30mg to 90mg daily for better symptomatic control. It was recommended that the patient take Nitro prior to any physical activity at home. . # Hyponatremia: The patient's sodium was 132 on admission, but responded to normal levels with free water restriction while diuresing with Lasix. . # Contact: [Name (NI) 39475] (wife, [Name (NI) 382]-[Telephone/Fax (1) 39472], [Name2 (NI) ] (son)-[Telephone/Fax (1) 39476] . # Code status. The patient was full code during this admission, but it seems like he and his wife are moving more towards a less aggressive and more palliative focus of care. Of note, several attempts were made to address goals of care and code status during this hospital stay, but health literacy remains an issue as the patient's wife who is his HCP is unable to grasp the complexity of his multiple heart conditions and the poor prognosis that is associated with them. Social work was consulted and were of great help during this admission. Before discharge I spoke with the patient's son, [Name (NI) ], who acknowledged both of his parents difficulty in understanding the underlying prognosis. He indicated that his father has said in conversations with him that he would like to be DNI. This will need to be addressed further if the patient is admitted in the future. Medications on Admission: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: one half tablet every third day. 8. Metoprolol Succinate Oral 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 10. Outpatient Lab Work Please check INR on Monday [10-14] and call results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 719]. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:6 vils Refills:0 Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Isosorbide Mononitrate 30 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:2 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Warfarin 2 mg Tablet Sig: Take 1 tablet daily except every third day when you should take [1-26] tablet Tablet PO once a day. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO Take 2 tablets twice daily until [10-31], then 400mg QD until [11-7], then 200mg QD. Disp:QS Tablet(s) Refills:2 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Acute on chronic systolic heart failure, ventricular tachycardia, unstable angina Secondary diagnoses: -CHF with EF=30% -Ventricular tachycardia s/p ICD placement [10-2] -3 vessel coronary artery disease s/p multiple stents -Dyslipidemia -Hypertension -Aortic Stenosis ([Location (un) 109] 1.07, mean Grad 21 mmHg), EF 50% on ETT [2172] -Atrial Fibrillation -CVA with residual speech difficulties -Anemia Discharge Condition: Stable, afebrile, ambulatory. Discharge Instructions: You were admitted to [Hospital1 ] Hospital for shortness of breath and chest pain. You were found to have an exacerbation of your known heart failure which causes fluid to back up into your lungs making you short of breath. You were given furosemide to get the extra fluid out of your lungs. You weight increases by more than 3 lbs. You should also adhere to a low sodium diet (less than 2 grams of sodium daily). You were also found to have a fast rhythm called ventricular tachycardia. You were started on a medication called amiodarone which helps to prevent this rhythm from developing. The following changes have been made to your home medication regimen: -You will stop taking sotalol -You will increase your isosorbide dose to 90mg daily -Your metoprolol succinate dose will be 50mg daily -You will start taking furosemide 20mg daily at home -You will start taking amiodarone 400mg twice daily until [10-31], then 400mg daily until [11-7], then 200mg daily starting [11-8] You should follow-up with all of your outpatient medical appointments as listed below. Please seek medical care if you experience any concerning symptoms such as fevers, chills, continuous lightheadedness, chest pain that is unresponsive to three nitroglycerin tablets, or increased shortness of breath. Followup Instructions: You should follow-up with all of your outpatient medical appointments as listed below. 1. Provider: [Name10 (NameIs) 191] POST [Hospital 894] CLINIC Phone:[Telephone/Fax (1) 250] Date/Time:[2176-10-31] 8:50 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2176-11-6] 1:30 3. Provider: [Name10 (NameIs) 28239] [Name11 (NameIs) 13177], MD (cardiology) Phone: [0-0-] Date/Time: [2176-11-14] 10:00 4. Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3628] (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2176-11-20] 10:15 5. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2176-11-20] 11:00 [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883]	[ "424.1", "411.1", "458.29", "438.13", "V58.61", "414.01", "285.9", "V15.82", "V45.82", "272.4", "401.9", "428.0", "428.23", "410.72", "V45.02", "276.1", "427.1", "E942.0", "427.31" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12996, 13053	6303, 10614	349, 355	13515, 13547	3582, 6138	14903, 15844	2703, 2891		11707, 12973		13074, 13157		10640, 11684		6155, 6280	13571, 14880									2906, 3563	13178, 13494	1877, 2274																			278, 311							383, 1767											2305, 2410				1789, 1857	2426, 2687
19,544	180,092	844	Discharge summary	report	Admission Date: [2200-3-24] Discharge Date: [2200-4-5] Date of Birth: [2137-1-6] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Tetracycline / Codeine Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea/Chest pain Major Surgical or Invasive Procedure: [2200-3-24] - Re-do sternotomy, AVR (21mm St. [Male First Name (un) 923] mechanical) History of Present Illness: This 62 year old patient with previous coronary artery bypass grafting in [2180] presented at this time with symptoms of chest pain and dyspnea on exertion. He was investigated and was found to have residual disease in the obtuse marginal graft and also severe aortic stenosis and mild to moderate mitral regurgitation. He had no viable leg veins to be used as conduits and hence preoperatively, the obtuse marginal vein graft was stented successfully and he was electively admitted for aortic valve replacement with or without mitral valve repair or replacement. Past Medical History: Coronary artery disease s/p CABGx4 [6-/2181] CRI with acute creatinine rise post cardiac catheterization MI [2193] PVD AF DVT Diabetes HTN Neuropathy/Retinopathy Iron deficiency anemia Depression/Anxiety s/p Subdural hematoma with evacuation Multiple PCI's Atrial Flutter ablation [2190] Multiple toe amputations Green Field Filter placement s/p Right lower extremity bypass Left saphenous vein harvest Aortic stenosis Social History: Lives with wife in [Name (NI) 5871], MA. Prior alcohol and drug abuse (pills/cocaine). He is disabled. Smoked [12-2] ppd stopping in [2195]. Family History: 2 uncles died of [Name (NI) 5290] at age 57 and 60. Physical Exam: 52 SB BP (R) 132/70 (L) 140/74 98% RA Weight 230 73" GEN: WDWN in NAD. Multiple bruises noted on arms from scratching SKIN: Warm, dry. Chronic venous stasis changes of bilateral LE HEENT: NCAT, OD blindness, OS PRL/EOMI, OP benign. Teeth in fair repair. NECK: Supple, No JVD, delayed carotid upstrokes w/ transmittyed murmur vs. Bruit. LUNGS: Clear. Well healed sternotomy HEART: RRR, Nl S1-S2, +S3, IV/VI systolic murmur. ABD: Obese, benign EXT: 2+ LE edema, No Left toes, 3 remaining right toes. + Stasis dermatitis. Pulses faint to 1+ of Bilateral LE's VARICOSITIES: Right incision from groin to mid calf. Left incision from mid thigh to groin. No varicosities. NEURO: A+Ox3. Gait slightly unsteady. Strength 5/5, OD blindness. Pertinent Results: [2200-4-1] 05:50AM BLOOD WBC-9.5 RBC-2.73* Hgb-8.3* Hct-25.2* MCV-92 MCH-30.3 MCHC-32.9 RDW-16.9* Plt Ct-333 [2200-4-1] 05:50AM BLOOD Plt Ct-333 [2200-4-1] 05:50AM BLOOD Glucose-100 UreaN-24* Creat-1.6* Na-135 K-4.2 Cl-98 HCO3-24 AnGap-17 [2200-3-29] EKG Probable sinus but possibly ectopic atrial tachycardia. Since the previous tracing of [2200-3-24] the rate has increased and pacing is no longer seen. The rapid is accompanied by inferolateral ischemic ST-T wave abnormalities. [2200-3-29] CXR The patient is status post median sternotomy and aortic valve replacement as well as coronary artery bypass surgery. The cardiac silhouette is enlarged but stable compared to the previous postoperative radiographs. There has been interval resolution of bibasilar atelectasis. The right hemidiaphragm has an unusual tenting at its mid portion, likely due to mild right upper lobe volume loss as the minor fissure is also slightly elevated. A small amount of pleural fluid in the subpulmonic space could also produce this appearance of the diaphragm. Healed rib fractures on the left are incidentally noted as well as coronary artery stents. [2200-3-24] ECHO PRE-BYPASS: 1.The left atrium is markedly dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2.The right atrium is markedly dilated. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 3.Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include inferior and septal basal and mid moderate hypokinesis. . 4.There is moderate global right ventricular free wall hypokinesis. 5. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. Mild to moderate ([12-2]+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-2]+) mitral regurgitation is seen. 8. There is no pericardial effusion. POST CPB: Moderately depressed LV systolic function. Moderate RV free wall hypokinesis which improved gradually with inotropic support. Mechanical valve in aortic position/wellseated with good leaflet excursion, trace AI. Mitral regurgitation is of mild intensity now. Brief Hospital Course: Mr. [Known lastname 5872] was admitted to the [Hospital1 18] on [2200-3-24] for elective surgical management of his aortic valve disease. He was taken directly to the operating room where he underwent a redosternotomy with an aortic valve replacement using a 21mm St. [Male First Name (un) 923] mechanical Regeant valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname 5872] [Last Name (Titles) 5058] neurologically intact and was extubated. Aspirn, plavix, beta blockade and a statin were resumed. Coumadin was started for anticoagulation for his mechanical aortic valve. He developed atrial fibrillation for which amiodarone was started with conversion to normal sinus rhythm. On postoperative day two, he was transferred to the cardiac surgical nursing floor for further recovery. Mr. [Known lastname 5872] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. A psychiatry consult was obtained for some postoperative confusion and crying episodes. Fluoxetine was continued and frequent family/staf reorientation was encouraged. One month follow-up was recommended. Mr. [Known lastname 5872] developed sternal drainage and vancomycin and levaquin was started. Vancomycin was discontinued on [4-2], he has remained afebrile with a normal WBC. His sternal drainage has subsided, and he is ready to be discharged today. He will follow-up here next week for a wound check. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD (). 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 12. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 13. Lantus 100 unit/mL Solution Sig: 10 Units 10 Units Subcutaneous QPM. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 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. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:1 vial Refills:2 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:1 vial Refills:2 7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take for 1 month. Disp:30 Tablet(s) Refills:0 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take for 1 month. Disp:60 Tablet(s) Refills:0 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 12. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily) for 2 days: Take 4mg Saturday and Sunday then VNA to draw INR, and call results to Dr. [Last Name (STitle) 5873] for continued dosing. Disp:120 Tablet(s) Refills:2 13. Prozac 40 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 14. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 15. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:60 Tablet Sustained Release(s) Refills:1 16. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 17. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: AS MR CAD ^ chol PVD AF DM-2 HTN anemia depression Sternal drainage Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# FOR 10 weeks [Last Name (NamePattern4) 2138]p Instructions: with Dr. [Last Name (STitle) ] in [1-3] weeks with Dr. [Last Name (STitle) 5874] in [1-3] weeks with Dr. [Last Name (Prefixes) ] in 4 weeks Completed by:[2200-4-5]	[ "357.2", "396.2", "250.60", "V45.81", "401.9", "414.00", "997.1", "427.31" ]	icd9cm	[ [ [] ] ]	[ "35.22", "88.72", "39.61" ]	icd9pcs	[ [ [] ] ]	10047, 10096	5205, 6806	320, 415	10208, 10215	2484, 4911		1655, 1712		7880, 10024		10117, 10187		6832, 7857			10239, 10365				10416, 10606					1727, 2465																					262, 282							443, 1014															1036, 1468	1484, 1639			4921, 5182
10,569	115,107	2738	Discharge summary	report	Admission Date: [2141-5-4] Discharge Date: [2141-5-10] Date of Birth: [2082-7-4] Sex: F Service: SURGERY Allergies: Metformin / Metoprolol Succinate Attending:[First Name3 (LF) 301] Chief Complaint: Cholecystitis Major Surgical or Invasive Procedure: Open Cholecystectomy with liver biopsy [2141-5-4] History of Present Illness: The patient is a 58-year-old woman who was complaining of attacks of epigastric pain for the last 2 months. She has been seen in the hospital, and she has known about her gallstones for the last 5 years but has tried to avoid surgery. Ultrasound confirms gallstones and a contracted gallbladder. Liver function tests were normal and repeated within normal limits with a total bilirubin of 1.6. The patient has had a decreased appetite and reports a 10- pound weight loss. She has been previously evaluated by her report with a CAT scan which has been normal. She was seen in my office this weekend with persistent right upper quadrant pain and we proceeded with a laparoscopic cholecystectomy. . Past Medical History: Cholecystitis Pulmonary Hypertension (primary vs. rheum condition vs undiagnosed cardiac dz DMII CAD. Cath [9-/2136] severe LM with 50% ostial stension. Hypothyroidism ?pan-hypo pit: partially empty sella on MR [2131], though has not required hormone replacement.anemia Hypertension Social History: The patient is from [Country 480]. She lives with her husband and has supportive children. Family History: noncontributory Physical Exam: ON admission: v/s 97.2, 60, 133/76, sat 97% on room air, RR 20 Gen: elderly female in no acute distress, partial english-speaking, slightly mal-nourished appearing HEENT: MMM, EOMI, no icterus Neck: supple, no masses CV: RRR, no murmur Pulm: coarse BS Abd: soft, NT/ND, normoactive BS, no masses Extr: warm, well-perfused Pertinent Results: [2141-5-4] 04:28PM BLOOD WBC-12.1# RBC-4.08 Hgb-10.7* Hct-35.2* MCV-86 MCH-26.2* MCHC-30.4* RDW-13.9 Plt Ct-275 [2141-5-5] 02:00AM BLOOD WBC-9.0 RBC-3.98* Hgb-10.5* Hct-33.8* MCV-85 MCH-26.4* MCHC-31.1 RDW-14.1 Plt Ct-233 [2141-5-5] 04:56PM BLOOD WBC-11.1* RBC-3.88* Hgb-10.2* Hct-33.0* MCV-85 MCH-26.2* MCHC-30.7* RDW-13.9 Plt Ct-232 [2141-5-6] 03:57AM BLOOD WBC-8.5 RBC-3.62* Hgb-9.4* Hct-30.4* MCV-84 MCH-26.0* MCHC-31.0 RDW-14.1 Plt Ct-199 [2141-5-6] 11:45AM BLOOD WBC-8.8 RBC-4.01* Hgb-10.5* Hct-34.0* MCV-85 MCH-26.3* MCHC-31.0 RDW-14.0 Plt Ct-193 [2141-5-7] 06:00AM BLOOD WBC-7.6 RBC-3.75* Hgb-9.8* Hct-31.2* MCV-83 MCH-26.1* MCHC-31.3 RDW-13.9 Plt Ct-190 [2141-5-8] 05:45AM BLOOD WBC-5.0 RBC-3.61* Hgb-9.6* Hct-29.7* MCV-82 MCH-26.5* MCHC-32.2 RDW-13.8 Plt Ct-206 [2141-5-8] 05:45AM BLOOD PT-14.5* PTT-34.3 INR(PT)-1.4 [2141-5-4] 04:28PM BLOOD Glucose-164* Creat-0.9 Na-143 K-3.2* Cl-106 HCO3-28 AnGap-12 [2141-5-5] 02:00AM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-141 K-4.9 Cl-108 HCO3-27 AnGap-11 [2141-5-5] 04:56PM BLOOD Glucose-93 UreaN-16 Creat-0.8 Na-141 K-4.5 Cl-107 HCO3-25 AnGap-14 [2141-5-6] 03:57AM BLOOD Glucose-68* UreaN-14 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-25 AnGap-14 [2141-5-6] 11:45AM BLOOD Glucose-72 UreaN-13 Creat-0.8 Na-141 K-4.6 Cl-106 HCO3-26 AnGap-14 [2141-5-7] 06:00AM BLOOD Glucose-73 UreaN-15 Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 [2141-5-8] 05:45AM BLOOD Glucose-155* UreaN-7 Creat-0.5 Na-139 K-3.7 Cl-102 HCO3-31* AnGap-10 [2141-5-4] 04:28PM BLOOD CK(CPK)-78 [2141-5-5] 02:00AM BLOOD CK(CPK)-250* [2141-5-6] 03:57AM BLOOD ALT-18 AST-48* AlkPhos-41 Amylase-27 TotBili-1.9* [2141-5-7] 06:00AM BLOOD ALT-19 AST-41* AlkPhos-40 Amylase-22 TotBili-2.2* [2141-5-8] 05:45AM BLOOD ALT-14 AST-26 AlkPhos-34* Amylase-16 TotBili-1.0 DirBili-0.4* IndBili-0.6 [2141-5-6] 03:57AM BLOOD Lipase-9 [2141-5-7] 06:00AM BLOOD Lipase-11 [2141-5-8] 05:45AM BLOOD Lipase-17 [2141-5-4] 04:28PM BLOOD Calcium-8.5 Phos-5.2# Mg-1.3 [2141-5-5] 02:00AM BLOOD Calcium-8.2* Phos-4.7* Mg-1.7 [2141-5-6] 03:57AM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.1# Mg-1.6 [2141-5-8] 05:45AM BLOOD Albumin-2.7 Calcium-8.0* Phos-1.7* Mg-1.4* [2141-5-5] 05:07PM BLOOD Lactate-1.1 [2141-5-5] Chest Xray: no acute cardiopulmonary process MICRO [2141-5-4] Intraoperative Swab culture: gram stain, culture negative [2141-5-6] Urine culture: negative [2141-5-6] Blood culture: negative [2141-5-7] Sputum culture: negative Brief Hospital Course: This is a 58 year old female who was admitted for elective laparoscopic cholecystectomy for cholecystitis. Intraoperatively the case was converted to an open cholecystectomy (please see the operative note of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for full details). During the case she was noted to have bradycardia with bigeminy and hypotension requiring lidocaine for conversion to sinus rhythm. She was transferred to the ICU setting post-operatively for close monitorring and remained there for 4 days. Cardiology was consulted and recommended close monitoring and repletion of electrolytes. She essentially did well in her post-operative course with no further cardiologic events . On post-op day 3 she had some tachypnea and an ABG demonstrated mild hypoxia; she was treated with chest PT and nebulizers with resolution of her symptoms. She was started on a clear diet on post-op day 4 which was advanced to a regular diet on post-op day 5 which she tolerated well. She was weened off of her morphine to oral narcotics by post-op day 4 with good pain control. She worked with physical therapy and was cleared for home safety. Her JP drain was removed on post-op day 6. She was discharged to home on post-op day 6 with planned follow-up with Dr. [Last Name (STitle) ] in [11-20] weeks. All questions were answered to her satisfaction upon discharge. Medications on Admission: Levothyroxine 175 mg oral qd MSContin 15 mg oral [Hospital1 ] Meclizine 25 mg oral TID prn Protonix 40 mg oral QD Viagra 25 mg oral TID Toprol XL 25 mg oral QD Avandia 4 mg oral QD Aspirin 325 mg oral QD Discharge Medications: 1. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 levothyroxine 175', mscontin 15", meclizine 25"' prn, protonix 40', toprol xl 25', cortisporin [Hospital1 ] to ears, avandia 4', asa 325', . Levothyroxine 175 mg oral qd MSContin 15 mg oral [Hospital1 ] Meclizine 25 mg oral TID prn Protonix 40 mg oral QD Viagra 25 mg oral TID Toprol XL 25 mg oral QD Avandia 4 mg oral QD Aspirin 325 mg oral QD Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Cholecystitis Secondary: pulmonary hypertension, coronary artery disease, Diabetes Mellitus Discharge Condition: Good. Tolerating POs. Ambulating without assistance. Good pain control Discharge Instructions: You may continue your pre-admission medications (including aspirin) in addition to the medications we have prescribed for you. Do not drive while taking narcotics. Call the office or come to the ER with any abdominal pain not improved with your oral narcotics, nausea/vomitting, drainage from your incision, or fever to 101. You may shower and resume you regular activity but no heavy lifting or baths for 2 weeks. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Minimally Invasive Surgery, Call to schedule an appointment within 1-2 weeks [Telephone/Fax (1) 2723] Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) ] [Hospital1 7975] INTERNAL MEDICINE Where: [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976] Date/Time:[2141-5-24] 2:00 Provider: [Name10 (NameIs) 1571] BREATHING TEST Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2141-5-30] 9:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5265], M.D. Where: [Hospital6 29] REHAB SERVICES (DYSPNEA) Phone:[Telephone/Fax (1) 612] Date/Time:[2141-5-30] 10:00 Completed by:[2141-5-10]	[ "414.01", "416.0", "574.10", "V64.41", "253.2", "250.00", "397.0", "401.9", "396.3", "244.9", "458.29", "E878.6", "789.5", "427.89" ]	icd9cm	[ [ [] ] ]	[ "51.22", "45.41", "50.12" ]	icd9pcs	[ [ [] ] ]	6637, 6695	4482, 5877	303, 359	6840, 6912	1902, 4459	7375, 8212	1527, 1544		6135, 6614		6716, 6819		5903, 6112			6936, 7352									1559, 1559																					250, 265							387, 1084									1574, 1883						1106, 1399	1415, 1511
69,000	147,214	37278	Discharge summary	report	Admission Date: [2124-11-14] Discharge Date: [2124-11-17] Date of Birth: [2041-2-6] Sex: M Service: SURGERY Allergies: Aspirin / Gantrisin / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 473] Chief Complaint: CC: abdominal pain, nausea/vomiting Major Surgical or Invasive Procedure: ERCP: [2124-11-15]: After injection of contrast, multiple irregular filling defects were seen in the common bile duct, common hepatic duct causing partial obstruction. Per ERCP report, those were found to be stones which were extracted with a balloon. Multiple filling defects were also seen in the gallbladder. History of Present Illness: 83yo man with multiple medical problems including AFIB on coumadin, CHF, and severe AS presents from OSH with acute onset RUQ pain at noon earlier today that lasted 4 hours and was associated with nausea and vomiting x 1. Patient states he felt much better after he vomited and his pain is actually much improved now, although has received narcotic. Has had similar pain in remote past when had kidney stones. Denies shortness of breath or chest pain, fevers, chills, dysuria, diarrhea or blood in stools. Past Medical History: CAD AFIB AS (diameter 1.2) CHF EF 40-60% asthma gout hypercholesterolemia cardiomyopathy PSH: AAA s/p EVAR at [Hospital1 2025] [2120] Ventral hernia repair Right Inquinal hernia repair x 2 left eye cataract Social History: non-smoker, 2-3oz wine per day, married, 3 daughters Family History: FH: CAD Physical Exam: Gen: pleasant elderly gentleman laying comfortably in bed, NAD HEENT: Anicteric, EOMI, MMdry CAD: irregular rhthym Resp: CTAB, no crackles Abd: soft, ND, tender RUQ without rebound or guarding Rectal: guaiac negative Ext: 2+ LE edema, warm, well-perfused Pertinent Results: [2124-11-13] 11:57PM BLOOD WBC-12.8* RBC-3.57* Hgb-11.3* Hct-34.9* MCV-98 MCH-31.7 MCHC-32.4 RDW-16.2* Plt Ct-269 [2124-11-17] 05:34AM BLOOD WBC-5.7 RBC-2.94* Hgb-9.4* Hct-28.5* MCV-97 MCH-32.0 MCHC-33.0 RDW-15.6* Plt Ct-211 [2124-11-17] 05:34AM BLOOD Plt Ct-211 [2124-11-17] 05:34AM BLOOD PT-20.4* PTT-32.2 INR(PT)-1.9* [2124-11-13] 11:57PM BLOOD Glucose-146* UreaN-22* Creat-1.4* Na-141 K-4.0 Cl-106 HCO3-22 AnGap-17 [2124-11-17] 05:34AM BLOOD Glucose-72 UreaN-19 Creat-1.1 Na-140 K-3.7 Cl-106 HCO3-29 AnGap-9 [2124-11-13] 11:57PM BLOOD ALT-374* AST-436* CK(CPK)-47 AlkPhos-302* TotBili-3.1* [2124-11-17] 05:34AM BLOOD ALT-128* AST-39 AlkPhos-170* TotBili-1.0 [2124-11-13] 11:57PM BLOOD cTropnT-0.11* [2124-11-14] 05:09AM BLOOD CK-MB-3 cTropnT-0.05* [2124-11-14] 02:20PM BLOOD cTropnT-0.03* [2124-11-15] 01:38AM BLOOD CK-MB-4 cTropnT-0.03* ERCP [2124-11-14]: FINDINGS: Initial scout films show an aortoiliac graft. After injection of contrast, multiple irregular filling defects were seen in the common bile duct, common hepatic duct causing partial obstruction. Per ERCP report, those were found to be stones which were extracted with a balloon. Multiple filling defects were also seen in the gallbladder. Impression: A gaping major papilla was found, suggestive of a recently passed stone A single periampullary diverticulum with large opening was found at the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. Many irregular stones ranging in size from 6 mm to 10 mm that were causing partial obstruction were seen at the common bile duct and common hepatic duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A sphincteroplasty to 12mm was performed using a wire guided CRE balloon to allow stone extraction. [4-26] stones were extracted successfully using a 12 mm balloon. Otherwise normal ercp to third part of the duodenum Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of his abdominal pain. The patient was admitted to the ICU given his multiple medical problems. [Name (NI) ] underwent ERCP on [2124-11-14]. He tolerated the procedure well. He was transfered to the floor without incident on [2124-11-16]. Neuro: The patient received IV morphine after his procedure with good effect and adequate pain control. CV: The patient was consistently bradycardic during this admission with heart rate frequently going down to the mid-30s transiently, although he remained asymptomatic. A cardiology consult was obtained and followed him during the course of his stay. No intervention was deemed necessary at this time and he will be followed as an outpatient for his cardiac issues. The patient remained otherwise stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient reported some shortness of breath after his ERCP. Chest x-ray revealed pulmonary edema. His breathing improved and his oxygen requirement decreased with diuresis with lasix. He was weaned off oxygen without difficulty on [11-17]. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-procedure, the patient was given sips of clears. Diet was advanced when appropriate, which was well tolerated, and he was placed on a regular diet on [2124-11-16]. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Foley was placed to aide in the monitoring of his fluid status. Foley was removed on [2124-11-17] and the patient had no difficulty voiding spontaneously. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The patient was placed on Zosyn on admission. When he was tolerating PO intake, his antibiotics were changed to oral Augmentin. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; he received 2 units of fresh frozen plasma for an INR of 1.7 in preparation for his ERCP. His coumadin was restarted on [11-15] and his INR was followed. Dosing was adjusted accordingly. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with the assistance of a walker, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan, including follow up with his PCP for INR checks and with cardiology, as well as with surgery. Medications on Admission: Prednisone 5qAM/2.5 qPM Allopurinol 300 QD Prilosec 20 QD Serevent 1 puff [Hospital1 ] Pulmicort 2 puffs [Hospital1 ] Lipitor 20 QD Altace 2.5mg [Hospital1 ] Flomax 0.4 QPM Colchicine Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 4. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 9. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [3-27] hours as needed for pain for 7 days. Disp:42 Tablet(s) Refills:0 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Choledocolithiasis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: Please call your doctor or 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 is 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. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) 20141], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2124-12-21] 9:40 Please call Dr.[Name (NI) 9886] office in 3 weeks for follow up appointment [Telephone/Fax (1) 2835] Please continue to attend all previously scheduled appointments, including your INR and lab check with your PCP on [Name9 (PRE) 766] [2124-11-20]. Completed by:[2124-11-17*]	[ "574.91", "576.1", "366.9", "790.92", "E934.2", "424.1", "V58.65", "V15.88", "428.23", "403.90", "414.01", "274.9", "427.89", "285.29", "412", "427.31", "458.8", "272.4", "493.90", "585.9", "790.5", "428.0", "425.4", "426.13" ]	icd9cm	[ [ [] ] ]	[ "51.88", "51.85", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	8142, 8148	3957, 6980	350, 670	8211, 8211	1841, 3934	9662, 10087	1535, 1545		7227, 8119		8169, 8190		7006, 7204			8388, 9639									1560, 1822																					274, 312							698, 1209										8225, 8364					1231, 1448	1464, 1519
8,452	162,934	4590	Discharge summary	report	Admission Date: [2135-4-27] Discharge Date: [2135-4-30] Date of Birth: [2080-11-23] Sex: M Service: MEDICINE Allergies: Reglan / Protonix Attending:[First Name3 (LF) 6195] Chief Complaint: hypotension Major Surgical or Invasive Procedure: R IJ placement History of Present Illness: Mr. [Known lastname 10936] is a 54 yo man with ESRD on home PD, CAD s/p MI with 3-vessel disease, ischemic cardiomyopathy with EF 20%, who presents with hypotension. Mr. [Known lastname 10936] reports that for the past 3-4 days he has been noting mild cough productive of white sputum. He has also noticed that his blood pressure, which is baseline systolic was 80 systolic today. He did feel light headeded but denies loss of consciousness or neausea. He denies any respiratory distress, fevers, urinary symptoms, focal pain, abdominal pain, nausea, vomitting, or other localizing symptoms. Baseline exercise tolerance is ~1 block and unchanged recently. Baseline 1-pillow orthopnea is also unchanged. He does endorse slight increase in chronic LE edema . In the ED, initialy VS: BP 60/44, O2 90% RA in triage, but first set of VS in core BP 121/101, RR 19, HR 72, T 98.3. He was given 1.5L NS. CXR did not demonstrate any significant change from prior. Exam was without localizing features apart from an elevated JVP. LIJ was placed and norepinephrine started. Vancomycin 1 g and zosyn 4.5 g were also administered as well as 10 mg dexamethasone. Urine and blood cultures were sent. Bedside echo demonstrated global hypokinesis, thought to be similar to prior. EKG showed ST depressions in v3-v6 and new QW in II, new from prior. Labs were notable for trop elevated above baseline but no CK elevation. Cardiology was consulted. They felt that this was either demand ischmia or a missed cardiac event. They recommended Plavix and [Known lastname ], which were given, but no heparinization unless CK became elevated. Subsequent EKGs were unchanged. VS prior to transfer (on .09 of norepinephrine): HR 78, BP 104/85, 20, 97% 4L, CVP 26 . Past Medical History: # Recent septic shock: [1-26]. Suspected source was left foot ulcer/cellulitis. This was treated with vanc/cipro/zosyn, and stress-dose corticosteroids. Wound swab from a LLE ulcer grew MSSA and antibiotics were changed to nafcillin x 1 day and then Unasyn. He was sent home on Keflex for a total 14 day course of antibiotics. No other positive culture data. # Recent c diff infection: [2-/2135], s/p 21 days PO vanc # Insulin dependent diabetes type I - complications of neuropathy, retinopathy, gastroparesis (somewhat responsive to erthromycin) # Renal transplant, [2119], now on PD since [5-27] - followed by Dr [Location (un) 805] # CAD - 3VD, DES to OM [3-26] - Cardiac cath [12-14] showed 3VD, no intervention was performed. - Cardiac surgery planed for surgery pending resolution of medical issues - during admission [1-26] for sepsis, pt noted to have demand ischemia with CK peaking at 647 and troponin 1.59. # Systolic CHF: ECHO [1-26] showed EF 20 % with hypokinesis of the inferior septum and lateral wall; akinesis of the posterior wall. # Polycythemia [Doctor First Name ] # PVD # HTN # h/o Osteomyelitis of R 5th metatarsal in [2128] # Eosinophilic gastritis # Stoke in [2123] with right hand weakness, resolved on its own Social History: no smoking, ETOH, or illicit drug use Family History: One sister has a congenital [Last Name 4006] problem. Mother and another sister with bipolar disorder on lithium. Physical Exam: On arrival to MICU: Afebrile, BP 110/70 on .09 levophed, O2 97% RA, HR 70s General: comfortable appearing man lying flat in bed in no distress, friendly and conversant [Name (NI) 4459]: Sclera anicteric, Moon face Neck: supple, JVP to jaw Lungs: bilateral expiratory crackles 1/3 up lung fields, no wheezing or rhonchi Abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, PD catheter site clean, dry, nontender Ext: cool distal extremities, faint pedal pulses. ~ 1 cm eschar on R heal, nontender and nonerythematous, s/p L 2nd toe amputation, site without skin lesions, 1+ pitting edema to mid-calf bilaterally On Discharge: BO stable off pressors. Pertinent Results: Admission labs: [2135-4-27] 08:10PM WBC-4.7 RBC-3.64* HGB-9.4* HCT-30.4* MCV-84 MCH-25.7* MCHC-30.8* RDW-16.6* [2135-4-27] 08:10PM NEUTS-69.2 LYMPHS-20.4 MONOS-5.7 EOS-4.6* BASOS-0.1 [2135-4-27] 08:10PM GLUCOSE-169* UREA N-66* CREAT-9.5# SODIUM-134 POTASSIUM-3.4 CHLORIDE-93 TOTAL CO2-22 ANION GAP-22 [2135-4-27] 08:17PM LACTATE-2.7* K+-3.5 [2135-4-30] 05:05AM BLOOD WBC-4.6 RBC-3.44* Hgb-9.2* Hct-29.2* MCV-85 MCH-26.7* MCHC-31.4 RDW-17.2* Plt Ct-175 [2135-4-30] 05:05AM BLOOD Glucose-117* UreaN-71* Creat-8.2* Na-134 K-3.8 Cl-96 HCO3-20* AnGap-22* [2135-4-30] 05:05AM BLOOD Calcium-7.4* Phos-10.6* Mg-2.2 [2135-4-28] 02:09AM BLOOD PTH-1670* CXR: Comparison is made with prior study performed six hours earlier. Cardiomegaly is grossly unchanged. Right IJ catheter tip is in the SVC. Left lower lobe retrocardiac opacities have improved consistent with improved atelectasis. There is no pneumothorax. The component of mild pulmonary edema has resolved. There is persistent right lower lobe opacity consistent with aspiration or pneumonia. If any, there is a small right pleural effusion. Brief Hospital Course: 54 year old man with 3VD, CHF, recent sepsis, ESRD on PD, DM1, admitted with hypotension. . # Hypotension: Differential includes cardiogenic vs distributive vs hypovolemic causes. Among cardiogenic causes, this may represent an acute exacerbation of his chronic CHF or a new cardiac event. He may be septic, although afebrile and without localizing signs or symptoms. CXR with possible RLL infiltrate, not impressive.. Awaiting urine. Foot does not appear infected. Regarding the possibility of hypovolemic shock, he may be over-dialyzed. He does state that he has noticed a decrease in his weight and poor PO intake. . On admission to the MICU, levophed was quickly weaned off. BP was initially 110s but trended down to the 90s. He received an additional 500cc of IVF. . SVCO2 was 77%, arguing against heart failure. TTE was ordered to further evaluate. For the possibility of sepsis, vancomycin and piperacillin-tazobactem were started but discontinued after there was no evidence of sepsis. Blood, urine, PD fluid, sputum cultures, stool for c diff if diarrhea were ordered. Lactate was down trending. He was given stress-dose steroids. Most likely was a combination of poor systolic function, poor PO intake, and adrenal insufficiency. # EKG changes: Patient has known 3VD and systolic dysfunction with EF 20% with new QW on EKG. Although troponin was elevated significantly above baseline, CK was not. This likely represented a recent cardiac event with CK now resolved and troponin trending down. Bedside echo in ED without clear evidence of new WMA. Official TTE was ordered. Per cardiology recommendations in [Last Name (LF) ], [First Name3 (LF) ] and Plavix were continued and no heparinization. Metoprolol and ACE were held given hypotension. . He likely also had demand ischemia in the ED related to poor perfusion pressures with shock. Cardiac enzymes were trended. . # ESRD: c/b failed renal transplant, on nocturnal PD. No urgent indication for dialysis on admission, although BUN/creatinine higher than previously in OMR, likely secondary to missing HD the night prior. Renal was consulted and PD started. Sensipar, calcitriol, renagel were continued. Per renal recommendation, cyclosporin was discontinued. . # Anion gap: AG 19, from [2-1] previously. Likely secondary to renal failure and mildly elevated lactate. . # Diabetes type I: He was given home dose of insulin lantus and humalog sliding scale. . Patient stated his desire to be full code. Medications on Admission: Cinacelcet 30 mg daily Sevelamer HCl 800 mg TID W/ [Month/Year (2) ] Clopidogrel 75 mg Daily Prednisone 5 mg Daily Cyclosporine 25 mg daily Metoprolol Succinate 25 mg SR daiyl Aspirin 81 mg Daily Simvastatin 80 mg Daily Calcitriol 0.25 mcg Daily Lantus 20u qAM ISS hydralazine 10 mg qid Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) as needed for nasal congestion for 3 days. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:270 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: hypotension heart failure secondary: Adrenal insufficiency End stage renal disease Diabetes type I Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were seen and treated in the hospital for low blood pressure requiring admission to the medical intensive care unit in order to maintain your blood pressure to adequte levels. The most likely cause of your low blood pressure may have been due to over-dialyzing with peritoneal dialysis at home resulting in removing too much fluid. It may also have been caused by your lack of appetite for five days resulting in reduced fluid intake. Given new findings on your Echocardiogram one other possibility for your low blood pressures may have been due to a mild heart attack. During your hospital course you were started on antibiotics for presummed septic infection but these medications have been discontinued given no signs or symptoms of infection. You were also started on high dose steriods because your body could not produce these steriods on its own during a stressful event such as low blood pressure. These high dose steriods will be stopped when you leave the hospital. You will need to schedule an appointment in two weeks with your Cardiologist Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] as well as with your primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) ]. Your Recommended diaylsis course is below: Please start Peritoneal Dialysis with 1.5% dextrose alternating with 2.5% dextrose, 1700mL volume, 6 hour dwell and 4 exchanges. Followup Instructions: You will need to make an appointment with DR. [First Name (STitle) ], [Name8 (MD) 251], M.D. within the next two weeks.[Telephone/Fax (1) 3637] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2135-6-2] 11:30 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2135-6-2] 10:45 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6198] MD, [MD Number(3) 6199]	[ "E879.1", "285.21", "238.4", "536.3", "428.0", "403.91", "V12.54", "412", "362.01", "276.52", "250.61", "255.41", "535.70", "443.9", "585.6", "250.51", "428.22", "414.01", "458.21" ]	icd9cm	[ [ [] ] ]	[ "38.93", "54.98" ]	icd9pcs	[ [ [] ] ]	9415, 9478	5479, 7972	291, 307	9622, 9622	4320, 4320	11210, 11756	3470, 3590		8314, 9392		9499, 9601		7998, 8291			9770, 11187									3605, 4262															4276, 4301						240, 253							335, 2086					4337, 5456					9637, 9746					2108, 3399	3415, 3454
46,089	187,568	9459	Discharge summary	report	Admission Date: [2181-1-4] Discharge Date: [2181-1-6] Date of Birth: [2098-11-3] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 2745] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: This is an 82 year old male with a history of prostate cancer who presented to an OSH with lower extremity weakness and was transfered to [Hospital1 18] for hyperkalemia. The patient states that over the last few weeks, he has had occasional lower extremity weakness which only occurs at night. He has had no difficulty during the days, and when it does occur, it has resolved by morning. However, on the day of admission, the patient states he felt weak during the day, and in fact required use of his wife's walker. Even with the walker, he had difficulty with ambulation and fell (he states his legs crumpled - non-traumatic, did not hit his head, no LOC). This prompted her to call an ambulance for evaluation at the hospital. At the OSH, the patient was found to have a K of 8.9, other labs as below. He was given albuterol nebs, 1 amp dextrose, 10 units of insulin sub q, kayexelate 30 mg x1, 1 amp of NaBicarb and 1 amp of calcium gluconate. Repeat K was 7.6. ECG's showing mild peaking of T waves. The patient was then transfered to [Hospital1 18]. In the ED here, initial K was 7.2. He was given repeat doses of 10 units insulin 10 IV, 1 amp of D50, Calcium gluconate 1 amp and bicarb 1 amp. Repeat K was 6.4 prior to transfer to the ICU. ECGs with improvement from prior, no peaking of T waves here. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, lightheadedness, gait unsteadiness, vision changes, headache, rash or skin changes. He does report 3 days of loose stools prior to admission, up in frequency from once daily to 3 times daily. He was taking Immodium for his symptoms. Pertinent positives as per HPI. Past Medical History: -Atrial fibrillation on coumadin -Prostate ca, diagnosed in [2165] ([Doctor Last Name ] 6 (3+3)) underwent radiation therapy in [2165], in [2170] placed on vaccine protocol with no improvement in his progression. He then began a dietary intervention protocol in [2171] which was stopped in [2173] due to lack of improvement. Followed by regular bone scans and CT scans without evidence of metastatic disease. Of note, in [Month (only) 205] the patient was hospitalized with urosepsis presumably from a urethral stricture, in [2180-7-21] he had an acute bladder outlet obstruction which resulted in an increase in his creatinine, though this has since resolved. He also had an SBO in [Month (only) ] which was treated with NGT. Last PSA in [10-28] was 75 -Spinal stenosis - recent lumbar spinal steroid injection on [2180-12-28], no complications -Hypertension -Bowel obstruction during childhood, s/p resection Social History: Lives at home with his wife. Is retired, active around the [Last Name (un) ] communication, delivers meals for Meals on Wheels. 30 pack year smoking history, quit 35 years ago. Denies illicit drug use, rare etoh. Family History: NC Physical Exam: On Presentation: VSS GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Large left-sided well-healed incision from childhood surgery, soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing bilaterally. No gait disturbance currently, sensation intact in bilateral lower extremities SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2181-1-4] 07:15AM WBC-7.7 RBC-4.20* HGB-14.0 HCT-41.4 MCV-98 MCH-33.2* MCHC-33.8 RDW-14.9 [2181-1-4] 07:15AM NEUTS-80.0* LYMPHS-12.8* MONOS-6.0 EOS-0.9 BASOS-0.3 [2181-1-4] 07:15AM PLT COUNT-186 [2181-1-4] 07:15AM PT-19.7* PTT-33.8 INR(PT)-1.8* [2181-1-4] 07:15AM GLUCOSE-80 UREA N-46* CREAT-1.7* SODIUM-138 POTASSIUM-7.2* CHLORIDE-117* TOTAL CO2-14* ANION GAP-14 [2181-1-4] Renal U/S: FINDINGS: Limited study given habitus and poor acoustic window performed without a radiologist present. The right kidney measures 9.5 cm. The left kidney measures 10.2 cm. No mass, stone or hydronephrosis detected within the kidneys. The bladder is moderately distended with fluid without focal lesion detected within. IMPRESSION: Mildly limited study. No hydronephrosis. [1-4] 2 view CXR: FINDINGS: The cardiac silhouette is of upper normal limits. There is a slightly tortuous thoracic aortic contour. The hilar and mediastinal contours are otherwise unremarkable. The pulmonary vasculature is normal. The lungs are clear bilaterally without pleural effusion or pneumothorax. There are mild degenerative changes in the underlying osseous structures. There is normal bowel gas in the visualized abdomen. IMPRESSION: No acute cardiopulmonary process Brief Hospital Course: This is an 82 year-old male with a history of prostate cancer who presented with lower extremity weakness and was admitted from OSH with severe hyperkalemia to 8.9. # Hyperkalemia: Initially, unclear etiology. Renal function was close to baseline (most recent labs at [Location (un) 620] show creatinine of 1.8, last here was 1.6). No new medications other than vitamin D. Patient denied any high potassium food intake. The patient had been having frequent loose stools so he should have been wasting K from the GI tract. The patient had been on metoprolol for a long time so acute increased K was not likely related. The patient was evaluated by the renal service and diagnosed with underlying hyporeninemic hypoaldosteronism with a significant metabolic acidosis in the setting of his profuse diarrhea thta may have precipitated transcellular shift of potassium out of the cells causing his hyperkalemia. The initial outside hospital potassium level of 8.9 was believed to likely not have been accurate. The patient's potassium was controlled and the patient was discharged on lasix 20 mg po qd and a low potassium diet with close outpatient monitoring of potassium levels and outpatient renal f/u. # Lower extremity weakness: Patient reports this has been ongoing for several weeks to months. He has had frequent surveillance PET scans and CT scans, last in [Month (only) 205] of this year, without evidence of metastatic disease. Acute exacerbation of his symptoms was likely secondary to his severe hyperkalemia. With improvement in his hyperkalemia, his lower extremity weakness resolved and he was able to ambulate well independently. # Prostate cancer: Followed by Dr. [Last Name (STitle) ] at [Location (un) 620]. No evidence of metastatic disease at this time, though PSA has been increasing over time, most recently 75. Primary oncologist was made aware of admission. # Atrial fibrillation: Was subtherapeutic on admission and was bridged on a heparin gtt and continued on home coumadin. Medications on Admission: Amlodipine 5 mg daily Calcium/vitamin D 5000 units (started [12-25]) Metoprolol 50 mg [Hospital1 ] B12 250 mcg daily Allopurinol 300 mg daily ASA 81 daily Flomax 0.4 mg daily Betoptic eye drops Coumadin 5 mg daily MVI Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Severe Hyperkalemia Bilateral Lower Extremity Weakness Metabolic Acidosis secondary to Diarrhea and renal dysfunction Hyporeninemic Hypoaldosteronism Stage 3 CKD Prostate Ca s/p XRT Discharge Condition: Vital Signs Stable Potassium of 5.3 Discharge Instructions: Patient to return to ED if he has recurrent leg weakness, heart palpitations, chest pain, difficulty breathing, severe diarrhea, fevers, chills. Followup Instructions: Patient to arrange f/u with his PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] at [Telephone/Fax (1) 29252] next week and patient was instructed to get his chem 10 checked on Tuesday, [1-9] at his PCP office to monitor his hyperkalemia.	[ "427.31", "729.89", "255.10", "585.3", "276.7", "185", "276.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8837, 8843	5523, 7547	293, 299	9068, 9107	4215, 5500	9301, 9552	3356, 3361		7824, 8814		8864, 9047		7573, 7801			9131, 9278									3376, 4196																					245, 255							327, 2125															2147, 3105	3121, 3340
73,606	125,730	54099	Discharge summary	report	Admission Date: [2143-4-25] Discharge Date: [2143-5-2] Service: SURGERY Allergies: Demerol Attending:[First Name3 (LF) 6088] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2143-4-25] OPERATION: 1. Ultrasound-guided puncture of the left brachial artery. Catheterization of the celiac artery. 2. Abdominal aortogram. 3. Primary stenting of the celiac artery. 4. Selective arteriogram of the celiac artery. 5. Thrombectomy and repair of the left brachial artery. History of Present Illness: 86F presents with acute onset post-prandial pain this morning after eating breakfast. She states she has been having intermittent episodes of post-prandial abdominal pain for the past 2 months. The episodes would resolve on their own. This morning's episode has persisted and nothing alleviates it. She does report some nausea but has had no emesis. Poor PO intake today. She has a colonoscopy in [Month (only) 956] for guaiac positive stool and was found to have a bleeding cecal AVM. Normal BM's, no diarrhea. Denies fever and chills. Her abdominal pain is diffuse but mainly located in the lower quadrants. It is a [9-29] in intensity and pain meds do not help. She has had numerous CT scans in the past, all showing SMA occlusion with high grade stenosis of the celiac axis. Past Medical History: 1. chronic GI bleed secondary to AVM. 2. Chronic renal insufficiency - baseline cr 1.4-1.7 3. Cold agglutinin disease-- followed at heme/onc at Farber on procrit every other week, baseline Hct 25-30 4. warm agglutinin disease secondary to Nardil. 5. Low back pain. 6. Left leg pain - patient was treated with injections at Pain Clinic for her left leg pain. It has not resolved. 7. Depression. 8. Peritonitis. 9. Clubbing of the platelets. 10. Status post left carpal tunnel surgery. 11. Status post cholecystectomy [62] years ago. 12. CVA with residual L sided weakness 13. PVD w/ bilateral arterial stents 14. RAS ?s/p stenting per husband Social History: Lives at home with husband but he is currently hospitalized as well. HHA assists 24-7. Walks with walker. Former 50pack year smoker, quit many years ago. No ETOH, no illicits. Family History: Mother with CHF, father MI at 78. Physical Exam: Gen: elderly female in moderate distress, being treated with medications for comfort. alert and oriented x 3 Cardiac: RRR Chest: labored breating (better when medicated), lungs clear to auscultation Abd: soft, diffusely tender Rectal: guaiac positive stool(on admission) Ext: feet warm, MAEW, sensation and motor intact Pulses: palpable femoral pulses bilaterally, dopplerable PT/DP Pertinent Results: [2143-4-27] 04:35AM BLOOD WBC-9.3 RBC-3.12* Hgb-10.3* Hct-29.4* MCV-94 MCH-32.9# MCHC-35.0 RDW-24.0 Plt Ct-139* [2143-4-27] 04:35AM BLOOD Glucose-131* UreaN-33* Creat-1.9* Na-142 K-4.0 Cl-106 HCO3-24 AnGap-16 [2143-4-25] 05:26PM BLOOD ALT-15 AST-35 LD(LDH)-371* AlkPhos-58 Amylase-76 TotBili-1.5 [2143-4-25] 05:26PM BLOOD Lipase-36 [2143-4-27] 04:35AM BLOOD Mg-2.1 MRSA SCREEN (Final [2143-4-28]): No MRSA isolated. [2143-4-25] 5:47 am URINE Source: Catheter. FINAL REPORT [2143-4-26] URINE CULTURE (Final [2143-4-26]): NO GROWTH. Brief Hospital Course: Ms. [Known lastname 93440] was admitted to Vascular Surgery from the ED on [2143-4-25]. CT scan showed evidence of bowel ischemia and known SMA occlusion and celiac axis stenosis. She was afebrile with a normal WBC butdid have a left shift with 93 neutrophils. General surgery was consulted and they do feel that she has signs of ischemia on exam but do not feel that she has frank peritonitis. They did not feel that she needs an exploratory laparotomy immediately. The pt was sent to the vascular floor, made NPO and started on zosyn. She was taken to the endovascular suite on [2143-4-25] where she underwent the following:1. Ultrasound-guided puncture of the left brachial artery. Catheterization of the celiac artery. 2. Abdominal aortogram. 3. Primary stenting of the celiac artery. 4. Selective arteriogram of the celiac artery. After the procedure was complete the brachial sheath was removed and direct pressure was held over the arteriotomy. However, after 5 minutes, the hand appeared to be somewhat mottled and there was no longer a pulse of the brachial artery or the radial and ulnar arteries. The pt then underwent a thrombectomy and repair of the left brachial artery where 2-3 cm of fresh thrombus was removed from the artery proximally. She tolerated the procedures well and was taken to the pacu for recovery. She was transfused 2 units of prbcs in the pacu for low hgb/hct and responded appropriately. She was a bit hypotensive and received a fluid bolus and a one time does of ephedrine sulfate as well. When stable she was transfered to the CVICU for further monitoring. She was monitored closely and her pain was controlled with mulitple medications. On [2143-4-26] Dr. [Last Name (STitle) ] had a discussion with the pt's family regarding management and prognosis. It was felt that there was no further surgical intervention that could be done for Ms. [Known lastname 93440] and that her mulitple illnesses complicated by this acute problem gave her a high mortality rate. The family and pt decided on a DNR/DNI status. Later that night she was placed on an epinephrine gtt for hypotension and low cardiac index. On [4-27] Ms. [Known lastname 93440] seemed to be in a bit more distress, having increased pain and anxiety/ aggitation. She was given IV haldol several times and her po and iv pain medications were adjusted several times. She remained comfortable over the weekend and was transfered to the vascular floor on [4-27]. She did well on [4-28] and again her pain medications were titrated. On [4-29] the palliative care team was called and consulted with the pt and family. A plan for hospice care was initiated and the pt was made comfort measures only (CMO) and placed on a regimen of oral morphine, zyprexa, and ativan for pain and anxiety control. She was in distress intermitently throughout the day and her meds were titrated appropriately with the help of the paliative care team. She expired at 5:15 AM on [2143-5-2]. Medications on Admission: amlodipine 5mg daily, atenolol 12.5mg [Hospital1 ], cymbalta 120mg daily, folate 5mg daily, mirtazapine 15mg qhs, protonix 40mg [Hospital1 ], prednisone 1mg daily, seroquel 100mg qhs, trazodone 50mg prn, zolpidem 7.5mg qhs, aspirin 81mg daily, caldium, B12, colace, iron, MVI, thiamine Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Acute on chronic mesenteric ischemia. Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "283.0", "790.01", "E878.8", "585.9", "997.2", "444.21", "403.90", "724.2", "447.4", "V66.7", "438.89", "729.89", "557.1", "311", "443.9", "729.5", "557.0" ]	icd9cm	[ [ [] ] ]	[ "88.42", "88.47", "00.40", "99.04", "39.50", "39.90", "38.03", "00.45" ]	icd9pcs	[ [ [] ] ]	6741, 6750	3348, 6364	228, 527	6832, 6841	2703, 3325	6897, 6907	2247, 2284		6709, 6718		6771, 6811		6390, 6686			6865, 6874									2299, 2684																					174, 190							555, 1355															1377, 2036	2052, 2231
5,761	117,599	8984	Discharge summary	report	Admission Date: [2130-2-17] Discharge Date: [2130-2-25] Date of Birth: [2053-8-29] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1943] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: Intubation/mechanical ventilation Arterial line placement Central venous line placement History of Present Illness: 76 yo M w/ St. [Male First Name (un) 1525] AVR, Afib, CHB pacer dependent, prostate CA on lupron/ketaconazole/hydrocortisone presents from home after acutely developed chills and vomiting this morning. After the vomiting episode, his family reported worsening mental status and he was taken to an OSH ED. There he was found to be hypotensive, febrile 102, WBC 12, got trace fluids 250cc. A CT head and CT ab/pelvis were unremarkable, UA negative, CXR was concerning for bilaterally pulmonary infiltrates. There they administered avelox 400mg IV, CTX 1gm IV, and vanco 1gm x1 and he was transferred to [Hospital1 18] ED. On arrival, he was hypotensive initially improved with IVF 2L, and was started on dopamine. A CVL was placed in the right IJ and he was intubated for respiratory failure on lying flat. Labs in the ED were notable for WBC 14. INR 4.4. Cr 1.7 and Lactate 2.7. Blood and urine cultures were sent. Prior to transfer, VS HR 73 BP 97/46 RR 16 100% AC 550/16/5/100%, and he was on fentanyl, versed bolus for sedation. On the floor, he was intubated and sedated. Family was at bedside to confirm details as above. There have been no sick contacts and patient has not been out of the house for the past 5 days. Review of systems: (+) Per HPI (-) Family denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Prostate cancer: On Lupron last [2130-1-26], ketoconazole and hydrocortisone(off since [10-31] [1-24] elevated LFTs). - Renal tumor, found incidentally on CT scan, most recently imaged in [2128-9-22]. - Right lower lobe lung nodule, followed regularly by a CT scan. - AVR - [First Name8 (NamePattern2) ] [Male First Name (un) 1525] at [Hospital1 ] in [2107] - Complete heart block status post pacemakerx2, last in [Month (only) ] [2127]. - Lower extremity edema from venous stasis. - History of Reiter's syndrome in his 20s. - Atrial fibrillation - Hypertension PAST SURGICAL HISTORY: Status post TURP in [2125] Status post right hip replacement in [2124] Social History: The patient is retired, formerly worked at [Company 2676] as a contractor and IRS. He reports rare ethanol. He is a former smoker, stopped 10 years ago and has a roughly 75-pack-year history. He currently lives with his wife in [Name (NI) 4310] and does all his ADLs but minimally active at baseline. Family History: The patient has two children and three grandchildren. Father died at 64 years old of an MI, also had diabetes. Mother died of old age and also had [Name (NI) 2481] disease. Only other diabetic is a paternal grandmother. [Name (NI) ] history of CAD, other oncologic disorders. Physical Exam: VS: 101.4 78 127/55 23 97%RA General: intubated and sedated HEENT: Sclera anicteric, MMM, oropharynx clear, OG tube with billous aspirate Neck: supple, JVP elevated to 10cm, no LAD Lungs: Diffuse rales, no wheezing or ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, hyperpigmentation of b/l shins Pertinent Results: [2130-2-17] 02:50PM BLOOD WBC-14.1# RBC-4.37 Hgb-13.0* Hct-38.3* MCV-88 MCH-29.7 MCHC-33.9 RDW-13.8 Plt Ct-128* [2130-2-17] 02:50PM BLOOD Neuts-90.3* Lymphs-5.0* Monos-3.8 Eos-0.7 Baso-0.2 [2130-2-17] 02:50PM BLOOD PT-41.3* PTT-40.4* INR(PT)-4.4* [2130-2-17] 09:07PM BLOOD Fibrino-337 [2130-2-17] 09:07PM BLOOD FDP-0-10 [2130-2-17] 02:50PM BLOOD Glucose-123* UreaN-25* Creat-1.7* Na-141 K-3.8 Cl-109* HCO3-26 AnGap-10 [2130-2-17] 02:50PM BLOOD ALT-30 AST-57* LD(LDH)-405* CK(CPK)-43* AlkPhos-137* TotBili-0.6 [2130-2-17] 02:50PM BLOOD Lipase-40 [2130-2-17] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01 [2130-2-17] 09:07PM BLOOD CK-MB-3 cTropnT-0.02* [2130-2-18] 04:04AM BLOOD CK-MB-3 cTropnT-<0.01 [2130-2-17] 09:07PM BLOOD CK-MB-3 cTropnT-0.02* [2130-2-18] 04:04AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.7 CXR AP [2130-2-17]: 1. Appropriate positions of endotracheal tube and right IJ line with no pneumothorax. 2. New retrocardiac airspace opacity which may represent focal pulmonary edema or atelectasis, though aspiration cannot be excluded. 3. Stable cardiomegaly and mild pulmonary vascular congestion. ECHO [2130-2-20]: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. An aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. There is an aortic prosthesis - which appears most likely a bioprosthesis. The gradient is higher than expected for this kind of prosthesis. [2130-2-21] 7:33 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2130-2-23] FECAL CULTURE (Final [2130-2-23]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2130-2-23]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2130-2-21]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2130-2-17] 9:58 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. FINAL REPORT [2130-2-20] Respiratory Viral Culture (Final [2130-2-20]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [2130-2-18]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. [2130-2-17] 3:15 pm URINE HEME S# 1220C URS/LEG ADDED [2130-2-17]. FINAL REPORT [2130-2-18] Legionella Urinary Antigen (Final [2130-2-18]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. CXR: HISTORY: A 76-year-old man with CHF, increasing shortness of breath. Assess for interval change. IMPRESSION: AP chest compared to [2-20]. Mild pulmonary edema has improved in the left lung, worsened at the right base. Moderate-to-severe cardiomegaly unchanged, pleural effusion, minimal if any. Transvenous right atrial and right ventricular pacer leads are in standard placements, unchanged. No pneumothorax. Of note, pulmonary edema was not present on [2-19]. [2130-2-24] 06:40AM BLOOD WBC-5.9 RBC-4.39* Hgb-12.8* Hct-38.5* MCV-88 MCH-29.2 MCHC-33.4 RDW-13.9 Plt Ct-206 [2130-2-25] 09:15AM BLOOD WBC-3.9* RBC-4.14* Hgb-12.9* Hct-37.7* MCV-91 MCH-31.0 MCHC-34.1 RDW-14.0 Plt Ct-183 [2130-2-23] 05:25AM BLOOD PT-62.1* PTT-42.7* INR(PT)-7.1* [2130-2-23] 05:00PM BLOOD PT-40.4* PTT-38.3* INR(PT)-4.2* [2130-2-25] 09:15AM BLOOD PT-14.1* PTT-81.5* INR(PT)-1.2* [2130-2-24] 06:40AM BLOOD Glucose-116* UreaN-39* Creat-1.4* Na-147* K-3.7 Cl-112* HCO3-27 AnGap-12 [2130-2-25] 09:15AM BLOOD Glucose-123* UreaN-27* Creat-1.5* Na-143 K-3.4 Cl-106 HCO3-29 AnGap-11 [2130-2-23] 05:25AM BLOOD ALT-25 AST-25 [2130-2-18] 04:04AM BLOOD CK-MB-3 cTropnT-<0.01 [2130-2-20] 04:30AM BLOOD CK-MB-7 cTropnT-0.02* [2130-2-25] 09:15AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.0 [2130-2-21] 03:46AM BLOOD PSA-95.2* [2130-2-25] 04:22AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.016 [2130-2-25] 04:22AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2130-2-25] 04:22AM URINE RBC-100* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 Brief Hospital Course: Mr. [Known lastname 31] is a 76 yo M w/ AVR on coumadin, CHB pacer dependent, Afib, prostate CA on hydrocortisone po presents from home with acute onset chills and vomiting followed by septic shock and respiratory failure. # Septic Shock - Felt to be most likely [1-24] urosepsis given + urine cultures (40,000 e. coli and +group B strep) and h/o urosepsis with only 10,000 pseudomonas growing in urine 3 yrs ago after urologic procedure. CXR concerning for concurrent pneumonia in the left intrahilar region. CXR also concerning for pulmonary edema or ARDS vs. infiltrate. Ddx includes gastroenteritis (viral and bacterial), aspiration pneumonia, biliary source. Abdominal exam benign and CT ab/pelvis w/out contrast unremarkable at OSH. Also AI a concern given home steroid use. No clear obstructive or cardiogenic component based on clinical exam on admission. Pt initially covered broadly for abdominal source and pneumonia with IV cefepime, flagyl, azithro all started on [2130-2-17]. Azithro was discontinued on [2130-2-19]. Given home hydrocortisone, started stress dose steroids. His septic shock quickly improved with abx, steroids, and IVF. Patient required a period of mechanical ventilation and pressors (levophed) but responded well to treatment. Ultimately, his antibiotics coverage was narrowed to Cefpodoxime for a full 14 day course for pneumonia and UTI. [2-25] is day 8. # Hypoxic Respiratory Failure - Patient required intubation in setting of lying flat with line placement. CXR consistent with volume overload, patient has history of dCHF. Cardiac enzymes negative, ECHO on [2130-2-20] showed dilated LA, mod dilated ascending aorta, no masses or vegetations, mild MS, trivial MR, mild PAH. Pt was extubated on [2130-2-18] without complications. Started diuresis on evening of [2130-2-19] given increasing rales, CVP of 15. Diuresed well with IV Lasix with improvement in his respiratory status. Upon transfer to the Medicine floors, Lasix was briefly held given his acute renal insufficiency, with improvement in his Creatinine. It was restarted the day prior to discharge. His pulmonary status remained stable. # Emesis - Possibly secondary to urosepsis vs viral/bacterial gastroenteritis vs pneumonia vs. intubation/sedation. No evidence of obstruction. LFTs underwhelming, exam benign. OSH non-contrast CT ab/pelvis unremarkable. Resolved with zofran prn. OGT pulled. Stool cx unremarkable and c diff negative. # Acute Renal Failure - Likely prerenal in setting of hypotension and later poor PO intake, with FeNa of 0.2% and resolved with IVF. Baseline 1.3 ([2130-1-26]), up to 1.7 on admission. Discussed with wife that recently hydrocortisone/ketaconazole were resumed and she was concerned that these caused renal impairment in past. Per oncology, plan is to restart ketoconazole at time of discharge from hospital. Patient's lasix and lisinopril were briefly held upon transfer to the regular Medicine floor, and he was encouraged to liberalize his PO fluid intake, with good gradual improvement of his Creatinine back to baseline. His lasix and lisinopril are scheduled to be restarted on [2130-2-25]. # AVR/CHB pacer dependent - [First Name8 (NamePattern2) ] [Male First Name (un) 1525] on coumadin. Supratherapeutic likely [1-24] ketoconazole interaction and then antibiotics interaction (patient received levaquin at OSH). Coumadin continues to be held in setting of elevated INR. When his INR was 7+, given risk for falls, patient received Vitamin K 2mg PO X1 which dropped his INR to 1.3. His goal is 2.5-3.5. Given concerns for thrombolic events with his prosthetic valve, patient was started on heparin gtt. He was also resumed on Warfarin 5mg daily. he was offerred a PICC but refused. He may be amenable to PICC placement in the future. Heparin gtt should be continued for 48 hours after INR is therapeutic 2.5-3.5. INR should be checked daily while titrating INR. # Delirium: Patient was hyperactively delirious in the ICU, likely due to the multiple factors of ICU admission, recent intubation, sedative/hypnotic medications, stress dose steroids, pneumonia/UTI etc. He was treated with Zydis given concern for laryngospasms with Haldol, to good effect. On the Medicine floors, he continued to wax and wane and showed signs of emotional lability (tearful). Delirium precautions were maintained and brief hypernatremia was aggressively managed with D5 1/2NS. His sodium was 143 the day of discharge. He was emotionaly labile the day of discharge, with frequent crying. - Continue delirium precautions: OOB --> chair, physical therapy, family at bedside when possible, maintain sleep/wake cycle, avoid sedative/hypnotic medications, minimize drains/lines - Patient was found to be coughing with pills. Continue aspiration precautions and crush meds, moist ground solids, thin liquids, 1:1 supervision with meals - Zydis as needed # Prostate CA: Oncology recommended repeat PSA which is elevated to 95, approximately doubled from one month ago. Held ketoconazole in setting of acute illness and supratherapeutic INR. po hydrocortisone initially switched to IV given shock but patient has been on home po hydrocortisone regimen since [2130-2-20]. The patient will need to follow-up with his outpatient oncologist after discharge. His ketoconazole will be restarted the day of discharge. In addiiton, he will need to have a psa re-checked the week of [3-11] and results faxed to his oncologist's office. The patient will also need outpatient follow-up for sclerotic iliac lesions noted on CT pelvis from [Hospital ] [Hospital 1459] hospital. An ekg should be checked daily while restarting the ketoconazole. Ketoconazole can prolong the QTc interval, if the QTc prolongs then ketoconazole should be discontinued. Medications on Admission: Econazole [Spectazole] 1 % Cream [Hospital1 ] to feet Hydrocortisone 20mg QAM, 10mg QPM Ketoconazole 400mg [Hospital1 ] Furosemide 40 mg Tablet once a day Lisinopril 40 mg Tablet daily Lupron 1 mg/0.2 mL Kit every 3 months Metoprolol Succinate 25 mg Tablet Sustained Release daily Potassium Chloride 10 mEq Tablet Sustained Release daily Warfarin Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer vial Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheezing. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb vial Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for Dyspepsia. 8. Olanzapine 5 mg Tablet Sig: 0.5-1 Tablet PO QID (4 times a day) as needed for Agitation. 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 6 days: Last day is [2130-3-3]. 10. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea/vomiting. 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Sodium Chloride 0.9 % 0.9 % Piggyback Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 16. Heparin (Porcine) in D5W 20,000 unit/500 mL Parenteral Solution Sig: 1350 (1350) units Intravenous infusion: Weight based dosing protocol. Once INR at goal 2.5-3.5, continue heparin gtt for 48-72 hours more before discontinuing. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 18. Ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 19. insulin sliding scale 20. Outpatient Lab Work Please check a PSA in 2 weeks, which will be the week of [2130-3-11]. Please fax the reuslts to Dr.[Name (NI) 31162] office. 21. Econazole 1 % Cream Sig: One (1) application Topical twice a day: apply to feet. 22. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary Diagnoses: Pneumonia Urinary tract infection Sepsis Respiratory distress Delirium Secondary Diagnoses: Prostate cancer Aortic valve replacement (St. [Male First Name (un) 1525]) Complete heart block s/p pacermaker X2 Venous stasis changes Atrial fibrillation Hypertension Discharge Condition: Mental Status: Confused - sometimes, emotionally labile Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: -You were admitted with chills and vomiting. You were found to have a urinary tract infection and pneumonia that progressed to septic shock. You developed respiratory distress, likely given extra fluid build-up in your lungs. Your kidneys were also found to be functioning less well, likely due to the septic shock. You were briefly intubated and on medications to keep your blood pressure normalized. You were treated with antibiotics and responded well. Your kidney function improved and the fluid build-up in your lungs resolved. You also developed some confusion due to the many insults to your body (ICU stay, strong medications - steroids, sedatives, pneumonia/UTI, intubation/extubation etc). This will take some time to resolve, and you continued to improve during your hospital stay. You can continue to work on this by working with physical therapy at Rehab, getting out of bed to the chair often, having family around. -It is important that you continue to take your medications as directed. We made some changes to your medications during this admission. Your ketoconazole was restarted. Your metoprolol was increased from once daily to twice daily. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: APPOINTMENT #1: Department: CARDIAC SERVICES When: MONDAY [2130-5-15] at 1:30 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2130-5-15] at 2:00 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Please make an appointment to see your primary care doctor, Dr. [First Name8 (NamePattern2) 449] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] within 2-3 weeks. You can reach his office at: [Telephone/Fax (1) 250]. Please also make an appointment to see your genitourinary oncologist who manages your prostate cancer, Dr. [Last Name (STitle) ]. You will need to have your PSA level checked two weeks after discharge. Dr.[Name (NI) 31162] phone number is ([Telephone/Fax (1) 31163]. Please contact your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 250] to schedule an appointment upon discharge from [Hospital1 ].	[ "790.6", "239.5", "428.32", "518.81", "599.0", "995.92", "403.90", "486", "038.42", "790.92", "185", "287.5", "585.3", "459.81", "V58.61", "428.0", "427.31", "V45.01", "038.0", "276.0", "787.01", "785.52", "293.0", "V43.64", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "31.42", "38.91", "96.71", "96.07" ]	icd9pcs	[ [ [] ] ]	18669, 18769	10088, 15924	279, 368	19097, 19097	3971, 10065	20700, 21953	3097, 3382		16329, 18646		18790, 18881		15950, 16306			19298, 20677							2675, 2755		3397, 3952	18902, 19076																	1647, 2025			230, 241							396, 1628										19112, 19274					2047, 2652	2771, 3081
820	193,603	5793	Discharge summary	report	Admission Date: [2144-2-23] Discharge Date: [2144-2-29] Date of Birth: [2077-4-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2234] Chief Complaint: CC:[CC Contact Info 23015] Major Surgical or Invasive Procedure: None History of Present Illness: 66 yo M with metastatic papillary renal cell carcinoma, known mets to lungs, brain, back, heart came into the ED today with [2-16] d h/o weakness, dizziness, fatigue. He has h/o RV mass and "abnormal EKG" in the past. He had [1-15] syncopal episodes in that time and fell on back yest with residual L lower back pain. Seen at [Hospital6 33] yest with EKG showing A-fib, rapid ventricular response, RBBB, T wave abnormality. Received 150 mg Amiodarone, 1 mg Dilaudid (back pain) and was transferred at his request to [Hospital1 18]. . Regarding his cancer history, developed left lower back pain towards the end of 7/[2142]. Workup included a CT scan of his abdomen dated [2142-8-5], which showed a 10.1 x 8.2 cm lobulated enhancing soft tissue mass causing distortion of the underlying renal architecture of the left kidney. He was concurrently diagnosed with a pulmonary embolism and eventually underwent a left radical nephrectomy with inferior venacavotomy and complete excision of the renal vein with inferior vena caval reconstruction and removal of tumor thrombus. This was performed on [2142-8-16]. The pathology from the nephrectomy showed renal cell carcinoma of papillary subtype, which was 11.5 cm in greatest dimension. He was followed clinically following this period but developed metastatic disease in the lumbar spine, which was symptomatic as well as enlarging pulmonary nodules. He underwent radiation to the lumbar spine, which resulted in significant amelioration of symptoms. He has receveid 4 cycles of temsirolimus with compllication of pneumonitis. On [1-15], Mr, [Known lastname 22956] was admitted to [Hospital1 18] with right hand numbness which perisisted. HIS head CT revealed a left parietal hemorrhage with some mild mass effect. He was given a Keppra load of 1000 mg a day and was taken off subsequently. His head MRI revealed at least one metastatic focus that was hemorrhagic in the left posterior frontal lobe, precentral in location. He was seen by Dr. [Last Name (STitle) 4253] at that time for consultation. He was taken off of the Lovenox and was discharged to home with follow up with neurology. MRI imaging on [2-17], according to Dr. [Name (NI) 23016] note, revealed, "a good resolution of the blood in the left posterior frontal metastasis; however, now, the right temporal FLAIR signal abnormality appears to have bled and is now approximately about 1.5 cm with some mild surrounding edema". On that day in onc clinic, his Sutent dose was decreased to 37.5mg daily secondary to symptoms. . Of note, he has a history of PE that was diagnosed incidentally along with RCC ([7-19]), with no sx at that time. He was started on coumadin which was continued until [2143-8-8] then changed to Lovenox but D/C'd in [Month (only) ] when brain mets were discovered and now has continued to be off anticoagulation completely. . In the ED tonight T98 HR 100 RR 18 BP 101/66 Sat 98% 2L. EKG showed NSR at 93 bpm, 1 AVB, RBBB, no acute ischemic changes. He was tired with a nonfocal exam. CXR: mass-like airspace dz in R lung base (old). He had a D-dimer sent which was >5000. He subsequently underwent a V/Q scan yielding a large area of mismatched hypoperfusion in the right upper lobe with a moderately high risk ratio for pulmonary embolism. Given inability to anticoagulate him, IR was called and plan on placing an IVC filter in the am. In the meantime, they recommended Mucomyst and Bicarb O/N pre-procedure as he has a chronic renal insufficiency. . ROS: He reports fatigue requiring him to sleep approximately 10-12 hours a day. He has occasional shortness of breath and dyspnea on exhertion. His oxygen saturation with ambulation was documented by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 99%-100%. He reports cough in the mornings but not everyday. He denies any epistaxis. His nausea is poorly controlled with ondansetron. Past Medical History: # Papillary renal cell carcinoma- presented in [7-19] with L flank pain, s/p L radical nephrectomy with IVC/thrombus/renal vein resection, IVC reconstruction, ([8-19]), s/ XRT to L1-L2 region for spine metastases. Known RV tumor thrombus since [8-20]. Currently undergoing treatment with temsirolimus at 37.5 mg intravenously once weekly. # Pulmonary embolism- diagnosed incidentally along with RCC ([7-19]), no sx at that time; started on coumadin which was continued until [2143-8-8] then changed to Lovenox # Hypertension- on beta blocker # Hypercholesterolemia- on statin # Chronic renal insuffiency- initial creat 1.2-1.5, up to 3.5 s/p surgery and complicated by ATN, most recently 2.1-2.3. # Type 2 diabetes- on insulin # Peripheral vascular disease # Depression- on mirtazipine and buproprion # Chronic normocytic anemia # h/o colonic polyps # h/o pancreatitis # s/p CCY Social History: Patient is married, retired manager for [Company 22957] Phone Company. He is a prior tobacco smoker for approximately 20 pack years, quit 20 years ago. He has two children who are alive and well. He denies current alcohol use. Family History: The patient's mother died at the age of 68 from complications relating to lung cancer. Father died at the age of 51 from myocardial infarction. He had a sister with type 2 diabetes who died from complications. Family history is negative for any genitourinary malignancy. Physical Exam: Physical exam: VS 98.4 142/74 9 16 O2Sat 96% RA Gen: NAD, AAOx3 HEENT: PERRLA, dry mm NECK: no LAD, no JVD, no carotid bruit COR: S1S2, regular rhythm, no m/r/g, normal PMI, no hives PULM: CTA b/l, no wheezing or rhonchi ABD: Normoactive bowel sounds, soft, nd, nt, well healed scar under diaphragms Skin: warm extremities, no rash, no swelling EXT: 1+ DP, no edema/c/c, negative [Last Name (un) 4709] sign MS: Mild CVA tenderness mid back and limited movement to [5-23] pain NEURO: A and O x 3 and CN II-XII intact. No decreased sensation of extremities. 4/5 strength x 4 ext. Pertinent Results: Admit labs: [2144-2-22] 05:30PM WBC-12.9# RBC-4.17 HGB-12.6* HCT-36.4* MCV-87 MCH-30.2 MCHC-34.6 RDW-19.3* [2144-2-22] 05:30PM NEUTS-89.7* LYMPHS-7.7* MONOS-2.3 EOS-0.2 BASOS-0.2 [2144-2-22] 05:24PM GLUCOSE-148* UREA N-41* CREAT-2.3* SODIUM-136 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-16* ANION GAP-18 [2144-2-22] 05:24PM CK(CPK)-67 [2144-2-22] 05:24PM cTropnT-0.10* [2144-2-22] 05:24PM PT-11.5 PTT-25.1 INR(PT)-1.0 [2144-2-22] 05:24PM D-DIMER-5943* ========================================================= EKG: NSR at 93 bpm, 1 AVB, RBBB . [2-22] CXR: FINDINGS: Two views are compared with very recent study dated [2144-2-17]. There is a patchy airspace process at the right lung base, likely in the middle lobe, not much changed. There are also number of small nodular opacities elsewhere, likely corresponding to known pulmonary metastases. However, no new focal airspace process is identified to suggest acute consolidation. The cardiomediastinal silhouette and pulmonary vessels are unchanged, with no pleural effusion or other evidence of CHF. . [2-22] Lung Scan 1. Large area of mismatched hypoperfusion in the right upper lobe with a moderately high risk ratio for pulmonary embolism. . MR 2/4/8 IMPRESSION: Slight decrease in size of previously seen metastatic focus in the left frontal lobe. New hemorrhagic lesion, presumably a metastasis in the right frontal lobe, with the multiple hyperintense lesions in the frontal and parietal lobes now more likely representing tumor. Left-sided arachnoid cyst is unchanged. Per online medical record, Dr. [Last Name (STitle) 4253] has already reviewed the imaging with the patient. Discharge labs: [2144-2-29] 06:50AM BLOOD WBC-4.3 RBC-3.25* Hgb-10.0* Hct-30.2* MCV-93 MCH-30.9 MCHC-33.3 RDW-19.9* Plt Ct-162 [2144-2-22] 05:30PM BLOOD Neuts-89.7* Lymphs-7.7* Monos-2.3 Eos-0.2 Baso-0.2 [2144-2-29] 06:50AM BLOOD Plt Ct-162 [2144-2-29] 06:50AM BLOOD Glucose-113* UreaN-19 Creat-1.8* Na-135 K-4.5 Cl-106 HCO3-19* AnGap-15 [2144-2-23] 06:52AM BLOOD ALT-8 AST-18 LD(LDH)-794* CK(CPK)-58 AlkPhos-181* Amylase-51 TotBili-0.4 [2144-2-23] 06:52AM BLOOD CK-MB-NotDone cTropnT-0.09* [2144-2-23] 12:40AM BLOOD cTropnT-0.09* Brief Hospital Course: [Hospital Unit Name 153] Course:(As dicatated by ICU team) 66 yo M with metastatic papillary renal cell carcinoma, known mets to lungs, brain, back with Afib w/ RVR from OSh found now to have lg PE on VQ scan and planned for IVC filter per IP in am. Patient was admitted to the ICU after episode of stable VTach. He was evaluated by EP, who recommended 48 hours of IV amiodarone. He was then started on an amiodarone taper as follows: amiodarone 400mg PO TID x 1 week ([Date range (1) 23017]) then amiodarone 200mg TID x 3 weeks ([2-19]) Then amiodarone 400mg daily thereafter (reevaluate afterone month) He had no further episodes of VTach. Per EP, he should not be shocked for stable VTach because of risk of embolizing his cardiac met. . # PE: Per above, hx of PE incidentally found in [2142]. He was started on coumadin which was continued until [2143-8-8] then changed to Lovenox but D/C'd in [Month (only) ] when brain mets were discovered and now has continued to be off anticoagulation completely. Now with new PE per V/Q scan. Not a candidate for anticoagulation given hemorrhagic mets to brain seen on recent MR . # Metastatic papillary renal cell carcinoma: See interval history above. Per last onc note, he will return to the onc clinic in two weeks' time for follow up prior to beginging his new cycle of temsirolimus. He will also undergo CT scan of torso post his next cycle in 6 weeks time. . # Hypertension- continued beta blocker . # Back pain- With hx of known mets to L1 and L2 and now s/p fall. . # Hypercholesterolemia- continued statin . # CRF: Creatinine has been ranging between 2.2 and 3.0 over the last month in the context of receiving temsirolimus. Appears slightly dry on exam, no oliguria Hydrated, creatinine 1.8 on discahrge. . # Type 2 Diabetes mellitus: Continued 70/30 and NPH Severely reduced dose on discharge given poor PO and overall grave prognosis . # Depression: Ongoing. - continued Mirtazapine and Venlafaxine . # Comm: Recent RN note from [First Name8 (NamePattern2) ] [Name (NI) 23018] states: "Also discussed Hospice nurse with both wife and son: wife said husband would not allow it (? seeing if they could say they were the VNA rather than Hospice to the pt); son much more receptive to looking into this option." This needs to be further discussed during this admission. Spoke with wife this pm who would appreciate a palliative care consult and discussion of hospice options, maybe for future initiation. Pt amenable to hospice discussions but not ready to "throw in the towel". - Palliative care consulted throughout. = = = = = = = = = = = = = = = = = ================================================================ He was called out to hospialist service evening of [2-28]. I assumed care on [2-29]. Plan in place from ICU to discharge patient home. Family and patient aware that given VT, multiple co morbidities including metastatic cancer to heart and brain, multiple VTE with CI to anti coagulation, very high risk to have life threatening event at home. I made no significant changes to his medication regimen. Medications on Admission: Mirtazapine 15 mg PO HS Simvastatin 40 mg PO DAILY Venlafaxine XR 75 mg PO DAILY HISS Insulin 70/30 20U in am, NPH 22U in pm, additional SSC Metoprolol 25mg [Hospital1 ] Keppra 500mg 2x/day Zofran 8mg rapid dissolve 2x/day Sutent 37.5mg daily (per recent onc notes, differs in OMR) Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous at bedtime. 5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous qAM. Disp:1000 units Refills:0 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 2 days. Disp:12 Tablet(s) Refills:0 7. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: start after 2 days of TID dosing. Disp:14 Tablet(s) Refills:0 8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day: start in 10 days after finishing TID and [Hospital1 ] dosing. Disp:30 Tablet(s) Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Insulin Regular Human 100 unit/mL Cartridge Sig: as directed units Injection as directed: please see attached sliding scale. 11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: 1. Metastatic Renal Cell Cancer metastatic to lung, brain, back, heart 2. Pulmonary Emboli 3. Atrial Fibrillation 4. Ventricular Tachycardia 5. Hypertension 6. Hyperlipidemia 7. Type II DM 8. Depression Discharge Condition: Afebrile, taking PO, ambulating Discharge Instructions: Follow up as below. all medications as prescribed. There have been changes. As we discussed, if you develop chest pain, shortness of breath, change in mental status, fevers, chills or any other new concerning symptoms, call 911. As we discussed, you are at very high risk of recurrent life threatening arrythmia known as ventricular tachycardia or atrial fibrillation. The amiodorone is to help decrease the risk of you going into these abnormal rhythms. Followup Instructions: FOllow up with Dr. [Last Name (STitle) ]: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2144-3-9] 3:00 Provider: [Name10 (NameIs) 10838] [Name11 (NameIs) ], [MD Number(3) 1240]:[Telephone/Fax (1) 22] Date/Time:[2144-3-9] 3:00	[ "250.00", "V10.52", "197.0", "198.5", "272.4", "427.31", "198.3", "198.89", "276.2", "585.9", "427.1", "V58.67", "403.90", "415.19" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13389, 13440	8701, 11823	347, 354	13687, 13721	6424, 8117	14229, 14570	5530, 5803		12159, 13366		13461, 13666		11849, 12136			13745, 14206			8134, 8678						5833, 6405																					276, 309							383, 4341															4363, 5264	5280, 5514
13,728	171,866	440	Discharge summary	report	Admission Date: [2149-6-2] Discharge Date: [2149-6-5] Date of Birth: [2081-3-23] Sex: M Service: CHIEF COMPLAINT: Left lower lobe pneumococcal pneumonia, congestive heart failure. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 1968] is a 68-year-old white male with a history of CAD status post three vessel CABG, EF less than 20%, mild COPD, hypertension, history of head and neck cancer, history of Hodgkin's disease, status post resection in [2144], in remission, who presents with left sided chest pain, worsening dyspnea on exertion, shortness of breath and cough. Roughly two months ago the patient was still able to walk about one mile without problems, however, in the last month he has started to notice increasing fatigue and dyspnea on exertion. Three weeks ago he began coughing with fevers up to 101 and mild chills intermittently. In the last two weeks he has also noted increased sneezing and severe non productive cough. Two days ago he developed [2158-1-26] constant stabbing chest pain under the left breast, pleuritic in nature, worse with cough and unresponsive to Nitroglycerin. It was also worse with walking. His episodes of pain occur approximately one hour at a time and he does experience shortness of breath but no nausea, vomiting, diaphoresis or radiation. The patient denies headaches, neck stiffness, sore throat, abdominal pain, myalgias, arthralgias and dysuria. He has never been intubated. He does not have a history of pneumonia. In the Emergency Room he was tachypneic into the 30's, initially satting 77%. He was then placed on a partial non rebreather mask at 15 liters and was noted to sat in the low 90's. He was given 40 mg of IV Lasix and diuresed about 150 cc of urine. Chest x-ray obtained in the AW showed mild failure and a retrocardiac opacity. He received 325 mg of Aspirin. Blood cultures times two were obtained and he was given one dose of Levofloxacin. His initial ABG was as follows: 7.49/32/38. PHYSICAL EXAMINATION: On admission, vital signs, temperature 103.0 (rectal), pulse 109, blood pressure 98/44, respiratory rate 26, O2 saturation 96% on 15 liters partial non rebreather mask. General, alert and oriented times three, pleasant, in mild respiratory distress with face mask on but talking in full sentences. HEENT: Pupils were equal, round and reactive to light, extraocular movements intact, oropharynx was dry. There is fullness of the neck but no lymphadenopathy. Heart, normal S1 and normal S2, no S3, no murmurs or rubs. PMI non displaced. Lungs, bronchial breath sounds bibasilarly left greater than right. No rales. Abdominal, obese, soft, nontender, non distended, normoactive bowel sounds, no CVA tenderness. Extremities, 1+ DP and PT pulses bilaterally, trace bilateral pitting edema up to the knees. LABORATORY DATA: White blood cell count 21.5, hematocrit 41.2, platelet count 311,000, neutrophils 92%, bands 7%, lymphs 0%, basos 1%, sodium 137, potassium 4.5, chloride 100, CO2 20, BUN 33, creatinine 1.7, glucose 100. PT 20.7, PTT 41.5, INR 2.8. Urinalysis, yellow, clear, specific gravity 1.014, no nitrites, no red blood cells, no white blood cells, no bacteria, no yeast. Chest x-ray #1 perihilar edema bilaterally, #2 left retrocardiac opacity, effusion vs infiltrate. EKG, sinus tachycardia with rate 108, normal axis, normal intervals, no acute ST-T wave abnormalities. PROBLEM LIST: 1. Possible pneumonia. 2. Possible CHF exacerbation. 3. Increased creatinine. 4. Chest pain. HOSPITAL COURSE: The patient was brought to the MICU on a partial 15 liters of oxygen flowing through partial non rebreather mask. His oxygen saturations were in the mid to high 90's on this and his tachypnea began resolving quickly. The patient was ruled out for an MI by cardiac enzymes and serial EKG's and he was started on 500 mg IV q d of Levofloxacin. His blood pressure in the MICU was initially 80/40 and there was concern that central access would need to be placed to evaluate the etiology of his hypotension. However, his blood pressure responded well to normal saline boluses of 250 cc each. He did not experience further hypotension for the rest of his admission. All of his home medications were continued except for Carvedilol which was held as we were concerned for possible CHF exacerbation. On day #2 of his admission he began to diurese well on his home regimen of Lasix and his oxygen requirement was quickly weaned from 15 liters partial non rebreather mask to 4 liters of nasal cannula oxygen. On day #2 of his admission the blood cultures came back 4/4 bottles positive for pneumococcus which was pansensitive. Theory then to explain his acute and severe hypoxia was that his gas exchange was impaired by pneumococcal pneumonia and a transient bacteremia which may have dropped his SVR and caused him to temporarily decompensate from a cardiac standpoint. In order to further evaluate his cardiac function, a transthoracic echocardiogram was obtained which was most notable for a normal LV wall thickness and cavity size and an ejection fraction of 30-40%. This is in contrast to an echocardiogram done in [2146] which showed an anteroapical aneurysm in the LV and an ejection fraction of less than 20%. His initial AP chest x-ray was followed up with PA and lateral to further evaluate this retrocardiac opacity and the lateral appeared more consistent with an infiltrate than an effusion. On day #3 of his admission the sensitivities came back on the blood cultures, strain of strep pneumonia was sensitive to Penicillin and so the patient's regimen was switched to 2,000,000 units q 4 hours of Penicillin G. The patient tolerated this well, showing no acute allergic reactions. Since being admitted to the MICU, Mr. [Known lastname 1968] has been stable from a hemodynamic standpoint and a gas exchange standpoint. On day #3 of his admission a PT consult was obtained and Mr. [Known lastname 1968] was able to walk around the [Hospital1 ] without any difficulty or desaturation. MEDICAL ISSUES: 1. Congestive heart failure. 2. Resolving pneumococcal pneumonia. 3. Coronary artery disease, status post three vessel CABG and silent MI. 4. Mild Chronic obstructive pulmonary disease. 5. Crohn's disease. 6. Head and neck squamous cell carcinoma. 7. Advanced Hodgkin's disease status post resection in [2144]. 8. Nephrolithiasis. DISCHARGE MEDICATIONS: Penicillin VK 2,000,000 units qid, Lipitor 10 mg po q d, Lasix 40 mg po q d, K-Dur 20 mEq po bid, Coumadin 2.5 mg po q d, Synthroid 300 mcg po q d, Carvedilol 6.25 mg po q d, Cozaar 50 mg po q d, Amiodarone 200 mg po bid, Theophylline 24 hours 300 mg po q d, Dipentum 250 mg po bid. CONDITION ON DISCHARGE: Stable. Discharged to home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Doctor Last Name 3769] MEDQUIST36 D: [2149-6-4] 18:09 T: [2149-6-4] 18:31 JOB#: [Job Number 3770]	[ "201.90", "412", "481", "428.0", "V10.89", "V45.81", "414.01", "555.9", "496" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]									6468, 6752					3564, 6444																							2039, 3434									147, 214							243, 2016						3448, 3546											6777, 7070
56,562	168,326	37753	Discharge summary	report	Admission Date: [2137-12-11] Discharge Date: [2137-12-23] Date of Birth: [2083-6-3] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization with 2 bare metal stents to right coronary artery Endotracheal Intubation Foley Catheter Right Femoral Triple Lumen Central Venous Catheter Right Radial Arterial Line History of Present Illness: 54 yo female with no significant past medical history presented to OSH with progressive dyspnea. Per report collected from husband, mother and [Name (NI) ] nurse, the patient had symptoms of a URI, ie dry cough, for about one week. On the day of admission the patient reported chest pain and dyspnea while driving home from work. EMS was called, and she was unable to speak in full sentences. . Initial vitals on arrival to OSH 97.5 [Telephone/Fax (3) 84559]8 78% RA. The patient had a CTA to rule out PE, which showed moderate right and small left pleural effusions, diffuse ground-glass densities, bibasilar consolidations. PE, aortic dissection and aneurysm were ruled out. Urinalysis, tox screen and LFTS were normal. At the OSH, her creatinine .9. BNP 2331 and troponin .11. Pt was given 325mg ASA, NTG .4mg SLx3, lasix 40mg IV x2 and put on BiPap. In short order, the pt was then intubated using etomidate, vecc and succ and started on a nitro drip. Propofol was used for sedation and a PEEP of 20 was noted. Pt subsequently became hypotensive and was put on both levophed and dobutamine drips. The patient was given ceftriaxone and azithro for antibiotic coverage and a urine legionella was sent. A central line was placed in the right femoral vein. The patient was then transferred to [Hospital1 ] for further management. . In the [Hospital1 18] ED, initial vitals, 98.8 92 105/82 28 100% on FiO2 100% Peep 20 RR 25set. Pressors were discontinued. EKG showed sinus rhythm no signs of ischemia noted. Cardiology consulted who initially recommended conservative management with repeat enzymes and felt trop bump likely related to demand. CXR showed bilateral process. Pt given vanc in addition to azithro and ceftriaxone, and 4L IVFs. Pt was switched from propofol to fentanyl/versed. A limited ultrasound was performed that did not show any free fluid in the abdomen or pericardial effusion. Pt also received 40meq KCL IV x1. Pt was also noted to be trace guaiac positive. . The patient was admitted to the MICU initially. Her vitals on arrival were 100 88 148/91 28 100% FiO2 80%, Peep 16. Repeat EKG showed T wave inversion in I and aVL. Cardiology [Name (NI) 653], EKGs faxed, felt to be unchanged. A TTE showed mod LVH, normal cavity size, probable mild regional LV systolic dysfunction with EF 55-60%, and basal inferior hypokinesis. The patient was taken to the cath lab and was found to have 3 vessel disease with diffusely diseased LAD, OM stenosis and RCA stenosis. Two baremetal stents were placed in the RCA, and the other lesions were unable to be intervened upon. The patient was transferred to the CCU for management of her coronary artery disease. The patient was ruled out for flu. . Unable to obtain a review of symptoms secondary to sedation and intubation. Past Medical History: Arthritis Social History: Married. Her husband, [Name (NI) ] is her health care proxy. Mother was a former nurse here at the [Hospital1 ]. [First Name (Titles) ] [Last Name (Titles) ] contacts. Pt is a lawyer at the Federal Reserve Bank in [Location (un) 86]. She was fully functional prior to admission. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Mother: Hypertension Father: Deceased [3-18] "massive coronary." PGF: Deceased [3-18] MI Cousin, same age: CAD requiring CABG Physical Exam: GENERAL: Sedated, intubated, arousable to stimuli. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of to the level of the mandible. 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. Rales bilaterally anteriorly, expiratory wheezes bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ Bilateral lower extremity edema. Arterial and venous sheaths in place on the left. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2137-12-11] 01:40AM BLOOD WBC-13.6* RBC-4.00* Hgb-10.6* Hct-32.4* MCV-81* MCH-26.5* MCHC-32.7 RDW-19.7* Plt Ct-387 [2137-12-11] 01:40AM BLOOD Glucose-132* UreaN-36* Creat-1.2* Na-143 K-3.0* Cl-108 HCO3-21* AnGap-17 [2137-12-11] 01:40AM BLOOD CK(CPK)-156* [2137-12-11] 01:40AM BLOOD CK-MB-15* MB Indx-9.6* proBNP-3622* [2137-12-11] 01:40AM BLOOD cTropnT-0.56* [2137-12-11] 05:28AM BLOOD CK(CPK)-275* [2137-12-11] 05:28AM BLOOD CK-MB-30* MB Indx-10.9* cTropnT-1.70* [2137-12-11] 12:57PM BLOOD CK(CPK)-314* [2137-12-11] 12:57PM BLOOD CK-MB-24* MB Indx-7.6* cTropnT-2.89* [2137-12-12] 09:45AM BLOOD CK(CPK)-192* [2137-12-12] 09:45AM BLOOD CK-MB-13* MB Indx-6.8* cTropnT-2.05* [2137-12-12] 12:55AM BLOOD calTIBC-203* Ferritn-884* TRF-156* [2137-12-18] 07:10AM BLOOD VitB12-1400* Folate-9.1 [2137-12-11] 05:28AM BLOOD %HbA1c-5.3 [2137-12-11] 05:28AM BLOOD Triglyc-99 HDL-36 CHOL/HD-4.1 LDLcalc-91 [2137-12-18] 07:10AM BLOOD TSH-34* [2137-12-18] 07:10AM BLOOD Free T4-0.72* [2137-12-19] 05:00AM BLOOD Cortsol-17.6 [2137-12-11] 01:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . GRAM STAIN (Final [2137-12-14]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2137-12-16]): SPARSE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA \| TRIMETHOPRIM/SULFA---- 2 S . CXR [12-11] - Bibasilar consolidations . EKG - NSR, TWIs I and aVL, suggestion of ST depression in lateral leads, LVH . TELEMETRY: Normal sinus rhythm at a rate of 70bpm . 2D-ECHOCARDIOGRAM: Suboptimal image quality. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is probably mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric jet of at least mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . ETT: none . CARDIAC CATH: LMCA ostial 20%, distal 20% LAD - calcified, diffuse disease, prox 30%, severe disease from mid vessel onwards with calcified 80% disease at S3 after D1, 90% between S3 and S4, aneurysmal lesion after S4, diffuse disease in the distal LAD to 80-90%, culminating in a 90% stenosis in the apical LAD before it wraps around the apex. LCx - heavily calcified, ostial 20%, proximal 30-40% at OM3, small OM1, modest caliber OM2, subtotal occlusion of small but moderate length OM3, diffuse plaquing in mid LCx into large LPL/OM4, 90% stenosis in distal AV groove CX into modest caliber long OM5/LPL RCA - heavily calcified, proximal tubular 80% followed by mild diffuse disease throughout the mid RCA with worse disease beginning after modest AM2 to 85% in a diffusely diseased segment involving a large lower AM (Perfusing the distal inferior septum) with more diffuse disease in the distal AV groove RCA supplying a branching RPDA and RPL as well as a separate distal AV groove RCA beyond the RPDA, subtotal occlusion of origin of AM2 with TIMI 2 flow in the AM2 and TIMI 2 fast flow into the RPDA. . HEMODYNAMICS: moderate-severe elevation of PCW with severely elevated LVEDP and moderate-severe pulmonary arterial hypertension. . CT head [12-18]: 1. No evidence of hemorrhage, vascular territorial infarct, or generalized cerebral edema. 2. Small hypoattenuation foci in the right caudate nucleus/corona radiata of indeterminate chronicity. While these may represent chronic lacunar infarcts, more acute embolic events cannot be totally excluded in this setting. These findings could be better-characterized with MRI with diffusion imaging if clinically indicated. EEG FINDINGS: ABNORMALITY #1: Brief bursts of [6-20] Hz theta frequency slowing were seen involving the both temporal regions independently, left>>right, and synchronously. ABNORMALITY #2: Occasional bursts of generalized [6-20] Hz theta frequency slowing was seen. BACKGROUND: In the most organized portion of this tracing, a moderately well-organized [10-24] Hz alpha frequency background was seen. HYPERVENTILATION: Was contraindicated due to the patient's history of cardiac disease. INTERMITTENT PHOTIC STIMULATION: Could not be performed as the test was requested as a portable study. SLEEP: There were no normal sleep or wake transitions seen. CARDIAC MONITOR: Revealed a generally regular rhythm with average rate of 72 bpm. IMPRESSION: This is a mildly abnormal EEG due to the presence of bursts of independent and synchronous bitemporal slowing, suggesting subcortical dysfunction in these areas. The presence of occasional bursts of generalized slowing suggests a mild encephalopathy or extensive regions of bilateral deep or midline lesions. No evidence of ongoing seizures was seen. MRI 1. Multifocal regions of restricted diffusion could represent evolving infarcts versus chronic microvascular white matter ischemic disease with no territorial infarct. 2. Multifocal regions of nodular enhancement, both superficial and deep within the brain parenchyma, including the left pons. Primary differential considerations include evolving enhancing infarcts versus metastatic disease and correlation with the patient's history is needed. Short-term followup examination to document stability and/or resolution of these findings is suggested. IMPRESSION: As seen on the previous MRI of [2137-12-19] diffusion images demonstrate hyperintense areas with equivocal low signal on ADC map indicative of acute/subacute infarcts. Some of the lesions seen on diffusion images are too small to characterize but the others demonstrate equivocal low signal on ADC to indicate acute/subacute infarcts. MRA HEAD: The head MRA is limited by motion and covers only partially the brain. Flow signal is seen in the sylvian branches of both MCA and in both anterior cerebral arteries in A2 region. IMPRESSION: Severely limited MRA provides no important diagnostic information. If clinically indicated repeat study can be obtained. Brief Hospital Course: # CAD: The patient has evidence of coronary artery disease and likely had an NSTEMI within the last one to two days. The patient had 2 BMS placed in her RCA and is otherwise being medically managed for her diffuse three vessel CAD, as the rest of her CAD could not be intervened upon. Started on ASA, [Date Range ] (x at least 1 month), statin, BB. Do not miss [First Name (Titles) 691] [Last Name (Titles) ] [Last Name (Titles) 4319] or stop taking [Last Name (Titles) ] unless Dr. [Last Name (STitle) ] agrees with this plan. . # PUMP: Echo with preserved systolic function however cath shows evidence of biventricular diastolic dysfunction. Initially had symptoms of fluid overload but has been euvolemic with no signs of CHF and stable weight for the last 5 days. Currently on no diuretics. Will need TTE in 3 months. . # Respiratory Distress: Most likely [3-18] volume overload in the setting of subacute NSTEMI and diastolic dysfunction. However, the patient has other radiology findings which point towards consolidation. Treated the patient for both CAP and pulmonary edema with course of CTX + azithro, and aggressive diuresis with lasix. Flu negative. Patient's respiratory status improved significantly after several days of diuresis and patient was extubated. Of note, patient had significant hypertension with SBP > 200 when attempting to wean sedation for extubation. Patient had to be placed on nipride gtt to control BP during weaning. After successful extubation, patient was weaned off of nipride and switched to PO anti-hypertensives. Sputum cx grew out scant Stenotrophomonas, of unclear significance, not treated. . # Hypertension: Following extubation, patient's BP was well controlled on PO labetalol + lisinopril. As patient has had no primary care for 15 years, unclear if this is long standing but diastolic dysfunction suggests it is. . # Hypothyroidism: TSH inc and T4 low. No known hx of hypothyroidism. Started PO replacement. Cortisol level WNL. F/u TSH in [2-15] months. . # Confusion: Noted since extubation, initially thought [3-18] meds however failed to resolve with time and space. CT head showed old lacunar infarct, diffusion weighted MRI was suspicious for acute/subactue stroke. EEG showed mild encephalopathy with bitemporal subcortical dysfunction, no seizure activity. Our suspicion is that her labile and volatile bp changes at the OSH with documented SBPs of 220 follow by 60 possibly lead to these infarcts. Her profound hypothyroidism may contribute. Per speech therapy, pt unable to follow more than simple commands, has very poor short term memory and likely will be unable to care for herself. Neuro consult felt that her mental status is slowly improving and she will f/u in the stroke clinic in 4 weeks. pt will need extensive OT support to help in her cognitive recovery. Please see OT referral note. Medications on Admission: Aleve prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Multivitamins with Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take in am, on an empty stomach and 1 hour prior to any food or other pills. Disp:30 Tablet(s) Refills:2 10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): continue until one week after rash resolves. Disp:1 tube Refills:2 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-15] inhalations Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Non ST Elevation Myocardial Infarction Acute Diastoic congestive Heart Failure Aspiration Pneumonia Non-embolic cerebral vascular accident Hypothyroidism Tinea Corporis Discharge Condition: Activity Status:Ambulatory - requires assistance or aid (walker or cane) Mental Status:Confused - always Level of Consciousness:Alert and interactive Discharge Instructions: You had a heart attack and some fluid accumulation in your lungs. You received 2 bare metal stents in your right coronary artery. It is crucial that you take all of your medicines every day and don't miss [First Name (Titles) 691] [Last Name (Titles) 4319] of your aspirin and [Last Name (Titles) ]. You will be on the following new medicines: 1. [Last Name (Titles) ], a platelet medicine to keep the stent open. 2. Aspirin: to keep your stent open 3. Labetolol: a medicine to keep your blood pressure and heart rate low 4. Lisinopril: a medicine to lower your blood pressure 5. Atorvastatin: a medicine to lower your cholesterol 6. Thiamine: a vitamin 7. Folic acid: a vitamin . During your stay, you were also noted to be more confused than your baseline and having difficulty walking. MRI of the brain revealed changes consistent with a stroke, possibly related to episodes of severe hypertension that occurred at the beginning of your hospitalization. Maintaining tight blood pressure control is essential to prevent further damage to the brain. It is essential that you continue the labetolol and lisinopril to maintain control of your blood pressure. You will also need rehabilitation from your stroke which will occur at rehab. . Additionally, you were found to have hypothyroidism during your stay. You were started on levothyroxine (synthroid) once daily and will need to have your thyroid function monitored by your primary care physician [Last Name (NamePattern4) ] 6 weeks. It is important that you continue to take this medication, first thing in the morning, on an empty stomach and 60 mins prior to any food or any of your other medications. . You completed a seven day course of antibiotics for your aspiration pneumonia and do not require further antiobiotics. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Follow a low sodium diet Followup Instructions: Primary Care: Dr. [First Name8 (NamePattern2) ] [Name (STitle) 6522] with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 250] Friday, [12-27] at 2:10pm. Their office is located in the [Hospital Ward Name 23] Building, [Location (un) ] on the [Hospital Ward Name 516] of [Hospital1 18]. . Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/time: [2138-1-7] 4:00. Dr.[Name (NI) 5907] office is located on the [Location (un) 436] of the [Hospital Ward Name 23] Building, on the [Hospital Ward Name 516], [Hospital1 18]. . Neurology: Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) 1794] ([Telephone/Fax (1) 2528] Date/Time: [1-27] at 2:30pm. [Hospital Ward Name 23] clinical Center, [Hospital Ward Name 516], [Location (un) 442].	[ "E935.2", "799.02", "410.71", "110.5", "348.30", "401.0", "416.8", "458.29", "716.90", "434.91", "244.9", "428.31", "294.9", "414.01", "428.0", "507.0", "285.9", "518.82", "792.1", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.57", "38.91", "00.46", "36.06", "96.72", "96.6", "00.66", "00.41", "37.23", "96.04", "99.20" ]	icd9pcs	[ [ [] ] ]	16128, 16200	11744, 14651	324, 517	16413, 16486	4854, 11721	18559, 19499	3783, 3918		14711, 16105		16221, 16392		14677, 14688			16589, 18536									3933, 4835																					277, 286							545, 3359										16500, 16565					3381, 3392	3408, 3767
28,944	117,432	51367	Discharge summary	report	Admission Date: [2143-8-15] Discharge Date: [2143-8-24] Date of Birth: [2098-12-27] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Hydralazine Attending:[First Name3 (LF) 613] Chief Complaint: Hypertension, headache Major Surgical or Invasive Procedure: Arterial line placement-right radial. History of Present Illness: Mr. [Known lastname 784] is a 44 y/o man with h/o malignant hypertension and ESRD on HD (s/p recent removal of failed transplanted kidney in [7-19]) who presents with headache X 5 days and hypertension. The patient noted occipital headache for past 5 days. Similar in character & location to prior headaches associated with high blood pressure. No visual symptoms. No numbness/tingling of either arm or leg. No fevers or neck stiffness. Did not take any meds for the pain. Took blood pressure which was 190s/110s at home; tells me that last week, when he was feeling well, he saw blood pressures in the range of 115-120 systolic. Contact[Name (NI) ] PCP office today and seen at [Company 191] where his BP was 180/120 on the L and 190/110 on the right. He was directed to the emergency room at that time for further workup and treatment. In the ED, the patient's initial BP was 241/130 with HR 62. He was treated with 40 mg IV labetalol and a nitroglycerin drip. He complained of headache and was treated with IV dilaudid after which time he was nauseous and vomited several times. He received zofran for his nausea and was given 2 L NS. His blood pressure improved to 170s-180s/90s and he was transferred to the MICU. On arrival to the MICU, the patient is complaining of [4-20] posterior headache. No visual symptoms. Slight shortness of breath (for past several days). No chest pain. No abdominal pain, dysuria, fevers, constipation/diarrhea, or blood in his stool. No particular precipitating event per his report. He has been compliant with all medications by his report. He denies any increased salt intake or alcohol intake. He also denies illicit drug use. He is dialyzed on MWF so is due on [8-16]. Past Medical History: - ESRD secondary to chronic ureterovesical junction obstruction leading to bilateral hydronephrosis, on hemodialysis - S/p living-related renal transplant [2134] ([Name (NI) 106515] brother), failed, now on hemodialysis since [12-18] - Malignant hypertension - PRES - s/p SAH - Gout - Peptic Ulcer disease - Bladder neck stricture - Atypical chest pain Social History: 40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment building with his wheelchair-bound wife where he works as superintendent. Family History: Father had MI mid 50s. No DM. Brother had cancer of jaw which was resected. Physical Exam: VS - Temp 96.6 F, BP 185/113, HR 53, R 12, O2-sat 99% 2L NC GENERAL - alert male, pleasant, appropriately interactive, in no acute distress HEENT - PERRL bilaterally, EOMI, no scleral icterus, MMM, tongue midline NECK - supple, no thyromegaly or lymphadenopathy, JVD at 7 cm LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory effort HEART - RRR, normal S1 & S2, loud crescendo-decrescendo murmur heard best at LUSB radiating to carotids ABDOMEN - normoactive bowel sounds, nondistended, soft, no appreciable tenderness to palpation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no peripheral edema, 2+ DP & radial pulses bilaterally NEURO - A&O X 3. CN II-XII intact. Strength 5/5 bilateral biceps, triceps, hand grip, hip flexors, ankle dorsiflexion & plantarflexion. DTRs 2+ bilaterally at biceps. Sensation to light touch intact bilateral upper & lower extremities. No pronator drift. Finger to nose testing intact. Pertinent Results: Admission Labs: [2143-8-15] 08:50PM BLOOD WBC-4.0 RBC-4.26* Hgb-12.1* Hct-37.3* MCV-88 MCH-28.4 MCHC-32.4 RDW-14.0 Plt Ct-191 [2143-8-15] 08:50PM BLOOD Neuts-65.7 Lymphs-25.8 Monos-5.7 Eos-2.3 Baso-0.4 [2143-8-15] 08:50PM BLOOD Plt Ct-191 [2143-8-16] 01:10AM BLOOD PT-15.7* PTT-40.4* INR(PT)-1.4* [2143-8-15] 08:50PM BLOOD Glucose-95 UreaN-42* Creat-11.0* Na-141 K-4.8 Cl-99 HCO3-25 AnGap-22* [2143-8-15] 08:50PM BLOOD ALT-2 AST-12 CK(CPK)-25* AlkPhos-71 TotBili-0.3 [2143-8-15] 08:50PM BLOOD cTropnT-0.02* [2143-8-16] 06:44AM BLOOD CK-MB-NotDone cTropnT-0.03* [2143-8-15] 08:50PM BLOOD Calcium-9.8 Phos-6.6* Mg-2.2 [2143-8-16] 06:44AM BLOOD Cortsol-27.3* [2143-8-16] 11:47PM BLOOD Cortsol-21.4* Metanephrines: <0.20 Discharge Labs: [2143-8-24] 06:30AM BLOOD WBC-4.1 RBC-4.25* Hgb-12.4* Hct-37.9* MCV-89 MCH-29.3 MCHC-32.8 RDW-13.4 Plt Ct-164 [2143-8-24] 06:30AM BLOOD Plt Ct-164 [2143-8-24] 06:30AM BLOOD Glucose-101 UreaN-37* Creat-8.7# Na-140 K-4.6 Cl-98 HCO3-30 AnGap-17 [2143-8-16] 06:44AM BLOOD CK(CPK)-24 [2143-8-24] 06:30AM BLOOD Calcium-10.0 Phos-6.4* Mg-2.2 Studies: [2143-8-15] CT head: HEAD CT WITHOUT IV CONTRAST: There is no fracture, hemorrhage, edema, mass effect, or shift of normally midline structures. The visualized paranasal sinuses again demonstrate a small amount of secretion in the right sphenoid sinus, which demonstrates a slight decrease in degree of aerosolization. The soft tissues are unremarkable. IMPRESSION: No evidence of hemorrhage. Findings posted to the ED dashboard at time of scan completion. [2143-8-16] Echo: The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. 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 ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Dilated thoracic aorta. [2143-8-17] CXR: FINDINGS: There is a right IJ line with tip in the SVC/RA junction. The heart remains mildly enlarged. There is no focal infiltrate or effusion. Brief Hospital Course: 44 y/o M with h/o malignant hypertension & ESRD on HD (s/p recent removal of transplanted kidney) admitted with hypertensive urgency with headache. . #. Hypertensive urgency: Patient's blood pressure at [Company 191] in the 180s-190s systolic but up to 240s/130s in the ED. He received labetalol with good effect but HR down to 50s. Because he was bradycardic, nitroglycerin gtt was started. Arterial line placed on arrival to the MICU registering blood pressures 50 points higher systolic than noninvasive monitoring. The morning following admission, his oral antihypertensives were restarted and renal was consulted for urgent dialysis. During this time he was still requiring nitro gtt for BP control. In the course of restarting all home meds he had a drop in BP and thus, his meds were staggered. Also per renal recs, minoxidil was initiated for further control. Following the minoxidil, he had one episode of orthostasis. Unclear if minoxidil was the cause. On the day of transfer to the floor, he was 190s/100s in the am, but once he received his meds he dropped 100-110s/60s. . On the floor, the patient BP remained initially labile with peaks in the 200s and lows systolic 100s-110s. He was asymptomatic with high blood pressures at this time, but did complain of some lightheadedness with ambulation when he blood pressure was systolic 110s. The patient had two episodes of dizziness in the setting of SBP in the 100-110s which were attributed to the combination of 120mg nifedepine and 600mg labetalol given at night. At the time of discharge his regimen consisted of: AM: lisinopril 40mg, Nifedipine CR 30mg, Labetalol 400mg, metoprolol XL200mg, minoxidil 5mg and valsartan 160mg. Noon: Labetalol 400mg, minoxidil 5mg. PM: Nifedipine CR 90mg, Labetalol 600mg, lisinopril 40mg. He wears a Clonidine patch 0.3 put on every Sunday and was being treated with oral Clonidine 0.1mg for elevated blood pressures. He will continue with his outpatient dialysis schedule and will go to his HD center on a regular basis for BP checks. He was also scheduled to see Dr. [Last Name (STitle) ] in follow up on [8-27]. #. Headache, resolved: Likely related to his hypertension. Had a negative head CT upon admission. In the MICU, the patient was treated for pain with morphine as well as with compazine for nausea. The headache resolved by time of transfer with improved BP control. . #. ESRD on HD: HD on MWF. The patient received sevelamer & renal vitamin. Electrolytes were managed per Renal during dialysis. Plan for follow up with Dr. [Last Name (STitle) ] to discuss future options. Medications on Admission: Renagel 1600 mg TID Omeprazole 20 mg daily Renal caps (renal MVI) daily Lisinopril 40 mg [Hospital1 ] Nifedipine ER 120 mg daily carvedilol 50 mg [Hospital1 ] diovan 160 mg [Hospital1 ] hydralazine 50 mg PO q6h labetalol 400 mg TID clonidine patch 0.3 weekly Discharge Medications: 1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for PRN insomnia. 5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Labetalol 200 mg Tablet Sig: 2-3 Tablets PO three times a day: 400 mg at 6 AM and 2 PM, and 600 mg at 10 PM. Disp:210 Tablet(s) Refills:0 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:60 Tablet Sustained Release 24 hr(s) Refills:0 8. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily): take at 8am. Disp:30 Tablet Sustained Release(s) Refills:0 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime): Please take at 8pm. Disp:30 Tablet Sustained Release(s) Refills:0 11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) as needed for headache associated with high blood pressure. Disp:30 Tablet(s) Refills:0 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: - Hypertensive urgency. - End stage renal failure. Discharge Condition: Stable. Discharge Instructions: You were admitted for elevated blood pressure and headaches. Your high blood pressure was treated with a combination of antihypertensive medications as well as hemodialysis. Your headaches were felt to be due to elevated blood pressure. In the future, please come to the dialysis center to have your blood pressure recorded everyday. This has been arranged for you by your dialysis doctors. If you experience similar headaches please take 0.1mg Clonidine by mouth. If the headaches are not alleviated by clonidine or if you experience other symptoms such as blurry vision, please return to the emergency room. Followup Instructions: Please keep your primary care doctor's appointment with Dr. [Last Name (STitle) ] on Tuesday, [8-27] at 4pm. His phone number is [Telephone/Fax (1) 250]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "274.9", "285.21", "275.3", "585.6", "346.80", "V42.0", "403.01", "593.4", "780.52" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.91" ]	icd9pcs	[ [ [] ] ]	11019, 11077	6498, 9119	311, 351	11181, 11191	3744, 3744	11852, 12143	2678, 2755		9441, 10996		11098, 11160		9145, 9418			11215, 11829			4522, 4905						2770, 3725																					249, 273							379, 2115		4914, 6475			3760, 4506										2137, 2504	2520, 2662
18,270	145,517	28071	Discharge summary	report	Admission Date: [2131-10-24] Discharge Date: [2131-10-28] Date of Birth: [2055-3-23] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: back pain and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 76 yo female transferred to Ed here from [Hospital3 ] Hosp. after w/u revealed aortic aneurysm. Pt. had back pain and vomiting. per pt. pain was not new and has had the same in the past.Denies CP or SOB. Had uncontrolled HTN and BP in ER systolic 200. CT from OSH showed aortic aneurysm from arch to renal arteries; very tortuous and no dissection flap. Max. diameter 5.5-6.3 cm. No evidence of leak. Tiny left pleural effusion noted. On arrival, nipride and esmolol drips started. Past Medical History: GERD back pain fibromyalgia anxiety lens replacement cholecystectomy T and A Social History: single, retired, lives alone no ETOH 150 pack/years ; quit 18 years ago Family History: no premature disease parents with CVA and CAD Physical Exam: 117/69 HR 80 no bruits S1 S2 present soft abd, NT symmetrically good peripheral pulses NAD PERRLA,EOMIMAE [5-18] neck supple, nontender, +BS CTAB with scant basilar crackles Pertinent Results: [2131-10-28] 08:01AM BLOOD WBC-7.2 RBC-2.21# Hgb-5.9# Hct-16.8# MCV-76 MCH-26.7* MCHC-35.0 RDW-15.5 Plt Ct-65# [2131-10-28] 08:01AM BLOOD WBC-7.2 RBC-2.21# Hgb-5.9# Hct-16.8# MCV-76* MCH-26.7* MCHC-35.0 RDW-15.5 Plt Ct-65# [2131-10-28] 08:01AM BLOOD PT-14.0 PTT-43.0* INR(PT)-1.2* [2131-10-28] 08:01AM BLOOD Plt Smr-VERY LOW Plt Ct-65# [2131-10-28] 08:01AM BLOOD Glucose-289 UreaN-12 Creat-0.7 Na-166* K-5.4* Cl-111* HCO3-48* AnGap-12 [2131-10-28] 08:01AM BLOOD Calcium-14.9* Phos-3.2 Mg-2.6 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 68293] [Hospital1 18] [Numeric Identifier 68294]TTE (Complete) Done [2131-10-25] at 10:20:47 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2055-3-23] Age (years): 76 F Hgt (in): 61 BP (mm Hg): 103/56 Wgt (lb): 200 HR (bpm): 85 BSA (m2): 1.89 m2 Indication: Left ventricular function. Check Valves ICD-9 Codes: 424.1 Test Information Date/Time: [2131-10-25] at 10:20 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [Name2 (NI) 8154] Bzymek, RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: Definity Tech Quality: Suboptimal Tape #: 2006W048-0:31 Machine: Vivid [7-21] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 4.9 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.8 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Ejection Fraction: 70% to 80% >= 55% Left Ventricle - Lateral Peak E': 0.13 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 10 < 15 Aortic Valve - Peak Velocity: 2.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 19 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 7 mm Hg Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A ratio: 0.83 Mitral Valve - E Wave deceleration time: 218 ms 140-250 ms Findings Intravenous administration of echo contrast was used due to poor native endocardial border definition. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Markedly dilated descending aorta AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No valvular AS. The increased transaortic gradient related to high cardiac output. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Conclusions The left atrium is normal in size. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is markedly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Interpreting physician ?????? [2128] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [10-24] and tight BP control titrated. Vascular consult also obtained and CTA of torso done. Transferred to floor and transitioned to oral BP control. Cardiology and pulmonary consults also completed to help stratify risk of possible surgery. Surgery was planned for early the next week. On the early morning of [10-28], the pt. suffered an asystolic cardiac arrest with ACLS protocol done and shocked when Vfib occurred. Went into PEA and did not respond despite 25 minutes of resuscitative attempts. Expired at 8:05 AM. Family subsequently notified. Medications on Admission: xanax nexium ASA Discharge Disposition: Expired Discharge Diagnosis: thoracoabdominal aortic aneurysm GERD fibromyalgia Discharge Condition: expired Completed by:[2132-2-8]	[ "441.6", "511.9", "518.0", "530.81", "278.00", "729.1", "492.8", "401.9", "724.2" ]	icd9cm	[ [ [] ] ]	[ "96.04", "99.60", "38.91" ]	icd9pcs	[ [ [] ] ]	6764, 6773	6127, 6697	345, 351	6867, 6904	1336, 6104		1071, 1118				6794, 6846		6723, 6741												1133, 1317																					283, 307							379, 866															888, 966	982, 1055
19,291	161,246	23742	Discharge summary	report	Admission Date: [2149-4-16] Discharge Date: [2149-4-30] Date of Birth: [2074-6-12] Sex: M Service: CARDIOTHORACIC Allergies: Celebrex / Biaxin / Levaquin Attending:[Last Name (NamePattern1) 1561] Chief Complaint: dysphagia, mult pna, tracheal stent placed w/ good results, now here for trachealplasty Major Surgical or Invasive Procedure: trachealplasty bronchoscopy History of Present Illness: Pt is a 74 y/o male with long-standing tracheobronchial malacia, CAD s/p CABG [2133], PVD, AV-block, COPD, h/o UGIB who was admitted for tracheobronchoplasty by interventional pulmonology, after having a silicone Y-stent placed as a temporizing measure in mid-[Month (only) 958]. He first began having symptoms as a child, with frequent respiratory infections, that resolved in his 40's but recurred around the time of his CABG. Since then, he has had frequent pneumonias (5-6 per year) with year-round copious secretions and severely limiting persistent shortness of breath. The temporary stent afforded immediate and significant symptomatic relief, and he was admitted for a more permanent option. Bronchitis since childhood, PVD, H/o GI bleed, Hyperlipidemia, CAD c CABG '[33] -> progressive SOB, pul. infect., inability to clear secretions, dyspnea. Y-stent placement in '[49] lead to immediate relieve, hence scheduled for definitive surgery. Past Medical History: PMH: 1.)Tracheobronchial malacia 2.)Hypertension 3.)Coronary artery disease s/p CABG [2133] 4.)Peripheral vascular disease 5.)AV-block 6.)Chronic obstructive pulmonary disease 7.)H/O Upper GI bleed Social History: SocHx: He has worked as a manufacturing engineer and is currently retired. He is married with seven children, eight grandchildren, and three great grandchildren. He smoked from age 13 to age 59 two packs a day. FHx: His father had coronary artery disease with myocardial infarction and died from what he believes is a cerebral vascular accident. His mother lived to age [Age over 90 ] after being diagnosed for decades with congestive heart failure. He has one half-brother who died of epilepsy. No sisters. [Name (NI) ] of his children are healthy. Family History: FHx: His father had coronary artery disease with myocardial infarction and died from what he believes is a cerebral vascular accident. His mother lived to age [Age over 90 ] after being diagnosed for decades with congestive heart failure. He has one half-brother who died of epilepsy. No sisters. [Name (NI) ] of his children are healthy. Pertinent Results: [2149-4-16] 04:07PM GLUCOSE-86 UREA N-9 CREAT-0.8 SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11 [2149-4-16] 07:58PM PT-12.6 PTT-29.7 INR(PT)-1.0 [2149-4-16] 04:07PM WBC-6.8 RBC-4.20# HGB-10.7# HCT-35.6# MCV-85 MCH-25.5 MCHC-30.1* RDW-18.0* [2149-4-16] 04:07PM CALCIUM-9.8 PHOSPHATE-4.0 MAGNESIUM-2.2 Brief Hospital Course: Pt admitted [4-16] for stent removal by bronchcoscopy and trachealplasty [2149-4-17]. Bronch revealed stent in good position, and removed. Trachealplasty and RML decortication [4-17] tolerated well, extubation post-op, pain control w/ dilaudid epidural, CT x1@ R to sx w/ small leak. Pt transfer to SICU overnight for airway observation and aggressive pulmonary toilet. VAnco for 48 hours. POD#1- bronch done w/ moderate LLL secretions. Transfer to [Hospital Ward Name 121] 2 @ 1600 w/ CPT q2, IS q1, pul toilet, reg diet post bronch gag present. POD#2- unable to clear secretions w/ nebs and CPT, bronch done w/ clearance of mod RLL and LLL secretions. Aggresseive pul toilet cont w/ dilaudid epidural, CT> sx. Brief episode of Af,AF to 140, VSS, converted to NSR @80 w/ pvc spontaneously. Cont on Dilt SR for BP/rate control. Vanco x48h completed. POD#3- starting to expectorate secretions on own, course BS, occ wheezes,CPT q3, CT to w/s then d/c, PT consult, OOB to chair, BAL results= pseudomonas> ceftaz and levofloxacin started. POD#4- Bronch done- BAL LLL- large amt creamy secretions. Dilaudid epidural cont. Swallow eval initiated. Atial ectopy cont- Dilt SR cont. OOB w/ 1 assist POD#5- Epidural capped, flagged and d/c w/ transition to percocet. Unable to clear secretions easily, SOB+ w/ minimal exertion, OOB w/ assist. Swallow eval on modified thicker liquids and softer solids,- incomplete vocal cord closure-? indicates aspiration. POD#[6-13]- Pt cont to progress w/ aggressive pulmonary toilet, OOB>chair and ambulation, PO percocet w/ good relief, daily bronchs for copious secretions, inability to adequately clear secretions, swallow eval by FEES, and video. POD#11 ([2149-4-28])- Marked improvement in status, ambulation w/ spotter, able to clear secretions, continues aggressive pul toilet, alb/mucomyst nebs pain med prn, po intake w/ soft solids- w/ chin tuck, BM- today. POD#[12-16] Pt conts to do well. Increased endurance and increased strength of cough and ability to clear secretions. [Last Name (un) ] po's well w/o obvious signs of aspiration. Medications on Admission: Lipitor 20', aspirin 81', tiazac (dilt SR 240'), albuterol nebs prn Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Nortriptyline HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks. Disp:42 Tablet(s) Refills:0 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks. Disp:21 Tablet(s) Refills:0 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Albuterol Sulfate 0.083 % Solution Sig: [1-5] Inhalation Q4-6H (every 4 to 6 hours) as needed. 11. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:600 ML(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 22201] VNA Discharge Diagnosis: PMH: 1.)Tracheobronchial malacia 2.)Hypertension 3.)Coronary artery disease s/p CABG [2133] 4.)Peripheral vascular disease 5.)AV-block 6.)Chronic obstructive pulmonary disease 7.)H/O Upper GI bleed Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] if you experience shortness of breath, increased cough and secretions, fever or chills. Followup Instructions: Call Dr.[Name (NI) 1816] office for appointment in 2 weeks ([Telephone/Fax (1) 170]) Completed by:[2149-5-26]	[ "996.59", "491.22", "V45.81", "E878.8", "414.01", "519.1", "041.11", "787.2", "041.7", "427.1", "507.0", "511.0" ]	icd9cm	[ [ [] ] ]	[ "34.51", "96.05", "33.24", "98.15", "96.56", "99.04", "31.79", "33.23", "33.48" ]	icd9pcs	[ [ [] ] ]	6393, 6453	2972, 5084	391, 420	6699, 6705	2601, 2949	6905, 7029	2233, 2582		5202, 6370		6474, 6678		5110, 5179			6729, 6882																														264, 353							449, 1415															1437, 1641	1657, 2217
32,639	119,019	48666+59109	Discharge summary	report+addendum	Admission Date: [2188-3-25] Discharge Date: [2188-3-31] Service: MEDICINE Allergies: Penicillins / Amoxicillin / Morphine Sulfate / Erythromycin Attending:[First Name3 (LF) 689] Chief Complaint: shortness of breath, cough, chills Major Surgical or Invasive Procedure: Intubation [2188-3-25] - [2188-3-26] History of Present Illness: 86 year old female with multiple medical problems including a.fib s/p pacemaker, CRF and diverticulosis presents from [Hospital1 1501] with hypoxia, cough, sob and chills. The patient was discharged from [Hospital1 18] to rehab facility on [2188-3-17] after a 14 day admission for BRBPR complicated by hospital acquired pneumonia (LLL infiltrate). She was treated with levofloxacin and vancomycin, and completed a 14 day course on [2188-3-24]. Over past 5 days, she has had persistent cough, worsening dyspnea, chills, but no fever. Cough was minimally productive and per family report, pt was able to ambulate with walker short distances and sit in chair 2 days ago. Per her baseline, she lives alone and gets help with ADL's although she has been hospitalized twice in past 3 months with rehab stays in the interim. No tobacco, EtOH. . In the ED: T 97.1 HR 90 BP 118/57 RR 24 SaO2 96%RA. She became hypoxic to SaO2 80%RA which improved -> SaO2 90% 2L NC -> SaO2 100% face mask. She became acutely hypoxic SaO2 70's% with no improvement on non-rebreather and she was intubated with removal of mucous plug and copious sputum. CXR revealed new RLL infiltrate. She received ASA 325mg x1, zosyn 4.5g IV and vanc 1g IV and levaquin 500mg iv, fentanyl 50mcg iv, versed 2mg iv. She was admitted to the MICU after intubation in the ED Past Medical History: 1)Atrial fibrillation -s/p DDD pacer (for tachy-brady syndrome) -On coumadin -Echo from [1-/2188] with small LV chamber and EF >60% 2)GI bleed, most recent [2-/2188] -Colonoscopy [2185]: Grade III internal hemorrhoids, multiple severe diverticuli in sigmoid colon, descending colon. -Normal EGD [2185] 3)Stable IV Chronic kidney disease -Baseline Cr 2.4-2.6 -home diet: low sodium, low potassium 4)Hiatal hernia 5)Chronic back pain (spinal stenosis, facet degeneration, spondylolisthesis s/p laminectomy, ?osteoporosis) 6)Bilateral cataracts 7)s/p TAH and appendectomy 8)R cerebellar stroke 9)Anemia of chronic disease, ?pernicious anemia 10) ?allergic bronchitis, many years ago Social History: Lives alone in [Initials (NamePattern4) ] [Last Name (NamePattern4) ], gets help with ADLs, recently discharged from [Hospital 100] rehab. Non-smoker, non-drinker. Family History: NC Physical Exam: MICU Admission Exam: Physical Exam: T: 98.9 BP: 131/66 P: 83 RR: 35 O2 sats: 100% Vent: AC Vt 400mL RR 20 FiO2 60% PEEP 10 . Gen: Elderly woman, intubated and sedated with daughter at bedside. HEENT: NCAT, intubated Neck: No bruits, no JVP appreciated CV: irregularly irregular. No m/r/g appreciated, although previous documentation of Grade II/VI SEM at RUSB. Resp: Diffuse expiratory rhonchi bilaterally. Abd: NABS, soft, nondistended. Pt sedated, difficult to assess tenderness GU: Erythematous patch on vulva extending to gluteal cleft Ext: warm, well-perfused, no clubbing/cyanosis/edema. DP 2+ bilat. Neuro: Sedated but responsive to verbal stimuli with nodding yes/no Skin: Large ecchymoses on RUE, GU rash as noted, no petechiae or other rash. Skin is wrinkly, somewhat loose, otherwise intact. Pertinent Results: LABS ON ADMISSION, [2188-3-25]: Chem7: 142/4.9/105/27/40/2.6<115 CBC: 7.0>10.4/32.8<268 Diff: 79N 0Bands, 13.4L, 4.9M, 2.3E MCV 94, +hypochromia, anisocytosis, poiklocytosis, macrocytosis, ovalocytosis, occasional schistocytes . ABG at time of intubation/acute resp distress: 12noon: 7.33/54/379, PEEP 12 Lactate 1.2. . PT 36.2 PTT 34.8 INR 3.9 proBNP 3287 Lactate 1.5 TropT: 0.08 CK 98 CK-MB: not done UA: clear, yellow, spec [Last Name (un) ] 1.009, pH 5.0., negative for leuk/nitr/blood/prot/glu/ket . Micro: Blood cx [2188-3-25]: no growth Sputum from ETT [2188-3-25]: GRAM STAIN (Final [2188-3-26]): [11-8] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE: no growth LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED. . Subsequent labs: [2188-3-28] 06:48AM BLOOD WBC-6.4 RBC-3.35* Hgb-10.1* Hct-31.4* MCV-94 MCH-30.2 MCHC-32.2 RDW-14.2 Plt Ct-236 [2188-3-30] 06:25AM BLOOD WBC-7.2 RBC-3.09* Hgb-9.5* Hct-28.7* MCV-93 MCH-30.7 MCHC-33.1 RDW-13.8 Plt Ct-253 [2188-3-31] 06:00AM BLOOD WBC-4.8 RBC-2.69* Hgb-8.4* Hct-25.0* MCV-93 MCH-31.1 MCHC-33.5 RDW-13.6 Plt Ct-209 [2188-3-31] 11:20AM BLOOD Hct-27.2* [2188-3-26] 03:26AM BLOOD PT-42.5* PTT-39.9* INR(PT)-4.7* [2188-3-27] 02:32AM BLOOD PT-46.8* PTT-41.6* INR(PT)-5.3* [2188-3-28] 06:48AM BLOOD PT-45.1* PTT-41.1* INR(PT)-5.0* [2188-3-29] 03:30PM BLOOD PT-33.3* PTT-35.4* INR(PT)-3.5* [2188-3-30] 06:25AM BLOOD PT-24.9* PTT-33.9 INR(PT)-2.4* [2188-3-31] 06:00AM BLOOD PT-20.7* PTT-29.3 INR(PT)-1.9* [2188-3-31] 06:00AM BLOOD Glucose-99 UreaN-46* Creat-2.0* Na-143 K-3.9 Cl-107 HCO3-28 AnGap-12 [2188-3-28] 06:48AM BLOOD ALT-19 AST-19 LD(LDH)-205 AlkPhos-76 TotBili-0.3 [2188-3-28] 06:48AM BLOOD Albumin-3.3* Calcium-8.5 Phos-4.0 Mg-1.9 [2188-3-28] 06:48AM BLOOD Vanco-16.3 . IMAGING CXR [2188-3-25]: Persistent left lower lobe consolidation, compatible with pneumonia. New haziness in the right lower lung is concerning for new pneumonia. Small bilateral pleural effusions.. . CXR [3-25]: AP chest compared to [3-25]: Opacification of the base of the left lung is a longstanding feature, due to contributions from a hiatus hernia that lies to the left of midline, large left heart and a large and tortuous descending thoracic aorta, as well as undoubted atelectasis, since there is leftward mediastinal shift. Since [91]:47 a.m. on [3-25], the right pleural effusion, which decreased, has not recurred and atelectasis at the right base has returned, but not as severe. There is new heterogeneous opacification in the right upper lobe marginated by the minor fissure and exaggerated by overlying skin fold but still concerning for possible aspiration pneumonia. Moderate cardiomegaly is longstanding and pulmonary artery dilatation indicates pulmonary arterial hypertension. Transvenous right atrial and right ventricular pacer leads are unchanged in their respective positions. The nasogastric tube ends in the hiatus hernia and an ET tube is in standard placement. No pneumothorax. . [3-26] CXR Mild pulmonary edema has developed, accentuating what is probably new pneumonia in the right upper lobe. Small left pleural effusion has developed. Moderate cardiomegaly is longstanding. ET tube and transvenous right atrial and right ventricular pacer leads in standard placements, respectively. Nasogastric tube ends in the moderate to large hiatus hernia to the left of the midline but above the diaphragm. No pneumothorax. . [3-27] CXR No major radiographic change as compared to the previous examination, status post extubation and removal of the nasogastric tube. . [3-31] PORTABLE CXR: The heart size is moderately enlarged but stable. Mediastinal contours are stable as well including bulging of the main pulmonary artery which may be related to pulmonary hypertension. The left basal consolidation is again noted, grossly unchanged. The air-filled cavity in the left lower lung projecting also over the lower mediastinum is most likely related to large hiatal hernia containing stomach or bowel. Small left pleural effusion cannot be excluded. The right upper lobe linear opacity is again noted consistent with atelectasis/small area of aspiration. There is no evidence of failure. . [3-26] An AP view of the pelvis and AP and modified lateral views of the left hip were obtained. There is some superior medial left hip joint space narrowing. The femoral head has a normal contour. Minimal lateral osteophyte formation is seen. No fracture is seen. The right hip joint space is better maintained. There are extensive degenerative changes in the lower lumbar spine. IMPRESSION: There are mild osteoarthritic changes. . [3-26] RIGHT KNEE XR AP and lateral views were obtained. No fracture is seen. There is chondrocalcinosis with joint space narrowing. No clear joint effusion is seen. IMPRESSION: There are fairly severe tricompartment osteoarthritic changes. Brief Hospital Course: 86yoF with a. fib and CRF presents with persistent pneumonia and acute hypoxic respiratory failure after failed treatment with levo/vanc x14days. Initially admitted to the MICU and transferred to the floors on [2188-3-27]. . MICU COURSE: She was intubated in the ED and found to have a mucus plug and possible RUL pneumonia. She was treated empirically with vanc/zosyn (started [3-25]). She was successfully extubated on hospital day 2 and her oxygen saturations improved and she remained hemodynamically stable. She continued to desaturate to SaO2 low 90's% when off oxygen and was very talkative and quickly returned to SaO2 98% at 4L NC. She also learned to suction her own oral secretions and continued to cough. . Remaining hospital course by problem: . # Pneumonia: O2 status improved amd she was weaned from 4L--> 96%RA. Blood cultures and sputum cultures grew no organisms so Vancomycin was discontinued on [3-31] and she was continued on zosyn (2.25g IV q8hrs) for empiric coverage for a 14 day course (to finish [4-7]). An insentive spirometer was kept by the bedside. . # Chronic Renal failure: Cr was monitored daily and antibiotics were adjusted accordingly. Overall Cr was stable per pt's baseline 2.1-2.6. Cr 2.0 on discharge. . # A.fib- The patient is rate controled at home with diltiazem 180mg [Hospital1 ] (extended release). Due to some hypotension she was on dilt 30mg qid in the MICU and then was titrated up to her home dose on the floor and monitored on telemetry. HR in 90s. . # Coagulopathy: INR increased to > 5.0 off of home dose coumadin (3mg daily). Coumadin was held upon admission and was restarted at home dose on [2188-3-30]. INR on d/c is 1.9. Please continue home dose coumadin and recheck INR tomorrow to ensure no further drop. . # Anemia: HCT drifted down 32 -> 29 without clinical signs of hematemesis, hematochezia/melena, and she has been hemodynamically stable. She had an overnight HCT drop from 28.7 to 25 on [3-31], but when rechecked on [3-31] HCT was 27.2. She is hemodynamically stable with no evidence of bleed on exam or per nursing. She should continue her home dose vitamin B12 and her HCT should be followed over the next few days to ensure stable blood levels. . # Arthritis: Stable severe arthritis per xray, no new fractures. She was continued on home dose oxycodone 2.5mg [Hospital1 ] and tylenol prn. PT was consulted and recommended rehabilitation for improved strength. . # FEN: Regular; Low sodium / Heart healthy, Potassium: 2 gm Consistency: Regular; Thin liquids Alternate between bites of food and sips of liquid. If not tolerating thin liquids, should be changed back to nectar thickened. . # PPX: bowel regimen, GI ppx. Heparin SC was held as INR 5. Can be restarted now that INR 1.9. . # Code: FULL . # Access: PIV, patient refusing PICC. PIV should be changed every 72hours for IV antibiotic administration. . # Communication: [First Name8 (NamePattern2) 3551] [Known lastname 13972], daughter/HCP [Telephone/Fax (1) 102350] [Name (NI) 16376] [Name (NI) ], grandson [Telephone/Fax (1) 102351] [Doctor First Name ], daughter (cell) [Telephone/Fax (1) 102352]; (home) [Telephone/Fax (1) 102353] . # Dispo: rehab Medications on Admission: Calcitriol 0.25 mcg PO q"usual frequency" Cyanocobalmin 1000 mcg po daily Darbepoetin Alfa In Polysorbat 40 mcg/0.4 mL SC q2weeks Docusate Sodium 100 mg PO BID Prilosec 40 mg PO daily Oxycodone 5 mg PO BID PRN pain. Warfarin 3 mg PO daily Diltiazem HCl 180 mg PO BID Levofloxacin 250 mg PO Q48H: Last day [3-24]. Senna 8.6 mg Tablet PO BID prn constipation. Ipratropium Bromide 0.02 % Solution Neb INH Q6H during Tx for PNA Fluticasone 110 mcg/Actuation Aerosol INH 2 Puff [Hospital1 ] during Tx for PNA Codeine Sulfate 30 mg PO Q4 PRN cough Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous Q36 for 7 days: given on [3-17], last dose to be [3-24]. Trough levels to be >15. Discharge Medications: 1. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS (at bedtime) as needed. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO daily (). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day): hold for SBP<100, HR<60. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16). 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 17. Piperacillin-Tazobactam Na 2.25 g IV Q8H Duration: 14 Days day 1: [2188-3-25] (through [2188-4-7]) Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary: 1. Aspiration pneumonia 2. Atrial fibrillation 3. Supratherapeutic INR 4. Chronic renal insufficiency 5. Anemia 6. Osteoarthritis Discharge Condition: Oxygenating well on room air, slight cough, self-suctions, A+Ox3, deconditioned. Discharge Instructions: You were admitted to the hospital because of hypoxia. You were found to have a mucous plug and an aspiration pneumonia and you were intubated. You were treated with antibiotics and successfully extubated. You should continue to take antibiotics for a 14 day course as prescribed. . Your INR was supratherapeutic on admission and your coumadin was initially held. Eventually your INR fell and we restarted your coumadin on [2188-3-30]. You should continue taking your home dose of coumadin and have your INR checked on [4-1] to ensure it is not falling further (INR was 1.9 on [3-31], goal [2-17]). . Your blood level was a little low on the morning of discharge. We rechecked it and it was higher but still lower than normal. Please have your hematocrit checked on [4-1] to monitor your blood levels. . Please take your medications as prescribed. Please go to all follow up appointments. If you have shortness of breath, fever, chest pain, palpitations, lightheadedness, blood in your stool, or any other concerning symptoms, please call the doctor or come to the hospital. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2188-5-20] 4:30 Completed by:[2188-3-31] Name: [Known lastname 5384],[Known firstname 1440] Unit No: [Numeric Identifier 16515] Admission Date: [2188-3-25] Discharge Date: [2188-3-31] Date of Birth: [2101-11-18] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / Morphine Sulfate / Erythromycin Attending:[First Name3 (LF) 161] Addendum: please note change in d/c meds. list now includes aranesp and calcitriol. Discharge Medications: 1. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS (at bedtime) as needed. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 7. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO daily (). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day): hold for SBP<100, HR<60. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16). 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 17. Piperacillin-Tazobactam Na 2.25 g IV Q8H Duration: 14 Days day 1: [2188-3-25] 18. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3 times per week. 19. Aranesp SureClick -Polysorbate 40 mcg/0.4 mL Pen Injector Sig: Forty (40) mcg Subcutaneous every other week. Discharge Disposition: Extended Care Facility: [Hospital3 728] & Retirement Home - [Location (un) 729] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 165] MD [MD Number(1) 166] Completed by:[2188-3-31]	[ "553.3", "790.92", "518.81", "V58.61", "V45.01", "507.0", "427.31", "562.10", "585.9", "285.9", "715.98" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	18068, 18313	8507, 9244	301, 347	14397, 14480	3496, 8484	15623, 16278	2653, 2657		16301, 18045		14235, 14376		11790, 12496			14504, 15600									2708, 3477																					227, 263					9272, 11764		375, 1722															1744, 2442	2458, 2637
80,142	126,608	41563	Discharge summary	report	Admission Date: [2140-6-13] Discharge Date: [2140-6-20] Date of Birth: [2060-12-17] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1515] Chief Complaint: Critical Aortic Stenosis Major Surgical or Invasive Procedure: CoreValve placement Pulmonary Intubation with Uvula trauma History of Present Illness: Adapted form Dr.[Name (NI) 32659] note [6-13]: . Mr. [Known lastname 66958] is a 79 year old man with known severe AS, CHF, HTN, Hyperlipidemia, pulmonary hypertension, CAD s/p CABG, carotid stenosis, AFib, DM, CKD, COPD on home O2 who was being transferred from [Hospital1 2025] for evaluation for aortic stenosis treatment options. He has been on home oxygen therapy since a CHF exaccerbation approximately one year ago. . Five months ago he underwent an emergent appendectomy secondary to rupture ([2140-1-31]) followed by prolonged hospitalization complicated by CHF and volume overload. Since then, he has had 7 readmissions for shortness of breath, CHF, ileus, and pneumonia. . On [2140-4-10] he was admitted to [Hospital3 4107] with CHF exacerbation. He also complained of intermittent chest pressure at rest and with exertion. He was diuresed and by report lost 10 pounds. He was transferred to [Hospital1 2025] for evaluation of AVR. At [Hospital1 2025], he was noted to have severe aortic stenosis with a valve area of 0.7cm2, peak gradient of 71mmHg, and mean gradient of 42mmhg, also LVH and LVEF 70% and pulmonary artery hypertension at 63mmHg. He was evaluated for percutaneous aortic valve repair, it was noted that his aortic valve area is 25mm which is too large to accomodate the valves used by the PARTNERS [Name (NI) ]. [Name2 (NI) ] was evaluated by [Hospital1 2025] for surgical aortic valve replacement and the mortality calculated was 14%, making him a candidate for percutaneous aortic valve replacement. . According to the discharge summary, he also had a CT angiogram which showed that his iliac arteries are too narrow to allow a trans femoral approach using the [Doctor Last Name ] device (6 mm). He underwent cardiac cath which showed severe three vessel disease with patent LIMA to LAD and SVG to Circumflex grafts but severely diseased SVG to RCA that was not ameniable to percutaneous intervention. . As part of his workup at [Hospital1 2025], he underwent carotid ultrasound which showed patent [Doctor First Name 3098] s/p endarterectomy but the [Country ] was severely narrowed, he underwent carotid angiogram which confirmed 80% stenosis of the [Country ]. Vascular surgery was consulted who recommended deferring endartectomy until after aortic valve repair. . He complained of minimal shortness of breath at rest and is able to ambulate around home slowly with mod DOE. He has not used his O2 in about 1 month since furosemide dose increased and swelling improved. He is NYHA Class II. . On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. He denied recent fevers, chills or rigors. He denied exertional buttock or calf pain. He had very itchy and burning LE bilat that was keeping him awake at night. Also c/o "[Last Name (un) 62001] horse" cramping in his right neck area, but has not taken any pain medicine for this. All of the other review of systems were negative. . Cardiac review of systems was notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, +Dyslipidemia, +Hypertension . 2. CARDIAC HISTORY: -CABG: s/p CABGx3(LIMA->LAD, SVG->LCX, PDA) [2127] -PERCUTANEOUS CORONARY INTERVENTIONS: Last at [Hospital1 2025]: severe native three vessel disease with patent LIMA to LAD and SVG to Circumflex grafts but severely diseased SVG to RCA that was not ameniable to percutaneous intervention. -PACING/ICD: none . 3. OTHER PAST MEDICAL HISTORY: 1. Severe aortic stenosis 2. CAD 3. Atrial fibrillation 4. Hyperlipidemia 5. Pulmonary hypertension 6. Right carotid artery stenosis 7. Diabetes 8. Chronic Kidney Disease 9. COPD, has not used O2 in the past month 10. BPH 11. Anemia 12. Obesity 13. Right shoulder nerve injury secondary to trauma 14. s/p L CEA [2127] 15. s/p ruptured appendix-s/p laparascopic appy [1-14] 16. s/p R foot fx [1-14] Social History: He has been widowed 6 years. Retired penitentiary worker. Landscaping/tree surgeon up to 8yrs ago. Lives with daughter [Name (NI) ], sister [Name (NI) ] lives in [Name (NI) 2498]. Independent ADL's. Walks with a cane to go up and down stairs. [Doctor First Name ] is at home with him at all times. Has [Hospital3 ] Visting nurse. Has home telemonitoring. RN comes once/week. Has O2 that he used 24 hours in the past but none x 1 month after aggressive diuresis. Followed by [Hospital3 ] at [Hospital3 74487]: [Location (un) ] at [Telephone/Fax (1) 90400] to reschedule at discharge. . -Tobacco history: 3 ppd for about 35 years. 120 pack year. Quit 35 years ago. -ETOH: recovered alcoholic, stopped drinking x 14 years ago. -Illicit drugs: none. Family History: Father had CAD, died post-operatively from hernia repair of dehissance. Mother died at 83 from stroke. Brother with stroke, sisters healthy but with HTN. Physical Exam: VS: T= 97.7 BP=157/80 HR=74 RR= 16 O2 sat= 100% RA Height: 66 inches weight: 87.5 kg . GENERAL: WDWM in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Spittiing saliva into a facecloth. NECK: Supple with JVP of 6 cm. Has mobile 1 cm mass post to carotid lymph nodes that is non-tender and chronic per pt. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irreg irreg rhythm. [4-10] holosystolic murmur at RUSB, radiating throughout the precordium and to right carotid. Left carotid with soft bruit. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at right base, no wheezes or rhonchi. ABDOMEN: Soft, NTND. Obese. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. Has scattered small hematomas on right upper quad from insulin shots per pt. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Has reddened non-raised red plaques, Left> Right with closing open areas d/t scratching. PULSES: Right: Carotid 2+ with bruit Femoral 2+ Popliteal 1+ DP trace PT dopp Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP trace PT dopp Pertinent Results: Labs on admission: [2140-6-13] 01:20PM BLOOD WBC-8.8 RBC-3.52* Hgb-8.8* Hct-27.1* MCV-77* MCH-25.0* MCHC-32.4 RDW-15.7* Plt Ct-276 [2140-6-13] 01:20PM BLOOD PT-16.0* PTT-24.8 INR(PT)-1.4* [2140-6-13] 01:20PM BLOOD Glucose-111* UreaN-30* Creat-1.5* Na-137 K-4.0 Cl-95* HCO3-33* AnGap-13 [2140-6-13] 01:20PM BLOOD ALT-16 AST-20 CK(CPK)-33* AlkPhos-83 TotBili-0.5 [2140-6-13] 01:20PM BLOOD Albumin-4.2 Calcium-8.8 Phos-4.5 Mg-2.1 . Labs on Discharge: [2140-6-20] 07:05AM BLOOD WBC-6.7 RBC-3.65* Hgb-9.4* Hct-29.0* MCV-80* MCH-25.7* MCHC-32.4 RDW-15.1 Plt Ct-205 [2140-6-20] 07:05AM BLOOD PT-22.3* PTT-29.1 INR(PT)-2.1* [2140-6-20] 07:05AM BLOOD Glucose-143* UreaN-26* Creat-1.4* Na-139 K-3.7 Cl-98 HCO3-33* AnGap-12 [2140-6-17] 04:45AM BLOOD ALT-11 AST-20 LD(LDH)-201 AlkPhos-61 TotBili-0.5 [2140-6-20] 07:05AM BLOOD proBNP-3091* [2140-6-20] 07:05AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8 [2140-6-17] 04:45AM BLOOD Hapto-213* [2140-6-16] 04:55AM BLOOD calTIBC-251* Ferritn-124 TRF-193* . Last ECHO: [6-20]: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. A paravalvular aortic valve leak is probably present. Mild (1+) aortic regurgitation is seen. There is mild functional mitral stenosis (mean gradient 6 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2140-6-16], mild paravalvar AR (para Corevalve) is now seen. . ECG [6-20]: Atrial fibrillation with two wide complex beats of uncertain mechansim but maybe ventricular escape beats or possible pacer fusion complexes. Consider left ventricular hypertrophy, although it is non-diagnostic. Delayed R wave progression with late precordial QRS transition. Lateral lead ST-T wave chnages are non-specific but cannot exclude possible left ventricular hypertrophy or ischemia. Findings are non-specific. Clinical correlation is suggested. Since the previous tracing or [2140-6-18] delayed R wave progression is less prominent and intermittent wide complex beats are present. . CXR [6-14]: REASON FOR EXAM: Status post CoreValve placement. Comparison is made with prior study performed a day earlier. Cardiomegaly is stable. Right IJ catheter tip is in the cavoatrial junction or upper atrium. If any, there is a small left pleural effusion. Bibasilar atelectasis have worsened. The patient is status post CoreValve placement. Small right pleural effusion is also stable. There is minimally increase in mild vascular congestion. Sternal wires are aligned. . Cath report pending Brief Hospital Course: # Severe AS: s/p CoreValve placement percutaneously. Tolerated procedure well. complication of uvula trauma from intubation. Uvula hematoma noted with ecchymotic area and some bleeding immediately post extubation. Cold water gargles and lidocaine spray recommended. Has since resolved. All pre admission cardiac medicines restarted and uptitrated once BP was stable. Coumdin restarted. Pt will need aspirin and plavix daily for one month to prevent blood clots on CoreValve. . # Coronary Artery Disease: s/p CABG (currently with diseased SVG to RCA that is not amenable to percutaneous intervention). Pt did not have chest pain or signs of ACS during hospital stay. Aspirin was continued. Plavix started as above. Imdur was dicontinued in the setting of low blood pressure immediately after CoreValve placment and not restarted on discharge. Metoprolol was held during post procedure phase for evidence of transient LBBB and pauses during his CCU stay. As bradycardia and HB is a known complication of CoreValve Placement, would restart metoprolol as outpt. . # Chronic Diastolic Congestive Heart Failure: Euvolemic during hospital stay. Furosemide restarted and uptitrated to 120 mg [Hospital1 ], [Month (only) ] from 180 [Hospital1 ] on admission. Lisinopril was started and tolerated well by pt. Pt instructed on daily weights and low Na diet. . # Atrial Fibrillation: Long standing issue for pt, has been stable on coumadin. Restarted coumadin [6-15] and INR 2.1 at discharge. Communicated with [Location (un) ] at [Hospital3 ] at discharge. Should restart metoprolol as above. . # Anemia: has baseline microcytic anemia with Hct 28-29, elevated RDW, on chronic iron supplementation, trended down 5.5 points since admission and was transfused PRBC X1 on [6-16] for Hct 22 with bump to 24.8. Stable since. Workup reveals low reticulocyte counts and iron profile consistent with anemia of inflammation rather than iron deficiency (low iron, low TIBC, ferritin > 100). Hemolysis labs negative. TSH normal. Stool guaiac is positive likely due to hemoptysis. Unclear when last colonoscopy is but may consider to r/o occult bleeding. . # Hyperlipidemia: stable, Crestor was continued. . # Diabetes Mellitus Type 2: gets NPH 25 QAM + 15 QPM at home + novolog ISS. This was continued during hospitalization and at discharge. . # COPD: Stable. On Advair and Spiriva at home, these were continued at discharge. . # Chronic Kidney disease: creatinine at baseline ~ 1.5. Furosemide dose is lower on discharge. . COMMUNICATION: with daughter [Name (NI) ]: [Telephone/Fax (1) 90401] cell [Telephone/Fax (1) 90402] home Medications on Admission: 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 2. Furosemide 80 mg 2 tabs PO/NG ONCE [Hospital1 ] 3. Metoprolol Tartrate 50 mg, 0.5 tabs [Hospital1 ] 4. Omeprazole 20 mg PO daily 5. Potassium Chloride 20 mEq PO BID 6. Rosuvastatin Calcium 40 mg PO HS 7. Tamsulosin 0.4 mg PO HS 8. Tiotropium Bromide 1 CAP IH DAILY 9. travoprost 0.004 % OS daily 10. Vitamin D 1000 UNIT PO/NG DAILY 11. Docusate Sodium 100 mg PO BID 12. Ferrous Sulfate 325 mg PO/NG [Hospital1 ] 13. Magnesium Oxide 400 mg PO/NG DAILY 14. NPH 25 units before breakfast, 15 units before dinner 15. Novolov sliding scale 16. Imdur 60 mg daily 17. Warfarin 5mg daily, has not had in 5 days. 18. Aspirin 81 mg daily Discharge Medications: 1. Oxygen therapy O2 2-4 L continuous via NP at rest and portable for O2 sat 85% on RA. 2. Outpatient Lab Work Please check INR, Chem-7 and CBC on Wednesday [6-22] with Chem-7 and CBC results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 90403] cell AND [Telephone/Fax (1) 32656] fax and INR to [Hospital3 ] at [Hospital3 74487]: [Location (un) ] at [Telephone/Fax (1) 90400] 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QPM (once a day (in the evening)). 6. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day. Disp:60 Tablet, ER Particles/Crystals(s) Refills:2 7. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic once a day: left eye. 11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous once a day: before breakfast, 15 units before dinner. Disp:1 bottle Refills:2 16. Novolog 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: as per sliding scale. 17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 19. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 20. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 21. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Critical Aortic Stenosis s/p CoreValve placement Acute on Chronic Diastolic Congestive Heart Failure Coronary Artery Disease Chronic Obstructive Pulmonary Disease Atrial Fibrillation Chronic Kidney Disease Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a CoreValve replacement of your aortic valve on [6-14]. You had a pacer wire for a few days and you tolerated the procedure well. During the intubation, your uvula was traumatized and there was some bleeding. This has resolved and is healing well. You were anemic and needed a transfusion of blood. You were continued on your iron to treat your anemia. You needed more oxygen during your hospital stay and will need to go home with portable oxygen in addition to the oxygen tank. Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Decrease furosemide to 120 mg twice daily to diurese extra fluid 2. Discontinue Metoprolol for now 3. Stop Imdur 4. STart Lisinopril to lower your blood pressure and help your heart pump better 5. Start Vitamin C to take with the iron to help the iron absorb from your stomach 6. STart clopidogrel (Plavix) every day to prevent blood clots on the new valve. You should not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking this medicine unless Dr. [Last Name (STitle) ] tells you to. Followup Instructions: Primary Care: [Last Name (LF) 90404],[First Name3 (LF) ] J. [Telephone/Fax (1) 51001] [2140-6-27] at 3pm . Cardiology: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [2140-6-30] at [Hospital3 ], please confirm time (already booked) . Department: CARDIAC SERVICES When: FRIDAY [2140-7-15] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Initial (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: FRIDAY [2140-7-15] at 10:00 AM With: ECHOCARDIOGRAM [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2140-6-22]	[ "585.9", "E870.8", "250.00", "428.33", "427.31", "V70.7", "424.1", "428.0", "403.90", "E878.8", "E849.7", "496", "998.2", "285.9", "414.02" ]	icd9cm	[ [ [] ] ]	[ "35.22", "88.56", "37.23", "35.96", "88.42" ]	icd9pcs	[ [ [] ] ]	16031, 16082	10191, 12843	330, 391	16341, 16341	6853, 6858	17711, 18615	5428, 5583		13605, 16008		16103, 16320		12869, 13582			16492, 17688									5598, 6834		3845, 4162																			266, 292			7322, 10168				419, 3735									6872, 7302	16356, 16468	4193, 4613				3757, 3825	4629, 5412
11,559	103,284	21540	Discharge summary	report	Admission Date: [2189-10-17] Discharge Date: [2189-11-3] Date of Birth: [2132-7-16] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 20846] Chief Complaint: 57 year old male with polycythemia [Doctor First Name ] for twelve years, who after long period of medical management had splenectomy at [Hospital6 ] complicated by hypotension and drop in hematocrit, also with renal failure with creatinine to 2.6, then transferred to [Hospital1 18] and blood in right upper quadrant on CT scan. Major Surgical or Invasive Procedure: exploratory laparotomy and hematoma evacuation History of Present Illness: 57 year old male with polycythemia [Doctor First Name ] for twelve years, who after long period of medical management had splenectomy at [Hospital6 ] complicated by hypotension and drop in hematocrit, also with renal failure with creatinine to 2.6, then transferred to [Hospital1 18] and blood in right upper quadrant on CT scan. Past Medical History: polycythemia [Doctor First Name ], myelolplastic metaplasia, ankylosing spondylitis, open splenectomy Social History: married, lives with wife and son, no tobacco, no alcohol Family History: mother with lung cancer, father with DM, no history of hematologic disorders Physical Exam: 97.6 degrees, HR 112, 104/78, 100% on NRB Ill appearingm pleasant, appears slightly short of breath NCAT slight scleral icterus, dry mucous membranes, PERRL, EOMI tachy, s1 and s2, no m/r/g CTAB with slightly decreased breath sounds at bases bilaterally, no wheezes or crackles distended with surgical staples in place, nontender to palpation, some ascites no clubbing, cyanosis, edema CNII-XII intact, normal strength and sensation Pertinent Results: [2189-11-1] 10:25AM BLOOD Hct-28.7* [2189-11-1] 10:25AM BLOOD Hct-28.0* [2189-11-1] 12:30AM BLOOD Hct-25.2* [2189-10-31] 07:14AM BLOOD Hct-28.3* [2189-10-31] 01:15AM BLOOD Hct-27.6* [2189-10-30] 05:30AM BLOOD WBC-32.3* RBC-3.27* Hgb-8.6* Hct-29.4* MCV-90 MCH-26.4* MCHC-29.4* RDW-22.3* Plt Ct-591* [2189-10-28] 05:40AM BLOOD WBC-35.2* RBC-3.08* Hgb-8.0* Hct-27.7* MCV-90 MCH-26.0* MCHC-28.9* RDW-21.2* Plt Ct-538* [2189-11-2] 05:35AM BLOOD PT-15.1* PTT-54.6* INR(PT)-1.4 [2189-11-1] 07:17PM BLOOD PT-15.4* PTT-69.2* INR(PT)-1.5 [2189-11-1] 10:25AM BLOOD PT-15.8* PTT-75.8* INR(PT)-1.6 [2189-11-1] 10:25AM BLOOD PT-15.5* PTT-71.0* INR(PT)-1.5 [2189-10-31] 04:30PM BLOOD PT-15.4* PTT-63.6* INR(PT)-1.5 [2189-10-31] 07:14AM BLOOD PT-16.2* PTT-88.9* INR(PT)-1.7 [2189-10-31] 01:15AM BLOOD PTT-97.9* [2189-10-30] 04:00PM BLOOD PTT-79.1* [2189-10-30] 05:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-591* [2189-10-30] 05:30AM BLOOD Plt Smr-VERY HIGH Plt Ct-591* [2189-10-28] 10:15AM BLOOD PTT-76.9* [2189-10-28] 12:00AM BLOOD PTT-51.5* [2189-10-18] 09:43PM BLOOD Plt Smr-VERY HIGH Plt Ct-627* LPlt-3+ [2189-10-18] 05:26PM BLOOD Plt Smr-VERY HIGH Plt Ct-645* [2189-10-18] 05:26PM BLOOD PT-15.2* PTT-28.9 INR(PT)-1.5 [2189-10-18] 05:32AM BLOOD Plt Ct-632* LPlt-3+ [2189-10-20] 09:41PM BLOOD Plt Smr-VERY HIGH Plt Ct-864* LPlt-3+ [2189-10-21] 09:45AM BLOOD Plt Ct-948* LPlt-3+ [2189-10-21] 09:46PM BLOOD Plt Smr-VERY HIGH Plt Ct-976* LPlt-3+ PltClmp-1+ [2189-10-23] 03:54AM BLOOD PT-15.7* PTT-36.9* INR(PT)-1.6 [2189-10-23] 02:26PM BLOOD PT-16.3* PTT-65.8* INR(PT)-1.7 Brief Hospital Course: Patient admitted to [Hospital1 69] to medical service and serial hematocrit checks performed, initially at 20.8, patient transfused 1 unit of packed red blood cells and surgery consulted. Patient was seen by surgery at 130am on [10-18] and patient was then brought to operating room for exploratory laparotomy where clot was found and removed from splenic artery/vein. The patient was admitted to the SICU at this time and was resuscitated appropriately with 3 units PRBC and 2 units FFP and was followed by the hematology service. Hematocrit was being checked serially every 6 hours. The ventilator was slowly weaned at this time, epidural catheter that had been placed at the outside hospital was discharged, and hydroxyurea and supportive care for myeloid metaplasia was continued. On [10-20] patient found to have portal vein thrombosis on liver ultrasound and no PE on CTA. Patient started on heparin drip and coagulation labs followed closely. Also found to have a pneumonia on CXR and culture and started on Zosyn which was then switched to vanco, imipenem, flagyl. On [10-22] while patient in angio suite for portal vein thrombectomy he became bradycardic and then pulseless with hypotension, patient resuscitated, given atropine, epinephrine, ACLS protocol followed, fluid bolus given, heart rate returned to baseline after brief bout of SVT and patient returned to SICU. Solumed and benadryl also given in case of dye reaction. Cordis and Swan catheters placed for further monitoring. TPN started on [10-24] and stopped on [10-29]. Heparin drip continued and goal of PTT 60-80 established and drip adjusted accordingly throughout his stay here. On [10-27] patient extubated and Swan line removed, NG tube removed and patient discharged to floor from ICU. Coumadin started with goal INR of 2.5 to 3.0, this was slow to rise to the therapeutic levels. C diff negative. Also given lasix [Hospital1 ] for purposes of diuresis. On [10-31] patient's PICC line removed due to bleeding at the site. Pressure dressing applied and HCT checked and no transfusion deemed necessary for HCT 25.2. Bleeding controlled and patient throughout without any complaints of lightheadedness, dizziness, palpiations, chest pain, or shortness of breath. Imipenem was then stopped and patient was now not on any antibiotics. On the day of discharge patient stable and tolerating a regular diet. Medications on Admission: hydroxyurea, diclofenac, zantac Discharge Medications: 1. Hydroxyurea 500 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 1 doses. 9. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: polycythemia [Doctor First Name ], myelolplastic metaplasia, ankylosing spondylitis, open splenectomy, portal vein thrombosis Discharge Condition: good Discharge Instructions: Patient to be discharged to rehab facility. Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Proceed to the ER/EW/ED if your wound becomes red, swollen, warm, or produces pus. You may remove your dressings 2 days after your surgery if they were not removed in the hospital. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Continue taking your home medications unless otherwise contraindicated and follow up with PCP. Followup Instructions: Patient to follow up with Dr. [Last Name (STitle) ] in two weeks, call to confirm appointment. [Telephone/Fax (1) 34711]	[ "452", "720.0", "486", "238.7", "458.29", "V09.0", "572.8", "E879.8", "790.92", "038.11", "584.9", "998.11", "E878.8", "996.74", "995.91" ]	icd9cm	[ [ [] ] ]	[ "99.04", "96.04", "88.61", "96.72", "97.49", "38.91", "38.93", "54.12", "89.64", "99.15" ]	icd9pcs	[ [ [] ] ]	6821, 6918	3529, 5966	658, 707	7092, 7098	1843, 3506	8354, 8486	1297, 1375		6048, 6798		6939, 7071		5992, 6025			7122, 8331									1390, 1824																					277, 620							735, 1078															1100, 1207	1223, 1281
42,031	193,362	31675	Discharge summary	report	Admission Date: [2125-7-8] Discharge Date: [2125-7-26] Date of Birth: [2092-6-13] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Headaches Major Surgical or Invasive Procedure: [2125-7-9] Right parietal craniotomy and mass resection [2125-7-9] Right hemicraniectomy and evacuation of epidural hematoma, ICP monitor placement Treacheostomy IVC filter placement PEG tube placement History of Present Illness: 33 yo w/ embryonal testicular CA s/p orchiectomy in [2114], w/ known re-occurence in [2122] presents to [Hospital1 18] ED w/ headache and vomiting. Patient reports that headache started 1 week ago and was concurrent with some difficulty with visual tracking. Headache waxed and waned over the past week until today when it was the worst and patient had several episodes of vomiting. Patient reports some increasing fatigue over the past week. Denies weakness, numbness, tingling, or double vision. Past Medical History: HIV, Hep B, testicular CA Social History: SHx: The patient is working 10 hours a day four to five days a week in an office. He quit smoking this past spring, having smoked one pack per day for 17 years. He drinks socially alcohol, denies any recent drug use but does have a distant history of some recreational drug use. Family History: non-contributory Physical Exam: T:98.6 BP: 135/70 HR: 109 RR:16 O2Sats: 100% Gen: comfortable, NAD Abd: Soft, nt/nd Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date.. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing 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 and tone bilaterally. No abnormal movements, tremors. Strength full power [4-4] throughout. Pronator drift of left hand. Sensation: Intact to light touch bilaterally. Coordination: normal on finger-nose-finger PHYSICAL EXAM UPON DISCHARGE Opens eyes to voice. Following simple commands RUE/RLE. Minimal spontaneous movement LUE, triple flexion only to LLE. Treach/Peg in place. Incision clean, dry and intact. Pertinent Results: ADMISSION LABS: [2125-7-8] 01:00AM PLT COUNT-230 [2125-7-8] 01:00AM NEUTS-76.7* LYMPHS-19.4 MONOS-2.9 EOS-0.7 BASOS-0.2 [2125-7-8] 01:00AM WBC-7.6 RBC-3.30* HGB-12.4* HCT-36.4* MCV-110* MCH-37.5* MCHC-34.0 RDW-13.2 [2125-7-8] 01:00AM GLUCOSE-122* UREA N-17 CREAT-1.2 SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 DISCHARGE LABS: COMPLETE BLOOD WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2125-7-26] 10:14 6.4 2.64* 9.0* 26.6* 101* 34.1* 33.9 19.2* 281 BASIC COAGULATION (PT, PTT, INR) [2125-7-26] 10:14 12.1 23.3 1.0 MRI Head [7-8] Large heterogeneous, hemorrhagic right parietal mass, without evidence of associated edema. This appearance is compatible with an embryonal testicular carcinoma metastasis, though the absence of surrounding edema is unusual. Other diagnostic considerations in a HIV-positive patient include lymphoma, particularly given the periventricular location, but the absence of associated edema is also atypical for lymphoma. CT head [7-8] Right parietal parenchymal lesion abutting the lateral ventricle, with probable surrounding edema (versus cystic components). While this is concerning for a mass, infection is also possible, given the patient's immunocompromised status. Recommend contrast-enhanced MRI for further evaluation. CT head post op [7-8] 1. Large right frontal epidural hematoma and subdural hematoma with concern for active bleeding. Transtentorial as well as subfalcine herniation with shift of normally midline structures measuring approximately 1.7 cm. Edema within the right frontal and parietal lobe is also noted. 2. Post-surgical changes including pneumocephalus and right parietal craniotomy. CT head post epidural evacuation 1. Decreased pneumocephalus 2. Decreased shift from midline - now 5mm, previously 9mm, 3. Stable effacement of temporal [Doctor Last Name 534] of right lateral ventricle 4. No new hemorrhage [7-9] Head CT: IMPRESSION: 1. Post-surgical changes consistent with hematoma evacuation, including partial craniectomy and extensive pneumocephalus. Interval decrease in midline shift towards the left, now measuring 9 mm. 2. Interval development of focal intraparenchymal small hemorrhages in the right frontal, parietal, and right cerebral convexity. Close interval followups CT scanning is recommended. [7-10] Head CT:IMPRESSION: 1. Slight increase in right frontal pneumocephalus. 2. Persistent leftward shift of normally midline structures of approximately 6 mm. 3. Focal parenchymal hemorrhages in the right frontal and parietal lobes, overall similar in appearance, with no significant new hemorrhage. [7-12] Head CT: IMPRESSION: 1. Hypodense areas in the right frontal and parietal lobes are more conspicuous than on prior study and more extensive in location than the prior mass. Another hypodense area on the anterior right frontal lobe is more defined. This may represent edema, ischemia, infarct or tumor infiltration. Recommend MRI and follwo up(if not contra-indicated) for better assessment of these hypodense areas. 2. Decreased pneumocephalus. 3. Stable leftward shift from normally midline structures [7-13] Head CT: IMPRESSION: Since the previous CT of [2125-3-1] both the intracranial pressure monitoring device has been removed. There is craniectomy with multiple hypodensities in the right cerebral hemisphere unchanged from previous study with foci of hemorrhage and pneumocephalus. No new hemorrhage is seen. [7-14] Head MRI: IMPRESSION: 1. Extensive predominantly cortical infarcts are seen in the frontoparietal and occipital lobes. Given somewhat atypical vascular distribution, the infarcts could be venous rather than arterial in origin. Petechial hemorrhages are identified within the infarcts. 2. Status post craniotomy in the occipital region with resection of the previously seen enhancing mass. Subtle enhancement remains in this region which could be postoperative in nature. 3. Craniectomy identified as seen on the previous CT. [7-18] Head CT: 1. Collection in right anterolateral aspect of the anterior cranial fossa is now fluid-filled with minimal residual pneumocephalus. 2. Overall, no significant change from [2125-7-13] study. [7-21] Head CT: IMPRESSION: 1. Overall stable appearance of the brain status post right parietal mass resection and epidural and subdural hematoma evacuation with stable 4-mm left shift, without new focus of hemorrhage. Small anterior surgical bed collection with a trace pneumocephalus is unchanged. 2. Paranasal sinus disease. Chest XR [7-24] FINDINGS: In comparison with the earlier study of this date, the tip of the PICC line lies in the mid-to-lower portion of the SVC. Little change in the appearance of the heart and lungs. This information was discussed by the resident on call with the IV access obtained. Head CT [7-26]: 8mm increase in extra-axial fluid collection. No other intracranial changes or findings Brief Hospital Course: [7-8] Pt is a 33m with previous history of testicular cancer s/p orchiectomy and chemotherapy. He was intially diagnosed with this in [2114] and had his procedure at that time. Pt has complained of 2 weeks of headaches that have become progressively worse over the last 3 days. CT of the head upon admission showed a right parietal mass with surronding vasogenic edema. There was minimal midline shift and no hydrocephalus. MRI +/- contrast showed an enhancing mass within the right parietal lobe and the plan was for open biopsy on Monday [7-9]. [7-9] Pt taken to the OR for R parietal craniotomy on this day. Post operatively the patient was unable to extubate and was not waking up after anesthesia. The patient was immediately taken for CT of the head. Head CT showed large right sided epidural hematoma anterior to the resection cavity with 1.7cm of midline shift. Pt was taken back to the operating room from CT scan and underwent emergent evacuation of epidural hematoma and R hemicraniectomy. An ICP monitor was placed at the time of surgery to further monitor intracranial pressures. Pt was transfered to the ICU and remained intubated and sedated. A head ct obtained showed good evacuation of hematoma, resolution of midline shift and no hyrdocephalus. [7-10] Head ct was stable with no new hemorrhage. His baseline exam on this day showed no eye opening, PERRLA, withdraw BLE R>L, flexion RUE, extensor posturing LUE, no eye opening. On the evening of [7-10] Pt's ICP's began to increase into the mid 20's where they had previously been [7-15]. He was intially started on mannitol 25g IV q6 but this had little effect of lowering ICP. Pt was given an additional dose of 50g IV and ICP returned to a normal range. Stat head ct showed no change when compared to previous exam. [7-11] Pt ICP continued to increase on this day and consistently within range of 25-27. Pt was treated with a one time bolus of 23% sodium chloride and was continued on mannitol 50g IVq6. His ICP did decrease to a range of 20-21. His exam on this day remained unchanged as did his ct head. [7-12] Pt cont on mannitol and decadron, neurological exam & ICP's remained stable. tumor markers were sent by the oncology team. 8/13 ICP bolt was removed without difficulty. Vancomycin was discontinued. Mannitol wean was initiated. [7-14] neurologically stable [7-15] Family meeting with Dr. [First Name (STitle) ]. Family decided to proceed with Trach/Peg/IVC Filter [Date range (1) 57944]: neurological exam slightly improved. Pt more readily following commands on right side of body. Decadron wean initiated on [7-17] when mannitol was completely off. Tracheostomy, PEG and IVC filter placed on [7-17] without complications. Tube feeds started on [7-18] and tolerated well. [7-19] CT head obtained for routine evaluation. No new changes when compared to prior exams. Pt was transfered to the step down unit on this day. Pt eyes open to noxious and following commands on the right side. Minimal movement in LUE to deep noxious, no movement of LLE. [7-20] Pt noted to be febrile on this day with an increasing WBC count and increased amounts thick secretions requiring deep suction. Sputum cultures sent and positive for H. Flu. Pt was started on levaquin. [Date range (1) 35200] ID team consulted and recommended to discontinue levaquin and start vancomycin and ceftazadime for broad spectrum coverage. ID team recommended a 7 day course of these antibiotics. A PICC line was obtained for continued IV therapy. His WBC count continued to trend down from 17.3 to 10.5 and he remained afebrile. Pt random vancomycin level on [7-23] was 6.7 and he was continued with his dosing of 1g IV q8. A trough level on [7-24] was 14.3. On [7-25] it was noted that his LFTs were slightly elevated on the date that Ceftaz was initiated. It was decided to d/c the Ceftaz and continue with Meropenum and Vanc. His RUE was noted to be slightly swollen when compared to the LUE. A subsequent RUE UE revealed a superficial clot. NSAIDs and warm packs were given. On [7-26] he was given a bed a [Hospital3 ]. His final labs were unremarkable, and his head CT was grossly unchanged. Medications on Admission: ABACAVIR-LAMIVUDINE [EPZICOM] - 600 mg-300 mg Tablet - one Tablet(s) by mouth once daily AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL XR] - 10 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth daily CLINDAMYCIN PHOSPHATE - 1 % Gel - apply thin layer once daily LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth once daily at bedtime as needed for insomnia OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [12-2] Tablet(s) by mouth q 4h RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - one Tablet(s) by mouth twice daily Discharge Medications: . 1. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO BID (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 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. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 doses. 15. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever. 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea [1-2] brain met. 17. Morphine 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for head pain [1-2] brain metastasis. 18. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 10 days. 19. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 8H (Every 8 Hours) for 10 days. 20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: Brain Tumor Epidural Hematoma Likely PNA RUE superficial thrombus Discharge Condition: . Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. 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. 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. ?????? If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? 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. 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. You have an appointment with Dr. [Last Name (STitle) ] (Oncology) on [9-6] at 11:30 *****Weekly AFP, LDH and HCG should be drawn weekly at the Rehab Facilitly and faxed to the hematology Clinic at ([Telephone/Fax (1) 74439]. Completed by:[2125-7-26**]	[ "389.9", "070.30", "432.0", "348.4", "348.5", "285.29", "482.2", "784.0", "197.6", "V08", "V15.82", "V10.47", "305.90", "V87.41", "787.03", "196.1", "453.81", "790.4", "E878.8", "E933.1", "427.89", "780.97", "997.02", "518.81", "V45.77", "263.9", "198.3", "348.89" ]	icd9cm	[ [ [] ] ]	[ "38.93", "31.1", "38.7", "88.51", "01.10", "01.24", "96.6", "01.25", "01.59", "01.23", "03.31", "93.59", "38.91", "96.72", "43.11" ]	icd9pcs	[ [ [] ] ]	14594, 14665	7795, 12045	328, 540	14775, 14777	2771, 2771	17746, 18249	1445, 1463		12621, 14571		14686, 14754		12071, 12598			14913, 17723			3143, 4737						1478, 1605																					279, 290							568, 1080	1858, 2752			7056, 7772	2787, 3127					14792, 14889					1102, 1130	1146, 1429
18,958	122,422	1912	Discharge summary	report	Admission Date: [2189-8-20] Discharge Date: [2189-8-24] Date of Birth: [2144-6-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 477] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 45 y/o man with PMH of metastatic renal cell carcinoma with known malignant pleural effusions who presents with [Known lastname ] and increased dyspnea. The patient had melenotic stools yesterday morning and was taken to [Hospital1 ] after his wife called EMS. At [Hospital1 ], he was noted to have overt [Hospital1 ] and Hct 23.8. CXR revealed worsening left pleural effusion. He was treated with levofloxacin 500 mg IV X 1 and 1 L NS. His BP was 80s-90s/40s-50s with HR in the 100s. He was placed on Bipap for transfer. As his primary physicians are at [Hospital1 18], he was sent here for further management via [Location (un) 7622]. . He also had increased dyspnea for the past few days per his wife. She reports decreased amounts of pleural fluid drainage from his PleurX catheter (150-170 cc daily down from 200 cc daily). He has had increased abdominal girth lately and is status s/p 3 L paracentesis on [8-17] per Dr. [Last Name (STitle) ]. His PleurX catheter was also drained at that time. Wife reports no fevers or sputum production. She has noted him to have new hiccups with altered respiratory pattern, especially at night (loud inspiratory sounds, like hiccups). . In the ED, initial vitals T 97.5, BP 116/59, HR 105, 100% on BIPAP. In our ED, he received vancomycin 1 g IV and zosyn 4.5 g IV X 1. He also received vitamin K 10 mg SC due to elevated INR. He was found to have elevated potassium and received calcium gluconate 1 amp X 1, kayexalate 30 g PR X 1, insulin 10 U X 1, and dextrose 1 amp IV X 1. Follow up blood sugar was 78 and he received a second dose of dextrose 1 amp IV. He also received morphine 4 g IV X 1. . On arrival to the ICU, the patient endorses worsening dyspnea and chest pain which he cannot localize. He also notes upper abdominal pain. He denies pain in other places. He did vomit yesterday but cannot tell me when that occurred. He does not recall when he first saw blood in the stool. . ROS: No fevers, chills. No sore throat. Decreased PO intake and some choking with PO intake. No sputum production. + recent hiccups per wife. + nausea (uses reglan/ativan at home). + one episode of vomiting (brown in color). + abdominal pain. Wife reports usual amount of urine output with usual urine color. Overall body swelling similar to prior. Past Medical History: Renal cell carcinoma - debulking nephrectomy with regional lymph node dissection on [2187-11-16] - dendritic cell fusion vaccine trial- [2-6] -Sutent & Gemzar on ([Date range (3) 10646]) Protocol # 04-385; taken off study for posterior leukoencephalopathy (see DC summary [2188-7-23]) -torisel ([Date range (1) 10647]) -sutent,continuous ([Date range (3) 10648]) Social History: He is married with 3 children. Employed as a lawyer at a pharmaceutical company. He denies tobacco, alcohol, or IVDA. Family History: Sister with [Name (NI) 4522] disease. No other history of gastrointestinal diseases. Physical Exam: VS: T 96.8 rectal BP 124/67 P 91 RR 20 O2 100% on 6L NC GEN: cachectic male in minimal distress, frequently shutting eyes but answering questions and responding appropriately, total body anasarca HEENT: MM slightly dry, OP clear, tongue midline, sclerae pale, EOMI, PERRL bilaterally RESP: coarse breath sounds bilaterally, R > L, decreased breath sounds bilateral bases, dullness to percussion at bases, no wheezing CV: heart sounds distant, no appreciable murmur EXT: right arm in sling, 3+ pitting edema SKIN: no rash NEURO: alert, oriented to self, place, and month ([8-18])answering questions, intermittently drowsy, PERRL, EOMI, tongue midline, moving left arm spontaneously Pertinent Results: ========= Labs ========= [2189-8-21] 12:28AM BLOOD WBC-20.1* RBC-2.40# Hgb-8.0# Hct-23.9* MCV-100* MCH-33.2* MCHC-33.3 RDW-19.7* Plt Ct-37* [2189-8-20] 11:39AM BLOOD WBC-18.8* RBC-1.88* Hgb-6.2* Hct-19.8* MCV-106* MCH-33.1* MCHC-31.4 RDW-19.2* Plt Ct-44* [2189-8-20] 07:45AM BLOOD WBC-21.1* RBC-2.19* Hgb-7.2* Hct-22.6* MCV-103* MCH-33.1* MCHC-32.1 RDW-20.3* Plt Ct-76* [2189-8-21] 12:28AM BLOOD Neuts-94.1* Lymphs-3.0* Monos-2.9 Eos-0 Baso-0 [2189-8-20] 11:39AM BLOOD Neuts-93.2* Lymphs-3.3* Monos-3.3 Eos-0 Baso-0.1 [2189-8-20] 07:45AM BLOOD Neuts-93* Bands-1 Lymphs-1* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2189-8-20] 07:45AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Stipple-1+ [2189-8-21] 12:28AM BLOOD Plt Ct-37* [2189-8-21] 12:28AM BLOOD PT-18.4* PTT-41.2* INR(PT)-1.7* [2189-8-20] 11:39AM BLOOD Plt Ct-44* [2189-8-20] 11:39AM BLOOD PT-19.7* PTT-44.3* INR(PT)-1.8* [2189-8-20] 07:45AM BLOOD Plt Smr-VERY LOW Plt Ct-76* [2189-8-20] 07:45AM BLOOD PT-19.1* PTT-41.7* INR(PT)-1.8* [2189-8-21] 12:28AM BLOOD Glucose-100 UreaN-108* Creat-2.8* Na-133 K-6.5* Cl-105 HCO3-18* AnGap-17 [2189-8-20] 11:39AM BLOOD Glucose-115* UreaN-101* Creat-2.7* Na-132* K-6.5* Cl-103 HCO3-17* AnGap-19 [2189-8-20] 07:45AM BLOOD Glucose-116* UreaN-98* Creat-2.7* Na-131* K-6.7* Cl-103 HCO3-17* AnGap-18 [2189-8-20] 07:45AM BLOOD ALT-9 AST-11 CK(CPK)-63 AlkPhos-194* TotBili-0.6 [2189-8-20] 07:45AM BLOOD cTropnT-0.08* [2189-8-20] 07:45AM BLOOD CK-MB-NotDone [2189-8-21] 12:28AM BLOOD Calcium-7.3* Phos-8.6* Mg-2.7* [2189-8-20] 11:39AM BLOOD Calcium-6.9* Phos-8.7* Mg-2.8* [2189-8-20] 07:45AM BLOOD Albumin-1.4* Calcium-7.1* [2189-8-20] 09:03PM BLOOD Type-[Last Name (un) ] pO2-32* pCO2-34* pH-7.39 calTCO2-21 Base XS--4 [2189-8-20] 12:21PM BLOOD Type-[Last Name (un) ] Temp-36.0 O2 Flow-3 pO2-34* pCO2-34* pH-7.36 calTCO2-20* Base XS--5 Intubat-NOT INTUBA Comment-NC [2189-8-20] 08:54AM BLOOD pO2-73* pCO2-36 pH-7.29* calTCO2-18* Base XS--8 Comment-PORTA CATH [2189-8-20] 07:48AM BLOOD pO2-62* pCO2-33* pH-7.34* calTCO2-19* Base XS--6 Comment-PORTA CATH . ========= Radiology ========= CXR [2189-8-20] - IMPRESSION: Increased lung consolidation, most likely atlectasis, although pneumonia cannot be excluded. Slight increase in size of left pleural effusion. . CT head [2189-8-20] - IMPRESSION: No acute intracranial hemorrhage or significant edema. - Bilateral LE ultrasound [2189-8-20] - IMPRESSION: No evidence of DVT of the right or left leg. Extensive subcutaneous edema. ======== Cardiology ======== TTE [2189-8-20] - Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. Torn mitral chordae are present. There is a moderate sized, circumferential pericardial effusion. In diastole, the effusion size anterior to the right ventricle is 1.1 cm. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. No RA or RV collapse is seen. IMPRESSION: Moderate pericardial effusion with early signs of impaired ventricular filling. No echocardiographic signs of frank tamponade. . ECG [2189-8-20] - Sinus tachycardia with a premature atrial contraction. Poor R wave progression. Non-specific ST-T wave changes. Low QRS voltage. Compared to the previous tracing of [2189-7-27] sinus tachycardia and premature atrial contraction are new. There is decreased QRS voltage. . ECG [2189-8-21] - Sinus tachycardia. Lead V3 is missing. Poor R wave progression which is non-diagnostic. Non-specific ST-T wave changes. Low QRS voltage in the precordial leads. Compared to the previous tracing of [2189-8-20] there is no significant diagnostic change. Brief Hospital Course: # Acute renal failure/Hyperkalemia: Patient was admitted to the ICU from the ED. Creatinine up to 2.7 (up from 2.3 on recent labs), likely secondary to hypovolemia (decreased PO intake in combination with intravascular depletion due to hypoalbuminemia and GI bleed). Patient received insulin, kayexelate, and calcium gluconate. A goals of care meeting took place between the patient's outpatient oncology team and the ICU team, and family chose to make patient comfort measures only. He was transferred to the Oncology floor and expired on [2189-8-24] at 7:06 am. Primary cause of death was hyperkalemia from acute renal failure and secondary cause of death was GI bleed and Renal Cell Carcinoma. # Dyspnea: Has known left-sided pleural effusion with Pleurex catheter in place. Pulmonary embolism is a possibility given underlying malignancy but lower extremities Patient was not a candidate for anticoagulation given GIB, regardless. . # GI bleeding: Guaiac positive stool but not gross blood per rectum. Has a history of hemorrhoidal bleeding, but not clear that this is due to hemorrhoids. Wife reports [Name2 (NI) ] with some small amount of red blood in stool day prior to admission. . # Leukocytosis: Likely leukomoid reaction [1-3] underlying malignancy though does now have 1% bandemia (which is new). Was started on Vancomycin and Zosyn until patient was made CMO in the ICU. Medications on Admission: * tylenol prn * colace 100 [Hospital1 ] * dilaudid prn (not yet taking) * glycerin suppository prn * lactulose prn constipation * levothyroxine 50 mcg daily * lorazepam 2 mg qhs and q6h prn * reglan 10 mg four times daily for nausea * milk of mag prn constipation * oxycodone 20 mg TID * percocet 5/325 mg prn * senna prn * vitamin b12 * vitamin c * zantac 75 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Renal cell carcinoma Hyperkalemia Acute Renal Failure Gastrointestinal Bleed Discharge Condition: expired [Name6 (MD) ] [Name8 (MD) 490] MD, [MD Number(3) 491] Completed by:[2189-8-25]	[ "197.2", "584.9", "276.7", "198.5", "198.3", "578.9", "V10.52" ]	icd9cm	[ [ [] ] ]	[ "34.91" ]	icd9pcs	[ [ [] ] ]	9854, 9863	8002, 9402	322, 328	9983, 10116	4078, 7979		3268, 3358		9825, 9831		9884, 9962		9428, 9802												3373, 4059																					275, 284							357, 2704															2726, 3116	3132, 3252
19,855	164,122	48071+48072+59057+59058	Discharge summary	report+report+addendum+addendum	Admission Date: [2100-12-3] Discharge Date: [2100-12-8] Service: [Hospital1 ] HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ] year old gentleman who was a former head of pathology here for many years who was recently discharged from the [Hospital1 190] status post right open reduction and internal fixation complicated by aspiration pneumonia with recent swallowing evaluation which showed severe profound oropharyngeal dysphagia with inability to safely swallow saliva; this is on top of his chronic neurologic dysphagia for the past ten years and had an acute decline postoperatively. He has also had decreased appetite and change in his speech, but that is only when he is not using his dental bridge. He has also had some increase in somnolence and some chronic cough with mucosy sputum production. He denies fevers, chills and is otherwise doing well postoperatively. He has not been drinking fluids because of fear of aspiration. He was admitted for dehydration, failure to thrive and concern for aspiration. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Coronary artery disease, status post myocardial infarction with an ejection fraction of 50%, three plus mitral regurgitation and two plus tricuspid regurgitation; moderate paroxysmal atrial fibrillation. 3. Hypertension. 4. Gait instability. 5. Glaucoma. 6. Osteoporosis. 7. Cataract. 8. History of tuberculosis, status post right open reduction and internal fixation on [11-6]. 9. Hypothyroidism. 10. Aspiration pneumonia. 11. Anemia. MEDICATIONS ON ADMISSION: 1. Isosorbide. 2. Metoprolol. 3. Procardia XL. 4. Digoxin. 5. Brimonidine drops. 6. Colace. 7. Senna. 8. Tylenol p.r.n. 9. Levoxyl. 10. Coumadin. 11. Ensure supplements. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Is a former pathologist here at the [Hospital1 1444] for many years. He lives with his wife but currently at rehabilitation postoperatively for rehabilitation after hip surgery. Otherwise, no smoking or alcohol history. FAMILY HISTORY: Mother with cardiac disease and a father who had a cerebrovascular accident. PHYSICAL EXAMINATION: Vital signs on admission were temperature 97.3 F.; blood pressure 160/52; pulse 52; respiratory rate 20; O2 95% on room air. In general, he is awake, alert and oriented, in no acute distress. Clinically, chronically ill appearing, cachectic gentleman. HEENT: Pupils equally round and reactive to light. Positive scleral icterus. Positive pallor of conjunctivae. Mucous membranes were moist. Positive thrush. Positive tongue deviation. Clear oropharynx. Positive temporal wasting, positive subclavicular wasting. Chest was clear to auscultation bilaterally. Cardiovascular is irregularly irregular. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities with no cyanosis, clubbing or edema. One plus dorsalis pedis pulses bilaterally. Status post right open reduction and internal fixation with stable hips. Neurologic examination with good strength and sensation bilateral extremities. LABORATORY: On admission white blood cell count 11.3, hematocrit 39, platelets 249, 90% neutrophils, 5% lymphs, 5% monocytes. Sodium 127, potassium 4.7, chloride 90, bicarbonate 28, BUN 39, creatinine 0.9, glucose 118. Chest x-ray with left lower lobe opacity, otherwise unchanged. HOSPITAL COURSE: A [Age over 90 ] year old gentleman status post recent admission for open reduction and internal fixation with progressive dysphagia and recurrent aspiration here with failure to thrive and dehydration. 1. FAILURE TO THRIVE: The patient accepted placement of an NG Dobbhoff tube for nutrition. The patient had an NG tube placed on the night of admission and was started on tube feeds and titrated up per nutrition consultation and tolerated the feeds well. The patient's medicines were also given through the Dobbhoff tube. The patient had repeat evaluation by Speech and Swallow who continued to see severe profound dysphagia, unchanged from his last admission. The patient then agreed to have PEG tube placed per Surgery for continued nutrition which can be continued in rehabilitation. This was placed on [2100-12-7], without difficulty and the patient had 24 hours postoperatively to wait before using the tube, but then will be restarted at tube feeds at 70 cc an hour of the Probalance and the tube will be flushed with 100 cc of free water every six hours. The patient will continue to have residuals checked every six hours and tube feeds will be held if residuals are greater than 200 cc. The patient's electrolytes were continued to be monitored and replaced as started refeeding. The patient's potassium, phosphorus and magnesium remained low and continued to be repleted throughout the course of his admission. 2. DEHYDRATION: The patient's electrolytes on admission were very consistent with dehydration. The patient had urine electrolytes sent off with the FENA of 0.1% which was also consistent with a prerenal syndrome. The patient had a good ejection fraction from recent echocardiogram and was hydrated aggressively over the first 24 to 48 hours and then as tube feeds were started, the patient's intravenous fluids were discontinued until the patient was again NPO and then tube intravenous fluids were again restarted; otherwise the patient symptomatically improved. His oral thrush improved with hydration and was symptomatically better. 3. DYSPHAGIA, ASPIRATION: The patient had the left lower lobe findings on chest x-ray with history of aspiration and known dysphagia and was restarted on a course of Levofloxacin and Flagyl, which will be continued for another ten days post discharge. The patient was also seen and evaluated by the Neurology Service with plans for a CT scan of the head which showed no intracranial mass lesion or shift of structures. No major or minor vascular or territorial infarctions were apparent. The density of the brain parenchyma was within normal limits. There was evidence of atrophy of the brain and incidental note of calcifications within the tentorium and dural calcifications located at the falx were noted. Otherwise, no signs of hemorrhage. The patient was also to have a tensilon test to rule out myasthenia [Last Name (un) 2902]; results of that test were still pending at the time of this dictation. 4. CARDIOVASCULAR: The patient was still in atrial fibrillation and was continued on his nitrites and beta blockers and calcium channel blockers. The patient's medicines had to be arranged in the non-extended release form so as could be crushed to be given through the NG tube and later through the G-tube. Otherwise, the patient was doing well except postoperatively did go into rapid atrial fibrillation which responded to intravenous metoprolol and was stable on arrival to the floor. Otherwise, the patient did have some episodes of hypertension on the floor with blood pressures up to 170/80 systolic likely secondary to missing his longer acting calcium channel blocker which was restarted then on a three times a day regimen so as to be continued to be able to be crushed through his G-tube. The patient's Coumadin was held prior to surgery and postoperatively for one day. The patient's INR will continue to be followed and coumadin to be be restarted 1 day post peg at 1 mg q. h.s. dose. 5. HYPOTHYROIDISM: The patient's TSH regimen of Levoxyl was stable and otherwise no difficulties. 6. CONSTIPATION: For the patient's constipation, he previously had been on fiber secondary to use of the G-tube and was started on Lactulose as a daily 30 cc q. day with colace syrup twice a day. 7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was on the tube feeds as described above and had his electrolytes repleted again as his potassium, magnesium and phosphate secondary to refeeding syndrome and were watched very closely and repleted as needed. PROPHYLAXIS: The patient was started on Lansoprazole which can be given through his tube for his GI prophylaxis. Coumadin was being held for two days and otherwise was continued. The patient had a Physical Therapy evaluation that continued to work with him using the walker and the patient will return to rehabilitation to continue with Physical Therapy. CONDITION AT DISCHARGE: Good. The patient is ambulating with assistance of a walker, oriented to time and place. He is tolerating feeds through tubes and otherwise not requiring oxygen. DISCHARGE STATUS: Discharged to [Hospital3 ] for continued physical therapy and strength training. DISCHARGE DIAGNOSES: 1. Failure to thrive. 2. Dehydration. 3. Dysphagia. 4. Aspiration pneumonia. 5. Atrial fibrillation. 6. Hypertension. 7. Hypothyroidism. 8. Constipation. 9. Refeeding syndrome. DISCHARGE MEDICATIONS: 1. Tylenol 325 mg to 650 mg p.o. q. four to six p.r.n. 2. Isosorbide dinitrate 10 mg p.o. three times a day. 3. Metoprolol 12.5 mg p.o. three times a day. 4. Digoxin 0.125 mg p.o. q. day. 5. Levothyroxine 50 micrograms p.o. q. day. 6. Milk of magnesia 30 ml p.o. q. six p.r.n. 7. Lansoprazole 30 mg per NG q. day. 8. Docusate 100 mg NG twice a day. 9. Lactulose 30 ml per G tube q. day. 10. Nifedipine 10 mg NG q. eight. 11. Flagyl 500 mg NG q. eight. 12. Levofloxacin 500 mg NG q. day. 13. Coumadin 1 mg per G tube q. day. 14. Brimonidine one drop o.s. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with his primary care physician in seven to ten days. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2100-12-7] 16:37 T: [2100-12-7] 18:00 JOB#: [Job Number 101383] Admission Date: [2100-12-3] Discharge Date: [2100-12-11] Service: ADDENDUM: This is an Addendum to the previous Discharge Summary. CONCISE SUMMARY OF HOSPITAL COURSE (CONTINUED): On [12-8], at 12:30, the patient was found to be unresponsive. The patient was evaluated and had some unusual findings with his eyes. Both were bilaterally constricted. The patient had not received any narcotics, and the only medications were intravenous Lopressor and intravenous antibiotics. Otherwise, the Neurology team was called, and the patient was evaluated and found not to follow commands or have any speech. The pupils did react in the dark (right greater than left), and the patient did have some decreased tone in his left extremity and increased tone on his right side with upgoing toes on the left. The Neurology team was consulted (as noted above), and the patient was taken emergently to the magnetic resonance imaging for a STAT magnetic resonance imaging/magnetic resonance angiography for plans to possible intervene if the patient was having a stroke. While in the magnetic resonance imaging machine, the patient woke up and started moving all extremities and speaking. The patient was calmed down enough to continue the examination. The patient's magnetic resonance imaging was read as having no areas of restricted diffusion consistent with an infarction, but there was mild microvascular changes in the cerebral white matter which were unchanged from his [2097] magnetic resonance imaging. The magnetic resonance angiography of the head had no evidence of significant stenosis with some slight motion artifact. Otherwise, the patient had an electroencephalogram the following evening which was consistent with mild abnormality in the waking and sleeping states due to bursts of generalized slowing. This was a very nonspecific finding but implied dysfunction in the midline structures. Some of this could have represented excessive drowsiness. Otherwise, there were no areas of prominent focal slowing, and there was no epileptiform features. Again, and abnormal cardiac rhythm was noted. The patient had a further neurologic workup including a tensilon test which was stopped secondary to bradycardia; however, an acetylcholine antibody receptor was sent off and was still pending at the time of this dictation. Otherwise, the patient remained neurologically intact and was stable following this episode. The patient continued to have an irregularly irregular rhythm. The patient was started on Lovenox treatment dosing until his Coumadin resulted in a therapeutic INR. The leading diagnosis for the event was brief transient ischemic attack which had resolved by the time the patient was in the scanner. The patient was to continue to be anticoagulated with a goal INR of 2 to 3 and was to continue Lovenox bridging until he reaches that goal. Otherwise, the patient remained neurologically intact and stable. The following day, the patient did have some increasing gas; however, after tube feeds were held and given some simethicone this resolved. The patient did have a little bit of diarrhea with his tube feeds which was likely secondary to daily lactulose. The lactulose was held. This can be restarted on an as needed basis for constipation. Otherwise, the patient was continued on his antibiotics of levofloxacin and Flagyl for aspiration. The patient was to complete a 10-day course which was to be completed on [12-13]. Otherwise, the patient was continued on his prophylactic regimen of proton pump inhibitor, bowel regimen, and Lovenox and Coumadin as described above. The patient's blood pressure remained elevated at times. The patient was unable to take nifedipine secondary to an inability to crush the tablet for administration through his gastrojejunostomy tube. The patient's blood pressure regimen was titrated with a heart rate of 60 and was continued on 12.5 mg of metoprolol three times per day but had an increased isosorbide dinitrate regimen of 20 mg three times per day. Also, the patient had a note of left upper extremity swelling medial to his elbow which was noted on [12-10]. The patient was scheduled for an ultrasound this extremity to rule out deep venous thrombosis; the results of which were still pending at the time of this dictation. Otherwise, the patient had no pain and no erythema at this site, but did have some soft tissue swelling at this area. CONDITION AT DISCHARGE: Condition on discharge was good. The patient was ambulating with the assistance of a walker. The patient was able to sit upright without difficulties. The patient was not requiring oxygen. The patient was mentating appropriately. DISCHARGE STATUS: Discharge status was to [Hospital3 1761] for continued physical therapy. DISCHARGE DIAGNOSES: 1. Failure to thrive. 2. Dehydration. 3. Aspiration pneumonia. 4. Dysphagia. 5. Transient ischemic attack. 6. Reseeding syndrome. 7. Atrial fibrillation. 8. Hypertension. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Tylenol 325 mg to 650 mg per gastrojejunostomy tube q.4-6h. as needed. 2. Levothyroxine 50 mcg per gastrojejunostomy tube once per day. 3. Milk of Magnesia 30 mL per gastrojejunostomy tube q.6h. as needed. 4. Lansoprazole 30 mg per gastrojejunostomy tube once per day. 5. Colace 100 mg per gastrojejunostomy tube twice per day. 6. Digoxin 0.125 mg per gastrojejunostomy tube once per day. 7. Levofloxacin 500 mg per gastrojejunostomy tube once per day (to be completed on [12-13]). 8. Flagyl 500 mg per gastrojejunostomy tube q.8h. (to be completed on [12-13]). 9. Lovenox 50 mg subcutaneously q.12h. (to be discontinued with therapeutic INR). 10. Warfarin 1 mg per gastrojejunostomy tube once per day (goal INR of 2 to 3). 11. Simethicone 40 mg to 80 mg per gastrojejunostomy tube four times per day as needed (for gas). 12. Metoprolol 12.5 mg per gastrojejunostomy tube three times per day. 13. Isosorbide dinitrate 20 mg per gastrojejunostomy tube three times per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician [Last Name (NamePattern4) ] 7 to 10 days. 2. The patient was instructed to follow up with his neurologist in two to three weeks. 3. The patient was instructed to follow up with his orthopaedist as previously scheduled. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2100-12-10] 11:26 T: [2100-12-10] 11:33 JOB#: [Job Number 101384] Name: [Known lastname 16301], [Known firstname 77] G./MD Unit No: [Numeric Identifier 16302] Admission Date: [2100-12-3] Discharge Date: [2100-12-22] Date of Birth: [2008-7-12] Sex: M Service: ADDENDUM: On the morning of the day of anticipated discharge ([2100-12-12]) the patient was found to be unresponsive and severely acidemic with an arterial blood gas with a pH of 7.25, a PCO2 of 91, a PO2 of 124. With concern for hypoventilation and increasing acidemia, the patient was intubated on the floor and transferred to the Unit. Eventually, upon intubation had a bronchoscopy done which showed tube feeds in the patient's lungs. He had aspirated tube feeds through his percutaneous endoscopic gastrostomy tube into his lung and were the source of his hypoventilation. These were removed, and eventually the patient was weaned off pressors and the patient was extubated successfully while broadly covered on antibiotics for aspiration pneumonia. The patient was treated under the sepsis protocol. Eventually, the patient was extubated and transferred to the floor where he did well. The patient did well on the floor for a few days but then became more hypoxic. On repeat chest x-rays had worsening airspace disease, and antibiotics were re-broadened. Although, the patient did remain afebrile, he continued to have lots of secretions and was continued with chest physical therapy and as needed suctioning. Tube feeds were held because of concern for aspiration. Eventually, his percutaneous endoscopic gastrostomy tube was converted to a gastrojejunostomy tube to reduce the risk of aspiration. He was continued on Lovenox for his chronic atrial fibrillation anticoagulation. However, the patient had been fairly stable on the morning of [12-22] when the patient was desaturating on his nasal cannula and became poorly responsive. Other vital signs were stable. The patient was seen with cold extremities. A gas was drawn initially which was 7.39, with a PO2 of 61. The patient was deep suctioned and started to respond more, in terms of moving extremities and coughing. The tube feeds were stopped at that time, and five minutes later the patient was poorly responsive again. Vital signs remained stable. However, a repeat gas had a pH of 7.29, with a PCO2 of 80. Otherwise, for concerns of his unresponsiveness the patient was reintubated on the floor and sent to the Unit as fluids were started. On arrival to the Unit, a family meeting discussion was held regarding the patient's wishes and desires which resulted it was decision to make the patient comfort measures only and to extubate for patient comfort and start morphine as needed to help keep comfortable. Eventually, the patient was transferred back to the floor where he was again found unresponsive without heart sounds or a pulse, and was pronounced dead at 9:20 p.m. on [2100-12-22]. The family and attending were notified, and the patient's family requested a postmortem. CONDITION AT DISCHARGE: Discharged to the morgue. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Dysphagia. 3. Failure to thrive. 4. Dehydration. 5. Atrial fibrillation. 6. Hypertension. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-766 Dictated By:[Name8 (MD) 1404] MEDQUIST36 D: [2101-2-14] 13:37 T: [2101-2-14] 14:33 JOB#: [Job Number 16303] Name: [Known lastname 16301], [Known firstname 77] G./MD Unit No: [Numeric Identifier 16302] Admission Date: [2100-12-3] Discharge Date: [2100-12-22] Date of Birth: [2008-7-12] Sex: M Service: [Hospital1 248] On the morning of anticipated discharge on [2100-12-12], the patient was found to be unresponsive. He had a gastrone which was 7.29/91/124. He was severely acidemic from hypoventilation and was transferred to the Medical Intensive Care Unit where he was intubated. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-766 Dictated By:[Name8 (MD) 1404] MEDQUIST36 D: [2101-2-14] 01:37 T: [2101-2-14] 17:16 JOB#: [Job Number 16304]	[ "507.0", "038.9", "276.5", "244.9", "427.31", "435.9", "518.81", "787.2", "785.52" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "96.04", "96.72", "43.11" ]	icd9pcs	[ [ [] ] ]							2065, 2143	19605, 20694	8849, 9426			14854, 15893	1585, 1804	3393, 8332		9450, 14282		15926, 19542																			2166, 3374		19557, 19584														131, 1060															1082, 1559	1821, 2048
79,348	154,288	9090	Discharge summary	report	Admission Date: [2182-5-11] Discharge Date: [2182-5-19] Date of Birth: [2130-8-26] Sex: F Service: MEDICINE Allergies: Penicillins / Fentanyl Attending:[First Name3 (LF) 949] Chief Complaint: flank pain Major Surgical or Invasive Procedure: RIJ History of Present Illness: 51yo female with a history of hepatic cirrhosis due to alcohol, alcohol abuse, chronic pancreatitis, and asthma was admitted from the Emergency Department with flank pain. Patient is a very poor historian due to alcohol intoxication. . She reports that she has had multiple falls over the last 1.5 weeks due to gait instability and dizziness. She reports that she had not been drinking alcohol during these falls. Then on the morning of admission she developed marked worsening of her pain for which she drank two drinks of vodka and cranberry juice on the morning of admission. . Of note, she has had the following multiple admissions since [12-28]: - [Date range (2) 31375] - pancreatitis, abdominal pain, and alcoholism - 1/22-27/09 - hematemesis requiring endoscopy with banding - 2/14-17/09 - abdominal pain - 2/23-26/09 - abdominal pain, alcohol intoxication - 3/27-27/09 - nausea and vomiting, signed out AMA when narcotics were not given - [Date range (1) 31376] - hematemesis with EGD demonstrating varices - [Date range (1) 31377] - nonspecific abdominal pain - [2182-4-2] - abdominal pain and alcohol intoxication . Upon arrival to the ED, temp 99.5, HR 90, BP 79/47, RR 16, and pulse ox 97% on RA. Her exam was notable for generalized abdominal pain. Her labs were notable for ALT 45, AST 138, TB 3, serum EtOH 266, serum acetaminophen 10.2, and INR 1.8. CT scan in the ED was notable for patchy ground glass opacities throughout the lungs, pancreatitis, liver cirrhosis, and air in the biliary tree. She received ceftriaxone 2g IV x 1, dilaudid 2mg IV x 2, ampicillin / sulbactam, levofloxacin 750mg IV x 1, vancomycin 1g IV x 1, and norepinephrine. Past Medical History: 1. Alcoholic Cirrhosis - dx in [2178] - complicated by varices, ascites, encephalopathy 2. Chronic pancreatitis 3. ETOH abuse - history of DT's in the past 4. Asthma - history of intubation in the past 5. Uterine and cervical CA s/p hysterectomy - s/p hysterectomy ([2166]) Social History: 1. Alcoholic Cirrhosis - dx in [2178] - complicated by varices, ascites, encephalopathy 2. Chronic pancreatitis 3. ETOH abuse - history of DT's in the past 4. Asthma - history of intubation in the past 5. Uterine and cervical CA s/p hysterectomy - s/p hysterectomy ([2166]) Family History: - Mother - died in her early 70s from GI bleeding; EtOH - Father - died in mid-70s from cancer, possibly mesothelioma as he worked in shipping yard; EtOH Physical Exam: Gen: no acute distress, resting comfortably in bed, smelling of alcohol, occasional slurred speech HEENT: Clear OP, dry mucus membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: decreased breath sounds at the bases bilaterally with no wheezes, rales, or rhonchi ABD: + BS, Soft, diffusely tender to palpation with no rebound or guarding EXT: trace lower extremity edema. 2+ DP pulses BL SKIN: No rashes NEURO: A&Ox3. CN 2-12 intact. 5/5 strength throughout. Normal coordination. Gait assessment deferred Pertinent Results: [2182-5-11] 04:45PM BLOOD WBC-5.3 RBC-2.66* Hgb-8.9* Hct-26.8* MCV-101* MCH-33.6* MCHC-33.3 RDW-20.5* Plt Ct-46* [2182-5-11] 04:45PM BLOOD Neuts-48* Bands-0 Lymphs-30 Monos-12* Eos-5* Baso-2 Atyps-3* Metas-0 Myelos-0 [2182-5-11] 06:31PM BLOOD PT-19.8* PTT-37.5* INR(PT)-1.8* [2182-5-11] 04:45PM BLOOD Glucose-118* UreaN-15 Creat-1.1 Na-138 K-3.7 Cl-107 HCO3-21* AnGap-14 [2182-5-11] 04:45PM BLOOD ALT-45* AST-138* AlkPhos-183* TotBili-3.0* [2182-5-11] 04:45PM BLOOD Lipase-136* [2182-5-11] 04:45PM BLOOD Albumin-2.9* [2182-5-11] 04:45PM BLOOD ASA-NEG Ethanol-266* Acetmnp-10.2 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2182-5-11] 04:54PM BLOOD Lactate-2.7* . - [2182-5-11] - ECG - sinus rhythm at ~80bpm, normal axis, no acute ST changes - [2182-5-11] - CT Head IMPRESSION: No acute intracranial hemorrhage or fracture. Prominent sulci and ventricles, compatible with brain atrophy, unchanged since [2176]. - [2182-5-11] - CT C spine IMPRESSION: No evidence of fracture or malalignment. - [2182-5-11] - CT Chest / Abd / Pelvis IMPRESSION: 1. Peripancreatic inflammatory stranding with peripancreatic fluid, most compatible with acute pancreatitis. 2. Cirrhotic liver, with evidence of portal hypertension. 3. Air within the biliary tree and gallbladder, which were not evident on prior study on [2182-3-28]. Correlate with any recent interventions such as ERCP. 4. Patchy bilateral airspace ground-glass opacities, which may be infectious or inflammatory in etiology, with a suggestion of a tiny right pleural effusion. - [2182-5-11] [Month/Day/Year 5283] US IMPRESSION: 1. Cirrhotic liver with new thrombosis of the main portal vein which was not present on the multiphasic CT of the abdomen of [2182-3-28]. 2. Air within the gallbladder, better appreciated on CT from today. No gallstones. 3. Nonvisualization of the left hepatic vein. CXR: Lung volumes are lower, mediastinal vasculature is appreciably more distended and pulmonary vessels are mildly dilated, all suggesting volume overload and borderline cardiac decompensation. Heart size is normal but increased since yesterday. Right jugular line ends centrally MRCP: [2182-5-13] IMPRESSION: 1. Findings compatible with cirrhosis with fatty change in the liver. The portal venous system is patent. 2. Ascites as well as peripancreatic fluid. There is mild heterogeneous enhancement of the head of the pancreas. Findings are probably due to pancreatitis. Recommend clinical correlation. 3. Bilateral pleural effusions and atelectasis at the lung bases, right greater than left. [Month/Day/Year 5283] U/S [5-18] IMPRESSION: 1. Cirrhosis, with splenomegaly. 2. No evidence of cholecystitis. 3. No evidence of ascites, with a note made of a right pleural effusion. Brief Hospital Course: 51yo female with history of alcoholic cirrhosis, alcohol abuse, and chronic pancreatitis was admitted from the ED with septic shock. 1. Septic Shock Etiology of her septic shock is likely GPC bacteremia. Source is not clear. No obvious skin source. ? IVDU. Relatively immunocompromised. She was hypotensive in the Emergency Department on arrival, although her blood pressure has improved with IVF boluses. Now off pressors. Plan is the following: - follow-up final read of CT scan and [Month/Year (2) 5283] US -> findings c/w pancreatitis, PV thrombosis, a few ground glass opacities - follow-up blood and urine cultures - continue broad spectrum antibiotics with vancomycin and cipro/flagyl, - pain control with IV morphine for now - IVF resuscitation with NS to aim for MAP > 60, goal UOP 30mL/hour 2. Acute Pancreatitis The patient was initally hypotensive in the ED with SBP's in the 70's. She was initailly on norepi for blood pressure support. She was initially treated boadly with antibiotic, initally ceftriaxone 2g IV x 1, ampicillin / sulbactam, levofloxacin 750mg IV x 1, vancomycin 1g IV x 1 in the ED. The patient had findings consistent of pancreatitis on CT scan, most likely related to alcoholism. Additional possibilities include gallstone pancreatitis, although no significant findings of gallstones were seen on [Month/Year (2) 5283] US. She was seen by surgery who followed her during her admission. She was given aggressive fluid resuscitation initally in the MICU and weaned off pressors shortly after admission. Her antibiotics were narrowed to vancomycin/cipro/flagyl. The patient's blood pressure remained stable and she was transferred to the floors. She underwent MRCP that was also consistent with pancreatitis. She also underwent a repeat [Month/Year (2) 5283] that did not show obstruction or ascites. Her antibiotics were discontinued. She initally required pain regimen with IV dilaudid and was transitioned to po dilaudid for pain control. The patient's diet was advanced and tolerating a regular diet at the time of discharge. Pneumobilia Patient has findings of pneumobilia on CT scan of unclear etiology. Differential diagnosis includes a recent ERCP, although no record of recent procedure. Infection with gas-forming organism, cholangitis, or emphysematous cholecystitis were other possibilites. She was treated broadly intially and narrowed to cipro/flagyl. She remained stable and MRCP and repeat [Month/Year (2) 5283] did not comment on further pneumobilia. Her antibiotics were discontinued and she remained stable. Alcohol Intoxication Patient has evidence of alcohol intoxication on exam and also with serum alcohol of 162 on admission. The patient has had multiple admissions in the past with alcohol intoxication. She was monitored on CIWA scale and continued thiamine, multivitamins, and folate. She was also seen by social work. Acute Renal Failure The patient's creatinine was 1.1, which is increased from baseline of .5-.7. Etiology is most likely prerenal in the setting of infection, although she is still at risk for ATN given hypotension in the ED. There was no evidence of urinary obstruction on CT Abd/Pelvis. Her creatinine initally improved after IVF, however began to rise again consistent with ATN. Her creatinine peaked at 1.3 and improved to 0.9 at the time of discharge. Anemia: The patient had Hct of 26.8 on admission. She was guaiac negative in the ED. On [5-17] her Hct declined to 21.3. She was guaiac negative, hemolysis labs were negative, and no obvious source of bleeding was seen. She was transfused 2U pRBC and Hct increased appropriately. Her Hct remained stable for the rest of her admission. Cirrhosis Patient has known alcoholic cirrhosis with associated complications of varices, portal gastropathy. The patient was continued on lactulose. She did not have any symptoms of encephalopathy during her admission. Her diuretics were initally held due to ARF, but restarted once her creatinine improved. She did complain of continued lower extremitiy edema following aggressive fluid resucitation in the MICU. Her lasix and spironolactone were titrated up with improvement in edema. The patient was ambulating without difficulty. Portal Vein Thrombosis Patient has findings on [Month/Year (2) 5283] US with new portal vein thrombosis; however given her history of variceal bleed in the past, she was not started on anticoagulation. Medications on Admission: (from previous discharge summary on [2182-4-2]) 1. Omeprazole 40mg daily 2. Lactulose 30mL PO tid 3. Nadolol 20mg PO daily 4. Sucralfate 1g PO qid 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit [Unit Number ] capsule qid 6. Thiamine 100mg PO daily 7. Multivitamin 1 tab daily 8. Folate 1mg PO daily 9. Albuterol prn 10. Morphine 15mg PO q6-8 hours Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:1 Bottle Refills:2 5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): This medication requires monitoring with lab work. Please obtain your labs next week. . Disp:30 Tablet(s) Refills:2 6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch Transdermal once a day. Disp:28 Patches Refills:2 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): This medication requires monitoring with lab work. Please obtain your labs next week. . Disp:30 Tablet(s) Refills:2 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): This medication requires monitoring with lab work. Please obtain your labs next week. . Disp:30 Tablet(s) Refills:2 10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours for 10 doses: please do note drive or operate machinery. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Pancreatitis Alcohol Abuse Cirrhosis Ascites Discharge Condition: ambulating, tolerating minimal po Discharge Instructions: You were admitted to the hospital with pancreatitis and low blood pressure. You required a brief stay in the ICU. You got fluids and antibiotics. Your blood pressure normalized and you came to the regular medical floor. Here, your pancrease enzymes became normal. Your antibiotics were stopped and you remained without a fever. Your kidney function was mildly impaired, but this corrected with fluids and albumin. Also, an ultrasound showed a blood clot in the blood vessel that leads to your liver. It was felt that the risk of bleeding by putting you on blood thinners, however, was too great, given your falls and alcohol use. This should be followed as an outpatient. You also had a low blood count and were given 2 units of blood. You had an isolated episode of fast heart rate, that was due to anxiety and improved with valium. You heart rate has been stable thoughout your admission. It is important that you take your medications as prescribed. It is also important that you attend all follow up appointments. You have been in and out of the hospital very frequently as a result of your alcohol use. Alcohol use is causing serious medical problems. [Name (NI) ] should stop drinking alcohol, and seek help in stopping. You are discharged on a lower dose of Lasix (40mg) and Spironolactone (100mg). These medications can have their doses increased as an outpatient in follow up. These medications will help the swelling in your legs, but it will take some time. Furthermore, these medications require monitoring with lab work. There is a perscrition enclosed for the lab work to be obtianed before you appointment with your primary care physician. Followup Instructions: Please contact the office of [Name (NI) ] [Name (NI) ] at [Telephone/Fax (1) 250] to schedule an appointment sometime in the next 1-2 weeks. You have not kept many appointments so one was not made for you while you were here. If you call, however, they will schedule you an appointment. It is very much hoped that you contact this physician and follow up with her. Completed by:[2182-5-24]	[ "263.9", "577.0", "493.90", "305.01", "789.59", "584.9", "V10.42", "571.2", "577.1", "458.9", "452", "155.1", "276.51", "724.2" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	12438, 12444	6210, 10685	293, 298	12550, 12586	3380, 6187	14297, 14705	2634, 2790		11099, 12415		12465, 12529		10711, 11076			12610, 14274									2805, 3361																					243, 255							326, 2012															2034, 2318	2334, 2618
64,024	102,769	42802+58555+58557	Discharge summary	report+addendum+addendum	Admission Date: [2191-1-5] Discharge Date: [2191-1-6] Date of Birth: [2143-3-21] Sex: F Service: NEUROSURGERY Allergies: Fioricet / ibuprofen Attending:[First Name3 (LF) 78] Chief Complaint: elective right pcomm aneurysm coiling Major Surgical or Invasive Procedure: Angiogram [2191-1-5] History of Present Illness: History of Present Illness: On her most recent hospitalization this 47 y/o right handed woman with a history of Gastric bypass [2182] (rogue-n-y), anxiety/depression, and a pacemaker for "palpitations" who presents as an OSH transfer for Left side body numbness. She states that the symptoms began on [Holiday ] eve morning when she woke up with her left hand feeling totally numb with pins and needles feeling. She thought she slept on it and that was the reason for the sensation but the sensation failed to remit or change over the proceeding days. There was no interval changes/evolution of the numbness/paresthesia until last night when suddenly before going to bed she felt her whole left side become numb with paresthesia. She called her neighbor who suggested she go to the hospital for workup but she declined and thought it would go away. This morning it had not resolved and so she called the ambulance afraid she had a stroke. She otherwise endorses weakness of the left, no bowel or bladder incontinence, no recent fever or illness, or big weight changes. No recent vaccinations. Of note she has not taken her vitamin supplements in years, she was recently prescribed eye glasses which she does not have with her, she had a recent diagnosis of a 3rd nerve palsy but was unsure on which side but believes it was the left with no clear reason as to why, but does state that she also had an infection of her eyes and had taken some eye drops for this. Currently she presents for coiling of incidental right pcomm aneurysm coiling that was discovered during this prior hospital stay. Past Medical History: Anxiety/depression Gastric bypass [2182] HTN Left? 3rd nerve palsy / currently right eye is dilated .5mm compared to left bilateral knee replacement X2 on the left pacemaker for "palpitations" hysterectomy cholecystectomy Headaches (migraine) Social History: trying to quite smoking, did not get pack year history, no etoh or other drug use endorsed. Family History: States they are all diseased. Physical Exam: History of Present Illness: The pt is a 47 y/o right handed woman with a history of Gastric bypass [2182] (rogue-n-y), anxiety/depression, and a pacemaker for "palpitations" who presents as an OSH transfer for Left side body numbness. She states that the symptoms began on [Holiday ] eve morning when she woke up with her left hand feeling totally numb with pins and needles feeling. She thought she slept on it and that was the reason for the sensation but the sensation failed to remit or change over the proceeding days. There was no interval changes/evolution of the numbness/paresthesia until last night when suddenly before going to bed she felt her whole left side become numb with paresthesia. She called her neighbor who suggested she go to the hospital for workup but she declined and thought it would go away. This morning it had not resolved and so she called the ambulance afraid she had a stroke. She otherwise endorses weakness of the left, no bowel or bladder incontinence, no recent fever or illness, or big weight changes. No recent vaccinations. Of note she has not taken her vitamin supplements in years, she was recently prescribed eye glasses which she does not have with her, she had a recent diagnosis of a 3rd nerve palsy but was unsure on which side but believes it was the left with no clear reason as to why, but does state that she also had an infection of her eyes and had taken some eye drops for this. Past Medical History: Anxiety/depression Gastric bypass [2182] HTN Left 3rd nerve palsy bilateral knee replacement X2 on the left pacemaker for "palpitations" hysterectomy cholecystectomy Headaches (migraine) Social History: trying to quite smoking, did not get pack year history, no etoh or other drug use endorsed. Family History: States they are all diseased. Admission Physical Examination: Physical Exam: General: Awake, cooperative Neurologic: -Mental Status: Alert, oriented to person place and time. Able to relate history without difficulty. Attentive, able to name DOW backward without difficulty. Language is fluent with intact repetition and comprehension. Speech was not dysarthric. Able to follow both midline and appendicular commands. Current knowledge demonstrated with knowledge of current presidents name . There was no evidence of apraxia or neglect. Able to recall all her medications and dosage with no problems. -Cranial Nerves: I: Olfaction not tested. II: Right pupil 3mm left 2.5mm. III, IV, VI: EOMI without nystagmus. V: Facial sensation decreased on the left to light touch, minimally VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. x [Doctor Last Name ] Tricep minimally weak at 5-/5 XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. left pronator drift, no athetosis type movements noted. No tremor, asterixis noted. Slow initiation of movement on the left. Delt Bic Tri WrE FFl FE IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 5 5 5- 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 On Discharge: Nonfocal examination Slight pain in R groin radiating to LE, no hematoma or edema Pertinent Results: CEREBRAL ANGIOGRAM [2191-1-5] R PCOM aneurysm successfully coiled with no rupture of aneurysm. Preserved flow of the R PCOM artery. Brief Hospital Course: Pt was admitted through the sds department for elective coiling of Right pcomm aneurysm. She underwent the procedure without issue. The only difficulty was that peripheral IV access was not able to be obtained. SHe had a left femoral vein line placed for venous access (4Fr short). She was sent to the ICU for observation overnight. On [1-6], patient remained intact. She report slight pain in the RLE starting in her groin and radiating to the thigh, no hematoma or edema was seen. She was started on neurontin 300mg TID for radicular pain. She was discharged home after ambulating and voiding appropriately. Medications on Admission: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1) Capsule,Extended Release 24 hr PO DAILY (Daily). 4. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. 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 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. Disp:30 Tablet(s) Refills:0 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1) Capsule,Extended Release 24 hr PO DAILY (Daily). 8. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:90 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: right pcomm artery aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Dr. [First Name (STitle) ] / neurosurgery at [Telephone/Fax (1) ] in 6 months /with MRI MRA /Dr [First Name (STitle) ] protocol Completed by:[2191-1-6] Name: [Known lastname ],[Known firstname 14532] Unit No: [Numeric Identifier 14533] Admission Date: [2191-1-5] Discharge Date: [2191-1-6] Date of Birth: [2143-3-21] Sex: F Service: NEUROSURGERY Allergies: Fioricet / ibuprofen Attending:[First Name3 (LF) 40] Addendum: At time of discharge the pt reported that she was having some [Doctor Last Name 14534] in her left eye. She was seen and evaluated by Dr. [First Name (STitle) ]. Her neuro exam was otherwise unchanged. neurology was consulted to see her ( she was just recently admitted to their service for left sided numbness, tingling and weakness). She was transferred to floor status and then later refused to stay the night. This was discussed with Dr. [First Name (STitle) ] and he was agreeable for her to d/c home to follow up with neurology as an oupt. Discharge Disposition: Home [Name6 (MD) ] [Last Name (NamePattern4) 43] MD [MD Number(2) 44] Completed by:[2191-1-6] Name: [Known lastname ],[Known firstname 14532] Unit No: [Numeric Identifier 14533] Admission Date: [2191-1-5] Discharge Date: [2191-1-6] Date of Birth: [2143-3-21] Sex: F Service: NEUROSURGERY Allergies: Fioricet / ibuprofen Attending:[First Name3 (LF) 40] Addendum: Patient was discharged with Percocet 5/325mg tabs - take one tab every 4hrs as needed for pain. Discharge Disposition: Home [Name6 (MD) ] [Last Name (NamePattern4) 43] MD [MD Number(2) 44] Completed by:[2191-1-6*]	[ "401.9", "437.3", "V43.65", "300.4", "378.52", "V45.86", "346.90", "V45.02", "305.1" ]	icd9cm	[ [ [] ] ]	[ "88.41", "39.72" ]	icd9pcs	[ [ [] ] ]	12288, 12428	5951, 6572	319, 345	8483, 8483	5791, 5928	10560, 11649	4207, 4249		7649, 8382		8432, 8462		6598, 7626			8634, 9618	9644, 10537					4836, 5675			4286, 4328												4271, 4271			5689, 5772						242, 281							2450, 3866										8498, 8610					3888, 4081	4097, 4191
9,818	149,679	46385+46386	Discharge summary	report+report	Admission Date: [2153-11-15] Discharge Date: [2153-12-8] Date of Birth: [2098-12-8] Sex: M Service: CHIEF COMPLAINT: Hypotension. HISTORY OF THE PRESENT ILLNESS: The patient is a 54-year-old male with a history of endocarditis secondary to methicillin-sensitive Staphylococcus aureus in [2152-2-27] and two courses of osteomyelitis. He underwent a dental procedure approximately six weeks prior to presentation when he had 14 teeth removed. He reports that he received amoxicillin for one week before and after the procedure. Shortly after the procedure, the patient began to notice fatigue, malaise, and subjective fevers. The patient also appreciated pruritic nontender lesions on both of his hands approximately three days prior to presentation. He also appreciated a similar lesion on his right knee. He denied any shortness of breath, chest pain, nausea, vomiting, or diaphoresis. In the Emergency Department, he was found to be slightly tachycardiac. His systolic blood pressure was initially 130 mm but it dropped to 70. The blood pressure did not respond to 4 liters of normal saline infusion. Two blood cultures were drawn and peripheral dopamine was started. The patient was admitted to the Medical Intensive Care Unit and was covered broadly with ampicillin, gentamicin, and metronidazole. PAST MEDICAL HISTORY: 1. Endocarditis in [2152-2-27]. The patient received six weeks of oxacillin to treat methicillin-sensitive Staphylococcus aureus. 2. Osteomyelitis also in [2152-2-27], lesion in the L2-3 vertebra. The patient also reports osteomyelitis approximately ten years ago in the right foot. He was treated at that time at the [Hospital6 1708] with unknown antibiotics. 3. Ethanol abuse. 4. Intravenous drug abuse. 5. Hepatitis C. 6. Hypertension. 7. Bilateral lower extremity vasculitis secondary to hyperglobulinemia diagnosed by skin biopsy. 8. Remote history of gastrointestinal bleeding, likely due to varices. 9. HIV negative. Tuberculin skin testing was negative as well. MEDICATIONS ON PRESENTATION: 1. Captopril. 2. Folic acid. 3. Neurontin. 4. Vitamin B. 5. Ultram. The doses for these medications were not known at the time of admission. ALLERGIES: The patient reports an allergy to aspirin for which he develops a rash. SOCIAL HISTORY: As stated above, the patient is an injection drug user. He reports that he does not share needles. He has not worked in several years. He was a draftsman. He denied tobacco use. He has not consumed alcohol since [2151-12-30]. FAMILY HISTORY: His mother died of stomach cancer recently. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate 130, blood pressure 126/63, respiratory rate 16, oxygen saturation 96% on room air, temperature 98.6. HEENT: Slightly icteric sclerae. Neck: Jugular veins were flat. The thyroid was not palpable. Nodes: There was no cervical or supraclavicular axillary adenopathy. Heart: Tachycardiac, normal S1 and S2. Initially there was no S3, S4, murmurs, rubs, or gallops. Lungs: Good effort, normal excursion. Clear to auscultation and percussion bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended. Back: No CVA tenderness. Extremities: No edema. Chronic venostasis changes bilaterally in his lower extremities. He had initially one 3 by 2 cm right knee purpuric nontender lesion and bilateral palmar palpable purpuric 3 by 3 mm lesions. LABORATORY EVALUATION: Significant for a white blood cell count of 13, hematocrit 42.7, platelets 88,000. Chemistry panel initially showed a creatinine of 1.0, INR 1.8. Aminotransferase: ALT 100, AST 106, albumin 3.4. CK 459, MB 37, MB index 8.1, troponin 9.8. Urine toxicology screen was negative. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit where he was continued on the antibiotics above. He underwent transesophageal echocardiography which revealed a vegetation on the aortic valve. Several blood cultures revealed a methicillin-sensitive Staphylococcus aureus. The patient's blood pressure ultimately stabilized and he was transferred to the Medical floor. 1. CARDIOLOGY: The patient's antibiotic regimen was initially oxacillin with three days of gentamicin. The gentamicin was then discontinued. The patient was continued on oxacillin; however, approximately ten days into his stay, the patient's total bilirubin and aminotransferases (ALT, AST) started to rise. Oxacillin was discontinued. Nafcillin was started; however, the liver abnormalities persisted. The patient was ultimately switched to vancomycin for the remainder of his hospital course. The patient's hemodynamic status remained stable throughout the duration of his course. The PR interval, although initially slightly above 200 milliseconds remained well below 200 milliseconds after initiation of antibiotic therapy. 2. GASTROINTESTINAL: As stated above, the patient developed a hepatitis that was initially attributed to his use of oxacillin. A liver biopsy was entertained; however, this was put off for approximately one week as the ALT, AST, and total bilirubin plateau'd. He underwent EGD which revealed varices and portal gastropathy consistent with cirrhosis likely due to hepatitis C. New hepatitis serologies did not show a superimposed infection with another viral [Doctor Last Name 360]. 3. NUTRITION: The patient initially, upon transfer to the Medical floor, had a poor appetite for several days. He lost approximately ten pounds. The Nutrition Service was consulted. The patient refused nasogastric intubation initially. However, as his endocarditis responded to vancomycin, his appetite improved and his albumin started to increase slightly. The remainder of this discharge summary will be dictated separately. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Last Name (NamePattern4) 96234] MEDQUIST36 D: [2153-12-10] 04:06 T: [2153-12-10] 16:13 JOB#: [Job Number 98566] Admission Date: [2153-11-15] Discharge Date: [2153-12-13] Date of Birth: [2098-12-8] Sex: M NOTE: This is a Discharge Summary Addendum. It will cover the period of [2153-12-9] until [2153-12-13]. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR SYSTEM: The patient with endocarditis. He was started on vancomycin. Once the sensitivities came back, he was switched to nafcillin and then nafcillin/oxacillin; for which it was believed he had an adverse reaction where his liver transaminases began to elevate. The decision was made to switch the patient to intravenous vancomycin, on which he will remain for six 2. INFECTIOUS DISEASE ISSUES: The patient was followed by the Infectious Disease Service who recommended that the patient remain on vancomycin until [2153-12-30]. This will complete a 6-week course from the patient's first set of negative cultures. Of note, the patient's plasma creatinine should be checked on an every-other-day basis to adequately dose his vancomycin. If the patient's creatinine is greater than 1.3, his vancomycin dose should be every 18 hours. If his creatinine is 1.2 or less, then the patient's vancomycin dose should be given every 12 hours. The patient was scheduled for a followup with the Infectious Disease Service on [12-21] on the sixth floor of the [Doctor Last Name 780] Building at 9 a.m. 3. GASTROINTESTINAL SYSTEM: The patient with a history of hepatitis C with cirrhosis. During this admission, his ALT and AST started to become elevated. He was switched from oxacillin/nafcillin to vancomycin. The Hepatology Service followed the patient and initially wanted a liver biopsy to further evaluate the cause of the elevated transaminases. A computed tomography scan was performed which showed a stable appearance of multiple wedge-shaped infarcts involving the right kidney and spleen along with a cirrhotic liver. On the day the patient was scheduled to have his biopsy, his transaminases improved, and the decision was made to postpone a liver biopsy at that time. DISCHARGE DISPOSITION: He was discharged to a rehabilitation home for intravenous antibiotic treatment. DISCHARGE INSTRUCTIONS/FOLLOWUP: (His discharge instructions were) 1. The patient was to follow up with the Infectious Disease Service on [2153-12-21] at 9 o'clock. 2. The patient was also to follow up with Cardiothoracic Surgery following completion of his intravenous antibiotics for evaluation of valve replacement. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Vancomycin 1000 mg intravenously q.12h.; note, the patient should have his plasma creatinine checked every other day, and his vancomycin dose should be adjusted accordingly. If his plasma creatinine is less than 1.3, the patient should have 1000 mg intravenously every 12 hours. However, if his creatinine is 1.3 or greater, then his vancomycin should be dosed every 18 hours. 2. Ambien 5 mg to 10 mg p.o. q.h.s. as needed. 3. Lactulose 30 mL p.o. q.8h. p.r.n. (titrate to two bowel movements per day). 4. Spironolactone 25 mg p.o. q.d. (hold for a systolic blood pressure of less than 100). 5. Oxycodone sustained release 10 mg p.o. every 12 hours. 6. Metoprolol 12.5 mg p.o. b.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Lisinopril 5 mg p.o. q.h.s. 9. Tramadol 100 mg p.o. q.4-6h. as needed 10. Sodium chloride nasal spray 1 to 2 sprays per nostril q.i.d. as needed. 11. Bacitracin ointment applied to the lesions on the right knee and left buttocks biopsy sites every day. 12. Gabapentin 300 mg p.o. q.d. 13. Pantoprazole 40 mg p.o. q.d. DISCHARGE DIAGNOSES: (Discharge diagnoses included) 1. Endocarditis; Staphylococcus aureus. 2. Malnutrition 3. Former history of alcohol and intravenous drug use -- in remission. 4. Hepatitis C with cirrhosis. 5. Hypertension. 6. Bilateral lower extremity edema vasculitis. 7. Acute renal failure. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Name8 (MD) 6284] MEDQUIST36 D: [2153-12-13] 08:16 T: [2153-12-13] 08:34 JOB#: [Job Number 31813]	[ "447.6", "572.3", "789.5", "571.5", "456.21", "421.0", "070.51", "584.9", "511.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "42.23", "45.16" ]	icd9pcs	[ [ [] ] ]	8260, 8342						2601, 2667	9820, 10357				8696, 9798		3803, 6385				8376, 8669																	6418, 8236											150, 1351																2682, 3785						1373, 2331	2348, 2584
61,606	111,954	39755	Discharge summary	report	Admission Date: [2173-9-9] Discharge Date: [2173-10-10] Date of Birth: [2122-7-8] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[Male First Name (un) 5282] Chief Complaint: Acute renal failure and liver transplant evaluation Major Surgical or Invasive Procedure: Paracentesis Esophagogastroduodenoscopy Hysteroscopy and polypectomy History of Present Illness: Ms. [Known firstname ] [Known lastname ] is a 51 year old lady with history of ESLD secondary to HCV/EtOH (?) cirrhosis (c/b ascites, encephelopathy, and jaundice, variceal status unknown), HIV (recent VL undectectable per pt, off of HAART), diabetes mellitus, and hypertension who presents for liver transplant evaluation. Ms. [Known lastname ] is seen by a hepatologist Dr. [Last Name (STitle) ] in [Location (un) 6691], MA who referred her to Dr. [Last Name (STitle) 497] for transplant evaluation. Patient was seen in clinic and admitted for blood work and therapeutic paracentesis. She reports that she was diagnosed with HCV in [2165] and her course has become more complicated in the past year, with ascites, yellowed eyes, and episodes of "memory loss" that improve with lactulose. She has had multiple paracenteses in the past year- her last one was about two weeks ago, when she reports they removed about 6 liters. She denies a history of varices, but reports she has never had an EGD or colonoscopy. Patient reports she is currently with some abdominal and lower back discomfort secondary to her ascites, but denies focal abdominal pain. Reports she feels cold, but denies objective fevers. Denies nausea, vomiting, hematemesis, black tarry stools, and BRBPR, but reports occasional hemorrhoidal bleeds. On ROS, she does report some SOB associated with her increasing abdominal girth, which has also limited her ability to walk around. Also notes loose stools with her lactulose. Some itchy bumps on arms and chest in the past week, which she has been scratching. + vaginal bleeding attributed to recent d/c of tamoxifen; + hemorrhoids. Denies CP, palpitations, productive cough, headaches, visual changes, myalgias, arthralgias, and dysuria. Past Medical History: HCV- diagnosed in [2165] HIV- diagnosed in [2152]; off of HAART; VL undectable 2 months ago per patient Diabetes mellitus on insulin Hypertension Breast cancer s/p lumpectomy, radiation and tamoxifen in [2167] Hyperlipidemia Social History: Lives in [Location 6691], MA with her daughter and daughter's boyfriend and three grandchildren. Has two sons, one in North [Name (NI) ], and the other one "locked up." Currently on disability, but was previously employed in maintenance and food services at [Last Name (un) 6058]. Quit smoking in [2167], smoked 2-2.5 packs for 30+ years. History of heavy alcohol use in past- 6 pack + bottle of wine in past, but has been sober since [2164]. Remote history of cocaine, crack, LSD, and marijuana as a teen. Denies any history of heroin or IVDU. Family History: Mother with hepatitis C, "liver cancer," and diabetes. Sister passed away from diabetes. Physical Exam: On admission: VS: T 97.0 BP 126/89 HR 71 RR 20 O2sat 100% on RA Gen: thin woman, sitting in bed in NAD HEENT: + scleral icterus; buccal mucosal telangiectasias, clear oropharynx, and moist mucus membranes; poor dentition CV: RRR, no murmur, rubs, gallops Pulm: CTAB, no wheezes, rhonchi, rales Abd: soft, but tensely distended, + fluid wave; non-tender to palpation; +BS; no rebound or guarding; no hepatosplenomegaly appreciated; + umbilical hernia Extr: 3+ lower extremity edema in legs, 1+ in thighs; WWP, 2+ DPs and PTs Neuro: A&Ox3; delayed response time; no asterixis or tremor; CNII-XII evaluated and intact; 5/5 strength in upper and lower extremities; no pronator drift; sensation grossly intact Skin: multiple excoriations on arms and chest; no [Location (un) ] erythema or spider angiomas identified Pertinent Results: Admission Labs: [2173-9-9] 07:20PM WBC-5.5 RBC-2.92* HGB-9.4* HCT-27.2* MCV-93 MCH-32.2* MCHC-34.4 RDW-17.3* [2173-9-9] 07:20PM NEUTS-42* BANDS-0 LYMPHS-43* MONOS-8 EOS-4 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 [2173-9-9] 07:20PM PLT SMR-VERY LOW PLT COUNT-49* [2173-9-9] 07:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2173-9-9] 07:20PM PT-18.2* INR(PT)-1.6* [2173-9-9] 07:20PM HCV Ab-POSITIVE* [2173-9-9] 07:20PM ETHANOL-NEG [2173-9-9] 07:20PM CEA-5.4* AFP-11.0* [2173-9-9] 07:20PM HBsAg-NEGATIVE HBs Ab-BORDERLINE HAV Ab-POSITIVE IgM HBc-NEGATIVE [2173-9-9] 07:20PM TSH-2.5 [2173-9-9] 07:20PM FREE T4-1.5 [2173-9-9] 07:20PM HDL CHOL-22 CHOL/HDL-5.6 [2173-9-9] 07:20PM calTIBC-157* FERRITIN-420* TRF-121* [2173-9-9] 07:20PM ALBUMIN-2.6* CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-2.1 IRON-139 CHOLEST-123 [2173-9-9] 07:20PM GGT-151* [2173-9-9] 07:20PM ALT(SGPT)-24 AST(SGOT)-53* ALK PHOS-82 TOT BILI-1.8* [2173-9-9] 07:20PM GLUCOSE-101* UREA N-25* CREAT-1.8* SODIUM-130* POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11 [2173-9-11] 09:53PM BLOOD Smooth-NEGATIVE [2173-9-18] 07:20AM BLOOD RheuFac-33* [2173-9-11] 09:53PM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [Last Name (un) ] . Micro: [9-10] Peritoneal fluid- GS 1+ polys; cx no growth [9-10] URINE CULTURE (Final [2173-9-12]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. (pan sensitive) [9-10] HIV-1 Viral Load/Ultrasensitive: 30,600 copies HCV-Ab: Positive HCV VIRAL LOAD:1,770,000 IU/mL. HBsAg: Negative HBs-Ab: Borderline Positive -- C/W Titer Of Roughly 10 Miu/Ml HAV-Ab: Positive IgM-HBc: Negative HSV 1 IGG TYPE SPECIFIC AB 3.44 H HSV 2 IGG TYPE SPECIFIC AB >5.00 H Rubella IgG/IgM Antibody: positive RAPID PLASMA REAGIN TEST: NR VARICELLA-ZOSTER IgG SEROLOGY: pos CMV IgG ANTIBODY: pos CMV IgM ANTIBODY: pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB: Pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB: Pos [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB: Pos TOXOPLASMA IgG ANTIBODY: Equivocal 7 IU/ML [9-13] Peritoneal fluid- GS negative; 1PMN; cx negative (prelim) [9-16] Urine cx- MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION [9-17] Blood cx- pending [9-17] Peritoneal fluid- GS negative; cx- no growth (prelim) . Studies: [9-10] TTEcho: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . [9-10] Abd U/S w/ Doppler: 1. Nodular hepatic architecture with no focal liver lesion identified. 2. Patent portal vein, however, a small nonocclusive thrombus is seen within the left portal vein. 3. Large amount of ascites. A mark was made at the right lower quadrant for a paracentesis to be performed by the clinical staff. . [9-14] EGD: Grade I varices. . [9-17] CXR: In comparison with the study of [9-15], there is no evidence of focal pneumonia. There are continued low lung volumes. Dobbhoff tube extends at least to the second portion of the duodenum. There is, however, an area of opacification in the right upper zone medially that appears to be contiguous with the medial aspect of the clavicle and could well represent an expansile lesion. For further evaluation, views of the clavicle and sternoclavicular joints are recommended. If this proves to be a skeletal finding, cross-sectional imaging would be helpful. . [9-17] Rt Clavicle XR: No expansile lesion identified. There are mild degenerative changes of the sternoclavicular joint. If there is pain relating to the right sternoclavicular joint, then MRI of the sternoclavicular joints could certainly be performed to further assess. . [9-21] CT Abd/Pelvis: 1. Massive ascites seen throughout the abdomen and pelvis. 2. No radiographic evidence of ileus. 3. Thickened endometrial wall vs endometrial cavity, recommend further evaluation with ultrasound to characterize the uterus as differential diagnosis includes endometrial carcinoma . [9-22] Peritoneal Fluid: NEGATIVE FOR MALIGNANT CELLS. . [9-22] Pelvic Ultrasound: Markedly abnormal endometrium, which is thickened, heterogeneous and vascularized as described above, concerning for endometrial neoplasm. Recommend tissue sampling for further evaluation. Brief Hospital Course: 51 year old woman with history of ESLD [1-26] HCV/EtOH (?) c/b ascites, encephelopathy and jaundice, HIV, DM, and HTN who presented for liver transplant evaluation with acute kidney failure. # ESLD- Patient was admitted from clinic for liver transplant evaluation. Her MELD was 20 on [9-10]. Transplant evaluation labs were sent, including: AFP 11, CEA 5.4, HCV VL 1.7 million, CMV IgG, IgM positive, RPR NR, toxo IgG equivocal, VZV IgG pos, HIV VL 30,600, Hep A IgG pos, Hep B sAg neg, sAb borderline pos, cAb IgM neg. EBV IgG and IgM positive, anti-smooth mscl negative, [Doctor First Name ] 1:40 pos, alpha 1 antitrypsin negative. PPD was placed and was negative. She had an abdominal U/S with dopplers which showed hepatic nodularity and a small non-occlusive thrombus in the left portal vein, but patent main portal vein. She underwent EGD, which showed grade 1 varices. She was evaluated by nutrition and started on tubefeeds to improve her nutritional status. She developed encephalopathy while hospitalized with asterixis on exam and mild confusion which improved with lactulose. She continued to have tense ascites requiring frequent paracenteses of 2-3L. Albumin was given directly after these procedures. She was also treated empirically with ceftriaxone for possible SBP, although all paracentesis were not consistent with SBP. Her bilirubin continued to rise throughout the admission, her encephalopathy was stable. She completed pre-transplant evaluation with the exception of a colonoscopy. A long discussion was held with the family and patient about utility of pursuing a liver transplant given poor prognostic comorbidities in her such as HIV, HCV, renal insufficiency, and a difficult social/financial situation. The pt stated on numerous occasions that she would rather go home and spend time with her family than continue with the transplant evaluation, and she was ultimately discharged home with hospice care. . # Impaired renal function - Baseline creatinine was around 1.0 in [2173-2-22] per outpatient ID records, but as of [Month (only) 205] patient has had worsening function attributed to diuretics & pre-renal causes. On admission, patient's was creatinine 1.8. UA showed 100+ hyaline casts and urine sodium <10. Diuretics were held and albumin administered with initial response (creatinine trended down to 1.3), but subsequently bumped back up to 1.6 and was no longer responsive to albumin. She was started on octreotide and midodrine for treatment of presumed HRS. Renal was consulted considering significant blood in her UA (attributed to her hemorrhoids), and proteinuria (attributed to her diabetes). MPGN related to HCV was felt to be unlikely given no acanthocytes on smear, but complements, cyro, and RF were sent. Her creatinine eventually increased and peaked at 3.1. She was treated for hepatorenal syndrome with daily octreotide, midodrine, and albumin. Her renal function improved slightly to 2.5 but did not normalize prior to discharge. Renal transplant team was consulted and concluded that she would not be a candidate for renal transplant even in the setting of liver transplant. . # Anemia - Normocytic. Pt had Hct drop to 19.3 from 21.5 on [9-12], without evidence of GI bleeding and received 1 unit pRBCs. She received a second unit on [9-16] with appropriate bump. Iron studies were sent and were not significant for iron deficiency. She was transferred to the MICU on [9-20] due to bleeding from her recent paracentesis site. Her hematocrit dropped to 22.8 at this time and she was given 2 units PRBCs. She was also give cryo for an FFP of 90 and FFP, although it was not felt that she was in DIC. This bleeding resolved, but she began to have vaginal bleeding in moderate amounts on [9-21]. She had workup for her vaginal bleeding (see below) and it eventually slowed. She required intermittent blood transfusions to maintain her hematocrit. She remained hemodynamically stable throughout. . # HCV/EtOH (?) Cirrhosis c/b ascites, encephelopathy, jaundice, and Grade I varices on EGD ([9-14]). Duplex doppler abdominal U/S showed a nodular hepatic pattern, non-occlusive left portal vein thrombus, and patent main portal vein. Serum EtoH negative and pt reports no EtOH since [2164]. Currently w/ acites and mild jaundice, but no active bleeding or encephelopathy. Patient was continued on her home nadolol and lactulose. Her diuretics were held given her renal function. She was given a low sodium diet with nutritional supplements, evaluated by nutrition with placement of a Dobhoff and initiation of tube feed nutritional supplements. LFTs were trended. She did not have any episodes of variceal bleeding. She underwent several therapeutic paracentesis (usually 2-3 liters) which were negative for SBP as above. . # HIV- Patient's ART was recently discontinued by her outpatient ID specialist Dr. [Last Name (STitle) 87563] secondary to an undetectable VL and labile renal function. During this hospitalization VL was 30,600 and CD4 count = 436. PPD was placed and was negative. ID was consulted and recommended deferring reinitiation of ART in the pre-transplant setting until patient's renal function stabilized. Patient was scheduled to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] in [Month (only) 359], who will work in collaboration with Dr. [Last Name (STitle) 87563] to initiate an appropriate ART regimen. HIV genotype is pending. ID recommended sending HLA B5701 and intiated HAART therapy with etravirine, abacavir, lamivudine, raltegravir. . # Urinary tract infection- Patient was found to have UTI with pan sensitive Klebsiella pneumoniae on culture. She was treated with 3 days of ciprofloxacin. Later in admission she was found to have VRE UTI and treated with 10 day course of daptomycin. . # Tinea corporis- Patient complained of itching and was noted to have two round hyperpigmented plaques with scaling (KOH +)- one on her right chest and one on her neck. She was started on miconazole for tinea corporis and dermatology was consulted given multiple folliculocentric papular excoriations on her chest of unknown etiology. Dermatology recommended continuing anti-fungal treatment for the tinea corporis and symptomatic anti-pruritic treatments. They felt her excoriations were consistent with pityrosporum folliculitis (which she is predisposed to given her HIV and DM) and recommended continued topical anti-fungals and anti-pruritic treatments with sarna, loratidine, and atarax if needed. . # Vaginal bleeding - 2 weeks after admission pt developed profuse vaginal bleeding in setting of coagulopathy (with concomitant bleeding from paracentesis site and IV lines), she was transferred to the MICU where she was transfused and stabilized. An ultrasound was done which revealed a very thickened endometrium at 4cm, likely due to polyp. She had an endometrial biopsy with was negative for malignancy. Her vaginal bleeding continued and pt was using [3-29] pads per day, dropping HCT and requiring transfusions. Etiology of thick endometrium was likely hyper-estrogenic state, coagulopathy, and taking tamoxifen in the past for breast ca. When the bleeding did not subside, she had hysteroscopy with polypectomy, no ablation was done given too much bleeding during the procedure. After procedure, bleeding stabilized with exception of one large volume bleed, she continued to use [12-26] pads/day but did not require further transfusions. Discussion was had about possible hysterectomy but the surgery would be too high risk given her hepatic impairment. . # Diabetes mellitus- Patient was initially continued on her home lantus 16 units qHS and a sliding scale was added. After tube feeds were started, patient's sugars jumped up and she required a new regimen and her lantus was uptitrated. Her home sitagliptin was held while she was an inpatient. Feeding tube was taken out prior to discharge and she can resume her admission insulin requirements. . # Home hospice - pt was discharged on midodrine, omeprazole, cipro, lactulose, rifaximin, and PRN meds (simethicone, ketoconazole, cortisone, morphine, ativan) Medications on Admission: Medications at home: (from admission note) Lactulose (1x per day) Lantus 16 units qHS Prilosec Sitagliptin 50 mg (?) Nadolol 20 mg Lasix 40 mg Spironolactone 50 mg [pravastatin, zetia, calcium, lisinopril 10 mg ? per outpt ID note] Zerit liquid 40 mL [Hospital1 ] Kaletra 5 mL [Hospital1 ] Viread 300 mg (ART d/c-ed on [2173-7-7]) . Medications on transfer: Lantus 50 units daily Humalog sliding scale insulin Influenza Virus Vaccine 0.5 mL IM NOW X1 Ketoconazole 2% 1 Appl TP [Hospital1 ] Please apply to lesions on chest and neck. Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY Acetaminophen 500 mg PO/NG Q6H:PRN Pain Lactulose 30 mL PO/NG Q6H titrate to [2-25] BM daily Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN bloating, gas pain Midodrine 10 mg PO TID Albumin 25% (12.5g / 50mL) 50 g IV ONCE Duration: 1 Doses ([9-24] @ 1643) Multivitamins 5 mL PO/NG DAILY CeftriaXONE 2 gm IV Q24H Nadolol 40 mg PO DAILY Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol Octreotide Acetate 200 mcg SC Q8H Fexofenadine 60 mg PO DAILY:PRN itching Ondansetron 4 mg IV Q8H:PRN nausea Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol Rifaximin 550 mg PO/NG [Hospital1 ] Heparin Flush (10 units/ml) 2 mL IV PRN line flush Sarna Lotion 1 Appl TP [Hospital1 ]:PRN itching Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN rectal discomfort Simethicone 40-80 mg PO/NG QID:PRN gas pain Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Discharge Medications: 1. [Hospital ] Hospice care of the Berkshires emergency kit for patient [Known firstname ] [Known lastname ] to be discharged from the hospital to home [10-9] 2. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO q3-4hr as needed: 5-20mg PO/SL q3-4hr prn. Disp:100 ml Refills:0 3. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO q3hr as needed. Disp:50 Tablet(s) Refills:0 4. ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:0 5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for itching. Disp:30 Tablet(s) Refills:0 6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. Disp:100 Tablet, Chewable(s) Refills:0 7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours). Disp:3600 ML(s) Refills:0 9. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for rectal discomfort. Disp:1 tube Refills:0 10. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 11. 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 12. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: HospiceCare of the Berkshires Discharge Diagnosis: Primary: Cirrhosis Hepatorenal syndrome Uterine polyp VRE UTI Anemia . Secondary: HIV HCV DM HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at the [Hospital1 18]. You were admitted to the hospital because of kidney failure. While you were in the hospital you were treated with medications and your kidney function improved. You were also found to have a urinary tract infection which was treated with antibiotics. During your hospitalization we began evaluation for a possible future liver transplant. Your liver function continued to get worse, however. After a long discussion with you and your family, you decided that you would like to go home without pursuing the liver transplant. We removed your feeding tube before you went home and took a lot of fluid out of your abdomen. You should continue to have weekly taps to take fluid out of your belly when it becomes uncomfortable. You will also continue some medications for your kidneys and your liver (listed below). . Continue midodrine for your kidneys Continue omeprazole Continue ciprofloxacin to prevent infection Continue lactulose and rifaximin to help prevent confusion The rest of your medications are "as needed" for symptoms Followup Instructions: home hospice will arrange for the rest of your care Completed by:[2173-10-11]	[ "041.04", "584.9", "599.0", "V85.1", "285.1", "263.9", "621.0", "627.1", "572.4", "482.0", "042", "789.59", "V10.3", "401.9", "998.11", "799.4", "V09.80", "E879.8", "572.3", "E849.7", "303.93", "456.21", "572.8", "276.1", "287.49", "571.2", "070.71", "583.9", "041.3", "782.1", "250.00" ]	icd9cm	[ [ [] ] ]	[ "54.91", "68.29", "96.6", "68.23", "68.16", "38.97", "46.32", "38.93" ]	icd9pcs	[ [ [] ] ]	20215, 20275	8939, 17139	328, 399	20417, 20417	4013, 4013	21724, 21808	3073, 3163		18669, 20192		20296, 20396		17165, 17165			20572, 21701					17186, 17510				3178, 3178																					237, 290							428, 2215					4030, 8916				3192, 3994	20432, 20548				17535, 18646	2237, 2475	2491, 3057
26,274	158,626	42960	Discharge summary	report	Unit No: [Numeric Identifier 92734] Admission Date: [2129-5-23] Discharge Date: [2129-5-28] Date of Birth: Sex: F Service: TRANSPLANT SURGERY DISCHARGE DIAGNOSES: Status post remote kidney transplant. Confusion. Hypertensive crisis. Acute tubular necrosis. PROCEDURES: No major procedures during this admission. HISTORY: The patient presented on [2129-5-23] complaining of confusion. She is a 46-year-old female with a history of type 1 diabetes and end-stage renal disease on hemodialysis, which have now both resolved status post kidney and pancreas transplant. She presented to ED complaining of word-finding difficulty that was associated with a headache. On presentation, her blood pressure was 253/135. She had apparently had prior episodes of similar symptoms, which usually resolved on their own. On prior occasions, head imaging showed no pathology. She denied any stiff neck, fever, chills or respiratory symptoms. She had no dysuria or frequency. The relation between her blood pressure crisis and confusion had been appreciated in the past. She had no history of seizures with these episodes and no recent head trauma. PAST MEDICAL HISTORY: Diabetes type 1. Status post pancreas transplant in [2-22]. End-stage renal disease status post kidney transplant. Hypertension. Coronary artery disease status post CABG in [2-21]. Diarrhea. Depression. Gastroparesis. Hearing loss. Right-hand fracture. Claudication. Asthma. Osteopenia. Hyperlipidemia. MEDICATIONS ON PRESENTATION: 1. Rapamycin 3 mg q.d. 2. Prednisone 5 mg q.d. 3. Imuran 50 mg q.d. 4. Bactrim Single Strength 1 q.d. 5. Multivitamin 1 q.d. 6. Vasotec, dosage unknown. 7. Lopressor, dosage unknown. 8. Norvasc, dosage unknown. PHYSICAL EXAMINATION: Vitals: Pulse 90, blood pressure 253/135, respirations 20, and 99 percent on room air. General: A well-developed female, confused, alert, oriented x1 to person, mumbled responses requiring frequent prompting. She did move all extremities well and ambulated steadily. Head is normocephalic, atraumatic. Extraocular muscles are intact. She has anicteric sclerae. Right pupil is mildly reactive, left pupil is nonreactive to light. No lymphadenopathy. Neck: Supple. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, with a well-healed midline incision, with no hernia. Extremities: Show no edema. LABORATORY DATA: White count is 6, hematocrit 37.1, and platelets 145. Electrolytes: sodium 131, potassium is 4.6, chloride 104, bicarbonate 17, BUN is 42, creatinine is 4.2 and glucose 106, lactate is 1.5. ALT is 15, AST is 37, alkaline phosphatase is 67, total bilirubin is 0.2. Urine tox screen is negative. IMAGING DATA: Chest x-ray showed no infiltrate. CT of the head showed no infarct, no bleed. EKG was unchanged from prior. ASSESSMENT: This is a 46-year-old female with a history of diabetes type 1 status post pancreas and kidney transplant, on immunosuppression, who presents with confusion. The plan is to admit the patient to the ICU for IV, blood pressure management, Neurology consult, frequent neurologic checks, Transplant Nephrology consult regarding her recently rising creatinine and to continue immunosuppression. Neurology saw the patient, and during her ICU course, she also had an MRI of her head, which was negative. Her blood pressure was initially controlled on labetalol drip, which she responded nicely to, and her PO regimen was increased and she was able to be weaned off her Lopressor drip. The patient's mental status returned to baseline after her blood pressure control was obtained. Additionally, an LP was performed, which was negative. The patient had no respiratory issues on this admission. GI: She tolerated a regular diet without difficulty. GU: Again, the patient's creatinine remained in the 4s. She had a recent biopsy, as her creatinine has been rising steadily in the last couple of months, and this showed apparently no evidence of rejection. A concern for possible renal artery stenosis was ruled out with an MRI/MRA of her abdomen which showed widely patent transplant renal artery. She has been making good urine, over 2 liters a day, and her immunosuppressions have been continued. She is deemed stable for discharge today to home. DISCHARGE INSTRUCTIONS: Follow up in Transplant Center on Monday for labs. CONDITION ON DISCHARGE: Stable. She is alert and oriented. She has a GCS of 15. She is oriented x3 and has no focal neurologic deficits. Her abdomen is soft and benign. Her lungs are clear. Heart is regular in rate and rhythm. DISCHARGE MEDICATIONS: She was sent home with prescription for, 1. Lipitor 10 q.h.s. 2. Imuran 25 q.d. 3. Desipramine 150 q.d. 4. Doxazosin 1 q.h.s. 5. Folate 1 q.d. 6. Hydralazine 25 every 6 hours. 7. Labetalol 300 every 12 hours. 8. Multivitamin q.d. 9. Protonix 40 q.d. 10. Prednisone 5 q.d. 11. Sirolimus 3 q.d. 12. Bactrim Single Strength 1 every Monday, Wednesday and Friday. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Last Name (NamePattern1) 13138] MEDQUIST36 D: [2129-5-28] 11:54:33 T: [2129-5-29] 21:12:22 Job#: [Job Number 92735]	[ "787.91", "V45.81", "996.81", "337.1", "584.5", "414.00", "401.0", "536.3", "V42.83" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]								209, 1198	4729, 5376							4419, 4471																					1811, 4394																															1221, 1788		4496, 4705
78,870	164,649	5105	Discharge summary	report	Admission Date: [2132-8-7] Discharge Date: [2132-8-27] Date of Birth: [2049-2-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3326] Chief Complaint: Post-PEG placement Major Surgical or Invasive Procedure: PEG History of Present Illness: 83 year old woman with history significant for bronchiectasis complicated by indolent Mycobacterium abscessus infection for which she is on azithromycin and linezolid. Her course has been complicated by anorexia and failure to thrive and she was referred for elective percutaneous gastrostomy tube for feeding. She is presently in bed, she complains of extreme fatigue, nausea, and mild abdominal pain. She denies fevers, chills, chest pain, shortness of breath - she does have a chronic cough productive of sputum. ROS otherwise negative/ Past Medical History: Bronchiectasis Atypical mycobacteria infection (mycobacterium abscessus) Hypertension Hypercholesterolemia Weight loss Osteoporosis Social History: Lives independently with husband. [Name (NI) ] pets. Tobacco: Past smoking history of approximately [1-23] cigarettes/day over 33 years, though quit 32 years ago. EtOH: Denies Illicits: Denies Family History: Father died of heart attack at age 70. Mother died at age [Age over 90 ]. Older sister had diabetes and died at age [Age over 90 ]. [Name (NI) ] sister had breast cancer and died at age 85. No history of sudden death in family. No other contributory family history. Physical Exam: GENERAL: Thin, ill appearing, VITALS: 97 170/80 65 94RA HEENT: WNL COR: Regular S1 and S2 CHEST: Coarse breath sounds/soft crackles left. ABD: Soft, thin, PEG CDI EXT: Cool, no rash. NEURO: Alert, interactive, gross strenght normal and symmetrical Pertinent Results: None available Brief Hospital Course: #.ANOREXIA/MODERATE MALNUTRITION: Patient initially admitted for PEG placemen. Tube feeds were advanced to a goal of 45cc/hr on [2132-8-9]. Abdominal pain and nausea slowly resolved. Diet advanced to full liquids on [2132-8-10]. . #.Dyspnea: On the floor, patient became acutely dyspneic on the morning of [2132-8-10], thought to be [12-24] pulmonary edema in the setting of IVF. Pt received Hydralazine 10mg IV x 2, 2 inches of nitropaste, Lasix 20mg IV x 1, and Cefepime with improvement in her blood pressure and dyspnea. She was weaned from 5L of O2 to RA by 5pm. CXR was read as asymmetric pulmonary edema vs. multifocal pneumonia. On [8-11], the patient had a similar episode of acute shortness of breath. Her BP was >200/100. She again receive hydralazine, nitropaste and lasix. Though her BP came down to 180s she was unable to wean from 02 and required NRB. She was transferred to the MICU for respiratory distress. She was initially managed on non-invasive positive pressure ventilation. However, she had icreasing work of breathing, rising CO2 and was intubated for respiratory failure. CT of the lungs showed new multifocal pneumonia on top of the patient's existing cavitary lung disease. The patient was initially treated with Vanco/Cefepime/Cipro and she was continued on her home regimen of linezolid/azithromycin for her mycobaterium abscessus. Sputum culture and mini-BAL grew pseudomonas and the patient was continued on Cefepime/Cipro. The patient's pneumonia initially did not clinically improve (no improvement in ventilation and worsening in imaging). Repeat sputum cultures grew pseudomonas that was intermediate sensitivity to cefepime and ID was consulted. The patient was then switched to meropenem and inhaled tobramycin for a planned 21 day course. The patient's respiratory status clinically improved over the next week and she was weaned from the ventilator. A family meeting was held on [8-25] to decide about goals of care and future need for tracheostomy. The patient's primary pulmonologist, primary infectious disease doctor, ICU team, case manager, husband and daughter were all present. The patient was intubated but not sedated. A decision was made to extubate the patient, make her DNR/DNI and send her home with hospice care. After extubation the patient remained with 02 sats >90% on 5-6L 02. Her meropenem and inhaled tobramycin were stopped on discharge. . #Hypotension: Thought [12-24] sepsis/pneumonia and sedation. Patient became hypotensive peri-intubation and levophed was started to maintain MAPs>65. Access was initially difficult so a femoral line was initially placed. This was replaced by a central line the next morning. A line was also placed. The patient required levophed intermittently during the first week she was intubated. As her infection was treated and her sedation was weaned off, the patient was able to maintain her blood pressure on her own and became hypertensive. She required fluid boluses on 2 mornings for MAPs<65 and she responded quickly. She was started back on a lower dose of her hydralazine which was titrated up throughout her ICU stay. . # Acute Renal Failure: Pt's creatinine increased to a peak of 1.3 on [2132-8-9]; she was started on IVF with resolution of her renal failure. IVF were stopped on [2132-8-10] due to acute dyspneic episode, and electrolytes and creatinine remained stable. . # MYCOBACTERIAL ABSCESSUS INFECTION: Pt was continued on Linezolid/Azithromycin throughout her hospital stay. Her primary infectious disease doctor [First Name (Titles) ] [Name (NI) 653] and agreed with this plan. She will continue these medications on discharge. . Medications on Admission: Albuterol Inhaler 2 PUFF IH Q6H Alendronate Sodium 5 mg PO 1X/WEEK HydrALAzine 50 mg PO BID Linezolid 600 mg PO QD Lisinopril 40 mg PO DAILY Mevacor NF 20 mg Oral QD Nadolol 100 mg PO DAILY Aspirin 325 mg PO DAILY Azithromycin 250 mg PO DAILY PANTOPRAZOLE 40 mg Tablet DAILY CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] DEXTROMETHORPHAN 30mg/5 mL Liquid - [Hospital1 ] PRN MULTI-VITAMIN Discharge Medications: Per hospice protocol, including linezolid and azithromycin for M.abscessus and home 02. Discharge Disposition: Home With Service Facility: [Hospital 269] Hospice Care Discharge Diagnosis: Pseudomonal Pneumonia Chronic atypical mycobacterial pneumonia Sepsis requiring intubation and vasopressors Hypertension . Discharge Condition: Stable, 02 sats >90% on6L Discharge Instructions: You came to the hospital with shortness of breath and you were found to have pneumonia. You required a breathing tube and were in the ICU for several weeks. You were able to come off the breathing tube and together with your family it was decided that you would go home with hospice care. . Please take medications per hospice protocol. You should also continued to take the following medications: Azithromycin Linezolid Hydralazine Lisinopril . If you have any concerns about medications please feel free to call your hospice nurse or any of your doctors. . If you have any symptoms that are uncomfortable or concerning to you please call your hospice nurse first. If you are unable to reach your hospice nurse please call your primary care doctor. . Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724], Infectious Disease, Thursday [9-11], 2:30 PM in [Hospital Unit Name ], basement. . Otherwise, as needed	[ "031.8", "031.0", "584.9", "272.0", "V66.7", "733.00", "276.51", "E938.3", "482.1", "799.02", "518.81", "307.9", "V85.0", "401.9", "535.40", "285.9", "038.9", "518.4", "494.1", "272.4", "530.19", "513.0", "783.21", "V44.1", "V15.82", "263.0", "995.92" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "96.72", "33.24", "38.91", "96.04", "00.14", "43.11" ]	icd9pcs	[ [ [] ] ]	6166, 6229	1900, 5613	332, 337	6396, 6424	1861, 1877	7227, 7416	1298, 1577		6054, 6143		6250, 6375		5639, 6031			6448, 7204									1592, 1842																					274, 294							365, 908															930, 1063	1079, 1282
24,593	176,966	22704	Discharge summary	report	Unit No: [Numeric Identifier 58800] Admission Date: [2187-6-24] Discharge Date: [2187-7-5] Date of Birth: [2109-4-25] Sex: M Service: VSU ADMISSION DIAGNOSIS: Neck mass. DISCHARGE DIAGNOSIS: Death. CHIEF COMPLAINT: This is a 78-year-old male with an enlarging neck mass. HISTORY OF PRESENT ILLNESS: This 78-year-old male with a 6- week history of a sore throat, dysphagia and difficulty breathing who appeared to have a thyroid mass on exam by his physician. [Name10 (NameIs) ] underwent a CT scan with fine needle aspiration which was indeterminate in an outside hospital and he was seen by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] who felt that based on the symptoms of his thyroid mass that it may be a thyroid cancer. He was therefore booked for an operative thyroidectomy. The patient was admitted to the hospital on [4-24] of [2187] for thyroidectomy. PAST MEDICAL HISTORY: Past medical history is significant for peripheral vascular disease, aortic aneurysm, CREST syndrome, scleroderma, CAD with CHF, paroxysmal atrial fibrillation, iron deficiency anemia, gout, chronic renal failure, deep venous thrombosis, asbestosis, hypertension, hypothyroidism. PAST SURGICAL HISTORY: Past surgical history is significant for bilateral femoral to dorsal pedal bypass grafts with saphenous vein for treatment of bilateral thrombosed popliteal aneurysms. MEDICATIONS ON ADMISSION: Aspirin, Synthroid, Lopressor, Protonix, Lasix, insulin. ALLERGIES: An allergy to Coumadin as well as a questionable allergy to heparin. SOCIAL HISTORY: He is married with 6 children, a retired electrician, 1 pack per day smoking history for 4 years. He quit 45 years ago. He rarely drank alcohol. REVIEW OF SYSTEMS: Significant for occasional shortness of breath, dyspnea on exertion, otherwise unremarkable. HOSPITAL COURSE: The patient was admitted to the surgical service and on [6-26], underwent a neck exploration with biopsy of the central portion of the thyroid and tracheostomy for an obstructing goiter. That was subsequently revealed to be lymphoma. On the 31st, he underwent a percutaneous endoscopic gastrostomy for nutrition. He was seen by hematology/oncology on [6-28] for treatment of his B-cell lymphoma and he was transferred to the hematology/oncology service for that. On [7-3], however, he underwent a CT scan for abdominal pain and was found to have a ruptured retroperitoneal aortic aneurysm. He was emergently taken to the operating room by Dr. [Last Name (STitle) 1391] and he underwent a repair of a ruptured aortic aneurysm. Postoperatively, he was noted to have pale bilateral lower extremities. By postoperative day #1, these were beginning to demarcate at the mid thigh. At this time, he was intubated in the intensive care unit. He was taken back to the operating room for bilateral femoral embolectomies because of progressive ischemia of his bilateral lower extremities. This happened on [7-4]. Postoperatively, however, he had persistent ischemia of both lower extremities. By [7-5], he was respirator-dependent with rising creatinine kinase. His extremities were completely demarcated at the mid thigh and given his degree of progressive renal failure/anuria, hypotension requiring pressors, respiratory failure requiring ventilator support and peripheral vascular disease with ischemia of both lower extremities that was going to require bilateral lower extremity amputations, his family deemed that they did not want to pursue any further aggressive treatment options and the patient was made comfort measures only. The patient expired on [7-5] at 6:50 p.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern4) 25081] MEDQUIST36 D: [2187-7-5] 21:43:32 T: [2187-7-5] 22:08:25 Job#: [Job Number 58801]	[ "V16.7", "V66.7", "428.0", "202.80", "585.9", "V16.51", "441.3", "996.74", "518.81", "427.31", "V16.1", "286.9", "710.1" ]	icd9cm	[ [ [] ] ]	[ "06.12", "99.25", "99.07", "96.6", "38.93", "38.44", "43.11", "31.1", "99.04", "39.49" ]	icd9pcs	[ [ [] ] ]											216, 224		1453, 1593	1888, 3959									1257, 1426															182, 194					1776, 1870			242, 299							328, 929															952, 1233	1610, 1756
10,041	168,954	25808	Discharge summary	report	Admission Date: [2137-7-15] Discharge Date: [2137-8-7] Date of Birth: [2110-1-15] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5880] Chief Complaint: paraplegia Major Surgical or Invasive Procedure: C5 vertebrectomy & C4-6 fusion [7-16] Bronchoscopy [7-18] IVC filter placement [7-19] Posterior C5 fusion w/ iliac crest autograft [7-21] Open tracheostomy & GJ tube placement [7-26] History of Present Illness: 27 healthy man who dove into shallow water & hit his head. Afterwards, he was unable to feel the lower half of his body. After being diagnosed with a C5 fracture, he was transferred to [Hospital1 18] for further management. Past Medical History: none Social History: noncontributory Family History: noncontributory Physical Exam: Cooperative, GCS 15 AVSS NCAT, no hemotympanum PERRLA, EOMI +c collar, trachea midline, C spine tenderness RRR CTAB Soft NT ND Pelvis stable, +priapism Extrem: WWP, 2+/= DP's, 0/5 strength, no sensation Pertinent Results: [2137-8-6] 08:54AM BLOOD WBC-22.8* RBC-3.07* Hgb-9.5* Hct-27.4* MCV-89 MCH-31.0 MCHC-34.7 RDW-13.2 Plt Ct-401 [2137-8-6] 08:54AM BLOOD Glucose-107* UreaN-29* Creat-0.6 Na-136 K-4.2 Cl-98 HCO3-28 AnGap-14 [2137-8-2] 02:24AM BLOOD PT-13.3 PTT-23.8 INR(PT)-1.2 Brief Hospital Course: Procedures: [7-16] C5 vertebrectomy & C4-6 fusion [7-18] Bronchoscopy [7-19] IVC filter placement [7-21] Posterior C5 fusion w/ iliac crest autograft [7-26] Open tracheostomy & GJ tube placement Systems Based Review: NEURO: Neurosurgery & spine services consulted on admission. Taken to OR on HD2 for operative repair of C5 fracture, with ultimate posterior fusion on HD7. Sedated during endotracheal intubation. Gradually weaned off sedation after trach placed. Still receives ativan & roxicet prn. CV: Slightly hypertensive throughout admission. Was receiving prn lopressor, but is now normotensive without medications. RESP: Trach placed on [7-26]. Weaned off mechanical ventilation but some LLL collapse & MRSA pneumonia prevented complete freedom from mech ventilation. FEN/GI: Off IV fluids. Tube feedings at goal rate (promote w fiber at 100cc/hr) via J port of GJ tube. Having solid bowel movements. C diff negative x 3. HEME: stable hct. lovenox QD & IVC filter for DVT/PE prophylaxis. ID: continue linezolid x 1 week after discharge for MRSA pneumonia. [7-17] s/c h flu. [7-25] s/c MSSA. [7-27] s/c MRSA ENDO: regular insulin sliding scale. DISP: full code Medications on Admission: none Discharge Medications: 1. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous once a day. Disp:30 syringes Refills:2 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily). Disp:30 dose Refills:2 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection ASDIR (AS DIRECTED): follow attached sliding scale-. Disp:30 dose Refills:2 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:1 inhaler Refills:5 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:1 inhaler Refills:5 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:250 ML(s) Refills:3 8. Acetaminophen 160 mg/5 mL Elixir Sig: Two (2) teaspoon PO Q4-6H (every 4 to 6 hours) as needed. Disp:250 ML Refills:2 9. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day): 100mg/dose. Disp:250 ML Refills:2 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 11. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for prn insomnia. Disp:30 Tablet(s) Refills:0 12. Linezolid 100 mg/5 mL Suspension for Reconstitution Sig: Thirty (30) ML PO twice a day for 1 weeks: 600 mg/dose. Disp:420 ML Refills:0 13. Lorazepam 2 mg/mL Syringe Sig: One (1) ML Injection q2h as needed for anxiety. Disp:30 ML Refills:0 Discharge Disposition: Extended Care Facility: the [Last Name (un) ] center Discharge Diagnosis: C5 fracture Spinal cord compression Quadriplegia MRSA pneumonia Haemophilus pneumonia Discharge Condition: stable Discharge Instructions: [Hospital 5442] rehab & conditioning per protocol. Tube feedings & medications as prescribed. Followup Instructions: Continue your treatment at the [Hospital3 64269] in [Location (un) 9012]. you may follow up with us at [Hospital1 18] if you have any problems. Completed by:[2137-8-6]	[ "V09.0", "E883.0", "482.41", "806.09", "512.8", "998.81", "518.5", "482.83" ]	icd9cm	[ [ [] ] ]	[ "84.51", "96.04", "33.24", "96.6", "81.03", "38.7", "77.79", "96.72", "81.62", "38.91", "00.14", "33.21", "31.1", "45.13", "03.09", "43.11", "81.02", "03.53", "38.93" ]	icd9pcs	[ [ [] ] ]	4415, 4474	1412, 2637	324, 529	4604, 4612	1118, 1389	4759, 4946	863, 880		2692, 4392		4495, 4583		2663, 2669			4636, 4736									895, 1099																					274, 286							557, 786															808, 814	830, 847
8,338	177,505	21033	Discharge summary	report	Admission Date: [2199-4-2] Discharge Date: [2199-4-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9554] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 84 year old diabetic female s/p LAD and CX DES admitted from the cath lab w/ MI. Stented in [4-8], recathed [2199-2-1] d/t +ETT, atypical symptoms. Second cath:patent LAD stent with a stable distal occlusion,80% ostial ramus lesion with a 70% mid lesion in the vessel with moderate tortuosity. 30% LCX, mid LCX stent widely patent. RCA known occluded. Ramus felt to be unchanged from cath [4-8]. Site thought to be difficult for intervention, so medical management recommended. Pt was admitted on [2199-4-2] to [Location (un) ] with heart failure, back and arm pressure. Ruled in w/ trop 20.48 ,sat is only 90-93% on 100% NRB. Did not respond to 80mg Lasix, rec'd 1U PRBC's for Hct 26. Past Medical History: 1. Diabetes mellitus on oral agents 2. Hypertension 3. Hyperlipidemia 4. A questionable history of transient ischemic attacks 5. Chronic renal insufficiency at baselin around 2.5 6. Peripheral vascular disease with left leg claudication 7. Gastroesophageal reflux disease- but no hx of EGD per pt 8. Anemia secondary to chronic renal insufficiency, iron deficiency- on iron and procrit. 9. CAD with known 3VD s/p LAD and LCX stent [04]. pacer for bradycardia post cath 11. Mild diastolic heart failure Social History: The patient has never smoked and does not drink alcohol. She lives alone. She has a daughter who lives next door. Family History: No family history of early coronary artery disease. Her brother had a myocardial infarction in his 80s. Physical Exam: Unresponsive, breathless, pulsless Brief Hospital Course: The patient developed hypotension and bradycardia after the right femoral venous sheath was pulled. She was given atropine 0.5 mg twice for presumed vagal response, hypotension persisted and she was started on dopamine gtt and given IVF as a bolus. Minutes later she developed respiratory distress, a code was called for PEA and respiratory arrest. The patient was intubated, given epinephrine 1mg IV x3, as well as atropine and bicarb, resuscitative efforts were stopped after 25 minutes. [Name (NI) ] granddaughter was present at the bedside for the large part of the resuscitation. She declined the autopsy, medical examiner declined the case. Medications on Admission: Lasix, nitroglycerin, heparin gtt Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: PEA arrest Respiratory Arrest Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ] MD [MD Number(2) 2139]	[ "272.0", "410.71", "V45.01", "414.01", "401.9", "250.00", "593.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]	2655, 2664	1889, 2542	271, 296	2738, 2747		2800, 2933	1710, 1815		2626, 2632		2685, 2717		2568, 2603			2771, 2777									1830, 1866																					221, 233							324, 1034															1056, 1563	1579, 1694
9,630	113,377	1219	Discharge summary	report	Admission Date: [2191-4-19] Discharge Date: [2191-4-21] Service: [Doctor Last Name 1181] HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old male with a history of coronary artery disease and radiation proctitis who presents with bright red blood per rectum on the morning of admission. The patient had a bloody bowel movement in his diaper at his nursing home and needed to be changed four times since that morning. His blood pressure was 110/60 and a heart rate of 70 in the field. The patient was transferred to the [Hospital1 69] for further evaluation. In the Emergency Department the patient was given two large bore intravenouses and he was given intravenous fluids. Gastrointestinal bleed scan was attempted and there was no clear evidence of a gastrointestinal bleed. Of note during the bleeding scan the patient's blood pressure dropped to the 70s and 80s and the patient was transferred back to the Emergency Department before the scan could be officially completed. The patient was asymptomatic throughout. PAST MEDICAL HISTORY: 1. Coronary artery disease status post anterior myocardial infarction, status post coronary artery bypass graft in [2182], status post percutaneous transluminal coronary angioplasty in [2186]. 2. Congestive heart failure with an EF of 25% according to a [2186] echocardiogram with mild AS and aortic regurgitation and moderate mitral regurgitation. 3. Prostate cancer status post radiation therapy in [2183], complicated by radiation proctitis and bleeding. 4. Dementia secondary to Alzheimers. 5. Anemia. ALLERGIES: Bee stings. MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Sorbitol 30 q.d. 3. Ambien 5 q.d. 4. Hydrocortisone 1% to scalp. SOCIAL HISTORY: The patient is a retired postal clerk. He lives at [Hospital 100] Rehab Facility since [2188]. He is married with three children. Health care proxy is [Name (NI) ] [Name (NI) 7692]. PHYSICAL EXAMINATION: On examination the patient's temperature is 96.9, pulse 82, blood pressure 126/38 that fell to 88/60 over the course of the day. Respiratory rate 18. Satting 97% on room air. In general, he was an elderly man sitting, awake, alert, but not oriented to person, place or time. Head and neck examination extraocular movements intact. Mucous membranes are moist. Conjunctiva were well perfuse with no cervical lymphadenopathy. Cardiac examination he had a 4 out of 6 systolic ejection murmur and a 2 out of 6 diastolic murmur at the left upper sternal border. His lung examination was limited due to lack of cooperation, but it seemed that he had decreased breath sounds at the bases. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities had no clubbing, cyanosis or edema. LABORATORY DATA: White blood cell count of 7.5 with a normal differential. Hematocrit 34.0 and platelets 236. His chem 7 showed a sodium of 142, potassium 4.9, chloride 106, bicarb 30, BUN 28, creatinine 1.0, glucose 107. His PTT was 24.8, INR 1.0, urinalysis negative. He had an electrocardiogram that was done that showed Q waves in 2, 3, F and Qs in V1 through V6 with left bundle branch block and PR prolongation. There was no substantial change from previous electrocardiograms. Chest film was performed, which showed no acute cardiopulmonary disease. HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient's gastrointestinal bleed was felt likely due to radiation proctitis since the presentation was less consistent with diverticular bleed or an AVM. The patient was admitted to the Medical Intensive Care Unit for close hemodynamic monitoring and serial hematocrits. The patient's hematocrit did trend down over the course of the day and was given one unit of packed red blood cells over the entire course of his admission with an appropriate bump in his hematocrit and no further bleeding. The patient had a sigmoidoscopy, which showed an ulcer in the rectum, but was limited by poor prep. The patient was kept overnight in the Intensive Care Unit and was transferred out to the floor the following day without complications. The patient denies any further evidence of gastrointestinal bleeding. Follow up flexible sigmoidoscopy showed the ulcer in the rectum, but was otherwise normal and these were biopsied. This will be followed up as an outpatient the differential being benign ulcers versus malignancy. 2. Cardiac: The patient has a history of congestive heart failure, but he tolerated the packed red blood cells and fluid boluses well. His Atenolol was held out of concern for hypotension. There were no ill effects from a congestive heart failure standpoint. The patient remained satting well on room air and he did not have any evidence for congestive heart failure. In addition, the patient has a history of coronary artery disease, however, there was no evidence of ischemia on electrocardiogram. 3. Code: The patient is DNR/DNI. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To [Hospital 100] Rehab Facility. DISCHARGE DIAGNOSES: 1. Rectal ulcer. 2. Lower gastrointestinal bleed. 3. Radiation proctitis. DISCHARGE MEDICATIONS: 1. Sorbitol 30 q.d. 2. Ambien 5 q.h.s. 3. Hydrocortisone 1% to scalp. 4. Atenolol 25 q day, which should only be started once the patient's blood pressure has normalized back to his baseline. FOLLOW UP PLANS: The patient should follow up with his primary care physician within one to two weeks. The biopsy will be sent to his primary care physician and further evaluation and treatment can be decided at that time. [Name6 (MD) 1592] [Name8 (MD) 1593], M.D. [MD Number(2) 1594] Dictated By:[Last Name (NamePattern1) 7693] MEDQUIST36 D: [2191-4-21] 11:05 T: [2191-4-21] 11:08 JOB#: [Job Number 7694]	[ "578.9", "569.41", "331.0", "285.9", "V45.81", "V10.46", "294.10", "428.0" ]	icd9cm	[ [ [] ] ]	[ "48.23", "45.25" ]	icd9pcs	[ [ [] ] ]								5103, 5181	5204, 5879				1663, 1756	3393, 4990																							1998, 3375																142, 1062															1084, 1637	1773, 1975	5015, 5082
11,720	185,755	21526	Discharge summary	report	Admission Date: [2130-1-29] Discharge Date: [2130-3-22] Date of Birth: [2095-11-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3326] Chief Complaint: Abdominal pain and fevers. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 56752] presented from the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in NH where he presented for evaluation of subjective fever and mild abdominal discomfort. He noted that he had been feeling nauseous for the past week, correlating with when he began taking his AZT. This was discontinued but his sensation of nausea has persisted. Two days PTA, he began feeling a mild discomfort in the periumbilical region which has persisted. The pain is intermittent and mild, unchanged with eating or position. He denied diarrhea, BRBPR, recent dietary changes, or other symptoms. In the ED at the [Hospital1 ], he was noted to have a temperature of 100.2F and was given a dose of ceftriaxone prior to transfer to the [Hospital1 18]. He completed a course of augmentin 4 days PTA. Past Medical History: 1. NK T cell lypmhoma of the nose (dx [9-10]) - s/p CHOP x 3 with high-dose methotrexate with minimal response - started on anti-EBV treatment (valgancyclovir, AZT) in [12-10] - started XRT [2130-1-11] Social History: Pt. is married, lives is [Location (un) 3844] and works as a carpenter. He used to smoke but has recently quit. He drinks alcohol occasionally Family History: Mother with renal cell cancer. Grandparents with CAD. No hx of lymphoma or leukemia in family Physical Exam: T 100.5, HR 96, RR 18, BP 126/78, O2 Sat 98% RA Gen: comfortable, NAD, non-toxic appearing. HEENT: PERRL, EOMI, oropharynx unremarkable. Neck: Supple, no JVD. LN: enlarged LN fixed and mildly tender in the upper right anterior cervical distribution, shotty cervical LAD bilaterally,no other LAD in the axillary, supraclavicular, or inguinaldistributions. Heart: RRR, no M/R/G. Lungs: CTA bilaterally. Abd: Soft, minimally tender to the lower left of the umbilicus. No palpable masses, no rebound or guarding, normoactive bowelsounds, no HSM. Ext: no C/C/E Skin: no rash noted. Pertinent Results: Labs on admission: [2130-1-30] 06:35AM BLOOD WBC-1.3# RBC-3.67 Hgb-9.9* Hct-30.0* MCV-82 MCH-26.9* MCHC-32.9 RDW-19.4* Plt Ct-200 [2130-1-31] 07:00AM BLOOD Neuts-40* Bands-12* Lymphs-32 Monos-0 Eos-0 Baso-8* Atyps-4* Metas-4* Myelos-0 [2130-1-30] 06:35AM BLOOD Glucose-97 UreaN-9 Creat-0.9 Na-139 K-4.3 Cl-103 HCO3-31* AnGap-9 [2130-1-30] 06:35AM BLOOD AST-32 LD(LDH)-360* AlkPhos-63 Amylase-58 TotBili-0.3 [2130-1-30] 06:35AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2 Final labs: [2130-3-22] 11:04AM BLOOD WBC-1.7* RBC-3.21* Hgb-9.4* Hct-26.7* MCV-83 MCH-29.2 MCHC-35.1* RDW-19.0* Plt Ct-37* [2130-3-21] 10:38AM BLOOD Neuts-74* Bands-14* Lymphs-2* Monos-6 Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0 [2130-3-22] 11:04AM BLOOD PT-12.0 PTT-65.9* INR(PT)-0.9 [2130-3-18] 04:33PM BLOOD PT-16.3* PTT-150* INR(PT)-1.7 [2130-3-22] 11:04AM BLOOD Fibrino-189 [2130-3-22] 06:00AM BLOOD FDP-10-40 [2130-3-22] 06:00AM BLOOD Fibrino-206 D-Dimer-5710* [2130-3-22] 06:00AM BLOOD Gran Ct-870* [2130-3-17] 04:33AM BLOOD Ret Aut-2.1 [2130-3-22] 11:04AM BLOOD Glucose-111* UreaN-48* Creat-2.9* Na-139 K-3.7 Cl-103 HCO3-24 AnGap-16 (peak Cr): [2130-3-18] 04:54AM BLOOD Glucose-102 UreaN-172* Creat-8.8* Na-137 K-4.2 Cl-105 HCO3-14* AnGap-22* [2130-3-22] 06:00AM BLOOD ALT-28 AST-192* LD(LDH)-1104* AlkPhos-232* TotBili-14.2* [2130-3-20] 04:52AM BLOOD Lipase-98* [2130-3-22] 06:00AM BLOOD Albumin-2.5* Calcium-9.0 Phos-2.7 Mg-2.0 [2130-3-20] 04:52AM BLOOD Hapto-<20* [2130-3-12] 04:54AM BLOOD Triglyc-971* LDLmeas-<50 [2130-3-19] 04:14AM BLOOD Ammonia-66* [2130-3-22] 03:55PM BLOOD Lactate-3.5* Micro data: Over 90 cultures of various types were drawn. Positives include: [2-16] sinus aspirate Aspergillus [Country 11730] [2-24] sinus aspirate Aspergillus [Country 11730] (subsequent culture negative) [3-4] + VRE on screening rectal swab [3-17] R neck wound swab positive for VRE Imaging: [2130-1-30]: CT Sinus: IMPRESSION: 1) Left nasal cavity lesion with mixed attenuation, as described above. An MR is recommended for better evaluation of this lesion. 2) Maxillary retention cyst and mild ethmoid sinus mucosal thickening. CT TORSO [1-30]: IMPRESSION: 1) A 3-4 mm vague nodule in the right upper lobe, new since the previous exam. This is nonspecific and may represent infection or lymphoma. Attention to this can be paid on followup. 2) Small hypodense focus within the left kidney, also nonspecific, which may represent lymphoma. 3) No etiology for left upper quadrant pain or diarrhea identified. PET [1-30]: IMPRESSION: 1) Unchanged size, but decreased maximum SUV levels of the nasal cavity mass. 2) Increased FDG activity within the right submandibular node which appears new compared to the prior study. 3) Three focal new hepatic areas of increased FDG uptake representing distant metastatic involvement. [2130-2-13] CT abdomen/pelvis: IMPRESSION: 1. Multiple bilateral low-density lesions within the kidneys, in retrospect probably unchanged since [2130-1-30]. These have not progressed in the interval and are most likely related to lymphomatous involvement of the kidneys. 2. Vague stable lung nodules, with a new small focal patchy density within the left lung, probably due to focal atelectasis. 3. No clear explanation for the ongoing fevers identified. [2130-2-15] MRI abdomen: IMPRESSION: 1. Small subcapsular lesion within the posterior right lobe of the liver, with two prominent adjacent draining veins. This lesion may be related to prior biopsy or trauma. Please correlate with past medial history. Metastatic disease is not excluded, but the appearance would be most unusual for a metastatic lesion . 2. Small delayed phase enhancing lesion within the dome of the liver, most consistent with a hemangioma, but too small to fully characterize. 3. Multiple hypoenhancing lesions throughout both kidneys, consistent with lymphoma, and unchanged compared to CT [2-13], [2130]. [2-17] MR head: IMPRESSION: Stable appearance of the brain, compared to the previous MRI of [2129-12-17]. No abnormal intracranial enhancement. Decreased size of the intranasal mass since the [Month (only) 1096] MRI. [2-18] CT torso: IMPRESSION: 1) Diffuse bilateral increased thickness of the pulmonary interlobular septa, new compared to the prior study of [2130-2-13]. This has the appearance of interstitial pulmonary edema. Lymphangitic spread of tumor or lymphoma is in the radiologic differential diagnosis. This appearance would be atypical for infection but in the presence of possible mild bronchial wall thickening, infectious process cannot be entirely excluded. No intra-abdominal abscess is identified. 2) Vague right upper lobe nodule, stable. 3) Stable bilateral rounded ill-defined hypodensities in the kidneys, stable compared to the prior study. 4) Apparent left varicocele. If clinically indicated, correlation with ultrasound examination may be performed. [3-5] CT chest: IMPRESSION: 1) Interval formation of bilateral dependent areas of consolidation in the lower lobes suggestive of aspiration with or without overlying pnuemonia. 2) Persistent and increased interstitial and alveolar opacities bilaterally. Persistent thickening of the interlobular septa. The differential includes ARDS or less likely interstitial pulmonary edema or lymphatic spread of tumor or lymphoma. 3) Stable appearance of rounded hypoattenuating areas within the kidneys. These have increased in the short interval ([2130-1-30]) and may represent multifocal pyleonephritis, lymphoma or less likely infarcts. 4) No evidence of pulmonary embolism. [2130-3-9] RUQ ultrasound with Doppler: IMPRESSION: 1) Normal-appearing liver with patent portal and hepatic veins. 2) Gallbladder contains sludge, though there is no evidence of acute cholecystitis. No biliary ductal dilatation. [2130-3-10] PET: IMPRESSION: 1) Soft tissue within the nasal cavity without FDG avidity. 2) Decreased maximum SUV levels within two right jugular chain lymph nodes. 3) New and worsened SUV avidity involving a right spinal accessory lymph node, the pre-carinal lymph node, and two tiny para-vascular lymph nodes. 4) Diffuse anasarca and worsening pulmonary edema with bilateral effusions and atelectasis. 5) New ascites. 6) Bilateral enlarged kidneys, without excretion of FDG, consistent with renal failure. [2130-3-12] neck ultrasound: IMPRESSION: Edematous changes within the soft tissues of the right neck, and multiple lymph nodes, including enlarged nodes, the largest measuring 2.3 cm, without evidence of abscess or drainable fluid collection. [2130-3-14] RUQ ultrasound: IMPRESSION: 1) No stone is identified within the common bile duct. The common duct is not dilated. 2) Gallbladder sludge. Interval development of an echogenic nonshadowing structure within the gallbaldder, which likely represents tumefactive sludge ball. Small amount of free fluid surrounding the gallbladder. 3) Medical disease of the right kidney. Left kidney not imaged. [2130-3-16] MRCP: IMPRESSION: 1) Interval development of bibasilar atelectasis or pneumonia, ascites and anasarca. 2) Interval iron overload within the liver and spleen, which may be related to prior. 3) Splenomegaly. 4) No focal hepatic lesions to suggest candidiasis, no evidence of biliary ductal dilatation, no imaging evidence of pancreatitis. [2130-3-17] CT chest: IMPRESSION: Interval rapid increase in extent of marked, diffuse airspace opacities within the lungs, which most likely represents diffuse bilateral pneumonia, but aspiration or pulmonary edema should be considered as well [2130-3-21] bone marrow aspirate: hypocellular bone marrow with hemophagocytosis Brief Hospital Course: 1. abdominal pain - On admission, the patient had LLQ pain. The etiology of the pain was unknown. He was started on flagyl as he was also reporting [2-9] loose stools per day and had been on antibiotics intermittently for the past 2 months. Stool studies, including C. Diff were sent which were negative. On HD 2, the patient had a CT of the abdomen done which did not elucidate the cause of his abdominal pain. He was started on a morphine PCA for pain control. His abd pain subsequently improved and the PCA pump was no longer needed. No abdominal pathology was found. 2. fever/neutropenia - On transfer from the OSH, the patient's ANC was ~600. Over the first few hospital days, his ANC decreased to < 500. Blood and urine cultures were sent and were negative. The patient was started on flagyl for question of c. difficile colitis and cefepime for empiric coverage of neutropenic fevers. On HD 2, a CT torso was done which was notable for a vague nodule in RUL but no other source of fevers. It was felt that the fevers were most likely secondary to his lymphoma, so his cefepime was stopped. Later that evening, he had temperatures to 102F, associated with chills and mildly decreased blood pressure. The next morning he was restarted on cefepime and vancomycin and his IVFs were increased. He continued to be febrile so he was placed on caspofungin. After starting the antibiotics and solumedrol, the patient defervesced until HD #10. At this time, the pt. developed a low-grade fever in the context of beginning treatment with campath. The fever became persistent and of greater intensity over the course of the next 4 hospital days. Other than fever and rigors, the pt. had no other symptoms which were suggestive for the source of possible infection. He had a number of blood cultures drawn which and never grew any organisms. He was re-imaged, including CT scans of the sinuses and torso, and no source of infection was identified. The ID team was consulted and recommended altering the pt's antibiotic regimen to include ciprofloxacin, meropenem, ambisome, metronidazole, and vancomycin. A culture of nasal secretions was sent and grew out aspergillus [Country 11730]. He was maintained on caspofungin. He continued to have low-grade temps, with spikes daily, and repeat cultures did not grow any microorganisms. In particular, repeat nasal secretion culture showed only yeast, and no longer any Aspergillus. Pt's antibiotics were weaned gradually, first the cipro, then the ambisome, and the vancomycin. These were restarted as pt continued to be febrile, though without a clear source of infection. 3. nasal T-cell/NK cell lymphoma - The patient continued to receive his daily radiation treatments while an inpatient. A PET scan on HD 2 was concerning for a right cervical lymph node foci and 3 liver foci. It did suggest a decreased nasal tumor burden. The patient received etoposide, cisplatin, solumedrol for a five day course of chemotherapy (hospital days 5 to 9). He was started on a morphine PCA for increasing pain in the nasal area on the eighth hospital day. The pt was also treated with a three day course of campath on hospital days 13 to 15. As mentioned above, the pt began to develop fevers around the time of campath treatment. When no infectious etiology was discovered, and in the context of a rising LDH, it was felt that the fever was representative of escalating lymphoma. Accordingly, the pt was treated with a course of etoposide, cisplatinum, solumedrol and cytoxan on hospital days 22 to 27. The cisplatinum was discontinued after 2 days of treatment as the pt developed acute renal failure with a creatinine of 1.6 (FE Na 5.5%, suggesting acute tubular necrosis). As the pt continued to experience persistent fever, increasing LDH and lymphadenopathy, it was decided to pursue another treatment regimen. Accordingly, on hospital day 25, the pt began treatment with zidovudine and interferon alfa 2B. This chemotherapy resulted in further bone marrow suppression. Due to the ensuing pancreatitis and elevated LFTs, concern was raised for dissemination of lyphoma. A repeat PET scan was performed and did not show any evidence of dissemination. In fact, the nasal foci had improved greatly, and the liver foci on the previous PET disappeared. However, there were a couple of new lymph nodes that lit up on this second PET, indicating that his lymphoma was not eradicated. On [3-21], a sternal bone marrow aspirate was performed, showing involvement with pt's NK/T cell lymphoma, as well as hemophagocytosis (hemophagocytic syndrome being a known complication of this pt's lymphoma). 4. respiratory failure - Pt required ventilatory support for a large portion of his hospitalization. While on the BMT floor he often experienced episodes of SOB with his chemo treatments. There were several times when he became slightly hypotensive and was bolused with fluids and had some minor SOB. He then developed SOB and tachypnea that required transfer to the [Hospital Unit Name 153] for closer monitoring, and CT showed a diffuse process that was unclear but felt most likely to be capillary leak syndrome. He was also felt to have significant consolidation in the bases, though bronchoscopy and induced sputum samples did not grow any organisms. Repeat chest CTs showed interval increases in infiltrates and consolidation, but it was unclear whether this was due to fluid overload or to infection. Pt was extubated transiently, but needed to be reintubated for the PET scan. Afterwards, the extreme amount of chest wall edema was thought to be a major contributor to the inability to wean the patient from the ventilator. He desired to have the tube out in order to discuss his feelings with his family, but he was tachypneic and uncomfortable with decreased amounts of support. In addition, his sepsis was thought to be a major contributor, as it resulted in increased CO2 production and therefore greater work of breathing to ventilate adequately. Ultimately, the pt was extubated on the night of his expiration, as detailed below. 5. acute tubular necrosis - pt developed ATN in the setting of chemotherapeutic agents and hypoperfusion, and muddy brown casts were visualized in pt's urine sediment. A renal ultrasound showed no evidence of hydronephrosis, stone, or mass. He then worsened acutely about 2 days after a dye load for a CT angio was given. Pt's creatinine continued to climb despite supportive treatment, reaching a maximum of 8.8. As pt continued to have adequate urine output and did not experience severe electrolyte abnormalities, dialysis was held. However, his kidney function did not recover spontaneously as expected, and ultimately, due to fluid overload and massive anasarca, ultrafiltration was begun. Intravascular volume depletion and pt's hypotension limited the amount of fluid that could be removed safely. 6. elevated pancreatic enzymes - pt's lipase was intermittently elevated, at one point at 3600 (on [3-11]). He had significant abdominal pain only transiently. GI was consulted, and it was felt that he needed an MRCP of the abdomen to see if there was significant biliary obstruction, with the thought that he may need an ERCP. A RUQ ultrasound previously showed only sludge in the gallbladder. The MRCP was done, which showed no evidence of biliary ductal dilatation, nor radiographic evidence of pancreatitis. It was thought that these changes were medication-induced and that pt had previously developed pancreatitis due to propofol. His lasix drip was discontinued at this point, as this has been shown to induce pancreatitis, and his TPN was stopped, as well. An OJ tube was eventually placed for tube feedings, as he was deemed safe by GI to feed via OJ tube. He tolerated the tube feeds well. 7. tachycardia - Pt was noted to have episodes of tachycardia into the 120s, not corresponding with fever or pain. He was at those times given IV lopressor, which had good effect. Echocardiograms on [2-28] and [3-6] showed mildly depressed LVEF and global hypokinesis, which was thought to be secondary to cardiomyopathy due to critical illness. Pt's cardiac enzymes remained flat though mildly elevated, consistent with a demand ischemia in this setting. 8. hyperbilirubinemia - pt's bilirubin climbed during the course of his hospitalization. Repeated RUQ ultrasounds, and eventually an MRCP, excluded biliary dilatation. Pt was thought to be hemolyzing, as he had an elevated LDH and a low haptoglobin. In the setting of his bleeding and labs consistent with DIC towards the end of his hospitalization, it was thought that this might be a contributing cause to the hyperbilirubinemia, particularly after the discovery of hemophagocytosis on bone marrow aspirate. 9. neck infection - At the site of an earlier lymph node biopsy on the right side of the patient's neck (which revealed involvement of the lymphoma), he developed swelling and tenderness about one week prior to the end of his hospitalization. It began to spontaneously drain serosanguinous fluid, which was sent for culture and grew out VRE. Pt was maintained on daptomcyin during this time. Surgery was consulted, and the lymph node was removed. It was not thought that this source of infection could explain the patient's ensuing sepsis. 10. coagulopathy/DIC - Pt began to ooze from his line sites, as well as the site of surgical drainage of the above nidus of infection. His INR was up to 1.7, and his DIC and hemolysis panels were positive, though not floridly so. He was transfused with multiple units of FFP to try to lower his PTT, which was >150 at one point; he was given units of cryo to keep his fibrinogen > 150, and he was transfused with multiple units of platelets, given his thrombocytopenia and active oozing from sites as well as guaiac positive stool and NG aspirate. Clinical suspicion was high for a microangiopathic process. 11. encephalopathy - pt began to be more encephalopathic in the last few days of his life. This was thought to be of multifactorial etiologies, including uremia, infection, prolonged ICU stay, metabolic abnormalities, and long-standing sedatives and morphine. Pt requested to be kept comfortable near the end of his course, with a morphine drip added to help with sedation and pain relief. The goal was to try to alleviate some of the discomfort of being on the ventilator, without sedation too heavy to be compatible with communication with his family. 12. hypotension/sepsis - Pt became more hypotensive toward the end of his hospitalization. Although he had significant anasarca by this time, his CVP and decreasing urine output pointed to intravascular volume depletion. In addition, his very warm extremities and continued fevers suggested sepsis, as well, though a particular source could not be isolated, even with multiple cultures. Pt was undergoing ultrafiltration at this point, and it was difficult to keep up with his volume losses. At the same time, he was anemic and coagulopathic, and so he was transfused with multiple units of PRBCs and FFP in the last few days of his life. His urine output dropped off, he was becoming more and more encephalopathic, and his blood pressure was difficult to maintain. He was placed on pressors, and required more pressor support over the next 48 hours. Pt's family and the patient decided that given his grave prognosis in the setting of hemophagocytosis and evidence of lymphoma on bone marrow aspirate, that it would be reasonable to extubate the patient and withdraw pressors. The patient expired about 30 minutes later, with his family at the bedside. Post-mortem examination was declined. Medications on Admission: -Protonix 40mg PO once daily -Serax 15mg PO qhs PRN -Compazine 10mg PO q8 PRN -Zolpidem Tartrate 5-10mg PO qhs PRN Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: nasal T-cell/NK cell lymphoma acute tubular necrosis coagulopathy/disseminated intravascular coagulation shock, thought to be due to sepsis respiratory failure hyperbilirubinemia Discharge Condition: expired	[ "348.30", "682.1", "584.5", "276.0", "998.59", "202.18", "518.81", "038.9", "486", "995.92", "577.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "96.72", "38.95", "92.29", "45.15", "99.15", "86.04", "39.95", "41.31", "96.6", "99.25", "33.24", "38.93", "40.21", "96.04", "38.91" ]	icd9pcs	[ [ [] ] ]	22104, 22110	10163, 21909	343, 350	22333, 22343	2339, 2344		1631, 1726		22075, 22081		22131, 22312		21935, 22052												1741, 2320																					277, 305							378, 1213									2358, 10140						1235, 1451	1467, 1615
13,329	194,160	51448	Discharge summary	report	Admission Date: [2188-4-1] Discharge Date: [2188-4-18] Date of Birth: [2112-8-23] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Neurontin Attending:[First Name3 (LF) 7651] Chief Complaint: positive stress test, respiratory distress Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 75-year-old female with ESRD, hypertension, status post LRRT from her grandson in [2180] p/w positive stress test. Since her abdominal hernia repair c/b UTI and c. diff colitis, the pt has been back and forth between rehab and the hospital. Her most recent admission to [Hospital1 ] was for COPD exacerbation/pneumonia requiring intubation. She was discharged to an ECF, but presented to [Hospital1 882] on [3-28] with sharp left-sided CP and arm pain. She was diaphoretic w/o SOB or n/v. The pain was unrelieved w/ SLNG x3, but in the ambulance she received 2 nitro sprays and 4 baby ASA and her pain resolved. No EKG changes and enzymes negative. The pt states she has angina 2-3 times per month which usually resolves w/ [11-26] SLNG. This pain was much worse than her typical anginal symptoms. Chemical ST yesterday showed defects suggesting 3 vessel disease w/ no EKG changes. Per Dr [Name (NI) 171] pt receiving hydration, blood and mucomyst in anticipation of cardiac cath today. Of note, the pt had some SOB earlier today which resolved w/ nebs. Vitals on transfer were 98.8 60 sr no ect resp 18 139/77, 97% 2l nc 0/10 pain Patient was seen in the cath lab holding area and denied any CP, SOB, nausea, or any other symptoms at this time. Cardiac cath showed 3 vessel disease -> 60% mid lad, 70% circ, and subtotal RCA. He will be admitted for CABG evaluation. On arrival to the floor, patient comfortable w/ no complaints. VS 98.9 115/53 59 20 97 2LNC Past Medical History: ESRD s/p transplant ([2180]) CAD Diastolic CHF HTN COPD Chronic aortic dissection GERD moderate pulm HTN PSH: s/p TAH/BSO s/p appy s/p ventral hernia repair [3-30] Social History: Lives at home alone, but occasionally after hospitalizations has stayed with her daughter/granddauthger. Has been in rehab facility recently. Previously worked as a nurses aid. -Tobacco history: +smokes [2-29] cigarettes a day -ETOH: Endorses minimal EtoH use -Illicit drugs: Denies Family History: monther with MI at 68, father with MI at 70 Physical Exam: Admission PE VS: T= 98.9 BP= 115/53 HR= 59 RR= 20 O2 sat= 97% 2LNC General: comfortable at rest, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, NC in place Neck: supple, no LAD, no JVD CV: Regular rate and rhythm, [12-31] holosystolic mmurmur at apex, no murmurs, rubs, gallops Lungs: CTAB, diminished BS bilaterally Abdomen: Multiple surgical scars, palpable transplated kidney, soft, non-distended, mild tenderness throughout, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE Vitals - Tm/Tc:99.2/98 HR:59-63 BP:100-138/58-64 RR:18 02 sat: 95% 1L In/Out: Last 24H: 1250/1350 Last 8H: Weight:93 ( ) Tele: SR, no VEA FS: none GENERAL: 75 yo F in no acute distress HEENT: JVP non elevated CHEST: No wheezes or rhonchi, [Month (only) ] at bases, productive cough. CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding, neg HSM. neg [Doctor Last Name 515] sign. EXT: wwp, no edema. DPs, PTs 1+. NEURO: CNs II-XII intact. SKIN: no rash or open areas PSYCH: A/O Pertinent Results: Admission Labs [2188-4-1] 04:45PM BLOOD WBC-6.8 RBC-3.11* Hgb-9.2* Hct-28.0* MCV-90 MCH-29.6 MCHC-32.9 RDW-17.4* Plt Ct-313 [2188-4-1] 04:45PM BLOOD PT-13.9* INR(PT)-1.3* [2188-4-1] 04:45PM BLOOD Plt Ct-313 [2188-4-1] 04:45PM BLOOD Glucose-142* UreaN-37* Creat-2.2* Na-136 K-4.5 Cl-104 HCO3-18* AnGap-19 [2188-4-1] 04:45PM BLOOD ALT-4 AST-10 CK(CPK)-23* AlkPhos-73 Amylase-20 TotBili-0.4 [2188-4-1] 04:45PM BLOOD Cholest-138 Pertinent Labs [2188-4-2] 08:20AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.3* Hct-32.6* MCV-92 MCH-29.2 MCHC-31.6 RDW-17.6* Plt Ct-292 [2188-4-3] 07:47AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.7* Hct-28.8* MCV-91 MCH-30.5 MCHC-33.5 RDW-17.0* Plt Ct-296 [2188-4-4] 09:10AM BLOOD WBC-5.3 RBC-3.35* Hgb-10.0* Hct-31.6* MCV-95 MCH-29.9 MCHC-31.6 RDW-17.2* Plt Ct-287 [2188-4-5] 07:30AM BLOOD WBC-6.0 RBC-3.84* Hgb-11.2* Hct-35.7* MCV-93 MCH-29.1 MCHC-31.4 RDW-17.0* Plt Ct-401 [2188-4-6] 07:30AM BLOOD WBC-4.0 RBC-3.57* Hgb-10.3* Hct-33.1* MCV-93 MCH-29.0 MCHC-31.3 RDW-17.1* Plt Ct-342 [2188-4-7] 06:15AM BLOOD WBC-4.1 RBC-3.40* Hgb-9.6* Hct-31.3* MCV-92 MCH-28.2 MCHC-30.7* RDW-17.0* Plt Ct-351 [2188-4-2] 08:20AM BLOOD Glucose-91 UreaN-37* Creat-2.1* Na-136 K-4.2 Cl-103 HCO3-18* AnGap-19 [2188-4-3] 07:47AM BLOOD Glucose-105* UreaN-37* Creat-2.1* Na-136 K-4.3 Cl-104 HCO3-20* AnGap-16 [2188-4-4] 09:10AM BLOOD Glucose-96 UreaN-43* Creat-2.5* Na-132* K-5.1 Cl-100 HCO3-15* AnGap-22* [2188-4-5] 07:30AM BLOOD Glucose-159* UreaN-45* Creat-2.6* Na-131* K-5.1 Cl-98 HCO3-18* AnGap-20 [2188-4-6] 07:30AM BLOOD Glucose-82 UreaN-48* Creat-2.6* Na-133 K-5.0 Cl-100 HCO3-20* AnGap-18 [2188-4-7] 06:15AM BLOOD Glucose-91 UreaN-51* Creat-2.6* Na-128* K-5.1 Cl-96 HCO3-21* AnGap-16 [2188-4-1] 04:45PM BLOOD ALT-4 AST-10 CK(CPK)-23* AlkPhos-73 Amylase-20 TotBili-0.4 [2188-4-4] 09:10AM BLOOD CK(CPK)-290* [2188-4-5] 07:30AM BLOOD CK(CPK)-25* [2188-4-5] 03:10PM BLOOD CK(CPK)-28* [2188-4-4] 09:10AM BLOOD CK-MB-2 cTropnT-0.08* [2188-4-5] 07:30AM BLOOD CK-MB-2 cTropnT-0.09* [2188-4-5] 03:10PM BLOOD CK-MB-2 cTropnT-0.09* [2188-4-1] 04:45PM BLOOD %HbA1c-5.6 eAG-114 [2188-4-1] 04:45PM BLOOD Triglyc-115 HDL-37 CHOL/HD-3.7 LDLcalc-78 [2188-4-2] 08:20AM BLOOD tacroFK-4.0* [2188-4-3] 07:47AM BLOOD tacroFK-4.2* [2188-4-4] 09:10AM BLOOD tacroFK-6.2 [2188-4-5] 07:30AM BLOOD tacroFK-9.3 [2188-4-6] 07:30AM BLOOD tacroFK-8.5 [2188-4-5] 07:57AM BLOOD Type-ART pO2-107* pCO2-32* pH-7.40 calTCO2-21 Base XS--3 [2188-4-5] 07:57AM BLOOD Lactate-0.9 Imaging Cardiac Cath [4-1]: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated three vessel coronary artery disease. The LMCA was without angiographically apparent flow-limiting stenosis. The LAD had a 60% mid-vessel stenosis. The LCx had a 70% mid and distal stenosis. The RCA had subtotal distal stenosis with left to right collaterals. 2. Limited resting hemodynamics revealed systemic arterial hypertension with central aortic pressure of 156/46 mmHg. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Recommend CABG evaluation, Cardiac surgery emailed. 3. Hemastasis of left radial arteriotomy achieved via TR band. 4. Systemic arterial hypertension. PFTs [4-2]: SPIROMETRY 1:21 PM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.30 1.91 68 1.48 78 +14 FEV1 0.78 1.30 60 0.91 70 +16 MMF 0.41 1.90 22 0.38 20 -8 FEV1/FVC 60 68 89 61 90 +2 DLCO 1:21 PM Actual Pred %Pred DSB 7.06 15.98 44 VA(sb) 2.55 3.32 77 HB 10.30 DSB(HB) 7.93 15.98 50 DL/VA 3.11 4.82 65 CXR [4-2]: IMPRESSION: 1. Small bilateral pleural effusions and pulmonary [Month/Day (4) 1106] redistribution. 2. Likely pulmonary arterial hypertension Carotid [4-3]: Impression: Standard velocity criteria yield the following: Right ICA 40-59% stenosis. Left ICA 70-79% stenosis. However, there is substantial calcification bilaterally that limit the ability of duplex to accurately predict theseverity of stenosis. The Left vertebral artery appears occluded. No significant change from previous exam of [2185-11-30]. CXR [4-5]: IMPRESSION: CHF with predominant interstitial edema, which is new compared with [2188-4-2] at 17:00 p.m. Small bilateral effusions and patchy bibasilar opacity. CXR [4-8]: FINDINGS: In comparison with the study of [4-5], there is increased engorgement of ill-defined pulmonary vessels, consistent with worsening [Date Range 1106] congestion. Probable small pleural effusions with bibasilar compressive atelectasis. The cardiac silhouette actually appears slightly smaller than on the previous study. CXR [4-9]: In comparison with the study of [4-8], there has been substantial clearing of the bilateral pulmonary opacifications. There is still some indistinctness of engorged vessels, consistent with some residual elevation of pulmonary venous pressure. Left hemidiaphragm is more sharply seen, though there still may well be some small pleural effusion and atelectasis at the left base. ECHO [4-10]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is borderline/mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2188-2-5], findings are similar, and suggest significant diastolic dysfunction of the left ventricle coupled with borderline/mild mitral stenosis, with the predictable consequence of severe pulmonary hypertension. CXR [4-10]: As compared to the previous radiograph, the lung volumes have slightly increased, likely to reflect improved ventilation. There are still signs indicative of mild-to-moderate pulmonary edema, but these have improved as compared to the previous examination. Borderline size of the cardiac silhouette. No evidence of newly occurred parenchymal opacities. Minimal blunting of the left costophrenic sinus, potentially indicative of a small left pleural effusion. CXR [4-11]: New asymmetric opacification in the lateral aspect of the left mid and lower lung zones and perhaps a smaller area in the right upper lobe highlighting the minor fissure, in the absence of mediastinal or pulmonary [Month/Year (2) 1106] engorgement is most likely pneumonia. Covering resident was contact[Name (NI) ] by telephone at 10:45 a.m., 2minutes after recognition to discuss these findings. CT Chest noncon ([4-13]): 1. Airspace disease with air bronchograms in the left lower lobe with associated small left-sided pleural effusion and also nodular airspace process in the right middle lobe and ground glass opacity in left upper lobe lingula periphery may represent multifocal pneumonia in the appropriate clinical setting. Recommend followup to resolution. 2. Grossly stable calcified soft tissue nodule in the left central breast, may represent a fibroadenoma. Consider correlation with dedicated mammography for further assessment. 3. Calcified atherosclerotic [Month/Year (2) 1106] disease of the aorta and coronary arteries. 4. Mild centrilobular emphysematous changes in the lungs. CXR [4-14]: IMPRESSION: Improving multifocal pneumonia and pulmonary edema. Microbiology: urine [4-3]: no growth stool [4-3]: c. diff negative Respiratory Viral Culture (Final [2188-4-17]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [2188-4-15]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. Brief Hospital Course: ASSESSMENT AND PLAN: 75-year-old female with ESRD, hypertension, COPD, status post LRRT [2180] w/ cardiac cath showing 3VD who was deemed a non-surgical candidate for her coronary artery disease, and was managed for respiratory distress, likely secondary to COPD and dCHF. . CCU Course [2092-4-7]: Patient was transferred to CCU on [2188-4-8] for SOB. She was placed on Bipap and did well. Was weaned off of it rather quickly. She was also diuresed and tolerated it well. She was also hyperkalemic on transfer, which improved with diuresis and kayexelate. For blood pressure, would consider hydralazine as next medication (renal transplant team is okay with thims). On transfer back to the floor, respiratory status was improved and patient was comfortable and satting well on nasal cannula. . CCU Course [Date range (1) 19159] Patient was transferred to CCU [4-11] for SOB. Patient was diuresed with IV Lasix and responded well. Also has COPD vs. PNA, which is likely contributing to respiratory distress. . # CORONARIES: positive stress test concerning for 3 vessel disease sent to [Hospital1 18] for cardiac cath. cath showed LMCA without angiographically apparent flow-limiting stenosis, LAD had a 60% mid-vessel stenosis, the LCx had a 70% mid and distal stenosis, and the RCA had subtotal distal stenosis with left to right collaterals. Cardiac surgery was consulted for consideration of CABG. Several studies were obtained for pre-op assessment and the pt was cleared for CABG on [4-7]. However, in the setting of pneumonia and poor respiratory status, patient was determined not to be a surgical candidate at this time. . # COPD: the pt had significant rhonchi and wheezes during her hospitalization. she was placed on duonebs q2hrs and advair was added. considered starting a steroid course, but did not initially since pt was going to OR for CABG. ABG was done and did not show that pt was chronic retainer. Once patient was thought not to be candidate for CABG, started prednisone 40mg qd. she also completed a z-pack, a few days of levaquin and a few days of broad spectrum antibiotics. pulmonary was consulted and recommended switching to IV steroids which were given for 24 hours. . # Diastolic CHF: Chronic compensated with LVEF 55%. Diastolic disease [12-27] htn & DM. the pt had an episode where she flashed on [4-5]. the pt became hypoxic w/ O2 sats in the 70s and BP went up to 220s. she was started on a nonrebreather and given nebs. hydralazine did not bring down her BP, but she was given 80mg IV lasix total and started on nitro drip which brought BP to 140s. this episode resolved. Patient was started on torsemide 20mg PO. Weight at discharge is 88 kg. . # Hypertension: Patient blood pressures were quite elevated with SBPs in the 170s. Her anti hypertensive medication regimen was adjusted. Patient's blood pressures stable (< 140s) on day prior to discharge. On discharge, she was on Carvedilol 25mg PO bid, Isosorbide mononitrate 60 qd, Nifedipine 30 PO bid. . # Pneumonia: Found to have potential RLL pneumonia on CXR and CT chest. Started on Vancomycin/Cefepime on [4-12] for HCAP, but discontinued as no fevers, or WBC elevations, and most likely etiology of pulm issues CHF and COPD. . # RHYTHM: NSR . # Acute on chronic kidney disease s/p transplant: stable from a renal standpoint currently. renal transplant team followed. her tacrolimus was adjusted to 4mg on [4-6] for goal level ([3-31]). TRANSITIONAL ISSUES: - prednisone taper: 10 day taper of prednisone - sleep study as outpatient to evaluate for sleep apnea Medications on Admission: ALBUTEROL SULFATE 90 mcg- 2 puffss every 4 hrs prn ALENDRONATE 35 mg qweek AZATHIOPRINE 50 mg Daily BECLOMETHASONE DIPROP (AQ) [BECONASE AQ] 42 mcg -2 sprays each nares [Hospital1 ] CALCITRIOL 0.25 mcg Daily CINACALCET [SENSIPAR] 30 mg Daily CITALOPRAM 10 mg Daily DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] (Dose adjustment - no new Rx) - 150 mcg/0.3 mL Syringe - inject s/c every month DICLOFENAC SODIUM [VOLTAREN] 1 % Gel - apply to painful joint/area four times a day as needed for pain as directed FLUTICASONE 50 mcg Spray, Suspension [11-26] sprays in each nostril once a day FUROSEMIDE 40 mg Daily ISOSORBIDE MONONITRATE 30 mg Daily LABETALOL 300 mg TID NIFEDIPINE 30 mg Daily NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet sublingually every 5-10 minutes x 3 as needed for chest pain OMEPRAZOLE 20 mg DAily KAYEXALATE Powder- 15 Powders by mouth every Monday 2t twice a week TACROLIMUS [PROGRAF] 5 mg [Hospital1 ] ASPIRIN 81 mg Daily FERROUS GLUCONATE 324 mg Daily MULTIVITAMIN 1 Capsule daily NICOTINE 14 mg/24 hour Patch 24 hr - apply patch once daily Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Flonase 50 mcg/actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day. 5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q3H (every 3 hours). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. Aranesp (polysorbate) 150 mcg/0.3 mL Syringe Sig: One (1) injection Injection once a month. 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 19. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 20. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 21. benzonatate 200 mg Capsule Sig: One (1) Capsule PO three times a day. 22. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 23. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 25. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 26. insulin lispro 100 unit/mL Solution Sig: 0-10 units Subcutaneous three times a day: check fingersticks before meals, d/c once fingersticks consistantly < 150. 27. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 3 days: [Date range (1) 3045]. 28. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: [Date range (1) 16006]. 29. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: [Date range (1) 29429]. 30. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 2 days: last day [4-20]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: primary diagnosis: congestive heart failure COPD exacerbation health-care associated pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [Known lastname 106665], It was a pleasure taking care of you. You were admitted to the [Hospital1 69] for trouble breathing that we think was due to an exacerbation of your emphysema and pneumonia. You had a prolonged stay in the hospital and was treated with antibiotics, prednisone and nebulizers. Your kidney function has been stable. A cardiac catheterization showed some blockages in your heart arteries but you are not a candidate for surgery and given your pulmonary problems, a procedure to open the arteries was not attempted at this time. You will see Dr. [Last Name (STitle) 171] in a few weeks to discuss options. Weigh yourself every morning, call Dr [Last Name (STitle) 171] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. We made the following changes to your medication regimen: 1. Discontinue Lasix, take torsemide instead to remove fluid 2. Increase citolopram to 20 mg daily 3. Increase aspririn tp 325 mg daily 4. Increase isosorbide mononitrate to 60 mg daily 5. Increase omeprazole to 40 mg daily 6. Decrease tacrolimus to 4mg daily 7. change albuterol to nebs for now 8. Start colace and senna to prevent constipation 9. Start Advair inhaler to help with emphysema 10. Discontinue labetolol, take carvedilol instead to lower your heart rate and blood pressure 11. Start Bezonanate tablets for your cough 12. Start calcium and vitamin D to prevent thin bones 13. Start prednisone and taper over the next 11 days. 14. discontinue beclamethasone Followup Instructions: . Department: TRANSPLANT CENTER When: FRIDAY [2188-5-30] at 9:00 AM With: [Name6 (MD) 2105] [Name8 (MD) 2106], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: MONDAY [2188-6-30] at 9:50 AM With: [First Name8 (NamePattern2) 11136] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage We are working on a follow up appt in the Pulmonary department within 1-2 weeks. You will be called at home with the appointment. If you have not heard or have questions, please call [Telephone/Fax (1) 612]. Department: CARDIAC SERVICES When: MONDAY [2188-5-19] at 2:40 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "530.81", "V64.1", "491.21", "287.5", "414.01", "428.0", "276.4", "486", "V42.0", "305.1", "288.60", "585.6", "253.6", "428.33", "276.7", "272.4", "518.81", "441.00", "404.93", "416.8", "413.9" ]	icd9cm	[ [ [] ] ]	[ "37.22", "88.56" ]	icd9pcs	[ [ [] ] ]	20183, 20249	12622, 16116	329, 355	20388, 20388	3597, 6660	22110, 23222	2389, 2435		17384, 20160		20270, 20270		16268, 17361		6677, 12599	20571, 22087									2450, 3578																16137, 16242					247, 291							383, 1870							20289, 20367			20403, 20547					1892, 2067	2083, 2373
2,005	108,530	12813	Discharge summary	report	Admission Date: [2164-4-16] Discharge Date: [2164-4-23] Date of Birth: [2116-5-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: EGD with biopsies History of Present Illness: 47 F c hx alcohol and cocaine abuse, recent admission ([6-29]) for abdominal pain and GI bleed requiring exploratory laparotomy showing diffuse hypoperfusion of bowel. Presented to ED c 4 d hx of abdominal pain, chest pain, shortness of breath, vomiting, decreased PO intake. Bulk of history obtained from patient's boyfriend and mother, both who were not with patient through majority of course of illness. Intermittent vomiting, non-bloody. Significant alcohol intake over last 4 days; unclear quantity. + Cocaine use over 4 days, unclear [Name2 (NI) 39469]. No further details available re: nature of CP, SOB. Boyfriend visited patient this morning and encouraged pt. to call ambulance. . In ED, noted to be hypertensive (154/102), tachycardic (132) c lactate of 4.5. Anion gap 26. L subclavian line placed for sepsis protocol. Received vancomycin, levofloxacin, metronidazole, PPI. Also treated for alcohol withdrawal with 1 mg ativan. Had two episodes hematemesis in ED and NG lavage done, cleared after 250 cc. Also received 8 mg IV morphine for abdominal pain. Surgery and GI evaluated pt in ED. CT done showing no PE, marked esophageal and mild colonic wall thickening, and findings c/w chronic pancreatitis. Past Medical History: EtOH abuse Cocaine abuse s/p ex-lap with cholecystectomy and G/J tube placement [6-22] S/p skin graft to L foot for burn > 10 yrs ago Social History: Pt is presently living at [Hospital 16662] rehab facility. Pt reports quitting EtOH 2 months ago. Pt had been drinking a pint of vodka per day x 20 years. Pt denies other drug use although documenation in the medical record notes hx of cocaine use. Pt reports 8py hx of tobacco. Pt continues to smoke 6 cigarettes per day. Pt is not employed and is on public assistance. Family History: non-contributory Physical Exam: VS - 126/89, 146, 96.6, 21, 100% GEN - Middle aged woman difficult to arouse HEENT - Dry MM, + skin tenting over forehead, JVP not elevated LUNGS - CTA anteriorly, axillae HEART - tachycardic, no murmurs, rubs; decrease in tachycardia rate to 130s c carotid massage. ABD - 10 cm linear scar midline abdomen, + tenderness to palpation RLQ, LLQ. No rebound, no guarding. Hemorrhoids on anus exam, no leaking blood from anus. Guiaic neg in ED. EXT - dry, no edema, cool feet, warm ankles, 2+ DP/PT pulses NEURO - responsive to voice, follows simple commands, difficult to engage in conversation Pertinent Results: <b>labs</b> - see below; notable for K 2.6, Cl 114, CO2 10, AG 21. HCT 23.7, down from 33.7 on presentation to ED <b>imaging</B> - CT abd - 1. Marked esophageal and mild colonic wall thickening. This appearance could be secondary to an infectious or inflammatory process. The distribution is less suggestive of an ischemic etiology. 2. No PE. 3. Findings consistent with chronic pancreatitis. <b>micro</b> - [4-16] bctx p * 2 <b>EKG</b> - sinus tachycardia c nl axis; ? negative deflection in aVL - ? lead reversal. Tall p waves diffusely. ST depressions inferior leads, lateral leads. T wane inversions inferiorly new. . Brief Hospital Course: # GIB - EGD showed severe esophagitis, gastritis, duodenitis. Started on PPI [Hospital1 ]. Also had positive H.pylori and started on 2 wk course of amoxicillin and clarithromycin. . # Ischemic Colitis: cocaine known to cause ischemic colitis and ulcerations in the GI tract. Patient continued to have pain abdomen with guarding. She had elevated Alk Phos which was trending down. Her pain had significantly improved on the day of amission and was able to tolerate her food very well. . # Alcohol Abuse/cocaine - She was monitored on CIWA scale for alcohol withdrawal; her last dose of ativan was given on [4-17]. Social work was consulted regarding her polysubstance abuse, and physical therapy was consulted given her chronic weakness secondary to past surgery. . # Abdominal Pain - likely from ischemic colitis vs sever gastritis/duodenitis vs pancreatitis flare. Improved during course of hospitalization. Medications on Admission: MVI Calcium Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 10 days. Disp:40 Capsule(s) Refills:0 5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 10 days. Disp:40 Tablet(s) Refills:0 6. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 10 days. Disp:40 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Erosive Gastritis Esophagitis + H. pylori Polysubstance abuse Discharge Condition: Stable, tolerating PO Discharge Instructions: You were admitted with abdominal pain; an EGD demonstrated erosive gastritis and esophagitis, and H. pylori testing was positive. You should continue to take pantoprazole twice daily and finish the entire course of antibiotics as prescribed. . If you develop worsening abdominal pain, fever, chills, nausea, vomiting, diarrhea, or other conerning symptoms, please seek medical attention immediately. . Followup Instructions: Please follow up with Dr. [Last Name (STitle) 23934] within 2 weeks of discharge from the hospital.[Telephone/Fax (1) 39470] Completed by:[2164-4-24]	[ "291.81", "305.1", "041.86", "401.9", "535.51", "305.61", "535.60", "305.01", "557.0", "577.1", "530.10" ]	icd9cm	[ [ [] ] ]	[ "45.16", "38.93" ]	icd9pcs	[ [ [] ] ]	5282, 5288	3503, 4422	331, 351	5394, 5418	2844, 3480	5869, 6033	2197, 2215		4484, 5259		5309, 5373		4448, 4461			5442, 5846									2230, 2825																					275, 293							379, 1621															1643, 1783	1799, 2181
82,436	155,071	40117+58352	Discharge summary	report+addendum	Admission Date: [2171-1-24] Discharge Date: [2171-2-4] Date of Birth: [2093-6-29] Sex: M Service: CARDIOTHORACIC Allergies: Percodan / Metformin / Codeine Attending:[First Name3 (LF) 1406] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2171-1-28] Coronary artery bypass graft x3, with the left internal mammary artery to the left anterior descending artery and reversed saphenous vein grafts to the posterior descending artery and the diagonal artery. [2171-1-24] Cardiac cath History of Present Illness: 77 year old male who presented [2171-1-23] to [Hospital3 ] with CP. Patient reported that on day of admission, he was eating breakfast when he developed mid-sternal Chest pain, +radiation to jaw and arms a/w weakness, without nausea/diaphoresis/palpitations. Initial labs were significant for WCC 8.2, HCT 39.4, Cr 1.0, Troponin 7. EKG was unchanged. Patient was admitted to the floor for further evaluation. While there, patient had single episode of sinoatrial pause lasting 6 seconds on telemetry, prompting a transfer of the patient to the ICU. Trop peaked 15.4. He was then transferred to [Hospital1 18] for cardiac catheterization. Cath revealed severe coronary disease and he was referred for cardiac surgery. Past Medical History: Diabetes Dyslipidemia Gastroesophageal reflux diease and peptic ulcer Macular degeneration Prostate Cancer Tobacco abuse(one pack a day smoker) Osteoprosis s/p prostectomy Bilateral Hearing loss Social History: Race:caucasian Last Dental Exam:edentulous Lives with:wife Occupation:[Name2 (NI) 88145] worker Tobacco:1ppdx 70 years ETOH:1 drink every 3-4 weeks Family History: non-contributory Physical Exam: Pulse:52 Resp:14 O2 sat:97/RA B/P Left:146/70 Height:5'[70]" Weight:144 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally, anteriorly [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact[x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [2171-1-24] Cardiac Cath: 1. Coronary angiography in this right dominant system revealed three-vessel disease. The LMCA had no angiographically apparent disease. The LAD had 70% stenosis in the mid-portion prior to an aneurysm. The D1 had a 70% ostial stenosis. The LCx had a small ostial OM1 stenosis of 70%. The RCA had a 95% ostial stenosis. 2. Resting hemodynamics revealed elevated left-sided filling pressure with an LVEDP of 18 mmHg. There was mild systemic arterial systolic hypertension with an aortic blood pressure of 145/52 mmHg. There was no aortic valve gradient seen on careful pullback from left ventricle to aorta. 3. Left ventriculography revealed an EF of 50% with inferobasilar hypokinesis. [2171-1-28] Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending 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. There is no pericardial effusion. Post: The patient is now s/p CABGX3. The patient is now on a neosynephrine drip @0.6mcg/kg/min. LV function is preserved @55%. There is persistent mild mitral regurgitation. The aorta is similar to prebypass with no dissection flaps observed. [2171-1-24] 04:00PM BLOOD WBC-9.5 RBC-3.92* Hgb-11.3* Hct-34.0* MCV-87 MCH-28.8 MCHC-33.2 RDW-14.2 Plt Ct-334 [2171-2-2] 06:20AM BLOOD WBC-8.6 RBC-3.36* Hgb-9.6* Hct-28.7* MCV-85 MCH-28.7 MCHC-33.6 RDW-14.3 Plt Ct-555* [2171-1-24] 04:00PM BLOOD PT-13.4 INR(PT)-1.1 [2171-1-28] 12:47PM BLOOD PT-14.1* PTT-39.7* INR(PT)-1.2* [2171-1-24] 04:00PM BLOOD Glucose-102* UreaN-18 Creat-0.9 Na-136 K-3.6 Cl-105 HCO3-24 AnGap-11 [2171-2-2] 06:20AM BLOOD Glucose-128* UreaN-25* Creat-1.2 Na-139 K-4.3 Cl-102 HCO3-28 AnGap-13 [2171-1-25] 06:05AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 [2171-2-1] 05:00AM BLOOD Mg-2.0 [2171-1-24] 04:00PM BLOOD Triglyc-120 HDL-37 CHOL/HD-4.7 LDLcalc-112 [2171-1-24] 04:00PM BLOOD %HbA1c-6.6* eAG-143* Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 42086] was transferred to [Hospital1 18] for cardiac cath. Cath revealed severe three vessel coronary disease. Following cath he was admitted for pending surgery. He underwent usual cardiac surgery work-up, along with medical management and awaiting Plavix washout. Mr. [Known lastname 42086] was brought to the operating room on [1-28] for coronary bypass grafting x 3. Please see operative report for details. He tolerated the operation well and was transferred to the cardiac surgery ICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation and pressors, awoke neurologically intact and extubated. His chest tubes were removed and he was transferred to the surgical step down floor on post-op day one. He experienced atrial fibrillation and was placed on amiodarone, after which he converted to a sinus rhythm. He worked with physical therapy for strength and mobility. He made good progress and on post-operative day five he was ready for discharge to rehab ([Location (un) ] House) with the appropriate medications and follow-up appointments. Medications on Admission: Glyburide 2.5mg PRN per patient MEDICATIONS ON TRANSFER Protonix 40mg daily Insulin sliding scale Nictine patch 14mg Glyburide 1.25mg qAM ASA 325mg daily Plavix 75mg daily Lipitor 80mg daily Heparin IV Morphine 1mg q4hr prn pain Plavix - last dose:600 mg [2171-1-24] Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 400mg twice daily x 7 days. Then 200mg twice daily x 7 days. Finally, 200mg daily until stopped by cardiologist. 11. Insulin-Insulin sliding scale per attached sheet Discharge Disposition: Home With Service Facility: [Hospital3 3765] Hospice Program Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x3 Past Medical History: Diabetes Dyslipidemia Gastroesophageal reflux diease and peptic ulcer Macular degeneration Prostate Cancer Tobacco abuse(one pack a day smoker) Osteoprosis s/p prostectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema-2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Please call to schedule appointments with your Surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 170] in 3 weeks Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7756] [Telephone/Fax (1) 71179] in [3-29] weeks Primary Care Dr [Last Name (STitle) 3390]: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21637] in [4-30] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2171-2-2] Name: [Known lastname 13983],[Known firstname 33] Unit No: [Numeric Identifier 13984] Admission Date: [2171-1-24] Discharge Date: [2171-2-4] Date of Birth: [2093-6-29] Sex: M Service: CARDIOTHORACIC Allergies: Percodan / Metformin / Codeine Attending:[First Name3 (LF) 135] Addendum: Pt was cleared for discharge to home ( not rehab) on POD #7. ( see brief hospital course). Brief Hospital Course: He developed RUE phlebitis and was started on keflex for a one week course. He was cleared for discharge to home ( instead of rehab) on POD #7.F/U appts were advised. Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. Disp:50 Tablet(s) Refills:0 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 400mg twice daily x 7 days. Then 200mg twice daily x 7 days. Finally, 200mg daily until stopped by cardiologist. Disp:100 Tablet(s) Refills:1 11. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for phlebitis for 1 weeks. Disp:21 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 13985] Hospice Program Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x3 Past Medical History: Diabetes Dyslipidemia Gastroesophageal reflux diease and peptic ulcer Macular degeneration Prostate Cancer Tobacco abuse(one pack a day smoker) Osteoprosis s/p prostectomy postop RUE phelebitis [First Name11 (Name Pattern1) 77] [Last Name (NamePattern4) 137] MD [MD Number(2) 138] Completed by:[2171-2-4]	[ "389.9", "E935.8", "997.2", "530.81", "362.50", "442.3", "733.00", "250.00", "427.31", "305.1", "V10.46", "272.4", "451.84", "E879.0", "410.71", "414.01", "292.81", "533.90" ]	icd9cm	[ [ [] ] ]	[ "88.77", "39.61", "88.56", "99.29", "37.22", "88.53", "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	11565, 11633	9794, 9962	307, 559	7583, 7804	2398, 4638	8644, 9771	1720, 1738		9985, 11542		11654, 11714		5837, 6111			7828, 8621									1753, 2379																					257, 269							587, 1317															11736, 12087	1551, 1704
10,356	114,160	7622	Discharge summary	report	Admission Date: [2127-4-29] Discharge Date: [2127-4-30] Date of Birth: [2065-9-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: acidosis Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: 61 yoM w/ h/o Type II DM and EtOH abuse p/w N/V X 1 day. Pt reports N/V starting this a.m. (no hematemesis), vomiting 2X/hr. He also notes intermittent central chest pain, [3-20] without radiation, associated with SOB since this a.m. Non-exertional, non-pleuritic without associated LH, palpitations. He also notes intermittent, non-productive cough. (+) chills, no fever. No abdominal pain, diarrhea, BRBPR, melena, dysuria, hematuria, polyuria, polydipsia. He reports that he drinks 5-6 EtOH drinks (brandy)/day (last drink yesterday). He reports he has not been taking his medications (including insulin) for several weeks. In the ED, ABG 6.94/11/165 with lactate 23.4. He received lopressor 5 mg IV X 1, Ceftriaxone 2 g IV X 1, 2L NS. * ROS: Pt denies headache, rhinorrhea, recent weight loss, LE edema, increased abdominal girth, orthopnea, PND. (+) poor PO intake. Past Medical History: 1) EtOH abuse: denies prior DTs/seizures 2) Type II DM 3) Hyperlipidemia 4) Hypertension 5) Abnl LFTs: suspected secondary to EtOH abuse Social History: EtOH 5 drinks per day. (+) tob [4-11] cig /day x 40yr, no other drug use Family History: M MI in 60s Physical Exam: 92.7, 97, 140/94, 23, 100% 2L NC tachypnic, speaking in short sentances PERRL, EOMI, icteric, nl conjunctiva, OMM dry, OP clear, neck supple, no LAD, no JVD RRR II/VI SM at apex CTAB hypoactive BS, soft, NT, liver edge 7cm below RCM, no splenomegaly no c/c/e, 2+ DP b/l CN II-XII intact, 5/5 strength, sensation intact, 2+ DTRs, no asterixis Pertinent Results: [2127-4-29] 11:30PM GLUCOSE-153* UREA N-18 CREAT-1.5* SODIUM-137 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-5* ANION GAP-34* [2127-4-29] 11:30PM ALT(SGPT)-94* AST(SGOT)-331* LD(LDH)-321* CK(CPK)-143 ALK PHOS-82 AMYLASE-430* TOT BILI-6.3* [2127-4-29] 11:30PM LIPASE-1333* [2127-4-29] 11:30PM CK-MB-4 cTropnT-<0.01 [2127-4-29] 11:30PM ALBUMIN-3.3* CALCIUM-6.9* PHOSPHATE-6.8* MAGNESIUM-1.6 [2127-4-29] 11:30PM TSH-0.66 [2127-4-29] 11:30PM WBC-10.3 RBC-3.12* HGB-9.9* HCT-31.9* MCV-102* MCH-31.8 MCHC-31.1 RDW-13.5 [2127-4-29] 11:30PM NEUTS-85* BANDS-3 LYMPHS-11* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [2127-4-29] 11:30PM PLT COUNT-105* [2127-4-29] 11:30PM PT-21.2* PTT-57.0* INR(PT)-2.8 [2127-4-29] 11:30PM FIBRINOGE-106* [2127-4-29] 10:49PM GLUCOSE-145* LACTATE-12.7* [2127-4-29] 10:30PM GLUCOSE-147* UREA N-17 CREAT-1.4* SODIUM-139 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-<5* [2127-4-29] 10:30PM ALT(SGPT)-75* AST(SGOT)-272* LD(LDH)-277* ALK PHOS-70 AMYLASE-366* TOT BILI-5.4* [2127-4-29] 10:30PM LIPASE-1190* [2127-4-29] 10:30PM ALBUMIN-2.9* CALCIUM-6.5* PHOSPHATE-6.8# MAGNESIUM-1.5 [2127-4-29] 10:30PM TRIGLYCER-265* [2127-4-29] 10:30PM WBC-10.6 RBC-2.79# HGB-8.6# HCT-28.8# MCV-103 MCH-30.9 MCHC-30.0* RDW-13.4 [2127-4-29] 10:30PM NEUTS-85* BANDS-1 LYMPHS-13* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2* [2127-4-29] 10:30PM PLT SMR-LOW PLT COUNT-95* [2127-4-29] 10:30PM PT-19.1* PTT-91.9* INR(PT)-2.3 [2127-4-29] 08:35PM URINE HOURS-RANDOM [2127-4-29] 08:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2127-4-29] 08:35PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.015 [2127-4-29] 08:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG [2127-4-29] 08:35PM URINE RBC-[4-12]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[4-12] [2127-4-29] 07:58PM TYPE-ART TEMP-36.7 O2 FLOW-2 PO2-165* PCO2-11* PH-6.94* TOTAL CO2-3* BASE XS--29 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2127-4-29] 07:58PM LACTATE-23.4* [2127-4-29] 07:58PM freeCa-1.20 [2127-4-29] 07:44PM LACTATE-22.0* [2127-4-29] 07:27PM GLUCOSE-179* LACTATE-24.4* K+-5.3 [2127-4-29] 07:15PM GLUCOSE-170* UREA N-19 CREAT-2.1# SODIUM-134 POTASSIUM-5.4 CHLORIDE-82* TOTAL CO2-5* ANION GAP-52* [2127-4-29] 07:15PM ALT(SGPT)-98* AST(SGOT)-250* LD(LDH)-277* CK(CPK)-87 ALK PHOS-111 AMYLASE-483* TOT BILI-7.8* [2127-4-29] 07:15PM LIPASE-1642* [2127-4-29] 07:15PM cTropnT-<0.01 [2127-4-29] 07:15PM CK-MB-NotDone [2127-4-29] 07:15PM IRON-269* [2127-4-29] 07:15PM ALBUMIN-4.9* CALCIUM-10.2 PHOSPHATE-12.1# MAGNESIUM-2.6 [2127-4-29] 07:15PM calTIBC-274 VIT B12-1031 FOLATE-11.4 FERRITIN-GREATER TH TRF-211 [2127-4-29] 07:15PM ASA-4 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2127-4-29] 07:15PM ASA-5 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2127-4-29] 07:15PM WBC-10.4# RBC-3.84* HGB-12.0* HCT-39.4* MCV-103* MCH-31.3 MCHC-30.5# RDW-13.5 [2127-4-29] 07:15PM NEUTS-82.9 BANDS-0 LYMPHS-12.2* MONOS-4.6 EOS-0.1 BASOS-0.2 [2127-4-29] 07:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2127-4-29] 07:15PM PLT SMR-LOW PLT COUNT-125* [2127-4-29] 07:15PM PT-17.8* PTT-42.6* INR(PT)-2.0 [2127-4-29] 07:15PM FIBRINOGE-158 D-DIMER-2354* [2127-4-29] 07:14PM cTropnT-<0.01 . EKG: ST @ 108 bpm, TWF I, avL [Street Address(2) 4793] depressions V3-V6 Brief Hospital Course: A: 61 year old male w/ h/o alcohol abuse, Type II DM presents with AG acidosis, pancreatitis, liver failure, and acute renal failure. . The patient was brought to the MICU and intubated for airway protection. Over the course of the next 24 hours the patient's condition rapidly deteriorated. His blood pressure continued to decline despite the administration of large quantities of IVFs (+15L), levophed, and vasopressin. He developed acute liver failure and pancreatitis which was accompanied by gross abdominal distension, bladder pressure as high as 50 and respiratory distress requiring an FiO2 100% & PEEP 35. . The famiy was advised that the patient would need an abdominal fasciotomy to decrease the abdominal pressures, and they were informed of the risks associated with this procedure. They chose to change management goals of DNR & no surgery. The patient expired at 6:50PM on [2127-4-30] from respiratory arrest. Medications on Admission: lipitor 70/30 viagra cartia lisinopril Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Respiratory arrest . Pancreatitis Liver failure Sepsis Acidosis Acute renal failure Discharge Condition: Dead Discharge Instructions: . Followup Instructions: .	[ "276.2", "995.92", "518.81", "038.9", "V58.67", "785.50", "263.9", "570", "285.9", "577.0", "V15.81", "789.09", "276.5", "584.9", "571.1", "250.00", "305.00", "286.6" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.91", "96.71", "99.04", "96.04" ]	icd9pcs	[ [ [] ] ]	6727, 6736	5674, 6609	322, 335	6864, 6870	1904, 5651	6920, 6925	1514, 1527		6698, 6704		6757, 6843		6635, 6675			6894, 6897									1542, 1885																					274, 284							363, 1244															1266, 1404	1420, 1498
4,292	161,237	1441	Discharge summary	report	Admission Date: [2126-3-13] Discharge Date: [2126-3-16] Date of Birth: [2054-1-23] Sex: M Service: SURGERY Allergies: Penicillins / Metoprolol Attending:[First Name3 (LF) 668] Chief Complaint: infected AV graft Major Surgical or Invasive Procedure: [2126-3-14] AV graft revision History of Present Illness: History of Present Illness (per Dr. [First Name (STitle) 8589]: Mr. [Known lastname 4643] is a 71 year old male w/ past medical history of ESRD via a LUE AVG presents for evaluation for infected AVG. Call from Dr. [Last Name (STitle) ] at Care- Mr. [Last Name (NamePattern4) 8590] [Last Name (NamePattern5) ] AVG was found to be thrombosed at his chronic HD unit in [Hospital1 ]. Pt. was sent to AV Care for a thrombectomy where the graft was evaluated and felt to be infected. Pt's last HD was on Monday. He has a h/o prior graft infection and revision. Past Medical History: Past Medical History (per OMR): CABG ([2115]) -- (LIMA->LAD, SVG->RPDA, SVG->RPL2, SVG->Diagonal),Chronic LV Diastolic Dysfunction, HTN, Hyperlipidemia, ESRD on HD since [2122], Anemia of CKD -- baseline hematocrit low 30s, Hypertensive Encephalopathy, Vascular Dementia, Subcortical WMD w/ Brain atrophy, Sleep apnea, Osteoarthritis, Spinal Stenosis, Peripheral Neuropathy, Left hip fracture ([2125-11-1])-- s/p ORIF of left femoral neck fracture, Depression, Sleep Apnea, GERD, BPH, Nephrolithiasis . Past Surgical History: [2125-8-27] Fistulogram with 8-mm balloon angioplasty of the venous outflow lesion. ([Doctor Last Name ]) [2125-5-31] AV graft redo and thrombectomy ([Location (un) ]) [2125-5-31] evac hematoma and thrombectomy [2125-3-31] Excision of left arteriovenous graft for infcetion. ([Doctor Last Name ]) [2125-3-30] Bedside ligation of left upper arm arteriovenous graft and drainage of likely infected hematoma. ([Location (un) ]) [2124-3-22] Left upper arm arteriovenous graft. ([Location (un) ]) - vagotomy and Bilroth procedure for ulcers - Cholecystectomy Social History: Married with one son and one daughter. [Name (NI) 8588] independent in ADLs, including ambulation, prior to hip fracture. # Alcohol: None # Tobacco: Quit smoking 20 years ago -- Smoked up to 1 PPD for 20-30 years # Drugs: None Family History: # Father -- died after surgery for brain tumor # Mother -- died of a stroke at age 879 # Sister -- Parkinsons disease and diabetes, age 76 # Sister -- massive MI and passed away in her 60s # Sister (mother of [Name2 (NI) 802] [Doctor First Name 717] -- HTN and HLD, but otherwise well # Brother -- HTN, HLD, DM2 Physical Exam: ADMISSION PHYSICAL EXAM: 97.7 67 119/82 16 98% GEN: no acute distress CV: nl S1, S2, RRR Resp: CTA b/l Abd: soft, nontender, nondistended, +BS Ext: No edema LUE: Graft with thrill, erythematous, warm, and tender to touch. No purulent discharge DISCHARGE PHYSICAL EXAM: 97.7 67 119/82 16 98% GEN: no acute distress CV: nl S1, S2, RRR Resp: CTA b/l Abd: soft, nontender, nondistended, +BS Ext: No edema LUE: Graft with thrill, erythematous, warm, and tender to touch. No purulent discharge Pertinent Results: LABS: . [2126-3-13] 11:40PM GLUCOSE-103* UREA N-87* CREAT-8.5* SODIUM-131* POTASSIUM-6.1* CHLORIDE-97 TOTAL CO2-16* ANION GAP-24* [2126-3-13] 11:40PM CALCIUM-9.7 PHOSPHATE-7.8* MAGNESIUM-3.0* [2126-3-13] 11:40PM WBC-8.7 RBC-3.39* HGB-10.6* HCT-32.2* MCV-95 MCH-31.1 MCHC-32.8 RDW-18.1* [2126-3-13] 11:40PM PLT COUNT-273 [2126-3-13] 08:22PM LACTATE-1.9 K+-5.1 [2126-3-13] 08:05PM GLUCOSE-121* UREA N-89* CREAT-8.6* SODIUM-134 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-18* ANION GAP-22* [2126-3-13] 08:05PM CK(CPK)-33* [2126-3-13] 08:05PM cTropnT-0.04* [2126-3-13] 08:05PM CK-MB-3 [2126-3-13] 08:05PM WBC-8.1 RBC-3.37* HGB-10.4* HCT-32.3* MCV-96 MCH-30.9 MCHC-32.3 RDW-18.0* [2126-3-13] 08:05PM NEUTS-68.1 LYMPHS-17.0* MONOS-5.7 EOS-8.0* BASOS-1.2 [2126-3-13] 08:05PM PLT COUNT-276 [2126-3-13] 07:54PM LACTATE-0.8 K+-2.7* [2126-3-13] 07:54PM HGB-6.8* calcHCT-20 [2126-3-13] 05:15PM PT-23.3* PTT-30.3 INR(PT)-2.2* [2126-3-13] 04:44PM LACTATE-1.2 K+-6.5* [2126-3-13] 04:15PM GLUCOSE-88 UREA N-92* CREAT-9.0# SODIUM-128 POTASSIUM-10.0* CHLORIDE-90* TOTAL CO2-21* ANION GAP-27* [2126-3-13] 04:15PM estGFR-Using this [2126-3-13] 04:15PM WBC-8.1# RBC-4.00* HGB-12.5* HCT-38.1* MCV-95 MCH-31.2 MCHC-32.7 RDW-17.9* [2126-3-13] 04:15PM NEUTS-72.4* LYMPHS-13.7* MONOS-6.6 EOS-6.3* BASOS-1.0 [2126-3-13] 04:15PM PLT COUNT-289 . IMAGING: CXR Date: [2126-3-13] IMPRESSION: Brief Hospital Course: Mr. [Known lastname 4643] was admitted on [2126-3-13] with an infected AV graft in his left upper extremity. He was admitted into the ICU after he was found to have an elevated potassium. In the ICU, he had a femoral line placed for vascular access. He had blood cultures drawn. He received dialysis in the ICU and was started on IV vancomycin 1000mg. He remained afebrile in the ICU. On [2126-3-14], he was taken to the OR and had a partial excision of his AV graft. He [Date Range 8337] the procedure well and was taken to hemodialysis via femoral line post-operatively. His arm was bandaged with an ACE wrap and remained cleaned, dry and intact. He was resumed on a regular diet when he was transferred to the floor. On [2126-3-15], he was taken to hemodialysis in the morning. He received another dose of vancomycin. He remained afebrile throughout the day. He received 2 units of FFP due to an elevated INR of 2.7. IR placed a tunnelled hemodialysis catheter and MR. [Known lastname 4643] [Last Name (Titles) 8337] the procedure without any complications. On [2126-3-16], pt was discharged home with plan to complete 6 week course of Vancomycin per HD protocol and agreement and understanding of plan verbalized by patient. Medications on Admission: - clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY - Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. - tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). - levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY - pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). - citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. - lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left hip 12 hours on, 12 hours off. - warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dose will be adjusted by PCP after discharge. - simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY - amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): - nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Use as directed. - acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Do not take more than 4000 mg in 24 hours. - gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime - Aggrenox 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap, Multiphasic Release 12 hr PO twice a day. Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:42 Tablet(s) Refills:0 8. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Please continue vancomycin for a total of 6 weeks after discharge. You will receive your dose of vancomycin at your dialysis sessions. You first dose of vancomycin was given on [2126-3-13]. Discharge Disposition: Home With Service Facility: allcare vna Discharge Diagnosis: Primary Diagnosis: Infected AV graft . Secondary diagnosis" ESRD . Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 4643], It was a pleasure taking care of you during your hospitalization. You were admitted after you developed an infected AV graft. During your hospital stay, the AV graft was removed and was replaced by another AV graft. We encourage you to keep your incision covered. You may remove the dressing in 2 days. You were started on vancomycin during your hospitalization. You will need to continue this antibiotic for 6 weeks after discharge. You will receive your vancomycin dose at your hemodialysis sessions. . Please make sure you weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . Please follow-up with Dr. [First Name (STitle) ] in 1 to 2 weeks after discharge. If you have any questions or concerns about how to care for your AV graft, please call his office at ([Telephone/Fax (1) 673]. If you develop any swelling, redness, or purulent drainage from your graft, you should also contact our office immediately. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 to 2 weeks after discharge. Please see below for your appointment details: . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2126-3-28] 1:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2126-3-25] 3:40 . Completed by:[2126-3-16]	[ "285.21", "V12.71", "585.6", "403.91", "E879.1", "272.4", "724.00", "996.62", "428.32", "327.23", "428.0", "530.81", "715.90" ]	icd9cm	[ [ [] ] ]	[ "39.42", "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	8498, 8540	4749, 6015	301, 337	8651, 8651	3221, 4726	9825, 10293	2374, 2696		7518, 8475		8561, 8561		6041, 7495			8802, 9802							1508, 2108		2736, 2956																					244, 263							365, 947							8580, 8630			8666, 8778					969, 1485	2124, 2358		2981, 3202
31,966	162,702	45640	Discharge summary	report	Admission Date: [2159-9-17] Discharge Date: [2159-9-19] Service: MEDICINE Allergies: Depakote ER Attending:[Last Name (NamePattern4) 290] Chief Complaint: Cough, Fever Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]yo M presenting with productive cough and fever. Onset: 3d prior, pt notes productive (yellow sputum, no blood) cough. Preceeded by 14d of non-productive cough with outpatient eval that included Z-pack (last dose 10d prior). Course: increasing severity of cough over last 3 days. Associated Sx: 1d of elevated T to 101.6 max, decreased energy this AM with inability to exit bed. Denies additional ASx including SOB, CP, n/v, change in GI or GU habits, HA, chills, change in vision, pre-syncope, syncope, or seizure activity. Denies any known immunosuppression or recurrent infections. Per son, pt was not at baseline mental status this AM; following the below treatment within the ED, the son reports that his father has now returned to his baseline. . In the ED, initial vs were: Temp:97.4 HR:74 BP:92/37 Resp:18 O(2)Sat:97 normal. Physical exam was consistent with decreased volume status and pneumonia (Crackles at the right base, diminished breath sounds on the left base). A cxray confirmed the LLL alveolar process consistent with PNA. . Clinical course complicated by 1 episode of hypotension (asymptomatic) with a systolic pressure in the 80s. Patient was rehydrated with 1.5L of NS; his BP returned to his baseline SBP in the 90s. In additional, pt received initial course of Abx for CAP, ceftriaxone and levofloxacin following blood Cx, urine Cx, and sputum Cx. In addition, the patient had an intermediate troponin, 0.04, with no evidence of an acute process on EKG. He has had this in the past, although his most recent troponin was negative. The ED team discussed this with cardiology and provided the patient with a 325mg of aspirin here in the ED. . On the floor, the pt has remained appropriate and provided the above history; his 24hour aide is at his bedside and confirms the aforesaid details. Past Medical History: 1. Complex partial seizures 2. Prostate cancer, diagnosed 5 years ago. Being followed expectantly and treated with Proscar. 3. Sleep apnea with daytime sleepiness and sleep disordered breathing noted in past. Trialed on Modafanil but this caused oral buccal dyskinesias. Did not tolerate BiPap. Daytime sleepiness improved after discontinuation of Depakote. 4. History of orthostatic hypotension in remote past, on Cortef 5. Left eye cataract status post surgery 6. Ptosis on right as a result of surgery for detached retina 7. Peripheral neuropathy 8. ? Esophageal diverticulum 9. Pacemaker Social History: The pt is widowed since [2151]. Retired at age 70. Was on the Board of Directors at [Hospital1 18]. Former smoker of 10 pack years but quit 50+ years ago. Drinks one shot or cocktail nightly. Has 24 hour housekeeping and homecare assistance, driver. Walks with cane for past one year. Family History: Noncontributory. Physical Exam: Vitals: T: 97.4 BP: 130/56 P:75 R:16 O2:99% on RA General: Alert, oriented to person and place, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear with no pharyngeal exudate Neck: supple, JVP not elevated, no LAD Lungs: Crackles LLB CV: Paced AV at 75bpm, 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 or cyanosis, 1+ edema from feet through ankles BL. Pertinent Results: CLINICAL INFORMATION: [Age over 90 ]-year-old male with history of fever, cough, rule out infiltrate. COMPARISON: [2157-4-22]. FINDINGS: Patchy left base opacity raises concern for consolidation/pneumonia. There is slight blunting of the left costophrenic angle may be due to a trace effusion. Mild right base atelectasis is noted. Cardiac silhouette is mildly enlarged. The aorta is calcified and tortuous. No pulmonary edema is seen. A dual-lead left-sided pacemaker is again seen, unchanged in position, with leads extending in the expected positions of the right atrium and right ventricle. Degenerative changes are seen at the right shoulder and acromioclavicular joints. There is diffuse osteopenia. Evidence of DISH is seen along the thoracic spine. Brief Hospital Course: [Age over 90 ]yo M presenting with s/sx consistent with CAP. MICU Course: [Date range (3) 97316] Patient was admitted to MICU overnight for observation. He was started on cetriaxone and levofloaxacin for CAP coverage when admitted and then transitioned to clindamycin. When admitted was transiently hypotesnive to SBP 90s. He was encouraged to take PO and SBPs remained in 110s. Initial labs also showed a troponin leak with no evidence of ischemia. This was thought to be [1-2] demand. Serial troponins stable. No interventioned was needed. INR was subtherapeutic on admission and coumadin was increased for one dose. Repeat INR was within therapeutic ranges. He was transferred to the floor where he was HD stable and had no oxygen requirement. He was discharged to complete a 10 day course of Clindamycin and follow up with his PCP. [Name10 (NameIs) ] discharge medication list and scheduled f/u appointments can be found below. Medications on Admission: Kepra [12-2] 750mg [Hospital1 ] avodart 0.5mg qhs coumadin 2.5 to 5mg daily hydrocort 10mg [Hospital1 ] restatis (cyclosporine) bilateral 1 drop daily Azopt 1 % risolimide Discharge Medications: 1. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO twice a day. 2. levetiracetam 750 mg Tablet Sig: 0.5 Tablet PO twice a day. 3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three times a day for 5 days. Disp:16 Capsule(s) Refills:0 4. cyclosporine 0.05 % Dropperette Sig: One (1) Drop Ophthalmic DAILY (Daily). 5. brinzolamide 1 % Drops, Suspension Ophthalmic 6. warfarin 1 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 7. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO at bedtime. Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Community Acquired Pneumonia 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 18] because you had symptoms that were concerning for a community acquired pneumonia. We initiated treatment with antibiotics. While you were here you had an episode of low blood pressure that resolved when we gave you fluids. We would like you to take the following medicines: 1) Clindamycin 300 MG three times a day for 5 more days 2) Warfarin 1.5mg every other day You should continue to take your other medicines as directed by your primary care physician. [Name10 (NameIs) ] [Name11 (NameIs) 97317] also continue to drink fluids when you are thirsty. The antibiotics you are on can interfere with your blood thinners. It is important that you have your blood tested within 48 hours of going home so that any adjustments in dosing can be made. Followup Instructions: PCP appointment with Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) ] MD [Last Name (Titles) 766] [2159-9-24] at 3pm please call [Telephone/Fax (1) 7318] if you are unable to make the appointment or need to reschedule. Department: NEUROLOGY When: THURSDAY [2159-9-27] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16747], M.D. [Telephone/Fax (1) 16748] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2159-10-16] at 1:30 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2159-10-16] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "276.50", "V12.51", "788.41", "411.89", "365.9", "482.9", "724.2", "327.23", "V45.01", "345.50", "337.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6178, 6264	4448, 5398	239, 245	6337, 6337	3656, 4425	7334, 8639	3060, 3078		5633, 6155		6285, 6316		5424, 5610			6513, 7311									3093, 3637																					187, 201							273, 2116										6352, 6489					2138, 2732	2748, 3044
23,936	183,933	6550	Discharge summary	report	Admission Date: [2178-2-27] Discharge Date: [2178-3-14] Date of Birth: [2134-3-29] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Esophageal perforation Major Surgical or Invasive Procedure: Right thoracotomy with mediastinal debridement and repair of esophageal perforation. History of Present Illness: The patient is a 43 y/o male with a h/o esophageal stricture s/p balloon dilatation 7 years ago doing well with no symptoms unil 1-2 months ago when he began having pain and difficulty swallowing. The patient presents today complaining of a piece of steak that got caught in the middle of his chest and caused him to have pain. The patient vomited the piece of steak up and had a few episodes of bloody emesis in the ED that has since now resolved. NG lavage was negative. The patient currently complains of right sided chest pain that is worse with inspiration. No shortness of breath or chest pain. On CT imaging, the patient was found to have a thickened mid esophagus with what appears to be contained leak at the level of the carina. There is also what appears to be intraesophageal air as well as a small area of pneumomediastinum adjacent to the esophagus very concerning for esophageal perforation. Over the course of his hospitalization, in the emergency room, he developed tachycardia up to 145, a temperature up to 102.5, a white count which was initially normal at 10, and diaphoresis. Past Medical History: 1. Esophageal stricture s/p balloon dilatation 2. Barrett's esophagus 3. Kleinfelters 4. Raynaud's 5. depression Social History: The patient works as a truck driver and lives with his family. He denies alcohol or tobacco use. Family History: His mother has diabetes. Physical Exam: T 102.5 P 145 BP 126/86 R 24 SaO2 96% Gen - no acute distress Heent - extra-ocular muscles intact, pupils equal round and reactive, slerae anicteric, no cervical lymphadenopathy Lungs - clear Heart - regular rate and rhythm Abd - soft, nontender, nondistended, bowel sounds audible Extrem - no lower extremity edema Pertinent Results: [2178-2-26] 08:01PM BLOOD WBC-10.2 RBC-5.44 Hgb-16.9 Hct-48.8 MCV-90 MCH-31.1 MCHC-34.6 RDW-13.8 Plt Ct-287 [2178-2-26] 05:55PM BLOOD PT-11.3 PTT-24.0 INR(PT)-1.0 [2178-2-26] 05:55PM BLOOD Glucose-102 UreaN-16 Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-28 AnGap-12 Brief Hospital Course: Based on the constellation of findings, it was determined that the best treatment was to take the patient to the OR for a right thoracotomy with mediastinal debridement and repair of esophageal perforation. The patient tolerated the surgery well and was transferred to the ICU intubated in order to allow the esophagus to heal. An NG tube was placed to decompress the stomach. Broad spectrum antibiotics were started empirically. TPN was started to provide nutrition. Initially, there was difficulty in weaning the patient to extubate because of agitation. The thought was that his surgical pain from the thoracotomy could have been contributing to this so an intercostal nerve block was performed by the acute pain service. However, this was unsuccessful in stemming the agitation. The patient was started on a Precidex drip and finally was able to be extubated on post-op day 4. The patient remained stable and was transferred to the floor. His bowel function returned, his NG tube was d/c'd, and he had a barium swallow and a CT scan which did not reveal an anastomotic leak. He was started on a diet and was able to tolerate a soft regular diet on discharge. On post-op day 11, the patient spiked a fever. He was pancultured and a chest x-ray revealed a new right middle/lower lobe infiltrate. Cultures had no growth. The patient was started on Vancomycin and Zosyn for presumed pneumonia. He was discharged on a 7 day course of Augmentin. Psychiatry was consulted to provide recommendations for managing the patient's depression. Physical therapy was consulted to assist the patient with ambulation. The patient was discharged on post-op day 15 in good condition with pain well controlled, in good spirits, and able to ambulate independently. Medications on Admission: 1. Testosterone Cypionate 200 mg/mL Oil Sig: Two (2) mL Intramuscular every 2 weeks. 2. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:60 Tablet(s) Refills:2 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 5. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Testosterone Cypionate 200 mg/mL Oil Sig: Two (2) mL Intramuscular every 2 weeks. 7. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. Chest x-ray Please obtain chest x-ray prior to follow up visit with Dr. [Last Name (STitle) 952]. Discharge Disposition: Home Discharge Diagnosis: Esophageal perforation Depression Discharge Condition: Good Discharge Instructions: Call your doctor or seek immediate medical attention if you experience any fevers, chills, lightheadedness, dizziness, shortness of breath, chest pain, palpitations, severe abdominal pain, nausea/vomiting, or increased drainage, redness, or bleeding from surgical wound. No driving while taking pain medications. You may use dry dressing to cover wound. No tub baths or swimming. No heavy lifting for 1 month. Soft solid diet. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12293], MD Date/Time:[2178-3-26] 10:00 Please follow up with Dr. [Last Name (STitle) 952] in [2-10] weeks. Call [Telephone/Fax (1) 170] for appointment. Please obtain chest x-ray prior to follow up visit.	[ "311", "486", "518.5", "293.0", "401.9", "578.0", "758.7", "278.00", "338.18", "443.0", "530.3", "519.2", "530.85", "530.4" ]	icd9cm	[ [ [] ] ]	[ "04.81", "99.15", "96.34", "96.72", "38.93", "42.7", "34.3", "86.74", "42.23", "42.82" ]	icd9pcs	[ [ [] ] ]	5828, 5834	2515, 4284	352, 439	5912, 5919	2222, 2492	6395, 6698	1842, 1868		4642, 5805		5855, 5891		4310, 4619			5943, 6372									1883, 2203																					290, 314							467, 1575															1597, 1712	1728, 1826
353	131,488	9275	Discharge summary	report	Admission Date: [2151-10-1] Discharge Date: [2151-10-20] Date of Birth: [2089-7-23] Sex: M Service: MEDICINE Allergies: Ativan / Tetracycline Attending:[First Name3 (LF) 5368] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: Hemodialysis Placement and removal of several temporary HD catheters Placement of permanent HD line TEE History of Present Illness: HPI: 62 yo M w/ h/o ESRD on HD, CAD s/p CABG, PVD s/p bilateral BKA, and h/o MRSA ([6-1]) / MSSA ([12-2]) / and fungal ([8-2]) line sepsis a/w F x 1 day. Patient reports onset of fevers this AM. BS have been well controlled on his po meds. He called his doctor and was told to go to the ER given his h/o line infections. Patient's most recent bacteremia was [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 31789] in [8-2]. Patient was tx w/ ambisome x 2 weeks via a PICC. His line was changed just 6 weeks ago. Of note, patient has difficult access and has bilateral IJ clots. Of note, patient has been having hypotn at [Month/Day (1) 2286] and has thus been on reduced doses of his bp meds x 2 weeks. He denies cough, SOB, N, V, D, abd pain, dysuria, catheter tenderness, or rash. No pain/erythema surrounding old clotted graft site. In ED, patient spiked T 102.3, dropped his bp to 97/60 despite IVFs, and desat'd to 88% on RA. Vanc, levo, and flagyl were administered and he has received a total of 4 L NS. Initial lactate 3.9 but trended down to 2.0 w/ IVFs. Despite IVF, he required very low dose levophed to maintain MAP > 65. . All: ativan, tetracycline -> lip swelling Past Medical History: PCP: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ## ESRD on HD (South Suburban, [Telephone/Fax (1) 31790], MWF) - considering tx in future thus no current plan for fistula/graft to replace lines despite recurrent line infxns; makes good urine ([11-29] pint - pint qd) ## CAD s/p CABG ## PVD s/p bilateral BKA ## h/o MRSA line sepsis [4-1] and [6-1] - tunneled line replaced [6-1], TEE [2151-6-29]: neg for veg, tx w/ 6 weeks vanc ## T1DM ## h/o L arm AV graft, clotted ## h/o MSSA bacteremia [12-2] ## htn ## bilateral IJ clots, on coumadin ## pancreatic cysts w/ plan for outpatient CT [10-12] and OP f/u [10-15] ## CHF: ECHO [2151-9-2] - EF 55%, 1+ MR #[Medical Record Number ]h/o fungal line sepsis: [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 31789] ([2151-8-27]), tx w/ ambisome x 2 weeks via PICC, repeat cx [8-30] and [9-1] negative, line changed 6 weeks ago ## s/p flu vacc Social History: Lives in [Location 5110] with his mother. A retired pharmacist. Smokes occ cigar (1-2 per week), no etoh. Family History: Mother and father with DM, father with PVD. No h/o CAD. Physical Exam: T 100.1 (Tm 102.3) bp 126/60 (min 97/60) hr 103 rr 18 O2 100% on 100% NRB (after desat to 88% on RA)->96% RA FS 112 genrl: in nad, lying on right side due to c/o back pain neck: no jvd cv: rrr, no m/r/g, soft s1/s2 pulm: left tunneled line w/ some surrounding erythema and overlying clot, very minimal bibasilar crackles, no wheeze/ronchi/rhales abd: nabs, soft, nt/nd, no masses/hsm extr: s/p bilateral BKA, left upper arm w/ residual graft material but not erythmematous/tender, left femoral line neuro: a, ox3, maew Pertinent Results: REPORTS: . TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. . CXR: IMPRESSION: No pneumonia. Interval removal of [Location 2286] catheter. . ADMISSION LABS: . [2151-10-1] 11:30AM URINE RBC-0-2 WBC-[1-30] BACTERIA-OCC YEAST-NONE EPI-0-2 [2151-10-1] 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-NEG [2151-10-1] 11:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2151-10-1] 11:30AM PT-17.7* PTT-28.4 INR(PT)-2.2 [2151-10-1] 11:30AM PLT COUNT-127# [2151-10-1] 11:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [2151-10-1] 11:30AM NEUTS-81 BANDS-8* LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2151-10-1] 11:30AM WBC-7.8 RBC-3.86# HGB-12.9# HCT-36.4# MCV-95 MCH-33.5 MCHC-35.5* RDW-15.9* [2151-10-1] 11:30AM CORTISOL-27.1* [2151-10-1] 11:30AM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-3.4# MAGNESIUM-1.8 [2151-10-1] 11:30AM CK-MB-2 cTropnT-0.07* [2151-10-1] 11:30AM LIPASE-27 GGT-16 [2151-10-1] 11:30AM ALT(SGPT)-13 AST(SGOT)-15 LD(LDH)-176 ALK PHOS-84 TOT BILI-0.6 [2151-10-1] 11:30AM CK(CPK)-59 [2151-10-1] 11:30AM GLUCOSE-131* UREA N-55* CREAT-6.9# SODIUM-140 POTASSIUM-5.2 CHLORIDE-94* TOTAL CO2-28 ANION GAP-23* [2151-10-1] 11:47AM LACTATE-3.9* [2151-10-1] 05:57PM LACTATE-2.0 K+-5.7* [2151-10-1] 07:45PM PLT COUNT-111* [2151-10-1] 07:45PM WBC-6.6 RBC-3.17* HGB-10.5* HCT-31.2* MCV-99* MCH-33.2* MCHC-33.7 RDW-15.9* [2151-10-1] 07:45PM GLUCOSE-62* UREA N-53* CREAT-7.0* SODIUM-139 POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-19 . EKG: sinus tachy 103 bpm, 1st degree AVB, wide QRS, TWI V23 . ADDITIONAL LABS: [2151-10-17] 06:30AM BLOOD WBC-6.0 RBC-3.27* Hgb-10.8* Hct-31.3* MCV-96 MCH-32.9* MCHC-34.4 RDW-16.0* Plt Ct-212 [2151-10-12] 06:00AM BLOOD WBC-8.4# RBC-3.33* Hgb-10.9* Hct-33.1* MCV-99* MCH-32.8* MCHC-33.1 RDW-16.5* Plt Ct-238 [2151-10-8] 06:23AM BLOOD WBC-5.1 RBC-3.04* Hgb-10.4* Hct-30.6* MCV-101* MCH-34.4* MCHC-34.2 RDW-15.9* Plt Ct-206 [2151-10-5] 04:28AM BLOOD WBC-4.5 RBC-2.97* Hgb-10.0* Hct-29.7* MCV-100* MCH-33.6* MCHC-33.5 RDW-15.6* Plt Ct-154 [2151-10-3] 03:18AM BLOOD WBC-7.9 RBC-3.22* Hgb-10.4* Hct-31.2* MCV-97 MCH-32.5* MCHC-33.5 RDW-16.0* Plt Ct-105* [2151-10-1] 11:30AM BLOOD WBC-7.8 RBC-3.86# Hgb-12.9# Hct-36.4# MCV-95 MCH-33.5 MCHC-35.5* RDW-15.9* Plt Ct-127# [2151-10-15] 08:30AM BLOOD Neuts-77.4 Lymphs-16.6* Monos-3.7 Eos-2.0 Baso-0.3 [2151-10-4] 06:00AM BLOOD Neuts-73* Bands-5 Lymphs-12* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 [2151-10-14] 06:12AM BLOOD PT-13.4* PTT-29.4 INR(PT)-1.2 [2151-10-12] 06:00AM BLOOD Plt Ct-238 [2151-10-11] 05:51AM BLOOD Plt Ct-223 [2151-10-9] 06:27AM BLOOD PT-13.7* PTT-28.5 INR(PT)-1.3 [2151-10-4] 06:00AM BLOOD Plt Smr-LOW Plt Ct-131* [2151-10-17] 06:30AM BLOOD Glucose-204* UreaN-63* Creat-7.7# Na-139 K-4.6 Cl-101 HCO3-23 AnGap-20 [2151-10-16] 09:20AM BLOOD Glucose-269 UreaN-48* Creat-6.6* Na-136 K-4.5 Cl-98 HCO3-23 AnGap-20 [2151-10-16] 06:50AM BLOOD Glucose-188* UreaN-48* Creat-6.4# Na-140 K-4.9 Cl-103 HCO3-22 AnGap-20 [2151-10-15] 08:30AM BLOOD Glucose-229 UreaN-61* Creat-7.9# Na-139 K-5.1 Cl-101 HCO3-21 AnGap-22* [2151-10-14] 06:12AM BLOOD Glucose-164* UreaN-48* Creat-6.8# Na-140 K-4.7 Cl-102 HCO3-22 AnGap-21 [2151-10-13] 08:11AM BLOOD Glucose-134* UreaN-60* Creat-8.0* Na-139 K-5.3* Cl-99 HCO3-22 AnGap-23* [2151-10-12] 06:00AM BLOOD Glucose-161* UreaN-52* Creat-7.0# Na-139 K-4.9 Cl-100 HCO3-25 AnGap-19 [2151-10-11] 05:51AM BLOOD Glucose-197 UreaN-88* Creat-9.7* Na-136 K-5.0 Cl-96 HCO3-23 AnGap-22* [2151-10-2] 02:10AM BLOOD Glucose-114* UreaN-53* Creat-7.1* Na-137 K-5.0 Cl-97 HCO3-21* AnGap-24* [2151-10-14] 06:12AM BLOOD ALT-4 AST-8 LD(LDH)-128 AlkPhos-83 TotBili-0.3 [2151-10-2] 03:27PM BLOOD CK(CPK)-86 [2151-10-1] 11:30AM BLOOD CK(CPK)-59 [2151-10-1] 11:30AM BLOOD ALT-13 AST-15 LD(LDH)-176 AlkPhos-84 TotBili-0.6 [2151-10-1] 11:30AM BLOOD Lipase-27 GGT-16 [2151-10-2] 03:27PM BLOOD CK-MB-NotDone cTropnT-0.11* [2151-10-2] 02:10AM BLOOD CK-MB-2 cTropnT-0.09* [2151-10-1] 11:30AM BLOOD CK-MB-2 cTropnT-0.07* [2151-10-17] 06:30AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9 [2151-10-15] 08:30AM BLOOD Calcium-8.9 Phos-5.6* Mg-2.1 [2151-10-11] 05:51AM BLOOD Calcium-9.4 Phos-5.6* Mg-2.3 [2151-10-6] 04:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1 [2151-10-2] 03:27PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.6 [2151-10-1] 11:30AM BLOOD Cortsol-27.1* [2151-10-14] 06:12AM BLOOD Vanco-8.9* [2151-10-13] 08:11AM BLOOD Vanco-9.9* [2151-10-12] 06:00AM BLOOD Vanco-11.8* [2151-10-11] 05:51AM BLOOD Genta-3.4* Vanco-16.1* [2151-10-8] 06:23AM BLOOD Genta-3.6* Vanco-18.1* [2151-10-5] 04:28AM BLOOD Genta-3.2* Vanco-17.4* [2151-10-3] 03:18AM BLOOD Genta-5.4 [2151-10-2] 10:54PM BLOOD Type-ART pO2-75* pCO2-45 pH-7.35 calHCO3-26 Base XS-0 [2151-10-2] 10:35PM BLOOD Type-ART pO2-36* pCO2-50* pH-7.32* calHCO3-27 Base XS-0 [2151-10-2] 08:39PM BLOOD Type-ART Temp-39.7 pO2-78* pCO2-36 pH-7.43 calHCO3-25 Base XS-0 Intubat-NOT INTUBA [2151-10-2] 01:45AM BLOOD Type-ART Temp-38.7 Rates-/22 O2 Flow-2 pO2-84* pCO2-37 pH-7.42 calHCO3-25 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2151-10-2] 08:39PM BLOOD Lactate-2.2* [2151-10-2] 01:45AM BLOOD Lactate-2.0 K-4.9 [2151-10-1] 05:57PM BLOOD Lactate-2.0 K-5.7* [2151-10-1] 11:47AM BLOOD Lactate-3.9* [2151-10-2] 10:35PM BLOOD O2 Sat-63 [2151-10-2] 01:45AM BLOOD O2 Sat-95 . MICRO: [2151-10-16] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-16] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-13] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-12] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-12] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-12] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [2151-10-11] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-11] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {ENTEROCOCCUS FAECALIS} SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S CHLORAMPHENICOL------- =>64 R LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S PENICILLIN------------ 8 S VANCOMYCIN------------ =>32 R [2151-10-10] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-10] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-9] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-8] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-8] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-8] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-7] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-7] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-6] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-6] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-5] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE} STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S [2151-10-5] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL negative [2151-10-2] CATHETER TIP-IV WOUND CULTURE-FINAL {STAPH AUREUS COAG +} STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R [2151-10-2] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL cancelled [2151-10-1] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING [2151-10-1] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} [2151-10-1] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} [2151-10-1] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +}; ANAEROBIC BOTTLE-FINAL {STAPH AUREUS COAG +} STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R [2151-10-1] URINE URINE CULTURE-FINAL negative Brief Hospital Course: 62 yo Male w/ h/o DM, ESRD on HD, CAD s/p CABG, PVD s/p bilateral BKA, and h/o MRSA ([6-1]) / MSSA ([12-2]) / and fungal ([8-2]) line sepsis admitted with fever and hypotension. . #. Sepsis: Pt was transferred to the MICU [12-30] hypotension and decreased O2 sats (secondary to fluid overload and likely line sepsis). Pt was treated with low dose levophed for hypotension unresponsive to IVF. He subsequently was taken off pressors and was transferred back to the floor. He satted well on RA during the remainder of the admission. Patient had [5-3] blood cultures from [2151-10-1] which grew staph aureus (MSSA) from dilaysis catheter. Cath tip (L femoral line) from [10-5] grew coag neg staph (oxacillin resistant). Blood cx from [10-11] grew [11-29] bottles with VRE (linezolid resistant). Pt had been on vanco (dosed by level) for most of his hospital stay to treat his MSSA line sepsis, however this was switched to linezolid once pt grew VRE from his blood. The linezolid was subsequently d/c'd, as the VRE was found to be linezolid resistant. Pt was then put on Unasyn, to be given daily for VRE coverage. The sensitivites were then changed, as the VRE was found to be sensitive to linezolid. Finally, for discharge the patient was transitioned to linezoid 600mg po for 14 days, and cefazolin 1gm IV after each HD for 14 days. . #) Pancreatic mass: pt had prior MRCP, which was consistent with a pancreatic duct tumor. This will need to be addressed as an outpatient, as this has not been a focus of this admission, given pt's other acute problems. [Name (NI) ] has been instructed to follow up with Dr. [Last Name (STitle) ]. . # Constipation: Pt had almost 2 week bout of constipation, which resolved s/p manually disimpaction x 4 plus numerous enemas. . #. Conduction delay: Over past 2 months, pt has had increasing PR interval. Originally concerning for possible abscess or vegetation, however pt had negative TTE and TEE. . #. Bilateral IJ clots: Mr [Known lastname 7363] was originally on coumadin, although this was held during most of this admission, given the need for multiple [Known lastname 2286] line placements. This continued to be held on discharge as the patient had to return in 2 days for a repeat graft attempt. . #. CAD s/p CABG: Continued ASA, statin We held Mr [Known lastname 31791] BB and ACE given hx of hypotension; These were not restarted at time of discharge as he was continuing to e normotensive (to slightly hypotensive during HD). . #. CHF: Low normal EF by last echo. After an episode of desaturation prior to MICU transfer, pt has had good respiratory status and has been satting in 90's on RA. . #. ESRD: Continued HD per renal. - renal following. Pt usually dialyzed MWF. - pt's temporary R femoral [Known lastname 2286] catheter was removed prior to discharge - needs permanent tunneled cath for [Known lastname 2286]; transplant [Doctor First Name ] attempted on graft, which was unsuccessful. A second graft will be attempted [2151-10-22]. Pt is also n schedule with IR for placement of another temporary line should the graft be non-functional again. . #. Chronic anemia: Stable. On epogen. . #. T1DM: Held glipizide. RISS while in house. Restarted glipizide on discharge as pt eating normally. . #. FEN: We monitored K closely and any other indications for acute hemodialysis. Pt was on a renal diet. . #. PPX: PPI, hep SC, MRSA/VRE precautions, OOB to chair. . #. Access: Pt had a R femoral temporary [Month/Day/Year 2286] catheter, needs permanent access. One graft failed, as described above, and he will return for a second attempt Friday [2151-10-22]. Also on schedule for IR that afternoon in case graft fails and he needs another temporary line. . #. Full code . #. Communication: [Name (NI) ] [Name (NI) ] (mother) [Telephone/Fax (1) 31792] . #. Dispo: Pt had lived at home with mother prior to admission. Cleared by PT for discharge back to home. Medications on Admission: Coumadin 4 mg PO DAILY Glipizide 7.5 mg PO QAM, 5 mg PO QPM Calcium Acetate 1334 mg PO TID Lisinopril 2.5 mg PO DAILY (reintro [9-23], normally 10 qd) Metoprolol 12.5 mg PO BID (reintroduced [9-23], normally 25 [Hospital1 ]) Sevelamer 800 mg PO TID Simvastatin 40 mg PO DAILY B Complex-Vitamin C-Folic Acid 1 mg Capsule DAILY ASA 81 mg po qd Discharge Medications: 1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Medication Glipizide 7.5mg po QAM and 5mg po QPM 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 8. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:28 Tablet(s) Refills:0 9. Cefazolin 1 g Piggyback Sig: One (1) gram Intravenous after each hemodialysis for 14 days. Discharge Disposition: Home Discharge Diagnosis: Line sepsis ESRD Discharge Condition: Stable. Discharge Instructions: Please seek medical attention immediately if you experience chest pain, shortness of breath, nausea, vomiting, diarrhea, or fevers/chills. Please take all medications as prescribed. Please attend all follow-up appointments. Please return Friday [2151-10-22] as instructed by Transplant Surgery for repeat graft surgery. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2151-11-2] 9:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2151-11-18] 2:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2152-1-25] 10:20 Please call Dr. [Last Name (STitle) ] for an appointment in the next 2-3 weeks at [Telephone/Fax (1) 1231] Completed by:[2151-10-20]	[ "424.0", "V49.75", "428.0", "996.62", "564.00", "585.6", "V58.61", "250.01", "577.8", "995.91", "285.21", "V45.81", "038.11", "403.91" ]	icd9cm	[ [ [] ] ]	[ "39.27", "39.95", "88.72", "38.95", "99.07" ]	icd9pcs	[ [ [] ] ]	18399, 18405	13217, 17223	305, 410	18466, 18476	3417, 4073	18851, 19453	2801, 2858		17627, 18376		18426, 18445		17249, 17604			18500, 18828									2873, 3398																					244, 267							438, 1652					4089, 13194										1674, 2658	2674, 2785
29,110	167,257	32628	Discharge summary	report	Admission Date: [2150-8-25] Discharge Date: [2150-8-30] Date of Birth: [2101-3-16] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 824] Chief Complaint: Left renal stone Major Surgical or Invasive Procedure: Left percutaneous nephrolithotomy, left ureteral stent placement History of Present Illness: It was a pleasure to see Ms. [Known lastname 76050] who in the past was found at the [Hospital 882] Hospital on followup CT here in our emergency room to have a left staghorn calculus. She has had ongoing pain. She also had significant retroperitoneal lymphadenopathy. She has had persistent left lower back pain radiating around to her pelvis. She does not have any CVA tenderness at this time. I am going to be repeating her CT scan with and without IV contrast. If there is persistent lymphadenopathy we may want to have her further evaluated by medical oncology. She also reports to me that she has had a previous back infection. She reports she has had an infection of her spine questionable osteomyelitis which was treated with antibiotics, we will be having further discussion after evaluation with a CT and after further evaluation potentially by medical oncology about treating her left staghorn calculus, this would most likely involve a percutaneous nephrolithotomy. Past Medical History: DMII HTN Non-obstructing staghorn calculus (3.9 x 1.7 x 3cm) - diagnosed at [Location (un) 76051]Hospital in [Month (only) ] (per prior d/c summary) spinal osteomyelitis - [2146] (reportedly from [Hospital1 112] records) MSSA endocarditis - [2146] (reportedly from [Hospital1 112] records) Hepatitis C - date unknown (reportedly from [Hospital1 112] records) h/o depression in past Insomnia s/p laparascopic cholecystectomy s/p c-section . Social History: Social History: Married, lives w family. 10 cigs/d. no etoh. no drugss per patient but she has used heroin per prior notes. . Family History: Family History: Mother - diabetes . Physical Exam: She is an obese woman. She is rather anxious this morning. She states that she is not feeling quite well and is flushed. Her abdomen is obese. She has no CVA tenderness. She has mild low back pain and tenderness. Pertinent Results: [2150-8-25] 05:44PM GLUCOSE-161* UREA N-11 CREAT-0.9 SODIUM-138 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-20* ANION GAP-14 [2150-8-25] 05:44PM MAGNESIUM-1.5* [2150-8-25] 05:44PM WBC-21.2# RBC-2.88# HGB-9.2# HCT-27.1# MCV-94 MCH-31.9 MCHC-33.9 RDW-14.3 [2150-8-25] 05:44PM PLT COUNT-217 [2150-8-25] 05:44PM PT-14.7* PTT-24.0 INR(PT)-1.2* [2150-8-25] 04:53PM HGB-11.9* calcHCT-36 Brief Hospital Course: Pt was admitted to the urology service after undergoing left percutaneous nephrolithotomy. Please see op note for details, however, the case was notable for significant bleeding and antegrade nephrostogram was unclear. She was admitted to the [Hospital Unit Name 153] after [Hospital1 ] and received serval blood transfusions. She was resuscitated and recived iv cefepime and gentamicin. SHe fevered overnight and subsequently this resolved. Urine and blood cultures were negative. She was decompressed with a 16 Fr foley as a left PCN and on roughly POD 4 an antegrade nephrostogram failed to show contrast passage to the bladder. She was then taken back to the OR for a left ureteral stent placement. After this, the PCN was clamped and she did not have pain. The PCN was removed POD 5 and the foley was removed the AM of pod 6. At discharge she was without significant pain, eating and drinking, passing flatus. She did have some leakage from the left PCN site which was managed with compression dressing. Medications on Admission: Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 2.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H PRN as needed for pain. 3.Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H PRN as needed for pain for 2 weeks. Disp:20 Tablet(s) Refills:0 4.Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5.Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:60 Capsule(s) Refills:0 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left nephrolithiasis Discharge Condition: Good Discharge Instructions: No vigorous physical activity for 2 weeks. Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. You may shower and bathe normally. Do not drive or drink alcohol if taking narcotic pain medication. Resume all of your home medications, but please avoid aspirin/advil for one week. Call Dr.[Name (NI) 76052] ([Telephone/Fax (1) 164]) for follow-up and stent removal. If you have fevers > 101.5 F, vomiting, severe abdominal pain, or large amounts of blood in your urine, call your doctor or go to the nearest emergency room. You may have leakage on the left side. PLease bandage appropriately and the leakage should decrease. If you still have trouble with leakage by Wednesday, call Dr.[Name (NI) 825] office. Followup Instructions: Call for appointment with Dr. [Last Name (STitle) 770] at [Telephone/Fax (1) 164]	[ "E878.8", "285.1", "038.9", "998.11", "995.91", "250.00", "401.9", "592.0", "998.59", "599.0" ]	icd9cm	[ [ [] ] ]	[ "59.8", "55.03", "38.91", "99.04" ]	icd9pcs	[ [ [] ] ]	4516, 4522	2801, 3828	330, 397	4587, 4594	2363, 2778	5424, 5517	2087, 2109		4256, 4493		4543, 4566		3854, 4233			4618, 5401									2124, 2344																					274, 292							425, 1418															1440, 1911	1943, 2055
19,799	181,295	22022	Discharge summary	report	Admission Date: [2132-9-23] Discharge Date: [2132-10-31] Date of Birth: [2080-1-31] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: hypotension and acute respiratory failure [Hospital ] transferred from [Hospital 57637] hospital Major Surgical or Invasive Procedure: s/p OLT and CRT [2132-10-14] liver biopsy [2132-10-22] History of Present Illness: 52 y/o with history of hep c and ESLD was admitted to [Hospital3 57638] center for increase in abdominal distension. Pt was recently discharged from [Hospital3 ] for SBP, LLE cellulitis and ARF. Pt was discharged home with three days of antiobiotics of ceftraixone and flagyl. Pt retured to [Hospital3 ] on [9-11] with with increase in abdominal distension and ha d a therapeutic paracentesis performed on [2132-9-12] for 1.5 liters. Pt soon developed ARF which was though to be pre-renal and was subsequently treated with IVFs and albumin. On note; prior to transfer to [Hospital1 18] patient was experiencing worsening encepholapathy while on lactulose, enterococcus in urine. Past Medical History: PMH: Hep C/ESLD HTN anemia grade 2 esophageal varices osteopenia encephalopathy Social History: NA Family History: NA Physical Exam: on discharge: VITALs: afebrile, with stable signs HEENT: NCAT; eomi CV: RRR ABD: soft, well healing incision + staples EXT: no edema BACK: sacral ulcer Pertinent Results: ________________________________ 52M s/p OLT ([10-12]), s/p CRT ([10-14]), liver bx ([10-22]) PMH: encephalopathy, grade II esophageal varicies, cirrhosis/ESLD, hepC, cellulitis, HTN, anemia, osteopenia, portal htn [Last Name (un) 1724]: Lasix 40', protonix 40', ultram 50", amiloride 5', tums 500", crystalace 20", nadolol 40', allopurinol 100", cef 2', epo 80kqwk CULT: [10-21] urine: enterococcus sp. (R to Vanco); blood neg [10-20] R IJ Enterococcus sp. (R to Vanco), MRSA; quad tip neg [10-18] blood neg [10-15] PA tip VRE; Quinton neg; trauma line neg [10-14] sputum neg [10-12] ascites neg [10-9] ascites neg Rad: [10-29] renal scan P [10-24] U/S: small hematoma adjacent to the transplanted kidney, flow demonstrated, slightly elevated resistive indices [10-24] CXR: persistent LLL opacity suggesting pneumonic consolidation, new areas of lucency, increased upper zone redistribution of the pulmonary vessels suggesting worsening mild CHF [10-21] U/S: excellent blood flow to liver, mild mid portal vein stenosis, unchanged [10-15] u/s: slightly improved flow through HA, new extra-hepatic fluid collection [10-19] renal scan: faint tracer in L kiney and sm tracer in transplanted kidney excreted to bladder PATH: [10-22] liver bx: no acute cellular rejection Brief Hospital Course: This 52 y/o gentleman underwent aggressive ICU care after being transferred from [Hospital3 ] center. On his [Location (un) ] over, the patient dropped his blood pressure and was started on levophed. Patient was respiratory stabilized and stated on octretide ad midodrine for hepatorenal syndrome. Renal was consulted and advised that the patient be started on CVVH to remove the additional volume to help with his respiratory status. Patient initally required multiple transfusions and INR was reversed from 3.6. Simulataneousily and was weaned from neophed. Patient underwent a bronch to help distinguish his respiratory status and was found to have minimal secretions. Pt was started on TPN for nutritional support since his admission. Patient's hematocrit soon stabalized. Antibiotics were vanc, zosyna nd levlo for coverage of possible pneumonia and fluconazole for candid a prophylaxis. The patient underwent routine renal and liver transplant work-up. On [2132-9-25] patient was started on trophic tube feeds. patient continued on CVVH since [2132-9-24] with a goal to get him to a negative fluid status. Patient continued to have cyclic improvement in the ICU in respect to his respiratory status and management. Slowly the patient began to improve on the vent and became more responsive. A dobhoff tube was placed on the 13th (post-puyloric) to iniate his tube feeds. Because of continued mucousal bleeding, the patient underwent a EGD on [2132-10-3] that illustrated a varices; portal gastrppathy; gastritis and an otherwise normal EGD. The otolaryngology service was consulted to evaluate the continued mucousal bleeding and it was thought to be secondary to the dobhoff placement and anticipated that the bleeding would subside as the coagulopathy was reversed. However the patient continued to have oozing and his right nares was packed extensively with gelform and surgicel. The patient was continued on lactulose during this admission and his encephalopahy began to improve concurrently with his respiratory status -- his propofol was discontinued on [2132-10-5]. On [10-5], the zosyn, vanc and levoquin were discontinued and was coninued on ambsione which was started on the 10th. On [2132-10-12] the patient underwent a Ortothopic liver transplant -- please see operative note for further information and on [10-14] the patient underwent a cadaveric renal transplant. Post-operative the patient return to the ICU for close hemodynamically monitoring. His transplant took a few day to initially function -- he creatine remained elevated and he underwent a renal biopsy on the [10-17], but failed to have enough of specimen. however, a repeat biopsy was not performed because his creatine plateaued and slowly decreased over the next two weeks in addition to producing more urine. He underwent a nuclear renal scan on [10-24] that illustrated functioning kidneys. Pt was trasnferred from the ICU to the floor on [10-24] and continued to need [Hospital 17073] rehab and physical strength training in light of prolonged hospital stay. This gentleman has done remarkedly well and has almost reached this immunosupression levels of neoral and is starting to have an appetite. He will however be sent with continous tube feeds of nepro 45 cc/hr. he will be sent to rehab with close follow -up and support from the [Hospital1 18] transplant office. Medications on Admission: Lasix 40', protonix 40', ultram 50", amiloride 5', tums 500", crystalace 20", nadolol 40', allopurinol 100", cef 2', epo 80kqwk Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QD (). Disp:30 Tablet(s) Refills:2 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [3-25] hours. Disp:30 Tablet(s) Refills:2 6. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 7. Cyclosporine Modified 100 mg Capsule Sig: Two (2) Capsule PO twice a day: NEORAL: (no substition); please take as directed by the [Hospital1 18] transplant suregy office; total of 275 mg po twice a day. Disp:120 Capsule(s) Refills:2 8. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO twice a day: NEORAL: (no substition); please take as directed by the [Hospital1 18] transplant suregy office; total of 275 mg po twice a day. Disp:180 Capsule(s) Refills:2 9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:qs Capsule, Delayed Release(E.C.)(s) Refills:2 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:qs qs Refills:0 12. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:qs Tablet(s) Refills:2 13. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day: take as directed by the [Hospital1 18] transplant surgery office. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 1970] - [Hospital1 1559] Discharge Diagnosis: s/p liver transplant and cadaveric renal transplant [2132-10-14] End stage liver disease/cirrhosis Hepatitis C encephalopathy grade 2 esophageal varices anemia hypertension portal HTN osteopenia multiple blood transfusions seconardy to hypovolumia and chronic disease s/p OLT and CRT [2132-10-14] ESLD/cirrhosis Hep C encephalopathy grade 2 esophageal varices anemia HTN portal HTN osteopenia Discharge Condition: Fair Discharge Instructions: keep incision clean and dry. continue taking medication as directed by the transplant surgery office; continue to get labs every monday and Thursday the following labs are needed: CBC, chem 7, ca, mag, phos, AST/ALT/Alk phos/ T bili/Albumin. also please draw a cyclosporine drug level two hours after the patient takes his am dose. Please fax these lab results to [Telephone/Fax (1) 697]. please call [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] with any questions or issues at [Telephone/Fax (1) 673] Followup Instructions: follow up on [2132-11-14] with Dr. [Last Name (STitle) 816] at [Hospital 18] medical center [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2132-10-31]	[ "070.54", "401.9", "276.1", "507.0", "572.4", "784.7", "572.2", "571.2", "789.5", "038.9", "286.9", "456.21", "518.82", "995.92", "537.89" ]	icd9cm	[ [ [] ] ]	[ "50.11", "99.05", "55.23", "99.07", "96.6", "33.23", "38.95", "96.72", "00.93", "39.95", "50.59", "45.13", "21.01", "99.15", "54.91", "55.69", "99.04" ]	icd9pcs	[ [ [] ] ]	8338, 8408	2911, 6329	419, 484	8854, 8860	1546, 2888	9443, 9705	1355, 1359		6507, 8315		8429, 8833		6355, 6484			8884, 9420									1374, 1374															1388, 1527						275, 381							512, 1216															1238, 1319	1335, 1339
43,243	181,417	54880	Discharge summary	report	Admission Date: [2166-7-23] Discharge Date: [2166-8-12] Date of Birth: [2093-12-10] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2751] Chief Complaint: hypotension Major Surgical or Invasive Procedure: bronchial stent revision History of Present Illness: Ms. [Known lastname 90972] is a 72 yo F with a history of stage IIIb squamous cell carcinoma (dx [1-/2166], s/p chemo/radiation in [State ], recently c/b bronchial obstruction in right mainstem and bronchus intermedius requiring stenting). She came to the hospital today for scheduled bronchial stent revision. Per report she had a rigid bronchoscopy which showed that the previously placed silicon stent in her right mainstem bronchus was in good position but the lumen was clogged up with necrotic tissue/ tumor and secretion. Therapeutic aspiration was performed and a wash was done. [Doctor Last Name ] ballon was used to dilate the completely occluded RML. There were no clear operative complications and blood loss was estimated at 5cc. However while in the PACU the patient had persistent hypotension to the 70s systolic and she received a total of 2.5 liters of fluid. She was also given 40mg of solumedrol out of concern for adrenal insufficiency (was recently on a short course of prednisone several weeks ago, not currently on steroids). She was not given any antibiotics. At the time of initial MICU resident evaluation in the PACU the patient was afebrile, HR 74 SBP 70/52, 96% on 4liters. She was mentating well and oriented X3 Past Medical History: -Depression -Stage IIIb squamous cell carcinoma s/p chemo/rads -Diagnosis [2166-1-30] -Chemotherapy and Radiation in [State 108], details not currently available -[2166-6-20] underwent cryodebridement of the RMS tumor and balloon dilatation of the right main stem and right upper lobe bronchus. She also had a thoracentesis with 800mL removed, cytology negative. - [2166-6-26] CXR showed large effusion-> PleurX placement. - [2166-7-11] Rigid bronchoscopy with Cryo debridement of the tumor. 12x30 mm Silicone stent was placed in the RMS and [Hospital1 ]. - [2166-7-23] Washing of debris occluding previously placed silicone stent. Tumor destruction with cryo ablation, argon plasma coagulation. [Doctor Last Name ] balloon dilatation of the RML and the RLL. Social History: -Originally from [Location (un) ] but moved to [Location (un) 112115] several years ago where she had continued to work as an accountant up until very recently (despite undergoing chemotherapy). Approximately 2 months ago she moved back to [Location (un) 86] to be closer to her son [Name (NI) ] who is undergoing a stem cell transplant at [Hospital1 18]. She is currently living with her other son [Name (NI) ]. -Smoking history quit this past [Month (only) 958] at time of diagnosis has a 50+ pack year history -Alcohol: none -Illicits: none Family History: -Son with leukemia Physical Exam: 8.2, 101/54, 84, 20, 96% 2L Chronically ill HEENT, EOMI, PERRLA, OP clear Lungs w/ decreased bs at bases, few rhonchi, R pleurex Heart nl S1, S2 no gallops Abd soft, NT/ND no HSM EXT no edema, clubbing SKIN no petechiae NEURO alert oriented, fluent speech, no focal findings PSYCH pleasant Pertinent Results: ADMISSION LABS: [2166-7-23] 09:42PM BLOOD WBC-30.4# RBC-3.08# Hgb-10.3# Hct-31.6# MCV-103* MCH-33.4* MCHC-32.5 RDW-12.9 Plt Ct-489* [2166-7-23] 09:42PM BLOOD PT-15.3* PTT-26.4 INR(PT)-1.4* [2166-7-23] 09:42PM BLOOD Glucose-88 UreaN-11 Creat-0.4 Na-142 K-4.1 Cl-103 HCO3-31 AnGap-12 [2166-7-23] 09:42PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9 [2166-8-7] 06:00AM BLOOD WBC-10.8 RBC-2.38* Hgb-7.7* Hct-24.2* MCV-102* MCH-32.2* MCHC-31.6 RDW-13.6 Plt Ct-393 [2166-8-7] 06:00AM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-145 K-3.4 Cl-97 HCO3-42* AnGap-9 [2166-8-2] 01:18PM BLOOD calTIBC-195* VitB12-1309* Folate-14.5 Ferritn-788* TRF-150* ECHO [2166-7-31]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. 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 60%). The right ventricular cavity is dilated with normal free wall contractility. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion CHEST CT [2166-8-1]: 1. Near complete right lung opacification is largely due to a combination of volume loss and infection. The right pleural effusion is small-moderate, extending to the apex. The PleurX catheter ends in the right posterior costophrenic sulcus within a small amount of fluid. 2. Moderate left pleural effusion with adjacent atelectasis. The aerated left lung is clear with mild emphysema. 3. Patent but narrowed right mainstem bronchus. Narrowed bronchus intermedius and right upper lobe bronchus terminating abruptly. Soft tissue encasing the bronchus is likely consistent with known malignancy and is best evaluated with contrast. 4. 12-mm left pericardial lymph node. Brief Hospital Course: 72F with stage IIIb squamous cell carcinoma (diagnosed [1-/2166], s/p chemo/XRT) recently c/b bronchial obstruction in right mainstem and bronchus intermedius requiring stenting and multiple IP procedures, with R PleurX catheter in place, transferred to ICU for hypotension post-bronchoscopy, currently off pressors. ACTIVE ISSUES #) Hypotension: Patient with baseline blood pressures in the systolic 80s-low 100s per her report and OMR notes. She was started on neosynephrine, which was eventually able to be weaned for goal SBPs 90-low 100s. She was emperically covered with vancomycin and zosyn but all cultures were negative and she was narrowed to augmentin to cover for post-obstructive PNA, however re-started back on vanc/zosyn when she decompensated after a further bronch procedure. TTE showed no evidence of tamponade, but showed a trivial pericardial effusion. After transfer to [Hospital Unit Name 153], she did not require pressors and her hypotension resolved. The differential was thought to include sepsis secondary to post-obstructive PNA, but more likely SIRS response post-bronchoscopy. Adrenal insufficiency was ruled out with normal AM cortisol. Patient was weaned off pheylephrine, midodrine, and fludrocortisone and her BP has been stable on the floor. #) Possible post-obstructive pneumonia: Pt with tenuous respiratory status, spiked fever during ICU stay, and treated presumptively for possible post-obstructive PNA. Completed a 2 week course of antibiotics including vancomycin/Zosyn x 8 days (in addition to Augmentin x5 days earlier). #) Dyspnea/Respiratory failure (hypercarbic and hypoxemic): Thought to be likely multifactorial in etiology, in setting of lung cancer, obstructive lesion, RUL collapse, pleural effusion, possible post-obstructive pneumonia, and ? underlying COPD. No previous diagnosis of COPD, though imaging this admission has been suggestive of COPD. She received Advair and albuterol nebs with good relief. She has PleurX in place for palliative drainage of her right pleural effusion. This is draining very minimal fluid and can now be checked qweekly (last drained Thursday [8-7]). The patient was offered palliative thoracentesis for the left pleural effusion by interventional pulmonary and she has declined. She has continued O2 requirement of [3-7] L NC and desats easily with minimal exertion. Even sitting up to eat can cause dyspnea. This is not expected to improve much further, unfortunately, and care should be focused on relieving symptoms. Have discussed with interventional pulmonary and it is unlikely that further procedures would greatly change her course given her end-stage disease (see goals of care below) We have initiated oral morphine for relief of dyspnea and she feels it does help her symptoms somewhat. She does need encouragement to take this regularly. Would offer it to her 30 min before planned activity, such as bathing, ambulation. Offer at bedtime as well. #) Lung Cancer: Stage IIIb squamous cell carcinoma. Not a candidate for further radiation therapy. No further interventions possible by interventional pulmonary for her extensive disease, including right mainstem bronchial lesion. Seen by oncology in-house who felt that benefit of further outpt chemo would likely be limited. Dr. [First Name (STitle) ] (hospitalist) spoke with her oncologist Dr. [Last Name (STitle) 58562] at [Hospital3 ] [Company 2860], who agreed that she is a poor candidate for further systemic therapy. #) Anemia of chronic disease: currently stable with Hct 23-24. No need to check regular labs at this point. #) Depression: Continue home regimen sertraline. #) Goals of care: Pt expressed interest in palliative care/hospice options and she was seen by our palliative care team. Palliative care was consulted and they recommended oral morphine prn dyspnea, as above. The patient expressed an interest in going to rehab following this stay, but is open to pursuing hospice care in the near future. (unfortunately we discovered her insurance does not have a hospice benefit). Pt is aware her overall prognosis is poor. Her treatment is palliative only, focused on relieving symptoms and helping her regain mobility if possible. If her condition should decline, she should be offered the option of comfort-focused care (rather than transfer to hospital), with the goal of aggressive symptom relief and a focus on quality of life. Further hospitalizations would likely not reverse the course of her illness, as she is a poor candidate for further invasive procedures (such as interventional pulmonary). Her code status is DNR/DNI. #) Patient coping, family stressors: Pt was most recently living in [State 108], but traveled back to MA to support her son who is currently undergoing bone marrow transplant at [Hospital1 18]. Her ex-husband (father of her two sons) recently died several months ago and this has been an additional stressor. She met with SW several times during this stay as well as with palliative care. She is close with her two sons (including a healthy son living in [Name (NI) 32775], MA). She could benefit from continued SW support. She also received Reiki session for relaxation and seemed to benefit from this as well. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. guaiFENesin NF 1,200 mg Oral [Hospital1 ] 2. Sertraline 50 mg PO DAILY 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 4. Sodium Chloride 3% Inhalation Soln 5 mL NEB [Hospital1 ] Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. Sertraline 50 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] RX fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose qs 1 inhale twice per day Disp #1 Cartridge Refills:0 4. Senna 1 TAB PO BID:PRN Constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice for day as needed for Disp #60 Tablet Refills:0 5. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 6. Bisacodyl 10 mg PO DAILY:PRN constipation 7. Docusate Sodium (Liquid) 100 mg PO BID hold for loose stools 8. Guaifenesin ER 600 mg PO Q12H 9. Morphine Sulfate (Oral Soln.) 2.5-5 mg PO Q2H:PRN shortness of breath RX morphine 10 mg/5 mL [12-4] - [12-2] tsp by mouth q2hr;prn Disp #1 Bottle Refills:0 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Miconazole Powder 2% 1 Appl TP TID:PRN rash RX miconazole nitrate [Anti-Fungal] 2 % apply daily TID;prn Disp #1 Tube Refills:0 Discharge Disposition: Extended Care Facility: Colony House Discharge Diagnosis: Post-obstructive pneumonia Lung cancer, squamous cell carcinoma Hypotension Hypoxemia 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 initially admitted here for placement of a stent in your lung. You had a complicated course here including low blood pressures and possible pneumonia, and you required care in our ICU. You have completed your antibiotic course and have been stable on the regular floor. Although your lung cancer is advanced, we are focusing on helping you feel as good as possible. You have been started on oral morphine to help with shortness of breath, and we encourage you to take this as needed. Followup Instructions: If you are able to travel, you are welcome to follow-up with your PCP or oncologist. Otherwise, your care will be managed by the providers at the rehab facility. PCP: [Name10 (NameIs) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 36014] [Telephone/Fax (1) 84953] Oncology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 58562] [Telephone/Fax (1) 85183], [Hospital3 ] [Company 2860]	[ "486", "162.8", "V49.86", "519.19", "285.29", "V15.82", "V87.41", "786.09", "311", "996.59", "995.93", "496", "E878.8", "998.00", "V15.3", "V58.65" ]	icd9cm	[ [ [] ] ]	[ "32.27", "33.91", "32.01", "33.78", "96.05" ]	icd9pcs	[ [ [] ] ]	12077, 12116	5415, 10716	317, 343	12246, 12246	3401, 3401	12943, 13392	3055, 3076		11074, 12054		12137, 12225		10742, 11051			12421, 12920									3091, 3382																					266, 279							371, 1630					3418, 5392					12261, 12397					1652, 2449	2465, 3039
2,981	184,421	29120	Discharge summary	report	Admission Date: [2138-11-20] Discharge Date: [2138-12-1] Service: MEDICINE Allergies: Penicillins / Lisinopril / Tetracycline / Proton Pump Inhibitors (Benzimidazole) Attending:[First Name3 (LF) 1666] Chief Complaint: Gram Negative Rod Sepsis Major Surgical or Invasive Procedure: Left IJ line, ART line History of Present Illness: Mr. [Known lastname ] is an 84yo man with h/o DM, HTN, pacemaker, GERD and esophagitis who presented to [Hospital 1474] hospital today after having rigors and with back pain after a fall last week. He was found to be febrile to 101, tachy to HR 120s, with ? of irregular heart beat, with BP initially 100/70s -->80s/60s, and WBC 1.0. He was diagnosed with sepsis of unclear source and was treated with 2 L NS, a LIJ was placed, Neo was started for hypotension, and he was given Ceftazidime, Vancomycin, Metronidazole for broad coverage given fear of neutropenia. Cardiac Enzymes were drawn and were negative. EKG was unremarkable. troponin I was 0.6. He was transferred to [Hospital1 18] for likely ICU admission. . On arrival here his temp was 99.0 degrees, CVP 18. He was switched to levophed for blood pressure control with systolics ranging in the 90s-100s. He had no back or abdominal tenderness. EKG showed a new Q in II as well as biphasic T waves and a troponin of 0.27. The patient was discussed with cardiology who found this unlikely to be primary ACS and recommended serial cardiac enzymes, but not want to start a heparin drip. He received a total of 3L of fluid to maintain his blood pressures, was later weaned from pressors and transferred to the general medicine floor for further management. Past Medical History: pacemaker gastritis, esophagitis with esophageal ulcer HTN DM2 GERD BPH s/p TURP colon ca s/p colectomy and chemo [2129] DJD depression/anxiety nephrolithiasis spinal stenosis dysphagia - with recent negative workup by ENT, neuro, GI frequent UTIs dementia Social History: lives at home with his wife of 64 years. ambulates with cane. Veteran. Family History: brother CAD, mother and sister colon ca, father RCC Physical Exam: VS HR 81, BP 114/74 , 98% on 4LNC Gen: NAD, pleasantly confused, talkative HEENT: PERRLA, MM dry, NCAT Neck: supple, L IJ in place cor: rrr, s1s2, no r/g/m pulm: CTAB abd: soft, nt, nd, +bs, no hsm, no RUQ tenderness ext: 1+ edema BLE symmetrically skin: no rashes back: non tender paraspinally, no CVAT Pertinent Results: Admission labs: 133 102 46 --------------< 148 3.3 18 1.9 Trop: 0.27 CK: 46 . Ca: 7.7 Mg: 1.9 P: 1.1 ALT: 92 AP: 177 Tbili: 2.4 Alb: 3.0 AST: 182 [Doctor First Name ]: 17 Lip: 11 . 14.8 10.9 >----< 79 41.2 N:59 Band:36 L:2 M:1 E:0 Bas:0 Atyps: 1 Metas: 1 . PT: 14.1 PTT: 33.7 INR: 1.3 . U/A: negative Lactate:3.3 . Trends: WBC: 10.9 - 12.2 - 9 - 11 - 10.9 - 18.4 - 12.7 HCT: 41.2 - 39.6 Plt: 79 - 33 - 35 - 52 - 69 Creatinine: 1.9 to 1.5 (baseline appears to be 1.5-1.6) ALT: 92 - 59 - 34 AST: [Medical Record Number 70100] - 49 APhos: 177 - 129 - 134 TBili: 2.4 - 2.6 - 1.8 - 1.4 . CK: 46 - 40 - 36 on admission then 24 - 23 on [11-25] Trop: 0.27 - 0.13 - 0.15 on admission then 0.03 x3 on [11-25] . Micro: C diff neg x3 Urine cx NGTD blood cx NGTD OSH blood cx E. Coli (with pos u/a) sensitive to cipro . Imaging: [2138-11-20]: RUQ U/S: Mild gallbladder wall edema with multiple gallstones. The gallbladder wall edema is a nonspecific finding that may be seen in the presence of cholecystitis, third spacing, or liver disease such as hepatitis, or pancreatitis among others. If there is continued clinical concern for acute cholecystitis, further evaluation with a HIDA scan is recommended. . [2138-11-21]: HIDA: Partial gallbladder filling, which is not consistent with acute cholecystitis. . Admission EKG: Sinus rhythm with possible ventricular pacing fusion complexes Borderline first degree A-V delay Left atrial abnormality Inferior infarct, age indeterminate Consider anterior myocardial infarction, age indeterminate ST-T wave abnormalities - cannot exclude in part ischemia Clinical correlation is suggested No previous tracing available for comparison . [2138-11-21]: ECHO: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. LV systolic function appears depressed. Overall left ventricular systolic function cannot be reliably assessed. 3. The aortic root is mildly dilated. 4. The aortic valve leaflets are mildly thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. . Admission CXR: left lower lobe atelectasis . [2138-11-22]: EKG: Atrial fibrillation with intermittent ventricular paced beats. Non-specific T wave abnormalities. Since the previous tracing of [2138-11-21] ventriciular rate is slower, intermitent ventricular paced beats are present and further T wave abnormalities are seen. . [2138-11-25]: CXR: Improvement of previously described mostly unilateral pulmonary edema but bilateral pleural effusions remaining. No new areas of parenchymal densities have developed Brief Hospital Course: By problem: . # Gram negative rod septicemia: Patient initially presented with leukocytosis and bandemia and later was found to have e. coli bacteremia in [4-8] blood cultures from the OSH. While in the MICU the patient was treated with vancomycin, metronidazole and levofloxacin initially. Once speciation of the bacteria was known antibiotics were changed to meropenem. Source of this infection is unclear, but likely either a UTI or GI source. Initial ultrasound and LFTs seemed consistent with a biliary tree infection, though HIDA scan showed no signs of cholecystitis. Given that the patient has a history of UTI's, it seems more likely that the patient had a urinary source. The patient initially presented with hypotension requiring pressors, but was quickly weaned off. Then on [11-22] the patient was then again hypotensive and required pressors briefly (5-6 hours). They were quickly weaned. The day prior to the floor, he was transitioned to meropenem and vanco. His sensitivities from OSH were obtained and grew E. Coli pan-sensitive. He was stable and transferred to the floor on [11-24]. His abx were changed to cipro po. He spiked a temperature to 103 the first night on the floor and changed briefly back to meropenem. He also was hypotensive to 85 systolic. He responded to 250cc bolus and his cardiac enzymes and EKG were normal. Thereafter, he remained stable and we aim to treat with cipro for 14days of total of ciprofloxacin. . # Cards Vascular: Initially he had EKG changes (as above) and elevated troponin in face of flat CKs: Unable to compare troponin here to at OSH given different lab values. He was evaluated by cards who recognized that the LBBB was a paced rhythm and that his labs were not consistent with ACS. We cycled his enzymes again while on the floor (after episode of hypotension) and they remained low. - Echo was done to evaluate cardiac function and showed depressed cardiac function, but no signs of wall motion abnormality. . # Lower Extremity [Name (NI) 70101] Pt reports chronic [Location (un) ] likely secondary to venous insufficiency. Pt also received fluids during his hospitalization to support his blood pressures. In time the pt will will mobilize this fluid and he was actively diuresed prior to discharge and his potassium was repleted. He should be further diuresed as an facility. . # Thrombocytopenia- Patient had rapid drop in platelets. Given this it was concerning that the patient may have had a TTP/HUS like syndrome. However, smear was negative for schistocytes. Additionally a HIT antibody was checked and negative. Platelets have recovered without treatment making the likely cause sepsis. Upon discharge his platelets were above 100 and we restarted ranitidine. . # Acute on chronic renal failure: Baseline appears to be 1.6 and patient returned to baseline quickly. He remained at or near 1.6 throughout his stay. . # Dementia: The patient has a history of dementia and we continued his home regimen. We used lorazepam and olanzapine as needed for agitation. . # Diarrhea: The patient had diarrhea intermittently throughout the hospitalization. He had three negative c. diff toxin assays performed. . # h/o esophagitis/gastritis and esophageal ulcers: pt has intolerance to PPIs. will give H2 blocker. However given that the patient had thrombocytopenia, the H2 blocker was stopped. It should be restarted when the patient has better platelet function. . # DM: we treated with ISS. . # FEN: regular diabetic low salt low fat diet with ground consistency per OSH. He was seen by speech and swallow who cleared him for this diet. . # code status: full code, confirmed this with pt's family Medications on Admission: aricept 5mg po qday aspirin 81mg po qday proscar 5mg po qday imdur 1 tab po qday celexa 1 tab po qday klonopin [Hospital1 ] ranitine 40mg po tid detrol 2 tabs po qhs ativan 0.5 po q6h prn B12 1000mcg IM qmo accupril 10mg po qday hctz 12.5 mg po qday MVI insulin slide scale Discharge Medications: 1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Detrol 1 mg Tablet Sig: Two (2) Tablet PO once a day. 6. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a month. 7. Insulin Lispro (Human) 100 unit/mL Solution Sig: variable units Subcutaneous ASDIR (AS DIRECTED): please use standard sliding scale. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:9 Tablet(s) Refills:0 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for anxiety. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: Hold for sedation or RR<10. Discharge Disposition: Extended Care Facility: [Hospital 2971] Rehabilitation and Nursing Center - [Hospital1 1474] Discharge Diagnosis: Primary: - GNR septicemia - Hypotension - thrombocytopenia - CHF systolic - DM2 - Transaminitis; resolved - dementia Secondary: - s/p pacemaker placed for tachy/brady syndrome - PAF - gastritis, esophagitis with esophageal ulcer - HTN - GERD - BPH s/p TURP - colon ca s/p colectomy and chemo [2129] - DJD - depression/anxiety - nephrolithiasis - spinal stenosis - dysphagia - with recent negative workup by ENT, neuro, GI - CRF with baseline cr 1.6 Discharge Condition: fair Discharge Instructions: You were admitted to the intensive care unit with an infection in your blood. You were treated with antibiotics and monitored closely. You required approximately 4L of fluid and briefly required medications to keep your blood pressure in the normal range. You were transitioned out of the ICU and remained stable. . Please take your medications as instructed. Please contact your physician or return to the emergency department if you experience fevers, chills, hypotension, chest pain, shortness of breath. Followup Instructions: Please contact your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Telephone/Fax (1) ] to make a followup appointment in the next two to three weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673]	[ "287.5", "794.8", "599.0", "294.8", "585.9", "038.42", "787.91", "995.92", "V45.01", "401.9", "428.20", "584.9", "V15.88", "530.81", "459.81", "427.31", "250.00" ]	icd9cm	[ [ [] ] ]	[ "00.17", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	10421, 10524	5181, 8884	314, 338	11021, 11028	2471, 2471	11589, 11896	2078, 2131		9213, 10398		10545, 11000		8910, 9190			11052, 11566									2146, 2452																					250, 276							366, 1689					2487, 5158										1711, 1974	1990, 2062
19,246	129,654	2756	Discharge summary	report	Admission Date: [2129-9-24] Discharge Date: [2129-9-28] Date of Birth: [2067-10-24] Sex: F Service: MEDICINE Allergies: Ceclor / Cephalexin / Codeine / Sulfonamides / Alprazolam Attending:[First Name3 (LF) 5295] Chief Complaint: hypotension Major Surgical or Invasive Procedure: PICC placement History of Present Illness: 61 yo woman with extensive PMHx (including severe ischemic CM, EF 25-30%, on home dopamine gtt) admitted with hypotension. She went to [Hospital1 ] [Location (un) 620] after she fell twice at home (per husband). Her first fall was not witnessed and the 2nd was witnessed by her husband. She had no head trauma. Clinic notes state that she has been gaining weight over the past week and has not been takin gher perscribed Lasix dose. + dietary non-compliance Past Medical History: 1. CAD s/p CABG [2120] 2. ischemic cardiomyopathy s/p ICD 3.CHF 30% on chronic dopamine pump at 8mg/kg/min since [2124] 4. Afib/Aflutter s/p ablation s/p PPM 5. h/o GIB + AVM 6. PUD 7. s/p MVR on coumadin (INR goal 2.0-2.5 since has multiple GIB with higher INR) 8. h/o [Year (4 digits) 13607] bacteremia with septic emboli 9. h/o anemia Social History: no ETOH, still smoking. lives with husband, has [Name (NI) 269] service Family History: noncontrib Physical Exam: Vitals: T= 96.6, HR = 80 AV paced, BP = 66/44 (dopa 19.7, levo 0.015) - 102/43 (dopa 19.7, levo 0.086), RR = 13 , SaO2 = 100% on 3L. General: Pleasant female, appears chronically ill, sleepy HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. JVD to jaw. Chest: Her chest rose and fell with equal size, shape and symmetry, lungs with bibasalier crackles. No erythema around PICC line, non tender. CV: PMI appreciated in the fifth ICS in the midclavicular line without heaves or thrills, RRR, normal S1 and S1 [12-24] HSM. Abd: Normoactive BS, NT and ND. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: NO cyanosis, no clubbing, 1+ edema with 2+ dorsalis pedis pulses bilaterally Integument: no rash Neuro: CN II-XII symmetrically intact, PERRLA. Pertinent Results: [2129-9-27] 07:43AM BLOOD WBC-5.2 RBC-3.75* Hgb-10.8* Hct-31.9* MCV-85 MCH-28.8 MCHC-33.9 RDW-17.3* Plt Ct-157 [2129-9-24] 11:38PM GLUCOSE-149* UREA N-100* CREAT-2.4* SODIUM-131* POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-16 [2129-9-24] 11:38PM HCT-28.8* [2129-9-24] 11:38PM PT-26.9* PTT-33.6 INR(PT)-4.5 [2129-9-24] 11:38PM FIBRINOGE-580* [2129-9-24] 04:15PM GLUCOSE-170* UREA N-108* CREAT-2.9* SODIUM-127* POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-17* ANION GAP-20 [2129-9-24] 04:15PM CK(CPK)-75 [2129-9-24] 04:15PM CK-MB-NotDone cTropnT-<0.01 [2129-9-24] 04:15PM WBC-10.2# RBC-3.35* HGB-10.1* HCT-29.4* MCV-88 MCH-30.2 MCHC-34.4 RDW-17.3* [2129-9-24] 04:15PM PLT COUNT-99* [2129-9-24] 10:20AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2129-9-24] 10:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [2129-9-24] 10:20AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 [2129-9-24] 09:37AM LACTATE-2.2* [2129-9-24] 08:45AM GLUCOSE-84 UREA N-115* CREAT-3.5# SODIUM-127 POTASSIUM-5.7* CHLORIDE-93* TOTAL CO2-15* ANION GAP-25* [2129-9-24] 08:45AM ALT(SGPT)-107* AST(SGOT)-83* CK(CPK)-70 ALK PHOS-119* AMYLASE-60 TOT BILI-1.2 [2129-9-24] 08:45AM LIPASE-33 [2129-9-24] 08:45AM CK-MB-6 [2129-9-24] 08:45AM cTropnT-0.02* [2129-9-24] 08:45AM CALCIUM-8.3* PHOSPHATE-7.3# MAGNESIUM-2.7 [2129-9-24] 08:45AM WBC-3.2* RBC-3.08* HGB-8.9* HCT-27.0* MCV-88 MCH-28.8 MCHC-32.8# RDW-18.0* [2129-9-24] 08:45AM NEUTS-78* BANDS-11* LYMPHS-9* MONOS-0 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2129-9-24] 08:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-3+ POLYCHROM-2+ OVALOCYT-2+ BURR-1+ TEARDROP-OCCASIONAL [2129-9-24] 08:45AM PLT SMR-LOW PLT COUNT-113* [2129-9-24] 08:45AM PT-21.9* PTT-34.1 INR(PT)-3.0 CHEST (PORTABLE AP) [2129-9-24] 8:35 AM CHEST (PORTABLE AP) Reason: r/o chf [Hospital 93] MEDICAL CONDITION: 61 year old woman with hypotension, low ef REASON FOR THIS EXAMINATION: r/o chf HISTORY: Hypotension. Low ejection fraction. PORTABLE AP CHEST, 1 VIEW: FINDINGS: Comparison is made to [2129-3-27]. The patient is status post sternotomy. There is a left-sided pacemaker with lead tips in the region of the RA and RV. There is a prosthetic mitral valve. The heart is enlarged with slight increase in size compared to the prior exam. There is new vascular congestion and indistinctness consistent with CHF, although there is no interstitial or alveolar edema. There are no large pleural effusions and there are no focal areas of consolidation. IMPRESSION: Cardiomegaly with CHF. ECHO: GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency study performed by the cardiology fellow on call. Conclusions: The left ventricular cavity is dilated. Overall left ventricular systolic function is severely depressed. The right ventricular cavity is dilated. Right ventricular free wall motion appears grossly preserved. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present and appears well-seated. Leaflet motion is probably preserved (views suboptimal). Mitral regurgitation is present but cannot be quantified. The tricuspid valve leaflets are mildly thickened with moderate to severe tricuspid regurgitation. There is no pericardial effusion. Compared to the prior study of [2129-9-8], the basal septum now appears slightly less vigorous; overall left ventricular systolic function appears slightly more depressed. Peak transmitral velocity appears similar. Brief Hospital Course: 1. Septic shock: the patient had GNR bacterima likely from PICC line. She was placed on Zosyn and Levo and continued Levo as an outpatient. She was weaned off the Levophed and her dopamine was dropped down to her home infusion dose. Her PICC line was changed. 2. CHF excerbation: The patient has end-stage CHF and is on home dopamine infusion. A bedside echo showed EF 20 - 25 % and no effusion. She was diuresed 8lbs overweight with Lasix. 3. Mechanical valve: Her coumadin was brefily held when she was admiited for a INR 3.3. This was restarted prior to DC. 4. ARF: Cr 3.5 from baseline of 1.2 most likely from hypoperfusion. This resolved with correction of her failure and hypotension. 5. CAD: Her ASA and ACEI were titrated up. She was ruled out for an MI 6. Hyperkalemia: Got kayexalate in the ED. Resolved Medications on Admission: ASA, Amio 200mcg, Coreg 6.5 mg [Hospital1 ], Lasix 80 mg [Hospital1 ], Lipitor 10mg, Vasotec 5mg [Hospital1 ], Trazodone 100mg qPM, Zoloft 100mg [Hospital1 ], Ativan 1mg TID, Rantidine 150mg [Hospital1 ], Coumadin 6mg, Metamusil, COlace Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-[Hospital1 2974]). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:14 Tablet(s) Refills:0 12. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Insulin Regular Human Subcutaneous 14. Lasix 40 mg Tablet Sig: Three (3) Tablet PO qAM. 15. Lasix 40 mg Tablet Sig: Two (2) Tablet PO qPM: Take 120mg at night if your weight is above 150 lbs. 16. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:1 17. Dopamine in D5W 3.2 mg/mL Solution Sig: Eight (8) mcg/kg/m IV infusion Intravenous continuous infusion: weight [2129-9-28] = 67.9 Kg. Disp:30 bags Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: GNR sepsis congestive heart failure Discharge Condition: good Discharge Instructions: Weigh yourself every morning, call Dr. [First Name (STitle) 2031] if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 L Always wash your hands before handling your PICC line. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2129-10-10] 2:30 Please have [Month/Day/Year 269] check INR on [Month/Day/Year 2974] [9-30] and send results to Mr. [Name13 (STitle) 2031] at [Hospital 1902] clinic. Very important!	[ "425.4", "995.92", "584.9", "V45.81", "428.0", "785.52", "038.49", "996.62", "V58.61", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "00.17" ]	icd9pcs	[ [ [] ] ]	8675, 8724	6002, 6824	331, 347	8804, 8810	2253, 4283	9052, 9439	1325, 1337		7131, 8652	4320, 4363	8745, 8783		6850, 7108			8834, 9029									1352, 2234																					280, 293	4392, 5979						375, 842															864, 1215	1231, 1309
10,377	104,725	436	Discharge summary	report	Admission Date: [2137-7-28] Discharge Date: [2137-7-31] Date of Birth: [2077-7-1] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Latex / Demerol / Codeine / Penicillins / Propoxyphene Attending:[First Name3 (LF) 2108] Chief Complaint: Overdose Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is a 60-year-old female with past medical history significant for Bipolar disorder, borderline personality disorder, multiple suicide attempts, h/o alcoholism, PTSD, COPD on home O2, breast cancer s/p lumpectomy who presented to ED via EMS after being found disoriented and wandering around her housing complex barefoot with 1 empty and 1 full bottle of clonazepam. She had 1 empty bottle of clonazepam filled [7-14] with 0 tablets and a 2nd bottle of clonazepam filled with 39 pills (filled yesterday, so 21 tablets gone). She is supposed to be taking up to 4 pills per day per [Month/Year (2) ]. Patient states on further history that she dropped "a bunch" of her clonazepam tablets fell on the floor. She repeatedly denies any overdose. She was initially very agitated and unable to give detailed history. She also c/o pain all over her body pain and was slightly tremulous at rest. Per patient, she also complained of having recently run out of her home 02 a "few days ago" which she takes for history of COPD. In the ED, initial vital signs were: T 100.1, HR 83, BP 116/86, RR 20 and O2 sat 99% 2L . She denied fevers, cough, dysuria or abdominal pains on ROS in ED. She was a limited historian however, and difficult as she refused FSG and refused attempt at LP. Despite negative ETOH level she claims she has been drinking a bottle of wine daily but also made several confusing statements about timeline of her ETOH use so it is unclear if she actively using alcohol now. CT head and CXR in ED were both negative. EKG also showed normal intervals, NSR with no concerning ST changes. While in ED, she received 1.5L NS IVFs. 2mg Ativan, 5mg Haldol and 50mg Benadryl for agitation which slowly improved through the afternoon. She was also given 1x dose 2g Ceftriaxone to cover possible urinary source and meningitis per ED resident although given no headaches and normal neuro exam there was limited concern for meningitis as her AMS improved in the ED. Given notice of recent TSH of 50 that has been untreated an endocrinology consult was also called from [Location ] and patient was given 200mcg IV levothyroxine. Per report, endocrinology service did not feel she was in overt myxedema coma but felt her metabolism of recent drugs likely impaired given her severe hypothyroidism. On arrival to [Hospital Unit Name 153], initial vital signs were: T 99.3F, BP 107/58, HR 77, RR 22 and O2 sat 98% on 2L NC. She seemed mildly confused and very easily agitated and refused to answer multiple questions. In no apparent distress. Past Medical History: -h/o cervical fracture ( wears soft collar 24 hours ) -h/o hypokalemia -history of laxative abuse -anorexia nervosa -Bipolar disorder -Borderline personality disorder -h/o seizures in setting of alcohol withdrawal -PTSD -H/O multiple suicide attempts - cut wrists and multiple drug overdoses in past -mild systolic CHF ( EF 45% to 50% ) [1-/2136] -breast cancer s/p lumpectomy (no chemo or radiation therapy) -H/O Bell's palsy -[Name (NI) 3672] Pt is on 2L oxygen at home. (FEV1 48%; reduced DLCO, but restrictive physiology on PFTs) -Fibromyalgia -Inflammatory osteoarthritis -attention deficit disorder -CVA many years ago -TAHBSO- for cancer in [2113] Social History: Lives alone in section 8 housing and has visiting nurse 5-6 days a week. She is married but states she has been separated from her husband for over 15 years. On [Year (4 digits) 3710] now. States she quit smoking 7 months ago and had smoked 80 pack year history prior to that. History of alcohol and cocaine abuse in the past. States she stopped going to AA meetings this year and has been drinking a bottle of wine daily (although ETOH level not detected). Family History: Mother - CAD, Breast cancer Father - pancreatic cancer, lung cancer Physical Exam: Vitals: T 99.3F, BP 107/58, HR 77, RR 22 and O2 sat 98% on 2L NC. General: Alert and oriented to year, person, place. No acute distress but very easily irritated and mildly tremulous during exam. Rapid angry speech at times. HEENT: PERRL. EOMI. Sclera anicteric, dry MM, oropharynx clear. No thrush. Nares clear, NC in place. Neck: soft neck brace in place, supple, JVP not elevated, no LAD, no thyromegaly and no notable thyroid nodules Lungs: Clear to auscultation bilaterally, mild end expiratory wheezes at mid fields over backside but no 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: foley in place Ext: very thin extremities, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs [3-1] in tact, face and neck sensation in tact but patient unwilling to cooperate with rest of neuro exam. Pertinent Results: [2137-7-30] 11:10AM BLOOD WBC-11.5* RBC-2.99* Hgb-10.3* Hct-32.5* MCV-109* MCH-34.5* MCHC-31.8 RDW-12.7 Plt Ct-347 [2137-7-28] 02:00PM BLOOD WBC-17.2# RBC-2.94 Hgb-9.9* Hct-29.5* MCV-100* MCH-33.7* MCHC-33.5 RDW-13.5 Plt Ct-521# [2137-7-28] 02:00PM BLOOD Neuts-85.5 Lymphs-10.4* Monos-3.5 Eos-0.4 Baso-0.2 [2137-7-29] 02:04AM BLOOD PT-11.3 PTT-22.6 INR(PT)-0.9 [2137-7-30] 07:20AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-129* K-3.9 Cl-99 HCO3-23 AnGap-11 [2137-7-28] 02:00PM BLOOD Glucose-116* UreaN-27* Creat-1.1 Na-131* K-4.5 Cl-92* HCO3-24 AnGap-20 [2137-7-29] 02:04AM BLOOD ALT-21 AST-53* AlkPhos-67 TotBili-0.1 [2137-7-28] 02:00PM BLOOD ALT-20 AST-43* AlkPhos-69 TotBili-0.2 [2137-7-28] 02:00PM BLOOD Lipase-15 [2137-7-30] 07:20AM BLOOD Calcium-8.3* Phos-1.9# Mg-1.7 [2137-7-29] 02:04AM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.2 Iron-42 [2137-7-29] 02:04AM BLOOD calTIBC-241 Ferritn-115 TRF-185* [2137-7-28] 02:00PM BLOOD Osmolal-274* [2137-7-28] 02:00PM BLOOD TSH-28* [2137-7-29] 02:04AM BLOOD T4-6.2 T3-85 calcTBG-1.12 TUptake-0.89 T4Index-5.5 Free T4-1.0 [2137-7-29] 02:04AM BLOOD Cortsol-48.9* [2137-7-28] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2137-7-28] 02:15PM BLOOD Lactate-1.6 ECG [2137-7-28]: Sinus rhythm with sinus arrhythmia, likely left ventricular hypertrophy. Non-specific ST-T wave changes. Compared to the previous tracing of [2137-4-6] findings are similar. [2137-7-28] CXR PORTABLE AP: INDICATION: 60-year-old female with altered mental status. COMPARISON: [2137-6-5]. CHEST, AP: The lungs are clear, other than some mild retrocardiac atelectasis. The cardiomediastinal and hilar contours are normal. There are no pleural effusions. No acute fractures are identified. IMPRESSION: No acute intrathoracic process CT HEAD W/O CONTRAST [2137-7-28]: FINDINGS: There is no acute intracranial hemorrhage, large areas of edema, large masses or mass effect. [Doctor Last Name ]-white matter differentiation is preserved. The ventricles and sulci are normal in size and configuration. Mucosal thickening/mucous retention cyst is noted within the left maxillary sinus. Otherwise, the visualized paranasal sinuses and mastoid air cells are clear. Visualized soft tissues of the orbits and nasopharynx are within normal limits. IMPRESSION: No acute intracranial process. Brief Hospital Course: 60yo F with h/o bipolar disorder, borderline personality disorder, PTSD, fibromyalgia, multiple suicide attempts, COPD on home O2, cervical neck fracture (in chronic brace), and severe OA who presents with altered mental status after questionable overdose. Questionable Overdose/AMS: Head CT in ED was within normal limits and neuro exam also non-focal. No evidence of infection, the patient also admits to ETOH so her initial presentation could have been withdrawal and seizure but no witnessed seizure activity and ETOH serum negative (although w/d obviously still would be possible in the setting of neg ETOH). The patient was found to be unresponsive in the setting of an open klonopin bottle on the floor, although the patient adamantly denied a suidcide attempt this was still a very likely possibility as she was on multiple sedating medications and no other organic cause for change in level of consciousness could be found. In addition patient improved with time / medication washout. BIPOLAR DISORDER: The patient was on multiple psychotropic medications. These were held inpt, risperdal 1mg po qhs was started back while inpatient. The patient is medically cleared for discharge to a psychiatric facility. HYPONATREMIA: She had dilute urine but admits to taking in large amounts of water, hypothyroidism also a likely contributer. 1 liter free H2O restriction and levothyroxine. COPD: no active flare. continue low flow 2-3L O2 via nasal cannula for O2 sats >90% goal, on home O2. Fever: Unclear etiology. Also has an elevated WBC to 17 with 85% PMN shift. CXR with no clear infiltrates. She has fairly normal UA despite complaints of dysuria "off and on". No abdominal pain but does mention recent diarrhea. Lactate is WNL at 1.6 and patient has stable vitals throughout hospitalization. 2 days of afebrile prior to discharge. Hypothyroidism: Endocrine consulted, continue levothyroxine 50mcg daily and recheck TSH in 6 weeks. Cervical spine fracture (in chronic brace): --continue soft neck brace --pain control with lidocaine patch --Tylenol PRN (serum tox acetominophen level negative) Mild systolic CHF: last EF 45% back in [2136-1-19]. Written for home dose of 40mg PO BID lasix. Seems dry on exam and states she has been having diarrhea for few days. Continue lasix 40mg po daily and follow up as outpatient. Contact: sister and HCP [Name (NI) ] [Name (NI) 3699] (h) [Telephone/Fax (1) 3700] (c) [Telephone/Fax (1) 3701] other sister BJ (h) [Telephone/Fax (1) 3702] (c) [Telephone/Fax (1) 3703] Medications on Admission: ALBUTEROL SULFATE - 0.83 mg/mL Solution for Nebulization - 1 (One) vial inhaled via nebulizaiton up to 4 times daily as needed for shortness of breath or wheezing ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 (Two) puffs inhaled 4-5 times a day as needed for shortness of breath or wheezing AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth three times a day BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg Tablet - 1 Tablet(s) by mouth q 6hr as needed for prn HA CLONAZEPAM - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth four times a day CVS GENTLE LAXATIVE PILLS - - as directted by physician three times [Name Initial (PRE) ] day ESSENTIAL SOY BY MOTHER SOY [Name (NI) 3737] - - 10 cc mixed with liquid three times a day FEXOFENADINE - (Prescribed by Other Provider) - 180 mg Tablet - 1 (One) Tablet(s) by mouth once a day FLUOXETINE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 40 mg Capsule - 1 Capsule(s) by mouth once daily FLUTICASONE - 50 mcg Spray, Suspension - 1 to 2 sprays in each nostril twice a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - 1 (One) inhlations twice a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, Medicated - 3 patches on neck and 3 on back once a day keep on for 12 hours, remove for 12 hours MISOPROSTOL [CYTOTEC] - 100 mcg Tablet - two Tablet(s) by mouth twice a day MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime MORPHINE - 30 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s) sublingually every 5 minutes for 3 doses as needed for chest pain OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth [Hospital1 ] 1/2 hour prior to breakfast and dinner OXYCODONE - 5 mg Capsule - [1-19] Capsule(s) by mouth q 6 hr as needed for pain PERPHENAZINE - (Prescribed by Other Provider) - 8 mg Tablet - po Tablet(s) by mouth at bedtime POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 3 (Three) Tablet(s) by mouth twice a day RALOXIFENE [EVISTA] - (Prescribed by Other Provider) - 60 mg Tablet - 1 Tablet(s) by mouth once a day RISPERIDONE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime SULFASALAZINE - 500 mg Tablet - 2 Tablet(s) by mouth twice a day THICK IT - - Use with all oral liquids to create honey consistency Patient uses 1 30 ounce can monthly TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - one inhalation once a day TRAMADOL - 50 mg Tablet - 2 Tablet(s) by mouth qid prn TRAZODONE - (Dose adjustment - no new Rx) - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply small amount to rash twice a day Medications - OTC ANUSOL HC-1 - 1 % Ointment - 1 suppository rectally at bedtime day B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule - 1 Capsule(s) by mouth BIFIDOBACTERIUM INFANTIS [ALIGN] - 4 mg (1 billion cell) Capsule - 1 Capsule(s) by mouth once a day CALCIUM CARBONATE [CALCIUM 600] - (OTC) - 600 mg (1,500 mg) Tablet - one Tablet(s) by mouth twice a day CERAMIDES 1,3,[6-28] [CERAVE] - Cream - twice a day CHROMIUM PICOLINATE - (OTC) - 400 mcg Tablet - 2 (Two) Tablet(s) by mouth once a day DIPHENHYDRAMINE HCL [SIMPLY SLEEP] - (OTC) - 25 mg Tablet - 2 Tablet(s) by mouth at bedtime ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day FERROUS GLUCONATE - 324 mg (38 mg Iron) Tablet - 1 Tablet(s) by mouth twice a day FOLIC ACID - (Prescribed by Other Provider) - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day MAGNESIUM OXIDE - 400 mg Tablet - 1 Tablet(s) by mouth once a day NUTRITIONAL SUPPLEMENTS [BOOST SMOOTHIE] - Liquid - 6 cans by mouth once a day dx: severe weight loss, aspiration, and oxygen dependent COPD and atonic colon PRAMOXINE-MINERAL OIL-ZINC [ANUSOL] - (Prescribed by Other Provider) - Dosage uncertain SIMETHICONE - 80 mg Tablet, Chewable - one Tablet(s) by mouth 3 times a day as needed SODIUM PHOSPHATES [FLEET ENEMA] - 19 gram-7 gram/118 mL Enema - [1-19] Enema(s) rectally once a day as needed for constipation VITAMIN E - (OTC) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: Oversedation related to medication Secondary Diagnosis: Bipolar disorder Chronic systolic CHF Discharge Condition: stable Discharge Instructions: You were admitted after being confused and unresponsive, you have improved with time and witholding of your sedating psychiatric medications. These will be slowly reintroduced and titrated so you are being discharged to a psychiatric facility as you are medically cleared. Followup Instructions: Department: NUTRITION When: WEDNESDAY [2137-7-31] at 3:30 PM With: [First Name11 (Name Pattern1) 3679] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3680], RD [Telephone/Fax (1) 3681] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Hospital 1422] Campus: EAST Best Parking: Main Garage Department: GASTROENTEROLOGY When: WEDNESDAY [2137-8-7] at 12:45 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2837], MD [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "296.80", "715.90", "V15.82", "428.22", "305.00", "314.00", "244.9", "305.61", "309.81", "301.83", "560.89", "V46.2", "307.1", "V62.84", "428.0", "V10.3", "305.41", "780.60", "V10.42", "496", "V64.2", "276.1", "V12.54", "788.1", "780.97", "729.1" ]	icd9cm	[ [ [] ] ]	[ "94.65" ]	icd9pcs	[ [ [] ] ]	14803, 14873	7702, 10259	357, 363	15031, 15040	5236, 7679	15362, 16061	4155, 4225				14894, 14894		10285, 14780			15064, 15339									4240, 5217																					309, 319							391, 2969			14970, 15010				14913, 14949								2991, 3660	3676, 4139
40,094	193,368	34650	Discharge summary	report	Admission Date: [2147-11-23] Discharge Date: [2147-11-28] Date of Birth: [2096-2-3] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1384] Chief Complaint: Liver Failure Major Surgical or Invasive Procedure: [11-23] - Orthotopic Liver Transplantation History of Present Illness: 51 year old male who is status post OLT on [2147-10-8] complicated by conduit thrombosis resulting in graft failure.Patient has been well with no recent illnesses. His baseline diarrhea has been stable. Denies any fevers, chills, nausea, vomiting, abdominal pain, urinary symptoms or respiratory symptoms. Past Medical History: UC, primary sclerosing cholangitis, portal HTN, esophageal varices (scoped [2144] ?????? G1 esophageal, G1 w/portal HTN) Past Surgical History: lap umbo HR [2145] (Narahari), lap umbo HR [2146] ([Last Name (un) 79468]) Social History: He had a tattoo back in college. No transfusions. No IV drug use. No recreational drug use. No tobacco. He has had rare alcohol use in the last 15 years, social in the past. He lives with his wife and his teenage son; aged 17. He has a grown daughter aged 29, who lives nearby. Family History: Significant for a father who had liver disease, it is unclear whether he also had primary sclerosing cholangitis. No other family history. Physical Exam: Gen: NAD HEENT: MMM no lesions CV: RRR no MRG RESP: CTAB no WRR ABD: soft, NT, appropriately tender over incision. No guarding or rebound WOUND: abd incision and drain sites clean and dry with no erythema or drainage Ext: No LE edema Pertinent Results: [2147-11-27] 04:42AM BLOOD WBC-3.2* RBC-3.13* Hgb-9.6* Hct-28.0* MCV-89 MCH-30.6 MCHC-34.2 RDW-15.3 Plt Ct-116* [2147-11-27] 04:42AM BLOOD PT-12.6 PTT-22.0 INR(PT)-1.1 [2147-11-25] 03:00AM BLOOD Fibrino-520* [2147-11-27] 04:42AM BLOOD Glucose-154* UreaN-35* Creat-1.3* Na-136 K-4.6 Cl-101 HCO3-28 AnGap-12 [2147-11-27] 04:42AM BLOOD ALT-57* AST-29 LD(LDH)-219 AlkPhos-193* TotBili-0.7 [2147-11-27] 04:42AM BLOOD Albumin-2.8* Calcium-8.8 Phos-2.9 Mg-1.8 [2147-11-27] 04:42AM BLOOD tacroFK-6.4 Liver Duplex [11-24]: FINDINGS: There is normal hepatopetal flow within the main, right, left, as well as right anterior and posterior branches of the portal veins. The left, middle, and right hepatic veins demonstrate normal venous waveforms with normal directional flow. The main, left and right hepatic arteries demonstrate normal arterial waveforms with normal range resistive indices. There is no evidence of stricture. IMPRESSION: Normal Doppler vascular examination of the liver. Brief Hospital Course: Pt was admitted for OLT on [2147-11-23]. The operation went well with no complications, see operative report for details. The patient was then transferred to the SICU in good condition. He stayed there overnight with no significant events. He was extubated on POD 2, was then given a clear liquid diet and transferred to the floor later in the evening. A liver duplex was found to be normal. His diet was advanced to regulars on POD 3. On POD4 he was tranfused 2U PRBC's for a Hct of 24, for which he responded appropriately. A roux tube cholangiogram showed patent bile ducts. By POD 5 the patient had all his drains removed, was ambulating and voiding independently, and his pain was well controlled with oral medications. He was discharged on oral lasix for further management of lower extremity edema. Medications on Admission: fluconazole 400', prednisone 15', docusate 100", famotidine 20", bactrim 400/80', oxycodone, MMF 500", valganciclovir 900', furosemide 20', augmentin 500/125 TID, tacrolimus 2", insulin sliding scale, caltrate 600'. Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:14 Tablet(s) Refills:0 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. insulin regular human 100 unit/mL Solution Sig: follow sliding scale Injection ASDIR (AS DIRECTED). 13. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: S/P OLT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for an elective liver transplantation. Your operation went well with no complications, and you were deemed ready for discharge 6 days later. You need to have labs drawn every Monday and Thursday. You can shower with soap/water. Pat dry. Do not apply ointment/powder/lotion to incision Place bandages as needed for drainage, but make sure to notify your surgeon if there is a lot of drainage or warmth/redness around your incision sites. Your staples will come out at your follow up appointment. No driving while taking pain medication No heavy lifting/straining Call the Transplant Office [Telephone/Fax (1) 673] if you have any of the following warning signs: fever, chills,nausea, vomiting, jaundice, inability to take any of your medications, increased incision pain, increased abdominal distension, incision appears red or has drainage/bleeding Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2147-12-7] 10:00 Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2147-12-15] 2:40 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2147-12-21] 9:30	[ "276.7", "568.0", "573.4", "444.89", "996.82", "V12.79", "E878.0", "572.3", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "54.59", "50.59", "87.54" ]	icd9pcs	[ [ [] ] ]	4898, 4904	2727, 3550	318, 367	4956, 4956	1689, 2704	6006, 6471	1278, 1419		3817, 4875		4925, 4935		3576, 3794			5107, 5983							877, 966		1434, 1670																					265, 280							395, 706										4971, 5083					728, 854	982, 1262
43,467	113,925	8728+56065	Discharge summary	report+addendum	Admission Date: [2168-1-15] Discharge Date: [2168-1-21] Date of Birth: [2099-2-25] Sex: M Service: UROLOGY Allergies: Percodan / Demerol / Shellfish Attending:[First Name3 (LF) 11304] Chief Complaint: bladder cancer Major Surgical or Invasive Procedure: laparoscopic cystectomy, ileal conduit History of Present Illness: bladder cancer Past Medical History: pmh: turbt [2165] gim/cis preop, htn, DM, copd Brief Hospital Course: Patient was admitted to the Urology service after undergoing radical cystectomy and ileal conduct. No concerning intraoperative events occurred; please see dictated operative note for details. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. With the passage of flatus, patient's diet was advanced. The patient was ambulating and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Patient is scheduled to follow up in one weeks time with in clinic for wound check and in 3 weeks time for stent removal. Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: use while taking narcotics, over the counter. Disp:60 Capsule(s) Refills:0 4. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Start the day before stents are scheduled to be removed. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [4-28] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of the ileal conduct. -Take ciprofloxacin for 3 days, starting the day before your stents are to be removed in the clinic Followup Instructions: 1 week for staple removal 3 weeks for stent removal Completed by:[2168-1-21] Name: [Known lastname 5722] [Known lastname 5723],[Known firstname 5724] Unit No: [Numeric Identifier 5725] Admission Date: [2168-1-15] Discharge Date: [2168-1-21] Date of Birth: [2099-2-25] Sex: M Service: UROLOGY Allergies: Percodan / Demerol / Shellfish Attending:[First Name3 (LF) 3840] Addendum: Patient was seen by cardiology for bigemeny seen on EKG. An echo was performed which was normal. Patient should followup with PCP regarding initiation of ace in inhibitor. Discharge Disposition: Home With Service Facility: [Hospital 136] Homecare Discharge Diagnosis: bladder cancer Discharge Condition: stable Discharge Instructions: -Please resume all home meds -Do not drive while taking oxycodone. -You may shower, but do not immerse incision, no tub baths/swimming. -Small white steri-strips bandages will fall off in [4-28] days, you may remove at that time if irritating. -Call if incision becomes markedly more red, swollen, or begins to drain purulent fluid, or for fever more than 101.5. -Please refer to visiting nurses (VNA) for management of the ileal conduct. -Take ciprofloxacin for 3 days, starting the day before your stents are to be removed in the clinic Followup Instructions: 1 week for staple removal 3 weeks for stent removal PCP regarding initiation of ace inhibitor [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3843] MD [MD Number(2) 3844] Completed by:[2168-1-21]	[ "427.89", "272.0", "E878.8", "250.00", "V87.41", "188.8", "401.9", "997.1", "185", "492.8", "196.6" ]	icd9cm	[ [ [] ] ]	[ "60.5", "57.71", "56.51", "54.21", "40.3" ]	icd9pcs	[ [ [] ] ]	3261, 3319	487, 1269	306, 346	3378, 3387		3984, 4236			1292, 1853		3340, 3357					3411, 3961																														252, 268							374, 390															412, 464
73,126	190,468	48142	Discharge summary	report	Admission Date: [2196-4-18] Discharge Date: [2196-4-22] Date of Birth: [2129-9-15] Sex: F Service: CARDIOTHORACIC Allergies: Erythromycin Base / Amoxicillin / Hydrochlorothiazide Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [2196-4-18] Mitral valve replacement (St.[Male First Name (un) 923] #27 tissue valve) History of Present Illness: 66 yo F with known mitral regurgitation with worsening symptoms, referred for cardiac catheterization. She complains that her dyspnea on exertion has progressively worsened and she is now experiencing dyspnea while lying in bed. Dr. [Last Name (STitle) ] is asked to see her for evaluation for mitral valve replacement. Past Medical History: Mitral Regurgitation Hypertension Hypercholesterolemia Spinal stenosis-undergoing eval for surgery Degenerative disc disease Breast Cancer treated with chemo, XRT and surgery [2184] Depression Past Surgical History: s/p right lumpectomy s/p tonsillectomy s/p myomectomy s/p total hysterectomy [2182] s/p knee surgery Social History: Race:African American Last Dental Exam:2 months ago Lives with:alone Occupation:Part-time receptionist Tobacco:quit [2163] ETOH:1 glass of wine per night Family History: Father died age 30 ?CAD, uncle died CAD age 42 Physical Exam: Pulse: 87 Resp:20 O2 sat:97%RA B/P Right:121/66 Left:116/65 Height:5'2" Weight:145 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur-I/VI soft systolic murmur at 4 LICS Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left:+2 DP Right: +2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right: none Left:none Pertinent Results: [2196-4-18] Echo: Pre-bypass: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate ([1-16]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with bileaflet retractions. The posterior leaflet is more severely retracted than the anterior leaflet. An eccentric, posteriorly-directed jet of Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is a trivial/physiologic pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. There is a well-seated bioprosthetic valve in the mitral position with good leaflet excursion. There is no transvalvular or paravalvular regurgitation. The mean transvalvular pressure gradient is 3 mm Hg at a cardiac output of 6 L/min. The left ventricular systolic function is borderline normal (LVEF 50%). Tricuspid regurgitation is moderate (2+). The TV diameter at end diastole was 3.5cm All other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were discussed with the surgeon intraoperatively. [2196-4-21] 05:45AM BLOOD WBC-10.6 RBC-2.94* Hgb-9.3* Hct-28.3* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.2 Plt Ct-176 [2196-4-18] 10:12AM BLOOD WBC-10.4 RBC-2.85# Hgb-9.2# Hct-26.8# MCV-94 MCH-32.3 MCHC-34.3 RDW-13.1 Plt Ct-150 [2196-4-18] 11:34AM BLOOD PT-14.0* PTT-38.2* INR(PT)-1.2* [2196-4-18] 10:12AM BLOOD PT-13.3 PTT-35.2* INR(PT)-1.1 [2196-4-21] 05:45AM BLOOD Glucose-98 UreaN-22* Creat-0.6 Na-134 K-4.7 Cl-101 HCO3-25 AnGap-13 Brief Hospital Course: Ms. [Known lastname ] was a same day admit after undergoing preoperative work-up as an outpatient. On [4-18] she was brought directly to the operating room where she underwent a mitral valve replacement. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CVICU intubated, sedated, requiring pressors to optimize her cardiac function. She was in critical but stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated without difficulty. Chest tubes and epicardial pacing wires were removed per protocol. Beta-Blocker and diuresis was initiated. She continued to progress and she was transferred to the step down unit on post-op day #1. Beta blockers were kept at a lower dose due to a SBP 90's. Physical therapy was consulted for evaluation of strength and mobility. The remainder of her hospital course was essentially uneventful. She was cleared by Dr.[Last Name (STitle) ] for discharge to home on POD#4. All follow up appointments were advised. Medications on Admission: Amphetamine-Dextroamphetamine 10mg po TID Bimatopropst (not taking) Citalopram 40mg po daily Fexofenadine 180mg po daily PRN allergies Hydrocodone-Acetaminophen 7.5mg-750mg, 1 tablet po q 6 hrs Indomethacin 75 mg po BID PRN Lisinopril 10mg po daily Simvastatin 20mg po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours. Disp:30 Tablet(s) Refills:0 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24) hours for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain for 7 days. Disp:20 Tablet(s) Refills:0 8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: caregroup vna Discharge Diagnosis: Mitral Regurgitation s/p mitral valve replacement Past medical history: Hypertension Hypercholesterolemia Spinal stenosis-undergoing eval for surgery Degenerative disc disease Breast Cancer treated with chemo, XRT and surgery [2184] Depression Past Surgical History: s/p right lumpectomy s/p tonsillectomy s/p myomectomy s/p total hysterectomy [2182] s/p knee surgery 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] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [5-19] at 1:15 PM Please call to schedule appointments Primary Care Dr. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] in [1-16] weeks Cardiologist Dr. [Last Name (STitle) ]. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] in [1-16] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2196-4-22]	[ "599.70", "272.0", "V15.3", "722.10", "416.8", "V87.41", "V10.3", "424.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.23" ]	icd9pcs	[ [ [] ] ]	6765, 6809	4357, 5427	340, 436	7228, 7323	2076, 4334	7947, 8469	1328, 1376		5752, 6742		6830, 6880		5453, 5729			7347, 7924							7101, 7207		1391, 2057																					281, 302							464, 789															6902, 7078	1153, 1312
23,407	171,982	16020	Discharge summary	report	Admission Date: [2175-3-28] Discharge Date: [2175-3-29] Date of Birth: [2152-9-11] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: This was a 20-year-old male who was involved in [Initials (NamePattern4) ] [Last Name (NamePattern4) ] with the police, which ended by self-inflected gunshot wound to the right temple. The patient was intubated in the field and transferred to the [Hospital1 69] Emergency Room. Fentanyl and vecuronium was administered for the intubation. He had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] coma score of 3 on arrival, and was on full spinal package. Patient was hemodynamically stable in route. PAST MEDICAL HISTORY: Per the family. 1. Depression. 2. Intravenous drug use. 3. Hepatitis C. PAST SURGICAL HISTORY: No past surgical history. ALLERGIES: No known drug allergies. MEDICATIONS: Klonopin. PHYSICAL EXAMINATION: Patient had a temperature of 98.8, heart rate of 86, blood pressure 152/palp, 100%. Neurologic examination: The patient had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] coma score of 3. HEENT: Patient had burn marks to his right temple with a right temple entrance wound, a left temple exit wound with brain matter extruding, right periorbital ecchymosis. Pupils were fixed, dilated, and asymmetric, 5-8 mm right and left. Neck is in C collar. Trachea is midline. Chest was clear to auscultation bilaterally. Heart was regular, rate, and rhythm. Abdomen was soft and nondistended. No scars. Extremities were atraumatic, no deformities or dislocations. LABORATORIES: Initial laboratories showed a white count of 17.2, hematocrit of 29, and platelets of 325, INR of 1.2, and PTT was 41.2, sodium 141, potassium 3.4, chloride 106, CO2 22, BUN 20, and creatinine of 1.1, glucose of 372, amylase is 40. His serum tox screen was negative. Urine tox screen was positive for cocaine, methadone, opiates, and benzodiazepines. Initial arterial blood gas was 7.17, 63, 195, 24, and -6 with lactate of 7.9. CHEST X-RAY: Normal. CT SCAN: CT scan of his head showed right and left frontal intraparenchymal hemorrhages, skull fractures, subarachnoid hemorrhage, and pneumocephalus. ASSESSMENT: This 20-year-old male with self-inflicted gunshot wound to his temple without evidence of herniation clinically, and on CT scan, plan is Neurology: Mannitol, hold sedation, q1h neurologic examinations, and Neurosurgery consult. CV: Blood pressure, respiratory mechanically ventilate. GI: NPO nasogastric tube. GU: Foley to gravity, heme treat coagulopathy and decreased hematocrit. FEN: Normal saline at 75 an hour. Prophylaxis: Pepcid and pneumoboots. Organ bank is notified. The patient is transferred to the Intensive Care Unit for closer monitoring. Neurosurgery evaluated the patient and reviewed CT scan. Impression: The patient had minimal brainstem function at the medullary level and his condition is not reversible. This is discussed with Intensive Care Unit staff as well as patient's family. Additionally, Ophthalmology consult was obtained due to trauma to his orbits, and had bilateral oval compartment syndrome. Emergency bilateral canthotomy and cantholysis was performed for decompression with decrease in intraocular pressure. Patient also underwent placement of monitoring line, right radial A line, left subclavian triple lumen catheter. Patient was found to be coagulopathic and initial low hematocrit when he was admitted to the Intensive Care Unit of 21. Follow-up hematocrit was 14. Patient had a difficult cross-match responsible for the delay in transfusion. Four units were available and were rapidly transfused with a follow-up hematocrit of 21. An additional 4 units were then transfused to a hematocrit of 26, and then an additional 2-32. Additionally, the patient received a total of 8 units of fresh-frozen plasma to correct his coagulopathy. A unit of cryoprecipitate and a unit of platelets. Patient's family was at the bedside including his mother, father, and [Name2 (NI) 1685] brother. [Name (NI) ] proceeded to have clinical evidence of herniation with bradycardia and hypotension. The patient was then started on dopamine to support him hemodynamically. Attending was notified, at this time brain death criteria were fulfilled. The organ bank was again notified and responded, approached the patient concerning organ donation. Apnea was performed which was positive. Patient was pronounced brain dead at 5:01 am. Organ donation was discussed with the patient again, and they agreed to proceed. At this time, the medical examiner will be notified of the patient's case. TIME OF DEATH: 5:01 am [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (STitle) 45848] MEDQUIST36 D: [2175-3-29] 05:59 T: [2175-3-31] 07:42 JOB#: [Job Number 45849]	[ "362.30", "348.8", "305.50", "958.8", "E955.0", "070.54", "801.25", "311", "305.60" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.04", "38.93", "89.64", "08.51", "96.71" ]	icd9pcs	[ [ [] ] ]																							825, 915														938, 5004																172, 705															728, 801
13,306	188,375	6828	Discharge summary	report	Admission Date: [2193-1-8] Discharge Date: [2193-1-15] Date of Birth: [2143-2-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4654] Chief Complaint: hypoxia and hypercarbia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 174] is a 49 year old male with a PMH of HTN, DMII, OSA, COPD, CAD s/p IMI and stenting who presents with increasing shortness of breath, dizzyness, and bilateral lower extremity swelling over the past 2 weeks. The patient felt like he was fighting a cold 2 weeks ago and took Airborne. His symptoms improved, but then he developed a runny nose and post nasal drainage and began coughing grey-[Known lastname ] sputum from his lungs. His dyspnea occurs primarilly with movement/exertion, not at rest. Over this time period he has also developed worsening bilateral lower extremity edema that has been painful at times at the ankles. He denies any prior history of lower extremity edema. He has also been waking up at night sitting up on the side of his bed with his CPAP mask off and feeling somewhat confused. He has had a decreased appetite for the last 3-4 days with decreased PO intake. He has also felt "dizzy" and when asked to clarify this states that he has felt lightheaded, as if he would faint, at times. . He presented to the [Hospital 191] clinic earlier today and was noted to have a heart rate of 120 with an 02 sat of 78%. He was sent to the ED for further evaluation. Vitals on presentation to the ED were T 99.1, BP 136/90, HR 100, O2sat of 92% 2L. He received aspirin 325 mg PO, Levofloxacin 750 mg IV, and Lasix 10 mg IV. On initial presentation on the floor, the patient was comfortable, in no distress, able speak and relate history easily, 92%4L. On falling asleep w/o his usual home BiPap w/ 3L, he desaturated to 78%RA. He was triggered due to hypoxia. On arousing the patient up, the patient was awake, alert, not complaining of SOB, but drowsy. Initially, his O2 sat rose to 89% on 4L. Respiratory therapy was called to arrange for patient's BiPap. He was also given lasix 20mg IV to which he promptly urinated 650cc. He also received a combivent. His clinical status continued to deteriorate with 02 sat 80-85% on 10L. ABG was 7.42/90/45. He was placed on CPAP and transfered to the ICU. . ROS: As above. In addition he also endorses diarrhea yesterday only that has since resolved. He chronically sleeps on 2 pillows at night and has to sleep on his left side as he cannot breathe if he lays on his back. He also uses CPAP at night. He has had no fevers, chills, vertigo, headache, chest pain, melena, BRBPR, myalgias, arthralgias, or dysuria. Past Medical History: # CAD: 2VD s/p inferior STEMI & BMS->LCX [2183] - cath [5-15]: 30% prox LAD, 60% mid-LCx before patent OM1 stent, 100% RCA occlusion with good L->R collaterals # PVD s/p stenting of the right common iliac artery, [2183] # CHF, preserved EF on MIBI [4-14], ECHO [1-12] # COPD, FEV1 1.7 [3-16] # OSA on CPAP # Diabetes mellitus, type 2, HbA1c 6.2 in [3-16] # Hypercholesterolemia # Hypertension # Obesity Social History: He works in shipping & receiving, was formerly a machinist. He quit smoking in [2190], but formerly smoked ~ 2ppd x many years. Has a couple of beers per month. Past history of marijuana use many years ago, but none currently. No IVDU. Family History: Father died at 59 in his sleep from MI, had COPD. Mother died at 79 and had breast cancer. He has a sister with "heart disease" and a stroke in her 30s. Physical Exam: Vitals: T 98.1, BP 106/80, HR 100, RR 22, 93% on 4L NC Gen: Obese caucasian male sitting up in bed in NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RRR. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: Decreased breath sounds bilaterally, no wheezes, crackles, or rhronchi ABD: normo-active BS, soft, NT, ND. EXT: 3+ edema in the feet bilaterally, 2+ to mid shins bilaterally. DP pulses not palpable. SKIN: Multiple non-blanching, petechiae-like red dots on the anterior lower legs bilaterally. Erythematous, blanching, slightly scaly maculopapular rash over abdomen, thighs, and back, blanching. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. [2-8]+ reflexes, equal BL. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2193-1-8] 01:20PM PLT SMR-NORMAL PLT COUNT-217 [2193-1-8] 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2193-1-8] 01:20PM NEUTS-72* BANDS-0 LYMPHS-17* MONOS-8 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2193-1-8] 01:20PM WBC-8.8 RBC-6.05 HGB-18.3* HCT-56.3* MCV-93 MCH-30.3 MCHC-32.6 RDW-13.1 [2193-1-8] 01:59PM CK-MB-12* MB INDX-11.8* proBNP-1797* [2193-1-8] 01:59PM cTropnT-0.03* [2193-1-8] 01:59PM CK(CPK)-102 [2193-1-8] 01:59PM estGFR-Using this [2193-1-8] 01:59PM GLUCOSE-117* UREA N-14 CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-40* ANION GAP-8 [2193-1-8] 03:50PM PT-14.4* PTT-26.0 INR(PT)-1.3* [2193-1-8] 05:15PM URINE URIC ACID-OCC [2193-1-8] 05:15PM URINE HYALINE-0-2 [2193-1-8] 05:15PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [2193-1-8] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [2193-1-8] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2193-1-8] 10:36PM O2 SAT-75 [2193-1-8] 10:36PM LACTATE-0.7 [2193-1-8] 10:36PM TYPE-ART PO2-45* PCO2-94* PH-7.27* TOTAL CO2-45* BASE XS-11 INTUBATED-NOT INTUBA COMMENTS-CPAP [2193-1-8] 10:54PM LACTATE-0.9 [2193-1-8] 10:54PM TYPE-ART PO2-59* PCO2-94* PH-7.28* TOTAL CO2-46* BASE XS-13 INTUBATED-NOT INTUBA COMMENTS-CPAP 15L . EKG ([2193-1-8]): Sinus rhythm at the upper limits of normal rate. Right inferior axis. RSR' pattern in lead V1. Borderline intraventricular conduction delay. Low precordial voltage. Since the previous tracing of [2192-5-8] the inferior Q waves are less prominent now. Early precordial ST segment elevations are no longer present. Clinical correlation is suggested. . CXR ([2193-1-8]): Limited study with increased left basilar density, which may reflect atelectasis and effusion though pneumonia cannot be excluded. Correlation with lateral view may aid in diagnosis. . CXR ([2193-1-9]): In comparison with the study of [1-8], there is again blunting of the left costophrenic angle with opacification at the base. Again, there is asymmetry of the density of the lungs with the left being somewhat darker. Mild prominence of interstitial markings persists that could represent some asymmetric pulmonary edema. . TTE ([2193-1-9]): The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricleappears mildly dilated and hypokinetic. No pathologic valvular abnormality seen. Mild pulmonary artery systolic pressure hypertension. Brief Hospital Course: 49 year old male with COPD (FEV1 1.7 [3-16]), CAD, HTN, DMII, OSA on CPAP who presents with SOB and LE swelling transferred to the unit for hypercarbic and hypoxic respiratory failure. . Respiratory failure: Transferred from floor to ICU for combined hypercarbic and hypoxic respiratory failure. Etiology unclear but likely a combination of chronic lung disease and mild CHF. Chronically elevated Hct suggested chronic hypoxia, likely due to a combination of COPD and OSA. pH of 7.3 with pCO2 of 82 suggests chronic respiratory acidosis with metabolic compensation. BL pCO2 likely ~ 70. No obvious infection on CXR to suggest pna. Increased LE edema and elevated BNP raised possibility of CHF. He ruled out for acute MI and TTE was limited but LV function was thought to be normal with mild RV dilation and hypokinesis. He initially required noninvasive positive pressure ventilation which was weaned off on hospital day #2. He was treated for COPD exacerbation with IV solumedrol which was transitioned to oral prednisone on hospital day # 3. He received levofloxacin for possible atypical pneumonia for a 5 day course. He was continued on his home Advair and received albuterol and atrovent nebulizers. He diuresed well with IV lasix. He remained relatively hypoxic requiring 5L via nasal cannula to maintain O2 sats in the 90s and required noninvasive mechanical ventilation overnight to maintain oxygenation. Both bipap and noninvasive cpap were used during his stay however the patient could not tolerate bipap despite trying on different masks. He preferred to stay on O2 NC which at 5L maintained O2 saturations from mid 80s to low 90s. It was felt the patient would benefit from pulmonary rehabilitation and at the patient's preference he was given contact information to schedule this as an outpatient. The patient was newly started on furosemide 10mg daily. He was counselled to weigh himself daily, call his PCP for any weight increase >3lbs and to adhere to a low salt diet. The patient ambulated with PT the day prior to discharge and maintained an oxygen saturation of >90% on oxygen, 4L by NC. . Dizziness/lightheadedness: Unclear cause. Potentially due to significant hypoxia as was in 70s on RA at outpt appointment on admission. He had no further symptoms throughout his hospitalization. No arrhythmias on telemetry. Symptoms did not recur during his stay. . Erythrocytosis. The patient was found to have profound erythrocytosis to Hct of 60. He was evaluated by the heme-onc consult service who felt this most likely represented secondary polycythemia due to chronic hypoxia. Epo level was sent and is pending at the time of discharge. Due to the marked elevation in Hct, the patient was felt to be at risk for symptoms associated with his condition. He was initiated on phlebotomy and underwent 1U removal with Hct decline to 57. He will follow-up in the hematology clinics for ongoing care of this issue including ongoing phlebotomy with likely goal Hct 55. It is possible though unlikely that the patient will experience hypoxia associated with this loss in oxygen carrying capacity. . Diabetes: well controlled according to most recent HbA1C. On metformin as outpt. Metformin was held during admission and he was controlled with insulin sliding scale. He was restarted on metformin prior to discharge. . Hypertension: Patient was normotensive throughout admission with low normal SBPs in 90s with sleep. He was continued on his home regimen of lisinopril and metoprolol. . CAD: s/p IMI in past by report and prior stenting. Large reversible defect in inferior wall in [3-16] but no intervenable CAD on cath in [5-15]. No chest pain on history and he ruled out for MI with serial enzymes. He was continued on asa, statin, beta blocker, and ace inhibitor. . Diastolic heart failure. As described above, the patient was confirmed on TTE to have diastolic heart failure. He was started on simvastatin for this issue as well his history of CAD. . OSA: As above, required noninvasive mechanical ventilation overnight to maintain oxygenation. . Code: The patient is full code. Medications on Admission: Advair 250/50 1 puff [Hospital1 ] Lisinopril 10 mg PO daily Metformin 500 mg PO BID Metoprolol 50 mg PO BID Nitroglycerin 0.4 mg prn Spiriva 1 cap daily Tolterodine SR 4 mg daily Aspirin 325 mg PO daily Melatonin 3 mg QPM MVI with minerals daily pt. was prescribed Rosuvastatin 40 mg but is not currently taking this medication due to insurance issues. Discharge Medications: 1. Tolterodine 2 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 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) as needed for constipation. 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:4 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 11. Melatonin 3 mg Tablet Sig: One (1) Tablet PO qpm. 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Take one pill every 3-5 minutes for chest pain. If you are taking this medication you should call your doctor or 911. Disp:15 tabs Refills:3 14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:4 15. Outpatient pulmonary rehab Attend outpatient pulmonary rehab for ongoing care. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. COPD exacerbation 2. Acute on chronic diastolic heart failure 3. Obstructive sleep apnea 4. Secondary polycythemia . Secondary: 1. Coronary artery disease 2. Peripheral vascular disease 3. Diabetes mellitus, type 2 4. Hypercholesterolemia 5. Hypertension 6. Obesity Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for shortness of breath and you were found to have low oxygen levels. You were given diuretics (water pills) to help remove fluid from your lungs and you were given steroids and antibiotics for an exacerbation of your COPD. You improved with these treatments but continued to require supplemental oxygen at night while sleeping. You do not need to continue use of your CPAP machine at night. Please follow-up with with your primary care doctor and your pulmonologist for further care of this issue. . You were also found to have extremely high blood counts. This is likely due to chronic low oxygen levels in the blood. You must follow-up in the hematology clinics as scheduled for ongoing care of this issue including regular blood removal. . Take all medications as prescribed. New medications that you should take every day are furosemide and simvastatin. Adhere to a low salt diet (less than 2grams/day) and weigh yourself daily. Call your doctor for any increase in weight greater than 3 lbs. . Call your doctor or return to the hospital for any new or worsening shortness of breath, chest pain, swelling in the ankles or weight gain >3lbs. Followup Instructions: Primary care: Dr. [First Name (STitle) ] on [1-21] at 3pm. Hematology: Dr. [Last Name (STitle) 6944] ([Telephone/Fax (1) ]) [2193-1-23] at 2:20PM. Pulmonology: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) ]) Monday [2193-2-4] 11:00AM. Call your primary care doctor's office to obtain insurance referral for this visit. You have an appointment with Dr [First Name (STitle) ] in Vascular Medicine on [2-8] at 9:40am. This appointment was scheduled to discuss your symptoms of peripheral vascular disease. You have a follow up appointment with Dr. [Last Name (STitle) ] in podiatry on Monday [2-18] at 11am. Please call ([Telephone/Fax (1) 9525] to schedule a follow up appointment with your sleep doctor [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Please keep all other appointments as listed below: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2193-3-28] 11:20 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2193-4-3] 1:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2193-4-3] 1:00 [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658]	[ "428.33", "440.20", "V45.82", "250.00", "401.9", "414.01", "518.81", "289.0", "272.0", "412", "428.0", "276.2", "V58.67", "327.23", "491.21", "244.9", "486" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	13993, 13999	7981, 12089	337, 343	14321, 14330	4491, 7958	15559, 16964	3505, 3659		12497, 13970		14020, 14300		12115, 12474			14354, 15536									3674, 4472																					274, 299							371, 2778															2800, 3232	3248, 3489
5,046	107,908	11667	Discharge summary	report	Admission Date: [2145-11-15] Discharge Date: [2145-11-19] Date of Birth: [2094-9-22] Sex: F Service: SURGERY GOLD HISTORY OF PRESENT ILLNESS: This was a 51-year-old female with a history of alcohol abuse, chronic pancreatitis, and cirrhosis, status post gastrojejunostomy secondary to duodenal stricture with a past medical history of diabetes mellitus, intermittent exacerbations of chronic pancreatitis, and osteoporosis. The patient was admitted on [2145-11-15], and presented with the presumptive diagnosis of choledocholithiasis, metabolic alkalosis, sudden onset, which was thought to be secondary to decompensated liver failure. She was admitted to the [Company 191] Medicine Service where she was cared for initially on the floor and evaluated by the Liver Service as well. On [2145-11-16], the patient received a CT scan which demonstrated a probable small bowel obstruction. Given her continued decompensation, it was thought to be a combination of hepatic encephalopathy, worsening .................. status. The patient was transferred to the Medical Intensive Care Unit on the [Hospital Ward Name 516]. On [11-16], a Surgery consult was obtained. On review of the [Hospital 228] hospital course, it was noted that there was a question of small bowel obstruction per CT scan; however, given the patient met criteria for Child C cirrhosis, was a very poor surgical candidate. A series of discussions were undertaken with the family as to whether or not they wished to pursue surgical correction of the small bowel obstruction. It was decided by the family they would pursue this option, and on the evening of [2145-11-17], the patient was taken to the Operating Room by [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] where she underwent exploratory laparotomy. At the time, it was noted that the patient had a thick adhesion upon which there was a lobulized loop of jejunum. An approximate 10 cm segment of the jejunum was resected. The patient tolerated this procedure. She was transferred to the Surgical Intensive Care Unit on the [Hospital Ward Name 516]. Over night from [11-17], until the evening of [11-18], the patient was noted to be increasingly alkalotic despite supportive care measures by the Intensive Care Unit staff. It was decided, with the patient becoming progressively more obtunded, her abdomen more distended, difficulties managing her blood pressure, and acid based status, to return with the patient to the Operating Room on the evening of [2145-11-18]. At that time, the patient underwent a second exploratory laparotomy where she was noted to have a large amount of peritoneal fluid which was evacuated by suction. At that time, exploratory laparotomy, there was evidence of diffuse ischemic and infarctive disease of the small bowel. At that time, it was decided to close the patient and return her to the Intensive Care Unit. Discussions with the family where undertaken, and it was decided at that time to withdraw support and make the patient COMFORT CARE MEASURES ONLY. The patient was taken off pressors and intravenous fluids in the Surgical Intensive Care Unit. She was bolused with Dilaudid. Approximately 45 min after withdraw of support, the patient expired. Following this, the family declined a postmortem examination. DISCHARGE DIAGNOSIS: Demise secondary to cardiac arrest in the setting of septic shock and small bowel obstruction. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Name8 (MD) 36963] MEDQUIST36 D: [2145-11-19] 09:50 T: [2145-11-22] 10:46 JOB#: [Job Number ]	[ "572.2", "574.51", "567.2", "571.2", "560.81", "557.0", "569.83", "276.4", "998.0" ]	icd9cm	[ [ [] ] ]	[ "54.59", "45.62", "54.25", "96.04", "54.12", "96.71" ]	icd9pcs	[ [ [] ] ]											3412, 3768																																										176, 3390
63,571	168,597	53551+59538	Discharge summary	report+addendum	Admission Date: [2152-5-18] Discharge Date: [2152-5-22] Date of Birth: [2088-1-8] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: CABG x 4 (LIMA-> LAD, RSVG-> [Last Name (LF) ], [First Name3 (LF) ], PDA) [2152-5-18] History of Present Illness: 64 year old male with history of MI back in [2135] who reported new onset chest pain while on treadmill and with mowing the lawn. The pain is intermittent and he can usually work thru the discomfort. He was referred to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and had a stress test done on [2152-3-8]. Stress test showed [Street Address(2) 12501] depression inferiorlaterally and imaging showed severe, partially reversible defect in mid,basal and apical segement of inferior wall with EF gaited at 22%. He subsequently underwent cardiac cath which revealed severe three vessel coronary artery disease. He is now referred for surgical revascularization. Past Medical History: Coronary artery disease, History of IMI [2135] - Hypertension - Hyperlipidemia - Diverticulosis - Rotator cuff impingement syndrome - Metabolic syndrome, Glucose intolerance - History of Nephrolithiasis 80's - Umbilical Hernia(asymptomatic) Past Surgical History - Appendectomy Social History: Race: Caucasian Lives with: Wife Occupation: [Name2 (NI) ] manager for [Company 72169]. Cigarettes: Quit [2144], 40+ PYH ETOH: < 1 drink/week [] [1-4] drinks/week [x] >8 drinks/week [] Illicit drug use: Denies Family History: Family History: Denies premature coronary artery disease Physical Exam: Physical Exam: [2152-4-19] Pulse: 73 Resp: 16 O2 sat: 98% room air B/P Right: 148/94 Left: 148/87 Height: 5'9" Weight: 203 General: WDWN 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 [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None 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: none Left: none Pertinent Results: Echocardiogram [2152-5-18] Conclusions PRE BYPASS 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. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 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%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is AV paced. There is normal right ventricular sustolic function. The left ventricle displays low normal systolic function with an EF in the 50% range. Poor image quality prevents exclusion of a focal wall motion abnormality. Valvular function is unchanged from the pre-bypass exam. The thoracic aorta is intact after decannulation. . [2152-5-22] 05:09AM BLOOD WBC-10.8 RBC-3.00* Hgb-9.1* Hct-26.6* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.3 Plt Ct-225 [2152-5-21] 05:00AM BLOOD WBC-9.3 RBC-2.85* Hgb-8.7* Hct-25.3* MCV-89 MCH-30.4 MCHC-34.3 RDW-13.3 Plt Ct-151 [2152-5-22] 05:09AM BLOOD Glucose-109* UreaN-18 Creat-0.8 Na-138 K-4.1 Cl-100 HCO3-27 AnGap-15 [2152-5-21] 05:00AM BLOOD Glucose-119* UreaN-20 Creat-0.8 Na-137 K-3.8 Cl-101 HCO3-29 AnGap-11 [2152-5-22] 05:09AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [Known lastname 110069] was a same day admit. He was brought to the operating room on [5-18] where the patient underwent CABGx4 by Dr [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He required volume and neo for BP support. He extubated without difficulty. The patient was neurologically intact and hemodynamically stable, he weaned of neo without difficulty. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor on POD#1 for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient has a history of borderline diabetes. He required Lantus and sliding scale insulin. [Last Name (un) ] was consulted. He will not be discharged on insulin, but he is instructed to log his blood glucose and follow-up with [Last Name (un) ]. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Lovastatin NF 40 mg Oral daily 5. Ranitidine 75 mg PO BID:PRN indigestion 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Ranitidine 75 mg PO BID:PRN indigestion 3. Hydrochlorothiazide 25 mg PO DAILY 4. Lovastatin NF 40 mg Oral daily 5. Metoprolol Tartrate 37.5 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg 1.5 Tablet(s) by mouth three times a day Disp #120 Tablet Refills:0 6. Oxycodone-Acetaminophen (5mg-325mg) [11-29] TAB PO Q4H:PRN pain RX Endocet 5 mg-325 mg [11-29] Tablet(s) by mouth q4-6h Disp #40 Tablet Refills:0 7. DME glucometer and test strips Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Coronary artery disease, History of IMI [2135] Hypertension Hyperlipidemia Diverticulosis Rotator cuff impingement syndrome Metabolic syndrome, Glucose intolerance History of Nephrolithiasis 80's Umbilical Hernia(asymptomatic) Past Surgical History: Appendectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema 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 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], [2152-6-1] 10:15 Surgeon Dr. [First Name (STitle) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2152-6-28] 1:00 Cardiologist Dr. [Last Name (STitle) ] [2152-6-9] at 11:00a Please call to schedule the following: [Hospital ] clinic: [Telephone/Fax (1) 3402] Primary Care Dr. [Last Name (STitle) 8505],[First Name3 (LF) ] [Telephone/Fax (1) 8506] in [3-2] 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:[2152-5-22] Name: [Known lastname 18053],[Known firstname ] J Unit No: [Numeric Identifier 18054] Admission Date: [2152-5-18] Discharge Date: [2152-5-22] Date of Birth: [2088-1-8] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 741] Addendum: lopressor dose increased 50mg po TID Discharge Disposition: Home With Service Facility: [Location (un) 1082] VNA [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2152-5-22]	[ "401.9", "458.29", "414.01", "412", "250.00", "413.9", "530.81", "272.4" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.13" ]	icd9pcs	[ [ [] ] ]	9100, 9282	4353, 5708	321, 422	7029, 7197	2514, 4330	7915, 9077	1731, 1774		6069, 6635		6738, 6970		5734, 6046			7221, 7892							6993, 7008		1804, 2495																					270, 283							451, 1148															1171, 1455	1471, 1699
26,019	191,525	25769	Discharge summary	report	Admission Date: [2168-11-28] Discharge Date: [2168-12-5] Date of Birth: [2103-1-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1973] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 65 y.o. F with h/[Initials (NamePattern4) ] [Last Name (NamePattern4) 55294], [First Name3 (LF) ] 10% on [1-/2168], s/p AICD who was recently admited for CHF exacerbation on [2168-11-18] and discharged on [2168-11-23] after aggressive diuresis, who now returns with abdominal pain and BRBPR. Patient states she has been having 10 days of abodminal cramping. She also noticed bloody stools for last 2 days. Patient is a difficult historian but it appears that her abdominal pain has been intermittent, without associated triggers/relief factors, lasting minutes, crampy like. Patient does not appear to report an associated with pain and BRBPR. She does report subjective fevers after taking her coumadin. She denies any lightheadedness, no cp, no sob, no lower extremity swelling. . In ED, patient initially with BP 80/40 that came up to SBP of 90s after 1L NS. Of note, in [Hospital 1902] clinic she has documented SBP of 94/50 bilaterally during her [8-/2168] visit. Patient was also found to have elevated INR and was given 10 mg of Vitamin K PO and also received 1 u PRBCs. . ROS: no recent weight change, no n/v, no diaphoresis, nl appetite, has been trying to adhere to low salt diet, no palpitations, no dysuria/hematuria, no vaginal discharge. States to be compliant with her meds, but does not remmember them. Past Medical History: 1. ? Coronary artery disease. Per daughter, she has been told that she had a heart attack in the past. However cath [1-/2168] with any evidence of CAD 2. CHF, with EF 10% [1-/2168] (NYHA class III) 3. Hypertension 4. Status post eye surgery 5. Prior episodes of malaria in [Country 16573] in [2132] 6. s/p AICD placement [2168-2-4] 7. reports prior history of Hepatitis - per records HCV negative, Hep B immunized. Social History: She moved from [Country 16573] to [Location (un) 86] in [2166]. She currenlty lives with her daughter, who is a science teacher. She does not smoke, no EtOH. Family History: n/c Physical Exam: Vitals: 98.1 94/60 60 paced 99% RA RR 14 Gen: pleasant, thin, elder female, NAD, speaking full sentences HEENT: NC, AT, anicteric, clear OP, no JVD appreciated, no LAd CV : distant HS, nl s1, s2, no extra HS appreciated, unable to hear prior apex murmur Abd: decrease BS x 4 quadrants, mild epigastric guarding, no HSM appreciated Ext: no edema, no cyanosis, no petechia, no echymosis Rectal: per ED, gross blood with clots, no active bleeding. GYN: per ED: bimanual exam negative for blood, no CMT Pertinent Results: [2168-11-28] 04:35PM BLOOD WBC-5.2 RBC-4.17* Hgb-12.2 Hct-35.2* MCV-84 MCH-29.3 MCHC-34.7 RDW-14.4 Plt Ct-215 HCT 35 to 33 --> 1 unit PRBCs -->38, slowly drifted back to 33 on [12-2] [2168-11-28] 04:35PM BLOOD PT-100.7* PTT-38.1* INR(PT)-14.1* [2168-12-2] 04:34AM BLOOD PT-13.5* PTT-24.8 INR(PT)-1.2* [2168-11-28] 04:35PM BLOOD Glucose-145* UreaN-38* Creat-2.1* Na-131* K-5.7* Cl-93* HCO3-29 AnGap-15 [2168-12-2] 04:34AM BLOOD Glucose-105 UreaN-19 Creat-1.1 Na-142 K-3.4 Cl-103 HCO3-33* AnGap-9 [2168-11-28] 04:35PM BLOOD ALT-26 AST-51* CK(CPK)-199* AlkPhos-106 Amylase-110* TotBili-0.9 [2168-11-30] 05:13AM BLOOD Amylase-84 [2168-11-28] 04:35PM BLOOD Lipase-85* [2168-11-30] 05:13AM BLOOD Lipase-51 [2168-11-29] 04:06AM BLOOD TSH-6.9* [2168-11-30] 05:13AM BLOOD T4-10.4 T3-45* Free T4-1.5 [2168-11-30] 05:13AM BLOOD Digoxin-1.4 [2168-11-28] 04:38PM BLOOD Lactate-2.6* K-5.0 [2168-11-28] 10:47PM BLOOD Lactate-1.7 . Reports: CXR [11-28]:Marked cardiomegaly, possible small right pleural effusion. No evidence of CHF. EKG: Ventricular paced rhythm Atrial mechanism uncertain Since previous tracing of [2168-11-22], no significant change . Colonoscopy - Polyps in colon, grade III internal hemorrhoids with recent stigmata of bleed. [2168-12-5] 04:40AM BLOOD WBC-4.1 RBC-3.70* Hgb-11.3* Hct-31.8* MCV-86 MCH-30.6 MCHC-35.6* RDW-15.3 Plt Ct-130* [2168-12-5] 04:40AM BLOOD Plt Ct-130* [2168-12-5] 04:40AM BLOOD Glucose-103 UreaN-13 Creat-1.1 Na-137 K-3.7 Cl-99 HCO3-33* AnGap-9 [2168-12-5] 04:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3 Brief Hospital Course: Patient was admitted to the ICU. She was given fluids and developed shortness of breath. She was diuresed with lasix and her symptoms improved. Gi consult evaluated the patient and performed a colonoscopy. Colonoscopy showed large grade 3 internal hemorrhoids as the likely source of her bleed, also polyps in the ascending colon that were not removed as they were small and INR was 1.5. Surgery was then consulted to determine the method of controlling her bleeding. At time of transfer to the floor, the patient had no new complaints: no abdominal pain, chest pain, shortness of breath, fever, chills or any other concerns. Her last blood BM was the previous day and her BM's on the day of transfer were normal. She notes increased urination, most likely secondary to the lasix. The patient was stable on the floor with stable hematocrits in the low 30's and no blood in her stool on subsequent BM's. She had no symptoms of her CHF such as shortness of breath or lower extremity edema. She was kept on her digoxin, morning and evening home lasix doses and carvedilol. Valsartan was restarted however the patient became hypotensive and was then discontinued. On CTA of the patient's abdomen the week prior to admission, the liver showed some hepatic congestion most likely secondary to her right heart failure. The general surgeons were concerned with this finding and requested a RUQ ultrasound to rule out hepatic pathology. The RUQ US only showed a questionable septated fluid collection around the gallbladder which was found to be ascites fluid on a repeat abdominal CT scan. The general surgery team recommended outpatient follow up and management of the hemorrhoids. Medications on Admission: 1. Valsartan 40 mg QD 2. Carvedilol 3.125 mg PO BID 3. Amiodarone 200 mg PO BID 4. Warfarin 6 mg Tablet qHS 5. Digoxin 125 mcg Tablet every other day 6. Spironolactone 25 PO DAILY 7. Lasix 120mg in AM and 80mg in PM Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO Q AM (). Disp:30 Tablet(s) Refills:2 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO Q PM (). Disp:30 Tablet(s) Refills:2 5. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal QD PRN (). Disp:1 tube Refills:0 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Disp:60 Recon Soln(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Grade 3 internal hemorrhoids Discharge Condition: stable and improving Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Continue to take your lasix as previously prescribed. You should NOT take amiodarone or valsartan due to your low blood pressure. You should continue to take your lasix, digoxin and carvedilol. You should call your primary doctor or return to the emergency department if the bleeding in your stool worsens and you begin to feel lightheaded, weak, or any other concerns. You will need to follow up with the general surgeons to have the hemorrhoids evaluated and treated. Followup Instructions: hospital course. Follow up with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120](Surgeon) on Tuesday [12-13] at 1PM at [Location (un) ] [Hospital Ward Name 23] Building [Location (un) ]. ([Telephone/Fax (1) 3378]	[ "428.0", "455.2", "584.9", "425.4", "401.9", "428.22", "285.1", "276.51", "789.5", "V45.02", "211.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.23", "99.07" ]	icd9pcs	[ [ [] ] ]	7164, 7170	4556, 6247	321, 334	7243, 7266	2918, 4533	7890, 8151	2377, 2382		6514, 7141		7191, 7222		6273, 6491			7290, 7867									2397, 2899																					276, 283							362, 1715															1737, 2174	2190, 2361
29,707	127,406	32989	Discharge summary	report	Admission Date: [2118-1-28] Discharge Date: [2118-2-23] Date of Birth: [2071-6-5] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5667] Chief Complaint: Motor vehicle accident Major Surgical or Invasive Procedure: L subclavian central line . [1-28] - exploratory laparotomy, I&D Left open fibula fracture/LLE four compartment fasciotomies, vac placement, closed reduction left hip dislocation, xploration of peroneal nerve, Non fixation treatment of fibula fracture . [1-29] - I&D LLE, closure medial fasciotomy/vac change . [2-3] - repeat irrigation and debridement of left lower extremity wound and transposition of tibialis anterior muscle flap for coverage of tibia. . [2-10] - Transposition of medial gastrocnemius flap/Split thickness skin graft, meshed at 1:5:1 measuring 35 x 15 cm History of Present Illness: 46 yo M unrestrained driver in MVC brought to [Hospital 8125] hospital. Not following commands, confused. Intubated at OSH for mental status. Given 2L NS at OSH for SBP 90 and 2u PRBC during transfer with return of SBP to 100. Also with L hip dislocation unable to be reduced at OSH. L open fib fracture reduced at OSH with return of distal pulses. Arriving intubated, hypotensive and tachycardic. Past Medical History: unknown Social History: Ethanol 282 on arrival Family History: Noncontributory Physical Exam: On admission P 97 BP 160/98>>89/64 RR 13 sat 100% on vent Gen: intubated, sedated HEENT: in C-collar. Otherwise, wnl. Chest: clear and symmetric, tachy. Abd: equivocal FAST with questionable fluid in morrisons [Hospital 42265]. Ext: L open fibular fracture with large open skin defect. GU: foley in place with clear urine. Neuro: intubated, sedated, but nods to some questions. Pertinent Results: [2118-1-28] 01:30AM BLOOD WBC-12.7* RBC-4.59* Hgb-14.0 Hct-43.2 MCV-94 MCH-30.5 MCHC-32.5 RDW-13.6 Plt Ct-206 [2118-1-28] 05:30AM BLOOD WBC-8.4 RBC-3.52* Hgb-10.7# Hct-30.7# MCV-87# MCH-30.4 MCHC-34.7 RDW-14.4 Plt Ct-144* [2118-1-29] 09:30AM BLOOD Hct-21.0* [2118-1-30] 05:40AM BLOOD WBC-7.0 RBC-3.05* Hgb-9.2* Hct-26.3* MCV-86 MCH-30.1 MCHC-34.9 RDW-15.1 Plt Ct-100* [2118-2-4] 05:45AM BLOOD WBC-9.2 RBC-2.74* Hgb-8.2* Hct-24.5* MCV-89 MCH-29.8 MCHC-33.4 RDW-15.5 Plt Ct-373 [2118-1-28] 01:30AM BLOOD PT-13.6* PTT-24.3 INR(PT)-1.2* [2118-1-28] 01:30AM BLOOD Plt Ct-206 [2118-2-4] 05:45AM BLOOD Plt Ct-373 [2118-1-28] 01:30AM BLOOD Fibrino-208 [2118-1-28] 06:50PM BLOOD CK(CPK)-[Numeric Identifier 76726]* [2118-1-29] 05:47AM BLOOD CK(CPK)-[Numeric Identifier 76727]* [2118-2-3] 12:14PM BLOOD CK(CPK)-1183* [2118-2-4] 05:45AM BLOOD ALT-93* AST-121* LD(LDH)-529* AlkPhos-75 TotBili-1.2 [2118-1-28] 05:30AM BLOOD Calcium-6.7* Phos-1.3* Mg-1.3* [2118-2-3] 12:14PM BLOOD Calcium-7.9* Phos-3.4 Mg-1.7 [2118-2-4] 05:45AM BLOOD Albumin-2.5* [2118-1-28] 01:30AM BLOOD ASA-NEG Ethanol-282* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2118-1-28] 01:34AM BLOOD Glucose-259* Lactate-5.6* Na-143 K-6.3* Cl-111 calHCO3-16* [2118-1-29] 12:18AM BLOOD Glucose-143* Lactate-3.0* Xray chest/pelvis:IMPRESSION: Probable posterior dislocation of the left hip. No evidence of traumatic injury in the chest. Xray pelvis: IMPRESSION: Reduction of hip dislocation. Possible acetabular fracture. CT Head: No evidence of fracture or intracranial hemorrhage. Somewhat indistinct [Doctor Last Name 352]-white differentiation raises the possibility of diffuse axonal injury/shear injury. NOTE ON ATTENDING REVIEW: There is a linear lucency in the lesser [Doctor First Name 362] o sphenoid on the lft side ([3-10]), which can be a vascular groove, appearing more prominent due to rotated position or linear minimally displaced fracture. Assessment is somewhat limited due to pt. rotation. CT facial bones will be useful in characterizing this with proper positioning of pt. CT C-spine: IMPRESSION: No evidence of fracture or malalignment. CT chest/abd/pelvis:IMPRESSION: 1. Relocation of the left hip with probable small fracture of the posterior roof of the left acetabulum. 2. Patchy opacity in the right middle lobe and hazy centrilobular nodularity within the left upper lobe anteriorly most consistent with pneumonia. Bilateral lower lobe atelectasis and small bilateral pleural effusions. 3. Fatty liver. 4. Left adrenal lesion, incompletely evaluated. Follow up with CT adrenal protocol in 6 months is recommended. 5. Expected postoperative pneumoperitoneum. CT L lower extremity: IMPRESSION: 1. Short segment nonopacification of the anterior tibial artery at the level of a comminuted distal fibular fracture, compatible with post-traumatic arterial injury, possibly dissection. 2. Small pseudoaneurysm with associated extravasation of a very small vessel medial to the tibial shaft. 3. Comminuted fibular fractures with a large open soft tissue defect. LLE fluoro: FINDINGS: Multiple images of bilateral hips show relocation of the left hip when compared to the earlier radiograph from two hours previous. Digital images of the left ankle (AP) shows a fracture of the distal shaft of the fibula, approximately 10 cm above the ankle joint. Please refer to the operative note for additional details. Cardiac Echo: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size is normal. with hypokinesis of the basal half of the free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. 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. IMPRESSION: Normal right ventricular cavity size with free wall hypokinesis c/w possible contusion. Preserved global left ventricular systolic function. No definite valvular dysfunction. CT sinus: IMPRESSION: No fracture. The previously identified linear lucency in the lesser [Doctor First Name 362] likely represents a vascular groove. Brief Hospital Course: Mr. [Known lastname 4469] was transferred from [Hospital 8125] hospital. In the trauma bay, he was found to be hypotensive despite 2L of fluid and 2u PRBC before arrival. FAST exam was equivocal with questionable blood in [Location (un) 6813] [Last Name (LF) 42265], [First Name3 (LF) ] the patient was taken to the OR for exploratory laparotomy which was negative for injury. Subsequently, orthopedics performed a closed reduction of his hip dislocation as well as a irrigation and debridement of the open fibular fracture with four compartment fasciotomies and peroneal nerve exploration. Vac dressings were placed on the fasciotomy wounds. Peri-op antibiotics were given. The Left acetabular fracture was determined to be non-operative. Patient was managed on a bicarb drip given his significantly elevated CPK. . On [1-29], a repeat washout of his wound, medial fasciotomy closure and vac change of the lateral fasciotomy was performed. He self-extubated on [1-29] and did not require re-intubation. Also on [1-29], an ECHO demonstrated an area of free wall motion abnormality consistent with possible cardiac contusion, however, he remained hemodynamically stable. On [1-30] he was transferred to the floor. He experienced some delerium post-op and was managed on a CIWA scale for possible ETOH withdrawal. Mental status subsequently cleared on [2-1], and his bicarb drip and central line were DC'd. Antimicrobial coverage for his leg wound was initially covered by vancomycin and was transitioned to cefazolin on [1-31]. . On [2-3] plastic surgery took the patient back to the OR for a repeat washout of his wound with I&D. He was transiently delerious and agitated in the PACU, but recovered spontaneously overnight. Physical therapy and occupational therapy evaluated the patient. He was given a multi-podus boot and later fitted for an AFO for LLE foot drop. His abdominal staples were removed on [2-7] and the wound was clean, dry and intact. . On [2-10] the pt returned to the OR for improved coverage of his leg wound with a medial gastrocnemius flap covered with a split thickness skin graft measuring 35 x 15 cm. Pt was then transfered to the plastic surgery service for continued care of his LLE. [1-/2039] Lovenox was started for anticoagulation. The wound vac over the skin graft remained on until [2118-2-16]. At this time, xeroform dressing, kerlix and ACE wrap covered the wound and he remained in an AFO boot. His activity was increased at this time to a dangle protocol of total 15min at a time, four times daily in the knee immobilizer. His dangle time increased 5 minutes each day. He began ambulating with physical therapy [2-17] with restrictions of no weight bearing. He remained non weight bearing but allowed to ambulate with crutches or walker, with knee immobilizer in place. Dangle protocol 30min at a time, QID. Patient will be discharged to a rehab facility on [2118-2-23]. Medications on Admission: none Discharge Medications: 1. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:20 Capsule(s) Refills:0 2. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours). Disp:30 syringes Refills:2 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:75 Tablet(s) Refills:0 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. Disp:60 Tablet(s) Refills:0 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:60 Tablet(s) Refills:0 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:100 ML(s) Refills:0 Discharge Disposition: Extended Care Facility: JML in [Hospital1 1562] Discharge Diagnosis: s/p motor vehicle crash Open fibular fracture LLE compartment syndrome left hip dislocation with posterior wall acetabular fracture Degloving injury left medial tibia Discharge Condition: stable Discharge Instructions: You were treated in the hospital after a motor vehicle accident. You had an exploratory operation of your abdomen which showed no injury, and you sustained an open fracture to your leg that was cleaned and repaired with multiple surgeries by both orthopedic and plastic surgeons. You were also seen by physical therapists and occupational therapists during your hospitalization. Please call your doctor or return to the ED for any fevers >101.5, increased pain, nausea/vomiting, any redness or drainage from the wound or any numbness, weakness or tingling in your leg or any other symptom that should worry you. You will be prescribed pain medication, please do not drive or operate heavy machinery while on this medication due to the fact these medications may cause drowsiness or somnolence. You may take a stool softener or milk of magnesia should you feel constipated. Please take antibiotics as prescribed. Do not stop taking the medication until told so by a doctor. You should be non weight bearing on your left lower leg. When ambulating, use a walker or crutches with your left leg in a knee immobilizer. You should remain non weight bearing until your follow up visit. Dangle protocol - dangle your left leg for a period of 30 min four times per day for two days. After this you may increase to 35 min, four times per day until seen at follow up. Followup Instructions: Follow up with Dr. [Last Name (STitle) 1005] in orthopedic clinic in 2 weeks, call [Telephone/Fax (1) 1228] to schedule that appointment. . Please follow up with Dr. [First Name (STitle) ] in the plastic surgery clinic. Please call to make an appointment.	[ "293.9", "823.92", "891.0", "835.00", "958.92", "E819.0", "808.0" ]	icd9cm	[ [ [] ] ]	[ "83.79", "79.66", "79.09", "04.04", "83.82", "86.22", "54.11", "86.69", "38.93", "96.71", "79.75", "83.14" ]	icd9pcs	[ [ [] ] ]	10897, 10952	6446, 9447	336, 938	11163, 11172	1896, 3461	12589, 12860	1460, 1477		9502, 10874		10973, 11142		9473, 9479			11196, 12566									1492, 1877																					274, 298							966, 1373		3470, 6423													1395, 1404	1420, 1444
17,997	186,252	1197	Discharge summary	report	Admission Date: [2125-8-18] Discharge Date: [2125-8-21] Date of Birth: [2080-11-28] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old female with severe diabetes type 1 with end-stage renal disease, coronary artery disease and the patient is also blind. She was recently admitted prior to this admission on [2125-8-10] to [2125-8-17] diagnosed with acute rheumatic fever. During that admission she developed a small pericardial effusion. She had positive ASO titer and she developed progressive migratory arthralgias. She was discharged on prednisone and erythromycin. On the day of admission she awoke feeling shaky with a temperature of 99, no sweats at that time. Her fasting sugar was 334. She went back to sleep and woke up a couple of hours later feeling just generally uncomfortable, achy and weak. She also noted that she had decreased hearing bilaterally. Her fasting sugar at that point was 265 and she administered subcutaneous insulin. Her blood pressure at home was measured 44/32 in the emergency room. When she arrived it was 74/45. She reports no headache, no sore throat, no cough, no sputum, no shortness of breath, no chest pain, palpitations, lightheadedness, loss of consciousness, no further joint pains, rash, nausea, vomiting or diarrhea. The patient was not feeling lightheaded and was mentating properly. In the emergency room she received 500 cc of fluid and her blood pressure slowly increased to the 90s or 100s systolic, always mentating well. She also received prednisone, erythromycin, Percocet, Lactulose and Tylenol that day. PAST MEDICAL HISTORY: 1. Type 1 diabetes diagnosed at age seven. She is fine from retinopathy. 2. End-stage renal disease on peritoneal dialysis. 3. Coronary artery disease. 4. Neuropathy. 5. History of anemia on Epogen. 6. Acute rheumatic fever diagnosed on the last admission. 7. Questionable transient ischemic attack about 15 years ago. 8. History of hypertension. ALLERGIES: Keflex causes swelling and itching. Penicillin causes swelling and itching. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Prednisone. 3. Erythromycin. 4. Epoetin. 5. Protonix. 6. Insulin. 7. Ticlopidine. 8. B12. 9. Calcium. 10. Vitamin C. 11. Lopressor. 12. Calcitriol. 13. Lipitor. SOCIAL HISTORY: She lives with her husband. She drinks alcohol socially; no tobacco or drugs. FAMILY HISTORY: There is a family history of diabetes. PHYSICAL EXAMINATION: In the emergency room on initial physical examination her blood pressure was 97/60, oxygen saturation 96% on room air, temperature 98.2, respiratory rate 17. In general she was in no acute distress, alert and oriented. HEENT: Behind the left tympanic membrane she had a small amount of fluid and the right tympanic membrane was clear and normal. Neck: Supple with no lymphadenopathy. Tender to palpation over the trapezoid muscle. Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Lungs: Clear to auscultation bilaterally. Abdomen: Positive bowel sounds, mildly distended, nontender. Extremities: Warm, 3+ edema to the knee. LABORATORY DATA: On initial laboratory studies she had a sodium of 127, potassium 3.6, chloride 86, bicarbonate 24, BUN 72, creatinine 9.4, which is about her baseline. Glucose 196. HOSPITAL COURSE: The patient's beta blocker, Lopressor, was held. Her blood pressure remained stable throughout the remainder of her hospitalization. On the first morning of her hospitalization, [2125-8-19], she developed a leukocytosis with a left shift, eight bands. Blood cultures, urine cultures and sputum cultures were obtained and antibiotics were not initially started. The patient was not febrile and had no symptoms of infection. On [2125-8-20] the patient's urine culture showed 10,000 to 100,000 Gram-negative rods. It grew out Klebsiella, which was pansensitive. She was started on levofloxacin. The patient was also followed by rheumatology throughout her hospitalization. Her ESR, CRP were also repeated. CRP had decreased from previous admission. ESR had increased from 65 to 122. She also had a repeat echocardiogram which showed decreasing small effusion. Rheumatology suggested prednisone taper to decrease by 5 mg every day. The patient was also seen by cardiology. She was ruled out for an myocardial infarction and they suggested holding her Lopressor for the hypotension. The nephrology service suggested that her Lopressor not be restarted until she was back to her baseline dry weight from dialysis. The patient was also closely followed by [Last Name (un) ] and suggested that she continue her sliding scale as the prednisone was increasing her insulin requirements. The patient's blood pressure remained stable through [2125-8-21]. She was discharged to home in stable condition. DISCHARGE DIAGNOSES: Hypotension likely secondary to beta blocker, Lopressor, that was started on the previous admission and possibly hypovolemia. DISCHARGE INSTRUCTIONS: The patient is to follow up with nephrology, Dr.[Doctor Last Name 4849] in one week; cardiology with Dr. [Last Name (STitle) ] in one week; with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 174], in the next two weeks; infectious disease at [Telephone/Fax (1) 457], call to make follow-up appointment; and her rheumatologisst in one to two days. The patient has the doctor's phone number. She will also follow up with audiology, patient is to call in one week to make an appointment. DISCHARGE MEDICATIONS: 1. Erythromycin 250 mg q. 12 hours. 2. Aspirin 81 mg q. day. 3. Prednisone 25 mg on the [2125-8-22], 20 mg on [2125-8-23], 15 mg on [2125-8-24], 10 mg on [2125-8-25], 5 mg on [2125-8-26], and then she is to discontinue the prednisone. 4. Pantoprazole 40 mg q.d. 5. Ticlopidine 250 mg b.i.d. 6. Vitamin B12, 50 mcg tablets q.d. 7. Calcium carbonate 500 mg tablets q.d. 8. Atorvastatin 10 mg three times a week. 9. Sevelamer 800 mg three times a day. 10. Calcitriol 0.5 mcg q.d. 11. Vitamin C 500 mg b.i.d. 12. Lactulose q. 6 hours as needed for constipation. 13. Folic acid 1 mg q.d. 14. Levofloxacin 250 mg q. 48 hours for seven days. 15. Erythropoietin injection once per week. 16. Insulin as per her home regimen. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 7586] MEDQUIST36 D: [2125-8-21] 12:41 T: [2125-8-21] 12:55 JOB#: [Job Number 7587]	[ "583.81", "403.91", "599.0", "250.41", "E849.0", "E942.6", "250.51", "458.2", "276.5" ]	icd9cm	[ [ [] ] ]	[ "54.98" ]	icd9pcs	[ [ [] ] ]							2435, 2475	4906, 5033	5619, 6616				2132, 2321	3358, 4884		5058, 5596																					2498, 3340																161, 1638															1661, 2105	2338, 2418
290	138,303	23390	Discharge summary	report	Unit No: [Numeric Identifier 60026] Admission Date: [2179-1-26] Discharge Date: [2179-2-8] Date of Birth: [2104-9-8] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Esophageal dysplasia, high grade. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old white male with a history of significant for high-grade esophageal dysplasia who presented to [Hospital6 649] on [2179-1-26], for elective thoracoscopic and laparoscopic esophagogastrectomy. PAST MEDICAL HISTORY: Hypertension. Depression. MEDICATIONS ON ADMISSION: Hydrochlorothiazide 50 mg daily, Atenolol 25 mg daily, Lipitor 10 mg daily, Fluoxetine 20 mg, Prilosec, Multivitamin, Aspirin 81 mg once daily. ALLERGIES: None. SOCIAL HISTORY: The patient has a remote smoking history. He quit in [2138]. He denied alcohol and recreational drug use. FAMILY HISTORY: Noncontributory. REVIEW OF SYMPTOMS: He reports feeling well on the day of surgery. He denied recent fever, chills, nausea, vomiting, shortness of breath, chest pain, or light-headedness. PHYSICAL EXAMINATION: Vital signs: Temperature 97.9, heart rate 80, blood pressure 168/89, respirations 12, oxygen saturation 96 percent on room air. General: The patient was alert and oriented. He was comfortable. HEENT: Pupils equal, round and reactive to light. No scleral icterus. No jugular venous distension. No lymphadenopathy. No thyromegaly. Chest: Clear to auscultation bilaterally. Heart: Regular, rate, and rhythm without murmur. Abdomen: Nondistended, soft, nontender to palpation. Extremities: Distal neurovascular intact. HOSPITAL COURSE: The patient presented to [Hospital3 ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] on [2179-1-26], for elective laparoscopic and thoracoscopic esophagogastrectomy and placement of a feeding jejunostomy tube for high-grade esophageal dysplasia. The patient underwent the procedure on [2179-1-26]. The patient tolerated the procedure well. After recovery in the Postanesthesia Care Unit, he was transferred in stable condition to the Surgical Intensive Care Unit intubated. On postoperative day 1, he remained intubated and was in stable condition. He did require two fluid boluses for low urine output. On postoperative day 2, the patient continued to remain clinically stable but intubated. He continued to be weaned from his vent, and on postoperative day 3, he presented with a temperature spike for which blood cultures, urine culture, and sputum culture were obtained. He also went into rapid atrial fibrillation and was promptly converted to sinus rhythm with intravenous Lopressor, which he would remain on. He continued to be weaned from his vent and was extubated on postoperative day 3, which he tolerated well. He continued on tube feeds, which were advanced to goal. On postoperative day 4, he began to get out of bed with Physical Therapy. On postoperative day 5, he was transferred to the floor in stable condition. He underwent a swallow study which was negative for leak. His chest tube remained draining serosanguineous fluid. He was started on sips, which he tolerated well. On postoperative day 7, he was advanced to a clear-liquid diet, which he tolerated well. He continued to ambulate easily and often. On postoperative day 8, he was advanced to a regular diet, which he tolerated well. His chest tube was discontinued; however, he did have a fever spike to 102 degrees. Blood cultures, urine culture, and chest x-ray were obtained. Chest x-ray was suggestive for right middle lobe/right lower lobe. He was started on Zosyn. On postoperative day 9, he was noted to have increased erythema with exudate from around his [Location (un) 1661]-[Location (un) 1662] drain site. Vancomycin was started. His neck incision was partially opened but revealed no signs of infection at the incision site. He continued to remain stable and afebrile, tolerating a regular diet, and ambulating often. His Vancomycin and Zosyn were discontinued on postoperative day 12. On postoperative day 12, his [Location (un) 1661]-[Location (un) 1662] drain from his neck was removed, which he tolerated well. On postoperative day 13, he was discharged to home in good condition afebrile and vital signs within normal limits. He was ambulating easily. He was given a seven-day supply of Levaquin. FOLLOW UP: The patient is to follow-up with Dr. [Last Name (STitle) ] within the next few days after discharge. He is to call Dr.[Name (NI) 45689] office at [Telephone/Fax (1) 2981] for a follow-up appointment. DISCHARGE MEDICATIONS: Protonix 40 mg once daily, Percocet 1- 2 tab p.o. q.4-6 hours as needed, Ambien 5 mg p.o. q.h.s., Levaquin 500 mg p.o. daily x 7 days, Metoprolol 50 mg p.o. t.i.d., Hydrochlorothiazide 25 mg p.o. once daily, Lipitor 10 mg p.o. once daily, Aspirin 81 mg p.o. once daily, Fluoxetine 20 mg p.o. once day, Multivitamin, Albuterol Ipratropium inhaler as needed. MAJOR SURGICAL/INVASIVE PROCEDURES: Laparoscopic thoracoscopic esophagogastrectomy with placement of a feeding jejunostomy tube. CONDITION ON DISCHARGE: Good. DISCHARGE INSTRUCTIONS: The patient is to keep the wound area clean and dry. He is to take his medications as prescribed. He is to seek medical attention if he experiences fevers, chills, nausea, vomiting, or increased neck, chest, or abdominal pain. [First Name11 (Name Pattern1) 333] [Last Name (NamePattern4) 366], [MD Number(1) 367] Dictated By:[Last Name (NamePattern1) 16264] MEDQUIST36 D: [2179-2-8] 11:25:32 T: [2179-2-8] 15:56:37 Job#: [Job Number ]	[ "750.9", "599.0", "401.9", "998.2", "427.31", "E878.6", "311", "998.81", "486" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "33.41", "46.39", "43.99", "96.6" ]	icd9pcs	[ [ [] ] ]							876, 1068		4663, 5152				566, 730	1640, 4413		5209, 5708																4425, 4639					1091, 1622									195, 230							259, 488															511, 539	747, 859	5177, 5184
23,775	143,025	17716+17717	Discharge summary	report+report	Admission Date: [2145-4-22] Discharge Date: END OF THE MONTH INTERIM SUMMARY Date of Birth: [2145-4-22] Sex: M Service: NEONATOLOGY INTERIM NOTE: The patient is a 3,780 gm full-term male infant with prenatal diagnosis of chylous ascites. He was born to a 29-year-old G4, P1 now 2 mother. PRENATAL SCREENS: Blood type A+, antibody positive, rubella immune, RPR nonreactive, Hep-B surface antigen negative, GBS negative. The patient was born by C-section for failure to progress. The Apgar scores were 7 at 1 minute and 9 at 1 minute. The mother was transferred from [Name (NI) ]. PHYSICAL EXAM ON ADMISSION: Weight 3,780 gm, length 19-1/2", head circumference 35.5 cm. A nondysmorphic male infant in no respiratory distress. Anterior fontanel soft, open, flat. Oropharynx benign. Palate intact. Ears and nares patent. Neck supple, no masses. Lungs clear to auscultation bilaterally, no grunting, flaring or retractions. Cardiovascular - S1, S2, regular, no murmurs heard, warm and well-perfused. The abdomen was moderately distended with a positive fluid wave. There was no hepatosplenomegaly and no masses. GU - normal male with bilaterally descended testes. Anus was patent and normally placed. The spine was intact. The hips were stable without clunk. The extremities were normal in appearance. There was full range of motion. Neurologic exam - appropriate for gestational age and nonfocal. There was normal strength and tone and normal newborn reflexes were present and symmetric. The skin was without lesions. HOSPITAL COURSE BY SYSTEMS - 1) CARDIOVASCULAR: As part of the evaluation for the chylous ascites, an echo was obtained on day of life two. Initially the report showed some mild depressed LV function, but subsequently was read as normal; however, cardiology would want a follow-up echo prior to discharge. 2) RESPIRATORY: Initially, the patient had no respiratory distress and was in room air; however, on day of life 13 when some ascites did accumulate, the patient briefly, for approximately a day or two, was in nasal cannula. Now remained stable in room air. 3) GI: An abdominal ultrasound on day of life one showed normal kidneys, bladder and solid organs, and the presence of moderate to severe ascites. A tap of the acidic fluid was performed on day of life one and revealed a white blood cell count of 7,800, 0 polys, 100% lymphocytes, red blood cells [Pager number ]. This was consistent with chylous ascites. Surgery was consulted. Dr. [Last Name (STitle) 7860] recommended that the patient be made NPO for two weeks. At the end of this period of being NPO, the patient was trialed on PO Portagen. The patient tolerated PO's well; however, within several days the ascites recurred with marked weight increase and increase in abdominal girth. So, on [5-13], on day of life 21, the patient was again made NPO, this time for a four week course. On [6-12], the patient will again be challenged with Portagen. If, at that time, the ascites does reaccumulate, the plan is for the patient to be transferred to [Hospital3 1810] for an exploratory laparotomy. Our plan, on [6-11], the day prior to restarting Portagen, is to obtain an abdominal ultrasound to get a baseline imaging of the abdomen. 4) FEN: The patient, while NPO, was maintained on PN and lipids. The patient has a peripherally inserted central catheter. The electrolytes were monitored closely and remained stable. The LFTs likewise were monitored, and the patient has developed a mild direct hyperbilirubinemia. On day of life 38, the total bili was 3.2, and the direct bili was 2.3. A week later, on day of life 45, the total bili had climbed to 4.0; however, the direct bili had dropped to 1.8. The patient's most recent weight, on day of life 45, was 4,430 gm. 5) HEME: The patient's hematocrit on admission was 43.4 with a platelet count of 397. 6) ID: The patient's initial white blood cell count was 10.2, 68 polys, 1 band. On day of life 13, the patient appeared clinically unwell, having some apnea and bradycardic spells, and mottling of the skin. A repeat CBC was drawn at that point which revealed a white blood cell count of 6.8, hematocrit 36, platelet count 287. The patient was empirically started on vanc and gentamicin and a blood culture was sent. That blood culture ended up growing Staph epi. The patient completed a seven-day course of oxacillin to which this organism was sensitive. An LP was performed on day of life 20 and revealed 3 white blood cells, 13 red blood cells. The patient has had no further infectious issues. The patient has developed bilateral small, easily reduced inguinal hernias. 7) NEURO: A head ultrasound on day of life 11 was within normal limits. 8) Abdominal imaging: An upper GI with small bowel follow through was also performed on day of life 11 and was within normal limits. The patient has also had an MRI of the abdomen; it too was within normal limits. 8) SOCIAL: The parents are involved with [Known firstname 49275] care. They do live quite a distance in the [Hospital1 ] area and have a toddler at home which sometimes prohibits more frequent visits than they would like. They have remained updated and have been followed by social work throughout [Known firstname 49275] hospitalizations. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 49276] MEDQUIST36 D: [2145-6-7] 14:11 T: [2145-6-7] 13:20 JOB#: [Job Number 49277] Admission Date: [2145-4-22] Discharge Date: [2145-7-7] Date of Birth: [2145-4-22] Sex: M Service: ADMISSION DIAGNOSES: 1. Newborn ex-full-term male infant. 2. Prenatal diagnosis of abdominal ascites. DISCHARGE DIAGNOSES: 1. Now day of life 76 ex-full-term male infant. 2. Isolated chylous ascites stable; stable. 3. Bilateral inguinal hernias. 4. Treatment for sepsis from [2145-5-5] through [2145-5-12]. 5. Treatment for bacteremia from [2145-6-11] through [2145-6-29]. 6. Status post peripherally inserted central catheter line removal. IDENTIFICATION: Baby boy [Name2 (NI) ] [Known lastname 49278] is now a day of life 76 ex-full-term infant with a prenatal diagnosis of chylous isolated abdominal ascites who was admitted on his date of birth ([2145-6-22]) to the [Hospital1 188] Neonatal Intensive Care Unit secondary to evaluation and management of his isolated chylous ascites. HISTORY OF PRESENT ILLNESS: Baby boy [Name2 (NI) ] [Known lastname 49278] is a now day of life 76 ex-full-term infant who was delivered on [2145-6-22] via a cesarean section secondary to failure to progress. The mother is a 29-year-old gravida 4, para 1 (now 2) mother with prenatal laboratories significant for blood type A positive, antibody screen negative, Rubella immune, rapid plasma reagin nonreactive, hepatitis B surface antigen negative, and group B strep negative. Apgar scores were 7 at one minute and 9 at five minutes. He was admitted to the Neonatal Intensive Care Unit at [Hospital1 1444] secondary to his isolated chylous ascites. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed weight was 3780 grams, length was 19.5 inches, and head circumference was 35.5 cm. In general, a nondysmorphic male in no distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Anterior fontanel open, flat, and soft. Ears and nares were patent. The palate was intact. The oropharynx was benign. The neck was supple. No masses. The lungs were clear to auscultation bilaterally without any grunting, flaring, or retractions. Cardiovascular examination revealed normal first heart sounds and second heart sounds. A regular rate and rhythm. No murmurs were heard. Warm and well perfused. The abdomen was moderately distended with a positive fluid wave. There was no hepatosplenomegaly, and no masses appreciated. Genitourinary examination revealed normal male with bilateral descended testes. The anus was patent and normally placed. The spine was intact. The hips were stable without clicks or clunks. Extremities were normal in appearance with full range of motion. Neurologic examination revealed appropriate for gestational age and nonfocal. There was normal strength and tone, and newborn reflexes were present and symmetric. The skin was without lesions. PHYSICAL EXAMINATION ON DISCHARGE: Discharge physical examination revealed weight on discharge was 5510 grams, Length 57cm, HC 39.5cm, heart rate was 146, and respiratory rate was 36. No blood pressure noted. Temperature was 98.4 degrees Fahrenheit. In general, [Known lastname ] was active and alert and was in no apparent distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Anterior fontanel open, flat, and soft. The faces were normal with normally set ears. There were no pits or tags. Red reflexes were present bilaterally. Extraocular movements were intact. Pupils were equal, round and reactive to light. The nose was without discharge, and the nares were patent bilaterally. The oropharynx revealed mucous membranes were moist without any erythema. The neck was without masses and supple. No lymphadenopathy. The chest was clear to auscultation bilaterally without grunting, flaring, retracting, wheezes, or crackles. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No third heart sounds or fourth heart sounds. No murmurs or rubs were appreciated. Femoral pulses were 2+ bilaterally. Capillary refill time was rapid. Warm and well perfused. The abdomen was soft, round, and distended. Abdominal circumference was approximately 40 cm. There was a positive fluid wave. No hepatosplenomegaly or masses were appreciated. Bowel sounds were normoactive. Genitourinary revealed normal male genitalia with testes descended bilaterally. There were bilateral inguinal hernias present which were large and easily reducible bilaterally. No bowel sounds were heard over the inguinal hernias. The anus was patent. Extremity examination revealed he moved all extremities well. There was normal bulk, tone, and strength. Normal range of motion. Five fingers and toes were present bilaterally. The hips were stable without clicks or clunks bilaterally. Neurologic examination revealed appropriate and active. Made eye contact and followed past 180 degrees. He had a grasp, and suck, and Moro reflex as well. He has developed a nice social smile. Deep tendon reflexes at the patellar tendons were 2+ bilaterally. The skin was without lesions. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR SYSTEM: As part of an evaluation for chylous ascites, and echocardiogram was obtained on day of life two. Initially, the report showed some mild depressed left ventricular function but was subsequently read as normal. A follow-up echocardiogram which was performed on [2145-6-10] was also determined to be normal and without any evidence of any cardiac dysfunction. 2. RESPIRATORY ISSUES: As noted, the patient had no respiratory distress and was on room air. However, on day of life 13 when some ascites did accumulate, the patient briefly (for approximately a day or two) was on nasal cannula. Since that time, he has been maintained on room air without any difficulties. 3. GASTROINTESTINAL ISSUES: An abdominal ultrasound on day of life one showed normal kidneys, bladder, and solid organs, and the presence of a moderate to large amount of ascites. A peritoneal tap of the ascitic fluid was performed on day of life one and revealed a white blood cell count of 7800, 0 polys, 100% lymphocytes, and 938 red blood cells. The ascites was determined to be consistent with chylous ascites. Surgery was consulted, and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7860] became [Known lastname 49279] primary surgical physician. [Name10 (NameIs) ] recommended that the patient be made nothing by mouth for two weeks. At the end of his 2-week period of nothing by mouth, [Known lastname ] received a trial on oral Portagen, and he tolerated oral feedings well. However, within several days, the ascites recurred with a marked weight increase and an increase in abdominal girth and feeding intolerance. On [2145-5-13] (on day of life 21), [Last Name (un) ] was gain made nothing by mouth; this time for a 4-week course to be ended on [2145-6-12]. At that time, [Last Name (un) ] was allowed to feed, and he rapidly gained full feed volumes and became an ad lib feeder on Portagen 20. On [2145-6-18], and abdominal ultrasound was obtained to determine if the ascitic fluid had returned; and indeed, his abdominal ultrasound did demonstrate a moderate amount of ascitic fluid. His abdominal girth at that time was approximately 35 cm and stable. Over the course of the next several days, his abdominal circumference increased to 37 cm, and a repeat abdominal ultrasound was obtained which again showed a moderate amount of ascites. Over the course of the next several days, his abdominal circumference, after being stable at approximately 37 cm, increased to 41 cm to 42 cm; over the weekend of [6-26] through [2145-6-27]. An abdominal ultrasound was obtained on [2145-6-29] was demonstrative of a large amount of ascitic fluid. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7860] had been kept abreast of his clinical course, and when his abdominal circumference seemed steady at approximately 37 cm, it was thought that he could be discharged and then sent home with followup on a close schedule with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7860]. However, with the increase of his abdominal circumference secondary to a further accumulation of ascitic fluid, it was felt that he might again be a candidate for an exploratory laparotomy to try to determine the source of his lymphatic leak. He had an exploratory laparotomy tentatively scheduled for [2145-7-8]. In lieu of his surgery, he was allowed to continue to orally feed, and his abdominal circumference actually stabilized at approximately 39 cm to 41 cm over the course of the following week; such that by [2145-7-7], his abdominal circumference had been stable at 39 cm to 41 cm for approximately one week. He had continued to feed on Portagen 20; however, his feeding volumes at any one feed was limited to 150 cc per feed. Despite this, he continued to feed well and had taken in approximately 167 cc/kg per hour on the day prior to his discharge. 4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: As previously noted, [Known lastname ] was made nothing by mouth upon admission to the [Hospital1 69] Neonatal Intensive Care Unit, and was maintained on total parenteral nutrition and lipids. He had a peripherally inserted central catheter placed, and his total parenteral nutrition was administered through that line. [Known lastname ] was then attempted on feeds, and as previously noted he reaccumulated ascitic fluid and was thus made nothing by mouth for a 1-month period. During that time he was again maintained on total parenteral nutrition via his peripherally inserted central catheter. His nutrition was optimized; however, he did begin to develop a mild direct hyperbilirubinemia with a peak of 4. However, his direct bilirubin declined to 1.8 and then declined further once he was maintained on full feeds. As noted above, [Known lastname ] was restarted on Portagen 20 feeds on [2145-6-12]. He continued on oral feeds throughout the remainder of his admission. At the time of discharge, [Known lastname ] was taking approximately 160 cc/kg to 170 cc/kg per day of Portagen 20 with his feeds limited to 150 cc per feeding. 5. HEMATOLOGIC ISSUES: Baby boy [Known lastname 49278] had no difficulties in terms of his hematologic status. His hematocrit did reach a nadir of 23.4% on [2145-6-14]; however, he was not transfused, and his reticulocyte count was determined to be 3% at that time. Subsequent hematocrit levels were measured on [2145-6-21] at 27.5 with 5.4% reticulocytes and at 36.4% on [2145-6-29] with 3.9% reticulocytes. He is on iron sulfate therapy. 6. INFECTIOUS DISEASE ISSUES: In terms of Infectious Disease issues, baby boy [Name (NI) 49278] did experience a period of bacteremia in which he appeared to be clinically unwell and experienced apnea as well as bradycardic spells accompanied by modeling of his skin color. A complete blood count was drawn at that time which revealed a white blood cell count of 6.8, hematocrit was 36, and platelet count was 287,000. He was started empirically on vancomycin and gentamicin, and a blood culture was sent at that time. The blood culture grew out Staphylococcus epidermidis, and he was given a 7-day course of oxacillin to which this organism was determined to be sensitive; surprisingly. A lumbar puncture was performed on day of life 20 which was not concerning for infection. As previously noted, on [2145-6-11], baby boy [Name (NI) 49278] developed fever as well as irritability. He was started on a sepsis evaluation. A blood culture was drawn at that time, and antibiotics were started; consisting of vancomycin, gentamicin, and cefotaxime. A urine culture, as well as a lumbar puncture, as well as a complete blood count were obtained at that time. The urinalysis was benign; however, the urine culture grew out Escherichia coli. The lumbar puncture was benign. Sensitivities for these organisms were determined. The Escherichia coli was determined to be sensitive to cefotaxime, and gentamicin therapy was discontinued at that time, and he completed seven days of cefotaxime therapy for a positive urine culture. Baby boy [Known lastname 49278] also completed 14 days of ampicillin therapy for his enterococcus infection. Coincidentally, his peripherally inserted central catheter was removed well prior to the discontinuation of his antibiotic therapy. Baby boy [Known lastname 49278] had a follow-up urine culture which was negative, and a follow-up blood culture which was also sterile. He was discharged to home without any concerns regarding infectious disease. As noted prevviously, renal ultrasound was unremarkable with no evidence of obstruction. A VCUG has not been performed but would be recommended if another urinary tract infection occurred. 7. NEUROLOGIC ISSUES: A head ultrasound was obtained on day of life 11 and was within normal limits. 8. SURGICAL ISSUES: As noted above, baby boy [Name (NI) 49278] had a surgical consultation from Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7860] from [Hospital3 18242] [Location (un) 86]. He continues to be involved in his surgical care. The long-term outlook for [Known lastname ] was still yet to be determined. The possibilities were many and include; (1) spontaneous improvement and regression of his chylous leak; (2) steady state chylous leak with reabsorption occurring at approximately the same rate as his leak, and thus a stable chylous ascites which will be followed as an outpatient; or (3) worsening of his chylous ascites prompting a possible exploratory laparotomy to determine if a site of chylous leak can be found and can be repaired. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7860] will manage [Known lastname 49279] chylous ascites as an outpatient, and his first appointment with Dr. [Last Name (STitle) 7860] is on [7-14] at the [Hospital3 1810]. Also of note, [Last Name (un) ] has large bilateral inguinal hernias which will need to be repaired. He was tentatively scheduled for bilateral inguinal hernia repair on [2145-7-21] with Dr. [Last Name (STitle) 7860] as his surgeon. Also to be done at that time is a circumcision. 9. SENSORY/AUDIOLOGY: Hearing screen was performed with automated auditory brain stem responses and [Known lastname ] passed this screening examination in both ears. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. His first appointment with Dr. [Last Name (STitle) ] is on Thursday, [2145-7-8]. FEEDINGS ON DISCHARGE: Portagen 20 ad lib with a maximum of 150 cc per feed. MEDICATIONS ON DISCHARGE: Iron sulfate 25 mg/cc; he was to receive 0.45 cc p.o. once per day. STATE NEWBORN SCREEN: State newborn screening status was normal. IMMUNIZATIONS RECEIVED: [Known lastname ] has received a hepatitis B vaccine (#1 and #2). He has also revealed his first IPV, his first DAPT, his first HIB, and his first Prevnar vaccination. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Last Name (NamePattern1) 49280] MEDQUIST36 D: [2145-7-7] 12:29 T: [2145-7-7] 12:52 JOB#: [Job Number 49281] cc:[Last Name (NamePattern1) 49282]	[ "779.81", "041.4", "771.81", "771.82", "V30.01", "550.92", "457.8", "038.19", "779.89" ]	icd9cm	[ [ [] ] ]	[ "88.72", "93.90", "88.97", "03.31", "99.15", "54.91", "87.62", "38.93" ]	icd9pcs	[ [ [] ] ]								5879, 6584				20793, 21448																							10876, 20377	5774, 5858			20392, 20696	20711, 20766													6613, 8575									644, 5753
21,795	156,494	13823	Discharge summary	report	Admission Date: [2177-8-20] Discharge Date: [2177-8-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4765] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: [Age over 90 ]-year-old woman with h/o CAD s/p CABG, AF, [11-25]+ AR, 2+ MR, 3+ TR, moderate systolic pulm HTN, EF 40%, p/w intermittent SOB over past 2 days in the setting of URI. In the past two days, she developed rhinorrhea, nasal congestion, and productive cough. Has some degree of SOB at baseline, but notes that these episodes have become more frequent in the past two days. When coughing, she endorses slight right shoulder pain, that resolves immediately following coughing episodes. She denied any chest pain, fever, chills, nausea, vomiting, palpitations, lightheadedness, or pain. Of note, patient recently fell, but did not endorse any head trauma, only a bruised shin. * In the ED, noted to have T 98, HR 59 - 70, BP 135/33, R 15, sats 96% 4LNC. She was given ASA 162mg, and lasix 40mg IV x 1 with about 850cc urine output and some improvement in symptoms. She was noted to have an elevated BNP (11,888, while before 6264) and a D-dimer of 1882. She was sent for a CTA, which was negative for a PE. Past Medical History: -Presumed Alzheimer's Dementia -Valvular heart disease: Last echo [7-29]--Biatrial enlargement, global (RV & LV) HK, 2+ AR, 2+MR, 3+TR -CAD s/p CABG [2164] [Hospital1 112] for exertional angina -Multiple thoracic compression fractures -AF - diagnosed in [1-26] -hospitalization in [1-26] with bibasilar pna complicated with ARF and hypernatremia and AF -RCC s/p Nephrectomy -Hypothyroidism -h/o RP bleed in [12-30] while on plavix -AVNRT/AVRT: short bursts noted on Holter in the past Social History: Patient lives in apartment that is attached to daughter's home. Denies alcohol or tobacco, currently. Family History: Coronary artery disease. Physical Exam: On admission, per night float: Vitals: T 96.4 BP 148/76 HR 64 R 22 Sat 97% 4LNC * PE: G: Elderly female, NAD, slightly dyspneic with speaking--[12-27] words between breaths HEENT: Clear OP, MMM Neck: Pulsatile carotids--prominent v waves noted on external jugular veins, internal limited by carotid pulses. Likely elevated JVP/CVP. Lungs: Decr BS R base vs L. Crackles (wet) BL. Cardiac: RR, NL rate. [12-28] diastolic murmur loudest at LLSB with rad to apex. [12-30] holosystolic murmur loudest at both LLSB and apex, no rad, with associated soft S1 c/w MR/TR. Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. R shin ecchymosis. Neuro: Slightly disoriented, but able to answer questions appropriately and give some history--notes that she does not remember some of the history given in the ED. Pertinent Results: [2177-8-21] 12:50PM BLOOD WBC-6.2 RBC-4.71 Hgb-14.4 Hct-42.3 MCV-90 MCH-30.5 MCHC-34.0 RDW-14.9 Plt Ct-161 [2177-8-19] 09:00PM BLOOD WBC-5.3 RBC-4.71 Hgb-14.5 Hct-42.3 MCV-90 MCH-30.7 MCHC-34.2 RDW-14.7 Plt Ct-146* [2177-8-21] 12:50PM BLOOD PT-12.7 PTT-45.3* INR(PT)-1.1 [2177-8-21] 12:50PM BLOOD Glucose-138* UreaN-25* Creat-1.1 Na-144 K-4.7 Cl-105 HCO3-27 AnGap-17 [2177-8-19] 09:00PM BLOOD Glucose-90 UreaN-28* Creat-1.1 Na-149* K-3.5 Cl-109* HCO3-27 AnGap-17 [2177-8-20] 10:12AM BLOOD CK-MB-NotDone cTropnT-0.01 [2177-8-19] 09:00PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier 41522]* [2177-8-21] 12:50PM BLOOD Calcium-9.3 Phos-3.5 Mg-4.2* [2177-8-19] 11:50PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . Urine culture ([8-19]): No growth. . CTA([8-20]): IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate right effusion, with ground-glass opacity in the right upper lobe. 3. Cardiac enlargement, and reflux of contrast into distended hepatic veins. The appearance is suggestive of cardiac failure overall. 4. Similar thoracic and lumbar compression fractures. 5. Unchanged appearance of multiple aortic aneurysms, with extensive atherosclerotic disease. 6. Occlusion of the right external iliac artery, which does not opacify with contrast. . CXRAY([8-19]): New right-sided pleural effusion. . CXRAY ([8-21]): Interval improvement in the right-sided pleural effusion. . EKG ([8-19]): Atrial fibrillation at 64. ST depressions in V2-V6. Brief Hospital Course: Hospital course on the floor: 1) Dyspnea: - On [8-19], patient presented with increased shortness of breath. Patient has several cardiac risk factors and on examination, she had an elevated JVP, worsened chest xray and BNP levels consistent with a CHF exacerbation (BNP 11,888, when previously 6264). Initially, she required 4L of NC oxygen supplementation, but she was slowly weaned to 2L and then room air, where her oxygen saturations were 95%. - In the ED, patient related no chest pain. Her troponins were negative, and EKG revealed no evidence of acute coronary compromise. On the basis of elevated D-dimer, CTA was performed, which did not reveal a pulmonary embolus. - During admission, goal was to gently diurese patient, as she received nephrotoxic contrast during CTA. Net fluid goal was -500cc to -1 liter daily and achieved through IV lasix 20mg, initially, and then switched to 40mg PO and then 20mg PO. Continued to hold lisinopril and switched atenolol to metoprolol, as atenolol is renally cleared and creatinine clearance likely to decrease, acutely, from nephrotoxic contrast administration. * 2) Congestive heart failure: - Patient was transitioned from atenolol 25mg qd to metoprolol 25mg [Hospital1 ] during hospitalization, as there was concern that patient's kidneys would become compromised following CTA. - Goal was gentle diuresis during hospitalization. Achieved through IV lasix and then slowly titrated to PO lasix. During hospitalization, patient's heart rate increased to 130's. Corrected with 250 cc bolus of NS. * 3) Peripheral Vascular Disease: - During admission, noted that patient did not have palpable dorsalis pedis pulses. Feet were warm and sensation was intact. Physical examination findings were supported by Doppler ultrasound--no dorsalis pedis pulses auscultated, but patent posterior tibialis pulses, bilaterally. Ct of abdomen and chest noted an "unchanged appearance of multiple aortic aneurysms, with extensive atherosclerotic disease. Occlusion of the right external iliac artery, which does not opacify with contrast." Senior resident [First Name8 (NamePattern2) ] [Doctor Last Name ] conveyed these findings with patient's PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. * 4) Hypernatremia: - Sodium levels slightly elevated upon admission, but through gentle diuresis normalized. * 5) Hypothyroid: - Continued synthroid during admission. * 6) Osteoporosis: - Continued Vitamin D (increased to 800u) and fosamax q wk. Initially held calcium supplements, given serum calcium equal to 10. Albumin 4.0. * CCU course: The patient was admitted to the CCU on [8-24] for hypotension. She was noted to have had a 10-point Hct drop in the prior 24 hours and a CT showed a hematoma in the anterior rectus sheath. She was started on pressors, but after discussion with the family, given her DNR/DNI status and their knowledge her wishes at end of life the decision was made to change goals of care to comfort measures only. Pressors were withdrawn and the patient expired on [2177-8-26]. Medications on Admission: -Cholecalciferol 400u PO DAILY -Cyanocobalamin 1000 mcg PO DAILY -Levothyroxine 25 mcg PO DAILY -Calcium Carbonate 1000 mg PO QD -Aspirin 162 mg PO DAILY -Vitamin A 10,000 unit PO DAILY -Furosemide 20 mg PO DAILY -Atenolol 25 mg PO once a day. -Advair Diskus 250-50 mcg Two (2) puffs Inhalation once a day. -Lisinopril 2.5 mg PO once a day--held in past few months due to low blood pressure -Detrol 2 mg PO once a day. -FOSAMAX 70 mg PO once a week Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: Primary: hemorrhagic shock anterior rectus sheath hematoma Congestive heart failure. Valvular Heart Disease Coronary Artery Disease Atrial Fibrillation Presumed Alzheimer's Dementia . Secondary: Peripheral Vascular Disease RCC- Status post nephrectomy Hypothyroidism Multiple thoracic compression fractures History of retroperitoneal bleed in [12-30] while on plavix AVNRT/AVRT: short bursts noted on Holter in the past Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A	[ "396.3", "398.91", "244.9", "V45.81", "V10.52", "995.92", "511.9", "486", "427.31", "038.9", "584.9", "331.0", "276.0", "397.0", "294.10" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	8137, 8156	4483, 7608	283, 290	8624, 8633	2882, 4460	8685, 8691	2013, 2039		8108, 8114		8177, 8603		7634, 8085			8657, 8662									2054, 2863																					223, 245							318, 1345															1367, 1878	1894, 1997
27,231	138,952	764	Discharge summary	report	Admission Date: [2121-5-30] Discharge Date: [2121-7-5] Date of Birth: [2055-7-11] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5547] Chief Complaint: Small bowel obstruction Major Surgical or Invasive Procedure: ex lap, bowel resection, [Doctor Last Name ] ostomy ([5-30]), percutaneous tracheotomy, CT guided drainage with catheter placement to abdominal fluid collection, left sided thoracostomy, bronchoscopy, central line placement History of Present Illness: 65 y/o F s/p total gastrectomy for signet ring cell gastric adenocarcinoma with Roux-en-Y esophagojejunostomy and feeding jejunostomy tube placement presented on POD #10 with acute onset of RUQ pain. Patient had recent swallow study showing no evidence of a leak and had been tolerating a clear liquid/full liquid diet until presenting to the hospital on [5-30]. Patient also complained of nausea, vomiting, fevers and chills. She had her last bowel movement on the morning of admission. Past Medical History: Breast CA s/p hysterectomy and Chemo (adriamycin and tamoxifen) GERD, Hypercholesterolemia, Glaucoma Physical Exam: CV: asystole, no heart rhythm Resp: no breath sounds, no respirations - spontaneous or otherwise Neuro: pupils dilated to 5mm, unreactive to light bilaterally; no response to noxious stimuli Pulses: radial, femoral and carotid pulses absent bilaterally Pertinent Results: [2121-7-2] 02:29AM BLOOD WBC-34.0* RBC-2.87* Hgb-8.3* Hct-25.4* MCV-89 MCH-28.8 MCHC-32.5 RDW-18.5* Plt Ct-515* [2121-7-3] 02:41AM BLOOD WBC-32.2* RBC-2.71* Hgb-8.1* Hct-25.3* MCV-93 MCH-30.1 MCHC-32.2 RDW-19.2* Plt Ct-503* [2121-7-4] 02:48AM BLOOD WBC-26.5* RBC-2.82* Hgb-8.2* Hct-26.3* MCV-93 MCH-29.1 MCHC-31.2 RDW-19.2* Plt Ct-468* [2121-7-3] 02:41AM BLOOD PT-16.5* PTT-31.1 INR(PT)-1.5* [2121-7-3] 02:41AM BLOOD Plt Ct-503* [2121-7-3] 02:00PM BLOOD PTT-62.2* [2121-7-4] 02:48AM BLOOD PT-15.4* PTT-28.4 INR(PT)-1.4* [2121-7-4] 02:48AM BLOOD Plt Smr-HIGH Plt Ct-468* LPlt-1+ [2121-7-2] 02:29AM BLOOD Glucose-115* UreaN-37* Creat-0.5 Na-148* K-4.4 Cl-108 HCO3-35* AnGap-9 [2121-7-3] 02:41AM BLOOD Glucose-133* UreaN-39* Creat-0.6 Na-146* K-4.8 Cl-106 HCO3-37* AnGap-8 [2121-7-4] 02:48AM BLOOD Glucose-154* UreaN-44* Creat-0.7 Na-140 K-5.2* Cl-101 HCO3-31 AnGap-13 [2121-7-2] 02:56PM BLOOD CK(CPK)-11* [2121-7-2] 10:35PM BLOOD CK(CPK)-20* [2121-7-3] 02:41AM BLOOD ALT-46* AST-51* LD(LDH)-433* AlkPhos-92 Amylase-108* TotBili-0.8 [2121-7-3] 06:40AM BLOOD CK(CPK)-14* [2121-7-4] 02:48AM BLOOD ALT-43* AST-46* LD(LDH)-458* AlkPhos-92 Amylase-132* TotBili-0.8 [2121-7-2] 02:29AM BLOOD Lipase-101* [2121-7-3] 02:41AM BLOOD Lipase-74* [2121-7-4] 02:48AM BLOOD Lipase-98* [2121-7-2] 02:56PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2121-7-2] 10:35PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2121-7-3] 06:40AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2121-7-2] 02:29AM BLOOD Albumin-2.9* Calcium-8.4 Phos-2.6* Mg-2.1 [2121-7-3] 02:41AM BLOOD Albumin-2.7* Calcium-8.7 Phos-4.2# Mg-1.9 [2121-7-4] 02:48AM BLOOD Albumin-2.8* Calcium-8.3* Phos-6.5# Mg-2.2 [2121-7-2] 09:10PM BLOOD Type-ART pO2-199 pCO2-66* pH-7.32* calTCO2-36* Base XS-5 [2121-7-2] 10:45PM BLOOD Type-ART pO2-190* pCO2-65* pH-7.36 calTCO2-38* Base XS-8 [2121-7-3] 12:27AM BLOOD Type-ART pO2-228* pCO2-73* pH-7.29* calTCO2-37* Base XS-6 [2121-7-3] 02:20AM BLOOD Type-ART pO2-202* pCO2-71* pH-7.34* calTCO2-40* Base XS-9 Intubat-INTUBATED [2121-7-3] 04:07AM BLOOD Type-ART pO2-67* pCO2-63* pH-7.37 calTCO2-38* Base XS-7 [2121-7-3] 09:11AM BLOOD Type-ART pO2-81* pCO2-73* pH-7.32* calTCO2-39* Base XS-7 [2121-7-3] 12:55PM BLOOD Type-ART pO2-72* pCO2-62* pH-7.38 calTCO2-38* Base XS-8 [2121-7-3] 05:54PM BLOOD Type-ART pO2-67* pCO2-73* pH-7.30* calTCO2-37* Base XS-6 [2121-7-4] 03:22AM BLOOD Type-ART pO2-70* pCO2-85* pH-7.24* calTCO2-38* Base XS-5 [2121-7-4] 04:27AM BLOOD Type-ART pO2-99 pCO2-76* pH-7.28* calTCO2-37* Base XS-5 [2121-7-4] 09:56AM BLOOD Type-ART pO2-88 pCO2-72* pH-7.30* calTCO2-37* Base XS-5 [2121-7-2] 09:10PM BLOOD K-3.7 [2121-7-3] 02:20AM BLOOD K-4.0 [2121-7-3] 09:11AM BLOOD Glucose-138* Lactate-1.0 K-4.3 [2121-7-3] 12:55PM BLOOD Lactate-1.1 K-4.2 [2121-7-3] 05:54PM BLOOD Glucose-129* K-4.8 [2121-7-4] 09:56AM BLOOD K-4.4 [2121-7-2] 02:12AM BLOOD freeCa-1.06* [2121-7-2] 02:59PM BLOOD freeCa-1.04* [2121-7-2] 09:10PM BLOOD freeCa-1.07* [2121-7-3] 02:20AM BLOOD freeCa-1.19 [2121-7-3] 09:11AM BLOOD freeCa-1.19 [2121-7-3] 12:55PM BLOOD freeCa-1.15 [2121-7-3] 05:54PM BLOOD freeCa-1.13 Brief Hospital Course: Ms. [Known lastname ] presented on [2121-5-30] with RUQ pain, nausea, vomiting, fevers and chills s/p total gastrectomy for signet ring cell gastric carcinoma. The patient was consented for an exploratory laparotomy that evening for evidence of small bowel obstruction. The patient had difficulty with intubation and aspirated at that time. At that time a small bowel obstruction at the jejunostomy site with a leak at the jejunostomy site was found. The patient was transferred to the SICU after surgery where she was placed on a ventilator. The patient developed atrial fibrillation with a heart rate into the 150-160s and decreasing blood pressure on the morning of POD #1. Cardioversion was attempted with reversion back into atrial fibrillation, so a neosynephrine drip was started to increase the blood pressure and a diltiazem drip was started. The pulse decreased to the 120s at that time. The patient was started on IV antibiotics - Vancomycin, Zosyn and Fluconazole for gram positive cocci, gram negative rods and gram positive rods in her sputum and from her wound. The patient received a 2D echo on [2121-6-2] which revealed an ejection fraction > 60%, mild left atrial enlargement, biventricular function, normal wall thickness, 1+ mitral regurgitation and normal pulmonary capillary wedge pressures. On [2121-6-4] a chest xray showed bilateral pleural effusions with the left greater than the right in size. On [2121-6-5], the patient had a bout of hypoxemia requiring a bronchoscopy - the attending noted that the patient had a bilateral pneumonia with upper zone predominance indicative of ventilator associated pneumonia. Her chest CT from the same date showed large multifocal consolidation bilaterally, no abcesses and moderate pleural effusions. A bronchoscopy on that date showed no endobronchial lesion, minimal airway erythema and secretions bilaterally. On [2121-6-8], the patient had a CT scan which revealed a perihepatic fluid collection which was drained by IR on [2121-6-9], the fluid was found to be blood and air, no abscess. On POD 10 ([6-10]), the patient had a fever of 103.4 with no obvious source of infection. The patient's old central line was removed and another one was placed on this same day. On [2121-6-11] the patient's heart rate and blood pressure increased acutely with a drop in oxygen saturations. A torso CT scan was ordered this same day which revealed worsening left lung infiltrates involving the entire lung, no signs of effusion, some residual free air over the liver but no evidence of fluid, abscess or a contrast leak. On [2121-6-12], a percutaneous tracheotomy was performed. On [2121-6-13], a stool culture was sent due to large loose bowel movements and was found to be positive for C. difficile. This same day, the patient developed hypotension which resolved with albumin and levophed. Infectious Disease was consulted on [6-14], for unresolving pneumonia, and recommended starting Vancomycin and Flagyl. On [2121-6-17] an NG tube was placed. On this day, Ms. [Known lastname ] developed atrial fibrillation again which was rate controlled with diltiazem and amiodarone. A repeat chest CT on [2121-6-18] shows worsening lung consolidation and increased free air above the liver. There are no intraabdominal fluid collections or abscesses and the jejunostomy site has no air or fluid in the area surrounding it. The free air appears to be due to a duodenal stump leak. A repeat exploratory laparotomy was attempted on this date but was unsuccessful due to her loops of small bowel being adherent to the peritoneal wall along the length of the midline incision. A culture of the peritoneal fluid was sent at that time which grew [Female First Name (un) ] albicans. On [2121-6-20], the patient was requiring increased ventilatory support, increasing pressor support and had worsening abdominal distention. The patient had decreased oxygen saturations when an attempt was made to do a CT guided drainage of the patient's new air/fluid level in left hemithorax suspicious for an empyema. Thoracic Surgery was consulted on this same day and thoracostomy tube was placed on her left side. Approximately 450cc of serosanguinous fluid was drained and sent for analysis and culture which grew propionobacterium acnes. A chest xray showed resolution of a moderate pleural effusion. On [2121-6-22] the patient had bilious emesis, an NG tube was placed. On [2121-6-23], the patient was found to be grossly edematous and had her thoracostomy tube discontinued due to low output. The patient was also noted to have a patchy macular rash on her face and abdomen at this time. On [2121-6-25], Ms. [Known lastname ] was noted to have vesicular lesions on her hands. Dermatology was consulted and performed a skin biopsy on the lesions which appear to be a result of a drug hypersensitvity. The patient also had a percutaneous drainage of her RUQ near the duodenal stump. A drainage catheter was placed within the porta hepatis. The fluid sent from this drainage grew sparse [Female First Name (un) ] albicans. On [6-26], Ms. [Known lastname ] had increased drainage and pressure from RUQ wound. We opened 4 staples and drained bilious fluid, cultured the fluid and packed the wound. The fluid grew [Female First Name (un) ] albicans. A chest xray from [6-27] shows diffuse alveolar opacities. Chest xray on [2121-6-29] shows decreased bilateral opacification. Ms. [Known lastname ] received an echocardiogram on [6-30] shows a dilated right ventricle and free wall hypokinesis. On [2121-7-2], an attempt to get a CT scan resulted in an episode of hypotension and increased ventilatory support. On [2121-7-3], the patient's right IV became infiltrated with 90cc of contrast. Plastic surgery was consulted for IV infiltration and suggested keeping the arm elevated with serial examinations. The CT scan showed worsening bilateral airspace disease and no drainable fluid collection in the abdomen. Given continued clinical deterioration despite full ventilatory support and levophed requirement, the primary team decided to meet with the family to discuss withdrawal of care. On [2121-7-4], the primary team met with Ms. [Known lastname 5548] family regarding withdrawal of care due to patient's multisystem organ failure with a low likelihood of survival given worsening status on maximum support. Both health care proxies agreed with withdrawal of medical support with the expectation that the patient would succumb to the illness shortly afterwards. On [2121-7-5], the patient was given last rites by a priest and switched to comfort measures only. Ms. [Known lastname ] became asystolic at 1805 when the family was at her bedside. Medications on Admission: Metoprolol 50 mg [Hospital1 ] Percocet Timolol 0.3% qd each eye Zocor 20mg qday Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Multi system organ failure Discharge Condition: Deceased	[ "998.59", "008.45", "V10.3", "518.82", "997.1", "427.31", "933.1", "V10.83", "999.9", "112.5", "507.0", "365.9", "998.2", "995.92", "V10.05", "V64.1", "567.29", "038.9", "692.9", "997.4", "V66.7", "486", "511.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.61", "54.11", "31.1", "34.04", "33.23", "45.02", "54.91", "33.21", "96.6", "96.56", "45.62", "86.11", "99.15", "46.73", "99.04" ]	icd9pcs	[ [ [] ] ]	11752, 11761	4769, 11589	337, 570	11831, 11842	1504, 4746				11723, 11729		11782, 11810		11615, 11700												1230, 1485																					274, 299							598, 1091															1113, 1215
1,767	129,892	26343	Discharge summary	report	Admission Date: [2163-2-13] Discharge Date: [2163-2-26] Date of Birth: [2091-1-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p cardiac catheterization on [2163-2-13] History of Present Illness: 72 year old female with DM (NIDDM), AFib on sotalol and digoxin, HTN found by EMS at home to be tripoding, unable to speak more than one word at a time. She denied CP, but said she got suddenly SOB at 11:30 p.m. the night prior and said she felt like she "was dying." Per family, she has not had any known recent fevers and her abdomen apparently looked more distended per the family but she was not complaining of this. In the ambulance, she was in sinus rhythm, HR 87 w/ LBBB compared to prior with 2mm ST elevations in V1-V2 with TWI and ST depressions in V4-6, I, II and TWIs in II, III, aVF (only change in III with upright QRS compared to prior). Pt then develeoped a wide complex tachy concerning for VTach and was shocked with 200J x 2 and 360J x 1. At [Hospital 46] Hosp, she was loaded with Amio 150mg and put on Amio gtt 1 mg/kg/min. She was intubated with initial gas 7.07/60/163. She received Lasix 20 iv x 2, 4 mg Morphine and placed on Nitro gtt for bp in 160's, ASA 325, Hep and Integrelin gtts and given Rochepin 1g x 1. Trop < 0.02, Dig level < 0.04 at OSH. Pt also received Plavix 600mg x1. Pt was found to be in DKA with BS 384 and anion gap 17, given 5 u insulin and placed on insulin gtt. She was transferred to [Hospital1 18] for cath w/ ABG 7.12/52/236 and lactate 11. In the cath lab, pt was HD unstable on Nitro with sbp drop to 30's. Nitro was stopped and Dopamine was started. She had episodes of VTach and shocked twice. She remained hypoxic despite mech ventilation and PaO2 50-60's. Levophed was added. Cath showed no significant CAD. Limited Ventriculogram showed EF 35%, PA gram without thrombus, and ? healed VSD with ? Right to Left shunt given decreased PaO2. IABP placed and she was transferred to CCU on dopa and Levophed gtts. Past Medical History: Diabetes Mellitus AFib Hypercholesterolemia HTN Colectomy [3-3] diverticulitis/sigmoid resexn 2 yrs prior PVD/Right S Fem Art stenosis Social History: Lives with husband. [Name (NI) ] 6 children. Family History: Non-contributory Physical Exam: 96.2F HR 70 BP 88/39 RR 22 100% Mech Vent Gen: sedated and intubated HEENT: intubated CV: distant S1, S2, RRR, no murmurs appreciated Pulm: CTA-Ant Abd: (+) BS, soft, ?distended, NT Ext: cool feet, faint PT dopplerable pulses b/l. Left groin with IABP line, dsg C/D/I. Rectal: guaiac negative brown stool Pertinent Results: EKG: Sinus, HR 87, old LBBB, ST elevations in V1-2 (old) and V3, ST depressions in V5-6 (old). . [2163-2-13] 06:35AM WBC-22.1* RBC-3.83* Hgb-12.3 Hct-35.4* MCV-93 MCH-32.0 MCHC-34.6 RDW-14.2 Plt Ct-296 Neuts-82* Bands-2 Lymphs-12* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2163-2-13] 06:35AM Glucose-354* UreaN-31* Creat-1.3* Na-135 K-4.0 Cl-103 HCO3-20* AnGap-16 freeCa-1.03* . [2163-2-13] 06:35AM BLOOD ALT-49* AST-44* LD(LDH)-270* CK(CPK)-61 AlkPhos-77 Amylase-44 TotBili-0.3 Lipase-33 . [2163-2-13] 06:35AM CK(CPK)-61 CK-MB-NotDone cTropnT-0.05* [2163-2-13] 02:15PM CK(CPK)-134 CK-MB-5 . [2163-2-13] 06:35AM Fibrino-245 D-Dimer-[2070]* FDP-10-40 Hapto-139 [2163-2-13] 06:35AM BLOOD Albumin-3.3* [2163-2-13] 10:42AM BLOOD Digoxin-<0.2* [2163-2-13] 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG . [2163-2-13] 06:22AM BLOOD Type-ART PEEP-12 pO2-65* pCO2-47* pH-7.26* calHCO3-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED . Cath [2-13]: EF 35% LMCA 30% LAD 30% LCx 20% RCA mild dz RA 18 RVEDP 15 PA 48/25 PCWP 20 LVEDP 18; C.O 2.94 and CI 1.75 (post-IABP) mod MR, no right-to-left shunt ? healed VSD, no PA thrombus. . Portable chest, [2163-2-13] An intraaortic balloon pump is present with the radiodense tip terminating approximately 3 cm below the superior aspect of the aortic knob. An endotracheal tube terminates about 4.5 cm above the carina, and a Swan-Ganz catheter terminates in the right interlobar pulmonary artery. The cardiac silhouette is normal in size. There is vascular engorgement, and there is a bilateral pattern of perihilar alveolar opacities, with sparing of the extreme lung periphery. This is asymmetric, right greater than left, and is superimposed upon a more diffuse interstitial pattern with bilateral septal thickening. An area of hyperlucency is seen adjacent to both heart borders and probably is related to pulsation artifact. Anterior medial pneumothoraces are considered less likely, but attention to these areas on followup chest radiograph is suggested. IMPRESSION: 1. Lines and tubes in satisfactory position. 2. Extensive pulmonary edema. 3. Hyperlucency adjacent to both heart borders. . [2163-2-13] KUB: A nonobstructive bowel gas pattern is visualized. Contrast material is identified within the renal collecting systems and bladder. Correlation with timing of contrast administration is suggested, as no contrast enhanced CT scans are reported at this institution. A nasogastric tube is noted within the stomach. Femoral vascular catheters are noted bilaterally, with a left femoral venous line coursing into the IVC. On a separately dictated chest radiograph, this is shown to represent a pulmonary arterial catheter. . [2163-2-16]: Non-contrast axial head CT. FINDINGS: There are multiple hypodense foci scattered throughout the subcortical white matter of both cerebral hemispheres, representing the sequela of small vessel infarction. The [Doctor Last Name 352]-white matter junction is intact. The ventricles, cisterns, and sulci demonstrate no effacement. There is no mass effect or shift of normally midline structures. There is a fluid level within the sphenoid sinus, likely be secondary to intubation. Bilateral mastoid air cells demonstrate some opacification that could be air, fluid, or combination of the two, again likely the result of intubation. The other paranasal sinuses are clear. The osseous structures are unremarkable. Calcification of the cavernous carotid arteries is secondary to atherosclerotic disease. IMPRESSION: No evidence for intracranial hemorrhage. MR brain is recommended for the evaluation of acute brain ischemia, if of clinical concern. . [2163-2-17]: MRI OF THE BRAIN. FINDINGS: There are areas of abnormality on the diffusion-weighted sequence in the left parietal and left occipital lobe. There are corresponding abnormalities on the FLAIR sequence consistent with subacute infarcts. The areas of abnormality are small consistent with multiple emboli and multiple distributions. There is no definite evidence of mass effect or hemorrhage. There are multiple T2 high signal intensity foci in the periventricular white matter and centrum semiovale consistent with microvascular angiopathy. There is no evidence of a focal extra-axial lesion or fluid collection. IMPRESSION: Multiple diffusion abnormalities in the left hemisphere as described. Some of these are referable to the middle cerebral artery circulation, some referable to the posterior. It is noted that there is a fetal type posterior communicating artery on the left, so that these might represent systemic emboli but may also represent emboli from a left carotid lesion. MRA OF THE CIRCLE OF [Location (un) ] AND ITS MAJOR TRIBUTARIES. FINDINGS: There is no definite evidence of aneurysm. The left vertebral artery is not visualized and may be occluded below the level of foramen magnum. There is a fetal type posterior communicating artery on the left, supplying the left posterior cerebral artery. The P1 portion of the left posterior cerebral artery is diminutive. There appears to be some reduced flow in the posterior cerebral artery on the left compared to the right. IMPRESSION: Fetal type posterior communicating artery on the left, so that the lesions noted on the brain MR may be coming from the carotid circulation. There is some diminished flow in the left posterior cerebral artery, consistent with some obstruction. . [2163-2-17]: Carotid Ultrasound: Heterogeneous calcific plaque involving the internal carotid arteries bilaterally. The peak systolic velocities on the right are 141, 69, and 69 cm/sec for the ICA, CCA, and ECA respectively. Similar values on the left of 120, 80, and 71 cm/sec. There is antegrade flow involving both vertebral arteries. IMPRESSION: Findings as stated above which indicate bilateral 40-59% ICA stenoses. . [2163-2-18]: LDL 67 HDL 38 TGs 144 . [2163-2-22]: CT Abd/Pelvis TECHNIQUE: Axial non-contrast CT images of the abdomen and pelvis were obtained. Sagittal and coronal reconstructions were also performed. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are dependent atelectases, but otherwise, the lung bases are clear. There is a huge hematoma with a fluid- fluid level involving the left psoas muscle, and bilaterally, there are also multiple smaller hematomas in the iliacus muscles as well. The large left psoas hematoma measures 11 x 12 mm in axial dimensions, and it is surrounded by some inflammatory stranding. The iliacus muscles bilaterally are expanded, with fluid- fluid levels within these as well. There are calcifications in the femoral arteries bilaterally, which cannot be evaluated well. CT OF THE PELVIS WITHOUT IV CONTRAST: The sigmoid shows an anastomotic site consistent with prior resection. The uterus, adnexal regions, and bladder are unremarkable. There is Foley catheter and air within the bladder. There is no inguinal or pelvic lymphadenopathy. There is no hematoma in either groin. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: Large acute hematomas involving the left psoas, and bilateral iliacus muscles. . [2163-2-22]: Left Groin ultrasound FINDINGS: Ultrasound examination of the vascular structures of the left groin show normal compressibility, waveform, and color flow within the left common femoral vein and superficial femoral vein. No pseudoaneurysm or evidence of AV fistula is seen. No thrombus is seen within the common femoral vein. IMPRESSION: No evidence of pseudoaneurysm or AV fistula within the imaged vascular structures of the left groin. . [2163-2-24]: Hct 30.5 [2163-2-25]: Hct 30.8 [2163-2-26]: Hct 30.6 Brief Hospital Course: 72 yo F with DM, HTN, AFib presents after resp distress, intubated, VTach s/p shock x 5, transferred from OSH for cath without signficant CAD, requiring pressors, IABP placed, in DKA, WBC 22, lactate 11 at OSH and 3 here. Extubation was attempted once and patient required re-intubation for respiratory distress and was found to have acute pulmonary edema. Patient was then noted to be moving all extremities except her right arm. Head CT was done and evidence of CVAs. Head MRI/MRA was then done and she was found to have occipital and parietal strokes (likely sub-acute), likely emboli from Atrial Fibrillation, although carotid ultrasounds also revealed 40-59% bilateral Internal carotid artery stenosis. In retrospect, it was thought that inciting event was likely the stroke, patient may have aspirated making her short of breath as well as a component of pulmonary edema from mitral regurgitation (and worsening of pulm edema from tachycardia). Patient was diuresed for several days, continued on antibiotics and successfully extubated on [2163-2-19]. Patient was talking clearly with inability to move right arm on the day of extubation, but each day improved was moving arm, hand and fingers prior to discharge. On [2-22], patient was noted to have back pain and decreased hematocrit. Stat Abd/Pelvis CT scan was performed and she had a large retroperitoneal bleed into left psoas and bilateral iliacus muscles. Vascular surgery was consulted the same day, q6 hematocrits were performed and patient was transfused 2 units pRBCs on the first day with FFP (given increased INR/PTT on heparin, coumadin and aspirin at the time). The following day she was tranfused 3 additional units and one unit of FFP. She was given one dose of vitamin K. Left femoral ultrasound on [2-22] was performed and no evidence of pseudoaneurysm or AV fistula was seen. Retroperitoneal was thought to be spontaneous from anticoagulation. Aspirin, Heparin and Coumadin was held. . 1. CV: Ischemia: no significant CAD on cath, no evidence of MI. On ASA. Pump: EF 35-40%. Checked Echo on [2-15] and [2-18] EF 30-35%. Preload: goal i's and o's even to slightly negative on lasix doses. Contractility: Requiring dopamine on admission and then stopped. Afterload: Intra-aortic balloon pump d/c'ed on [2-14]. Off pressors with goal MAP > 60. Rhythm: Amio added for ? AFib on [2-14]. This was d/c'ed on [2-15]. pt appeared to be in AFib w/ RVR. Started on Esmolol on [2-15] w/ period of rate control and sinus rhythm but then went back into AFib w/RVR HR 105-130. Amiodarone was restarted with better rate controlled, received several days of Amio 400 mg po TID, plan for 1 week of Amio 200 mg po tid, then 1 week Amio 200 po bid then switch to Amio 200 po qday. Added beta-blocker for additional rate control. Given atrial fibrillation and evidence of CVAs on Head MRI/CT, patient would likely benefit from long term anti-coagulation. Anti-coagulation was held when patient found to have retroperitoneal bleed, but should restart, plan to start Aspirin one week after discharge and coumadin 2 weeks after discharge. . 2. ID: Possible infection on admission given elevated WBC ct and ?DKA of unknown source on admission. Empirically started on Zosyn and Levoflox (for double gram negative coverage), Vanco and Flagyl. CXR w/pulm edema and KUB wnl. Patient febrile on [2-13]. [Last Name (un) ] stim test wnl. D/C Flagyl on [2-14], d/c'ed Zosyn on [2-15], d/c'ed Vanco on [2-16]. No OSH Cxs. UA negative. Restarted on Vanco and Zosn when spiked temp and completed 5 additional days of these antibiotics for possible nosocomial pneumonia. . 3. DM: possible DKA on admission, on insulin gtt on admission. Changed to RISS on [2-14]. Monitored finger sticks. . 4. Resp: Intubated on admission. Pt was extubated on [2-15], but desatted, increased HR, resp distress, reintubated for likely pulmonary edema. She was successfully extubated on [2-20] without further events, breathing comfortably. . 5. Neuro: patient noted to not be moving R arm on [2-16]. Head CT with multiple foci of ischemic/embolic change. Consulted Neurology. Head MRI with occipital and parietal emboli. Started Heparin gtt but stopped when patient noted to have retroperitoneal bleed. Checked carotid U/S with b/l 40-59% ICA stenosis. Neuro recommended aspirin 325mg po qday to start one week after hematocrit stable. . 6. FEN: NPO, monitor lytes in setting of DKA. . 7. GI: Protonix [Hospital1 ] for UGI Bleed, consider Protonix gtt, however, concerned about volume overload, so will cont [Hospital1 ] for now. NG lavage with coffee grounds and some bright red blood on [2-13]. q6-8 hr Hcts, transfuse prn. Consulted GI on [2-13], appreciate recs, no urgent need for scope unless increased UGI bleed. Abd XRay done, no obstruction seen. . 8. Heme: decreased Hct on admission, likely from UGI bleed which has since stabilized. Patient received 2 unit pRBCs on [12-3]. Patient then found to have retroperitoneal bleed on [2-22], anti-coagulation with aspirin, coumadin, heparin held, patient received 5 additional units of pRBCs and FFP. Hematocrit stabilized on [2-24]. . FULL CODE . Disposition: Patient to go to acute rehab facility per physical therapy recommendations. She made signficant progress in moving her right arm s/p CVA but is deconditioned from 2 weeks hospitalization. She was started on Amiodarone and Toprol for Atrial fibrillation control. Plan for Amiodarone was to complete 1 week of Amiodarone 200 po tid and can transition to Amio 200 po bid on [2-28] to complete 1 week and then transition to 200 mg po qday. It was felt that patient would benefit from long term aspirin as well as coumadin. Aspirin to be started one week after discharge from the hospital and Coumadin to be started two weeks after discharge from the hospital with close monitoring of PT/INR. Hematocrits should also be checked every few days, although has been stable in the several days prior to discharge. Patient to follow-up with cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] as outpatient and follow-up with primary care physician as she should have close follow-up while on coumadin. Medications on Admission: sotalol 80 po qday Digoxin 125 mcg qday Nulev 1 tab po prn cilostazol (Pletal) 100 mg po bid diphenoxylate 2.5 [Hospital1 ] prn zocor 20 mg po qday glyburide 2.5 po qday avandia 4 mg po qday metformin 1000 mg po bid ASA 81 qday Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: Please start on [2163-2-28]. 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: please start after [Hospital1 ] dosing finishes. 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Outpatient Lab Work Please have your hematocrit checked on [2163-2-28]. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital of [Location (un) ] & Islands - [Location (un) 6251] Discharge Diagnosis: Atrial fibrillation Systolic congestive heart failure mitral regurgitation diabetes mellitus cerebrovascular accident Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, abdominal or back pain, numbness, weakness or difficulty with speech. Followup Instructions: You have a follow-up appointment scheduled with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] on [2163-3-3] at 4:15 p.m. at [Street Address(2) 14531] in [Hospital1 1474]. Please call [Telephone/Fax (1) 3183] to reschedule if you are unable to keep this appointment. Please schedule follow-up with your primary care physician after you leave the rehabilitation facility. Completed by:[2163-2-26]	[ "458.29", "428.20", "578.9", "424.0", "401.9", "427.31", "414.01", "443.9", "486", "250.00", "434.91", "459.0", "287.5", "427.1", "428.0", "285.1", "272.0", "785.51", "429.9" ]	icd9cm	[ [ [] ] ]	[ "99.20", "96.71", "38.93", "99.62", "88.53", "88.56", "96.04", "99.07", "37.23", "99.04", "88.43", "37.61" ]	icd9pcs	[ [ [] ] ]	18116, 18228	10588, 16956	334, 382	18390, 18399	2815, 10565	18618, 19064	2452, 2470		17238, 18093		18249, 18369		16982, 17215			18423, 18595									2485, 2796																					275, 296							410, 2207															2229, 2369	2385, 2436
40,595	116,518	34888	Discharge summary	report	Admission Date: [2144-10-15] Discharge Date: [2144-10-24] Date of Birth: [2068-3-4] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 492] Chief Complaint: Transferred from [Hospital 61603] Hospital in NY for treatment of Tracheoesophageal Fistula Major Surgical or Invasive Procedure: [10-15] 1. Rigid bronchoscopy at the yellow Dumon bronchoscope, Flexible bronchoscopy with therapeutic aspiration, Bronchoalveolar lavage of the left lower lobe, Balloon dilatation, left main stem, Stent placement. Ultraflex 40 x 14 covered stent, left main stem, Silicone Y-stent placement. [10-16] Flexible bronchoscopy, Stent revision, Therapeutic aspiration of secretions [10-16] Thoracentesis under thoracic ultrasound. [10-18] Flexible bronchoscopy, Therapeutic aspiration of secretions. Placement of A-line, CVL R IJ (both removed) History of Present Illness: The patient is a 76 yo non-smoker with NSCLCA, dx'd 1 year ago s/p chemo/XRT, believed to be in remission who was [2144-9-23] for a TIA who was found to have a tracheo-esophageal fistula (large defect in esophagus, two small defects in distal trachea lateral to LMS and carina) who underwent Esophageal stent 1 wk ago but remained intubated on vent with difficult weaning. Bronch one week ago demonstrated erosion of stent thru posterior tracheal membrane. The patient was transferred per the family's request for further management of the TEF. Past Medical History: HTN, AFib NSCLCA: originally treated with tarceva only, then LAD progressed and treated with chemo/XRT. LUL opacity developed after XRT and attributed to post rad changes (per son) - PET negative and has subsequently decreased in size, Vertigo, h/o hemoptysis while AC, B TKR, ccy, breast ca s/p lumpectomy Social History: Strong family support, married with two sons Family History: noncontributory Physical Exam: Upon discharge: NAD A and Ox3 PERRL, dry mucus membranes, no JVD, R CVL dressing IJ in place irreg irreg ? sys murmur at URSB coarse bs at bases b/l soft NT/ND Foley in place no c/c slight edema LE 2+ DP b/l L PICC UE R arm severe ecchymoses Pertinent Results: [2144-10-23] 02:42AM BLOOD WBC-5.9 RBC-2.70* Hgb-7.9* Hct-23.8* MCV-88 MCH-29.2 MCHC-33.1 RDW-19.6* Plt Ct-118* [2144-10-15] 11:09AM BLOOD WBC-7.0 RBC-2.94* Hgb-8.8* Hct-26.6* MCV-90 MCH-29.9 MCHC-33.1 RDW-20.6* Plt Ct-95* [2144-10-23] 02:42AM BLOOD Plt Ct-118* [2144-10-15] 11:09AM BLOOD PT-12.7 PTT-53.3* INR(PT)-1.1 [2144-10-23] 02:42AM BLOOD Glucose-148* UreaN-22* Creat-0.4 Na-136 K-3.5 Cl-99 HCO3-29 AnGap-12 [2144-10-15] 11:09AM BLOOD Glucose-81 UreaN-47* Creat-0.7 Na-145 K-4.4 Cl-109* HCO3-29 AnGap-11 [2144-10-18] 02:27AM BLOOD ALT-31 AST-18 LD(LDH)-402* AlkPhos-118* TotBili-0.6 [2144-10-23] 02:42AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7 [2144-10-15] 11:09AM BLOOD Albumin-2.9* Calcium-7.9* Phos-4.2 Mg-2.1 [2144-10-23] 02:41AM BLOOD Vanco-12.3 [2144-10-23] 11:49AM BLOOD Type-ART pO2-106* pCO2-31* pH-7.56* calTCO2-29 Base XS-6 [2144-10-15] 11:17AM BLOOD Type-ART pO2-213* pCO2-48* pH-7.39 calTCO2-30 Base XS-3 Brief Hospital Course: PROCEDURES DURING ADMISSION [10-15] 1. Rigid bronchoscopy at the yellow Dumon bronchoscope, Flexible bronchoscopy with therapeutic aspiration, Bronchoalveolar lavage of the left lower lobe, Balloon dilatation, left main stem, Stent placement. Ultraflex 40 x 14 covered stent, left main stem, Silicone Y-stent placement. [10-16] Flexible bronchoscopy, Stent revision, Therapeutic aspiration of secretions [10-16] Thoracentesis under thoracic ultrasound. [10-18] Flexible bronchoscopy, Therapeutic aspiration of secretions. Placement of A-line, CVL R IJ # TRACHEOESOPHAGEAL FISTULA The patient was transferred intubated from [Hospital 61603] Hospital in NY on [10-15] for stent revision to a tracheo-esophageal fistula. On [10-16] she underwent a CT scan that revealed collapse of the left lung with partial sparing of the lingula. Left main bronchus stent was seen in place and was patent, although there was diffuse attenuation of the airways distal to the stent on the left, with moderate pleural effusions b/l. That day she underwent rigid and flexible bronchoscopy with therapeutic aspiration, BAL of left lower lobe, Balloon dilatation, left main stem Ultraflex 40 x 14 covered stent, and left main stem Silicone Y-stent placement. THe patient tolerated the procedure well, although she remained with copious secretions, and so underwent stent revision on [10-16] and again on [10-18]. On [10-17] she was extubated, which she tolerated well although with need for frequent suctioning, chest PT, and required therapeutic bronchoscopy for secretions on [10-18]. She was also maintained on scheduled nebulizers and prednisone. On [10-21] she underwent a Barium swallow to assess for the TEF, but the patient was unable to complete the study as she aspirated the Barium during the study. However, contrast was seen within the left main stem bronchus and distal airways, most likely reflecting aspiration although without lateral views, persistent tracheoesophageal fistula could not be excluded. On [10-22] she had a follow up CXR that revealed: The stent, central venous access line, and abdominal drain are in unchanged position. The right-sided basal consolidation has decreased in extent. The left retrocardiac atelectasis is unchanged. Also unchanged is still moderate cardiomegaly. Unchanged mediastinal widening and increase in mediastinal diameter. No newly occurred focal parenchymal opacities. # VENTILATOR ASSOCIATED PNEUMONIA The BAL on [10-18] revealed MRSA > 100K, and so the patient was started on IV vancomycin for a total therapy duration of two weeks. She remained afebrile and hemodynamically stable throughout her stay. #PLEURAL EFFUSION On [10-16] the patient underwent thoracentesis given radiologic and clinic findings that was transudative in nature, with Glucose 214, LDH 170, and total protein of 2.5. She was also started on lasix for diuresis. # HYPERTENSION The patient's hypertension was eventually controlled through a combination of clonidine patch, enalapril, labetolol, and metoprolol. # ATRIAL FIBRILLATION The patient has a history of Atrial fibrillation and was initially placed on IV diltiazem and esmolol for rate control, which was then converted to PO meds via the PEG; however, her rate was not controlled until she was digoxin loaded on [10-19] and her rate slowed from AF in the 120s to the 80s. She was then placed on her home dose of digoxin 0.125 mg/day, which controlled her rate throughout her stay. # ATRIAL THROMBUS The CT on [10-16] revealed a filling defect along posterosuperior wall of left atrium could represent direct extension of tumor or intraluminal thrombus. Given this finding in the presence of Atrial Fibrillation, she underwent an echocardiogram that revealed a possible 1.1cm mass in the body of LA,Mild-moderate mitral regurgitation, Mild pulmonary artery systolic hypertension, mild symmetric left ventricular hypertrophy, but normal cavity size and global systolic function (LVEF>55%). She was then placed on therapeutic lovenox for the fibrillation and the thrombus, and given her history of a TIA, even though she is at a risk for falls. # DYSPHAGIA The patient had a PEG tube placed by IR on [10-16] given that she was intubated for feeding. She was started on tube feeds [10-17], which she tolerated, and she was kept NPO given that she aspirated during her [10-21] Barium swallow. # C DIFFICILE The patient was transferred from [Location (un) 61603] with a history of C difficile diarrhea, and so she was kept on her PO vancomycin. # ANEMIA The patient was admitted from [Location (un) 61603] with anemia (Hct 26.6), which has slowly trended down to 23.8, likely secondary to phlebotomy. This should be followed in the future, and her baseline anemia is of unknown etiology. Medications on Admission: catapres TTS qwed, nexium 40 qday, solumedrol 10 qday, reglan 10 q6, enalapril 1.35 q4, haldol 1 q4prn, vanc 250 q6, xopenex Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Location (un) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Vancomycin 250 mg Capsule [Location (un) ]: One (1) Capsule PO Q6H (every 6 hours). 3. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Ointment [Location (un) ]: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day): Hold for loose stool. 5. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day): Hold for loose stool. 6. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day): Hold for SBP < 110, HR < 60. 7. Insulin Regular Human 100 unit/mL Solution [Hospital1 ]: One (1) Injection ASDIR (AS DIRECTED). 8. Acetylcysteine 20 % (200 mg/mL) Solution [Hospital1 ]: One (1) ML Miscellaneous Q6H (every 6 hours). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours). 10. Guaifenesin 100 mg/5 mL Syrup [Hospital1 ]: 5-10 MLs PO BID (2 times a day). 11. Metoclopramide 10 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 13. Prednisone 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Diltiazem HCl 90 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QID (4 times a day) as needed for atrial fibrillation: Hold for HR < 60, SBP < 110. 15. Enoxaparin 80 mg/0.8 mL Syringe [Last Name (STitle) ]: One (1) Subcutaneous Q12H (every 12 hours). 16. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Decrease pending creatinine levels. 17. Enalapril Maleate 10 mg Tablet [Last Name (STitle) ]: Four (4) Tablet PO DAILY (Daily) as needed for HTN: Hold for SBP <110. 18. Clonidine 0.3 mg/24 hr Patch Weekly [Last Name (STitle) ]: One (1) Patch Weekly Transdermal QWED (every Wednesday). 19. Hydrochlorothiazide 12.5 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily): Hold for SBP < 110. 20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [Last Name (STitle) ]: Five (5) ML PO BID (2 times a day). 21. Digoxin 250 mcg/mL Solution [Last Name (STitle) ]: One (1) Injection DAILY (Daily). 22. Labetalol 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Hold for SBP < 110, HR < 60. 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 24. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days: Last day [10-30]. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Location (un) 686] Discharge Diagnosis: Tracheo-esophageal Fistula, HTN, Atrial Fibrillation, Atrial Thrombus, dysphagia PMx: Non-small cell lung cancer s/p chemo, XRT, Atrial Fibrillation, HTN, Vertigo, h/o hemoptysis while AC, B TKR, ccy, breast ca s/p lumpectomy Discharge Condition: Stable Discharge Instructions: 1. Give medicines as prescribed (through the J tube unless otherwise specified); adjust 2. q2 hour chest PT and suction 3. Oxygen therapy to maintain saturations 90-95% 4. Physical therapy 5. Check CBC, electrolytes once weekly; transfuse as needed 6. Check digoxin level in one week Followup Instructions: 1. Follow-up with Dr [Last Name (STitle) ]; call office for appointment 2. Follow up with your primary care physician 3. [Month (only) 116] reconsider your lovenox therapy in future as determined by safety given your atrial thrombus but also your fall risk [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494] Completed by:[2144-10-24]	[ "162.9", "V87.41", "E878.1", "401.1", "008.45", "790.29", "997.31", "427.31", "482.42", "511.9", "518.81", "285.9", "530.89", "427.32", "V02.54", "424.0", "530.84", "519.19", "V58.61", "787.24", "V15.3", "518.0", "996.59", "V10.3" ]	icd9cm	[ [ [] ] ]	[ "96.05", "96.56", "33.22", "96.71", "33.23", "99.15", "93.90", "96.6", "34.91", "43.11", "33.91" ]	icd9pcs	[ [ [] ] ]	11129, 11196	3208, 8074	374, 931	11467, 11476	2216, 3185	11815, 12227	1921, 1938		8249, 11106		11217, 11446		8100, 8226			11500, 11792									1953, 1953																					239, 336						1970, 2197	959, 1512															1534, 1843	1859, 1905
23,245	110,900	44280	Discharge summary	report	Admission Date: [2126-10-15] Discharge Date: [2126-11-12] Date of Birth: [2052-5-23] Sex: F Service:Blue General Surgery The patient expired on [2126-11-12]. Briefly, the patient is a 74-year-old female with a history of autoimmune hepatitis and cirrhosis, who had a previous umbilical hernia repair, which was noticed to have persistent operating room on [2126-10-18] for repair of the fascial adhesions. However, the wound continued to drain ascites in copious amounts. The patient was reoperated on [2126-10-21] and a Marlex mesh was placed in order to close the fascial defect. As the patient has a baseline history of cirrhosis, the patient's threatening upper GI bleed from esophageal varices and gastric varices which were unable to be controlled by esophagogastroscopy and banding. The patient emergently underwent a TIPS procedure via Radiology on [2126-10-27]. The bleeding was assumed to be controlled, and the patient was relatively stable. She was maintained on octreotide and azathioprine for her autoimmune hepatitis. She is also on Solu-Medrol. After the TIPS procedure, however, the patient's bilirubin was noted to be rising from 2.9 into the 6 range. The bilirubin continued to rise into the range of 23 to 25. Postoperative there was too much shunt from the TIPS procedure, and the patient was taken to partially occlude the TIPS catheter. She underwent downsizing of the TIPS on [2126-11-8]. Patient tolerated the procedure fairly well, however, her bilirubin continued to rise. The patient was becoming hypotensive in the Intensive Care Unit and required constant monitoring. Multiple discussions were held with the family regarding patient's general health status. It was carefully noted to the family that the patient's baseline liver failure would not allow her to fully recover, and she when slowly, she would continue to deteriorate. However, at this time the patient's family wanted everything done. Pulmonary artery line was placed in order to help manage the patient's hypertension and fluid status. Also her perineum was tapped for 1 liter of ascites fluid. During this time, also, the patient's urine output began to dwindle, and the patient became enuretic on [2126-11-10]. The patient's respiratory status became very marginal and she was also becoming more encephalopathic. At this time, an ultrasound was also done which confirmed a very little flow through the TIPS. At this time, discussion again was held with the family explaining the patient was going to be requiring intubation and due to baseline health status, would most likely not be able to be extubated. She would also require dialysis as her kidneys have become nonfunctional. Patient's daughter, who is also the healthy proxy, understood the gravity of the situation, and pursued to make the patient comfort measures only. Patient's daughter was explained that this would include no chest compressions, no chemicals, interventions, no mechanical ventilation, and no medications. If we did this, patient would most likely pass away over the next 24 hours. Health-care proxy daughter was aware and in compliance with the following plan. This patient was made CMO. She was not intubated and no dialysis was pursued. The patient was also placed on a Morphine drip at 5 mg an hour to make her comfortable as she was complaining of pain. The following morning, [2126-11-12] at 4:35 am, patient was found to be asystolic. Upon examination, she had no pulse, no blood pressure. The patient was pronounced dead at 4:35 am on [2126-11-12]. The family was made aware, and the daughter consented to autopsy which will be happening this morning. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Name8 (MD) 3181] MEDQUIST36 D: [2126-11-12] 07:28 T: [2126-11-12] 07:37 JOB#: [Job Number 94954]	[ "998.31", "518.5", "571.5", "996.59", "553.1", "571.49", "789.5", "456.20", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "96.04", "33.22", "86.89", "96.06", "96.72", "53.41", "54.91", "96.05", "42.33", "96.6", "38.91", "39.1", "86.3", "53.49" ]	icd9pcs	[ [ [] ] ]
21,972	114,309	28599	Discharge summary	report	Admission Date: [2140-8-16] Discharge Date: [2140-8-18] Date of Birth: [2072-4-27] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2387] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: -Cardiac catheterization with left circumflex stenting; stenting of dissected obtuse marginal 1 vessel following deployment of left circumflex stent -Transesophageal echocardiogram -Electrocardioversion History of Present Illness: Mr. [Known lastname 39008] is a 68 year old male with history of hypertension and hyperlipidemia, who presented to [Hospital1 18] on the morning of admission for elective catheterization to evaluate intermittent anginal symptoms. The patient reports that 2 days prior to admission he climbed the equivalent of 7 flights of stairs, after which he noted a pain across his hard palate. He denies any chest pain, or associated shortness of breath, nausea, vomiting, diarrhea, radiation of the pain to his neck or arm, however he did have diaphoresis. The pain in his mouth subsided only after about 2.5 hours of rest. He reports another episode of mouth pain later that night, while resting in bed, relieved by getting out of bed and sitting in a chair. . The following morning his wife drove him to [Hospital3 ], where serial cardiac enzymes were negative. His EKG did not demonstrate ST changes, however did incidentally demonstrate atrial flutter with variable block and HR 50-110. He had an echo there which demonstrated a nondilated LV with mild LVH and anterior apical hypokinesis and an EF of 45%. He was started on IV heparin. It was decided to proceed with cardiac catheterization, for which he was transferred to [Hospital1 18]. . Catheterization on the day of admission revealed a flow-limiting stenosis of the left circumflex artery that was stented with a 5.0 DES. While finishing the cath, the patient began complaining of severe substernal chest pain, with noted ST elevations on monitor. The vessels were re-imaged, now with complete lack of flow in OM1. Guidewires were able to be passed, and the entrance to OM1 was stented. It is presumed that the initial stent partially overlapped the opening of OM1, with dissection and propagation of clot just underneath, occluding the vessel lumen. Final images demonstrated resumed flow in this vessel. He was transferred to the CCU in stable condition, for monitoring overnight. . On further questioning, he describes exertional pain in his hard palate for at least the last few months. He admits that he doesn't exercise or go up and down stairs on a regular basis. He notes that he did have a nuclear stress test in [2134] that he reports was normal. He subsequently has had a stress echo every two years, last in [2138], which have repeatedly demonstrated borderline LVEF of 50-55%, with LVH. Past Medical History: PAST MEDICAL HISTORY: 1) Hypertension with LVH 2) Hyperlipidemia: Last cholesterol panel [7-28] with LDL 73, HDL 31, TC 130. 3) Low back pain 4) Colonic polyps 5) Cholecystectomy 6) Hemorrhoidectomy Social History: Lives with his wife in [Location (un) 11790], RI. Smoked 3 PPD for many years, but quit in [2122]. Drinks 2-4 drinks per day (scotch, wine). Denies IVDU. Family History: Both parents deceased; father with an MI at uncertain age, mother with a cerebrovascular accident at 89. No family history of diabetes. Physical Exam: PHYISCAL EXAMINATION: 97.7, 113/65, 93, 14, 96% RA GENERAL: Overweight caucasian male resting supine in bed, appearing comfortable. HEENT: Anicteric sclerae, moist mucous membranes. COR: Distant heart sounds. Regular rhythm, normal rate. LUNGS: Clear to auscultation anteriorly. ABD: Normoactive bowel sounds, soft, non-tender, non-distended. GROIN: Right groin with sheath in place; no evidence of hematoma. EXTREMITIES: DP palpable on L, with non-palpable PT. DP non-palpable on right, PT palpable. No edema. Cool. Pertinent Results: [2140-8-16] 07:52PM CK(CPK)-71 . C.CATH Study Date of [2140-8-16] * Not Signed Out * 1. Selective coronary angiography of this right dominant system revealed a one vessel coronary disease. The LMCA had a separate ostium from the LCx and was patent. The LAD had moderate luminal irregularities but no flow limiting disease. The LCx had a 90 % proximal stenosis. The OM1 was a large vessel with a 50% stenosis at its origin. The RCA had mild luminal irregularites. It gave off an RV marginal branch that had an 80% stenosis. The RPLV and RPDA were both widely patent. 2. Left ventriculography was deferred. -- Percutaneous coronary revascularization of an additional vessel was performed using placement of drug-eluting stent(s). Brief Hospital Course: 68 year old male with HTN, hyperlipidemia, who presented with presumed unstable angina, with cath revealing a 90% proximal LCx lesion which was stented, complicated by edge dissection and occlusion of flow to OM1, subsequently stented as well, with full restoration of flow. Transferred to the CCU from cath for monitoring overnight given complication. Also with atrial flutter of unclear duration. Pt stable post-cath. . 1) Coronary artery disease/post-procedure ST-elevations: Following stenting of proximal circ lesion, the pt developed anginal-equivalent symptoms (jaw pain). Cath lab tele reportedly showed ST-elevations. Angiography showed occlusion of flow to OM1, which was just distal to newly placed stent. The OM was stented and flow returned quickly and fully. Symptoms resolved & EKG done just after catheterization was without ST elevations. Pt's CK's did not rise, suggesting that, in fact, he may not have actually had ST-segment elevations on tele. Nevertheless, he was managed as having ACS. He was treated with ASA 325 mg daily, plavix 75 mg daily, atorvastatin to 80 mg, and metoprolol 25 TID. His ACE-I was held during hospitalization (with concern of possibly developing dye nephropathy). The pt underwent TTE which revealed an EF of 45-55% as well as suspected distal septal and inferior hypo to akinesis of the inferior wall. He had an uneventful recovery from the catheterization. . 2) Atrial flutter: Noted to be in flutter at OSH of unclear duration. Started on heparin at outside hospital. Post-cath, he was restarted on heparin, since he remained in flutter. He underwent TEE & subsequent cardioversion with conversion to NSR on day of discharge. Warfarin & lovenox initiated post-cardioversion with plan of discontinuing lovenox once INR therapeutic. . 3) HTN: BP well controlled during hospitalization. Held on ACE-I (ramipril) for large dye load, though renal function remained stable after cath. . 4) Hypercholesterolemia: As above, atorvastatin 80 mg. Medications on Admission: Home Meds: Toprol XL 50 mg daily Ramipril (Altace) 5 mg daily ASA 81 mg daily Atorvastatin 20 mg daily Multivitamin daily Lorazepam 1 mg QHS PRN Naproxen prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 7. Ramipril 5 mg Capsule Sig: One (1) Capsule PO once a day. 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Naproxen Oral 10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:14 Refills:2 11. Outpatient Lab Work Please place standing order for INR checks every 3-5 days for the next few weeks. Next check on Monday [8-22]. Please have results faxed to Dr. [Last Name (STitle) ] (phone number [Telephone/Fax (1) 2394]) and Dr. [Last Name (STitle) 68506] (phone number [Telephone/Fax (1) 69211]). Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Unstable angina 2) Dissection of Obtuse Marginal coronary vessel following left circumflex stenting 3) Atrial flutter Secondary: 1) Hypertension with LVH 2) Hyperlipidemia: Last cholesterol panel [7-28] with LDL 73, HDL 31, TC 130. 3) Low back pain 4) Colonic polyps 5) Cholecystectomy 6) Hemorrhoidectomy Discharge Condition: good Discharge Instructions: -Please take your new medications: coumadin and lovenox as prescribed. You will need to give yourself the lovenox injections (as shown) until your INR level is >2.0. After you reach this therapeutic INR, you will only need to take the coumadin and have regular blood tests with your PCP to monitor INR. -Please have your blood drawn to check your INR on Monday [8-22] with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 68506] (phone #[Telephone/Fax (1) 69211]). He will monitor your care. -You have been started on a new medication called Plavix you need to take this medication along with Aspirin EVERY day, as it will help to keep your stents open. Do not stop these medications unless Dr. [Last Name (STitle) ] instructs you to do so. Also, you should take aspirin 325mg, instead of 81mg daily. -Your Lipitor (atorvastatin) dose was increased to 80mg, please take this new dose daily. -Please call your doctor or go to the ER if you have chest pain, jaw pain, shortness of breath, nausea, vomiting, light-headedness, or any other change in your health. Followup Instructions: -Please see Dr. [Last Name (STitle) ] on [9-14] at 2:30pm in his office. Telephone #[Telephone/Fax (1) 2394]. Please call if you have any questions or need directions. -Please see Dr. [Last Name (STitle) 68506] on [8-31] at 11:45am for a follow-up appointment.	[ "401.9", "410.81", "V15.82", "427.32", "997.1", "998.2", "427.31", "272.4", "724.2", "V12.72", "414.01" ]	icd9cm	[ [ [] ] ]	[ "00.41", "88.72", "99.61", "00.46", "88.56", "36.07", "37.22", "36.06", "00.66" ]	icd9pcs	[ [ [] ] ]	8229, 8235	4826, 6832	297, 502	8602, 8608	4053, 4803	9814, 10099	3350, 3488		7041, 8206		8256, 8581		6858, 7018			8632, 9791									3503, 4034																					242, 259							530, 2924															2968, 3152	3168, 3334
18,254	151,644	48016	Discharge summary	report	Admission Date: [2198-12-6] Discharge Date: [2198-12-19] Date of Birth: [2134-9-9] Sex: F Service: CARDIOTHORACIC Allergies: Dilantin Kapseal Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2198-12-6]: 1. Mitral valve replacement with a 25/33-mm On-X mechanical valve, reference number [Serial Number 101277], serial number [Serial Number 101278]. 2. Pericardial reconstruction with CorMatrix pericardial closure device, reference number [Serial Number 42232], lot number [Serial Number 101279]. History of Present Illness: 64 year old female with a PMH of ESRD [2-21] IgA nephropathy, a-fib/flutter (on coumadin in the past, recently being held for hx of septic emboli), MSSA bacteremia/endocarditis in [9-/2198] and hypertension who was brought in from dialysis with a chief complaint of chest tightness x 1 hour and shortness of breath for 1 day. She felt well begninning of last week. However, she started having dyspnea over night when she was trying to go to bed and had to sit up. Also states that she was having dry cough. Overnight, she had some anxiety given her dypsnea. When she was at dialysis in the morning, she noticed some chest pressure/tightness, which was substernal, without radiation or frank pain. She had palpitations during the episode, however they have now resolved. She denies fever or chills. Per report she was hypotensive during the session, though her BP improved with stopping dialysis and her symptoms of tightness resolved. She has been at rehab since her discharge from hospital for MSSA bacteremia/endocarditis and for shortness of breath (during which she was found to be in afib and her amiodarone was restarted). She is known to cardiac surgery and being evaluated for a mitral valve replacement. Past Medical History: Mitral regurgitation- Mitral Valve Replacement [2198-12-6] PMH: 1. Atrial fibrillation/flutter 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy s/p cadaveric kidney transplant in [2173] which has eventually failed, and started on hemodialysis in [2193]. Dialysis on Mo/We/Fri. 3. Upper GI bleeding in [2195-2-20] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel s/p clipping, cauterization and PPI. 4. Diastolic heart failure supported by an echocardiography from [2195-12-21]. 5. History of malignant hypertension, which was complicated by seizure on [2193-5-20]. Not on antiepileptic meds. 6. Depression. 7. Rheumatic fever in childhood Social History: Originally from [Country 65588], single, used to live by herself in [Location (un) 686], and has no children. Has been in the rehab facility or the hospital from [Month (only) ] to [Month (only) ] in [2198]. Ambulates w/walker at rehab facility. She quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol, and denies illicit drug use. She used to work part-time in a coffee shop, but currently does not work. She is Buddhist. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Her father died at the age of 80. Her mother died at the age of 64 from lung CA. She has a sister with breast CA. MI in uncle in his 60s. Physical Exam: Pulse:82 Resp:18 O2 sat: 94/RA B/P Right:127/60 Left:unable to obtain d/t fistula Height:62" Weight:36.6 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] 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: dop Radial Right: plap Left: palp LUE AV fistula Carotid Bruit Right: none Left: none Pertinent Results: [2198-12-6] ECHO 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. There is severe mitral annular calcification. There is severe thickening of the mitral valve chordae. Posterior leaflet motion is restricted due to heavy calcification. There is mild valvular mitral stenosis (area 1.5-2.0cm2). An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. There is a small pericardial effusion. Bilateral pleural effusions are seen. Dr. [Last Name (STitle) 914] was notified in person of the results at time of surgery. POST-BYPASS: The patient is AV paced. The patient is on no inotropes. Biventricular function is unchanged. No regional wall motion abnormalities are seen. There is a well-seated, well-functioning mechanical prosthesis in the mitral position. No mitral regurgitation is seen. No paravalvular leak is seen. Characteristic washing jets are present. There is a mean gradient of 3 mmHg at a cardiac output of 4.3 L/min. Aortic regurgitation is unchanged. Tricuspid regurgitation is unchanged. The aorta is intact post-decannulation. . MRA BRAIN W/O CONTRAST Study Date of [2198-12-14] 8:30 PM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2198-12-14] 8:30 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST Clip # [Clip Number (Radiology) 101280] Reason: infarct/rule out bleed [Hospital 93] MEDICAL CONDITION: 64 year old woman with hx bihemispheric small infarcts likely due to MV vegetation. Now s/p MVR with change in MS REASON FOR THIS EXAMINATION: infarct/rule out bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: GMSj FRI [2198-12-14] 11:54 PM MRI Brain: No intra- or extra- axial hemorrhage No midline shift, no signs of herniation New punctate areas of restricted diffusion in the right parietal, left and right frontal, and right occipital lobes and in the splenium of the corpus callosum on the left - findings concerning for embolic infarcts. Chronicity is uncertain and some of these regions appear hyperintense on FLAIR sequences suggesting a subacute process - though others are not clearly delineated. Preliminary findinds d/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] (cardiac surgery) at 11:30 pm on [2198-12-14] by telephone. GSenapati [Pager number 101281] Wet Read Audit # 1 Final Report EXAM: MRI of the brain. CLINICAL INFORMATION: Patient with bihemispheric small infarcts, likely due to mitral valve vegetation, now status post MVR with change in mental status. TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial images of the brain were acquired. 3D time-of-flight MRA of the circle of [Location (un) 431] obtained. 2D time-of-flight MRA of the head and neck was obtained. Comparison was made with the previous MRI examination of [2198-11-13]. FINDINGS: BRAIN MRI: There are several areas of restricted diffusion seen predominantly in the deep white matter of both cerebral hemispheres. In comparison to the prior study it demonstrates evolution of some of the previously seen infarcts which are now seen as T2 shine through. However, the other areas appear to be representing acute infarcts. Given the multiplicity as well as the involvement of both cerebral hemispheres and multiple vascular territories including the splenium of left side of the corpus callosum, the findings are suggestive of embolic infarcts. There is no evidence of acute or chronic hemorrhage seen. Moderate-to-severe changes of small vessel disease and brain atrophy identified. Soft tissue changes seen in the mastoid air cells, right greater than left side. Retention cyst is seen in the left maxillary sinus. IMPRESSION: Multiple acute predominantly deep white matter infarcts are identified which are new since the previous MRI examination. Several previously seen infarcts have evolved. Small vessel disease and brain atrophy seen. No midline shift. MRA HEAD: The head MRA demonstrates normal flow signal in the arteries of anterior and posterior circulation. No evidence of stenosis or occlusion of the major vascular structures seen. No evidence of aneurysm greater than 3 mm in size. MRA NECK: The neck MRA obtained with 2D time-of-flight study demonstrates no vascular occlusion or stenosis in the carotid or vertebral arteries. IMPRESSION: Normal MRA of the neck. DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2198-12-15] 1:28 PM Imaging Lab . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [2198-12-10] 11:45 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2198-12-10] 11:45 AM LIVER OR GALLBLADDER US (SINGL Clip # [Clip Number (Radiology) 101282] Reason: RUQ PAIN; ?CHOLECYSTITIS [Hospital 93] MEDICAL CONDITION: 64 year old woman with abd pain. S/p MVR for endocarditis. Ess nl LFTs but fever yest w/ GNR in blood. REASON FOR THIS EXAMINATION: ? cholecystitis Final Report INDICATION: 64-year-old female with abdominal pain status post MVR for endocarditis. Question cholecystitis. COMPARISON: CT and ultrasound dated [2198-10-7]. FINDINGS: Evaluation is somewhat limited by presence of a midline abdominal dressing. Allowing for such, the liver demonstrates no focal or textural abnormality. There is no biliary dilatation. The common duct measures 5 mm. The gallbladder, however, appears to demonstrate slightly increased wall thickening as compared to [2198-10-7], with a suggestion of trace pericholecystic fluid. The gallbladder remains mildly distended, with a few sub-3-mm anterior wall polyps, of doubtful clinical significance. Son[Name (NI) 493] [Name2 (NI) ] sign is negative. The spleen is 10 cm and within normal appearance. There is no appreciable abdominal ascites. Normal hepatopetal flow is seen in the portal vein. IMPRESSION: 1. Persistent gallbladder distention with new wall thickening as compared with [2198-10-7], with trace pericholecystic fluid in this patient with normal albumin. Acute cholecystitis cannot be excluded. If there is a persistent clinical suspicion, a HIDA scan should be performed for further evaluation. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 8083] [Name (STitle) 8084] DR. [First Name8 (NamePattern2) 7722] [Last Name (NamePattern1) 7723] Approved: MON [2198-12-10] 9:36 PM Imaging Lab ECHO [2198-12-17] 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. There are prominent pectinate muscles in the right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. A bileaflet mechanical mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal disc motion and transvalvular gradients. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen (normal for this prosthesis). There is no pericardial effusion. IMPRESSION: Well-seated, normally functioning bileaflet mechanical mitral valve prosthesis. Mild mitral regurgitation. No echocardiographic evidence of intracardiac thrombus or endocarditis seen I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2198-12-17] 18:30 Brief Hospital Course: Ms. [Name13 (STitle) 101283] was admitted to the [Hospital1 18] on [2198-12-6] for surgical management of her mitral valve disease. She was taken to the operating room where she underwent a mitral valve replacement using an on-x mechanical valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next several hours, she awoke neurologically intact and was extubated. The renal service was consulted given her history of IgA nephropathy and end stage renal disease on hemodialysis. Hemodialysis was initiated for volume removal. She was initially dialyzed daily for volume overload, and returned to her Monday, Wednesday, Friday schedule when she stabilized. She remained in the unit for sinus bradycardia. The electrophysiology service was consulted. She was found to have a ventricular escape rhythm with a rate of 40bpm. EP felt that her rhythm would recover and a pacer would not be necessary. Anti-coagulation was initiated with Warfarin for the mechanical Mitral Valve. ID followed for endocarditis. There was no growth on valve tissue sent from OR. She did develop Pseudomonas and Morganella bacteremia. Antibiotics were adjusted accordingly to Cefepime. The patient improved on this and the course will complete on [2198-12-23]. Ultrasound revealed gall-bladder wall thickening. This will be pursued with HIDA if bacteremia does not resolve. Transplant surgery was consulted to evaluate the left upper extremity AV fistula as the possible source of bacteremia. Dr. [Last Name (STitle) ] determined this was an unlikely source. There are aneurysmal areas of the fistula that will need to be evaluated as an outpatient with Dr. [Last Name (STitle) ], following discharge. It is recommended to avoid scabbed areas when accessing AVF for HD. Left upper extremity was found to be edematous. Ultrasound was negative for DVT. INR became supra-therapeutic quickly in the setting of poor appetite and nutritional depletion. She was given FFP and Coumadin doses were very carefully titrated. The patient received a PICC on [2198-12-10] for continued IV antibiotic therapy. Rapid atrial fibrillation developed. The patient converted to Sinus Rhythm with IV Amiodarone and IV Lopressor. She remained in Sinus Rhythm with 1st degree AV block on PO Amio and Coreg. Amiodarone was discontinued for prolonged QTC. Chest tubes and pacing wires were discontinued without complication. The patient was transferred to the telemetry floor for further recovery. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She did develop some confusion in dialysis on [12-14]. MRA of the brain revealed multiple embolic infarcts- acute/ and sub acute. Neurology was consulted and felt it unlikely that the emboli are septic. On [2198-12-16] a TEE was done and cardiac thrombus was ruled out emboli. The patient's mental status cleared, and her blood pressure was allowed to remain above 120mmHg systolic, as she remained oriented under this condition. By the time of discharge on POD #13 the patient remained deconditioned ambulating short distances with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to the [Hospital 100] Rehab MACU in good condition with appropriate follow up instructions. Medications on Admission: 1. CefazoLIN 2 g IV MONDAY AND WEDNESDAY Give dose after HD 2. CefazoLIN 3 g IV Q FRIDAY Give dose after HD 3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) 8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY 9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation 13. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS 14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) 15. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One [Age over 90 ]y (120) mL PO twice a day 16. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY 17. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B-complex with vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 9 days. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Cepacol Sore Throat Mucous membrane 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 16. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 17. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 4 days: end date [2198-12-23]. 19. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. warfarin 1 mg Tablet Sig: dose based on INR Tablet PO Once Daily at 4 PM: very sensitive to coumadin-has been on 0.5mg coumadin. 22. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Mitral regurgitation- Mitral Valve Replacement [2198-12-6] PMH: 1. Atrial fibrillation/flutter 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy s/p cadaveric kidney transplant in [2173] which has eventually failed, and started on hemodialysis in [2193]. Dialysis on Mo/We/Fri. 3. Upper GI bleeding in [2195-2-20] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel s/p clipping, cauterization and PPI. 4. Diastolic heart failure supported by an echocardiography from [2195-12-21]. 5. History of malignant hypertension, which was complicated by seizure on [2193-5-20]. Not on antiepileptic meds. 6. Depression. 7. Rheumatic fever in childhood Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with APAP Incisions: Sternal - healing well, no erythema or drainage Edema -trace Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] 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) 914], [Telephone/Fax (1) 170] Date/Time:[2198-12-24] 2:00pm in the [Hospital ] medical office building [Doctor First Name ] [Hospital Unit Name ] Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 62] Date/Time:[2198-12-19] 11:40 Please call to schedule appointments with: Transplant Surgery for AV fistula: [Telephone/Fax (1) 673] (Dr. [Last Name (STitle) ] or Dr. [First Name (STitle) ] Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 250] 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 Labs: PT/INR for Coumadin ?????? indication- mechanical Mitral Valve Goal INR 3.0-3.5 First draw [2198-12-20], then Monday Wednesday, Friday until stabilized. MD to dose daily Completed by:[2198-12-19]	[ "997.1", "996.81", "996.73", "426.11", "041.6", "V85.0", "997.02", "311", "428.0", "E878.0", "285.21", "434.11", "276.7", "428.32", "799.4", "041.7", "288.60", "427.31", "403.91", "790.7", "518.51", "585.6", "276.1", "V45.11", "E878.2", "427.32", "V12.51", "998.59", "427.89", "442.0", "424.1", "V12.55", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.97", "88.72", "39.61", "37.49", "39.95", "35.24" ]	icd9pcs	[ [ [] ] ]	19669, 19735	12883, 16301	302, 632	20490, 20655	4081, 6177	21629, 22662	3112, 3337		17599, 19646	9766, 9872	19756, 20469		16327, 17576			20679, 21606									3352, 4062																					243, 264	9904, 12860						660, 1882															1904, 2617	2633, 3096
3,742	158,507	22471	Discharge summary	report	Admission Date: [2189-4-17] Discharge Date: [2189-4-24] Date of Birth: [2137-6-22] Sex: M Service: MEDICINE Allergies: Zosyn / Oxaliplatin Attending:[First Name3 (LF) 5552] Chief Complaint: Bloody diarrhea, coffee-ground emesis Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 51M h/o metastatic colon cancer s/p [2189-4-14] irinotecan, presented with watery black stools x24H, nausea, and non-bloody/non-coffee-ground emesis x1 one day prior to admit. During this time, pt noted that chronic baseline diarrhea [on Lomotil (diphenoxylate, atropine), loperamide, tincture of opium] increased significantly, with black stools and no frank blood. . ED course: # Vitals: SBP 80 --> SBP 100 with 1L IVF bolus; HR 70s-90s # Labs: Hct 36.1 (baseline) # Clinical course: --Black guaiac positive stool in vault --NG lavage with 900cc: Clot, fresh blood --SVT to 200 bpm --> Adenosine x2, diltiazem --> NSR # Meds: Pantoprazole 40mg IV, erythromycin 125mg IV for motility . MICU course: Admitted for urgent EGD. Hct stable while in MICU. . Initial ROS: (+) Gassy discomfort, chills, lip blisters since last chemo (-) Abdominal pain, LH/dizziness, F, CP/SOB, HA/sensory changes, URI sx, myalgias/arthralgias Past Medical History: POncH # Colon cancer (T3N1, stage IIIB, dx [5-/2185]) c/b liver, pancreas, lung mets - s/p L colectomy - s/p adjuvant Folfox/bevacizumab x8 cycles - s/p segmental liver resection ([4-/2186]) - s/p pancreatic cyberknife tx ([2-/2187]) - chronic splenic vein occlusion - irinotecan - d/c chemotherapy [12/2187] s/p oxaliplatin reaction - Current therapy: Irinotecan ([5-/2188] - current) Q2WKS c/b diarrhea . PMH # Hypertension # Depression # pAfib ([2181]) Social History: # Professional: Production planner in radionuclide product plant # Personal: Single # Tobacco: Past smoker # Alcohol: None # Recreational drugs: None Family History: Noncontributory Physical Exam: # VS: T 98.4, BP 89/76, HR 80, RR 21, O2sat 100% RA GEN: NAD HEENT: Crusted lesions on upper lip, OP clear, MMM, no LAD, neck supple, no JVD CV: RRR, S1S2 (S2 loud), no m/r/g RESP: CTAB ABD: Soft, NTND, BS+ EXT: No c/c/e, WWP Pertinent Results: [2189-4-17] 09:45AM WBC-4.5 RBC-4.05* HGB-12.1* HCT-36.1* MCV-89 MCH-29.7 MCHC-33.4 RDW-14.6 [2189-4-17] 09:45AM NEUTS-81.3* BANDS-0 LYMPHS-14.5* MONOS-1.3* EOS-2.5 BASOS-0.4 [2189-4-17] 09:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2189-4-17] 10:11AM PT-13.2 PTT-25.2 INR(PT)-1.1 . Studies: . # CT TORSO W/CONTRAST [2189-4-19] 3:53 PM 1. Compared to prior exam from [2189-2-5], there is slight increase in the size of poorly defined pancreatic mass. 2. Marginal increase in size of Left supraclavicular/retroperitoneal lymphadenopathy, hepatic lesions, and left lower lobe metastatic lesion. 3. Chronic occlusion of the splenic vein/artery and SMV, with extensive network of varices as described above. . # EGD [2189-4-18]: No esophageal varices. Varices at the stomach. A large ulcerated mass lesion was seen in the region of the angularis (distal body/prox antrum). No visible vessel, oozing or active bleeding was seen. Blood in the stomach. Otherwise normal EGD to second part of the duodenum. . # Gastric mass biopsy [2189-4-21] 1. Adenocarcinoma, see note 2. Immunostains of the tumor are strongly positive for cdx2 and cytokeratin CK-20; and focally positive for CK-7 with satisfactory controls. 3. Separate fragments of gastric fundic mucosa without dysplasia. Note: The tumor histology and immunoprofile are most suggestive of a metastatic colonic carcinoma. Brief Hospital Course: 51M h/o metastatic colon cancer, admitted with UGIB [1-31] ulcerated stomach mass, found to have metastatic colon cancer to incisura of stomach. . # UGIB: UGIB found to be [1-31] ulcertated mass [1-31] metastatic colon cancer per pathology obtained during EGD. Pt was started on pantoprazole 40mg PO daily, as well as inpatient XRT to stomach x 2 sessions. Upon discharge, pt was scheduled to complete XRT as outpatient, with hct stable x 48 hours. . # Anemia: Anemia was considered likely [1-31] UGIB and ACI given metastatic colon cancer. Pt received PRBC as necessary, and upon discharge, hematocrit had been stable x48H. . # Tachycardia: Pt was noted to be in AVRT/AVNRT in the ED, considered 2/2 blood loss. Tachycardia resolved with IVF, blood transfusion, and pt was maintained on metoprolol 12.5 mg PO BID. . # Metastatic colon cancer: Pt was found to have metastatic colon cancer to the stomach and was started on XRT as inpatient, with irinotecan chemotherapy held during XRT course. . # Cold sores: Pt's HSV lip lesions resolved without intervention during inpatient admission. . # Full code Medications on Admission: Metoprolol 25mg PO daily Creon 20mg daily Loperamide 4mg PO QID PRN Lomotil 2.5mg-0.025mg 1-2 tabs PO QID PRN Opium tincture QID PRN KCL 20mEq [Hospital1 ] Clonazepam 1mg PO daily MVI . ALL: Piperacillin/tazobactam --> Hives Oxaliplatin --> Red man syndrome Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM: Take upon awakening. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). Disp:120 Cap(s) Refills:2 6. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO four times a day as needed for diarrhea. Disp:30 Capsule(s) Refills:5 7. Lomotil 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for diarrhea. Disp:40 Tablet(s) Refills:5 8. Opium Tincture 10 mg/mL Tincture Sig: One (1) mL PO four times a day as needed for diarrhea. Disp:120 mL Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day. Disp:60 Tab Sust.Rel. Particle/Crystal(s) Refills:2 10. Multiple Vitamin-Minerals Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis . # Upper GI bleeding # Metastatic colon cancer at stomach incisura # Paroxysmal atrial fibrillation . Secondary diagnosis . # Hypertension # Depression Discharge Condition: Stable hematocrit over the last 48 hours. Discharge Instructions: You were admitted because you were bleeding in your stomach. We did an esophagogastroduodenoscopy and found a bleeding mass in your stomach, which was metastatic colon cancer. We started you on radiation therapy to the stomach, and you stopped bleeding. . We also found that your heart rate was initially fast when you were bleeding, but then it normalized when we transfused blood. . You have two more follow-up appointments to get radiation therapy to your stomach (see below). Please take your anti-nausea medication before you arrive for your radiation therapy appointments. . We have added a new medication to your regimen: # FOR YOUR STOMACH: Take pantoprazole 40mg every 24hours. . Otherwise, we have not changed your medications. . If you have any worrisome symptoms, call Dr. [Last Name (STitle) ] and go to the emergency room. Followup Instructions: You have a radiation oncology appointment on Monday at 8:15 am, and another appointment on Tuesday as well. . WHEN YOU GO FOR YOUR RADIATION ONCOLOGY APPOINTMENT, YOU MUST LATER GO TO [Hospital Ward Name ] 9 AND GET YOUR BLOOD COUNTS CHECKED. THIS IS CRITICAL. DO NOT FORGET. You do not need an appointment; instead, just walk in. . Your cancer appointment: . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2189-5-4] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2189-5-4] 1:00 Completed by:[2189-4-26]	[ "197.7", "197.8", "401.9", "444.89", "V10.05", "578.9", "427.89", "197.0", "054.9", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.13", "45.16", "92.29", "99.04" ]	icd9pcs	[ [ [] ] ]	6584, 6590	3764, 4888	318, 346	6804, 6847	2267, 3741	7740, 8434	1989, 2006		5201, 6561		6611, 6783		4914, 5178			6871, 7717									2021, 2248																					241, 280							374, 1300															1322, 1804	1820, 1973
44,770	162,818	40217	Discharge summary	report	Admission Date: [2192-12-18] Discharge Date: [2192-12-25] Date of Birth: [2131-2-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1257] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 7111] is a 61 y/o M s/p a recent admission for fatigue with liver and pleural biopsies significant for poorly differentiated carcinoma who presents from home with nausea and vomiting. His symptoms began in [8-24], when he presented to an outside hospital with weight loss, fevers, and chills and was found to have multiple liver masses that were previously thought to be abscesses. He is s/p multiple drains and antibiotic courses, most recently a six week course of ceftriaxone and flagyl completed on [12-13] for presumed liver abscesses. Of note, there have been no positive cultures from the fluid taken from these abscesses to date so he has been on empiric antibiotic courses. He was started on PO cipro on [12-13] for a planned 2 week course. . Patient reports nausea and dry heaves since [12-13] and vomiting since yesterday. Reports 3-4 episodes of non-bloody, non-bilious vomiting; no coffee grounds, mostly food contents. Denies unusual eating habits, reports PO intake had been okay since discharge. He has also had DOE since that time, with a cough that has persisted for several months. Denies diarrhea/abd pain/constipation/melena/hematochezia or fevers and chills. He also endorses a 60lb unintentional weight loss in the last [2-15] months. . In the ED initial VS were: 98.3, 110, 97/58, 16, 97%. He was given zofran and 2.5L of IVF with improvement in his blood pressure to 107/57. Labs in the ER were notable for lactate of 2.3, white count of 50.4 with 96% neutrophils, AST of 96, HCT of 24.1 and he was admitted to medicine for management of his n/v. Vital signs prior to transfer were: 98, 89, 107/57, 16, 100% on RA. . ROS was otherwise essentially negative (no chest pain, palpitations, orthopnea, PND, lower extremity edema, changes in color of stool, urine, no rashes, recent travel). Past Medical History: Hospitalized in [2150] for severe gastroenteritis Ventral hernia R scrotal cyst s/p removal in [2170] Social History: Lifelong smoker, previously 1 PPD, currently [12-16] PPD; History of heavy EtOH use ([2-15] hard shots/per day) until quit 2 years ago. Denies IVDU or other illicits. Lives with wife in [Name (NI) ], MA. No children, retired from armed services in [2187]; has service around the world including [Country 3992]. Family History: Father died at age 57 with liver cirrhosis. Mother died from lung cancer in 80s. Physical Exam: On admission: Vitals: T: 96.3 BP: 96/58 P: 86 R: 20 SaO2: 95% on RA GENERAL: cachectic male sitting up in bed in NAD HEENT: Normocephalic, atraumatic. + temporal wasting. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. + white exudate on tongue. Neck: Supple, No LAD, No thyromegaly. CARDIAC: Distant heart sounds. Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP= 5 cm above clavicle. LUNGS: decreased BS in right base and mild expiratory wheezes in b/l bases; no rales or rhonchi ABDOMEN: Soft, NT, ND. + hepatomegaly; no splenomegaly appreciated. + active bowel sounds; area of drain (lateral RUQ) with dried scab, no surrounding erythema or exudate EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. No spider angiomas or jaundice appreciated. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Decreased hand grip (unable to flex fingers) on L, otherwise 5/5 strength throughout. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, though mildly tangential On discharge: Vitals: T: 97.3 BP: 109/72 P: 92 R: 20 SaO2: 93-95% on RA GENERAL: cachectic male in NAD HEENT: Normocephalic, atraumatic. + temporal wasting. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. Neck: Supple CARDIAC: Regular rhythm, normal rate. Normal S1, S2. + rub; No murmurs or [Last Name (un) 549]. No JVD. LUNGS: decreased BS and faint crackles in right base; left field clear; no rales or rhonchi ABDOMEN: Soft, NT, ND. + hepatomegaly. + active bowel sounds EXTREMITIES: 1+ ankle edema. 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. No jaundice. NEURO: A&Ox3. Pertinent Results: ADMISSION LABS: [2192-12-18] 07:20AM WBC-50.4* RBC-2.75* HGB-7.6* HCT-24.1* MCV-88 MCH-27.6 MCHC-31.5 RDW-18.5* [2192-12-18] 07:20AM NEUTS-96* BANDS-0 LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2192-12-18] 07:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2192-12-18] 07:20AM PLT SMR-VERY HIGH PLT COUNT-602* [2192-12-18] 07:20AM PT-15.4* PTT-26.1 INR(PT)-1.4* [2192-12-18] 07:20AM GLUCOSE-93 UREA N-12 CREAT-0.4* SODIUM-129* POTASSIUM-3.5 CHLORIDE-89* TOTAL CO2-30 ANION GAP-14 [2192-12-18] 04:00PM CALCIUM-7.9* PHOSPHATE-3.1 MAGNESIUM-2.0 [2192-12-18] 07:20AM ALT(SGPT)-40 AST(SGOT)-96* TOT BILI-0.9 [2192-12-18] 07:20AM LIPASE-20 [2192-12-18] 07:20AM ALBUMIN-2.8* [2192-12-18] 11:19AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 [2192-12-18] 11:19AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [2192-12-18] 08:57AM LACTATE-2.3* MICRO: [2192-12-18] BLOOD CULTURE No growth [2192-12-18] URINE No growth [2192-12-19] BLOOD CULTURE No growth [2192-12-21] BLOOD CULTURE NGTD (pending on discharge) [2192-12-25] C DIFF TOXIN - Negative STUDIES: [2192-12-18] CXR: Improved expansion but otherwise relatively stable exam again demonstrated marked elevation of the right hemidiaphragm. There is a presumed right pleural effusion with likely loculated component. However, conceivably these pleural findings could also reflect a solid component and metastatic pleural disease cannot be entirely excluded particularly in light of given history. There is likely associated atelectasis due to the volume loss at the right lower lobe. An early developing infiltrate is difficult to entirely exclude, but is felt less likely. [2192-12-18] CT ABD W CONTRAST: 1. Progression of large complex hepatic lesion which now occupies greater than 60% of the hepatic parenchyma. Findings are concordant with recent biopsy results of poorly differentiated carcinoma. At this point, there are no imaging features suggestive of abscess. 2. Increase in size and of numerous pulmonary nodules seen on limited views of the lung bases. 3. New appearance of multiple mesenteric implants suggestive of metastatic disease. [2192-12-19] R HIP XR: Longitudinally oriented lucency with ground glass internal matrix and thick sclerotic rim. The appearance is most suggestive of fibrous dysplasia rather than metastasis. Lucency in the left sacral ala most likely represents bowel gas, but repeat pelvic film within the next several weeks could help to confirm this. [2192-12-20] CXR: The right basal metastatic deposits are redemonstrated, surrounded by lymphangitic spread of the tumor. No new consolidations have been seen. The left lung is unchanged. No new effusion or pneumothorax have been demonstrated. [2192-12-21] EKG: Sinus tachycardia. Anterolateral ST segment elevation suggests an acute injury pattern. Consider acute myocardial infarction. Compared to the previous tracing of [2192-12-5] sinus tachycardia and ST segment elevation are new. [2192-12-21] Echo: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion, primarily anterior to the right ventricle. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate-sized pericardial effusion without echocardiographic signs of tamponade. Normal global and regional biventricular systolic function. [2192-12-22] Echo: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion primarily along the right AV groove. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2192-12-21], the effusion is smaller. Tamponade is not suggested on either study. [2192-12-22] CXR: Cardiomediastinal silhouette is unchanged including the right mediastinal shift. There is interval progression of the left retrocardiac consolidation that might represent interval development of atelectasis, aspiration, or pneumonia. Right multifocal basal abnormalities including lungs and pleura are unchanged. Upper lungs are essentially clear. No interval development of pneumothorax is demonstrated on the current radiograph. DISCHARGE LABS: 136 97 11 ------------ 50 3.1 31 0.4 Ca: 7.9 Mg: 2.0 P: 3.2 7.8 43.1 > < 391 24.4 Brief Hospital Course: 61 year old male with recent pleural and liver biopsies consistent with undifferentiated carcinoma presenting with nausea and vomiting, course complicated by pericardial effusion. . ##Nausea/vomiting: Patients symptoms were attributed to his underlying malignancy with significant involvement of his liver (mass occupies >60% of hepatic parenchyma on CT Abd). Patient was hydrated with IVF and given zofran and compazine. His symptoms improved and was tolerating a regular diet with minimal symptoms at the time of discharge. . ##Carcinoma: Patient with recent right pleural biopsy and liver biopsy suggestive of undifferentiated carcinoma though primary source unclear. Hematology/oncology was notified about the patient's admission and planned for outpatient discussion of treatment options following discussion at tumor board meetings. CT abdomen was performed and showed interval progression of the mass in the liver, increase in size and number of pulmonary nodules and new appearance of multiple mesenteric implants. No abscess noted. Preliminary diagnosis was discussed with patient and social work was consulted to help with new diagnosis. Patient aware of diagnosis but perhaps unable to comprehend full implications. Will follow up with outpatient oncologist Dr. [Last Name (STitle) 1852] on [2192-12-28]. . #. Pericardial Effusion: On day of planned discharge, patient was found to be tachycardic and hypotensive. ECG showed diffuse ST elevations and patient had a triphasic rub on cardiac exam. Code STEMI was called and patient was noted to have a small to moderate-sized pericardial effusion without echocardiographic signs of tamponade on bedside echo. He was subsequently transferred to the CCU team. He was stable overnight in the CCU, and echo the next day showed smaller effusion size. Given recent diagnosis of carcinoma, this effusion is likely malignant in origin. It was felt that there was no need for urgent pericardiocentesis and patient was tranferred back to the medicine team. . ## Fevers: Patient with intermittent fevers during admission, as high as 101.9. CXR without signs of new infection, no abscess on CT abdomen, no diarrhea, and blood cultures from [12-18] and [12-19] with no growth to date. Patient's home ciprofloxacin was d/c-ed on admission given lack of focal signs of infection. His fevers were attributed to his underlying malignancy. . ## Leukocytosis: Slightly above baseline on admission. Has undergone previous hematology work up and attributed to reactivity to malignancy. Infectious workup as above. White count was trended and trended down to his baseline. . ##Dyspnea: Dyspnea primarily on exertion w/o sxs of heart failure. Rt sided pleural effusion on CXR. No other new infiltrates suggestive of pneumonia. Was anemic, as low as 20.8, below baseline of around 26. Patient was transfused 3 units during hospitalization. After fluid resuscitation in the setting of his hypotensive episode (see above), patient developed a 4 liter oxygen requirement. He was gradually diuresed and at the time of discharge was sat-ing 95% on RA. His underlying dyspnea was attributed to pleural effusion and general deconditioning given malignancy. . ##Hyponatremia: Hyponatremic to 129 on admission. Attributed to patient's dehydration in the setting of nausea and vomiting. Improved with fluid rehydration. Sodium was 136 on discharge. . ## Anemia: Patient with anemia below previous baseline of 26. Nadir was 20.8. Iron studies during previous admission consistent with anemia of chronic disease. No signs of active bleeding on exam (guaiac negative) and HD stable. Patient was transfused 3 units and discharge hct was 24.4. . ##Elevated AST: Newly elevated AST and ALKP. Remaining LFTS normal. Likely secondary to progression of liver mass. AST trended down to normal during hospitalization. Alk phos remained elevated (271 on discharge). . ## Code status: FULL CODE Pending on Discharge: [12-21] Blood culture (NGTD) Medications on Admission: Oxycodone 5 mg Q3H as needed for pain Ciprofloxacin 500 mg PO daily Discharge Medications: 1. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:30 Tablet(s) Refills:0 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 3. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days: Please take while taking lasix. Disp:3 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Nausea and vomiting Metastatic undifferentiated carcinoma involving lung and liver (primary unknown) Pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 7111], You were admitted to the hospital with nausea and vomiting. We believe that these symptoms are likely related to your underlying cancer involving your liver. We treated you with anti-nausea medications and intravenous fluids. You also had a CT of your abdomen to assess the progression of your liver disease. During your hospitalization you had fevers- we do not believe these are related to an infection, but are more likely related to your underlying cancer. You also had a short stay in the cardiac intensive care unit as there was fluid around your heart, probably also related to the cancer- studies showed that your heart is working properly and the fluid is decreasing in size. You will need to follow up with Dr. [Last Name (STitle) 1852], your oncologist to discuss further evaluation and management of your cancer. Please also follow up with your primary care doctor as below. We have made the following changes to your medications: - START taking lasix for 3 days (until you see Dr. [Last Name (STitle) 1852] to reduce the amount of fluid in your lungs - START taking potassium while you are taking lasix - START taking compazine as needed for your nausea - STOP taking ciprofloxacin It was a pleasure taking care of you at the [Hospital1 18]. We wish you all the best. Followup Instructions: Please follow up at the following appointments: Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [2192-12-28] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD [Telephone/Fax (1) 8770] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please follow up with your primary care doctor Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] as below: [Last Name (LF) 766], [2192-12-31] at 2:45PM [Street Address(2) 88303] [Hospital1 392], [Numeric Identifier 10727] Phone: [Telephone/Fax (1) 88304] Completed by:[2192-12-25]	[ "780.61", "276.8", "428.0", "428.31", "285.22", "787.01", "261", "198.89", "V16.1", "288.60", "198.5", "197.7", "199.1", "197.2", "783.7", "276.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14084, 14090	9500, 13437	325, 333	14265, 14265	4580, 4580	15773, 16482	2716, 2798		13604, 14061		14111, 14244		13511, 13581			14416, 15373			9378, 9477						2813, 2813															13451, 13485		15402, 15750				266, 287							361, 2218					4596, 9362				2827, 3930	14280, 14392					2240, 2352	2368, 2700
78,020	121,764	6825+6826	Discharge summary	report+report	Admission Date: [2197-7-19] Discharge Date: [2197-7-20] Date of Birth: [2135-8-29] Sex: M Service: MEDICINE Allergies: Persantine IV / Indocin Attending:[First Name3 (LF) 2387] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 61M w/hx of CAD, 4 MIs s/p stents, CABG, s/p PPM/ICD, CHF, DM, s/p RCA stent on [7-17] discharged [7-18] presenting with chest pain, shortness of breath, and palpitations. Patient reports that following discharge he was pain free and feeling well, until after breakfast this morning when he developed chest pain radiating down his left arm and into his jaw. The pain resolved on its own, and he later developed "jackhammer"-like pounding in his chest which lasted 45-60minutes and was associated with shortness of breath. It resolved into chest pain, but returned an hour later. He put his nasal cannula on at 3L NC with no improvement in shortness of breath. His BP was 70/40 (normal 95-100/65). During the fourth episode of similar nature, he called his cardiologist who asked him to come to [Hospital3 ]. At the hospital, his cardiologist recommended he go to [Hospital1 18] for further assessment. . Of note, the patient was recently admitted on [2197-7-14] with chest pain, shortness of breath and weight gain of 8lb from baseline. Patient was diuresed and was at dry weight of 245 at the time of discharge. During that admission, he also developed chest pain without EKG changes or CE elevations. He was taken to the cath lab and a DES was placed in the RCA. . In the ED, patient's vital signs were 97.3 79 91/59 18 100% 3L RA. Cardiac enzymes were flat, EKG was unchanged and CXR showed no acute pulmonary process. Patient was hypotensive, and received a total of 2L of NS. As patient has a history of PE, ultrasound of IVC was performed to investigate for congestion, but was negative. Patient's cardiologist, Dr. [Last Name (STitle) ], came to see the patient and felt that the chest pain was more consistent with anxiety. He had low suspicion for ACS or in-stent thrombosis of RCA given patient's history, exam, and unchanged EKG. . On arrival to the floor, patient's vital signs were 98.1 BP 104/70 HR 85 RR 20 )2Sat 100% on 2L. Patient was complaining of [6-11] chest pressure without radiation. He was alert and comfortable, speaking in full sentences. EKG was unchanged from baseline. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN 2. CARDIAC HISTORY: -CAD, AMI in [2184]. -BMS of LAD X 2 in 1/99. -CABG: 3 vessel CABG in [2185] (LIMA-LAD, SVG-Diag, SVG- OMB) -Stent of RCA ([1-10]), apical LV aneurysm -PACING/ICD: ICD placed s/p VF arrest in cath lab in [2188] . 3. OTHER PAST MEDICAL HISTORY: CHF EF 20% H/o PE in [2188]- subsegmental Hyperlipidemia BPH Gout H/o GI bleed from gastritis requiring 12 units RBC Chronic back pain with herniated discs per patient Social History: Lives with his wife in [Name (NI) 14840]. Retired firefighter. Owns a liquor store and four seafood/sushi restaurants which his two children run. Tobacco: 40pack-year history, quit in [2184] Alcohol: occasional/rare wine Illicits: Denies Family History: There is no family history of premature coronary artery disease or sudden death. Mother- died of encephalitis in 50s Father- died at age 65 of bone CA Sister- DM Physical Exam: Admission physical exam: VS: 97.3 79 91/59 18 100% 3L RA GENERAL: Obese male lying comfortably in bed in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, MMM. NECK: Supple with JVP of 3 cm. CARDIAC: Distant heart sounds [1-4] body habitus. RRR with normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Respirations unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Diminished air movement throughout. ABDOMEN: Soft, NT, ND. +BS EXTREMITIES: WWP, no edema, cyanosis or clubbing SKIN: chronic venous stasis changes on anterior calves 1+ DP/PT pulses bilaterally, 2+ radial pulses bilaterally Discharge physical exam: He was AAOx3, afebrile with HR 70s-80s, BP 90s-100s/60s-70s, breathing comfortably on room air. Pertinent Results: Admission labs/studies: WBC 4.4 Hct 12.9 Hgb 37.1 Plts 191 PT 13.2 PTT 20.5 INR 1.1 Na 142 K 4.9 Cl 103 HCO3 30 BUN 39 Cr 2.0 Glucose 97 CKMB 2 Trop <0.01 . EKG ([2197-7-19] @ 23:57): Sinus rhythm, rate 80bpm, normal intervals, Q waves in I/avL and V3-V6, right bundle branch block. Unchanged from prior EKG from [2197-7-18]. . CXR ([2197-7-19]): No acute cardiopulmonary process. TTE [2197-7-18]: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the septum, distal anterior, and apical segments.. The remaining segments contract normally (LVEF = 45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Images are suboptimal and dysnnchrony could not be adequately assessed, but global comparison of no pacing, simultaneous, biventricular, and RV only pacing suggested that the best contraction pattern/systolic function with simultaneous pacing. Discharge Labs: [2197-7-20] 05:37AM BLOOD WBC-3.4* RBC-3.80* Hgb-11.8* Hct-34.4* MCV-90 MCH-30.9 MCHC-34.2 RDW-12.9 Plt Ct-181 [2197-7-20] 05:37AM BLOOD Glucose-101* UreaN-37* Creat-1.7* Na-141 K-4.5 Cl-104 HCO3-31 AnGap-11 [2197-7-20] 05:37AM BLOOD CK-MB-2 cTropnT-<0.01 Brief Hospital Course: Primary Reason for Hospitalization: 61 yo [Male First Name (un) 4746] with extensive cardiac history including CAD, s/p numerous MIs, CABG, PCIs with stents, presenting with chest pain and hypotension. . Active Issues: # Chest pain: Patient has history of chronic angina, and in setting of normal enzymes and unchanged EKG, this is most likely cause of pain. Hypovolemia may also have contributed by decreasing coronary perfusion causing demand ischemia. EKG and cardiac enzymes were reassuring for no ACS. An alternative etiology is that he has an arrythmia leading to tachycardia and demand ischemia, however interrogation of the patients pacemaker did not reveal abnormal activity. The pacers settings was initally set to only record abonormal rhythms at rates of greater than 160 bmp this threshold was decreased. CE and EKG remained stable throughout admission. Pain was controlled with dilaudid 2mg IV as needed and SL nitro as BP tolerated. He was continued on home aspirin and plavix. His imdur was restarted as blood pressures had improved. He continued to have intermittent chest pain, and after speaking with his outpatient cardiologist Dr. [Last Name (STitle) 2912] he was advised to stay an additional night for monitoring. Dr. [Last Name (STitle) 2912] also suggested that some of his chest pain could be due to cervical spondylosis and recommended C-spine imaging. However pt expressed a strong desire to return home. Given that his symptoms were consistent with his chronic angina and he has short-term follow up arranged with his outpatient PCP and cardiologist, he was discharged home. . # Hypotension: Patient had SBP 70s down from baseline 95-100s in the ED and felt lightheaded with chest pain. Pressures returned to baseline with 2L NS. Most likely due to volume depletion [1-4] diuresis during recent admission for volume overload, exacerbated by blood pressure lowering medications and home diuretics. Hypovolemia was also corroberated by pressure response to fluid resuscitation, labs consistent with hemoconcentration and elevation of creatinine. Home carvedilol, lisinopril, spironolactone and bumetanide were held overnight on the night of admission. Carvedilol was restarted on HD1 as blood pressures had improved. He was advised to resume all of his home medications on the day after discharge and to follow up with his PCP and cardiologist. . # Acute Renal Failure: Patient has a baseline Cr 1.2-1.3 from [2194], and the day prior to this admission creatinine was 1.5. Creatinine 2.0 on this admission, thought likely pre-renal etiology. Initial concern for contrast nephropathy given recent cath, but his creatinine improved with IV fluids. Lisinopril, spironolactone and bumetanide were held initially but restarted on discharge. Patients creatine improved to 1.7 at the time of discharge. . Chronic Issues: # CHF: EF 20%. Patient was at dry weight of 145lbs at the time of admission and appeared euvolemic on exam with no jugular venous distention or peripheral edema. Carvedilol, spironolactone and lisinopril were held overnight in the setting of hypotension and acute kidney injury. He was asked to restart these medications the morning after discharge. . # Hyperlipidemia: Patient was continued on home pravastatin throughout admission. . # Chronic back pain: Patient was continued on home oxycontin [Hospital1 ] and gabapentin. He received 2mg IV dilaudid as needed for breakthrough pain. . # Diabetes: Patient was continued on home glipizide and a diabetic diet. Blood sugars were well controlled throughout admisison. . # Depression: Patient was continued on home escitalopram. . # GERD: Patient was continued on home pantoprazole given history of GI bleed. . # BPH: Patient was continued on tamsulosin throughout admission. #Transitional issues: - Patient was DNI, but wanted to pursue cardiac resuscitation. - Patient should have an ER care plan established for future chest pain presentations. - He should resume all of his home medications after discharge and follow up with his outpatient PCP and cardiologist. Medications on Admission: aspirin 325mg PO daily clopidogrel 75mg PO daily carvedilol 12.5mg PO BID lisinopril 2.5mg po daily pravastatin 40mg po daily Ranexa 1,000mg ER po BID spironolactone 12.5mg PO qMONWEDFRI bumetanide 1mg PO BID tamsulosin 0.8mg ER PO qHS pantoprazole 40mg PO BID escitalopram 20mg PO daily fenofibrate 145mg PO daily lorazepam 1mg PO BID isosorbide mononitrate 30mg PO daily potassium chloride 40mEq PO daily trazodone 150mg PO daily OxyContin 40mg PO BID gabapentin 400mg PO q8h glipizide 5mg PO daily multivitamin 1tab PO daily FiberCon po daily Vitamin D 1,000 unit PO daily ferrous sulfate 325 mg PO daily Vitamin B-1 100mg PO daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. ranolazine 1,000 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. 5. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. 9. trazodone 150 mg Tablet Sig: One (1) Tablet PO once a day. 10. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 12. spironolactone 25 mg Tablet Sig: [12-4] Tablet PO Monday, Wednesday, Friday. 13. OxyContin 10 mg Tablet Extended Release 12 hr Sig: Four (4) Tablet Extended Release 12 hr PO twice a day. 14. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 15. bumetanide 1 mg Tablet Sig: One (1) Tablet PO twice a day. 16. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO HS (at bedtime). 17. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 19. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 20. multivitamin Capsule Sig: One (1) Capsule PO once a day. 21. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 23. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO daily (). 24. FiberCon 625 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Coronary artery disease Secondary: Acute renal failure Chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 18] because you were having chest pain and low blood pressure. Your cardiac enzymes were normal and your EKG showed no new changes, which was reassuring that this was not an acute cardiac problem. It is most likely due to your chronic angina in the setting of dehydration. You received IV fluids and your diuretics were held for one day. We spoke with your outpatient cardiologist, Dr. [Last Name (STitle) 25833], who recommended that you stay overnight for an additional study of the neck. However, because you expressed desire to leave and your chest pain was similar to your baseline chest pain and did not require further intervention, you were discharged home with follow up arranged with your outpatient providers. While you were here, we held some of your home medications because of your low blood pressure and dehydration. These medications should be restarted tomorrow morning ([7-21]). Please continue to take all of your medications as prescribed by your providers. We have scheduled appointments for you to follow up with your outpatient primary care physician and cardiologist after leaving the hospital. If you are unable to make these appointments, please call and reschedule. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] A. Location: [Hospital6 ] Address: [Apartment Address(1) 25834], [Location (un) ],[Numeric Identifier 9749] Phone: [Telephone/Fax (1) 19752] Appointment: Monday [2197-7-31] 9:30am Name: [Last Name (LF) 2912], [First Name7 (NamePattern1) 2174] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] BLDG, [Apartment Address(1) 8540] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 8542] Phone: [Telephone/Fax (1) 8543] Appointment: Tuesday [2197-8-1] 2:30pm Admission Date: [2197-7-23] Discharge Date: [2197-7-26] Date of Birth: [2135-8-29] Sex: M Service: MEDICINE Allergies: Persantine IV / Indocin Attending:[First Name3 (LF) 2387] Chief Complaint: chest pain, shortness of breath, and left lower extremity pain Major Surgical or Invasive Procedure: None. History of Present Illness: 61M w/hx of CAD, 4 MIs s/p stents, CABG, s/p PPM/ICD, CHF, DM, s/p RCA stent on [7-17] with multiple recent admissions for chest pain, presenting with chest pain and palpitations in addition the left lower extremity pain. Patient reports that he has been having "[Doctor Last Name ]-hammer like palpitations" since his discharge on [7-20]. He has also felt lightheaded and short of breath with the chest pain. He has been taking his home medications as prescribed, and took 4 SL nitroglycerins today. He took a walk today and after 500 yards had such severe palpitations that he had to turn around. He took his blood pressure and it was 70/43. His wife called the ambulance at that time. . Patient is also complaining of left lower extremity pain. He reports that the pain began on Tuesday, [7-18], during his initial admission. He mentioned the pain to the team at that time, but per patient's report, the team did not think it was significant. During his last admission, patient did not mention that the pain was continuing as he thought that it was not significant. Patient denies any swelling or redness in the left lower extremity but reports that it has been "a different color" than the right. . Patient went to [Hospital ] hospital where he was given a total of 2500cc IVF for low blood pressure and started on a heparin drip given concern for ACS. He had one set of negative cardiac enzymes and was transferred to [Hospital1 18] for further care. . On arrival to [Hospital1 18], VS were T 97.9 P 80 BP 72/51 RR 18 Sat 99% 4L nc. Blood pressures improved into the 90s systolic. A second set of cardiac enzymes were negative, BNP was normal and EKG was unchanged from baseline. Blood pressure dropped into the 70s systolic. An arterial line was placed which was [Location (un) 1131] 20mmHg above cuff pressure, showing SBPs of 100s so pressors were turned off after 30min and BPs stayed stable in 90-100s. Patient was also complaining of a swollen and painful left leg. Given patient's history of a prior PE, a LLE ultrasound was performed in the ED which showed evidence of clot in one of the left peroneal veins but no other deep veins. . Of note, the patient was recently admitted on [7-19] for chest pain and palpitations of a similar nature. Symptoms were consistent with angina, however, could not rule out tachycardia. Pacer had not recorded any periods of rate>160, but was reset to record with rates >135. During the previous admission, CE were negative and EKG was unchanged. . On arrival to the floor, patient's vital signs were T97.7 BP 107/64 HR 80 RR 14 02Sat 98%on RA. Patient was complaining of ongoing chest pain and was extremely anxious about the potential for a clot in his leg or of another cardiac event. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN 2. CARDIAC HISTORY: -CAD, AMI in [2184]. -BMS of LAD X 2 in 1/99. -CABG: 3 vessel CABG in [2185] (LIMA-LAD, SVG-Diag, SVG- OMB) -Stent of RCA ([1-10]), apical LV aneurysm -PACING/ICD: ICD placed s/p VF arrest in cath lab in [2188] . 3. OTHER PAST MEDICAL HISTORY: CHF EF 20% H/o PE in [2188]- subsegmental Hyperlipidemia BPH Gout H/o GI bleed from gastritis requiring 12 units RBC Chronic back pain with herniated discs per patient Social History: Lives with his wife in [Name (NI) 14840]. Retired firefighter. Owns a liquor store and four seafood/sushi restaurants which his two children run. Tobacco: 40pack-year history, quit in [2184] Alcohol: occasional/rare wine Illicits: Denies Family History: There is no family history of premature coronary artery disease or sudden death. Mother- died of encephalitis in 50s Father- died at age 65 of bone CA Sister- DM Physical Exam: Admission Physical Exam: VS: T97.7 BP 107/64 HR 80 RR 14 02Sat 98%on RA GENERAL: Obese male lying comfortably in bed in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, MMM. NECK: Supple with JVP of 3 cm. CARDIAC: Distant heart sounds [1-4] body habitus. RRR with normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Respirations unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Diminished air movement throughout. ABDOMEN: Soft, NT, ND. +BS EXTREMITIES: WWP, no edema, cyanosis or clubbing SKIN: chronic venous stasis changes of anterior calves 1+ DP/PT pulses bilaterally, 2+ radial pulses bilaterally Discharge Physical Exam: Vitals - Tm/Tc: 97.6 BP: 129-144/67-75 HR: 80-83 RR: 18 02 sat: 97% RA Weight: 103.7 (104.4) GENERAL: 61 yo M in no acute distress, lying in bed HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP unable to assess CHEST: CTABL no wheezes, no rales, no rhonchi, [Month (only) ] overall CV: S1 S2 Normal, distant, no murmurs appreciated ABD: soft, non-tender, obese, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs trace NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, gait WNL. Pertinent Results: Admission labs: WBC 4.6 Hgb 11.6 Hct 32.9 Plts 165 N:62.0 L:26.1 M:8.5 E:2.8 Bas:0.5 PT: 14.0 PTT: 150 INR: 1.2 Na 137 K 4.5 Cl 101 HCO3 29 BUN 45 Cr 1.6 Gluc 125 proBNP: 349 Trop-T: <0.01 . EKG ([2197-7-23] @ 15:50): Sinus rhythm, normal axis, normal intervals, right bundle branch block, Q waves in I/avL. Unchanged from prior . CXR ([2197-7-23]): no acute cardiopulmonary process . Lower extremity ultrasound ([2197-7-23]): Evidence of clot in one of the left peroneal veins. Otherwise, normal flow and compressibility throughout the remainder of the veins. . GENERAL: 61 yo M in no acute distress, lying in bed HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP unable to assess CHEST: CTABL no wheezes, no rales, no rhonchi, [Month (only) ] overall CV: S1 S2 Normal, distant, no murmurs appreciated ABD: soft, non-tender, obese, BS normoactive. no rebound/guarding. EXT: wwp, no edema. DPs, PTs trace NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, gait WNL. SKIN: no rash PSYCH: A/O, slightly tearful when talking about his family. Discharge Labs: [2197-7-26] 07:00AM BLOOD WBC-4.5 RBC-3.91* Hgb-11.8* Hct-34.8* MCV-89 MCH-30.2 MCHC-34.0 RDW-12.9 Plt Ct-185 [2197-7-25] 12:17PM BLOOD PTT-67.8* [2197-7-26] 07:00AM BLOOD Glucose-118* UreaN-28* Creat-1.3* Na-142 K-4.3 Cl-106 HCO3-29 AnGap-11 [2197-7-26] 07:00AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.2 Brief Hospital Course: Primary Reason for Hospitalization: 61 yo [Male First Name (un) 4746] with extensive cardiac history including CAD, s/p numerous MIs, CABG, PCIs with stents, presenting with chest pain and hypotension. . Active issues: # Hypotension: While patient was hypotensive on presentation to the ED with systolics in 70s, once arterial line was placed in ED, pressures were noted to be 20mmHg above cuff [Location (un) 1131], and consistent with patient's baseline pressures of systolic 90s. LE ultrasound indicating DVT, and given associated chest pain, hypotension may be due to pulmonary embolism. However, did not appear to be a hemodynamically significant PE given resolution of patient's hypotension with fluid resuscitation and that arterial line is showing normal, baseline pressures. In addition, a component of patient's initial hypotension was likely due to over medication at home as patient took several SL nitro pills. Patient received 2.5L IVF in ED with improvement in symptoms. Patient's home carvedilol, lisinopril, and isosorbide mononitrate were held initially. In additon, diuretics (bumetanide and spironolactone) were held in setting of potential hypovolemia. His home imdur was restarted as pressures tolerated. At discharge, his blood pressure medications included lisinopril 2.5 mg daily, carvedilol 3.125 mg [Hospital1 ], Imdur 90mg daily. His spirinolactone was discontinued, and his home Bumex was resumed. . # Chest pain: Patient's chest pain was thought to be multifactorial in nature. Patient has history of chronic angina, and in setting of normal enzymes and unchanged EKG there was low suspicion for ACS. As patient was hypovolemic in the ED, CP may also have been due to demand ischemia. He was continued on his home aspirin and plavix throught the admission. His imdur was initally held in the setting of hypotension but was restarted as pressures tolerated, and he was continued on his home ranolazine. Pulmonary embolus was a concern given his history of PEs, hypotension, and unilateral lower extremity edema and pain. CTA was deferred in setting of ARF. However V/Q scan was negative for pulmonary embolus. Patient's report of pounding chest pain was intially concerning for tachycardic arrhythmia. On previous admission, pacer was reset to record rates >135 in order to capture arrythmia, however no tachyarryhtmia recorded on pacemaker interrogation. Patient also c/o chest wall "jumping" and it was noted that his pacer appeared to be affecting the phrenic nerve causing intermittent contraction of the diaphram and likely contributing to his pain. Per the patient he had several episodes of theses contraction since his pacer settings were changed on his previous hospitalization. His pacer LV output was decreased from 2.0 to 1.75 volts and the patient did not have further episodes. He will need to have his pacer reinterrogtated in [1-5] weeks. # DVT- As noted above the patient presented with unilateral leg swelling and pain ans was found to have left peroneal DVT. CTA was deferred in setting of ARF. Patient was started on heparin drip at OSH, which was continued due to high suspicion for pulmonary embolism. V/Q scan was however negative for pulmonary embolism. His heparin was continued throughout his hospitalization. Given his previous history of PE hematology was consulted regarding the need for lifelong anti-coagulation and felt that although the risk of PE with DVT below the knee is low, his other comorbidities and frequent hospitalizations increase his risk and therefore he would benefit from anticoagulation for 3 months. The patient has a history of non-compliance to coumadin and was therefore started on lovanox. He was scheduled to have follow-up testing of anti-Xa levels 3 days after discharge to ensure therapeutic dosing, and to follow up in the [Hospital ] clinic as an outpatient after discharge. # Acute on Chronic Renal Failure: Patient has a baseline Cr 1.2-1.3 from [2194], and at the time of last discharge was 1.7. This was thought likely to be pre-renal [1-4] hypovolemia causing decreased kidney perfusion. His lisinopril was intially held, and his blood pressure medications were decreased due to hypotension, as above. Creatinine improved throughout hospitalization with improved blood pressure and was 1.3 at the time of discharge. Lisinopril was resumed on day of discharge. . Stable issues: # Chronic systolic heart failure: Known EF 20%. Clinically euvolemic on exam with no jugular venous distention. His home carvedilol dose was decreased and spirinolactone was discontinued due to his hypotension, as above. Lisinopril was intially held due to renal failure as above, but on discharge was resumed at his home dose. # Hyperlipidemia: Continued home pravastatin and fenofibrate. . # Chronic back pain: continued home oxycontin [Hospital1 ] and gabapentin. . # Diabetes: On glipizide at home. On diabetic diet during admission. Blood sugars were well controlled on home regimen throughout admission. # Depression/Anxiety: Continued outpatient escitalopram, lorazepam and trazodone. His ativan dose was increased to 1mg PO TID (patient has been taking this dose at home). . # GERD: continued PPI. . # BPH: continued tamsulosin. # Transitional issues: - Re-interrogate pacer in [1-5] weeks, pt is calling for an appt at [Hospital1 18] device clinic - Lovenox has been dosed according to weight but an activated Factor 10 level needs to be drawn 6 hours after the morning dose. This can be done during the appt with Dr. [Last Name (STitle) 2912] on [Last Name (STitle) 2974] [2197-7-28]. The goal level is 0.6-1.0. Please page the hematology oncology fellow on call at [Hospital1 18] for medication adjustment help if needed. Pager number is [Telephone/Fax (1) 10339]. - Hematology office will call pt at home with an appt within a month. Medications on Admission: aspirin 325mg PO daily clopidogrel 75mg PO daily carvedilol 12.5mg PO BID lisinopril 2.5mg po daily pravastatin 40mg po daily Ranexa 1,000mg ER po BID spironolactone 12.5mg PO qMONWEDFRI bumetanide 1mg PO BID tamsulosin 0.8mg ER PO qHS pantoprazole 40mg PO BID escitalopram 20mg PO daily fenofibrate 145mg PO daily lorazepam 1mg PO BID isosorbide mononitrate 90mg PO daily potassium chloride 40mEq PO daily trazodone 150mg PO daily OxyContin 40mg PO BID gabapentin 400mg PO q8h glipizide 5mg PO daily multivitamin 1tab PO daily FiberCon po daily Vitamin D 1,000 unit PO daily ferrous sulfate 325 mg PO daily Vitamin B-1 100mg PO daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pravastatin 20 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 Q12H (every 12 hours). 5. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 7. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO DAILY (Daily). 8. Outpatient Lab Work Please check CBC, chem-7 and activated factor 10 during your appt with Dr. [Last Name (STitle) 2912] 9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO BID (2 times a day). 12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 14. trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 15. oxycodone 20 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 16. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 17. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 19. FiberCon Oral 20. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 21. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day. 23. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:60 syringes Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: 1. Deep venous thrombosis 2. Pulmonary embolism Secondary Diagnosis: Chronic Systolic congestive heart failure Chronic Angina Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had right leg pain and palpitations with low blood pressure at home. You received intravenous fluid and was tramsferred to [Hospital1 18] for treatment. A clot was found in your right lower leg that was causing your pain. A hematology team evaluated you in the hospital and recommended that you resume Lovenox injections. You will see the hematologist again after your discharge to decide about further testing. Your kidney function worsened before you were admitted but is now back to your baseline function. The palpitations were caused by the ICD wire, the settings on the ICD were adjusted and seemed to correct the problem. Weigh yourself every morning before breakfast, call Dr. [Last Name (STitle) 2912] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at discharge is 246 pounds. . We made the following changes to your medicines: 1. Increase your lorazepam to 1mg three times a day for your anxiety 2. Decrease carvedilol to 3.125 mg twice daily 3. Discontinue tamsulosin. Please call Dr. [Last Name (STitle) 2912] if you have trouble urinating, the medicine can be restarted at a lower dose 4. Decrease bumex to 1mg daily 5. Discontinue spironolactone for now. 6. Start Lovenox 100 mg twice daily Followup Instructions: Please follow-up with: Name: [Last Name (LF) 2912], [First Name7 (NamePattern1) 2174] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] BLDG, [Apartment Address(1) 8540] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 8542] Phone: [Telephone/Fax (1) 8543] Appt: This [Last Name (LF) 2974], [7-28] at 11:45am Name: [Last Name (LF) ],[First Name3 (LF) ] A. Location: [Hospital6 ] Address: [Apartment Address(1) 25834], [Location (un) ],[Numeric Identifier 9749] Phone: [Telephone/Fax (1) 19752] Appt: [7-31] at 9:30am	[ "785.1", "403.90", "311", "412", "300.4", "413.9", "415.19", "V45.02", "600.00", "530.81", "V12.51", "V45.81", "428.0", "338.29", "428.32", "585.9", "414.01", "V45.82", "272.4", "453.42", "458.9", "250.00", "724.5", "584.9", "428.22" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	30571, 30577	22047, 22255	15369, 15377	30768, 30768	20517, 20517	32195, 32854	19035, 19198		28634, 30548		30598, 30598		27975, 28611			30919, 32172			21710, 22024						19238, 19858		18320, 18549														9806, 10077					15267, 15331		22270, 27309					15405, 18194			30688, 30747		20533, 21694		30617, 30667			30783, 30895	18580, 18753	27332, 27949	8852, 9785		18238, 18300	18769, 19019		19883, 20498
19,361	120,609	29307	Discharge summary	report	Admission Date: [2177-8-4] Discharge Date: [2177-8-19] Date of Birth: [2116-4-5] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [2177-8-12] - Aortic Valve Replacement w/ [First Name8 (NamePattern2) 6158] [Male First Name (un) 923] Regent Mechanical Valve [2177-8-7] - Cardiac Catheterization History of Present Illness: Ms. [Known lastname 9464] is a 61 y/o F with PMH notable for severe AS presenting as transfer from [Hospital6 6640] for further management of worsening dyspnea on exertion. The patient presented to Sturdy with a 3 week history of worsening dyspnea, especially with exertion. The patient was feeling more and more short of breath with minimal activity (such as folding laundry); of note, she has been quite inactive for some time due to her MVC in [1-/2177] with resultant multiple orthopedic injuries. She required a long rehab stay and has just recently increased her activity level. On [8-2], she contact[Name (NI) ] EMS due to worsening dyspnea; en route to the hospital, she received lasix but was ultimately intubated in the Sturdy ED due to respiratory distress. CXR at that time demonstrated pulmonary edema and ? of pneumonia; she was treated with levofloxacin and vancomycin and briefly required pressors. Swan-Ganz catheter was placed which demonstrated PCWP of 20; she was diuresed and ultimately extubated on [8-3] without complication. . During this time, she ruled in by enzymes for NSTEMI (trop I 14.2) but denied ever having chest pain. Echocardiogram on [8-4] demonstrated severe AS with mean gradient 44 mmHg and valve area 0.6 cm2. LVEF was slightly depressed at 45%. She requested transfer to [Hospital1 18] for further care; on arrival, she denies any difficulty breathing. In fact, she is irritated by the nasal cannulae at the present time. She denies any chest pain. She has residual pain in her left clavicle and occasionally in her sternum due to her numerous prior fractures. Past Medical History: Severe aortic stenosis Prior CVA ([1-8]) DM 2 (diagnosed [2172]) Carotid endarterectomy ([5-/2177]) MVC with multiple injuries including fractured hip s/p repair, sternal fracture, rib fractures Gout Psoriasis Osteoarthritis Myocardial infarction Social History: The patient lives alone and has two sons in the area who visit her often. She is a prior smoker but quit following her MVC last [Month (only) 1096]. She does not use alcohol; previously drank only occasionally. She has been on disability due to back pain since the [2140]. Family History: Her mother and father both had heart disease with MIs in their 70s. Physical Exam: T 97, BP 127/91, HR 101, RR 25, O2 99 % on 3L NC, 95% on RA Gen: elderly female in NAD, comfortable, and speaking in full sentences HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. MMM. Neck: Supple with JVP of 8 cm. CV: PMI nondisplaced, midclavicular line. RR, normal S1, S2. [4-8] systolic murmur at upper sternal borders radiating to carotids. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles evident bilaterally to apices. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits appreciated. Ext: No peripheral edema. R femoral bruit but unclear if radiation from AS murmur. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ no bruit; Femoral 2+ with slight bruit; 2+ DP Left: Carotid 2+ with no bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2177-8-7] Cath: 1. Coronary angiography of this right dominant circulation demonstrated non-obstructive coronary disease. The LMCA had minimal disease. The LAD had minimal disease. The LCX was large with 3 OM branches and non-critical disease. The RCA had a small 40% proximal lesion. 2. Resting hemodynamics revealed normal left and right filling pressures. The mean RA pressure was 6 mm Hg. The mean PCW pressure was 9 mm Hg. Fick CI was slightly low at 2.18 l/min/m2. There was no pulmonary hypertension. 3. Interrogation of the aortic valve revealed a mean gradient of 40.03 mmHg with a calculated area of 0.70 cm2. 4. The patient experienced a likely vagal event with hypotension and bradycardia, treated and resolved following administration of atropine 1 mg and intravenous fluids. [2177-8-8] CNIS: 1. Occluded right ICA. 2. Hypoechoic left ICA plaque, no significant associated stenosis however (graded as less than 40%). [2177-8-11] Head CT: No evidence of hemorrhage or acute infarct. Encephalomalacia changes consistent with chronic infarct of the left centrum semiovale. [2177-8-12] Echo: PRE-BYPASS: 1. The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with apical hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. 4. There are simple atheroma in the aortic arch. There are complex (>4mm)atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Severe (4+)mitral regurgitation is seen. Both leaflets are slightly restricted. Annulus measures 3.6cm in the commisural axis. Vena contracta is 0.6 -0.7 cm. Systolic blunting is noted in the pulmonary veins. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine andf epinephrine. 1. A well-seated bileaflet valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 20 mmHg). Washing jets are noted. Leaflets appear to open well. 2. MR is significantly improved and now is mild in severity. 3. Biventricular systolic function is improved 4. Aorta and interatrial septum are intact post decannulation 5. Other findings are unchanged [2177-8-15] CXR: Improved left lower lobe atelectasis, small bilateral pleural effusions. [2177-8-5] 12:27AM BLOOD WBC-7.1 RBC-4.13* Hgb-12.2 Hct-35.1* MCV-85 MCH-29.4 MCHC-34.7 RDW-17.6* Plt Ct-103# [2177-8-12] 02:09PM BLOOD WBC-7.8 RBC-3.11 Hgb-9.0* Hct-27.2* MCV-87 MCH-28.8 MCHC-32.9 RDW-16.6* Plt Ct-126* [2177-8-19] 06:35AM BLOOD Hct-27.6* [2177-8-18] 08:50AM BLOOD WBC-5.8 RBC-3.24* Hgb-9.4* Hct-28.8* MCV-89 MCH-28.9 MCHC-32.6 RDW-16.5* Plt Ct-223 [2177-8-5] 12:27AM BLOOD PT-12.6 PTT-27.3 INR(PT)-1.1 [2177-8-19] 06:35AM BLOOD PT-21.4* PTT-92.1* INR(PT)-2.1* [2177-8-5] 12:27AM BLOOD Glucose-118* UreaN-20 Creat-1.0 Na-145 K-3.9 Cl-109* HCO3-26 AnGap-14 [2177-8-9] 05:45AM BLOOD Glucose-116* UreaN-21* Creat-0.8 Na-144 K-3.9 Cl-106 HCO3-27 AnGap-15 [2177-8-17] 10:25AM BLOOD Glucose-74 UreaN-17 Creat-0.9 Na-142 K-3.9 Cl-103 HCO3-26 AnGap-17 [2177-8-19] 06:35AM BLOOD K-4.2 [2177-8-9] 05:45AM BLOOD ALT-26 AST-46* LD(LDH)-345* AlkPhos-79 Amylase-50 TotBili-0.4 Brief Hospital Course: Ms. [Known lastname 9464] is a 61 year old female with known severe aortic stenosis transferred from OSH after episode of respiratory distress leading to intubation due to pulmonary edema. She was extubated prior to transfer to [Hospital1 18]. She underwent cardiac evaluation including cardiac catheterization which confirmed severe aortic stenosis and clean coronary arteries(see result section for further detail). Further evaluation included carotid ultrasound and head CT scan. Carotid ultrasound showed a complete occlusion of the right internal carotid artery, with some hypoechoic plaque/wall thickening involving the left internal carotid artery but no significant associated stenosis. Given prior history of hemorrhagic stroke, she underwent head CT scan which revealed encephalomalacia changes consistent with chronic infarct of the left centrum semiovale. There was no evidence of hemorrhage or acute infarction. The neurology service was consulted to assess risk of perioperative stroke. It was concluded that a 2% risk was present but there was no contraindication to proceed. Workup was otherwise unremarkable and she was cleared for surgery. On [8-12], Dr. [Last Name (STitle) ] performed an aortic valve replacement utilizing a mechanical valve. For surgical details, please see separate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. Her CSRU course was otherwise unremarkable and she transferred to the SDU on postoperative day one. Given her mechanical valve, she was started on Warfarin. She transiently required intravenous Heparin for a subtherapeutic prothrombin time. Preoperative medications were resumed. Over several days, she continued to make clinical improvements with diuresis and made steady progress with physical therapy. Given her steady progress, she was medically cleared for discharge on postoperative day seven. Prior to discharge, plan were made for INR to be followed by Dr [First Name4 (NamePattern1) 3979] [Last Name (NamePattern1) ]. Medications on Admission: on transfer): albuterol q2H prn duoneb glipizide 5 mg [Hospital1 ] metformin 500 [Hospital1 ] lisinopril 5 [Hospital1 ] protonix 40 daily fluticasone 2 puffs [Hospital1 ] lovenox 100 mg [Hospital1 ] metoprolol 25 mg Q8H simvastatin 40 mg QHS aspirin 325 mg daily lorazepam prn lasix 40 mg IV X 1 . Meds prior to admission (unsure of doses): protonix 40 mg daily glucophage [Hospital1 ] glipizide [Hospital1 ] plaquenil allopurinol ASA Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 8. Outpatient [Name (NI) ] Work PT/INR for coumadin dosing - please check mon/wed/fri with results to Dr [First Name4 (NamePattern1) 3979] [Last Name (NamePattern1) ] office phone # [Telephone/Fax (1) 7960] fax [Telephone/Fax (1) 17382] Goal INR 2.5-3.0 for mechanical Aortic valve 9. Toprol XL Oral 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 11. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 1 doses: 7.5 mg today, INR to be drawn by VNA on [8-20], and called to Dr. [Last Name (STitle) ] for continued dosing. Disp:60 Tablet(s) Refills:0 12. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:60 Tablet(s) Refills:0 15. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Community VNA, [Location (un) ] Discharge Diagnosis: Aortic Stenosis s/p AVR Osteoarthritis Hypertension Hypercholesterolemia Gout CVA [1-8] Diabetes Mellitus type 2 Carotid endarectomy Psoriasis Discharge Condition: Good Discharge Instructions: shower daily and pat dry incisions no lotions, creams, powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call surgeon for redness, drainage, or fever greater than 100.5 Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) ] in 1 week ([Telephone/Fax (1) 62833]) please call for appointment Dr [Last Name (STitle) ] in [3-8] weeks ([Telephone/Fax (1) 7960]) please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Labs: PT/INR for coumadin dosing - please check mon/wed/fri with results to Dr [First Name4 (NamePattern1) 3979] [Last Name (NamePattern1) ] office phone # [Telephone/Fax (1) 7960] fax [Telephone/Fax (1) 17382] Goal INR 2.5-3.0 for mechanical Aortic valve Completed by:[2177-8-19]	[ "428.0", "410.71", "V17.3", "274.9", "250.00", "424.1", "443.9", "496", "433.10", "V15.82", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.53", "37.23", "88.56", "35.22", "39.61", "89.60" ]	icd9pcs	[ [ [] ] ]	12232, 12298	7527, 9673	327, 508	12488, 12494	3794, 4751	12757, 13475	2768, 2837		10186, 12209		12319, 12467		9699, 10163			12518, 12734									2852, 3775																					280, 289							536, 2172				4760, 7504											2194, 2454	2470, 2752
19,080	141,030	23375+23376	Discharge summary	report+report	Admission Date: [2177-1-1] Discharge Date: [2177-2-7] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1055] Chief Complaint: Transferred from OSH with ARF, CHF, RLE DVT Major Surgical or Invasive Procedure: Renal biopsy Placement of RIJ tunneled HD catheter EGD([1-23]) Colonoscopy [1-23] History of Present Illness: 82 yo female with h/o Sjogren's Syndrome, ? vasculitis, LE periph neuropathy, HTN, who presents from OSH with RLE DVT, ARF, CHF and ascites. Pt c/o increased weakness, anorexia x [2-2] wks and 1-2 days of dyspnea. + non-productive cough with exertion. No F/C. No CP. No HA. No dysuria. No hematuria. No abd pain/melena/BRBPR. Increased stool frequency from 1 to 2-3x/day. No loose stools. Hct at OSH=21, Cr=2.9, Transaminitis Past Medical History: Sjogren's superficial vasculitis HTN Anemia Peripheral Neuropathy Hyperchol. Raynaud's Hypoalbuminemia Social History: Lives at home with 83 yo sister. Retired in [2162] from career as admin asst.; Never married. No children. No smoking hx, and [3-6] EtOH drinks/wk. Family History: Fatehr died at age 35 from stomach CA. Mother died at age 89. No FH of liver, kidney, premature cardiac dx, malig, Lupus, or Sjogren's Physical Exam: 97.1, 157-194/70-72, 94-100, 18, 98% on 2L Gen:NAD HEENT:PERRL, EOMI, anicteric, JVP ~12 cm. No LAD CV:Tachy, No MRG Pulm:[Month (only) ] BS at bases bilat. Abd:Soft, slightly distended, No HSM. NABS Ext:3+ pitting edema to knee, R>>L. Spotty hyperpig on pretib bilat. 2+ dps. RUE with 3+ pitting edema Neuro:CN II-XII intact. [Month (only) ] sensation in LE to knee R>>L. Skin:Non-blanching purpural lesions on R upper back and L antecubital region. Pertinent Results: [2177-1-1] 11:55PM BLOOD WBC-9.4 RBC-2.33* Hgb-6.1* Hct-19.4* MCV-83 MCH-26.0* MCHC-31.3 RDW-18.2* Plt Ct-254 [2177-1-1] 11:55PM BLOOD Neuts-89.8* Lymphs-7.8* Monos-2.0 Eos-0.4 Baso-0 [2177-1-1] 11:55PM BLOOD PT-17.0* PTT-150* INR(PT)-1.8 [2177-1-2] 11:01AM BLOOD Thrombn-150* [2177-1-1] 11:55PM BLOOD Ret Aut-5.8* [2177-1-1] 11:55PM BLOOD Glucose-87 UreaN-45* Creat-2.6* Na-132* K-3.9 Cl-99 HCO3-25 AnGap-12 [2177-1-1] 11:55PM BLOOD ALT-79* AST-103* CK(CPK)-39 AlkPhos-303* Amylase-46 TotBili-0.4 [2177-1-1] 11:55PM BLOOD Lipase-32 [2177-1-2] 11:01AM BLOOD TotProt-6.5 Albumin-2.3* Globuln-4.2* Calcium-8.0* Phos-4.8* Mg-1.9 [2177-1-1] 11:55PM BLOOD TotProt-6.7 Albumin-2.3* Globuln-4.4* Iron-16* Cholest-116 [2177-1-1] 11:55PM BLOOD calTIBC-172* VitB12-1261* Folate->20.0 Hapto-67 Ferritn-1338* TRF-132* [2177-1-5] 06:00AM BLOOD Cryoglb-POSITIVE F [2177-1-16] 06:19AM BLOOD Cryoglb-POSITIVE F [2177-1-1] 11:55PM BLOOD TSH-3.3 [2177-1-9] 06:52AM BLOOD PTH-272* [2177-1-1] 11:55PM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE [2177-1-2] 11:01AM BLOOD C3-53* C4-0* [2177-1-1] 11:55PM BLOOD HCV Ab-NEGATIVE [2177-1-1] 11:55PM URINE Color-Yellow Appear-SlHazy Sp [Last Name (un) ]-1.013 [2177-1-1] 11:55PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [2177-1-1] 11:55PM URINE RBC-[12-21]* WBC-[4-5] Bacteri-NONE Yeast-NONE Epi-0-2 [2177-1-1] 11:55PM URINE CastHy-0-2 -- Urine cx neg x4. Blood cx neg x2. HCV viral load neg. --- RLE Doppler [1-2]:IMPRESSION: Right popliteal deep venous thrombosis ---- RUE Doppler [1-2]:IMPRESSION: No DVT ---- Abd U/S [1-2]:IMPRESSION: 1) Moderate volume of ascites as above. 2) Bilateral pleural effusions. 3) Patent portal and hepatic veins. ---- Torso CT [1-3]:IMPRESSION 1. Large bilateral pleural effusions, pericardial fluid, a small amount of ascites, and subcutaneous edema. The findings are suggestive of anasarca. 2. No mass lesions identified to suggest solid malignancy. 3. Left renal cysts. 4. Abnormal right hemipelvis with mottled bony architecture and irregular trabecular pattern. The appearance is nottypical for Paget's disease,but this is not excluded. Also considered is fibrous dysplasia. Metastatic disease is unlikely given the appearance and distribution.Correlate with bone scan if indicated. 5. Diverticulosis without evidence of diverticulitis ---- Echo [1-3]:Conclusions: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. R 2. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 4. There is moderate pulmonary artery systolic hypertension. 5. There is a trivial/physiologic pericardial effusion. ---- CXR [1-10]:IMPRESSION: 1. Interval progression of a small right pleural effusion with adjacent atelectasis/consolidation. The persistence of a left pleural effusion and central vascular engorgement raises the possibility of acute congestive heart failure. Clinical correlation and follow up after therapy for failure is recommended to exclude underlying consolidation at the bases. 2. Right-sided PICC with tip at cavoatrial junction. ---- CXR [1-12]:IMPRESSION: 1) Worsened CHF. 2) No change in effusions, left greater than right. ---- CXR [1-15]:IMPRESSION: Tubes and lines as described above. No evidence of pneumothorax. Increased peri-hilar parenchymal opacity with hazy opacity in right upper lobe, with pleural effusion, most likely representing worsening pulmonary edema.Superimposed infection cannot be excluded. Left lower lobe atelectasis vs. pneumonia. Please correlate clinically. ---- CXR [1-20]:IMPRESSION: Slight interval resolution of pulmonary edema. Persistent left lower lobe opacity. ---- CXR [2177-2-3]: There has been significant interval worsening of bibasilar infiltrates when compared with prior exam. These findings are consistent with volume overload/persistent CHF. There is evidence of bilateral pleural effusions, left greater than right. This is accompanied by significant decrease in aeration in bilateral upper lungs zones, again consistent with CHF. Brief Hospital Course: 1) Acute Renal Failure- She initially presented with a creatinine of 2.6. Her baseline was not totally normal, with recent Cr=1.6, but this was definitely a change. The immediate cause was not known. She had an initial UA which showed blood, but no infection. No evidence of casts under microscope. No RBC casts to suggest GN. ALso had a protein:creatinine ratio done which indicated possible nephrotic level proteinuria. Renal team was consulted to help sort out her complicated picture. Her sediment was examined multiple times under the microscope, with no evidence of RBC casts. She also didn't appear pre-renal. No obstructive etiology. Kidneys appeared normal on abd/pelvis CT and abd U/S(except for benign cyst in L kidney). Her renal fucntion was followed daily. She continued to make urine at reduced levels and never became oliguric. She did have progressive failure during her stay though, with Cr and BUN rising daily. Many rheumatologically based etiologies were considered given her known Sjogren's, including: Sjogren's itself, SLE, Cryoglobulinemia. Also considered glomerulonephritis given the hematuria, despite absence of RBC casts. Vasculitis considered. As renal failure progressive, team decided to perform renal biopsy. This was initially delayed as pt was on ASA, and had this stopped 5 days before bx. She was also given platelets before biopsy. In addition, ~5 days before biopsy, pt was started on high dose (60 mg qday) of prednisone. This did not appear to make a difference in her renal course at the time. The biopsy went well and pathology came back as mixed picture of the following: 1) Pauci-immune endo- and extra-capillary proliferative glomerulonephritis with associated necrotizing arteritis and hyalin deposits suggestive of cryoglobulins 2) Papillary cortical neoplasm. This is further described by the following comments: Comment: The complex findings in this biopsy are difficult to fully categorize. There is definitely evidence of an active vasculitic process, however there is significantly more endocapillary proliferation than is typically seen in a pauci-immune ANCA associated type of vasculitis. Possible cryoglobulins are seen by light microscopy, but there is no evidence of immune complexes by immunofluorescence or electron microscopy ( ? sampling). In addition, double contours are infrequent. 2. The tubular immune complexes seen likely relate to this patients known Sjogren's syndrome. 3. The papillary neoplasm is an incidental finding of uncertain significance. If it is part of a larger neoplasm then a renal cell carcinoma is a possibility. If the neoplasm is entirely present in the core taken, then it is best considered a cortical adenoma. Clinical correlation is indicated. Around the same time, a 24 hour urine collection was sent for protein levels. This returned a sub-nephrotic level of protein. As she is small woman without much muscle mass, her Prot:Cr ratio had overestimated the amount of protein in her urine. This, along with the biopsy, make her picture much more c/w a GN. She had many rheumatological studies sent as well. Pertinents include: neg Anti-Sm and RNP, making SLE less likely. Neg ANCA and AMA. + anti-cardiolipin IgM, but neg-B2-glycoprotein. Strongly Positive RF, and elevated IgG and IgM levels without monoclonal band. Finally, complement levels were low, with C4<C3. And lastly, positive cryoglobulins x2. Given the initial biopsy findings, she was started on mycophenolate mofetil. This did not appear to have much of a clinical effect, and when final path report returned as c/w pauci-immune GN possibly due to vasculitis and without evidence of cryos, she was switched to monthly pulse dose cytoxan. Her high dose prednisone was continued as well. Around the same time, as her renal function deteriorated, she began to retain more volume and became symptomatically SOB, requiring increasing amounts of O2. For this reason, she had a tunneled HD catheter placed in RIJ on [1-14] by IR and dialysis/ultrafiltration was started that afternoon. She had fluid removed almost daily for 2 weeks, resulting in a great improvement in her pulmonary status. She was weaned to room air after significant amount of fluid removed. She was weaned off HD by the time of discharge, and at d/c is producing around 30cc urine per hour. The exact cause of her ARF is still unclear, but she has positive cryoglobulins and low complement. No suggestion of immune complexes on biopsy/EM though. At this point, she is on prednisone and cytoxan, and she will be re-evaluated monthly to decide if she needs to continue ultrafiltration, or if her kidneys have recovered function. Her 1st dose of cytoxan was on [2177-1-17]; this will need to be dosed every month under the guidance of Dr. [Last Name (STitle) 4090]. She will need to continue very slow prenisone taper over a period of months, initially tapering the daily dose by 5mg per week for 1 week, and then by 2.5mg per week thereafter. 2)HTN-She was hypertensive for much of her admission. This is believed to be secondary to her volume overload status. She came in on Norvasc 5. This was held, and she was started on diltiazem in escalating doses. She was also started on isordil. An ACE-I was not initiated in setting of ARF. BP began to normalize as her fluid level was decreased with UF, but then increased again after UF was stopped. She was started on lasix at the end of her admission for assistance in fluid management and BP control. She was always asymptomatic. Her BP and med requirements are expected to decrease if her renal function improves. She will continue diltiazem, isordil, and lasix after d/c. If BP remains elevated, clonidine patch may be indicated to improve BP control. 3) Peripheral Neuropathy-This has been a major complaint of hers over last several months, but has not been as bad here. Believed to be related to Sjogrens/vasculitis. Sural nerve biopsy considered but not done. Nerve conduction studies as outpt showed mod-severe sensorimotor neuropathy. Her neurontin was increased to 100 mg tid, but held there due to worry of sedation in her. This seemed to bother her less and less as her stay went on. At d/c, she remains unable to walk on her feet without discomfort. She will require aggressive PT after d/c. 4) Rheum-As above, rheumatology team was contact[Name (NI) ] and commented on various possibilities to explain symptoms. Again, ultimate cause unknown, but could still be result of cryoglobulins vs vasculitis vs SLE. Studies sent as above point away from SLE and towards cryo. Regardless, she was started on immunosuppressives and steroids with resulting improvement. 5) DVT-She had new RLE DVT by LENI on admission. RUE was ok. She was started on heparin gtt. This was stopped several times for various procedures but remained on otherwise. She had no evidence of PE. 3 weeks into stay, platelets started dropping. HITT was considered, and pt was switched to Argatroban. HITT antibodies were sent x3 and were negative. Heparin was restarted, and platelets increased despite heparin infusion, so most likely etiology of thrombocytopenia was cytoxan effect. Reason for DVT not known, but was in bed for 3 months previously, so could have been due to this. Full hypercoag w/u was not sent in acute setting. She was treated w/ coumadin for long-term anticoagulation in the hospital. At d/c, INR is therapeutic at 2.8. She will require close monitoring of INR and coumadin dosing after d/c, for at least 6 months of anticoagulation with goal INR [3-6]. Total duration of therapy to be determined by her PCP. 6) Anemia-She had a problem with anemia during admission. Has had this long term. Iron studies suggest anemia of chronic disease as low TIBC. Fe low, but ferritin very high, pointing away from Fe-def anemia. She was started on Epogen and received several blood transfusions over course of stay. Considered bleeding, and pt did have several bloody stools near end of admission. GI consulted at this point, and she had a colonoscopy and EGD which showed proctitis and gastritis/esophagitis. GI team did not have good explanation for these findings, but did say could all be part of a vasculitis. Given no obvious source of bleeding, her heparin was restarted and her Hct was monitored closely. HCT remained stable in the mid-30s during the later part of her admission. At d/c, HCT is stable w/ no evidence of bleeding. 7) ID-Her WBC ct climbed to ~25 after initiaition of prednisone. Unclear if infection or steroid effect. WOuldn;t mount fever on high dose prednisone. Started on levofloxacin several times for borderline UAs, and for possible PNA given inability to r/o on CXR due to heart failure obscuring image. This was eventually stopped. Her WBC ct then trended down. Unsure if treated infection or not. Also, initiated Bactrim ppx for PCP given high level of immunosuppression. This was then stopped ~10 days later due to concern that this was causing thrombocytopenia. No other evidence of infection clincally or on lab tests. She had initially elevated LFTs, and hepatitis serologies were sent and negative. [Month (only) 116] have been up due to hepatic congestion in setting of heart failure. 8) Pulmonary-As above, pt initially with heart failure due to volume overload. Had echo which showed nL EF and valves. SHe was diuresed effectively with Lasix and pulmonary status improved. AS disease progressed, function started to worsen, and CXRs were c/w pulmonary edema. Escalating doses of lasix were used, but her kidneys stopped responding after a point. Her O2 was gradually turned up, and at this point, HD initiated. Result in resolution of O2 requirement as fluid was taken off. She had question of obscured consolidation on several CXRs, and was treated on levo due to high WBCs and possible PNA. This was stopped after several day course. Unknown whether had a true PNA or not. Was oxygenating well on D/C 9) CV-Echo as above. Otherwise, had persistent pulmonary edema as a result of hypoalbuminemia and volume overload. This resolved on HD, and remained well controlled on lasix after HD was stopped. HTN as above. 10) Derm-She had palpable purpura on her arms and trunk during admission. This faded over time. Derm was consulted while rash present and biopsied area on back. This showed "Necrotizing arteritis affecting small deep dermal artery and upper dermal venule". Team felt was c/w a vasculitis or her Sjogren's. 11) Heme-Investigated possible hemolysis, and had low haptoglobin meaurements. Was in setting of blood transfusions though, so not sure if accurate. Bilirubin always WNL. At d/c, there is no evidence of hemolysis. 12)GI- Bleeding as above. Also, had mildly elevated transaminases. Can be caused by Sjogren's alone. Hepatitis serologies negative. CT without stone or obstruction, and she had no abd pain. Likely all due to underlying problems and not primary liver issue. 13)Hyponatremia-Pt developed hyponatremia here, but was never symptomatic. This is believed to be related to her underlying renal/volume overload issues, and plateaued near 128 after she started UF/HD. Again, she never developed symptoms. At d/c, sodium remains low but is slowly improving. She will need to continue fluid restriction to less than 2L per day, and reassess on follow-up. 14)Paget's Disease-Incidental finding on torso CT was likely Paget's disease in pelvis. She was treated pamidronate IV for this and had no complications. 15)Secondary Hyperparathyroidism:Pt had PTH level that was very high, likely result of her renal failure. Started her on calcitriol for this. Also on Tums as a phophate binder as needed. Can monitor need for this as kidneys recover. 16) Thrombocytopenia: Pt had gradually dropping platelet levels about 3 weeks into stay as above. Considered HITT and sent PF4 antibody, but plts continued to drop off of heparin. Considered Bactrim as possibility, so this was stopped, but no change in plt trajectory. Other considerations were Levaquin and diltiazem. Levo had been stopped. Plts reached a nadir 10 days after receiving Cytoxan for her proliferative GN, this is characteristic of Cytoxan making this a possible culprit. Pt had been on Argatroban while ruling out HIT (had 2 negative HIT ab) but then replaced on Heparin gtt/Coumadin on [1-28]. Plts improved daily, now normalized at d/c. 17) Pneumonia: 1 week before d/c, she was observed to by hypothermic, w/ temp down to 94F. She complained of cough at this time. CXR demonstrated increased volume overload in the lungs bilaterally, but did not show clear evidence of infiltrate. Given hypothermia and cough, she was treated empirically w/ vancomycin and zosyn to begin an 8 day course. At d/c, cough is improving and hypothermia has resolved, w/ current temp 96.6F. There is no evidence of active infection. She will need to continue vancomycin and zosyn after d/c to complete her 8 day course, w/ last dose of zosyn to be given on [2177-2-10]. 18) Communication: questions about this patient and her complex hosptial course may be directed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 2756], pager # [Numeric Identifier 9522]) Medications on Admission: Neurontin 100 qhs Simvastatin 5 qday Norvasc 5 qday ASA 325 qday Vit E 100 U qday Calcium citrate po BID art tears MVI Discharge Medications: 1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 2. Artificial Saliva 0.15-0.15 % Solution Sig: 5-10 MLs Mucous membrane PRN (as needed). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 7. Diltiazem HCl 60 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) for 7 days. 13. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Epoetin Alfa 10,000 unit/mL Solution Sig: [Numeric Identifier 961] ([Numeric Identifier 961]) units Injection QMOFR (Every Monday and Friday). 15. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM. 17. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: 2.25 gm Intravenous Q8H (every 8 hours) for 3 days: last dose to be given on [2177-2-10]. 18. Vancomycin HCl 10 g Recon Soln Sig: Five Hundred (500) mg Intravenous once for 1 doses: give 1 500mg dose on [2177-2-8], then discontinue medication. 19. Prednisone 5 mg Tablet Sig: Forty Five (45) mg PO QAM for 7 doses: give for 7 days, then decrease dose to 40mg. 20. Prednisone 5 mg Tablet Sig: Forty (40) mg PO QAM for 7 days: give from [2177-2-15] to [2177-2-21], then decrease dose to 37.5mg. 21. Prednisone 5 mg Tablet Sig: 37.5 mg PO QAM for 7 doses: give from [2177-2-22] to [2177-2-28], then taper daily dose by 2.5mg per week. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: 1. Acute renal failure due to pauci-immune glomerulonephritis 2. CHF/volume overload 3. Hyponatremia 4. Hypoalbuminemia 5. Peripheral Neuropathy 6. Paget's Disease 7. Secondary Hyperparathyroidism 8. Thrombocytopenia 9. HTN 10.Anemia 11. GI bleed 12. Cryoglobulinemia 13. RLE DVT 14. Anasarca 15. Hematuria 16. Sjogren's Syndrome Discharge Condition: Stable to go to rehab, oxygenating on room air, no signs of active infection. Discharge Instructions: Please tell the doctors/staff at rehab if you have any shortness of breath, chest pain, dizziness, abdominal pain. Also tell them if you have any other symptoms which are concerning to you. You will need antibiotics for 3 days after discharge, and will need daily lasix. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 4090] on [2177-2-11] at 11AM at the [Hospital ] Clinic ([Telephone/Fax (1) 27738]) Follow-up with your PCP (SUTARIA,DHIREN K. [Telephone/Fax (1) 59986]) in [3-6] weeks. Admission Date: [2177-2-8] Discharge Date: [2177-2-28] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 6346] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Exploratory laparotomy, splenic flexure takedown, left colectomy, colonic intraoperative lavage, appendectomy, colorectal anastomosis and gastrostomy History of Present Illness: 82F with Sjogrens, vasculitis, GI bleed, HTN who p/w GIB. Pt was recently admitted fr [2177-1-1] to [2177-2-7]. That extended admission, pt initially p/w R popliteal DVT, renal failure, CHF, and ascites, and was ultimately diagnosed with a poliferative GN, as well as numerous other incidental findings. She was Tx w/prednisone and Cytoxan and creatinine stabilized. Course was c/b thrombocytopenia (etiology ultimately thought to be Cytoxan). RIJ tunneled catheter was placed, and she was treated for significant volume overload with UF. . Course also c/b palpable purpura, thought to be vasculitis secondary to Sjogren's, hyponatremia, and was started on 10-day course of vanc/zosyn for possible hospit-acquired PNA. . Her course was also c/b anemia, and a thorough GI workup was undertaken: -EGD showed gastritis/esophagitis -colonoscopy showed proctitis with erythema and small ulcers, diverticulosis, and grade 2 internal hemorrhoids, and a cecal polyp. . Today, at nursing home, pt experienced ~500cc BRBPR and was transferred back to [Hospital1 18] for further evaluation. . In ED NG lavage negative (250cc but no bilious return). She was given 2U FFP. Pt was worked up by NF for planned medicine floor admission. However, pt's Hct 35->28 & pt had large B.M. of maroon-colored stool. GI contact[Name (NI) ] & will see in AM. Plan ICU monitoring given large blood loss. Past Medical History: Acute renal failure, pauci-immune glomerulonephritis. S/p RIJ tunneled HD catheter RLE DVT GI bleed Diverticulosis Sjogren's Syndrome ?vasculitis pleural effusions, pericardial effusion Raynaud's Cryoglobulinemia papillary neoplasm is an incidental finding of uncertain significance renal cysts HTN hyperlipidemia Anemia CHF/volume overload Hyponatremia Hypoalbuminemia Peripheral Neuropathy Paget's Disease Secondary Hyperparathyroidism Thrombocytopenia (thought related to cytoxan) Hematuria Social History: Came fr rehab facility. Lives at home with 83 yo sister. Retired in [2162] from career as admin asst.; Never married. No children. No smoking hx, and previously [3-6] EtOH drinks/wk. Family History: Father died at age 35 of stomach CA. Mother died at age 89. No known FH of liver, kidney, premature cardiac dx, malig, Lupus, or Sjogren's. . Meds on admission (see end of note) Physical [Month/Day (3) ]: T 95.4 HR 73 BP 194/69 to 220/80 RR 20 95% RA Gen: patient appears stated age, found lying flat in bed, in NAD HEENT: Sclera anicteric, conjunctiva uninjected, PERL, EOMI, MMM, no sores in OP Neck: no JVD, no LAD, nl ROM Cor: RRR nl S1 S2 no M/R/G Chest: clear to percussion and asculation Abd: soft, NT/ND, +BS. No HSM appreciated. EXT: no calf tenderness. No edema Neuro: MS [First Name (Titles) ] [Last Name (Titles) ], CN II-XII in tact, UE/LE strength 5+ bilaterally, 2+ DTRs (biceps, triceps, patellar), nl cerebellar [Last Name (Titles) ] Pertinent Results: . . . . . . . . . . . . . . . . . . . . . . . . Brief Hospital Course: A/P: 82F w/MMP including Sjogren's, renal failure secondary to proliferative GN, RLE DVT, who represents to ED (on same day as discharge after lengthy hospital stay) with GIB in setting of coumadin anticoagulation. . # GIB: given FFP in ED, holding coumadin, follow INR, consider vit K. After large maroon BMs in ED and Hct 35->28 (although partly dilutional fr 2U FFP). - follow serial Hcts. 2 large-bore PIVs. Ordered 2U PRBC. T&C add'l units. - GI saw pt in ED & plan flex sig in a few hours after saline or tap water enemas . # RLE DVT - holding coumadin, given recurrent GIB, may require filter. . # Proliferative GN/renal failure: Cr 2.7 now, somewhat increased from recent baseline of 2.2, though was as high as 4.0 on recent admission. - Cont prednisone qd, has been weaning by 5mg per week on alternating days (currently 50mg/45mg, started [2177-2-3]) - cont monthly Cytoxan (s/p 1st dose on [1-17]) - Cont lasix (80 daily), Calcitriol, Vit D, CaCO3 . # PNA: recently started on empiric therapy for ?hospital-acquired PNA on vanco/zosyn - was due for last vanco dose 1/8, will dose after level returns. - cont zosyn through [2-10] . # Hyponatremia: stable, continue fluid restriction 1500cc . # Anemia: likely multifactorial, w/ contribution from iron deficiency, GI bleeds, and Cytoxan. Cont Epo Q M,W,Fr . # HTN: continue diltiazem, isordil (note: lopressor seems associated w/hypothermia in this pt. Will avoid lopressor) . # Neuropathy: stable on Neurontin . # Sjogren's: stable currently. Continue artif tears, saliva . # Skin: pressure sores - has two sacral decubs. Nepro supplementation, wound care. . # FEN: low sodium Renal diet; fluid restriction; follow lytes PPI - bowel regimen, sc heparin # PPX: sucralfate, PPI; NO pneumoboots given known DVT # Access: PIV # Code: full # Dispo: back to rehab when stable # Communication: questions about this patient and her complex hosptial course may be directed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Patient was taken to OR on [2-13] for: Exploratory laparotomy, splenic flexure takedown, left colectomy, colonic intraoperative lavage, appendectomy, colorectal anastomosis and gastrostomy POD 1: Postoperatively she was admitted to the SICU and kept intubated overnight. She was kept on Levo and Flagyl. Heme-onc was consulted because of bleed and h/o DVT. Following the labeling of Tc-[Age over 90 ]m red blood cells a GI bleed study was performed over a 9 minute period. The study does not demonstrate any evidence of active GI bleeding. POD 2 Vascular surgery was consulted and an A-gram showed: The arterial blood supply of the right colon is unremarkable. There is no evidence of active extravasation or early draining veins. No active bleeding is noted in the small bowel. Note is made of diffuse hyperemia of the entire small bowel in the parenchymal space without evidence of active extravasation. The stomach and duodenum are unremarkable on the celiac angiogram. She underwent bronchoscopy that did not show any mucous plugging. POD 8 Pt was extubated. POD 9 a duplex doppler: REASON: Prior popliteal DVT. Evaluate for extension from the tibial veins to the common femoral veins. There is no evidence of thrombus obstruction. There is normal compression, augmentation, and phasicity. Compared to the prior study, which identified the right popliteal vein thrombus, there is nothing visualized on the current study. POD 10 a speach and swallow study showed: The pt was able to tolerate small cup sips of nectar thick liquid and bites of puree without overt s/s of aspiration. She will require assistance at meals. She will require cues to swallow 2X per bite of food. Ms. [Name14 (STitle) 59987] will likely not be able to take in enough po at this time to maintain weight/nutritional status and should continue being fed primarily via PEG, with supplemental po's, with goal of weaning from tube feeds. RECOMMENDATIONS: 1.DIET: Nectar thick liquids/pureed solids The pt should continue to be fed primarily via peg at this time with supplemental po's as stated above 2.Pt will require assistance at meals Small cup sips of nectar thick liquid Always start meal with sips of liquid Pt should be cued to swallow 2X per bite Alternate between one bite food/one sip liquid 3.Consider nutrition consult to determine caloric/supplemental needs for pt receiving tube feeds and po's with goal to wean from peg POD 13 Patient is being discharged on a Prednisone taper.Steroid taper. She is currently on prednisone 35 QD. [Date range (1) ] 35 QD [Date range (1) 23502] 30 QD [3-6] -[3-8] 25 QD [3-9] -[3-15] 20 QD [Date range (1) 59988] 15 QD [Date range (1) 41025] 10 QD [Date range (1) 59989] 5 QD Note: Dr. [First Name (STitle) 2819] does not want the patient to be anticoagulated at this point. Other consults during her complicated hospital stay include GI and Renal. Medications on Admission: Meds on admission: 1. Polyvinyl Alcohol 1.4 %, 1-2 Drops Ophthalmic PRN 2. Artificial Saliva PRN 3. MVI 4. folic acid 1 mg qd 5. Cyanocobalamin 1000 mcg DAILY 6. Neurontin 100 mg TID 7. Diltiazem 90 mg QID 8. Isosorbide Dinitrate 40 mg TID 9. Calcium Carbonate 500 mg TID W/MEALS 10. Trimethoprim-Sulfamethoxazole 80-400 mg 1 Tablet PO DAILY 11. Calcitriol 0.25 mcg PO DAILY 12. Clotrimazole 10 mg Troche QID for 7 days 13. Ranitidine 75 mg Tablet [Hospital1 ] 14. Epoetin Alfa 10,000 unit/mL Solution Sig: [Numeric Identifier 961] U Inj QMOFR 15. Warfarin 1 mg Tablet HS 16. Furosemide 40 mg QAM 17. Piperacillin-Tazobactam 2.25gm IV Q8H x 3 days (last dose [2177-2-10]) 18. Vancomycin: give 1 500mg dose on [2177-2-8], then discontinue medication. 19. Prednisone 45 mg PO QAM for 7 doses decrease dose to 40mg Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One (1) Dropperette Ophthalmic PRN (as needed). 2. Artificial Saliva 0.15-0.15 % Solution Sig: 5-10 MLs Mucous membrane PRN (as needed). 3. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 4. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Mucous membrane PRN (as needed). 5. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 9. Acetaminophen 160 mg/5 mL Elixir Sig: Two (2) PO Q8H (every 8 hours) as needed for pain. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Diltiazem HCl 360 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily): Hold for SBP < 100 or Pulse < 60. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): see taper. Tablet(s) 15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Lower gastrointestinal bleeding ARF DVT diverticulosis Sjogrn's syndrome Raynaud's HTN hyperlipidemia anemia s/p tunneled line Discharge Condition: Stable Discharge Instructions: 1. Keep wound area clean and dry. Take medications as prescribed. Seek medical attention if you experience fever, chills, nausea, vomiting, increased abdominal pain, or bleeding. 2. Remove staples in one week. 3. Steroid taper. She is currently on prednisone 35 QD. [Date range (1) ] 35 QD [Date range (1) 23502] 30 QD [3-6] -[3-8] 25 QD [3-9] -[3-15] 20 QD [Date range (1) 59988] 15 QD [Date range (1) 41025] 10 QD [Date range (1) 59989] 5 QD 4. Dr. [First Name (STitle) 2819] does not want her to be anticoagulated at this point. Followup Instructions: Please contact Dr.[Name2 (NI) 11471] office at [Telephone/Fax (1) 2998] within the first few days after discharge to schedule a follow-up appointment. Completed by:[2177-2-28]	[ "789.5", "276.1", "784.7", "285.1", "562.12", "535.01", "416.8", "583.0", "V58.65", "287.5", "401.9", "710.2", "286.9", "280.0", "707.03", "486", "518.81", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "45.75", "46.96", "99.15", "99.04", "96.34", "33.22", "96.6", "47.19", "44.43", "88.47", "96.04", "43.19", "45.23", "21.01", "45.24", "45.13", "99.07" ]	icd9pcs	[ [ [] ] ]	33583, 33655	26228, 31197	23053, 23205	33826, 33834	26156, 26205	34458, 34647	25367, 26137		32075, 33560		33676, 33805		31223, 31228			33858, 34435									1281, 1741																					22986, 23015							23233, 24626									31242, 32052						24648, 25143	25159, 25351
10,057	125,206	3300	Discharge summary	report	Admission Date: [2183-1-1] Discharge Date: [2183-2-3] Date of Birth: [2127-12-9] Sex: F Service: MEDICINE Allergies: Codeine / Darvon / Nafcillin Attending:[First Name3 (LF) 689] Chief Complaint: s/p recent fall with "inability to walk." Major Surgical or Invasive Procedure: #L2-S1 laminectomy, foraminotomy, facetectomy, irrigation, for severe spinal stenosis and epidural abscess on [2184-1-2]. #C2-C7 laminectomy, irrigation for epidural abscess. C3-C7 posterior instrumentation and fusion for cervical instability on [2183-1-8]. #Aspiration of retropharyngeal abscess. #Chest tube placement for pulmonary empyema. #Bilateral knee arthrocentesis, partial synovectomy, surgical debridement and washout for septic joints on [2183-1-10]. #Debridement of postoperative lumbar wound, decompression of L4-L5 and repair of dural leak on [2183-1-25]. History of Present Illness: pt is a a 55 F with h/o RA (on methotrexate, enbrel, prednisone) and spinal stenosis who presented to [Hospital1 18] on [2184-1-1] s/p recent fall with "inability to walk." Pt apparently had developed increasing weakness of her lower extremities with some urinary incontinence. Upon arrival to [Name (NI) ] pt was treated with narcotics for pain of the left lower extremity and back, and developed mental status changes. Her O2 sats acutely dropped, (etiology unclear, [2-7] narcotics versus infiltrate), with tachycardia to 140s, hypoxia to 88%, and CTA showing RLL/RML opacity but no PE. Pt was intubated for airway protection and transferred to MICU. . MRI spine on [1-1] revealed severe L3-L5 spinal stenosis for which pt underwent lumbar decompression of L2-S1 on [1-2] with gross pus evident in epidural space. X-ray of the foot revealed left ankle fracture, for which she was placed in a walking cast. She also had cervical and retropharyngeal abscesses, for which she underwent cervical decompression and drainage of cervical abscesses, from C2-C7, with instrumentation and fusion from C3-C7, on [2183-1-8]. Retropharyngeal abcesses were drained, and she had bilateral knee arthrocentesis and washout for septic joints. Pt was treated with vancomycin after nafcillin resulted in rash (pt seen by derm, termed "drug hypersensitivity"). In addition, on [1-3] pt noted to have SVT, with rate up to the 160s, and SBP decrease. She was cardioverted x2 and started on amiodarone, which has since been discontinued. Pt seen by cardiology, without apparent further recommendation. . Pt most recently taken to OR on [2183-1-25] for debridement of postoperative lumbar wound, and decompression of L4-5 and repair of dural leak after pt was persistently febrile and MRI of lumbar spine showed fluid collection (+GPC per aspiration). Pt last febrile on [1-25]. . Pt exubated on [1-21] per notes, and now breathing comfortably on RA. Lower extremity weakness appears largely resolved, though pt signficantly deconditioned [2-7] hospitalization. Per ortho/spine, pt full weight bearing, though must wear hard cervical collar at all times, and TLSO brace whenever out of bed. Past Medical History: HTN Rheumatoid arthritis depression migraine hiatal hernia anxiety spinal stenosis lumbar radiculopathy myofascial pain Social History: Single, She is [Name8 (MD) ] RN but has been working as a nurse's aid. Drinks EtOH rarely, denies smoking or other drug use. Family History: Mother with CAD, duodenal ulcers. Father with CAD died of esophageal CA with mets to the brain. Breast cancer in paternal aunt. Physical Exam: On presentation to the ED: VS: 98.3 132 142/72 16 95%RA GEN: Uncomfortable with movement HEENT: PERRLA, EOMI, sclera anicteric, OP clear, dry mucous membranes, no LAD CV: tachy, nl s1, s2, no m/r/g. PULM: CTA anteriorly ABD: soft, mild diffuse tenderness EXT: warm, 2+ dp/radial pulses BL. finger ulnar deviation, swollen PIP and MCP joints. echymosis of left ankle NEURO: alert & oriented x 3, CN II-XII grossly intact. PSYCH: tangential Pertinent Results: [2183-1-1] 03:55PM GLUCOSE-133* UREA N-48* CREAT-0.8 SODIUM-141 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14 [2183-1-1] 04:03PM LACTATE-2.1* [2183-1-1] 05:22PM TYPE-ART O2-100 PO2-250* PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 AADO2-429 REQ O2-73 INTUBATED-INTUBATED VENT-CONTROLLED [2183-1-1] 03:55PM GLUCOSE-133* UREA N-48* CREAT-0.8 SODIUM-141 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14 [2183-1-1] 05:42PM PT-12.3 PTT-28.2 INR(PT)-1.1 [2183-1-1] 03:55PM ALT(SGPT)-28 AST(SGOT)-48* LD(LDH)-228 ALK PHOS-184* AMYLASE-24 TOT BILI-0.5 [2183-1-1] 03:55PM CK-MB-5 cTropnT-<0.01 [2183-1-1] 03:55PM ALBUMIN-2.4* [2183-1-1] 03:55PM WBC-4.6 RBC-3.93* HGB-10.6* HCT-30.8* MCV-78* MCH-27.0 MCHC-34.5 RDW-18.0* [2183-1-1] 03:55PM NEUTS-72* BANDS-13* LYMPHS-9* MONOS-5 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2183-1-8] 02:44AM BLOOD Neuts-90.8* Bands-0 Lymphs-7.3* Monos-1.4* Eos-0.4 Baso-0 [2183-1-17] 05:26PM PLEURAL WBC-450* RBC-1570* Polys-11* Lymphs-62* Monos-2* Meso-12* Macro-2* Other-11* [2183-1-17] 05:26PM PLEURAL TotProt-1.6 Glucose-130 LD(LDH)-147 [2183-1-9] 08:44AM JOINT FLUID WBC-6500* RBC-3700* Polys-97* Lymphs-1 Monos-2 [2183-1-7] 11:55AM JOINT FLUID WBC-[Numeric Identifier 15362]* RBC-[Numeric Identifier 15363]* Polys-85* Lymphs-3 Monos-12 [2183-1-9] 08:44AM JOINT FLUID Crystal-NONE [2183-1-7] 11:55AM JOINT FLUID Crystal-NONE [2183-1-24] 11:45AM OTHER BODY FLUID TotProt-1.5 [2183-1-24] 11:45AM OTHER BODY FLUID TotProt-0.4 Glucose-54 [2183-1-31] 05:52AM BLOOD WBC-9.5 RBC-3.28* Hgb-9.3* Hct-29.3* MCV-89 MCH-28.3 MCHC-31.7 RDW-16.2* Plt Ct-521* [2183-1-31] 05:52AM BLOOD Neuts-70.0 Lymphs-19.0 Monos-7.1 Eos-3.0 Baso-0.9 [2183-1-31] 05:52AM BLOOD Glucose-79 UreaN-9 Creat-0.4 Na-134 K-3.5 Cl-98 HCO3-29 AnGap-11 [2183-1-30] 06:30AM BLOOD ALT-16 AST-33 LD(LDH)-406* CK(CPK)-26 AlkPhos-112 TotBili-0.7 [2183-1-30] 11:31PM BLOOD CK(CPK)-9* [2183-1-31] 05:52AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1 [2183-1-30] 05:08PM BLOOD TSH-1.2 [2183-1-30] 05:08PM BLOOD Free T4-1.4 [2183-1-2] 03:21PM BLOOD Cortsol-7.5 [2183-1-29] 05:40AM BLOOD CRP-66.6* [2183-1-2] 10:15AM BLOOD PEP-HYPOGAMMAG IgG-312* IgA-119 IgM-35* IFE-POSSIBLE T [2183-1-30] 06:30AM BLOOD Vanco-30.7* [2183-1-31] 05:52AM BLOOD WBC-9.5 RBC-3.28* Hgb-9.3* Hct-29.3* MCV-89 MCH-28.3 MCHC-31.7 RDW-16.2* Plt Ct-521* [2183-1-27] MRSA blood cultures negative [2183-1-27] VRE rectal swab negative . IMAGING: CT ABDOMEN W/CONTRAST [2183-1-1] 6:01 PM 1. No major organ injury in the abdomen. 2. Bilateral acute and chronic rib fractures as described above, as seen on the prior chest CT. 3. Bilateral pleural effusion with bibasilar atelectasis as seen on the prior CT. 4. Small left retroperitoneal fluid. . CTA CHEST W&W/O C &RECONS [2183-1-1] 11:40 AM 1. Airspace opacities in the lower lobe and right middle lobe with volume loss suggesting atelectasis, but pneumonia cannot be completely excluded on the radiology basis. 2. Bilateral pleural effusions. 3. No pulmonary embolus identified. 4. Multiple old fractures of the ribs bilaterally at different stages. Some are clearly healed, some are healing and some appear somewhat acute. Clinical correlation is recommended. . MR L SPINE W/O CONTRAST [2183-1-1] 5:56 PM At L2/3, moderate canal stenosis due to degenerative changes and epidural lipomatosis. At L3/4 and L4/5, severe canal stenosis and severe right foraminal stenosis due to combination of degenerative changes, disk herniations, and epidural lipomatosis. . CHEST (PA & LAT) [2183-1-1] 8:45 AM Bibasilar atelectasis with possible infiltrate at the right base. No other obvious acute findings. . ANKLE (AP, MORTISE & LAT) LEFT [2183-1-1] 7:04 AM 1. Base of fifth metatarsal fracture. 2. Possible nondisplaced distal fibular fracture. . ECG Study Date of [2183-1-1] 4:23:48 PM Sinus tachycardia Right bundle branch block Low voltage Inferior ST segment elevation suggestive of inferior myocardial infarction Since previous tracing of [2182-12-2], inferior changes are new - clinical correlation is suggested . ECHO Study Date of [2183-1-3] The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. . MR [Name13 (STitle) ] W& W/O CONTRAST [2183-1-11] 9:43 PM 1. Overall improved prevertebral area of abscess seen on [2183-1-6]. Secondary to inadequate post-contrast T1-weighted images, the tissue remaining in this area could represent either persistent abscess versus postoperative changes. If clinically indicated, a repeat, contrast-enhanced scan could be performed. 2. Unchanged intraspinal epidural signal that overall appears less extensive compared to previous exam. 3. New hyperintense signal at the T2 to T3 interspace could represent progression of discitis. 4. Likely bilateral pleural effusions. Infectious etiology cannot be ruled out based on these images secondary to poor post-contrast study. . CHEST PORT. LINE PLACEMENT [2183-1-31] 9:55 AM Interval placement of right-sided PICC line with tip in the right atrium. Brief Hospital Course: Upon arrival to [Name (NI) ] pt was treated with narcotics for pain of the left lower extremity and back, and developed mental status changes. Her O2 sats acutely dropped, (etiology unclear, [2-7] narcotics versus infiltrate), with tachycardia to 140s, hypoxia to 88%, and CTA showing RLL/RML opacity but no PE. Pt was intubated for airway protection and transferred to MICU. . MRI spine on [1-1] revealed severe L3-L5 spinal stenosis. X-ray of the foot revealed left ankle fracture, for which she was placed in a walking cast. She also had cervical and retropharyngeal abscesses, and was transferred to the SICU. . SICU Course Pt was admitted to SICU post-operatively after L3/L4 & L5/s1 decompression/laminectomy for epidural abscess on [1-2]. Neuro: PT was admitted with altered MS, and was maintained on propofol while intubated for sedation. . CV: PT had episode of SVT on [1-3], was shocked twice and returned to [Location 15364] was consulted and recommended amiodarone, which was d/c'd prior to transfer to floor. Pt had a TEE on [1-14] that was negative for thrombus (concern for septic emboli). Pt also had an IVC filter placed on [1-14] for PE prophylaxis. Pt was maintained on lopressor with tight BP control while in the SICU, and she had no further cardiac issues. . Resp: Pt was extubated initially on [2183-1-5], but was re-intubated on [2183-1-6] [2-7] respiratory distress. On [1-9], pt had R VATS/decortication/washout for R empyema, and on [1-17] pt had a pleural tap; the pleural fluid from [1-9] grew MSSA, and the pleural fluid from [1-17] was no growth. Additionally, the pt had 2 [Doctor Last Name ] drains post-operatively that were pulled on [1-16] and [1-22]. . Musculoskeletal: Pt had L3/L4 and L5/S1 laminectomy/decompression on [1-2], on [1-7] pt had C5-6 ACDF w/ICBG & Post Cervical decompression for cervical prevertebral abscess, on [1-9] pt had knee tap with MSSA and subsequent bilat knee washouts (left knee was not infected - the drains were d/c'd on [1-11]. On [1-24], pt went to IR for drainage of L3,4,5 collection (approx 10cc out). On [1-25], pt returned to OR w/ ortho spine for debridement of postoperative lumbar wound, and decompression of L4-5 and repair of dural leak after pt was persistently febrile and MRI of lumbar spine showed fluid collection (+GPC per aspiration). Pt last febrile on [1-25]. . ID: Pt was initially started on nafcillin/gentamicin; initial Cx were positive for MSSA and pt was maintained on nafcillin until [1-13], when she developed a drug rash and was changed to vancomycin. Additionally, on [1-18] pt developed papular rash over posterior thighs and peri-rectal area and was started on acyclovir. Pt was intermittently febrile without obvious source throug much of ICU stay, but was afebrile for several days prior to transfer to floor. Her pertinent Cx data is below: . [1-25]: abscess Cx: coag + staph [1-21]: UCx/BCx - NG [1-18]: +HSV2; skin tiss: rare CSNx2, enterr, coryn, diptheriod 1/12,11: BCx/Ucx/Scx/pleural/cath - all NG 1/7,8: Ucx/Scx/BCx/cdiffx2 - all NG [1-10]: L knee/cath - NG; R knee/pleur - MSSA; [1-9]: tissue/pleur - MSSA [1-8] Bld Cx neg; [1-7] tissue/joint/wound: MSSA; [1-2] C5-C6 Cx: MSSA 12/27,28,31: BLd Cx MSSA GI: While patient was intubated, she was started on tubefeeds for nutrition; following extubation, pt was advanced to a regular diet without problem. Pt was maintained on GI ulcer prophylaxis with H2-blocker while in the ICU. . Medicine Floor Course . #Neuro: mental status improved spontaneously. Neuro exam stable. CN2-12 intact, MAE. 4/4 strength B/L uppers, left > right. LE grossly intact bilaterally. wiggles left toes. hip flexion, knee flexion and extension [1-10] b/l. [5-10] [Last Name (un) 15365] and plantar flexion of right LE. left LE wiggles toes, mobility limited by cast. Per ortho/spine, pt full weight bearing, though must wear hard cervical collar at all times, and TLSO brace for 6 weeks whenever sitting up unsupported or out of bed. -Vancomycin was continued per ID recs for multiple abcesses, at least 8 week duration s/p [1-25] debridement. Hardware cleared for repeat MRI if needed. . # ID: last fever on [1-22] was 102.3, pt was followed by ID for multiple spinal abcesses, on vancomycin for MSSA given pt had rash in reaction to nafcillin (seen by derm, "drug hypersensitivity reaction" on [2183-1-13]). Pt was placed on acyclovir for perianal ulcers which grew HSV 2 on [2183-1-18], but this was d/c'ed [2183-1-28]. Leukocytosis trending down with normal diff. Prednisone for RA as above, but further immunosupression was avoided. Vancomycin was continued for now, plan for 8 week course s/p last debridement on [2183-1-25]. Vancomycin end date is [2183-3-24]. A psoas abcesses was too small to drain per IR. Bilateral knee swelling s/p arthrocentesis and washout decreased over time, without redness tenderness. Needs weekly CBC w/diff, BUN/creat ratio, vanco trough. . # PULMONARY: pt initially presented without respiratory symptoms, however was intubated in ED [2-7] increasing mental status changes (?[2-7] narcotic medications) for airway protection. subsequent CT showed ?right side pneumonia. Pt extubated on [1-5] s/p OR for spinal procedure, then reintubated on [1-6] (presumably [2-7] developing empyema felt [2-7] septic emboli for which pt went to OR on [1-9] for VATS and chest tube placement, though not clear), and extuabted on [1-21]. [Name (NI) 15366], pt without SOB, on RA. chest tube removed [1-27], and CXR s/p removal showing small right side effusion, no PTX, no pneumonia. O2 was weaned, and ipratropium nebs continued. . # CARDIAC: Pt was placed on telemetry. Episode of SVT on [1-30] to 120s, no chest pain or SOB. EKG showed sinus tachy, old RBBB and new ST depressions in V3, V4 and inferior leads. ST depressions quickly resolved. Troponin and CK-MB were negative x 3. Metoprolol increased in house to 75mg PO TID. ASA was started. . # RENAL: pt with foley in place, presumably placed given initial urinary incontinence, however, pt may be able to urinate on her own now. for now will continue foley given pt difficulty on bedpan. creatinine trending downward from 1.1. on admission to 0.5 presently, likely represents loss of muscle mass. . # GI: pt with h/o hiatal hernia, on omeprazole at home. Did not have complaints of abdominal pain presently, LFTs and alk phosphate mildly elevated on admission, now within normal limits. Pt tolerating regular diet without difficulty. Per intervential radiology, psoas abcess too small to drain. Lansoprazole continued given steroid regimen. . # GU: no urinary complaints presently, foley in place presumably [2-7] incontinence earlier during admission. . # ENDO: pt on prednisone chronically for RA, and initially received pulse dose of steroids (hydrocort/fludrocort) given concern for adrenal insufficiency. insulin sc sliding scale was dc/d on [2-1] due to blood sugars less than 150 for 24 hours. pt seen by endocrine service who recommend minimum dose of prednisone 10mg po qdaily give almost certain component of adrenal insufficiency. home regimen of prednisone 15mg qdaily (home regimen for RA) was continued . # PAIN: pt with h/o LBP [2-7] spinal stenosis, and myofascial pain syndrome. pt being seen by pain service during this admission. pt on ultram, oxycodone, and indomethacin at home. Was placed on hydromorphone transiently, but this decreased her alertness. now on percocet [1-7] tab PRN, fentanyl patch, standing acetaminophen and ibuprofen with meals . # RHEUM: Pt with h/o RA, on enbrel, methotrexate, indomethacin, sulfadiazine (?) at home, however (except prednisone) all are being held presently in light of multiple infections. Knee exam without obvious effusion presently, healing well s/p athrothrocentesis. will follow for now and encourage PT. Continued on nsaids for RA. DMARDS were not restarted due to abscesses. Should followup with her outpatient rheumatologist. . # PSYCH: Pt with h/o anxiety and depression, presently somewhat anxious, especially during movement, transition to sitting. Ativan was continuedprn. . #FEN: Advanced to regular diet with ensure for increased caloric intake. Mg and K were replete lytes as needed. . #PPx: Pt was given lovenox and IVC filter for DVT prophylaxis. PPI given steroid regimen. Bowel regimen . # DC to Rehab. Medications on Admission: HCTZ lisinopril 20 mg daily Toprol-XL 50 mg daily Caltrate Zovirax p.r.n. methotrexate 2.5 mg eight every week omeprazole 20 mg daily Indocin SR 75 mg b.i.d. prednisone 15 mg qd Cafergot sulfadiazine 500 mg b.i.d. Lidex ointment which she is not using actively now Ultram 50 mg q.6h. p.r.n. Fosamax one every week oxycodone one to two q.6h. p.r.n. Cymbalta 60 mg daily iron one b.i.d. Ambien CR 12.5 mg q.h.s Enbrel Discharge Medications: 1. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [Month/Day (2) ]: One (1) Appl Ophthalmic PRN (as needed). 3. Docusate Sodium 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day). 4. Miconazole Nitrate 2 % Powder [Month/Day (2) ]: One (1) Appl Topical QID (4 times a day) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Metoclopramide 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Camphor-Menthol 0.5-0.5 % Lotion [Last Name (STitle) ]: One (1) Appl Topical DAILY (Daily) as needed. 8. Mupirocin Calcium 2 % Cream [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for chronic pain. 10. Fentanyl 100 mcg/hr Patch 72HR [Hospital1 ]: One (1) Transdermal Q72H (every 72 hours). 11. Enoxaparin 30 mg/0.3 mL Syringe [Hospital1 ]: One (1) Subcutaneous Q12H (every 12 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 14. Simethicone 80 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gassy pain. 15. Tramadol 50 mg Tablet [Hospital1 ]: One (1) Tablet PO QID (4 times a day). 16. Acetaminophen 650 mg Suppository [Hospital1 ]: One (1) Suppository Rectal Q6H (every 6 hours) as needed for T>101.4. 17. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: Three (3) Tablet PO TID (3 times a day). 18. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 19. Oxycodone-Acetaminophen 5-325 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 20. Ibuprofen 600 mg Tablet [Hospital1 ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. Diphenhydramine HCl 25 mg Capsule [Hospital1 ]: One (1) Capsule PO HS (at bedtime) as needed. 22. Lorazepam 0.5-2 mg IV Q4H:PRN 23. Prednisone 5 mg Tablet [Hospital1 ]: Three (3) Tablet PO DAILY (Daily). 24. Vancomycin in Dextrose 1 g/200 mL Piggyback [Hospital1 ]: One (1) Intravenous Q18HR () for 7 weeks. 25. 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. 26. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: - Rheumatoid arthritis - Lumbar spinal stenosis - Cervical and lumbar epidural abscesses - Bacteremia - Fractured left ankle - Pulmonary empyema - Septic knee joints Discharge Condition: Stable Discharge Instructions: Please continue your hospital medications at rehab. Please obtain the following blood tests every week: CBC with differential, BUN/creatinine, vanco trough. Fax the results to the infectious disease clinic ([Telephone/Fax (1) ]. Followup Instructions: [Hospital1 18] CARDIOLOGY: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2183-2-12] 2:40pm PLEASE FOLLOWUP WITH RHEUMATOLOGY OUTPT PHYSICIAN. You have a follow-up appointment with your infectious disease provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2183-3-4] 10:30 You have a follow-up appointment with your orthopedic spine surgeon, DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 1228] Date/Time:[2183-3-13] 10:45	[ "E928.9", "693.0", "714.0", "427.1", "344.60", "344.00", "728.89", "518.81", "401.9", "E930.0", "038.11", "054.9", "995.92", "478.24", "324.1", "998.2", "711.06", "730.18", "510.9", "722.71", "567.31", "825.25", "V58.65" ]	icd9cm	[ [ [] ] ]	[ "96.04", "99.04", "99.62", "38.93", "00.17", "03.59", "81.03", "34.51", "96.72", "81.63", "99.07", "81.91", "84.51", "81.02", "80.51", "96.6", "38.7", "77.79", "83.95", "89.64", "99.05", "88.72", "03.09", "80.76" ]	icd9pcs	[ [ [] ] ]	21755, 21825	9845, 18438	328, 918	22035, 22044	4083, 9822	22327, 23016	3469, 3600		18904, 21732		21846, 22014		18464, 18881			22068, 22304									3615, 4064																					247, 290							946, 3164															3186, 3307	3323, 3453
24,687	145,249	94	Discharge summary	report	Admission Date: [2145-12-9] Discharge Date: [2145-12-16] Date of Birth: [2097-8-4] Sex: M Service: MEDICINE Allergies: Bactrim Ds / Indomethacin / Linezolid Attending:[Last Name (NamePattern4) 290] Chief Complaint: found down Major Surgical or Invasive Procedure: Intubated; extubated successfully History of Present Illness: 48 y.o. M with h/o AIDS (CD 4 105 [11-13]), HCV, asthma, h/o TB, h/o PCP, [Name10 (NameIs) 1023] was found down today by VNA [12-9] sitting in urine "indian" style. Unknown down time, patient was last seen on [2145-12-6]. Patient was responsive to touch with grimaces, but not following comands. [Name (NI) 1094] brother was [Name (NI) 653] and full code was confirmed in ED, along with confirmation by PCP. [Name10 (NameIs) ] was subsequently intubated after Etomidate/Succinylcholine. Patient's VS were 96.8, patient was placed on bearhugger, they were 101.6 upon transfer to the MICU. Patient's HR was 122 initially, after given 1 L NS, then 3 L LR, and his HR was down to 60-70s. His SBP remained in 140s-160s. Patient was oxygenating well on 2L (100%) but was intubated for airway protection. Patient was started on propofol gtt for precautions. He was started on vanco/zosyn/CTX. Patient of note recently admitted on [11-30] to [12-2] after being found down, however patient left after full completion of medical therapy. It is very likely that he is noncompliant with his medications. Patient in ED had a L IJ placed, RIJ was attempted but was complicated by R carotid puncture. Patient subsequently has a 6 cm hematoma on the R side. His CTA is also concerning for possible opportunistic infectious including TB. ROS: patient unable to provide. Past Medical History: 1. HIV/AIDS - last CD4 105, VL > 100,000 on [11-13], off HAART because of suicidality and depression, on dapsone ppx for PCP [Name Initial (PRE) ] [Name10 (NameIs) 1095] noncompliant 2. Hepatitis C 3. Asthma 4. h/o Tuberculosis ([2129], now resolved) 5. h/o PCP x 2 6. h/o pericarditis ([2139]) 7. h/o pneumococcal pneumonia with bacteremia ([11-10]) 8. h/o LLL pneumonia ([12-11]) 9. h/o MAC on BAL ([5-11]) 10. h/o Neuropathy, thought [1-8] HIV 11. Disseminated herpes zoster [2144] 12. ? depression. 13. h/o pseudomonal pneumonia (+BAL- pan sensitive) Social History: +smoker-- <1 ppd X 25 years, + h/o IVDA in past, + MJ 3 marajuanas per week, No etoh per pt. sexually active "occasionally" with one [Last Name (un) 1063], same partner for the last 4 years. Family History: NC Physical Exam: Physical Exam: 101.5 122 111/87 19 100% 50%/500x 14 5 GENERAL: frail, cachectic appearing male, comfortable, no responding to pain, temporal wasting HEENT: neck collar, R hematoma ~ 3 cm. CV: tachycardic, dynamic precordium, no extra HS appreciated LUNGS: CTAB/l, no focal findings appreciated, good air movement b/l ABDOMEN: + BS, snt/nd, no guarding EXTREMITIES: no edema, several bruises on b/l lower extremities, + 1 DP b/l Neuro: responds to painful stimuli, does not follow commands, opens eyes to pain, no blink reflex Pertinent Results: [2145-12-9] 01:00PM PT-14.5* PTT-29.6 INR(PT)-1.3* [2145-12-9] 01:00PM PLT SMR-NORMAL PLT COUNT-337 [2145-12-9] 01:00PM WBC-9.0# RBC-4.60# HGB-14.9# HCT-45.3# MCV-99* MCH-32.5* MCHC-33.0 RDW-14.6 [2145-12-9] 01:00PM NEUTS-53 BANDS-4 LYMPHS-35 MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2145-12-9] 01:00PM CALCIUM-10.5* PHOSPHATE-6.9# MAGNESIUM-3.0 [2145-12-9] 01:00PM cTropnT-0.03* [2145-12-9] 01:00PM LIPASE-37 [2145-12-9] 01:00PM ALT(SGPT)-82* AST(SGOT)-113* CK(CPK)-3996* ALK PHOS-58 AMYLASE-139* TOT BILI-0.8 [2145-12-9] 01:00PM GLUCOSE-142* UREA N-89* CREAT-1.6* SODIUM-160* POTASSIUM-3.4 CHLORIDE-121* TOTAL CO2-22 ANION GAP-20 [2145-12-9] 01:07PM LACTATE-4.8* K+-3.8 [2145-12-9] 01:16PM LACTATE-3.4* [2145-12-9] 01:50PM AMMONIA-21 [2145-12-9] 05:37PM ACETMNPHN-NEG [2145-12-9] 08:59PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG mthdone-NEG [2145-12-9] 09:04PM ASA-5 ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG studies: CT abd/pelvis [2145-12-9]: 1. Nodular opacities within a bronchovascular distribution most notable in the left lung base and less so on the right most consistent with aspiration pneumonia given clinical history. However given immunocompromised status atypical infections including tuberculosis must be considered and respirtory precautions advised. 2. Cystic pancreatic tail lesion also noted on study from [2141] without detectable change. 3. Generalized cachexia, likely AIDS-wasting syndrome . CT C-spine [2145-12-9]: 1. Right supraclavicular fossa hematoma corresponding with recent central venous line attempt in this location. 2. No evidence of acute fracture or dislocation. 3. Partially imaged right apical opacity and right apical subpleural blebs. . CT head [2145-12-9]: 1. No acute hemmorage or mass effect. 2. Mild cerebral atrophy which is not age appropriate consistent with HIV encephalopathy. 3. Confluent regions of hypoattenuation in the deep white matter which is unchanged from [Month (only) 1096] yet new since [2141]. While this may represent sequlae of HIV encephalopathy, an underlying infectious etiology such as PML may be considered and an MRI may be helpful. . CXR [2145-12-9]: IMPRESSION: 1. Slightly low lying ET tube, approximately 3 cm above the carina. This could be withdrawn slightly. 2. Small, patchy opacities at the left lung base which appear to correspond to tree-in-[Male First Name (un) 239] opacities seen on previous chest CT . MRI head [2145-12-10]: 1. No evidence of bacterial or fungal infection. However, extensive white matter hyperintensity is often found in patients with HIV encephalopathy. 2. Several foci of apparent infarction or encephalitis in the corpus callosum raise the possibility of meningitis. . Echo [2145-12-13]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A 24mmHg peak mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [2144-2-6], left ventricular systolic function is now dynamic with a higher heart rate and mild resting mid-cavitary gradient. Is there a history to suggest a high output state (e.g., thiamine deficiency, hyperthyroidism, anemia, fever, etc.? . CT chest w/o contrast [2145-12-16]: . . Micro: Blood cultures [2145-12-9], 2 sets - No growth final Blood fungal culture [2145-12-9] - No Growth (preliminary) Urine legionella [2145-12-9] - negative Blood for Cryptococcal Ag [2145-12-9] - negative TOXOPLASMA IgG ANTIBODY (Final [2145-12-10]): EQUIVOCAL FOR TOXOPLASMA IgG ANTIBODY BY EIA. 4 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [2145-12-10]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. CMV [2145-12-9] - positive for IgG, negative for IgM, viral load undetectable Sputum [2145-12-9] - SPARSE GROWTH OROPHARYNGEAL FLORA. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. WORK-UP IDENTIFICATION AND SENSITIVITIES PER DR.[First Name (STitle) ] PAGER [Numeric Identifier 1097] [2145-12-13]. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. WORK-UP IDENTIFICATION AND SENSITIVITIES PER DR. [First Name (STitle) ] PAGER [Numeric Identifier 1097] [2145-12-13]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2145-12-10]): NEGATIVE for Pneumocystis jirvovecii (carinii). ACID FAST SMEAR (Final [2145-12-10]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. CSF [2145-12-10] - negative for cryptococcal Ag, HIV viral load: Greater than 100,000 copies/ml, Culture: GRAM STAIN (Final [2145-12-10]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2145-12-13]): NO GROWTH. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BAL [2145-12-10]: culture: no growth stool [2145-12-10]: Negative culture and POSITIVE for Cdiff [2145-12-10] Rapid respiratory screen: VIRAL CULTURE (Preliminary): No Virus isolated so far. BAL [2145-12-10]: RESPIRATORY CULTURE (Final [2145-12-13]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. ~1000/ML. 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. ~[2137]/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [2145-12-13]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR Sputum [2145-12-12]: RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. ASPERGILLUS SPECIES. 1 COLONY ON 1 PLATE. FURTHER IDENTIFICATION TO FOLLOW. ACID FAST CULTURE (Pending): ACID FAST SMEAR (Final [2145-12-13]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. [2145-12-14]: Blood cultures x 2 - NGTD [2145-12-14]: Urine culture: No growth (final) Brief Hospital Course: 48 y.o. M with h/o HIV/AIDs, h/o TB, PCP, [Name10 (NameIs) ] infections, noncompliant with his medications, recent history of falls/traumas found down for possibly three days, minimally responsive, intubated for airway protection. The course also complicated by R neck hematoma due to line placement, alkalosis, hypernatremia, hypercalcemia, improved ARF, elevated lactate, transaminitis. # AMS - multifactorial. Was found down and c-collar placed. Came with elevated CKs consistent with Rhabdomyalysis, improved with IVFs. Concern for toxic metabilic encephalopathy (infection, hypernatremia, hypercalcemia) as well as HIV encephalopathy. He was intubated for airway protection. He was treated with broad ABX as detailed below. Metabolic abnormalities improved with IVFs, and he had a negative LP for infection, but. MRI was also negative for stroke or mass lession. His mental status improved and he was extubated, but he is not at baseline (he walked out of [Hospital1 18] on [2145-12-1] after signing out against medical advise). CT c-spine was negative for fracture, but his C-collar was not cleared due to ongoing altered mental status. He currently follows some commands but remains globally weak and will require a neurology consult to address this and his mental status. He was given limited narcotics for pain of undetermined source (seemed in pain with even light touch to skin). Would recommend not using too much narcotics for pain as it will likely cloud mental status. # ID - AIDs pt not on HAART. Infectious disease team was consulted and followed throughout his hospitalization. Initially, he was covered broadly initially with vanco/cefepime/flagyl. He was also on Acycovir to cover for HSV encephalitis, but this was stopped when CSF was negative for HSV. The pt underwent LP and Bronchoscopy. He had blood, urine, sputum, stool, and CSF sent for culture. Stool was positive for Cdiff on [2145-12-10]. He needs to continue on flagyl for 14 days after all other ABX completed. Sputum was positive for MRSA on [2145-12-10], and he needs a 14 day course of vancomycin (currenly, today [12-16] is day #8). He also had pseudomonas (sparse growth) in sputum and GNRs not otherwise speciated in his sputum [2145-12-12], and Cefepime changed to Zosyn and then to Meropenem for gram negative coverage. Meropenem course is 15 days (currently, today [2145-12-16] is day #5). Of note, 1 colony of Aspergillus was grown on [2145-12-12] from sputum and a CT chest was done on [2145-12-16] which did not reveal evidence of invasive aspergillus. Galactomannan was sent and needs to be followed up. ID recommended NOT to start treatment for aspergillus. Pt needs to follow up with ID, Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057], within 2-3 weeks. Appointment needs to be scheduled. # Hypernatremia - Felt due to poor free water intake intake and dehydration while on ground at home. He was given IVFs and free H20 and his sodium returned to [Location 213] (139 at time of discharge). # C-collar - CT c-spine negative, but could not clear collar due to altered mental status. Pt needs to have this cleared at rehab # Rhabdomylosis - likely due to being down, CK peaked at 3996, and improved to normal with IVFs. Renal failure resolved. # ARF - likely prerenal with component of rhabdomylosis. Cr 1.6 upon admission, improved to 0.6 by the time of discharge. # transaminitis - Known Hep C. Levels were monitored and trended down to normal by the time of d/c. # R neck hematoma - stable clinically. Serial Hcts were checked and remained stable. # PPx - H2 [Hospital1 ], Heparin SQ, senna/colace # FEN: He was initiated on tube feeds. He needs a speech and swallow evaluation to see if he can protect his airway with PO intake. Hypernatremia and hypercalcemia resolved with IVFs # Access: PICC # Full code # Contact: Brother [Name (NI) 71], contact phone number [Telephone/Fax (1) 1078] Medications on Admission: Dapsone 100 mg PO DAILY Azithromycin 600 mg - 2 PO 1X/WEEK Neurontin 400 mg TID Morphine 45 mg MS [First Name (Titles) ] [Last Name (Titles) 1098] S&S Oxycodone 5 mg QID PO Trazadone 50 mg qHS Vitamin B12 100 mcg daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Meropenem 500 mg IV Q6H 1st day [12-12] 8. Morphine Sulfate 2-4 mg IV Q4H:PRN pain 9. Famotidine 20 mg IV Q12H 10. Vancomycin 1000 mg IV Q 24H please hold until Vanco level <20 11. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Altered Mental Status MRSA PNA Discharge Condition: Stable, mental status begining to clear Discharge Instructions: You were admitted to the hospital with altered mental status. We are treating you for a number of infections. At rehab: -- He needs to continue on flagyl for 14 days after all other ABX completed. -- Sputum was positive for MRSA on [2145-12-10], and he needs a 14 day course of vancomycin(currenly, today [2145-12-16] is day #8). -- He also on meropenom for broader GNR coverage. Meropenem course is 15 days (currently, today [2145-12-16] is day #5). -- Of note, 1 colony of Aspergillus was grown on [2145-12-12] from sputum and a CT chest was done on [2145-12-16] which did not reveal evidence of invasive aspergillus. Galactomannan was sent and needs to be followed up. ID recommended NOT to start treatment for aspergillus. -- Pt needs to follow up with ID, Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057], within [1-9] weeks. Appointment needs to be scheduled. -- Needs a speech and swallow when his mental status clear. -- CT c-spine negative, but could not clear collar due to altered mental status. Pt needs to have this cleared at rehab -- He currently follows some commands but remains globally weak and will require a neurology consult to address this and his mental status. He was given limited narcotics for pain of undetermined source (seemed in pain with even light touch to skin). Would recommend not using too much narcotics for pain as it will likely cloud mental status. Followup Instructions: -- Pt needs to follow up with ID, Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) 1057], within [1-9] weeks. Appointment needs to be scheduled. -- Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2145-12-28] 11:10 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "348.39", "482.41", "998.12", "275.42", "008.45", "V09.0", "V15.81", "042", "584.9", "070.54", "799.4", "276.0", "E870.9", "728.88", "V12.01" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.72", "96.6", "38.93", "03.31" ]	icd9pcs	[ [ [] ] ]	16554, 16609	11466, 15491	316, 352	16684, 16726	3198, 9359	18226, 18663	2628, 2632		15768, 16531		16630, 16663		15517, 15745			16750, 18203									2662, 3179				9398, 9506		10765, 10948			10989, 11168											11201, 11443	266, 278							380, 1782															1804, 2400	2416, 2612
13,514	152,841	19156	Discharge summary	report	Admission Date: [2155-2-3] Discharge Date: [2155-2-18] Date of Birth: [2076-7-10] Sex: F Service: NEUROLOGY Allergies: Clindamycin / Penicillins Attending:[First Name3 (LF) 618] Chief Complaint: Confusion Major Surgical or Invasive Procedure: -Angiography -CT -MRI -EEG -TTE History of Present Illness: Patient is a 78 year old right handed female with past medical history of hypertension, rheumatoid arthritis, post herpetic neuralgia, right foot drop who presented to [Hospital1 18] ED on [2154-2-1] as a transfer from [Hospital3 ] with right frontal intraparenchymal hemorrhage. Patient was confused and unable to give own history; history provided by family. Per patient's daughter and son, patient was talking on phone to out of state daughter earlier today around 10am. Apparently, she sounded confused and not quite herself. Then later on around 1pm, she was talking to second daughter via telephone. She noted patient to be confused and repeating words. Her speech was mumbled at times but not slurred. Daughter went to her house and transported her to [Hospital3 ] ED, concerned she was confused or anxious. Daugther did not note any face droop, weakness, incoordination. Prior to taking her to ED, patient got dose of own home Lorazepam. On arrival to [Hospital3 ], vitals T 99.2, P 82, BP 147/74, RR 17. Per [Hospital3 ] notes, she apparently was no longer confused. Head CT showed right frontal intraparenchymal hemorrhage. Dilantin 1 gram was started and patient was transferred here. On arrival here, BP 170/90, HR 80, RR 16. BP 143-175 systolic. Complained of irritation and burning at Dilantin infusion site so infusion stopped. Received Phosphenytoin 1 gram and Labetalol 10 mg IV. Unable to get MRI images due to agitation, confusion, even after 2 mg Ativan. Intubated in ED for altered mental status, airway protection. Post intubation, BP still elevated so urged ED staff to start Labetalol or Nipride gtt to get BP under control. Past Medical History: 1. Hypertension 2. Gastroesophageal reflux 3. Rheumatoid arthritis 4. Postherpetic neuralgia with L3-L5 dermatomes, followed at [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Center 5. Right foot drop 6. Glaucoma 7. History of right lower extremity cellulitis 8. Lumbar radiculopathy L4-L5 9. Bilateral femur replacements 10. Multiple hand surgeries 11. Status post appendectomy Social History: Per family, lives alone and is indepdendent in all activities of daily living prior to this hospitalization. No alcohol, tobacco, drug use history. Son [Name (NI) ] is Health Care Proxy, His contact info is [Telephone/Fax (1) 52262] (cell) and [Telephone/Fax (1) 52263] (home). Daugher [Doctor First Name ] is [Telephone/Fax (1) 52264] (cell) and [Telephone/Fax (1) 52265] (home). Family History: Noncontributory. Physical Exam: PHYSICAL EXAM: Tc: 98 BP: 123/81 HR: 98 RR: 18 O2Sat.: 98/RA Gen: WD/WN female, agitated, pulling at lines, tubes. HEENT: NC/AT. Anicteric. MMM. Neck: Some restriction to passive range of motion. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: Decreased breath sounds right lower lobe. Otherwise clear to ausculation bilaterally. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Right foot drop. Marked rheumatic changes in hands bilaterally. Neuro: Mental status: Intermittently has eyes closed, but opens eyes to voice and shaking shoulder. Able to tell me name, [2-1], "hospital" and her address. Unable to come up with date spontaneously, but picks [2154] out of list. Unable to tell me months of year forwards or backwards despite repeated prompting. With repeated prompting, is able to follow simple midline and appendicular commands (close and open eyes, show 2 fingers, hold up extremities). Able to cross midline in that correctly uses left hand to touch right ear when commanded to. No apraxia, neglect. Able to repeat simple sentences. ?Mild dysarthria. Speech otherwise fluent. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4.5 to 3 mm bilaterally. Blinks to threat bilaterally. Fundi with sharp disc margins, no papilledema. III, IV, VI: Eye movements in all fields of gaze. V, VII: Facial strength and sensation intact and symmetric. +Brisk corneal reflexes bilaterally. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical +Gag. [Doctor First Name 81]: Unable to fully assess. XII: Tongue midline without fasciculations. Motor: Diffusely decreased bulk. Increased tone bilateral lower extremities>upper extremities. Myoclonic jerks vs. clonus observed in bilateral lower extremities. Left pronator drift. No asterixis. Right foot drop (old per family). Hold all extremities up against gravity, provides some resistance but would not cooperate with formal resistance testing. Sensation: Withdraws all to nailbed pressure briskly. Reflexes: B T Br Pa Ac Right 3 3 3 4 3 Left 3 3 3 4 3 Sustained clonus at knees bilaterally and several beats of clonus at ankles. Left toe upgoing, right toe downgoing. Coordination: Unable to assess. Gait: Unable to assess. Pertinent Results: [2155-2-3] 05:48AM TRIGLYCER-145 HDL CHOL-33 CHOL/HDL-4.3 LDL(CALC)-81 [2155-2-3] 05:48AM WBC-3.2* RBC-3.68* HGB-11.2* HCT-33.8* MCV-92 MCH-30.5 MCHC-33.1 RDW-14.0 [2155-2-2] 08:05PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2155-2-2] 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2155-2-2] 07:45PM GLUCOSE-92 UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12 [2155-2-2] 07:45PM CK(CPK)-75 [2155-2-2] 07:45PM CK-MB-5 cTropnT-0.01 ----- MRI/A brain [2155-2-3]: There is a well circumscribed round heterogeneous lesion in the interhemispheric fissure, just to the right of midline, measuring approximately 1.5 cm in diameter with magnetic susceptibility. Possibilities to consider are: pericallosal branch aneurysm, which is partially thrombosed vs. atypical cavernous angioma. This lesion does not have a typical appearance for a meningioma. Acute areas of brain ischemia involving the left frontal lobe and left corona radiata. MR angiography of the Circle of [Location (un) 431] and its tributaries. ----- CT head [2155-2-3]: 13 mm rounded hyperdensity at the parafalcine right frontal lobe. In comparison to the outside CT performed at 16:51, [2155-2-2] at [Hospital6 ], this visually has not significantly changed in appearance, althoug calibration markers for size were not printed on the images provided (these images are not available during attending review). Appearances are most suggestive of hemorrhage into mass lesion. Alternatively, it could be calcification in a lesion such as a meningioma. Follow-up recommended. ----- CT torso [2155-2-3]: 1) No evidence of abdominal or pelvic malignancy. 2) Endotracheal tube with its tip just proximal to the carina, this could be retracted several centimeters. 3) Diffuse septal thickening with honeycombing predominantly affecting the peripheral/subpleural and basal regions, likely consistent with UIP/IPF. ----- TTE: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The aortic valve leaflets (3) are mildly thickened. 3. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 4. No cardiac source of embolus seen. ----- CT/CTA head [2155-2-12]: Again noted is a well-circumscribed, round hyperdensity in the right parafalcine location measuring about 1.4 cm representing an aneurysm. This is unchanged in appearance compared to the prior study. Again noted is bilateral hypodensities in the subcortical white matter of the frontal lobes, stable in appearance. There is no evidence of acute hemorrhage or mass effect. The [Doctor Last Name 352]-white differentiation is preserved. Again noted is a partially thrombosed aneurysm in the A2 segment of the left anterior cerebral artery. The distal A2 segment arises from the aneurysm. Compared to the angiographic study, the size appears to be stable. No other aneurysms are defined. Brief Hospital Course: Patient is a 78 year old female with past medical history of hypertension, rheumatoid arthritis, GERD who presented to [Hospital1 18] on [2155-2-3] after a confusional spell. Found to have a right frontal abnormality on head CT. Originally, this abnormality appeared to be consistent with intracerebral hemorrhage, thus she was admitted to the ICU for blood pressure control and neuro monitoring. She was also intubated in the ED for agitation. MRI later on hospital day #1 was consistent with a thrombosed aneurysm of the left ACA with concomitant left ACA stroke and scattered smaller strokes. She underwent angiogram on [2155-2-5] which confirmed the presence of thrombosed aneurysm on LEFT ACA A2 division; no intervention was done due to the stable, thrombosed nature of aneursym. Lumbar puncture was performed on [2155-2-6] to determine the presence or absence of xanthocrhomia. CSF was negative for xanthochromia, thus it is unlikely that she bled from this aneurysm. Plan was for patient to undergo repeat vascular imaging (either CTA or repeat angio) to determine if the aneurysm has grown. In the mean time, she was started on low dose heparin gtt with goal PTT 40-60 per Dr. [Last Name (STitle) 1132] for her strokes given that they likely originated from the thrombosed aneurysm. Repeat CTA on [2155-2-12] demonstrated stable appearance of the aneursym. As such, she was started on aspirin. She will need to follow up with Dr. [Last Name (STitle) 1132] approximately 4 weeks after discharge for repeat imaging and/or repeat angiogram. Additionally, she will need to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Hospital 4038] Clinic at [Telephone/Fax (1) 52266] one month after discharge from rehab. Prior to learning that the frontal lobe abnormality was an aneurysm, she underwent a CT torso looking for malignancy out of concern the left frontal lesion was a malignancy. CT torso was negative for signs of malignancy, and breast exam was normal. She also underwent transthoracic echo and blood cx x 3 to rule out endocarditis. Workup was negative. For BP control and prevention of vasospasm, she was started on nimodipine. She was started on a statin for her stroke for secondary prevention. Blood pressure was ultimately well controlled with a beta blocker and amlodipine. She was loaded with dilantin (once at OSH and once in our ED, although it's unclear how much of the original load she recieved) given that this lesion in her brain is in a hightly epielptogenic location, the cingulate cortex. Her original complaint of confusion may have been due to seizures. Per neurology, she is to continue on Dilantin indefinitely, at least until time of follow up in [Hospital 4038] Clinic. Goal corrected level is between [10-9]; of note, patient's albumin level has been between 2.5-2.9. EEG [2155-2-6] was consistent with encephalopathy but had no evidence of ongoing seizure activity. In term of her respiratory issues, she has a history of interstitial lung disease at baseline secondary to rheumatoid arthritis. She was intubated for airway protection on admission and remained intubated for MRI, angio, LP, etc. She was extubated on [2155-2-6]. Unfortunately, she developed laryngeal edema (vocal cords, etc) with stridor and had to be re-intubated on [2155-2-6]. She was placed on dexamethasone for edema and extubation was retried. Ultimately, she failed extubation again and underwent tracheostomy placement [2155-2-13]. She is in process of weaning from ventilator support, but we expect this will be limited until her upper airway edema resolves. CT torso [2155-2-17] showed stable interstitial lung disease but no evidence of acute cardiopulmonary process. In terms of infectitious disease issues, she was first febrile on [2155-2-6]. Initial infectious work up was negative. She then respikes [2155-2-9] and had persistent daily fevers up until [2155-2-17]. Work up revealed Vancomycin sensitive Enterococcal urinary tract infection and Levoquin sensitive Klebsiella urinary tract infection. Blood cultures demonstrated coagulase negative Staph aureus on two different dates. Given her immunosuppressed status, ID recommended resiting her intravenous and PICC lines and treating the coagulase negative Staph aureus. On discharge, she still needs 5 additional days of Levaquin and 10 days of Vancomycin. PICC line was resited [2155-2-18]. For her rheumatoid arthritis she continued oxycodone for pain control and her outpatient meds of Arava and Prednisone. For post stroke glycemic control, she was on an insulin sliding scale. We expect this can be discontinued while at rehab should her blood sugars stay well controlled. She currently has a Dobhoff tube in for feeds. She was unable to cooperate with a formal swallow evaluation due to altered mental status in setting of her urinary infections. She should have a repeat swallow evaluation while at rehab so that tube feeds can be discontinued. If she fails repeat swallow evaluation, she will need evaluation of PEG placement. In terms of hematologic issues, she was found to be anemic with hct dropping as low as 24 during this admission. At one point, she was transfused 2 units packed red blood cells. Work up revealed an anemia of chronic disease, likely related to her rheumatoid arthritis. At time of discharge, hematocrit was stable. At time of discharge, she was awake, alert. She was able to communicate by writing, shaking head yes/no, and by mouthing out answers. However, at times her answers were inconsistent and inappropriate. She might benefit from a formal language evaluation to assess for receptive aphasia. She had no acute cranial nerve abnormalities. She was able to move all extremities spontaneously, with minimal right lower extremity weakness and old right foot drop. She will need continued physical and occupational therapy in order to maximize her functional status. Medications on Admission: 1. Protonix 40 mg po qd 2. Norvasc 5mg po qd 3. Arava 20 mg po qd 4. Prednisone 2 mg po qd 5. Ambien 5 mg po qHS 6. Actonel qWeek 7. Xalatan 1 drop each eye qHS 8. Oxycontin 30 mg po qd 9. Ativan prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 4. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd (). 5. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Atorvastatin Calcium 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone HCl 5 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)) as needed. 11. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Regular Human 100 unit/mL Solution Sig: variable per adult sliding scale units Injection ASDIR (AS DIRECTED): per adult sliding scale. 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 18. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 19. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 20. Loperamide HCl 1 mg/5 mL Liquid Sig: Two (2) mg PO QID (4 times a day) as needed. 21. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 22. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO every eight (8) hours. 23. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 24. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg Intravenous Q24H (every 24 hours) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Thrombosed left ACA aneurysm 2. Left ACA/MCA infarcts 3. Enterococcus urinary tract infection 4. Klebsiella urinary tract infection 5. Possible coagulase negative S. aureus bacteremia 6. Status post tracheostomy 7. Rheumatoid arthritis 8. Hypertension 9. Gastroesophageal reflux 10. Postherpetic neuralgia with L3-L5 dermatomes, followed at [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Center 11. Right foot drop 12. Glaucoma 13. History of right lower extremity cellulitis 14. Lumbar radiculopathy L4-L5 15. Bilateral femur replacements 16. Multiple hand surgeries 17. Status post appendectomy Discharge Condition: Neurologically stable. Is alert, oriented to self, place, intermittently to date. Confused at times with inappropriate answers to questions, question receptive aphasia. No cranial nerve deficits. Moves all extremities spontaneously with mild weakness in right leg in upper motor neuron pattern. Discharge Instructions: Please call primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) 8079] or Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of Neurology at [Hospital1 18] for any worsening confusion, lethargy, focal numbness, weakness, difficulty with speech, visual changes, incoordination, or any other worrisome symptom. Followup Instructions: Patient will need follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the [Hospital 18] [Hospital 4038] Clinic approximately one month after discharge from Rehab. Call [Telephone/Fax (1) 44] to schedule an appointment. Patient will also need follow up in one month's time (late [Month (only) 958]) with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132] of [Hospital1 18] Neurosurgery. Call [Telephone/Fax (1) 1669] to schedule an appointment. Patient will need to follow up with her PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) 8079] after discharge from Rehab. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "041.11", "478.6", "437.3", "V58.65", "285.29", "515", "599.0", "041.3", "518.81", "401.9", "714.0", "530.81", "434.11" ]	icd9cm	[ [ [] ] ]	[ "31.1", "96.04", "99.04", "38.93", "88.41", "96.72", "00.14", "38.91", "96.6", "03.31" ]	icd9pcs	[ [ [] ] ]	16866, 16945	8468, 14485	295, 328	17618, 17914	5326, 8445	18364, 19156	2906, 2924		14736, 16843		16966, 17597		14511, 14713			17938, 18341									2954, 3485																					246, 257							356, 2035	4150, 5307									3500, 4134					2057, 2466	2482, 2890
12,281	132,902	23257+57347	Discharge summary	report+addendum	Admission Date: [2185-1-8] Discharge Date: [2185-2-15] Date of Birth: [2117-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Abdominal pain with fever Major Surgical or Invasive Procedure: Exploratory laparotomy Pancreatic abscess drainage Feeding jejunostomy IVC filter placement 4 [Location (un) 1661]-[Location (un) 1662] tube placements Foley catheter placement Cholecystostomy tube placement Nasogastric tube placement History of Present Illness: Mr. [Known lastname 59755] is a 67-year-old gentleman who developed gallstone pancreatitis and persistent fevers one month ago while visiting [Country 2559]. He was recently admitted to a local hospital with a diagnosis of pancreatic abscess as well as bilateral pulmonary emboli and left popliteal DVT. He was treated with intravenous antibiotics and heparin. However, he continued to have fevers and gram negative bacteremia was subsequently found on culture. CT scan demonstrated extensive pancreatic abscess and gas within the abscess cavity. He was then trasnferred to [Hospital1 18] for planned surgical intervention. Past Medical History: DVT and PE gallstone pancreatitis diverticulosis liver cysts s/p partial hepatectomy BPH dyslipidemia Social History: Lives with his wife. Denies tobacco. Occasional EtOH. Family History: non-contributory Physical Exam: temp 102.6 HR 104 BP 102/72 RR 22 Oxygen 94% 2L NAD mildly tachypneic HEENT: anicteric, dry mucous membranes Neck: supple, no JVD CV: tachycardic, regular rhythm, no murmurs Pulm: [Hospital1 ]-basilar crackles R > L Abdomen: soft, non-tender, non-distended, no rebound or guarding Extremeties: no LE edema, no peripheral stigmata of endocarditis Neuro: A + O x 3 Pertinent Results: [2185-1-8] 08:28PM BLOOD PT-18.5* PTT-31.8 INR(PT)-2.2 [2185-2-11] 04:56AM BLOOD PT-19.0* PTT-35.1* INR(PT)-2.3 [2185-1-8] 08:28PM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-140 K-3.6 Cl-103 HCO3-26 AnGap-15 [2185-2-11] 04:56AM BLOOD Glucose-98 UreaN-6 Creat-0.5 Na-139 K-3.4 Cl-105 HCO3-30* AnGap-7* [2185-1-8] 08:28PM BLOOD ALT-8 AST-18 LD(LDH)-88* AlkPhos-46 Amylase-17 TotBili-0.8 [2185-2-5] 05:08AM BLOOD ALT-8 AST-10 AlkPhos-80 Amylase-24 TotBili-0.9 [2185-2-2] 04:15PM BLOOD Lipase-1172* [2185-2-3] 05:10AM BLOOD Lipase-832* [2185-2-4] 06:00AM BLOOD Lipase-66* [2185-2-2] 04:15PM BLOOD ALT-28 AST-119* AlkPhos-193* Amylase-321* TotBili-1.3 [2185-2-3] 05:10AM BLOOD ALT-17 AST-42* AlkPhos-170* Amylase-393* TotBili-0.7 [2185-2-4] 06:00AM BLOOD ALT-13 AST-14 AlkPhos-104 Amylase-81 TotBili-0.9 [2185-1-8] 08:28PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.1 Mg-1.9 [2185-2-11] 04:56AM BLOOD Calcium-7.6* Phos-3.6 Mg-2.0 CT PELVIS W/CONTRAST [2185-1-8] 11:25 PM Extensive interconnecting fluid collections with enhancing walls and gas within them, consistent with extensive peripancreatic abscess. No evidence of pancreatic necrosis or pseudocyst formation. CT ABDOMEN W/CONTRAST [2185-1-17] 6:12 PM 1. Interval placement of multiple surgical drains including a cholecystostomy tube with significant interval improvement of the previously identified peri-pancreatic abscess. 2. Development of a small fluid collection in the anterior mid abdomen. CHEST (PORTABLE AP) [2185-2-4] 6:16 PM Left lower lobe collapse and/or consolidation. Note change in position of tip of right subclavian PICC line, now coursing cranially toward jugular vein. CHEST (PA & LAT) [2185-2-12] 10:48 AM There is a triangular opacity in the right lower lung consistent with a small right lower lobe infiltrate. There are small bilateral pleural effusions. Compared to the film from a week ago, the right lower lobe infiltrate is new. Brief Hospital Course: Mr. [Known lastname 59755] was admitted on [2185-1-8] and taken to the operating room the following day for an exploratory laparotomy and drainage of a peripancreatic abscess. He tolerated the procedure well. For details of the procedure, see operative note. He was started on unasyn and gentamicin as treatment for his gram negative bacteremia. Following the procedure he was tranferred to the surgical ICU for further observation, fluid resuscitation and further management. Lower extremity ultrasound confirmed a left popliteal DVT, for which an IVC filter was placed on [2185-1-10]. He was started on imipenem and extubated while in the ICU. He was transferred to the floor on POD 6 after being afebrile for 24-48 hours and with a white blood cell count that was within normal limits. He had four JP drains as well as a chole drain in place upon transfer. He was started on TPN and tube feeds on POD 9. His NGT was removed on POD 10. The following day (POD 11) three of his JP drains were withdrawn slightly; the day after that JP #1 was removed altogether. On POD 15 the output from JP #4 was noted to be bilious and found to have a Total Bili of 53.4. The ERCP fellow was consulted after a tube study revealed a bile leak near the cholecystostomy tube site. After two unsuccessful attempts at ERCP (due to an edematous duodenum), he was treated with ocreotide, which resulted in his drain output reducing dramatically over the following few days. On POD 28 he was noted to have loose watery stools that tested positive for C. difficile. He was started on metronidazole. The following day JP #3 was removed. On POD 31 JP #2 was removed and his imipenem was stopped. He started coumadin on POD 30 and was theraputic on POD 33, at which time his heparin was stopped. On POD 35, he was having more solid stooling and his flagyl was summarily stopped. He was tolerating a regular, low-fat diet but continued his tube feeds by POD 36. He was then discharged to a Rehab facility on POD 37 in good condition, ambulating and tolerating a low-fat diet with tube feed supplementation. He is asked to follow-up with Dr. [Last Name (STitle) ] in [2-13] weeks. Medications on Admission: Tenazapam 7.5mg PO QHS Promethazine 25mg PO QD:PRN Protonix 40mg PO QD Pancrease 4500 TID Heparin gtt Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:qs Tablet(s) Refills:2 6. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:qs Capsule(s) Refills:2 7. Megestrol Acetate 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:qs Tablet(s) Refills:0 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 ] Center Discharge Diagnosis: s/p exploratory laparotomy and drainage of pancreatic abscess on [2185-1-9] DVT and PE s/p placement of IVC filter gallstone pancreatitis diverticulosis liver cysts s/p partial hepatectomy BPH dyslipidemia Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in [2-13] weeks. Call ([Telephone/Fax (1) 15148] to schedule an appointment. Name: [Known lastname 10972],[Known firstname 3061] Unit No: [Numeric Identifier 10973] Admission Date: [2185-1-8] Discharge Date: [2185-2-15] Date of Birth: [2117-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3524] Addendum: Patient is asked to continue his metronidazole for six more days (i.e. for a total of 14 days) for his C. difficile infection. Furthermore, patient is asked to follow-up with Dr. [Last Name (STitle) ] in 1 month; he is aked to continue the octreotide in the meantime. And he is to follow-up with Dr. [Last Name (STitle) 7116] (PCP) for his warfarin (coumadin) dosing. Discharge Disposition: Extended Care Facility: [Hospital3 643] Center [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2207] MD [MD Number(1) 3525] Completed by:[2185-2-15]	[ "576.8", "567.2", "790.7", "599.7", "415.19", "553.21", "577.0", "568.0", "788.20", "575.0", "008.45", "575.8" ]	icd9cm	[ [ [] ] ]	[ "93.59", "87.54", "45.13", "52.13", "96.6", "52.22", "51.03", "99.15", "46.39", "53.51", "38.93", "54.59", "38.7", "54.4" ]	icd9pcs	[ [ [] ] ]	9470, 9680	3896, 6092	339, 584	7666, 7672	1887, 3873	8543, 9447	1463, 1481		6244, 7339		7433, 7645		6118, 6221			7696, 8520									1496, 1868																					274, 301							612, 1249															1271, 1374	1390, 1447
4,314	117,480	12477	Discharge summary	report	Admission Date: [2183-6-12] Discharge Date: [2183-7-14] Date of Birth: [2112-1-2] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old gentleman who was at the [University/College ] Club when he fell over the railing of a stairway with approximately a 20-foot fall. He apparently landed on his head and had documented loss of consciousness and was found confused with significant blood loss on the back of his head. Initially, the patient was not moving his bilateral lower extremities but was eventually noted to have movement in his lower extremities in the Emergency Department. The patient remained hemodynamically stable upon transport. PAST MEDICAL HISTORY: Alcohol and cardiomyopathy. PAST SURGICAL HISTORY: Unknown. MEDICATIONS ON ADMISSION: Medications upon admission were unknown. ALLERGIES: PENICILLIN. SOCIAL HISTORY: The patient is visiting from [State 4565] and has a longstanding alcohol abuse history. The patient had been drinking and was intoxicated on the evening of his fall. PHYSICAL EXAMINATION ON PRESENTATION: Heart rate of 94, blood pressure of 113/62, respiratory rate of 24, saturations of 95% on a breather. In general, a confused male in no acute distress. Head, eyes, ears, nose, and throat revealed blood coming from his ear and occipital laceration. Pupils were 3 mm bilaterally and reactive. Cervical collar was in place. Chest with symmetrical lung expansion. No deformities or crepitus. Clear to auscultation bilaterally. Heart had a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Pelvis was stable and nontender. Back revealed crepitus over his upper back. Rectal revealed guaiac-positive stool. Normal rectal tone. Extremities revealed a left forearm laceration, but moved all extremities to pain stimuli. PERTINENT LABORATORY DATA ON PRESENTATION: Initial laboratories revealed a hematocrit of 41.3. PTT of 29.2, INR of 1.4. Blood urea nitrogen of 15 and creatinine of 1.1. Alcohol level of 237. Creatine kinase was 1205, MB of 15. RADIOLOGY/IMAGING: Initial chest x-ray showed no pneumothorax, no widened mediastinum. Pelvis showed possible bilateral superior and inferior pubic rami fractures. CT of head showed a subarachnoid bleed with basilar skull fracture. A CT of the chest showed a fracture of multiple thoracic vertebrae, hemothorax on the right. CT of the abdomen showed no intra-abdominal injury. A liver mass; possible tumor or contusion. CT of the abdomen also revealed L3 lumbar body compression fracture, bilateral pubic rami fractures, bilateral two sacral fracture. IMPRESSION: A 72-year-old male, status post approximately 12-foot to 20-foot fall with subarachnoid hemorrhage, basilar skull fracture, multiple thoracic and lumbar spine fractures, bilateral pubic rami fractures, and altered mental status. HOSPITAL COURSE: In summary, the patient had a very prolonged and complicated hospital course. The patient was intubated for altered mental status and to facilitate obtaining the studies. The patient became hemodynamically unstable while in the Emergency Department and was transferred initially to the Surgical Intensive Care Unit where he had a Swan-Ganz catheter placed to optimize fluid management. The patient was found to have a very poor ejection fraction and required fluid and pressors to maintain his blood pressure. It was unclear what his baseline cardiac status was; however, per his cardiologist in [State 4565], he had a very poor ejection fraction of approximately 20%, and his baseline blood pressure was approximately 100 to 110 systolic. The patient was not felt to be hemodynamically unstable due to blood loss, but a chest tube was placed in his right chest to relieve the hemothorax, but there was not noted to be excessive blood loss in his right chest tube. His hematocrit remained stable. 1. NEUROLOGY: The patient was found to have a subarachnoid hemorrhage. In addition, a Neurosurgery consultation was obtained which noted bilateral frontal contusions, a right subdural hematoma, and had a ventriculostomy shunt placed. He remained unresponsive for the initial part of his hospital course and was not moving his extremities except his left upper extremity to deep painful stimuli. The patient began growing rare enterococcus out of his cerebrospinal fluid and was treated with a course of antibiotics for this. The patient remained off station and eventually slowly began improving his mental status. Approximately three weeks into his course, he began to become more an more responsive. A repeat CAT scan of his head showed mild improvement in his injuries with no worsening. Eventually, the patient returned to being fully responsive, appropriate, answering questions, and following full commands. 2. CARDIOVASCULAR: The patient was noted to have an initial episode of hypotension and was managed with a Swan-Ganz catheter, intravenous fluids, and pressors. His echocardiogram showed global hypokinesis with an ejection fraction of just less than 20%, and he was eventually weaned off of his pressors. He was not felt to have any ongoing blood loss as the cause of his hemodynamics. It was felt that the stress of the trauma combined with his poor cardiac function at baseline prevented him from compensation and to maintain appropriate cardiac output. His blood pressure stabilized at his customary range of systolics of 100 to 110 off pressors, and he was continued on his home medication regimen of amiodarone, Lasix, and lisinopril. 3. RESPIRATORY: The patient's course was complicated by a right hemothorax for which a chest tube was placed and successfully drained. The patient did develop ventilatory-associated pneumonia and grew out methicillin-resistant Staphylococcus aureus as well as Pseudomonas. He was treated with prolonged courses of antibiotics including vancomycin and imipenem and slowly responded with improvement in his ventilator status. As the patient's mental status improved, he was able to be weaned off the ventilator. He did have a tracheostomy placed due to his expected prolonged course with the anticipation that once he woke up fully he should be able to weaned off of his tracheostomy. 4. GASTROINTESTINAL: The patient had no evidence of intra-abdominal injury and tolerated tube feeds intermittently throughout his stay. The patient was continued throughout the course but did develop a Clostridium difficile colitis due to his multiple antibiotic regimen for his ventilatory-associated pneumonia. He was begun on Flagyl 500 mg t.i.d. for this with good effect for his diarrhea. 5. ORTHOPAEDIC: The patient had operative repair of both his thoracic spine fractures and his sacral fracture. He had a spinal fusion of thoracic 5 through 8 for unstable fractures as well as stabilization of S1 pedicle fractures. His pubic rami fractures were felt to be stable, and he will have full recommendations with regard to his weightbearing status and mobility in a subsequent Discharge Summary. The patient was not noted to have any further orthopaedic injuries. 6. INFECTIOUS DISEASE: As stated, the patient had multiple infections including ventilatory-associated pneumonia and enterococcus bacteremia and enterococcus in his cerebrospinal fluid. The patient had a full course of antibiotics to treat this with good improvement and sterilization of his cerebrospinal fluid and blood. Ventilator-associated pneumonia was treated with vancomycin and imipenem; although he did maintain persistently positive cultures while on this regimen. He developed Clostridium difficile colitis from the multiple antibiotic regimens and was started on Flagyl which was be continued at the time of this dictation. His Flagyl was begun on [7-5], and he will likely need a 14-day course of this; although the specific instructions will be in a follow-up dictation. The patient's fever trended down, and his white blood cell count stabilized, and his antibiotic regimen will be tailored prior to discharge. 7. HEMATOLOGY: The patient's hematocrit stabilized, although it was slightly low in the 26 to 28 range. The patient was started on erythropoietin as it was felt by his cardiologist that optimization of his oxygen carrying capacity would help his poor ejection fraction and overall oxygenation. The patient was started on erythropoietin, and his hematocrit stabilized at approximately 30, requiring no further transfusions. His coagulation studies remained stable, and he had no further hematologic issues. HOSPITAL COURSE SUMMARY: In summary, the patient's neurologic status slowly improved throughout his hospital course here. However, he did require a tracheostomy and a percutaneous endoscopic gastrostomy tube placement for ventilatory wean and tube feeding while he was weaned. His multiple orthopaedic injuries were either fixed or immobilized including operative repair/internal fixation of his thoracic spine and lumber spine. The patient was treated for multiple infections, and final recommendations as to the course of his antibiotics will be contained in a follow-up Discharge Summary. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Last Name (NamePattern1) 32895] MEDQUIST36 D: [2183-7-11] 12:29 T: [2183-7-12] 04:21 JOB#: [Job Number 38726]	[ "482.41", "805.4", "806.39", "958.4", "303.00", "803.12", "425.5", "E880.9", "860.2" ]	icd9cm	[ [ [] ] ]	[ "02.2", "43.11", "81.05", "34.04", "81.07", "03.53", "38.7", "31.1" ]	icd9pcs	[ [ [] ] ]													829, 896	2927, 9494									792, 802																														171, 715															739, 768	913, 2909
82,605	197,131	37767	Discharge summary	report	Admission Date: [2176-1-30] Discharge Date: [2176-2-10] Date of Birth: [2113-12-18] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Nickel / Statins-Hmg-Coa Reductase Inhibitors Attending:[First Name3 (LF) 1505] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [2176-1-31] 1. Minimally Invasive Mitral Valve Repair with 30mm St. [Male First Name (un) 923] Annuloplasty Ring. 2. Chest wall reconstruction with [Doctor Last Name 4726]-Tex mesh. History of Present Illness: This is a 61 year old female with a long standing history of mitral valve prolapse and regurgitation followed by serial echocardiograms. She has noticed increased fatigue and decreased exercise tolerance. Most recent echo showed severe mitral regurgitation. She was admitted for cardiac catheterization prior to mitral valve surgery. Past Medical History: Mitral regurgitation/Prolapse History of Arrhythmia (took Amiodarone [2160]-96) Osteoporosis (intolerance to Fosamax) Gastroesophageal reflux disease Thyroid Goiter Sleep apnea (uses CPAP) Meningioma [2163] Migraines Congestive heart failure Cataracts Bronchitis (most recently [11-2]) History of hypokalemia secondary to Ace Inhibitors s/p C-section s/p Tonsillectomy s/p Laparoscopy [2170] & [2172] (endometriosis/abd. mass) Social History: Occupation: School nurse [First Name (Titles) ] [Last Name (Titles) ] instructor Lives with: Husband [Name (NI) ]: Caucasian Tobacco: Quit [2163] with 30 pk yr history ETOH: Several drinks/month Family History: No premature coronary artery disease Physical Exam: Pulse:65, Resp: 20, O2 sat: 95%RA, BP Right: 122/78 General: WDWN male in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur IV/VI SEM 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: Left: PT [Name (NI) 167]: Left: Radial Right: 2+ Left:2+ Carotid Bruit bilateral-likely SEM transmission. pulses 2+ (B) Brief Hospital Course: Mrs. [Known lastname ] was admitted and underwent cardiac catheterization which showed normal coronary arteries. The remainder of her preadmission testing was unremarkable and she was cleared for surgery. On [1-31], Dr. [Last Name (STitle) ] performed a minimally invasive mitral valve repair. The operation was complicated by loss of intercostal muscle and chest wall instability which required chest wall reconstruction by Dr. [Last Name (STitle) ]. Please see operative notes for further details. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. Due to inadequate pain management, the pain service was consulted to assist in postoperative management. It took several days to wean from inotropic support and she required units of packed red blood cells for postoperative anemia. Also experienced postoperative atrial fibrillation for which lopressor, Multaq and Warfarin anticoagulation was initiated. She made slow, clinical improvement and eventually transferred to the step down unit on postoperative day six. Postoperative course further complicated by C. difficile colitis which was treated with PO Flagyl. She was evaluated and treated by physical therapy for stength and conditioning. She was cleared for discharge to home on POD#10. Medications on Admission: Tylenol PM, Multivitamin, Prilosec 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 4. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 months. Disp:90 Tablet(s) Refills:0 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gi upset. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:9 Tablet(s) Refills:0 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:7 Tablet(s) Refills:0 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 7 days. Disp:7 Capsule, Sustained Release(s) Refills:0 12. Coumadin 1 mg Tablet Sig: as directed for afib Tablet PO once a day: dose to be determined by Dr. [Last Name (STitle) 78260]. Goal INR 2-2.5. Disp:120 Tablet(s) Refills:2 13. Outpatient Lab Work INR check on [2176-2-11] and results called to Dr. [Last Name (STitle) ] office [Telephone/Fax (1) 170] for coumadin dosing. NEXT INR check [2176-2-12] and as directed by Dr. [Last Name (STitle) 78260] and results called to Dr.[Name (NI) 84572] office [Telephone/Fax (1) 7660], fax [Telephone/Fax (1) 66051] Discharge Disposition: Home With Service Facility: [Hospital1 ] home care Discharge Diagnosis: Mitral Regurgitation, s/p Mitral Valve Repair Chronic Diastolic Congestive Heart Failure Postoperative Atrial Fibrillation Postoperative C. difficile Colitis Postoperative Anemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady incisional 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: Cardiac Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Thoracic Surgeon Dr. [Last Name (STitle) 11482] [Name (STitle) ] [Telephone/Fax (1) 4741] in [4-30] weeks. Primary Care Dr. [Last Name (STitle) 78260] in [1-27] weeks Cardiologist Dr. [First Name4 (NamePattern1) 4597] [Last Name (NamePattern1) 4783] (cardiology) in [1-27] weeks, appointment on [2176-2-22] at 11:15 Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2176-2-10]	[ "285.9", "458.29", "008.45", "530.81", "327.23", "733.00", "428.32", "346.90", "511.9", "599.0", "733.19", "427.31", "240.9", "428.0", "424.0", "V12.41", "338.18" ]	icd9cm	[ [ [] ] ]	[ "03.90", "88.56", "37.23", "39.61", "93.90", "34.79", "35.12" ]	icd9pcs	[ [ [] ] ]	5690, 5747	2299, 3676	335, 531	5970, 6069		6610, 7235	1611, 1649		3762, 5667		5768, 5949		3702, 3739			6093, 6587									1664, 2276																					288, 297							559, 895															917, 1366	1382, 1595
81,543	186,026	44753	Discharge summary	report	Admission Date: [2141-10-29] Discharge Date: [2141-11-5] Date of Birth: [2092-4-6] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / Bactrim Attending:[First Name3 (LF) 668] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: [2141-10-29] - EGD. Blood clots and oozing at pyloris, no ulcers noted. Coffee ground old blood noted in the stomach body. [Hospital1 ]-CAP Electrocautery was applied at pylorus for hemostasis successfully. History of Present Illness: HPI: 49M s/p CRT, recent readmission for hypertension, CHF, and hyperglycemia, discharged 1 day ago, now back with h/o rectal bleeding since this AM, c/o dark colored bleeding PR x 3, intermittent dizziness, denies f/c/n/v/d or other symptoms. States his urine output and appearance have not change, no dysuria, no hematuria, no history of GIB. Past Medical History: 1. CAD s/p [Hospital1 ] to OM1 in [9-2] and [Month/Day (1) ] to RCA in [5-5] 2. End-stage renal disease, on HD since [6-3] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [2137-3-29]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Kidney transplant, right iliac fossa [2141-10-14]. Social History: The patient lives with his wife and 2 sons in [Name (NI) 669]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [Last Name (un) 95749]-[Doctor Last Name 3532] disease. Physical Exam: Vitals: T: 98F, BP 159/61, 78, 20, 100% on 2L O2 General: lying in bed, in nad HEENT: NC/AT Lungs: ctab CV: S1s2+ Abdomen: soft, bowel sounds present, mild tenderness lower abdomen, nr, ng Ext: dp+ no c/c/e CNS: aox3 Pertinent Results: [2141-10-29] EGD - Blood clots and oozing at pyloris, no ulcers noted. Coffee ground old blood noted in the stomach body. [Hospital1 ]-CAP Electrocautery was applied at pylorus for hemostasis successfully. . [2141-11-1] - Renal Ultrasound: CONCLUSION: 1. Velocities and waveforms in the main transplant renal artery are once again abnormally elevated and once again suggestive of renal artery stenosis. 2. There is evidence of an AV fistula in the lower pole which was not previously seen, presumably related to the recent biopsy. Cortical perfusion in the lower pole is somewhat lessened compared to the upper and middle thirds of the transplant, suggesting possible steal phenomenon in the AVF. . [2141-10-29] 11:03PM POTASSIUM-4.4 [2141-10-29] 11:03PM HCT-26.2* [2141-10-29] 06:30PM POTASSIUM-4.7 [2141-10-29] 06:30PM HCT-27.0* [2141-10-29] 03:00PM POTASSIUM-5.9* [2141-10-29] 03:00PM HCT-22.4* [2141-10-29] 11:55AM PT-14.2* PTT-30.4 INR(PT)-1.2* [2141-10-29] 09:52AM TYPE-ART PH-7.34* COMMENTS-GREEN TOP [2141-10-29] 09:52AM GLUCOSE-224* LACTATE-1.5 NA+-144 K+-5.6* CL--112 TCO2-20* [2141-10-29] 09:52AM freeCa-1.14 [2141-10-29] 09:35AM GLUCOSE-237* UREA N-75* CREAT-3.8* SODIUM-143 POTASSIUM-6.2* CHLORIDE-113* TOTAL CO2-18* ANION GAP-18 [2141-10-29] 09:35AM estGFR-Using this [2141-10-29] 09:35AM cTropnT-0.19* [2141-10-29] 09:35AM WBC-9.5 RBC-2.75* HGB-8.1* HCT-25.3* MCV-92 MCH-29.6 MCHC-32.1 RDW-16.0* [2141-10-29] 09:35AM NEUTS-89.9* LYMPHS-6.7* MONOS-1.7* EOS-1.2 BASOS-0.6 [2141-10-29] 09:35AM PLT COUNT-224 [2141-10-28] 06:05AM GLUCOSE-143* UREA N-70* CREAT-4.2* SODIUM-143 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-23 ANION GAP-14 [2141-10-28] 06:05AM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-2.1 [2141-10-28] 06:05AM tacroFK-9.0 [2141-10-28] 06:05AM WBC-6.6 RBC-3.36* HGB-9.5* HCT-30.5* MCV-91 MCH-28.1 MCHC-31.1 RDW-15.5 [2141-10-28] 06:05AM PLT COUNT-203 [2141-11-5] 06:05AM BLOOD WBC-4.0 RBC-2.94* Hgb-8.4* Hct-25.9* MCV-88 MCH-28.7 MCHC-32.5 RDW-15.4 Plt Ct-177 [2141-11-5] 06:05AM BLOOD Plt Ct-177 [2141-11-5] 06:05AM BLOOD Glucose-102 UreaN-34* Creat-2.7* Na-143 K-4.9 Cl-116* HCO3-21* AnGap-11 [2141-11-5] 06:05AM BLOOD ALT-4 AST-6 AlkPhos-87 TotBili-0.3 [2141-11-5] 06:05AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.9 [2141-11-4] 06:00AM BLOOD tacroFK-13.5 Brief Hospital Course: The patient was admitted to the transplant surgery service on [2141-10-29] for UGIB which was thought to be due to NSAID and plavix use. Patient was admitted to the ICU and recieved over 8 units of PRBC. EGD showed fresh oozing from pyloric folds. No ulcers were identified despite repeated washing and observation of the area. Empiric thermal therapy applied to area. Rest of stomach & duodenum normal. Patient was treated with IV PPI infusion. On presentation patient's creatine was elevated to 6.2. Given his recent renal transplant there was concern for rejection. Renal U/S showed some evidence of an AV fistula in the lower pole of the kidney which may have been the result of a prior biopsy. Vascular surgery was called for a potential biopsy however patient creatinine responded well without any intervention. On the [4-3] his creatinine was 2.5. Prior to discharge, patient blood pressure was noted to be over 200 systolic. Patients blood pressure medications were modified with help of cardiolgy. Patient was monitored overnight. At the time of discharge patient was stable, taking adequate oral intake and ambulating at lib. Medications on Admission: Clopidogrel 75' Toprol XL 200'', Cellcept [Pager number ]'', Nystatin 5 mL, Pregabalin 25', Percocet prn, Trazodone 50 prn, [Pager number ] 325, Ranitidine 150 hs, ISMN 90', Valgan 450', Insulin 70/30, Tacro 9'', Nifedipine 90' Discharge Medications: 1. Insulin NPH/Humalog Insulin Regimen. 2. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for anxiety. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:120 Capsule(s) Refills:2 11. Nifedipine 60 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO DAILY (Daily). Disp:60 Tablet Extended Rel 24 hr(s) Refills:2 12. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Upper GI bleed Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-7] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please call the office of Dr.[First Name (STitle) ] (transplant surgery) at ([Telephone/Fax (1) 3618] to schedule a follow-up appointment in [12-30] weeks. . Please call the office of Dr.[Last Name (STitle) ] (nephrology) at ([Telephone/Fax (1) 10248] to schedule a follow-up appointment in [12-30] weeks. Provider: [Name10 (NameIs) 2841] LABORATORY Phone:[Telephone/Fax (1) 2846] Date/Time:[2141-11-6] 1:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-11-8] 8:00 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-11-14*] 8:20	[ "271.0", "276.0", "E878.0", "580.89", "250.61", "996.81", "250.41", "070.32", "428.0", "428.22", "362.01", "276.7", "414.01", "327.23", "250.51", "357.2", "E934.8", "285.21", "V45.82", "535.41", "401.9", "E935.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	7379, 7436	4829, 5975	310, 527	7495, 7504	2381, 4806	9145, 9896	1759, 2128		6262, 7356		7457, 7474		6001, 6239			7528, 9122									2143, 2362																					255, 272							555, 902															924, 1562	1578, 1743
55,265	191,108	52084	Discharge summary	report	Admission Date: [2132-1-27] Discharge Date: [2132-3-3] Date of Birth: [2068-5-27] Sex: M Service: SURGERY Allergies: Iodine Attending:[First Name3 (LF) 974] Chief Complaint: S/p MVC unrestrained passenger car vs. tree, pinned against winshield +loc +etoh Major Surgical or Invasive Procedure: Endotracheal intubation VATS x2 - [2-13], [2-22] History of Present Illness: 63 y/o unrestrained passenger car vs. tree, pinnned against windshield, +LOC, +EtOH Past Medical History: HTN, gout, previous exploratory laparotomy Social History: +ETOH Family History: NC Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented x1, No acute distress Resp: CT d/c with dressings CDI. Reg even rate no audible wheeze, decreased BS on L Cardiac: rrr, no rubs, murmurs, gallops Abd: +BS, obese, ND, NTTP Extremities: bilateral upper distal radius fractures splinted Splints: clean/dry/intact Sensation intact to light touch, Neurovascular intact distally, Capillary refill brisk, 2+ pulses, Weight bearing: non weight bearing on bilateral upper extremities Left Antecubital fossa: C/D/I with dry gauze Pertinent Results: [2132-1-27] 07:30PM WBC-12.3* RBC-5.09 HGB-15.5 HCT-42.0 MCV-82 MCH-30.4 MCHC-36.9* RDW-13.9 [2132-1-27] 07:30PM PLT COUNT-197 [2132-1-27] 07:30PM PT-13.1 PTT-25.6 INR(PT)-1.1 [2132-1-27] 07:30PM FIBRINOGE-361 [2132-1-27] 07:30PM ASA-NEG ETHANOL-31* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2132-1-27] 07:30PM LIPASE-39 [2132-1-27] 07:30PM UREA N-14 CREAT-0.8 [2132-1-27] 07:42PM GLUCOSE-136* LACTATE-3.0* NA+-140 K+-4.1 CL--99* [2132-1-27] 07:42PM PO2-68* PCO2-35 PH-7.43 TOTAL CO2-24 BASE XS-0 COMMENTS-GREEN TOP [2132-1-27] 09:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2132-1-27] 09:27PM LACTATE-2.6* trends: [2132-2-12] 02:08AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.6* Hct-28.5* MCV-87 MCH-29.5 MCHC-33.7 RDW-14.8 Plt Ct-556* [2132-2-13] 02:34AM BLOOD WBC-13.6* RBC-2.86* Hgb-8.6* Hct-24.8* MCV-87 MCH-30.2 MCHC-34.8 RDW-14.7 Plt Ct-470* [2132-2-13] 03:39PM BLOOD WBC-19.5* RBC-2.67* Hgb-8.2* Hct-24.0* MCV-90 MCH-30.9 MCHC-34.3 RDW-14.9 Plt Ct-476* [2132-2-14] 02:46AM BLOOD WBC-21.0* RBC-2.79* Hgb-8.7* Hct-25.0* MCV-89 MCH-31.0 MCHC-34.7 RDW-15.0 Plt Ct-475* [2132-2-15] 01:45AM BLOOD WBC-11.6* RBC-2.61* Hgb-8.2* Hct-23.0* MCV-88 MCH-31.4 MCHC-35.7* RDW-15.3 Plt Ct-388 [2132-2-26] 04:21AM BLOOD WBC-8.6 RBC-2.98* Hgb-8.9* Hct-26.1* MCV-87 MCH-29.8 MCHC-34.1 RDW-15.3 Plt Ct-287 [2132-2-16] 01:34AM BLOOD Neuts-76* Bands-4 Lymphs-13* Monos-3 Eos-2 Baso-1 Atyps-0 Metas-1* Myelos-0 [2132-2-22] 05:30AM BLOOD Neuts-77.6* Lymphs-16.3* Monos-3.8 Eos-1.8 Baso-0.5 [2132-2-6] 02:00AM BLOOD PT-14.3* PTT-29.7 INR(PT)-1.2* [2132-2-9] 02:29AM BLOOD PT-15.1* PTT-28.9 INR(PT)-1.3* [2132-2-13] 02:34AM BLOOD PT-16.6* INR(PT)-1.5* [2132-2-19] 01:46AM BLOOD PT-15.9* INR(PT)-1.4* [2132-2-21] 01:46AM BLOOD PT-21.0* INR(PT)-2.0* [2132-2-22] 05:30AM BLOOD PT-20.4* PTT-33.7 INR(PT)-1.9* [2132-2-25] 09:02AM BLOOD PT-18.1* PTT-36.3* INR(PT)-1.7* [2132-2-26] 04:21AM BLOOD PT-16.4* PTT-34.6 INR(PT)-1.5* [2132-1-28] 12:28AM BLOOD Glucose-145* UreaN-15 Creat-0.8 Na-135 K-4.8 Cl-102 HCO3-21* AnGap-17 [2132-1-29] 02:00AM BLOOD Glucose-158* UreaN-22* Creat-1.5* Na-132* K-8.7* Cl-104 HCO3-23 AnGap-14 [2132-2-7] 01:52AM BLOOD Glucose-173* UreaN-54* Creat-1.7* Na-147* K-3.9 Cl-109* HCO3-29 AnGap-13 [2132-2-8] 02:59AM BLOOD Glucose-136* UreaN-57* Creat-2.0* Na-148* K-3.9 Cl-111* HCO3-31 AnGap-10 [2132-2-12] 02:08AM BLOOD Glucose-133* UreaN-76* Creat-2.4* Na-145 K-3.3 Cl-110* HCO3-27 AnGap-11 [2132-2-14] 02:46AM BLOOD Glucose-138* UreaN-81* Creat-2.7* Na-145 K-4.6 Cl-109* HCO3-26 AnGap-15 [2132-2-17] 04:20AM BLOOD Glucose-129* UreaN-66* Creat-1.9* Na-144 K-4.0 Cl-110* HCO3-24 AnGap-14 [2132-2-18] 02:26AM BLOOD Glucose-133* UreaN-80* Creat-2.3* Na-141 K-3.9 Cl-110* HCO3-23 AnGap-12 [2132-2-21] 01:46AM BLOOD Glucose-92 UreaN-47* Creat-1.4* Na-143 K-3.7 Cl-111* HCO3-25 AnGap-11 [2132-2-26] 07:29AM BLOOD Glucose-88 UreaN-31* Creat-1.1 Na-140 K-4.2 Cl-109* HCO3-23 AnGap-12 [2132-2-28] 04:26AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-139 K-3.8 Cl-108 HCO3-26 AnGap-9 [2132-1-28] 12:28AM BLOOD ALT-83* AST-59* LD(LDH)-304* CK(CPK)-356* AlkPhos-46 TotBili-0.6 [2132-2-2] 02:05AM BLOOD ALT-31 AST-57* LD(LDH)-186 TotBili-0.5 [2132-2-16] 01:34AM BLOOD ALT-57* AST-87* AlkPhos-54 TotBili-0.4 [2132-2-22] 07:45AM BLOOD ALT-40 AST-39 AlkPhos-75 TotBili-0.5 DirBili-0.3 IndBili-0.2 [2132-1-28] 12:28AM BLOOD CK-MB-8 cTropnT-0.03* [2132-1-30] 03:57PM BLOOD CK-MB-4 cTropnT-0.05* [2132-2-16] 11:59PM BLOOD CK-MB-NotDone cTropnT-0.13* [2132-2-17] 07:14PM BLOOD CK-MB-NotDone cTropnT-0.12* [2132-1-27] 07:42PM BLOOD Glucose-136* Lactate-3.0* Na-140 K-4.1 Cl-99* [2132-1-27] 09:27PM BLOOD Lactate-2.6* [2132-2-1] 03:07AM BLOOD Lactate-2.3* [2132-2-10] 04:27AM BLOOD Glucose-170* Lactate-1.8 K-4.2 [2132-2-20] 02:01AM BLOOD Lactate-1.4 Micro: 12/25,26 Blood - S. aureus pan-S - x 3 cultures [2132-1-31] 1:30 am BLOOD CULTURE Source: Line-CVL. . FINAL REPORT [2132-2-2] Blood Culture, Routine (Final [2132-2-2]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [2132-1-31]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] AT 1725, [2132-1-31]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [2132-1-31]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . [2132-2-2] 12:57 pm CATHETER TIP-IV Source: L SC CVL. FINAL REPORT [2132-2-5] WOUND CULTURE (Final [2132-2-5]): STAPH AUREUS COAG +. >15 colonies. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S . [1-30] UCx-Enterococcus 4k . [2-2] UCx FINAL REPORT [2132-2-5] URINE CULTURE (Final [2132-2-5]): STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S NITROFURANTOIN-------- 32 S OXACILLIN-------------<=0.25 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S [2-2] Sputum: Rare GNR Source: Endotracheal. FINAL REPORT [2132-2-5] GRAM STAIN (Final [2132-2-3]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2132-2-5]): RARE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). RARE GROWTH. . [2-4] tissue culture: MSSA Source: L antecubital vein. FINAL REPORT [2132-2-9] GRAM STAIN (Final [2132-2-5]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] AT 535 [2132-2-5]. TISSUE (Final [2132-2-8]): 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. SENSITIVITIES: MIC expressed in MCG/ML ______________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2132-2-9]): NO ANAEROBES ISOLATED. . [2-11] MRSA screen: no MRSA [2-13] Lung bx: neg [2-13] Pleural fluid: neg [2-13] BRONCHOALVEOLAR LAVAGE BRONCIAL WASH. FINAL REPORT [2132-2-26] GRAM STAIN (Final [2132-2-13]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2132-2-16]): OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ESCHERICHIA COLI. ~8OOO/ML. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ ESCHERICHIA COLI \| ENTEROBACTER CLOACAE \| \| ESCHERICHIA COLI \| \| \| AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S CEFUROXIME------------ 16 I 16 I CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S PIPERACILLIN---------- 32 I <=4 S 32 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S FUNGAL CULTURE (Final [2132-2-26]): YEAST. . [2-13] UCx: Yeast >100,000 [2-14] Cdiff negative X 2 [2-16] Urine: yeast 10,000-100,000 [2-16] SPUTUM Site: ENDOTRACHEAL FINAL REPORT [2132-2-19] GRAM STAIN (Final [2132-2-17]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Final [2132-2-19]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. MODERATE GROWTH. YEAST. SPARSE GROWTH OF 2ND COLONIAL MORPHOLOGY. [2-18] RSC tip: no growth final [2-18] BCx neg [2-18] MRSA negative [2-19] and [2-20] UCx: No growth final [2-20] BCx: negative [2-22] C-diff X1: no growth . Radiographic studies: [2132-1-27] CT HEAD W/O CONTRAST IMPRESSION: Two small foci of subarachnoid hemorrhage. There is also a small inter-falx subdural hematoma. . [2132-2-5] CT HEAD W/O CONTRAST IMPRESSION: Slight redistribution of subarachnoid hemorrhage in the left frontal paramedian region, with overall decrease in bifrontal subarachnoid hemorrhage density. Small left parafalcine subdural hematoma has decreased in density or resolved. No evidence of new acute abnormalities. . [2132-1-27] RIGHT WRIST, AP, LATERAL, AND OBLIQUE VIEWS: Overlying cast obscures fine detail. There is a transverse fracture through the distal radius, with a small displaced fragment along the ulnar aspect. No definite intra- articular extension noted. There is also a fracture through the distal ulna and extending into the styloid process. No additional fractures are identified. LEFT WRIST, AP, LATERAL, AND OBLIQUE VIEWS: There is an oblique fracture through the left radial styloid process. No definite ulnar fracture is identified. No additional fractures are identified. There are degenerative changes at the first CMC and first PIP joints. . [2132-1-28] ECHOCARDIOGRAPHY REPORT IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Significant aortic valve stenosis. . [2132-1-29] ECHOCARDIOGRAPHY REPORT Conclusions The left atrium is mildly dilated. The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 4 to 5 mmHg) due to mitral annular calcification. Physiologic mitral regurgitation is seen (within normal limits). [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. . [2132-2-2] PORTABLE AP chest IMPRESSION: 1. Left-sided rib fractures. 2. Marked interval worsening in left-sided pleural effusion. 3. Support lines unchanged. . [2132-2-5] CT CHEST W/O CONTRAST IMPRESSION: 1. Small to moderate left pleural fluid traversed by pleural tube is nonhemorrhagic and largely dependant. A small nonhemorrhagic paramediastinal component is loculated. Considerable left lower lobe atelectasis accounts for much of radiographic opacity. 2. Severe aortic calcifications and left ventricular prominence suggest aortic stenosis. 3. Early multifocal pneumonia or widespread aspiration. 4. Bronchomalacia, not fully evaluated. 5. Severely displaced left [6-14] rib fractures. . [2132-2-8] RENAL U.S. IMPRESSION: No evidence of hydronephrosis or nephrolithiasis. The study and the report were reviewed by the staff radiologist. . [2132-2-10] CT CHEST W/O CONTRAST IMPRESSION: 1. Little change to complete left lower lobe collapse and hydropneumothorax. 2. Severe aortic valve calcifications and mitral valvular calcifications. 3. 6-mm noncalcified pulmonary nodules in the middle lobe, which warrant further evaluation with CT after acute process has resolved. 4. Enlarged precarinal lymph node which is nonspecific. 5. Grossly comminuted rib fractures, as before. . [2132-2-17] CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST IMPRESSION: 1. Increase in small pockets of gas in the atelectatic left lower lobe, a finding that is not well evaluated but suggests cavitation in necrotizing pneumonia. 2. No significant change in mixed attenuation left hydropneumothorax. 3. Several small pulmonary nodules in the right middle lobe will require followup after the acute episode. 4. Small retroperitoneal hemorrhage extending along the left iliac vessels. 5. Tiny volume ascites. 6. Multiple comminuted displaced left rib fractures. 7. Aortic valve calcifications, which is associated with aortic stenosis. . [2132-2-18] WRIST(3 + VIEWS) BILAT FINDINGS: There are comminuted fractures of bilateral distal radii. In the left wrist, on the lateral view, there is mild volar tilt of the radial articular surface, which measures [9-15] degrees and is unchanged from the prior study. In the right wrist, there is neutral alignment of the right radius on the lateral view. There is limited visualization of the carpal bones due to overlying cast. In particular, the degenerative changes in the carpus seen in bilateral wrists on the prior CT are not as optimally seen. Soft tissues appear prominent about both wrists. IMPRESSION: Cast placement in bilateral wrists. Neutral alignment of right radius and slight volar tilt of left radius. Unchanged from prior exam. . [2132-2-22] CHEST (PORTABLE AP) IMPRESSION: Decreased left lateral pleural effusion/hemothorax status post second left chest tube placement. Multiple left lateral rib fractures. Weighted enteric feeding tube tip projects just within the stomach and should be advanced. . [2132-2-25] CHEST (PA & LAT) Study Date of 6:05 PM FINDINGS: In comparison with the study of [2-24], the left-sided chest tubes remain with the side port of one being external to the pleural cavity. Little change in the left pleural effusion and atelectasis. Multiple left-sided rib fractures persist. . [2132-2-26] CHEST (PA & LAT) Final Report FINDINGS: In comparison with the study of [2-25], with the chest tubes on waterseal, there is a small pneumothorax. This information was telephoned to Dr. [Last Name (STitle) ]. . [2132-2-27] CHEST (PA & LAT) The current study demonstrates no evidence of right pneumothorax. The chest tube is in unchanged position. Cardiomediastinal silhouette is unchanged. There are again noted healed fractures of the right upper ribs. Pleural effusion is most likely bilateral. There is no change in the appearance of the left lower lung retrocardiac opacity most likely consistent with atelectasis. . [2132-2-27] CHEST (PA & LAT) Final Report REASON FOR EXAMINATION: Discontinuation of the chest tube. PA and lateral upright chest radiograph were compared to the prior study obtained the same day earlier at 12:03 P.M. The left chest tube has been removed. The left basal opacity is unchanged as well as known left pleural effusion accompanying multiple left rib fractures. No pneumothorax is demonstrated. . [3-2] Bilateral wrists Three views of the left wrist in plaster shows no change relative to [2132-2-18], in the partially healed, physiologically aligned, impacted fracture of the distal left radius . Three views of the right wrist show no appreciable change in the fractures of the distal right radius and ulna, with relative preservation of physiologic relationship with respect to the proximal carpal row. As before, there is appreciable bone resorption at the major fracture plane in the radius. The previously noted fracture of the carpal navicular is not demonstrated well this examination. The region of expansile lucency in the capitate could be due to disuse. There are no new findings to indicate interim healing. Brief Hospital Course: Mr. [Known lastname 58066] presented to the ED after a MVC where he was the unrestrained passenger with +LOC and was found pinned underneath the windshield of the car. He was seen at OSH and found to have SAH and transferred to [Hospital1 ] for further management. CT c-spine and torso were obtained at OSH and were notable only for L rib fractures [6-14]. Bilateral wrist films were obtained demonstrating R distal radius, ulna, and scaphoid fxs and L distal radius and scaphoid fractures. Orthopaedics was consulted and the L wrist was reduced at the bedside and splinted. On [1-27] pt went to OR for possible operative repair of wrists however surgery was deferred secondary to T wave inversions. Cardiology was consulted and an echocardiogram was obtained which demonstrated an EF > 55% and pt was started on nitro gtt. On [1-28] pt exhibited symptoms of EtOH withdrawal and was treated c/ clonidine, benzos, and lopressor. Pt progressed to severe DTs and required intubation, ativan and midazolam gtts, valium, haldol and propofol throughout his course. On [1-30] he became febrile and was noted to have cellulitis at old peripheral IV site and started on vancomycin. Blood cultures from [1-30] and [1-31] were noted to be growing MSSA and IV catheter tip from [2-1] also c/ MSSA. His central lines were removed. On [2-3] CXR demonstrated opacification in the L lung and chest tube was placed. He was given lasix to assist in diuresis. On [2-4] he underwent CT head for continued sedation (although thought to be secondary to high doses of benzos pt received for DTs) which showed no new intracranial process. CT chest showed continued pleual effusion and CT was repositioned. Zosyn and cipro were started for emperic coverage for possible pneumonia after BAL grew GPC and GNR. Due to continued fevers site of thrombophlebitis was excised and grew MSSA. During his course he received tube feeds and subq heparin for prophylaxis. His mental status slowly improved and he was extubated [2-8]. Pt's course has been c/b hemothorax. Pt went to OR [2-13] for VATS thoracostomy and flexible bronch; he was intubated for the procedure and extubated on [2-14]. Hospital course further c/b GIB, worsening lung opacifications, and eventually required reintubation on [2132-2-17]. Patient underwent bronchoscopy on [2132-2-18] which revealed moderate to severe tracheobronchomalacia. Patient was successfully extubated on [2132-2-19] and has remained stable. A L subclavian was placed on [2-19]. Colchicine was started at therapeutic level on [2-20] for fever with suspected gout and was changed to a prophylactic dose 2 days later. On [2-21] patient was transfered out of the ICU. After extubation he had persistant hemothorax on the L that was unable to be drained by chest tubes. He underwent an additional VATS on [2-22] to drain the persistent collection and had intra-plueral tpa 3x ([2-23], [2-24], [2-25]). He then had both of his chest tubes pulled and post-CT removal CXR showed no residual pneumothorax. While in the ICU, the patient had a traumatic foley placement when foley was changed for funguria and was evaluated by urology. Subsequent UCx were negative for yeast. After this incident he had no further issues with his foley. The patient remained afebrile on the floor and antibiotics were d/c on [2-26]. The patient had diarrhea on the floor and a flexicele was placed on [2-25]. Blood, urine, and sputum cultures remained negative after the thrombophelbitis was treated. CDiff was negative x3 and diarrhea was attributed to colchicine which was d/c on [2-27]. On [2-27] Psychiatry left their final recs - follow up with a therapist or a psychiatrist of his choice as needed. As far as rehab, if the patient becomes agitated, the staff should try using Zyprexa PRN as he responded well on that particular medication in the ICU. On [3-2], the patient got bilateral xrays of his wrists to assess healing. XR films demonstrate little healing. Orthopedic surgery was contact[Name (NI) ] regarding the results of the films. On [3-3] Medications on Admission: atenolol, colchicine, indomethacin, simvastatin, ASA 81mg Discharge Medications: 1. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Acetaminophen 500 mg Capsule Sig: [2-8] Capsules PO Q6H (every 6 hours) as needed for pain. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: hold for diarrhea. 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation: please hold for diarrhea. 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) 2.5mg/3ml Inhalation Q6H (every 6 hours) as needed for Reactive airways. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for reactive airway disease. 13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Right traumatic subarachnoid hemorrhage Left temporal intraparenchymal hemorrhage Right distal radius, ulna, and scaphoid fractures Left distal radius and scaphoid fractures Alcohol withdrawal Thrombophlebitis Bacteremia Discharge Condition: Stable Discharge Instructions: If you experience any shortness of breath, chest pain, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may/not bear weight on your arms. Please use your slings for comfort. You may resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please do not drive or operate any machinery while taking this medication. Feel free to call our office with any questions or concerns. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 739] from neurosurgery in one month. Call [Telephone/Fax (1) 1669] to make an appointment. Please follow up with Dr [Last Name (STitle) 1005] with repeat xrays of both arms/wrists in 2 weeks. Please call [Telephone/Fax (1) 1228] to schedule your follow-up appointment. Let the secretary know that you need to have repeat xrays scheduled for that day before your appointment. Please follow up with Dr. [Last Name (STitle) ] in clinic in 2 weeks with a chest xray (PA/Lat). You can call ([Telephone/Fax (1) 1504] to schedule an appointment and let the secretary know that you will need to have an xray scheduled prior to your appointment as well. Per psychiatry, the patient can follow up with a therapist or a psychiatrist of his choice as needed.	[ "997.31", "807.05", "401.1", "285.1", "427.31", "291.0", "867.0", "E816.1", "852.26", "861.01", "305.1", "530.81", "790.7", "274.9", "853.06", "682.3", "041.4", "519.19", "E879.8", "518.5", "584.9", "814.01", "999.39", "E928.9", "276.9", "813.44", "041.11", "860.2", "451.82" ]	icd9cm	[ [ [] ] ]	[ "34.04", "99.04", "38.91", "34.09", "99.07", "96.72", "33.24", "79.02", "45.23", "33.22", "94.62", "96.04", "45.13", "96.6" ]	icd9pcs	[ [ [] ] ]	26299, 26372	20451, 24628	345, 403	26637, 26646	1211, 20428	27293, 28117	621, 625		24736, 26276		26393, 26616		24654, 24713			26670, 27270									640, 640															655, 1192						225, 307							431, 516															538, 582	598, 605
52,329	172,780	43733	Discharge summary	report	Admission Date: [2131-4-17] Discharge Date: [2131-4-18] Date of Birth: [2059-6-27] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 618] Chief Complaint: altered mental status, left sided weakness Major Surgical or Invasive Procedure: none History of Present Illness: [Known firstname ] [Known lastname 93995] is a 71 yo right handed man with a history of dementia transferred from [Hospital ] Hospital. History from the transfer records state that the patient was brought to the hospital this morning from his [Last Name (un) ] Rehabiliation center for a change in mental status. Apparently the patient is normally alert, oriented and appropriate. This morning during AM care he was not following commands, had left facial and arm weakness. He was also noted to be unable to follow objects with his eyes. Fingerstick was 279. Vitals at [Hospital ] hospital were: 161/72 18 99% 2 L. Labs were notable for Na 125, Cl 89, glucose 404, BUN 23, Cre 1, WBC 11 and HCT 34. CT of the head was obtained and showed a right frontal intraparenchymal hemorrhage. The patient was given 4 units of insulin and transferred to [Hospital1 18] for further evaluation. Currently, the patient feels fatigued. He states that he has felt "funny" since yesterday, when he was having numbness and tingling in his feet (pt reports bilateral symptoms though he has a left BKA). He also feels his thinking is off. He has had tingling in his fingers as well for the last week. Otherwise, he denied headache, loss of vision, blurred vision, diplopia, dysarthria, lightheadedness, vertigo, tinnitus or hearing difficulty. He denied difficulties producing or comprehending speech. Denied focal weakness, bowel or bladder incontinence or retention. He states that he walks with crutches/prosthetic at baseline, but mostly uses a wheelchair. Past Medical History: -Dementia- diagnosed [2128] as combination of Alzheimers disease and alcoholic dementia; this was in the setting of osteomyelitis and his symptoms improved (somewhat) following amputation of his left leg. -Diabetes -CAD s/p stent, patient reports 5 yrs ago, on Plavix -[Name (NI) ] wife reports "[Name2 (NI) ]", patient reports having difficulty walking and talking -Neuropathy -Cellulitis -Pressure ulcers -Dysphagia -Hypertension -Venous Insufficiency -Anemia -Osteoarthritis -hx Alcohol abuse -Hx of Mood Disorder -Hx of delusional disorder Social History: Married. Has been in Rehab since [Month (only) 359] when he developed pneumonia and was unable to be cared for at home. He as a remote history of tobacco (>20 years ago) and alcohol abuse. No drugs. Family History: Grandfather with stroke and MI Mother with Diabetes 5 brothers and sisters which are reportedly in good health Physical Exam: T 97.8 BP 162/70 HR 80 RR 18 98 O2% General: Awake, NAD. Head and Neck: no cranial abnormalities, no scleral icterus noted, mm dry, no lesions noted in oropharynx Neck supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm, No murmurs. Abdomen: soft, non-tender, normoactive bowel sounds. Extremities: left BKA. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to [2131-8-18], [Location (un) 86]. Was able to count backwards from 10. Perseverative and spends much of the interview picking at his fingers. Minimal spontaneous speech. Language is fluent with intact repetition and comprehension. Decreased prosody. There were naming errors (called hammock=knapsack, collar=twig and knuckles=fingers), and occasional stuttering ("bo, [Location (un) ]"). Occasional errors with [Location (un) 1131] "they heard him break on the radio last night". The patient was able to read without difficulty. Speech was mildly dysarthric. There was no evidence of apraxia or neglect, calculations intact. He could follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. Pt would not cooperate with fixation enough to fully test visual fields; they were grossly full to movement. III, IV, VI: restricted upgaze. Impaired smooth persuit, particularly to the left. V: Facial sensation intact to light touch. VII: Mild left facial droop (has facial hair which obscures full view) but also weakness of the right orbicularis which can be opened easily on forced eye closure. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and sternocleidomastoid bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, increased tone/rigidity throughout, slightly more on the right than the left with. Pt unable to fully supinate his arms, but no clear pronator drift and able to sustaine both arms antigravity bilaterally. Delt Bic Tri WrE FFl FE IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5- 5 4 5 5 4+ 5 5 5 ------------------- R 5 5 5 5 5 4+ 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, No extinction to double simultaneous stimuli. -Reflexes: Brisk thoughout the upper extremities with + peck and jaw jerk. + Glabellar and snout reflexes. Absent patellar bilaterally and achilles on the right. Plantar response was flexor on the right. -Coordination: No intention tremor, no dysmetria on FNF. -Gait: deferred at this time. Pertinent Results: [2131-4-17] 03:25PM BLOOD WBC-11.8* RBC-3.87* Hgb-12.3* Hct-34.6* MCV-89 MCH-31.8 MCHC-35.6* RDW-12.7 Plt Ct-267 [2131-4-17] 03:25PM BLOOD Neuts-76.8* Lymphs-15.6* Monos-5.6 Eos-1.3 Baso-0.8 [2131-4-17] 03:25PM BLOOD PT-11.3 PTT-20.9* INR(PT)-0.9 [2131-4-17] 03:25PM BLOOD Glucose-303* UreaN-23* Creat-0.9 Na-128* K-4.9 Cl-92* HCO3-27 AnGap-14 [2131-4-18] 02:19AM BLOOD Glucose-182* UreaN-22* Creat-1.0 Na-131* K-4.6 Cl-94* HCO3-29 AnGap-13 [2131-4-17] 03:25PM BLOOD ALT-41* AST-35 LD(LDH)-198 AlkPhos-141* TotBili-0.5 [2131-4-17] 03:25PM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9 Cholest-158 [2131-4-17] 03:25PM BLOOD Triglyc-124 HDL-33 CHOL/HD-4.8 LDLcalc-100 [2131-4-17] 06:04PM BLOOD %HbA1c-7.9* eAG-180* UA negative Urine and blood cx pending CXR: No acute cardiopulmonary abnormality. Head CT (personal read): 3.5x3.0 cm Right frontal IPH. No evidence of subarachnoid, subdural blood, no ventricular extension. Diffuse sucal widening elsewhere. MRI/A: R IPH as above. 2 very small additional microbleeds on suspectibility sequences. No vascular malformation. No underlying mass. Brief Hospital Course: NEURO: [Known firstname ] [Known lastname 93995] is a 71 yo right handed man wit an extensive past medical history including Alzheimers dementia, CAD s/p stent, diabetes s/p L BKA, vascular disease. He presented from his nursing home with impairment of following commands and left sided weakness. CT of the head at [Hospital ] Hospital demonstrated a cortical-based right frontal intraparenchymal hemorrhage. At [Hospital1 18], he was admitted for observation to the neuro ICU. The most likely etiology for the IPH is amyloid angiopathy. The patient has a history of Alzheimers dementia, which is associated with the same type of amyloid deposition. The location of the bleed is also extremely characteristic for amyloid. There are 2 other very small microbleeds seen on MRI suspectibility images. MRI/A did not show any other underlying mass for bleed, such as vascular malformation or tumor. Neurologic exam on discharge was notable for L lower facial weakness. He also had paratonia, limited upgaze, grasp, snout, glabellar, and jaw jerk reflexes. His speech is sparse with occasional stuttering and semantic errors. Naming was intact for high but not low frequency objects, repetition and comprehension was intact. There was no neglect. In regards to his underlying dementia, the patient did exhibit signs of Parkinsonism including cogwheeling with distraction, and should be monitored carefully to see if he develops additional Parkinsonian features. At this point, his dementia is still relatively mild, and it is difficult to accurately diagnose the type during one brief hospital visit. He will follow up closely with his primary neurologist in [Hospital1 ]. BLOOD PRESSURE: Blood pressure was well controlled on home dose of atenlol. His blood pressure should be maintainned at SBP 140-160. His lisinopril was held, and should be restarted in the next week or so as his blood pressure tolerates. CAD: Plavix was held, and should be restarted in 2 weeks. FEVER: Patient had fever to 101.3 on evening of admission. CXR was clear, UA negative, urine and blood cx pending. He remained afebrile. WBC trended down. This may have been reactive to the intracranial bleed itself. FEN: Hyponatremic on admission, most likely hypovolemic hyponatremia as it improved with 1L NS overnight. Patient passed speech and swallow evaluation for regular consistency diet. ENDO: continued home regimen of insulin FOLLOW UP: He should have another CT with contrast in about 2.5-3 months which could be done at [Hospital1 ] to make sure that there is no pathological lesion or a mass that is underlying the hemorrhage. F/u with Neurology in 3 months. Medications on Admission: Atenolol 50 mg PO DAILY Lisinorpil 25mg daily Vitamin B Complex 1 CAP PO DAILY Atorvastatin 10 mg PO DAILY Ascorbic Acid 500 mg PO BID Insulin/lantus 20mg QHS, Insulin/Humalog 5/4/6 units Breakfast, lunch and dinner Donepezil 5 mg PO HS Mirtazipine 7.5mg QHS Plavix 75mg daily Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 6. Humalog 100 unit/mL Solution Sig: see comments Subcutaneous three times a day: 5/4/6 units Breakfast, lunch and dinner . 7. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital 6594] Rehab. and Nursing Center Discharge Diagnosis: intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a bleed in your brain. This was likely caused by amyloid angiopathy, which is deposits of abnormal proteins in the blood vessels of your brain that make them rupture. Your Plavix will be held for 2 weeks. Your lisinopril will be held temporarily. Followup Instructions: Please schedule a head CT with contrast in 2.5 to 3 months, this can be done at [Hospital ] Hospital if preferred. Please schedule an appointment with Dr. [Last Name (STitle) 58298] in 3 months. [Telephone/Fax (1) 2574] [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "437.9", "331.0", "780.60", "277.39", "V49.76", "285.9", "250.00", "431", "414.01", "715.90", "294.10", "276.1", "331.82", "459.81", "355.9", "V45.82", "787.20", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10412, 10484	6778, 9208	347, 353	10556, 10556	5635, 6755	11026, 11353	2782, 2895		9778, 10389		10505, 10535		9476, 9755			10732, 11003						4113, 5616			2910, 3359							9219, 9450														265, 309							381, 1963										10571, 10708					1985, 2543	2559, 2766
22,951	183,894	26557	Discharge summary	report	Admission Date: [2136-9-10] Discharge Date: [2136-9-23] Date of Birth: [2061-7-3] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 5755] Chief Complaint: hypotension Major Surgical or Invasive Procedure: tibeocalcaneal fusion History of Present Illness: This is a 75 yo M with charcot deformity of the left lower extremity admitted for left tibeocalcaneal fusion Social History: From NH in [Location (un) 38864]. No tob or IVDU. Unclear history of alcohol use. Family History: N/C Physical Exam: From ICU admit: bp 132/62 hr 108 rr 18 (intubated) O2 100% on vent genrl: in distress, appears in pain, uncomfortable with tube heent: ncat, perrla, mmm neck: no jvd, neck supple cv: irreg, irreg, slightly tachycardic, no m/r/g pulm: CTA (anteriorly) abd: nabs, soft, nt/nd extr: left leg in cast, left foot cold, right foot with diminished pulses Pertinent Results: [2136-9-10] 04:00PM GLUCOSE-161* UREA N-16 CREAT-0.9 SODIUM-139 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [2136-9-10] 04:00PM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-1.9 [2136-9-10] 04:00PM DIGOXIN-1.3 [2136-9-10] 04:00PM WBC-2.8* RBC-3.36* HGB-9.4* HCT-27.3* MCV-81* MCH-27.9 MCHC-34.3 RDW-17.5* [2136-9-10] 04:00PM PLT COUNT-115* [2136-9-10] 04:00PM PT-13.3* PTT-27.6 INR(PT)-1.2* [2136-9-10] 07:37PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2136-9-10] 07:37PM URINE RBC-22* WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . C DIFF NEGATIVE X 3 BLOOD CX [2136-9-11]: NO GROWTH URINE CX [2136-9-10]: CONTAMINATED. . COLON BX PATHOLOGY: PENDING . CXR [2136-9-10]: PA AND LATERAL CHEST: Compared to [2136-8-2]. Heart size is normal. Mediastinal and hilar contours are unremarkable. There is a left-sided subclavian line with its tip in the region of the left brachiocephalic vein just short of midline. No focal consolidation or other acute cardiopulmonary process. Stable appearing calcified pleural plaques. IMPRESSION: No acute cardiopulmonary process. . Ten radiographs of the left foot are submitted. The external fixator seen on [2136-9-10] has been removed. Previously seen antibiotic beads are no longer present. Patient is now seen to be status post arthrodesis of the first tarsal-metatarsal joint. A bone stimulator is present with the electrodes seen along the junction of the tibia and hindfoot. Vascular calcifications are noted. Limited assessment of the knee joint is grossly unremarkable. Fine osseous and soft tissue detail is obscured by overlying casting material. Postoperative change involving the second through fifth metatarsals remains similar in appearance. Proximal phalanx of the third toe is again noted to be surgically absent. With the exception of the first ray arthrodesis, the forefoot findings remain similar in appearance. . FLUOR GUIDED PICC PLACEMENT: IMPRESSION: Successful placement of 4 French single lumen PICC line placement via left brachial vein approach. Final catheter length is 47 cm. Tip position is in the high right atrium. The catheter is ready to employ. Post- procedural orders written. . PORT ASSESSMENT BY FLUORO: DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the procedure to be performed, the site of the procedure, appropriate requisition, and appropriate informed consent. Once the above were verified, the patient was positioned in supine fashion on a special procedures table. The left- sided single lumen chest port was noted to have an access needle in place underneath the transparent dressing. Utilizing usual aseptic precautions, the hub of the access needle was accessed and contrast administered by hand injection under fluoroscopy. Images demonstrate the proximal limb of the port catheter to be retained in the distal left brachiocephalic vein, just distal to the confluence of both the right and left brachiocephalic veins in close apposition to the vein wall inferiorly. Infusion of the port and the port catheter was then possible, however, aspiration was not possible. No superior vena cava obstruction is seen. The contrast column was seen in continuity to the level of the right atrium. (A DSA venogram was performed and recorded.) IMPRESSION: Suboptimal tip positioning of port catheter in left brachiocephalic vein as described above. No evidence of SVC stenosis. Unable to aspirate from the catheter. . CT CHEST WITH IV CONTRAST: Airway patent to the segmental level. There are no pathologically enlarged lymph nodes in the axilla, mediastinum, or hilum. Scattered shotty mediastinal lymph nodes, all less than a centimeter in short axis. There is prominent coronary artery and diffuse vascular calcification. Central venous line in place with its tip in the distal SVC. Heart, pericardium, and great vessels are otherwise unremarkable. Mild emphysema. There are several tiny pulmonary nodules less than 5 mm in diameter. The most prominent is in the right upper lobe (series 9, image 21) measuring 4 mm. Tiny (2-mm) pulmonary nodules in the right lower lobe (9, 37), and left lower lobe (9, 40). Tiny nonspecific subpleural nodular opacity in the right upper lobe (9, 25). Extensive calcified pleural plaques, likely the sequela of prior asbestos exposure. Dependent posterior pleural thickening/small effusions. CT ABDOMEN WITH AND WITHOUT IV CONTRAST: Non-contrast portion of the scan demonstrates diffuse dense vascular calcification, gallstones, and large right-sided renal calculi, one within the pelvis at the mid pole and the other within the proximal ureter. There are some surrounding inflammatory changes, but no evidence of significant hydronephrosis from these calculi. Small non- obstructing left-sided calculi are also present. Mild-to-moderate splenomegaly is noted. Contrast-enhanced portion through the abdomen demonstrates a nodular liver with volume redistrubution with patchy perfusion of the peripheral aspect of the right lobe, and it is difficult to exclude an infiltrating lesion, especially in segment V/VI. Additionally, there are several small hypoattenuating lesions within segment [Last Name (LF) 7060], [First Name3 (LF) 690], III, and VI, which are too small to characterize. While these lesions may represent small cysts or hemangiomas, metastases are not excluded. Portal venous system appears patent. No thrombus is visualized within the hepatic veins. Minimal fullness of the anterior limb of the left adrenal gland without distinct nodularity. There are several tiny shotty mesenteric and retroperitoneal lymph nodes, most prominent around the celiac axis, however, none are pathologically enlarged by CT criteria. CT PELVIS WITH IV CONTRAST: There is circumferential mural thickening around the proximal sigmoid, concerning for primary colon cancer. There are diffuse diverticuli in this region, but no surrounding stranding to suggest acute diverticulitis. However, more superiorly along the lateral aspect of the descending colon, there are mild inflammatory changes and fluid, nonspecific in nature. Within the pelvis, there are small subcentimeter, but borderline left retroperitoneal nodes, measuring up to 8 mm in diameter. Additionally, in the left deep pelvis just medial to the lower pole of the left kidney and at the level of the aortic bifurcation, there is a 3.3 x 3.3 well- circumscribed cystic lesion demonstrating a dense fluid level dependently, which could represent a necrotic lymph node. This node displaces, but does not appear to obstruct the left ureter. Remainder of the colon demonstrates no evidence of other areas of lesions or mural thickening. There are vascular borderline enlarged bilateral inguinal lymph nodes. BONE WINDOWS: There are diffuse degenerative changes and evidence of diffuse idiopathic skeletal hyperostosis involving the thoracic levels anteriorly, but no suspicious lytic or blastic lesions. Isolated hyperdense focus in the right femur is likely a bone island. MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images confirm the above findings. IMPRESSION: 1) 4-cm segment of circumferential wall thickening involving the proximal sigmoid colon, presumably corresponding to the concerning mass seen on colonoscopy. 2) Nodular liver with volume redistribution suggestive of cirrhosis. Trace ascites and splenomegaly. 3) Heterogeneous perfusion of the peripheral right lobe of the liver, most prominent in segment VI; difficult to exclude an infiltrating lesion; additionally there are several small hypoattenuating lesions in both lobes, too small to characterize; MRI is recommended for further characterization. 4) Approximately 3-cm well-circumscribed cystic lesion medial to the lower pole the left kidney, of uncertainty etiology; possibly a duplication cyst or necrotic lymph node. 4) Borderline enlarged, hyperperfusing inguinal lymphadenopathy and subcentimeter, nonspecific left retroperitoneal lymph nodes. 5) Several small (<5mm) pulmonary nodules bilaterally; short term follow-up is recommended. 6) Right renal parenchymal and proximal collecting system calculi. Brief Hospital Course: # CHRONIC LEFT FOOT OSTEOMYELITIS WITH CHARCOT FOOT DEFORMITY: Patient was admitted for left tibeocalcaneal fusion for treatment. His surgery was complicated by 2 L estimated blood loss intraoperatively with subsequent hypotension requiring ICU admission. Patient quickly stabilized and surgery was completed on [2136-9-18]. This second, less invasive surgery went will with an estimated 75 cc blood loss. Patient remained hemodynamically stable postop. Patient has been on vancomycin/levofloxacin/flagyl in house and will continue on vancomycin and flagyl x 2 weeks more, with possible extended course based on follow-up with Dr. [Last Name (STitle) ]. Patient has PICC in place for IV antibiotics. He has been afebrile and wbc stable. His pain is controlled with prn oxycodone. He will need continued PT but is non-weight bearing on the left lower extremity. No bandage dressings are needed. These will be done by Dr. [Last Name (STitle) ] in follow-up. . # ACUTE BLOOD LOSS ANEMIA / HYPOTENSION / COLON MASS: Patient had an estimated 2 liter blood loss intraoperatively. He had been transfused preop for hct 27, given history of bleeding with surgery but postop hct 26. Patient was hypotensive to sbp 70s-80s requiring ICU admission for levophed to maintain MAP > 60. Suspect component of anesthesia, pain med, and blood loss were all contributors. He was bolused (total approx 15 liters) in the ICU and quickly weaned off pressors. He has received a total of 13 units of PRBC in house. His hematocrit slowly trended down on the floor with guaic positive stool and minimal bleeding on the bandage. GI was consulted and did a colonoscopy in house which showed an erythematous, friable, protruding, malignant appearing circumferential mass with ulceration and contact bleeding in the mid sigmoid at 30 cm. Surgery was consulted and recommended a CEA and CT scan. CT torso shows no clear mets but possible liver lesions which will be assessed intraoperatively by biopsy or ultrasound if the patient wishes to pursue operative treatment. CEA was normal (< 1.0). Patient will need follow-up scheduled with Dr. [Last Name (STitle) 1120] to discuss possible surgical options. Currently, pathology is pending. Patient declined offer to discuss these findings with his family. Hematocrit will need to be rechecked in 2 days (29.2 prior to discharge). EGD showed erythema, granularity, and congestion in the stomach body compatible with gastritis and gastric erosion with active oozing of blood. [Hospital1 ]-CAP was successfully applied for hemostasis. Patient is to continue on [Hospital1 ] PPI and avoid NSAIDs. He is currently off ASA. . # PORT FAILURE: Port placed at outside facility 1 year ago. We were unable to aspirate off the port but it does flush. IR study shows port is not in proper position and in a low flow vessel. Outpatient follow-up will need to be arranged for removal. . # Thrombocytopenia - Platelets decreased from 261 to 67 postop. HIT antibody was negative and DIC panel unremarkable. Suspect this was dilutional due to IVF and PRBC. Platelets improved to 198 prior to discharge. He had no further bleeding in the setting of his low platelets and thus did not require a platelet transfusion. . # Coagulopathy: INR also slightly elevated preop, as well as PTT. Again, suspect this was dilutional. However, INR improving with SQ vitamin K. . # PAF: Patient is not on anticoagulation, but will follow-up with his PCP as an outpatient to consider starting this. He is on digoxin for rate control. . # Diastolic CHF: Patient is preload dependent. He is on standing lasix at home, which has been restarted. . # H/O ETOH abuse: Patient had no requirement for benzos on his CIWA scale. He is on thiamine, folate, and a multivitamin. . # Hyperglycemia: Patient was started on metformin last admission. This can be restarted if his creatinine is stable in 2 days. He was taking metformin 500 mg po bid. He is on a regular sliding scale insulin scale currently for blood sugar control. Consider restarting ASA once GI issues resolve. . # PPX - Lovenox for DVT ppx until ambulating. MRSA precautions. . # Access - PICC in place . # Dispo: patient discharged back to [Hospital 38864] Rehab and Nursing Center Medications on Admission: percocet, iron 325 mg po tid, protonix 40 mg po qd, thiamine 100 mg po qd folate 1 mg po qd, digoxin 250 mcg po qMon,Wed,Fri and 125 mcg qTues,Thurs,Sat; lasix 20 mg po qd Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous once a day: until ambulating. 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks: PATIENT TO FOLLOW-UP WITH DR. [Last Name (STitle) 15351] REGARDING POSSIBLY EXTENDING ANTIBIOTIC DURATION. 10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 2 weeks: PATIENT TO FOLLOW-UP WITH DR. [Last Name (STitle) 15351] REGARDING POSSIBLY EXTENDING ANTIBIOTIC DURATION. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: per sliding scale. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: hold for rr < 8 or oversedation. Discharge Disposition: Extended Care Facility: [Hospital 38864] rehab Discharge Diagnosis: colon mass, probable malignancy left foot chronic osteomyelitis s/p tibeocalcaneal fusion acute blood loss anemia port-a-cath failure history of type 2 diabetes history of paroxysmal atrial fibrillation history of diastolic heart failure Discharge Condition: good: pain controlled, afebrile, hematocrit stable Discharge Instructions: Please monitor for temperature > 101, decreased mental status, bright red blood in the stool, diarrhea, or other concerning symptoms. Please avoid taking your aspirin for now. Please follow-up with Dr. [First Name (STitle) ] to discuss when it is safe for you to restart this medication. Followup Instructions: Please call to schedule follow-up with Dr. [Last Name (STitle) ] for this week. Phone: ([Telephone/Fax (1) 4335] Please call to schedule follow-up with Dr. [Last Name (STitle) 1120] on the same day to discuss possible surgical options for your colon mass, which is likely cancer. Phone: ([Telephone/Fax (1) 3378] Please follow-up with the surgeon that placed your port, to schedule a surgery to have that removed as it is not working and puts you at risk of developing a clot in your blood vessel. This should be done within the next 1-2 weeks. Please follow-up with Dr. [First Name (STitle) ] in [12-5] weeks for a routine check-up. Phone: [Telephone/Fax (1) 65565]	[ "427.31", "501", "428.30", "535.01", "153.3", "998.11", "250.00", "458.29", "730.17", "401.9", "713.5", "996.1", "285.1", "250.60" ]	icd9cm	[ [ [] ] ]	[ "77.78", "84.72", "99.04", "78.18", "38.93", "78.17", "81.11", "00.17", "44.43", "45.25" ]	icd9pcs	[ [ [] ] ]	15199, 15252	9207, 13487	292, 316	15534, 15587	967, 9184	15929, 16631	575, 580		13709, 15176		15273, 15513		13513, 13686			15611, 15906									595, 948																					241, 254							344, 454																470, 559
10,957	157,977	17343	Discharge summary	report	Admission Date: [2172-10-30] Discharge Date: [2172-11-13] Date of Birth: [2140-12-29] Sex: M Service: MEDICINE Allergies: Vancomycin / Norvasc / Iodine; Iodine Containing / Tums Anti-Gas/Antacid / Compazine / Thymoglobulin / Dilaudid Attending:[First Name3 (LF) 3624] Chief Complaint: Acute renal failure on labs, sent in from home Major Surgical or Invasive Procedure: Left below the knee amputation (BKA) PICC line placement History of Present Illness: 31yo man with type I diabetes mellitus and with h/o ESRD s/p living related donor kidney transplant [2169-7-18], s/p cadaveric pancreas transplant [4-/2170], admitted with abnormal lab studies. Patient was admitted to [Hospital1 18] [Date range (3) 48551] with a left leg infection in setting of multiple nonhealing fractures following an accident at work, treated with iv antibiotics, and currently planning for amputation. He was again admitted in [6-/2172] with rejection and reaction to azathioprine. The renal transplant team has been varying his immunosuppressant regimen to allow for bone healing as well as preventing rejection. He was seen in clinic today and found to have a rising creatinine and acidosis. Additionally, he vomited a few times on the day prior to admission in the setting of severe pain in his left. He has also been dyspneic on exertion due to progressive anemia and was recently started on erythropoietin injections. He denies having had fevers, chills, cough, chest pain, abdominal pain, diarrhea, constipation. Past Medical History: h/o type I diabetes mellitus s/p pancreas transplant [2170-5-20] ESRD s/p living related renal transplant [2172-7-17] Recurrent UTIs Blind in left eye d/t toxoplasmosis infection Occlusion of radial/ulnar arteries s/p eye laser surgery Diabetic retinopathy Neuropathy Fistula right arm Social History: Lives with his parents; previously worked in a warehouse. Recently quit smoking, smoked 1 pack per week, no ETOH, no drugs Family History: Noncontributory. No history of diabetes Physical Exam: PE: T 100.5 HR 89 BP 107/70 RR 18 99%RA Wt 73.4kg GEN: alert and oriented x3, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes LYMPH: no anterior/posterior cervical, occipital, or supraclavicular adenopathy CARDIOVASCULAR: PMI nondisplaced, regular rate and rhythm without murmurs, rubs, or gallops LUNGS: clear to auscultation and percussion bilaterally without rhonchi, wheezes, or crackles ABDOMEN: midline ventral hernia at surgical scar, soft, nontender, nondistended with normal active bowel sounds. no masses. no hepatosplenomegaly by percussion or palpation. kidney palpable in right lower quadrant, nontender EXTREMITIES: left lower extremity edematous, painful to palpation SKIN: erythema left ankle, numerous tattoos Pertinent Results: [2172-11-13] 05:06AM BLOOD WBC-4.0 RBC-2.85* Hgb-7.7* Hct-23.7* MCV-83 MCH-27.1 MCHC-32.6 RDW-17.3* Plt Ct-487* [2172-11-9] 05:00AM BLOOD WBC-4.6 RBC-3.96* Hgb-10.6# Hct-31.7# MCV-80* MCH-26.6* MCHC-33.2 RDW-16.0* Plt Ct-405 [2172-10-30] 12:10PM BLOOD WBC-1.6* RBC-2.75* Hgb-6.8* Hct-22.5* MCV-82 MCH-24.8* MCHC-30.3* RDW-15.0 Plt Ct-381 [2172-11-13] 05:06AM BLOOD Neuts-34* Bands-31* Lymphs-8* Monos-13* Eos-3 Baso-0 Atyps-2* Metas-8* Myelos-0 Promyel-1* [2172-11-12] 04:52AM BLOOD Neuts-65 Bands-0 Lymphs-12* Monos-16* Eos-1 Baso-0 Atyps-0 Metas-5* Myelos-1* [2172-11-11] 05:16AM BLOOD Neuts-25* Bands-32* Lymphs-3* Monos-28* Eos-0 Baso-3* Atyps-0 Metas-7* Myelos-2* [2172-11-13] 05:06AM BLOOD Glucose-90 UreaN-25* Creat-3.4* Na-141 K-4.4 Cl-106 HCO3-25 AnGap-14 [2172-11-3] 03:25PM BLOOD Glucose-124* UreaN-43* Creat-5.1* Na-141 K-5.7* Cl-108 HCO3-20* AnGap-19 [2172-10-30] 12:10PM BLOOD UreaN-56* Creat-5.5# Na-142 K-5.0 Cl-105 HCO3-19 AnGap-23* [2172-11-12] 04:52AM BLOOD ALT-5 AST-17 AlkPhos-59 Amylase-38 TotBili-0.3 [2172-11-13] 05:06AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.2 [2172-11-11] 05:16AM BLOOD PEP-HYPOGAMMAG IgG-394* IgA-73 IgM-25* IFE-NO MONOCLO [2172-10-30] 12:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [2172-10-30] 12:10PM BLOOD PTH-173* [2172-10-30] 12:10PM BLOOD %HbA1c-6.4* [2172-10-30] 12:10PM BLOOD HCV Ab-NEGATIVE [2172-11-11] 05:16AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- TEST [2172-10-31] 06:30AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-Test . CT HEAD [2172-11-11] 9:37 AM 1. No intracranial bleed or obvious masses. 2. Persistent left globe opacification consistent with known history of retinal hemorrhage and toxoplasmosis. . PATH: Duodenum \DIAGNOSIS: Duodenal bulb: Stromal hemosiderin deposition, otherwise unremarkable duodenal mucosa. Stains to confirm nature of pigment will be sent as an addendum. . [2172-11-9] Pathology Tissue: LEFT BELOW KNEE AMPUTATION. pending . XRAY LLE [2172-10-31] 10:01 PM IMPRESSION: As compared to [2172-5-5], progressive disintegration of the bony structure at the level of the ankle, concerning both the tibia, the fibula, and the talus. These changes are congruent with chronic osteomyelitis. . CT LLE; [2172-10-31] 2:47 PM IMPRESSION: 1. Reticular subcutaneous edema and muscle edema of the left lower extremity, however, no discrete abscess or fluid collection is seen. Lack of intravenous contrast did limit the sensitivity for detection of small abscesses. 2. Progressive collapse of the tibiotalar joint with resorption of the distal tibia and collapse and resorption of the talar dome. Hardware unchanged in position. Fractured third distal most screw again noted. The findings are congruent with reported history of chronic osteomyelitis, however neuropathic joint would have a similar appearance. . RENAL U/S: [2172-10-31] 2:09 PM IMPRESSION: Resistive indices obtained within the renal transplant are at the upper limits of normal. No evidence of hydronephrosis. . Brief Hospital Course: 31 yo man with h/o ESRD s/p living related renal transplant [2168] and type I diabetic s/p pancreas transplant [2169], admitted with acute renal failure/elevated creatinine, anion gap metabolic acidosis, and progressive anemia. . # Fevers / Osteomyelitis Patient presented with neutropenia and fevers. The neutropenia was considered secondary to tacrolimus / sirolimus toxicity. He was initially started on cefepime / daptomycin for febrile neutropenia (vancomycin allergic). Blood cultures were positive for enterococcus sensitive to ampicillin. X-rays of the left leg showed chronic osteomyelitis. He was provided opiate pain medication for pain control. He was started on daptomycin and cefipime, when he was febrile w/ neutropenia before culture data returned and then transitioned to IV ampicillin. TTE was unremarkable for endocarditis. Orthopedic surgery was consulted which recommended elective amputation. He underwent elective BKA on the left leg. PT was consulted and started working on [Hospital 48552] rehabilitation. He will perform PT at HOME. He will follow up w/ vascular surgery ([Doctor Last Name ]) in [1-26] weeks. Given his risk of poor post-surgical healing, stump shinkers should not be used. ID was consulted on the patient to manage the enterococcal bacteremia; ID will follow his CBC and renal function to determine appropriate renal dosing of ampicillin if his renal function continues to improve. He will continue on a course of ampicillin at home for 2 weeks from the date of BKA. . # Respiratory Failure On hospital day 6 the patient was found by the renal fellow at 11am to be unresponsive w/ shallow infrequent respirations. His pupils were non-responsive and dilated. He recieved 15 mg of MSIR at 4am. He had been given MSIR 15 mg [Hospital1 ] x 6 days with occasional IV supplementation. He was immediately provided narcan and a CODE BLUE was called. He awoke immediately and suffered withdrawal symptoms of rigors, chills, and vomiting. He was transferred to the MICU for observation. His MICU course was notable for 2 additional doses of narcan for mild somnolence without frank respiratory depression. He was also noted to have intermittent hypertension which were attributed to both acute opiate withdrawal induced by the narcan. His opiate dosing was changed to dilaudid to decrease the build-up of active metabolites. IV Diliaudid ended up causing nausea / vomiting, and he was transitioned to tylenol. Gabapentin was also used temporarily, which he tolerated well. . # Neutropenia Initially neutropenic, likely secondary to medications (rapamycin toxicity). He was placed on neutropenic precautions. His immunosuppression medications were lower after finding supra-therapeutic levels. His ANC trended upward over several days as the rapamycin / sirolimus levels trended down. He was not treated w/ filgastrim. . # Cellular Atypia / PTLD After the patient's WBC# started to return to normal, the differential and manual analysis were noted to have many atypical cell lines and morphologies. Heme-Onc was consulted to comment on whether these abnormalities were consistent w/ a lymphoproliferative process. Heme/Onc considered the atypia secondary to a reactive process (s/p infection / suppression). However, EBV viral load was measured to assess for risk of post transplant lymphoproliferative disorder. This was communicated w/ his primary nephrologist and he will follow up next week. . # Nausea / Vomiting The patient suffered intractable nausea / vomiting after his repiratory code, and especially after the surgery. He remained free of abdominal pain. The N/V was zofran, and a head CT was also performed to rule out metastasis / mass lesions (unremarkable for this). Amylase / Lipase were normal repeatedly; his sxs were not considered secondary to pancreatitis or rejection. His IV dilaudid was stopped and he felt better immediately. . # ARF on CKD Urine studies showed ATN. Blood levels of tacrolimus / sirolimus were checked and found to be markedly elevated (Tac 10.8; Sirolimus 13.6). ARF / ATN was considered secondary to med toxicity. He was not considered to be rejecting his transplanted kidney or pancreas. His sirolimus and tacrolimus doses were titrated and followed daily. He was provided IVFs and his creatinine trended downward, although not quite back to his previous baseline. He will follow up w/ renal next week for labs and re-visit w/ Dr. [Last Name (STitle) ]. . # HTN Pt remained hypertensive during hospitalization, however was asymptomatic. His home metoprolol dose was increased to 200 mg [Hospital1 ] from 100mg toprol long acting. He was transiently treated w/ PO and IV hydralazine. He will continue to follow for BP control as an outpatient. . # Anemia He received 2 units of PRBCs initially and another 2 units just prior to his BKA. His hct continued to trend down slowly, considered secondary to ESRD. Epogen was continued and he will be discharged on home epogen dose, 10,000 units / weekly. . # Depression Continued Lexapro . # Hypercholesterolemia Continued Lipitor . PENDING STUDIES CMV viral load Pathology- > BKA LLE Blood cultures Medications on Admission: Prednisone 5mg daily Bactrim SS 1 tab daily Prilosec 20mg [Hospital1 ] Prograf 2mg [Hospital1 ] Lexapro 10 mg daily Lipitor 40 mg QHS Toprol 100 mg QAM Oscal + D 500 mg tab QPM Ferrous sulfate 325 mg TID Epogen 14,000units weekly Discharge Medications: 1. Outpatient Lab Work BUN / Creatinine; LFTs; CBC; please have checked on [11-18], faxed attn: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443], [Telephone/Fax (1) 1419] 2. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) g Intravenous twice a day: LAST DOSE 12/31. Disp:qs Refills:2 3. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: heparin flush per protocol NEHT. Disp:qs ML(s) Refills:0 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for PCP [Name Initial (PRE) 1102]. 6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [5-1] hours as needed. Disp:15 Tablet(s) Refills:0 13. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:2 14. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1) Intravenous once a day: Sodium Chloride (normal saline) flush per protocol NEHT. Disp:qs Refills:2 15. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 16. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:120 Capsule(s) Refills:2 18. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a week. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Primary: - Osteomyelitis - s/p below the knee amputation - Bacteremia Secondary: - Type 1 DM - S/p Pancreas + Kidney transplants - S/p fall and ORIF L ankle /leg Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with fever, kidney failure, and leg pain. You were found to have an infection of your bone. You were started on IV antibiotics for this. The orthopedic surgery team evaluated you and recommended amputation below the left knee. You will need to follow up with them for this. You were also found to have renal failure. Your immunosuppression drugs doses were lowered. . MED Changes: 1. Start taking the sirolimus 1 mg tomorrow ([11-15]) at 6AM, and then alternate daily with the siroliums 2 mg tablet. 2. Metoprolol, 200 mg twice daily 3. EPO 10,000 units once weekly 4. Ampicillin: 2 g IV twice daily until [11-23]. Dr. [Last Name (STitle) 7443] may also contact you to increase the dose / frequency. . If you experience the following, call your doctor or return to the ED for evaluation: fevers > 101, chills, nightsweats, palpitations, shortness of breath, worse leg pain, open sore in the leg and / or drainage of pus, cough, fatigue, weakness, rashes, decreased urine output. Followup Instructions: Please keep the below appointments. . Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2172-11-16] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2172-12-8] 9:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2172-12-7] 9:30 . You will need to have follow up labs faxed to the Infectious Disease clinic. Please fax BUN / CREATININE / Liver function tests to [Telephone/Fax (1) 1419]. [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629]	[ "403.90", "996.81", "357.2", "V42.83", "276.2", "238.79", "E878.0", "790.7", "041.04", "250.61", "584.5", "276.51", "518.5", "285.21", "730.16", "362.01", "250.51", "288.04", "585.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "84.15", "38.93", "45.16" ]	icd9pcs	[ [ [] ] ]	13599, 13682	6012, 11213	422, 481	13888, 13897	2938, 5989	14977, 15747	2048, 2089		11502, 13576		13703, 13867		11239, 11479			13921, 14954									2104, 2919																					336, 384							509, 1572															1594, 1890	1906, 2032
932	114,330	12315	Discharge summary	report	Admission Date: [2123-2-16] Discharge Date: [2123-2-22] Date of Birth: [2059-5-4] Sex: M Service: HI[Last Name (STitle) 2710]OF PRESENT ILLNESS: This 62 year-old diabetic male with a history of atypical chest pain and dyspnea on exertion referred for cardiac catheterization after a positive stress test. Cardiac catheterization showed ejection fraction of 60%, 60% left main disease, 80% left circumflex, 70% RCA. The patient remained in house after his cardiac catheterization and was taken to the operating room on [2123-2-16] with Dr. [Last Name (Prefixes) ]. PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes mellitus. 2. History of prostate cancer status post prostatectomy 10 years ago. 3. Asbestosis. 4. Hypertension. 5. A 30 to 40 pack year smoking history, quit in the 70s. 6. Status post biopsy of a right anterior tibial lesion with a follow up bone scan and CT scan of the abdomen and pelvis to rule out metastasis from prostate cancer. Results are unknown. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Imdur 30 milligrams po q day. 2. Lipitor 20 milligrams po q day. 3. Glucotrol 5 milligrams po q day. 4. Tiazac 360 milligrams po q day. 5. Diovan 80 milligrams po q day. 6. Aspirin 325 milligrams po q day. LABORATORY DATA: White blood cell count 7.5, hematocrit 46.2, platelet count 184,000, sodium 140, potassium 4.5, chloride 106, bicarb 26, BUN 19, creatinine 1.2. Blood sugar 150. HO[Last Name (STitle) ] COURSE: The patient was taken to the operating room on [2123-2-17] with Dr. [Last Name (Prefixes) ] for CABG times three. In the operating room it was difficult to place a Foley catheter preoperatively. Urology was consulted. Flexible cystoscopy showed a bladder neck stricture. A wire was placed and the stricture was dilated. A Foley catheter was inserted. The patient underwent CABG times three, LIMA to diagonal, saphenous vein graft to RCA, saphenous vein graft to OM. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned and extubated from mechanical ventilation on postoperative day one. The patient remained in the Intensive Care Unit requiring Neo-Synephrine infusion to maintain adequate blood pressure. The patient was transferred out of the Intensive Care Unit on postoperative day two. The patient's chest tubes were removed on postoperative day two. Post chest tube removal chest x-ray demonstrated a small left apical pneumothorax from which the patient was asymptomatic. The patient was transferred to the floor and began ambulating with Physical Therapy. The patient's temporary pacing wires were removed on postoperative day three. The patient's Foley catheter was removed on postoperative day five. The patient is to void prior to discharge otherwise Foley catheter will be re-inserted. Repeat chest x-ray on [2123-2-21] demonstrated a continued small left apical pneumothorax unchanged from previous chest x-ray of [2123-2-18]. It is felt that the size and stability of the pneumothorax did not require any intervention. The patient was cleared for discharge on [2123-2-22] to rehabilitation facility as it was felt that the patient would need continued physical therapy and short term rehabilitation. CONDITION AT DISCHARGE: Tmax 100.4 F, T current 99.1 F. Pulse 94, sinus rhythm. Blood pressure 122/52. Oxygen saturation 94% on two liters nasal cannula. The patient's weight on [2123-2-22] is 105 kilograms. The patient was 99 kilograms preoperative. White blood cell count 9.9, hematocrit 26.9, platelet count 233,000, sodium 140, potassium 4.3, chloride 100, bicarbonate 31, BUN 19, creatinine 0.9, blood sugar 169. The patient is alert and oriented times 3, neurologically grossly intact. Cardiovascular - regular rate and rhythm. No audible rub or murmur. Extremities are warm and well perfused. Respiratory - breath sounds are decreased bilaterally with crackles at the left base. GI - abdomen is obese, soft, positive bowel sounds, nontender, nondistended, positive bowel movement. Extremities - right lower extremity incision is clean, dry and intact. The patient has Dermabond over the incision. Sternal incision - Steri Strips are intact, no erythema or drainage is noted. There is scant amount of serosanguinous drainage from the medial chest tube site with no erythema noted. DISCHARGE MEDICATIONS: 1. Lopressor 50 milligrams po bid. 2. Lasix 20 milligrams po bid times 10 days. 3. KCL 20 milliequivalents po bid times 10 days. 4. Colace 100 milligrams po bid. 5. Ranitidine 150 milligrams po bid. 6. Enteric coated aspirin 325 milligrams po q day. 7. Lipitor 20 milligrams po q HS. 8. Glucotrol 5 milligrams po q day. 9. Ibuprofen 400 milligrams po q four to six hours prn. 10. Oxycodone 5/325 one to two tablets q four to six hours prn. 11. Dulcolax suppository one po q day prn. 12. Regular sliding scale insulin for blood sugar of 150 to 200 give three units subcutaneous; for blood sugar 201 to 250 give five units subcutaneous; blood sugar 251 to 300 give seven units subcutaneous; blood sugar 301 to 350 give 9 units subcutaneous. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post CABG. 2. Noninsulin dependent diabetes mellitus. 3. History of prostate cancer status post prostatectomy ten years. 4. Bladder neck stricture, status post dilation. 5. History of asbestosis. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient is to be discharged to a rehabilitation facility in stable condition. The patient is to follow up with Dr. [Last Name (STitle) 8952] in three to four weeks. The patient is to follow up with Dr. [Last Name (Prefixes) ] in three to four weeks. The patient is to follow up with Dr. [Last Name (STitle) ] upon discharge from rehabilitation. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 3870] MEDQUIST36 D: [2123-2-22] 09:26 T: [2123-2-22] 09:44 JOB#: [Job Number 38407]	[ "250.00", "401.9", "501", "272.0", "596.0", "V10.46", "414.01", "411.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.23", "36.15", "36.12", "57.92", "88.56", "88.53" ]	icd9pcs	[ [ [] ] ]									4441, 5190		5211, 6120																						1093, 3332						3347, 4418																													633, 1067
2,289	133,310	20524+20525	Discharge summary	report+report	Admission Date: [2134-3-3] Discharge Date: [2134-3-15] Date of Birth: [2070-11-9] Sex: M Service: NSU INTERIM CARE SUMMARY DATE OF TRANSFER TO HEMATOLOGY/ONCOLOGY SERVICE: [2134-3-15] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 54910] is a 62-year-old male who had known metastatic melanoma. His initial illness began in [2130], where he had a dark line across his right great toenail which widened. He had seen a podiatrist. The lesion was getting bigger and ulcerative. The toenail was removed. He was referred to [Hospital3 ] in [2133-3-19] and had an amputation of his right toe. In [2134-1-19], he had an extensive work-up. A full body CT showed bilateral small pulmonary nodules, and the spleen limber for which MRI of the body was recommended, and prominent left pelvic and periaortic lymph nodes were not determined to be pathologic at that time. MRI of the whole spine showed diffuse metastatic disease without spinal cord involvement. A bone marrow biopsy on [2-8] was positive for extensive melanoma involvement. A head CT showed a left frontal metastasis. He was seen by Dr. [First Name8 (NamePattern2) 52041] [Last Name (NamePattern1) 22152] from neuro-oncology at that time. It was recommended that he have surgical removal and be treated with SRS in the resection cavity. However, he on [2134-3-2] developed sudden right-sided weakness and underwent an emergent craniotomy. PHYSICAL EXAMINATION: On admission, his vital signs were 98.9, blood pressure 188/102, respirations 20. He was in no acute distress, but uncomfortable. LUNGS: Clear. ABDOMEN: Benign. He had no movement in his right side. HOSPITAL COURSE: He was taken emergently to the operating room and underwent a left-sided frontal craniotomy. Postoperatively, he responded to voice, but was not able to move his right side postoperatively. He had full movement of his left side. He remained in the postanesthesia recovery unit overnight on the evening of [2134-3-3] for pain control and to check his neurologic signs. A postoperative MRI showed postoperative changes in the posterior left frontal lobe with no increased mass effect as compared to his preop study. There was linear enhancement along the anterior aspect of the operative site, and a small amount of residual tumor could not be excluded. There was an area of T1 hyperintensity and susceptibility effect in the operative site which might be related to a small amount of blood products following the surgery. He remained in the ICU until [2134-3-5] for blood pressure control monitoring and due to his dense right hemiparesis and fever to the 102 range. He was more sleepy. He had a chest x-ray and a urine. Initially, the urine looked like it was positive for a UTI, but the cultures were negative. He did have a chest x-ray that was questionable for pneumonia and was started on Levaquin for that. He continued to have high fevers through the [2134-3-12]. He continued to have full work-up surveillance cultures which showed no source of infection. At that time, we had recommended a meningitis work-up, and Mr. [Known lastname 54910] refused to have an LP done. Four different medical providers, including his oncologist, Dr. [Last Name (STitle) ], spoke with him of the importance of having a work-up for meningitis. On [3-10], he had complained of excruciating back pain which was not relieved with Dilaudid, percent and his MS Contin. A pain service consultation was obtained, which they recommended placing him on a PCA overnight to get his pain under control, and then he was started on morphine sulfate IR 15-30 mg q.3-4h. p.o. p.r.n., and morphine sulfate SR 30 mg q. 8h., Tylenol 500 mg q.4h., and within 2 days his pain was much better under control. His Dilantin was stopped, thinking that may have related his fevers, and he was started on Keppra. He continued to have fevers, though they lessened to 101 for the 25 through the 28. He remained neurologically stable, awake, alert, oriented x3, moving his left side spontaneously with minimal to no movement in his right side, tolerating a regular diet, and his pain was much more controlled on his morphine sulfate SR, and his morphine sulfate IR, and it was felt that he could benefit from spinal radiation therapy. For that reason, he is being transferred to the hematology/oncology service of Dr.[Name (NI) 54911] service to have radiation to his back. On the morning of transfer, his hematocrit was 26, and they recommended 2 units of blood. However, before he left he was unable to be typed and screened due to his appointment for radiation oncology. His neurosurgery follow-up should be in the brain tumor clinic in the next 3 weeks. He should be kept on Decadron 2 mg p.o. q.12h. and Keppra 500 mg p.o. b.i.d. His staples have been removed, and his incision is dry and intact without signs of infection. The patient is being transferred to the hematology/oncology service. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 8632] Dictated By:[Last Name (NamePattern1) 12790] MEDQUIST36 D: [2134-3-15] 08:49:23 T: [2134-3-15] 10:02:24 Job#: [Job Number 54912] Admission Date: [2134-3-2] Discharge Date: [2134-3-22] Date of Birth: [2070-11-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 45556] Chief Complaint: Right sided weakness. Major Surgical or Invasive Procedure: Craniotomy on [2134-3-3]. History of Present Illness: The pt. is a 63 year-old gentleman with a history of [Doctor Last Name ] stage IV metastatic melanoma who initially presented to [Hospital1 18] on [2134-3-2] with acute-onset right-sided weakness and expressive dysphasia. He was originally scheduled to undergo craniotomy and stereotactic surgery on [2134-3-8] for known metastatic lesions to the brain. He was started on dacarbazine on [2134-3-1] and presented on the following day with the acute onset of right-sided weakness and dysphasia. He was found to have increased size of a left frontal lobe mass (1cm on [2134-1-29] to 3cm on [2134-3-2]) with vasogenic edema exerting a mass effect. He was taken to the OR for a craniotomy on [2134-3-3] and a stereotactically-guided procedure was performed and the left frontal mass was removed. The mass was noted to have associated hemorrhage. Since surgery, he has been treated in the NSICU for blood pressure management (nipride, then labetolol drip, now on p.o. lopressor), blood transfusions, seizure ppx. and pain control. His course has been complicated by post-operative fever and FTT in addition to significant pain. He was transferred to OMED to initiate palliative XRT and continued pain control. On transfer to medicine on [2134-3-15], the pt. offered no specific complaints. He stated that his back pain was currently well-controlled. He denied recent fever, chills, shortness of breath, chest pain, nausea, vomiting, abdominal pain. Past Medical History: -[Doctor Last Name ] stage IV metastatic melanoma Oncologic Hx: In mid [2131], the pt. developed a dark line running horizontally across his right great toenail. Over that time, the area widened apparently, and an opening appeared close to the cutical, which moved with the outward growth of the nail. He noted that bloody fluid eventually leaked from this opening, A medial and lateral biopsy of the nail bed was performed and initial biopsy was read as potentially a lymphoma. However, follow-up pathology report was read as an ungal melanoma. His R great toe was amputated on [2133-4-11]. His melanoma returned on R great toe stump and biopsy on [2134-2-4] showed dermal metastatic melanoma. A full body CT/PET was performed and showed metastatic lesions to the vertebral bodies, spleen, liver, and brain (L frontal lobe). -s/p R great toe amputation on [2133-4-11] -s/p appendectomy -s/p umbilical hernia repair -s/p T and A Social History: The pt. is a retired mechanical designer. He lives with his wife. [Name (NI) ] is a former cigarette smoker (30 pack year history). Former 10drink/wk alcohol use. Family History: Remarkable for mother and a sister with stroke. Physical Exam: Vitals: T: 98.7F P: 100 R: 26 BP: 160/82 SaO2: 98% RA General: Awake, alert, appears comfortable and in NAD. HEENT: Craniotomy scar noted over L frontal bone, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: tachycardic, RR, nl. S1S2, no M/R/G noted Abdomen: soft, nontender to palpation, mildly distended, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 2 (not date/time). Attends to examiner and follows commands. Expressive aphasia with intact repitition and comprehension. Perseverative thought process at times. -cranial nerves: II-VI intact, R flattenend nasolabial fold, VIII-XII intact. -motor: Tone spastic on right. Normal bulk throughout. delt. bic. tric. wr.fl. wr. ext. ffl. IP Quad Ham TibA. [Last Name (un) ]. [Last Name (un) 938] R 0 0 0 0 0 0 1 1 1 1 1 N/A L 4+ 5 5 5 5 5 4+ 5 4+ 5 5 5 No abnormal movements noted. -sensory: No deficits to light touch appreciated, although exam limited. -cerebellar: No nystagmus, dysarthria. -DTRs: bic. tri. [Last Name (un) ]. ffl. patellar Achilles Plantar response R 3 3 3 3 3 2 N/A L 2 2 2 2 2 1 withdrawal +[Doctor Last Name 937] sign bilaterally R>L Pertinent Results: Radiologic Data: -MRI of head, [2134-3-3]: Study performed demonstrating left frontal metastatic lesion, which has increased in size compared to [2134-2-20]. Vasogenic edema has also increased. No new lesions are identified -MRI of head, [2134-3-4]: There are postoperative changes in the posterior left frontal lobe with no increase in mass effect compared to the preoperative study. There is linear enhancement along the anterior aspect of the operative site and a small amount of residual tumor cannot be excluded. There are areas of T1 hyperintensity and susceptibility effect in the operative site which might be related to small amounts of blood breakdown products following the surgery, although they are also identical in signal intensity to the original melanoma Labs on transfer: [2134-3-15] 05:50AM BLOOD WBC-7.2 RBC-3.02* Hgb-8.7* Hct-26.9* MCV-89 MCH-28.7 MCHC-32.2 RDW-14.6 Plt Ct-184 [2134-3-15] 05:50AM BLOOD Glucose-108* UreaN-9 Creat-0.4* Na-138 K-3.3 Cl-101 HCO3-28 AnGap-12 Brief Hospital Course: For details of the hospitalization prior to [2134-3-14], please refer to the HPI. 1. Metastatic melanoma: Upon transfer to medicine, the goal of care was palliation with XRT to bony metastases. He underwent five sessions of XRT. His pain was controlled with morphine and acetaminophen. The phsyical therapy and speech therapy services were consulted to work with the pt regarding his neurologic residua. He was maintained on keppra for seizure prophylaxis. He was also maintained on dexamethasone for cerebral edema. 2. HTN: The pt. had elevated blood pressure after surgery as discussed in the HPI. On transfer to medicine, he was placed on metoprolol with adequate blood pressure control. 3. Anemia: Secondary to bone marrow involvement with melanoma as diagnosed on bone marrow biopsy. He was transfused a total of 2 units of PRBCs after transfer to medicine for Hct < 25. His Hct was stable and over 30 for the last 5 days of admission. 4. RLL pneumonia: The pt. developed low-grade fever seven days prior to discharge. A chest x-ray was performed that showed a questionable right lower lobe pneumonia. He was started on empiric levofloxacin and metronidazole and subsequently defervesced. He was discharged with a prescription for a seven day course of these antibiotics to complete a 14 day course. 5. BRBPR: The pt. was noted to have scant BRBPR on [2134-3-17]. His hematocrit remained stable. Rectal exam disclosed internal hemorrhoids. He was also maintained on a PPI and carafate for GI prophylaxis while on dexamethasone. Medications on Admission: Medications on transfer: -acetaminophen 500mg po/pr q4h -bisacodyl 10mg po/pr daily;prn -dexamethasone 2mg po q12h -docusate 100mg po bid -ferrous sulfate 325mg po daily -gabapentin 600mg po tid -heparin 5000units sc tid -regular insulin sliding scale -keppra 500mg po bid -lorazepam 0.5mg po bid;prn -metoprolol 75mg po tid -milk of magnesia 30ml po tid;prn -morphine SR 30mg po tid -morphine IR 15-30mg po q3-4h;prn -pantoprazole 40mg po daily -senna 2tab po qhs Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. Disp:30 Suppository(s) Refills:2 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:500 ML(s) Refills:2 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:qs qs Refills:2 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). Disp:180 Tablet(s) Refills:2 9. Morphine Sulfate 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:90 Tablet Sustained Release(s) Refills:0 10. Morphine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. Disp:120 Tablet(s) Refills:0 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: -metastatic melanoma -s/p R craniotomy and stereotactic removal of brain metasases -hypertension -right lower lobe pneumonia, resolved Discharge Condition: Stable. Discharge Instructions: Please continue all medications as prescribed. If you experience any concerning symptoms, please call your oncologist or come to the emergency department for evaluation. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9402], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2134-3-24] 2:30 Provider: [Name10 (NameIs) ],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [Hospital 273] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2134-3-24] 2:30	[ "V10.82", "197.8", "197.7", "486", "198.3", "285.22", "401.9", "198.5", "455.2" ]	icd9cm	[ [ [] ] ]	[ "92.29", "99.04", "01.59" ]	icd9pcs	[ [ [] ] ]	15111, 15173	11112, 12673	5617, 5648	15352, 15361	10071, 11089	15580, 15954	8346, 8395		13189, 15088		15194, 15331		12699, 12699	1712, 5539		15385, 15557						9301, 10052			8410, 9086												1494, 1694									5556, 5579							5676, 7165										9101, 9284				12724, 13166	7187, 8143	8159, 8330
27,116	125,849	17322	Discharge summary	report	Admission Date: [2184-6-11] Discharge Date: [2184-6-15] Date of Birth: [2131-9-14] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: unruptured Right MCA aneurysm clipping Major Surgical or Invasive Procedure: RIGHT CRANIOTOMY FOR RIGHT MCA ANEURYSM CLIPPING History of Present Illness: The patient is a 53-year-old male with an unruptured middle cerebral artery aneurysm which is difficult to coil due to the broad-based nature of the aneurysm. Past Medical History: hep C depression chronic low back pain right mca aneurysm sleep apnea pt denies HTN Social History: no smoking / no etoh / currently recently seperated from wife / he is living with his mother. Family History: unknown Physical Exam: on discharge Pt is awake alert and oriented without focal neurological deficit. his VS are stable / he is afebrile. Pertinent Results: [Known lastname ],[Known firstname ] [Medical Record Number 48492] M 52 [2131-9-14] Radiology Report CT HEAD W/O CONTRAST Study Date of [2184-6-12] 9:48 AM [Last Name (LF) ],[First Name3 (LF) ] J. NSURG TSICU [2184-6-12] SCHED CT HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 48493] Reason: eval for acute changes Final Report HISTORY: 52-year-old male status post right MCA clipping, post-operative day #1. Evaluate for acute changes. COMPARISON: [2184-6-11]. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. FINDINGS: The patient is status post right MCA aneurysm clipping via a right frontal craniotomy. Aneurysm clip produces streak artifact limiting assessment of adjacent regions. Again demonstrated a moderate amount of hyperdense right extra-axial fluid, compatible with post-surgical changes, with small amount of pneumocephalus overlying the right as well as the left frontal lobes. Since the prior study, there has been either no significant interval change or perhaps minimally decrease in size of the right extra-axial hyperdense collection. There are no new foci of hemorrhage, edema, shift of normally midline structures, or acute major vascular territorial infarction. Ventricles and sulci are normal in caliber and configuration, without evidence of hydrocephalus. Visualized paranasal sinuses and mastoid air cells are aerated. Osseous structures are unremarkable, other than a right frontal and temporal bone craniotomy. IMPRESSION: Status post right MCA aneurysm clipping, with right frontal post- operative subdural hematoma and areas of pneumocephalus, not significantly changed from the prior study. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2184-6-12] 3:36 PM [Known lastname ],[Known firstname ] [Medical Record Number 48492] M 52 [2131-9-14] Radiology Report CAROT/CEREB [Hospital1 ] Study Date of [2184-6-11] 12:32 PM [Last Name (LF) ],[First Name3 (LF) ] J. SDS [2184-6-11] SCHED CAROT/CEREB [Hospital1 ] Clip # [Clip Number (Radiology) 48494] Reason: (R) crani for MCA aneurysm clippingAnesthesia has been book Contrast: OPTIRAY Preliminary Report CLINICAL HISTORY: 52-year-old male with status post clipping of the right MCA aneurysm. Informed consent was obtained as part of the neurosurgery procedure. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications and alternative management. Risks explained included stroke, loss of vision and speech, temporary or permanent, with possible treatment with stent and coils if needed. The patient was brought to the Interventional Neuroradiology Theater and placed on the biplane table in supine position. Both groins were prepped and draped in the usual sterile fashion. Access to the right common femoral artery was obtained using a 19-gauge single wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions. Through the needle, a 0.35 [Last Name (un) 7648] wire was introduced and the needle taken out. Over the wire, a 5 Fr vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units in 500 cc of saline) with a continuous drip. Through the sheath, a 4 Fr [First Name9 (NamePattern2) 48495] [Last Name (un) ] was introduced and connected to continuous saline infusion (with mixture of 1000 units of heparin in 1000 cc of saline). The following vessels were selectively catheterized and arteriograms were performed from right internal carotid. Multiple oblique images and ___ images were performed. FINDINGS: Good opacification of all the major branches from the right middle cerebral artery. The aneurysm is well clipped. There is good positioning of the aneurysm clip noted. No other residual aneurysm noted. IMPRESSION: Excellent clipping of the right middle cerebral artery aneurysm with no evidence of residual aneurysm. All the measured branches of the right middle cerebral artery are patent. The procedure was uneventful and the patient tolerated the procedure well with no complications. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Brief Hospital Course: Pt was admitted for the noted procedure. He underwent anesthesia and awoke without complication. He was transfered to the floor after meeting pacu criteria. He was advanced in his diet and activity and written for pain control meds. Post procedure imaging remained stable. he is tolerating PO/ ambulating independently and feels well enough to go home today - he is being discharged to home wihtout services to follow up in 4 weeks without imaging. He will stay on dilantin till that time. He did have a subgaleal drain that was removed on [Doctor Last Name ] day # 1. His incision is clean and dry with intact staples. Medications on Admission: effexor Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Four (4) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): YOU MUST CONTINUE THIS MEDICATION UNTIL CLEARED BY DR [First Name (STitle) ]. IT IS TO PREVENT SEIZURES . Disp:90 Capsule(s) Refills:2 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Outpatient Lab Work please have a dilantin level drawn every friday and have the results fax'd to your primary care physician for drug level monitoring. Discharge Disposition: Home Discharge Diagnosis: right MCA aneurysm clipping via open craniotomy Discharge Condition: NEUROLOGICALLY INTACT Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE RETURN TO THE OFFICE IN [7-8] DAYS FROM YOUR DATE OF YOUR PROCEDURE FOR REMOVAL OF YOUR STAPLES. PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [First Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NOT NEED ANY CAT SCANS AT THAT TIME. Completed by:[2184-6-15]	[ "V43.65", "305.1", "784.2", "530.81", "724.2", "327.23", "784.0", "437.3", "070.70" ]	icd9cm	[ [ [] ] ]	[ "39.51", "88.41" ]	icd9pcs	[ [ [] ] ]	6972, 6978	5529, 6159	356, 407	7070, 7094	991, 5506	8381, 8691	831, 840		6218, 6949		6999, 7049		6185, 6195			7118, 8358									855, 972																					278, 318							436, 597															619, 704	720, 815
51,943	151,415	53714	Discharge summary	report	Admission Date: [2126-4-7] Discharge Date: [2126-4-9] Date of Birth: [2048-6-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3326] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: None. History of Present Illness: 77M w hx/o CAD s/p stent, diverticulosis, duodenal stricture, perforated appendicitis in [2117] who was transferred from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital where he p/w 2-3 days worsening LLQ abdominal pain associated with vomiting x 1 day. Denies diarrhea, hematemesis, hematochezia, melena. Endorses constipation (cannot remember last BM), decreased flatus x days. Also denies fever, chills. . At OSH, pt was found to have elevated lipase & CT torso revealing celiac stenosis. Found to be hypoxic to 81% on RA, complaining of SOB. Improved to 90% on 2L. Pt has a history of SOB x 2-3 years; states that he can only walk approximately [Age over 90 ] yards before being limited by SOB. No orthopnea, PND, LE swelling. Pt received 1L IVF at OSH. . Vital signs in [Hospital1 18] ED: 99.6 100 157/68 16 90% 2L (97 on 6L) . Pt noted to be somnolent in ED; ABG showed: 7.18/85/75/33 which subsequently worsened to 7.16/95/105/36 on O2. . The patient was started on BiPap; repeat ABG in [Hospital Unit Name 153]: 7.24/79/67/36 . Initial labs here also significant for lipase 379, no other LFT abnormalities. His OSH CT chest was negative for PE but CT abdomen revealed critical stenosis of celiac artery. As such, vascular was consulted. They did not feel there was any acute intervention that needed to take place given normal lactate & resolution of pain. . REVIEW OF SYSTEMS: (+): Per HPI, abdominal pain, SOB, decreased BM & flatus, nausea & emesis x 1 (-) 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 diarrhea. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -CAD s/p stent -HTN -HLD -Diverticulosis -Perforated appendicitis [2117] s/p appy -Duodenal stricture -Ccy roughly one year ago Social History: - Tobacco: Smoked 1 ppd x 20 years as well as 6 cigars per day - Alcohol: [1-25] drinks of hard liquor daily (partner disputes this) - [Name (NI) 3264]: Denies - Lives at home with significant other - Previously married, wife died in [2109] Family History: - Son died of brain ca at 42 - Faither died of lung ca at 73 - Mother died of old age Physical Exam: DMISSION PHYSICAL EXAM: 98.3 83 134/52 15 95 on BiPap GEN: Somnolent, arousable to vocal stimulation. NECK: Unable to assess JVD [1-24] habitus HEENT: EOMI. OP clear COR: +S1S2 faint, no m/g/r. PULM: Distant BS bilaterally throughout. Faint crackles at bases. [Last Name (un) ]: +NABS in 4Q. Soft, NTND EXT: 2+ DP pulses bilaterally, no edema. NEURO: Oriented to person, time, place. DISCHARGE PHYSICAL EXAM: 98.6 87 151/71 18 94 on RA GEN: Awake, alert. NECK: Unable to assess JVD [1-24] habitus HEENT: EOMI. OP clear COR: +S1S2 faint, no m/g/r. PULM: Distant BS bilaterally throughout. Faint crackles at bases. [Last Name (un) ]: +NABS in 4Q. Soft, NTND EXT: 2+ DP pulses bilaterally, no edema. NEURO: Oriented to person, time, place. Pertinent Results: LABS ON ADMISSION: [2126-4-7] 02:30AM BLOOD WBC-9.4 RBC-3.92* Hgb-13.2* Hct-41.1 MCV-105* MCH-33.7* MCHC-32.1 RDW-13.2 Plt Ct-169 [2126-4-7] 02:30AM BLOOD Neuts-88.2* Lymphs-8.5* Monos-2.7 Eos-0.4 Baso-0.2 [2126-4-7] 02:30AM BLOOD PT-12.1 PTT-34.9 INR(PT)-1.1 [2126-4-7] 02:30AM BLOOD Glucose-162* UreaN-13 Creat-1.0 Na-140 K-4.3 Cl-103 HCO3-32 AnGap-9 [2126-4-7] 02:30AM BLOOD ALT-16 AST-20 AlkPhos-59 TotBili-0.3 [2126-4-7] 02:30AM BLOOD Lipase-379* [2126-4-7] 02:30AM BLOOD Albumin-4.2 [2126-4-7] 04:04AM BLOOD Type-ART pO2-75* pCO2-85* pH-7.18* calTCO2-33* Base XS-0 [2126-4-7] 02:38AM BLOOD Lactate-1.0 LABS ON DISCHARGE: [2126-4-9] 02:51AM BLOOD WBC-7.7 RBC-3.52* Hgb-11.3* Hct-35.2* MCV-100* MCH-32.2* MCHC-32.1 RDW-12.8 Plt Ct-146* [2126-4-9] 02:51AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-140 K-4.0 Cl-103 HCO3-31 AnGap-10 [2126-4-8] 04:12AM BLOOD ALT-14 AST-20 LD(LDH)-129 AlkPhos-51 TotBili-0.6 [2126-4-9] 02:51AM BLOOD Calcium-8.5 Phos-1.7* Mg-1.9 [2126-4-7] 08:03PM BLOOD Type-ART O2 Flow-2 pO2-63* pCO2-66* pH-7.30* calTCO2-34* Base XS-3 CXR ([2126-4-7]): FINDINGS: There is prominence of the pulmonary vasculature with mild cephalization. Additionally, there are bilateral increased interstitial markings. These findings are suggestive of mild pulmonary edema. Cardiomediastinal silhouette is normal. No acute fractures are identified. IMPRESSION: Mild pulmonary edema. RUQ U/S ([2126-4-9]): FINDINGS: The liver demonstrates normal echotexture. No focal hepatic lesions are seen. Portal venous flow is hepatopetal. Patient is status post cholecystectomy. Spleen is within normal limits in size. There is no intra- or extra-hepatic biliary ductal dilatation. The CBD measures 3 mm in size. Pancreas is not well visualized. The right kidney measures 12 cm in size and the left kidney measures 9.0 cm in size. There is a well-defined hyperechoic focus measuring about 4 mm in size within the left mid kidney likely representing a small angiomyolipoma. No free fluid is seen in the abdomen. IMPRESSION: Status post cholecystectomy. No evidence of intra- or extra-hepatic biliary ductal dilatation. No obvious choledocholithiasis identified. Brief Hospital Course: REASON FOR HOSPITALIZATION: 77 M hx/o CAD s/p stent, diverticulosis, ccy, appy presents to OSH wiht LLQ pain, elevated lipase, found to be hypoxic now with hypercarbia. ACUTE DIAGNOSES: # Acute on Chronic Respiratory Acidosis: Pt with primarily hypercarbic respiratory failure of unclear etiology. Given his smoking history, there was an initial concern that he may have COPD, but his CT chest was unremarkable. He most likely has Obesity Hypoventilation Syndrome vs. Obstructive Sleep Apnea. His CT PA was negative for PE, pneumonia. It was initially put on BiPap on the floor but his CO2 did not decrease below 60s, which is likely his baseline PCO2. It was recommended that he undergo outpatient PFTs as well as a formal sleep study. . # Pancreatitis: Lipase elevated to 300s on admission to [Hospital1 18] from 800 at OSH. No other LFT abnormalities. Pt is s/p cholecystectomy roughly one year ago. Initially, pt endorsed drinking [1-25] hard alcoholic beverages nightly, but this was contested by his significant other. Alcohol was thought to be potential contributing factor to this flare of pancreatitis. On review of his abdominal CT, a mass was noted in the head of the pancreas which was thought to represent cyst vs. pseudocyst vs. possible tumor. It was recommended that he undergo MRCP as an oupatient. His RUQ ultrasound was unremarkable and he was tolerating a normal diet without recurrence in his abdominal pain at the time of discharge. # Severe Celiac Artery Stenosis: The patient CT abdomen revealed severe stenosis of the celiac artery. Lactate was trended serially and was not elevated. The patient denied a history of food aversion and weight loss. Vascular surgery evaluated the patient and did not believe that any acute intervention was needed. The patient's abdominal pain was attributed to pancreatitis. CHRONIC DIAGNOSES: # HTN: Lisinopril was initially held in the setting of pancreatitis. It was resumed on discharge. His dose was decreased from 80 mg to 40 mg (max dose). # HLD: The patient's simvastatin was decreased from 80 mg to 40 mg QD. TRANSITIONAL ISSUES: # Pancreatic Mass: This will need to be followed with MRCP as an outpatient. # L Renal Mass: This should be followed and reimaged on an outpatient basis. # Code Status: Full code (confirmed with patient) Medications on Admission: -Aspirin 81mg -Lisinopril 80 mg QD -Nifedipine 80 mg QHS -Simvastatin 80 mg QD -Vitamin C -Folic Acid 50 mg QD -Omeprazole 20 mg QD Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. simvastatin 40 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. Vitamin C Oral 6. folic acid 1 mg Tablet Sig: Five (5) Tablet PO once a day. 7. nifedipine 20 mg Capsule Sig: Two (2) Capsule PO once a day. 8. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: - Pancreatitis - Acute on Chronic Respiratory Acidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 8071], it was a pleasure to participate in your care while you were at [Hospital1 18]. You came to the hospital after you had abdominal pain. We found that you had episode of inflammation in your pancreas called pancreatitis. We also discovered that you had too much carbon dioxide in your blood which could be due to a sleep disorder or breathing disorder which you should be evaluated for once you leave the hospital. You had an ultrasound of your upper abdomen which did not reveal any abnormalities. Review of your CT scan for [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], however, showed an abnormality on your pancreas that should be followed up on an outpatient basis. Please have your primary care doctor arrange for you to have an imaging study called an "MRCP" to further evaluate this abnormality on the pancreas. (See below.) MEDICATION CHANGES: - Medications ADDED: None. - Medications CHANGED: ---> Please decrease your dose of simvastatin from 80 to 40 mg daily ---> Please decrease your dose of lisinopril from 80 to 40 mg daily (this is the maximum dose of this medication) - Medications STOPPED: None. Followup Instructions: Please call your primary care doctor to be seen for a follow up appointment within the next week. Dr. [First Name (STitle) 5846] can be reached at [Telephone/Fax (1) 28612]. We reviewed the CT scan of your chest, abdomen, & pelvis that was performed at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital. There is an abnormality in your pancreas that needs to be followed up. We recommend that you have another type of imaging study called an MRCP as an outpatient. You should talk to your PCP about this study and a referral to a gastroenterologist. We recommend that you have pulmonary function tests as well as a sleep study on an outpatient basis.	[ "414.01", "272.0", "278.03", "276.2", "V45.82", "518.83", "496", "401.9", "278.01", "447.4", "327.23", "577.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8861, 8867	5788, 7893	318, 326	8985, 8985	3537, 3542	10336, 11029	2651, 2739		8305, 8838		8888, 8964		8148, 8282			9136, 10030									2778, 3151																7915, 8122		1792, 2208	10050, 10313		263, 280			4201, 5765				354, 1773									3556, 4182	9000, 9112					2230, 2364	2380, 2635		3176, 3518
58,483	124,917	54053	Discharge summary	report	Admission Date: [2190-5-21] Discharge Date: [2190-5-29] Date of Birth: [2158-7-5] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4691] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: None History of Present Illness: 31M med flight from scene single vehicle MVC, unrestrained, positive alcohol. He was initially alert and oriented with no clear injuries, but in route became unresponsive with reported respiratory arrest and was intubated in the helicopter. He reportedly was a difficult intubation there is significant amount of emesis and blood in the airway, although he was intubated on the first pass. Past Medical History: depression, anxiety, mild asthma Social History: Lives with wife and 2 children + ETOH abuse, had been sober x5 yrs, but started to drink again in [2189-12-15] Family History: non-contributory Physical Exam: On arrival to [Hospital1 18]: VS: afebrile, P 114 BP 140/81 R 11 O2 94% vent Constitutional: Intubated, sedated Neuro: Pupils equal, 3-->2 sluggish bilaterally HEENT: atraumatic, TM's clear b/l Resp: CTAB CV: tachycardic, regular rhythm, no m/r/g Abd: soft, nontender, nondistended, abrasions to lower abd DRE: decreased rectal tone LE: skin warm, pink and well perfused, no edema Skin: multiple abrasions R buttock, abdomen, RUE On Discharge: T99 HR 99 BP 114/62 RR16 94%RA Constitutional: Comfortable Resp: CTAB CV: RRR Abd: soft, nontender, nondistended Skin: multiple well-healing abrasions over RUE and back. no erythema or discharge Pertinent Results: [2190-5-21] CT Head w/out contrast: 1. No acute intracranial process. 2. Small frontal subgaleal soft tissue hematoma. 3. Opacification of the right maxillary sinus and nasal cavity with intermediate [Doctor Last Name ] measurements, likely due to chronic sinusitis and secretions rather than hemorrhage. 4. Bony defect at the medial wall of the right maxillary sinus is likely postsurgical after nasal antral window. Linear lucency at the anterior nasal spine of the maxilla is likely a vascular channel rather than a fracture given lack of soft tissue swelling. [2190-5-21] CT C-spine w/out contrast: 1. No fracture or acute subluxation. 2. Opacification of the right maxillary sinus and the nasal cavity, likely due to a combination of chronic sinus disease and secretions after intubation. [2190-5-21] CT abdomen/pelvis/chest w/ contrast: 1. Large bilateral posterior lung opacities and diffuse ground-glass opacities in both lungs, likely due to aspiration given the clinical history (of an aspiraton event) and the secretions layering in the distal trachea. 2. No other acute injury of the chest, abdomen and pelvis. [2190-5-22] TTE: Mild symmetric LVH with normal global and regional biventricular systolic function. No clinically-significant valvular disease seen [2190-5-26] ANKLE (AP, MORTISE & LAT) RIGH; FOOT AP,LAT & OBL RIGHT PORT: No acute abnormality. [2190-5-28] Chest X-ray (PA & LAT): PA and lateral chest radiographs demonstrate low lung volumes with linear atelectasis at the left lung base. The lungs are otherwise clear, representing improvement from prior exams. The cardiomediastinal silhouette is normal. There is no pleural effusion or pneumothorax. [2190-5-28] RUQ Ultrasound: IMPRESSION: Diffuse increased echotexture of the liver as can be seen with hepatic steatosis. Advanced conditions of the liver such as cirrhosis or fibrosis is not excluded. No evidence of cholecystitis or gallstones Labs on admission: [2190-5-21] 01:45AM WBC-13.5* RBC-4.89 HGB-14.5 HCT-45.4 MCV-93 MCH-29.7 MCHC-32.0 RDW-12.6 [2190-5-21] 01:45AM ASA-NEG ETHANOL-243* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2190-5-21] 01:45AM LIPASE-59 [2190-5-21] 01:55AM URINE RBC-3* WBC-1 BACTERIA-MOD YEAST-NONE EPI-0 TRANS [2190-5-21] 01:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2190-5-21] 01:57AM GLUCOSE-212* LACTATE-5.2* NA+-142 K+-3.1* CL--103 Labs on Discharge: [2190-5-29] 05:20AM BLOOD WBC-15.0* RBC-3.81* Hgb-11.4* Hct-35.2* MCV-92 MCH-29.8 MCHC-32.3 RDW-13.2 Plt Ct-379 BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-140 K-3.7 Cl-103 HCO3-26 ALT-53* AST-43* AlkPhos-94 TotBili-0.7 BLOOD Lipase-588* Brief Hospital Course: Mr [Known lastname 5239] was admitted to the Trauma ICU [2190-5-21] upon arrival to [Hospital1 18]. He was already intubated. His ICU course was dominated by respiratory failure and inability to wean from ventilator. It was felt he had an aspiration event, and that aspiration pneumonitis was the primary cause of the respiratory failure. Initially, he required muscular paralysis to maintain ventilator mechanics, this was weaned off within 48 hours. He continued to be hypoxic when attempting to wean him from CMV to CPAP, and CXR showed possible infiltrate, so he was bronched and started on empiric antibiotics for ventilator associated pneumonia. He continued to spike fevers daily until HD 4. When his BAL results came back as streptococcus pneumoniae, his antibiotics were briefly narrowed to ceftriaxone monotherapy, then re-broadened to Vanc/Cipro/Flagyl per the recommendation of an Infectious Disease consult. To further assist in weaning him from the ventilator, a lasix drip was begun HD 3 and run for 2 days with good diuresis. By HD 4, he was transitioned to CPAP and breathing well on his own mechanics. Also this day, he displayed groin and back erythema, thought to be a combination of fungal infection and drug reaction. On HD 5 he was weaned from propofol and versed to Precedex while simultaneously weaning his PEEP requirements. He was eventually extubated HD 6 and transferred to the floor. Also of note durinig his ICU course: He was evaluated on CIWA scales but did not score significantly. He had diarrhea while in the ICU, C.Dif was negative, resolved with fiber. He was maintained on prophylaxis while in the ICU: Heparin sub-cu, famotidine, VAP bundle. He had a left subclavian central line placed on [2190-5-21]. Floor course: On [2190-5-26] he was transferred to the floor. His fever curve was monitored and trended downward. His CVL was removed on [5-26] and cultured with no growth. By [5-27] he remained afebrile. However, he was noted to have a rising WBC count to 12 and then 16.9 (from 5.5). His chest xray on [5-28] showed no evidence of pneumonia and he was without cough or sputum. He was weaned off the oxygen with good oxygen saturation on room air. All antibiotics were discontinued at this point. Blood test showed elevated lipase to >800. RUQ US showed hepatic steatosis. Gastroenterology was consulted and felt this was likely due to alcoholic pancreatitis. Patient will follow-up in their clinic for this. Otherwise he remained hemodynamically stable. Physical therapy and occupational therapy evaluated him. Occupational therapy recommended outpatient follow-up with cognitive neurology. Patient was discharged and would like to go on voluntary admission to an alcohol rehab treatment facility. Medications on Admission: albuterol, sertraline 100 mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. sertraline 50 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. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: [2-15] Tablet, Chewables PO QID (4 times a day) as needed for heartburn. 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [Location (un) 3244] Treatment Center - [Hospital1 1562] Discharge Diagnosis: s/p MVC Aspiration pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a motor vehicle accident. You lost consciousness at the scene and vomited. You developed respiratory difficulty and required a breathing tube. You were treated with antibiotics for your respiratory infection and you have no further evidence of pneumonia. You were also found to have evidence of pancreatitis, like due to a high alcohol intake. You were evaluated by our occupational therapists, who recommended that you follow up as an outpatient with cognitive neurology. An appointment has been scheduled for you below. Continue to take your regular medication as prescribed. Followup Instructions: Follow-up with your primary care doctor within 1 week after discharge from inpatient care. Follow-up with [Hospital ] Clinic. Call [Telephone/Fax (1) 463] to confirm appointment on [2190-6-9] at 4pm Department: Cognitive Neurology Name: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] When: We are working on a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the Neurology department within 9-15 days to follow up on your head injury. You will be called with the appointment date and time. If you have not heard from the office in 2 business days please call the number listed below. Location: [Hospital1 18] - COGNITIVE NEUROLOGY UNIT Address: [Location (un) ], KS 257, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 1690] Completed by:[2190-6-1]	[ "997.31", "E930.0", "458.29", "693.0", "920", "493.90", "910.0", "041.5", "507.0", "303.01", "110.3", "276.2", "E879.8", "E930.5", "041.09", "912.0", "780.60", "518.51", "276.69", "577.0", "296.30", "E812.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.72", "33.24" ]	icd9pcs	[ [ [] ] ]	7924, 8015	4400, 7181	310, 317	8087, 8087	1640, 3606	8881, 9766	942, 960		7267, 7901		8036, 8066		7207, 7244			8237, 8858									975, 1411															1425, 1621						263, 272			4137, 4377				345, 737									3620, 4118	8102, 8213					759, 793	809, 926
10,767	158,200	21805	Discharge summary	report	Admission Date: [2104-12-11] Discharge Date: [2104-12-13] Date of Birth: [2028-9-19] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Intracranial hemorrhage Major Surgical or Invasive Procedure: -Status post intubation -Mechnical ventilation -Status post extubation History of Present Illness: This is a 76 year old woman with a past medical history significant for coronary artery disease status post myocardial infarction and stent placement, hypertension, paroxysmal supraventricular tachycardia, gastrointestinal bleeding and hypercholesterolemia who presents after being found down at home. She was apparently found at home unresponsive on her staircase with "pupils fixed and deviated downward and to the right" per EMS report. She was taken to [Hospital 8641] hospital. Blood pressure at [Location (un) 8641] was initially 169/91, and per report was "moving only left arm to painful stimuli" and left pupil was fixed and dilated. She was intubated at [Location (un) 8641], and was given labetolol and 2.5 gm of mannitol. She was med flighted by helicopter from [Hospital 8641] Hospital to [Hospital1 1170] after head CT there showed large left thalamic bleed. Repeat head CT after arrival to [Hospital1 18] showed extension of the bleed and now involvment of all ventricles, shift to the right, and obstructive hydrocephalus. The Neurosurgery team evaluated the patient in the ED and did not recommend any surgical intervention given extent of bleed and poor prognosis for meaningful recovery. Per discussion with Mrs.[Name (NI) 57229] son, her wishes in this case would be DNR/DNI with no aggressive surgical interventions. Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. Coronary artery disease, status post myocardial infarction 1-2 years ago, status post stents 4. History of gastrointestional bleeding 5. Paroxysmal supraventricular tachycardia Social History: Lived alone. Family History: Not known. Physical Exam: Vitals T 97.6; BP 150-177/80-110 ; HR 66 ; O2 sat 100% on vent General appearance: Intubated. No spontaneous eye opening. HEENT: Mucosa moist. Oropharynx clear. No scleral icterus or injection. Neck: In cervical collar. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm. Normal s1/s2 heart sounds. Abdomen: Soft, non-tender, non-distended. Extremities: Warm and well perfuse. 2+ peripheral pulses throughout. No edema. Neurologic: Mental Status: Intubated and sedated. Not following commands. Not opening eyes spontaneously and not moving spontaneously. Cranial Nerves: +Anisocoria, both pupils non-reactive, R 2mm, L 4mm. No Doll's eyes. No right corneal, +Left corneal. +Gag. Motor: +Decerebrate posturing on left to painful stimuli in LUE. No movement of RUE to pain. +Triple flexion in LEs to pain. Reflexes: Intact and symmetric, toes upgoing bilaterally. Sensation: No movement other than posturing/triple flexion to pain. Pertinent Results: [2104-12-10] 11:06PM WBC-10.1 RBC-3.75* HGB-12.3 HCT-35.4* MCV-95 MCH-32.8* MCHC-34.7 RDW-12.7 [2104-12-10] 11:06PM NEUTS-91.3* BANDS-0 LYMPHS-5.6* MONOS-2.6 EOS-0.3 BASOS-0.2 [2104-12-10] 11:06PM PLT COUNT-207 [2104-12-10] 11:06PM PT-12.6 PTT-27.2 INR(PT)-1.0 [2104-12-10] 11:06PM GLUCOSE-170* UREA N-16 CREAT-0.8 SODIUM-138 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17 ----- Head CT without contrast [2104-12-11]: There is an extensive left thalamic and basal ganglial intraparenchymal hemorrhage with extension of blood into the left midbrain and the left lateral ventricle. There is also blood in the right lateral ventricle, third ventricle, and fourth ventricle. There is mild subfalcine herniation, left to right. The lateral ventricles are dilated. There is left to right subfalcian herniation and transtentorial hernaition of the left medial temporal lobe, although the suprasellar cistern is preserved. he osseous structures and soft tissues are normal. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Prior studies are not available for comparison at the time of final review. There is subfalcine and transtentorial herniation secondary to a large hemorrhage centered in the left thalamus and basal ganglia. In addition, there is evidence of developing obstructive hydrocephalus. These findings were communicated with the neurosurgical house staff at the completion of the study. Brief Hospital Course: This is a 76 year old woman with history hypertension, hypercholesterolemia and coronary artery disease who presented with large intracranial hemorrhage after being found down at home. Most likely the etiology of this hemorrhage was hypertension. On initial exam, she had evidence of brainstem compression; however, she still had some brainstem reflexes. Per her family's wishes, we continued maximal medical management until they arrived to [Hospital1 18] and were able to make further decisions. She was admitted to the Neurology Intensive Care Unit. Medical management was continued with Mannitol, Dilantin for seizure prophylaxis and Nipride and/or Labetalol for blood pressure control. Serial exams demonstrated progression of brainstem compromise. Mannitol dosing was increased. After discussing gravity of clinical situation, the patient's family opted to focus on comfort measures only. She was extubated and expired shortly thereafter. Medications on Admission: 1. Protonix 2. Neurontin (not clear for what) 3. Toprol XL 4. Aspirin 5. ?Plavix We were unable to confirm her medication list or dosages. Discharge Medications: Not applicable. Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage. Discharge Condition: Expired. Discharge Instructions: Not applicable. Followup Instructions: Not applicable. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "V45.82", "853.09", "E880.9", "414.00", "331.4", "401.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	5772, 5781	4591, 5543	341, 413	5850, 5860	3103, 4568	5924, 6034	2102, 2114		5732, 5749		5802, 5829		5569, 5709			5884, 5901									2129, 2584																					278, 303							441, 1812	2723, 3084									2599, 2707					1834, 2056	2072, 2086
24,504	136,719	17372	Discharge summary	report	Admission Date: [2171-5-27] Discharge Date: [2171-5-31] Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: A 79-year-old female with hypertension, hypercholesterolemia, who presented to the [Hospital1 1444] for scheduled outpatient catheterizations now transferred to the Cardiac Care Unit after perforation of the left circumflex during cardiac catheterization. She had presented to the primary care physician 1-2 weeks ago with complaint of chronic leg pain that has not resolved with medical treatment and fatigue for the last few years. On review of systems at the primary care physician's office, she complained of occasional "pinching" lasting about a second, 1-2x a week. She also reports dyspnea with one flight of stairs. The primary care physician sent the patient for Persantine MIBI which showed moderate inferior ischemia extending to lateral wall on the MIBI section with ejection fraction of 79%. The patient was referred to [Hospital1 1444] for cardiac catheterization. During cardiac catheterization 90% hazy and heavily calcified proximal stenosis in the left circumflex was seen as well as moderate diffuse disease of the OM-1 and severely diffusely diseased right coronary artery with subtotal occlusion of the mid vessel was also seen. Rotational atherectomy of the proximal left circumflex was complicated by a perforation in the atrioventricular groove artery after OM-1 with obvious dye extravasation. Integrilin was discontinued. Heparin was reversed with protamine. Perforation was tamponaded with balloon and stented with Hepacoat stent. Intra-aortic balloon pump was placed prophylactically with good afterload reduction. ReoPro was started to replace Integrilin given its ability to reverse ReoPro with platelet transfusion. She had also gotten Plavix during the procedure. Of note, during cardiac catheterization, severe mitral regurgitation was also seen. In the cardiac catheterization laboratory, a tiny subcutaneous skin incision was made in preparation for a pericardial tap, however, emergent bedside echocardiogram showed no tamponade. The procedure was not done. There was oozing from the skin incision. REVIEW OF SYSTEMS: When the patient arrived to the Cardiac Care Unit, no chest pain, no shortness of breath, no lightheadedness, no nausea or vomiting, no abdominal pain, no paroxysmal nocturnal dyspnea, no orthopnea. She reports chronic lower extremity pain for the last four years diagnosed as peripheral vascular disease, which has been evaluated by a vascular surgeon. The patient is a poor historian. Is unable to explain some of her past medical history. Of note, she was started on dopamine and Levophed in the catheterization laboratory for transient hypotension. She was weaned off of Levophed when she got to the floor, and remained on 10 mcg/kg/hour of dopamine. PHYSICAL EXAMINATION: She was afebrile, blood pressure 127/62 on the dopamine, heart rate of 100, respiratory rate of 13, and O2 saturation 93-94% on 4 liters nasal cannula. She is an elderly woman in no acute distress. Mucous membranes dry. Jugular venous pressure about 6-7 cm. Her chest was clear to auscultation bilaterally anteriorly with a difficult examination given the balloon pump sound. There is oozing from the percutaneous skin [Doctor Last Name ] in the mid sternal area. She was tachycardic. There is a III/VI systolic murmur at the apex, also heart examination was obscured by the balloon sound. Her abdomen was soft with normoactive bowel sounds and balloon noise was heard. She had no edema in her extremities. She had 1+ dorsalis pedis pulses in the right lower extremity. No other palpable pulses, but dopplerable pulses. She had an A-line in the left groin. Arterial and venous sheath in the right groin. She is alert and oriented times three. LABORATORY DATA: Her white count was 19.9 with hematocrit of 25.3, platelets 241, 91% neutrophils, 0% bands. Chemistries: Sodium 133, potassium 4.3, chloride 102, bicarbonate 20, BUN 28, creatinine 1.1, glucose 148. Of note, her creatinine a week ago at the outside hospital was 1.4. She has chronic renal insufficiency. Calcium 8.5, phosphorus 4.3, magnesium 1.5, ALT and AST were normal 15 and 21. LDH of 307. Alkaline phosphatase 210, total bilirubin 0.4, TSH 1.4, free T4 1.4, total cholesterol was 197, triglycerides 221, HDL 39, LDL 114. INR 1.1, PTT 27.5. Chest x-ray showed no widen mediastinum, diffuse interstitial pattern consistent with mild congestive heart failure. PAST MEDICAL HISTORY: 1. She had the hypertension diagnosed in [2166]. She had a pacemaker placed in [2166], the reason for which the patient could not state. 2. Hypercholesterolemia. Lipitor was stopped two weeks ago for unclear reasons. 3. Chronic anemia. She had bone marrow biopsies, again the patient is unable to give the history for the cause of anemia. 4. Hysterectomy. 5. Appendectomy. 6. Peripheral vascular disease. 7. Glaucoma. 8. Question of thyroid disease that the patient claims is being treated with vitamin D. 9. She denies any diabetic history. ALLERGIES: She has no known drug allergies. MEDICATIONS: 1. Alphagan eyedrops. 2. Atenolol 100 mg po q day. 3. Hydrochlorothiazide 50 mg po q day. 4. Calcitriol 0.25 mg po q day. 5. Mavik 4 mg po q day. 6. Aspirin 81 mg po q day. 7. Lipitor 40 mg po q day, discontinued two weeks ago. SOCIAL HISTORY: She is married, raises her 16-year-old granddaughter, and denies tobacco or alcohol history. FAMILY HISTORY: She has no known family history of coronary artery disease. HOSPITAL COURSE: The patient was admitted to he Cardiac Care Unit for close monitoring. The dopamine was quickly weaned off. The patient was continued on ReoPro for 18 hours. She was continued on the aspirin and Plavix, and underwent serial echocardiograms which showed no pericardial effusions. Ejection fraction of greater than 55% and 3+ mitral regurgitation. The dopamine was weaned off. The intra-aortic balloon pump was also discontinued. Her cardiac enzymes were followed. She had a CK peak of 218 that gradually trended down. Her CK MB peaked at 7 which also trended down to troponin peak of 4.9. She remained chest pain free and was restarted on her metoprolol and ACE inhibitor, however, the ACE inhibitor was subsequently discontinued due to her acute renal failure. The patient required 4 units of packed red blood cells in the first 48 hours of hospital course to maintain her hematocrit above 30, and stayed stable thereafter with her hematocrit staying in the 32 range. The hospital course was also significant for acute renal failure thought to be secondary to the dye nephropathy from the cardiac catheterization. Creatinine went from 1.1 to 1.9 and subsequently decreased to 1.7. The ACE inhibitor was held. The urine was sent off for studies. It was negative for eosinophils. There was no muddy brown casts, the FENA was 0.9% which is equivocal. The patient's electrolytes required some repletion throughout the hospital stay. The patient remained stable and chest pain free, and was evaluated by Physical Therapy, who felt that she was safe to go home with home Physical Therapy, and home safety evaluations. Primary care physician was [Name (NI) 653], and was made aware of the events of the hospitalization. She was sent home in good condition with the diagnosis of native coronary artery disease status post percutaneous coronary intervention, complications from catheterization with left circumflex rupture, mitral valve regurgitation, pericardial disease unspecified. She was to followup with her primary care physician in three days and her cardiologist. Lipitor and Mavik were to be restarted by cardiologist. Her metoprolol was to be titrated up as per her physicians. MAJOR PROCEDURES DONE: 1. Cardiac catheterization. 2. Intra-aortic balloon pump placement. 3. Pulmonary artery catheter placement. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q day. 3. Alphagan eyedrops q8h. 4. Protonix 40 mg po q day. 5. Metoprolol XL 50 mg po q day. [First Name8 (NamePattern2) 870] [Last Name (NamePattern1) ], M.D. [MD Number(1) 5219] Dictated By:[Name8 (MD) 6371] MEDQUIST36 D: [2171-5-31] 08:54 T: [2171-6-4] 07:13 JOB#: [Job Number 48602]	[ "458.2", "401.9", "285.9", "424.0", "998.2", "423.9", "414.01", "272.4" ]	icd9cm	[ [ [] ] ]	[ "36.01", "88.56", "37.23", "36.06", "37.61", "99.20", "88.53" ]	icd9pcs	[ [ [] ] ]							5552, 5613		7993, 8395					5631, 7970																							2911, 4560						2228, 2888			105, 118							147, 2208															4582, 5424	5441, 5535
17,170	138,970	45871	Discharge summary	report	Admission Date: [2174-7-12] Discharge Date: [2174-7-15] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Rapid atrial fibrillation Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 410] is an 81 year old woman with PMH of Waldenstrom's macroglobulinemia, hypertension, hypercholesterolemia, diabetes mellitus type II and a past episode of atrial fibrillation 4 years ago (daughter thinks that she may have been cardioverted) who presented to her oncologist today for evaluation of a new IgG spike (2231mg/dL on SPEP [6-7] and 2983 on day of admission([7-12]), on IFE seen to be IgG Kappa) and transfusion. At her oncologist's office, she was noted to have an irregularly irregular pulse in the 150s. ECG demonstrated AFib and she was transferred to the ED of [Hospital1 18]. Past Medical History: Waldenstrom's macroglubulinemia diagnosed four years ago, treated with chemotherapy four years ago. New IgG spike as described in HPI. HTN Hypercholesterolemia DMII Hypothyroidism Chronic psoriatic arthritis Osteoporosis Hx Afib--pt unable to provide further hx; PMD thinks she may have been cardioverted four years ago Gait disorder Small vessel dz CRF- Creatinin 1.6 in [7-5] Warm autoantibodies Social History: Lives in apartment alone with help 3x/week. Once had VNA 2s/week but DCed. Has had multiple falls at home including passing out. No ethanol, no ivda, no tobacco. Family conflict between daughter and son about who takes care of mother. Family History: Noncontributory. No cardiac, DM, cancer reported by patient. Physical Exam: 97 110/80 109 18 98%2L Gen: Lying in bed in NAD HEENT: PERRLA, EOMI, neck supple, no LAD, mouth and oropharynx clear Chest: CTAB CV: Nl S1/S2; no JVD Abd: Soft, NT, ND, no organomegaly, NBS Ext: Warm X 4 with pulses X 4, no cyanosis, edema or clubbing Neuro: CN II-XII intact, A&O X 4, MMSE 27/30, complex, fluent and appropriate speech, sensation intact throughout, 2+DTRs, [3-7] strength throughout, unable to walk without assistance of cane and MD Pertinent Results: ECG: Afib @ 121 / min without ST-T changes compared to [2170-11-1]; lower voltage compared to prior CXR [7-12]: Enlargement of the cardiac silhouette which may represent cardiac enlargement vs. pericardial effusion. Mild left sided atelectasis. No evidence of CHF or pneumonia. [2174-7-12] 09:30PM PT-15.8* PTT-134.3* INR(PT)-1.6 [2174-7-12] 08:25AM GLUCOSE-127* UREA N-31* CREAT-1.5* SODIUM-138 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 [2174-7-12] 08:25AM LD(LDH)-410* TOT BILI-0.8 DIR BILI-0.3 INDIR BIL-0.5 [2174-7-12] 08:25AM CK-MB-2 [2174-7-12] 08:25AM CALCIUM-9.4 PHOSPHATE-4.2 MAGNESIUM-1.7 [2174-7-12] 08:25AM IgG-2983* IgA-258 IgM-489* [2174-7-12] 08:25AM WBC-3.8* RBC-2.82* HGB-9.3* HCT-27.5* MCV-97 MCH-32.9* MCHC-33.8 RDW-17.9* [2174-7-12] 08:25AM PLT COUNT-154 [2174-7-12] 08:25AM GRAN CT-2950 [2174-7-15] 12:40AM BLOOD WBC-15.6* RBC-3.09* Hgb-10.2* Hct-31.9* MCV-103* MCH-33.0* MCHC-32.0 RDW-19.4* Plt Ct-51* [2174-7-14] 10:33PM BLOOD WBC-11.6* RBC-3.04* Hgb-9.9* Hct-30.4* MCV-100* MCH-32.7* MCHC-32.7 RDW-19.4* Plt Ct-53* [2174-7-14] 09:56AM BLOOD WBC-5.7 RBC-3.56# Hgb-11.6# Hct-34.0# MCV-95 MCH-32.7 MCHC-34.3 RDW-18.8* Plt Ct-128* [2174-7-15] 03:58AM BLOOD PT-49.6* PTT-94.4* INR(PT)-15.5 [2174-7-15] 12:40AM BLOOD PT-40.8* PTT-87.5* INR(PT)-10.5 [2174-7-15] 12:40AM BLOOD Plt Ct-51* [2174-7-14] 10:33PM BLOOD Plt Ct-53* [2174-7-14] 10:33PM BLOOD PT-32.2* PTT-73.7* INR(PT)-6.6 [2174-7-14] 06:20PM BLOOD Plt Ct-90* [2174-7-14] 09:56AM BLOOD Plt Ct-128* [2174-7-14] 04:20AM BLOOD PT-16.1* PTT-92.4* INR(PT)-1.6 [2174-7-13] 04:00PM BLOOD PT-16.5* PTT->150* INR(PT)-1.7 [2174-7-13] 06:10AM BLOOD Plt Ct-139* [2174-7-15] 03:58AM BLOOD Fibrino-58* [2174-7-15] 12:40AM BLOOD Fibrino-68* [2174-7-14] 10:33PM BLOOD Fibrino-94* [2174-7-15] 03:58AM BLOOD Glucose-263* UreaN-47* Creat-2.5* Na-140 K-5.6* Cl-96 HCO3-8* AnGap-42* [2174-7-15] 12:40AM BLOOD Glucose-216* UreaN-49* Creat-2.4* Na-141 K-5.8* Cl-103 HCO3-5* AnGap-39* [2174-7-14] 10:33PM BLOOD Glucose-245* UreaN-51* Creat-2.3* Na-142 K-5.9* Cl-105 HCO3-6* AnGap-37* [2174-7-14] 06:20PM BLOOD Glucose-116* UreaN-48* Creat-2.2* Na-146* K-5.9* Cl-109* HCO3-9* AnGap-34* [2174-7-14] 09:56AM BLOOD Glucose-122* UreaN-45* Creat-1.7* Na-137 K-4.9 Cl-106 HCO3-15* AnGap-21* [2174-7-13] 06:10AM BLOOD Glucose-228* UreaN-34* Creat-1.7* Na-134 K-5.2* Cl-103 HCO3-16* AnGap-20 [2174-7-12] 08:25AM BLOOD Glucose-127* UreaN-31* Creat-1.5* Na-138 K-4.5 Cl-104 HCO3-22 AnGap-17 [2174-7-15] 12:40AM BLOOD CK(CPK)-403* [2174-7-14] 06:20PM BLOOD ALT-1706* AST-2086* LD(LDH)-1412* CK(CPK)-139 AlkPhos-67 Amylase-113* TotBili-2.9* [2174-7-13] 06:10AM BLOOD CK(CPK)-58 [2174-7-12] 08:25AM BLOOD LD(LDH)-410* CK(CPK)-43 TotBili-0.8 DirBili-0.3 IndBili-0.5 [2174-7-15] 12:40AM BLOOD IgG-1703* IgA-153 IgM-298* [2174-7-15] 04:31AM BLOOD Type-ART Temp-35.8 Rates-18/0 Tidal V-615 PEEP-8 O2-40 pO2-119* pCO2-18* pH-7.27* calHCO3-9* Base XS--16 -ASSIST/CON Intubat-INTUBATED [2174-7-15] 12:56AM BLOOD Type-ART Temp-35.8 Rates-18/11 PEEP-8 O2-40 pO2-148* pCO2-15* pH-7.13* calHCO3-5* Base XS--22 Intubat-INTUBATED [2174-7-14] 11:09PM BLOOD Type-ART Temp-35.8 Rates-18/13 Tidal V-650 PEEP-8 O2-60 pO2-231* pCO2-15* pH-7.19* calHCO3-6* Base XS--20 Intubat-INTUBATED [2174-7-14] 09:53PM BLOOD Type-ART Temp-35.9 Rates-18/10 Tidal V-600 PEEP-8 O2-60 pO2-207* pCO2-13* pH-7.11* calHCO3-4* Base XS--23 Intubat-INTUBATED [2174-7-14] 07:02PM BLOOD Type-ART pO2-285* pCO2-25* pH-7.14* calHCO3-9* Base XS--19 [2174-7-14] 05:54PM BLOOD Type-ART Tidal V-600 PEEP-10 O2-100 pO2-171* pCO2-38 pH-7.16* calHCO3-14* Base XS--14 AADO2-521 REQ O2-85 Intubat-INTUBATED [2174-7-14] 05:32PM BLOOD Type-ART pO2-56* pCO2-35 pH-7.32* calHCO3-19* Base XS--7 Intubat-INTUBATED [2174-7-15] 04:31AM BLOOD Lactate-26.9* K-5.5* [2174-7-15] 12:56AM BLOOD Lactate-26.1* K-5.7* [2174-7-14] 11:09PM BLOOD Lactate-23.2* K-5.5* [2174-7-14] 09:53PM BLOOD Lactate-21.0* K-6.9* [2174-7-14] 05:54PM BLOOD K-5.8* [2174-7-14] 05:32PM BLOOD K-6.8* Brief Hospital Course: 81 y/o female with history of Afib recently cardioverted, DM, HTN, Waldenstrom's macgroglobulinemia who coded on the floor yesterday after becoming increasingly acidotic, cyanotic and SOB. Pt initially came in on [7-12] after it was found at a routine outpt heme/onc appointment for Waldenstrom's that pt was in Afib by ECG. Pt was given IV and eventual po lopressor for control of rate due to Afib. Pt had TEE and was successfully cardioverted to sinus rhythm on [7-14] with no complications. It was noted few hours after successful cardioversion that pt was becoming increasing cyanotic (blue lips) and was having SOB. The code was called and pt was intubated and found to be bradycardic (?either sinus or junctional). Pt was given atropine and epi and went into PEA and chest compressions started for a few minutes, pt then went into VT rate of 150s and was shocked x1 back to sinus. Pt was started on Neo and brought to the MICU. In the MICU it was noted that pt continued to become increasingly acidotic and eventually started to show signs of DIC with low platelets, increased INR, and low fibrinogen level. Pt [Name (NI) ]3 has been steady decresing since admission from 22 to 15 to 9 after the code. Levophed was started and pt kept on Neo and Levo. Discussion with family agreed no heroic measures, antibiotics stopped and labs stopped. Pt was kept on pressors and eventually passed away. Medications on Admission: Disopyramide Lipitor 10mg once per day Avandia 4mg once per day Glyburide 5mg once per day Glucophage 500ng once per day Topamax 70mg qweek Ca ASA Levothyroxin 137.5 once per day Detrol 4mg once per day Lisinopril 5mg once per day Discharge Disposition: Extended Care Facility: expired Discharge Diagnosis: Deceased Discharge Condition: Deceased	[ "273.3", "276.2", "244.9", "272.0", "250.00", "286.6", "696.0", "401.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.91", "99.60", "88.72", "96.04", "38.93", "99.61" ]	icd9pcs	[ [ [] ] ]	8104, 8138	6412, 7823	282, 288	8190, 8201	2199, 6389		1646, 1709				8159, 8169		7849, 8081												1724, 2180																					217, 244							316, 948															970, 1374	1390, 1630
10,144	166,727	49694	Discharge summary	report	Admission Date: [2198-9-12] Discharge Date: [2198-9-15] Date of Birth: [2145-7-27] Sex: F Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Aortic insufficiency Major Surgical or Invasive Procedure: 1. AVR (21mm CE pericardial valve) History of Present Illness: 53 yo female with known valvular disease, monitored by serial echocardiograms for 10 y. Denies any symptoms. Most recent study showed severe aortic stenosis and [2-6] + aortic insufficiency. After discussion c pt., aortic valve replacement surgery was planned. Past Medical History: 1. Lupus, lupus nephritis 2. Aortic insufficiency 3. Mitral regurgitation 4. h/o gastritis 5. h/o pericarditis Social History: unremarkable Family History: unremarkable Physical Exam: Gen: NAD, weight stable, alert Skin: no eczema, no psoriasis HEENT: PERRLA, AT, NC Neck: soft, supple, no masses CV: RRR, grade 4/6 systolic ejection murmur Pulm: CTAB Abd: soft, NT, ND Ext: no C/C/E Neuro: grossly intact Brief Hospital Course: 53 yo female who was evaluated by cardiac surgery on [2198-9-6] then proceeded to the OR on [2198-9-12] for AVR c 21mm C/E pericardial valve. [Name (NI) ], pt went to the CSRU where course was unremarkable. All tubes and drains were removed per protocol. Pt was transferred to floor [2198-9-13] where she did very well. Pt. was cleared by physical therapy and by POD #3, pt. was deemed well enough to go home. Medications on Admission: 1. HCTZ 2. Lisinopril 3. MVI 4. Ativan prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:14 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Hydromorphone HCl 2 mg Tablet Sig: 0.5-1 Tablet PO Q2-4H (every 2 to 4 hours) as needed. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Aortic valve disease, aortic insufficiency, critical aortic stenosis 2. Lupus Discharge Condition: Good Discharge Instructions: 1. Resume medications as directed. 2. Activity restrictions as indicated. 3. Call office or go to ER if fever/chills, purulent drainage from incision, chest pain/SOB. Followup Instructions: PCP/Cardiology in [2-7] weeks. Provider: [Name10 (NameIs) ],[Name11 (NameIs) 1112] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month	[ "710.0", "424.1", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	2409, 2467	1123, 1553	333, 370	2592, 2598		2813, 3015	848, 862		1646, 2386		2488, 2571		1579, 1623			2622, 2790									877, 1100																					273, 295							398, 667															689, 802	818, 832
1,401	168,862	51752	Discharge summary	report	Admission Date: [2185-9-9] Discharge Date: [2185-9-17] Date of Birth: [2119-6-16] Sex: F Service: MEDICINE Allergies: Codeine / Aspirin Attending:[First Name3 (LF) 896] Chief Complaint: Hyponatremia and new lung masses evaluation Major Surgical or Invasive Procedure: None History of Present Illness: 66 F admitted [2185-9-9] with slurred speech concerning for TIA/CVA. Neuro was consulted and ultimately slurred speech resolved. Afib with RVR developed and she was admitted to cardiology. She spontaneously converted to sinus rhythm. Heparin gtt started. Pt has been awaiting liver biopsy for liver masses. CTA showed new pulmonary nodules concerning for metastatic disease. Scheduled for outpt liver biopsy, but now she is on heparin and may need liver biopsy as an inpatient. CEA, AFP, CA 125, CA [94]-9, SPEP sent. On oxygen now likely [2-8] new pleural effusion. Also with troponin leak likely [2-8] AFIB w/ RVR. Also patient has been hyponatremic since previous admission. Past Medical History: UGIB Paroxismal AF Lumbar and thoracic fusions s/p MVA. ACDF from the C4-C6 level. severe Osteoarthritis. hysterectomy and bladder suspension tonsillectomy bilateral tubal ligation osteoporosis rosacea chronic pain Social History: Lives with daughter at home. she has AFO after MVA, she used walker at home for ambulance. she had one fall only per daughter, does not think patient is at high risk for fall. Family History: No family hx of stroke or heart attack Physical Exam: VS: 98.0 136/79 94 22 96%1L GEN: Alert and oriented to person, place and situation; no apperent distress HEENT: no trauma, pupils round and reactive to light and accomodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: clear to auscultation bilaterally, decreased BS at bases GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis; + pitting edema to above knees B; NEURO: CN II-XII intact, no dysdiadokinesia, [5-11] motor function globally, no sensory deficits DERM: echymosis at left previous peripher IV site Pertinent Results: [2185-9-9] 01:05PM WBC-15.7 RBC-3.93* HGB-11.6* HCT-34.1* MCV-87 MCH-29.5 MCHC-33.9 RDW-14.5 [2185-9-9] 01:05PM NEUTS-87.8* LYMPHS-7.2* MONOS-4.2 EOS-0.2 BASOS-0.5 [2185-9-9] 01:05PM PLT COUNT-328 [2185-9-9] 01:05PM PT-14.9* PTT-20.3* INR(PT)-1.3* [2185-9-9] 01:05PM GLUCOSE-116* UREA N-10 CREAT-0.4 SODIUM-129* POTASSIUM-3.2* CHLORIDE-93* TOTAL CO2-23 ANION GAP-16 [2185-9-9] 01:05PM ALT(SGPT)-68* AST(SGOT)-68* LD(LDH)-595* CK(CPK)-278* ALK PHOS-324* TOT BILI-0.8 [2185-9-9] 01:05PM LIPASE-31 [2185-9-9] 01:05PM CK-MB-5 [2185-9-9] 01:05PM cTropnT-0.07* [2185-9-9] 01:05PM CALCIUM-8.4 PHOSPHATE-2.0* MAGNESIUM-2.5 [2185-9-9] 02:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [2185-9-9] 02:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2185-9-9] 02:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2185-9-9] 11:38PM PTT-32.1 [2185-9-9] 11:38PM cTropnT-0.12* [2185-9-9] Head CT: FINDINGS: Allowing for the moderate limitation, there is no evidence of hemorrhage. The ventricles and sulci are similar in configuration compared to the study one day ago. Evaluation of the visualized lung apices is limited by patient's respiratory motion. Biapical scarring is again noted. IMPRESSION: Markedly limited study secondary to patient's extensive spinal surgery with inability to lay flat inside the magnet. No evidence of hemorrhage. The findings were communicated to the primary team, Dr. [First Name (STitle) ] [Name (STitle) ] by Dr. [First Name8 (NamePattern2) 5586] [Last Name (NamePattern1) ] shortly after the completion of the study at 6 p.m. The study and the report were reviewed by the staff radiologist. [2185-9-9] Chest CT: COMPARISON: CT of the abdomen and pelvis, [2185-9-7]. TECHNIQUE: MDCT images were acquired through the chest before and after administration of 100 cc of Optiray intravenous contrast. Sagittal, coronal, and oblique reformats were generated and reviewed. FINDINGS: Study is extremely limited due to the presence of extensive streak artifacts due to the thoracic spine fixation hardware. Within this limitation, the main and the segmental pulmonary arteries are visualized and are free of emboli. However, the assessment of the subsegmental arteries is limited. The thoracic aorta is normal without evidence of acute aortic dissection. The heart and pericardium are unremarkable. The major airways are patent up to subsegmental levels bilaterally. Bilateral pleural effusions are large, likely simple. There is associated compressive atelectasis of both lower lobes, left greater than right. Innumerable pulmonary nodules seen diffusely distributed throughout both lungs, are consistent with metastatic disease. No significant axillary or hilar adenopathy is detected. A soft tissue density lesion in the subcarinal region measuring 51 x 30 mm (3:31), likely represents subcarinal adenopathy. Enlarged lymph nodes are seen in the epicardial region (3:62) and in the retrocrural region (3:69). The study is not tailored for evaluation of the subdiaphragmatic organs. Multiple hypoattenuating hepatic lesions are faintly visualized and not completely assessed. A large wedge-shaped opacity involving the superior pole of the spleen, is consistent with a splenic infarct. This, on retrospect, was present on the prior study. Minimal amount of perisplenic fluid is present. Lobulated soft tissue lesions are seen in the left upper quadrant, raising concern for peritoneal masses. OSSEOUS STRUCTURES AND SOFT TISSUES: The patient is status post posterior spinal fixation of the thoracic spine. No obvious hardware malalignment. At least two compression fractures are visualized in the imaged portion of the thoracic spine IMPRESSION: 1. No acute thoracic aortic pathology. 2. No pulmonary embolism is seen in the main and segmental arteries. Assessment of the sub-segmental arteries is limited due to extensive artifacts from spinal fixation hardware and pulmonary emboli cannot be excluded. 3. Bilateral large pleural effusions with associated compressive atelectasis of the lower lobes. 4. Innumerable pulmonary nodules and subcarinal lymphadenopathy, consistent with metastatic disease. 5. Multiple hepatic hypoattenuating masses are not completely assessed in this single phase study. 6. Wedge-shaped sharply marginated splenic hypoattenuation, likely represents a splenic infarct given the history of atrial fibrillation. Small amount of free fluid in the abdomen. 7. Multiple peritoneal soft tissue masses in the left upper quadrant are not completely assessed. Metastatic disease note excluded. Recommend further evaluation. The study and the report were reviewed by the staff radiologist. [2185-9-11] Na 128, cl 95, K 3.7, HCO2 23, BUN 9, Crt 0.3, Glu 107; Ca 7.6, phos 1.5, mg 2.5; wbc 15.5, hgb 11, hct 32.5, plt 410, 88 neut, 7.2 lymph, 4.2 mono; LDH 512; osmolal 261; INR 1.2 Brief Hospital Course: 1. Right MCA Stroke. Patient presented with aphasia which resolved soon after admission. She remained without neurologic signs until [2185-9-13] when she was noted to be less interactive, aphasic, and with an apparent left neglect versus paresis. A code stroke was called and a CTA showed occlusion of the right MCA. There were several attempts to contact her daughter to discuss risk and benefits of tPA, however there were no answer at her home phone number and her work number was non-functional. Given the gravidity of the her embolic CVA, it was clinically indicated for her to be started on tPA infusion. She was given tPA at approximately 4:00 PM, approximately four hours after she had last been seen without deficits. Her exam remained unchanged during her tPA infusion and later that night she vomited and was less responsive, moving only her RUE, slumped to the side in bed, not following commands. A STAT head CT showed left frontal and right occipital intraparenchymal hemorrhage, extending into the subarachnoid space, with edema. Neurosurgery felt that surgery would not be of benefit. At that time the patient's poor prognosis was explained, and they decided to make her CMO. On the evening of [9-17] the patient passed. An autopsy was consented to. Medications on Admission: Cymbalta 60 [Hospital1 ] Plaquenil 200 mg [Hospital1 ] [Doctor First Name ] 180 daily for seasonal allergies Fosamax 70 mg qwk Calcium 1500 mg qd MVA Prilosec 20 qd (for PUD) Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Stroke Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None	[ "199.1", "342.90", "197.7", "511.9", "275.41", "434.11", "197.0", "348.4", "784.3", "427.31", "733.00", "348.5", "253.6" ]	icd9cm	[ [ [] ] ]	[ "99.10" ]	icd9pcs	[ [ [] ] ]	8791, 8800	7242, 8524	320, 326	8850, 8859	2181, 3243	8912, 8919	1503, 1544		8762, 8768		8821, 8829		8550, 8739			8883, 8889									1559, 2162																					237, 282							354, 1054				3252, 7219											1076, 1293	1309, 1487

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