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21,669	198,727	46766	Discharge summary	report	Admission Date: [2166-4-11] Discharge Date: [2166-4-16] Date of Birth: [2095-6-12] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 70-year-old-female with a history of multiple cerebrovascular accidents, history of hypertension, and history of coronary artery bypass graft who presents to the Emergency Room with a complaint of lethargy stupor. While being bathed by the daughter she apparently had emesis and urinary incontinence as well. The family called an ambulance, and the patient was taken to the Emergency Room. Upon arrival, she was intubated urgently, and a CT scan revealed a massive left greater than right intraparenchymal hemorrhage with midline shift and the fourth ventricle compression. The patient's physical examination included decerebrate posturing. Blood pressures were in the 200 range systolic. Nipride was started urgently, and a ventricular drain was placed urgently and drained bloody cerebrospinal fluid, and was maintained 5 cm above the tragus. PAST MEDICAL HISTORY: Previous medical history includes hypertension and coronary artery bypass graft, and a history of as many as 11 prior cerebrovascular accidents with a residual known left hemiparesis since [2159]. The patient had been cared for by her daughter in her home, and in the remote past she also has a history of hypercholesterolemia, and pancreatitis, and a left femoral fracture, and a history of chronic obstructive pulmonary disease. PAST SURGICAL HISTORY: Previous surgical history also included an appendectomy as well as coronary artery bypass graft. ALLERGIES: She has an allergic history reaction to BACTRIM and TRAZODONE. MEDICATIONS ON ADMISSION: Her current medications at the time of admission included atenolol, Zyrtec, aspirin, Lipitor, Plavix, Lasix, and vitamin C. SOCIAL HISTORY: She had a 75-pack-year of cigarette smoking. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination she responded only to painful stimuli but moved all four extremities, was not responsive to verbal stimuli. Pupils were 3 mm bilaterally and nonreactive. There was negative doll's eyes, and no corneal reflexes were present. Chest showed a regular rate and rhythm of the heart, and the lungs were clear to percussion and auscultation bilaterally. The abdominal examination showed a soft, nontender, and nondistended abdomen. Extremities were without clubbing, cyanosis or edema. The Babinski was upgoing bilaterally, and she showed decerebrate posturing. HOSPITAL COURSE: Due to the clinical findings, the patient was initially admitted the Neurosurgical Intensive Care Unit. Her clinic status remained stable and unresponsive with decerebrate posturing and fixed pupils, and her ventricular intercerebral pressures stabilized, and the ventricular drain was removed early on [2166-4-16], and the patient was transferred to the floor. After multiple discussions with the family regarding the gravity of the patient's condition, the family agreed to begin comfort measures only care on the floor on [4-16], and this was done with continuation of intravenous fluids, and the patient was noted at 9:45 p.m. to have no vital signs, and the Neurosurgical staff was called to the floor to evaluate the patient, and indeed there was no evidence of pupillary reflex, no evidence of gag reflex. There was no withdrawal to painful stimuli. There was no corneal reflex. There was no spontaneous breathing, and no palpable pulse, and the patient was therefore pronounced deceased at 9:30 p.m. [Name6 (MD) 6911] [Name8 (MD) ], MD [MD Number(1) 6913] Dictated By:[Doctor Last Name 7311] MEDQUIST36 D: [2166-7-21] 17:37 T: [2166-7-24] 10:29 JOB#: [Job Number ]	[ "331.4", "401.9", "431", "414.01", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "02.2", "96.72" ]	icd9pcs	[ [ [] ] ]												1715, 1840	2543, 3794										1514, 1688																																								169, 1030																1053, 1490	1857, 2524
19,529	141,727	54080	Discharge summary	report	Admission Date: [2127-6-23] Discharge Date: [2127-7-8] Date of Birth: [2051-2-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Endometrial cancer Major Surgical or Invasive Procedure: TAH/BSO/staging for endometrial CA Central Line placement History of Present Illness: 76 yo GO found to have thickened endometrium on CT done for surveillance due to history of breast cancer. CT also showed bilateral ovarian cysts. Pt's CA-125 was elevated at 22 in [2-23] in [4-24]. D&C [2127-5-26] revealed endometrial adenocarcinoma. Pt presents now for TAH/BSO/staging for endometrial CA. Past Medical History: Past Surgical History: -R hip replacement -shoulder replacement -lumpectomy in [2121] for breast CA -D&C for menorrhagia in [2071]'s Past Medical History: 1. Breast CA s/p radiation therapy [2121], on adjuvant chemo 2. Osteoporosis with mult compression fx of vertebrae 3. OA of shoulder, hip s/p R hip replacement 4. A Fib, parox, on amio but no anticoag given fall hx and risk 5. Tachy-brady Synd, s/p PPM 6. Chronic hypoxia, followed by Pulm 7. Chronic recurrent b/l pleural effusions, s/p taps and biopsies with no evid of malignancy Social History: Lives at [Location ], not married. Remote Hx tobacco, occassional wine, no other drugs. Family History: Niece-breast CA, No endometrial/ovarian/colon CA Physical Exam: Pre-admission PE GENERAL: She appeared well and was moderately overweight. She was in no acute distress. SKIN: Sclerae anicteric. Lymph node survey was negative. ABDOMEN: Soft, nondistended and without palpable masses. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was very difficult to visualize, as the vagina was quite narrow and the apex was quite high. In addition, the patient had a great deal of difficulty in fully relaxing. Despite several attempts, the speculum could not be positioned such that the cervix was exposed. Any attempt at endometrial biopsy was therefore abandoned. Bimanual examination was similarly limited. The vaginal walls were smooth, and the cervix was normal to palpation. There were no palpable pelvic masses. RECTAL: Examination was confirmatory. There was no cul-de-sac nodularity and the rectum was intrinsically normal. Pertinent Results: [2127-6-23] 06:23PM BLOOD WBC-16.1* RBC-3.29* Hgb-11.2* Hct-33.2# MCV-101 MCH-33.9* MCHC-33.6 RDW-13.4 Plt Ct-260 [2127-6-24] 04:40PM BLOOD WBC-11.2* RBC-3.05* Hgb-10.3* Hct-31.2* MCV-102* MCH-33.8* MCHC-33.0 RDW-13.6 Plt Ct-234 [2127-6-27] 07:01AM BLOOD WBC-6.0 RBC-2.67* Hgb-9.1* Hct-26.4* MCV-99* MCH-34.2* MCHC-34.6 RDW-13.2 Plt Ct-217 [2127-7-2] 06:00AM BLOOD WBC-14.3* RBC-3.52* Hgb-11.2* Hct-33.7* MCV-96 MCH-31.9 MCHC-33.4 RDW-19.0* Plt Ct-356 [2127-7-6] 05:50AM BLOOD WBC-19.5* RBC-3.93* Hgb-12.2 Hct-37.4 MCV-95 MCH-30.9 MCHC-32.5 RDW-18.7* Plt Ct-543* [2127-7-8] 07:00AM BLOOD WBC-14.5* RBC-3.75* Hgb-11.8* Hct-36.0 MCV-96 MCH-31.3 MCHC-32.7 RDW-18.3* Plt Ct-431 [2127-6-29] 09:29AM BLOOD Neuts-90.6* Bands-0 Lymphs-5.2* Monos-2.5 Eos-1.4 Baso-0.4 [2127-7-2] 01:31PM BLOOD Neuts-74* Bands-1 Lymphs-11* Monos-4 Eos-6* Baso-1 Atyps-1* Metas-1* Myelos-1* [2127-6-29] 09:29AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ [2127-7-2] 01:31PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-1+ Polychr-NORMAL [2127-6-23] 06:23PM BLOOD Plt Ct-260 [2127-6-25] 03:57AM BLOOD PT-12.3 PTT-28.1 INR(PT)-1.1 [2127-7-8] 07:00AM BLOOD Plt Ct-431 [2127-6-23] 06:23PM BLOOD Glucose-268* UreaN-19 Creat-0.9 Na-139 K-4.3 Cl-107 HCO3-22 AnGap-14 [2127-7-7] 06:40AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-136 K-4.3 Cl-100 HCO3-24 AnGap-16 [2127-6-24] 12:44AM BLOOD CK(CPK)-59 [2127-7-6] 05:50AM BLOOD ALT-14 AST-16 LD(LDH)-245 AlkPhos-53 Amylase-133* TotBili-0.3 [2127-7-7] 06:40AM BLOOD ALT-12 AST-18 AlkPhos-50 Amylase-85 TotBili-0.4 [2127-7-6] 05:50AM BLOOD Lipase-153* [2127-7-7] 06:40AM BLOOD Lipase-77* [2127-6-24] 12:44AM BLOOD CK-MB-3 cTropnT-<0.01 [2127-6-30] 05:55AM BLOOD proBNP-6339* [2127-6-23] 06:23PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.6 [2127-6-29] 09:29AM BLOOD Albumin-2.9* Calcium-7.5* Phos-2.3* Mg-1.9 [2127-7-4] 07:30AM BLOOD TotProt-5.0* Mg-1.9 [2127-7-6] 05:50AM BLOOD Albumin-3.3* Mg-2.0 [2127-6-24] 04:40PM BLOOD Cortsol-29.2* [2127-7-3] 04:02PM BLOOD [Doctor First Name ]-NEGATIVE [2127-6-24] 04:16AM BLOOD Lactate-1.9 Na-134* K-4.0 Cl-106 calHCO3-24 [2127-6-24] 04:16AM BLOOD Hgb-10.0* calcHCT-30 [2127-7-6] 10:31AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2127-7-2] 12:18PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.005 [2127-6-24] 02:36AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.030 [2127-7-6] 10:31AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD [2127-7-2] 12:18PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2127-6-24] 02:36AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2127-7-6] 10:31AM URINE RBC-13* WBC-99* Bacteri-MOD Yeast-NONE Epi-<1 [2127-6-24] 02:36AM URINE RBC-52* WBC-11* Bacteri-NONE Yeast-NONE Epi-<1 RenalEp-2 [2127-6-24] 02:36AM URINE CastGr-2* CastHy-4* [2127-7-6] 10:31AM URINE AmorphX-RARE . Microbiology [2127-6-24] 2:36 am URINE FINAL REPORT [2127-6-25] URINE CULTURE (Final [2127-6-25]): NO GROWTH. [2127-7-2] 12:18 pm URINE FINAL REPORT [2127-7-6] URINE CULTURE (Final [2127-7-6]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| ESCHERICHIA COLI \| \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ <=1 S 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . [2127-7-2] 1:54 pm PLEURAL FLUID FINAL REPORT [2127-7-8] GRAM STAIN (Final [2127-7-2]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2127-7-5]): NO GROWTH. ANAEROBIC CULTURE (Final [2127-7-8]): NO GROWTH. . [2127-7-6] 10:31 am URINE FINAL REPORT [2127-7-7] URINE CULTURE (Final [2127-7-7]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 210-1766H([2127-7-2]). ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 210-1766H([2127-7-2]). Imaging: . CHEST PORT. LINE PLACEMENT [2127-6-24] 4:27 PM Portable chest radiograph compared to the previous one done the same day at 5:01 a.m. IMPRESSION: The right internal jugular line tip was inserted with its tip projecting over the distal portion of superior vena cava. There is no pneumothorax or enlarged pleural effusion. The heart size is enlarged but stable. Bilateral small amount of pleural effusion is unchanged, more on the right. The prosthesis in the left humerus and severe changes in the right humerus are stable as well. . CHEST (PORTABLE AP) [2127-6-24] 5:43 AM UPRIGHT AP VIEW OF THE CHEST: Mild cardiomegaly is unchanged. Left-sided dual chamber [Month/Day/Year 4448] with leads terminating in the right atrium and right ventricle is unchanged. Increased prominence of the azygos contour and increased right basilar hazy opacity reflect increasing asymmetric pulmonary edema, right greater than left. Small right pleural effusion has increased in size, and a small left pleural effusion is stable. Hiatal hernia is unchanged. There is no pneumothorax. Severe degenerative changes are present in the right shoulder, and the patient is status post left shoulder hemiarthroplasty. IMPRESSION: Increasing mild asymmetric pulmonary edema, right greater than left, with increasing small right pleural effusion. . TTE [2127-6-24] 1. The left atrium is markedly dilated. The right atrium is moderately dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 6. There is a moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. 7. Compared with the report of the prior study (images unavailable for review)of [2126-5-17], the pulmonary hypertension is worse. . EKG [2127-6-24] Atrial fibrillation with a rapid ventricular response. No change since the previous tracing of [2127-5-22]. Diffuse non-specific ST-T wave abnormalities persist. . EKG [2127-6-26] Atrial fibrillation with rapid ventricular response RSR' in V1 Generalized low QRS voltages Since previous tracing of [2127-6-25], no significant change . CHEST (PA & LAT) [2127-6-29] 10:20 AM FINDINGS: Comparison is made to the previous study from [2127-6-24]. There is a left humeral prosthesis. There is a left-sided dual-lead [Year (4 digits) 4448]. There is a right IJ central venous catheter with the distal tip in the proximal SVC. There is cardiomegaly, unchanged. There are persistent bilateral pleural effusions which are unchanged, right greater than left. Mild interstitial prominence is seen, which is stable. IMPRESSION: No interval change. Persistent cardiomegaly with bilateral pleural effusions and slight interstitial pulmonary prominence. . CTA CHEST W&W/O C &RECONS [2127-6-30] 7:46 PM COMPARISONS: Comparison is made to [2127-2-25]. CTA OF THE CHEST: There is significant interval worsening of bilateral pleural effusions, now moderate in size and right greater than left. There is bilateral basilar atelectasis. Again seen is a 1.7-mm lung nodule in the right lower lobe. This appears to be stable since [2125] suggesting benignancy. There is cardiomegaly. The great vessels appear unremarkable. The pulmonary vasculature is opacified without evidence of intraluminal filling defects to suggest the presence of pulmonary embolism. No mediastinal or hilar lymphadenopathy is seen. Several medistinal lymph nodes do not meet size criteria for pathologic enlargement. There are bilateral nodules within the thyroid lobes. The partially visualized upper abdominal organs are notable for abdominal ascites around the liver. Bone windows demonstrate severe degenerative changes in the thoracic spine, but no evidence of suspicious lytic or sclerotic lesions. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Interval increase in bilateral pleural effusions and bilateral basilar atelectasis. 3. Stable right lower lobe lung nodule. 4. Abdominal ascites. . ABDOMEN (SUPINE ONLY) [2127-7-2] 10:19 AM SUPINE ABDOMINAL RADIOGRAPH: There are mildly dilated loops of small bowel as well as air seen in the ascending, descending, and transverse colon. There is no evidence of obstruction. Clips are seen overlying the abdomen. The patient is status post prior vertebroplasty of a lower thoracic vertebra. There is a right-sided bipolar hemiarthroplasty. No bilateral pleural effusions. IMPRESSION: No evidence of obstruction. . [2127-7-3] ECHO with bubble study 1. The left atrium is markedly dilated. The right atrium is moderately dilated. 2. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 3. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. The right ventricular cavity is moderately dilated. 5. The aortic valve leaflets (3) are mildly thickened. 6. The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. 7. There is a moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. . CHEST (PA & LAT) [2127-7-6] 11:08 AM IMPRESSION: PA and lateral chest compared to [6-29] and 14: Small left and moderate right pleural effusion have improved since [6-29]. Now more heterogeneous opacification in the right and mid and lower lung than there was on [7-2]. Although this could be asymmetric edema, the simultaneous improvement in effusions suggest that this is pneumonia instead, quite likely aspiration. Right internal jugular line and transvenous right atrial and right ventricular pacer leads are unchanged in their standard positions. No pneumothorax. Brief Hospital Course: Ms. [Known lastname 109973] is a 76 yo lady with multiple medical problems admitted to the GYN service for TAH/BSO and transferred to the medicine service initially for hypotension post op and later for A.fib with RVR and CHF. Her hospital course is summarized below. . [Hospital Unit Name 153] course: The pt was admitted to the [Hospital Unit Name 153] for management of post-op (s/p TAH/BSO for endometrial ca) hypotension in the setting of post-op sedation. Ms. [Known lastname 109973] was treated with a pressor and boluses of LR with no significant improvement of BP (remained in low 100). She was noted to have a HCT drop (43->35) after fluid resuscitation. She was gradually weaned off pressors. The pt had very poor peripheral access so a R IJ was placed for fluid resuscitation. Her repeat HCT showed a further drop. The patient was noted to be in Afib on admission, consistent with her past medical history. Her cardiac enzymes were negative. [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim test was negative for adrenal insufficiency. . On the day after admission, the pt's EKG was significant for uniformly low voltages in all leads. A cardiac ECHO showed moderate pulmonary artery systolic hypertension, a moderate sized pericardial effusion (echo dense, consistent with blood, inflammation or other cellular elements) with no evidence of tamponade; these findings have been noted on previous ECHO dating back to 10/[2125]. The pt's CXR was significant for increased mild asymmetric pulmonary edema (R>L), with increasing small R pleural effusion. It was noted that her BPs would fall with each administration of narcotics; these were weaned off and her BPs remained stable. It was thought that her hypotension was likely due to iatrogenic narcotic use, and these were tapered off as tolerated. . Patient improved and transferred back to gyn service on [2127-6-25]. Patient remained in A.fib with transient episodes of RVR. Cardiology was consulted who suggested increase standing dose to Toprol 100mg qd + IV Lopressor 5mg prn. Patient had tachy episodes to 150s-170s x 2 on [6-25] & [6-26], EKGs showing afib w/RVR. [Month/Day (4) ] interrogated [6-26], functioning fine and only V-paces when bradycardic. Patient remained tachy to 120s on [6-28], per cards changed Toprol to Lopressor 50mg PO TID, titrate to 75 mg TID for adequate beta blockade. CXR on [6-29] CXR showing effusion and cardiomegaly unchanged from prior. . The medicine service continued to follow the patient while on the GYN service. The patient noted to be wheezing, desated transiently to 75% RA while ambulating. Patient known to have restrictive lung dz [2-20] to b/l pleural effusions and DOE and is followed in [Hospital ] clinic, who recommended home O2 w/exertion, however pt declined use of home O2 in the past. Patient continued sating mid 90s on RA (baseline). ROS negative aside from audible wheezing (new per patient)and dyspnea at rest "can't get enough air". Patient reported being able to walk to the door and back but develops palpitations and SOB. Prior was living in apartment and was able to do ADLs without similar limitations. The decision was made to transfer the patient to the medicine service for further management of her shortness of breath as well as difficult to control A.fib with RVR. Her hospital course on the medicine service is summarized below. . # Sob/Hypoxia: Likely Multifactorial given patient with known lung disease, b/l pleural effusions, stable pericardial effusion, CHF and volume overload, A.fib with RVR and platypnea-orthodeoxia (see below). PE was ruled out with CTA given patient was post op with tachycardia and SOB. On exam, patient was wheezing primarily upper airway with intermittent stridor. ENT was consulted who performed laryngoscopy which was non revealing. Patient was treated symtomatically with diuresis, Albuterol/Atrovent nebs prn, incentive spirometry. Thoracentesis was also performed for for syptom relief. This was negative for infection and was consistent with a transudative process. Patient improved gradually with ongoing diuresis and control of her A.fib with RVR. Upon discharge she was able to ambulate the floor while maintaining her saturations in the low 90s. Patient is to have close flow up after discharge for ongoing management. Patient would also benefit from home O2 however she continues to refuse this option since she does not feel the need for oxygen. She is discharged home to her assissted living. . # UTI: Pansensitive UTI with leukocytosis. Treated with cipro po for 7 day course. Patient remained afebrile. . # Platypnea-Orthodeoxia: Very unclear etiology. Patient noted to desat to low 80s upon sitting up on bed with improvement in her sats to mid 90's when lying supine. Patient also experience dyspnea with air hunger when sitting up. A positional echo was performed however it was negative for ASD/PFO. Patient then improved with ongoing diuresis. Patient was evaluated by the pulmonary service who recommended the above echo as well as [Doctor First Name ] to r/out CT disease. Other potential work up as an outpatient may include [Name (NI) 5283] son[Name (NI) ] or V/Q scan to assess for cirrhosis (unlikely) or vascular shunts. Given that the patient improved and was ambulating the pod while mataining her sats in the low 90s, the medicine team did not feel that she should remain in hospital for ongoing workup. # CVS: PUMP: EF >55%, transient hypotension s/p sedation and narcotic use s/p stay in ICU requiring transient pressors. Upon transfer to the medicine service the patient was clearly volume overloaded post op and after receiving fluids in the ICU. Her BNP significantly elevated. Patient was diuresed with IV lasix with goal I/Os negative 1L daily. She diuresed significantly to lasix with dramatic improvement in her symptoms. Patient was discharged home on 40 mg po lasix. She was continued on an ACEI and BB/CCB for rate control. She will need close PCP follow up for adjustment in her medications if needed. . RHYTHM: A.fib with RVR, SSS s/p PPM. Patient with chronic A.fib not on anticoagulation due to fall risk. Her HR has been relatively well controlled as an outpatient however patient went into RVR post op. Patient did not experience any chest discomfort but did have baseline shortness of breath. Her HR was controlled with lopressor which was uptitrated to 100 mg TID. Diltiazem was them added for further control. She was monitored on telemetry throughout with improvement in HR ranging 80-90s. Patient was discharged on 50 mg lopressor TID with 120 mg long acting CCB. She is followed by the cardiology clinic as an outpatient. . ISCHEMIA. No evidence of ischemia, no CP although patient has dyspnea on exertion likely secondary to her above pulmonary disease. CE negative x neg x 1 on [6-24]. Continued ASA, BB. . # Anemia: Stable at 33. On [6-27] transfused for Hct 26.4 likely [2-20] to post op blood loss. . # Endometrial CA: s/p tab/bso and lymph node dissection, followed by GYN service. The patient's wound remained clean, dry and intact. Staples removed prior to discharge. Patient scheduled with close GYN follow up as an outpatient. . # Access: poor PIV access; central line in RIJ - d/ced day prior to discharge. . # Prophylaxis: Pneumoboots, TEDS, Heparin SC TID, ambulation, po diet . Nutrition. Patient's diet was advanced as tolerated post surgery. She was eating well upon discharge. Her electrolytes remained stable. . Patient remained a full code throughout this admission. Medications on Admission: -Lasix 40mg PO qd -Toprol XL 100mg PO qd -Omeprazole 40 mg PO qd Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every [6-26] hours as needed for constipation. Disp:qs ML(s) Refills:0 2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for for gas and bloating. Disp:30 Tablet, Chewable(s) Refills:0 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:2 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed. Disp:30 Capsule(s) Refills:2 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:240 Tablet(s) Refills:2 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 10 days. Disp:30 Tablet(s) Refills:0 14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: [1-20] Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Disp:qs 1 Refills:0 15. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 16. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:30 Lozenge(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Endometrial cancer Discharge Condition: Stable Discharge Instructions: Pelvic rest x 6 wks (2 for laparoscopy) No heavy lifting x 6 wks Call for fevers >101o No driving while taking narcotics Followup Instructions: You have the following appointments scheduled: 1. Provider: [Name10 (NameIs) ],[First Name3 (LF) ] B. GYN ONC PPS (SB) Date/Time:[2127-7-24] 1:00 Provider: [Name10 (NameIs) ],[First Name3 (LF) ] B. [Telephone/Fax (1) 5777] 2. Provider: [Name10 (NameIs) ] CALL Phone:[Telephone/Fax (1) 59] Date/Time:[2127-8-26] 10:30 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2127-10-29] 4:00 Completed by:[2127-7-19]	[ "041.4", "458.29", "511.9", "E849.8", "427.31", "733.00", "182.0", "V10.3", "041.3", "733.13", "V45.01", "285.1", "428.30", "564.00", "E878.8", "599.0", "518.0", "507.0", "220", "428.0" ]	icd9cm	[ [ [] ] ]	[ "34.91", "54.23", "40.3", "65.61", "88.72", "54.24", "38.93", "68.4" ]	icd9pcs	[ [ [] ] ]	23846, 23904	14051, 21673	332, 391	23966, 23974	2432, 14028	24144, 24642	1439, 1489		21788, 23823		23925, 23945	21699, 21765			23998, 24121								784, 903		1504, 2413																												274, 294										419, 739																925, 1313	1329, 1423
65,284	118,522	31959	Discharge summary	report	Admission Date: [2128-12-26] Discharge Date: [2129-1-4] Service: SURGERY Allergies: Amoxicillin / Percocet Attending:[First Name3 (LF) 6346] Chief Complaint: Colocutaneous fistula, panniculitis, cellulitis Major Surgical or Invasive Procedure: [2128-12-26] EXPLORATORY LAPAROTOMY, COLOCUTANEOUS FISTULA TAKEDOWN, EXTENDED RIGHT COLECTOMY, LYSIS OF ADHESIONS, ILEOCOLOSTOMY, PERCUTANEOUS GASTROSTOMY TUBE, SOFT TISSUE DEBRIDEMENT & VENTRAL HERNIA REPAIR [2129-1-1] Wound exploration, VAC removal, skin and deep soft tissue debridement and VAC replacement History of Present Illness: [Age over 90 ] F with history of Afib, CAD, CHF and colocutaneous fistula presents with cellulitis, leukocytosis and colocutaneous fistula. History is unclear, but pt does report having a history of an incisional hernia in the past(possibly from a hysterectomy) which became complicated with a colocutaneous fistula. It is unclear how many surgical procedures she has undergone however she did present with an outside hospital operative report from [2125-12-14]. On [2125-12-14] pt underwent resection of infected mesh and closure of colocutaneous fistula. The mesh was resected and a 2 cm defect was found on the anterior abdominal wall. The defect was closed with a 2-0 Prolene in running fashion and 3-0 silk interrupted seromuscular closure was performed to re-enforce this defect. The fascia was closed with 1 nylon interrupted sutures and the sink was left open for packing. At some unclear point the hernia re-occurred. Per her daughter the patient started leaking feculent material this morning from her wound (similar to prior colocutaneous fistula) and she went to [Hospital3 ]. At [Location (un) ] it was noted that in addition to this feculent material draining from her abdomen she had cellulitis and panniculitis. CT scan was obtained and she was transferred to [Hospital1 18] for further care. She denies fevers, chills, nausea, emesis, diarrhea, constipation. Past Medical History: A. fib, vertigo, CAD, CHF PSH: hysterectomy, incisional hernia repair ~ 30 years ago c/b colocutaneous fistula, s/p resection of infected mesh and closure of colocutaneous fistula [2125-12-14] Family History: Noncontributory Physical Exam: Upon presentation to [Hospital1 18]: VS: 98.2 70 89/41 36 97% Gen: NAD, alert and oriented though does become easily confused CVS: irreg Pulm: no resp distress Abd: Soft but distended. Feculent material draining from R mid/lower abdomen from what appears to be a necrotic (dusky) colocutaneous fistula. There are 3 distinct opening in the skin. There is surrounding erythema overlying most of her pannus extending >30 cm in diameter across her abdomen consistent with cellulitis. The pannus is firm and tender. Pertinent Results: [2128-12-26] 08:58PM GLUCOSE-168* UREA N-26* CREAT-0.9 SODIUM-133 POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-18* ANION GAP-12 [2128-12-26] 08:58PM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-1.5* [2128-12-26] 08:58PM WBC-10.9# RBC-3.26* HGB-9.6* HCT-29.3* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.4 [2128-12-26] 08:58PM PLT COUNT-215 [2128-12-26] 08:58PM PT-15.6* PTT-30.5 INR(PT)-1.4* [2128-12-26] 12:45PM NEUTS-88* BANDS-6* LYMPHS-4* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2129-1-4] 05:14 11.2* 2.66* 7.8* 25.0* 94 29.3 31.1 15.4 170 IMAGING: - [12-26] CT A/P (OSH): (wet read) large incisional hernia w/colocutaneous fistula, small bowel is also within the hernia, no evidence of obstruction or clear evidence of compromised bowel (pneumatosis or wall thickening), soft tissue inflammation surrounding consistent with panniculitis, also a phlegmonous collection w/in ant abdominal wall. - [12-26] CXR: Heart size is enlarged. Mediastinum is unremarkable. Bilateral small amount of pleural effusion as well as left lower lobe atelectasis are new as compared to the prior study. - [12-27] CXR: The appearance of the cardiomediastinal silhouette as well as bibasal atelectasis and bilateral small pleural effusion is unchanged. No new consolidations or pneumothorax have been demonstrated. Brief Hospital Course: She was admitted to the ACS service and taken to the operating room on [2128-12-26] for exploratory laparotomy, colocutaneous fistula takedown, extended right colectomy, lysis of adhesions, ileocolostomy, percutaneous gastrostomy tube, soft tissue debridement and ventral hernia repair. Postoperatively she was taken to the ICU where she was noted to be in rapid atrial fibrillation. She was treated with Amiodarone drip and prior to transfer to floor she was ordered for oral amiodarone and given IV Lopressor. Upon transfer to floor her heart rate remained in the high 130's-140's range. She received additional IV Lopressor doses; Digoxin was recommended by Cardiology and a loading dose was given. Once her rate was controlled she was started on daily Digoxin but was noted with episodes of bradycardia; her Digoxin was changed to every other day dosing. Her Atenolol was restarted at 12.5 mg daily. Tube feedings via her gastrostomy tube were started early on; Nutrition was consulted for recommendations and changes made accordingly. She was also given an oral diet for which she is currently tolerating. On [1-1] she was taken back to the operating room for wound exploration, VAC removal, skin and deep soft tissue debridement and VAC replacement. There were no complications. The antibiotics that she had been started on postoperatively continued until [2129-1-4], these were administered via a PICC that was removed prior to discharge. She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay. She will be discharged with plans for continuing VAC dressing therapy. Medications on Admission: (per OSH records) Meclizine 12.5''', Levothyroxine 50', Allopurinol 150', atenolol 25', ASA 81', Ferrous sulfate 325', isosorbide 20' Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [Hospital1 ] (2 times a day). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): hold for HR <65. 4. atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): hold for HR <65 and/or SBP <110. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 9. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 10. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [12-26] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Colocutaneous fistula Ventral hernia Wound cellulitis Rapid atrial fibrillation Bradycardia Discharge Condition: Mental Status: Clear and coherent; hear of hearing. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were hospitalized with an infection along your colon which required an operation and also repair of your ventral hernia. A large dressing called a VAC dressing has been applied to your abdominal wound to help with healing and closure. This dressing will be changed every 2 days. It is expected that your wound will heal in time; it is very important that you maintain adequate nutrition. You are receiving nutrition through a feeding tube and also are on a regular diet. You have completed a course of antibiotics for the infection. Followup Instructions: Follow up next week in [Hospital 2536] clinic, call [Telephone/Fax (1) 600] for an appointment. Follow up with your PCP after discharge from rehab; you or your family will need to call for an appointment. Completed by:[2129-1-4]	[ "552.21", "682.2", "998.6", "799.02", "288.60", "568.0", "998.59", "428.0", "729.39", "518.0", "458.9", "414.01", "569.81", "V88.01", "427.31", "709.8", "E878.8", "997.1" ]	icd9cm	[ [ [] ] ]	[ "45.73", "54.3", "54.59", "43.11", "46.76", "45.93", "38.97", "96.6", "53.51" ]	icd9pcs	[ [ [] ] ]	7122, 7208	4288, 5927	278, 598	7344, 7344	2847, 4265	8050, 8293	2277, 2294		6112, 7099		7229, 7323	5953, 6089			7489, 8027										2309, 2828																												190, 240										626, 2039									7359, 7465							2061, 2261
72,854	173,819	3323	Discharge summary	report	Admission Date: [2167-2-23] Discharge Date: [2167-2-27] Date of Birth: [2098-7-23] Sex: F Service: NEUROLOGY Allergies: Sulfonamides Attending:[Last Name (NamePattern1) 1838] Chief Complaint: seizure Major Surgical or Invasive Procedure: none History of Present Illness: CC: code stroke called at 7:26 pm, at the patient's bedside by 7:30 pm. HPI: 68 year old left handed woman, with a history of dementia, HTN, previous breast cancer, who around 6:00 pm became confused. She had woken up from a nap, and was about to have a cup of tea with her son, and complained of a headache, and feeling sick. She stated to her son that she was having a sinus headache, and had complained of a headache before she went to bed the previous night. Her son [Name (NI) ] [Name (NI) 15427] was unable to describe the character or exact location of the headache. She started to want to vomit and began to gag. He seated his mother down on the couch, and she became more disoriented, so he called 911. By the time the EMS arrived, she was completely confused as to what they were doing in the room. A few minutes after they arrived around 6:20 pm, she started to slouch in the couch to the left, clench her hands and started shaking them, her legs were straight out, and she started frothing at the mouth with a glazed expression. She was unresponsive and mute. Prior to this, she had been able to answer and understand questions in her normal manner. The episode lasted 10-15 minutes, and her son thought that she was having a seizure. The EMS placed an oxygen mask on her face, and she remained unresponsive. Of note she had taken Ibuprofen and Tylenol the previous night for her headache, and when she woke up in the morning. Her son had offered to take her to the ER in the morning, but she mentioned that it was her usual sinus headache, which she saw her PCP [Name Initial (PRE) ]. According to her son, yesterday, they went to [Name (NI) 15428] as usual, and she was at her baseline. By the time that I saw her in the ER, she was already intubated and paralyzed for airway protection. An ROS was unobtainable. According to the ER physicians she had a flaccid right sided paralysis on arrival, which was not appreciable after intubation and paralysis. Past Medical History: Left breast cancer(in records, but son unaware of any history) asthma vs COPD. Also remote hx of GYN cancer (s/p hysterectomy in her 20s, further details unknown) hypertension Benicar stopped a month ago according to her son mild dementia on formal neuropsych testing(although son states deficits are no longer mild)-seen by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6817] [2167-11-11] - Mild intrahepatic biliary dilatation on U/S, Cholelithiasis w/o son[Name (NI) 493] evidence of acute cholecystitis & she had a UTI. Past Surgical History: Tonsillectomy, appendectomy, breast surgery, hysterectomy, and some sort of bladder neck suspension. Social History: SH: Lives in [Location ] with her son. She goes out of the house once a day to visit [Company 2486]. Capable of ADL's, but does not drive or balance a cheque book. Gave up smoking 20 years ago, prior to that she had been a heavy smoker for 40 years. She does not drink alcohol or use recreational drugs. She worked in a cafeteria. HCP/son [Name (NI) ] [Name (NI) 122] [Name (NI) 15427] [Telephone/Fax (1) 15429], full code for now PCP: [Name10 (NameIs) ] [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 2903] ([Hospital1 18]-[Location (un) ]) Family History: Her sister died recently of emphysema Physical Exam: T-afebrile BP-in the field her systolic BP had been in the 212, when she arrived in the ER it was 168/121, on propofol it was 140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177 Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender Breast: L breast scar noted, fullness noted in the left upper outer quadrant. ext: no edema Neurologic examination: Mental status: Intubated and sedated. Received Narcan (2) in the field, then she was intubated by rapid sequence method (etomidate+succ), and sedated with propofol (and also given some versed) Cranial Nerves: Pupils 2 mm bilaterally, sluggishly responsive to light. Corneals in tact. Dolls head reflex normal. Gag in tact. Motor: Withdraws all 4 extremeties to noxious stimulus. Reflexes: 2 and symmetric throughout, apart from Achilles jerks which are +1s. Right toe is upgoing Coordination & gait could not be assessed Labs: pH 7.33 pCO2 44 pO2 484 HCO3 24 BaseXS -2 [2167-2-23] 7:33p Green Top Na:142 K:3.6 Cl:100 TCO2:17 Glu:191 freeCa:1.16 Lactate:10.7 pH:7.22 Hgb:15.4 CalcHCT:46 Serum tylenol 18.8, rest of serum and Utox unremarkable Pertinent Results: [2167-2-23] 07:26PM BLOOD WBC-13.1* RBC-4.86 Hgb-14.3 Hct-43.3 MCV-89 MCH-29.5 MCHC-33.1 RDW-12.5 Plt Ct-384 [2167-2-24] 02:46AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.5 Hct-37.3 MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-270 [2167-2-23] 07:26PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0 [2167-2-23] 07:26PM BLOOD Fibrino-547* [2167-2-25] 03:05AM BLOOD ESR-30* [2167-2-25] 03:05AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-142 K-3.1* Cl-109* HCO3-25 AnGap-11 [2167-2-25] 03:05AM BLOOD ALT-9 AST-22 [2167-2-24] 02:46AM BLOOD CK(CPK)-88 [2167-2-24] 02:46AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2167-2-24] 02:46AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.6 CT head [2167-2-23] 1. Subarachnoid hemorrhage in the left posterior parietal cortex at the vertex. 2. No evidence of acute infarct. MRI is more sensitive for the detection of acute ischemia. MRI head, MRA / MRV [2167-2-23] 1. Extensive areas of signal abnormality with nodular enhancement throughout the brain, many of which are centered at the [Doctor Last Name 352]-white matter junction, with both supra- and infra-tentorial compartments involvement as well as involvement of deep [Doctor Last Name 352] nuclei. Differential considerations include an infectious process, which may be related to septic emboli (although the lack of more widespread associated blood products and infarction is unusual, given the extent of the abnormalities), atypical infections such as tuberculosis, neoplastic processes such as metastatic disease or lymphoma, toxic metabolic processes (given deep [Doctor Last Name 352] structure involvement and somewhat bilateral diffuse symmetric appearance), as well as other more atypical patterns of emboli, such as from an atrial myxoma or bland endocarditis. 2. The left parietal blood products seen on the preceding CT scan could be due to septic or bland embolism, or an infectious process. However, they could also be indicative of venous ischemia secondary to the underlying pathologic process. 3. No evidence of venous sinus thrombosis. While the large cortical veins appear patent, MRV is not sensitive for evaluation of cortical veins. 4. Unremarkable MRAs of the head and neck, without evidence of a hemodynamically significant stenosis or aneurysm. 5. Areas of increased signal intensity within the left lobe of thyroid gland, incompletely characterized on the current study. Correlation with thyroid laboratory data and/or ultrasound is recommended. TTE [2167-2-24] The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal global and regional biventricular systolic function. [2167-2-24] CXR FINDINGS: In comparison with the study of [2-23], the endotracheal tube and nasogastric tube have been removed. There is a vague suggestion of an area of increased opacification in the retrocardiac region on the left. This could merely reflect atelectasis or crowding of vessels. However, in view of the clinical symptoms, the possibility of a developing aspiration must be considered. This area should be closely checked on subsequent radiographs. On to recent studies, there is suggestion medial displacement of the stomach, which could be associated with enlargement of the spleen. MR HEAD W & W/O CONTRAST Study Date of [2167-2-26] 9:53 PM IMPRESSION: There has been significant interval improvement in the extent of T2/FLAIR-signal abnormality throughout the supra- and infratentorial compartments with a similar small volume of subarachnoid hemorrhage, compared to the prior study. The enhancement at these sites has resolved completely. The overall distribution and evolution strongly suggests the possibility of underlying PRES, which may be associated with both enhancement and hemorrhage in some cases. There is no associated infarct. Other toxic, neoplastic or metabolic etiologies as suggested in the report of the previous exam remain in the differential diagnosis, though are now considered significantly less likely. Brief Hospital Course: Ms. [Known lastname 15427] is a 68 year old left handed woman, with a history of dementia, HTN, a remote history of GYN cancer (in her 20s, s/p hysterectomy, further details unobtainable), presenting with several day history of headache followed by sudden-onset confusion, disorientation, and vomiting, with subsequent 10-minute GTC seizure. She was intubated upon arrival to the emergency department for airway protection and admitted to the neurology ICU. . Hospital course by problem; . Neurology; A CT head revealed a right parietal subarachnoid hemorrhage. An MRI showed extensive areas of signal abnormality with nodular enhancement throughout the brain on FLAIR and post-contrast studies. Given the clinical history, it was thought these may represent transient post-seizure changes. An MRA and MRV were unremarkable. She was transferred to the neurology floor. An MRI with and without contrast was repeated and showed significant interval improvement in the extent of T2/FLAIR-signal abnormality throughout the supra- and infratentorial compartments with a similar small volume of subarachnoid hemorrhage, compared to the prior study. The enhancement at these sites has resolved completely. The overall distribution and evolution strongly suggests the possibility of underlying PRES, which may be associated with both enhancement and hemorrhage in some cases. There is no associated infarct. The patient was started on keppra 750 mg [Hospital1 ] for seizure prophylaxis. . Respiratory; The patient was extubated on HD#1 and required a facemask for oxygenation for the following day. She was weaned to room air. . ID; The patient had a Tmax of 101 on HD#1 and has been afebrile since. She also has a leukocytosis with WBC 17. Blood cultures, urine cultures, and CXR have showed no sign of infectious process. The patient has no nuchal rigidity. . CV; The patient was monitored on telemetry with no significant events. A TTE was unremarkable. She was started on simvastatin. She was instructed to restart Benicar at discharge. . Medications on Admission: AZELASTINE [ASTELIN] - (Prescribed by Other Provider) - 137 mcg Aerosol, Spray - twice daily BECLOMETHASONE DIPROPIONATE [QVAR] - (Prescribed by Other Provider) - 80 mcg Aerosol - twice daily CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a day MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1 Tab(s) by mouth daily Medications - OTC DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 3. Benicar HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Memantine 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: left parietal subarachnoid hemorrhage seizure Discharge Condition: Mental Status: Awake, Alert, oriented x 2 (her baseline). Able to say DOW forward Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted after you had a seizure. You were found to a left-sided parietal subarachnoid hemorrhage in your brain. Your brain imaging also shows areas of your brain that may have been affected by high blood pressure in the setting of being off Benicar for the past month. Repeat imaging prior to your discharge showed that these areas were improving. You should re-start Benicar for blood pressure control. We also have started you on Simvastatin to help with your cholesterol level. In addition, since you had a seizure you have been placed on Keppra 750 mg twice daily for seizure prophylaxis. You should stay on Keppra for at least 6 months. Please take all medications as prescribed. Please follow-up with your neurologist, Dr. [Last Name (STitle) ], as listed below. Should you develop any symptoms as listed below or concerning to you, please call your doctor or go to the emergency room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2167-3-31] 5:30 Completed by:[2167-3-7]	[ "493.20", "401.9", "430", "V13.02", "294.8", "780.39", "V10.3", "V88.01", "348.5" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	13223, 13229	9673, 11731	290, 296	13319, 13319	5089, 9650	14454, 14667	3675, 3716		12480, 13200		13250, 13298	11757, 12457			13515, 14431								2910, 3013		3731, 4285																												243, 252										324, 2313	4519, 5070								13334, 13491					4309, 4309		2335, 2887	3029, 3659
24,546	184,549	49794+59200	Discharge summary	report+addendum	Admission Date: [2132-1-28] Discharge Date: [2132-2-3] Date of Birth: [2053-9-14] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 78 year old man with an abnormal stress test referred to [Hospital1 18] for cardiac catheterization prior to having surgery on his cervical spine. Two weeks prior to admission the patient complained of chest heaviness with pains radiating down his arms while lying in bed. He reports that for several days before that he started an exercise program involving new arm exercises. The pain lasted for five minutes and then resolved. He does report that over the last several years he has worked on a treadmill on a daily basis for 30 minutes without any symptoms. He had a Persantine stress test done on [1-17] that was negative for chest pain or EKG changes, however, nuclear imaging showed a small area of septal ischemia with an EF of 60 percent and normal wall motion. PAST MEDICAL HISTORY: The patient's past medical history is significant for chronic ataxia related to a cervical spine disease, chronic nystagmus, hyperkalemia, arthritis, spinal stenosis status post lumbar laminectomy, bilateral carpal tunnel surgery, trigger finger surgery and hernia repair, as well as BPH. ALLERGIES: The patient states an allergy to sulfa and to Keflex. MEDICATIONS: Meds on admission include Flomax, 0.4 daily; Avodart, 0.5 mg daily; Hydrochlorothiazide, 25 daily; aspirin, 325 daily. FAMILY HISTORY: Family history is noncontributory. SOCIAL HISTORY: Married. Retired electronics engineer. LABORATORY DATA: White count 11.6, hematocrit 45.4, platelets 375, INR 1.1. Sodium 143, potassium 4.9, chloride 104, CO2 34, BUN 28, creatinine 1.4, glucose 112. EKG was sinus rhythm at a rate of 70 with a left axis. PHYSICAL EXAMINATION: Height 5 feet 7 inches. Weight 140 pounds. Vital Signs: Temperature 98. Heart rate 78. Blood pressure 156/74. Respiratory rate 16. O2 sat 99 percent on room air. Neurologic: Alert and oriented. Moves all extremities. Follows commands. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Abdomen is soft and nontender and non-distended with normoactive bowel sounds. Extremities are warm and well perfused with no lower extremity edema. HOSPITAL COURSE: The patient was admitted to cardiology where he underwent cardiac catheterization. Please see the catheter report for full details. In summary, it showed left main 70 percent disease, LAD 80 percent disease, left circumflex 90 percent disease and RCA with 70 percent disease before the PDA. A ventriculostomy was not performed. Cardiac surgery was consulted. On [1-29] the patient was brought to the operating room, where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had a CABG times four with LIMA to the LAD, saphenous vein graft to diagonal, saphenous vein graft to OM and saphenous vein graft to RCA. His bypass time was 103 minutes with a cross clamp time of 82 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. His anesthesia was reversed, he was weaned from the ventilator and successfully extubated. He did well on the day of surgery, remaining hemodynamically stable, requiring only Neo-Synephrine infusion to maintain an adequate blood pressure. On postoperative day one the patient continued to be hemodynamically stable. His Neo-Synephrine infusion was weaned as tolerated. He was begun on gentle diuresis and he remained in the ICU for continuing hemodynamic monitoring. On postoperative day two the patient continued to do well. His Neo-Synephrine infusion continued to be weaned. His hematocrit was noted to be 23.6 and he received 2 units of packed red blood cells, following which the patient weaned from his Neo-Synephrine infusion completely. His chest tubes were removed and he was transferred from the Intensive Care Unit to the floor continuing postoperative care and cardiac rehabilitation. Over the next two days the [Hospital 228] hospital course was uneventful. His activity level was increased with the assistance of the nursing staff and physical therapy staff. He continued to be diuresed and his beta blockade was adjusted as tolerated. On postoperative day four it was decided that the following day the patient will be stable and ready to be discharged to rehabilitation. At the time of this dictation the patient's physical exam is as follows: Temperature 99. Heart rate 79. Sinus rhythm. Blood pressure 108/49. Respiratory rate 18. O2 saturation 93 percent on room air. Weight preoperatively was 66 kilos, at discharge 74 kilos. Neurologically alert and oriented. Moves all extremities. Strength equal bilaterally. Nonfocal exam. Pulmonary clear to auscultation with a few fine crackles at the bases. Cardiac: Regular rate and rhythm. S1 and S2 with no murmurs. Sternum is stable. Incision with staples. No erythema or drainage. The abdomen is soft and nontender and non-distended with normoactive bowel sounds. The patient's extremities are warm and well perfused with trace edema. Right endoscopic vein harvest site with Steri- Strips, clean and dry without erythema or drainage. Lab data: Hematocrit 26, sodium 142, potassium 4.2, chloride 104, CO2 36, BUN 20, creatinine 1.3, glucose 103. The patient is to be discharged to rehabilitation. His condition at the time of discharge is good. He is to follow up with Dr. [Last Name (STitle) 4469] in two to three weeks following his discharge from rehabilitation, and follow up with Dr. [Last Name (STitle) ] in four weeks from his discharge from [Hospital1 18]. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting times four with a LIMA to the LAD, saphenous vein graft to diagonal, saphenous vein graft to OM, and saphenous vein graft to RCA. 2. Chronic ataxia. 3. Chronic nystagmus. 4. Hyperkalemia. 5. Arthritis. 6. Spinal stenosis, status post lumbar laminectomy. 7. Status post carpal tunnel surgery. 8. Trigger finger surgery. 9. Hernia repair. 10. Benign prostatic hypertrophy. DISCHARGE MEDICATIONS: 1. Lopressor, 20 mg daily times 2 weeks. 2. Potassium chloride, 20 mEq daily times 2 weeks. 3. Colace, 100 mg [Hospital1 ] while taking any narcotic. 4. Aspirin, 81 mg daily. 5. Percocet 5/325, 1 to 2 tablets q4-6h as needed. 6. Plavix, 75 mg daily times three months. 7. Flomax, 0.4 mg at bedtime. 8. Avodart, 0.5 mg at bedtime. 9. Metoprolol, 25 mg [Hospital1 ]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1714], [MD Number(1) 1715] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2132-2-2] 15:44:28 T: [2132-2-2] 16:22:11 Job#: [Job Number 104067] Name: [Known lastname ],[Known firstname 970] Unit No: [Numeric Identifier 16864] Admission Date: [2132-1-28] Discharge Date: [2132-2-5] Date of Birth: [2053-9-14] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Keflex Attending:[First Name3 (LF) 4551] Addendum: Mr. [Known lastname ] remained an in-patient from [2-3] (time of discharge summary) through [2-5] due to lack of bed availability at rehabilitation facilities. This time was significant only for a contact dermatitis on his buttocks, extending down to his upper thighs, treated with Sarna lotion and non-bleached linens. He is at this time, ready for discharge to rehab. Discharge Disposition: Extended Care Facility: [Hospital3 3287] TCU [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 358] MD [MD Number(1) 359] Completed by:[2132-2-5]	[ "276.7", "379.56", "724.02", "600.00", "414.01", "781.3", "715.90", "692.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "89.68", "88.56", "39.61", "99.04", "36.15", "36.13", "37.22" ]	icd9pcs	[ [ [] ] ]	7800, 8005						1495, 1531	5903, 6362	6385, 7777				2369, 5882																												1833, 2351																						164, 964																987, 1478	1548, 1810
4,239	168,686	10915	Discharge summary	report	Admission Date: [2122-5-7] Discharge Date: [2122-5-21] Date of Birth: [2059-11-12] Sex: F Service: MEDICINE Allergies: Toprol Xl Attending:[First Name3 (LF) 5552] Chief Complaint: Cough, respiratory distress Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy with ultrasound Gastrostomy tube placement History of Present Illness: Pt is a 66F with complicated oncologic history, [Last Name (un) 35473] lymphoma s/p mantle radiation, breast ca s/p L mastectomy and recent diagnosis of squamous cell esophageal cancer. She was admitted [Date range (1) 35474] to the OMED service with worsening dysphagia, she was temporarily admitted to the MICU for elective intubation for endoscopy with subsequent food bolus removal with improvement in her symptoms. She was discharged to follow up with GI for repeat EUS/endoscopy and possible repeat esophageal dilatation. Other PMHx includes CAD s/p CABG and recent stent, pericarditis on chronic steroids, and recurrent L pleural effusion s/p talc pleurodesis. She has been holding her antiplatelet agents for several days prior to this procedure, and has not taken any of her medications prior to her procedure today. Post-procedurally the ICU team was called to evaluate the patient for hypotension and respiratory distress. During the procedure she received pressors transiently for SBP in 60s. Post procedurally her BP had been 60-120s, mostly in 60-80s, pt asymptomatic. She was also tachypneic to 30s and tachycardic to low 100s. She was mostly complaining of insessant cough with secretions. She otherwise was without complaint. No chest pain, minimal dyspnea, no pain elsewhere. . In the PACU she was given 1 albuterol neb for her cough and wheezes on exam and she improved markedly, her initial NC 02 was able to be weaned to 1L from 6L, she was sating 97-100% on this, desatting to 88% on RA. She received 500cc NS in addition to 1000cc she received during the procedure, she was also given 1 albuterol neb with marked improvement in symptoms. She was admitted to the [Hospital Unit Name 153] for further monitoring of her hypotension. . In the [Hospital Unit Name 153], the patient reported some improvement in her symptoms, no further coughing or respiratory distress, no dyspnea, now complaining of substernal pain/pressure, worse with swallowing, "I feel like I need to belch." Just started post-procedurally. Never happened before. Also with some anxiety, not knew. Denies HA, vision change, sore throat, nausea/vomiting, abd pain, diarrhea, constipation, melena or hematochezia. Has had b/l LE swelling since last hospitalization. At home was able to swallow soft solids, could not tolerate pills or solids. Otherwise ROS negative. Past Medical History: -Hodgkin Lymphoma: cervical and throacic, diagnosed at age 24, treated initially with radiation therapy. Recurrent disease treated with chemotherapy -Coronary artery disease: s/p PCI/stent and 2v CABG [8-/2114] -Hypothyroidism -s/p CCY, s/p appy -Chronic pericarditis on chronic prednisone. -Left breast cancer s/p mastectomy in [2103] with left lymphedema -Recurrent left pleural effusion s/p VATS, biopsy and talc pleurodesis in [2114] -Left diaphragmatic paralysis -Esophageal stricture s/p dilatation Social History: Former smoker, quit 15 years ago, occasional alcohol, married, lives with husband, has 4 grown children. Family History: Mother has dementia, 4 healthy children, GM with [Year (4 digits) 499] cancer in her 60s. Physical Exam: Vitals: T: 99.5 BP:88/47 P:96 R:26 SaO2: 98% 1L NC General: Awake, alert, anxious. HEENT: MM dry. Neck: supple, no elevated JVP Pulmonary: slight crackles left base, diffuse wheezes (improved after nebs). Cardiac: Tachycardic, 3/6 systolic murmur. Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities:1+ pitting edema, 2+ radial, DP pulses b/l. Swollen left arm Skin: superficial venous prominence, left chest. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. On discharge, afebrile T 99, BP 100/52 (96-118/52-70) HR 80s-100, RR 18 O2 94% RA Pertinent Results: Lab Data [2122-5-7] 04:02PM GLUCOSE-93 UREA N-8 CREAT-0.5 SODIUM-145 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-36* ANION GAP-11 [2122-5-7] 04:02PM WBC-7.6 RBC-3.34* HGB-8.9* HCT-28.5* MCV-85 MCH-26.7* MCHC-31.3 RDW-16.2* [2122-5-7] 04:02PM PLT COUNT-413 [2122-5-21] 05:35AM BLOOD WBC-15.1* RBC-3.02* Hgb-7.9* Hct-26.4* MCV-87 MCH-26.2* MCHC-30.0* RDW-16.5* Plt Ct-584* [2122-5-21] 05:35AM BLOOD Glucose-132* UreaN-24* Creat-0.7 Na-139 K-4.7 Cl-93* HCO3-39* AnGap-12 [2122-5-11] 05:20AM BLOOD ALT-14 AST-15 CK(CPK)-23* AlkPhos-78 TotBili-0.3 [2122-5-12] 05:35AM BLOOD proBNP-3606* [2122-5-21] 05:35AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.3 [2122-5-7] 04:02PM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-145 K-3.7 Cl-102 HCO3-36* AnGap-11 [2122-5-15] 05:05AM BLOOD Glucose-106* UreaN-19 Creat-0.5 Na-144 K-4.1 Cl-92* HCO3-44* AnGap-12 [2122-5-11] 05:20AM BLOOD PT-13.1 PTT-29.1 INR(PT)-1.1 [2122-5-15] 05:05AM BLOOD WBC-11.7* RBC-3.48* Hgb-9.3* Hct-29.9* MCV-86 MCH-26.6* MCHC-31.0 RDW-16.3* Plt Ct-369 [2122-5-19] 05:20AM BLOOD WBC-16.1* RBC-3.25* Hgb-8.6* Hct-28.1* MCV-86 MCH-26.5* MCHC-30.6* RDW-16.8* Plt Ct-430 Imaging: TTE [5-7]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. 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 is bicuspid. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild to moderate ([1-9]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae, as well as extensive fibrocalcific thickening of the mitral annulus and the contiguous annular portion of the leaflets (however, no frank mitral stenosis). Moderate (2+) 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 supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [2120-4-3], multiple abnormalities as previously noted persist without major change. CXR [5-7]: 1. Slight interval increase in bilateral pleural effusions. 2. Findings compatible with volume overload. Recommend repeat radiograph following diuresis. 3. Remainder of exam is otherwise unchanged. EGD/EUS [5-7]: Stricture of the upper third of the esophagus. Food in the upper third of the esophagus (foreign body removal). EUS was performed using a mini echoendoscope and therefore images were limited. T stage: The lesion involved the mucosa, submucosa and the muscularis. At one segment of the esophagus there was suspicion of invasion beyond the muscularis layer. Based on these findings this was staged as T2 / T 3 by EUS criteria. N stage: There were no evidence of enlarged peri-esophageal lymph nodes. This was staged N0. LUE U/S [5-9]: No deep venous thrombosis in the left upper extremity. Hip/femur x-rays [5-9]: No fracture. CXR [5-10]: Overall similar to [2122-5-8], but with relative increased opacity in both right and left mid zones compared with [2122-5-7]. The etiology is somewhat uncertain, but most likely relates to increase in the size of the pleural effusions and possibly due to some increase in CHF. TTE [5-12]: No significant pericardial effusion. Arterial Doppler LUE [5-15]: Unremarkable Doppler waveforms throughout the left extremity, signifying no significant stenosis. Brief Hospital Course: 1. Hypotension: Occurred after EUS/EGD. Per patient and recent notes, BP runs in 80-90s at home. At time of transfer to [Hospital Unit Name 153], was in 80s and asymptomatic. The most likely etiology was felt to be anesthesia effect versus dehydration. An echo was obtained to evaluate for effusion (negative). The pt responded well to fluid boluses and her chronic prednisone was increased from 7.5mg to 15mg then down titrated again to 7.5 mg daily. She was ruled out for NSTEMI. Her blood pressure remained stable on the floor in SBP 90-110 range, although with diuresis (see below), came down to SBP 100. She was continue [Male First Name (un) ] low dose lasix 10mg daily which she tolerated. She continued to be mildly orthostatic with PT but was asypmtomatic and became SOB with boluses. 2. Esophageal CA: Staged T2-3N0 by EUS criteria, with large exophytic mass in esophagus not amenable to further dilation. The pt was placed on a moist pureed diet per a speech and swallow evaluation. She was not felt to be a current candidate for surgery or XRT, but XRT would be considered in the future once her nutritional status improves. IR placed a G tube that was complicated by hypercapnea/hypoxia thought likely related to medication effect. However, once this resolved, tube feeds were started and advanced to goal without difficulty. 3. Acute on chronic diastolic heart failure: Not on home 02, initially on 6L NC after EGD, later weaned down to 3-4L. At this point, she seemed volume overloaded on exam and CXR. She was given boluses of 10mg IV furosemide prn with goal negative 500-1000ml daily. Pt noted improvement in her dyspnea with diuresis, and was weaned off supplemental O2, although diuresis was limited by borderline hypotension and orthostasis. She was also seen by IP, who felt that thoracentesis was not indicated. She was continue [Male First Name (un) ] lasix 10 mg PO daily. 4. Hypercapnea: Suspected that this was acute decompensation in setting of G tube placement, as patient is very sensitive to sedating medications. Also, she was later started on fluticasone/salmeterol and tiotropium for presumptive COPD given tobacco history. A final contributor may be her radiation-induced lung disease leading to impaired ventilation. Her hypercapnea was also noted to be chronic given a normal pH on ABG while pCO2 of 77. Although the elevated bicarb in this setting was largely compensatory, it was also in part from diuresis-induced contraction alkalosis. Remained stable 5. Left arm swelling: Most likely from lymphedema given breast CA history. Upper extremity ultrasounds showed no DVT or arterial stenosis. 6. CAD: Known CAD with stents and CABG. The pt did have some substernal discomfort at admission, likely in setting of EGD/insufflation although she had also been stressed with tachycardia, hypoxia, so demand ischemia was possible. She was ruled out for AMI. She remained off her anti-platelet agents in anticipation of her upcoming procedure, although they were later restareted. The pt's statin was continued. 7. Pericarditis: This appeared stable. The pt was continued on her home steroids, although the dose was temporarily increased to 15mg from 7.5mg in the setting of her hypotension. She was slowly weaned off of the 15mg dose to 7.5mg daily. 8. Buttock lesions: DFA was negative, viral culture pending for HSV and VZV. 9. Fall: Happened during transfer out of bed, landing on left hip. X-rays were negative and pain improved greatly, although she still noted intermittent pain. Was able to bear wweight without much pain. Repeat films done and were pending read at time of this summary Medications on Admission: 1. Levothyroxine 100 mcg Tablet [Male First Name (un) ]: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Male First Name (un) ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Prednisone 2.5 mg Tablet [Male First Name (un) ]: Three (3) Tablet PO DAILY (Daily). --> has not taken today 4. Simvastatin 10 mg Tablet [Male First Name (un) ]: One (1) Tablet PO DAILY (Daily). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr [Male First Name (un) ]: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). --> has not taken x 3 weeks, pill too big to swallow. 6. Aspirin 325mg daily--> off x 8 days 7. Plavix 75mg daily --> off x 8 days Discharge Medications: 1. Levothyroxine 100 mcg Tablet [Male First Name (un) ]: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet [Male First Name (un) ]: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable [Male First Name (un) ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Venlafaxine 75 mg Tablet [Male First Name (un) ]: One (1) Tablet PO BID (2 times a day). 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [Male First Name (un) ]: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 6. Sodium Chloride 0.65 % Aerosol, Spray [Male First Name (un) ]: [1-9] Sprays Nasal QID (4 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Month/Day (2) ]: One (1) neb Inhalation Q4H (every 4 hours) as needed for dyspnea. 8. Acetaminophen 500 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Prochlorperazine Maleate 10 mg Tablet [Month/Day (2) ]: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 10. Clopidogrel 75 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Month/Day (2) ]: One (1) puff Inhalation [Hospital1 ] (2 times a day). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [Hospital1 ]: One (1) Cap Inhalation DAILY (Daily). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Prednisone 5 mg Tablet [Last Name (STitle) ]: 1.5 Tablets PO DAILY (Daily). 15. Senna 8.6 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 16. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 17. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Benzonatate 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO TID (3 times a day) as needed for cough. 19. Furosemide 20 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Primary: Esophageal cancer Acute on chronic diastolic heart failure Chronic hypercapnia, multifactorial Secondary: Coronary artery disease Pericarditis Discharge Condition: Hemodynamically stable, BP 100/52 at discharge (90s-110s/50s-70s), 93-94% RA Discharge Instructions: You were admitted to [Hospital1 18] after your endoscopy due to lower blood pressure and oxygen levels. You initially required IV fluids, but later we gave you furosemide, a medication to remove fluid, as it has built up in the lungs. We were unable to dilate your esophagus during this admission. The radiation oncologists feel you would benefit from radiation therapy once your nutritional status is better. We are giving you feedings through a tube in your stomach to improve your nutrition. Please take all medications as prescribed and go to all follow up appointments. If you experience any fevers, chills, chest pain, shortness of breath, wheezing, lightheadedness, confusion, or any other symptoms, please seek medical attention or return to the ER immediately. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2122-5-28] 11:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23551], MD Phone:[Telephone/Fax (1) 447] Date/Time:[2122-5-28] 11:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 11767] Date/Time:[2122-7-14] 2:00	[ "719.45", "V10.3", "428.33", "423.8", "496", "530.3", "150.3", "E915", "458.9", "E885.9", "935.1", "276.4", "428.0", "201.98", "V45.81", "244.9", "457.1", "414.00", "799.02" ]	icd9cm	[ [ [] ] ]	[ "43.11", "45.13", "98.02", "88.74" ]	icd9pcs	[ [ [] ] ]	15152, 15226	8513, 12160	298, 370	15423, 15502	4403, 8490	16326, 16759	3463, 3559		12914, 15129		15247, 15402	12186, 12891			15526, 16303										3574, 4384																												231, 260										398, 2784																2806, 3325	3341, 3447
8,005	187,976	50151+59228	Discharge summary	report+addendum	Admission Date: [2160-3-5] Discharge Date: [2160-3-23] Date of Birth: [2084-4-16] Sex: M Service: Medicine [Hospital1 139] Firm Dicharge Date: To be determined, this dictation summary is from [2160-3-5] through [2160-3-23]. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old male with a history of COPD, asthma, cor pulmonale, hypertension, congestive heart failure with an ejection fraction of 35%, coronary artery disease with a history of a MI, and hepatitis C virus, who presented to an outside hospital ([Hospital1 1562]) with increased shortness of breath, expectoration of sputum, and wheezing. Patient had a recent hospitalization for COPD exacerbation and was then sent to a rehab facility for rehabilitation. He returned to the hospital with increasing shortness of breath. He was placed on broad-spectrum antibiotics to include vancomycin and Zosyn at that time. He then experienced improvement in his oxygen saturation initially, but was unable to obtain 100%. He had a CAT scan performed, which further delineated a left lower lobe density that had been seen on chest x-ray. This CAT scan of the chest demonstrated stenosis of the trachea. The patient was then transferred to [Hospital1 69] for further workup of his tracheal stenosis. PAST MEDICAL HISTORY: 1. COPD. 2. Asthma. 3. Bronchiectasis. 4. Cor pulmonale. 5. Resistant pseudomonas. 6. Lymphedema of the lower extremities. 7. Congestive heart failure with an ejection fraction of 55%. 8. Hypertension. 9. Coronary artery disease status post a MI. 10. Type 2 diabetes. 11. Hepatitis C. 12. Gout. 13. Hypogonadism. 14. Chronic renal failure. 15. Hepatitis C virus with increased bilirubinemia. PAST SURGICAL HISTORY: Left knee arthroplasty. MEDICATIONS ON ADMISSION: 1. Vancomycin 1 gram IV q.24h. 2. Levofloxacin 500 mg q.24h. 3. Methylprednisolone 30 mg IV. 4. Protonix 40 mg q.24h. 5. Terbutaline 0.25 mg. 6. Testosterone patch. 7. Regular sliding scale insulin. 8. Digoxin 0.125 mg p.o. q.d. 9. Actigall 300 mg p.o. t.i.d. 10. Morphine sulfate 2 mg IV q.2h. prn. 11. Tylenol 325-650 mg p.o. q.4-6h. prn. 12. Albuterol nebulizers one inhaler q.4-6h. prn. 13. Ipratropium bromide nebulizer one inhaler q.4h. 14. Lovenox 40 mg subq q.d. 15. NPH 20 units q.a.m. and 10 units q.p.m. ALLERGIES: Azithromycin, macrolide, tetracycline, and sulfa. SOCIAL HISTORY: The patient lives with his wife. [Name (NI) ] denies any tobacco or alcohol use. He was a former smoker. He is a retired insurance salesman. FAMILY HISTORY: The patient's mother has lung cancer. His father has passed away. PHYSICAL EXAM ON ADMISSION: Temperature 97.8, heart rate 105, blood pressure 135/76, and oxygen saturation 98% on 3 liters nasal cannula. In general: The patient is a well-developed and well-nourished Caucasian male in no acute distress. Chest: Lungs revealed decreased breath sounds throughout, bilateral wheezes, particularly in the upper airways. Cardiovascular: Tachycardic, no murmurs, rubs, or gallops, positive S1, S2. Abdomen: Soft, nontender, and nondistended, positive bowel sounds. Extremities: 3+ edema bilaterally up to quarter way up the legs bilaterally. LABORATORY VALUES ON ADMISSION: White blood cell count 14.4, hematocrit 33, platelets 137. Sodium 135, potassium 4.7, chloride 97, bicarb 27, BUN 34, creatinine 1.3, glucose 235, AST 106, ALT 109, alkaline phosphatase 460, total bilirubin 11.8, albumin 3.0, digoxin level 1.1, PT 10.6, PTT 25, INR 0.9. Sputum cultures from outside hospital were consistent with pseudomonas and MRSA, sensitive to Tobramycin and vancomycin. Blood cultures were all negative to date. An abdominal ultrasound from the outside hospital on [3-1] showed no dilation of the extrahepatic biliary tree, no calculi. A chest x-ray from [2160-2-29] revealed persistent retrocardiac opacity. An ultrasound of bilateral lower extremities from [2160-2-25] revealed no DVT. An EKG from [2160-2-28] revealed sinus tachycardia with PAC's and Q waves in II, III, and aVF. It also showed a left axis deviation, right bundle branch block, but no ST-T wave elevations. IMPRESSION: The patient is a 75-year-old male with multiple medical problems, who presents with tracheomalacia seen on chest CT. The patient was transferred from [Hospital 1562] Hospital to [Hospital1 69] for further workup of his tracheomalacia, bronchoscopy, and stent placement. HOSPITALIZATION COURSE FROM [2160-3-5] TO [2160-3-23]: The rest will be dictated at a later time. HOSPITALIZATION COURSE BY SYSTEMS: 1. Pulmonary: The patient was transferred to the [Hospital1 346] for a bronchoscopy to evaluate his tracheomalacia. He underwent an initial bronchoscopy on [2160-3-7]. He underwent a repeat bronchoscopy with three stents placed in the LMS, RBI, and distal trachea that contains silicone on [2160-3-11]. Cultures from this bronchoscopy were consistent with inflammation and not malignancy. He was placed on empiric antibiotics to include vancomycin, inhaled tobramycin, and intravenous Flagyl for pseudomonas and MRSA that were isolated from the outside hospital. Repeated ABGs were performed, which revealed compensated chronic respiratory alkalosis consistent with the patient's history of COPD and bronchiectasis. The patient was weaned as tolerated to what became his baseline of 97% on 3 liters of oxygen. The Interventional Pulmonology team followed the patient closely. Patient was started on a steroid taper, and at the time of this dictation, his prednisone was 30 mg p.o. q.d. He was also maintained on his albuterol and ipratropium bromide nebulizers with improvement of his symptoms. 2. FEN/GI: The patient had a right upper quadrant ultrasound at the outside hospital, which revealed no calculi and normal biliary tree. However, because his liver function tests continued to trend up and his bilirubin reached a peak of 12, a repeat ultrasound was obtained, which is again within normal limits. The patient underwent a MRCP, which showed a mass in the head of the pancreas. The ERCP team was consulted for further evaluation. At the time of this dictation, the patient is planned for a potential ERCP if he is cleared by Anesthesia. His AMA, [Doctor First Name ], alpha-fetoprotein, and hepatitis panel were all within normal limits except for a hepatitis C viral load of greater than 700,000. A SPEP and UPEP were within normal limits with no evidence of [Last Name (un) ]-[Doctor Last Name ] protein. He did have elevated calcium 125, carcinoembryonic antigen, and CA19-9 levels consistent with malignancy. Patient initially presented with asterixis, which improved when lactulose titrated up to [1-24] bowel movements a day. He was continued on nadolol for esophageal varices, ursodiol, and Protonix. The patient was started on a 2-gram sodium, low fat, low cholesterol diet. Nutrition consult was obtained, and the patient was started on a multivitamin, zinc supplementation, and vitamin C supplementation. He did have one day of peripheral nutrition. However, since his caloric count was within normal limits, this was discontinued. 3. Cardiovascular: The patient had evidence of congestive heart failure on admission. He diuresed well and became euvolemic at the time of this dictation with intravenous Lasix. The patient's daily weights were stable. He was continued on his digoxin as his level was within normal limits. He had an echocardiogram on [3-21], which revealed left atrial and left ventricular wall thicknesses, mild dilatation of left ventricle, ejection fraction of 25-30%, and resting wall motion abnormalities of the septal, inferolateral, and inferior akinesis with anterior hypokinesis. There was normal right ventricular chamber size, severe global right ventricular free wall hypokinesis, and moderate to 2+ mitral regurgitation. There is also moderate size pericardial effusion. Patient was continued on his home dose of metoprolol. 4. Infectious disease: The patient has completed a 14-day course of intravenous vancomycin for his tracheomalacia/bronchiectasis, which was found to contain MRSA and pseudomonas at the outside hospital. These antibiotics were discontinued on day #14. However, due to the rise in white blood cell count on [2160-3-22], vancomycin was restarted. The patient remained afebrile during this time. 5. Hematology: The patient has a normocytic anemia and a high RDW. There is a mixed picture of GI losses and liver disease, he has a normal iron level. He was transfused 1 unit of packed red blood cells in the Intensive Care Unit for a low hematocrit. He was found to have an elevated vitamin B12 level. 6. Endocrine: The patient had labile blood sugars throughout his hospitalization. His NPH on admission was 80 units q.a.m. and 20 units q.p.m. This was adjusted accordingly based on his glucose levels. His testosterone patch was discontinued as it was deemed unnecessary. A TSH level was checked, which was within normal limits. 7. Vascular: The patient had dressing changes of his lower extremity ulcers with Duoderm and Oxyzal. He also developed a blister on the dorsum of his left foot, which was lanced without complication on [3-16]. 8. Renal: The patient was noted to have a poor renal function with a creatinine clearance of 50 mL/minute, likely a complication of his type 2 diabetes. His creatinine was monitored and remained stable while diuresing with Lasix. 9. Psych: Patient expressed feelings of depression. For this reason, he was started on Celexa 10 mg p.o. q.d. x7 days through [2160-3-25]. He should then be changed to 20 mg p.o. q.d. and follow up with an outpatient Psychiatry as deemed necessary. This is a dictation of this patient from [2160-3-5] to [2160-3-23]. A further dictation for the remainder of the patient's hospitalization course will follow at a later time. DR.[Last Name (STitle) 5613],[First Name3 (LF) ] 12-AHU Dictated By:[Name8 (MD) 6206] MEDQUIST36 D: [2160-3-23] 18:34 T: [2160-3-25] 09:08 JOB#: [Job Number 104675] Name: [Known lastname ], [Known firstname 448] Unit No: [Numeric Identifier 16990] Admission Date: [2160-3-5] Discharge Date: [2160-3-31] Date of Birth: [2084-4-16] Sex: M Service: MED ADDENDUM: Please refer to previous discharge summary for history of present illness, physical exam, and pertinent laboratory, x-ray, EKG, and other tests on admission, and initial hospital course up to [2160-3-23]. FURTHER HOSPITAL COURSE BY SYSTEMS: 1. Pulmonary: Chronic obstructive pulmonary disease. On [3-26], the patient was felt to be improving and an attempt was made to wean the patient down to his baseline prednisone dose of 20 mg q.d. from a dose of 30 mg q.d. A salmeterol diskus was also started on [3-28]. On [3-29], the patient was felt to have increased wheezing and increased O2 requirement, and as a result was placed back on an increased prednisone dose of 40 mg q.d. On [3-30] the patient improved markedly and on day of discharge the patient was still having diffuse wheeze, but was felt to be at a optimum pulmonary status given his underlying disease. The patient should be weaned back to his baseline prednisone of 20 mg q.d. very slowly (i.e., no more than 5 mg decrease, no more frequent than every five days). 1. GI: A) Pancreatic mass: Initial plan had been to pursue ERCP for evaluation of the mass; however, ERCP service requested Anesthesia consult given the patient's underlying pulmonary and cardiac disease. Anesthesia requested further evaluation of the newly diagnosed poor left ventricular systolic function. A Cardiology consult was obtained and a stress test was recommended. A stress test was obtained, but in the meantime a family was also obtained to discuss the plan. The family was advised that ERCP would have approximately a 50 percent chance of being nondiagnostic and even if diagnostic, the patient would likely not be a candidate for aggressive treatment given underlying disease. As a result, the patient and family opted to forgo ERCP. B) Hyperbilirubinemia: Scleral icterus continued to improve and a repeat total bilirubin was noted to be decreased by half. This improvement after discontinuation of testosterone was thought to represent that cholestasis had been testosterone induced and was nonobstructive. C) Liver disease: The patient was continued on lactulose until the day of discharge when it was discontinued because the patient was not felt to have baseline requirement for it. It can be given prn to ensure approximately two loose stools per day. 1. Cardiac: A) Pump: The patient had an episode of increasing O2 requirement and increased pulmonary edema/pleural effusion on chest x-ray on [3-26]. The patient's Lasix was changed from 20 IV q.d. to 60 mg p.o. q.d. The patient diuresed well and was felt to be euvolemic at the time of discharge. Given the patient's underlying pulmonary disease, patient was thought to be unable to tolerate even minimal pulmonary edema and was felt to benefit from continued diuresis with Lasix 60 p.o. q.d. As stated above, the patient also underwent stress testing for evaluation of possible etiology of new left ventricular dysfunction. Cardiology recommended dobutamine stress given patient's inability to tolerate exercise and inability to tolerate Persantine given pulmonary disease. Stress testing showed no EKG change or anginal symptoms at peak stress but nuclear imaging revealed transient ischemic dilation, moderate partially reversible inferior wall defect, and global hypokinesis with ejection fraction of 31 percent. Cardiology service recommended optimizing medical management with aspirin and lipid control. B) Rate: On most recent EKG prior to discharge, the patient was in atrial fibrillation. Decision was made to restart Coumadin on the day of discharge. The patient should be started on 2.5 mg q.d. with adjustments made according to INR in the rehab facility. The Lovenox can be discontinued when the patient's INR has been between 2 and 3 for two days. 1. ID: The patient had been restarted on Vancomycin on [3-22] for an elevation in WBC count. The patient continued to remain afebrile without focal signs of infection or further increase in WBC counts, so the Vancomycin was discontinued on [3-26]. On [3-27], the patient had a spike in white blood cell count along with lethargy and confusion. The chest x-ray was not suggestive of further pneumonia. Urinalysis and Clostridium difficile testing were negative. Blood cultures showed no growth. The patient was not restarted on antibiotics and the WBC count continued to improve. 1. Heme: The hematocrit remained stable throughout the rest of the admission. 1. Vascular: The patient continued to have wound care of the lower extremity ulcers. 1. Renal: Creatinine remained stable for the remainder of the admission. 1. Psych: The patient's Celexa dose was increased to 20 mg p.o. q.d. as planned. 1. Neurologic: The patient had an episode of lethargy and confusion on [3-27] in the morning. Neurologic exam was nonfocal. ABG revealed no CO2 retention and the patient was not more hypoxic. No infectious etiology was identified. The patient's episode was believed to be related to the administration of Celexa, Morphine, and Ambien. Morphine and Ambien were discontinued, and Celexa administration was changed to before bed dosing. 1. Endocrine: The patient continued to have a.m. hypoglycemia. Evening NPH was discontinued, morning NPH was ultimately decreased to 40 q.a.m. and the patient was switched from a regular to a Humalog sliding scale with no q.h.s. sliding scale. Patient also received D10 at 20 cc an hour for one evening on [3-28] to prevent hypoglycemia. When prednisone dose increased again on [3-29], sugar control improved. Patient then had a high q.h.s. blood sugar in the 300s after [Location (un) 289] juice on [3-30]. As a result, the patient was restarted on q.h.s. sliding scale. Blood sugars were otherwise well controlled. The patient will require careful monitoring of blood sugar and adjustment of insulin regimen. Special attention should be made to ensure no further hypoglycemia as patient is weaned down on prednisone. C- peptide was sent to evaluate for possible insulinoma, but was still pending at the time of discharge. DISCHARGE MEDICATIONS: As on admission with the following modifications: 1. Discontinuation of all antibiotics. 2. Discontinuation of testosterone. 3. Prednisone at 40 mg p.o. q.d. 4. Patient restarted on Coumadin at 2.5 mg q.d. INR should be followed and patient discontinued off Lovenox when INR between [12-25] for two days. 5. NPH at 40 q.a.m. with no p.m. NPH and no Humalog sliding scale. 6. Addition of ascorbic acid 500 mg b.i.d. 7. Multivitamin one p.o. q.d. 8. Zinc one p.o. q.d. 9. Potassium supplementation at 40 extended release p.o. b.i.d. 10. Addition of Celexa at 20 mg p.o. q.h.s. Of note, please only give q.h.s. 11. Furosemide at 60 mg p.o. q.d. 12. Addition of salmeterol Diskus 50 mcg inhalation every 12 hours. 13. Patient was started on Plavix 75 mg q.d. 14. Patient started on captopril 12.5 mg p.o. t.i.d. 15. Metoprolol succinate 25 mg extended release p.o. q.d. 16. Lactulose prn. 17. Ambien prn insomnia, but should not be given standing. DISPOSITION: To rehabilitation facility. DISCHARGE STATUS: Patient mentating clearly, requiring 2 liters nasal cannula, incontinent, requiring assistance with most daily activities except feeding. DISCHARGE DIAGNOSES: 1. Tracheomalacia. 2. Chronic obstructive pulmonary disease. 3. Asthma. 4. Cor pulmonale. 5. Hypertension. 6. Congestive heart failure. 7. Coronary artery disease. 8. Hepatitis C. 9. Cirrhosis. 10. Chronic renal failure. 11. Anemia. 12. Hypogonadism. 13. Gout. 14. Diabetes mellitus type 2 (on insulin). 15. Pancreatic mass. 16. Cholestasis. 17. Venous stasis disease. 18. Depression. 19. Bronchiectasis. CODE STATUS: Full (during family meeting patient expressed that he would like to be intubated if necessary, but would not like to be on a ventilator for an extended period of time). FOLLOW UP: The patient should follow up with Pulmonary in 1- 2 weeks. Dr. [Name (NI) 781] was called prior to the patient's discharge and advised that he would contact the patient to arrange followup. The patient should also follow up with his primary care physician [Last Name (NamePattern4) ] [11-23] weeks to coordinate care of is diabetes, congestive heart failure, and liver disease. DR.[Last Name (STitle) 661],[First Name3 (LF) ] 12-AHU Dictated By:[Last Name (NamePattern1) 9336] MEDQUIST36 D: [2160-4-2] 15:02:41 T: [2160-4-3] 09:23:20 Job#: [Job Number 16991]	[ "403.91", "070.54", "428.0", "519.1", "518.5", "494.0", "707.0", "493.20", "486" ]	icd9cm	[ [ [] ] ]	[ "38.93", "33.24", "99.15", "96.04", "96.05", "99.04", "96.71", "38.91" ]	icd9pcs	[ [ [] ] ]							2567, 2649	18023, 18664	16785, 18002			1805, 2384								10704, 16761			1754, 1779											18676, 19302																													296, 1315								3250, 10676								1337, 1730	2401, 2550
75,510	111,445	41441	Discharge summary	report	Admission Date: [2142-4-29] Discharge Date: [2142-5-11] Date of Birth: [2064-2-6] Sex: F Service: MEDICINE Allergies: Doxycycline / lisinopril Attending:[First Name3 (LF) 2297] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms. [Known lastname 4886] is a 78-year-old female with past medical history significant for hypertension,type 2 DM, distant breast cancer, TTP (lengthy hospitalization [4-/2141] which required corticosteroids, plasmapheresis, and rituximab), relapsing polychondritis and ANCA positive pulmonary vasculitis. The patient was in her usual state of health this evening at 6:30 PM, speaking to her son on the phone. He said, to EMS (from whom we got direct sign-out), that his mother sounded slightly tired, but this is her baseline and otherwise was normal. He then came to see her after running errands about 1 hr later and found her lying in emesis and stool. She was unreponsive and he could not wake her. EMS called and found to develop a generalized tonic-clonic seizure. The seizure lasted about 3.5 mintues, then stopped spontaneously. She was then given Ativan 2mg, then intubated with succinylcholine 100mg and etomidate 20mg, followed by Versed 2.5 mg given concern about airway protection. She was then brought to [Hospital1 18]. Of note, son reports that this presentation is almost identical to her prior presentation last year, which required pheresis, and believes this was TTP. In the field EJ and IO access was obtained. She was in sinus rhythm, in the 80s, blood pressure was 200/80 mmHg, and breathing spotaneously (before intubation and medications). Finger stick was 175. In the ED CT head/Neck showed no acute intracranial hemorrhage. She does have subtle areas of hypodensities in left basal ganglia, pons, and midbrain maybe artifactual or represent ischemia. CTA basilar artery appears patent. Sedation was continued with propofol. EKG showed 1st degree avb. She was noted to be febrile to 102. CXR without pna. She was started on vanc/ctx/amp/acyclovir, but no LP was done due to low plt. UA showed no bacteria or leuks, but did have large blood, 300 glucose, 300 protein Of note, pt noted to have trop of 1.03, with flat MB. Cardiology was conuslted who felt no need for urgent cardiac intervention in setting of unchanged EKG. On transfer, VS were 106 146/80s, 99% on CMV fi02 100, peep 5, RR 16, TV 500. On arrival to the MICU, VS were 100.1 109 106/63 100% on above vent settings Past Medical History: - Diabetes, likely II - Hypertension, on several agents - Breast cancer, s/p left mastectomy, [2100]'s - GERD (inference, on omeprazole), and peptic ulcer disease - Gout - Coronary artery disease - H/o Shingles - Carpal tunnel - ANCA positive pulmonary vasculitis - S/P appendectomy - S/P cholecystectomy - S/P TAH-BSO, mastectomy, - S/P bilateral carpal tunnel release - Bone spurs Social History: Lives with her son. Doesn't smoke or drink. Family History: No early coronary artery disease. No other cancers Physical Exam: INITIAL PHYSICAL EXAM Vitals: Tmax: 37.8 ??????C (100.1 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 86 (80 - 110) bpm BP: 144/88(102) {103/60(71) - 144/88(102)} mmHg RR: 20 (17 - 20) insp/min SpO2: 100% Heart rhythm: 1st AV (First degree AV Block) O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 450 (450 - 500) mL RR (Set): 14 RR (Spontaneous): 1 PEEP: 5 cmH2O FiO2: 50% PIP: 24 cmH2O Plateau: 17 cmH2O SpO2: 100% ABG: 7.42/31/126/19/-2 Ve: 9.8 L/min PaO2 / FiO2: 252 General: intubated, sedated, not waking up or following commands. withdraws to pain in all 4 extremeties HEENT: Sclera anicteric, c-collar on CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly Abdomen: soft, non-tender, slightly distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No petichae Pertinent Results: INITIAL LABORATORY DATA [2142-4-29] 09:46PM BLOOD WBC-6.6 RBC-3.13* Hgb-9.9* Hct-30.7* MCV-98 MCH-31.7 MCHC-32.2 RDW-16.4* Plt Ct-33* [2142-4-29] 09:46PM BLOOD Neuts-80.9* Lymphs-11.9* Monos-6.2 Eos-0.5 Baso-0.6 [2142-4-29] 09:46PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Target-1+ Schisto-OCCASIONAL Tear Dr[Last Name (STitle) 833] [2142-4-29] 09:46PM BLOOD PT-12.5 PTT-42.1* INR(PT)-1.2* [2142-4-30] 01:01AM BLOOD Glucose-370* UreaN-42* Creat-2.0* Na-134 K-4.4 Cl-100 HCO3-19* AnGap-19 [2142-4-29] 09:46PM BLOOD ALT-31 AST-97* LD(LDH)-2419* CK(CPK)-307* AlkPhos-85 TotBili-3.1* DirBili-0.8* IndBili-2.3 [2142-4-29] 09:46PM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.03* [2142-4-29] 09:46PM BLOOD Albumin-3.2* Calcium-7.7* Phos-3.4 Mg-1.3* [2142-4-29] 09:46PM BLOOD Hapto-<5* [2142-5-1] 02:18PM BLOOD Vanco-22.5* [2142-4-30] 01:02AM BLOOD Type-ART Rates-/16 Tidal V-500 PEEP-5 FiO2-50 pO2-126* pCO2-31* pH-7.42 calTCO2-21 Base XS--2 -ASSIST/CON Intubat-INTUBATED [2142-4-29] 09:54PM BLOOD Glucose-241* Lactate-1.6 Na-136 K-4.6 Cl-103 calHCO3-21 RADIOGRAPHIC REPORTS [2142-4-29] CTA Head INDICATION: 77-year-old woman with altered mental status and seizures. COMPARISON: None. TECHNIQUE: Contiguous axial CT images through the head were obtained without contrast in the axial plane. After intravenous administration of contrast, MDCT images of the head and neck were obtained in the arterial phase and axial plane. MIPs, volume-rendered images, and curved reformats were generated and reviewed. FINDINGS: CT HEAD: There is no acute intracranial hemorrhage, vascular territorial infarction, edema, or mass effect seen. However, hypodense regions in left basal ganglia (2:14), pons (2:10) and midbrain maybe artifactual or represent edema, difficult to characterize further. Smaller hypodensities are seen in bilateral periventricular white matter concerning for small vessel ischemic disease. There is no hydrocephalus or midline shift. Dense atherosclerotic calcifications are seen in bilateral intracranial vertebral arteries and cavernous carotid arteries. No fracture is seen. CTA HEAD: Bilateral intracranial internal carotid arteries, vertebral artery, small basilar artery and their major branches are patent with no evidence of stenosis, occlusion, dissection, or aneurysm formation. Right vertebral artery is dominant. CTA NECK: There is a bovine arch configuration with a common origin of the innominate and left common carotid artery from the aortic arch. Bilateral common carotid arteries, internal carotid artery and vertebral arteries in the neck appear patent with no evidence of stenosis, occlusion, dissection or pseudoaneurysm formation. The right vertebral artery is dominant. The left vertebral artery appears congenitally hypoplastic. Both vertebral artery origins are patent. Visualized soft tissue structures in the neck appear unremarkable. IMPRESSION: 1. While there is no evidence of hemorrhage or acute vascular territorial infarction, there is subtle hypoattenuation in the basal ganglia, thalami, pons and midbrain, suspicious for edema. 2. Evidence of small vessel ischemic disease. 3. Unremarkable CTA of the head and neck, with no evidence of steno-occlusive disease. 4. No finding to suggest cerebral venous thrombosis. CT C-Spine FINDINGS: There is no evidence of acute fracture or malalignment. Multilevel degenerative joint changes are most pronounced at C6-C7 with intervertebral disc space narrowing, subchondral sclerosis and disc osteophyte complex formations. Evaluation of prevertebral soft tissue is limited due to ET tube placement. No critical central canal stenosis is noted. Calcifications of the ligamentum flavum are incidentally noted. Nonunion of the C1 posterior arch is present. The esophagus appears patulous with moderate amount of secretions, which may predispose the patient to aspiration. Imaged lung apices are clear. IMPRESSION: 1. No evidence of acute fracture or malalignment. Degenerative changes are most pronounced at C6-C7 level. 2. Dilated and patulous esophagus with moderate amount of secretions, may predispose patient to aspiration. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: 78 yof admitted to MICU for unresponsiveness, concern for TTP. Initially presented with thrombocytopenia, renal failure, seizures, fevers, and hemolytic anemia consistent with TTP. Intubated due to hypercarbic respiratory distress/ failure to maintain air way. Plasmapharesis was initiated without much improvement in clinical presentation. Head imaging revealed multiple cerebral and brainstem infarcts in context of TTP. Patient also sufferred a STEMI. Course was complicated by line infections and ventilator associated pneumonia. Family meeting was held which discussed poor prognosis and poor recovery given multiple organ distress and cerebral pathology. Patient was made DNR. On HD 13, sufferred a bradyarrhythmia, went into PEA arrest, and passed away. Autopsy was declined by HCP. Medications on Admission: ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth daily - No Substitution AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) GLIPIZIDE - 2.5 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth daily HYDRALAZINE - 50 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours ISOSORBIDE DINITRATE - 20 mg Tablet - 1 Tablet(s) by mouth three times a day METOPROLOL SUCCINATE - 200 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily take with 200mg tablets OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Tablet, Chewable - 1 Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1 Capsule(s) by mouth daily Discharge Medications: Patient Deceased Discharge Disposition: Expired Discharge Diagnosis: Patient Deceased Discharge Condition: Patient Deceased Discharge Instructions: Patient Deceased Followup Instructions: Patient Deceased	[ "790.7", "274.9", "E879.8", "417.8", "283.9", "041.85", "276.0", "434.91", "V49.86", "348.39", "427.5", "287.30", "999.32", "780.39", "782.4", "250.00", "V10.3", "401.9", "584.9", "997.31", "410.91", "518.81", "780.01", "530.81" ]	icd9cm	[ [ [] ] ]	[ "99.71", "38.97", "96.6", "38.93", "96.72", "96.04" ]	icd9pcs	[ [ [] ] ]	10236, 10245	8414, 9213	302, 314	10305, 10323	4095, 5713	10388, 10407	3068, 3121		10195, 10213		10266, 10284	9239, 10172			10347, 10365										3136, 4076																												245, 264										342, 2580			5722, 8391													2602, 2990	3006, 3052
52,529	161,228	53802	Discharge summary	report	Admission Date: [2184-4-26] Discharge Date: [2184-5-7] Date of Birth: [2112-5-28] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[First Name3 (LF) 5606] Chief Complaint: AMS and agitation Major Surgical or Invasive Procedure: [2184-4-30] - Lumbar puncture [2184-4-30] - G-J tube repositioning History of Present Illness: 71 yo M with Pt with hx of HTN, HL, OSA, s/p unrestrained MVC rollover on [2184-3-9] with TBI, L open ankle fracture, R closed ankle fracture and dislocation, scalp laceration discharged with hospital course complicated prolonged intubation, peri-operative PEA arrest and apnea post-op requiring tracheostomy placement on [2184-3-18]. He was discharged to rehab on [4-2] on trach collar, and was readmitted from [Date range (1) 110410] with fever and AMS. His infectious source during the last admission was felt to be related to his deep left leg wound, and he subsequently underwent BKA on [4-6] and revision on [4-8]. He also completed a course of vanco/zosyn during that admission. Per [Hospital3 ] in [Location (un) 8957], MA ([Telephone/Fax (1) 79922]), he was initially A&Ox1 when he arrived on [4-21]. Over the past 2 days prior to admission, he had become more agitated and aggressive. No report of fevers and no diarrhea, they reported that he had no BMs since [4-23]. He had been receiving Haldol 2mg via G-tube 3-4 times per day and Ativan 0.5mg-1mg for agitation. No report of other new medications started since recent discharge. Per his wife and son-in-law, his mental status has been very variable over the past 2 months. At his best, he is A&Ox1, calm, and recognized his family members although he is disoriented to time and place. They reoprt that he has not been sleeping much, if at all, since arriving to rehab last week. In the ED, initial VS were: BP 82/36 and SpO2 93% (on trach mask, FiO2 not recorded, rest of admission VS not recorded). He was febrile to 101.2 in the ED and received 2g CTX for presumed UTI (although UA with only 6WBCs and neg nitrite). Also received 1000cc NS and Ativan 0.5mg IV. Prior to transfer to [Hospital1 18], he received morphine 4mg IV x2 and Ativan 0.5mg IV x2. He required frequent trach suctioning and had copious thick secretions. CXR was not appreciably different from CXR prior to recent discharge. On arrival to the MICU, patient's VS were T 96.5 HR 99 BP 172/80 RR 20 SpO2 93% on trach mask 35% FiO2. He is agitated, swinging all 4 extremities and not interactive. Unable to follow simple commands and does not answer questions. Review of systems: Unable to obtain Past Medical History: HTN Hypercholesterolemia OSA s/p MVC with TBI s/p tracheostomy [2184-3-18] s/p PEG placement [2184-3-24] s/p ex-fix L ankle; closure scalp lac [2184-3-9] s/p ORIF R ankle, washout L ankle [2184-3-11] s/p Debridement L foot/heel. Longer trach [2184-3-26] s/p Left BKA [2184-4-6] for deep tissue infection with revision on [2184-4-8]. Social History: Presenting from rehab after recent seies of admissions. Married and has a daughter. Previously reported occasional EtOH per OMR, none while at rehab recently. Family History: Non-contributory Physical Exam: Admission exam: T 96.5 HR 99 BP 172/80 RR 20 SpO2 93% on trach mask 35% FiO2 General: Agitated and does not respond to voice HEENT: Sclera anicteric, MMM. Pupuls are sluggishly reactive (R more reactive than L) but equal in size Neck: supple, trach in place, unable to assess JVP given habitus CV: RRR, no appreciated m/r/g but exam limited by pt's agitation Lungs: Diffuse ronchi in anterior lung fields Abdomen: soft, no appreciable tenderness, obese. GU: Foley in place Ext: PICC in R arm, site is c/d/i. L BKA with mild erythema around the incision, no discharge. Sutures still in place. Neuro: Agitated and not following commands, moving all 4 extremities non-purposefully. Pertinent Results: Admission labs: [2184-4-26] 07:15PM BLOOD WBC-10.2 RBC-3.32* Hgb-9.9* Hct-30.6* MCV-92 MCH-29.7 MCHC-32.3 RDW-15.0 Plt Ct-316 [2184-4-26] 07:15PM BLOOD Neuts-82.4* Lymphs-9.3* Monos-5.8 Eos-1.9 Baso-0.6 [2184-4-26] 07:15PM BLOOD PT-11.9 PTT-28.4 INR(PT)-1.1 [2184-4-26] 07:15PM BLOOD Glucose-138* UreaN-27* Creat-1.1 Na-144 K-4.2 Cl-108 HCO3-26 AnGap-14 [2184-4-26] 07:15PM BLOOD CK(CPK)-47 [2184-4-27] 05:20AM BLOOD ALT-44* AST-32 LD(LDH)-236 CK(CPK)-30* AlkPhos-212* [2184-4-26] 07:15PM BLOOD CK-MB-2 cTropnT-0.01 [2184-4-26] 07:15PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1 [2184-4-26] 07:30PM BLOOD Lactate-1.3 [2184-4-26] 07:15PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.016 [2184-4-26] 07:15PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2184-4-26] 07:15PM URINE RBC-18* WBC-6* Bacteri-FEW Yeast-NONE Epi-0 [2184-4-26] 07:15PM URINE CastGr-9* CastHy-11* CSF studies: [2184-4-30] 06:31PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2685* Polys-64 Lymphs-25 Monos-5 Eos-6 [2184-4-30] 06:31PM CEREBROSPINAL FLUID (CSF) WBC-60 RBC-[Numeric Identifier 17260]* Polys-88 Lymphs-4 Monos-7 Eos-1 [2184-4-30] 06:31PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-77 [2184-4-30] 06:31PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND Discharge labs: [2184-5-6] 05:35AM BLOOD WBC-6.6 RBC-2.64* Hgb-8.0* Hct-23.9* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.5 Plt Ct-159 [2184-4-30] 03:54AM BLOOD Neuts-87.4* Lymphs-5.6* Monos-4.0 Eos-2.9 Baso-0.2 [2184-5-6] 05:35AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-142 K-3.6 Cl-104 HCO3-34* AnGap-8 [2184-5-6] 05:35AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1 Micro: -BCx x5: No growth; one blood culture still pending. -UCx x2: No growth -C. diff PCR: Negative -Sputum x2: No growth -CSF cx: No growth; HSV PCR negative -Wound culture: rare [Female First Name (un) 564] albicans Imaging: -CXR ([2184-4-26]): Findings most suggestive of mild vascular congestion without definite pneumonia. Patchy retrocardiac opacity appears minor and may be associated with coinciding atelectasis. If concern for the possibility of pneumonia persists, however, then short-term followup radiographs could be considered, preferably with PA and lateral technique if feasible. -CT head ([2184-4-26]): Stable appearance of the brain. -CTA chest/abd/pelvis ([2184-4-29]): 1. Limited assessment of the pulmonary vasculature due to poor IV access without evidence of central or large pulmonary embolism. 2. Heterogeneous renal enhancement. Correlate with urine culture to assess for pyelonephritis. 3. G-J tube bulb within the anterior abdominal wall (rectus abdominus muscle). 4. Small bilateral pleural effusions with dependent atelectasis vs consolidations. 5. Mildly enlarged mediastinal nodes. -G/J tube change ([2184-4-30]): Uncomplicated replacement/exchange of 18-French MIC GJ tube over a guidewire. Brief Hospital Course: 71 yo M with Pt with hx of HTN, HL, OSA, TBI s/p MVC, L open ankle fracture, R closed ankle fracture and dislocation, s/p PEA arrest and apnea post-op requiring tracheostomy placement on [2184-3-18] who now presents with AMS and agitation from rehab. Ultimately, his agitation was thought to be secondary to a malpositioned GJ tube and possible delirium from a pneumonia. His mental status at discharge is dramatically improved. Please see below. . # AMS and agitation: His baseline mental status is very poor after he suffered from a TBI after an unrestrained MVA earlier this year. At his best, he follows commands, nods appropriately, and makes eye contact with family members. His AMS and agitation this admission were likely [1-8] pain from improperly placed G-J tube, may also be from infection as discussed below. His agitation was initially controlled with IV Haldol and Ativan with moderate success. He briefly required propofol for agitation. His CT abd/pelvis showed that his G-J tube was misplaced with the balloon located in the abdominal wall. It is unclear whether pain from this malposition led to his agitation or whether he pulled the tube during his agitation. Regardless, his agitation improved after repositioning by IR and he no longer required standing Haldol or propofol. He was started on PRN fentanyl for pain control. During the last 24 hours of his hospitalization, his mental status was dramatically improved. He was conversational, oriented to self, hospital and season intermittently but still has some confusion and nonsensical conversations. However, this was much better than his initial presentation. . Both neuro and psych were consulted this admission for assistance with his agitation. EEG showed encephalopathy with epileptogenic potential per neurology and he was continued on keppra and started on depakote for mood stabilization. Depakote was later stopped per neuro's recs. The pt never had a seizure clinically or on EEG. A repeat EEG was done on [5-5] which did not show evidence of seizure so they recommended just continuing the low dose Keppra. His mental status was dramatically improved and he did not require additional mood stabilizing effects from the Depakote. He was also restarted on seroquel 100 PO qhs for sleep to help regulate his sleep wake cycle. . Of note,the pt reportedly did not respond well to Ativan at rehab in the past per the family. . # HCAP: Pt found to be febrile with leukocytosis, left retrocardiac opacity. Other sources of infection were ruled out including urinary, c.diff and intra-abdominal infxn. CSF cultures were negative and HSV PCR was negative. He also had an LP which was negative for a bacterial meninigitis. He was empirically started on acyclovir for HSV coverage which was negative when the HSV PCR came back negative. He was treated with 8 days for HCAP with vanc and zosyn ([Date range (1) ]) initially but he developed worsening fevers which were thought to be a drug reaction and was switched to vanc/meropenem ([2101-4-30]) and defervesced. ID followed the patient during this hospitalization. . # Hypernatremia: Na trended up to 149 and his free water flushes were increased to 150cc q4hr. His serum sodium improved with free water and D5 flushes. . # Hypertension: He was hypertensive to 190s systolic upon arrival to the OSH and had systolics up to the 170s at in the ED at [Hospital1 18]. His BP remained intermittently elevated to the 170-180s this admission, especially while he was unable to receive meds though his G-tube when is was malpositioned. Also, his lisinopril was initially held for elevated creatinine. His BP improved once he was restarted on all of his home medications. . # [Last Name (un) ]: Creatinine elevated this admission with peak creatinine of 1.4. This improved with holding lisinopril initially and IV hydration. Cr improved and he was restarted on lisinopril. . # Left BKA - ortho rec leaving cast on for now. [Month (only) 116] take off intermittently for a few minutes at a time for comfort prn. Discussed with surgery. Sutures should be removed next week in ortho clinic. He should be non weight bearing on the right and will have repeat x-rays when he follows up with ortho. . # Anemia: Hct remained at stable in the mid 20s this admission. . # Chronic respiratory failure: He initially had significant sputum production but it improved with suctioning and treatment for pneumonia. He was continued on albuterol and atrovent inhalers. . #FEN - The patient was on tube feeds for most of his hospitalization. Prior to discharge he had a speech and swallow who recommended thin liquids and ground solids. Tube feeds can be adjusted by nutrition depending on PO intake. . #PPX - PPI, heparin sc tid. . #Access - The patient had a right PICC line placed which was repositioned by IR on [5-5]. The subclavian line placed in the ICU was d/ced. Medications on Admission: -TF - osmolite 1.2 at 45cc/hr -Beneprotein 35g daily -Protonix 40mg IV daily -Labetalol 800mg G-tube q8h -Lansoprazole 30mg G-tube daily -Calcium carbonate 500mg G-tube tid -Seroquel 100mg tid -Colace 50mg [Hospital1 ] -MVI 1 tab daily -Heparin 5,000 units SC tid -Ipratropium 2 puffs q6h -Keppra 1500mg [Hospital1 ] -Lisinopril 40mg daily -Clonidine 0.3mg [Hospital1 ] -Amlodipine 10mg daily -Haldol 2mg G-tube q8h (started [2184-4-25]) -Ativan 0.25-1mg IV (started [2184-4-26]) Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. labetalol 200 mg Tablet [Last Name (STitle) ]: Four (4) Tablet PO TID (3 times a day). 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO TID (3 times a day). 4. quetiapine 25 mg Tablet [Last Name (STitle) ]: Four (4) Tablet PO QHS (once a day (at bedtime)). 5. heparin (porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 6. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO BID (2 times a day). 7. therapeutic multivitamin Liquid [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. clonidine 0.1 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO BID (2 times a day). 9. amlodipine 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [Last Name (STitle) ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for prn wheezing. 11. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [Last Name (STitle) ]: 4-6 Puffs Inhalation Q4PRN () as needed for prn wheezing. 12. lisinopril 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 13. levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: One (1) PO BID (2 times a day). 14. haloperidol lactate 5 mg/mL Solution [Last Name (STitle) ]: One (1) Injection Q4H (every 4 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge [Location (un) 9687]: Encephalopathy Malpositioned GJ tube Healthcare associated pneumonia Traumatic Brain Injury Left BKA Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Right LE is non weight bearing. Discharge Instructions: You were admitted for further evaluation of agitation. You were found to have a malpositioned feeding tube which was repositioned. You were also treated for pneumonia. Your mental status improved. You were evaluated by orthoepedic surgery who recommended leaving your sutures in on your left leg until next week. You should follow up with them as scheduled. Followup Instructions: You should follow up with your PCP when you are discharged from rehab. You should follow up in neurology in [1-9] months. Department: ORTHOPEDICS When: TUESDAY [2184-5-11] at 10:00 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2184-5-11] at 10:20 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "V44.0", "518.83", "276.0", "584.9", "285.9", "401.9", "996.59", "V15.52", "V49.75", "E929.0", "327.23", "536.42", "293.0", "486", "348.39", "E879.8" ]	icd9cm	[ [ [] ] ]	[ "96.71", "97.02", "03.31", "38.97", "38.93" ]	icd9pcs	[ [ [] ] ]	14110, 14323	7000, 11943	283, 359	14344, 14344	3979, 3979	14941, 15637	3245, 3263		12493, 14087			11969, 12470			14554, 14918			5368, 6977							3278, 3960																								2650, 2669				226, 245										387, 2631					3995, 5352				14359, 14530							2691, 3053	3069, 3229
31,260	107,777	2720	Discharge summary	report	Admission Date: [2109-4-1] Discharge Date: [2109-4-13] Date of Birth: [2045-4-2] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[First Name3 (LF) 800] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Temporary HD line placement Arterial Line Placement CVVH Hemodialysis Subclavean Central Line Placement History of Present Illness: 63 y/o F with hx of severe diastolic CHF, pulm HTN, afib, ulcerative colitis, and recent lower GI bleed who is transferred from [Hospital1 1774] with acute dyspnea and hypoxia. Per her daughter, she has been more dypsneic on exertion for the past week with episodes somewhat relieved with albuterol. The pt reports that she awoke at 3:15 AM with acute shortness of breath and wheezing. She denies chest pain, palpitations, fevers, chills, night sweats. She denies cough. An albuterol inhaler did not help, so she went to the [Hospital1 1774] ED. . In the [Hospital1 1774] ED, she placed on bipap with O2sat 100%. Her BP was initially 104/67, HR 55, RR13. CXR showed R pleural effusion. BNP was 1500, cardiac enzymes negative. HCT was noted to be 24.9 (baseline 24-27). At 6am her blood pressures dropped to 83/44 and she was given a 125cc NS bolus. ABG on bipap was 7.34/60/313/32. At 7:30am, Levophed gtt was started. At 8am she was transitioned to a NRB and was satting 100%. Her levophed was increased at 8:15am. . On arrival to the ICU, she reports comfortable breathing ever since being placed on O2. ROS is otherwise positive for more black stools over the past 2-3 days. . Of note, she was recently admitted [Date range (3) 13475] due to lower GI bleed and HCT of 17. She required 6 units PRBCs that admission and bleeding was felt to be due to lower GI angioectasia; colonoscopy was not done due to recent scope [1-30] which showed many angioectasias throughout the colon. HCT was stable at 24.7 on discharge and most recent HCT [3-26] was 27.4. She was also treated for congestive heart failure exacerbation and acute renal failure on that admission and was discharged on spironolactone, torsemide and metolazone still about 40 lbs above her dry weight. At her follow-up appointments, her weight was still stable, so spironolactone was increased on [3-15] by Dr. [Last Name (STitle) 118] (weight 199 lbs) and her torsemide on [3-18] by Dr. [First Name (STitle) 437] (weight 196 lbs). The pt reports medication compliance (does sometimes take medications late) and general diet compliance although "ate more over [Holiday ]." She does recall an episode of left leg pain two days ago while trying to go up stairs and feels she may have been when she started feeling more short of breath, although the acute episode of dyspnea was not until later. . Review of systems: (+) Per HPI. Ongoing occasional nausea, vomiting with emesis including medications at times. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies chest pain, chest pressure, palpitations, or weakness. 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: # Diabetes # Dyslipidemia (TG 53, Chol 145 HDL 71 LDL 63 on [10/2107]) # Hypertension # atrial fibrillation off coumadin secondary to GI bleed # severe diastolic dysfunction w/ right sided heart failure # severe pulmonary hypertension # severe tricuspid regurg (eval by card [Doctor First Name ], not op candidate) # EtOH remote history # PFO closure ([2108-3-21]) # ulcerative colitis # intermittent hyponatermia # elevated LFTs # angioectasia of the entire colon seen on colonoscopy [2109-1-30] Social History: -Married, separated from husband who is mentally ill, living with son and his family currently (supportive) -Tobacco history: No -ETOH: +prior h/o heavy EtOH use, current intermittent EtOH use -Illicit drugs: No Family History: -Father with MI at age 68 -Mother breast cancer at age 52 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Vitals: T 95.7, P 57, BP 104/71, RR 13, O2sat 100% 5L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, very promiment EJ, JVP elevated, no LAD Lungs: Mild rales bilaterally, no wheezes, or ronchi CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GI: Trace guaiac positive hard very dark brown stool GU: Foley in place Ext: warm, well perfused, 2+ pulses, 3+ edema bilateral to knees and up posterior aspects to lower back, LLE more erythematous with hematoma, calf tenderness bilaterally Neuro: AAOx3, mild asterixis b/l, otherwise nonfocal Pertinent Results: [2109-4-1] 09:32PM UREA N-102* CREAT-2.4* [2109-4-1] 09:32PM CK(CPK)-32 [2109-4-1] 09:32PM CK-MB-NotDone cTropnT-<0.01 [2109-4-1] 09:32PM HCT-26.8* [2109-4-1] 03:32PM URINE HOURS-RANDOM UREA N-335 CREAT-27 SODIUM-84 [2109-4-1] 03:32PM URINE OSMOLAL-348 [2109-4-1] 03:32PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2109-4-1] 03:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2109-4-1] 03:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2109-4-1] 03:32PM URINE RBC-0-2 WBC-[5-30]* BACTERIA-FEW YEAST-NONE EPI-0-2 [2109-4-1] 03:32PM URINE EOS-POSITIVE [2109-4-1] 12:00PM GLUCOSE-109* UREA N-100* CREAT-2.5* SODIUM-134 POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-26 ANION GAP-21* [2109-4-1] 12:00PM ALT(SGPT)-9 AST(SGOT)-44* LD(LDH)-283* CK(CPK)-39 ALK PHOS-194* TOT BILI-1.4 [2109-4-1] 12:00PM CK-MB-NotDone cTropnT-0.01 proBNP-6666* [2109-4-1] 12:00PM CALCIUM-9.4 PHOSPHATE-6.5# MAGNESIUM-2.4 [2109-4-1] 12:00PM TSH-4.7 [2109-4-1] 12:00PM WBC-12.1# RBC-3.33 HGB-8.9* HCT-28.8* MCV-87 MCH-26.9* MCHC-31.0 RDW-16.3* [2109-4-1] 12:00PM NEUTS-94.4* LYMPHS-3.0* MONOS-2.2 EOS-0.3 BASOS-0.1 [2109-4-1] 12:00PM PLT COUNT-236 [2109-4-1] 12:00PM PT-13.1 PTT-29.4 INR(PT)-1.1 [2109-4-1]: Portable CXR INDICATION: 63-year-old female with history of CHF, shortness of breath. [Month/Day/Year ] for pulmonary edema. COMPARISON: Chest radiograph [2109-2-26] and multiple priors. SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: In comparison to the most recent chest radiograph as well as the recent CT, there has been an increase in a right pleural effusion. Lung volumes are low, accentuating the heart size, but even allowing for technique very stable moderate cardiomegaly. The bony thorax is unremarkable. IMPRESSION: Increased right and continued left pleural effusion. [2109-4-1]: Portable CXR HISTORY: Central line placement. FINDINGS: In comparison with the earlier study of this date, there has been placement of a right subclavian catheter that extends to the mid-to-lower portion of the SVC. Otherwise, little change. The study and the report were reviewed by the staff radiologist. [2109-4-2]: TTE The left atrium is moderately dilated. The right atrium is moderately dilated. A septal occluder device is seen across the interatrial septum. The estimated right atrial pressure is 10-20mmHg. 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 low normal (LVEF 50-55%). The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-22]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is probably significant pulmonary hypertension although this could not be adequately quantified. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] Significant pulmonic regurgitation is seen. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. (Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures.) Compared with the prior study (images reviewed) of [2109-2-26], there is no significant change. [2109-4-2]: Renal Ultrasound INDICATION: Patient is a 63-year-old female with longstanding hypertension. [Month/Day/Year ] for renal artery stenosis. EXAMINATION: Renal ultrasound with Doppler. COMPARISONS: Comparison is made to CT from [2109-2-27] and renal ultrasound from [2109-2-25]. FINDINGS: The right kidney measures 9.2 cm. Left kidney measures 8.7 cm. Both kidneys are relatively normal in size for patient's stated age. Both kidneys are unremarkable in appearance with no evidence of hydronephrosis, nephrolithiasis, or discrete masses. Note is made of a small amount of pelvic free fluid. The bladder is collapsed about a Foley catheter. DOPPLER EXAMINATION: Both main renal arteries demonstrate a brisk upstroke and good diastolic flow. There is normal venous drainage with normal venous waveforms demonstrated. Resistive indices were measured as ranging from 0.61 to 0.83 within the left and 0.68 to 0.81 on the right. This is compatible with mild to moderately elevated resistive indices. IMPRESSION: 1. No son[Name (NI) 493] evidence of renal artery stenosis. Mild to moderately and symmetrically elevated resistive indices bilaterally. 2. Unremarkable appearance of the kidneys. 3. Small amount of pelvic free fluid. [2109-4-4]: CHEST RADIOGRAPH INDICATION: Chronic heart failure, shortness of breath, evaluation for interval change. COMPARISON: [2109-4-3]. FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged moderate cardiomegaly with basal areas of atelectasis and a small right-sided pleural effusion. No newly occurred focal parenchymal opacity in the lung parenchyma. Unchanged course and position of the two right-sided central venous access lines. No pneumothorax. Brief Hospital Course: # Dyspnea/Hypoxia: Pt presented with dyspnea and hypoxia; she was on Bipap and transitioned to NRB. She appeared fluid overloaded clinically and on CXR with a BNP of 6666. Acute onset raised concern for an inciting event, but no clear inciting factor apparent. She did have mild leukocytosis to WBC 12 but no fevers, cough, or clear consolidation suggestive of pneumonia. She is in chronic atrial fibrillation but is rate controlled. She had no chest pain to suggest ACS; EKG was at her baseline and 2 sets of cardiac enzymes were negative. A pulmonary embolus was considered but given no chest pain or tachycardia (on beta blocker) this was not felt to be a concern. Thyroid dysfunction unlikely to provoke acute decompensation. According to the patient's daughter, the presentation may have actually been more subacute over several days and there may have been a component of suboptimal dietary/medication compliance in this patient with baseline diastolic CHF that has been very difficult to manage. She was begun on CVVH on [2109-4-2] and diuresis was begun. Her admission weight was 87.6 kg and her maximum weight during admission prior to CVVH was 92 kg. She continued on CVVH with levophed as needed for pressure support until [2109-4-8]. She was transferred to the regular floor and continued to receive hemodialysis until discharge. She was discharged on her home regimen of metolazone, torsemide and spironalactone. Permanent transiton to hemodialsis had been discussed with her in detail but she much preferred the option of an oral antidiuretic regimen which she committed to be compliant with. . # Hypotension: The patient was hypotensive to the 80s systolic in the OSH ED and she was started on levophed. She continued requiring levophed for pressure support here in the ED and MICU and a central venous line was placed here in her right subclavian vein. The hypotension was felt to be cardiogenic in the setting of worsening diastolic CHF. There was no evidence for sepsis although the patient was found to have a UTI. Her hematocrit did show a slight drop but blood loss and hypovolemia were not felt to be contributing to her hypotension. Levophed was maintained as needed while diuresing aggressively with CVVH. . # Hematochezia: The patient was recently admitted for anemia and thought to have recurrent lower GI angioectasia bleeding. During this admission she continued to have guaiac positive stools but her hematocrit was relatively stable since her last discharge. Her hematocrit was monitored closely and she was transfused two units of packed red blood cells (one on [2109-4-3] and one on [2109-4-4]) with an appropriate increase in her hematocrit from 22.9 to 29.8. She continued taking her home pantoprazole, and sub-cutaneous heparin was avoided in the setting of her GI bleed. . # Acute renal failure: The patient was found to have BUN 100 and Cr 2.5 (baseline 1.7). This was thought likely due to decreased renal perfusion in the setting of decompensated heart failure. Creatinine began trending down as patient started on CVVH. Medications were dosed for the patient's creatinine clearance, and the patient was followed by the renal consult team; Dr. [Last Name (STitle) 118], the patient's nephrologist, saw her while in-house. She was begun on CVVH on [2109-4-2] and diuresis was begun. Her admission weight was 87.6 kg and her maximum weight during admission prior to CVVH was 92 kg. She continued on CVVH with levophed as needed for pressure support until [2109-4-8]. She was transferred to the regular floor and continued to receive hemodialysis until discharge. She was discharged on her home regimen of metolazone, torsemide and spironalactone. Permanent transiton to hemodialsis had been discussed with her in detail but she much preferred the option of an oral antidiuretic regimen which she committed to be compliant with. . # Elevated LFTs: The patient was noted to have mild AST and Alkaline phosphate elevation with normal ALT and total bilirubin. She had no abdominal pain and these values were felt to be due to congestive hepatopathy; they resolved with diuresis. . # Nausea: The patient had intermittent nausea, possibly related to uremia. Abdominal exam was benign and the patient was given zofran as needed. . # Atrial fibrillation: The patient remained stable with a slow ventricular response. Her home metoprolol was held in the setting of hypotension and she was not anticoagulated given her history of significant GI bleeding. . # Diarrhea / ulcerative colitis: Dr. [Last Name (STitle) 2987], the patient's gastroenterologist, was made aware of the patient's admission. On admission, the patient had no abdominal symptoms such as pain or diarrhea, and she did not seem to be having an acute ulcerative colitis flare. She did develop diarrhea with antibiotic treatment of her UTI that resolved when the antibiotics were stopped. She continued taking her Asacol though had some difficulties tolerating the medication without vomiting due to the size of the pill. Medications on Admission: Albuterol HFA 90 mcg 2 puffs PO QID PRN Ammonial Lactate 12% lotion [Hospital1 ] Dicloxacillin 500mg PO QID Folic Acid 1 tab PO qday Gabapentin 200mg PO qHS PRN leg spasm Mesalamine 800mg PO TID Metolazone 5mg PO BID Metoprolol Tartrate 25mg PO BID Metronidazole 0.75% cream [Hospital1 ] Omeprazole 20mg PO qday Oxycodone 5mg PO 5mg PO q6H Potassium Chloride 20meq with meals Promethazine 12.5-25mg PO q6H PRN Spironolactone 50mg PO qday Torsemide 60mg PO BID Trazodone 25mg PO qHS ASA 81mg PO qday Ferrous Sulfate 325mg PO BID Miconazole 2% cream Discharge Medications: 1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for PRN PAIN. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 11. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)) as needed for leg spasm. 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Acute on Chronic Diastolic Heart Failure. . Secondary Acute Renal Failure ulcerative colitis Diabetes Hypertension Discharge Condition: fully ambulatory with walker. Alert and oriented to person, place and time. Discharge Instructions: You were admitted to the hospital because you were having difficulty breathing. This was due to your heart failure which also caused renal failure. You required dialysis to remove all the extra fluid. A decision was made between you and your nephrologist not to pursue permanent dialysis but to continue using the diuretics you had been using at home.It is very important that you minimize salt in your diet to less than 2g/day and that you drink less than 1.5L of fluid a day and take all your medications. We stopped your omeprazole as we think this lowered your platelets. We stopped the potassium for the time being. You can discuss with Dr [Last Name (STitle) 118] when you should restart this. We ADDED iron sulphate 325mg daily. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: INTERNAL MEDICINE When: WEDNESDAY [2109-4-17] at 10:30 am With: [Last Name (NamePattern5) 6666], MD, MPH [Telephone/Fax (1) 4775] Building: [Location (un) 2790] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "285.21", "556.9", "041.4", "427.31", "250.00", "428.0", "599.0", "287.4", "397.0", "458.9", "584.9", "569.85", "585.4", "403.90", "511.9", "416.8", "333.94", "428.33" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.93", "38.95" ]	icd9pcs	[ [ [] ] ]	17987, 18036	11032, 16093	351, 456	18203, 18281	5119, 11009	19160, 19588	4176, 4349		16699, 17964		18057, 18182	16119, 16676			18305, 19137										4364, 5100																								2921, 3392				292, 313										484, 2902																3414, 3930	3946, 4160
20,929	108,938	20411+57157	Discharge summary	report+addendum	Admission Date: [2129-4-3] Discharge Date: [2129-4-11] Date of Birth: [2052-12-2] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: A 78-year-old female with history of atrial fibrillation, diabetes, and history of stroke was transferred from [Hospital 1474] Hospital to [Hospital1 18] CCU in cardiogenic shock. At home, the patient was found to be unresponsive with vomitus on her pillow. She was brought to [Hospital 1474] Hospital, where she was found to be in atrial fibrillation at 150 beats per minute. Initially she was normotensive, but became hypotensive with systolic blood pressures to the 60s. At that time, she was successfully d-c cardioverted into sinus rhythm in the 80s. She remained hypotensive and was therefore intubated for airway protection and started on dopamine. In addition, she was placed on Neo-Synephrine drip, dobutamine drip, and nesiritide drip. Prior admission to [Hospital1 18], she was on dobutamine 2.5 mcg/kg/minute and 30 mcg/minute of Neo-Synephrine. On those medications, her CVP was 10, pulmonary artery pressure of 46/15, wedge of 14, and cardiac output 3.5, and cardiac index 2.0, and SVR of 2514. She had a myocardial infarction with troponin I 13.8 and a peak CPK of 822. She had an echocardiogram that was preliminary read as an EF of 30%, apical hypokinesis, mild MR, TR, and PR. Prior to her transfer, she had a temperature max of 101.6, and was started on ceftriaxone, azithromycin, and Flagyl for presumed aspiration pneumonia. Her platelets were noted to decrease from admission from 148 to 90 prior to discharge while on Lovenox. This occurred over a two-day period. Patient arrived at [Hospital1 18] intubated, unalert, with heart rate irregular with a wide complex on telemetry, MAP of 50s-60s on Neo-Synephrine and dobutamine. She was started on an amiodarone, given 5 mg of Lopressor, and a heart rate decreased to the 80s. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 17526] MEDQUIST36 D: [2129-4-11] 12:00 T: [2129-4-11] 12:32 JOB#: [Job Number 54707] Name: [Known lastname ], [Known firstname 986] Unit No: [Numeric Identifier 10221] Admission Date: [2129-4-3] Discharge Date: [2129-4-12] Date of Birth: [2052-12-2] Sex: F Service: CCU ADDENDUM TO DISCHARGE SUMMARY PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Atrial fibrillation. 3. Left bundle branch block. 4. Depression. 5. History of cerebrovascular accident. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Digoxin 0.125. 2. Lopressor 50 twice a day. 3. Glyburide 10 twice a day. 4. Metformin 500 twice a day. 5. Lasix 20 once a day. 6. Univasc 7.5 once a day. 7. 2.5 three times a day. 8. Coumadin 5 once a day. MEDICATIONS ON TRANSFER: 1. Ceftriaxone one gram once a day. 2. Erythromycin 500 once a day. 3. Flagyl 500 three times a day. 4. Protonix. 5. Aspirin 325. 6. Amiodarone 400 twice a day, to be weaned. 7. Neo-Synephrine drip. SOCIAL HISTORY: Denied tobacco and alcohol use. FAMILY HISTORY: Unobtainable. PHYSICAL EXAMINATION: Pulse 106; blood pressure 93/60; respiratory rate 20; 100% on SIMV, PF-8, PEEP-5, Rate 8, FIO2 50%, tidal volume 300 to 500. Physical examination significant for no jugular venous pressure, irregular , S1 and S2. No murmurs appreciated. Coarse lung sounds throughout. Benign abdomen. Two plus edema bilaterally to shins; two plus and one plus dorsalis pedis pulses bilaterally. All other organ systems examined and found to be within normal limits. LABORATORY: White blood cell count 8.8, hematocrit 35.5, platelets 95, PT 25, INR 4.1, PTT 42.6, fibrinogen 346, D-Dimer 9799. Creatinine 1.2, BUN 36. Glucose 179, ALT 4750, AST 4739, LDH 2450. CPK 872, alkaline phosphatase 96, amylase 93, total bilirubin 1.7, direct bilirubin 0.9. Lipase 70. CK MB 7, troponin T 0.05. Albumin 3.3, digoxin 0.5. EKG showed wide complex tachycardia at 170 beats per minute; irregular with left axis deviation and atrial fibrillation. Chest x-ray showed cardiomyopathy, pulmonary vascular redistribution. HOSPITAL COURSE: 1. HYPOTENSION: The patient initially came in with cardiogenic shock. The patient had a low cardiac output and high SVR. There was no evidence of an ischemic event precipitating her low blood pressure. A Swan was placed. The Neo-Synephrine and dobutamine were discontinued and the patient was placed on Levophed the first night of admission. An echocardiogram showed an ejection fraction of 25 to 30% with trace aortic regurgitation, severe aortic stenosis, two plus tricuspid regurgitation and mild pulmonary hypertension but on day two of hospital stay, her low blood pressure resolved. The patient's beta blocker was initially held in the setting of hypotension but once her blood pressure stabilized, it was restarted and titrated up. 2. CORONARY ARTERY DISEASE: The patient's cardiac enzymes were cycled and showed a leak likely secondary to cardioversion at the outside hospital. She continued on aspirin and Plavix. The patient had a cardiac catheterization during her hospital stay to evaluate her for coronary artery disease and this showed normal coronary arteries. 3. SHOCK LIVER: The patient appeared to have transaminitis and damage to her liver secondary to hypotension. She came in with high liver function tests. Her statin was held during her hospital course. Her beta blocker was initially held. Her liver function tests have been trending down prior to discharge. 4. POSSIBLE ASPIRATION PNEUMONIA: At the outside hospital, the patient had a temperature of 101.4 F., and she was initially presented unresponsive and somnolent. Therefore, they started her on a seven day course of Levofloxacin and Flagyl for presumed aspiration pneumonia. There was no infiltrate on chest x-ray, however, since the patient had been started on antibiotics, we finished a seven day course. She remained afebrile during her hospital stay. 5. CONGESTIVE HEART FAILURE: The patient was admitted with pulmonary edema. She was started on Natrecor for one day. After that, she was diuresed with p.r.n. Lasix. Prior to discharge, she was placed on a maintenance dose of Lasix. The patient has severe aortic stenosis and is therefore preload dependent and must try to maintain patient weight and follow a low sodium diet. 6. ACUTE RENAL FAILURE: The patient's creatinine was elevated on admission and was trending down prior to discharge and is within normal limits on discharge. 7. THROMBOCYTOPENIA; During her three days at the outside hospital, the patient's platelets dropped from 148 to 93 in the setting of the use heparin. This is most likely too early to see heparin induced thrombocytopenia, however an HIC antibody was sent and found to be negative. Her platelets have been increasing since admission. 8.[Last Name (STitle) 10222] AORTIC STENOSIS: The patient was newly diagnosed to have severe aortic stenosis during this hospitalization. She was found to have an aortic valve diameter of 0.7 cm squared. She will return for follow-up with Cardiothoracic Surgery with Dr. [Last Name (Prefixes) ], for planned aortic valve surgery. As part of the cardiac work-up, the patient had carotid artery ultrasound which showed minimal plaque bilaterally with stenosis less than 40% on a portable study. 9. STAGE 2 DECUBITUS ULCERS: The patient was found to have stage 2 decubitus ulcers on her sacrum. A wound nurse evaluated the patient. She is being treated with Duoderm and frequent rotating from side to side with decreased pressure on her sacrum. 10. GUAIAC POSITIVE STOOL: The patient had one episode of guaiac positive stools. It is unclear if this was due to contamination from her ulcers. Further stool studies did not reveal occult blood. Recommend the primary care physician to [Name9 (PRE) 900] this as an outpatient work-up. 11. ATRIAL FIBRILLATION: The patient had atrial fibrillation with rapid ventricular response during her hospital stay. She was started on an Amiodarone drip. This was weaned off and she was maintained on beta blocker with good rate control. In addition, digoxin was started. 12. DIABETES MELLITUS: The patient's glucose levels were elevated during her hospital stay. She was maintained on insulin sliding scale. Due to her increased creatinine, her Metformin was held and restarted prior to discharge once her creatinine had returned to [Location 1867]. DISPOSITION: The patient is being discharged to an extended care facility. CONDITION AT DISCHARGE: Good, tolerating p.o. diet, ambulating with assistance, but unsteady on her feet; euvolemic. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6206], in seven to ten days to evaluate for her guaiac positive stools and for possibly restarting her statin. 2. The patient is to follow-up with Dr. [Last Name (STitle) ] on Thursday, [2129-4-17], at 01:30 for evaluating her for surgery. DISCHARGE MEDICATIONS: 1. Aspirin 325 once a day. 2. Digoxin 125 micrograms p.o. q day. 3. Toprol XL 100 q. day. 4. Furosemide 20 mg p.o. q. day. 5. Warfarin 5 mg p.o. q. h.s. 6. Insulin sliding scale. 7. Glyburide 5 mg p.o. twice a day. 8. Metformin 500 mg p.o. twice a day. 9. Wound care with normal saline, Duoderm wafers and air mattress. DISCHARGE DIAGNOSES: 1. Cardiogenic shock. 2. Atrial fibrillation. 3. Aortic stenosis. 4. Acute renal failure. 5. Shock liver (transaminitis in the setting of hypotension). 6. Pulmonary edema. 7. Stage 2 decubitus ulcer. 8. Thrombocytopenia of unknown etiology. 9. Chronic renal insufficiency. 10. Pneumonia 11. GI bleed [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3518], M.D. [MD Number(1) 3519] Dictated By:[Last Name (NamePattern1) 2823] MEDQUIST36 D: [2129-4-12] 12:18 T: [2129-4-12] 12:30 JOB#: [Job Number 10223]	[ "570", "785.51", "428.0", "507.0", "397.0", "584.9", "427.31", "287.5", "707.0" ]	icd9cm	[ [ [] ] ]	[ "00.13", "37.22", "96.04", "88.55", "96.71", "89.64", "88.52" ]	icd9pcs	[ [ [] ] ]							3264, 3279	9645, 10230	9294, 9624				4320, 8769		8903, 9271						2737, 2965																				3302, 4303		8785, 8879																				164, 2512															2990, 3197	2534, 2716	3214, 3247
7,784	157,822	7555	Discharge summary	report	Admission Date: [2128-6-15] Discharge Date: [2128-6-24] Date of Birth: [2057-4-23] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Percocet Attending:[First Name3 (LF) 1990] Chief Complaint: left hip pain Major Surgical or Invasive Procedure: total hip arthroplasty left History of Present Illness: 71yo F h/o ETOH cirrhosis, extensive ETOH abuse, s/p conversion to left total hip replacement with stage III osteonecrosis on [2128-6-15]. Pt was admitted to the ortho service for an elective Total knee replacement, intra-op EBL was 400cc. Post-op she was put on Dilaudid PCa, no basal rate. At 5am on [6-16], she triggered for hypoxia, O2 sat 58% on RA and 15cc UOP in the last 5 hours despite 500cc IVF bolus x3, T101.1, HR 130. She was immediately placed on NRB, and sats increased. she was stable overnight, received 3L LR overnight. on [6-16] she received an additional 3L LR and 1 U pRBCs for decreased HCT but no bleed from surgical site per Ortho. She was agitatedand received 1mg Ativan for presumed DTs, which resulted in severe somnolence and lethargy. she then dropped her O2 sats down in to the 80%s, she was tachycardic to the 130s and hypotensive to SBPs in 80s. . She was transferred to the [Hospital Unit Name 153] on [6-17] for further monitoring. A R subclavian CVL was placed for access. She never required intubation or pressors during her 5 day [Hospital Unit Name 153] stay. She was initiated on lactulose given [Doctor Last Name 688] mental status, as well as placed on a CIWA scale given her liver disease. It was felt her respiratory depression was iatrogenic in the setting of narcotics and poor liver clearance as well as likely aspiration PNA in the setting of her mental depression. . Given her fluid resuscitation, she was slowly diuresed during her [Hospital Unit Name 153] stay. Her PNA was treated with CTX 1g qD and she defervesced. She was slowly weaned down on narcotics/benzos and is tolerating them well. Her pain is adequately controlled on her current regimen. Past Medical History: -ESLD [1-16] etoh -Irritable bowel syndrome -Diverticulitis -Diverticulosis (colonoscopy [11-17]) -s/p cataract surgery b/l -Barretts esophagus (egd [2125]) -Gastritis (egd [2125]) -Grade I Varices GEJ (egd [2125]) -PUD (egd [2123], not seen on repeat [2125]) -L hip fx with screw placement in [State 108] [2123], now w/ OA and possible AVN -Atypical CP > stress test negative in [7-17] Social History: lives with husband, has 2 children, 25 pack year smoking history, she reports drinking [1-17] vodka tonics per day, but daughter and husband report that she actually drinks a lot more than that and hides ETOH in the house. Has been able to quit for a few months at a time in the past usu after hospitalizations, but then goes back to it. No h/o drug use. Family History: mother died of pancreatic cancer, father with heart disease. Physical Exam: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: left lower Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Extensor/flexor hallicus longus intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: [2128-6-15] 10:21AM PLT COUNT-169 [2128-6-15] 10:21AM WBC-8.6 RBC-3.13* HGB-10.1* HCT-29.2* MCV-93 MCH-32.3* MCHC-34.5 RDW-16.0* [2128-6-15] 08:50PM PT-15.0* INR(PT)-1.3* [2128-6-15] 08:50PM PLT COUNT-170 [2128-6-15] 08:50PM WBC-8.3 RBC-2.84* HGB-9.1* HCT-27.0* MCV-95 MCH-31.9 MCHC-33.6 RDW-16.4* [2128-6-15] 08:50PM estGFR-Using this [2128-6-15] 08:50PM GLUCOSE-101 UREA N-15 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12 Brief Hospital Course: 71 yo F with h/o extensive ETOH abuse, DTs during last hospitalization, and ETOH cirrhosis now s/p L total hip replacement transferred to [Hospital Unit Name 153] on ([6-16]) for hypoxia, respiratory suppression from iatrogenic narcotic o/d, likely aspiration pneumonia, and pulmonary edema then to floor once stable for continued management. . 1. Hypoxia Likely multifactorial; combination of iatrogenic pulmonary edema from aggressive volume repletion and aspiration pneumonia, and respiratory depression from narcotic o/d. Now well controlled, on 2L NC. - continued CTX qD for 8 days; at d/c transitioned to oral therapy with cefpodoxime 200 [Hospital1 ] for two days more at rehab (total of 10 days of therapy) - cont lasix 40mg [Hospital1 ] to help with diuresis - may have baseline o2 requirement from undiagnosed COPD; wean as tolerated - cont nebs prn . 2. Encephalopathy: greatly improved. Likely due to baseline cirrhosis and hepatic encephalopathy complicated by narcotics. -Controlled with lactulose 30 [Hospital1 ], goal of 3 BMs/day (decreased from qid due to frequent BMs today) - Minimized [Hospital1 ]/narcotics-->PO dilaudid 1mg Q8H PRN max. . 3. HCT drop 2/2 left thigh hematoma (site of operation) per CT - HCT stable at d/c - cont. to monitor with daily hct - Restarted on lovenox 40QD per ortho for dvt ppx. . 4. s/p L hip replacement - Rehab. - o/p follow up (arranged) . 5. h/o GIB (PUD on EGD in [2123], not seen on repeat in [2125]) - Continue PPI . 6. Cirrhosis Secondary to long standing etoh use. no evidence of portal HTN or ascites on exam. Evidence of mild hepatic encephalopathy present now which appears greatly improved. - cont lactulose - restarted spirinolactone and lasix (at 1/2 outpatient doses) at discharge as appears euvolemic now and may have been over-diureses slightly after ICU stay . 7. CODE: FULL Medications on Admission: Meds at home: Lasix 40 mg qd Folic Acid 1mg Iron 325 mg Acetaminophen/Codeine 1 tab prn Protonix 40 mg Spironolactone 100mg Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 9. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea/vomiting. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: Golden Lving Center-[Location (un) 5344] Discharge Diagnosis: DJD/AVN left hip c/b hypotension felt due to narcotics, possibly pneumonia. Discharge Condition: stable Discharge Instructions: Take all medications as prescribed Keep the incision clean and dry. Please apply a dry sterile dressing daily as needed for drainage or comfort. If you have any shortness of breath, 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 bear partial weight on your left leg. Please start all of the medications you took prior to your admission. Take all medication as prescribed by your doctor. Continue your Lovenox injections as prescribed to help prevent blood clots. Feel free to call our office with any questions or concerns. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[2128-7-14] 12:30	[ "518.5", "303.90", "571.2", "458.29", "E935.8", "715.35", "564.1", "998.12", "285.1", "997.3", "456.21", "V54.89", "305.1", "733.42", "507.0", "572.2" ]	icd9cm	[ [ [] ] ]	[ "81.51", "89.62", "78.65" ]	icd9pcs	[ [ [] ] ]	7202, 7273	3876, 5759	306, 336	7393, 7402	3358, 3853	8089, 8285	2947, 3009		5934, 7179		7294, 7372	5785, 5911			7426, 8066										3024, 3339																												253, 268										364, 2104																2126, 2554	2570, 2931
30,754	164,006	50391	Discharge summary	report	Admission Date: [2144-11-28] Discharge Date: [2144-12-3] Date of Birth: [2073-6-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7881] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with intervention (drug eluting stent to LAD) Hemodialysis History of Present Illness: Mr. [Known lastname 105012] is a 71 year old male with h/o CAD s/p overlapping DES to the LAD [6-26] then [8-28], recent admit for CP ([11-23]) had MIBI with no reversible defects, ESRD on HD, hyperlipidemia, HTN, DM2 who presents with chest pain since Thursday. Mr. [Known lastname 105012] had a DES placed in the mid LAD in [6-/2143] and DES placed to the proximal LAD in [Month (only) ] of this year. He was admitted on [11-23] for chest pain. He had three sets of enzymes - negative CK and trop stable at 0.20. He had an exercise MIBI that showed fixed moderate sized defect of the inferior and anterior wall and apex, no reversible defects were appreciated, exercise induced LV dilitation. He was discharged on [11-24]. He returns with 2 days of substernal squeezing chest pain which he feels is similar to prior. He has occasional sharp chest pains on the left side. He also has some back pain which he is attributing to lying on the stretcher for hrs. He has not slept in two days due to the chest pressure. He says that Friday evening the chest pain was at its worst, but still persists today. He has associated shortness of breath and nausea, no lightheadedness or diaphoresis. He has been taking NTG at home with some brief relief of chest pain. He is on HD for ESRD. Had HD yesterday without event. . In the ED, vital signs were BP 132/66, HR 72, RR 20, O2sat 100% on RA. He was given morphine 2mg with no relief of CP. SL NTG x1 with pain improved from [2-1] to [1-1]. He was given lopressor 50mg x1 and second SL NTG and became pain free. At 6PM CP returned, this time [4-30] pain and started on nitro gtt. Reportedly became CP free. Case discussed with cardiology in the ED and decision to start heparin gtt w/o bolus. Positive troponin (CK 415, MB 31, Trop 0.58). Other notable labs: WBC 13.7, Hct stable 37.9, creatinine 5.0. . Review of symptoms is positive for nausea, shortness of breath and fatigue. Negative for nausea, dizziness, palpitations, abdominal pain or syncope. He has not had any BRBPR or melena. . On arrival to the floor patient continues to have [3-31] substernal chest squeezing. He also says that his shortness of breath is increased from prior. He is on nitro gtt and heparin gtt. He is complaining of back pain. Past Medical History: CAD, s/p stent to the LAD on [2142] then overlapping DES to the LAD on [2144-8-26] Hypertension CHF- EF 55%, 1+ MR, mild LVH by echo [6-/2141] (EF 49% by stress MIBI [2144-8-21]) Diabetes Hyperlipidemia Heart block s/p pacemaker [2-/2142] Chronic renal failure on HD q MON, and Friday (plan for a transplant in the future) S/P right arm AV fistula [3-/2143] Cellulitis [6-/2141] Bilateral adrenal adenomas Diverticulosis Antral polyps Cholelithiasis by CT on [2143-7-16] S/P right CFA pseudoaneurysm repair [2143-7-16] for wound cellulitis post catheterization Social History: Restauranteur Denies etoh intake, tobacco use or illicit drug use 40 pk-yr history, quit 24 yr ago. Family History: Negative for coronary artery disease. Mother: died of multiple myeloma at age 84. Father: Died at age 30 as a casualty of war Physical Exam: VS 98.3, BP 148/89, HR 76, RR 20, O2sat 95% RA Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8 cm however difficult to assess [1-24] habitus, no carotid bruits CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [1-28] holosystolic murmur at the apex. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Clear bilaterally, no wheezes or rhonchi. Abd: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Back: No tenderness to palpation over vertebrae and no paraspinal tenderness Ext: Trace edema bilaterally. No femoral bruits. Pertinent Results: [2144-11-28] 07:50PM CK(CPK)-362* [2144-11-28] 07:50PM CK-MB-25* MB INDX-6.9* cTropnT-0.72* [2144-11-28] 12:30PM GLUCOSE-241* UREA N-32* CREAT-5.0* SODIUM-138 POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-31 ANION GAP-16 [2144-11-28] 12:30PM CK(CPK)-415* [2144-11-28] 12:30PM cTropnT-0.58* [2144-11-28] 12:30PM CK-MB-31* MB INDX-7.5* [2144-11-28] 12:30PM WBC-13.7* RBC-4.10* HGB-12.7* HCT-37.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-16.1* [2144-11-28] 12:30PM NEUTS-82.9* LYMPHS-10.7* MONOS-4.1 EOS-2.2 BASOS-0.2 [2144-11-28] 12:30PM PLT COUNT-293 Cardiology Report C.CATH Study Date of [2144-11-30] * Not Signed Out * BRIEF HISTORY: 71 year old man with CAD (Cypher to mLAD [6-26]; last catheterization on [8-28] with 2.5 x 18 and 3 x 13 Cypher DES to proximal and mid LAD); DM, ESRD on HD twice a week; hypertension, complete heart block s/p PM placement, surgically repaired R femoral pseudoaneurism, gastic ulcer/LGIB 2 months ago, who presented with an NSTEMI and was referred for a cardiac catheterization. INDICATIONS FOR CATHETERIZATION: NSTEMI; CAD; multiple prior PCIs PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the left femoral artery, using a 5 French left [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 2) MID RCA NORMAL 2A) ACUTE MARGINAL DIFFUSELY DISEASED 3) DISTAL RCA DIFFUSELY DISEASED ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 99 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD DIFFUSELY DISEASED 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX DIFFUSELY DISEASED 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 17) LEFT PDA DIFFUSELY DISEASED 17A) POSTERIOR LV DIFFUSELY DISEASED PTCA RESULTS LAD PTCA COMMENTS: Initial angiography revealed a 99% in-stent restenosis in the previously placed cypher stent in the proximal LAD. We planned to treat this lesion wiht ptca and stenting. Bivalirdudin was started prophyalctically for the procedure. A 6 frenech xblad3.5 guiding catheter provided adequate support for the procedure. A prowater wire crossed the lesion with minimal difficulty. The lesion was dilated with a 2.5x12mm voyager balloon at 10 atm. A 3.0x16mm taxus stent was then deployed at 16 atm. The stent was post dilated with a 3.5x15mm nc [Male First Name (un) ] balloon at 14 atm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and TIMI 3 flow. The patient left the lab free of angina and in stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour55 minutes. Arterial time = 0 hour51 minutes. Fluoro time = 14 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 180 ml, Indications - Hemodynamic Premedications: Versed 0.5 mg IV Fentanyl 50 mcg IV Bivalirudin 82.5 mg IV Bivalirudin 27.5 mg/hr gtt Ntg 300 mcg IC Anesthesia: 1% Lidocaine subq. Cardiac Cath Supplies Used: .014 [Doctor Last Name ], PROWATER 300CM 2.5 [Doctor Last Name ], VOYAGER 12MM 3.5MM [Doctor Last Name ], NC [Male First Name (un) ] 15MM 6 CORDIS, XBLAD 3.5 - ALLEGIANCE, CUSTOM STERILE PACK - GUIDANT, PRIORITY PACK 20/30 3.0MM [Company ], TAXUS 16MM COMMENTS: 1. Selective coronary angiography of this left dominant system demonstrated a diffuse CAD with a severe single vessel CAD. The LMCA was patent. The LAD had 99% ISR of a previously placed proximal Cypher DES; the distal LAD was a small and diffusely diseased vessel. The LCx had a severe diffuse disease of the OM2 branch and diffuse disease in the distal LCx. The RCA was a small non-dominant vessel with a diffuse disease. 2. Limited resting hemodynamics revealed systemic aortic normotension with an SBP of 126 mmHg. 3. Left ventriculography was deferred given elevated LVEDP and renal dysfunction. 4. Successful ptca and stenting of the proximal in-stent restenotic LAD lesion with a 3.0x16mm taxus stent which was post-dilated to 3.5mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and timi 3 flow (see ptca comments). FINAL DIAGNOSIS: 1. Diffuse CAD with a severe ISR of the proxiaml LAD Cypher DES. ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. CARDIOLOGY FELLOW: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],[First Name3 (LF) ] A. ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] P. ([Numeric Identifier 105015]) Brief Hospital Course: Patient is a 71 year old diabetic male with h/o CAD s/p DES x2 to mid/proximal LAD, HTN, hyperlipidemia who presents with 2 days of chest pain, positive enzymes. Heparin drip was started and patients chest pain was controlled with Nitro drip as well as morphine. Patient underwent cardiac catheterization and a drug eluting stent was placed in his LAD (full report attached). Post MI echo was significant for depressed left ventricular systolic function (LVEF= 40%) with apical akinesis, without obvious thrombosis. Given patients history of severe GI bleeding the decision was made to start patient NOT on Coumadin as patient already hypocoagulable due to aspirin, Plavix and hemodialysis. During the hospital course, after cardiac catheterization, patient developed mild respiratory distress with O2 saturation as low as 85% however without subjective feelings of shortness of breath or changes in mental status. Nevertheless patient was transferred to the ICU for close observation and was hemodialysed the following day, with significant improvement. His usual medical regiment of beta blocker, [Last Name (un) ] and Lasix were continued over the hospital course and his volume status was at baseline upon discharge. . Patient appeared sleepy and somnolent on several occasions throughout the day. As reported by his daughter this seems to be "normal" for him. We suggest further workup as out patient with sleep studies to rule out obstructive sleep apnea. Medications on Admission: Nifedipine 60mg [Hospital1 ] Aspirin 325mg daily Imdur 30mg HS Plavix 75mg daily Lipitor 20mg daily Calcium acetate 667 TID Lasix 80mg [Hospital1 ] Valsartan 160mg [Hospital1 *] Toprol 100mg qPM, 50mg qAM Amytriptyline 10mg HS Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 4. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary: Non-ST elevation myocardial infarction Acute systolic congestive heart failure End stage renal disease on hemodialysis . Secondary: Hypertension Diabetes mellitus, type 2 Hyperlipidemia Complete heart block status post pacemaker Bilateral adrenal adenomas Diverticulosis Antral polyps Cholelithiasis Status post right CFA pseudoaneurysm repair Discharge Condition: Afebrile. Stable vitals. O2sat on room air mid-90s. Ambulatory. Discharge Instructions: You were admitted for chest pain and found to have a mild heart attack. You underwent cardiac catheterization and were found to have narrowing in your coronary artery (LAD) at the place where you had a prior stent; a new stent was placed in this location. . After the procedure you developed trouble breathing related to fluid overload and required an overnight stay in the intensive care unit for dialysis. Your dialysis schedule will be increased to 3 times per week according to your renal doctors. . You were also noted to have poor contraction of a portion of your heart likely due to the heart attack. The location of this heart dysfunction increases your risk of stroke and therefore starting a medication to thin your blood (coumadin) was discussed with you. It was decided that ... . Please take all medications as prescribed 2gm sodium diet; fluid restriction 1500ml Measure weights daily, call your doctor if increase > 3 pounds New medications: Changed medications: Discontinued medications: . You absolutely must take both asprin and plavix every day without exception as missing any dose may lead to a repeat heart attack and death. . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [Name2 (NI) 11686] provider with any questions or if you need to reschedule. . Call your PCP to schedule [Name Initial (PRE) ] followup appointment in 2 weeks. . You will go for hemodialysis tomorrow (Friday [2144-12-4]) at your regular outpatient dialysis center. . Cardiology follow-up ...	[ "V45.1", "V45.82", "562.10", "V12.79", "250.00", "414.01", "574.20", "403.91", "V45.01", "288.60", "428.0", "272.4", "410.71", "227.0", "428.21", "585.6" ]	icd9cm	[ [ [] ] ]	[ "00.45", "36.07", "37.22", "88.56", "00.66", "00.40", "39.95" ]	icd9pcs	[ [ [] ] ]	12883, 12969	9981, 11448	327, 412	13366, 13432	4540, 5609	14839, 15215	3501, 3629		11737, 12860		12990, 13345	11474, 11714		9454, 9958	13456, 14816										3644, 4521															7741, 9437												5642, 7722	277, 289										440, 2745																2767, 3367	3383, 3485
21,079	128,484	21778	Discharge summary	report	Admission Date: [2144-1-21] Discharge Date: [2144-1-29] Date of Birth: [2087-12-1] Sex: F Service: SURGERY Allergies: Norvasc Attending:[First Name3 (LF) 148] Chief Complaint: pancreatic mass Major Surgical or Invasive Procedure: Pylorus sparing pancreaticoduodenectomy History of Present Illness: 56-year-old woman presented a month ago with a biliary stricture and a pancreatic head mass. She received a CT scan after her ERCP procedure and this demonstrated a large lesion in the head of the pancreas consistent with a pancreatic cancer. A fine needle aspiration for cytology demonstrated highly atypical epithelial cells. She was scheduled to see Dr. [Last Name (STitle) ] in the clinic for evaluation of the surgical resection, but in the interim became jaundiced and was transferred back to our facility for an emergent ERCP to drain her bile duct. Past Medical History: Diabetes mellitus Hypertension Pancreatic mass status post appendectomy Status post tubal ligation Social History: No alcohol or taobacco Family History: noncontributory Physical Exam: General: no apparent distress HEENT: neck supple, no lymphadenopathy Cardiac: regular rate and rhythm Lungs: clear to auscultation Abdomen Obese, soft, nontender and nondistended Extremities: no clubbing cyanosis or edema Neuro: alert and oriented, neurovascularly intact bilaterally On discharge the patient had a well healing abdominal incision that was clean dry and intact. The abdomen was soft, nontender and nondistended Pertinent Results: Discharge labs: [2144-1-24] WBC-9.4 RBC-3.23* Hgb-9.0* Hct-28.6* MCV-89 MCH-27.8 MCHC-31.3 RDW-13.8 Plt Ct-190 Glucose-153* UreaN-8 Creat-0.5 Na-137 K-3.5 Cl-101 HCO3-27 AnGap-13 Calcium-8.5 Mg-1.5* The pathology was pending at the time of discharge Brief Hospital Course: The patient underwent a pylorus sparing pancreaticoduodenectomy on [2144-1-21]. She tolerate dthe procedure well and the patient had an estimated blood loss of 650cc. The patient remained intubated on the night of the operation, given the length of the procedure. For this reason the patient was transfered to the surgical intensive care unit for monitoring postoperatively. The patient had some decreased urine output over the night of postoperative day 0, and the patient received some fluid boluses, which led to increased uring output. She received aggressive resucitation overnight. She had a favorable course for extubation on the morning of postoperative day 1 and the patient was extubated without event. She was placed on an insulin drip for tight glucose control. The patient also had an epidural for pain relief. The patient remained in the ICU overnight for low urine output. On postoperative day 2 this had improved substantially and the patient was ready for transfer to the surgical floor. [Initials (NamePattern4) ] [Last Name (NamePattern4) 387] consult was obtained to assist in tight glucose control. The patient was continued on the whipple clinical pathway and the epidural, NG and foley were discontined on post operative day 3. Her sliding scale was increased on post operative day 4. Physical therapy was consulted to help in mobility postoperatively. The patient also recieved sips on postoperative day 4. On post operative day 5 the PCA was discontinued, and the patient was transferred to PO pain meds and advanced to a clear liquid diet. On post operativd day 6 the patient ha flatus and was advanced to a full liquid diet. The patients JP amylase was checked and was within normal limits and the patient had 3 bowel movements. On post operative day 7 the patient was advanced to a regular diet and the patients JP drain was discontinued. The patient was in stable condition and ready for discharge to home with follow up with Dr. [Last Name (STitle) ] and The [Hospital ] Clinic. Medications on Admission: Lisinopril, protonix, lipitor, insulin Lantus/humalog, metformin, atenolol Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 2. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:120 Tablet(s) Refills:2 3. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. Disp:20 ml Refills:2 4. Other meds Continue your home medications: protonix 40qd, atenolol 25qd & lisinopril 20qd. Discontinue your metformin. Please take colace 100bid while you are using percocets.. 5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) dose Subcutaneous four times a day: follow attached sliding scale. follow up with [Last Name (un) 387] as instructed. Disp:5 ML Refills:2 Discharge Disposition: Home Discharge Diagnosis: Status post pylorus sparing pancreaticoduodenectomy Pancreatic mass Hypertension Diabetes Hypovolemia Oliguria Discharge Condition: Good Discharge Instructions: [Name8 (MD) ] MD with any worsening abdominal pain, intractable nausea or vomiting, inability to tolerate food, yellowing of your skin, Increased itching. You may shower, but do not bathe You should resume taking any medications you were taking prior to this hospitalization. You should not do any heavy lifting (objects greater than 5 pounds) for 6 weeks. You should resume your regular diet. Make sure that you take sufficient fluids You will be prescribed narcotics for pain relief. You should not drive while on these medications. These medications may also cause constipation and you should take a stool softner such as colace while on these medications. You should check your blood sugars several times a day and administer the regular insulin via a sliding scale provided in your discharge instructions Followup Instructions: You should follow up with Dr [Last Name (STitle) ] in 2 weeks. [Telephone/Fax (1) ]. Call with any other questions. You should follow up with Dr. [Last Name (STitle) 978] at the [Hospital 387] clinic today. Completed by:[2144-1-29]	[ "788.5", "276.5", "157.0", "250.00", "401.9", "759.6", "574.10", "577.1" ]	icd9cm	[ [ [] ] ]	[ "54.23", "50.19", "52.7", "40.3", "51.22" ]	icd9pcs	[ [ [] ] ]	4830, 4836	1855, 3900	282, 324	4991, 4997	1576, 1576	5864, 6119	1095, 1112		4025, 4445		4857, 4970	3926, 4002			5021, 5841			1592, 1832							1127, 1557					4463, 4807																							227, 244										352, 917																939, 1039	1055, 1079
24,745	147,586	10232	Discharge summary	report	Admission Date: [2139-2-20] Discharge Date: [2139-2-25] Date of Birth: [2081-3-16] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Nonfunctioning arteriovenous fistula. HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old male, with end-stage renal disease, who presents for AV fistula thrombectomy. PAST MEDICAL HISTORY: Significant for CAD, history of an inferior MI, CHF with an EF of 40%, peripheral vascular disease, end-stage renal disease dialyzed on Tuesday, Thursday and Saturday, diabetes type 2, hypertension, increased cholesterol, LAFB, BPH, history of MRSA, GERD, prostatitis, frequent UTIs, history of bradycardia, recent TMA. MEDICATIONS AT HOME: Plavix 75 once daily, Prevacid 15 once daily, captopril, insulin, Lipitor. Medication list not complete preoperatively. PHYSICAL EXAMINATION: Patient was alert. Lungs were clear to auscultation. Cardiac exam was regular rate and rhythm. Abdomen soft, nontender. Patient was taken to the OR on [2-20] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for attempted left AV fistula thrombectomy for thrombosed AV fistula. BRIEF HISTORY/HOSPITAL COURSE: Patient was brought to the operating room during the case. Please see operative report for details. During the case, a brachial pulse, a radial pulse was not palpable. Anesthesia was checked with. They noted that patient was in PEA arrest with blood pressure of 40/20 based on a right cuff. The graftotomy site was closed with 7-0 Prolene. The skin incision was stapled, and ACLS was begun. The patient was emergently intubated and received epinephrine, calcium, bicarbonate, and his blood pressure returned. He had pulses in his groin. A right femoral Quinton catheter was quickly placed for both IV, as well as dialysis access. A left femoral arterial line was placed, and a right IJ triple-lumen was placed almost simultaneously. During these times, the patient had received epinephrine, calcium. During this time his blood pressure dropped, and his heart rate dropped to the 40s. He received atropine and then converted to ventricular fibrillation, receiving cardioversion x3 with return of normal sinus rhythm. At this time, he was started on epinephrine drip for a blood pressure of 40/70 systolic range, and maintained in a normal sinus rhythm. He was then transferred to the PACU in critical condition. He was then transfused to the SICU. A TTE was performed which showed severely dilated right ventricle with severe global free wall hypokinesis was noted. the left ventricular function was mildly depressed globally. No evidence of dynamic LVOT obstruction was noted. The aorta was intact. The left atrium was of normal size. No spontaneous echo contrast or thrombus was seen in the body of the left atrium, or the right atrium, or right atrial appendage. No atrial septal defect was seen by 2-D or color Doppler. Overall, the left ventricular systolic function was mildly depressed. There was no mass or thrombus in the right ventricle. There was mild aortic leaflet thickening. No aortic valve stenosis. There was moderate thickening of the mitral valve leaflet. EF was greater than 55%. Compared with the findings of the prior study, images reviewed of [2138-12-24], there were no significant changes. On EKG, there were inferior Q waves in II, III, AVF and V1 through V6. Chest x-ray demonstrated positive cardiomegaly without effusion or CHF. He received cycle enzymes. On hospital day 2, the patient while he was eating denied any chest pain or shortness of breath. Blood pressure was 150/60 with a heart rate of 82. He was in no acute distress. His hematocrit was 32. He received hemodialysis via the groin catheter with gentle ultrafiltration. He was started on Epogen. Nephrology followed throughout the hospital course, making recommendations. Cardiology was consulted. A cardiac cath was done on [2-23]. This demonstrated 2-vessel disease. No intervention was done. He had heavily calcified LFA. The LVEDP was mildly elevated. There were some beats with early LV. Systolic pressure to negative 2 mmHg. His blood pressure was a little labile between 120 and 180 mmHg. Mild left ventricular diastolic dysfunction was noted. Peripheral arterial disease was noted, as well as systemic systolic arterial hypertension. There was trifurcation distal to the LMCA into the LCX and ramus origin not favorable for PCI. The distal LPL and ramus were not ideal targets for CABG. Moderate LAD disease. Medical therapy was recommended, and cardiac surgery evaluation was deferred. Electrophysiology evaluation was recommended to be considered, and reinforcement of secondary preventative measures against CAD, PVD and diastolic dysfunction were recommended. An EP consult was obtained. After review of history and diagnostics, no further recommendations were made. An EP study was deferred. The vascular team followed the patient. The patient is known to Dr.[Name (NI) 1392] service for recent right TMA and left toe gangrene. Vital signs are stable. He was afebrile. A left tunneled hemodialysis catheter was placed on [2139-2-23] using a 14.5 French double-lumen 23-cm cuff-tip tunneled dialysis catheter via the left subclavian access with the tip at the cavoatrial junction. The patient did go to dialysis and tolerated this well. On [2-24], 1.8 kg was ultrafiltrated. Blood pressures ranged between 140/60 down to 108/82, with heart rate in the 78-81 range. He received Epogen at hemodialysis. Patient on physical exam continued to be alert but mildly confused. O2 2 liters nasal cannula was utilized with sats ranging in the high-90s up to 97%. He has remained n.p.o. intermittently for possible EP study. This was deferred, and he was resumed on a renal diet. The patient completed a course of Flagyl that had been started previous to this admission. A CTA was done of the chest to assess for PE, given concern for right atrial enlargement. The CTA demonstrated no central pulmonary embolism, coronary artery calcification, small bilateral pleural effusions, and right lower lobe consolidation, multiple rib fractures, displaced midsternal fracture, which appeared to be new compared to the prior study. The EP consult team reviewed findings with Dr. [First Name (STitle) ], and no further studies were recommended other than medical management. Of note, the patient had a prior episode of PEA secondary to hypoglycemia. It was felt that the patient would be safe to return to rehab. Physical therapy followed the patient during this hospital course. It was noted that the patient had impairments associated with chronic polyneuropathy and amputation. He was functioning below his baseline. Rehab was recommended to increase functional mobility given deconditioning. During this hospital course, the patient's vital signs post arrest, he was afebrile, blood pressure was in the 140/60 range, heart rate in the 80s, O2 sat 94% on room air. His glucoses were controlled. He does not make urine. He was resumed on a renal diet. Of note, the patient has a clamped G-tube. His right TMA is open to air with black eschar along the TMA site. The left second toe appears necrotic. There were bright red areas noted at the toes and some black eschar on the left first toe. Multi-Podus boots were applied. During this hospital course, his hematocrit was relatively stable in the range of 34.7 down to 31. White count remained in the 6.1-6.9 range. Coags were normal. Sodium 142, potassium 4.3, chloride 102, bicarbonate 29, BUN 15, creatinine 4.4, and a glucose of 114 on [2-25]. CPKs were negative. His alkaline phosphatase was noted to be a little elevated at 183 on [2139-2-20]. Troponin was 0.15 on [2139-2-21]. Previous troponins were 0.15 and 0.1. Calcium was stable at 9, phosphorus 3.8-5.8, magnesium 1.6-1.9, albumin 3.0. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Included aspirin 325 mg p.o. once daily, lansoprazole 15 mg p.o. once daily, Nephrocaps 1 tab p.o. once daily, PhosLo 1334 mg p.o. t.i.d., insulin regular sliding scale q.i.d. p.r.n., captopril 12.5 mg p.o. t.i.d., Colace 100 mg p.o. b.i.d., heparin sodium 5000 units SC t.i.d., Tylenol with codeine 1-2 tabs p.o. p.r.n. q. [1-31] h, Plavix 75 mg p.o. once daily, labetalol 300 mg p.o. t.i.d. DISCHARGE DIAGNOSES: Thrombosed left arteriovenous fistula, Methicillin resistant Staphylococcus aureus, Clostridium difficile--resolving, pulseless electrical activity with ventricular fibrillation arrest, end-stage renal disease, hypertension, peripheral vascular disease, diabetes type 2, hyperlipidemia, gastroesophageal reflux disease. PLAN: Return to [Hospital3 ] to continue physical therapy. Of note, the left arteriovenous fistula has a bruit and thrill. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2139-2-25] 13:39:23 T: [2139-2-25] 14:57:16 Job#: [Job Number 34099]	[ "414.01", "996.73", "250.00", "427.5", "403.91", "997.1", "585.6", "428.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.22", "39.95", "39.49", "38.95" ]	icd9pcs	[ [ [] ] ]				7893, 7902				8346, 9050	7926, 8324				1193, 7871								710, 831																				854, 1175												172, 211										240, 344																367, 688
55,104	123,360	53703	Discharge summary	report	Admission Date: [2167-4-3] Discharge Date: [2167-4-10] Date of Birth: [2086-11-9] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 371] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2167-4-8]: PICC line placement History of Present Illness: Mr. [Known lastname 42484] is a 80 year old man with Crohn's disease s/p recent laparotomy, lysis of adhesions, and ileocecectomy with end ileostomy on [2167-3-12] for small bowel obstruction and anastamotic stricture. He was discharged to rehab on [3-17] after return of bowel function, tolerating a regular diet, on a steroid taper. He remained at rehab until today when he began having increasing abdominal pain after eating a large breakfast. He denies nausea and continued to have ileostomy output. He was taken to [Hospital 26380] Hospital where a CT scan showed a small amount of free intraabdominal air. He was reportedly hypotensive at the OSH. He was transferred to our ED for further evaluation. Upon arrival, his blood pressure was initially 86/58 however subsequently improved with a SBP in the 110s. Upon evaluation in the ED he actually reports the pain has improved somewhat. Past Medical History: Past Medical History: crohn's disease, CVA, PE, IVC filter, COPD Past Surgical History: ileocecectomy ~30 years ago, ileocectomy and take down of duodenal fistula as above [2167-3-12] Social History: The patient lives at home with his wife. [Name (NI) ] quit smoking 18 years ago. He drinks ~1 glass of wine per night..used to drink at least 4 cocktails per night. He worked in real estate. Family History: NC Physical Exam: On admission: Vitals: 99.8F 95 86/58 -> 110/60 16 100% RA GEN: A&O, lying in bed, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, mildly TTP, no RLQ TTP, mild LLQ TTP with sensation of mild fullness in LLQ, no rebound/gaurding Ext: No LE edema, LE warm and well perfused On discharge: Vitals: 97.6 55 122/80 18 95%RA GEN: A&O, NAD HEENT: Mild edema noted at old R IJ CVL site, dressing dry, no drainage, area soft, nontender. Trachea midline. No scleral icterus, mucus membranes moist. CV: RRR PULM: Breath sounds diminished at bases, otherwise clear throughout ABD: Soft, nondistended, nontender. Ileostomy with dark liquid stool output and gas. EXT: No edema. Warm, pink and well perfused. Pertinent Results: [2167-4-3] 07:05AM BLOOD WBC-16.1* RBC-3.57* Hgb-11.1* Hct-36.4* MCV-102* MCH-31.0 MCHC-30.4* RDW-15.5 Plt Ct-367 [2167-4-4] 02:09AM BLOOD WBC-13.2* RBC-2.75* Hgb-8.5* Hct-27.0* MCV-98 MCH-30.9 MCHC-31.4 RDW-15.0 Plt Ct-264 [2167-4-5] 02:02AM BLOOD WBC-12.0* RBC-2.63* Hgb-8.2* Hct-26.5* MCV-101* MCH-31.2 MCHC-30.8* RDW-15.4 Plt Ct-225 [2167-4-3] 01:27AM BLOOD Lactate-4.0* [2167-4-3] 01:59PM BLOOD Lactate-2.6* [2167-4-4] 02:26AM BLOOD Lactate-1.3 CT abd [4-2]: IMPRESSION: 1. 16 mm splenic artery pseudoaneurysm with focus of mural calcification. 2. Multiple intra-abdominal fluid collections which contain foci of gas with rim enhancement. Findings may be simply secondary to irrigation following laparotomy; however, intra-abdominal fluid collections or abscesses could have a similar appearance. 3. Unusual linear hyperdense focus in the third part of duodenum is of uncertain etiology but appears intraluminal and likely represents an ingested material. 4. satisfactory appearance following extended cecectomy and end ileostomy. Mild ileal mural thickening is suggestive of an enteritis but may be secondary to ongoing intra-abdominal inflammation. 5. Diverticulosis, but no evidence of acute diverticulitis at this time. 6. Small abdominal aortic aneurysm measuring 3.2 cm. CT abd [4-7]: 1. The intra-abdominal abscess is overall of similar volume compared to [2167-4-2], although the shape is variable. A tiny fluid tracks to the right upper quadrant with small foci of free air adjacent to the gallbladder, unchanged. 2. Gallbladder distention, with nonspecific wall stranding in the setting of anasarca. Distention is similar to [2167-3-10] but increased from [2167-4-2]. If clinically indicated, HIDA could be performed for further evaluation. 3. Abdominal aortic aneurysm to 3.1 cm is unchanged. Marked stenosis of the celiac artery origin and mild stenosis of SMA origin due to atherosclerotic plaque. 4. Bilateral pleural effusions are increased from [2167-4-2]. [2167-4-7] 04:05AM BLOOD ALT-20 AST-13 AlkPhos-77 Amylase-27 TotBili-0.6 [2167-4-7] 04:05AM BLOOD Lipase-12 [2167-4-10] 04:42AM BLOOD WBC-11.0 RBC-2.89* Hgb-8.8* Hct-28.1* MCV-97 MCH-30.5 MCHC-31.3 RDW-15.4 Plt Ct-296 [2167-4-10] 04:42AM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.4* [2167-4-10] 04:42AM BLOOD Glucose-151* UreaN-8 Creat-0.6 Na-138 K-3.1* Cl-103 HCO3-28 AnGap-10 [2167-4-10] 04:42AM BLOOD Albumin-2.3* Calcium-7.6* Phos-2.5* Mg-1.5* Brief Hospital Course: 80M w/ Crohn's disease s/p ileocecectomy for stricture and enteroenteric fistula, presented to [Hospital1 18] with a lactate of 4, a dirty U/A, and intraabdominal abscesses on CT abd. He was admitted to the ICU for aggresive fluid resuscitation. Over the course of his three days in the TICU he was administered 10 L crystalloid and albumin. His lactate improved and pressors were weaned. He was started on IV vanco and zosyn. IR was consulted for possible drainage of his multiple intraabdominal abscesses but it was determined initially that the abscesses were not amenable to drainage. A discussion was had with the patient's HCP regarding operative washout but the family decided against surgical intervention. Given his improved exam, laboratory values and stable hemodynamics, he was transferred to the floor on [2167-4-5] tolerating sips of fluids. On the floor maintenance IV fluids were continued and he remained hemodynamically stable. He remained afebrile and his WBC count trended downward to normal. However, he continued to have decreased oral intake and leukocytosis and so a repeat CT scan was obtained on [4-7] to assess whether the prior noted fluid collections would be amenable to drainage. However, the collections again were determined to not be amenable to drainage. Therefore, his IV antibiotics were continued but changed to cipro and flagyl for empiric coverage of his abscesses. A CVL in his right IJ had been placed on admission, and was removed on [2167-4-8]. A PICC line was inserted at that time with a plan for a 2 week total course of IV cipro/flagyl. His diet was slowly advanced as tolerated. Nutritional supplements were added to his diet. He was able to tolerate a regular diet without nausea/vomiting or abdominal pain. His home medications were resumed at that time and IV hydrocortisone was discontinued and his PO prednisone taper was resumed per GI recommendations from prior admission for management of Crohn's. As his oral intake increased, his ileostomy output was noted to increase as high as 2 liters per day. On [4-10] he was started on loperamide for this. He also required daily repletions of his electrolytes. His urine culture from admission return as MRSA. He had received 4 days of vancomycin coverage for this prior to his antibiotics being changed to cipro/flagyl. A foley catheter was inserted on admission given aggressive resuscitation and need for urine output monitoring. It was removed on [4-8]; however, he failed to void and the foley was replaced for urinary retention. He was encouraged to mobilize out of bed and ambulated as tolerated with a walker, with which he required assistance. Physical therapy was consulted for evaluation who recommended discharge to rehab when medically stable. He was started on SC heparin for DVT prophylaxis. His pain level was routinely assessed and well-controlled with tylenol. Of note, pt's INR was elevated on admission and throughout his hospital course (1.7-2.4). This was thought to be likely due to malabsportion and poor nutrition, and he was given IV vitamin K 2 mg X 2 and his INR came down to 1.4. On [4-10] he is afebrile and hemodynamically stable. He is tolerating a regular diet without abdominal pain or nausea/vomiting. His WBC count is within normal limits and he is making adequate amounts of urine. He is being discharged to rehab to continue his recovery. Medications on Admission: 1. pantoprazole 40 mg PO Q24H 2. mesalamine 1200 mg Delayed Release TID 3. simvastatin 20 mg PO DAILY 4. folic acid 1 mg PO DAILY 5. magnesium oxide 400 mg once a day. 6. Calcium 500 + D (D3) 500-125 mg-unit PO once a day. 7. Fish Oil 1,200-144-216 mg Capsule PO twice a day. 8. Iron (ferrous sulfate) 325 mg (65 mg iron)PO twice a day. 9. acetaminophen 500 mg Tablet Sig: Two Tablet PO TID 10. tramadol 25 mg PO Q6H as needed for pain. 11. prednisone 40 mg daily for 7 days. 12. prednisone 30 mg daily for 7 days 13. prednisone 25 mg daily for 7 days 14. prednisone 20 mg daily for 7 days 15. prednisone 15 mg daily for 7 days 16. prednisone 10 mg daily for 7 days: 17. prednisone 5 mg daily Discharge Medications: 1. prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 7 days. 2. prednisone 5 mg Tablet Sig: Three (3) Tablet PO daily () for 7 days. 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 7 days. 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for * days. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 12. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Two Hundred (200) mL Intravenous Q12H (every 12 hours) for 11 days. 13. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q8H (every 8 hours) for 11 days. 14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 15. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 16. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 ] Discharge Diagnosis: Multiple intra-abdominal abscesses Urinary tract infection- MRSA Sepsis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital with increased abdominal pain and other signs of infection. You had a CT scan which showed multiple intra-abdominal fluid collections. You were also found to have a urinary tract infection. You were started on intravenous antibiotics for this and a PICC line was placed. You are being discharged on 2 more weeks of antibiotics. You are now being discharged to a rehab facility to continue your recovery. You have 2 appointments scheduled below. Your GI follow up appointment that you initially had scheduled with Dr. [Last Name (STitle) 1940] has been rescheduled with her fellow Dr. [First Name (STitle) ]. The other appointment is in our surgery clinic. Please follow up at the dates and times listed below. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2167-4-21] at 3:30 PM With: [First Name8 (NamePattern2) 4503] [Last Name (NamePattern1) 4504], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2167-4-28] at 1:45 PM With: ACUTE CARE CLINIC with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2167-4-10]	[ "788.20", "599.0", "995.92", "998.59", "496", "567.22", "E878.8", "785.52", "569.83", "V45.72", "038.12" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10743, 10786	5070, 8483	317, 355	10902, 10902	2551, 5047	11853, 12646	1738, 1742		9228, 10720		10807, 10881	8509, 9205			11085, 11830								1407, 1509		1757, 1757																			2124, 2532									262, 279										383, 1296								1771, 2110	10917, 11061							1340, 1384	1525, 1722
27,504	122,586	31420	Discharge summary	report	Admission Date: [2112-9-15] Discharge Date: [2112-9-21] Service: MEDICINE Allergies: Prednisone Attending:[First Name3 (LF) 613] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a [Age over 90 ] yo M with a history of CAD/CHF, diabetes, who was found at his rehab to have respiratory distress. 911 was called and the patient was found by EMS to be "blue" and not responsive. He was felt to he hypervolemic and was given 80 mg lasix by EMS. Vitals were BP 88/50 HR 105 02 56% RA . On arrival to the ER, he was poorly responsive and was placed on CPAP with improvement in his 02 sats and mental status. As well, patient was started on levaquin and flagyl. . Upon arrival to the ED, he felt that his breathing was significantly improved. He denied chest pain, dizziness. Does report recent fever, chills, and does cough up yellowish sputum that isn't significantly chagned. He notes that he has had increased fluid intake but has been taking his lasix at his rehab. Per family he has had weight gain recently and has been feeling short of breath for the last 3 days. Of note, he was seen in [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) ] and treated with lasix for hypervolemia that was limited by his creatinine. He has recently been treated for a UTI with bactrim and denies urinary or GI symptoms. Past Medical History: CAD s/p at least 2 MIs per patient CHF with past hospital admissions for this Chronic Kidney Disease DM II Peptic Ulcer Disease s/p rx for H.pylori HTN h/o Testicular cancer h/o pancreatitis s/p cholecystectomy s/p L parotidectomy complicated by facial nerve paralysis Social History: no alcohol/tobacco, lives with wife but most recently from STR. Family History: NC Physical Exam: PE: T 96.2 131/54 82 16 94% on 4L I/O [Telephone/Fax (1) 73984] Net negative 1.5L FS 92 101 123 GEN: Alert and oriented x 3 HEENT: EOMI, PERRL, oropharynx clear, Neck: supple, no bruits, no JVD CV: RRR, S1S2, no m/r/g Pulm: crackles b/l, diffuse wheezes Abd: protuberant,distended, flank fullness, +bs Ext: 1+ edema, 1+DP/PT Pertinent Results: [2112-9-15] 04:00AM BLOOD WBC-14.8# RBC-4.40 Hgb-13.8* Hct-41.0 MCV-93 MCH-31.4 MCHC-33.7 RDW-14.2 Plt Ct-407 [2112-9-16] 04:27AM BLOOD WBC-5.1# RBC-3.39* Hgb-10.8* Hct-31.6* MCV-93 MCH-31.9 MCHC-34.2 RDW-14.0 Plt Ct-270 [2112-9-16] 04:02PM BLOOD WBC-4.5 RBC-3.39* Hgb-10.7* Hct-31.4* MCV-93 MCH-31.6 MCHC-34.1 RDW-14.0 Plt Ct-254 [2112-9-17] 07:25AM BLOOD WBC-4.1 RBC-3.68* Hgb-11.3* Hct-33.6* MCV-91 MCH-30.8 MCHC-33.7 RDW-14.3 Plt Ct-261 [2112-9-18] 07:45AM BLOOD WBC-4.6 RBC-3.74* Hgb-11.8* Hct-34.1* MCV-91 MCH-31.4 MCHC-34.5 RDW-14.2 Plt Ct-275 [2112-9-19] 06:40AM BLOOD WBC-4.3 RBC-3.75* Hgb-11.6* Hct-35.0* MCV-93 MCH-31.0 MCHC-33.2 RDW-14.1 Plt Ct-292 [2112-9-20] 06:35AM BLOOD WBC-4.6 RBC-3.81* Hgb-12.1* Hct-34.8* MCV-91 MCH-31.8 MCHC-34.8 RDW-14.3 Plt Ct-256 [2112-9-21] 05:45AM BLOOD WBC-4.3 RBC-3.86* Hgb-12.3* Hct-36.4* MCV-94 MCH-32.0 MCHC-33.9 RDW-14.1 Plt Ct-258 [2112-9-15] 06:00AM BLOOD Glucose-226* UreaN-48* Creat-3.8# Na-140 K-5.5 Cl-105 HCO3-23 AnGap-18 [2112-9-16] 04:27AM BLOOD Glucose-87 UreaN-54* Creat-4.1* Na-140 K-4.2 Cl-105 HCO3-25 AnGap-14 [2112-9-18] 07:45AM BLOOD Glucose-106* UreaN-47* Creat-3.2* Na-141 K-4.4 Cl-105 HCO3-27 AnGap-13 [2112-9-20] 06:35AM BLOOD Glucose-101 UreaN-50* Creat-3.0* Na-140 K-4.5 Cl-102 HCO3-27 AnGap-16 [2112-9-17] 07:25AM BLOOD ALT-18 AST-23 LD(LDH)-172 AlkPhos-87 TotBili-0.2 [2112-9-15] 08:26AM BLOOD CK-MB-NotDone cTropnT-0.07* [2112-9-19] 04:40PM BLOOD CK-MB-NotDone cTropnT-0.06* [2112-9-19] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.06* [2112-9-20] 06:35AM BLOOD cTropnT-0.06* [2112-9-18] 07:45AM BLOOD %HbA1c-6.4* [2112-9-15] 08:29AM BLOOD Type-ART pO2-53* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 Comment-SFM . CT head [9-15]: 1. No intracranial hemorrhage or mass effect. 2. Incompletely evaluated low-density lesion in the right maxillary antrum with extension to the nasopharynx. This finding could represent a retention cyst evolving to a mucocele or antrochoanal polyp. . CXR [9-15]: Bilateral pleural effusions with diffuse interstitial and alveolar opacities bilaterally consistent with pulmonary edema. . ECHO [9-15]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal and mid inferior hypokinesis (RCA territory). The remaining segments contract normally (LVEF = 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no frank aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild pulmonary hypertension. Elevated intracardiac filling pressures. . Renal u/s [9-16]: IMPRESSION: Unchanged cortical thinning without evidence for hydronephrosis. Brief Hospital Course: Patient is a [Age over 90 ] yo M with a history of CHF, CAD s/p 2 prior MIs with acute on chronic renal failure with respiratory distress triggered by congestive heart failure and possible pneumonia due to S. aureus infection. . # Respiratory distress: Thought likely secondary to worsening CHF. Admission weight was 175lbs, up from of 166lbs. However sputum cultures were positive for S.aureus sensitive to nafcillin and patient was started on 10 day course of levofloxacin for PNA. Pt was discharged on day 5 of levaquin. Patient was also provided tessalon perles and albuterol nebs for symptomatic relief. At the time of discharge patient was no longer short of breath and did not require 02 via nasal cannula. . # CHF exacerbation: On admission patient was in respiratory distress with worsening pulmonary edema on CXR and fluid retention with bilateral pedal edema. An ECHO was completed which demonstrated mild regional left ventricular systolic dysfunction with basal and mid inferior hypokinesis (RCA territory). The remaining segments contracted normally (LVEF = 50%) with mild systolic dysfunction. MI was considered as inciting factor but patient's CE's were flat. Patient was monitored on telemetry with no events. He was diuresed with lasix, and given hydralazine for afterload reduction and metoprolol for rate control. We decreased his dose of lasix to 20mg PO daily at time of discharge. Diuresis was limited by acute renal failure. His weight at discharge was 160 pounds. . # CAD: Patient has history of 2 prior MIs. While in house patient was ruled out for acute MI. CK's flat. Tn-T 2 sets mildly elevated to 0.02 and 0.03. 2nd set was completed after patient complained of lightheadedness. Tn was 0.06 at that time with flat CK's. ECHO revealed mild systolic dysfunction. Patient was continued on CAD regimen of ASA, and Bblocker. His Ace-I was held in setting of acute renal failure. As per renal team, ACE-I can be started in the future, but after renal function stable. Patient was started on low dose statin at time of discharge. Baseline LFTs normal. Should be monitored as outpatient. . # Acute on chronic renal failure. Baseline renal function (Cr 2.2). Patient has chronic kidney disease from Diabetes Mellitus and hypertension. Acute renal failure was likely prerenal in setting of CHF and poor forward flow. However, Feurea was greater than 60%. Renal ultrasound was negative for post obstructive cuase. Urine cultures were negative. UA sediment was bland with no casts. Patient was seen by renal consult team and given mixed picture, overall cause of acute renal failure was attributed mostly to prerenal cause. Regardless, patient's renal function improved with diuresis. Peak creatinine was 4.1 with steady decline to 3.0 at time of discharge. Diuresis was limited by fluid status and orthostatis. . # Diabetes: Oral hypoglycemics were held due to patient's poor renal function. WHile in house, patient had relatively good glycemic control and was covered with Sliding scale insulin. Patient was given information to set up outpatient appointment with [Last Name (un) ] Diabetes Center. . # Hypertension: Patient achieved blood pressure control with metoprolol and hydralazine. Patient's isordil was discontinued because patient complained of lightheadedness when taking this medication. Medications on Admission: Amlodipine 10 mg daily Aspirin 81 mg Colace Gabapentin 200 mg TID Flomax 0.4mg daily Isosorbide 120 mg daily HISS Lasix 40 mg [Hospital1 ] (unclear when given or started) [Name (NI) 55883] started [9-10] Bactrim daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO q AM. 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:2 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection QID per insulin sliding scale: Please give 2 units for BG 150-200, 4 units for BG 201-250, 6 units for BG 251-300, 8 units for BG 301-350, 10 units for BG 351-400, 12 units for BG>400. 10. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: 1. hypoxic respiratory failure 2. staph aureus pneumonia 3. acute on chronic renal failure Secondary: 1. systolic congestive heart failure 2. diabetes mellitus type II, uncontrolled 3. coronary artery disease 4. hypertension Discharge Condition: stable, no shortness of breath or clinical signs of heart failure Discharge Instructions: Please monitor your daily weights. Limit your salt intake and keep fluid intake less than 1 liter per day. If you gain or lose more than 2 pounds, contact your primary care physician. If you feel short of breath, have chest pain, palpitations or increased swelling of legs, please contact your doctor or come to the emergency room. We have started you on a new medication called hydralazine 20mg by mouth three times a day. Please continue to take this medication as instructed. You were also started on Metoprolol 37.5 mg to be taken three times a day. You have also been started on atorvastatin for your cholesterol. Note that you should no longer be taking amlodipine, isosorbide, or flomax. Also note that your lasix dose has been decreased. Do not discontinue your medications without consulting your physician. [Name10 (NameIs) ] will also need to continue taking the antibiotic levofloxacin for 5 more days for pneumonia. Please follow up with your geriatrician as below. Please follow up with your cardiologist as below. Please follow up with kidney doctor as well. Followup Instructions: Please follow up with [Last Name (un) ] Diabetes center to set up outpatient appt. You can reach them at ([Telephone/Fax (1) 3537] to schedule an appointment . Please make sure to attend the following appointments. Kidney doctor Provider: [First Name4 (NamePattern1) 1877] [Last Name (NamePattern1) ],MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 435] Date/Time:[2112-9-28] 1:00 . Geriatrician (PCP) Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2112-10-3] 9:00 . Cardiology: Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 3512] Date/Time:[2112-9-26] 9:00 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "518.81", "250.40", "584.9", "403.90", "428.43", "V10.47", "482.41", "428.0", "585.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10215, 10281	5462, 8796	225, 232	10560, 10628	2179, 5439	11759, 12670	1809, 1813		9077, 10192		10302, 10539	8822, 9054			10652, 11736										1828, 2160																												178, 187										260, 1419																1441, 1711	1727, 1793
9,403	185,502	15258	Discharge summary	report	Admission Date: [2127-9-4] Discharge Date: [2127-9-12] Date of Birth: [2072-6-18] Sex: F Service: HEPATOPANCREATICOBILIARY SURGICAL SERVICE. HISTORY OF THE PRESENT ILLNESS: Distal pancreatic mass. PHYSICAL EXAMINATION: The patient is a 55-year-old female, well-developed, well-nourished in no acute distress. HEENT: Mucous membranes moist, no ulcers present. Extraocular muscles are intact. Pupils equal, round, and reactive to light. No evidence of scleral icterus. No evidence of cervical lymphadenopathy. Cranial nerves II through XII grossly intact. CHEST: Chest was clear to auscultation bilaterally. No rhonchi or rales. CARDIAC: Regular rate and rhythm, no murmurs, no thrills, PMI in midclavicular line. ABDOMEN: [Doctor Last Name 406] drain insertion site, mild serosanguinous fluid drainage. Abdominal incision site with Steri Strips intact, no evidence of erythema, no evidence of induration, no evidence of serosanguinous discharge from the incision site. Abdomen was mildly obese. There was no evidence of distention. Abdomen was soft, minimal tenderness to palpation consistent with postoperative day. No evidence of rebound tenderness, no hepatosplenomegaly. EXTREMITIES: No evidence of rash or edema. LABORATORY DATA: Laboratory data revealed the following: Chemistry was within normal range at the date of discharge. SUMMARY OF HOSPITAL COURSE: [Known firstname 501] [Known lastname ] is a 55-year-old female with past medical history remarkable for hypertension, inflammatory bowel disease, status post BTL, DNC, lumpectomy times two, presenting with CT defined 3.2 x 2.0 cm solid mass at the tail of the pancreas. The patient underwent an uncomplicated elective distal pancreatectomy with splenectomy with staging laparoscopy. [Initials (NamePattern4) ] [Last Name (NamePattern4) 406] drain was placed in the left upper quadrant in proximity to pancreatic transection margin. The patient's postoperative course was unremarkable with rapid recovery of bowel function with corresponding tolerance of regular diet without nausea or emesis. By postoperative day #8, decision was made to discharge the patient. Since the [Doctor Last Name 406] drain was continuing to put out significant serosanguinous fluid drainage, the patient was discharged with drain in place with removal scheduled during follow up. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. Although the patient was offered home nursing care for drainage care, as well as dressing care, the patient elected the option to do these procedures by herself along with the help of her daughter. DISCHARGE DIAGNOSES: Status post distal pancreatectomy with splenectomy, staging laparoscopy. DISCHARGE MEDICATIONS: 1. Colace p.r.n. 2. Percocet 1 tablet to 2 tablets 4h.to 6h.p.r.n. pain not to exceed ten tablets in twenty-four hours. FOLLOWUP PLAN: The patient was requested to contact Dr . [First Name8 (NamePattern2) ] [Doctor Last Name ] office in 7 days to 10 days after discharge for follow up care. [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Name8 (MD) 44373] MEDQUIST36 D: [2127-9-17] 12:03 T: [2127-9-17] 12:17 JOB#: [Job Number 44374]	[ "157.2", "196.2" ]	icd9cm	[ [ [] ] ]	[ "52.52", "54.4", "41.5" ]	icd9pcs	[ [ [] ] ]								2721, 2795	2818, 3371																											1425, 2410					255, 1396																																								2435, 2699
3,929	112,987	4974	Discharge summary	report	Admission Date: [2142-1-26] Discharge Date: [2142-2-7] Date of Birth: [2083-10-25] Sex: M Service: TRANSPLANT HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 20622] is a 58 year-old gentleman status post cadaveric renal transplant, which had recently failed for which he was on hemodialysis. He had a recent hospitalization for acute cholecystitis. He represented in clinic with biliary colic and it was thought best that the patient undergo an elective cholecystectomy. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. Status post living related kidney transplant in [2130]. 3. Chronic renal insufficiency for which he is on hemodialysis. 4. Recurrent pneumonia. 5. Multiple pulmonary nodules. 6. MGUS with SPEP significant for monoclonal IGG spikes. 7. Obstructive sleep apnea. 8. Anemia. 9. Deep venous thrombosis of left thigh. 10. Coronary artery disease status post non ST elevation myocardial infarction in [2139-3-12]. 11. Left ventricular systolic as well as diastolic dysfunction with echocardiogram in [2141-8-8] with an ejection fraction of 40%. 12. Right pontine lacunar infarction. 13. Gastroesophageal reflux disease. 14. Diverticulosis. 15. C-difficile. 16. Methicillin resistant staph aureus bacteremia complicated by septic pulmonary emboli and empyema. 17. Hypoglycemic coma. ALLERGIES: Dicloxacillin and Compazine. MEDICATIONS ON ADMISSION: 1. ProAmatine 5 mg three tabs po t.i.d. 2. Prednisone 5 mg one tablet po q day. 3. Neurontin 300 mg two tablets po b.i.d. 4. Pravachol 40 mg one tablet po q day. 5. Atenolol 200 mg one tablet po q day. 6. Isosorbide 90 mg one tablet po q day. 7. Procardia 60 mg one tablet po q day. 8. Glargine 20 units one dose at bedtime. 9. Humalog insulin sliding scale. 10. Renagel 800 mg three tables po t.i.d. 11. Nephrocaps one capsule po q day. 12. Calcitriol vitamin D .25 micrograms one tablet po q day. 13. Levoxyl 25 micrograms one capsule po q day. 14. Protonix 40 mg one tablet po q day. 15. [Year (4 digits) ]. 16. Daily vitamins. 17. Tums. PHYSICAL EXAMINATION: Vital signs temperature 96.8. Blood pressure 145/57. Heart rate 73. Respiratory rate 18. Sating 97% on room air. General, he is a well developed, well nourished and in no acute distress. Head, eyes, ears, nose and throat normocephalic, atraumatic. Extraocular movements intact. Pupils are equal, round and reactive to light. Oropharynx was clear. Neck was supple. Chest was clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdomen was soft, nontender, nondistended. Bowel sounds present. No masses. PD catheter in place. Extremities are well perfuse. No clubbing, cyanosis or edema. LABORATORY: Laboratories on [1-18] sodium 139, potassium 2.9, chloride 96, bicarb 33, BUN 42, creatinine 5.0, glucose 172, ALT 25, AST 34, alkaline phosphatase 150, amylase 59, total bilirubin 0.8, direct bilirubin 0.3, albumin 3.3. White blood cell count 7.8, hematocrit 38.4 and platelets of 169. HOSPITAL COURSE: Mr. [Known lastname 20622] is a 58 year-old gentleman with long standing diabetes mellitus for which he underwent a cadaveric renal transplant that has failed and the patient is apparently on hemodialysis. He had a recent hospital admission for acute cholecystitis. He presented to [Hospital1 1444] on [2142-1-26] for an elective cholecystectomy. The patient was taken to the Operating Room wherein an initially a laparoscopic approach was initiated, however, this was converted to an open cholecystectomy secondary to anatomy. The patient tolerated the procedure well and was extubated and brought to the Recovery Room and later then to the floor. It was noted immediately postoperatively that the patient spiked a fever. He was pan cultured, blood cultures, urine as well as chest x-rays were performed all of which were negative. He was initially placed on Vancomycin and Levofloxacin and after consulting with infectious disease it was thought best to place the patient on Zosyn and Vancomycin for empiric treatment. The patient continued to have fever spikes throughout his hospital admission, however, his white blood cell count continued to be within normal limits. On postoperative day three the patient was found to be slightly unresponsive. It was felt best at this point to transfer the patient to the Intensive Care Unit for closer monitoring. Given his unclear source of fevers he continued to be hemodynamically stable and with improving mental status and defervesced it was thought that the patient would be stable for transfer back to the floor where he continued to slowly improve. A CAT scan of the abdomen was obtained, was showed some fluid in the gallbladder fossa, however, this was thought to be consistent with normal postoperative change. No abscesses were evident. The patient's diet was slowly advanced, which he tolerated. Throughout this time the patient was on hemodialysis. [Hospital ] clinic was consulted for management of blood sugar. By postoperative day twelve the patient continued to be afebrile for several days. His mental status had returned to baseline. It was felt best that the patient be discharged to a rehabilitation center for therapy for further recovery. The patient is to be discharged with one week of Augmentin to follow up at the Transplant Center in seven to ten days. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSES: History of cholecystitis status post elective open cholecystectomy complicated by postoperative fevers of unclear etiology. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg one tablet po q day. 2. Levothyroxine 25 micrograms one tablet po q day. 3. B-complex vitamin with folic acid one capsule po q day. 4. Tums 500 mg one tablet po b.i.d. 5. Calcitriol .25 micrograms capsule one capsule po q day. 6. Pantoprazole 40 mg one capsule po q day. 7. Nifedipine 60 mg one tablet po q day. 8. Calcium acetate 667 mg two tablets po t.i.d. with meals. 9. Isosorbide 60 mg one tablet po q day. 10. Colace 100 mg one tablet po b.i.d. 11. Gabapentin 300 mg one capsule po b.i.d. 12. Pravastatin 20 mg two tablets po q day. 13. Midodrine 5 mg one tablet po t.i.d. 14. Heparin subq 5000 units q 8 hours until fully ambulatory. 15. Tylenol 325 mg two tablets po q 4 to 6 hours prn pain. 16. Atenolol 100 mg tablet two tablets po q day. 17. Insulin, the patient is to follow the insulin regimen followed by the [Hospital ] Clinic. 18. Augmentin 500 mg one tablet po q day fro seven days. FOLLOW UP PLANS: The patient is to follow up at the Transplant Center at [Telephone/Fax (1) 673] at the [Last Name (un) 2443] Building on [2141-2-22] at 3:00 p.m. He is to continue to have regular laboratories drawn, which include a CBC, chem 10 as well as liver function tests. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Last Name (NamePattern1) 12360] MEDQUIST36 D: [2142-2-7] 01:14 T: [2142-2-7] 10:40 JOB#: [Job Number 20635]	[ "250.61", "403.91", "250.41", "574.10", "996.81", "998.89", "575.8", "998.11", "V64.41" ]	icd9cm	[ [ [] ] ]	[ "99.04", "39.95", "51.22", "39.98" ]	icd9pcs	[ [ [] ] ]								5522, 5647	5670, 7181			1439, 2102	3069, 5428																												2125, 3051																						172, 512																534, 1413		5453, 5501
31,483	199,513	18513	Discharge summary	report	Admission Date: [2178-12-8] Discharge Date: [2178-12-15] Date of Birth: [2119-8-10] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain/Myocardial infarction Major Surgical or Invasive Procedure: [2178-12-11] - Off Pump CABGx3 (Left internal mammary-Left anterior descending artery, vein graft-diagonal artery, vein graft-ramus) History of Present Illness: 59 y/o man who presented to MWMC on [2178-12-6] with chest pain. He ruled in for a NSTEMI ans subsequently underwent a cardiac catheterization which revealed severe two vessel disease. Due to the severity of his disease, he was transferred to the [Hospital1 18] on [2178-12-8] for surgical management. Past Medical History: HTN Hyperlipidemia MI [2174], [2178] Right Inguinal hernia repair [2157] hiatal hernia CAD s/p stentingx2 in [2174] Social History: Jehovah's witness. Never smoked and does not drink alcohol. Family History: NC Physical Exam: 64 sr 106-112/60 16 98.8 NAD RRR, no M/R/G CTAB ABD obese, soft, NT, ND EXT without edema, some varicosities A+Ox3, nonfocal, no carotid bruits Pertinent Results: [2178-12-8] 03:34PM GLUCOSE-84 UREA N-21* CREAT-1.0 SODIUM-140 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16 [2178-12-8] 03:34PM ALT(SGPT)-44* AST(SGOT)-51* ALK PHOS-86 AMYLASE-86 TOT BILI-1.0 [2178-12-8] 03:34PM WBC-6.9 RBC-4.23* HGB-13.1* HCT-36.1* MCV-85 MCH-31.0# MCHC-36.3* RDW-13.6 [2178-12-8] 03:34PM PT-11.4 PTT-29.7 INR(PT)-1.0 [2178-12-11] ECHO PRE Grafting 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST Grafting Left atrium is somewhat compressed. No other changes from pre grafting study. [2178-12-13] CXR There is no pneumothorax, pleural effusion, or appreciable mediastinal widening, following removal chest tubes. Right jugular introducer ends at the thoracic inlet. Heart size top normal increased slightly since [12-11]. Atelectasis crosses both mid lungs. There is no pulmonary edema. Brief Hospital Course: Mr. [Known lastname 23638] was admitted to the [Hospital1 18] on [2178-12-8] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner and deemed suitable for surgery. As he was a Jehovah's witness, it was elected to perform the case off bypass. Heparin was continued for anticoagulation and Mr. [Known lastname 23638] remained pain free. On [2178-12-11], Mr. [Known lastname 23638] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels off pump. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [Known lastname 23638] had awoke neurologically intact and was extubated. Plavix was started for his off pump bypass which he will take for three months. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. Beta blockade, aspirin and a statin were resumed. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Iron and vitamin C were started for his postoperative anemia. Mr. [Known lastname 23638] continued to make steady progress and was discharged home on postoperative day four. He will follow-up with Dr. [First Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Lisinopril 30mg QD Atenolol 50mg QD Lipitor Motrin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 3 months. Disp:90 Tablet(s) Refills:0 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months: For off pump CABG. Disp:30 Tablet(s) Refills:2 8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Take for 5 days with potassium and then stop. Disp:5 Tablet(s) Refills:0 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days: Take for 5 days with lasix and then stop. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: CAD s/p stentingx2 [2174] and CABG [2178-12-11] Hyperlipidemia HTN MI [2174], [2178] Hiatal hernia Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take lasix and potassium for 5 days then stop. 8) Take zantac (ranatidine for 3 months while taking plavix) 9) Take plavix for 3 months and then either discontinue or as instructed by Dr. [Last Name (STitle) 5874]. 10) Take iron and vitamin C as prescribed for 1 month. 11) Call with any questions or concerns. Followup Instructions: Please follow-up with [Last Name (STitle) 5059] Dr. [First Name (STitle) ] in 1 month. ([Telephone/Fax (1) 4044] Please follow-up with Dr. [Last Name (STitle) 5874] in [2-3] weeks. Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. [Telephone/Fax (1) 43460] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2178-12-15]	[ "E878.2", "285.9", "410.71", "414.01", "401.9", "272.4", "V45.82", "412" ]	icd9cm	[ [ [] ] ]	[ "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	5756, 5818	2598, 4039	354, 492	5977, 5985	1269, 2575	7005, 7423	1083, 1087		4141, 5733		5839, 5956	4065, 4118			6009, 6982										1102, 1250																												282, 316										520, 835																857, 990	1006, 1067
74,654	166,721	51954	Discharge summary	report	Admission Date: [2134-7-4] Discharge Date: [2134-7-17] Date of Birth: [2056-8-3] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1167] Chief Complaint: hypotension Major Surgical or Invasive Procedure: right heart cath with cardiac biopsy on [7-12] History of Present Illness: Mr [Known lastname 46] is a 77yo male with history of idiopathic cardiomyopathy (EF 25-30% [3-/2134]), atrial fibrillation (on coumadin), pulmonary hypertension, chronic renal insufficiency initially admitted to the [Hospital Unit Name 153] due to concern for hypotension transferred to the CCU for management of CHF. . Per report patient was sent in from the nursing home due to "abnormal labs" though had no focal complaints. He had been recently discharged from [Hospital1 18] on [6-29] with the diagnosis of DVT/PE, LLE cellulitis and PNA. He was continued on warfarin (once INR was not supratherapitic) and treated with doxycycline and levofloxacin with planned 10 day course to be completed on [2134-7-5] for the LLE cellulitis and PNA respectivly. Patient was sent from the nursing home because of "abnormal labs." No further history able to be obtained. Patient believes he is here because of pain in the leg. Overall says he feels OK, with main concern being leg pain in the left lower extremity. Says breathing is "good." Denies dyspnea, cough, productive cough, wheezing, pleuritic chest pain, fevers/chills, abdominal pain, dysuria. . In the ED, initial VS were: 97.4 107 91/65 20 98%. Labs were notable for WBC 22.3, creatinine of 5.0 up from baseline 2.5-3.1; glucose of 42 (received 2 amp of dextrose), INR of 4.1, despite not having taken coumadin in a week per report. Patient was started on vanc/cefepime due to concern for evolving sepsis vs pulmonary embolus given recent peroneal vein DVT/presumed PE. (though baseline SBP in 80-90's) CTA was held because of impaired renal function. A Right IJ central line was obtained along with two peripherals. Prior to transfer blood pressures remained in 80s-90s and Norepinephrine was started for pressure support. . In the [Hospital Unit Name 153] there was concern for septic shock and he was started on levophed, gental hydration, and placed on vanco/cefepime. His WBC remained constant in low 20's. He was changed to vanco/zosyn and his WBC trended down. His initial central venous sat was 70 increasing concern for sepsis. He was evaluated for infection source and his abd U/S and oral con CT were non-diagnostic. His CXR was concerning for a PNA, worsening over previous studies. Over his 3 day stay in the [Hospital Unit Name 153] his CO/CI worsened and his central venous sat decreaased to the 40's increasing concern for cardiogenic shock. His MAPs were low and his pressor was transitioned from levophed to doputamine without improvement. At this point he was transfered to the CCU for further evaulation and treatment. Past Medical History: - Idiopathic cardiomyopathy - Systolic and diastolic congestive heart failure EF 20% - Hyperlipidemia - diabetes mellitus type 2 - A-Fib on coumadin - hypertension (now with baseline sbps of mid 80s-100s) - pulmonary hypertension - left ventricular hypertrophy - chronic renal insufficiency, Cr baseline 2.5-3.1 in [2133] - history of shingles Social History: Patient lives at home with his wife. Ambulate with a cane usually. No history of tobacco use. No alcohol, no drugs. Family History: His parents may have had history of heart disease Physical Exam: Admission physical: T 98.2 HR 88 BP 110/80 16 100% 4LNC CVP 10 General: Alert, oriented to person, place, time, no acute distress HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated at ~7cm, no LAD CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crackles, otherwise CTA without wheezes, rales, ronchi Abdomen: Soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: 2+ peripheral edema left worse than right, left lower extremity with superficial ulceration without drainage on posterior aspect of calf Neuro: CNII-XII grossly intact, strength upper/lower extremities grossly intact, grossly normal sensation, gait deferred. . CCU Physical Exam: General: Alert, oriented to person, place, time, no acute distress HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated at ~7cm, no LAD CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crackles, otherwise CTA without wheezes, rales, ronchi Abdomen: Soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley Ext: 2+ peripheral edema left worse than right, left lower extremity with superficial ulceration without drainage on posterior aspect of calf Neuro: CNII-XII grossly intact, strength upper/lower extremities grossly intact, grossly normal sensation, gait deferred. Pertinent Results: Admission/Relevant Labs: [2134-7-4] 01:20PM BLOOD WBC-22.3* RBC-3.43* Hgb-11.2* Hct-33.6* MCV-98 MCH-32.6* MCHC-33.2 RDW-17.4* Plt Ct-142* [2134-7-4] 01:20PM BLOOD Neuts-91.3* Lymphs-4.5* Monos-3.5 Eos-0.6 Baso-0.1 [2134-7-4] 04:29PM BLOOD PT-41.3* PTT-46.1* INR(PT)-4.1* [2134-7-5] 10:21AM BLOOD Fibrino-597* [2134-7-4] 08:44PM BLOOD Glucose-110* UreaN-144* Creat-4.5* Na-126* K-4.0 Cl-92* HCO3-20* AnGap-18 [2134-7-4] 01:20PM BLOOD ALT-24 AST-64* CK(CPK)-587* AlkPhos-170* TotBili-2.1* [2134-7-4] 01:20PM BLOOD CK-MB-7 cTropnT-0.41* [2134-7-6] 06:46AM BLOOD proBNP-[Numeric Identifier 107550]* [2134-7-4] 08:44PM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1 [2134-7-5] 10:21AM BLOOD D-Dimer-577* [2134-7-5] 04:30AM BLOOD TSH-2.1 [2134-7-5] 04:30AM BLOOD Cortsol-28.8* [2134-7-4] 08:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2134-7-5] 04:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2134-7-6] 05:25PM BLOOD HIV Ab-NEGATIVE [2134-7-5] 04:30AM BLOOD HCV Ab-NEGATIVE [2134-7-4] 01:19PM BLOOD Lactate-1.7 [2134-7-5] 12:24AM BLOOD O2 Sat-71 [2134-7-5] 04:30AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-Test [2134-7-5] 02:35PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L RATIO-Test . Discharged labs: . Micro: Blood Cultures, urine culture: No growth C-diffx2 Negative . ABX XR [2134-7-5]: Single frontal image of the abdomen shows nonspecific bowel gas pattern with no evidence of obstruction. There is no pneumatosis or free gas. There are numerous seeds in the prostate unchanged since the most recent. CT of the abdomen and pelvis. There are degenerative changes of the lumbar spine. IMPRESSION: Nonspecific bowel gas pattern with no evidence of bowel obstruction. . ABD U/S [2134-7-5]: 1. Cholelithiasis and sludge without son[Name (NI) 493] evidence of acute cholecystitis. 2. Pulsatile portal vein and distended hepatic veins most likely related to right heart failure. . CXR [2134-7-6]: Considerable consolidation has developed at both lung bases in the absence of edema or even much vascular engorgement in the upper lungs, and therefore could be considered pneumonia rather than asymmetric edema. Severe cardiomegaly is chronic. Right internal jugular line ends centrally. . HIDA [2134-7-7]: Abnormal hepatobiliary study. Delayed uptake compatible with hepatic dysfunction. There is initial gallbladder visualization indicating no acute cholecystitis. The gallbladder does not respond to a CCK analog (sincalide) indicating gallbladder dysfunction. . CXR [2134-7-8]: FINDINGS: In comparison with study of [7-6], there is continued globular enlargement of the cardiac silhouette with essentially normal pulmonary vasculature, consistent with the clinical diagnosis of cardiomyopathy. The basilar regions are substantially clear than on the previous study with only minimal residual atelectatic change. . LENIs of LLE [2134-7-8]: IMPRESSION: No deep vein thrombosis in the left lower extremity. . LENIs: [2134-7-13]: No evidence of deep vein thrombosis in either leg. Note is made that the calf veins of the left leg could not be visualized due to open skin lesions. . Right Heart Cath with biopsy [2134-7-12]: Site Sys [Last Name (un) 6043] End Mean A Wave V Wave HR PA 64 22 32 79 RV 64 9 24 60 RA 18 21 21 94 . TTE: [2134-7-12] Overall left ventricular systolic function is severely depressed (LVEF= 20-30%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] Compared with the prior study (images reviewed) of [2134-6-28], the present study was done to localize right heart biopsy. Post biopsy, no evidence of pericardial effusion or VSD seen Brief Hospital Course: 77 yo M with CHF with idiopathic cardiomyopathy (EF 25-30% [3-/2134] echo), pulmonary hypertension, T2DM, afib (on coumadin), chronic renal insufficiency Cr baseline 2-2.5, recently discharged on [6-29] after several day admission for DVT and presumed PE, LLE cellulitis and PNA, initially re-presented ([7-4]) to [Hospital Unit Name 153] with hypoglycemia, [Last Name (un) ], leukocytosis, as well as hypotension. Transferred from [Hospital Unit Name 153] to CCU for presumed CHF and ?cardiogenic shock. . # HYPOTENSION: Patient presented to the [Hospital Unit Name 153] with hypotension in 70s-80s initially which in the setting of leukocytosis, low CVP and high central venous O2 gave concern for distributive/septic shock picture, despite lack of a clear source. However during his recent hospitalization one week prior to this admission, he was being treated for pneumonia and cellulitis which was most likely the source for his septic shock. In addition, patient had with elevated creatinine, dry appearance on exam suggestive of hypovolemic component. He was started on vanc and zosyn for broad coverage for septic shock and was given fluid cautiously given his known cardiomyopathy. An arterial line was started for invasive monitoring of blood pressure given variable cuff readings. In the [Hospital Unit Name 153] Levophed, which was started in the ED, was continued for pressure support. however patient remained hypotensive, and in context of known cardiomyopathy, dobutamine was started for inotropy. He was transfered to CCU for question of cardiogenic shock compoenent to his hypotension. On echo patient was found to have pattern of restriction physiology with question of amyloid; SPEP/UPEP were negative. He was considered to be preload dependend because of this restrictive physiology therefore he continued to receive small fluid boluses. Dopamine and levophed were weaned off on arrival to CCU. Patient's bp cotninued to remain in the 80s which was considered his baseline. He continued to have good mentation with his low BPs. He had a right heart cath with biopsy to get definiteve answer regaring his restrictive pattern. Cardiac biopsy showed amyloidosis. Repeat echo after biopsy showed worsening cardiomyoptahy. He did not have any significant improvement for functional standpoint. Therefore palliative care was consulted and family meeting held during which patient's poor prognosis was dicusses. Patient and family agreed to DNR/DNI status with discharge to [Hospital1 1501] and transition to hospice care. . # PNEUMONIA: Patient was to complete course of levofloxacin 750 mg IV Q48H for pneumonia from prior hospitalization. CXR appeared benign but given presentation concerning for septic shock and leukocytosis, he was covered for HCAP with vanc/zosyn. . # ATRIAL FIBRILLATION/FLUTTER: In the initial course of this hospitlization he continued to have frequent episodes of afib/flutter with RVR in the setting of holding metoprolol for his hypertension. However after controlling patient's pain (from LLE cellulitis and ulcer-->see below), his rate was brought under better control. He initially presented with supertherpuetic INR and his coumadin was held (--> see below). Once his INR became sub-therapuetic he was switched to hepain gtt. On discharge, unable to obtain labs as pt is a difficult stick and declined further attempts.He was discharge on 3mg of coumadin. He will have his next INR drawn at 8/19 at [Hospital1 1501]. . # LLE CELLULITIS/Overlying Ulcer: Patient was to complete doxycycline hyclate 100 mg PO Q12H for LLE cellulitis from his previous hospitalization. However he was covered with vancomycin and zosyn during this hospital stay given leukocytosis and spetic shock. His pain was controlled wtih tramadol, acetominophen and oxycodone. He was seen by wound care for management of his ulcers overlying the cellulitis. His ulcers were thought to be from poor perfusion to his lower extremity given severe history of CAD and PVD. He was also seen by vascular surgery who recommended adaptic to open air, compression wrap with coban and follow up in six weeks after discharge. Repeat LENIS did not show any DVTs in the lower extremity. # SACRAL PRESSURE ULCER: Wound care was consulted who continued to monitor his sacral ulcer and changed his dressing on daily basis. . # COAGULOPATHY: On admission he had an INR 4.1 despite reportedly not taking coumadin for two weeks. He did not have any active bleed. His elevated INR was thought to be from vitamin K defiency in the setting of poor po intake and continued antibiotcs use. He was given 1mg of vitamin K with decrease in INR to 1.8. He was started back on heparin gtt and restarted on coumadin. . # ACUTE ON CHRONIC RENAL FAILURE: His baseline Cr if 2-2.5 howver on admissin he presented with Cr of 5. His elevated Cr was thought to be prerenal in etiolgy given poor po intake and poor perfusion to the kidneys from his low BPs. Hi Cr responded well to fluids and returned back to baseline level. Per prior OMR outpatient renal notes he is not HD candidate per out-pt renal note. . # THROAT PAIN: Patient developed throat pain on hospital day 1. Physical exam Likely thrush, 1+ budding yeast on throat swab. HIV, HBV, HCV negative. Started nystatin swish and swallows. . # HYPOGLYCEMIA: Patient hypoglycemic requiring D10 drip initially. Thought to be secondary to renal failure and difficulty clearing home glipizide dosing. Improved after holding glipizide, and D10 was discontinued. Pt has been switched to glargine at night and oral diabetic meds discontinued. . # ABDOMINAL PAIN/MILD TRANSAMINITIS: Given leukocytosis and abdominal pain, cdiff was sent, which was negative. KUB was performed which was reassuring, and RUQ U/S was consistent with congestion, likely [12-31] CHF. HIDA scan also performed which was normal. . Transitions of Care: - Next INR to be drawn on [7-18] -Pt is DNR/DNI -Pt will follow up as an outpt with cardiology Medications on Admission: 1. Simvastatin 20 mg PO DAILY 2. Furosemide 20 mg IV DAILY:PRN SOB from pulmonary edema 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Torsemide 60 mg PO BID 5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [Hospital1 ]:PRN pruritis 6. GlipiZIDE 5 mg PO DAILY 7. ammonium,pot.& sodium lactates NF [11-30] grams TOPICAL [Hospital1 ] to legs 8. ammonium lactate NF 12 % Topical daily 9. Allopurinol 300 mg PO DAILY 10. Doxycycline Hyclate 100 mg PO Q12H for LLE cellulitis - last day is [2134-7-5] 11. Valsartan 40 mg PO DAILY 12. Levofloxacin 750 mg IV Q48H For pneumonia last day is [2134-7-5] Discharge Medications: 1. Allopurinol 300 mg PO DAILY 2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough pain 3. TraMADOL (Ultram) 50 mg PO BID 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Torsemide 60 mg PO DAILY 6. Warfarin 3 mg PO DAILY16 7. Acetaminophen 1000 mg PO Q 8H 8. Glargine 6 Units Breakfast Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] - [Location 8391] Discharge Diagnosis: Primary: - Septic Shock - Dilated cardiomyopathy with restrictive physiology secondary to amliod deposition disease. Secondary: - Acute on Chronic Renal Failrue - Atrial fibrillation/Flutter with rapid ventricular reposnse Discharge Condition: Mental Status: Clear and coherent. Sometimes disoriented Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Lethargic but arousable. Discharge Instructions: Dear Mr. [Known lastname 46], It was a pleasure taking care of your during this hospitalization. You were admitted because of low blood pressure which was thought to from combination of infection and your cardiomyopathy (worsening pump function of your heart). You were treated with antibiotics for your infection. You also had cardiac cathethrization (heart studies) which showed worsening of your heart function and a biopsy of the heart muscle was done and the results are pending. After a family meeting, you decided to change your code status to DNR/DNI with focus on aggressive symptom management. During this hospitalization you also had ulcers in your sacrum and in your leg which were cared for by wound care with regular dressing changes. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2134-7-19] at 10:30 AM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "250.00", "427.31", "038.9", "V12.51", "785.52", "425.7", "403.90", "276.1", "995.92", "112.0", "585.9", "707.20", "428.0", "425.4", "416.8", "V12.61", "584.9", "V66.7", "707.03", "486", "277.39", "V58.61", "459.81", "707.10", "272.4", "428.42", "V12.55", "682.6" ]	icd9cm	[ [ [] ] ]	[ "38.91", "37.21" ]	icd9pcs	[ [ [] ] ]	16636, 16753	9626, 15530	322, 374	17020, 17020	5171, 9603	18001, 18310	3549, 3601		16317, 16613		16774, 16999	15677, 16294			17220, 17978										4426, 5152																												271, 284										402, 3028									17035, 17196	15551, 15651						3050, 3399	3415, 3533
62,689	180,914	36564	Discharge summary	report	Admission Date: [2197-4-27] Discharge Date: [2197-5-4] Date of Birth: [2127-4-24] Sex: F Service: MEDICINE Allergies: ibuprofen / Codeine / Percocet / morphine Attending:[First Name3 (LF) 9160] Chief Complaint: Scheduled Admission for Lumbar Spinal Surgery Major Surgical or Invasive Procedure: Stage 1: L34 Lateral lumbar fusion MIS for L34 nonunion Stage 2: L34 PSF with laminectomy History of Present Illness: Ms. [Known lastname 4887] is a 70F with multiple medical problems including DM2, depression, h/o CVA, CRI, OSA (non-compliant with CPAP) and COPD admitted on [2197-4-27] for planned L3-L4 posterior spinal fusion in two stages. On [4-27] she underwent lateral interbody fusion at L3-L4 to provide interbody fusion support. On [4-28] she went back to the OR for the definitive L3-L4 fusion. Post operatively in the PACU she remained intubated due to apnea and agitation. She also became hypotensive with MAPs in the 40-50s for which she was started on a low dose of phenylephrine. She was transferred to TICU for monitoring still intubated and on 0.2 mcg/kg/min. She remained neurologically intact on exam and was switched from propofol to precedex in the TICU. She was weaned off pressors, extubated, and transferred to the ortho floor on [4-30]. On [5-1] the patient was noted to be more somnolent and confused. She was therefore transferred to the medicine service for further management. ROS: (+) Per HPI (-) Denied shortness of breath, chest pain, abdominal pain. Past Medical History: Cognitive Impairment. Exact diagnosis unclear. HTN COPD, not on home O2 Tardive Dyskinesia from Risperidone Stroke, details unclear Type 2 Diabetes Hypothyroidism Chronic renal insufficiency HLD OSA on CPAP/BiPAP (but does not wear) History of kidney stones Incontinence Gout Depression Morbid Obesity PSH: Appendectomy [2144] Cholecystectomy in [2147] Kidney stone removal in [2195] D&[Initials (NamePattern4) ] [2196-4-27], Previous Lumbar Spinal fusion Social History: - Tobacco: none - EtOH: None - Illicits: None - Lives in ALF "[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]" since her late 50s. Previously worked as a book-keeper. Never married or had kids. Has a health aide who visits 7 days per week [Hospital1 ]. Goes to adult day care 4 days/week. Family History: - Brother with mental handicap - Both parents with mental handicaps Physical Exam: At time of transfer to medicine service: VS: 98.8 154/49 81 18 97%2L BS 117 Gen: agitated but is oriented to person, hospital ([Hospital1 18]), and month HEENT: EOMI, Pupils are 2mm bilaterally and reactive to light, MMM, OP clear Neck: Right IJ CVL. No JVD appreciated although exam limited [12-29] CVL & body habitus. Echymossis on left neck ? IJ attempt ? CV: regular rate and rhythm, no murmurs Resp: CTAB anteriorly, exam limited by body habitus and poor inspiratory effort GI: soft, obese, NT, ND no HSM, +BS GU: Foley Catheter in place Ext: warm, well-perfused, obese, no C/C, 1+ lower extremity edema bilaterally, +pneumoboots, 2+ DP pulses bilaterally Neuro: exam very limited by patient's mental status but grossly intact with no focal deficit. She does not open her eyes spontaneously, but opens when asked. She is able to state the reason why she was admitted to the hospital and the name of her surgeon. She is able to move all 4 extremities without limitation and sensation is grossly intact to light touch. Prior to discharge: Gen: oriented to person, hospital ([Hospital1 18]), and month HEENT: EOMI, PERRL, MMM, OP clear Neck: No JVD appreciated although exam limited [12-29] CVL & body habitus. Echymosses on neck CV: regular rate and rhythm, no murmurs Resp: CTAB anteriorly, exam limited by body habitus and poor inspiratory effort GI: soft, obese, NT, ND no HSM, +BS GU: No foley Ext: warm, well-perfused, obese, no C/C, trace lower extremity edema bilaterally, +pneumoboots, 2+ DP pulses bilaterally Neuro: CNs [1-8] grossly intact.She is able to state the reason why she was admitted to the hospital and the name of her surgeon. She is able to move all 4 extremities without limitation and sensation is grossly intact to light touch. Strength grossly intact with no focal deficit or assymetry. Psych: Patient occassionally yells that she wants to go home, which according to her HCP is her baseline when she is in unfamiliar surroundings. Pertinent Results: [2197-4-27] 02:41PM BLOOD WBC-13.2* RBC-3.97* Hgb-12.1 Hct-36.6 MCV-92 MCH-30.4 MCHC-33.0 RDW-13.7 Plt Ct-222 [2197-4-28] 06:11AM BLOOD WBC-11.9* RBC-3.67* Hgb-11.0* Hct-34.4* MCV-94 MCH-29.9 MCHC-31.9 RDW-13.8 Plt Ct-188 [2197-4-28] 05:30PM BLOOD WBC-26.7# RBC-4.10 Hgb-12.4 Hct-38.4 MCV-94 MCH-30.2 MCHC-32.2 RDW-13.9 Plt Ct-232 [2197-4-29] 04:42AM BLOOD WBC-21.1* RBC-3.21* Hgb-9.7* Hct-29.5* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.3 Plt Ct-178 [2197-4-29] 09:32PM BLOOD WBC-20.4* RBC-2.92* Hgb-8.9* Hct-27.6* MCV-94 MCH-30.5 MCHC-32.3 RDW-14.2 Plt Ct-164 [2197-4-30] 03:03AM BLOOD WBC-19.1* RBC-3.05* Hgb-8.9* Hct-29.2* MCV-96 MCH-29.3 MCHC-30.6* RDW-13.8 Plt Ct-221 [2197-5-1] 10:32AM BLOOD WBC-13.7* RBC-2.86* Hgb-8.5* Hct-26.6* MCV-93 MCH-29.7 MCHC-31.8 RDW-14.1 Plt Ct-211 [2197-5-2] 04:30AM BLOOD WBC-12.7* RBC-2.81* Hgb-8.5* Hct-26.3* MCV-94 MCH-30.3 MCHC-32.3 RDW-13.9 Plt Ct-221 [2197-5-3] 05:14AM BLOOD WBC-14.4* RBC-3.01* Hgb-9.0* Hct-27.8* MCV-93 MCH-30.0 MCHC-32.4 RDW-13.8 Plt Ct-267 [2197-4-28] 05:30PM BLOOD PT-12.9* PTT-38.9* INR(PT)-1.2* [2197-4-27] 02:41PM BLOOD Glucose-91 UreaN-52* Creat-1.2* Na-142 K-4.5 Cl-103 HCO3-28 AnGap-16 [2197-5-3] 05:14AM BLOOD Glucose-123* UreaN-17 Creat-0.7 Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [2197-5-4] 05:38AM BLOOD WBC-11.4* RBC-2.81* Hgb-8.9* Hct-25.8* MCV-92 MCH-31.5 MCHC-34.4 RDW-13.3 Plt Ct-334 [2197-5-4] 10:40AM BLOOD Glucose-111* UreaN-12 Creat-0.7 Na-141 K-4.1 Cl-103 HCO3-30 AnGap-12 [2197-5-4] 10:40AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.2* [2197-4-28] 06:11AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.7 [2197-5-1] 10:32AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.7 [2197-5-1] 10:32AM BLOOD TSH-0.53 [2197-5-1] 10:32AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.012 [2197-5-1] 10:32AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [2197-5-1] 10:32AM URINE RBC-11* WBC->182* Bacteri-FEW Yeast-RARE Epi-1 TransE-1 [2197-5-1] 10:32AM URINE AmorphX-RARE [2197-5-1] 10:32AM URINE Mucous-RARE [2197-5-1] 10:32 am URINE Source: Catheter. FINAL REPORT [2197-5-2] URINE CULTURE (Final [2197-5-2]): YEAST. ~8OOO/ML. Lumbar Spine ([2197-4-27]) CLINICAL HISTORY: Patient with posterior fusion. FINDINGS: Views of the lumbar spine from the operating room demonstrates interval placement of a disc prosthesis at likely L3-L4. However, the inferior aspect of the sacrum is not included on the field of view. The total intraservice fluoroscopic time was 76.1 seconds. Please refer to the operative note for additional details. Lumbar Spine ([2197-4-28]) FINDINGS: There has been interval L3-L4 posterior fusion including placement of an interbody fusion spacer, although depiction is limited. ECG ([2197-5-1]) Sinus rhythm. Left axis deviation, left anterior fascicular block. Poor R wave progression, may be due to left anterior fascicular block. Possible left ventricular hypertrophy with ST segment changes, possibly due to repolarization abnormality. No previous tracing available for comparison. LENI ([2197-5-2]) IMPRESSION: No bilateral lower extremity deep venous thrombosis. Brief Hospital Course: Ms. [Known lastname 4887] is a 70F with multiple medical problems including DM2, depression, h/o CVA, CRI, OSA and COPD admitted on [2197-4-27] for L3-L4 posterior spinal fusion in two stages. Post-op course complicated by respiratory failure, hypotension, UTI and confusion which all resolved. ACTIVE ISSUES: ================ #) S/P Lumbar Spinal Fusion: [4-27]: L3-L4 lateral interbody fusion with interbody device and allograft. [4-28]: revision posterior decompression with far lateral decompression and instrumented fusion L3-L4 with autograft and allograft. She is being discharged on dilaudid prn for pain and an as needed bowel regimen. She will follow-up with her surgeon Dr. [Last Name (STitle) 1007] in clinic on [2197-5-16]. #) Pyuria: Patient developed delirium post-operatively which resolved after treatment with 3 days of IV ceftriaxone. However, urine culture later grew yeast (8000/mL), which was not subsequently treated since she was asymptomatic. #) Leukocytosis: WBC count 13.2 on day of admission and peaked as high as 26.7 before trending back down to 11.4 prior to discharge. Possibly was stress response from surgery although higher than one would expect from just that. However no fevers or localizing signs for systemic infection were noted. This was thought to be unlikely to be from cystitis alone. C. diff DNA amplification assay was negative. She remained afebrile without any symptoms (with improved mental status) through day of discharge. #) Acute Blood Loss Anemia: Related to surgery. Never had any bloody or dark stools. Hematocrit was stable for 4 days prior to discharge. #) Confusion: likely multifactorial from post-operative delirium. She had already mostly improved by the following morning, even prior to receiving antibiotics. Sedating medications were held and patient received antibiotics with complete resolution of symptoms and return to her baseline mental status by day of discharge, as confirmed by family member. #) Diarrhea- The patient developed watery, non-bloody diarrhea on [2197-5-3]. She had been constipated and received aggressive bowel regimen prior to onset of diarrhea. Other possibilities included C. diff but patient was afebrile with normal abdominal exam and had decreasing WBC. Stool was sent for C.diff toxin and returned negative. This could also have been antibiotic-associated diarrhea after receiving ceftriaxone for 3 days. By discharge, diarrhea had improved. She is being discharged on as needed loperamide. CHRONIC ISSUES: ================== #) Type 2 Diabetes: Patient is on Levemir, Metformin and Sitagliptin at home. She has not been on an aspirin or an ACE-I, which may be beneficial given her diabetic history. We will defer to her primary care physician on this matter. We resumed home regimen on discharge. #) COPD: Not on home O2 with no evidence of chronic CO2 retention. Continued prn Albuterol. #) OSA: Not on CPAP at home. #) Depression: Continued home duloxetine. TRANSITIONAL ISSUES: ====================== - Consider starting Aspirin and ACE-I as outpatient given diabetes. - Contact: [Name (NI) ] [Name (NI) 410] (Cousin/HCP) [Telephone/Fax (1) 82763] Medications on Admission: duloxetine 30mg daily levothyroxine 125mcg daily omeprazole 20mg daily sitagliptin 50mg daily allopurinol 100mg [Hospital1 ] metformin 850mg [Hospital1 ] mirtazapine 7.5mg qhs gabapentin 100mg TID simvastatin 20mg qd potassium citrate 10 mEq daily Levemir Flexpen Subcutaneous 100 unit/mL 10 unit every day at bedtime Albuterol inhaler PRN Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. potassium citrate 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 11. Levemir Flexpen 100 unit/mL (3 mL) Insulin Pen Sig: Ten (10) units Subcutaneous at bedtime. 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on/12 hours off. 14. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for constipation. 17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 18. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. 19. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO every four (4) hours as needed for pain: hold for sedation, RR < 12. Disp:56 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital 11851] Healthcare & Rehabilitation Center - [Location (un) 620] Discharge Diagnosis: Primary- Non [Hospital1 ] L34 with lumbar canal stenosis Secondary- Hypertension COPD Stroke Type 2 Diabetes Hypothyroidism Chronic renal insufficiency Hyperlipidemia OSA on CPAP/BiPAP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for the following operation: Lumbar Decompression With Fusion in two stages. While here, you were somewhat confused after the surgery but this resolved quickly. You were treated for a urinary tract infection and remained without fevers on discharge. You are being discharged to rehab before you go back home. No changes were made to your home medications. Please use dilaudid 1mg by mouth as needed for pain and use a bowel regimen if you become constipated. Per the orthopedic surgeons: Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever >101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: Department: [Location (un) ] PRIMARY CARE When: TUESDAY [2197-5-16] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 79306], MD [Telephone/Fax (1) 3736] Building: [Street Address(2) 82764] ([Location 15289], MA) [Location (un) 859] Campus: OFF CAMPUS Best Parking: Parking on Site [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162] Completed by:[2197-5-4]	[ "518.81", "311", "787.91", "738.4", "403.90", "458.0", "272.4", "599.0", "585.9", "285.1", "V12.54", "293.0", "733.82", "274.9", "327.23", "288.60", "278.01", "530.81", "724.03", "250.00" ]	icd9cm	[ [ [] ] ]	[ "84.52", "81.62", "80.51", "84.51", "81.36", "77.79", "81.37", "00.94", "80.54", "96.71" ]	icd9pcs	[ [ [] ] ]	13294, 13402	7785, 8089	347, 438	13636, 13636	4496, 7762	16487, 16953	2408, 2477		11399, 13271		13423, 13615	11026, 11376			13812, 14340										2492, 4477	14616, 14936								15973, 16464											14374, 14598	10817, 11000							262, 309		8104, 10317							14948, 15962	466, 1562									13651, 13788				10333, 10796			1584, 2063	2079, 2392
62,920	145,660	39663	Discharge summary	report	Admission Date: [2169-7-10] Discharge Date: [2169-8-15] Date of Birth: [2111-1-23] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: Polytrauma Major Surgical or Invasive Procedure: [2169-7-11] EXTERNAL FIXATION PELVIC FRACTURE [Doctor Last Name 7376] [2169-7-13] ORIF OF ANTERIOR RING; ORIF POSTERIOR RING; EXAM UNDER ANESTHESIA LEFT SHOULDER AND ELBOW;I AND D LEFT ARM AND WOUND CLOSURE [Doctor Last Name 1005] [2169-7-21] REVISION OF SACRAL SCREW WITH CANNULATED SCREW History of Present Illness: 58 y.o. male helmeted ([12-17] size helmet) motorcyclist presents after motorcycle crash. Patient was driving his motorcycle and struck the rear of a stopped motor vehicle in front of him. He was thrown approximately 15-20 feet and bystanders report LOC for 3-5 minutes. He was taken to an OSH and then flown to [Hospital1 18]. His GCS upon arrival to our ED was 14. He was noted to have blood draining from his left ear. CT scans were performed that showed left depressed skull fracture with associated SDH, left temporal bone fracture, ? basilar fracture with extension into carotid, open book pelvic fracture with pelvic hematoma, extraperitoneal bladder rupture, left [12-19] posterior rib fractures, posterior [4-21] fractures on left. Past Medical History: hypercholesterolemia, ?schizophrenia Social History: Patient lives in [State 531] and was visiting [Location (un) ], ? paranoid psychological delusions per HCP Family History: NC Physical Exam: PHYSICAL EXAM: O: T: 98.1 BP: 100/53 HR: 82 R 19 96% 2LO2Sats Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [3-18] reactive EOMs intact Significant L supraorbital hematoma. Dried blood in the nares bilaterally. Active bleeding from the L auditory canal. Neck: Supple. Lungs: CTA bilaterally. Significant contusion along L lateral chest wall Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. abrasions on B hands and B LE Neuro: Mental status: GCS 14 Oriented to person, place, and date. Recall: [2-15] objects at 5 minutes. 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, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact on R with only upward\gaze impaired on L No 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 [4-19] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Pertinent Results: [2169-7-10] 09:15PM WBC-22.4* RBC-3.93* HGB-12.7* HCT-37.0* MCV-94 MCH-32.4* MCHC-34.4 RDW-12.8 [2169-7-10] 09:15PM PLT COUNT-289 [2169-7-10] 09:15PM PT-12.8 PTT-25.6 INR(PT)-1.1 [2169-7-10] 09:15PM ASA-NEG ETHANOL-12* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2169-7-10] 09:25PM HGB-13.3* calcHCT-40 O2 SAT-97 CARBOXYHB-1 MET HGB-0 [2169-7-10] 09:25PM GLUCOSE-143* LACTATE-2.3* NA+-143 K+-3.2* CL--105 [2169-7-10] 09:15PM UREA N-16 CREAT-0.9 [2169-7-10] Head CT : 1. Thin acute left subdural hematoma and possible small focus of left frontal subarachnoid hemorrhage, as above. 2. Extensive left sided skull and skull base fractures, including left temporal bone fracture with extension through the petrous apex adjacent to the expected course of the internal carotid artery. Further evaluation with CTA is recommended to exclude vascular injury. Right maxillary sinus fracture. [2169-7-10] CT Torso : 1. Extensive pelvic fractures including a wide diastasis of the symphysis pubis and a longitudinal fracture traversing the sacrum, coccyx and L5 vertebral bodies. The sacral fracture abuts the central canal raising concern for possible nerve root/cord injury. Bladder injury can not be excluded on this study. Recommend delayed views through the bladder to further assess with more contrast excreted, may demonstrate evidence of a bladder rupture, although if none seen, can not be excluded. No Foley catheter in place for CT cystogram currently. Retrograde urethrogram can also be considered. 2. Extensive hematoma involving the perineum and base of the urethra as well as a foci of pelvic hyperdensity, raising concern for vascular injury. 3. Numerous left rib fractures as detailed above. [2169-7-10] Left elbow : Note is made of fragmentation at the olecranon process, which may be chronic or alternatively reflect acute injury. Otherwise, there is no evidence of additional fracture or dislocation. There are no radiopaque foreign bodies or soft tissue calcifications. [2169-7-10] CTA Neck : 1. Mild narrowing of the petrous segment of the left internal carotid artery compared to the right, may relate to vasospasm/some material within the carotid canal. There is decreased enhancement of the left cavernous sinus, in addition. Further evaluation with head and neck MR, with axial fat sat sequences to exclude intramural hematoma/dissection can be considered for better assessment. No flow limitation noted distally. 2. Diffuse narrowed caliber of the left vertebral artery, likely due to hypoplasia. However, evaluation at the level of C2 and C3 is limited due to prominent adjacent venous plexus. 3. Fluid in the paranasal sinuses and the mastoid air cells on the left side as described above. Please see the prior CT study, for details regarding the osseous and the soft tissue injuries. [2169-7-10] CT Pelvis : 1. Extraperitoneal bladder rupture. 2. Increased dense material in the right medial thigh as well as anterior subcutaneous tissues and rectus abdominal musculature, new from the previous study and reflecting interval bleeding since the preceding scan. [2169-7-11] CT Cystogram: 1. Extraperitoneal rupture of the urinary bladder, with contrast extravasating into the extraperitoneal pelvic cavity and extending to the right inguinal canal layering into the scrotum and along soft tissue of the anterior lower abdominal wall and right thigh. Fat stranding and hyperdense material along the right thigh and anterior subcutaneous tissues could be a combination of hematoma, urine and contrast. 2. Interval increase in size of the scrotum, with hyperdense fluid filling the scrotal sac, with increase amount compared to prior, likely mixed urine and contrast; however, cannot exclude hematoscrotum. 3. Severe pelvic fracture including wide diastasis of symphysis pubis and longitudinal fracture traversing L5 vertebral body and entire sacrum with distraction of fracture fragments at the sacrum of 1.3cm. [2169-7-15] MR L spine : 1. Anterior epidural hematoma, from L4-5 intervertebral disc level to S2, with displacement and deformity of the thecal sac along with crowding of the roots of the cauda equina and moderate-canal stenosis as described above. 2. Edema/contusion of the L5 vertebral body, spinous process as well as the L4-5 intervertebral disc space. 3. Degenerative changes at L4-5 level resulting in bilateral moderate neural foraminal narrowing and mild impingement on the L5 nerves on both sides. Other details as above. Evaluation at the level of the lower L5 and the sacrum is limited due to artifacts, from the hardware [2169-7-22] Liver US : 1. No source for elevated bilirubin identified with no intra- or extra-hepatic biliary dilatation. 2. Distended gallbladder without secondary signs of cholecystitis. 3. Moderate right pleural effusion with associated right lung atelectasis. [2169-7-29] EEG : This is an abnormal routine EEG due to the presence of sharply contoured theta slowing seen best over the left temporal region suggestive of an underlying structual lesion. Furthermore, the presence of frequent bursts of generalized delta slowing visualized throughout the record is suggestive of a deep midline structural abnormality. There was no epileptiform activity seen. [2169-7-31] CT Cystogram : 1. Markedly reduced but persistent leak of contrast outside the bladder secondary to traumatic bladder rupture. 2. Interval resolution of pelvic fluid collection. [2169-8-2] Left shoulder : 1) Complete dislocation of the AC joint. No frank fracture detected. No widening of the coracoclavicular ligament. Surrounding irregular density may represent post-traumatic calcification, suggesting a subacute injury. 2) There is evidence of several fractures involving the left- sided ribs. [2169-8-2] Left shoulder : 1) Complete dislocation of the AC joint. No frank fracture detected. No widening of the coracoclavicular ligament. Surrounding irregular density may represent post-traumatic calcification, suggesting a subacute injury. 2) There is evidence of several fractures involving the left- sided ribs Brief Hospital Course: Mr. [Known lastname 2470] was admitted to the T/SICU. He went to the OR emergently for an external fixation of his pelvic fracture with orthopedics. On POD 1 he remained stable. His hematocrit was monitored serially and was noted to dip from 35-28.5. On POD 2, orthopedics performed a bedside relocation of the left shoulder. His ETT was up sized from a 6.5 to an 8. On POD 3 he went back to the OR for a definitive ORIF of the anterior and posterior pelvis, reduction of left shoulder under fluoroscopy and washout of the L elbow wound. He was started on cefepime/vanco at Urology's request for the extraperitoneal bladder rupture. On POD [3-16] a repeat CTH was performed demonstrating a stable SDH but a new small L temporal lobe hematoma adjacent to evolving contusion. He was started on tube feeds. On POD [4-16] his chest xray showed worsening infiltrates so a bronch was done showing LUL & LLL mucus plugging and purulent fluid. On [7-17] his urine output decreased so a renal ultrasound was performed and negative for hydronephrosis. A FENa was calculated 0.23% and was given boluses with adequate response. He was also started on zosyn for GNR in sputum (Pseudomonas). On [7-18] he was extubated without issue. On [7-19] the patients oxygen saturations dropped with a chest xray showing fluid overload so he was diuresed with lasix. Following gentle diuresis his oxygen saturations improved and he was breathing comfortably. He was finally transferred to the Trauma floor on [2169-7-23] for further rehabilitation. Neuro: He was followed by Neursosurgery for his left parieto-occipitial skull fracture with small subjacent SDH which was manged nonoperatively, Serial head CT scans and his exam were followed closely. Seizure prophylaxis was not recommeded. He was also followed by Psychiatry for delirum and paranoia; he was started on anitpscychotics at HS with improvement in his sleep/wake cycle and his paranoia. An EEG was also done to assess for seizure activity, no epileptiform activity was seen. Cardiac: His blood pressure is 110/70 & HR 84 on Lopressor 50 mg [Hospital1 ]. He has no chest pain or shortness of breath and has remained free of any arrhythmias. Resp: His pseudomonas pneumonia resolved with double coverage with Tobra and Zosyn and he is currently off oxygen with RA saturations of 97%. He has no sputum production and has been afebrile. From a GI standpoint he is taking a regular diet and tolerating it well after passing a speech and swallow evaluation. He was also having regular bowel movements. GU : He underwent serial CT cystograms to assess the healing of his bladder rupture, his foley remmained in place. A repeat scan was done which showed improvment in the bladder leak, his foley was removed and he is voiding spontaneously. He is continued on his Flomax. M/S : His injuries prevent him from bearing any weight in his lower extremities for at least 8-12 weeks. He has a seperated left shoulder which will require follow up as an outpatinet in [Hospital 1957] clinic; discussion re: surgery will take place at that time. He worked with Physical and Occupational therapy and was eventually cleared for independent wheelchair/slide board transfers. Dispo: His hospital course was prolonged due to lack of insurance and inability to place in rehab facility. Several alternative options were explored and it was eventually decided with patient approval, that he go to an apartment in [Hospital3 ] area with family support. Medications on Admission: None Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [3-21] hours. Disp:80 Tablet(s) Refills:0 11. Drop arm commode Dx: Pelvic fracture 12. Wheelchair w/ removable arms and leg extensions Dx: pelvic fractures 13. slide board Dx: pelvic fractures Discharge Disposition: Home Discharge Diagnosis: s/p Motorcycle crash Injuries: Left depressed skull fracture Longitudinal left temporal bone fracture Left sphenoid fracture Left [12-19] rib posterior fracture Left [4-21] posterior and anterior fracture Transverse process fracture of sacrum to L5 Open book pelvic fracture Extraperitoneal bladder rupture Left AC shoulder separation Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: * You were admitted to the hospital after your motorcycle crash that caused multiple injuries. * You are improving daily but still need to non weight bear on your lower extremities due to your pelvic fracture. You must transfer with a slide board to get from bed to chair. * Your left shoulder will be followed as an outpatient and you may continue to use it to help move yourself. * Your catheter is staying in until your bladder is fully healed. * Continue to eat well and stay hydrated. Followup Instructions: Please call/or have the patient call ([Telephone/Fax (1) 88] to schedule a follow- up appointment with Dr. [Last Name (STitle) 739], Neurosurgery in 4 weeks, with a Non-contrast CT scan of the head. Office is located in the [Hospital ] Medical Building, [Hospital Unit Name 12193]. Follow up in [Hospital 20993] clinic for your shoulder in [12-17] weeks with Dr. [Last Name (STitle) 3144]; call [Telephone/Fax (1) 1228] for an appointment. Follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP orthopedics in week of [9-10] for imaging of your pelvis, call [Telephone/Fax (1) 1228] for an appointment. Follow up in [Hospital 159] clinic if any concerns related to your bladder or erectile issues; call ([Telephone/Fax (1) 772] if you need to be seen. Follow up with Psychiatry for assistance with setting up outpatient follow up appointment; call [Telephone/Fax (1) 1387]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2169-8-15]	[ "E915", "873.41", "348.30", "805.6", "807.07", "272.0", "860.0", "790.6", "805.4", "911.0", "E812.2", "482.1", "808.3", "785.50", "518.81", "808.9", "238.71", "801.22", "916.0", "881.01", "933.1", "293.0", "276.6", "298.9", "831.04" ]	icd9cm	[ [ [] ] ]	[ "78.69", "96.71", "78.59", "79.39", "87.77", "96.59", "79.09", "79.71", "33.24", "96.6", "38.91", "78.19", "79.69" ]	icd9pcs	[ [ [] ] ]	14135, 14141	9370, 12891	324, 636	14528, 14645	3172, 9347	15183, 16281	1632, 1636		12946, 14112		14162, 14507	12917, 12923			14669, 15160										1666, 2127																												274, 286										664, 1424									2142, 3153							1446, 1484	1500, 1616
53,514	140,923	53457+59481	Discharge summary	report+addendum	Admission Date: [2201-2-10] Discharge Date: [2201-2-20] Date of Birth: [2141-8-26] Sex: F Service: ORTHOPAEDICS Allergies: antihistamines / decongestants / Amitriptyline / Adhesive Bandage Attending:[Doctor Last Name 1350] Chief Complaint: Weakness. Inability to walk. Major Surgical or Invasive Procedure: 1. Laminectomy T6 without facetectomy. 2. Laminectomy T7 with facetectomy. 3. Costovertebral decompression T6, T7. 4. Extra cavitary corpectomy T6, T7. 5. Lateral extra cavitary arthrodesis T6, T7. 6. Posterior fusion T4 through T9. 7. Posterior instrumentation T4 through T9. 8. Open treatment thoracic fracture/dislocation posterior. 9. Incision and debridement deep abscess thoracic. 10.Open biopsy deep bone. 11.Local autograft for fusion. 12.Allograft for fusion. History of Present Illness: CC: Increasing numbness/tingling BLE with known paraspinal fluid collection, discitis, osteomyelitis HPI: 59y F who per review of OMR had a recent history of long admission for MRSA bacteremia thought [2-26] UTI complicated by hypotension, ICU admission, paraspinal abscess s/p drainage in [10-6] which was c/b pneumothorax, as well as IV contrast nephropathy, who has continued on IV Vanco as outpatient and now presents with increasing back pain and BIL LE numbness/tingling. Onset: [2200-9-25]. Charac: gradually worsening, midline lower thoracic back pain (unchanged location), dull ache at rest, now exacerbated to [11-4] sharp/stabbing pain with movement. Alleviated mildly with narcotics. ASx: 1 day of new numbness/tingling in BIL LE (radiating from lateral thigh to dorsum of feet BIL, severity has increased to point of unable to ambulate), -weakness, -f/c, -n/v/d, -HA/change in vision, -CP/SOB/cough, -abd pain, -dysuria, -GI incont, -GU retention. Per review of OMR: MRI of her thoracic spine on [2200-12-16], which showed a paraspinal fluid collection, discitis, osteomyelitis at the T6-T7 region without spinal cordcompression. Per review of OMR and confirmed with pt: [Name (NI) 3262]: paraspinal abscess/discitis/osteomyelitis per above recent admission for MRSA BACTEREMIA DM - TYPE 2 HYPERCHOLESTEROLEMIA DIABETIC ULCER OF THE TOE HYPERTENSION OBESITY - MORBID HISTORY TOTAL KNEE REPLACEMENT LEFT HISTORY TOTAL KNEE REPLACEMENT RIGHT ISCHEMIC COLITIS HYPOTHYROIDISM HEMORRHOIDS ANEMIA ESOPHAGEAL REFLUX HEADACHE - MIGRAINE, UNSPEC HISTORY OF APPENDECTOMY HYSTERECTOMY & OOPHORECTOMY . SHx: no alcohol distant smoking history denies drug abuse . Meds: ambien oxycodone morphine lorazepam sertaline iron lasix amlodipine lantus humalog fenofibrate gabapentin flonase albuterol levodoopa/carbidopa nystatin . All: amitryptiline anti-histamine jewelry tomatoes PE: Vitals: 97 100 130/80 18 100% r/a General: NAD Mental Status: AAOx3 Cranial nerves II-XII grossly intact. Vascular Radial Ulnar Fem [Doctor Last Name ] DP PT R 2 2 2 2 2 2 L 2 2 2 2 2 2 Sensory: UE C5 C6 C7 C8 T1 R intact intact intact intact intact L intact intact intact intact intact T2-L1 (Trunk) intact LE L2 L3 L4 L5 S1 S2 R intact intact decreased LT decreased LT intact intact L intact intact decreased LT decreased L intact intact Motor: UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8) FinAbd(T1) R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 LE Flex(L1) Add(L2) Quad(L3) TA(L4) [Last Name (un) 938](L5) Per(S1) GS(S1-2/T) R 4 4 4 4 4 4 4 L 4 4 4 4 4 4 4 Reflexes Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1) R 2 2 2 2 2 L 2 2 2 2 2 Babinski: downgoing Perianal sensation: intact Rectal tone: WNL Estimated Level of Cooperation: high Estimated Reliability of Exam: reliable IMPRESSION & RECOMMENDATIONS: 59yo F known paraspinal abscess, discitis/osteomyelitis at T6/T7 now with worsening midline lower T spine pain and subjective decrease in LT and proprioception along L4/L5 distribition; no appreciable weakness on exam. Past Medical History: see HPI Social History: see HPi Family History: see HPI Physical Exam: see HPI Pertinent Results: [2201-2-19] 01:23PM BLOOD WBC-8.7 RBC-3.30* Hgb-9.1* Hct-27.5* MCV-83 MCH-27.5 MCHC-33.0 RDW-15.3 Plt Ct-356 [2201-2-19] 11:58AM BLOOD WBC-8.7 RBC-3.33* Hgb-8.9* Hct-27.7* MCV-83 MCH-26.9* MCHC-32.3 RDW-15.1 Plt Ct-312 [2201-2-19] 05:49AM BLOOD WBC-8.0 RBC-3.19* Hgb-8.9* Hct-26.5* MCV-83 MCH-27.8 MCHC-33.4 RDW-15.3 Plt Ct-314 [2201-2-18] 05:13AM BLOOD WBC-8.3 RBC-3.18* Hgb-8.7* Hct-26.2* MCV-82 MCH-27.3 MCHC-33.2 RDW-15.4 Plt Ct-267 [2201-2-17] 08:30AM BLOOD WBC-9.0 RBC-3.32* Hgb-9.0* Hct-27.2* MCV-82 MCH-27.2 MCHC-33.2 RDW-14.9 Plt Ct-281 [2201-2-13] 05:29AM BLOOD WBC-9.3 RBC-3.32* Hgb-9.0* Hct-27.5* MCV-83 MCH-27.1 MCHC-32.7 RDW-14.8 Plt Ct-213 [2201-2-10] 02:50PM BLOOD WBC-12.1* RBC-4.41 Hgb-11.9* Hct-36.1 MCV-82 MCH-26.9* MCHC-32.9 RDW-14.5 Plt Ct-266 [2201-2-11] 04:57AM BLOOD Neuts-76.0* Lymphs-17.9* Monos-2.3 Eos-3.3 Baso-0.4 [2201-2-11] 04:57AM BLOOD ESR-88* [2201-2-19] 05:49AM BLOOD Glucose-130* UreaN-19 Creat-1.1 Na-137 K-3.9 Cl-105 HCO3-25 AnGap-11 [2201-2-18] 05:13AM BLOOD Glucose-142* UreaN-22* Creat-1.0 Na-131* K-3.8 Cl-101 HCO3-25 AnGap-9 [2201-2-17] 08:30AM BLOOD Glucose-93 UreaN-24* Creat-1.2* Na-133 K-3.6 Cl-98 HCO3-23 AnGap-16 [2201-2-16] 05:26AM BLOOD Glucose-124* UreaN-23* Creat-1.4* Na-132* K-3.7 Cl-96 HCO3-25 AnGap-15 [2201-2-15] 04:25AM BLOOD Glucose-135* UreaN-15 Creat-1.0 Na-135 K-3.8 Cl-98 HCO3-25 AnGap-16 [2201-2-14] 05:19AM BLOOD Glucose-299* UreaN-14 Creat-0.9 Na-136 K-3.7 Cl-99 HCO3-25 AnGap-16 [2201-2-11] 02:45PM BLOOD Glucose-212* UreaN-18 Creat-1.0 Na-134 K-4.2 Cl-104 HCO3-19* AnGap-15 [2201-2-19] 01:23PM BLOOD AST-41* LD(LDH)-209 [2201-2-14] 05:19AM BLOOD CK(CPK)-328* [2201-2-19] 05:49AM BLOOD Albumin-2.6* Calcium-8.2* Phos-4.7* Mg-1.5* [2201-2-12] 02:38AM BLOOD Type-ART pO2-172* pCO2-36 pH-7.36 calTCO2-21 Base XS--4 [2201-2-11] 07:47PM BLOOD Glucose-200* [2201-2-11] 11:05 am BIOPSY T7 BIOPSY. FINAL REPORT [2201-2-17] GRAM STAIN (Final [2201-2-11]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2201-2-17]): STAPH AUREUS COAG +. RARE GROWTH. Reported to and read back by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (NURSE) [2201-2-13] AT 0845. 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. Daptomycin AND LINEZOLID Susceptibility testing requested by DR. [Last Name (STitle) ] #[Numeric Identifier 100855] [2201-2-14]. Daptomycin MIC = 0.064 MCG/ML. Daptomycin Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [2201-2-15]): NO ANAEROBES ISOLATED. Final Report CLINICAL HISTORY: 59-year-old woman with known spine osteomyelitis and abscess. Presenting with weakness and numbness. To rule out increase in the size of the abscess. STUDY: MR thoracic and lumbar spine without contrast. COMPARISON STUDY: Outside MR thoracic spine dated [2200-12-16]. TECHNIQUE: Sagittal T1, T2, STIR and axial T2-weighted images were obtained of the thoracic and lumbar spine without administration of contrast. Post-contrast images could not be obtained as the patient has allergy to contrast. Some of the images are degraded by motion artifact. FINDINGS: THORACIC SPINE: Numbering used is shown on se 9, im 12. There is partial destruction of T6 and T7 vertebrae with associated altered marrow signal, appearing hypointense on T1- and T2-weighted images and mildly hyperintense on STIR images. There is involvement of intervening T6-T7 intervertebral disc. There is associated pre- and para-vertebral soft tissue at T6-T7 level. There is also associated anterior epidural component causing severe spinal canal stenosis at T6-T7 level and causing compression of the spinal cord. Hyperintense signal is noted in the spinal cord from T5 to T7 level which likely represents edema. Hyperintense signal is noted in the posterior paraspinal soft tissues at T6-T7 level which likely represents edema. Assessment for associated inflammation/infection is limited due to lack of IV contrast images. There has been interval progression of the disease from the prior study of [2200-12-16] with increased destruction of T6 and T7 vertebrae and new epidural component causing compression of the spinal cord. Rest of the thoracic vertebrae are normal in signal intensity and height. At C6-C7, there is central disc protrusion contacting the spinal cord. LUMBAR SPINE: The normal curvature of the lumbar spine is maintained. There is grade 1 anterolisthesis of L3 over L4 vertebra. The lumbar vertebral bodies are normal in height and marrow signal intensity. L2-L3 to L4-L5 discs are desiccated. There is decreased height of L2-L3 intervertebral disc. At L2-L3, there is disc bulge causing indentation of the ventral thecal sac. The disc with endplate and facet osteophytes causes mild bilateral neural foraminal stenosis. At L3-L4, there is uncovering of the disc with possible superimposed disc extrusion which along with facet arthropathy and ligamentum flavum thickening causes severe spinal canal stenosis with crowding and some degree of compression on the nerves of the thecal sac. The disc with endplate and facet osteophytes causes moderate right and mild left neural foraminal stenosis. Small synovial effusion is noted in bilateral facet joints. At L4-L5, there is diffuse posterior disc bulge causing indentation of the ventral thecal sac. There is associated ligamentum flavum thickening and facet arthropathy. The disc with endplate and facet osteophytes causes moderate right and mild left neural foraminal stenosis. At L5-S1, there is mild disc bulge without significant spinal canal or neural foraminal stenosis. The conus medullaris ends at L1 level. The pre- and para-vertebral soft tissues appear normal. The bladder is markedly distended. IMPRESSION: 1. Partial destruction with altered marrow signals of T6 and T7 vertebrae with involvement of intervening T6-T7 intervertebral disc suggestive of spondylodiscitis. There is associated pre- and para-vertebral soft tissue and epidural soft tissue at T6-T7 level. The epidural component causes severe spinal canal stenosis and compression of the spinal cord.Assessment for inflmmation, infection or abscess is limited on the present study and cannot be excluded. Hyperintense signal is noted in the spinal cord from T5 to T7 level which likely represents edema. The disease has significantly progressed since the prior study with increased destruction of T6 and T7 vertebrae with new pre- and para-vertebral and epidural soft tissue components and posterior spinous edema. Refer to the concurrent CT spine report for osseous details and posisbility of fracture with DISH. 2. Degenerative changes in the lumbar spine, most notable at L3-L4 level where there is severe spinal canal stenosis from disc bulge and possible extrusion and facet changes with crowding of the nerves of the thecal sac. The study and the report were reviewed by the staff radiologist. DR. [Last Name (STitle) ] K. CHAUDHARY DR. [First Name (STitle) 10627] PERI Approved: [First Name8 (NamePattern2) ] [2201-2-12] 9:33 AM Brief Hospital Course: Patient was admitted to the [Hospital1 18] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the ICU in a stable condition. Patient was extubated the next day and shofted to the floor. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Physical therapy was consulted for mobilization OOB. Patient was moved to the chair but was unable to walk. Infectious disease - changed the Vancomycin to Daptomycin post operatively. PICC line was removed and a new one inserted. [Last Name (un) ] were consulted for diabetes control and patient was managed on insulin sliding scale. On [2-16] patient developed raised creatinine levels. Renal were consulted and a diagnosis as prerenal [Last Name (un) ]. Patients renal function improved with hydration. During this admission 2 units of blood were transfused for blood loss anemia Trial of Foley removal failed as patient failed to void probably due to neurogenic bladder. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Medications: amlodipine, insulin glargine, oxycodone, morphine, prochlorperazine maleate, zolpidem, insulin lispro, Vitamin B Complex, sertraline, gabapentin, ergocalciferol (vitamin D2), pantoprazole, Lantus, carbidopa-levodopa, vancomycin Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 6. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:24 Tablet Extended Release(s) Refills:0 7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 9. oxycodone 20 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:72 Tablet(s) Refills:0 10. daptomycin 500 mg Recon Soln Sig: 650mg Recon Solns Intravenous Q24H (every 24 hours). 11. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. insulin pleae see separate sheet Discharge Disposition: Extended Care Facility: [Hospital 66] Rehab & Nursing Center - [Hospital1 392] Discharge Diagnosis: 1. T6, T7 diskitis. 2. T6, T7 osteomyelitis. 3. T7 fracture with kyphosis. 4. Spinal stenosis with incomplete spinal cord injury. 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: Immediately after the operation: - Activity: As tolerated - Rehabilitation/ Physical Therapy: o 2-3 times a day you should move to the chair. Activity as tolerated o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Neurological weakness. Unable to walk independently. Out of bed to chair recommended as frequently as possible. Should wear brace when the back is unsupported (example sitting in chair without back support or while walking). No need for brace in bed. Treatments Frequency: see discharge instructions. The incision can be kept open to air. If persisted discharge please contact [Numeric Identifier 18919]. Patient as history of diabetic foot. left second toe has a healing 0.5 mm superficial abrasion. Outpatient Lab Work please draw weekly cbc bun cr cpk lfts please fax results to dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] fax number is [Numeric Identifier 109921] Immediately after the operation: - Activity: As tolerated - Rehabilitation/ Physical Therapy: o 2-3 times a day you should move to the chair. Activity as tolerated o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Neurological weakness. Unable to walk independently. Out of bed to chair recommended as frequently as possible. Should wear brace when the back is unsupported (example sitting in chair without back support or while walking). No need for brace in bed. Treatments Frequency: see discharge instructions. The incision can be kept open to air. If persisted discharge please contact [Numeric Identifier 18919]. Patient as history of diabetic foot. left second toe has a healing 0.5 mm superficial abrasion. Followup Instructions: Follow up with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] after 2 weeks of discharge. Spine center: [Numeric Identifier 18919] Please follow up with Infectious disease DR [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital ] hospital call [Telephone/Fax (1) 109922] for appt Completed by:[2201-2-20] Name: [Known lastname 17881],[Known firstname 7174] Unit No: [Numeric Identifier 17882] Admission Date: [2201-2-10] Discharge Date: [2201-2-20] Date of Birth: [2141-8-26] Sex: F Service: ORTHOPAEDICS Allergies: antihistamines / decongestants / Amitriptyline / Adhesive Bandage Attending:[Doctor Last Name 147] Addendum: pt will be followed by [Hospital1 ] id not dr [Last Name (STitle) 17883] Major Surgical or Invasive Procedure: 1. Laminectomy T6 without facetectomy. 2. Laminectomy T7 with facetectomy. 3. Costovertebral decompression T6, T7. 4. Extra cavitary corpectomy T6, T7. 5. Lateral extra cavitary arthrodesis T6, T7. 6. Posterior fusion T4 through T9. 7. Posterior instrumentation T4 through T9. 8. Open treatment thoracic fracture/dislocation posterior. 9. Incision and debridement deep abscess thoracic. 10.Open biopsy deep bone. 11.Local autograft for fusion. 12.Allograft for fusion. Discharge Disposition: Extended Care Facility: [Hospital 4426] Rehab & Nursing Center - [Hospital1 3983] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 148] MD [MD Number(2) 149] Completed by:[2201-2-20]	[ "250.50", "244.9", "278.01", "733.13", "784.2", "737.10", "584.9", "V58.67", "722.92", "730.18", "731.8", "596.54", "362.01", "280.0", "276.1", "518.51", "V43.65", "041.12", "V85.42", "250.80", "401.9", "V70.7", "730.08" ]	icd9cm	[ [ [] ] ]	[ "03.53", "81.63", "77.79", "80.51", "38.97", "77.49", "81.05" ]	icd9pcs	[ [ [] ] ]	22695, 22942	12329, 13812	22201, 22672	15739, 15739	4274, 12306	21299, 22163	4222, 4231		14383, 15453		15586, 15718	13839, 14360			15915, 15915										4246, 4255	20767, 21019	21041, 21276							20260, 20749											18727, 18785								291, 321									19235, 20249	858, 2816									15754, 15891							4172, 4181	4197, 4206
46,781	193,079	38753	Discharge summary	report	Admission Date: [2120-12-23] Discharge Date: [2120-12-27] Date of Birth: [2053-8-26] Sex: F Service: NEUROLOGY Allergies: Hydromorphone Attending:[First Name3 (LF) 65686] Chief Complaint: headache, nausea & vomiting Major Surgical or Invasive Procedure: 1. Attempted drainage of brain cyst with neurosurgery on [12-25] 2. Brain cyst drainage with interventional radiology on [12-26] History of Present Illness: 67 right handed female with a history of Ovarian CA who presented with imbalance and a large cerebellar cystic lesion, she underwent stereotactic drainage and [Last Name (un) ] catheter placement on [2120-12-11]. She has been treated with Cyberknife locally, and recieved her last treatment This past Thursday [2120-12-19]. She States that she had a headache on Friday which resolved and was headache free over the weekend, but then again developed a headache accompanied by nausea and vomiting this morning. She Called her oncologist who advised her to take an extra dose of Decadron today and not start her taper and to come to the emergency department. She has taken 4mg of Decadron for the past few days. Past Medical History: Ovarian CA, Hypertension, arthritis, seasonal allergies, depression, hyperlipidemia, [Month/Day/Year 499] adenomas, asthma and TIA Social History: - denies tobacco and recreational drug use - rare alcohol use Family History: - father with [Name2 (NI) 499] cancer, deceased at 49 - brother with prostate cancer Physical Exam: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 6 to 4mm EOMs: intact Neck: Supple. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: slightly dysarthric with thick speech,good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,6 to 4 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 [5-8] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. PHYSICAL EXAM UPON DISCHARGE: ******* Pertinent Results: [2120-12-23] 11:18PM [Month/Day/Year 11516*]-125 POTASSIUM-3.9 CHLORIDE-87* [2120-12-23] 07:30PM GLUCOSE-157* UREA N-11 CREAT-0.5 [Month/Day/Year 11516]-125* POTASSIUM-3.1* CHLORIDE-85* TOTAL CO2-24 ANION GAP-19 BIOPSY of cystic lesion drainage: pending [12-23] HEAD CT IMPRESSION: 1. Left cerebellar hypodense lesion, with mild interval increase in size since the prior study. An MRI is recommended for further evaluation. 2. No evidence of acute intracranial hemorrhage. [12-24] BRAIN MRI IMPRESSION: 1. Enlargement in the size of the left posterior fossa cystic lesion despite drain in situ. Signal characteristics today are suggestive of subacute blood products. 2. Increase in the surrounding vasogenic edema and increased mass effect on the fourth ventricle and inferior displacement of cerebellar tonsils without new hydrocephalus. Brief Hospital Course: This is a 67 yo female with h/o stage IV ovarian ca s/p surgery, 6 cycles of [Doctor Last Name ]/taxol, cyst aspiration of a cerebellar lesion and Cyberknife treatments now admitted with increased HAs, n/v, dysarthria likely [2-6] increased edema in brain lesion. . # N/V/dysarthria: Pt was initially admitted to the neurosurgical service in the ICU for close observation. A head CT was performed which revealed cerebellar cyst versus edema. She was given 10mg decadron, IV hydration, Decadron 4mg Q6h. She underwent an MRI w and w/o contrast which showed enlargement in the size of the left posterior fossa cystic lesion and increase in the surrounding vasogenic edema and increased mass effect on the fourth ventricle. Overnight, she neurologically improved. Her dysarthria, H/A & N/V resolved. Pt was transferred to OMED floor, where she continued to be largely aymptomatic. Neurosurg attempted to drain from the cystic lesion, however, was unsuccessful. The drainage was then planned by IR the next day and approx 14cc of fluid was drained. The fluid was sent to the lab for analysis. likely [2-6] increased edema seen on imaging. Pt was continued on Reglan PRN, Compazine PRN and Zofran PRN for nausea. At discharge, Dexamethasone was started to be tapered. Pt was also initiated on Bactrim for PCP [Name Initial (PRE) ]. . # Hyponatremia: Her Na was initially 125. Likely SIADH [2-6] brain edema. Improved with fluid restriction and salt tabs. Na 133 on day of discharge. . # Stage IV ovarian cancer: Pt was continued on pain control with home Motrin, Oxycodone PRN. Pt has f/u MRI and appt on [2120-1-28] with Brain [Hospital 341] Clinic. Given pt's unusual metastatic spread of her ovarian cancer to the brain and history of prostate cancer in the family at a young age, it can be considered to do genetic testing (incl BRCA) as outpt. . # Depression/Insomnia: Pt was continued on home Citalopram and Ativan qhs PRN. . # HTN/HL: Pt was continued on home HCTZ, Lisinopril, Verapamil. It can be considered as outpt to discontinue HCTZ, given pt's persistent hyponatremia. Pt was continued on home Simvastatin. . # Pt was on a regular diet, oncology repletion scales. Pain control was with Motrin, Oxycodone PRN. Pt was on a bowel regimen and a PPI. Pt was on DVT PPx with SC Heparin. Pt was full code. Medications on Admission: DEXAMETHASONE - (Dose adjustment - no new Rx) - 1 mg Tablet - 2 Tablet(s) by mouth twice a day Taper as follows: take 2 mg [Hospital1 ] on [11-12], take 2 mg QAM and 1 mg QPM on [2122-12-24], take 2 mg once daily on [11-20], take 1 mg once daily on [2123-1-1]. Stop taking Decadron after your dose on [2121-1-3]. HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Capsule - 2 Capsule(s) by mouth DAILY (Daily) IBUPROFEN - (Dose adjustment - no new Rx) - 600 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime and as needed METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea, abdominal bloating take 30min before meals OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth DAILY (Daily) ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth q8hr as needed for nausea, vomiting OXYCODONE - 5 mg Tablet - [1-6] Tablet(s) by mouth q4hr as needed for pain PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1/2-1 Tablet(s) by mouth q6hr as needed for nausea, vomiting SCALP PROSTHESIS - - apply to head SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) VERAPAMIL - (Prescribed by Other Provider) - 240 mg Tablet Sustained Release - 1 Tablet(s) by mouth every twenty-four(24) hours Discharge Medications: 1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. verapamil 120 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q24H (every 24 hours). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. docusate [Month/Day (2) ] 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 7. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 8. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for nausea. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. [Month/Day (2) ] chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 15. dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 3 days. Disp:18 Tablet(s) Refills:0 16. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day for 3 days. Disp:12 Tablet(s) Refills:0 17. dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). Disp:36 Tablet(s) Refills:2 18. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:20 Tablet(s) Refills:0 19. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO MWF. Disp:12 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Cystic brain lesion 2. SIADH, low [Month/Day (2) ] 3. Stage IV Ovarian Cancer Secondary Diagnoses: 1. Depression 2. Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you during this admission. You were admitted for headaches, nausea, vomiting, and difficulty speaking. You had an MRI of your head that showed increased size of cystic lesion. Neurosurgery tried to drain the fluid but were unable to. You had a second procedure with interventional radiology, who was able to remove some fluid. Your headaches improved. The following medications were changed during this admission: START [Known lastname ] chloride 1mg, 2 tablets, three times daily (this is to maintain your [Known lastname ] levels at a normal level) START Oxycodone 5mg 1-2 tablets every four hours as needed for pain This medication can cause sedation, do not take this medication while if you feel sedated or confused. And you should not be driving while on this medication, or at all. START Bactrim DS (Oral) 800-160 mg Tablet, 1 tablet on Monday, Wednesday and Friday (this is an antibiotic that prevents an infection called PCP in the lungs; this is important to take since you are on steroids and may be more susceptible to infection) The dose of Dexamethasone was changed; Please follow the schedule below: START Dexamethasone 6mg by mouth twice daily for 3 days, then take 4mg twice daily for 3 days, then take 6mg daily in the morning. You should see your doctor in the interim to determine how long you need to be on the dexamethasone. Continue all other medications you were on prior to this admission. You have been continued on your home dose of hydrochlorathiazide 25mg daily. However, we would like you to discuss discontinuing this with your doctor. [First Name (Titles) 2172] [Last Name (Titles) ] has been low during this admission, which has been controlled with restriction of 1L of fluid and salt tabs. However, HCTZ can also lower the [Last Name (Titles) ]. Since you have been stable on this medication, you were continued on it. Though, please discuss this with your doctor at follow-up. In terms of travel, it is safe for you to visit you family. However, you should NOT drive. This can be very dangerous, especially since you recently had a procedure. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Followup Instructions: Please follow-up with the following appointments: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2121-1-10] 11:15 Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2121-1-13] 11:00 Provider: [First Name11 (Name Pattern1) 3750] [Last Name (NamePattern4) 3751], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2121-1-13] 11:00 Department: RADIOLOGY When: FRIDAY [2121-1-10] at 11:15 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST [Known lastname ] Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2121-1-13] at 11:00 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST [Known lastname ] Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2121-1-13] at 11:00 AM With: [First Name11 (Name Pattern1) 3750] [Last Name (NamePattern4) 3751], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST [Known lastname ] Parking: [Hospital Ward Name 23] Garage You will also need a follow-up brain MRI in one month. Dr. [Name (NI) 86075] office will be in contact with you regarding it. Completed by:[2120-12-27]	[ "E879.8", "787.01", "784.0", "272.4", "716.90", "401.9", "693.0", "183.0", "V12.54", "781.2", "348.5", "311", "V12.72", "253.6", "V45.2", "E935.2", "V87.41", "198.3", "998.12" ]	icd9cm	[ [ [] ] ]	[ "01.02" ]	icd9pcs	[ [ [] ] ]	9367, 9373	3554, 5910	306, 445	9573, 9573	2659, 3531	12295, 13763	1450, 1541		7453, 9344		9394, 9499	5936, 7430			9724, 12272										1556, 1703			9520, 9552																									239, 268								2628, 2640		473, 1196	1924, 2598								9588, 9700							1218, 1354	1370, 1434
25,787	180,521	42996	Discharge summary	report	Admission Date: [2145-3-25] Discharge Date: [2145-4-11] Date of Birth: [2114-1-5] Sex: F Service: NEUROSURGERY CHIEF COMPLAINT: Subarachnoid hemorrhage HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old female with no past medical history, who was at home ironing on the [12-25]. The patient felt no premonitory symptoms of hypertension or headache before feeling a [Doctor Last Name ] in the middle of her head. This was immediately followed by extreme pain and pressure in the cranium. The patient subsequently had feelings of nausea and vomited two times after that. She denies any complaints of chest pain or shortness of breath. Review of systems is also positive for photophobia and mild meningismus after this event. The patient was transferred directly to [Hospital1 190] Emergency Room for workup. PAST MEDICAL HISTORY: None PAST SURGICAL HISTORY: None MEDICATIONS: None ALLERGIES: None FAMILY HISTORY: Father had an intracerebral aneurysm, which was clipped successfully. PHYSICAL EXAMINATION: The patient presents with a temperature of 99.6, heart rate 76, blood pressure 153/86, respiratory rate 16, and an oxygen saturation of 100%. The patient was a middle-aged woman, in no apparent distress. She appeared awake, alert and oriented. The head was normocephalic, atraumatic. Pupils were bilaterally 2 to 1 mm, and briskly reactive. Extraocular movements were full. Neck examination showed decreased range of motion on flexion, with a normal rotation and extension. Heart was regular rate and rhythm, with a normal S1 and S2, without murmurs, gallops or rubs. The lung examination was clear to auscultation bilaterally. The abdomen was soft, nontender, nondistended, with present bowel sounds. Neurologic examination showed 5/5 strength testing in the bilateral deltoids, biceps, triceps, wrist extensors, wrist flexors, finger extensors, and grip. [4-17] muscle testing was also noted in the bilateral iliopsoas, knee flexors, knee extensors, dorsiflexors, and plantar flexors. There was no sensory loss noted within the upper or lower extremities. Fine finger movements appeared to be intact bilaterally. Cranial nerves II through XII appeared to be grossly intact. RADIOLOGIC EXAMINATION: Head CT showed subarachnoid hemorrhage, bilaterally symmetrical throughout the suprasellar cisterns and the sylvian fissures. There was no intraparenchymal hemorrhage, no intraventricular hemorrhage, no subdural or epidural bleed. There was no obvious aneurysm or midline shift. Four vessel angiogram was obtained on the [12-25]. Results of this study showed a left irregularly-shaped posterior communicating artery aneurysm, a small right ophthalmic aneurysm, and a tiny erratic duplicated common origin to the right anterior ____________, where a small aneurysm could not be ruled out. No other aneurysms were reported on the angiographic study. LABORATORY DATA: The patient presents with a white count of 12, hematocrit of 35, and a platelet count of 356. INR was 1.2, with a PTT of 27.3. Chem 7 was within normal limits, and an ionized calcium was 1.17. HOSPITAL COURSE: The patient was taken to the operating room on the [12-26] and underwent a left pterional craniotomy for aneurysm clipping. The patient had gone to Interventional Radiology for angiography, which showed a large irregular aneurysm at the origin of the left posterior communicating artery with signs of recent bleeding. The patient tolerated the procedure well and, by surgical report, there were no complications, and the clipping of the aneurysm appeared to be complete. A small Yasargil clip was used for the clip. Postoperatively, the patient was awake, alert and oriented x 3. Pupils were equally reactive and extraocular movements were full. A slight right facial weakness was noted. Strength testing was [4-17] throughout all muscle groups of the upper and lower extremities. Small amounts of swelling with fluid collection were noted at the incision site. The patient was transferred into the Surgical Intensive Care Unit from the Postoperative Care Unit, and did quite well. On postoperative day number one, the patient continued to be neurologically stable, and at this time the blood pressure was liberalized to a goal of 170. Hydration was continued with intravenous fluids at 125 cc/hour, and Decadron was decreased to 2 mg three times a day. The patient was advanced to a regular diet at this time. On postoperative day number two, the patient continued to be alert and oriented, with some noted paraphasic errors and substitutions on language examination. Strength examination continued to be intact, but there was facial weakness noted on the right side. Intravenous fluids were kept to 150 cc/hour, and Decadron taper was continued. Over the next few days, the patient was noted to have a mild right-sided downward drift with some right-sided hemiparesis in addition to her previously-noted right facial droop. Head CT was done at this time, showing infarction in the region of the left internal capsule, most likely secondary to occlusion of the left anterior ____________ artery or the left lenticular _____ artery. On examination, the patient was noted to be drowsy but fully arousable, with persistent right-sided weakness and language difficulties. Angiogram performed on the [1-1] showed mild amounts of mechanical vasospasm in the territory of the ___________________. The patient was not put on aggressive pressor therapy secondary to her clinical examination and the fact that the patient still had unprotected right ophthalmic aneurysm. The patient was weaned off of Neo and Decadron at this time. The patient was continued on aggressive hydration at this time. On the [1-3], the patient's examination had improved, with symmetric strength of the upper and lower extremities, and a persistent mild right facial weakness. The patient's speech was improved, and the patient was continued on euvolemic to hypervolemic therapy. The patient's right-sided mild weakness continued to wax and wane over the next few days but, in all, progressed in an improving direction. On the [1-5], the patient was transferred to the floor. Her examination at this time was awake and alert, oriented x 3. There was a mild pronator drift noted on the right. Repetition and naming were intact. Cranial nerves were noted to be intact. Sodium at this time was mildly decreased to 132, and was followed closely over the next few days. On the [1-6], the patient spiked a fever to 103.2, but did not have any complaints of chills or sweats. Urine and blood cultures were sent in addition to C. difficile cultures, all of which were negative. The patient also complained of severe low back pain at this time, with a [8-23] pain radiating down the left leg. The patient had not previously experienced similar pain in the past. Strength examination was noted to be [4-17] at this time. MRI scan was obtained at this time, which showed some mild to moderate amounts of blood in the spinal canal, however, there was no acute disc herniation or other compressive mass lesion. The patient required multiple fluid boluses over the next few days for intermittent headaches which were felt to possibly be related to vasospasm. The patient continued to do well, and her back pain improved upon appropriate pain medications. The patient was brought out of bed and ambulated on the [1-9], and did so without difficulties. Intravenous fluids were weaned to off over the next 24 hours. The Foley was taken out. The patient continued to void on her own, ambulate, and to take a regular diet. On the [1-11], the patient was afebrile, with stable vital signs. The patient's speech was intact, with a mild residual right facial droop. Back pain had continued to improve with Tylenol #3. Strength examination was intact, as was sensory examination. It was felt at this point that the patient was stable from a medical and surgical standpoint to be discharged home. DISCHARGE DISPOSITION: Home DISCHARGE CONDITION: Stable DISCHARGE MEDICATIONS: Tylenol #3 one to two tablets by mouth every four to six hours as needed, Colace 100 mg by mouth twice a day. DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr. [Last Name (STitle) 11875] in approximately two to three weeks, and is to call the [Hospital 16364] Clinic to establish a follow up appointment. The patient was instructed to call the neurosurgical office if she develops any new symptoms of worsening headaches, decreased mental status, unilateral weakness or numbness, or seizure activity. The patient is to continue to use Tylenol #3 for pain control as needed. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 23483] Dictated By:[Last Name (NamePattern1) 13463] MEDQUIST36 D: [2145-4-10] 23:00 T: [2145-4-11] 00:20 JOB#: [Job Number 92803]	[ "430", "997.02", "724.5" ]	icd9cm	[ [ [] ] ]	[ "39.51" ]	icd9pcs	[ [ [] ] ]	8144, 8150			8172, 8180			988, 1059		8205, 8316				3192, 8120		8342, 9079								924, 970																		1083, 3173												162, 187										217, 869																893, 899
67,390	103,841	1665	Discharge summary	report	Admission Date: [2108-6-29] Discharge Date: [2108-7-3] Date of Birth: [2049-3-3] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / Metoprolol Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2108-6-29] Coronary bypass grafting x 5: Left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary; reverse saphenous vein single graft from aorta to the second obtuse marginal coronary artery; as well as reverse saphenous vein double sequential graft from aorta to the posterior descending coronary artery and posterior left ventricular coronary artery History of Present Illness: 59 year old male in [2106-2-11] underwent a coronary CT as part of a research protocol which revealed a significant Left Circumflex stenosis. Follow up stress testing did not reveal any perfusion defects. On [2106-2-16] he underwent cardiac catheterization where he was found to have an 80% OM2. The RCA was patent and the LAD had a 50% stenosis in the proximal portion. An attempt to open the OM2 was made, although was unsuccessful as the lesion was calcified. The patient reports that about two months ago he developed new onset angina. He describes mid and upper left sided chest tightness associated with pain in the neck and left arm. This only occurs with exertion, ie. Two flights of stairs. In addition, he has noticed new dyspnea on exertion. These symptoms typically resolve with rest or SL nitroglycerin. Recent stress testing has revealed inferoseptal and posteroseptal ischemia. He was referred for cardiac catheterization. Cardiac catherization revealed multivessel coronary artery disease. Past Medical History: Coronary artery disease s/p failed OM2 PCI in [2106] HIV Trigeminal neuritis [2104] resection of basal cell cancer Asthma/seasonal allergies Hepatitis Anxiety Depression Tonsillectomy resection of pilonidal cyst Social History: Lives with: partner Occupation: unemployed dental ceramist ETOH: 2 glasses of wine per week +tobacco [5-17] cigs/day x 43 yr Family History: Father died of an MI at age 74 + MI Physical Exam: Pulse:67 Resp: 12, O2 sat: 100% B/P 144/ Height: 5'[10] in Weight:162Lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit none Right: 2+ Left:2+ Pertinent Results: [2108-6-29] Echo: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal for the patient's body size. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) 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 leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post Bypass: Patient is in sinus rhythm on phenylepherine infusion. Preserved biventricular function, LVEF >55%. Mitral regurgitation is now [1-13]+. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [7-2] CXR: In comparison with the study of [6-29], the various monitoring and support devices have been removed. Specifically, there is no evidence of pneumothorax. There has been an increase in opacification at the left base with silhouetting of the hemidiaphragm, consistent with atelectasis and pleural effusion. Less prominent atelectatic changes seen at the right base. The upper lungs remain clear. [2108-6-29] 04:50PM BLOOD WBC-13.6# RBC-2.59 Hgb-10.2* Hct-28.7* MCV-111* MCH-39.5* MCHC-35.5* RDW-14.1 Plt Ct-153 [2108-7-2] 06:00AM BLOOD WBC-10.5 RBC-2.62* Hgb-10.0* Hct-29.6* MCV-113* MCH-38.0* MCHC-33.7 RDW-14.1 Plt Ct-130* [2108-6-29] 04:50PM BLOOD PT-16.4* PTT-30.6 INR(PT)-1.5* [2108-6-29] 06:47PM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.2* [2108-6-29] 06:47PM BLOOD UreaN-10 Creat-0.9 Cl-108 HCO3-25 [2108-7-2] 06:00AM BLOOD Glucose-112* UreaN-10 Creat-1.3* Na-136 K-4.8 Cl-105 HCO3-26 AnGap-10 [2108-7-3] 06:00AM BLOOD UreaN-11 Creat-1.1 K-4.2 [2108-7-1] 05:01AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.4 Brief Hospital Course: Mr. [Known lastname 9624] was a same day admit and brought to the operating room on [6-29] where he underwent a coronary artery bypass graft surgery. See operative report for further details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and extubated without complications. He continued to progress but remained in the intensive care unit on Neo-Synephrine for blood pressure management. He was eventually weaned off and transferred to the telemetry floor on post operative day two. Chest tubes and epicardial pacing wires were removed per protocol. Physical therapy worked with him on strength and mobility. He continued to progress well and was ready for discharge with VNA services and the appropriate follow-up appointments on post operative day four. Medications on Admission: Trizivir 300mg-150mg-300mg one tablet twice a day Bupropion HCL 75mg two tablets every morning, one tablet every evening Pravastatin 10mg daily Viread 300mg daily Trazodone 150mg daily at bedtime Aspirin 325mg daily Coenzyme Q10 200mg daily Flaxseed Oil daily Efudex 5% cream as needed Hydrocortisone 2.5% cream as needed Anusol Suppository as needed Nitroglycerin .3mg SL prn Discharge Medications: 1. Trizivir 300-150-300 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 5. Viread 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for q AM: 150 mg in am and 75 mg in pm . Disp:60 Tablet(s) Refills:0 7. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): 150 mg in am and 75 mg in pm . Disp:30 Tablet(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PAIN. Disp:60 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 5 HIV Trigeminal neuritis [2104] resection of basal cell cancer Asthma/seasonal allergies Hepatitis A Anxiety Depression s/p Tonsillectomy s/p Resection of Plonidal cyst Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 9625] in 1 week ([Telephone/Fax (1) 798]) please call for appointment Dr [Last Name (STitle) ] in [2-14] weeks - please call for appointment Wound check appointment [Hospital Ward Name 121] 6 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2108-7-3]	[ "V12.09", "350.1", "458.29", "V10.83", "493.00", "414.01", "305.1", "V08", "E878.2", "300.4", "401.9", "272.4", "413.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.49", "36.14", "36.15" ]	icd9pcs	[ [ [] ] ]	7857, 7915	5104, 6008	296, 753	8191, 8197	2868, 5081	8708, 9128	2202, 2239		6435, 7834		7936, 8170	6034, 6412			8221, 8685										2254, 2849																												246, 258										781, 1797																1819, 2040	2056, 2186
21,968	122,413	29053	Discharge summary	report	Admission Date: [2126-12-28] Discharge Date: [2127-1-11] Date of Birth: [2053-12-30] Sex: M Service: MEDICINE Allergies: Adhesive Tape / Cyclobenzaprine / Ibuprofen / Ambien / Tramadol / Morphine / Isovue-370 Attending:[First Name3 (LF) 330] Chief Complaint: transfer from [Hospital 12017] [Hospital 12018] Hospital for further care Major Surgical or Invasive Procedure: HD History of Present Illness: Pt is a 72 yo male CAD s/p CABG complicated by persistent sternal wound infection/osteomyelitis growing pseudomonas, ARF on dialysis, CHF, and hepatic failure who is being transferred from OSH after a two month stay there for further care at [Hospital1 ] from the Liver service. . Pt s/p CABG on [2125-11-29]. His postoperative course was complicated by congestive heart failure, acute renal failure, atrial fibrillation, and persistent wound infection (pseudomonas, MRSA) with osteomyelitis. On [2126-10-13], Mr. [Known lastname 69992] was admitted to OSH with dyspnea/orthopnea and non-healing wound. MRI of chest done then showed erosive destruction of the sternum, consistent with osteomyelitis. He was followed by infectious disease and cardiothoracic teams and placed on zosyn/ceftazidime. After one week of purulent drainage from track in mid-portion of wound, it was found to be fluctuant. On [2126-10-21], pt went to the OR and underwent sternal debridement. This was complicated by an arterial bleed. It was found to be in the mammary artery and pt was placed on bypass temporarily in the OR. He was maintained on pressor support and ionotropes (unclear per d/c summary which ones) and ? seizure activity. Pt was already intubated (unclear when this was done) and maintained on propofol. He was taken back to the OR on [2126-10-24] for further debridement of his sternal wound and excision of infected bone. Pt was able to be extubated from the ventilator on [2126-10-26]. He started to be diuresed for CHF with lasix. . In terms of pt's renal function, creatinine rose to 3.9 with "good amounts of urine," ~30-50 cc/hr and normal potassium on a lasix gtt. Renal was consulted in pt's third week of stay. Dopamine gtt was added. Over the next few days, creatinine rose to 6.9. Dialysis was initiated on [2126-11-6] and pt is still on it. It is unclear per d/c summary what they thought that the underlying reason for renal failure was. . For the sternal wound infection, antibiotics were initiated once wound culture came back as pseudomonas as pt was started on zosyn and ceftazadine. Pt was debrided as above. He went back to the OR on [2126-11-12] for further debridement and teams tried to improve alimentation and started TPN. Wet--> dry dressing were continued and VAC was placed on [2126-11-27]. . In terms of hepatic failure: On [2126-11-17] pt complained of RUQ pain. A surgical consult was obtained and it was thought that the pt had acute cholecystitis. He underwent lap chole on [2126-11-17]. Vancomycin was added to abx regimen as above. On [2126-12-1], bilirubin was found to be elevated to 2, direct bili of 1.7. AP was ~1000, AST 89, ALT 60. LFTs steadily increased to Tbili 3.8 and pt complained of abdominal pain. On [2126-12-4] pt underwent ERCP and sphincterotomy where a small common bile duct stone was retrieved. On [2126-12-6], bili rose to 5.3, AP to 1149, Amylase 124, and lipase 485. WBC was 11.5. An abdominal CT was done for concern of pancreatitis but was negative; there was also no evidence of stones, nor dilatation of CBD. Over the next days, Tbili rose and pt became quite jaundice with decreased PO intake to bili of 13.8 on [2126-12-20] mainly direct. . Biopsy of the liver was done on [2126-12-19]; results were non-specific and showed only periportal inflammation. Prednisone was started by the liver service in an attempt "to treat his hepatic inflammation." Hepatitis panel was negative. On [2126-12-24] pt became more lethargic and concern was for protection of airway. He was reintubated. Multiple code discussions had and pt remained a full code. . He was weaned from ventilator on [2126-12-26] and extubated. Pt had a PEG tube placed a few weeks ago, but has had high residuals past few days. TPN reordered. KUB shows bowel gas pattern non consistent with ileus. CXR showed persistent CHF. Of note, abx switched in two days since d/c summary to below. Past Medical History: s/p CABG x 5 [2125-11-29] complicated by CHf, ARF, AF Persistent wound infection --found to be osteomyelitis admission [12-1] for MRSA bacteremia associated with this. Sternal debridement [12-31] with omental/pectoral flap. On linezolid for extended time. [9-1] wound debridement procedure performed. Multiple hospitalizations for CHF DM 2 with retinopathy, peripheral neuropathy Nephropathy [2-28] CKD from DM baseline cr 1.6-1.8 prior to above History of renal insufficiency HTN COPD GERD OA PVD with h/o RAS s/p stenting of right and left iliac arteries s/p lumbar laminectomy s/p colonic polypectomy h/o b/l thoracenteses ? h/o pectoral omental flap closue of wound MRSA sternal wound Anemia--unknown further h/o encephalopathy during previous hospitalizations--more unknown Diastolic dysfunction Mild pulmonary HTN Social History: Retired realtor, owned a construction company in past. Lives with wife. Former [Name2 (NI) 1818], quit 10 years ago; smoked 3 ppd. No EtOH. Family History: died of gastric cancer at 58. M: Died from CAD at 61. Physical Exam: VS: Tc: 97.5 Tm 99.2; BP: 111/57; HR: 73; RR: 20; O2: 92 3L NC Gen: NAD, mildly raspy voice, speaking in full sentences without difficulty, + anasarca Skin: scattered ecchymoses over R arm, +jaundice down to lower extremities HEENT: Pinpoint pupils but reactive 3-->2. EOMI without nystagmus. Sclera + icterus. OP dry. Neck: No LAD but wide neck girth. JVD difficult to detect CV: RRR S1S2. Difficult to auscultate Lungs: Limited by anterior exam. Crackles 1/3 up b/l. Chest: 18 cm x 7 cm open chest wound with good granulation tissue. 4 cm deep with openings at bottom. +yellow drainage Abd: +distention. +tymapanic. +feeding tube. +BS though hypoactive. Nontender. Liver ~1.5 cm below costal margin Back: no rashes. No spinal, CVA tenderness Ext: 3+ pitting edema in legs. Arms are grossly anasarcic with ecchomosis throughout arms. L PICC line in brachial artery. Neuro: Oriented to person. Knew he was at a hospital, though not which one. Thought it was [Month (only) ], then knew it was [Month (only) 1096], unsure of year. Grip [5-1] b/l. Would not cooperate with rest of exam. CN II-XII tested and intact. Pertinent Results: [2126-12-28] 05:50PM WBC-12.7* RBC-3.24* HGB-10.7* HCT-30.8* MCV-95 MCH-33.0* MCHC-34.6 RDW-20.8* [2126-12-28] 05:50PM NEUTS-82* BANDS-0 LYMPHS-8* MONOS-4 EOS-2 BASOS-0 ATYPS-0 METAS-2* MYELOS-2* [2126-12-28] 05:50PM PLT SMR-NORMAL PLT COUNT-175 LPLT-2+ [2126-12-28] 05:50PM PT-16.5* PTT-32.6 INR(PT)-1.5* [2126-12-28] 05:50PM TSH-0.37 [2126-12-28] 05:50PM TRIGLYCER-160* HDL CHOL-15 CHOL/HDL-6.5 LDL(CALC)-50 [2126-12-28] 05:50PM calTIBC-83* FERRITIN-1850* TRF-64* [2126-12-28] 05:50PM ALBUMIN-2.0* CALCIUM-8.1* PHOSPHATE-2.6* MAGNESIUM-2.1 URIC ACID-3.5 IRON-27* CHOLEST-97 [2126-12-28] 05:50PM LIPASE-44 [2126-12-28] 05:50PM ALT(SGPT)-50* AST(SGOT)-74* LD(LDH)-209 ALK PHOS-[2125]* AMYLASE-48 TOT BILI-15.8* DIR BILI-13.8* INDIR BIL-2.0 [2126-12-28] 05:50PM GLUCOSE-196* UREA N-54* CREAT-2.7* SODIUM-136 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15 [2126-12-28] 06:06PM LACTATE-1.7 [2126-12-28] 06:06PM TYPE-[Last Name (un) ] PH-7.35 [2126-12-28] 06:06PM freeCa-1.08* . CXR [12-28] - Pulmonary vascular congestion. Asymmetrically increased density in the lower left chest may represent superimposed pneumonia. Evidence for small right pleural effusion and possibly a small left pleural effusion. . Abd US c doppler [12-30] - IMPRESSION: 1. Coarsened echotexture of the liver without focal masses. Large amount of ascites is present, which is greater in the left lower quadrant than the right. Suitable spot was marked overlying both lower quadrants. 2. Normal Doppler ultrasound evaluation of the liver. 3. No renal stones or hydronephrosis on either side. . CT chest c IV contrast [12-31] - 1. Midline sternotomy defect still clearly visible without osseous bridging, with associated soft tissue stranding, air, and associated osseous changes consistent with the patient's reported clinical history of sternal wound infection/osteomyelitis. 2. Emphysema. 3. Aortic and coronary artery calcifications. 4. Ascites of intermediate density, that could suggest "complicated" fluid. 5. Curvilinear metallic object present adjacent to right pericardium and aortic root, concerning for a migrated sternotomy wire. This was discussed with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] at 10:10pm on [2126-12-31]. 6. Increased number of mediastinal nodes, most measuring less than 1 cm. These are likely hyperplastic. . CXR [1-5] - There has been no significant interval change in the right IJ or left subclavian lines. Again seen is indistinct pulmonary vasculature and patchy infiltrates involving the left lower lobe and right lower lobe with volume loss in these regions as well. It is unclear if the alveolar infiltrates are due to pulmonary edema or have an infectious etiology. Compared to the prior film, there has been no significant interval change. . Port CXR [1-7] - Right jugular dialysis catheter overlies right atrium. Tip of left subclavian CV line overlies proximal SVC. No pneumothorax. Right costophrenic angle region is not included on this film. No pneumothorax. Heart size is borderline for technique. There is tortuosity of the thoracic aorta and bibasilar linear atelectases as well as retrocardiac opacity consistent with atelectasis in the left lower lobe that is possibly slightly increased since the prior film of [1-5], 06. . TTE [1-8] - 1. Technically difficult study. Only limited views obtained. 2.The left atrium is mildly dilated. The left atrium is elongated. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably only mildly depressed. 4. Right ventricular chamber size appears normal. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload but could be a post-op septum. 5.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 7.There is no pericardial effusion. Brief Hospital Course: 72 yo male CAD s/p CABG, persistent sternal wound infection/osteomyelitis growing pseudomonas and MRSA, ARF on dialysis, CHF, and elevated LFTs who was transferred from OSH after a two month stay there for further care at [Hospital1 ] for further medical management. . COURSE ON MEDICINE FLOOR: 1) Elevated LFTs - Followed by the liver service. Likely [2-28] cholestasis from mediations and/or sepsis. s/p CCY and ERCP at OSH with sphincterotomy with stones removed from common bile duct. His synthetic function is intact (elevated INR to 1.5 likely in setting of poor PO intake), thus making hepatitic failure less likely. Had 5 L paracentesis on [12-30]. SAAG 1.0. Pertineal fluid cxs with no growth. Obtained liver bx slides from [Hospital 12017] Hospital for our path dept to review. Was continued on Lactulose 30 mg tid. Noted to be occcasionally more confused/encepalopathic which would wax and wane while on the floor. . 2) Wound infection/osteomyelitis - S/p multiple debridements and surgery for osteomyelitis. Superficial wound cx on admission here growing Diptheroids and Cornyebacterium. Deep wound cx with minimal growth of Corynebacterium. Pt remains AF. ID consulted who recommended switching antibiotics from IV tobra and daptomycin to IV ceftazidime as the only true culture data that we have is from his operative sternal debridement in [10-2] at OSH which was significant for ceftaz sensitive Pseudomonas aergunosa. CT chest with IV contrast performed that was not significant for changes suspicious for infection beyond the sternal region. However, a migrated sternal wire was noted between the aortic root and the pericardium. Was discussed with cardiac surgery who felt that wire did not impose immediate life threatening risk and that surgical management to remove the wire would not be needed urgently. There was a question of whether or not the wire may be a source of infection..... Plastics also followed pt and recommended placement of wound vac. Recommended holding off of further surgical management of sternal wound (i.e. flap revision) until pt's nutritional status was improved. . #) Migrated sternotomy wire - CT chest performed to r/o spread of infection significant for possible migrate sternotomy wire adjacent to R pericardium and aortic root (see above). Cardiac surgery consulted who felt that there was no need for urgent removal of sternotomy wire. No limitations on activity. . #) Chest Pain - Pt with chest pain on [1-4] during dialysis. Noted to have SBPs in 70s X 1 hr prior to chest pain. Pt was bolused with IVF prior to being taken off of dialysis with improvement in SBPs to 100s. Chest pain resolved. EKG without new ischemic changes. Was ruled out for MI X 3 sets of enyzmes. . # Hematochezia - Noted in rectal collection bag on morning of [1-7]. Had 2 point Hct drop. Remained hemodynamically stable in the am. As had rectal tube, there was a question of internal erosion causing blood vs. other LGI bleed. Pt was known to be guaiac positive. Repeat Hct check in 6 hrs remained stable. However, pt became hypotensive and hypoxic and was transferred to the MICU for further management. . # COPD - Oxygen requirement stable until pt became hypoxic on [1-7]. Unclear if pt has a h/o CO2 retention. Was continued on combivent, albuterol, ipratropium. . # Pain - Oxycodone 5 mg po q12h prn for pain. However, the pt responded quite well to frequent bed turning. . # ARF on hemodialysis - Followed by renal service and dialyzed q M,W,F,Sat. Unclear cause of acute on chronic renal failure at OSH. . # CHF- Admission CXR with fluid overload; however not impressively so. As pt anuric, had fluid removed at HD. . # h/o CAD - Had episode of CP at HD on [1-4] as above. No ischemic EKG changes. Ruled out by enzymes X 3. Continued on aspirin 325 mg. Was on metoprolol 12.5 mg [Hospital1 ] prior to this being d/c'd given concerns of hypotension. . # Anemia - Iron studies consistent with ACD. Pt guaiac positive here. Remained on protonix [Hospital1 ]. . # DM II - Upon transfer, pt was not on tube feeds or TPN and had been off of insulin for at least 2 days. Was placed on q4h regular insulin while tube feeds were retitrated up. Based off of pt's insulin requirement, lantus was titrated to 20 U qhs by time of transfer to MICU. Also remained on RISS. . # F/E/N - Pt's nutritional status remained major barrier for further surgical management per OSH d/c summary. Was on tube feeds and even TPN intermittently at OSH. Was evaluated by nutrition consult who recommended tube feeds with Nutren renal at 35 cc/hr with 45 g beneprotein additives. Ensure pudding qmeal. Also evaluated by speech and swallow who thought that pt was at risk for aspiration with thin liquids. Was cleared for soft solids and thick pureed liquids. All pills with applesauce or thickened pureed liquids. Reglan and vitamin C were continued. . # Access: L double port PICC -->brachial [2126-12-12]; Right subclavian tunneled dialysis port [2126-11-25]. COURSE IN ICU: Patient was transferred to the ICU for hypotension. This was thought most likely due to sepsis given his multiple potential infectious source. ID service suggested continuing him on ceftaz, vanco. He was started on levophed. Over the next few days, his levophed requirement increased and he was eventually on 3 pressors over night on [2127-1-9]. He also received 17L of NS/N1HCO3 on [2127-1-10]. Despite that, his blood pressure continues to drop. His lactate increased to 21 and he was persistently acidotic despite CVVHD. Surgery was consulted regarding presumed ischemic bowel and recommended agaist surgery. Family meeting was held and decided that he should be CMO. Patient was extubated. All drips were shut off. He was pronounced dead at 1.30AM on [2127-1-11]. Family declined autopsy. Medications on Admission: Medications on transfer: Albuterol nebs Ipratropium nebs Combivent 4 puffs q 4 hours Vitamin c 500 mg qday ASA 325 mg qday Tylenol prn Lotrimin to scrotum [Hospital1 ] Mycelex Troche 10 mg five times a day Lantus? Novolog ISS sc q4 hours Lovenox 30 mg sc--d/c'd day of transfer as guaiac positive stools Procrit 20,000 units qdialysis Immodium 2 mg [Hospital1 ] prn Reglan 5 mg IV q6 hr Metoprolol 2.5 mg IV q 4 hours Protonix 40 mg IV q12 hrs Prednisone 20 mg qday Ursodiol 300 mg [Hospital1 ] Becaplermin qam to sternal wound Tobramycin sulfate 65 mg qdialysis Caspofungin Acetate 35 mg IV daily Daptomycin 400 mg q48 hours Discharge Disposition: Expired Discharge Diagnosis: sepsis, hypotension Wound infection ischemic bowel atrial fibrillation Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2127-1-11]	[ "996.59", "428.0", "038.9", "276.2", "357.2", "250.60", "518.81", "041.7", "496", "576.8", "789.5", "730.18", "570", "V45.81", "403.91", "V58.67", "731.3", "567.29", "557.0", "585.6", "998.32", "998.59", "995.92", "572.2", "427.31" ]	icd9cm	[ [ [] ] ]	[ "93.59", "96.6", "54.91", "00.14", "99.04", "00.17", "96.71", "96.04", "39.95" ]	icd9pcs	[ [ [] ] ]	17497, 17506	10962, 16809	431, 435	17621, 17631	6705, 10939	17687, 17726	5489, 5544				17527, 17600	16835, 16835			17655, 17664										5559, 6686																												310, 393										463, 4448															16860, 17474	4470, 5312	5328, 5473
23,014	158,331	43567	Discharge summary	report	Admission Date: [2162-9-6] Discharge Date: [2162-9-16] Date of Birth: [2098-2-18] Sex: M Service: HISTORY OF PRESENT ILLNESS: In brief, the patient is a 64-year-old male with a significant history for coronary artery disease, status post three myocardial infarctions and also status post five vessel coronary artery bypass graft in '[50] and status post multiple percutaneous transluminal coronary angioplasties who recently had a catheterization done in [State 15946] and stent placed in [2162-4-25]. The patient did well until approximately three to four weeks prior to presentation when he began to experience increased dyspnea on exertion. One week prior to presentation, he had chest pain leading to a repeat catheterization at [Location (un) 47] on [8-31] which showed narrowing of the stent and an ejection fraction of approximately 20%. No intervention was done at that point. On the evening prior to admission, the patient was awoken with chest pressure radiating to the neck anginal equivalent which was relieved by sublingual nitroglycerin. This episode happened three times that night and finally on the fourth re-awakening, the patient presented to the Emergency Department at [Location (un) 47] and was transferred to the [Hospital6 256] for coronary revascularization. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Myocardial infarction x3 3. Coronary artery bypass graft 4. Systemic lupus erythematosus in remission HOME MEDICATIONS: 1. Coreg 6.25 mg po bid 2. Lasix 25 mg po qd 3. Imdur 30 mg po qd 4. K-Dur 10 milliequivalents po qd 5. Zestril 2.5 mg po bid 6. Multivitamin 7. Folate ALLERGIES: He has no known drug allergies. PHYSICAL EXAM: VITAL SIGNS: He was afebrile with stable vital signs HEART: Regular rate and rhythm with a 2 out of 6 systolic ejection murmur heard loudest at the apex. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No cyanosis, clubbing or edema. Palpable DPs bilaterally. PERTINENT LABS: His hematocrit was 44. White count was 8. Potassium was 3.9. BUN and creatinine was 18 and 0.9. His troponin was 29.7. HOSPITAL COURSE: The patient was medically managed initially and then underwent on [2162-9-10], coronary artery bypass grafting x2 and a mitral valve annuloplasty with placement of intra-aortic balloon pump. He was transferred to the Intensive Care Unit in relatively stable condition. On postoperative day #1, his balloon pump was weaned and the patient was transferred at 2 units of packed red blood cells. He also began to wean off the ventilator. On postoperative day #1 in the evening, the patient was noted to go into atrial fibrillation, for which he was controlled and started on amiodarone, after which he converted again to normal sinus rhythm. He was extubated during postoperative day #1. On postoperative day #2, the patient was noted to be relatively stable. His balloon pump had already been removed and on postoperative day #3, he was transferred to the floor on Lopressor and amiodarone in normal sinus rhythm. On the floor, the patient was noted to do extremely well. Physical therapy was consulted and the patient was ambulating extremely well with minimal assistance. On postoperative day #4, he remained afebrile with stable vital signs on Lopressor at 25 mg po bid and an amiodarone dose. His left chest tube was discontinued at this time and his right chest tube was removed the following day on postoperative day #5. Currently, the patient is postoperative day #6. He remains afebrile with stable vital signs and the patient is ambulating to a level 5 with physical therapy and wishes to be discharged home today. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSES: 1. Coronary artery disease 2. Mitral valve regurgitation, status post coronary artery bypass graft x2 and mitral valve annuloplasty SECONDARY DIAGNOSES: 1. Coronary artery disease 2. Myocardial infarction x3 3. Coronary artery bypass graft DISCHARGE MEDICATIONS: 1. Lopressor 25 mg po bid 2. Amiodarone taper 400 mg po tid x4 days, then [Hospital1 ] x7 days, qd x7 days, then 200 mg po qd 3. Lasix 20 mg po qd 4. K-Dur 20 milliequivalents po qd 5. Aspirin 81 mg po qd 6. Percocet 1 to 2 po q 4 to 6 hours prn 7. Colace 100 mg po bid 8. Percocet 9. Protonix 20 mg po qd DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient should follow up with Dr. [Last Name (Prefixes) ] in approximately three weeks. The patient should also follow up with his primary care doctor, Dr. [Last Name (STitle) ], in approximately three weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 3181] MEDQUIST36 D: [2162-9-16] 07:55 T: [2162-9-16] 09:01 JOB#: [Job Number ]	[ "424.0", "997.1", "710.0", "428.0", "427.31", "414.01", "411.1", "998.11", "285.1" ]	icd9cm	[ [ [] ] ]	[ "37.61", "37.64", "35.12", "36.12" ]	icd9pcs	[ [ [] ] ]				3767, 3775				3796, 3931	4066, 4901				2207, 3745												1747, 2049			3952, 4043		1527, 1732																																	159, 1350											2066, 2189					1372, 1509
68,915	190,316	44853	Discharge summary	report	Admission Date: [2198-12-18] Discharge Date: [2198-12-28] Date of Birth: [2121-9-5] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Biaxin / Sulfa (Sulfonamide Antibiotics) / Voltaren / Macrodantin / Imodium / moxifloxacin Attending:[First Name3 (LF) 602] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None this hospitalization History of Present Illness: This is a 77 year-old Female with a PMH significant for sick sinus syndrome (with permanent pacemaker placement in [2196]), RLD (oxygen-dependent on 3L via nasal cannula at baseline), CHF, TIA, paroxysmal atrial fibrillation (failed anti-arrhythmic therapy, rate-controlled at home with Metoprolol), HTN, neurogenic bladder with ileal conduit who was admitted on [2198-12-18] to the ACS surgery service for conservative management of a recurrent small bowel obstruction. . She presented with typical features of her prior small bowel obstructions, with nausea, bilious emesis and diffuse abdominal pain and no flatus. An NGT was placed on admission. She required T-SICU admission given some initial episodes of rapid ventricular response in the ED. She was conservatively managed with IV fluids (1L in T-SICU), NPO status and NGT management with improvement. She has return of flatus and her NGT was removed on [2198-12-21]. Did get a dose of IV Ceftriaxone given a positive U/A, but this was discontinued given her chronic ileal conduit catheterization. She also had a right tympanic membrane perforation with some bleeding ottorhea which resolved on [2198-12-23] with stable auditory exam. Her SBO improved and she resumed diet on [2198-12-25]. The patient has noted paroxysmal A.fib and had persistent episodes of RVR to a ventricular rate of 150s on [2198-12-26] with persistent hypotension to the 80-90s mmHg without only some lightheadedness; no chest pain, shortness of breath or syncope. Patient responded to IV Lopressor dosing. She had been maintained on Metoprolol 50 mg PO BID, Diltiazem 180 mg PO QID (home dose being daily) and Digoxin 0.0625 mg PO daily since return of bowel function. She was transferred to Medicine for further management of hypotension with A.fib and RVR. Of note, that patient had been admitted with a prior SBO in [2196] and required Cardiology consultation for a similar clinical picture. In the setting of being NPO she had several paroxysms of atrial fibrillation to a ventricular rate of 150 bpm. They recommended they recommended rate control with Lopressor and Diltiazem along with Digoxin - with transition to PO Metoprolol on discharge. Rhythm control was deferred given the paroxysmal nature and she had previously failed anti-arrhythmic therapy. . On the floor, she is without complaints. She notes only mild fatigue and no shortness of breath or chest pain. She denies palpitations, dizziness or diaphoresis. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Sick sinus syndrome ([Company 1543] Sensia dual-chamber pacemaker, last interrogation with Dr. [Last Name (STitle) ] on [2198-12-18] - placed [2197-3-9]) 2. Restrictive lung disease, chronic obstructive pulmonary disease (on 3L of home oxygen via nasal cannula) 3. Kyphoscoliosis with restrictive lung disease 4. Paroxysmal atrial fibrillation (previously failed Amiodarone and Dofetilide; on Coumadin) 5. Hypertension 6. Multiple prior small-bowel obstructions 7. Right lower extremity deep venous thrombosis 8. History of transient ischemic attacks 9. Hypothyroidism 10. Depression 11. s/p emergent appendectomy (in her 20s) 12. s/p multiple abdominal surgeries, exploratory laparotomies 13. s/p cystectomy with ileal conduit ([2183]) - indication was neurogenic bladder 14. s/p total abdominal hysterectomy, BSO 15. s/p exploratory laparotomy, LOA, SBR ([2-/2193]) 16. s/p diphragmatic hernia repair 17. s/p tonsillectomy 18. s/p hemorrhoidectomy 19. s/p thoracic spinal fusion (with [Location (un) 931] rods) Social History: Patient lives at an [Hospital3 ] facility. Widowed. Has four children that are all grown. Denies current tobacco use (smoked for 10 years, 10 pack-year; quit many years prior); ocassional wine with dinner ([11-19] glasses monthly); no recreational substance use. Functional in ADLs. Uses a motorized scooter to ambulate. Family History: Sister with bladder carcinoma. Physical Exam: DISCHARGE EXAM: . VITALS: 97.9 96.8 98/58 - 104/60 72-88 18 99% 3L NC I/Os: 1560 / 240 \| 2750 Foley (-1L) GENERAL: Appears in no acute distress. Alert and interactive. Elderly appearing female. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD 2-3 cm above clavicle at 30-degrees. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds at bases bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. Kyphoscoliosis noted. ABD: well-healed scars, soft, diffusely tender to deep palpation, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Ileal conduit with clean urine in bag. EXTR: no cyanosis, clubbing; trace bilateral edema to mid-shins. 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 5/5 bilaterally, sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION LABS: . [2198-12-18] 06:20PM BLOOD WBC-12.8# RBC-4.52 Hgb-14.9# Hct-44.1# MCV-98# MCH-33.0 MCHC-33.8 RDW-12.8 Plt Ct-247# [2198-12-18] 06:20PM BLOOD Neuts-86.7* Lymphs-9.1* Monos-2.5 Eos-0.7 Baso-0.9 [2198-12-18] 06:20PM BLOOD PT-39.9* PTT-54.2* INR(PT)-3.9* [2198-12-18] 06:20PM BLOOD Glucose-108* UreaN-46* Creat-1.3* Na-141 K-3.3 Cl-97 HCO3-31 AnGap-16 [2198-12-18] 06:20PM BLOOD ALT-29 AST-36 AlkPhos-41 TotBili-0.2 [2198-12-19] 12:43PM BLOOD CK(CPK)-93 [2198-12-18] 06:20PM BLOOD cTropnT-<0.01 [2198-12-19] 12:43PM BLOOD CK-MB-3 cTropnT-<0.01 [2198-12-18] 06:20PM BLOOD Albumin-4.7 [2198-12-19] 03:13AM BLOOD Calcium-9.0 Phos-4.0# Mg-1.5* [2198-12-27] 05:44AM BLOOD TSH-3.2 [2198-12-24] 04:44AM BLOOD Digoxin-0.5* . DISCHARGE LABS: . [2198-12-28] 05:03AM BLOOD WBC-4.5 RBC-2.97* Hgb-9.7* Hct-29.5* MCV-100* MCH-32.8* MCHC-32.9 RDW-12.9 Plt Ct-244 [2198-12-28] 05:03AM BLOOD PT-16.4* PTT-34.7 INR(PT)-1.5* [2198-12-28] 05:03AM BLOOD Glucose-80 UreaN-12 Creat-0.7 Na-142 K-3.8 Cl-108 HCO3-29 AnGap-9 [2198-12-26] 06:05AM BLOOD CK(CPK)-58 [2198-12-26] 06:05AM BLOOD CK-MB-2 cTropnT-<0.01 [2198-12-25] 09:30PM BLOOD CK-MB-3 cTropnT-<0.01 [2198-12-28] 05:03AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.1 . URINALYSIS: clear, negative for LE, negative for Nitr, no protein, WBC 11 . MICROBIOLOGY DATA: [2198-12-19] MRSA screen - negative . IMAGING: [2198-12-18] CT ABD & PELVIS WITH CO - There is marked and high-grade small-bowel obstruction. The distal ileum appears essentially collapsed as is the colon; the appearances are suggestive of a transition point in either the right lower quadrant, where multiple tethered loops of bowel are noted or else anteriorly adjacent to the stoma at the site of prior obstructions-these two areas are in close proximity. Brief Hospital Course: 77F with a PMH significant for sick sinus syndrome (with permanent pacemaker placement in [2196]), RLD/COPD (oxygen-dependent on 3L via nasal cannula at baseline), diastolic congestive heart failure, TIA, paroxysmal atrial fibrillation (failed anti-arrhythmic therapy, rate-controlled at home with Metoprolol), neurogenic bladder with ileal conduit who was admitted on [2198-12-18] to the ACS surgery service for conservative management of a recurrent small bowel obstruction and subsequently transferred to the medical service for management of atrial fibrillation and hypotension due to excess diltiazem. # RECURRENT SMALL BOWEL OBSTRUCTION - Admitted to surgical service with clinical and CT evidence of small bowel obstruction similar to prior episodes, without surgical indications per ACS. Conservatively managed with NGT, bowel rest until return of bowel function. Started tolerating regular diet, passing flatus - had BM x 1 morning of discharge. Minimal abdominal discomfort without distention. Electrolytes stable. Will follow-up in ACS surgery clinic. . # PAROXYSMAL ATRIAL FIBRILLATION/HYPOTENSION - Her PO Metoprolol was continued, but her Diltiazem was dosed too frequently and she became hypotensive to the 80-90s systolic range, with dizziness. Following this, her AV-nodal blockade was discontinued and she had episodes of rapid ventricular response. Cardiac biomarkers and EKGs reassuring. Once she was able to restart her home medications at Metoprolol 50 mg PO BID and Diltiazem 180 mg ER PO daily with Digoxin 0.0625 mg PO daily, she did well and had no further episodes of hypotension or symptomatic rapid AFib. We continued her Coumadin dosing at 3 mg PO daily and her INR on discharge was 1.5. She will follow-up in clinic for anticoagulation management. Since she was felt to be mildly volume down due to SBO and poor pos, her diuretics were held. She was restarted on Triamterene/HCTZ on discharge and was instructed to follow up with her PCP/Cardiologist in [1-20] days from discharge to discuss re-iniation of her her home lasix. She did not have any lower extremity edema prior to discharge. . # SICK SINUS SYNDROME, S/P PACEMAKER - [Company 1543] Sensia dual-chamber pacemaker, last interrogation with Dr. [Last Name (STitle) ] on [2198-12-18] - placed [2197-3-9]. Predominantly atrially paced without issues on prior interrogation. . # CHRONIC OSBTRUCTIVE PULMONARY DISEASE, RESTRICTIVE LUNG DISEASE - History of COPD/RLD (prior PFTs noting restrictive component) with heavy prior smoking history. Baseline regimen includes 3L via nasal cannula of supplemental home oxygen and Fluticasone-salmeterol with rescue inhaler. No evidence of active COPD exacerbation. Stable non-productive cough. Afebrile and leukocytosis resolved with SBO improvement. We continued her home COPD regimen and she was stable on her home oxygen requirement. . # HYPERTENSION - Home regimen includes diuretic (K-sparring combination), beta-blocker and calcium-channel blocker; outpatient notes reflect a blood pressure in the 94/70 mmHg range per Cardiology notes; patient thinks her BP is in the systolic 110s at baseline. Once her hypotension issues resolved, we resumed her beta-blocker, CCB amd her K-sparring, thiazide diuretic. Her PCP will determine the timing of restarting her Lasix dosing. . # HYPOTHYROIDISM - Last TSH check in [2-/2197] was 1.8 and normal; has been maintained on Levothyroxine 50 mcg PO daily without symptoms. We continued Levothyroxine 50 mcg PO daily. . TRANSITION OF CARE ISSUES: 1. We stopped her Lasix medication until discussing the dosing with her primary care physician in clinic next week. 2. Patient will continue Coumadin 3 mg PO daily and follow-up in clinic next week to have her INR checked and her anticoagulation managed. 3. Patient was noted to have a prior normocytic anemia with new onset of macrocytosis which should be followed up by her PCP and her hematocrit should be checked as needed. 4. Follow-up scheduled with ACS surgery and primary care physician. Medications on Admission: HOME MEDICATIONS (confirmed with patient's pharmacy, [Doctor Last Name 9231]) 1. Albuterol Proair 90 mcg HFA 1-2 puffs Q4H PRN wheezing 2. Diltiazem 180 mg ER PO daily 3. Duloxetine 60 mg PO daily 4. Lunesta 3 mg PO QHS 5. Fluticasone-salmeterol 230-21 mcg 1 puff INH [Hospital1 ] 6. Levothyroxine 50 mcg PO BID 7. Metoprolol tartrate 50 mg PO BID 8. Potassium chloride 20 mEq PO daily 9. Pramipexole 1.5 mg PO QHS 10. Ranitidine 300 mg PO QHS 11. Triamterene-HCTZ 37.5 mg-25 mg PO QHS 12. Warfarin 2 mg PO QHS 13. Lasix 20 mg PO QAM 14. Senna 8.6 mg 1 tablet PO BID 15. Vitamin D 400 units PO daily 16. Vitamin-B12 500 mcg PO daily 17. Multivitamin 1 tablet PO daily 18. Acidophilus 1 capsule PO daily 19. Pantoprazole 40 mg EC PO daily 20. Docusate sodium 100 mg PO BID 21. Digoxin 0.0625 mg PO daily Discharge Medications: 1. Outpatient [Name (NI) ] Work PT/INR - draw [2200-1-1] and please FAX results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Address: [Street Address(2) 12840],[Apartment Address(1) 12841], [Location (un) ],[Numeric Identifier 12842] Phone: [Telephone/Fax (1) 10813] Fax: [Telephone/Fax (1) 34311] 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day. 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. pramipexole 0.5 mg Tablet Sig: Three (3) Tablet PO qhs (). 9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO twice a day. 15. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO at bedtime. 16. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 18. Acidophilus 500 million cell Tablet Sig: One (1) Tablet PO once a day. 19. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. triamterene-hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1) Tablet PO once a day. 21. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO once a day. 22. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnoses: 1. Small bowel obstruction 2. Atrial fibrillation with rapid ventricular response 3. Hypotension . Secondary Diagnoses: 1. Sick sinus syndrome 2. Restrictive lung disease, chronic obstructive pulmonary disease 3. Hypertension 4. Multiple prior small-bowel obstructions 5. Right lower extremity deep venous thrombosis 6. History of transient ischemic attacks 7. Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [Hospital1 1535] on CC7 regarding management of your management of your small bowel obstruction, which improved with conservative management. You also had some issues with atrial fibrillation events that responded to medication. You were doing well prior to discharge. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If 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 an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: NONE . * The following medications were DISCONTINUED on admission and you should NOT resume: HOLD: Please stop taking your Lasix medication until discussing the dosing with your primary care physician in clinic next week. . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] When: Monday [2198-12-31] at 2:30 PM Address: [Street Address(2) 12840],[Apartment Address(1) 12841], [Location (un) ],[Numeric Identifier 12842] Phone: [Telephone/Fax (1) 10813] . Department: Cardiology Name: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] When: Thursday [2199-1-3] at 2:00 PM Address: [Street Address(2) 2687],STE 7C, [Location (un) ],[Numeric Identifier 822] Phone: [Telephone/Fax (1) 5768] . Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: MONDAY [2199-1-14] at 4:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "E942.4", "289.89", "427.31", "V45.4", "V46.2", "327.23", "276.0", "V45.01", "428.0", "493.20", "V58.61", "596.54", "428.30", "244.9", "560.9", "458.29", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14430, 14488	7356, 11405	400, 428	14927, 14927	5485, 5485	16812, 17708	4405, 4437		12266, 14407		14509, 14627	11431, 12243			15142, 16789			6282, 7333							4452, 4452			14648, 14906			4468, 5466																						346, 362										456, 2943					5501, 6266				14942, 15086							2965, 4043	4059, 4389
9,030	181,167	3723	Discharge summary	report	Admission Date: [2127-2-26] Discharge Date: [2127-3-11] Date of Birth: [2068-7-14] Sex: M Service: MEDICINE Allergies: Oxycodone / Zanaflex Attending:[First Name3 (LF) 689] Chief Complaint: falls Major Surgical or Invasive Procedure: RIJ History of Present Illness: The patient is a 58 YO man with h/o PE (on coumadin), CAD, s/p L BKA, who has had multiple recent mechanical falls (pt reports 15 falls over the past 5 days due to "right leg weakness"). He presented to the ED s/p another fall today. Pt reports "I just fell", but denies CP, SOB, LOC, or any pre-syncopal events. He does say he hit his head on the ground. After he fell, he was unable to get up and called his family. He was then taken to the ED. No reports of seizure activity. No fevers, chills, N/V/D. . In the [Name (NI) ], pt was found to have diffuse ecchymoses, INR > 22.8, and hct of 28 (recent baseline 38.1). He underwent pan-CT, which revealed only buttock contusions. He was thought to have a R hip fracture clinically, however this was not seen on CT or XR. He had SBP in 70's, so was given 3L NS, and SBP improved to 100's. He had O2sat in 80's on RA, which increased to 90's on 100% NRB. He received naloxone, vitamin K 10mg PO, Vanc 1g IV, CTX 1g IV, Dexamethasone 10mg IV, 2 U FFP, and 1 U PRBC's. A right IJ was placed, and he was transferred to the MICU for further care. Past Medical History: hypercholesterolemia HTN, CAD s/p CABG, PVD, h/o CVA, total thyroidectomy for thyroid CA, appendectomy, b IH repair history of seizures PE [11-20] on coumadin PSH: R fem-DP ([2116]), R revision ([2119]), L fem-[Doctor Last Name ] ([2115]), L re-do ([2121]), L SFA stent ([9-18]) Social History: He denies alcohol use. He smokes for 20 pack years. Family History: non - contributary Physical Exam: Vitals: T 98.7 BP [10/2080] (104-130/55-72) HR 97 (94-102) R 14 O2 96% 4lnc CVP 5-9 I/O [Telephone/Fax (1) 16793] Gen: lying comfortably in bed, NAD, diffuse ecchymoses over entire body HEENT: PERRL. OP clear. Lac on R side of forehead. L temporal ecchymoses. Neck: no obvious JVD, no LAD Cardio: RRR, nl S1S2, no m/r/g Resp: decreased BS bilaterally, no wheezes or crackles Abd: soft, nt, nd, +BS, diffuse ecchymoses Ext: s/p L BKA. RLE is warm, pedal pulses present. Radial pulses 2+, Diffuse ecchymoses on upper ext bilaterally. Neuro: A&Ox3. Moves all ext. 4/5 strength RLE. 5/5 strength UE bilaterally. Pertinent Results: [2127-2-26] 02:15PM BLOOD WBC-10.9 RBC-3.18* Hgb-9.1# Hct-28.0# MCV-88 MCH-28.7 MCHC-32.5 RDW-17.1* Plt Ct-255 [2127-2-28] 02:12AM BLOOD WBC-5.5 RBC-3.28* Hgb-9.6* Hct-28.2* MCV-86 MCH-29.3 MCHC-34.0 RDW-17.5* Plt Ct-160 [2127-2-26] 02:15PM BLOOD PT->150* PTT-105.5* INR(PT)->22.8* [2127-2-28] 02:12AM BLOOD PT-15.6* PTT-32.7 INR(PT)-1.4* [2127-2-28] 02:12AM BLOOD Plt Ct-160 [2127-2-28] 02:12AM BLOOD Glucose-113* UreaN-6 Creat-0.5 Na-136 K-3.6 Cl-98 HCO3-32 AnGap-10 [2127-2-26] 02:15PM BLOOD CK(CPK)-272* [2127-2-26] 09:58PM BLOOD ALT-16 AST-26 LD(LDH)-326* CK(CPK)-270* AlkPhos-105 Amylase-33 TotBili-0.8 [2127-2-27] 04:12AM BLOOD CK(CPK)-228* [2127-2-26] 02:15PM BLOOD CK-MB-4 cTropnT-<0.01 [2127-2-26] 09:58PM BLOOD CK-MB-4 cTropnT-<0.01 [2127-2-27] 04:12AM BLOOD CK-MB-4 cTropnT-<0.01 [2127-2-26] 09:58PM BLOOD Phenyto-28.0* [2127-2-28] 02:12AM BLOOD Phenyto-30.2* [2127-2-27] 11:17AM BLOOD freeCa-0.98* . R femur/hip XR: No evidence of fracture or dislocation. Degenerative changes of the hips. . CXR: There has been interval placement of right internal jugular approach central venous catheter, with catheter tip projecting over the distal SVC. There is no pneumothorax. Cardiac and mediastinal contours are unchanged. The right costophrenic angle is excluded on current radiograph. No focal areas of consolidation are seen. Note is made of sternotomy wires. . CT chest/abdomen/pelvis: Large contusions of the buttocks, right greater than left as well as smaller contusion of the left flank and lateral left chest. No other evidence of traumatic injury including no fracture. No change in slightly enlarged mediastinal lymph nodes. Small right renal cyst as well as small subcentimeter hypodense lesion of the right kidney, too small to definitively characterize. 17-mm hyperdense round lesion of the right kidney measures higher density than expected for simple cyst, but is unchanged compared to [2125-9-18] and may represent proteinaceous material within a cyst. Extensive [Year (4 digits) 1106] calcifications suggest history of diabetes. . CT head: No evidence of intracranial hemorrhage, mass effect, or fracture. . CT C-spine: No fracture. Mild degenerative changes of the cervical spine. . CT HEAD W/O CONTRAST [2127-3-2] FINDINGS: No intracranial hemorrhage, mass, shift of normally midline structures, hydrocephalus or infarction are identified. No underlying fractures are identified. Paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No masses or infarction identified. No fracture. . EEG [2127-3-4]: This 24 hour video EEG telemetry captured occasional generalized spike and slow wave or polyspike and slow wave discharges in drowsiness and sleep. This finding suggest an underlying primary generalized epilepsy. No electrographic seizures or pushbutton activations were captured. The slow and disorganized background with bursts of generalized theta or delta frequency slowing suggest an encephalopathy. Infection, medications, and metabolic disturbances are among the most common causes. . BILAT UP EXT VEINS US [2127-3-9] IMPRESSION: No evidence of upper extremity deep venous thrombosis. Brief Hospital Course: 58 YO M with h/o PE (on coumadin), CAD s/p CABG, s/p L BKA, who presents s/p fall with elevated INR, anemia, hypotension, and hypoxia. . 1) Hypotension: Likely [1-17] to dehydration from decreased PO intake and in the setting of blood loss. Resolved with 3u PRBC and fluids. CTA was negative for PE. CT chest/abdomen/pelvis/head negative for significant bleeding. His blood pressure had then remained stable while in the MICU and he was transferred to the medical floor. He had an episode of hypotension on HD 6 also with sinus tachycardia. EKG was stable and he re ruled out for MI by cardiac enzymes. This was thought to be due to poor po intake and his BP and HR responded to IVFs. With improvement in po intake, his blood pressure remained stable and his BB were restarted (BB for history of CAD). . 2) Hypoxia: Pt reports being on home O2 (appears to have been on 4L home O2 per last discharge in [11-20]). O2 requirement in past likely due to PE. CTA neg for new PE on this admission. Pt may also have been hypoxic [1-17] symptomatic anemia in setting of COPD (per CT read). Pt appeared to be at baseline on admission. He may need outpatient PFTs. . 3) Elevated INR: Pt has blood drawn by VNA, followed by "[Hospital1 882] Labs." He reports normal INR the week before admission. Ddx includes malnutrition in setting of elevated dilantin level. He was initially given Vit K and FFP to reverse INR. Home coumadin restarted [2-27] when INR < 3.0. He also received heparin IV bridge. His INR was subtherapeutic after several days of coumadin and his dose was increased. At the end of his hospital admission, the only issue keeping him in the hospital was heparin IV dependence while await INR to return to therapeutic range. He was discharged on enoxaparin, to be taken until his INR returned to therapeutic levels. His INR will be checked by his VNA. . 4) Seizure disorder: The patient has been taking dilantin for decades. He was started on coumadin in [11-20] after a PE. Dilantin and coumadin often can interact and it was thought that this interaction may have led to the supratherapeutic level of dilantin. His dilantin was held and his level was followed. At one point during the hospital course, there was a question as to whether the patient had a seizure. Neurology was involved and recommended and EEG. The EEG did show some abnormalities although not seizure activity. Neurology recommended discontinuing dilantin given drug interactions with coumadin and starting keppra. Keppra was started and dilantin was dicontinued. The change in medications was explained to the patient at the time of the change and at the time of discharge. He will have outpatient follow up with neurology. . 5) Anemia: likely [1-17] diffuse ecchymoses in setting of supratherapeutic INR. Pt was guaiac negative, so GIB unlikely. Iron studies, B12, folate all WNL. . 6) Frequent falls: pt with frequent falls at home (lives alone), likely mechanical in setting of worsening RLE ischemic neuropathy. Pt may have been pre-syncopal due to dehydration. He was evaluated by PT/OT and social work. PT had initially recommended rehab placement but the patient refused despite our efforts to convince to go to rehab. After several more days working with physical therapy, PT felt the patient was safe to go home with home physical therapy services. . 7) CAD: The patient has a history of CAD. EKG without ischemic changes and he ruled out for MI by cardiac enzymes. Initially ASA and plavix were held given elevated INR and transfusion requirement but were restarted once INR therapeutic. BB was also initially held as the patient was hypotensive but was restarted and titrated up to home dose once stable. . 8) Communication: with patient. The patient's medication changes were gone over with him in great detail. The patient was taught to use enoxaparin subcutaneous injections by the nursing staff. The keppra dose which was being titrated up was discussed with the patient and over the phone with VNA services. Medications on Admission: Confirmed with patient who provided a list.The patient was able to name most of his medications including doses and frequency from memory. -Aspirin 325 mg qd -Clopidogrel 75 mg qd -Gabapentin 800 mg q8h -Atorvastatin 20 mg qd -Levothyroxine 175 mcg qd -Dilantin (extended) 300mg tid, had been changed from 300qam and 200qpm once coumadin was initiated -Clonazepam 1 mg tid -Warfarin 2 mg qhs -lopressor 25mg po TID Oxcarbazepine 150 mg qhs (pt denies, but in last d/c summary) Remeron 45 mg qhs (patient denies) -Foltx 2.5-25-2 mg qd Albuterol 90 mcg prn Atrovent prn 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. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): Continue to have your INR checked and take as directed by you doctor. [Last Name (Titles) ]:12 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation every four (4) hours as needed for shortness of breath or wheezing. 11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 14 days: You will need to take this this medication as directed until INR is therapeutic (per your primary doctor). [Last Name (Titles) ]:28 injection Refills:0 12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)) for 3 days. [Last Name (Titles) ]:6 Tablet(s) Refills:0 13. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)) for 3 days. [Last Name (Titles) ]:9 Tablet(s) Refills:0 14. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). [Last Name (Titles) ]:180 Tablet(s) Refills:2 To be started after 3 day (once the other prescription for levetiracetam has been completed. 15. Outpatient Lab Work INR check [2127-3-13], results to PCP. [Name10 (NameIs) ] PCP continue to adjust coumadin level as appropriate. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnosis: - supratherapeutic INR - dilantin toxicity - hypotention - hypoxia . Secondary diagnosis - Seizure disorder - history of PE [11-20] - Hypertension - Coronary artery disease Discharge Condition: Able to use wheel chair, respiratory status stable on O2 (uses home O2) Discharge Instructions: You were admitted with an elevated coumadin level and elevated dilantin level. Your medications have been adjusted so that your medication levels will be therapeutic. You will need to have your INR level checked regularly. Please take all your medications as directed. Your coumadin level has been increased to 6mg by mouth once daily. You will need INR checks and have your primary doctor adjust your dose based on INR levels. Dilantin has been discontinued. You are not taking a new medication called keppra for your seizures. Keppra: take 1000mg by mouth each morning and 1500mg by mouth each evening x3 days. Then change to 1500mg by mouth twice daily. Continue to use O2 at home as your are doing. Please go to all follow up appointments If you develop fever, chills, worsening shortness of breath, chest pain, seizures or any other symptom that concerns you, call you doctor or if unavailable, go to the emergency room. Followup Instructions: Talk with your primary physician about getting your PFTs checked. Continue to have yoru INR checked Work with physical therapey . CARDIOLOGY: You have a follow up appointment with Dr.[Last Name (STitle) ] and [Location (un) 16794] on Friday [2127-3-14] at 10:30am. Their office has moved to the [Hospital6 2910], [Doctor Last Name 3649] building [Apartment Address(1) 16795]. If you have any questions please call ([Telephone/Fax (1) 16796] . [Telephone/Fax (1) ] SURGERY: You have a follow up appointment with Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2127-3-17] 2:30 . PRIMARY CARE: You have a follow up appointment with you PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 16791] on [2127-3-18] at 9:45. She will manage you coumadin and lovenox medications. You may call her at ([Telephone/Fax (1) 16797] if you have questions. . NEUROLOGY: You have a follow up appointmetn with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9504] on [2127-4-23] at 4:30 pm. You may call his office at ([Telephone/Fax (1) 16798]	[ "E934.2", "401.9", "287.9", "414.01", "V10.87", "244.0", "V45.81", "272.0", "285.9", "276.51", "995.29", "V58.61", "V49.75", "V15.88", "345.90", "E936.1", "458.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	12352, 12410	5749, 9802	286, 291	12650, 12724	2506, 4630	13707, 14932	1834, 1854		10421, 12329		12431, 12431	9828, 10398			12748, 13684										1869, 2487																												241, 248										319, 1416			4639, 5726			12450, 12629										1438, 1748	1764, 1818
29,123	139,732	30695	Discharge summary	report	Admission Date: [2187-10-2] Discharge Date: [2187-10-2] Date of Birth: [2126-5-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 61M PMH metastatic renal cell carcinoma was c/o increasing dyspnea and increasing abdominal girth/ascites beginning on [2187-9-27]. VNA noted that O2 sat was 70-80% on 3L NC and patient was increasingly dyspneic at rest; patient went to ER [9-27] for urgent paracentesis. After undergoing emergent therapeutic paracentesis the patient intially felt significantly improved, with decreased dyspnea and improved energy. However, over the course of the weekend he began to feel poorly again, with profound fatigue. His visiting nurse [First Name (Titles) ] [Last Name (Titles) ] and found his AST 1155 (up from 28 on [9-28])and ALT 902 (up from 10 on [9-28]). There was concern for portal vein thrombosis vs hepatic congestion. . In the ED, VS 98 100 126/97 28-30 67%4L->95%NRB. The patient had a bedside TTE which showed a moderate pericardial effusion but no signs of tamponade. . On arrival to the floor, the patient states his SOB is "OK." He complains of increased abdominal girth. He denies fevers, chills, chest pain, cough; ROS otherwise negative in detail. Past Medical History: -Metastatic renal cell carcinoma - diagnosed in [4-28] on chest CT for workup of chronic cough -Prior right medial cerebellar infarct (asymptomatic, seen on brain MRI) -Pulmonary Embolism s/p insertion of retrievable OptEase IVC filters in the right andleft IVCs (pt with duplicate IVC) on [2187-7-15] -HTN -Internal/external hemorrhoids -H/o ETOH abuse requiring hospitalization 28 years ago, no history of DTs Social History: The patient lives with his wife and children in [Location 72727] [State 350]. He smoked one pack per week for 30 years but quit 10 years ago. He formerly drank about [4-26] brandies every evening 28 years ago. Last drink 6 months ago - claims to drink on occasion at present. He lives close to New [Location (un) 8957], [State 350]. He has three sons, ages 35, 28, and 18, respectively. The 35 and 18-year-old live at home. Retired employement officer. Nephew is [Name (NI) ] attending at [Hospital1 18]. Family History: Significant for maternal grandfather with rectal cancer. Sister with breast cancer. No CAD, DMII. Physical Exam: Vitals: 97.6 109 137/93 20 93% NRB GEN: Lying in bed, tachpnic, talking HEENT: Sclera anicteric, PERRL, EOMI, MM dry CV: RRR, 3/6 SEM LUNGS: Crackles/rhonchi throughout, decreased BS right base ABD: Tense, NABS, NT, +shifting dullness EXT: 2+ pitting edema BL NEURO: AAOx3 Pertinent Results: [2187-10-1] 09:30PM WBC-6.5 RBC-3.48* HGB-11.0* HCT-33.8* MCV-97 MCH-31.6 MCHC-32.6 RDW-18.9* [2187-10-1] 09:30PM PLT COUNT-178# [2187-10-1] 09:30PM LIPASE-54 [2187-10-1] 09:30PM ALT(SGPT)-862* AST(SGOT)-914* ALK PHOS-109 AMYLASE-59 TOT BILI-0.4 [2187-10-1] 09:30PM GLUCOSE-122* UREA N-30* CREAT-1.6* SODIUM-125* POTASSIUM-5.9* CHLORIDE-80* TOTAL CO2-34* ANION GAP-17 [2187-10-1] 09:38PM LACTATE-4.4* [2187-10-1] 09:50PM PT-14.3* INR(PT)-1.3* [2187-10-1] 09:50PM POTASSIUM-5.2* [2187-10-2] 12:21AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2187-10-2] 12:21AM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2187-10-2] 04:15AM PTT-27.4 [2187-10-2] 04:15AM PLT COUNT-148* [2187-10-2] 04:15AM WBC-6.3 RBC-3.34* HGB-10.6* HCT-32.8* MCV-98 MCH-31.8 MCHC-32.4 RDW-19.0* [2187-10-2] 04:15AM ALBUMIN-2.9* CALCIUM-8.3* MAGNESIUM-1.9 URIC ACID-5.6 [2187-10-2] 04:15AM CK-MB-12* MB INDX-8.4* cTropnT-0.05* [2187-10-2] 04:15AM ALT(SGPT)-680* AST(SGOT)-624* LD(LDH)-423* CK(CPK)-143 ALK PHOS-102 TOT BILI-0.4 [2187-10-2] 04:15AM GLUCOSE-125* UREA N-31* CREAT-1.5* SODIUM-128* POTASSIUM-5.2* CHLORIDE-83* TOTAL CO2-39* ANION GAP-11 [2187-10-2] 08:51AM URINE EOS-NEGATIVE [2187-10-2] 08:51AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2187-10-2] 08:51AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2187-10-2] 08:51AM URINE HOURS-RANDOM UREA N-581 CREAT-94 SODIUM-LESS THAN [2187-10-2] 12:48PM TYPE-ART TEMP-35.0 PO2-60* PCO2-125* PH-7.17* TOTAL CO2-48* BASE XS-11 INTUBATED-NOT INTUBA . RUQ ultrasound: 1. No evidence of portal venous thrombosis. 2. Right liver lesion, stable in size, and consistent with a cyst on recent MRI. The appearance of new internal vascularity is likely artifactual. 3. Second cystic liver lesion also stable from prior MRI, is more concerning for metastatic disease . CXR: : Limited study demonstrating pulmonary edema with moderately large bilateral pleural effusions significantly worse since the [6-/2187] studies. Underlying or progressive known metastatic renal cell carcinoma cannot be excluded in the presence of these findings . Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF70%). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is a large pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse. There is left atrial diastolic collapse. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Brief Hospital Course: 1. Hypoxic respiratory failure: Likely multifactorial and due to increasing pleural effusions, ascites, and moderate pericardial effusion. All effusions thought to be malignant. The patient's respiratory status continued to decline and he was temporized on BiPAP. The decision was made to make the patient CMO and he expired. . 2. Metastatic RCC: with either malignant effusions or effusions from [Year (4 digits) 61468]. Pericardial effusion with evidence of tamponade. Decision made not to aggressively intervene on effusions. His oncologist was part of the family discussions regarding goals of care. . 3. Transaminitis: possibly related to [Last Name (LF) ], [First Name3 (LF) ] ddx. No further diagnostics pursued. . 4. Disposition: the patient was made CMO and expired with family at bedside. Medications on Admission: [First Name3 (LF) ] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Pericardial tamponade Pericardial effusion Pleural effusion Ascites Metastatic renal cell carcinoma Discharge Condition: expired Discharge Instructions: na Followup Instructions: na	[ "197.6", "276.1", "518.81", "197.2", "198.89", "401.9", "584.9", "V10.52", "V12.59" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7340, 7349	6421, 7238	335, 341	7493, 7503	2884, 6398	7554, 7560	2477, 2576		7312, 7317		7370, 7472	7264, 7289			7527, 7531										2591, 2865																												276, 297										369, 1462																1484, 1906	1922, 2461
73,859	126,784	45086+45087	Discharge summary	report+report	Admission Date: [2190-4-26] Discharge Date: [2190-5-4] Date of Birth: [2108-4-6] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Benzodiazepines / Ambien / trazodone / Doxepin / morphine / hydroxyzine / Ativan / Hydrocodone / Oxycodone Attending:[First Name3 (LF) 3190] Chief Complaint: Neck pain Major Surgical or Invasive Procedure: Anterior/posterior cervical fusion with instrumentation History of Present Illness: Ms. [Known lastname ] has a long history of neck pain. She has attempted conservative therapy but has failed. She now presents for surgical intervention. Past Medical History: Asthma, OSA, HTN, GERD with h/o difficulty swallowing, h/o hypereosinophilia Social History: Denies tobacco Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; + [Doctor Last Name 937], hyperreflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [2190-4-29] 05:44AM BLOOD WBC-18.4# RBC-3.99 Hgb-10.7* Hct-35.5* MCV-89 MCH-26.9* MCHC-30.3* RDW-15.9* Plt Ct-311 [2190-4-28] 06:05AM BLOOD WBC-11.5* RBC-3.42* Hgb-9.3* Hct-30.1* MCV-88 MCH-27.3 MCHC-31.0 RDW-15.8* Plt Ct-294 [2190-4-27] 06:30AM BLOOD WBC-14.7# RBC-3.75 Hgb-10.2* Hct-33.3* MCV-89 MCH-27.0 MCHC-30.5* RDW-16.0* Plt Ct-338 [2190-4-29] 05:44AM BLOOD Glucose-110* UreaN-10 Creat-0.5 Na-136 K-3.6 Cl-94* HCO3-32 AnGap-14 [2190-4-27] 06:30AM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-138 K-4.3 Cl-99 HCO3-29 AnGap-14 [2190-4-29] 05:44AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 Brief Hospital Course: Ms. [Known lastname ] was admitted to the [Hospital1 18] Spine Surgery Service on [2190-4-26] and taken to the Operating Room for an anterior cervical fusion C4-7. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#3 she returned to the operating room for a scheduled C3-7 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was stable. Post-operatively she developed delerium which she has encountered in the post after ansthesia per her family. She was closely monitored and narcotics limited. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 from the second procedure. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Atenolol Oral 50 mg 2 times per day Aspirin Oral 81 mg every day IC-Klorcon M20 1 tablet daily predniSONE Oral 5 mg every day Vitamin D Oral [Numeric Identifier 1871] unit twice monthly on the 1st and 15th of the month Venlafaxine Oral 75 mg every day Furosemide Oral 40 mg every day Advair Inhaler 250 mcg-50 mcg/Dose 2 puffs 2 times per day Spiriva Inhaler 18 mcg every day Ventolin Inhaler 1 puff 1-2 times daily as needed for shortness of breath or wheezing traMADol Oral 50 mg daily as needed for pain Benadryl Oral 25 mg every day at bedtime Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Cervical stenosis Post-op delerium Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Cervical Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a collar. This is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity as tolerated. C-collar for ambulation Treatments Frequency: Please continue to change the dressing daily and look for signs of infection. Followup Instructions: With Dr. [Last Name (STitle) 363] in 10 days Completed by:[2190-5-3] Admission Date: [2190-5-5] Discharge Date: [2190-5-11] Date of Birth: [2108-4-6] Sex: F Service: MEDICINE Allergies: Codeine / Benzodiazepines / Ambien / trazodone / Doxepin / morphine / hydroxyzine / Ativan / Hydrocodone / Oxycodone / tramadol Attending:[First Name3 (LF) 2145] Chief Complaint: AMS, New onset A. fib Major Surgical or Invasive Procedure: none History of Present Illness: 82 year old woman with a history of HTN, status post anterior posterior cervical spine fusion and discharge from the hospital 1 day PTA who presents with altered mental status and new atrial fibrillation. Per the daughters, patient was discharged yesterday afternoon to [Hospital3 ]. Prior to discharge, the patient had experienced a prolonged course of post-op delerium. On day of discharge, she was reportedly increasingly confused, with intermittent hallucinations (thought mother was in room, pointing at things not present). Patient had not eaten in several days and urine increasingly dark. She continued to be confused at rehab. She was noted on arrival to rehab to have BP 200/100. EKG with atrial fibrillation. The patient was asymptomatic, without chest pain, shortness of breath, palpitations. She was given labetalol 100 mg PO x 1, and became hypotensive to SBP in 80s; HR 90-140s. She was transferred to [Hospital1 18] for further management. In the ED, initial VS were HR 84 85/64. EKG showed Atrial fibrillation with RVR, with ST depressions II, III, V4-6. The patient was started on a diltiazem drip and was given 2L NS. D. dimer for PE returned 1400; she underwent CTA chest that was negative. She was noted to be hypokalemic to 2.9, mag 1.9. Potassium and magnesium were administered. For altered mental status workup, the patient underwent negative Urinalysis, CXR and CT head. Prior to transfer to the floor, she had one large, loose BM. On transfer to the ICU, VS: 98.2 103/71 109 22 100% 2LNC. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Asthma OSA HTN GERD with h/o difficulty swallowing h/o hypereosinophilia No history of diabetes, CHF or stroke Past Surgical History: AP cervical spine fusion C/S x2 CCY tonsillectomy ovarian cystectomy bil. cataract ligament repair right ankle Social History: Denies EtOH, Smoking, Illicit drug use; She lives in [Location 47] by herself. Discharged yesterday from hospital to [Hospital1 ]. Family History: Extensive history of diabetes; no heart disease Physical Exam: On Admission to MICU: Vitals: T 98.2 BP 108/75 HR 84 O2 100%RA General: Alert, pleasant; oriented to person, month; able to perform days of the week backwards but occasionally with very poor attention; no acute distress HEENT: Sclera anicteric, MM slightly dry, oropharynx clear, EOMI, PERRL Neck: anterior and posterior vertical incisions covered in steri-strips, clean/dry, intact; JVP not elevated, no LAD CV: Irregularly irregular S1 + S2, no murmurs, rubs, gallops Lungs: Scant bibasilar rales Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [2190-5-4] 10:10PM PT-13.1* PTT-27.0 INR(PT)-1.2* [2190-5-4] 10:10PM PLT COUNT-487* [2190-5-4] 10:10PM WBC-14.2* RBC-4.54 HGB-12.3 HCT-39.3 MCV-86 MCH-27.0 MCHC-31.3 RDW-14.6 [2190-5-4] 10:10PM NEUTS-87.1* LYMPHS-7.8* MONOS-4.0 EOS-0.9 BASOS-0.3 [2190-5-4] 10:10PM ALBUMIN-3.6 CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-1.9 [2190-5-4] 10:10PM GLUCOSE-215* UREA N-17 CREAT-0.8 SODIUM-137 POTASSIUM-2.9* CHLORIDE-93* TOTAL CO2-28 ANION GAP-19 [2190-5-4] 10:10PM ALT(SGPT)-19 AST(SGOT)-37 ALK PHOS-140* TOT BILI-0.5 MRI [2190-5-6] IMPRESSION: 1. No evidence of acute infarction. 2. Chronic microvascular ischemic disease. . CTA neck, head [2190-5-5] IMPRESSION: 1. Age-appropriate CT of the head, specifically without evidence of territorial infarct. While the posterior fossa and brainstem are not well visualized, MRI may be considered depending on the clinical context. 2. Atherosclerotic disease involving the bilateral bifurcations without high-grade stenosis. 3. Prevertebral fluid collection, associated with anterior fusion instrumentation. Given mild peripheral enhancement, the possibility of superinfection should be considered. . TTE [2190-5-5] IMPRESSION: There is a mobile echodensity seen on the posterior leaflet of the mitral valve. It appears calcified and is likely a torn chord. A calcified vegetation is also possible. There is probably significant mitral regurgitaion - left atrium is dilated and has elevated pressures (bows towards right atrium). Small, hyperdynamic left ventricle. These findings could be consistent with acute mitral regurgitation secondary to a torn chord. Moderate pulmonary artery systolic hypertension. . [2190-5-5] CTA chest IMPRESSION: 1. No CT evidence for acute intrathoracic process, no pulmonary embolism. 2. Coronary artery calcifications, of indeterminate hemodynamic significance. 3. Mid thoracic vertebral body compression deformities, age indeterminate, as seen on radiograph. . CT head [2190-5-4] IMPRESSION: No CT evidence for acute intracranial abnormality. . CXR [2190-5-4] IMPRESSION: 1. Top normal heart size without radiographic evidence for acute cardiopulmonary process. 2. Mid thoracic vertebral body loss of height, age indeterminate. Clinical correlation for pain is recommended. . EKG [2190-5-4] Atrial fibrillation with rapid ventricular response. ST-T wave abnormalities. No previous tracing available for comparison. Urine culture [2190-5-7]: KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. ENTEROBACTER CLOACAE COMPLEX. 10,000-100,000 ORGANISMS/ML.. KLEBSIELLA PNEUMONIAE \| ENTEROBACTER CLOACAE COMPLEX \| \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I 64 I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: 82 year old woman with a history of HTN, OSA, status post anterior posterior cervical spine fusion and discharge from the hospital 2 days ago who presents with altered mental status, new atrial fibrillation and HTN # New onset atrial fibrillation: Patient found to be in Afib with RVR at rehab, with EKG with ST depressions in V3-V6, II, III, and AVF. Received 1 dose of labetalol while at rehab, with resulting hypotension. In ED, patient started on a diltiazem drip and transferred to the ICU. In the ICU, diltiazem drip stopped and the patient was started on diltiazem 30 mg PO QID which has now been titrated to 90 mg po qid. This can likely be changed to a long-acting form in the near future. For now her daughters preferred in general to make as few medication changes as possible. Her home atenolol has been discontinued for now since she is on diltiazem. Given CHADS score 2, she was started on full strength aspirin. Anticoagulation is deferred for now due to recent spine surgery. Dr. [Last Name (STitle) 363] (ortho) said he would prefer to avoid anticoagulation for least 2 weeks post-operatively, at which point plavix could be considered. Her family also reports she may be a fall risk, so she may not be the best candidate for coumadin. Regarding etiology of new onset atrial fibrillation, likely due to a combination of UTI, the stress of surgery, poorly controlled pain and structurally dilated heart from the MV abnormality. Patient ruled out for MI by troponins x 3. No evidence of pulmonary embolism on CTA. TSH normal. . #Torn mitral valve cord and mitral regurgitation - Cardiology was consulted for both afib and torn MV cord. They rec'd TEE for further characterization. The family declined TEE because they felt it would not change management at this time. (daughter is [Name8 (MD) ] NP and is very involved). Her lasix is currently on hold as she appears euvolemic. Her volume status should be monitored closely at rehab and if any signs of overload, lasix can be resumed. She should f/u with her cardiologist at [Hospital ]. . # Delirium/metabolic encephalopathy/altered mental status - suspect multifactorial including recent surgery, hospitalization, UTI, medications (sensitive to opioids, tramadol, and most meds per family), sleep deprivation. Has hx delirium in the setting of other surgeries as well. Per family, baseline prior to surgery was normal without any signs of dementia. We have considered other sources of infection, aside from possible UTI, no clear infection. She does have seroma which Dr. [Last Name (STitle) 363] feels is normal post-op finding and does not feel needs to be tapped. Her mental status at discharge includes calm, pleasant, oriented to self, [Location (un) 86], [Month (only) 116] and Tuesday, but not the name of this hospital. She is cooperative with her care. We resumed remeron 7.5 mg po qhs after discussion with her daughter because she has had good response to insomnia in the past. - minimize any other sedating meds - please note that daughter would like to discuss before any meds are changed - frequent reorientation - treating UTI as below # Urinary tract infection: Due to a leukocystosis and altered mental status, the patient was started on ciprofloxacin to treat possible UTI (Klebsiella and Enterobacter) even though only 10,000 to 100,000 organism. She will complete a total 7 day course for complicated UTI (briefly had Foley). . # Diplopia: Initially there was concern for possible acute stroke. However a CTA head and neck neg in addition to MRI did not show a stroke. Neuro felt as though this was likely a mechanical problem related to strabismum . #Pain management s/p recent anterior/posterior cervical spine fusion surgery: Has been difficult issue, family feels that prior pain meds including morphine, dilaudid, oxycodone and tramadol have caused worsened MS. Family specifically requests no opioids or tramadol. At this time, her pain is reasonably controlled on tylenol, lidocaine patch. Note: Ortho did not want to use NSAID's because of incidence of malunion of the fusion. [Month (only) 116] be used outside of 2 weeks, though would need to consider her age as well (relative contraindication for NSAIDs). Family declined benzo's and flexeril for muscle stiffness She does have some right arm pain and has some weakness of deltoids R>L (4/5 strength). Her spine surgeon [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363] is aware of these symptoms and followed her in-house. She is to wear a soft collar when ambulating for comfort. She should f/u with Dr. [Last Name (STitle) 363] in clinic in approximately 10 days # Moderate malnutrition- The patiet's po intake is limited and has the tendency to get dehydrated. Feeding tube not within family's goals of care at this time. . # Hypertension: Atenolol discontinued, is now on diltiazem with stable BP. . # Hypereosinophilia: Chronic, on prednisone 5 mg daily. - Started on H2 blocker, calcium, and vitamin D for chronic prednisone use. #Activity: Ambulate as tolerated. Collar should be worn while walking. [Month (only) 116] be taken off while sitting in chair or lying in bed. No lifting anything greater than 10 pounds for 2 weeks. .. Goals- She is a full code, HCP is [Name (NI) ] (HCP) & Daughter [Name (NI) ] ([Telephone/Fax (1) 96367]) who is a NP and lives in [State 4565]. # Transitional Issues -Placement at Fairlwan in [Last Name (un) 17679] -Ensure good rate control for Afib. -Monitor fluid status, resume lasix if volume overloaded or develops peripheral edema -Cardiology and Ortho Spine f/u -Please note that daughters wish to be contact[Name (NI) ] with any medication adjustements. They strongly wish to avoid opioids and any other medications (including tramadol) that may altered her mental status. Medications on Admission: 1. docusate sodium 100 mg PO BID 2. senna 8.6 mg PO QHS 3. bisacodyl 5 mg - two Tablet PO DAILY 4. magnesium hydroxide 400 mg/5 mL - 30ML PO Q6H (every 6 hours) as needed for constipation. 5. prednisone 5 mg PO DAILY 6. venlafaxine 75 mg PO DAILY 7. furosemide 40 mg PO DAILY 8. fluticasone-salmeterol 250-50 mcg/dose Disk [Hospital1 ] 9. tiotropium bromide 18 mcg Capsule Inhalation DAILY 10. albuterol sulfate 90 mcg/actuation HFA - 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 11. lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY (Daily). 12. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. (causes confusion, hallucinations) 13. acetaminophen 1000 mg PO Q6H 14. aspirin 81 mg Tablet DAILY 15. tramadol 25 mg PO Q6H PRN pain ? Potassium (previously on it, but wasn't continued at last discharge) Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing, sob. 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on, 12 hours off for peri-incisional or back pain. 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): [Month (only) 116] discontinue when ambulating regularly. 10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hold for SBP <105, HR <50. 12. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 13. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 1970] - [Hospital1 1559] Discharge Diagnosis: Atrial fibrillation Delirium/metabolic encephalopathy Urinary tract infection Secondary: recent cervical spinal fusion hypertension diplopia Discharge Condition: Discharge condition: stable Mental status: alert, conversant, but variable orientation. Knows the date but does get confused about location Ambulatory status: ambulates with assistance and walker Discharge Instructions: You were admitted to the hospital from rehab for atrial fibrillation, high blood pressures and confusion. We added some medications to control your heart read and blood pressure. A echocardiogram was done to look at your heart and it showed that your mitral valve has some damage (torn cord). You should follow-up with your cardiologist Dr. [Last Name (STitle) ]. We also are treating a urinary tract infection with antibiotics. You will continue physical therapy at rehab. You should followup with Dr. [Last Name (STitle) 363] for your recent spine surgery. Followup Instructions: Please follow up with: Name: [Last Name (LF) 363], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] When: Monday [5-17] at 11:30am Monday [6-14] at 11:30am Friday [7-30] at 11:30am Location: [Hospital1 ] Address: [Location (un) ], [Hospital Ward Name 23] [Location (un) ], [Location (un) ],MA Phone: [Telephone/Fax (1) 3573] We are working on a follow up appt with Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the [1-4] weeks. You will be called at rehab with the appointment. If you have not heard or have questions, please call ([Telephone/Fax (1) 96368]. When you are released from your facility, you should followup with your [Telephone/Fax (1) 3390]: [Name Initial (NameIs) 3390]: [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 73578] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2190-5-18]	[ "427.31", "401.9", "599.0", "293.0", "424.1", "349.82", "368.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	23161, 23231	14907, 20816	8324, 8330	23438, 23445	11702, 14884	24236, 25266	10785, 10834		21730, 23138		23252, 23396	20842, 21707			23639, 24213								10498, 10611		10849, 11683	7664, 7712	7734, 7813																		5855, 6048				9921, 10341				8263, 8286						6084, 6534			6546, 7646	8358, 9902									23460, 23615							10363, 10475	10627, 10769
73,398	190,855	42008	Discharge summary	report	Admission Date: [2126-7-29] Discharge Date: [2126-8-1] Date of Birth: [2109-4-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 348] Chief Complaint: Tylenol overdose, as suicide attempt Major Surgical or Invasive Procedure: None. History of Present Illness: 17yoF with history of cutting who presents from [Hospital3 3765] for an intentional Tylenol overdose. . The patient reported she and her girlfriend broke up in the past week, and she has been feeling generally depressed. The evening of presentation, she reportedly ingested 100-200 tablets of 500 mg Tylenol tablets at 9pm last night (8 hours PTA at [Hospital1 18]), and presented to [Hospital3 3765] 2 hours following the ingestion. She denied ingestion of any other medications other than a 25cc bottle of loteprednol etabonate eyedrops. She denies previous suicide attempts but does have a history of cutting. She was feeling unwell and had numerous episodes of emesis, reportedly with whole pills visible while she was at [Hospital1 ]. She was given Zofran, 2L NS and Mucomyst 14 grams PO as they did not have IV NAC at [Hospital3 3765]. Her first (~3 hour) APAP level at 23:50 (2 hrs 20 minuts following ingestion) was 391, and her second (~6 hour) APAP level at 2:00 was 267. Her ALT was 47, AST was 64, and she was transferred to [Hospital1 18] for further management. . In the [Hospital1 18] ED, initial VS were: 98.6, 81, 135/72, 18, 100% She was noted to be tachypneic but otherwise arousable and interactive. Serum tox was significant only for APAP, urine tox was negative. She received a total of 4L NS and received IV NAC bolus and was started on her the 4 hour infusion of NAC (50 mg/kg at 12.5 mg/kg/hr). Her Tylenol level at 05:15 was 184. LFTs were ALT 45 from 47, AST 58 from 64, coags were normal. She has no history of liver disease. Toxicology was contact[Name (NI) ] and will be following. She received Benadryl 25 mg IV x1, Ativan 1 mg IV x1, and Compazine 10 mg IV x1. EKG was reportedly normal. Most recent vitals prior to transfer were: 98.9 89 140/64 18 99%/ra . On arrival to the MICU, the patient was somnolent but answering questions appropriately and denied pain including abdominal pain and denied nausea. . Review of systems: (+) Per HPI (-) Denies recent fever, cough, shortness of breath, or wheezing. Denies chest pain, nausea, vomiting, diarrhea, abdominal pain, dysuria. Past Medical History: - Depression with history of cutting, no prior history of suicidal ideations - ADHD Social History: Pt just started her [Male First Name (un) 1573] year of high school at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5176]; lives at home with her two adopted parents and their biological son in [Name (NI) ]. - Tobacco: Denies. - Alcohol: Occasional, last drink was [2126-5-17]. - Illicits: Denies. Family History: Unclear family history of "depression", patient is adopted. Biological son of adopted parents has history of anxiety, depression, and substance use. No family history of suicide. Physical Exam: EXAM ON ADMISSION: Vitals: T: 97.1 BP: 126/73 P: 78 R: 12 PO2: 100% RA General: Alert, somnolent but appropriate, no acute distress HEENT: Pupils equal and round, sclera anicteric, MMM, oropharynx clear Neck: supple CV: Regular rate and rhythm, normal S1 + S2, GII holosystolic murmer @LSB, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, ?palpable liver edge 1 inch below lower ribcage Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema , EXAM ON DISCHARGE: Same as above. Pertinent Results: LABS ON ADMISSION: [2126-7-29] 05:15AM BLOOD WBC-11.2* RBC-4.10* Hgb-13.0 Hct-35.9* MCV-88 MCH-31.8 MCHC-36.3* RDW-11.6 Plt Ct-288 [2126-7-29] 05:15AM BLOOD Neuts-88.6* Lymphs-9.6* Monos-1.6* Eos-0.1 Baso-0.1 [2126-7-29] 05:15AM BLOOD PT-13.2 PTT-23.8 INR(PT)-1.1 [2126-7-29] 05:15AM BLOOD Glucose-142* UreaN-8 Creat-0.7 Na-139 K-4.1 Cl-105 HCO3-18* AnGap-20 [2126-7-29] 05:15AM BLOOD ALT-45* AST-58* AlkPhos-67 TotBili-0.3 [2126-7-29] 05:15AM BLOOD Lipase-22 [2126-7-29] 10:01AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9 [2126-7-29] 10:01AM BLOOD HIV Ab-NEGATIVE [2126-7-29] 05:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-184* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [2126-7-29] 05:15AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.025 [2126-7-29] 05:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2126-7-29] 05:15AM URINE RBC-<1 WBC-5 Bacteri-FEW Yeast-NONE Epi-2 [2126-7-29] 05:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2126-7-29] 05:15AM URINE UCG-NEGATIVE . MICROBIOLOGY: [2126-7-29] 10:00 am MRSA SCREEN Nasal swab (Final [2126-7-31]): No MRSA isolated. . NOTABLE LABS ON DISCHARGE: [2126-7-31] 05:55AM BLOOD WBC-6.3 RBC-4.08* Hgb-13.0 Hct-36.4 MCV-89 MCH-31.9 MCHC-35.8* RDW-11.8 Plt Ct-251 [2126-7-31] 05:55AM BLOOD PT-12.5 PTT-25.3 INR(PT)-1.0 [2126-7-31] 05:55AM BLOOD Glucose-100 UreaN-9 Creat-0.7 Na-144 K-4.0 Cl-107 HCO3-26 AnGap-15 [2126-7-31] 05:55AM BLOOD ALT-38 AST-28 AlkPhos-62 TotBili-0.2 [2126-7-31] 05:55AM BLOOD Calcium-9.4 Phos-4.3# Mg-1.8 [2126-7-30] 02:15AM BLOOD Acetmnp-NEG Brief Hospital Course: 17yoF with history of depression with cutting behavior and ADHD who presented with suicide attempt of tylenol overdose. She is now medically cleared for inpatient psychiatric hospitalization. ACTIVE ISSUES . # Tylenol Overdose: Patient transferred from [Hospital3 3765] with Tylenol overdose. Her first (~3 hour) APAP level at 23:50 (2 hrs 20 minutes following ingestion) was 391, and her ALT was 47, AST was 64 prior to transfer to [Hospital1 18]. She received po NAC, as [Hospital1 ] did not have IV NAC. Her APAP level on initial transfer to [Hospital1 18] was 184 at 5:15am at which time the patient was given her first IV bolus of NAC and started on the 4 hour, then 16 hour infusion of IV NAC. Tylenol levels dropped to 0, liver enzymes normalized and remained normal, and INR peaked at 1.3 following the 21 hour NAC treatment. Hepatology was notified and toxicology was consulted as well. Pt was transferred out of MICU on [2126-7-30], and was clinically asymptomatic. Her LFTs and INR were all within normal by [2126-7-31] on discharge. . #. Depression: Patient followed by an outpatient psychiatrist. She was seen by psych consult team, who recommended discontinuing all her home psych medications including Lexapro. The patient was on a 1:1 sitter throughout hospital course for high suicide risk. Psychiatry placed her on section 12 and recommended discharge to inpatient psychiatric unit once medically cleared. . #. ADHD: Patient on Focalin and Intuniv as an outpatient but given current acute Tylenol ingestion, psychiatry recommended holding these medications. TRANSITIONAL ISSUES # Inpatient psychiatric hospitalization: Given her clinical scenario, the team of physicians agreed that Ms. [Known lastname 91201] would be best helped in an inpatient facility. She was medically cleared after her Tylenol overdose for discharge to a psychiatric facility. Her psychiatrists, inpatient and outpatient, will continue to communicate with each other regarding her plan for continued therapy. Medications on Admission: - Lexapro 20 mg daily - Intuniv 1 mg daily - Focalin 10 mg daily Discharge Medications: None Discharge Disposition: Extended Care Facility: [Hospital 13820] Hospital Discharge Diagnosis: PRIMARY: #) Intentional acetaminophen overdose/intoxication #) Depression SECONDARY: #) ADHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 91201]: . It was a pleasure taking care of you. You were admitted for tylenol overdose. We gave you medications to reverse tylenol toxicity until your tylenol level was zero. We monitored your liver function, which has now returned to [Location 213]. Our psychiatrists recommended to stop all your psychiatric medications. You are now medically cleared for discharge to an inpatient psychiatric unit for further evaluation and therapy. . The following medications were STOPPED: - Lexapro 20 mg by mouth daily - Intuniv 1 mg by mouth daily - Focalin 10 mg by mouth daily . Please let us know if you have any further questions. Followup Instructions: Patient is medically cleared for discharge to an inpatient psychiatric unit. Follow-up will be scheduled after this hospitalization. Completed by:[2126-8-1]	[ "314.01", "275.3", "E950.0", "300.4", "V62.84", "573.3", "787.01", "296.90", "965.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7737, 7793	5545, 7593	339, 346	7931, 7931	3821, 3826	8770, 8934	3002, 3184		7708, 7714		7814, 7910	7619, 7685			8082, 8747										3199, 3204																								2380, 2531				263, 301				5083, 5522						374, 2361		3786, 3802						3841, 5063	7946, 8058							2553, 2639	2655, 2986
76,501	188,262	35805	Discharge summary	report	Admission Date: [2154-12-25] Discharge Date: [2154-12-29] Date of Birth: [2086-12-9] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: [2154-12-25] Mitral Valve Repair utilizing a 26mm [Company 1543] Profile 3D Ring History of Present Illness: This is a 67 year old female with known mitral regurgitation. Preoperative echocardiogram and cardiac MRI confirmed severe mitral regurgitation and normal left ventricular function. Cardiac catheterization in [2154-8-21] showed normal coronaries with a mean PA pressure of 21mmHg. Prior to surgery, her symptoms were increasing shortness of breath and dizziness. Past Medical History: Mitral Reurgitation Hypertension Dyslipidemia History of Retroperitoneal Bleed - s/p Injection Hysterectomy Appendectomy Social History: Denies history of tobacco and ETOH. Unemployed. Lives with son. [Name (NI) 81438] speaking Family History: No premature coronary disease. Physical Exam: BP 129/67, P 78, RR 16 Wt 120 lbs Ht 61 inches General: Asian female in no acute distress Skin: Unremarkable HEENT: Oropharynx benign, sclera anicteric Neck: Supple, no JVD Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, normal s1s2, [2-24] holosystolic murmur Abdomen: benign Ext: warm, no edema Neuro: Non-focal Pulses: 2+ distallly, no carotid or femoral bruits Pertinent Results: [2154-12-28] 03:27AM BLOOD WBC-10.7 RBC-3.45# Hgb-10.7 Hct-29.7* MCV-86 MCH-31.1 MCHC-36.1* RDW-15.0 Plt Ct-139* [2154-12-25] 01:52PM BLOOD WBC-9.8# RBC-3.03# Hgb-9.7# Hct-25.9# MCV-86 MCH-31.9 MCHC-37.3 RDW-14.2 Plt Ct-169 [2154-12-28] 09:14AM BLOOD PT-12.4 PTT-25.1 INR(PT)-1.0 [2154-12-25] 01:52PM BLOOD PT-16.0* PTT-56.7* INR(PT)-1.4* [2154-12-25] 12:40PM BLOOD PT-15.3* PTT-53.9* INR(PT)-1.4* [2154-12-25] 12:40PM BLOOD Fibrino-94* [2154-12-28] 03:27AM BLOOD Glucose-104 UreaN-12 Creat-0.5 Na-137 K-4.2 Cl-102 HCO3-29 AnGap-10 [2154-12-25] 01:52PM BLOOD UreaN-10 Creat-0.5 Cl-114* HCO3-21* [2154-12-28] 03:27AM BLOOD Mg-2.2 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 81439] [Hospital1 18] [Numeric Identifier 81440] (Complete) Done [2154-12-25] at 11:29:37 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2086-12-9] Age (years): 68 F Hgt (in): 61 BP (mm Hg): 110/70 Wgt (lb): 114 HR (bpm): 70 BSA (m2): 1.49 m2 Indication: Intraop Mitral valve surgery. Assess valves, aortic contours, ventircular funciton. ICD-9 Codes: 440.0, 424.0 Test Information Date/Time: [2154-12-25] at 11:29 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 6507], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw 5 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.6 cm Left Ventricle - Fractional Shortening: 0.27 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 60% >= 55% Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg <= 10 mm Hg Aorta - Annulus: 1.7 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.1 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 13 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 1.7 cm Aortic Valve - Valve Area: 1.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. PERICARDIUM: No pericardial effusion. Conclusions Pre Bypass: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Although aortic valve area claculates to between 1.4 and 1.8 cm2 by continuity, and traces at 2.0 by plainemetery, the patient is very small (BSA 1.5), and the leaflets move and coapt normally. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen with A3 flail and some possible commisural involvement. The jet is eccentric and posteriorly directed. Post Bypass: Patient is AV paced on phenylepherine and propofol infusions. Preseved Biventricular function. LVEF 55%. There is a annular ring prosthesis (#26 3D ring per surgeon), MR [First Name (Titles) ] [Last Name (Titles) 81441]s is 1+ at worst, trace by chest closure. Peak and mean gradients across mitral valve are 12 and 8-9 mm Hg respectively. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. . I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2154-12-25] 16:32 [Known lastname ],[Known firstname 81439] [Last Name (NamePattern1) 81442] [Medical Record Number 81443] F 68 [2086-12-9] Cardiology Report ECG Study Date of [2154-12-25] 2:03:22 PM Sinus rhythm. Early repolarization. Normal tracing. Compared to the previous tracing of [2154-12-18] there is variation in precordial lead placement. The prior tracing suggested left ventricular hypertrophy. There is no diagnostic interim change. Read by: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] Intervals Axes Rate PR QRS QT/QTc P QRS T 61 206 86 458/459 63 56 Brief Hospital Course: Mrs. [Known lastname ] was admitted and underwent mitral valve repair by Dr. [Last Name (STitle) ]. For surgical details, please see seperate dictated operative note. She received cefazolin for perioperative antibiotics. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. Postoperative day one she was started on diuretics and betablockers, then transferred to the floor. She was transfused with blood for postoperative anemia. She developed atrial fibrillation postoperative day two and converted to normal sinus rhythm with lopressor and amiodarone after a few hours. She has had no further atrial fibrillation. Physical therapy worked with her on strength and mobility. She continued to do well and was ready for discharge home post operative day four. Plan for follow up with Dr [Last Name (STitle) ] in 2 weeks at [Hospital1 ] heart center. Sternal incision no erythema but small amount of resolving ecchymosis, no drainage, sternum stable Edema +1 lower extremeties, weight 57 kg at discharge preop 51 Medications on Admission: Amlodipine 10 qd Simvastatin 10 qd ??Ranitidine Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s)* Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. 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 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Mitral regurgitation - s/p Mitral Valve Repair Post operative atrial fibrillation Hypertension Dyslipidemia Peptic ulcer disease Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 No creams, lotions, powders, or ointments to incisions Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule all appointments [Hospital1 ] heart center [Telephone/Fax (2) 6256] to set appointment with Dr [Last Name (STitle) ] in two weeks, he has clinic on thrusdays at [Hospital1 ] Dr. [Last Name (STitle) 3659] in [1-22] ([Telephone/Fax (1) 6256]) Dr. [Last Name (STitle) 1256] in 1 week [Telephone/Fax (1) 81444] Completed by:[2154-12-29]	[ "997.1", "401.9", "V45.79", "272.0", "E878.8", "427.31", "V88.01", "285.1", "424.0", "533.90" ]	icd9cm	[ [ [] ] ]	[ "38.93", "39.61", "35.33" ]	icd9pcs	[ [ [] ] ]	9975, 9981	7619, 8766	333, 424	10154, 10161	1543, 7596	10508, 10907	1092, 1124		8864, 9952		10002, 10133	8792, 8841			10185, 10485										1139, 1524																												284, 295										452, 820																842, 964	980, 1076
70,620	119,183	50915	Discharge summary	report	Admission Date: [2157-4-27] Discharge Date: [2157-5-8] Date of Birth: [2077-10-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7299] Chief Complaint: Unresponsive episode. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname ] is a 79 M with schizophrenia (vs. schizoid personality), hypertension, hyperlipidemia, atrial fibrillation on Coumadin who is admitted following an episode of unresponsiveness at rehab. According to his caregiver [Name (NI) 8513] (who provides all history at this time), he had PPD checked several months ago "because it was due," though he was known to be PPD positive in the past. He was started on treatment with INH/B6. Following that medication change, he began to "go downhill" in terms of his health. He developed erratic INRs that were difficult to control. Approximately 1 month ago, he began complaining of dark, concentrated urine. He was admitted to [Hospital6 17032] last Friday with uncontrolled INR (exact value unknown), but was felt to be too weak for discahrge home (difficulty walking). He was therefore discharged to [Hospital 30527] on Monday. This morning, he was visited by his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 105828] who engaged him in a discussion of code status. The patient reported wanting to be DNR, though was okay with other medical interventions and he verbalized this to Dr. [Last Name (STitle) 105828] and signed a DNR paper. A short time later, he was found unresponsive at rehab. His heart rate was noted to be in the 20s and he was sent back to [Location (un) ] ED. . There, he received atropine and epinephrine and he was started on a dopamine gtt. He also received one dose of levofloxacin. The gtt was stopped prior to transfer by air lifting. During his flight, he received 3L of IVF. On arrival to the ED, HR 37 (has been 30s-40s), BP 80s-110s, a femoral line was placed and he was restarted on dopamine for pressure in the 80s. BP improved to 132/48 on dopamine. O2 sat was 91% on RA. CXR showed some fluid overload so fluids stopped (received 2-3L in ED). He received calcium chloride x 2 and bicarb 1 amp x 3. He was then started on bicarb/D5 gtt at 150/hr and transferred to the MICU. . On arrival to the floor, he was moving all extremities and mumbling but not answering questions coherently. He appeared uncomfortable. . ROS: Not possible at this time. Other than general malaise and dark urine, [Doctor First Name 8513] was unaware of any other specific complaints that the patient may have had. She is not aware that he has any renal failure at baseline. Past Medical History: --Atrial fibrillation on Coumadin --Hypertension --Hypercholesterolemia --Schizophrenia --Lost an eye in an alcohol-related accident years ago --Has one tooth but has never had dentures --Corns on feet, sees podiatrist Social History: Never married, no children. Lives in a home for adopted veterans. HCP is [Name (NI) 8513] who hosts the veterans (10 total). He owns four cats and likes golf. Has not worked in approximately 25 years; in the service he was in the Korean war. Quit drinking 18 years ago (very heavy prior to that) and quit smoking in [2143]. No IVDU or other drugs. He had one brother who passed away 8 years ago (also unmarried with no children). Family History: Non-Contributory Physical Exam: On Admission: GEN: Uncomfortable appearing, mumbling, not following commands HEENT: Left eye is missing. Right pupil is round and reactive. Poor dentition. JVP to ~10 cm. RESP: Shallow respirations, no audible wheeze/rales CV: Slow rate, no clear M/R/G ABD: Soft, no apparent TTP, non-distended, no rebound/guarding EXT: Corns on feet b/l. Feet cool to touch, DP pulses not palpable. NEURO: Moving all extremities. Unable to cooperate with remainder of exam. . On Discharge: GEN: Alert, interactive, NAD HEENT: Left eye is missing, right pupil equal and reactive, OP clear without exudate, lesion RESP: CTA-B, no w/r/c CV: RRR, no m/r/g, no edema, no JVD GI: soft, non-tender, nondistended, no appreciable HSM, + BS EXT: WWP, 2+ peripheral pulses NEURO: moving all extremities, intact sensation Pertinent Results: [2157-4-27] 10:29PM TYPE-ART TEMP-35.1 PO2-90 PCO2-28* PH-7.38 TOTAL CO2-17* BASE XS--6 INTUBATED-NOT INTUBA [2157-4-27] 10:29PM LACTATE-3.1* [2157-4-27] 08:59PM WBC-23.3* RBC-2.92* HGB-9.0* HCT-27.2* MCV-93 MCH-30.9 MCHC-33.1 RDW-15.2 [2157-4-27] 08:59PM NEUTS-91* BANDS-0 LYMPHS-3* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2157-4-27] 08:59PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL BURR-1+ FRAGMENT-OCCASIONAL [2157-4-27] 08:59PM PLT SMR-HIGH PLT COUNT-615* [2157-4-27] 07:49PM GLUCOSE-138* LACTATE-5.4* K+-4.9 [2157-4-27] 07:40PM GLUCOSE-149* UREA N-73* CREAT-5.7* SODIUM-142 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-12* ANION GAP-28* [2157-4-27] 07:40PM estGFR-Using this [2157-4-27] 07:40PM ALT(SGPT)-14 AST(SGOT)-43* ALK PHOS-62 TOT BILI-0.2 [2157-4-27] 07:40PM LIPASE-50 [2157-4-27] 07:40PM cTropnT-0.05* [2157-4-27] 07:40PM CALCIUM-10.1 PHOSPHATE-5.4* MAGNESIUM-2.5 [2157-4-27] 07:40PM PT-48.8* PTT-52.7* INR(PT)-5.3* [2157-4-27] 07:40PM URINE COLOR-AMBER APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2157-4-27] 07:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [2157-4-27] 07:40PM URINE RBC->1000* WBC->1000* BACTERIA-MANY YEAST-NONE EPI-0 [2157-4-27] 07:40PM URINE WBCCLUMP-MANY [2157-4-27] 07:40PM URINE EOS-NEGATIVE . On Discharge: Creatinine [2157-4-27] 07:40PM BLOOD Creat-5.7* [2157-4-29] 02:25AM BLOOD Creat-6.4* [2157-5-1] 07:05AM BLOOD Creat-7.4* [2157-5-2] 06:30AM BLOOD Creat-7.8* [2157-5-6] 05:55AM BLOOD Creat-5.7* [2157-5-8] 05:30AM BLOOD Creat-4.4* INR [2157-4-27] 07:40PM BLOOD INR(PT)-5.3* [2157-4-28] 02:50AM BLOOD INR(PT)-6.6* [2157-4-29] 02:25AM BLOOD INR(PT)-1.7* [2157-5-4] 06:40AM BLOOD INR(PT)-1.4* [2157-5-6] 05:55AM BLOOD INR(PT)-1.3* [2157-5-8] 05:30AM BLOOD INR(PT)-1.5* [2157-4-28]: The right kidney measures 10.8 cm and the left kidney measures 12.0 cm. There is no hydronephrosis seen bilaterally. No stone or solid mass is seen in either kidney. A simple cyst containing a wall calcification is seen laterally in the right kidney. This cyst measures 3.2 x 3.0 x 3.0 cm. A tiny simple cyst is seen in the interpolar region of the left kidney measuring 1.0 x 1.1 x 1.0 cm. . ECHO [2157-4-28]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is moderately dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderately dilated right ventricle with normal contractility. Mild symmetric LVH with normal regiona and global left ventricular systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. CXR ([2157-4-29]): FINDINGS: In comparison with the study of [4-28], there is little change in the diffuse opacifications bilaterally consistent with pulmonary edema. Enlargement of the cardiac silhouette persists. Brief Hospital Course: 79-year-old gentleman with a history of schizophrenia, hypertension, hyperlipidemia, A-fib on Coumadin who was found unresponsive at rehab and noted to be profoundly bradycardic on exam. . BRADYCARDIA --> ATRIAL FIBRILLATION with RVR: On admission, EKG showed afib with escape rhythm. Likely due to verapamil intoxication due to acute renal failure. Nodal agents were held and heart rate eventually normalized. Monitored on telemetry without repeat bradycardia. Once washout of the CCB was achieved, he then developed AF with RVR. He was rate-controlled with increasing doses of metoprolol, eventually well controlled on metoprolol 75mg XL qhs. On admission, INR supratherapeutic and coumadin held. Once patient was restarted on coumadin, his INR responded very slowly. His INR was subtherapeutic at the time of discharge and will need to be followed closely. OUTPATIENT ISSUES: -- Close monitoring of heart rate to ensure proper dosing of beta-blocker. -- Monitor weekly INR and ensure proper dosing of Coumadin. . # SEPSIS/HYPOTENSION with LLL PNEUMONIA: Likely due to a combination of cardiogenic and infectious factors. Question of left lower lobe pneumonia on imaging and UA suggestive of infection (however cultures with no growth). WBC count markedly elevated at 23 and lactate of 5.4 on admission. In the MICU, patient initially required dopamine drip but this was quickly weaned off. He was continued on broad spectrum antibiotics to cover HCAP initially with improvement in hemodynamics. However, he developed diarrhea and concern for C.diff, though toxin negative x2. Due to this, his broad spectrum antibiotics were narrowed upon reaching the medicine floor as he was otherwise asymptomatic with stable hemodynamics. At time of discharge, he was saturating >95% on room air without respiratory symptoms. . # ACUTE RENAL FAILURE with UREMIA: Baseline creatinine of 1.1 in [2156], increased to 2.2 in early [Month (only) 958], then >4 during recent admission. Based on muddy brown casts in urine sediment, he likely developed ATN in the setting of hypotension from bradycardia from high verapamil levels. A renal ultrasound did not show obstruction. Patient was given lasix with fair response of urine output. He was followed by nephrology in the ICU who held off on dialysis. Patient continued to make adequate urine throughtout his hospitalization, with post-ATN diuresis and subsequent improvement in his creatinine toward with stabilization of electrolytes. We also felt this uremia was contributing to an element of encephalopathy in addition to his baseline dementia. As his renal function improves, we expect he will be more oriented and he will have more of an appetite. OUTPATIENT ISSUES: -- Close monitoring of creatinine and electrolyte levels. -- Plan to restart home regimen of weekly ProCrit as outpatient -- follow-up with [Hospital1 18] Nephrology in [3-3] weeks as an outpatient -- Nutrition consultation while in rehab to ensure adequate PO intake . # URINARY RETENTION: Foley placed on admission in setting of renal failure to properly monitor ins and outs. Patient with evidence of urinary retention when foley discontinued on the floor. He was started on terazosin and the Foley was replaced. Once it was discontinued again, he was able to urinate on his own prior to discharge. OUTPATIENT ISSUES: -- If continued retention, he will need follow-up with urology. . # DIARRHEA: Patient with intermittent loose stools on the floor. Differential diagnosis included antibiotic side effect vs. C. difficile infection. Patient empirically treated with Flagyl ([5-3] - [5-6]), but C. Difficile toxin negative x 2 and decision was made to stop Flagyl. OUTPATIENT ISSUES: -- Monitor stool output, repeat C. difficile toxin if diarrhea recurs; low threshold to empirically treat with Flagyl. . # ISONIAZID, B6: By report, started on INH by outside provider in setting of positive PPD. LFTs were within normal limits, but scant data of INH leading to renal failure. During hospitalization decision made to discontinue INH. Patient received additional B6 during his hospitalization. No data suggestive that prolonged B6 needed in patients formerly treated with INH do decision made to discontinue B6 administration as well. OUTPATIENT ISSUES: -- Discuss with your PCP about the risks and benefits of possibly restart INH and B6. . # Schizophrenia vs. schizoid personality/Baseline Dementia. At baseline patient is minimally interactive and oriented x 2. At time of discharge patient restarted on home medical regimen of Razadyne. He appears to be at his baseline. Medications on Admission: --Gemfibrozil 600 mg Tab Oral 1 Tablet(s) Twice Daily --Zocor 10 mg Tab Oral 1 Tablet(s) Once Daily --Verapamil ER 240 mg 24 hr Cap Oral 1 Cap,Ext Release Pellets 24 hr(s) Twice Daily --Pyridoxine 50 mg Tab Oral 1 Tablet(s) Once Daily --Razadyne 8 mg Tab Oral 1 Tablet(s) Twice Daily --Isoniazid 300 mg Tab Oral 1 Tablet(s) Once Daily --Warfarin 1 mg PO BID --Procrit 10,000 U Q weekly Discharge Medications: 1. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 3. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 2 days. 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Razadyne 8 mg Tablet Sig: One (1) Tablet PO once a day. 6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Procrit 10,000 unit/mL Solution Sig: One (1) Injection once a week. 8. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 9. Outpatient Lab Work -Tuesday [2157-5-10] - please check INR, potassium, chemistry panel, and BUN/creatinine and forward to rehab MD. -Please check chemistry panel weekly thereafter Discharge Disposition: Extended Care Facility: [Hospital6 25759] Rehabilitation Discharge Diagnosis: Primary: Acute Kidney Injury Pneumonia Bradycardia, secondary to medication effect . Secondary: Dementia Atrial Fibrillation Hypertension Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [Known lastname ], It was a pleasure taking care of you at the [Hospital1 771]. You were admitted to [Hospital1 18] for evaluation and treatment of a slow heart rate and kidney dysfunction. . Regarding your constellation of symptoms, much was attributed to medications including verapamil intoxication and INH. These medication were discontinued and both your bradycardia and acute kidney injury resolved with time. . Your admission symptoms were also consistent with infection. Chest X-ray demonstrated possible pneumonia and urine analysis was suggestive of a urinary tract infection. You were treated with antibiotics and your white blood cell count, which is a marker of infection, improved. At the time of discharge you had completed a course of antibiotics, you were without fever and your white blood cell count was within normal limits. . CHANGES TO YOUR MEDICATIONS: -- STOP taking INH -- STOP taking B6 -- START taking calcium carbonate 500mg tablets. Take one tablet three times daily. -- START taking Potassium pills Regarding heart rate control: -- STOP taking Verapamil -- START taking Metoprolol XL. Take one 75mg tablet each night Regarding anticoagulation: -- INCREASE COUMADIN from 1mg daily to 3mg daily. Followup Instructions: Please follow-up with PCP after discharge from rehab. Please call the [Hospital 10701] clinic at ([Telephone/Fax (1) 10135] to schedule a follow-up appointment in about 2 weeks with Dr. [First Name (STitle) ] [Last Name (un) 48207]/Dr. [Last Name (STitle) 4883] to make sure your kidneys continue to improve. You should discuss with your PCP the risks and benefits of possibly restarting INH and B6 upon your discharge. Also, you should be seen by the nutritionists while you are in rehab to help you eat enough.	[ "276.2", "787.91", "427.89", "427.31", "V49.86", "295.90", "584.5", "401.9", "293.0", "294.8", "348.39", "799.02", "272.4", "507.0", "276.0", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "86.09" ]	icd9pcs	[ [ [] ] ]	13883, 13946	7905, 12530	325, 332	14143, 14143	4308, 5801	15598, 16137	3460, 3478		12966, 13860		13967, 14122	12556, 12943			14328, 15196										3493, 3493																			5816, 7882				15225, 15575					264, 287										360, 2746								3507, 3954	14158, 14304							2768, 2988	3004, 3444
83,441	110,504	36455	Discharge summary	report	Admission Date: [2134-5-6] Discharge Date: [2134-5-8] Date of Birth: [2062-2-16] Sex: M Service: MEDICINE Allergies: Aspirin / Ibuprofen Attending:[First Name3 (LF) 458] Chief Complaint: ASA desensitization Major Surgical or Invasive Procedure: Cardiac catherization with placement of drug-eluting stent to Right Coronary Artery Aspirin desensitization History of Present Illness: 72 y/o M with hypertension and asthma referred for aspirin desensitization prior to cardiac catheterization [5-7]. He describes taking aspirin many years ago in the hospital and having throat swelling and shortness of breath. He gets similar symptoms with ibuprofen. He does not get hives or itching. He has had recent intermittent episodes of substernal/midepigastric discomfort described as gas pain, lasting ~3 hrs., associated with belching, and relieved by TUMS. No associated dizziness, lightheadedness, diaphoresis, palpitations, shortness of breath, or vomiting. No component of exertion or position. No orthopnea, PND, or edema. Symptoms evaluated with ETT-MIBI [5-5] during which he exercised for 4:37 reaching 7 METS and 91% of max predicted HR. At peak exercise he had chest discomfort with 2-[Street Address(2) 82585] depressions inferiolaterally and ventricular ectopic activity with couplets - chest pain resolved with NTG. Initial images showed inferior defect. Also had asymptomatic 4-beat run of VT in immediate post-recovery period. TTE [5-6] showed normal LV size and systolic function (LVEF 65%), 2+ MR, 1+ TR, and trace AR. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative except as noted above. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Prostate Cancer s/p prostatectomy [2125] Nasal polyps Asthma s/p removal nasal polyps s/p tonsillectomy CRI - Cr 1.5 on [2134-5-5] Social History: One glass of wine daily. Quit smoking in [2085]. o tobacco or IVDU. Lives with wife in [Name2 (NI) ]. retired truck driver Family History: No h/o premature CAD or SCD. Mother died of breast CA at 52. Father died of lung CA at 72. Physical Exam: V/S: T 98.4 HR 95 BP 111/69 Gen: Well-appearing gentleman in NAD HEENT: NC/AT. Sclera anicteric. Conjunctiva pink, no xanthalesma. Neck: Supple with JVP of 6 cm @ HOB 45 deg. No carotid bruit. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI holosystolic murmur at apex, no thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [2134-5-6] 02:19PM BLOOD WBC-8.6 RBC-4.72 Hgb-14.5 Hct-41.9 MCV-89 MCH-30.6 MCHC-34.5 RDW-12.9 Plt Ct-307 [2134-5-6] 02:19PM BLOOD Neuts-65.4 Lymphs-24.8 Monos-7.1 Eos-2.2 Baso-0.6 [2134-5-6] 02:19PM BLOOD PT-13.6* PTT-24.6 INR(PT)-1.2* [2134-5-6] 02:19PM BLOOD Glucose-122* UreaN-27* Creat-1.3* Na-138 K-3.9 Cl-104 HCO3-24 AnGap-14 [2134-5-6] 02:19PM BLOOD Calcium-9.5 Phos-2.8 Mg-1.9 [2134-5-7] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91 . . Chest X-ray: Normal heart, lungs, hila, mediastinum and pleural surfaces aside from a descending thoracic aorta, which is at least tortuous and may be mildly dilated. Conventional radiographs recommended for initial assessment Cardiac cath:(Prelim report) Initial angiography showed 80% mid RAC and 50% distal RCA at crux. We planned to treat the mid RCA lesion with PTCA and stenting. Bivaliruding provided adequate support. The patient also received ASA and Plavix prior to the procedure. A 6 French JR4 guide provided adequate suport. Choice Floppy wire crossed the lesion without dufficulty and was positioned in the distal RPDA. A 3.0x12 mm Quantum Maverick RX predilated the lesion at 18 ATM. We then deployed a 3.0x15 mm Endeavor stent RX at 16 ATM. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dissection or distal emboli. We then successfully deployed a 6 French Angioseal closure device into the RCFA. The patient left the carth lab free from angina and in stable condition. COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated two-vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had sequential 50% stenoses in the mid- and distal-vessel. The LCX had mild insignificant plaque. The RCA had an 80% mid-vessel stenosis and a 50% stenosis at the PDA/PLV bifurcation. 2. Resting hemodynamics demonstrated high-normal biventricular filling pressures and mild pulmonary arterial hypertension as above. 3. Successful PTCA and stening of the mid RAC with 3.0x15 mm Endeavor DES. Final angiography showed 0% residual stenosis with TIMI 3 flow and no dssection or distal emboli. 4. Successful deployment of a 6 French Angioseal closure device to the RCFA. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful PTCA and stenting of the mid RCA with Endeavor DES. 3. Successful deployment of 6 French Angoseal device to the RCFA. . Discharge labs: [2134-5-8] 02:56AM BLOOD WBC-10.0 RBC-4.01* Hgb-12.4* Hct-36.4* MCV-91 MCH-31.1 MCHC-34.2 RDW-13.0 Plt Ct-288 [2134-5-8] 02:56AM BLOOD Glucose-87 UreaN-20 Creat-1.3* Na-140 K-4.4 Cl-106 HCO3-27 AnGap-11 [2134-5-8] 02:56AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 [2134-5-7] 05:25AM BLOOD Triglyc-119 HDL-45 CHOL/HD-3.6 LDLcalc-91 Brief Hospital Course: A/P: 72 M w/ HTN, CRI, asthma, and nasal polyps referred prior to cardiac catheterization for ASA desensitization following a positive ETT. He has Samter's syndrome given h/o asthma, nasal polyp's and aspirin allergy. He underwent aspirin desensitization per protocol and tolerated this well. It was emphasized he will need to consistently and reliably take an aspirin daily and that if he misses a dose, he could potentially have an adverse reaction such as anaphylaxis to aspirin or NSAID's. . Regarding his CAD, inferolateral EKG changes with exercise and preliminary MIBI images, isolated inferior Q on ECG suggest LCx vs. RCA disease. He was hydrated for cardiac catherization and pre=treated with mucomyst for renal protection given his history of chronic renal insufficiency. He then underwent cardiac cath which showed 50% stenoses in the mid and distal LAD, LCX with mild insignificant plaque and RCA with an 80% mid-vessel stenosis and a 50% stenosis at the PDA/PLV bifurcation. He underwent placement of a drug eluting stent in his RCA. No complications form the catheterization procedure. He was started on full dose aspirin and plavix and was continued on these medications at time of discharge. Medications on Admission: toprol XL 50mg qhs monopril 40mg daily diazide 37.5/25 (triamterene/HCTZ) fosamax 70mg daily advair 250/50 1 puff daily albuterol INH prn nasonex 1 sprah in am prednisone 2.5mg qod oscal +d 600 [Hospital1 ] tylenol 1gram qAM/qPM aleve 440mg aAM/aPM Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 3. Monopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Aspirin allergy Hypertension Chronic Renal Insufficency Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for aspirin desensitization procedure prior to cardiac catheterization. This procedure was successful. Cardiac catheterization showed a partial blockage in one of your coronary arteries that supplies blood to your heart and a stent was placed to help open this blood vessel. The following changes were made to your medications: 1) STARTED plavix 75mg daily - this should be continued for at least 1 year 2) STARTED aspirin 325mg daily. Because of your allergy, you need to make sure to take this EVERY DAY. If you miss more than a few days of aspirin your allergy might return. Followup Instructions: Please follow up with your cardiologist Dr. [First Name4 (NamePattern1) 8797] [Last Name (NamePattern1) 23246] in 1 month. An appointment has been made for you on [5-28] at 1:15pm. Please call [Telephone/Fax (1) 82345] with questions. Please follow up with your PCP as needed. Completed by:[2134-5-10]	[ "493.90", "414.01", "403.90", "V10.46", "585.9" ]	icd9cm	[ [ [] ] ]	[ "88.52", "00.40", "00.45", "99.20", "00.66", "88.56", "36.07", "37.23", "99.12" ]	icd9pcs	[ [ [] ] ]	8456, 8462	6175, 7386	297, 407	8586, 8595	3350, 3350	9258, 9586	2482, 2574		7689, 8433		8483, 8565	7412, 7666		5622, 5796	8619, 9235			5812, 6152							2589, 3331																												238, 259										435, 2140					3367, 5605											2162, 2315	2331, 2466
12,706	165,435	11053+56204	Discharge summary	report+addendum	Admission Date: [2109-11-18] Discharge Date: [2109-11-21] Date of Birth: [2049-9-30] Sex: F Service: [Hospital1 212] HISTORY OF THE PRESENT ILLNESS: This 60-year-old woman was admitted to the Medical Intensive Care Unit on [2109-11-18] for nausea, vomiting, abdominal and chest pain and hyperglycemia. She has a history of type 2 diabetes mellitus since [2085] for which she takes insulin. She also has a history of coronary artery disease, status post CABG in [2103], and had a Persantine MIBI test in [2109-6-27] revealing a fixed lateral defect, unchanged from prior study. She also has a history of heart failure with latest echocardiogram in [2109-1-25] revealing LVEF of 30%, global hypokinesis with basal posterolateral wall sparing, mild to moderate MR, and right ventricular systolic dysfunction. The patient had a fall on her right hip about two weeks ago and a reported syncopal episode as well three weeks ago. Since the fall she has been unable to walk secondary to pelvic pain, and had a negative hip x-ray taken at an outside hospital. The patient notes fatigue starting about three days prior to admission, nausea and vomiting two days prior to admission with epigastric pain, and chest pain the day prior to admission for which she took sublingual nitroglycerin with relief. She was taken by EMS to the ED where she was noted to have a blood sugar over 800. She did not take her insulin on the day of admission. She was admitted to the MICU, ruled out for myocardial infarction by enzymes, placed on an insulin drip, and fluid resuscitated. As of transfer to the [Hospital1 ] Service on [2109-11-19], the patient felt improved, with no pain, but continued fatigue. She denied pelvic pain at rest but has [9-5] pain with weightbearing. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Coronary artery disease, status post CABG. 3. Bilateral carotid stenosis, status post endarterectomy. 4. Dyslipidemia. 5. Hypertension. 6. Recurrent pancreatitis. 7. Autonomic dysfunction. 8. Cholecystectomy. ADMISSION MEDICATIONS: 1. Lisinopril 30 mg q.d. 2. Amlodipine 10 mg q.d. 3. Metoprolol 25 mg b.i.d. 4. Aspirin 325 mg q.d. 5. Lipitor 10 mg q.d. 6. NPH insulin 20 units q.a.m., 10 units q.p.m. 7. Regular insulin sliding scale. 8. Oxycodone p.r.n. 9. Protonix. 10. Ativan p.r.n. 11. Phenergan p.r.n. 12. Nitroglycerin p.r.n. 13. Ambien p.r.n. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives in [Location 1468] with her mother. She works for the IRS. She smokes cigarettes occasionally, cut back five years ago but smoked four packs per day previously and started at age 11. She has never used alcohol. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 99.6, heart rate 60-81, blood pressure 113/57, respirations 18, oxygen saturation 99% on room air. General: This is an elderly woman with a flat affect in no distress. HEENT: Anicteric sclerae and moist oral mucosa. Pulmonary: Lungs clear to auscultation bilaterally. Heart: Regular rate and rhythm, normal S1, S2, grade III/VI holosystolic murmur loudest at the apex, radiating to the axilla. Abdomen: Soft, mildly tender in all four quadrants but more tender in the right lower quadrant than the other quadrants. Decreased bowel sounds. Extremities: Without edema. LABORATORY DATA: White blood count 10.7, hematocrit 28, platelets 223,000. Sodium 142, potassium 4.4, chloride 108, total C02 23, BUN 33, creatinine 1.6, total bilirubin 0.2, AST 19, ALT 10. CK 53, 55, and 60. Troponin I 0.4. Blood culture from [2109-11-18] with no growth to date. HOSPITAL COURSE: 1. ENDOCRINE: The patient was transferred to the floor after resolution of her acute hyperglycemic episode. She remained normal glycemic and without an anion gap on her outpatient doses of NPH insulin without [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 5596] MEDQUIST36 D: [2110-3-20] 04:37 T: [2110-3-23] 17:14 JOB#: [Job Number 35733] Name: [Known lastname 6370], [Known firstname 6371] Unit No: [Numeric Identifier 6372] Admission Date: [2109-11-18] Discharge Date: [2109-11-20] Date of Birth: [2049-9-30] Sex: F Service: [Hospital1 ] Medicine This is a continuation of a discharge summary that was inadvertently discontinued. HOSPITAL COURSE BY SYSTEM: 2. Cardiovascular: The patient had a known history of coronary artery disease and congestive heart failure. She remained in sinus rhythm since admission, and aforementioned ruled out for myocardial infarction by cardiac enzymes. She did not have any further chest pain or shortness of breath throughout her admission. Her outpatient regimen of metoprolol, lisinopril, amlodipine, for hypertension, as well as aspirin and Lipitor for coronary artery disease were continued. 3. Renal: The patient was noted to have a creatinine of 1.1 in [2109-5-27]. She had levels as high as 2.4 in the midst of her heart failure exacerbation in [Month (only) 880]. Her admission creatinine was 2.4 on [11-18]. This creatinine trended down to a level of 1.4 at time of discharge with the administration of intravenous fluids. 4. Heme: Patient was noted to have a normocytic anemia. With the administration of intravenous fluids, her hematocrit decreased to a level of 26.1 on [11-20]. Iron studies revealed a normal iron of 64, decreased TIBC of 215, normal ferritin of 146, and B12 and folate within normal limits. Patient received a unit of packed red blood cells on [11-20] and appropriately increased her hematocrit to 31.2 prior to discharge. 5. Musculoskeletal: Patient was noted to have extreme pain on weightbearing. The differential diagnosis was felt to include a hematoma after her fall or a pelvic fracture. The patient received a CT scan of the pelvis which revealed a nondisplaced fracture through the right superior pubic ramus, most likely subacute to chronic in nature. The Orthopedic Service saw the patient and recommended weightbearing as tolerated, and follow up with Orthopedics two weeks postdischarge. The patient was arranged to followup Dr. [Last Name (STitle) 3266]. The patient was seen by Physical Therapy, and was able to ambulate with crutches prior to discharge. DISCHARGE DIAGNOSES: 1. Hyperglycemic ketotic nonacidotic state. 2. Type 2 diabetes mellitus. 3. Right superior pubic ramus fracture. 4. Coronary artery disease. 5. Left ventricular systolic dysfunction. 6. Hypertension. 7. Dyslipidemia. 8. Status post acute on chronic renal failure of prerenal etiology. 9. Anemia. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: Home. DISCHARGE INSTRUCTIONS: Anemia followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Hospital 112] Clinic in [11-28] weeks and Dr. [Last Name (STitle) 3266] in Orthopedics in two weeks. DISCHARGE MEDICATIONS: 1. Lisinopril 30 mg q day. 2. Atorvastatin 10 mg q day. 3. Amlodipine 10 mg q day. 4. Nitroglycerin prn. 5. Protonix 40 mg q day. 6. Metoprolol 25 mg [Hospital1 ]. 7. Insulin 20 units of NPH q am and 10 units q pm. 8. Aspirin 325 mg q day. 9. Calcium carbonate 500 mg tid. 10. Vitamin D 400 units q day. [Name6 (MD) ] [Last Name (NamePattern4) 424], M.D. [MD Number(1) 425] Dictated By:[Last Name (NamePattern1) 5970] MEDQUIST36 D: [2110-3-20] 16:56 T: [2110-3-21] 05:18 JOB#: [Job Number 6373]	[ "808.2", "401.9", "584.9", "250.11", "008.8", "V45.81", "E888.9", "593.9", "276.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				6841, 6874				6522, 6819	7131, 7696				3712, 4551		6899, 7108		2124, 2507		4578, 6501																																																				2797, 3694								1851, 2101	2524, 2782
53,722	188,000	46901	Discharge summary	report	Admission Date: [2195-8-6] Discharge Date: [2195-8-14] Date of Birth: [2109-3-19] Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[First Name3 (LF) 783] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: EGD History of Present Illness: 86 year old male with brittle TIDM, aortic insufficiency, and CKD presents with chest pain. The pain woke the patient from sleep last night. He felt a tightness in his anterior chest that wrapped around his chest like someone was tightening a towel around him. It lasted till the morning, and he can't recall when it stopped. His wife reports that he felt like food was caught in his stomach at dinner and he had a need to vomit. He also developed the hiccups and a headache, both rare for him. He denies exertional pain, denies diaphoresis, nausea, or associated shortness of breath. He denies any fever, chills, cough, nausea, vomiting. He never had significant chest pain before. The patient has been compliant with a new, more conservative insulin regimen since his last admission [2195-7-10], but recently lost control. He reports feeling thirsty the past few days, and developing suprapubic pain from not voiding. He otherwise denies fatigue, nausea, abdominal pain, chills, or headache over the past few days. He recently traveled to [Hospital3 ], has not had recent antibiotics. In the emergency room, initial vitals were T 97.4 HR 96 BP 157/40 RR 22 O2 100%. EKG showed 1st degree block, RBBB, no ST elevation, T-wave flattening in III and AVF, T-wave inversions V1-V3. Initial labs in ED were notable for trop of 0.20, Na was 119, K 5.8, bicarb 6 with AG of 24, BUN/Cr 82/3.7, baseline ~ 60/2.5. CBC shows leukocytosis of 21.7, with left shift 90.9%N. H/H 10.5/33.9, platelets 403. Rectal exam was heme negative. A CXR showed a heart of normal size, opacity behind heart cosistent with hiatal hernia, rotated lungs are clear, no effusions. His pain responded to nitroglycerin and he was bolused with 5000 units heparin and started on a heparin drip. He was given 81mg ASA, cardiology saw him and agreed. He was bolused 10U insulin and started 8 units/hr. Access with two peripherals 20 guage. Past Medical History: Endocarditis, [2184] strep Ao valve, gets f/up echos 1-2x yr w/cardiologist Dr [Last Name (STitle) ] Aortic insufficiency, moderate (latest echo in [11-15], normal LV size and function, ejection fraction greater than 70%, asymptomatic, requires abx prophylaxis) Hyperlipidemia -his last cholesterol was 210, but his HDL 56, LDL 104. Hypertension Type I Diabetes, latest hemoglobin A1c 10.7 on [2193-5-7] Chronic kidney disease (stage III, stable, baseline creat 1.6, K 4.5) Hypothyroidism GERD Partial knee replacements, L knee in [2190], R knee [6-/2192] BPH/Recurrent UTIs (TURP [5-/2173]) (Followed by Dr [Last Name (STitle) ] Tinnitus (decreased hearing by audiogram. Thought [1-8] sound trauma or gentamycin) Benign colonic polyps and diverticulosis Macular degeneration Abnormal Chest CT- needs follow-up Chest CT [2193-10-7] to re-evaluate nodules on chest CT performed for abnormal pulm exam Social History: Lives with his wife. [Name (NI) ] smoking hx of 1/2pk for 30yrs, quit many years ago. Ocassional alcohol. Denies past or present hx of IVDU or other recreational drugs. Family History: No cardiac history. Physical Exam: ADMISSION Physical Exam: Vitals: T: 97.2 BP: 130/39 P: 59 R: 17 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, pupils 2mm, round, reactive to light Neck: supple, JVP 8 cm, no LAD CV: Systolic crescendo/decrescendo murmur best heard at RUSB, radiating to carotids, regular rate and rhythm, normal S1 + S2, heartbeat palpable Lungs: Clear to auscultation bilaterally, good air movement, no crackles, wheezes, ronchi Abdomen: Distended, soft, non-tender, hypoactive bowel sounds, no organomegaly Back: No CVA tenderness bilaterally GU: Foley in place Ext: warm, well perfused, 2+ pulses bilateral radial and dorsalis pedis, no clubbing, cyanosis or edema. Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation, 1+ reflexes bilateral brachial and patellar, gait deferred Discharge Physical exam: VS from discharge: 97.4 102/45 57 20 95RA FSG208 24hr I/O: [Telephone/Fax (1) 99488] GEN: Alert, oriented, no acute distress HEENT: NCAT MMM EOMI, OP clear NECK: Right neck with bandage in place from IJ removal yesterday, site clean, dry intact. No visible JVD PULM: Rare wheeze, no crackles, rhonchi. CVS: Regular rate and rhythm, soft diastolic murmur (II/VI) heard best at RUSB, normal S1 + S2, ABD: Obese, soft NT ND normoactive bowel sounds EXT: WWP, [12-8]+ pitting edema noted to knees bilaterally, 2+ pulses palpable bilaterally NEURO: CNs2-12 intact, motor function grossly normal Pertinent Results: Admission Labs [2195-8-6] 09:10AM BLOOD WBC-21.7# RBC-3.53 Hgb-10.5* Hct-33.9* MCV-96 MCH-29.7 MCHC-30.9* RDW-13.6 Plt Ct-403 [2195-8-6] 09:10AM BLOOD Neuts-90.9* Lymphs-6.3* Monos-2.6 Eos-0.1 Baso-0.2 [2195-8-6] 09:10AM BLOOD PT-9.7 PTT-30.8 INR(PT)-0.9 [2195-8-6] 09:10AM BLOOD Glucose-791* UreaN-82* Creat-3.7* Na-119* K-5.8* Cl-95* HCO3-6* AnGap-24* [2195-8-6] 09:10AM BLOOD cTropnT-0.20* [2195-8-6] 02:06PM BLOOD CK-MB-20* MB Indx-9.7* [2195-8-6] 07:59PM BLOOD CK-MB-30* MB Indx-12.0* cTropnT-0.48* [2195-8-7] 09:15AM BLOOD CK-MB-38* cTropnT-0.85* proBNP-[Numeric Identifier 99489]* [2195-8-7] 05:00PM BLOOD CK-MB-33* MB Indx-10.3* cTropnT-0.86* [2195-8-6] 07:59PM BLOOD Calcium-7.1* Phos-4.4 Mg-2.0 [2195-8-6] 06:12PM BLOOD Type-ART Temp-36.4 pO2-90 pCO2-20* pH-7.22* calTCO2-9* Base XS--17 Intubat-NOT INTUBA DISCHARGE LABS: [2195-8-14] 06:40AM BLOOD WBC-13.6* RBC-3.28* Hgb-9.8* Hct-28.6* MCV-87 MCH-29.9 MCHC-34.4 RDW-14.6 Plt Ct-298 [2195-8-14] 06:40AM BLOOD Glucose-157* UreaN-67* Creat-2.8* Na-136 K-3.6 Cl-103 HCO3-26 AnGap-11 Studies: CXR [2195-8-6] FINDINGS: Single frontal portable view of the chest was obtained. The patient is rotated with respect to the film and is in lordotic position. The heart is of normal size. A large hiatal hernia is similar to prior. Lungs are clear without focal or diffuse abnormality. No pleural effusion or pneumothorax. No radiopaque foreign body. Mild degenerative changes are present in bilateral glenohumeral joints. IMPRESSION: No acute cardiopulmonary process. Echocardiogram [2195-8-7] Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with antero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve is not well seen. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is present but cannot be quantified (? Mild to moderate?). The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. EF 50%. Compared with the prior study (images reviewed) of [2193-11-19], regional LV systolic dysfunction is new. CXR ([8-7]): IMPRESSION: Since moderate cardiomegaly has worsened, it is possible that increased caliber to the upper mediastinum, particularly to the right, could be due to venous engorgement. There is no way that I can exclude a small mediastinal hematoma, but it would be reasonable to follow this with conventional radiographs rather than jump to a chest CT scan. There is no pneumothorax. Atelectasis, due in part to large hiatus hernia, is slightly more pronounced today than before. There is no pleural effusion. CXR ([8-8]): Right IJ catheter tip is at the cavoatrial junction or the upper right atrium. There is no pneumothorax. There is moderate cardiomegaly. There are low lung volumes. There is a large hiatal hernia. Bibasilar opacities are improved, more so on the right consistent with increasing atelectasis and small bilateral pleural effusions. There is moderate pulmonary edema. Brief Hospital Course: 86 year old male with TIDM, aortic insufficiency, CKD, and anemia presents with chest pain hyperglycemia. # Acute Coronoary Syndrome: NSTEMI with troponin trend 0.2 to peak at 0.8, CKMB 20-> 30. EKG with ischemic changes; T-wave flattening in III and AVF, T-wave inversions in V1-V3. RBBB and first degree block unchanged from prior. Echo showed mild regional left ventricular systolic dysfunction with antero-lateral hypokinesis, EF 50%. In the ED he was bolused with heparin and placed on heparin gtt. In the ICU was given atorvastatin, ASA 325mg, IV metoprolol, and nitro gtt. Cardiology was consulted, and the decision was made to forego catheterization in order to preserve kidney function. The patient's chest pain resolved and no further ST changes were noted on EKG. His heparin gtt was discontinued after he was discovered to have GI bleed. He had no further chest pain or arrythmias during the rest of the hospitalization. He was fluid overloaded and required Lasix IV diuresis before being transitioned to his home diuretic regimen. He was sent home on atorvastatin 80mg, ASA 81mg, carvedilol 25mg [Hospital1 ], plavix 75mg daily. He will follow up with Dr. [Last Name (STitle) 4104], his outpatient cardiologist. He was discharged with a weight of 83.5kg = 184lbs. #DKA: His course was complicated by DKA likely triggered by the acute MI. Initial anion gap 18, K 5.8, glucose 791, bicarb 6. He was resucitated with IV NS and ICU insulin protocol. Afterwards, his gap closed, was transitioned to SQ insulin with K repletion. Bicarb remained low and responded to sodium bicarb IVF replacement. Subsequently, he was followed by [Last Name (un) ] service to titrate his home insulin regimen. The final regimen is Lantus 8units qam and 7 units qpm. He will follow a sliding scale at breakfast, lunch, dinner, and bedtime. New sliding scale includes: <70 0units -> 71-200 1unit -> 201-250 2Units -> 251-300 3units -> 301-350 4units -> 351-400 5 units. # GI Bleed: Patient's crit dropped from 29.0 to 19.8 in 24 hours, given 5 units with appropriate response. Heparin gtt was stopped. Hospital day 4 crit again dropped, required 1 unit with appropriate response. A central line was placed and GI was consulted, EGD was initially deffered as the bleed was not considered life threatening and preference was to avoid cardiac stress of procedure outweighing stress of anemia. The patient has a history of upper GI bleed and had been off ASA before admission. He has a baseline anemia due to CKD with a crit in the low 30's. Plavix and ASA were held, then restarted, along with IV PPI. His Hct has since remained stable 28-29. EGD showed gastritis for which he was continued on omeprazole 40mg [Hospital1 ]. He will follow up with gastroenterology for follow-up of his GI bleeding and outpatient colonoscopy. # CHF exacerbation: He has a history of diastolic CHF and developed upper and lower extremity edema after his NSTEMI. He was also found to desaturate with repositioning requiring diuresis with IV Lasix boluses. On discharge he was restored to his home diuretic regimen. It is important that he has daily weights at the [Hospital 3058] rehab to ensure he remains euvolemic. He was discharged with a weight of 83.5kg = 184lbs. If he gains >3lbs daily, he should be seen urgently by his cardiologist Dr. [Last Name (STitle) 4104]. # HTN: In context of his NSTEMI, his home BP meds were initially held and he was started on a nitro gtt, lisinopril 20mg daily, nifedipine 10mg q8, metoprolol 25mg q6, and lasix. Weaned off nitro gtt in ICU. Thereafter he was hypertensive with SBPs to 190s requiring uptitration of his BP meds. On discharge he was uptitrated to felodipine 10mg daily, Lasix 40mg po daily, Hydralazine 25mg TID, Lisinopril 40mg [Hospital1 ] and carvedilol 25mg [Hospital1 ]. This should be further uptitrated by the physicians at [Hospital 3058] rehab as necessary. # Chronic renal failure - baseline cr around 2.8, admitted at 3.7 with bun in 80s in the context of dehydration from DKA. Likely acute prerenal on top of chronic disease from HTN and DM. Cr trended down to 2.8 in the ICU and remained at that level until discharge. # Hyponatremia: Likely multifactorial, including pseudohyponatremia in DKA- Na initially 119, corrected at 130 when accounting for hyperglycemia. Improved to baseline mid 130's with IVF. No further instances of hyponatremia. # Gait instabiltiy: He requires assistance with ambulation and transfers. He was seen by PT who recommended [Hospital 3058] rehabilitation. # Candidal esophagitis: This was visualized on EGD, no biopsy taken. He was started on a 3 week course of fluconazole 100mg which he should continue daily. # Aortic Insufficiency: stable. #Hypothyroidism: stable, he continued levothyroxine Transitional Issues: -Pt was discharged with volume status slightly positive, with a discharge weight of XX We did not want to achieve firm euvolemia because of his recent NSTEMI. Will continue him on his home diuretic regimen. However, it is important that he have daily weights taken at [Hospital 3058] rehab. If his weight increases by more than 3 lbs in one day or there is noticeable increase in his leg swelling, he should be seen by Dr. [Last Name (STitle) 4104] urgently. - [Hospital ] rehab for physical therapy need - Recent changes in BP meds were made and should be uptitrated as needed by his PCP. [Name Initial (NameIs) ] [Name11 (NameIs) ] will require Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[Name (NI) 581]. 1. Pravastatin 80 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Felodipine 10 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. HydrALAzine 25 mg PO BID 6. 70/30 28 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Levothyroxine Sodium 150 mcg PO DAILY 8. Lisinopril 40 mg PO BID 9. Vitamin D 1000 unit PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Felodipine 10 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. HydrALAzine 25 mg PO TID RX hydralazine 25 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:3 5. Glargine 8 Units Breakfast Glargine 7 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Vitamin D 1000 unit PO DAILY 9. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 10. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:3 11. Carvedilol 25 mg PO BID HOLD if SBP<100 or HR<60 RX carvedilol [Coreg] 25 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:3 12. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 13. Fluconazole 100 mg PO Q24H Duration: 25 Days RX fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth daily Disp #25 Tablet Refills:0 14. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:3 15. Senna 1 TAB PO BID:PRN Constipation RX sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #30 Capsule Refills:3 16. Ferrous Sulfate 325 mg PO DAILY 17. Lisinopril 40 mg PO BID Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: NSTEMI Gastritis Candidal esophagitis DKA GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you while you were admitted to [Hospital1 18]. You were admitted with chest pain and found to have a heart attack. For this you were treated with blood thinners and other medications. However this treatment was discontinued because you were found to have gastrointestinal bleeding. You required multiple blood transfusions to stabilize your blood levels. You tolerated this well and your blood levels have remained stable. Additionally, the gastroenterology doctors performed [Name5 (PTitle) ] upper endoscopy and found gastritis (inflammation of your stomach) and a slight yeast infection of your esophagus. For these issues you were treated with Omeprazole (a medication to reduce the acid levels in your stomach) and fluconazole (a medication to treat the yeast infection of your esophagus). Your blood sugars were also elevated and you required intravenous fluids and close management to bring your sugars back to normal limits. Your insulin regimen was readjusted by the diabetes specialists at [Last Name (un) ]. You will continue on this regimen at home. Specifically you will take a long acting insulin, Lantus, 7units in the morning and 8 units at bedtime. You will also check your sugars before every meal and take a shorter acting insulin if necessary. This is discussed in more detail in the medication section of the discharge. Lastly, we have adjusted your medication to keep your blood pressure under control. Please refer to the next page for these medication changes. It is very important that you weigh yourself every day to monitor for fluid overload. If you notice that your weight increases more than 3 pounds each day, please see your doctor immediately. Also if you notice worsening of swelling in your legs, difficulty breathing, or chest pain, please see your doctor immediately. Followup Instructions: Department: PODIATRY When: THURSDAY [2195-8-20] at 1:10 PM With: [First Name11 (Name Pattern1) 5445] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5446], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: [Hospital3 249] When: FRIDAY [2195-8-28] at 10:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2967], RNC [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr None Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2195-9-1] at 3:00 PM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2195-8-14]	[ "410.71", "585.3", "424.1", "250.83", "285.1", "V58.67", "793.19", "584.9", "112.84", "535.50", "428.0", "276.1", "403.90", "272.4", "428.33", "V58.66", "530.81", "349.82", "244.9", "V58.63", "578.9", "553.3", "250.13" ]	icd9cm	[ [ [] ] ]	[ "45.13", "38.97" ]	icd9pcs	[ [ [] ] ]	16214, 16284	8754, 13582	346, 352	16379, 16379	5037, 5906	18454, 19664	3468, 3489		14858, 16191		16305, 16358	14301, 14835			16530, 18431			5922, 8731							3529, 4392																					13603, 14275							296, 308										380, 2297									16394, 16506							2319, 3260	3276, 3452			4417, 5018
79,858	116,673	40433	Discharge summary	report	Admission Date: [2157-6-9] Discharge Date: [2157-6-23] Service: OBSTETRICS/GYNECOLOGY Allergies: Vicodin / Codeine Attending:[First Name3 (LF) 6743] Chief Complaint: Urinary retention, pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy, total abdominal hysterectomy, left salpingoophorectomy, excision of mass History of Present Illness: The patient is an 86 year old who was transfered from [Hospital ] hospital where she was admitted with urinary retention and a pelvic mass. The patient first noted bladder spasms and suprapubic pain about 6 weeks ago noticing that they were worse when standing. She presented to an OSH ED where she was found to have urinary retention. She had multiple subsequent ED visits at several hospitals in the [Location (un) 47] area where she had multiple catherizations. She had an indwelling catheter placed at one of those visits and has had it in for about 4 weeks. She had a CT scan done at [Hospital ] hospital on [2157-5-11] which described findings consistent with a multifibroid uterus. This report is not available here today. She had a cystography in the ED at [Hospital 47] hospital which according to her records was normal. She had a cystoscopy attempt which failed due to patient intolerance. She then had an MRI done on [2157-6-7] showing a 10 x 11.5 x 13cm midline heterogenous mass with fluid components and irregularly shaped peripheral nodules occupying much of the lower third of the pelvis. This mass was thought to possibly originate from the right ovary. The MRI also noted a normal- sized uterus with a 2mm endometrium but no fibroids. She had another cystoscopy today [2157-6-8] where multiple trigonal polyps were noted, biopsied and fulgurated. In addition. a bladder diverticulum was noted. Of note, the patient has been noted to have continued retention despite indwelling foley catheter. She reports suprapubic discomfort, discomfort from the catheter and bladder spasms at this time. Denies vaginal bleeding fever, chills, nausea, vomiting, loss of appetite. She does endorse some abdominal bloating but denies early satiety. Denies HA, CP, SOB, palpitations. Past Medical History: OB: G4P4 - uncomplicated vaginal deliveries Gyn: - Postmenopausal PMH: - HTN - HLD - CAD (4 vessel CABG) - Vertigo PSH: - L Oophorectomy for benign ovarian mass - Ventral hernia repair - 4 vessel CABG Social History: lives with husband, has two daughters, active at home, participates in social clubs. She is primary caregiver for her husband, who is blind. Daughters are closely involved and supportive. Phone [Telephone/Fax (1) 88614]. Quit tobacco > 50 years ago. No EtOH. Family History: NC Physical Exam: On admission: VS 99.4 132/56 76 18 95%RA Gen: Appears comfortable, NAD CV: RRR Lungs: CTAB Abd: Softly distended, dull, non-tympanic, (+) fluid wave. Nontender mobile mass palpated that occupies most of her pelvis extending 2cm below the umbilicus. Pelvic: No bleeding. The rest of the exam was deferred per patient request as she is not in a private room. Ext: No edema, NT GU: Foley [Last Name (un) ] in place draining [Location (un) 2452] urine c/w pyridium ingestion. On discharge: VS Tmax 99.8 Tc 97.6 HR 70 BP 164/74 RR 18 O2sat 98% RA NAD Some bruising on UEs b/l. PICC site c/d/i Abdomen soft, minimally tender, no rebound or guarding, + BS Incision with steri-strips, clean/dry/intact LE NT/minimal edema Pertinent Results: Heme: [2157-6-9] 06:42PM BLOOD WBC-5.8 RBC-3.73* Hgb-11.7* Hct-35.8* MCV-96 MCH-31.4 MCHC-32.7 RDW-14.1 Plt Ct-214 [2157-6-11] 07:03AM BLOOD WBC-4.4 RBC-3.41* Hgb-10.8* Hct-32.8* MCV-97 MCH-31.6 MCHC-32.8 RDW-13.8 Plt Ct-162 [2157-6-12] 06:53AM BLOOD WBC-3.7* RBC-3.32* Hgb-10.8* Hct-32.4* MCV-98 MCH-32.4* MCHC-33.2 RDW-14.3 Plt Ct-166 [2157-6-13] 06:50AM BLOOD WBC-4.9 RBC-3.33* Hgb-11.0* Hct-32.6* MCV-98 MCH-33.1* MCHC-33.7 RDW-14.0 Plt Ct-168 [2157-6-14] 08:29PM BLOOD WBC-12.0# RBC-3.59 Hgb-11.0* Hct-33.0* MCV-92 MCH-30.8 MCHC-33.5 RDW-15.7* Plt Ct-150 [2157-6-15] 04:13AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.3* Hct-30.3* MCV-93 MCH-31.5 MCHC-34.0 RDW-16.0* Plt Ct-164 [2157-6-15] 05:34PM BLOOD WBC-10.4 RBC-3.15* Hgb-9.7* Hct-29.0* MCV-92 MCH-31.0 MCHC-33.6 RDW-16.1* Plt Ct-137* [2157-6-16] 09:24AM BLOOD WBC-8.8 RBC-3.49# Hgb-10.8# Hct-30.9# MCV-89 MCH-30.9 MCHC-34.9 RDW-17.6 Plt Ct-130* [2157-6-16] 11:51PM BLOOD WBC-8.8 RBC-3.43* Hgb-10.4* Hct-30.4* MCV-89 MCH-30.2 MCHC-34.1 RDW-17.6* Plt Ct-149* [2157-6-17] 09:21PM BLOOD WBC-7.7 RBC-3.20* Hgb-9.8* Hct-28.4* MCV-89 MCH-30.7 MCHC-34.6 RDW-17.4* Plt Ct-136* [2157-6-18] 05:19PM BLOOD WBC-6.2 RBC-3.26* Hgb-10.2* Hct-29.9* MCV-92 MCH-31.3 MCHC-34.1 RDW-17.1* Plt Ct-183 [2157-6-21] 05:37AM BLOOD WBC-6.1 RBC-3.24* Hgb-9.8* Hct-29.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-16.3* Plt Ct-190 [2157-6-23] 05:43AM BLOOD WBC-4.6 RBC-3.23* Hgb-9.7* Hct-29.0* MCV-90 MCH-30.0 MCHC-33.5 RDW-16.0* Plt Ct-190 Coags: [2157-6-9] 06:42PM BLOOD PT-13.3 PTT-24.1 INR(PT)-1.1 [2157-6-14] 07:00AM BLOOD PT-12.7 PTT-33.1 INR(PT)-1.1 [2157-6-15] 01:28AM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2* [2157-6-15] 07:30PM BLOOD PT-13.3 PTT-29.7 INR(PT)-1.1 [2157-6-16] 11:51PM BLOOD PT-13.8* PTT-24.5 INR(PT)-1.2* [2157-6-18] 05:19PM BLOOD PT-13.3 PTT-24.0 INR(PT)-1.1 Chemistry: [2157-6-9] 06:42PM BLOOD Glucose-131* UreaN-19 Creat-1.2* Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 [2157-6-13] 06:50AM BLOOD Glucose-96 UreaN-17 Creat-1.1 Na-143 K-4.3 Cl-112* HCO3-21* AnGap-14 [2157-6-15] 04:13AM BLOOD Glucose-170* UreaN-16 Creat-1.4* Na-137 K-4.8 Cl-108 HCO3-18* AnGap-16 [2157-6-16] 02:31AM BLOOD Glucose-133* UreaN-25* Creat-1.5* Na-140 K-4.5 Cl-109* HCO3-23 AnGap-13 [2157-6-16] 11:51PM BLOOD Glucose-132* UreaN-23* Creat-1.3* Na-143 K-4.6 Cl-111* HCO3-20* AnGap-17 [2157-6-17] 03:44PM BLOOD Glucose-103* UreaN-26* Creat-0.9 Na-141 K-4.2 Cl-109* HCO3-26 AnGap-10 [2157-6-20] 05:24AM BLOOD Glucose-122* UreaN-22* Creat-0.7 Na-143 K-3.4 Cl-105 HCO3-31 AnGap-10 [2157-6-22] 04:08AM BLOOD Glucose-111* UreaN-24* Creat-0.8 Na-140 K-4.2 Cl-105 HCO3-28 AnGap-11 [2157-6-23] 05:43AM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-138 K-4.0 Cl-104 HCO3-30 AnGap-8 [2157-6-11] 07:03AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 [2157-6-13] 06:50AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1 [2157-6-14] 08:29PM BLOOD Calcium-8.6 Phos-4.2 Mg-1.5* [2157-6-16] 02:31AM BLOOD Calcium-7.5* Phos-3.4# Mg-2.1 [2157-6-18] 04:52AM BLOOD Calcium-8.6 Phos-2.0* Mg-2.0 [2157-6-20] 05:24AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0 [2157-6-23] 05:43AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 Urine: [2157-6-9] 07:20PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-6-16] 01:17PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-6-22] 01:31PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Cultures: [2157-6-9] 6:42 pm BLOOD CULTURE #1. FINAL REPORT [2157-6-15] Blood Culture, Routine (Final [2157-6-15]): NO GROWTH. [2157-6-9] 7:20 pm URINE Site: CATHETER FINAL REPORT [2157-6-10] URINE CULTURE (Final [2157-6-10]): NO GROWTH. [2157-6-14] 8:29 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2157-6-17] MRSA SCREEN (Final [2157-6-17]): No MRSA isolated. [2157-6-15] 10:14 am SPUTUM Source: Endotracheal. FINAL REPORT [2157-6-17] GRAM STAIN (Final [2157-6-15]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2157-6-17]): MODERATE GROWTH Commensal Respiratory Flora. [2157-6-16] 1:17 pm URINE Source: Catheter. FINAL REPORT [2157-6-17] URINE CULTURE (Final [2157-6-17]): NO GROWTH. [2157-6-16] 1:17 pm URINE Source: Catheter. FINAL REPORT [2157-6-17] Legionella Urinary Antigen (Final [2157-6-17]): 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. Imaging: CXR [6-13]: PA AND LATERAL CHEST RADIOGRAPHS: Anterior mediastinal wires are intact. The cardiac and mediastinal contours are normal. The aorta is tortuous with calcification at the knob. The lungs are clear. No pneumothorax or pleural effusion is noted. No evidence of metastatic disease is seen. IMPRESSION: No acute cardiopulmonary process. CXR [6-15]: CHEST RADIOGRAPH PORTABLE AP VIEW: Endotracheal tube tip terminates approximately 6.8 cm above the carina and advancing 3 cm is recommended. There are low lung volumes with no pneumothorax. The left costophrenic angle is mild blunted, likely positional. Cardiomediastinal and hilar silhouettes are stable. IMPRESSION: No acute cardiopulmonary abnormality. PICC placement [6-17]: IMPRESSION: Uncomplicated ultrasound and fluoroscopically-guided 5 French double-lumen PICC line placement via the left basilic venous approach. Final internal length is 49 cm, with the tip positioned in SVC. The line is ready to use. CXR [6-20]: PA and lateral upright chest radiographs were reviewed in comparison to [2157-6-15] and [2157-6-13]. Heart size is normal, unchanged. The left central venous line tip is at the junction of brachiocephalic vein and SVC. There is interval increase in bilateral pleural effusions, moderate. There is no pneumothorax. The upper lungs are essentially clear. Bibasilar atelectasis has developed in the interim. EKG: [6-10]: Sinus bradycardia. P-R interval prolongation. Left axis deviation. Modest lateral T wave changes which are non-specific. No previous tracing available for comparison. [6-13]: Sinus bradycardia with A-V conduction delay. Left anterior fascicular block. Modest low amplitude lateral lead T wave changes are non-specific. Since the previous tracing of [2157-6-10] probably no significant change. Pathology: Surgical specimen [6-14]: 1. Frozen section uterine tumor: Carcinosarcoma, see synoptic report. 2. Uterus: Carcinosarcoma. 3. Vaginal margin/cervix: Carcinosarcoma, see note. Note: The location of the tumor (vaginal or parametrial) is unclear due to tissue distortion. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 7108] reviewed and concurs. 4. Left tube and ovary: No malignancy identified. 5. Omentum biopsy: No malignancy identified. Endometrium: Hysterectomy, with or without Other Organs or Tissues Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [2155] MACROSCOPIC Specimen Type: Hysterectomy, left salpingo-oophorectomy, omentectomy, vaginal margin/cervix. Tumor Size: Greatest dimension: 5 cm (aggregate measurement from "uterine tumor" specimen). MICROSCOPIC Histologic Type: Carcinosarcoma, see comment. Histologic Grade: See comment. Washings/cytology: Not applicable. EXTENT OF INVASION Primary Tumor: pT3b (IIIA): Vaginal involvement (direct extension or metastasis) or parametrial involvement. Myometrial Invasion: Invasion present: 25%. Depth of invasion: 2 mm. Myometrial thickness: 8 mm. Cervix: Negative. Ovaries Right: Not applicable. Left: Negative. Fallopian tube Right: Not applicable. Left: Negative. Serosa: Negative. Omentum: Negative. Regional Lymph Nodes: pNX: Cannot be assessed. Distant metastasis: pMX: Cannot be assessed. Lymph-Vascular invasion: Absent. Additional findings: Adenomyosis. Comments: Histologic sections from the specimen labeled "uterine tumor" show a carcinosarcoma. The carcinomatous portion shows an intermediate grade (grade 2) adenocarcinoma with an endometrioid histology. The sarcomatous component is low grade with no heterologous elements seen. The vast majority of tumor burden seen in this case is in the "uterine tumor" specimen. There is a 2 mm focus of tumor present in the myometrium. Tumor is also seen at the vaginal margin/cervix. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 7108] has reviewed slides B, F, and U. Brief Hospital Course: Mrs [Known lastname ] was admitted to the GYN/ONC service for evaluation. She was found to not be in acute renal failure. The catheter was continued as she still was having urinary retention. She was seen by Dr. [Last Name (STitle) 2028] who agreed that surgical evaluation was necessary for evaluation of the tumor, however, not necessary in an urgent manner given that the patient was otherwise so stable. She was able to be added on to the OR for [6-14]. In the meantime, the pyridium was stopped. The urine culture from the outside hospital was negative so the Bactrim was stopped. An initial urine culture at [Hospital1 ] was also negative. The patient was started on oxybutinin 5mg [Hospital1 ] for bladder spasms which were intermittent. The tamusolin was discontinued. Her catheter had to be replaced on [6-11]. She was seen by medicine pre-operatively and they recommended changing atenolol to metoprolol 12.5mg [Hospital1 ]. They felt that although the patient had a history of CABG she did not need to have an echo prior to surgery given her excellent functional status at baseline. The patient went to the OR on [6-14]. The full operative note is available in the medical record, and was notable for finding that the pelvic mass was in fact an enlarged tumor-filled uterus. The patient had a cystoscopy intraop, demonstrating normal bladder mucosa and bilateral ureteral jets seen; proctoscopy to 25 cm also revealed normal findings. She received 3 units PRBCs intraop. An OGT had been placed. The patient was taken intubated to the ICU post-op. She was initially on pressors and these were able to be weaned. Her heparin was held given high risk of postoperative bleeding. She had some abnormal sputum and was started on vancomycin and cefipime. The culture returned with 3+ GPCs, and this was switched to vancomycin, zosyn, and levofloxacin. Her Hct post-op drifted down to 23 and she was transfused 2 units PRBCs, with return to 30. A PICC was placed by IR for access. She was started on TPN. Prior to her call-out to the floor, the vanc and zosyn were stopped and the levofloxacin was continued. On the floor, her diet was very slowly advanced. She was taking regular by POD #7. Her Hct was carefully watched, and her heparin was eventually restarted by [6-19]. She was continued on IV dilaudid and changed to PO meds with good relief. She did have a cough and was started on robitussin and tessalon pearls. A CXR was overall stable with no evidence of consolidation. Her BPs began to creep up and she was restarted on the metoprolol and norvasc on [6-20]. Norvasc was increased to 10mg daily on the day of discharge. The foley was removed on [6-21]. The patient passed her trial of void but was noted to be incontinent. She was able to notice when her bladder was full but felt that she was not mobile enough to get to the bathroom when having an urge. A bedside commode was placed. The incontinence improved by discharge but was still present at night. A UA was negative and a culture was pending on discharge. The TPN was stopped on [6-22]. The PICC line was pulled prior to discharge. She was discharged to rehab on POD#9. Medications on Admission: - Atenolol - Norvasc - Zocor - Flomax - Bactrim Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 days. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [Hospital1 ] (2 times a day). 5. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for cough. 7. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for BP <100/60 or HR <60. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 15644] Long Term Care - [Location (un) 47] Discharge Diagnosis: Pelvic mass, uterine cancer Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. For your bladder issues, please try to go to the bathroom frquently and regularly. This makes sure your bladder stays empty and helps you become continent of urine again. Followup Instructions: You will need to follow-up with Dr. [Last Name (STitle) 2028] in the next several weeks. Please call his office for an appointment, [Telephone/Fax (1) 5777] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753] Completed by:[2157-6-23]	[ "414.00", "403.90", "276.2", "568.0", "180.9", "041.89", "V45.81", "272.4", "427.89", "285.1", "458.9", "198.82", "788.20", "585.9" ]	icd9cm	[ [ [] ] ]	[ "57.32", "54.4", "54.59", "48.23", "38.97", "65.49", "68.49", "99.15" ]	icd9pcs	[ [ [] ] ]	17331, 17419	12920, 16118	268, 366	17491, 17491	3505, 12897	18649, 18967	2738, 2742		16216, 17308		17440, 17470	16144, 16193			17674, 18208							18223, 18626			2757, 2757																			3256, 3486									198, 230										394, 2214								2771, 3242	17506, 17650							2236, 2441	2457, 2722
27,711	135,403	52035	Discharge summary	report	Admission Date: [2187-10-7] Discharge Date: [2187-10-15] Date of Birth: [2115-9-15] Sex: M Service: MEDICINE Allergies: Percocet / Levofloxacin Attending:[First Name3 (LF) 338] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Arterial line CVL Tunnelled HD cath EGD CVVH History of Present Illness: patient intubated and sedated. History taken from family and from ED notes. . 72 yo M with PMH of CRI (baseline Cr 3), AVR '[74] with 3 vessel CABG, CVA with residual left eye vision deficit, s/p CEA [10-16], HSP in '[74] who presents with SOB. Per ED notes, he was complaining of midline abdominal pain along with DOE and SSCP. Lying flat made his CP worse. He denied cough, fevers. He did report decreased energy and appetitite, and also had some abdominal cramping. His wife says he did not have BRBPR or tarry stools (he does have dark stools but he take iron supplements). No new headaches, changes in vision. . In the ED, his initial vital signs were T 96.3, BP 93/45, HR 60, RR 24, O2sat 93% RA. 2 units of PRBC were ordered. He was initially given [Year (2 digits) ] 325mg and lasix 20mg IV. He was also given levofloxacin but this infusion was stopped given hives and itching. He was given benadryl. His BP dropped to 65/80. He was on non-invasive ventilation and it was decided that he needed to be intubated instead. He was given etomidate and succinylcholine. He was then given morphine and versed for sedation. He was then given D50, insulin, calcium gluconate for hyperkalemia. His BP required pressor support and he was started on dopamine gtt. He was taken for a CT abdomen without contrast to assess for AAA. A RIJ was placed. He was given flagyl 500mg IV. Past Medical History: -CVA s/p left visual changes -CABG with 3 vessel disease: in [2174]. (LIMA - LAD, SVG to ramus intermedius, SVG to large posterolateral branch of RCA) -AVR '[74] on coumadin: History of rhemuatic heart disease/aortic stenosis; with St. Jude's valve. -HSP in '[74]; after CABG unclear cause -chronic kidney disease stage IV from focal sclerosis -XRT for skin cancer right ear -gout -hyperlipidemia -History of colonic polyps, status post polypectomy. Repeat colonoscopy [9-13] showed 2 small polyps that were not removed as coumadin had not been held. Recommended to return in 3 years for polypectomy. Social History: lives with wife. has 4 sons. Quit tobacco in [2174], rare alcohol use. Family History: Father - cancer, unknown Mother - MI Physical Exam: vitals: T 96.3, BP 101/34, HR 77, RR 15, O2sat 100% Vent settings: AC 550 x 15 FIO2 1, PEEP 10 General: intubated and sedated HEENT: pin point pupils (on versed/fentanyl), MMM, anicteric sclera, RIJ in place with oozing at site and soft hematoma underneath CV: RRR, harsh systolic murmur heard throughout; no diastolic murmur appreciated Lungs: rhonchi bilaterally Abdomen: +BS, soft, NTND Ext: no edema, DP pulses 1+ symmetric Neuro: intubated and sedated. Moving all extremities freely . Pertinent Results: [2187-10-15] 03:13AM BLOOD WBC-10.0 RBC-2.73* Hgb-8.3* Hct-25.8* MCV-94 MCH-30.4 MCHC-32.2 RDW-16.9* Plt Ct-246 BLOOD Glucose-86 UreaN-48* Creat-2.6* Na-139 K-4.4 Cl-108 HCO3-18* AnGap-17 Brief Hospital Course: 72 yo M with PMH of CAD s/p CABG 3vd, CRI, AVR, CVA who presents with acute anemia, acute on chronic renal insuffiency, and respiratory distress in the setting of elevated INR. . # Respiratory distress: Patient was intubated on arrival to the MICU for respiratory distress in the ED thought to be related to fluid overload intially but cardiogenic causes could not be ruled out given his history of CAD s/p bypass and AV replacement and MS. [Name13 (STitle) ] also seemed to have a LLL infiltrate which could represent pneumonia. He was treated for azithromycin and ceftriaxone for a presumed pneumonia. He initally did well with diuresing and was extubated. He did not tolerate this and required reintubation within the 24-48hr after extubation. He then had some vomiting and devloped RLL consolidation which could be aspiration vs unilateral CHF in the setting of cardiac strain with elevated troponins (see below). He was started on CVVH to help remove fluid. He was continued on inhalers for this COPD treatment. . # acute on chronic renal failure: Cr baseline is 3. Cr peaked at 6.1 during admission and came down on CVVH to the 2.4 range. Volume status was improving on CVVH with renal consult following. He was still making urine as well. . # anemia: Had an elevated INR of 6.6 on presentation. HCT the month prior to admission was around 30 and he presented with HCT of 20.6. Given the rapid nature of the drop, he most likely had a bleed although no obvious source. It was thought that he had oozing from the colon and maybe the lung as well. He was given PRBCs. An EGD was normal with no signs of bleeding. He developed a troponin leak in the setting of his anemia. He was continued on heparin gtt given his mechanical aortic valve (was on coumadin prior to admission). . # hypotension: Resolved; weaned off pressors in last 24 hours. Thought due to volume status, as with CVVH his pressure rebounded. He then began to have hypotension with no obvious cause. ? septic shock with elevated WBC but no fever. Started empiric antibiotics. . # CAD s/p CABG: mild NSTEMI in setting of tachycardia and possible hypovolemia and anemia. Patient currently on heparin gtt for mechanical valve - cont [Last Name (LF) 30474], [First Name3 (LF) ], lipitor 80mg given recent NSTEMI - no signs of ischemia on EKG . # AVR: on coumadin. - Restarted hep gtt while in ICU given mechanical valve - coumadin once stabilized . # gout: restarted allopurinol at renal dosing . # FEN: Tube feeds # Access: RIJ placed on [10-7] in ED; R aline placed on [10-7]; 2PIV # Communication: wife [Name (NI) ], [Telephone/Fax (1) 107707] home and [Telephone/Fax (1) 107708] cell. sons: [Name (NI) ] [Name (NI) 8260] [Telephone/Fax (1) 107709]; [First Name8 (NamePattern2) ] [Known lastname 8260] [Telephone/Fax (1) 107710]; [First Name8 (NamePattern2) ] [Known lastname 8260] [Telephone/Fax (1) 107711]; [First Name8 (NamePattern2) ] [Known lastname 8260] [Telephone/Fax (1) 107712] # code: full On [2187-10-15] at 6:30PM, Patient passed away. During family meeting at 4PM earlier that day, family had decided to make patient CMO given that he would not have wished to become dialysis dependent and vent dependent. He was extubated and made comfortable and passed shortly thereafter. Family at bedside. . Medications on Admission: per family allopurinol 100 mg daily calcitriol 0.5 mcg daily folate 1mg daily furosemide 40 mg daily atorvastatin 80 mg daily lisinopril 5mg daily metoprolol 100 mg twice a day amlodipine 5mg daily Protonix 40 mg b.i.d. Tricor 145 mg daily warfarin 2.5 mg daily Zetia 10mg daily aspirin 81 mg daily iron daily fish oil twice a day vitamin C 1000mg daily Aranesp 60 mcg every week Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: n/a	[ "276.2", "285.21", "272.4", "274.9", "496", "276.8", "584.9", "410.71", "518.81", "438.7", "486", "458.9", "585.4", "785.51", "414.01", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.93", "33.22", "38.95", "45.13", "38.91", "96.72", "39.95", "96.04" ]	icd9pcs	[ [ [] ] ]	7119, 7128	3288, 6660	292, 338	7179, 7185	3072, 3265		2507, 2546		7091, 7096		7149, 7158	6686, 7068													2561, 3053																												245, 254										366, 1758																1780, 2399	2415, 2491
32,018	151,540	6834	Discharge summary	report	Admission Date: [2190-3-8] Discharge Date: [2190-3-30] Date of Birth: [2107-1-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Respiratory failure, pneumonia Major Surgical or Invasive Procedure: Intubation Tracheostomy placement PEG tube placement Central Venous Line Placement & d/c Arterial Line Placement & d/c Midline placement History of Present Illness: This is an 83 year old female with a history of HTN, back pain, and aortic insufficiency, presenting with SOB starting the night prior to admission. She has had cold symptoms with cough and apparent chills for about one week; her daughter describes onset of symptoms last Tuesday which improved Thursday/Friday. Yesterday, she noted increased shortness of breath with productive cough. Daughter denies any fever but endorses chills. The patient was seen at [Hospital ] Clinic earlier today and noted to be in respiratory distress; she had new atrial fibrillation on EKG. EMS was called to transport patient to the ED; she received 325 mg ASA en route. Patient denied chest pain and orthopnea in the emergency room. Initial ED vitals T 98, HR 100, BP 134/60, 98% on 100% NRB. She received 2 L NS and blood pressures remained 100-120 systolic throughout her ED course. She received 1 SL NTG for chest pain. Blood cultures were sent X 2 and she received levofloxacin 750 mg IV X 1 and ceftriaxone 1 g X 1. She was intubated with etomidate & succinylcholine; she was then sedated on propofol. FS was 256 which was treated with 6 U IV insulin. Oxygen saturation on FiO2 100%, 5 PEEP down to 88%. On arrival to the floor, the patient's initial blood pressures were 80s/60s. A line was placed in right radial artery. Past Medical History: cardiomyopathy, left ventricular ejection fraction of 35%-40% moderate to severe mitral regurgitation moderate to severe aortic regurgitation hypertension high cholesterol hx CVA >25 years ago (no residual deficits) h/o zoster back pain aortic insufficiency chronic anemia normal pressure hydrocephalus Social History: Lives with family. Otherwise not obtainable due to patient being sedated. Family History: Sister with CVA before age 60 Physical Exam: VS: T 97.2 HR 75 BP 105/50 RR 21 O2 95% on AC FiO2 100%, RR 14, Tv 400, PEEP 8 GEN: intubated, sedated, elderly female HEENT: MM slightly dry, PERRL LUNGS: decreased BS on right, crackles bilaterally CV: RRR, 2/6 systolic murmur at LUSB ABD: normoactive bowel sounds, nontender to palpation EXTREM: no peripheral edema, DP pulses 2+ Pertinent Results: ADMISSION LABS: =============== COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2190-3-30] 05:18AM 8.3 2.83 8.9* 26.3* 93 31.4 33.8 15.6* 196 . [2190-3-21] 02:04AM 16.2 3.24 10.0* 28.6* 88 30.7 34.9 15.6* 228 . [2190-3-9] 06:09AM 13.1 3.19 9.8* 29.9* 94 30.8 32.9 13.0 234 [2190-3-8] 11:25AM 7.9 3.55 10.3* 33.6* 95 29.1 30.8* 12.9 183 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [2190-3-30] 05:18AM 125* 19 0.6 139 4.0 106 26 . [2190-3-21] 02:04AM 100 39* 1.0 144 3.5 111* 26 [2190-3-9] 06:09AM 80 36* 0.8 137 4.0 104 20* [2190-3-8] 11:25AM 263* 34* 1.1 131* 5.0 92* 20* . MICROBIOLOGY: ============= Blood cultures on admission ([2190-3-8]) were negative Blood cultured during hospitalization were negative Urine cultures negative Catheter tip culture negative C.diff x 3 negative Urine legionella negative . STUDIES: ========= Admission CXR [2190-3-8] Severe cardiomegaly and possibly generalized aortic ectasia have worsened since [2188-3-29]. Moderate right pleural effusion is present, and opacification in the right upper lobe is probably pneumonia. There is some question of right hilar adenopathy. Left lung is grossly clear, and there is no left pleural effusion. The course of the nasogastric tube indicates that the esophagus follows the meandering aorta, but the tube needs to be advanced at least 10 cm to move all the side ports beyond the GE junction. ET tube is in standard placement. Moderate generalized distention of the gut is seen in the upper abdomen, no pneumoperitoneum. . Discharge CXR [2190-3-30] In comparison with the study of [3-28], there is again substantial enlargement of the cardiac silhouette with relatively mild elevation of pulmonary venous pressure, an appearance that raises the possibility of cardiomyopathy or pericardial effusion. The left hemidiaphragm and costophrenic angle are more sharply seen; indistinctness of the right base is again noted. . ECG [2190-3-8] Sinus rhythm. Atrial premature beats including a four beat run of probable atrial tachycardia. Left ventricular hypertrophy. Intraventricular conduction delay with left axis deviation, probably left anterior fascicular block. Delayed R wave progression could be due to left ventricular hypertrophy and/or intraventricular conduction delay or possible prior septal myocardial infarction, although baseline artifact makes assessment difficult. Non-specific ST-T wave abnormalities. Clinical correlation is suggested. Since the previous tracing of [2188-4-20] there may be no significant change but baseline artifact on both tracings makes comparison difficult. . CTA [2190-3-19] 1. Stable interval appearance of a large retroperitoneal hematoma as above. No evidence for active contrast extravasation or thoracic-abdominal aortic aneurysmal rupture or leak. Findings likely represent a spontaneous retroperitoneal hematoma. 2. Endotracheal tube malpositioned within the right mainstem bronchus. The tube requires urgent repositioning. 3. Moderate bilateral pleural effusions and basilar atelectasis. Nodular airspace opacification in the right upper lobe reflecting aspiration or evolving infectious process. 4. Bilateral hyperdense renal cysts. Brief Hospital Course: ASSESSEMENT/PLAN: 83 y/o F with known aortic insufficiency, HTN admitted with multifocal pneumonia and respiratory failure, retroperitoneal bleed, persistent respiratory failure, s/p trach and PEG. At time of discharge, is off antibiotics for multifocal pneumonia and being weaned off the ventilator. Her hematocrit has remained stable. . # Respiratory failure: secondary to multifocal community acquired pneumonia seen on CXR, intubated for respiratory distress and maintained on mechanical ventilation. She was treated with 8 day course of levofloxacin & ceftriaxone. No organism grew out of any blood, urine or sputum cultures obtained. Pt was extubated on [3-14] however reintubated several hours later due to ongoing respiratory distress and stridor despite nebulizer treatments and racemic epinephrine. s/p tracheostomy on [3-25] and a PEG tube was also placed at the same time for nutrition. She was diuresed daily to ensure success of weaning of ventilator. Of note, vancomycin & zosyn had been started empirically on [2190-3-19] in the setting of hypotension, however were d/c'ed as cultures were negative and evidence of blood loss as cause for hypotension was identified. Currently pt on PS & PEEP, attempting to wean off however have been unable to do spontaneous breathing trial so far. Pt is [Name (NI) 25853], PT evaluation obtained. . # Systolic CHF/CMP: EF 40% on echocardiogram done 06/[2188]. Pt was diuresed to decrease preload as well as improve respiratory effort and encourge weaning off the ventilator. Diamox was given to assist with diuresis given metabolic acidosis. Pt was started on Captopril during admission and continued for afterload reduction. . # Afib with RVR: Had episode of atrial fibrillation with RVR. Pt was started on diltiazem 30mg po QID, currently increased to 60mg po QID, also pt on digoxin daily. The patient will intermittently revert to atrial fibrillation, however is mostly in sinus rhythm. Will need digoxin levels at regular intervals, last digoxin level 1.0 on [2190-3-26]. . # Hypertension: Initially BP medications had been held as pt was hypotensive, however started captopril to assist with BP control as well as for CHF. We have continued diuresis with furosemide, however pt on HCTZ at home. Also pt on diltiazem currently for rate control. . # Retroperitoneal bleed: Pt became acutely hemodynamically unstable 10days after admission and was noted to have a 12 point hematocrit drop over the prior 24 hours. Imaging showed retroperitoneal bleed as well as a 5cm unruptured AAA. It was thought to be spontaneous in the setting of therapeutic subcutaneous heparin levels. Vascular surgery was involved, however felt that there were no surgical interventions. Pt received 5U PRBC's. Hematocrits are currently being monitored daily, and have remained stable. She has been on pneumoboots for DVT prophylaxis. subcutaneous heparin levels. . # Elevated blood sugars: Pt has no known diabetes, however likely related to tube feedings. Blood glucose were monitored on insulin sliding scale. . CODE STATUS: FULL Medications on Admission: Haloperidol - 0.5 mg Tablet - 1 Tablet(s) by mouth hs HYDROCHLOROTHIAZIDE - 25MG Tablet - EVERY DAY Metoprolol Succinate [Toprol XL] - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily Nifedipine - 90 mg by mouth once a day Potassium Chloride 10 mEq by mouth once a day Acetaminophen - 1000 mg Tablet by mouth tid as needed for pain Cyanocobalamin [Vitamin B-12] 500 mcg Tablet by mouth once a day Multivitamin by mouth once a day Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day): Please hold for loose stools. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed: Fever, pain. 5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [6-6] Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Please hold for SBP < 100 or HR < 55. 10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Please hold for SBP < 100. 11. Pantoprazole 40 mg Susp,Delayed Release for Recon Sig: Forty (40) mg PO once a day. 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 13. Haloperidol 1 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as needed for Agitation. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Multifocal pneumonia Respiratory failure Spontaneous retroperitoneal bleed Hypertension Discharge Condition: Stable, on ventilator with pressure support Discharge Instructions: You were admitted with multifocal pneumonia, which was severe enough to require intubation. A trach tube has been placed for assistance with breathing and mechanical ventilation as well as PEG to assist with nutrition. You also developed a fast HR during admission which is currently controlled. . We have made significant changes to your medications. We have started Captopril and diltiazem for BP pressure as well as to slow down your heart rate. Please discuss with the doctors at the facility to which your going about medications that you will be taking upon discharge from there. Followup Instructions: Follow up with your PCP [Name Initial (PRE) 176] 2 weeks after discharge from the rehab facility [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "568.81", "486", "799.02", "787.91", "285.1", "427.89", "790.29", "428.23", "V12.54", "294.8", "V70.7", "785.59", "276.50", "331.5", "584.5", "724.5", "518.81", "441.4", "396.3", "272.0", "401.9", "425.4", "276.2", "428.0", "427.31", "276.1" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "96.05", "38.91", "93.90", "43.11", "33.21", "96.04", "31.1", "31.42" ]	icd9pcs	[ [ [] ] ]	10850, 10921	6000, 9089	345, 483	11053, 11099	2665, 2665	11733, 11963	2265, 2297		9588, 10827		10942, 11032	9115, 9565			11123, 11710										2312, 2646																												275, 307										511, 1830					2681, 5977											1852, 2157	2173, 2249
20,388	166,203	6472	Discharge summary	report	Admission Date: [2110-5-30] Discharge Date: [2110-6-9] Date of Birth: [2039-1-15] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is a 71 year-old gentleman with a known history of coronary artery disease who underwent a PTCA and stent to his right coronary artery in [2109-5-7]. The patient developed angina while working in the garden on [5-29] which resolved with nitroglycerine. The patient was taken to an outside hospital where he was chest pain free and was transferred to [Hospital1 190] for cardiac catheterization. PAST MEDICAL HISTORY: 1) Coronary artery disease. 2) Status post PTCA and stent to his right coronary artery in 1/[2109]. 3) Hypertension. 4) Nephrolithiasis. 5) Mild dementia. 6) Benign prostatic hypertrophy. 7) Status post transurethral resection of prostate. 8) Status post bilateral cataract surgery. 9) Hypercholesterolemia. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1) Atenolol 100 mg p.o. q day, 2) Quinapril 20 mg p.o. b.i.d. 3) Lipitor 10 mg p.o. q day. 4) Enteric coated aspirin 325 mg p.o. q day. 5) Aricept 10 mg p.o. q day. 6) Multivitamin. HO[Last Name (STitle) ] COURSE: Patient was taken to the cardiac catheterization laboratory on [2110-5-30]. This showed ejection fraction of 50 percent, left ventricular and diastolic pressure of 14, 10 percent left main coronary artery lesion, 38 percent proximal LAD lesion, 30 percent first diagonal lesion, 80 percent OM1 lesion and 80 percent distal left circumflex lesion. Due to the diffuse nature of the coronaries the patient was referred for coronary artery bypass grafting. Patient remained in the hospital without any chest pain and was taken to the operating room on [6-2] for coronary artery bypass graft times four, LIMA to LAD, SVG to distal RCA, SVG to OM and SVG to diagonal. Patient was transported to the Intensive Care Unit on Neo-Synephrine infusion. Upon arrival into the Intensive Care Unit it was noted that patient had ST segment elevation in the inferior lead. Patient was hemodynamically stable at the time. It was arranged for the patient to go to the cardiac catheterization laboratory to assess the patency of the bypass graft. In the cardiac catheterization laboratory it was noted that the saphenous vein graft to the diagonal had a mid segment torsion or kink which represented an 80 percent stenosis. These findings were relayed to Dr. [Last Name (Prefixes) ] and it was elected to take the patient back to the operating room to reposition the graft. Patient returned from the operating room in stable condition with good hemodynamic parameters and without significant drainage from his chest tubes. On postoperative day one early the patient was weaned and extubated from mechanical ventilation with good gas exchange. The patient's femoral sheath was removed without complication and patient was cleared for discharge to the floor. However, it was decided that patient did not have adequate peripheral intravenous access and patient's right internal jugular Cordis was changed over a wire to a triple lumen catheter without incident. Patient was started on low dose Lopressor and the night of postoperative day number one patient had episode of rapid atrial fibrillation. The atrial fibrillation resolved spontaneously. Patient's Lopressor dose was increased. Patient's pacing wires were removed without difficulty. Patient continued to have a moderate amount of drainage from his chest tube. Patient began ambulating with physical therapy. On postoperative day number three patient received red blood cell transfusions due to patient being mildly hypotensive and lethargic. Patient again had another episode of rapid atrial fibrillation. Patient was started on oral amiodarone. Patient's beta blocker was decreased. By postoperative day number six patient was cleared by physical therapy. Patient's chest tubes had been removed without incident and by postoperative day number seven patient was discharged to home in stable condition. CONDITION ON DISCHARGE: Pulse 80 and sinus rhythm. Blood pressure was stable. Room air saturation 94 percent. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm without rub or murmur. Incision was clean, dry and intact. The sternum is stable. Abdomen positive bowel sounds, soft, nontender, nondistended. LABORATORY DATA: White blood cell count 7, hematocrit 32.3, platelet count 335. Sodium 137, potassium 4.2, chloride 102, bicarb 28, BUN 12, creatinine 0.8, glucose 104. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. times seven days. 2. Potassium chloride 20 mEq p.o. b.i.d. times seven days. 3. Enteric coated aspirin 325 mg p.o. q day. 4. Percocet 1 to 2 p.o. q 4 to 6 hours. 5. Lopressor 100 mg p.o. t.i.d. 6. Captopril 12.5 mg p.o. t.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Aricept 10 mg p.o. q day. DI[Last Name (STitle) 408]E INSTRUCTIONS: He is discharged to home in stable condition. He is to follow up with Dr. [Last Name (Prefixes) ] in four weeks. He is to follow up with Dr. [First Name (STitle) ] in two to three weeks and he is to follow up with Dr. [Last Name (STitle) 24857] in one to two weeks. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2110-6-10] 13:03 T: [2110-6-10] 13:25 JOB#: [Job Number 24858]	[ "413.9", "401.9", "E878.8", "996.03", "424.0", "427.31", "411.81", "414.01", "530.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "88.72", "37.78", "96.04", "39.61", "39.49", "88.53", "37.22", "88.56", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]									4638, 5546																										999, 4100																												176, 591																614, 972		4125, 4615
62,791	187,345	41355	Discharge summary	report	Admission Date: [2176-12-6] Discharge Date: [2176-12-9] Date of Birth: [2093-11-12] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 3256] Chief Complaint: GIB Major Surgical or Invasive Procedure: EGD History of Present Illness: 83yoM with h/o likely COPD, CKD, anemia, prostate ca who is called out of MICU Green after presenting with 2 weeks of epigastric pain for which he was taking OTC pain meds ( ? NSAIDs, Tylenol ), and then saw his PCP and was given stool softeners. Days later, he had black diarrhea episodes, the last episode of which was symptomatic with LH, dizziness, diaphoresis, abdominal pain. He went to the ED where he was hemodynamically stable, and Hct seen to drop from 33 at the end of [Month (only) ] to 25. Cr was also 2.0 up from apparent baseline 1.4-1.7. He got a CT abd without IV contrast that showed stranding around pancreatic head (cannot r/o pancreatitis) with peripancreatic soft tissue nodule, opacity at L base could be atelectasis, nonspecific RLL small nodular opacity (? inflammatory, recommend 6mo f/u), diverticulosis. . Pt was admitted to MICU Green for monitoring and for scope which happened today. He was seen to have gastritis, a single cratered 1.5 cm ulcer in the duodenal proximal bulb with mild oozing with significant erythema surrounding and edema; a gold probe was successfully applied for hemostasis; recommendations were for continued PPI [Hospital1 ], check Hpylori, and it was felt likely due to NSAID's but given the inflammation the possibility of malignancy (either duodenum or eroding into the duodenum) couldn't be excluded so plan a repeat EGD in 8 wks. He was also given 1u PRBC's yesterday. . On interview in Spanish in the ICU, pt denies pain, SOB, CP, abdominal pain, nausea, vomiting, or any other symptoms, is in jolly spirits, and just finished his meal. Past Medical History: - COPD/asthma, chronic respiratory symptoms, follwed previously with Dr. [Last Name (STitle) ] in [Hospital1 1474], now [Doctor Last Name ] at [Hospital1 18] - CKD - Prostate ca Dx [2173], intermediate-high grade by [Doctor Last Name ]; seen by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 656] at [Hospital1 18] - HTN - HL - Anemia, source GI - Osteoporosis - S/p thyroid surgery, followed at [Hospital1 18] - Chronic knee pain, s/p L knee surgery and cortisone injections - H/o PNA Social History: Originally from [University/College ], retired military officer then office jobs, came to US ~[2167]. Spanish speaking only. He lives with his daughter and his wife whose memory is failing. Has six children. No h/o EtOH use, smoked cigarettes [1-19]/day for 25 yrs then quit ~[2167]. Family History: Unknown mother and father. [Name (NI) ] has two sisters and six kids, without any history of lung disease in the family. Negative for prostate cancer. Physical Exam: 97 p81 134/40 100% 2L NC [Location 10226]1.4L Jolly, pleasant, well-appearing M in no distress, Spanish speaking, sitting at bedside chair. EOMI, no icterus. Mouth moist, normal appearing. Lungs CTAB no w/c/r/r, good air movement RRR without m/g or adventitious sounds Abd rotund, without TTP, soft, BS+ BLE without edema, warm, no cyanosis CN 2-12 intact, mood/affect appropriate and conversant, moving all extremities. Pertinent Results: [2176-12-6] 09:40AM BLOOD WBC-7.3 RBC-3.07# Hgb-7.7# Hct-25.3* MCV-83 MCH-24.9* MCHC-30.2* RDW-14.3 Plt Ct-357 [2176-12-6] 08:16PM BLOOD WBC-5.9 RBC-2.78* Hgb-6.9* Hct-22.3* MCV-80* MCH-24.8* MCHC-30.9* RDW-14.3 Plt Ct-297 [2176-12-7] 01:31AM BLOOD Hct-23.6* [2176-12-7] 06:14AM BLOOD Hct-23.2* [2176-12-7] 12:38PM BLOOD WBC-5.5 RBC-3.01* Hgb-7.6* Hct-24.6* MCV-82 MCH-25.3* MCHC-31.0 RDW-14.5 Plt Ct-273 [2176-12-8] 07:10AM BLOOD WBC-5.2 RBC-3.05* Hgb-8.0* Hct-25.5* MCV-83 MCH-26.2* MCHC-31.4 RDW-14.6 Plt Ct-307 [2176-12-9] 07:15AM BLOOD WBC-5.0 RBC-3.10* Hgb-7.8* Hct-25.3* MCV-82 MCH-25.1* MCHC-30.8* RDW-14.9 Plt Ct-315 [2176-12-6] 08:16PM BLOOD Neuts-47.6* Lymphs-34.7 Monos-6.4 Eos-10.9* Baso-0.4 [2176-12-6] 09:40AM BLOOD Neuts-69.4 Lymphs-20.3 Monos-3.7 Eos-5.9* Baso-0.7 [2176-12-6] 08:16PM BLOOD PT-11.3 PTT-27.2 INR(PT)-1.0 [2176-12-8] 07:10AM BLOOD Glucose-94 UreaN-22* Creat-1.4* Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 [2176-12-7] 01:31AM BLOOD Glucose-94 UreaN-34* Creat-1.6* Na-139 K-4.6 Cl-108 HCO3-24 AnGap-12 [2176-12-6] 08:16PM BLOOD Glucose-98 UreaN-39* Creat-1.6* Na-136 K-5.3* Cl-106 HCO3-22 AnGap-13 [2176-12-6] 09:40AM BLOOD Glucose-114* UreaN-49* Creat-2.0* Na-137 K-4.6 Cl-104 HCO3-18* AnGap-20 [2176-12-6] 08:16PM BLOOD Lipase-197* [2176-12-6] 09:40AM BLOOD Lipase-51 [2176-12-8] 07:10AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3 [2176-12-7] 01:31AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.4 [2176-12-6] 08:16PM BLOOD Calcium-8.4 Phos-2.5* Mg-2.4 [2176-12-6] 10:30AM BLOOD Glucose-110* Lactate-2.9* [2176-12-6] 09:02PM BLOOD Lactate-1.3 [2176-12-6] 09:45PM BLOOD Lactate-1.2 [2176-12-7] 1:39 pm SEROLOGY/BLOOD ADDED TO SPECIMEN 65833V. FINAL REPORT [2176-12-10] HELICOBACTER PYLORI ANTIBODY TEST (Final [2176-12-10]): NEGATIVE BY EIA. (Reference Range-Negative). [12-6] CT abd/pelvis IMPRESSION: 1. Mild stranding about the pancreatic head, cannot exclude acute pancreatitis, correlation with lipase is recommended. Finding (change in wet read) was discussed with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 63998] (ED resident) at 3 p.m. by Dr. [Last Name (STitle) 10304] by phone on [2176-12-6]. 2. Peripancreatic small soft tissue node. 3. Opacity at the left lung base could be atelectasis, cannot exclude pneumonia. Correlate clinically. 4. Nonspecific small nodular opacity at the right lung base could be inflammatory. If clinical concern, consider six-month followup. 5. Cholelithiasis. 6. Diverticulosis; however, no evidence of acute diverticulitis. 7. Mild loss of L5 vertebral body height of uncertain chronicity, likely degenerative. Correlate with pain. 8. Nonspecific stranding at the dome of the urinary bladder anteriorly could be urachal remnant. Attention on next followup. 9. Coronary artery calcification. Brief Hospital Course: 83yoM with h/o likely COPD, CKD, anemia, prostate ca who presents with Hct drop from bleeding duodenal ulcer possibly due to NSAID use, now s/p EGD and gold probe therapy. . 1. Bleeding duodenal ulcer: He was transfused 1u PRBC's in MICU and had EGD which visualized the ulcer and gold probe was applied to achieve hemostasis. Hct's were stable thereafter for 2 days; hemodynamics were stable. . Suspected due to NSAID use, but its endoscopic appearance on EGD was also worrisome for malignancy so pt will need close f/u after acute therapy to re-EGD him. This was imparted to the pt, the family, the pt's PCP and the fellow who performed the first EGD. His Hct's were trended post procedure and were stable for 2 days. Hpylori was negative but was pending by discharge; the pt and family were instructed to touch base with his PCP to follow up the results of this. He was also instructed several times to avoid NSAID's. . 2. ? pancreatitis: his initial lipase was normal but when repeated later the same day was elevated to >3x ULN; he also appears to have peripancreatic stranding concerning for a pancreatitis. Suspect there was peri-pancreatic inflammation from the ulcer and perhaps some duodenal ulcer penetrance. However, also concerning for ? malignancy during EGD and symptoms will need to be followed up. . Regardless, he was eating full meals, having bowel movements, no abdominal pain, abdomen exam soft without TTP -- so even if pancreatitis, not particularly clinically worrisome. . 3. CKD: Pt was above his Cr baseline on admission, but back baseline by discharge . 4. RLL nodular opacity: low WBC count, no reported coughs, no fevers to suggest PNA. Prior smoking history. Will need f/u as outpt with repeat imaging in 6 mos. . 5. Follow up: The pt's PCP, [Name10 (NameIs) ] fellow performing the EGD, inpatient service attending were all emailed to close the loop regarding need for repeat EGD, inability to make follow up appointments given the holidays, and need for f/u H.Pylori. In addition, will need lung nodules followed up in 6 mos. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1 to 2 puffs(s) inhaled every four (4) hours as needed for cough, shortness of breath or wheezing ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider: [Name Initial (NameIs) ] pt from Dr [First Name (STitle) ], Endocinology) - 50,000 unit Capsule - 1 Capsule(s) by mouth q1st & 15th day each mo FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (visit reconciliation) - 100 mcg-50 mcg/Dose Disk with Device - 1 (One) inhalation(s) inhaled twice a day LEVOTHYROXINE - (visit reconciliation) - 137 mcg Tablet - 1 (One) Tablet(s) by mouth once a day as needed for IN THE MORNING ON AN EMPTY STOMACH LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth once a day ZOLEDRONIC ACID [ZOMETA] - (Prescribed by Other Provider: [Name10 (NameIs) ] [First Name (STitle) ], Endocrinology [Hospital1 2177]) - 4 mg/5 mL Solution - annual . Medications - OTC ACETAMINOPHEN - 650 mg Tablet - 1 (One) Tablet(s) by mouth three times a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - [12-17] Tablet(s) by mouth once a day as needed for constipation DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth twice a day stool softener . Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-17] inhalation Inhalation every 4-6 hours as needed for nausea. 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO on the first and 15th of every month, per Dr. [First Name (STitle) ] in Endocrinology. 3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): In the morning on an empty stomach. 5. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Zometa 4 mg/5 mL Solution Sig: One (1) Intravenous every year, per Dr. [First Name (STitle) ] in Endocrinology. 7. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet, Effervescent PO once a day. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: Stool softener: continue taking this if you were taking it before admission. 9. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation: Stool softener: continue taking this if you were taking it before admission. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): This is an acid suppressing medication for your stomach . Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Bleeding duodenal ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], it was a pleasure taking care of you at the [Hospital1 1535]. You were admitted with abdominal pain and black stools and found to have a drop in your blood level from 33 to 25. You had and EGD (endoscopy) which visualized a bleeding ulcer in your duodenum; this was fixed during the procedure and your blood levels were stable afterwards. As we discussed, you will need to have a repeat EGD in 8 weeks to make sure it is OK, this has been scheduled as below. As we also discussed, the blood test for a bacteria in your stomach called "H. Pylori" is also pending but this can be followed up with Dr. [First Name (STitle) ]; if it is positive you will need antibiotics. The following changes were made to your medication regimen: 1. START Pantoprazole 40 mg twice a day: this is an acid suppressing medication for your stomach. You should discuss this new medication change with your doctors. Followup Instructions: As we discussed, we were unable to schedule a follow up appointment for you because it is the day after [Holiday ], however I called the office and told them to call you with an appointment; I have also emailed your primary care doctor to let him know to get in touch. You will need to see your PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] within the next 2 weeks. If you do not hear from him, please call [Telephone/Fax (1) 608] to schedule an appointment. You will also need to see a GI doctor in follow up, but the same situation as above -- we were unable to schedule an appointment, but the doctors have [Name5 (PTitle) 19301] notified. If you do not hear from them in the next few days, please call [Telephone/Fax (1) 9557] to schedule an appointment. However, the appointment for the repeat EGD was able to be scheduled as below: Department: DIGESTIVE DISEASE CENTER When: MONDAY [2177-1-27] at 9:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5085], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: MONDAY [2177-1-27] at 9:00 AM You also had this appointment previously scheduled: Department: RADIOLOGY When: TUESDAY [2176-12-10] at 9:30 AM With: ULTRASOUND [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE Completed by:[2176-12-12]	[ "272.4", "493.20", "V10.46", "535.50", "403.90", "733.90", "537.1", "285.1", "532.40", "585.9" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	11328, 11334	6390, 8137	276, 281	11401, 11401	3432, 6367	12502, 14154	2807, 2964		9831, 11305		11355, 11380	8480, 9808			11551, 12479										2979, 3413									8148, 8454																			233, 238										309, 1916									11416, 11527							1938, 2473	2489, 2791
14,240	152,609	49060	Discharge summary	report	Admission Date: [2148-11-9] Discharge Date: [2148-11-15] Date of Birth: [2098-10-28] Sex: F Service: [Location (un) 259] HISTORY OF PRESENT ILLNESS: The patient is a 50 year old woman with a very extensive past medical, psychiatric and neurologic history who was transferred back to medicine service after left hip repair. Patient had been admitted on [2148-11-9], for hyponatremia. She had suffered a hyponatremia was noted on routine blood work. Patient has a significant history of epilepsy which required two lobectomies and titration of a variety of antiepileptic drugs. She has had multiple admissions for hyponatremia down to the 120s before. Previous workup revealed a SIADH picture. Because the SIADH was thought to be secondary to her antiepileptic medications, patient was previously treated has been following her and drew a sodium which revealed sodium of 120 on [11-8]. After further questioning, patient reports her usual seizure activity, partial complex of left hand and arm twitching times one two days prior to admission. She had not had a prior seizure in over a year. On admission she was noted to have a large protruding mass over the left thigh, extremely tender and erythematous. Pain films revealed a new fracture of the left acetabulum. Patient has a history of bilateral hip fractures, although she only recalls a left hip fracture. An abscess over the site was drained. Cultures grew gram positive cocci in pairs and clusters. She went to the operating room on [2148-11-10], where hardware from previous repair was removed. Cultures were taken in the operating room. She received four units of packed red blood cells and Lasix. When patient was seen she complained of left knee pain, severe in intensity. She reports having had similar knee pain in the past and was admitted in [2146-9-4] due to similar complaints. Denies dyspnea, fever, chills, chest pain. Denies headaches. Has not had a seizure during this admission. PAST MEDICAL HISTORY: Complex partial seizures. Status post right temporooccipital lobectomy with VP shunt and partial left hemiparesis in [2127]. Depression. Obsessive compulsive disorder. Chronic left lower extremity edema. Right hip fracture to the left and fracture of the lateral ischial ring on the right side. Left hip fracture dislocation status post left hip replacement. History of methicillin resistant Staphylococcus aureus growth in the left joint status post total hip replacement. Anorexia, binging eating disorder. Osteoporosis status post multiple fractures. Severe left knee pain likely referred from the left hip. Premenopausal. History of B-12 deficient anemia. History of incontinence status post urinary stent. Constipation. Peripheral vascular disease left lower extremity. History of cellulitis in left lower extremity. Osteoporotic compression fractures. Syndrome of inappropriate diuretic hormone thought to be secondary to psychiatric medications. SOCIAL HISTORY: She lives in [Location (un) 55]. She denies ethanol use. Denies tobacco use. She graduated from high school as well as from [Hospital1 102955]with a bachelor's in religion. She attended [Hospital1 102956] School. She was forced to leave her studies after the second year secondary to her seizure disorder. She has never been married. She has no children. She currently lives alone in an apartment in [Location (un) 55]. She has a personal care attendant who works with her five days a week. MEDICATIONS ON ADMISSION: Carbamazepine 200 mg p.o. t.i.d. (this must be brand name Tegretol), docusate sodium 100 mg p.o. t.i.d., oxycodone sustained release 20 mg p.o. q.eight, Tylenol, senna one tab p.o. b.i.d., Dulcolax 10 mg p.o. p.r. q.d., vancomycin 1 gm IV q.12, Protonix 40 p.o. q.24, midodrine 10 mg p.o. t.i.d., Percocet one to two tabs p.o. q.four to six hours p.r.n., calcium, fluocinolone cream, risperidone 1 mg p.o. b.i.d., raloxifene 60 mg q.d., phenobarbital 30 p.o. t.i.d., multivitamin, lactic acid lotion, ibuprofen 400 mg p.o. q.eight p.r.n., hydrocortisone cream 1% t.p. b.i.d., tiagabine 4 mg p.o. b.i.d., alendronate sodium 70 mg p.o. q.Monday, oxybutynin 10 mg p.o. b.i.d., baclofen 10 mg p.o. q.i.d., hydroxyzine 25 p.o. q.four to six hours p.r.n., amoxapine 25 p.o. t.i.d., Coumadin 5 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature 98.4, heart rate 70 to 80, blood pressure 100/60, respirations 12 to 16, oxygen saturation 99% on 2 liters nasal cannula. In general, this was an alert female with slow speech pattern, however, she was talkative with sporadic intermittently tearful episodes. HEENT: extraocular movements intact. Pupils were equal, round, and reactive to light and accommodation bilaterally. Oropharynx had poor dentition, but otherwise clear. Mucosal membranes were moist. Neck no LAD, supple, palpable VP shunt on right side of neck. Heart widely split S2 with loud P2, regular rate, mild [1-10] HSM radiating to the axilla. Lungs had no wheezes or crackles limited anteriorly. Abdomen normal bowel sounds, distended, mildly tympanitic, nontender, no rebound or guarding. Extremities: left hip covered with bandage, has drain collecting sanguineous fluid. Left knee appears more swollen than right. No clear collection of fluid. Nontender to palpation. Both lower extremities were cool to touch. Had dopplerable PT and DP pulses bilaterally. Left lower extremity from knee to foot is erythematous, not so in right lower extremity. On neuro exam cranial nerves II-XII intact. Left arm [3-8], right side [4-7]. Has limited ankle dorsiflexion and plantar flexion. Left subclavian line nontender. LABORATORY DATA: White cell count 12.9, hematocrit 43.7, platelets 272. INR 1.2. Urinalysis showed 30 protein, 3 white cells. Chest x-ray confirmed good central line placement from subclavian. Left hip film showed a large soft tissue density projected over the left groin. This appeared to be a fractured left acetabulum with continued protrusion of the acetabular component of the total hip prosthesis into the pelvis. HOSPITAL COURSE: After the patient returned from surgery where infected hardware was removed, her hyponatremia was managed with fluid restriction and sodium tablets. Sodium remained stable at 130 over the two to three days prior to discharge. The sodium supplementation helped her chronically low blood pressure. Her midodrine was therefore discontinued. She was continued on vancomycin. Wound cultures returned with cultures positive for MRSA. ID consult was requested and recommended very long term antibiotic use with vancomycin 1 gm IV q.12 hours for a total of four to six months. Followup with ID was to be scheduled by rehab staff within three to four weeks after discharge from the hospital. The patient was started on Coumadin for anticoagulation with a goal of 1.5 to 2.0. She was discharged on Coumadin 5 mg p.o. q.d. Regarding epilepsy, patient remained seizure free during her hospital stay. Her seizure episode was thought to be caused by hyponatremia. Per ID recommendation an MRI of the left thigh was performed. This showed old left supracondylar fracture with high suspicion for complications with osteomyelitis with discrete interosseous abscess. There was also inflammatory change present within the joint and soft tissue, particularly the posterior compartment. However, no discrete soft tissue abscess was appreciated. Orthopaedic surgeon, Dr. [Last Name (STitle) 7111], was consulted again and recommended conservative management with long term vancomycin with no surgical intervention at that time. Infectious disease was consulted as well and they agreed with the plan. The patient was discharged to rehab on [2148-11-15], on the following medications. DISCHARGE MEDICATIONS: 1. Coumadin 5 mg p.o. q.d. 2. Lactulose 30 mg p.o. q.eight p.r.n. 3. Tiagabine 4 mg p.o. h.s. 4. Oxycodone extended release 10 mg p.o. q.12. 5. Amoxapine 50 mg p.o. b.i.d. 6. Tegretol (this must be brand name Tegretol) 200 mg p.o. t.i.d. 7. Vitamin D 50,000 units p.o. twice a week on Wednesday and Saturday for a total of six doses, then resume 800 IU q.d. 8. Sodium tabs 4 gm p.o. t.i.d. 9. Colace 100 mg p.o. b.i.d. 10. Senna one tab p.o. b.i.d. 11. Eucerin cream q.i.d. p.r.n. 12. Dulcolax 10 mg p.o. p.r. q.d. 13. Vancomycin 1 gm IV q.12. Duration to be determined by infectious disease. At this time the anticipated duration is four to six months. 14. Oxybutynin 10 mg p.o. b.i.d. 15. Protonix 40 mg p.o. q.d. 16. Risperidone 1 mg p.o. b.i.d. 17. Percocet one to two tabs p.o. q.four to six hours p.r.n. 18. Calcium carbonate 1250 p.o. b.i.d. 19. Fluocinolone cream b.i.d. 20. Raloxifene 60 mg p.o. q.d. 21. Phenobarbital 30 mg p.o. t.i.d. 22. Multivitamin one tab p.o. q.d. 23. Lactic acid lotion. 24. Ibuprofen 400 mg p.o. t.i.d. 25. Hydrocortisone cream 1% b.i.d. 26. Alendronate sodium 70 mg p.o. q.Monday. 27. Baclofen 10 mg p.o. q.i.d. 28. Hydroxyzine 25 mg p.o. q.four to six hours p.r.n. 29. Ditropan XL 10 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: CBC, chem-7, albumin, calcium will need to be checked every week at minimum. Calcium must be followed given high dose of vitamin D. Followup appointments will need to be set up by rehab staff with infectious disease specialist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1774] or Dr. [Last Name (STitle) 1005] at [Telephone/Fax (1) ], in three to four weeks after discharge and orthopaedic surgeon, Dr. [Last Name (STitle) 7111], in four to five weeks after discharge. Discharge diet high protein, high salt with fluid restriction of 1 liter a day. CONDITION ON DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Seizures. 2. Acetabular fracture. 3. Infected hardware status post removal. 4. Hyponatremia. 5. Osteomyelitis of left femoral bone. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1775] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1776] Dictated By:[Doctor Last Name 16524] MEDQUIST36 D: [2148-11-15] 16:29 T: [2148-11-15] 17:35 JOB#: [Job Number 102957]	[ "253.6", "733.00", "443.9", "996.66", "345.90", "808.0", "730.05" ]	icd9cm	[ [ [] ] ]	[ "38.93", "80.05" ]	icd9pcs	[ [ [] ] ]								9828, 10278	7912, 9160			3577, 4416	6204, 7889		9185, 9775																										4439, 6186																						186, 2021																2044, 3017	3034, 3550	9800, 9807
66,061	193,621	28558	Discharge summary	report	Admission Date: [2124-1-8] Discharge Date: [2124-1-17] Date of Birth: [2065-7-15] Sex: M Service: MEDICINE Allergies: Aspirin / [Hospital1 ] Tylenol Plus Attending:[First Name3 (LF) 30] Chief Complaint: Back pain Major Surgical or Invasive Procedure: 1. Partial vertebrectomy of T12-L1 and L2. 2. Fusion T12-L2. 3. Spacers x2. 4. Instrumentation T12-L2. 5. Autograft. 1. Total laminectomy of T11, T12, L1 and L2. 2. Fusion T11 to L3. 3. Instrumentation T11 to L3. 4. Autograft. 5. Epidural catheter placement. History of Present Illness: Mr. [Known lastname 29721] is a pleasant 58yoM with h/o recurrent MRSA infections with lumbar spine and right humerus involvement on chronic doxycycline for suppressive tx, IVDU and HCV without cirrhosis who presents after outpt CT abdomen/pelvis showed evidence of T12 discitis. Pt has a complicated infectious disease history and is followed by Dr. [Last Name (STitle) 13895] in [Hospital ] clinic. He has h/o multiple MRSA infections since [2118] including epidural abscess, discitis, vertebral osteomyelitis, septic arthritis of R shoulder, bilateral hips, and R foot, and multiple back surgeries for drainage/debridement (of note, no hardware placed). His hospital courses have been complicated by DVT (completed 3 mos of lovenox therapy) and atrial fibrillation. His most recent hospitalization was in [11-19], when he presented with fever to 103, leukocytosis, and elevated ESR/CRP. No organism grew on blood cx, but given his h/o recurrent MRSA he was treated with IV vanc x8 weeks, completed in [1-21]. Since then he has been on chronic doxycycline suppressive therapy. . Pt states his back pain has generally been at his baseline. His pain is typically R paraspinal in lumbar region but more recently has had increased pain in his middle back. The pain is worse in the AM and with movement, particularly when moving from sitting to standing. Has also had R leg weakness that has resulted in falls recently, states he has had this weakness for a few months. No numbness or tingling of extremities, no perineal numbness, no bowel/bladder incontinence. . He presented to [Hospital ] clinic for f/u on [2123-12-22], and noted occ R flank pain. He had CT abdomen/pelvis as outpatient, which had findings concerning for T12 spondylodiscitis. His ID specialist Dr. [Last Name (STitle) 13895] [Name (NI) 653] him and urged him to go to the ED for further evaluation, but pt did not want to go to [Hospital1 18] due to transportation issues. He presented to his local OSH, where he was given IV vanc 1g x1 and IV zosyn 3.375g x1. He was transferred to [Hospital1 18] for further eval. . In the ED, initial VS were Temp: 98 HR: 74 BP: 131/78 Resp: 16 O(2)Sat: 98%RA. He received IV dilaudid for pain. Labs were notable for nl WBC, elevated ESR 23 and CRP 12. He was evaluated by [Hospital1 ] spine who recommended ID c/s, possible OR washout. He was admitted to medicine. . Upon transfer to the floor, vitals are T 97.3, BP 132/80, HR 66, RR 18, O2sat 94% on RA. He describes his pain as [9-20] but similar to his chronic pain, R-sided lumbar pain that radiates to his R hip. Denies recent fevers/chills (notes that with his previous infections he had fevers, chills, malaise). Denies N/V. His R flank pain has resolved. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria Past Medical History: -MRSA Epidural abscess, discitis, vertebral osteomyelitis and R humerus intraosseous abscess [6-/2121] s/p laminectomies/debridement and IV abx course, recurrence despite Bactrim suppression (incomplete adherence suspected) and repeat IV abx course ending [1-/2122] on indefinite doxycycline suppression. Aspiration of back (?anatomy) at [Hospital3 ] [5-/2122] with bloody fluid but growth of MRSA, treated with 8 days iv vanco/pip-tazo and transitioned back to doxycycline there until he ran out [2122-11-11]. Of note, no known foreign bodies or hardware. -Epidural abscess ?[2118] that he recalls was treated at [Hospital1 336] and [Hospital1 ]. Ongoing back pain. -MRSA sepsis [1-13] infected shoulder [2-17] -Removal tip of L 1st digit. -HCV, never treated. Genotype 1a, VL 3.3 million [2121]. Never biopsied. No cirrhosis on CT abdomen [2120]. -Afib (intermittent) -DVT per OMR. Off warfarin recently; managed by PCP. Social History: Prior lives normally in [Location (un) 5503] with his girlfriend. [Name (NI) ] has a 32yo daughter who is a surgeon in [State 2690]. He grew up in [State 48158] on a reservation and moved to [Location (un) 86] about 25 years ago. He notes that most of the people on the reservation died. He has two sisters and a brother with the same father but a different mother. [Name (NI) ] states that he is a fisherman. He admits to a history of IV drug use, including intravenous cocaine and heorin. He has been sober for the last 17 years, and he notes that he had not used any IV drugs in the last 17 months until last [Name (NI) 2974] (day prior to admission). He use heroin to help control his pain last [Name (NI) 2974]. He smokes about [12-13] ppd cigarettes for about 10-20yrs. Ambulates with cane. Family History: Multiple siblings with osteoarthritis and joint replacements. Has some family history of hyperlipidemia. No family history of diabetes or cancer known. He has one brother and two sisters. Physical Exam: Admission PE: VS - Temp 97.3F, BP 132/80, HR 66, R 18, O2-sat 94% RA GENERAL - pleasant, obese male in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - multiple tattoos on arms, no jaundice, no spinder angiomatas or palmar erythema LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [3-16] with R hip flexion and R foot dorsiflexion. Otherwise [4-15] strength throughout, sensation grossly intact throughout, DTRs 2+ in RLE and 1+ in LLE, toes downgoing bilaterally, no clonus, cerebellar exam intact, gait assessment deferred Discharge PE: VS: 98, 100s-110s/60s, 80s, 20, 93%3L Gen: comfortable, NAD, multiple tattoos HEENT-MMM, EOMI, neck supple, no lymphadenopathy, trachea midline Lungs- CTABL, no wheezes, rhonic CV- RRR, S1S2, no M,R,G, no thrills Abdom- soft,ND, BS+, no masses, TTP on L lateral abdomen at site of drain removal Ext- no peripheral edema Neuro- U/LE strength 5/5 Spine- dressing in place, no drainage noted, no erythema around incision site Pertinent Results: Labs on Admission: [2124-1-8] 02:00AM BLOOD WBC-6.4 RBC-4.60 Hgb-14.2 Hct-41.6 MCV-91 MCH-30.8 MCHC-34.1 RDW-13.3 Plt Ct-128* [2124-1-8] 02:00AM BLOOD Neuts-74.2* Lymphs-18.3 Monos-5.7 Eos-1.4 Baso-0.3 [2124-1-8] 02:00AM BLOOD PT-11.9 PTT-31.2 INR(PT)-1.1 [2124-1-11] 07:40PM BLOOD Fibrino-534* [2124-1-8] 02:00AM BLOOD ESR-23* [2124-1-8] 02:00AM BLOOD Glucose-89 UreaN-13 Creat-0.9 Na-139 K-3.8 Cl-107 HCO3-23 AnGap-13 [2124-1-8] 02:00AM BLOOD ALT-16 AST-23 AlkPhos-124 TotBili-0.4 [2124-1-9] 01:15PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.4* [2124-1-8] 02:00AM BLOOD CRP-12.2* [2124-1-11] 07:46PM BLOOD Type-ART pO2-143* pCO2-51* pH-7.36 calTCO2-30 Base XS-2 [2124-1-8] 02:36AM BLOOD Lactate-1.3 Discharge Labs: [2124-1-17] 04:35AM BLOOD WBC-7.1 RBC-2.67* Hgb-8.3* Hct-25.1* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.5 Plt Ct-198 [2124-1-17] 04:35AM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-138 K-4.1 Cl-99 HCO3-32 AnGap-11 [2124-1-17] 04:35PM BLOOD ALT-18 AST-32 LD(LDH)-266* AlkPhos-98 TotBili-0.3 [2124-1-17] 04:35PM BLOOD Albumin-3.1* [2124-1-17] 04:35PM BLOOD CRP-138.7* [2124-1-17] 04:35PM BLOOD ESR-116* Microbiology: [2124-1-8] 2:00 am BLOOD CULTURE FINAL REPORT [2124-1-14] Blood Culture, Routine (Final [2124-1-14]): NO GROWTH. [2124-1-8] 2:00 am URINE Site: CLEAN CATCH FINAL REPORT [2124-1-9] URINE CULTURE (Final [2124-1-9]): <10,000 organisms/ml. [2124-1-8] 1:43 am BLOOD CULTURE FINAL REPORT [2124-1-14] Blood Culture, Routine (Final [2124-1-14]): NO GROWTH. [2124-1-9] 10:30 am TISSUE T12-L1 [Month/Day/Year ]. GRAM STAIN (Final [2124-1-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2124-1-12]): NO GROWTH. ANAEROBIC CULTURE (Final [2124-1-15]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2124-1-9] 10:30 am SWAB T12-L1 DISC SPACE. GRAM STAIN (Final [2124-1-9]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2124-1-14]): [Female First Name (un) ] PARAPSILOSIS. SPARSE GROWTH. SPECIATION AND FLUCONAZOLE SENSITIVITY REQUESTED BY [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8021] #[Numeric Identifier 8022]. SENSITIVE TO Fluconazole , sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [Hospital1 69] Clinical Microbiology Laboratory.. ANAEROBIC CULTURE (Final [2124-1-15]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): [Female First Name (un) ] PARAPSILOSIS. ID PERFORMED ON CORRESPONDING ROUTINE CULTURE. [2124-1-14] 9:23 pm URINE Source: CVS. FINAL REPORT [2124-1-15] URINE CULTURE (Final [2124-1-15]): NO GROWTH. Imaging: MRI of the thoracic and lumbar spine without and with gad IMPRESSION: Findings concerning for progressive discitis at T12-L1 and possibly at L1-L2. Probable abscess within the disc space at T12-L1. Extensive pre- and paravertebral soft tissue abnormality at the involved levels. Extensive epidural enhancement which may be related to prior surgery or infections. No large epidural abscess is noted at this time. CT OF THE CHEST WITH IV CONTRAST: There is mild upper zone paraseptal emphysema (2:16). A small left pleural effusion tracks along the dependent regions and the left major fissure (301b:63). Bilateral dependent atelectasis is slightly worse on the left. A left-sided PICC terminates at the lower SVC (2:21). The heart size is normal. There is no pericardial effusion. The great vessels are patent and normal in caliber. No large central pulmonary embolus is detected, though this examination is not optimized for evaluation of the pulmonary arteries. Scattered prominent and enlarged axillary and mediastinal lymph nodes are seen, including a prevascular node measuring 10 mm along the short axis (2:18), 11mm pre-and subcarinal nodes, and a 12 mm right hilar node. CT OF THE ABDOMEN WITH IV CONTRAST: Since the [2124-1-6] examination, the patient has undergone laminectomy and posterior fusion of T11 through L3 via two posterior rods, one left paravertebral rod, and 13 screws. There is also partial vertebrectomy of T12 through L2. Interosseous disc spacers are seen at T12 through L2 (301B:46,47). The tissue immediately adjacent to the surgical hardware is difficult to evaluate due to extensive streak artifacts. There is no evidence of hardware failure. Two surgical approaches are detected. The first lies along the midline dorsal to the thoracolumbar spine. There is expected post-surgical subcutaneous fat and soft tissue stranding, with a small foci of air (2:40). No fluid collections are seen. The second surgical approach is via the left flank, where there is soft tissue stranding at the entry site (2:57), and a partial left tenth rib resection (2:49). A small focus of subcutaneous and intramuscular air is seen anteriorly (2:65). Thickening of the left lateroconal fascia is present, with a small focus of air at the lateral-most aspect (2:75,78). Fluid tracks along the left posterior pararenal space (2:79). There is asymmetric thickening of the left psoas muscle (2:78), which appears to abut a relatively hypodense triangular-shaped prominence (2:80). This may represent a small fluid collection, thickened muscle, or phlegmon. No fluid collections are seen. A coarse calcification overlying the left psoas muscle (2:77) may represent a surgically-related loose body, as this was not visualized on the [2124-1-6] CT examination. The evaluation of the solid abdominal organs is limited due to extensive metallic streak artifacts. A small hepatic cyst is seen near the falciform ligament (2:50). There is no intra- or extra-hepatic bile duct dilation. The gallbladder, stomach, spleen, right adrenal gland, right kidney, pancreas, and intra-abdominal loops of small and large bowel are normal. The left adrenal gland is not well visualized due to metallic artifacts. A subcentimeter hypoenhancing cortical lesion within the left kidney (2:75) may represent a small cyst, but is too small to characterize. Numerous prominent retroperitoneal and paraaortic lymph nodes are present (2:76,79). There is no intra-abdominal ascites. There is bony fusion of multiple lower lumbar vertebral bodies (301B:44), as seen on prior examinations. The upper thoracic spine demonstrates mild degenerative change. IMPRESSION: 1. Post-vertebrectomy and fusion of the thoracolumbar spine, with post-surgical changes at both the midline posterior and left flank approach. No definite fluid collections detected. Inflammatory changes and soft tissue thickening along the left lateroconal fascia and posterior pararenal space may be postsurgical, but superimposed infection cannot be excluded with this technique. 2. Enlarged mediastinal and retroperitoneal lymph nodes, likely reactive. 3. Small left pleural effusion. Mild adjacent atelectasis. 4. Mild paraseptal emphysema. Pathology: T12-L1 [Year (4 digits) 500], excision: Necrotic and viable [Year (4 digits) 500], cartilage and fibrotic tissue. No active inflammation seen. Clinical: Osteomyelitis T12-L2. Gross: The specimen is received fresh labeled with the patient's name, "[Known lastname 29721], [Known firstname 25812]", the medical record number and "T12-L1 [Known firstname 500]." It consists of multiple fragments of red - tan [Known firstname 500] and cartilage measuring 5.0 x 4.7 x 0.8 cm in aggregate. Four representative sections are submitted in cassettes A-D. Brief Hospital Course: 58yo M with h/o recurrent MRSA infections with lumbar spine and right humerus involvement on chronic doxycycline for suppressive tx, IVDU and HCV without cirrhosis who presents with osteomyelitis of the spine. . #[Name (NI) 69169] Pt noted to have T12-L1 involvement on imaging. He underwent OR debridement and fusion of the involved vertebrae. The surgery was complicated by a significant amount of blood loss requiring PRBC transfusion. Cultures from the OR debridement grew non-albicans [Female First Name (un) ]. Infectious disease was consulted and recommended treatment with Doxycycline and Fluconazole for a prolonged course consisting of atleast six months. He was afebrile on this regimen and did not have a leukocytosis at time of discharge. . #Pain-The acute pain service was consulted post-op for assistance with pain management. They recommended restarting Methadone 10mg TID. We also added PO Dilaudid to this regimen for break through pain. He was given prescriptions for both Dilaudid and Methadone post discharge with a supply that should last until his follow up appointment with his primary care physician. . # HCV: Stable, no evidence of decompensated cirrhosis during this hospitalization. #Transitional: Per Infectious Disease request an ESR, CRP and Liver function tests were obtained prior to discharge for them to follow up considering Fluconazole was started for treatment. He has follow up appointments with his primary care physician and the [Name9 (PRE) ] service as well. Medications on Admission: 1. DOXYCYCLINE HYCLATE - 100 mg Capsule - 1 Capsule(s) by mouth twice daily 2. Methadone 10mg TID 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. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:42 Tablet(s) Refills:0 3. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:60 Tablet(s) Refills:3 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Disp:30 30 Refills:2 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 7. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 6138] Home Care Services Discharge Diagnosis: Primary Diagnosis: Osteomyelitis of Spine Secondary Diagnosis: Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 29721], It was a pleasure taking care of you at [Hospital1 827]. You were admitted to the hospital with an infection in your spine. You underwent a debridement of the infection by Orthopedics and have been placed on an antifungal medication and an antibiotic medication to treat your infection. Changes to your medications: START: Docusate Sodium 100mg twice per day for constipation Fluconazole 400mg daily for your spine infection Polyethylene Glycol 17g pack per day for constipation Senna 8.6mg twice per day for constipation Dilaudid 2mg as needed for pain No other changes were made to your medications. Please see below for follow up appointments that have been made on your behalf. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2124-1-24] at 11:00 AM With: DR [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/[Company 191] POST [Hospital 894] CLINIC [Hospital Ward Name ] 6TH FL CENTRAL SUITE Phone: [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Department: INFECTIOUS DISEASE When: WEDNESDAY [2124-2-2] at 10:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13896], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: TUESDAY [2124-2-8] at 3:25 PM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ], [Name8 (MD) ] MD Specialty: ORTHOPAEDICS Location: [Hospital1 ] Address: [Last Name (LF) ], [First Name3 (LF) ] BLDG. RM 239, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3573] Appointment: [Telephone/Fax (1) ] [1-28] AT 1:30PM	[ "458.29", "348.30", "496", "997.49", "338.12", "305.1", "780.62", "730.18", "730.08", "998.11", "304.00", "720.9", "V15.81", "560.1", "110.1", "E878.8", "V12.04", "427.31", "112.89", "V12.51", "286.9", "738.4", "285.1", "070.54", "E849.7", "737.19" ]	icd9cm	[ [ [] ] ]	[ "81.62", "03.90", "81.63", "80.99", "84.52", "77.79", "81.05", "81.04", "84.51" ]	icd9pcs	[ [ [] ] ]	17654, 17728	15203, 16719	307, 567	17848, 17848	7089, 7094	18746, 20424	5505, 5694		16867, 17631		17749, 17749	16745, 16844			17999, 18325			7842, 9097							5709, 6631								10105, 15180															18354, 18723			6645, 7070		258, 269										595, 3635				17813, 17827		17768, 17792		7108, 7826	17863, 17975							3657, 4635	4651, 5489
49,999	119,576	16895	Discharge summary	report	Admission Date: [2172-10-29] Discharge Date: [2172-11-2] Date of Birth: [2122-7-26] Sex: F Service: MEDICINE Allergies: Rifampin Attending:[First Name3 (LF) 425] Chief Complaint: initiation of Remodulin therapy Major Surgical or Invasive Procedure: [2172-10-30] - Placement of a single-lumen tunneled catheter (Hickman) History of Present Illness: Ms. [Known lastname 47598] is a 50 year-old lady with a PMH of cryptogenic cirrhosis c/b porto-pulmonary hypertension with severe pulmonary hypertension, who presents for placement of a tunnelled PICC and initiation of Remodulin treatment. Patient reports that her liver disease was diagnosed after her LFTs were checked in [2157] for initiation of an antidepressant. Subsequently, she had a biopsy confirming cirrhosis, secondary to PSC, which has been complicated by portal hypertension, Grade II esophageal varices and portopulmonary symptoms. Patient has been treated on sildenafil for pulmonary hypertension. Despite treatment, a right heart cath in [2172-7-23] showed severe pulmonary hypertension with mean PAP 52mmHg, max PASP 86mmHg, PVR 555, and PCWP 12. Persistent pulmonary hypertension is precluding liver transplant; therefore, patient was directly admitted for IR placement of tunnelled PICC for initiation of Remodulin. . On the floor, initial vital signs were 96.9 122/70 78 16 100%RA. Patient was feeling very good. She reports fatigue, which has been chronic for her; she has always attributed this to her liver disease. No other symptoms. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Pulmonary hypertension, severe on RHC [7-/2172] - Primary biliary cirrhosis (stage III by biopsy [2163]) complicated by portal HTN, grade II esophageal varices, and portopulmonary syndrome - Pneumonia x2 - UTI in [2172-5-22] (treated with Z pack) - Depression - Tuberculosis in a lymph node, treated with rifampin, which made her sick Social History: Patient lives in [Location (un) ] with roommates. She has two grown children who lives in TX (30 and 25). She works as a house cleaner. Formerly smoked tobacco 1 pack per three days, quit many years ago. Very rare wine cooler, as she is sensitive to alcohol (stays in her system a long time). No current or past drug use. Family History: Father with heart disease, mother with heart disease (had CABG). Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 96.9 122/70 78 16 100%RA General: Alert, oriented, no acute distress, very pleasant HEENT: Sclera anicteric, MMM, oropharynx clear, no subungual icterus 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, no caput medusae Ext: Warm, well perfused, 2+ pulses, +clubbing of fingers bilaterally, no cyanosis or edema Skin: No spider angiomata or palmar erythema Neuro: No asterixis. CNs II-XII grossly intact, moving all extremities without difficulty. Mentation clear. Pertinent Results: ADMISSION LABS: [2172-10-29] 10:10PM BLOOD WBC-2.0* RBC-4.15* Hgb-13.1 Hct-39.1 MCV-94 MCH-31.6 MCHC-33.5 RDW-16.2* Plt Ct-60* [2172-10-29] 10:10PM BLOOD PT-13.7* PTT-48.5* INR(PT)-1.3* [2172-10-29] 10:10PM BLOOD Glucose-126* UreaN-9 Creat-0.6 Na-141 K-3.8 Cl-111* HCO3-25 AnGap-9 [2172-10-29] 10:10PM BLOOD ALT-62* AST-103* AlkPhos-271* TotBili-2.8* [2172-10-29] 10:10PM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9 . IMAGING: Chest x-ray [2172-10-30]: FINDINGS: Right dual lumen HD catheter through the right internal jugular approach terminates at lower SVC. There is no pneumothorax. No evidence of pleural effusion. Mild vascular congestion is present, however, no evidence of pulmonary edema. No opacities concerning for pneumonia. Heart size, mediastinal and hilar contours are normal. . DISCHARGE LABS: [2172-11-1] 01:54PM BLOOD WBC-2.4* RBC-4.26 Hgb-13.6 Hct-40.3 MCV-95 MCH-31.8 MCHC-33.7 RDW-16.3* Plt Ct-59* [2172-11-1] 01:54PM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-140 K-3.7 Cl-109* HCO3-27 AnGap-8 [2172-11-1] 01:54PM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 Brief Hospital Course: Ms. [Known lastname 47598] is a 60 year old lady with a PMH of cryptogenic cirrhosis c/b porto-pulmonary hypertension with severe pulmonary hypertension, who presents for placement of a tunnelled PICC and initiation of Remodulin treatment. . ACTIVE ISSUES: # PULMONARY HYPERTENSION - Patient's only related complaint has been fatigue. She suffers from severe pulmonary hypertension secondary to portopulmonary syndrome which was confirmed on right heart catheterization with no response to Sildenafil therapy. The patient was admitted for initiation of Remodulin therapy via a tunnelled Hickman line, which was placed this admission. During this admission, she tolerated uptitration of the medication with only a mild headache and some non-specific left flank discomfort which resolved without issues. She was monitored closely after initiation of treatment. Extensive education regarding Remodulin therapy was performed. She will be discharged with the Remodulin infusion pump. . CHRONIC ISSUES: # PRIMARY BILIARY CIRRHOSIS - The patient has a known diagnosis of primary biliary cirrhosis (stage III by biopsy in [2163]) complicated by portal hypertension, grade II esophageal varices, and portopulmonary syndrome which led to her pulmonary hypertension (as noted above). She is stable on Nadolol 10 mg PO daily and Ursodiol 600 mg PO BID. We continued these therapies without issue. . TRANSITION OF CARE ISSUES: CODE STATUS: FULL ISSUES TO ADDRESS AT FOLLOW UP: 1. continuation of remodulin Medications on Admission: 1. Nadolol 10 mg PO daily 2. Sildenafil 20 mg PO TID 3. Ursodiol 600 mg PO BID Discharge Medications: 1. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 4. treprostinil sodium 1 mg/mL Solution Sig: 5.25 ng/kg/min Injection Continuous infusion. Disp:30 days Refills:0 Discharge Disposition: Home With Service Facility: ALL CARE VNA Discharge Diagnosis: Primary Diagnoses: 1. Severe pulmonary hypertension . Secondary Diagnoses: 1. Primary biliary cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient Discharge Instructions: . You were admitted to the Coronary Care Unit (CCU) at [Hospital1 771] on [Hospital Ward Name 121] 6 regarding management of your pulmonary artery hypertension and for the initiation of Remodulin (Treprostinil) therapy, which you tolerated well. You had a tunneled line placed and this therapy was initiated. You were discharged in stable condition. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If 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 an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Treprostinil sodium 5.25 ng/min via continuous subcutaneous infusion pump . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: Sildenafil . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2172-11-9] at 1:45 PM With: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29018], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Dr [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 2398] [Last Name (NamePattern1) ] is your new physician at [Name9 (PRE) 191]. He works closely with Dr [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ], [First Name3 (LF) ] both will be involved in your care. Please call your insurance and name Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] as your PCP. [Name10 (NameIs) ] MUST BE DONE BEFORE YOUR APPOINTMENT. Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2172-11-11] at 9:40 AM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [2172-11-11] at 10:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PFT When: WEDNESDAY [2172-11-11] at 10:00 AM Department: LIVER CENTER When: THURSDAY [2172-11-12] at 10:45 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "572.3", "416.8", "571.5", "V15.82", "456.21", "311", "V58.69", "V49.83", "V13.02", "571.6" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	6780, 6823	4680, 4926	301, 378	6971, 6971	3564, 3564	8824, 10589	2720, 2786		6312, 6757		6844, 6898	6209, 6289			7154, 8801			4389, 4657							2826, 3545			6919, 6950						6153, 6183																			230, 263		4941, 5666			1605, 1984					406, 1587					3580, 4372				6986, 7098				5682, 6142			2006, 2356	2372, 2704
44,298	134,239	34808	Discharge summary	report	Admission Date: [2187-6-24] Discharge Date: [2187-7-5] Date of Birth: [2126-1-19] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Known firstname 4748] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2187-6-24]: Open repair of ruptured abdominal aortic aneurysm with 18 x 30 Hemashield tube graft. [2187-6-28]: Cardiac Cath. Thrombotic LAD stent. PCI with [Name Prefix (Prefixes) ] [Last Name (Prefixes) 8532] and POBA within History of Present Illness: The patient is a 61-year-old male who originally presented to an outside hospital with complaint of increasing abdominal and back pain with CT scan performed at an outside hospital demonstrating an 8.2-cm ruptured infrarenal abdominal aortic aneurysm with retroperitoneal containment. He was transferred to [Hospital1 1444] emergently for emergent operative repair of ruptured aortic aneurysm. Past Medical History: CAD s/p PCI with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 ('[80],'[82] @ [Hospital1 112]) HTN Hyperlipidemia Disc compression Right knee surgery Adenoidectomy Social History: Tobacco: prior smoker, denies current use ETOH: occasional Ilicit: denies Lives w/ wife in [Name (NI) ]. No medical insurance at this time - pays cash for all doctors [Name5 (PTitle) 2176]. Family History: denies CAD, aortic aneurysms Physical Exam: discharge: gen - wdwn obese male in nad, alert and oriented x 3 card - rrr, no m/r/g lungs - cta bilat abd - soft +bs, no m/t/o; midline incision c/d/i extremities - mild edema bilat groin - puncture sites c/d/i, no hematoma Pertinent Results: [2187-6-24] 09:20PM BLOOD WBC-21.2# RBC-4.21 Hgb-12.2* Hct-36.5* MCV-87 MCH-29.0 MCHC-33.4 RDW-15.3 Plt Ct-135* [2187-6-25] 02:05AM BLOOD WBC-14.4* RBC-4.08* Hgb-12.2* Hct-34.1* MCV-84 MCH-29.8 MCHC-35.6* RDW-15.7* Plt Ct-149* [2187-6-25] 05:41AM BLOOD Hct-31.4* [2187-6-25] 10:48AM BLOOD WBC-11.8* RBC-4.00* Hgb-11.6* Hct-33.3* MCV-83 MCH-29.0 MCHC-34.9 RDW-15.9* Plt Ct-116* [2187-6-25] 03:27PM BLOOD Hct-30.8* [2187-6-26] 02:39AM BLOOD WBC-10.3 RBC-3.19* Hgb-9.5* Hct-26.3* MCV-82 MCH-29.8 MCHC-36.1* RDW-16.1* Plt Ct-87* [2187-6-26] 01:52PM BLOOD Hct-26.5* [2187-6-26] 09:05PM BLOOD Hgb-8.6* Hct-24.2* [2187-6-27] 09:10AM BLOOD Hct-24.9* [2187-6-27] 05:12PM BLOOD Hct-26.4* [2187-6-28] 01:39AM BLOOD WBC-6.6 RBC-3.15* Hgb-9.0* Hct-25.6* MCV-81* MCH-28.7 MCHC-35.2* RDW-16.6* Plt Ct-96* [2187-6-28] 05:58PM BLOOD Hct-29.8* [2187-6-28] 07:07PM BLOOD WBC-2.4# RBC-3.69 Hgb-10.5* Hct-31.2* MCV-85 MCH-28.4 MCHC-33.5 RDW-16.5* Plt Ct-125* [2187-6-28] 11:04PM BLOOD WBC-7.6# RBC-3.25* Hgb-9.8* Hct-27.3* MCV-84 MCH-30.3 MCHC-36.1* RDW-16.2* Plt Ct-139* [2187-6-29] 01:24AM BLOOD Hct-27.6* [2187-6-29] 03:59AM BLOOD WBC-7.3 RBC-3.27* Hgb-9.6* Hct-27.4* MCV-84 MCH-29.4 MCHC-35.2* RDW-16.9* Plt Ct-139* [2187-6-29] 08:14AM BLOOD Hct-22.1* [2187-6-29] 02:40PM BLOOD WBC-7.7 RBC-3.49* Hgb-10.6* Hct-29.7# MCV-85 MCH-30.3 MCHC-35.6 RDW-16.2* Plt Ct-150 [2187-6-29] 07:50PM BLOOD Hct-28.6* [2187-6-30] 12:46AM BLOOD Hct-29.0* [2187-6-30] 03:30AM BLOOD WBC-7.0 RBC-3.26* Hgb-10.0* Hct-27.9* MCV-86 MCH-30.5 MCHC-35.7* RDW-16.4* Plt Ct-139* [2187-6-30] 02:12PM BLOOD Hgb-10.5* Hct-30.4* [2187-7-1] 01:22AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.2* Hct-29.6* MCV-87 MCH-30.1 MCHC-34.5 RDW-16.0* Plt Ct-177 [2187-7-1] 02:35PM BLOOD Hgb-10.7* Hct-31.3* [2187-7-2] 03:24AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.6* Hct-30.8* MCV-88 MCH-30.4 MCHC-34.6 RDW-15.6* Plt Ct-191 [2187-7-3] 03:21AM BLOOD WBC-6.5 RBC-3.78* Hgb-10.9* Hct-32.5* MCV-86 MCH-28.7 MCHC-33.5 RDW-15.3 Plt Ct-202 [2187-6-24] 09:20PM BLOOD Glucose-224* UreaN-14 Creat-1.0 Na-140 K-5.4* Cl-109* HCO3-17* AnGap-19 [2187-6-25] 02:05AM BLOOD Glucose-232* UreaN-14 Creat-1.1 Na-131* K-5.4* Cl-108 HCO3-19* AnGap-9 [2187-6-26] 02:39AM BLOOD Glucose-124* UreaN-14 Creat-1.1 Na-136 K-4.2 Cl-105 HCO3-22 AnGap-13 [2187-6-26] 01:52PM BLOOD Glucose-118* UreaN-16 Creat-1.2 Na-132* K-4.2 Cl-104 HCO3-21* AnGap-11 [2187-6-27] 12:58AM BLOOD Glucose-132* UreaN-18 Creat-1.3* Na-134 K-4.1 Cl-103 HCO3-25 AnGap-10 [2187-6-28] 01:39AM BLOOD Glucose-132* UreaN-25* Creat-1.4* Na-141 K-3.9 Cl-104 HCO3-29 AnGap-12 [2187-6-28] 07:07PM BLOOD Glucose-157* UreaN-24* Creat-1.4* Na-144 K-3.8 Cl-102 HCO3-29 AnGap-17 [2187-6-28] 11:04PM BLOOD Glucose-147* UreaN-24* Creat-1.2 Na-142 K-4.0 Cl-103 HCO3-28 AnGap-15 [2187-6-29] 03:59AM BLOOD Glucose-124* UreaN-25* Creat-1.3* Na-143 K-3.9 Cl-103 HCO3-30 AnGap-14 [2187-6-29] 08:06AM BLOOD Na-141 K-4.2 Cl-102 [2187-6-29] 07:50PM BLOOD Na-142 K-3.9 Cl-103 [2187-6-30] 03:30AM BLOOD Glucose-120* UreaN-23* Creat-1.3* Na-143 K-4.0 Cl-104 HCO3-29 AnGap-14 [2187-6-30] 02:12PM BLOOD Na-142 K-4.2 Cl-102 [2187-7-1] 01:22AM BLOOD Glucose-106* UreaN-26* Creat-1.4* Na-142 K-3.8 Cl-103 HCO3-33* AnGap-10 [2187-7-1] 09:50PM BLOOD Glucose-154* Na-144 K-3.8 Cl-104 [2187-7-2] 03:24AM BLOOD Glucose-125* UreaN-27* Creat-1.2 Na-143 K-3.9 Cl-104 HCO3-33* AnGap-10 [2187-7-3] 03:21AM BLOOD Glucose-126* UreaN-28* Creat-1.3* Na-143 K-4.0 Cl-105 HCO3-33* AnGap-9 [2187-6-24] 09:20PM BLOOD CK(CPK)-35* [2187-6-25] 02:05AM BLOOD ALT-16 AST-17 AlkPhos-53 TotBili-1.1 [2187-6-25] 10:48AM BLOOD CK(CPK)-736* [2187-6-28] 07:07PM BLOOD ALT-47* AST-61* LD(LDH)-301* CK(CPK)-319 AlkPhos-102 Amylase-37 TotBili-1.7* [2187-6-29] 03:59AM BLOOD ALT-75* AST-227* LD(LDH)-518* AlkPhos-99 TotBili-1.5 [2187-6-30] 03:30AM BLOOD ALT-60* AST-173* AlkPhos-86 TotBili-1.6* [2187-6-24] 09:20PM BLOOD CK-MB-3 cTropnT-<0.01 [2187-6-25] 02:05AM BLOOD CK-MB-4 cTropnT-0.04* [2187-6-25] 10:48AM BLOOD CK-MB-7 cTropnT-<0.01 [2187-6-28] 07:07PM BLOOD CK-MB-6 cTropnT-0.12* [2187-6-24] 09:20PM BLOOD Calcium-8.5 Phos-5.2# Mg-1.4 [2187-6-25] 02:05AM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.2# Mg-2.4 [2187-6-26] 02:39AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8 [2187-6-26] 01:52PM BLOOD Mg-2.1 [2187-6-28] 01:39AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.1 [2187-6-28] 07:07PM BLOOD Albumin-2.8* Calcium-11.0* Phos-4.7# Mg-2.4 Iron-40 [2187-6-29] 03:59AM BLOOD Calcium-9.4 Phos-3.1# Mg-2.4 [2187-6-29] 08:06AM BLOOD Mg-2.3 [2187-6-29] 02:35PM BLOOD Mg-2.2 [2187-6-29] 07:50PM BLOOD Calcium-9.3 Mg-2.1 [2187-6-30] 03:30AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1 [2187-6-30] 02:12PM BLOOD Mg-2.1 [2187-7-1] 01:22AM BLOOD Calcium-9.8 Phos-2.9 Mg-2.1 [2187-7-1] 09:50PM BLOOD Mg-1.9 [2187-7-2] 03:24AM BLOOD Calcium-10.0 Phos-3.1 Mg-2.3 [2187-7-3] 03:21AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.1 [2187-6-25] 03:33PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.026 [2187-6-25] 03:33PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2187-6-25] 03:33PM URINE RBC-105* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2187-6-24] 9:20 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2187-6-27] MRSA SCREEN (Final [2187-6-27]): No MRSA isolated. [2187-6-25] 3:33 pm URINE Source: Catheter. FINAL REPORT [2187-6-26] URINE CULTURE (Final [2187-6-26]): NO GROWTH. [2187-6-29] 3:59 am BLOOD CULTURE Source: Line-art. FINAL REPORT [2187-7-5] Blood Culture, Routine (Final [2187-7-5]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [2187-6-30]): Reported to and read back by [Initials (NamePattern4) ] [Last Name (NamePattern4) ], PA ON [2187-6-30] AT 0545. GRAM POSITIVE COCCI IN CLUSTERS. [2187-6-29] 5:14 am BLOOD CULTURE Source: Line-L antecub PIV. FINAL REPORT [2187-7-5] Blood Culture, Routine (Final [2187-7-5]): NO GROWTH. [2187-7-1] 2:35 pm BLOOD CULTURE Source: Line-RIJ cordis #1. Blood Culture, Routine (Pending): [2187-7-1] 3:21 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 79707], [Known firstname ] [Hospital1 18] [Numeric Identifier 79708] (Complete) Done [2187-6-28] at 7:47:15 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [Known firstname ] [Initial (NamePattern1) ] [Hospital1 ] C [Last Name (NamePattern1) 67728] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2126-1-19] Age (years): 61 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Emergency TEE request for cardiopulmonry arrrest in CVICU following post ruptured AAA surgery 3 days ago? A quick TEE to rule out major reasons for cardiovascular arrest for done ICD-9 Codes: 410.91, 424.0 Test Information Date/Time: [2187-6-28] at 19:47 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3893], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.0 cm Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([1-14]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. Resting tachycardia (HR>100bpm). The rhythm appears to be atrial flutter. Results were personally REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the anterior septum in the base, mid and apical segments. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). with mild global free wall hypokinesis. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-14]+) mitral regurgitation is seen. There is no pericardial effusion. The ICU physician [Name9 (PRE) 79709] and vascular fellow were notified in person of the results Impression: Severe hypokinesis of the anterior septum suggestive of acute MI. NO pericardial effusion. NO evidence of PE. No evidence of thoracic aortic dissection.Valve findings do not explain sudden cardiac arrest. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 79707], [Known firstname ] [Hospital1 18] [Numeric Identifier ]Portable TTE (Complete) Done [2187-6-29] at 2:41:03 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [Known firstname ] [Initial (NamePattern1) ] [Hospital1 ] C [Last Name (NamePattern1) 67728] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2126-1-19] Age (years): 61 M Hgt (in): 71 BP (mm Hg): 110/54 Wgt (lb): 302 HR (bpm): 91 BSA (m2): 2.51 m2 Indication: Congestive heart failure. Coronary artery disease. Left ventricular function. Myocardial infarction. VF arrest. ICD-9 Codes: 428.0, 410.91, 414.8, 424.0 Test Information Date/Time: [2187-6-29] at 14:41 Interpret MD: [Name6 (MD) ] [Name8 (MD) 4082], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [First Name5 (NamePattern1) 3403] [Last Name (NamePattern1) ], RDCS Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2011W000-0:00 Machine: Vivid q-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 9 < 15 Aorta - Sinus Level: 3.8 cm <= 3.6 cm Aorta - Ascending: 4.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 2.5 cm Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.13 Mitral Valve - E Wave deceleration time: 200 ms 140-250 ms TR Gradient (+ RA = PASP): 30 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [2184-8-31]. LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild-moderate regional LV systolic dysfunction. Apical LV aneurysm. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free wall. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal image quality - poor suprasternal views. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the distal half of the anterior septum and anterior walls, distal septum and apex. The apex is mildly aneurysmal. The remaining segments contract normally (LVEF = 40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (mid LAD distribution). Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [2184-8-31], the regional left ventricular systolic dysfunction is new and c/w interim ischemia/infarction. CLINICAL IMPLICATIONS: Based on [2183] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Mr.[Known lastname ] is a 61M transferred to the [Hospital1 18] from an OSH on [2187-6-24] for AAA rupture, taken to the OR immediately and underwent open repair of ruptured abdominal aortic aneurysm with 18 x 30 Hemashield tube graft. Intraoperatively, there were brief periods of hypotension which required intermittent phenylephrine boluses. At the end of the surgery, he was transferred to the CVICU on minimal inotropic support. His immediate post operative course was uneventful, though he did develop BRBPR on [6-25]. This was not accompanied by any hemodynamic instability or change in hematocrit. [2187-6-25] flex sig was done by gen [Doctor First Name ] and showed no transmural ischemia but did demonstrate mucosal ischemia at 20 cm. The pt was started on cipro/flagyl [6-27] for bowel ischemia. The pt remained intubated until POD #4 around noon-1pm, extubation was difficult likely [2-14] hypervolemia and he was aggressively diuresed. . Of note, in the setting of AAA rupture, aspirin and plavix were held. . The pt was comfortable and hemodynamically stable until around 655pm when he was talking to family entered afib and then vfib arrested. A code blue was called and the pt received chest compressions, three rounds of electrical cardioversion (200-300-300), 2 doses of epinephrine. He went from vfib into torsades into afib and was intubated. Amio gtt was started. TEE was performed by anesthesia and showed dyskinesis of the anteroseptum. ECG showed STE in AvR, V1 with ST depressions in the lateral percordial leads and inferiorly. He was taken emergently for catheterization and given integrillin x2, plavix 600mg and was started on a heparin gtt. Cath showed instent thrombosis of the LAD stent. Balloon inflation was used to recannulate the stent and the proximal edge of the stent was covered with a 3mm Promus. Swan was placed for invasive monitoring, with PCWP 25 and mixed venous O2 62%. . In the CVICU the pt had SBPs in the 80s-90s and was tachycardic to the 110s-130s with atrial fibrillation. He received a synchronized shock at 200J and converted to normal sinus with SBPs stable in the 90s. He remained intubated and sedated on fentanyl/propofol, and continued on amio, asa, plavix. CCU Course: The patient had Vfib arrest the evening of [6-28] ~ 7 pm. A code blue was called. The patient received chest compressions, 3 rounds of electrical cardioversion, and 2 doses of epi. He went from vfib into torsades and then atrial fibrillation. TEE was performed and showed dyskinesis of the anteroseptum. EKG showed STE in aVR, with diffuse ST depressions. He was taken emergently to the cath lab, where R radial catheterization was performed. Heparin gtt, integrillin, and plavix 600 mg were started (ASA and plavix had been held in the setting of AAA rupture). Cath showed instent thrombosis of the LAD - ballon angioplasty was performed and a DES was placed proximally. Swan was placed for invasive monitoring with PCWP of 25 nad mixed venous sat of 62%. 2U PRBCs were transfused on [6-29] AM for a Hct drop to 22.1 overnight. Cardiology recommended transient amiodarone gtt x ~ 24 hrs, continuation of ASA 325 mg, Plavix 75 mg per day, Prasugrel 10 mg per day, Atorvastatin 80 mg per day. On [6-29], patient's care returned to the vascular team. Repeat ECHO demonstrated mild to moderate regional left ventricular systolic dysfunction with akinesis of the distal half of the anterior septum and anterior walls, distal septum and apex and an EF of 40%, consistent with the territory of infarction. He had a 5-beat run of NSVT that was treated with potassium repletion and increase in beta-blockade. Patient remained intubated after his code until extubaion on [6-30]. He was diuresed on a Lasix gtt and amiodarone gtt was discontinued for PO amiodarone. On [7-1] patient passed his bedside swallow evaluation and was started on a clear diet, which he tolerated. He remained in the CVICU until [7-2] when he was stable to transfer to the stepdown VICU. Cardiology continued to follow him and titrated his medications apporpiately. He was out of bed and worked with physical therapy on multiple occasions. He ambulated independently and did stairs without difficulty. His diet was advanced and he tolerated a regular diet without problems. Nutritionist saw him and felt he had appropriate intake. On [7-5] he was completely stable and had finished his amio load. He was deemed stable for discharge home. He has appointments to follow up with his cardiologist Dr. [Last Name (STitle) 79710] in a week and will be seeing a new PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] within the next 2 weeks. He will return to see Dr. [Last Name (STitle) 1391] in [2-15] weeks. Medications on Admission: simvastatin ?, asa 325, plavix 150', metoprolol Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prasugrel 10 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:80 Tablet(s) Refills:2 4. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp:36 Tablet(s) Refills:0 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:24 Tablet(s) Refills:0 10. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: - Ruptured infrarenal abdominal aortic aneurysm - Thrombosed LAD stent causing VFIB arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [6-20] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [2-15] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions You also had thrombosis of your coronary stent and had a new drug eluding stent placed. You have been placed on a new medicine called Prasugrel and should not stop this medication under any circumstances unless cleared by your cardiologist. Followup Instructions: Please call Dr. [Last Name (STitle) 11918] office for follow up in 4 weeks [Telephone/Fax (1) 1393] Dr. [Last Name (STitle) 8421] (cardiology) [2187-7-10] 4:15pm [Telephone/Fax (1) 45578] [Hospital 79711] Medical [Telephone/Fax (1) 79712] Dr. [Last Name (STitle) ] will be your new PCP. [Name10 (NameIs) ] nurse will review your hospital paperwork and call you with an appointment. If you do not hear from her in the next 2 days, please call to follow up. Completed by:[2187-7-5]	[ "557.9", "997.1", "578.1", "441.4", "518.81", "411.81", "427.31", "272.4", "285.1", "427.1", "401.9", "V85.41", "278.00", "427.32", "458.29", "996.72", "287.5", "427.41" ]	icd9cm	[ [ [] ] ]	[ "88.72", "00.40", "99.20", "45.24", "99.62", "00.45", "36.07", "96.04", "96.71", "00.66", "38.44", "88.56" ]	icd9pcs	[ [ [] ] ]	23482, 23488	17503, 22298	316, 562	23623, 23623	1727, 8258	26733, 27258	1436, 1466		22397, 23459		23509, 23602	22324, 22374			23774, 26037	26063, 26710								15911, 17220	1481, 1708							17243, 17480							8396, 11418														262, 278										590, 991									23638, 23750							1013, 1204	1220, 1420
32,327	185,874	5687	Discharge summary	report	Admission Date: [2157-6-30] Discharge Date: [2157-7-4] Date of Birth: [2096-3-21] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[First Name3 (LF) 3984] Chief Complaint: Confusion Major Surgical or Invasive Procedure: none History of Present Illness: History was obtained primarily from the pt's wife. Mr. [Known lastname 6626] is a very pleasant 61 yo man with severe chronic venous stasis dermatitis and frequent LE cellulitis, DM2, CAD, diastolic dysfunction, COPD (FEV1 0.82, 33% predicted) and osteoarthritis who was brought in to the ED this morning because of confusion. . The wife reports that he was in his USOH, which is generally poor, until about four days PTA, when she noted the onset of mild confusion. She was unable to encourage him to come to his PCP or to the ED. She reports that he began having nausea and dry heaving as well, and he was unable to keep down significant oral intake. She reports that he also had decreased urine output ocver the past two days PTA. In addition, she reports that he has been having visual hallucinations at home. . Although he has OSA and has chronic difficulty sleeping, she reports that he has had even more difficulty lately. . She does not report significant change in the appearance of the pt's legs, although they chronically appear infected. He has not recently been on antibiotics (last course reportedly in [9-1]). . She deniss that he has had fevers or chills, but he has had some myoclonic jerks. . The pt denies shortness of breath, chest pain or bleeding from anywhere. He reports chills, but no fevers. He denies a cough or significant sputum production. . In the ED, his initial VSs were 99.2, 76, 108/75, 90%RA. His initial FSBS was 60, and he was given a [1-26] amp of D50 with some improvement in his confusion. He also received vancomycin, cefepime, aspirin, and calcium gluconate and insulin for hyperkalemia. Past Medical History: DM CAD--> s/p cardiac cath in [2153], RCA stent but needs others per cardiologist; Hemodynamic evaluation demonstrated mildly elevated right and left heart filling pressures with mean RA of 10mmHg, mean PCWP of 18mmHg and LVEDP of 22mmHg. There was evidence of moderate pulmonary HTN with a PAP of 50/18mmHg. CHF-->EF 50% OA--> bilateral hips, significantly limits mobility Ankylosing spondylitis OSA--> doesn't use his CPAP Social History: Lives with wife and son. [Name (NI) 6934] with cane; limited by significant OA in hips, deconditioning. Smokes 1ppd for ~25 years. Does not drink alcohol or use illicit drugs. Family History: n/c Physical Exam: Vitals: T: 97.3 BP: 93/40 P: 103 R: 25 SaO2: 95% 2LNC General: Chronically ill appearing, midlly drousy but easily rousable, tangential HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry Neck: no significant JVD Pulmonary: Lungs CTA bilaterally anteriorly, no wheezes, ronchi or rales Cardiac: distant heart sounds, RR, nl S1 ? loud P2, no murmurs, rubs or gallops appreciated Abdomen: soft, mild tenderness to deep palpation in RUQ/epigastrum, no rebound, normoactive bowel sounds Extremities: Ichthyotic [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816] with erythematous weping areas more distally. Toenails uncut and large. Pertinent Results: [2157-6-30] 11:03AM WBC-21.7# RBC-3.74 HGB-10.9# HCT-32.1# MCV-86# MCH-29.1 MCHC-33.9 RDW-14.6 [2157-6-30] 11:03AM NEUTS-87* BANDS-2 LYMPHS-1* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2157-6-30] 11:03AM PLT SMR-NORMAL PLT COUNT-375# [2157-6-30] 11:03AM GLUCOSE-138* UREA N-114* CREAT-2.7# SODIUM-125 POTASSIUM-6.9* CHLORIDE-89* TOTAL CO2-23 ANION GAP-20 . LE NIVS: No evidence of deep vein thrombosis in the lower extremities. . CXR: Mild bibasilar atelectasis, with small left pleural effusion. . Foot Xray: Severe diffuse soft tissue swelling of the feet and ankles with underlying neuropathic changes and osteopenia. No evidence of soft tissue gas. Possible soft tissue ulcer along the posterior aspect of the right foot at the heel. Brief Hospital Course: 61-year-old man with severe LE stasis dermatitis, DM2, osteoarthritis, COPD, OSA presented with sepsis secondary to cellulitis, also with confusion, acute renal failure and possible UTI, complicated by acute hypercarbic respiratory failure. Given his extremely poor prognosis, he and the family decided on comfort measures only. He expired quietly and peacefully on [2157-7-4]. Medications on Admission: Oxycodone long-acting 40mg PO tid Oxycodone-acetaminophen 1-2 tabs prn Lisinopril 2.5 daily Metoprolol XL 25 daily Atorvastatin 40 daily Furosemide 80 qam, 20 qpm Metformin XL 2g daily Glyburide 10 daily Rosiglitazone 8mg daily Allopurinol 300 daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "707.14", "276.1", "518.81", "728.88", "428.0", "707.03", "250.00", "038.9", "682.7", "584.9", "272.0", "459.81", "327.23", "995.92", "428.32", "276.7", "496", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4821, 4830	4105, 4488	275, 281	4881, 4890	3305, 4082	4946, 5082	2622, 2627		4789, 4798		4851, 4860	4514, 4766			4914, 4923										2642, 3286																												226, 237										309, 1955																1977, 2408	2424, 2606
25,588	135,412	17237	Discharge summary	report	Admission Date: [2161-7-2] Discharge Date: [2161-7-6] Date of Birth: [2090-4-21] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 71 year old nun who felt mildly lightheaded and tripped while going to the bathroom late at night. She remembers falling and then does not recall the events afterward. Initially she was transported to an outside hospital where she was found to have a laceration over her left eye which was sutured as well as C-5 and C-6 anterolisthesis on cervical spine films. She was left in a collar and started on Solu-Medrol bolus and drip. She was unable to move any of her distal extremities. PAST MEDICAL HISTORY: Lupus with nephropathy. Status post CVA in [2155] with mild residual right sided weakness in both the upper and lower extremities. Chronic constipation. Hypertension. Osteoarthritis. Right TKR. OUTPATIENT MEDICATIONS: Zestril 10 mg q.d., HCTZ 50 mg q.d., quinine p.r.n., Colace and Senokot p.r.n., Darvocet p.r.n., ASA 81 mg q.d., Tums 1.5 gm q.d., Fosamax. ALLERGIES: The patient states she is allergic to sulfa drugs, however, has been taking hydrochlorothiazide without difficulty. SOCIAL HISTORY: The patient is a nun at a local convent. PHYSICAL EXAMINATION: Vital signs initially were 96.8, 69, 143/79, 18, 95 percent in room air. Patient was GCS 15, in no acute distress, with a left head laceration over the left eye, well sutured without hematoma. Pupils were equal and reactive to light and accommodation approximately 3 mm. Extraocular motions were intact. She had regular heart rate. Lungs were CTA bilaterally. Nontender ribs. Abdomen soft without tenderness. Pelvis was stable to [Doctor Last Name ]. Extremities were without sensation in both the hands and the feet. Deep tendon reflexes were hyper-reactive at the patellae and Achilles tendons bilaterally. She had hip flexion [12-31] bilaterally without movement at the knees, ankles or toes. She had 3/5 strength bilaterally at the shoulders, [12-31] at the elbows and without movement of her hands or fingers. Rectal had decreased tone and trace guaiac positive. LABORATORY DATA: Initial laboratory work significant for hematocrit of 36.2. Sodium 129. Normal cardiac enzymes. EKG revealed sinus rhythm without ST changes. Initial radiology was negative chest and pelvic x-rays. Head CT was negative for acute bleed, mass or shift. C-spine CT was negative for fracture. Abdomen CT was negative for solid organ injury. There was some fluid around the rectum and a hypodense pancreatic lesion of which there was unclear etiology. HOSPITAL COURSE: The patient was admitted to the trauma SICU for suspected central cord syndrome. Solu-Medrol was continued. An orthopaedic spinal consult was obtained as well as a neurology consult. Her condition improved with the steroids. On hospital day two she was taken to the O.R. by Dr. [Last Name (STitle) 363] for posterior cervical laminectomy and fusion decompression between C-4 and C-7, after her MRI demonstrated a C5-C6 cord contusion with marked spinal stenosis in the area. Her course continued to improve and she was extubated without event and transferred to the floor where she has regained almost all of her gross motor function and is limited primarily now by fine motor control in her upper extremities. She shows more residual weakness on her right upper and lower extremities than the left side. This may be consistent with her prior CVA. The patient is discharged to a rehab facility in order to obtain occupational and physical therapy. She was given a soft collar to wear for comfort, but it is not mandatory that she wear this. She was restarted on her home medications. She should receive followup with Dr. [Last Name (STitle) 363] in 10 days. She should also receive followup some time in the future as an outpatient for her heme positive stools, given her advanced age which puts her at risk for colon cancer. Patient should receive followup serum chemistries as her sodium has been 129 to 130 throughout hospitalization, to insure that it does not trend down further. CONDITION ON DISCHARGE: The patient is discharged on [2161-7-6] in stable condition. DISCHARGE DIAGNOSES: 1. Status post fall. 2. Spinal stenosis. 3. Central cord syndrome and cord contusion at C5-C6. 4. Status post decompression of the posterior cervical lamina and fusion plating of C5-C6 and C6-C7 vertebrae. DISCHARGE MEDICATIONS: 1. Docusate 100 mg p.o. b.i.d. 2. Lisinopril 10 mg p.o. q.d. 3. Hydrochlorothiazide 50 mg p.o. q.d. 4. Quinine 325 mg p.o. h.s. p.r.n. paresthesias. 5. Calcium carbonate 500 mg p.o. t.i.d. 6. Multivitamin one p.o. q.d. 7. Benadryl 25 mg p.o. q.h.s. p.r.n. insomnia. 8. Acetaminophen 650 mg p.o. q.four to six hours p.r.n., not to be taken concurrently with Percocet. 9. Oxycodone/acetaminophen 5/325 mg one to two tablets p.o. q.four to six hours p.r.n. 10. Bisacodyl 10 mg rectal suppository b.i.d. p.r.n. constipation. 11. Famotidine 20 mg p.o. b.i.d. for at least 10 days as patient received high dose steroids which puts her at risk for stress ulcer. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 11889] Dictated By:[Last Name (NamePattern1) 42402] MEDQUIST36 D: [2161-7-6] 14:37 T: [2161-7-6] 14:39 JOB#: [Job Number 48306]	[ "710.0", "401.9", "583.81", "714.0", "952.03", "438.20", "722.0", "E885.9" ]	icd9cm	[ [ [] ] ]	[ "80.51", "81.02", "81.03" ]	icd9pcs	[ [ [] ] ]								4267, 4478	4501, 5443				2649, 4155																									915, 1185			1267, 2631																						158, 664																687, 890	1202, 1244	4180, 4246
60,441	112,475	37936	Discharge summary	report	Admission Date: [2187-4-12] Discharge Date: [2187-5-3] Date of Birth: [2133-11-27] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1384] Chief Complaint: Acute Renal Failure Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 53 year old man with HCV cirrhosis, complicated by recurrent ascites, SBP, encephalopathy, and portal hypertensive gastropathy who is being sent in by the liver center after yesterday's labs showed an elevated creatinine. Unfortuantely, the lab work is not available in our system. . He has had multiple admissions in the past six months for acute on chronic renal failure. His urine lytes are usually c/w with pre-renal azotemia. Renal U/S have showed no hydronephrosis. He typically improves with fluids, midodrine and octreotide. With renal failure, he has also had several episodes of hyperkalemia. . His most recent admission was from [Date range (1) 84789] for ARF, hyperkalemia, and refractory ascites. He had 9 L paracentesis on [2187-4-5]. Pt has no complaints since his discharge on Friday. He denies any change in urine output, dysuria. He has not been taking any medications other than prescribed--no NSAIDS. His wife only noticed his tremors worsened today. . ROS: (+) Diarrhea with lactulose (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: Hepatitis C diagnosed [2177] - viral load 335k [11/2186] - recurrent/refractory ascites requiring frequent paracenteses - history of hepatic encephalopathy - portal gastropathy without esophageal varices HepB coreAb positive, surface Ag negative [11/2186] Low back pain s/p disc surgery [2178], [2180] Radial right wrist fx at the end of [11-10] after fall Hemachromatosis, HETEROZYGOUS FOR THE C282Y MUTATION Spur cell hemolytic anemia -[2187-4-19] piggyback liver transplant Social History: He is married and lives with his wife. [Name (NI) ] is not working currently. Stopped smoking 6-7 months ago. Smoked 1 PPD since age 15. No alcohol in 2 years. Multiple tattoos. His wife organizes his medications. Family History: His father had ETOH cirrhosis. No history of kidney problems. Physical Exam: Vitals: T: 98.1, P: 87, BP: 119/75, R: 18, SaO2: 100RA General: Awake, alert and oriented x3, refused to do MOYB but did them forwards, NAD. HEENT: NC/AT, no scleral icterus noted, MMM Neck: supple, no LAD Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M noted Abdomen: positive bowel sounds, soft, nontender, distended but not tense. Extremities: 1+ pedal edema to knees bilaterally Skin: spider angiomas on chest, maculopapular rash on abdomen Neurologic: sl asterixis Pertinent Results: [2187-5-3] 06:30AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.8* Hct-30.1* MCV-95 MCH-30.7 MCHC-32.5 RDW-16.4* Plt Ct-232 [2187-4-28] 06:30AM BLOOD PT-11.7 PTT-26.7 INR(PT)-1.0 [2187-5-3] 06:30AM BLOOD Glucose-79 UreaN-42* Creat-2.0* Na-137 K-5.4* Cl-111* HCO3-19* AnGap-12 [2187-5-3] 06:30AM BLOOD ALT-30 AST-21 AlkPhos-346* TotBili-2.4* [2187-5-3] 06:30AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.6 Brief Hospital Course: 53 y.o. man with HCV cirrhosis, complicated by recurrent ascites, SBP, encephalopathy, and portal hypertensive gastropathy was admitted with recurrent acute on chronic renal failure that was managed with albumin, midodrine, and octreotide after paracentesis. Cr slightly improved to 2.6. Lactulose and rifaxamin were continued. Cipro was continued for sbp prophylaxis. On [2187-4-19], a liver donor became available and he underwent piggyback liver transplant. Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. Induction immunosuppression was given (solumedrola and cellcept). Five liters of ascites were removed. There was a size mismatch between the donor (smaller)and recipient bile duct. This was adjusted for by cutting a slit on top of the donor liver, using interrupted 5-0 PDS to accomplish a biliary anastomosis. Two drains were placed in the usual locations (posterior to liver and hilar area). Postop, he was transferred to the SICU for management. VRE rectal screen was positive. He experienced a lot of pain on top of his chronic back pain and required large amounts of narcotics. On postop day 1, he was extubated and resumed his home doses of oxycontin. Re-intubation for pulmonary edema was required on postop day 4. He was also found to have myocardial stunning from the stress of surgery. BNP was 39,512. Cardiology was consulted. Cardiac enzymes were negative. Diuresis and metoprolol were given. No cardiac event occurred and he was eventually extubated. Chest CT was negative for PE and notation was made of bilateral pleural effusions. Hepatic vasculature was patent. On [4-23], TTE demonstrated EF of 30%. There was moderate regional left ventricular systolic dysfunction with infero-lateral and apical akinesis, trace MR and borderline pulmonary artery systolic HTN. He was extubated on [4-25]. Of note, JP drains had large bilious outputs requiring albumin and fluid replacement. LFTs increased initially with t. bilirubin peaking at 12 then decreasing. Liver duplex demonstrated patent hepatic vasculature, but suboptimal visualization of the inferior vena cava, no intrahepatic biliary ductal dilation and a small amount of ascites. On [4-26], ERCP was performed noting extravasation of contrast from the biliary anastomosis was seen, with contrast tracking along the JP drain. A 10cm 8 French stent was placed. LFTs then continued to improve with JP drain outputs dropping and appearing non-bilious. He was transferred out of the SICU on [4-28] to the Med-[Doctor First Name ] unit where he continued to do well. Diet was advanced and tolerated. Glucoses were elevated requiring NPH daily with intermittent sliding scale regular insulin. Lateral JP was removed on [5-2]. Lateral JP creatinine was 2.3 with serum bili of 2.7. The medial JP remained in place. PT worked with him noting impulsivity and need for a rolling walker. He was cleared for home with home PT thru VNA. Medication teaching was done and he did fairly well with reinforcement. Insulin administration and glucoses checks were reviewed. He required assist from his wife for management of this. This plan was for VNA services to provide monitoring/instruction. Immunosuppression consisted of cellcept 1 gram [Hospital1 ] that was well tolerated. Steroids were tapered to 20mg daily per protocol and Prograf which was started on postop day 0 was adjusted per trough levels. On the day of discharge, Prograf trough was 10.9. Prograf was decreased to 4mg [Hospital1 ]. Creatinine increased postop to 3.6 after CT, but gradually decreased to 1.8. On the day of discharge, creatinine was 2.0 and potassium was 5.4. He was instructed to follow a carbohydrate consistent, 2gram potassium diet. He was discharged to home with VNA of Southeastern MA ([Telephone/Fax (1) 80441]). He had resumed his home dose of oxycontin 80mg tid with prn oxycodone 10mg approximately 3-4 times a day for breakthru pain. Medications on Admission: Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H as needed for pain. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO TID Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID Magnesium Oxide 400 mg Tablet daily Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID Pantoprazole 40 mg Tablet, Delayed Release daily daily Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Thiamine 100 daily Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA). Clotrimazole 10 mg 5 times a day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:42 Tablet(s) Refills:0 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day. Disp:1 bottle Refills:2 14. Insulin Regular Human 100 unit/mL Solution Sig: follow printed scale Injection four times a day. Disp:1 bottle Refills:2 15. Outpatient Lab Work STAT Labs: cbc, chem 10, alt, ast, alk phos, t.bili, trough prograf Fax results to [Hospital1 18] [Telephone/Fax (1) 697] attention [First Name4 (NamePattern1) 1060] [Last Name (NamePattern1) 8147] RN 16. insulin syringes NPH qd and prn sliding scale regular Low dose syringe with 25-26 gauge needle supply: 1 box refill: 1 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: HCV cirrhosis s/p liver transplant [2187-4-19] pulmonary edema, resolved myocardial stunning, resolved hyperglycemia on steroids Chronic back pain Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane)-impulsive with activities/walking Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if you have any of the warning signs listed below You will need to get labs drawn every Monday and Thursday Empty and write down drain output. Bring record of drain outputs to next transplant office appointment Apply dry gauze to your drain daily Check your blood sugars prior to meals and give insulin as directed on sliding scale No driving while taking pain medication You may shower No heavy [Last Name (un) 37604]/straining Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2187-5-7] 8:00 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2187-5-14] 10:30 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2187-5-24] 10:00 Completed by:[2187-5-3]	[ "070.32", "411.89", "070.54", "997.1", "249.00", "572.4", "585.9", "E878.2", "724.5", "V02.59", "275.0", "789.59", "338.29", "283.19", "428.0", "286.6", "997.4", "V09.80", "572.3", "537.89", "268.9", "E932.0", "276.52", "584.5" ]	icd9cm	[ [ [] ] ]	[ "50.59", "96.72", "96.04", "96.6", "51.85", "51.87", "88.72", "00.93" ]	icd9pcs	[ [ [] ] ]	9996, 10052	3434, 7414	291, 297	10247, 10247	3010, 3411	10980, 11470	2427, 2490		8312, 9973		10073, 10226	7440, 8289			10461, 10957										2505, 2991																												232, 253										325, 1646									10262, 10437							1668, 2175	2191, 2411
2,243	176,457	4988	Discharge summary	report	Admission Date: [2184-12-29] Discharge Date: [2185-1-4] Date of Birth: [2117-2-5] Sex: M Service: MEDICINE Allergies: Protamine Attending:[Last Name (NamePattern1) 7539] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: 1. Placement of PICC line [2185-1-3] History of Present Illness: 67 y/o M h/o DM, CRI, PVD S/P bilat BKA, CAD S/P 4v CABG in 94, S/P mult PTCAs (most recent in [11-1]). Presents with acute onset of CP at rest. Was [Location (un) 1131] paper, when felt unwell. Went to bed, did not improve. Had CP, n/v, SOB, diaphoresis, rigors. Describes CP as similar to pain at time of MI, substernal sharp, no radiation. Took nitro x 4, without relief. . Found to be in ventricular bigeminy by EMS, given lidocaine 100mg x 1. Also received an additional 2 NTG without improvement in pain. . In ED, found to have STE v1-v3, ST depressions in I, aVL, v4-v6. Given ASA, B-blocker, heparin gtt, morphine. Became painfree. Repeat ECG showed improvement, but not normalization of ST segments. Per previous discussions, and discussion in ED with cards fellow, opted for medical management. . Admitted to CCU Past Medical History: 1) CAD s/p 4v CABG [2172]: LIMA to D1, SVG to LAD, SVG to RCA, SVG to OM s/p mult PTCAs: PCI SVG ->LAD x 3, LCx x 2 most recent cath showed: R dominant LMCA: patent LAD: occluded proximally, SVG -> LAD occluded at ostium LCx: patent stents RCA: diffuse 80%, collateralization to LAD 2) CHF: 35-40% EF with regional LV dysfunction in 12/[2183]. 3) PVD- s/p BKA bilaterally in [2174] 4) Gastroparesis 5) Hypothyroid 6) DM II 7) CKD baseline around 1.4 Social History: Patient quit tobacco 37 years ago, used to smoke 2-3 packs a day for 15 years. Occasional alcohol use. No illicit drug use including IV drug use. Lives with wife in [Name (NI) 1468]. Retired. Family History: Father died in 50's from CAD Physical Exam: Vitals - T 99.7, HR 88, BP 112/80, RR 18, O2 sat 100% General - comfortable, NAD HEENT - OP clr, MMM, JVP 10 cm CVS - RRR, nl s1 s2, no m/r/g Lungs - coarse bibasilar crackles, no wheezes Abd - NABS, soft, NT/ND, no g/r Groin - bilat femoral bruits, R>L Ext - surgically absent bilaterally RLE: small <1cm ulcer, no surrounding erythema LLE: ~1cm ulcer, min purulent discharge, + surrounding erythema, non-tender Pertinent Results: Admission Labs: [2184-12-29] 08:20PM PT-12.7 PTT-26.3 INR(PT)-1.1 [2184-12-29] 08:20PM PLT COUNT-239 [2184-12-29] 08:20PM ANISOCYT-1+ MICROCYT-1+ [2184-12-29] 08:20PM NEUTS-93.5* LYMPHS-2.8* MONOS-3.0 EOS-0.5 BASOS-0.1 [2184-12-29] 08:20PM WBC-20.1* RBC-4.04* HGB-11.5* HCT-34.4* MCV-85 MCH-28.6 MCHC-33.6 RDW-16.3* [2184-12-29] 08:20PM CK-MB-NotDone cTropnT-0.07* [2184-12-29] 08:20PM CK(CPK)-73 [2184-12-29] 08:20PM GLUCOSE-420* UREA N-49* CREAT-1.8* SODIUM-131* POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-19* ANION GAP-22* Additional Pertinent Labs/Studies . Trends: WBC: 20.1 ([2184-12-29]) -> 22.9 ([2184-12-30]) ->> 11.7 Hct: 34.4 ([2184-12-29]) ->> 29.6 Creatinine: 1.8 ([2184-12-29]) ->> 1.1 CK: 73 -> 183 -> 140 -> 290 MB: x -> 12 -> 5 -> 5 Trop: .07 -> 1.18 -> 0.82 -> 0.61 . [2184-12-30] 09:03AM BLOOD %HbA1c-7.5* . Microbiology: Blood cultures: [2184-12-30] ; [2185-1-1] : no growth to date Urine cultures: [2184-12-31]: No growth . . ECG ([2184-12-29] 20:03): NSR @ 93, 2mm STE v1, ~1mm STE v2-v3, 2mm STD I, 1mm STD aVL, 2mm STD v4, 1mm STD v5-v6 . . Imaging: CHEST - PORTABLE AP ([2184-12-29]): Heart size is within normal limits. Multiple surgical clips are again demonstrated. The lungs are clear. No pleural effusion. No evidence of pneumothorax. Pulmonary vasculature does not appear engorged. . TTE ([2184-12-30]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately-to-severely depressed (ejection fraction 30 percent) secondary to severe hypokinesis of the entire interventricular septum and inferior free wall; the posterior wall is also somewhat hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. . LEFT KNEE ([2184-12-30]): Left knee, AP and lateral views show below-the-knee amputation. The stump margin at the tibia is well corticated except medially there is some indistinctness which may indicate early infection, however, there is no evidence of bone destruction to suggest frank osteomyelitis. The stump margin of the fibula is irregular with a small amount of heterotopic bone formation. Note is made of chondrocalcinosis in the knee. There is a small knee effusion. Small retropatellar osteophytes are present. There is soft tissue swelling at the margin. . EXTREMITY US ([2184-12-30]): Grayscale images of the left stump demonstrate an extensive fluid collection surrounding the stump with some internal echoes within it. Soft tissue edema is also seen. No color flow is seen in this area. Brief Hospital Course: 1) Ischemia - Patient presented with chest pain and changes on ECG concerning for ongoing ischemia, particularly ST elevation of V1-V3 as well as aVR with reciprocal depressions in I,II, aVL and V4-V6. Given his known severe CAD and lack of intervenable targets, the patient elected for medical therapy. Treatment was initiated with BB, statin, Heparin gtt, Plavix, ACE. The patient's cardiac markers were trended through his hospital course with peak CK 290 on [2184-12-31]. For the first few days of his stay, the patient had ongoing chest pain that was managed with morphine sulfate as well as SL Nitro that was eventually transitioned back to patient's home regimen of Imdur 90mg po bid. . 2) Pump - Patient's previously documented EF was 35-40% in [11-1]. A repeat echocardiogram performed during hospitalization showed an EF of 30%, likely secondary to progression of his ischemic cardiomyopathy. His I/Os and weights were monitored QD, and he remained euvolemic by exam. He was continued on an ECE-I for depressed EF. The patient would likely meet criteria for an ICD given his depressed EF and runs of NSVT. However, this was deferred given his code status. . 3) Rhythm - Patient was noted to have ventricular bigeminy by EMS en route to [Hospital1 18], which was successfully treated with a one-time administration of lidocaine. He was monitored on telemetry during hospitalization, which showed NSR, but with occasional PVCs and frequent atrial ectopy. He was also noted to have a few runs of NSVT (< 10 beats) on telemetry, which were asymptomatic and hemodynamically stable. . 4) Left BKA stump cellulitis - On admission the patient reported a history of rigors, chills, and a fever to 103 prior to hospitalization. He was noted to have a small ulcer on his left BKA stump that was draining purulent material and with a surrounding cellulitis. He was emperically started on Unasyn and evaluated by the vascular surgery service who recommended an ultrasound of the extremity. The U/S suggested the presence of a fluid collection. However, vascular service reviewed the images and did not feel there was a discrete pocket of fluid ammenable to drainage. The patient continued IV antibiotics with Unasyn while in house for an emperic 10 day course (ending on [2185-1-8]) which will be completed at the extended care facility. With treatment, the patient was noted to have a normalizing fever curve, resolving leukocytosis, and decreased erythema of the left stump. All blood cultures drawn throughout hospitalization were negative at the time of discharge. A lactate on the day of admission was 1.2. . 5) Chronic Renal Insufficiency - Patient has known CRI with a baseline creatinine previously reported to be 1.4-1.8. His creatinine was monitored during this hospitalization, and remained stable, with a baseline of 1.1-1.2. . 6) Diabetes - Patient was followed by the [Last Name (un) ] Diabetes consult service for aid in diabetes management. His blood sugars were monitored by finger sticks, and covered with a humalog sliding scale. His fixed dose insulin regimen was titrated up for hyperglycemia. At discharge, his regimen consisted of 32U NPH/18U reg QAM; 10U reg QPM, 16U NPH QHS. He was also discharged with instructions to follow up in [Hospital ] clinic the next day for reevaluation. . 7) Access - A PICC line was placed under radiographic guidance on [1-3]. . CODE - DNR/DNI verified with patient on admission Medications on Admission: lasix 60-80mg po qd, imdur 90mg [Hospital1 ], NPH30U qam with R18U qam +ISS, levoxyl 70ug, lipitor 80qhs, lisinopril 15 qd, MS contin 15-30mg prn, nitro tab, plavix 75 qd, roxicet prn, toprol 100qd. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO BID (2 times a day). 16. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty (30) U Subcutaneous once a day. 18. Insulin Regular Human 100 unit/mL Cartridge Sig: Eighteen (18) U Injection once a day. 19. Ampicillin-Sulbactam 3 gm IV Q6H Start [2184-12-29] need total of 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary: 1. ST-elevation myocardial infarction 2. Left LE stump cellulitis . Secondary: 1) CAD s/p 4v CABG [2172]: LIMA to D1, SVG to LAD, SVG to RCA, SVG to OM s/p mult PTCAs: PCI SVG ->LAD x 3, LCx x 2 2) CHF: EF 30% 3) PVD - s/p BKA bilaterally in [2174] 4) Gastroparesis 5) Hypothyroid 6) DM II 7) CRI baseline around 1.4 Discharge Condition: Fair. Patient is clinically stable, euvolemic, and O2 sats > 93% on room air. Patient has known severe CAD with multiple interventions previously. Patient is currently being managed only medically per his wishes. Discharge Instructions: 1. Please take all medications as prescribed. - You were started on an antibiotic called Unasyn. Please complete a full 10 day course (ending on [1-8]). 2. Please keep all outpatient appointments, including your appointment at the [Last Name (un) ]. Please call your prosthetic clinic to have your prosthetic refitted. 3. Weigh yourself every morning, [Name8 (MD) 138] MD if weight increases more than 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: 1500cc/day 4. Call if you have fevers, worsening pain, redness, or discharge from the left BKA stump. Followup Instructions: 1. Please follow up with the [Hospital ] clinic (Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 20667]. . 2. Please follow up with your cardiologist Dr. [First Name (STitle) 437] after discharge. You have an appointment with Dr. [First Name (STitle) 437] on Wednesday [2-23] at 09:30. The office of Dr. [First Name (STitle) 437] will contact you to try and get you an earlier appointment given your recent MI. Please call his office at ([Telephone/Fax (1) 13786] for questions or scheduling needs if you have not heard from them within one week. . 3. Please follow up with your PCP [Name Initial (PRE) 2169]: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Location (un) 2788] INTERNAL MEDICINE Date/Time: [2185-1-6] 3:00 . 4. Please follow up with the vascular surgery office of Dr. [Last Name (STitle) ], ([Telephone/Fax (1) 18181]. You have an appointment on [1-13], [2183] at 2:45 at [Hospital Unit Name 20668]. Please call for scheduling needs or questions. . 5. Please call the prosthetics office where you receive your care for a follow up appointment and wound care given your recent infection. Completed by:[2185-1-4]	[ "428.0", "443.9", "V45.81", "682.6", "707.12", "536.3", "997.62", "V49.75", "357.2", "585.9", "250.61", "250.51", "276.1", "244.9", "410.71", "362.01", "414.8" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10981, 11053	5481, 8943	288, 331	11433, 11648	2412, 2412	12271, 13499	1932, 1962		9196, 10958		11074, 11412	8969, 9173			11672, 12248										1977, 2393																												238, 250										359, 1191					2428, 5458											1213, 1702	1718, 1916
11,861	173,048	22373	Discharge summary	report	Admission Date: [2126-4-9] Discharge Date: [2126-4-16] Date of Birth: [2105-5-5] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1055] Chief Complaint: Hyperglycemia. Major Surgical or Invasive Procedure: Intubation R subclavian central line placement History of Present Illness: 20 yo woman with DM 1 s/p multiple admissions for DKA (most recent was [2126-3-28]), hyperlipidemia and depression presents to [Hospital1 18] ED with DKA. Throughout the day, she was not answering her home phone and family came to her house to find her lying in bed, obtunded, with FSG "critically high." EMS was called and she was brought the the ED where she was found to be hypothermic, hypotensive with SBP in 70s, with critically high glucose and ABG 6.79/20/80. She was given 12 L NS, 3 units prbcs, 6 units insulin IV then insulin gtt at 6 U/h, 9 amps of bicarb (over 3 hours), 80 meq KCl, Ceftriaxone and was eventually intubated to aid with hyperventilation. Peri-intubation, her abd exam was noted to be more distended, and U/S revealed she was noted to have free fluid in her abdomen. CT abd revealed diffuse bowel wall edema with free fluid (but no air) in the abdomen. No acute surgical issues. Patient was brought to MICU for further eval and treatment of DKA. In the MICU patient was found to be severly acidemic with a pH of 6.8. In the ICU patient was given aggresive IVF and put on insulin drip until anion gap acidosis corrected. Patient was also hypotensive and hypothermic in the MICU and started on empiric treatment with levo/flagyl/vanco for possible sepsis, cultures were sent. Patient anion gap acidosis eventually corrected and she weaned off the insulin drip and started on SC insulin. Patiented was extubated on [2126-4-11]. Past Medical History: 1. Diabetes Type I diagnosed in [2120] after her first pregnancy. Most recent Hgb A1C 10.4 % ([7-/2125]) 2. Hyperlipidemia 3. S/P MVA [5-4] - lower back pain since then. + back muscle spasm treated with tylenol. 4. Goiter 5. Depression 6. DKA admissions 7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [2122], not menstruating secondary to being on Depo-Provera shots 8. Genital Herpes Social History: -Born and raised in [Location (un) 669], the patient lived in house with siblings, mother, grandmother, and [Name2 (NI) 12232] when growing up. -Moved to her own apartment last [Month (only) 958]. -Graduated from [Initials (NamePattern4) ] [Last Name (NamePattern4) 669] High School. No hx of learning disability. -Attended job corp training following h.s., but presently unemployed feeling too overwhelmed between diabetes care and caring forher son. -Has dated boyfriend, [Name (NI) ] since age 14 (he is father of her son). -Feels close to mother, sister, and [Name2 (NI) 12232] who live nearby. -Denies abuse in childhood or adulthood. -Denies legal problems. Family History: GM with Type I diabetes. Otherwise non-contributory. Relatives with "acid in blood" not related to diabetes. Physical Exam: PE: T: 99.7 BP: 134/80 (117-143/60-80) P: 97-118 RR 20-30 02Sat:100% GEN - Somnolent but answering questions. Mildy tachypneic. HEENT - PERRl, EOMI, neck is supple, no LAD appreciated HEART - Tachy, reg rhythm, no murmurs appreciated LUNGS - B/l rales at bases. No wheeze or rhonchi. No accessory muscles ABD - Mild distension, non-tender, + BS normoactive. EXT - upper and lower ext warm and well perfused. Pt is anasarcic. NEURO - Alert and oriented x3, somnolent but responding to all questions appropriately. Pertinent Results: [2126-4-9] 10:29PM CREAT-1.4* SODIUM-159* [2126-4-9] 10:29PM CORTISOL-39.7* [2126-4-9] 10:29PM FDP-10-40 [2126-4-9] 10:29PM FIBRINOGE-176 D-DIMER-612* [2126-4-9] 09:08PM TYPE-ART TEMP-34.4 RATES-30/5 TIDAL VOL-550 PEEP-8 O2-40 PO2-88 PCO2-17* PH-7.26* TOTAL CO2-8* BASE XS--16 INTUBATED-INTUBATED [2126-4-9] 09:08PM GLUCOSE-486* LACTATE-2.1* K+-2.8* [2126-4-9] 09:03PM GLUCOSE-524* SODIUM-157* POTASSIUM-3.0* CHLORIDE-128* TOTAL CO2-8* ANION GAP-24* [2126-4-9] 09:03PM ALT(SGPT)-457* AST(SGOT)-1215* LD(LDH)-978* ALK PHOS-73 AMYLASE-203* TOT BILI-0.6 [2126-4-9] 09:03PM LIPASE-78* [2126-4-9] 09:03PM ALBUMIN-2.6* CALCIUM-5.7* PHOSPHATE-1.7# MAGNESIUM-1.4 [2126-4-9] 09:03PM CORTISOL-40.5* [2126-4-9] 09:03PM WBC-34.5* RBC-4.40# HGB-12.8# HCT-39.4 MCV-90# MCH-29.1 MCHC-32.5# RDW-14.2 [2126-4-9] 09:03PM NEUTS-75* BANDS-10* LYMPHS-9* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-5* MYELOS-0 [2126-4-9] 09:03PM PLT SMR-NORMAL PLT COUNT-157 [2126-4-9] 07:40PM TYPE-ART PO2-278* PCO2-23* PH-7.19* TOTAL CO2-9* BASE XS--17 [2126-4-9] 07:40PM GLUCOSE-556* LACTATE-2.3* NA+-154* K+-3.3* [2126-4-9] 06:17PM TYPE-ART PO2-81* PCO2-27* PH-6.86* TOTAL CO2-5* BASE XS--30 INTUBATED-INTUBATED [2126-4-9] 06:17PM LACTATE-3.1* [2126-4-9] 06:17PM HGB-9.9* calcHCT-30 [2126-4-9] 05:53PM GLUCOSE-723* LACTATE-2.4* K+-7.0* [2126-4-9] 05:53PM HGB-7.9* calcHCT-24 [2126-4-9] 04:52PM TYPE-ART PO2-292* PCO2-11* PH-6.80* TOTAL CO2-2* BASE XS--34 INTUBATED-NOT INTUBA [2126-4-9] 04:52PM O2 SAT-97 [2126-4-9] 04:42PM TYPE-[Last Name (un) ] PO2-56* PCO2-20* PH-6.75* TOTAL CO2-3* BASE XS--36 [2126-4-9] 04:42PM GLUCOSE-891* LACTATE-4.1* [2126-4-9] 04:42PM O2 SAT-77 [2126-4-9] 04:30PM GLUCOSE-942* UREA N-49* CREAT-2.3* SODIUM-146* POTASSIUM-5.2* CHLORIDE-119* TOTAL CO2-<5.0 NOTIF [2126-4-9] 04:30PM CK(CPK)-25* [2126-4-9] 04:30PM ALBUMIN-1.8* CALCIUM-5.6* PHOSPHATE-9.2# MAGNESIUM-2.1 [2126-4-9] 04:10PM TYPE-ART PO2-80 PCO2-20* PH-6.79* TOTAL CO2-3* BASE XS--33 INTUBATED-NOT INTUBA [2126-4-9] 04:10PM O2 SAT-90 [2126-4-9] 04:02PM TYPE-MIX PH-6.81* [2126-4-9] 04:02PM GLUCOSE-EXCEEDS RE LACTATE-3.5* NA+-142 K+-4.0 CL--112 [2126-4-9] 04:02PM freeCa-0.97* [2126-4-9] 03:35PM UREA N-41* CREAT-2.0# [2126-4-9] 03:35PM CK(CPK)-38 AMYLASE-102 [2126-4-9] 03:35PM CK-MB-1 cTropnT-<0.01 [2126-4-9] 03:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2126-4-9] 03:35PM URINE HOURS-RANDOM [2126-4-9] 03:35PM URINE HOURS-RANDOM [2126-4-9] 03:35PM URINE GR HOLD-HOLD [2126-4-9] 03:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2126-4-9] 03:35PM WBC-39.4* RBC-3.03* HGB-8.6* HCT-32.2* MCV-106* MCH-28.3 MCHC-26.6* RDW-13.6 [2126-4-9] 03:35PM PT-17.7* PTT-34.2 INR(PT)-2.1 [2126-4-9] 03:35PM PLT COUNT-230 [2126-4-9] 03:35PM FIBRINOGE-168 [2126-4-9] 03:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.023 [2126-4-9] 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2126-4-9] 03:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2126-4-9] 03:35PM URINE GRANULAR-0-2 COARSE GRANULAR CASTS . . CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases are notable for a consolidation in the left lower lobe. The right lower lobe has atelectasis. Bilateral tiny pleural effusions are seen. No pericardial effusion is noted. Within the abdomen, there is a large amount of ascites, new since the last examination. The entire GI tract is edematous, with enhancing walls. No evidence of perforation is seen. Several foci of air bubbles within the lumen of the GI tract are nondependent, probably reflecting air within lumina, not intramural air. The gallbladder wall is markedly edematous. The liver shows marked edema of the portal triads. The kidneys, adrenal glands, pancreas, spleen are otherwise unremarkable. A nasogastric tube is seen coiling in the stomach. CT OF THE PELVIS WITH IV CONTRAST: As noted above, there is a large amount of ascites, with several loops of fluid-filled edematous bowel, both small and large, floating within it. Bowel also notable for hyperemia, as noted throughout the GI tract. No definite free air is seen within the pelvis. Air is noted within the lumina of several loops of bowel, in a nondependent fashion. The uterus is notable for arterial enhancement of the broad ligament and endometrium. No region of obstruction is seen. A Foley is seen within the bladder, which is collapsed. Distal ureters are unremarkable. There is intraluminal air within the right inguinal region, intraluminal, probably representing recent phlebotomy. A small focus of air is also seen within the IVC. Osseous structures are unremarkable. Coronal and sagittal reconstructions confirm the findings above. MPR value 3. IMPRESSION: 1) Markedly edematous, hyperemic bowel from stomach to rectum, without evidence of obstruction. Ascites within the abdomen and pelvis, along with gallbladder wall edema and portal triad edema. A precise etiology for the ascites and bowel wall edema is not identified. 2) Left lower lobe consolidation, with tiny bilateral pleural effusions. Preliminary findings were discussed with Dr. [Last Name (STitle) 957] at approximately 7:30 p.m. on [2126-4-9]. . . CXR [2126-4-12]: There has been interval extubation and removal of a nasogastric tube. A right subclavian vascular catheter continues to cross the midline into the left brachiocephalic vein rather than coursing within the superior vena cava. The mediastinal contours appear slightly increased in the interval but may be accentuated by the degree of rightward patient rotation. Vascular crowding related to low lung volumes likely account for the accentuated appearance of the perihilar vasculature. However, it is difficult to exclude a component of mild volume overload. Bilateral hazy opacity suggests the possibility of layering effusions on this semi-erect study. Note is made of obscuration of the periphery of the left hemidiaphragm which appears more prominent than on the previous exam. Previously noted left retrocardiac opacity appears less prominent. IMPRESSION: 1) Decreased left retrocardiac opacity, which may relate to a resolving area of atelectasis or pneumonia. There remains obscuration of the peripheral left hemidiaphragm, which may be due to left pleural effusion and possibly a focal area of atelectasis or pneumonia in this area. 2) Persistent malpositioning of right subclavian vascular catheter, coursing into the left brachiocephalic vein. . . CXR [2126-4-14]: FINDINGS: A right central venous catheter is seen with the tip directed into the brachiocephalic vein. There is no PTX. There is no evidence of consolidation or effusion. Pulmonary vascular markings, cardiac silhouette and mediastinal contours are normal. IMPRESSION: Right CVL in the same place as prior study. Lungs are clear. . . Brief Hospital Course: ASSESSMENT: This is a 20-year-old female who presents with severe DKA. She has a history of multiple admissions in the past for DKA with the most recent being [3-28]. 1. DKA: The patient was admitted to the emergency department and was severely acidemic on admission with initial pH of 6.78 and a bicarbonate of 2. The patient was intubated for hyperventilation and received 9 amps of bicarbonate during resuscitation. She then received twelve liters of normal saline and was started on insulin drip. Cause of her severe DKA on this admission was unclear. CT scan of the abdomen was performed on admission which showed diffuse edema and question of an infiltrate on the chest CT. The patient also had elevated LFTs in the 12,000s on admission, which then trended down after resuscitation. She was extubated two days after admission and was weaned off the insulin drip three days after admission. The patient was transitioned to subcutaneous insulin that afternoon and her gap closed by 3:00 p.m. The patient was transferred to the medicine floor after her anion gap closed and continued to do well. The patient was followed by [Last Name (un) ] who made specific recommendations for her sliding scale with Glargine. At the time of discharge, the patient was continued on her 30 units of Glargine at night in addition to her sliding scale which was altered based on the patient's daily fingersticks. The patient's potassium and phosphate were aggressively repleted. The patient was tolerating p.o.'s by hospital day #3 and was out of diuresing. She required no further IV hydration after starting p.o.'s. . The cause of her DKA was unclear. The patient states that she felt nauseous and had an episode of vomiting prior to losing consciousness. However, of note, she denies fevers, upper respiratory symptoms, and other sick exposures. It is unclear how long the patient was down. However, based on labs on admission, it appears that the patient was down for an extended period of time. . 2. Hypotension. When the patient was admitted to the emergency department, her blood pressure was in the 70 systolic. Differential diagnosis at that time included sepsis, hyperthermia, cardiac ischemia, adrenal insufficiency, and hypovolemia. The patient did not require pressors in the MICU, but did receive twelve liters of normal saline and three units of packed red blood cells. In the ICU, the patient's sputum was cultured and was positive for Staph. aureus coag. positive. She was therefore started on vancomycin. Further speciation showed that the Staph. aureus was sensitive to oxacillin. However, patient's respiratory symptoms had completely resolved and therefore she was not continued on antibiotics as it was felt that this was the contaminant and the patient was colonized with Staph. aureus. Follow up CXR was clear as well. The patient's stool cultures were all negative for C. diff and blood cultures were all negative. Urine cultures were negative as well. The patient's cardiac enzymes were cycled in the MICU for possible cardiac ischemia and these were negative. The cortisol skin test results were performed and adrenal insufficiency was ruled out. The patient's blood pressure stabilized after fluid resuscitation and normalization of her blood sugars. . 3. Metabolic acidosis. This is most likely secondary to DKA on admission and resolved on transfer to the medicine floor. . 4. Acute renal failure. Again, this is likely due to both volume depletion and poor fluid flow given that the patient was down for an extended period of time. On admission, her creatinine was 2.3. This resolved back to her baseline of 0.6 on discharge. The patient had good urine output with no further evidence of renal failure on discharge. . 5. Abdominal distention. After resuscitation, patient's abdominal distention resolved. The markedly edematous colon that was seen on the initial CT was likely to be due to third spacing secondary to shock. The patient was having normal bowel movements by the time of discharge. . 6. Transaminitis and elevated INR. Again, this was thought to be secondary to shock liver. The patient's transaminitis resolved by the time of discharge and INR was back down to baseline of 1. . 7. Social. Patient has had twelve admissions to the ICU over the past two years with DKA. Therefore, both social work and case management became involved as on this admission, the patient was home alone with her 2-year-old son. DSS was contact[Name (NI) ] as it was felt that the patient would be unable to care for her son, if she was unable to care for herself at home. The purpose of contacting DSS was to allow for the patient to gain additional services in order to help care for her son so that she can take better care of her own health. A family meeting was called with the patient's mother and three aunts. This was explained extensively and also explained the details of the patient's illness and the need to keep her extremely healthy. This past admission, the patient may not have survived, if she had not been resuscitated within an hour of finding her. The resolution after this family meeting was that the patient's godmother will move in with the patient to help her care for her son and for herself. The godmother and another family member will also accompany the patient to all appointments. The patient will try to attend all of her appointments or reschedule appointments as needed. The patient will also meet with a nutritionist at [Last Name (un) ] and attend support group meetings as needed. DSS will come to the patient's house to assess the living situation and service options. The patient was given a sliding scale and will be seen by [Last Name (un) ] today after discharge to review her findings again. The patient was instructed to keep a log of all of her blood sugars for her appointment. Both the family and the patient seemed very pleased with this plan with the ultimate goal to keep the patient out of the hospital and healthy. . 8. Prophylaxis. The patient received Protonix while in the ICU and was on subcutaneous heparin. . 9. Hyperlipidemia. The patient was continued on her Lipitor. . 10. FEN. The patient was maintained on a diabetic diet and her potassium and phosphate were aggressively depleted. The patient's code status was full during this admission. Medications on Admission: lantus 30U qpm humolog SS by carb counting ASA 81 mg lipitor 40 qd zestril 10mg qd depo provera Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED). 3. Lantus 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous at bedtime. Disp:1 cartridge Refills:2 4. Med Alert Button Sig: One (1) once a day. Disp:1 Button Refills:0 5. Urine dip sticks Sig: One (1) strip once a day as needed: To check for Ketones in your urine. . Disp:1 Container Refills:0 6. wrist cock up brace Sig: One (1) brace once a day: Please wear each night. . Disp:1 brace Refills:0 7. Depo-Provera 150 mg/mL Syringe Sig: One (1) dose Intramuscular Q 3months. 8. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day: (Lisinopril). Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Diabetes Type 1 Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you develop a fever, nausea/ vomiting/ diahrrea, shortness of breath or chest pain. Please call your doctor (Dr. [Last Name (STitle) 3617] at [Telephone/Fax (1) 2378]) if your blood sugar is >300 or persistently in the 200's throughout the day. Please call your doctor with any questions about your symptoms. PLAN: 1) Your Godmother ([Doctor First Name ]) will move in with you. 2) Your Godmother or another family member will accompany you to all medical appointments. Please try to attend all of your appointments or reschedule your appointments for more convenient times as needed. 3) At your next appointment at the [Last Name (un) ] center, please ask about a Nutritionist and Support group meetings. 4) DSS will call you to set up an appointment to talk about possible services and options to help you care for both your own health as well as your son's health and wellbeing. 5) Please take all of your medications as prescribed. Continue to use your sliding scale for insulin and your Lantus (Glargine) at bedtime. This scale may be adjusted after your next appointment at the [Last Name (un) ] Center. 6) Please keep a log of all of your blood sugars and bring this log with you to your appointments. - Please follow-up with your PCP on [4-18] at 11am. - Please follow-up with Dr. [Last Name (STitle) 3617] on [4-17] at 8:45am. If you are unable to make this appointment, please try to follow-up with Dr. [Last Name (STitle) 3617] or his Nurse Practitioner in [12-2] weeks. Followup Instructions: - Please follow-up with your PCP on [4-22] at 11am. Please have labs drawn (CBC, LFT's and chem 7). . - Please follow-up with Dr. [Last Name (STitle) 3617] on [4-17] at 8:45am. If you are unable to make this appointment, please try to follow-up with Dr. [Last Name (STitle) 3617] or his Nurse Practitioner in [12-2] weeks. . Provider: [Name10 (NameIs) ] Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 274] Date/Time:[2126-4-30] 10:30 . Please follow-up with your Dentist for tooth pain within the next 1-2 weeks.	[ "240.9", "482.41", "570", "276.0", "785.52", "584.9", "038.9", "518.81", "276.5", "287.4", "250.33", "285.9", "995.92" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "99.04", "99.07", "96.71" ]	icd9pcs	[ [ [] ] ]	18179, 18185	10850, 17251	282, 331	18267, 18275	3665, 10827	19878, 20452	2999, 3110		17398, 18156		18206, 18246	17277, 17375			18299, 19855										3125, 3646																												228, 244										359, 1826																1848, 2273	2289, 2983
28,660	128,487	16047	Discharge summary	report	Admission Date: [2189-1-30] Discharge Date: [2189-2-7] Date of Birth: [2113-5-27] Sex: F Service: MEDICINE Allergies: Zestril / Maxaquin / Norvasc / Percocet Attending:[First Name3 (LF) 2962] Chief Complaint: CAD s/p cath with evolving hematoma Major Surgical or Invasive Procedure: - Cardiac catheterization and bare metal stent to LAD - Surgical repair of pseudoaneurysm History of Present Illness: Mrs. [Known lastname 45917] is a 75 year old woman with hypertension, CHF with diastolic dysfunction, PAF, type II diabetes, prior MI, lung cancer and s/p partial lung resection who was hospitalized at [Hospital1 18] from [2188-12-13] to [2188-12-23] for SOB and cough. She was treated for a CHF exacerbation as well as pneumonia. At the time of admission, she had hypertensive urgency with systolic blood pressures in the 200 range. She developed flash pulmonary edema requiring intubation x 3 days. Post intubation, she subsequently developed several episodes of hyptertension, requiring a nitro gtt. A renal ultrasound was negative for renal artery stenosis. Urinary metanephrines were also sent to rule out pheochomocytoma and were negative. Transient ischemic changes were noted on EKG during her hypertensive episodes. Troponin levels were elevated to a peak of 0.77 but CPK??????s were negative. An [Month/Day/Year 113] done on [2188-12-13] revealed hyperdynamic systolic function. There was severe mitral annular calcification and moderate thickening of the mitral valve chordae with at least mild to moderate [1-21]+ mitral regurgitation. Small pericardial effusion. . A pMIBI done in [12/2187] was negative for perfusion defects and showed an EF of 54% . Following discharge, the patient was seen by Dr. [Last Name (STitle) ] on [2189-1-19]. At that time, she was complaining of swelling in both hands and legs as well as in her face. She was also complaining of 3 pillow orthopnea at that time. She denises any PND. She denies any lightheadedness. She denies any claudication symptoms. She continues to have swelling her legs but reports that the swelling in her hands and face has improved. She reports having one episode of chest pain the other night after dinner. She said it occurred intermittently at rest over a few hours and then finally resolved spontaneously. She denies having any associated symptoms and states that this is the only episode of chest pain she has had since her hospitalization. Past Medical History: Cardiac risk factors: Diabetes, Hypertension . Cardiac History: no prior CABG, PCI, or PPM . PMH: Pneumonia [12-27] Hypertension Diabetes II Lung cancer s/p partial resection [2179] TAH/BSO Anxiety Chronic urticaria/hives Venous stasis Restless leg syndrome Chronic Renal Failure Mild to moderate mitral regurgitation Paroxysmal Atrial fibrillation on coumadin Cholecystectomy Milk ducts removed Cyst removed from buttocks Eye surgery for glaucoma Cataract surgery Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Family History: Non-contributory Physical Exam: VS: 99.8 144/50 53 19 97% on 1.5L General: Anxious appearing female in NAD HEENT: NCAT, MMM, o/p clear CV: RR, nl s1/s2 LUNGS: Clear anteriorly, unable to auscultate posteriorly due to hematoma ABD: Soft, NTND, NABS, no flank tenderness Ext: Large groin hematoma, currently with pressure dressing in place, palpable distal pulses bilaterally Pertinent Results: [2189-1-30] 10:00AM BLOOD WBC-9.2 RBC-3.64* Hgb-11.1* Hct-31.6* MCV-87 MCH-30.5 MCHC-35.0 RDW-15.6* Plt Ct-305 [2189-1-31] 05:22AM BLOOD WBC-7.9 RBC-3.05* Hgb-8.7* Hct-26.0* MCV-85 MCH-28.7 MCHC-33.6 RDW-14.5 Plt Ct-247 [2189-2-1] 05:08AM BLOOD WBC-8.8 RBC-2.87* Hgb-8.4* Hct-24.4* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.2 Plt Ct-214 [2189-2-1] 12:45PM BLOOD WBC-11.1* RBC-3.20* Hgb-9.6* Hct-27.7* MCV-86 MCH-30.1 MCHC-34.8 RDW-15.1 Plt Ct-246 [2189-2-1] 05:25PM BLOOD WBC-9.8 RBC-3.10* Hgb-9.2* Hct-26.6* MCV-86 MCH-29.8 MCHC-34.7 RDW-14.2 Plt Ct-175 [2189-2-2] 10:20AM BLOOD WBC-10.3 RBC-3.40* Hgb-9.9* Hct-29.3* MCV-86 MCH-29.3 MCHC-33.9 RDW-15.4 Plt Ct-224 [2189-2-2] 09:17PM BLOOD WBC-15.1* RBC-3.48* Hgb-10.4* Hct-30.1* MCV-87 MCH-30.0 MCHC-34.7 RDW-15.4 Plt Ct-281 [2189-2-3] 05:47AM BLOOD WBC-11.5* RBC-3.53* Hgb-10.5* Hct-30.5* MCV-86 MCH-29.6 MCHC-34.3 RDW-15.2 Plt Ct-265 [2189-2-4] 06:13AM BLOOD WBC-6.0 RBC-3.06* Hgb-9.0* Hct-26.6* MCV-87 MCH-29.6 MCHC-34.0 RDW-15.2 Plt Ct-225 [2189-2-5] 07:15AM BLOOD WBC-6.8 RBC-2.98* Hgb-8.8* Hct-26.2* MCV-88 MCH-29.6 MCHC-33.6 RDW-15.2 Plt Ct-241 [2189-2-5] 06:10PM BLOOD WBC-7.1 RBC-3.01* Hgb-8.8* Hct-26.5* MCV-88 MCH-29.2 MCHC-33.2 RDW-15.0 Plt Ct-224 [2189-2-6] 07:15AM BLOOD WBC-6.8 RBC-3.13* Hgb-9.1* Hct-27.3* MCV-87 MCH-29.1 MCHC-33.2 RDW-15.0 Plt Ct-227 [2189-1-30] 10:00AM BLOOD PT-13.2 INR(PT)-1.1 [2189-1-31] 05:22AM BLOOD PT-14.9* PTT-31.1 INR(PT)-1.3* [2189-2-1] 05:08AM BLOOD PT-13.5* PTT-29.3 INR(PT)-1.2* [2189-2-2] 10:20AM BLOOD PT-13.1 PTT-28.7 INR(PT)-1.1 [2189-2-2] 09:17PM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1 [2189-2-3] 05:47AM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1 [2189-2-4] 06:13AM BLOOD PT-13.9* PTT-30.8 INR(PT)-1.2* [2189-1-30] 10:00AM BLOOD Glucose-183* UreaN-44* Creat-1.3* Na-142 K-4.0 Cl-103 HCO3-26 AnGap-17 [2189-1-31] 05:22AM BLOOD Glucose-58* UreaN-42* Creat-1.4* Na-142 K-3.6 Cl-103 HCO3-28 AnGap-15 [2189-2-1] 05:08AM BLOOD Glucose-94 UreaN-54* Creat-2.6# Na-138 K-3.7 Cl-100 HCO3-28 AnGap-14 [2189-2-1] 12:45PM BLOOD Glucose-195 UreaN-54* Creat-2.9* Na-136 K-3.9 Cl-101 HCO3-25 AnGap-14 [2189-2-1] 05:25PM BLOOD Glucose-94 UreaN-56* Creat-3.0* Na-137 K-4.3 Cl-101 HCO3-23 AnGap-17 [2189-2-2] 10:20AM BLOOD Glucose-191* UreaN-60* Creat-3.5* Na-134 K-4.5 Cl-99 HCO3-23 AnGap-17 [2189-2-2] 09:17PM BLOOD Glucose-169* UreaN-64* Creat-3.8* Na-136 K-4.7 Cl-101 HCO3-24 AnGap-16 [2189-2-3] 05:47AM BLOOD Glucose-156* UreaN-67* Creat-4.0* Na-134 K-4.7 Cl-99 HCO3-24 AnGap-16 [2189-2-4] 06:13AM BLOOD Glucose-81 UreaN-70* Creat-3.6* Na-137 K-3.6 Cl-102 HCO3-26 AnGap-13 [2189-2-4] 05:10PM BLOOD Glucose-113* UreaN-70* Creat-3.1* Na-137 K-3.8 Cl-102 HCO3-25 AnGap-14 [2189-2-5] 07:15AM BLOOD Glucose-123* UreaN-69* Creat-2.7* Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [2189-2-5] 06:10PM BLOOD Glucose-140* UreaN-69* Creat-2.5* Na-138 K-4.1 Cl-102 HCO3-26 AnGap-14 [2189-2-6] 07:15AM BLOOD Glucose-132* UreaN-67* Creat-2.1* Na-139 K-4.0 Cl-104 HCO3-26 AnGap-13 [2189-1-30] 09:49PM BLOOD CK(CPK)-56 [2189-1-31] 05:22AM BLOOD CK(CPK)-48 [2189-2-2] 09:17PM BLOOD CK(CPK)-73 [2189-2-3] 05:47AM BLOOD CK(CPK)-72 [2189-2-2] 09:17PM BLOOD CK-MB-NotDone cTropnT-0.19* [2189-2-3] 05:47AM BLOOD CK-MB-NotDone cTropnT-0.23* [2189-1-31] 05:22AM BLOOD Calcium-8.0* Phos-4.7* Mg-2.3 [2189-2-1] 05:08AM BLOOD Calcium-8.1* Phos-5.3* Mg-2.3 [2189-2-1] 12:45PM BLOOD Calcium-7.8* Phos-5.7* Mg-2.3 [2189-2-1] 05:25PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.4 [2189-2-2] 10:20AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.2 [2189-2-2] 09:17PM BLOOD Calcium-8.2* Phos-7.1* Mg-2.3 [2189-2-3] 05:47AM BLOOD Calcium-8.5 Phos-7.5* Mg-2.4 [2189-2-4] 06:13AM BLOOD Calcium-8.1* Phos-6.5* Mg-2.3 [2189-2-4] 05:10PM BLOOD Calcium-8.2* Phos-5.0* Mg-2.4 [2189-2-5] 07:15AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.4 [2189-2-5] 06:10PM BLOOD Calcium-8.1* Phos-3.7 Mg-2.4 [2189-2-6] 07:15AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.4 [2189-2-3] 05:47AM BLOOD C3-131 C4-45* . [2189-1-31] 6:43 pm URINE Source: Catheter. FINAL REPORT [2189-2-3] URINE CULTURE (Final [2189-2-3]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ 8 S LINEZOLID------------- 2 S NITROFURANTOIN-------- 64 I TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . CT ABD/Pelvis [2189-1-30]: IMPRESSION: 1. Large hematoma within the anterior subcutaneous soft tissues of the proximal right thigh. Pseudoaneurysm seen on ultrasound appears to lie laterally to the hematoma and the relationship to the femoral vasculature is not well demonstrated on this non- contrast- enhanced CT. 2. No retroperitoneal hematoma present. . FEMORAL VASCULAR US RIGHT Reason: PSA, AVF. [Hospital 93] MEDICAL CONDITION: 75 year old woman with hematoma, bruit right groin. REASON FOR THIS EXAMINATION: PSA, AVF. INDICATION: 75-year-old woman with hematoma and bruit of the right groin after recent catheterization. No comparison is available. TECHNIQUE AND FINDINGS: [Doctor Last Name ] scale, color flow and Doppler images of the right groin area were obtained. There is a mostly anechoic lesion within the lateral groin which, based on the internal color flow pattern, is consistent with a pseudoaneurysm measuring approximately 3.4 x 1.9 x 1.7 cm. A [Location (un) 45918] of the pseudoaneurysm is identified which measures approximately 4 mm in diameter. The relationship of this pseudoaneurysm to the common and superficial femoral artery is not clear on the images provided. A large focus of hematoma is noted medial to the pseudoaneurysm measuring approximately 5.7 x 1.7 x 1.6 cm. IMPRESSION: Pseudoaneurysm within the right groin. The relationship of the pseudoaneurysm to the adjacent common femoral and superficial femoral arteries is not clear at this time, and a [Location (un) 45918] to the common femoral artery is possible. A follow-up ultrasound to better delineate the relationship of the pseudoaneurysm to the adjacent vessels may be of benefit. . FEMORAL VASCULAR US RIGHT [2189-1-31] 2:19 PM FEMORAL VASCULAR US RIGHT Reason: HX PSEUDO PLEASE EVAL FOR INTERVAL CHANGE [Hospital 93] MEDICAL CONDITION: 75 year old woman with pseudo-aneurysm and hematoma noted on ultrasound of [1-30]. REASON FOR THIS EXAMINATION: Please evaluate for interval change. Also please try to determine vessel of origin and neck. HISTORY: 75-year-old female with right groin pseudoaneurysm and hematoma seen on ultrasound from [2189-1-30]. Please evaluate for interval change. FINDINGS: Targeted ultrasound was performed in the patient's right groin in the area of known hematoma and pseudoaneurysm. Pseudoaneurysm in the right groin currently measures 3.5 x 5.5 x 2.4 cm, and measured 3.4 x 1.9 x 1.7 cm one day earlier, now with areas of increased internal grayscale echogenicity seen superolaterally, likely thrombus. Color Doppler evaluation continues to demonstrate swirling internal vascularity, consistent with pseudoaneurysm. On current study, the neck is well visualized and evaluated, approximately 6 mm at its origin, and approximately 1.6 cm in length, arising off the anterior aspect of the common femoral artery. Again seen medial to the pseudoaneurysm is a large groin hematoma, which measures 6.0 x 2.9 x 5.7 cm., unchanged. IMPRESSION: 1. Slight increase in size of long-necked pseudoaneurysm arising from the right common femoral artery in the right groin, although exact comparison is difficult given the interval formation of echogenic material consistent with thrombus within the pseudoaneurysm. 2. Unchanged appearance of hematoma medial to the pseudoaneurysm. . RENAL U.S. PORT; DUPLEX DOPP ABD/PEL Reason: please eval for hydro, and please do dopplers to emaluate re [Hospital 93] MEDICAL CONDITION: 75 year old woman with DM, CAD, diastolic CHF who now has acute on chronic renal failure after cath on [1-30] complicated by bleed from pseudoaneurysm REASON FOR THIS EXAMINATION: please eval for hydro, and please do dopplers to emaluate renal arteries RENAL ULTRASOUND ON [2-3] CLINICAL HISTORY: Renal failure, acute on chronic. Question hydro. FINDINGS: Grayscale and color Doppler ultrasound imaging of the kidneys was performed. The kidneys maintain normal size with slightly echogenic cortices. The right kidney measures 11.1 cm, the left kidney measures 10.8 cm. There is no hydronephrosis. There is a large 3.6-cm right lower pole cyst. Otherwise, the contours are smooth. Doppler analysis of the renal vascular system reveals markedly elevated resistance internally, with resistive indices approximating 1.0. Renal veins remain patent. IMPRESSION: No hydronephrosis. Somewhat echogenic kidneys, and elevated resistive indices. . [Month/Year (2) ] [2189-2-3]: Conclusions The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small-to-moderate sized pericardial effusion, primarily posterior to the RA and around the LV, without echocardiographic signs of tamponade. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. Small-to-moderate pericardial effusion. Compared with the prior study (images reviewed) of [2188-12-13], elevated RA pressures and mild pulmonary hypertension are identified. The other findings are similar. . CXR [2189-2-5]: IMPRESSION: Progressive improvement in pulmonary edema. Persistent bilateral effusions, left worse than right, with ongoing left base atelectasis. . Cath [2189-1-30]: COMMENTS: 1. Coronary angiography in this right dominant system revealed severe single vessel disease. The LMCA had no significant disease. The LAD had a calcified mid 70-80% stenosis. The LCx had a calcified proximal 40-50% stenosis. The RCA had mild luminal irregularities. 2. Limited resting hemodynamics revealed an elevated left sided filling pressure with LVEDP of 26 mmHg. There was severe arterial systemic systolic hypertension with SBP of 238 mmHg. 3. Left ventriculography was deferred. 4. Successful stenting of mid LAD with MiniVision 2.5x18mm stent post-dilated proximally to 2.75mm. 5. Renal angiography revealed 30% stenosis on right and no disease on left. 6. During sheath pull patient developed sizable hematoma requiring blood transfusion. She also developed a pseudoaneurysm which required surgical repair 2 days after the cath. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe left ventricular diastolic dysfunction. 3. Successful stenting of mid LAD with bare metal stent. 4. No renal artery stenosis. 5. Cath complicated by hematoma and pseudoaneurysm requiring surgical repair. Brief Hospital Course: # Coronary artery disease: The patient was initially admitted to the CMI service for catheterization to evaluate for coronary artery disease. She had a BMS placed to her LAD. Status post BMS to LAD as above. Cath complicated by evolving hematoma/pseudoaneurysm, see below. She was continued on aspirin and plavix for the next 30 days. She is to discontinue her coumadin for that time. Once plavix is discontinued, she will restart coumadin at her prior home dose. She was additionally continued on her statin. She was discharged on her home regimen of metoprolol. . # Right groin pseudoaneurysm: On post-cath check was noted to have a new bruit. This was evaluated by femoral ultrasound and the patient was found to have a large pseudoaneurysm. Initially, this was stable. Over the next 24 hours, patient required 3 units of prbcs. She was reevaluated and on repeat US was found to have an enlarging hematoma. Vascular surgery was consulted and the pseudoaneurysm was repaired in the OR. After repair, the hematoma was stable and her Hct continued to improve for the duration of her hospitalization. She will follow up with Dr. [Last Name (STitle) 1391] in 2 weeks for staple removal. This appointment has been arranged for her. . # Hypertensive Urgency/Respiratory distress: On [2-2], in the setting of decreasing urine output, the patient began to become anxious, and her systolic blood pressure was found to be in the 200s. She began to develop respiratory distress. She was emergently started on a nitro drip in the setting of flash pulmonary edema from hypertensive urgency and diastolic dysfunction. Her blood pressure was sustained in the 200s and a code blue was called. The patient was intubated and taken to the CCU. She was then transiently hypotensive with sBP in the 70s likely secondary to sedation given during intubation, and required peripheral dopamine overnight. She was successfullly extubated on [2189-2-3]. Her pulmonary edema improved as did her blood pressure. She was transferred back to the medical floor on [2189-2-4]. . # Acute Renal Failure: Patient began to develop increasing creatinine and low urine output 2 days after her catheterization after her pseudoaneurysm repair. Baseline creatinine 1.3-1.5, and reached a peak of 4. This was thought to be a combination of contrast-induced nephropathy combined with hypovolemia as a result of acute blood loss from her pseudoaneurysm. She was initially started on a lasix drip in the setting of low urine output and volume overload after her flash pulmonary edema. Her creatinine began to improve over time as did her urine ouput. A renal ultrasound was done which showed no evidence of hydronephrosis and a renal angiogram was negative for RAS. Her creatinine had returned to near baseline prior to discharge. . # Pump: [Date Range ] during this admission showing LVEF>55%. History of chronic diastolic dysfuction. She will be discharged on her home regimen of Lasix. . # Valves: 1+ MR [First Name (Titles) ] [Last Name (Titles) ] this admission, no current issues. . # Rhythm: History of paroxysmal afib, now in sinus. On coumadin as an outpatient. As per Dr. [Last Name (STitle) ], she will continue ASA, plavix for 30 days, resume coumadin once discontinues plavix. No telemetry events. . # Anemia: Baseline Hct of 28-30 with Hct prior to cath 31.6. Has been stable and increasing since pseudoaneurysm repair. Near baseline at the time of discharge. . # UTI: Patient was found to have a VRE UTI during her admission. She was started on IV Ampicillin based on sensitivities and is discharged on Amoxicillin to complete a 10 day course of antibiotics. She should have a repeat UA once she has been treated to confirm complete resolution of her UTI. . # Agitation/anxiety: Patient has significant anxiety at baseline. Takes ativan qhs at home with occasional prn doses. During her last admission, 1mg IV ativan caused increased agitation. She was started on oxazepam 15mg qhs with once daily prn dosing for anxiety attacks as well as sertraline 50mg qhs. Currently on ativan PO and sertraline 75 qhs. She was continued on her outpatient regimen. . # DM II: ISS during admission. On Glyburide at home. Last HgbA1c 6.6 in [9-27]. Restarted on home regimen on discharge. . # Code - FULL . # Contact: [Name (NI) 4906] [Name (NI) 45919] [Telephone/Fax (1) 45920]. Medications on Admission: Coumadin, MWF 5mg, 6mg other days, last dose [2189-1-25] Aspirin 162mg daily in the am Lasix 40mg, 2 tablets in am, 1 tablet in the PM Metoprolol XL 100mg daily in the am Hydralazine 75mg TID Glyburide 2.5mg [Hospital1 ] Cosupt eye gtts 1 gtt right eye [Hospital1 ] Colace 100mg 1-2 times daily Imdur 60mg 2.5 tablets daily Pravastatin 40mg daily in the PM Xalatan eye gtts 1 gtt both eye qhs Lorazepam 1mg Qhs Trazadone 25mg qhs Sertraline 75mg daily qhs 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:0 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:4 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DINNER (Dinner). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 15. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Imdur 60 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO once a day. 17. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days. Disp:18 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Bear [Doctor Last Name ] Nursing Ctr. Discharge Diagnosis: CAD Hypertension Chronic diastolic dysfunction Vancomycin-resistant UTI Right groin pseudoaneurysm status post repair Discharge Condition: Hemodynamically stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liter/daily. Please take Aspirin and Plavix for 1 month. Please hold Coumadin for this duration then restart coumadin once you have completed your plavix. While you were here, you were found to have a blockage in one of your coronary arteries which was opened. You then developed a collection of blood in your leg (pseudoaneurysm). You had this repaired surgically, and it has been stable. You should not do any strenuous activity for the next few weeks. In addition, your kidney function decreased while you were here. It has been steadily improving. However, you should follow up with a Nephrologist as below when you are discharged to follow your kidney function. You were also found to have a urinary tract infection. Please take your Amoxicillin as prescribed. You should have a repeat urine test once you have completed your antibiotics to make sure that you have cleared your infection. Your primary care doctor can do this for you. We have discontinued your hydralazine since your blood pressure has been lower while you were here. You should follow up with your primary care doctor to determine if you need this medication or not. If you develop any chest pain, leg pain, shortness of breath, decrease in your urine amounts, or any other symptom that concerns you, please seek medical attention immediately. Followup Instructions: Please keep the following follow up appointments: Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2189-5-7] at 4:30pm. The phone number there is ([Telephone/Fax (1) 7236]. Provider: [Name10 (NameIs) 1576],[First Name8 (NamePattern2) 2352] [Doctor Last Name 4694] APG (SB) Phone:[Telephone/Fax (1) 1579] Date/Time:[2189-2-16] 9:10 Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391] on Wednesday, [2-25] at 2:30 pm for staple removal. Please call his office at ([Telephone/Fax (1) 4852] with any questions. In addition, you should follow up with a Nephrologist to further evaluate your renal function. You can call ([Telephone/Fax (1) 773] to set up this appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2964] MD, [MD Number(3) 2965]	[ "998.12", "584.9", "585.3", "V17.3", "428.32", "V10.11", "997.2", "427.31", "403.90", "250.40", "599.0", "285.1", "518.81", "428.0", "041.04", "V09.80", "414.01", "458.8", "442.3" ]	icd9cm	[ [ [] ] ]	[ "83.09", "96.71", "00.40", "88.56", "39.52", "96.04", "36.06", "99.04", "00.45", "00.66", "37.22" ]	icd9pcs	[ [ [] ] ]	21632, 21700	15126, 19527	335, 426	21862, 21887	3628, 8688	23381, 23407	3232, 3250		20046, 21609	11772, 11927	21721, 21841	19553, 20023		14848, 15103	21911, 23358										3265, 3609																												260, 297	11956, 14831						23432, 24284			454, 2512																2534, 3009	3025, 3216
58,634	137,133	47532	Discharge summary	report	Admission Date: [2104-3-2] Discharge Date: [2104-3-25] Date of Birth: [2039-12-30] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2836] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: [2104-3-3]: EGD/EUS [2104-3-8]: Exploratory laparotomy, lysis of adhesions, washout of succus and pus; transcutaneous gastrostomy tube, drain placement and delayed abdominal wound closure. [2104-3-11]: Re-exploration, biopsy of liver and tumor cavity, open cholecystostomy tube placement and placement of vacuum dressing over 50 cm2. [2104-3-18]: Micromesh closure of abdominal wall, 25 x 15 cm and negative pressure last dressing. History of Present Illness: 64M with a history of Hep C and hemachromatosis who was transferred from [Hospital3 10310] Hospital this evening for UGI bleed. He reports that he has been experiencing vague central abdominal pain for approximately 2 weeks. In the last 5 days, the pain has gotten progressively worse. Two nights ago he developed nausea and had one episode of vomiting of primarily previously ingested food. His pain and nausea led him to present to [Hospital3 85745] Hospital this evening where he was administered oral contrast for a CT scan. The contrast caused him to become nauseous again and he developed vomiting of coffee ground emesis. An NGT was inserted and the coffee ground did not clear with NG lavage. He does report feeling some dizziness/lightheadedness when he stands and it was noted at the OSH that he had orthostatic hypotension. He was given a total of 1800cc of crystalloid and no blood products before being transferred here. The patient reports that he has had vague abdominal pains on and off for several years but these episodes were typically mild and resolved spontaneously. He also endorses a 100lb weight loss over the last 4 years ever since his stroke, not all of which was intentional. Mr. [Known lastname 100481] is followed by Dr. [Last Name (STitle) 100482] (GI physician) at [Hospital ] Hospital. According to the patient, his last upper endoscopy was in [2082] when his hemachromatosis was diagnosed at [Hospital1 2025]. At that time, he remembers that he was told that he had enlarged bile ducts and a liver masses. He underwent a biopsy of this liver mass and the pathology was reportedly negative. His last colonoscopy was approximately 2 years ago and he says they found and removed some polyps. Past Medical History: hemachromatosis, hep C, HTN, BPH, stroke ~4 yrs ago without any residual deficits, IDDM type II Social History: Lives at home with wife and son, daughter is away at college. ~25 pack year remote smoking history. Drinks alcohol occasionally/socially. Denies recreational drugs. Family History: mother had gastric cancer in her 80's, father had prostate cancer. No other malignancy or hemachromatosis that he knows about. Physical Exam: On Discharge: VS: 98.3, 65, 135/70, 20, 94% RA GEN: AAO x 3, NAD CV: RRR, no m/r/g Lungs: CTAB, diminished b/l on bases Abd: ~ 20cm x 10cm midline incision with VAC dressing, - 125 mmHg continuous suction (During transport VAC would be changed to wet-to-dry dressing). Midline G-tube capped, site with dry dressing and c/c/d. RLQ with JP to bulb and PTC drain to gravity, site with dry dressing and c/d/i. Coccyx: Stage I pressure ulcer - healing Extr: Warm, thin, +1 pitted edema b/l Pertinent Results: [2104-3-3]: EGD: Food in the stomach body Ulcer in the second part of the duodenum EUS: Changes of Chronic pancreatitis in the body and tail of pancreas. Large pancreatic mass 7.85cm x 5.3cm in the pancreatic head. FNA performed. Celiac lymph nodes. FNA of the celiac nodes performed. DDx: Pancreatic mass that is possibly malignancy (adenoCA), degenerated IPMN, MCN, cystic NET and inflammatory mass. [2104-3-3]: Cytology Panc head mass: POSITIVE FOR MALIGNANT CELLS, Consistent with adenocarcinoma. [2104-3-3]: Cytology Celiac LN: POSITIVE FOR MALIGNANT CELLS, Consistent with metastatic adenocarcinoma [2104-3-8]: CT chest: 1. Small pneumoperitoneum, abdominal CT is recommended for further assessment. Small amount of free fluid in the partially visualized upper abdomen. 2. Moderate right and small left pleural effusions with bibasilar opacities, likely atelectasis, new since [2104-3-1]. 3. Small pericardial effusion, new since [2104-3-1]. 4. No evidence of metastatic disease to the chest. [2104-3-8] CTA chest: 1. No evidence of PE, as clinically questioned. 2. Stable bilateral pleural effusions with adjacent compressive atelectasis. Small hypodense foci within the atelectasis at the right base could represent small loculation of fluid versus infection. 3. Tiny foci of pneumoperitoneum within the partially imaged upper abdomen. A followup abdominal-pelvic CT is recommended. [2104-3-8] CT abdomen: 1. Large heterogeneous enhancing pancreatic mass replacing the pancreatic head, neck, and uncinate process, not significantly changed in size or appearance since the prior outside hospital study, given differences in technique. 2. Likely invasion of the pancreatic mass into the duodenum, with findings concerning for ulceration of these structures, which if perforated may explain the tiny foci of pneumoperitoneum with the right upper quadrant. Gross defect not clearly identified, but presumably from bowel given the tiny foci of pneumoperitoneum. 3. Dilated pancreatic duct containing a focal defect anteriorly which empties into a 2.0 x 4.0 x 3.5 cm walled-off fluid collection, consistent with a pseudocyst, anterior to the pancreas. 4. Distal pancreatic duct is not dilated, but contains calcifications consistent with chronic pancreatitis. 5. 9.7 x 9.4 x 3.6 cm infrahepatic fluid collection, likely abscess. 6. 4.1 x 3.3 x 3.7 cm left hemipelvic fluid collection, likely abscess. 7. Small abdominal and pelvic ascites with peritoneal enhancement, suggesting inflammation. Fluid is thought to be secondary to either leakage from pancreatic duct versus contents from the stomach and/or duodenum due to ulceration by the pancreatic head mass. 8. Abnormal small bowel mucosal enhancement and diffuse dilatation of both the large and small bowel with no definite transition point. Given the evidence of peritoneal inflammation, this likely represents an ileus secondary to a chemical peritonitis rather than a bowel obstruction. [2104-3-11] Pathology Examination: SPECIMEN SUBMITTED: CYST WALL, LIVER BIOPSY, GALL STONES. Procedure date Tissue received Report Date Diagnosed by [2104-3-11] [2104-3-11] [2104-3-18] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mn???????????? Previous biopsies: [Numeric Identifier 100483] left lateral segment liver biopsy. DIAGNOSIS: A. Pancreatic cyst wall: 1. Fibrinopurulent exudate and granulation tissue, consistent with abscess. 2. No malignancy identified. 3. No microorganisms are seen on GMS or PAS stains. B. Liver, wedge biopsy: Atypical bile duct proliferation with associated acute and chronic inflammation, favor bile duct hamartoma. C. Gallstones: Gross examination only. [2104-3-22] 16:06 COMPLETE BLOOD COUNT White Blood Cells 14.7* 4.0 - 11.0 K/uL PERFORMED AT WEST STAT LAB Red Blood Cells 2.91* 4.6 - 6.2 m/uL PERFORMED AT WEST STAT LAB Hemoglobin 9.2* 14.0 - 18.0 g/dL PERFORMED AT WEST STAT LAB Hematocrit 27.3* 40 - 52 % PERFORMED AT WEST STAT LAB MCV 94 82 - 98 fL PERFORMED AT WEST STAT LAB MCH 31.6 27 - 32 pg PERFORMED AT WEST STAT LAB MCHC 33.6 31 - 35 % PERFORMED AT WEST STAT LAB RDW 15.3 10.5 - 15.5 % PERFORMED AT WEST STAT LAB BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 485* 150 - 440 K/uL [2104-3-25] 04:23 RENAL & GLUCOSE Glucose 195* 70 - 100 mg/dL IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES PERFORMED AT WEST STAT LAB Urea Nitrogen 20 6 - 20 mg/dL PERFORMED AT WEST STAT LAB Creatinine 0.8 0.5 - 1.2 mg/dL PERFORMED AT WEST STAT LAB Sodium 132* 133 - 145 mEq/L PERFORMED AT WEST STAT LAB Potassium 4.9 3.3 - 5.1 mEq/L PERFORMED AT WEST STAT LAB Chloride 104 96 - 108 mEq/L PERFORMED AT WEST STAT LAB Bicarbonate 23 22 - 32 mEq/L PERFORMED AT WEST STAT LAB Anion Gap 10 8 - 20 mEq/L CHEMISTRY Calcium, Total 7.9* 8.4 - 10.3 mg/dL PERFORMED AT WEST STAT LAB Phosphate 3.9 2.7 - 4.5 mg/dL PERFORMED AT WEST STAT LAB Magnesium 2.1 1.6 - 2.6 mg/dL PERFORMED AT WEST STAT LAB Brief Hospital Course: Mr. [Known lastname 100481] was admitted to the SICU with a GI bleed and a CT from the OSH showing a large pancreatic head mass. He was made NPO with an NGT/foley. He was febrile to 102.6 and pan cultured. He underwent an EUS/EGD which demonstrated an ulcer in the second part of the duodenum. The EUS also demonstrated a large pancreatic mass 7.85cm x 5.3cm in the pancreatic head. An FNA performed. Large celiac lymph nodes were also seen and biopsied. His hematocrit and vital signs were stable so he was transfered to the floor on [3-3]. The NGT was removed. His diet was advanced to clears and an H pylori was sent (result negative). He was started on cipro per GI recs after the EGD/EUS. His FNA results were positive for locally advanced unresectable pancreatic cancer. On [3-5] he triggered for low 02 sats. Chest xray showed a large gastric bubble. On [3-6] he was advanced to fulls and his oxygen requirement was weaned down. On [3-7] Oncology was consulted. He had a non-contrast CT of the chest for staging purposes per oncology. The patient was unable to tolerate POs likely secondary to gastric outlet obstruction so a PICC line was placed and TPN was started on [3-7]. The intention was to do a palliative bypass the following week when he stabilized medically. On [3-8] the patient became hypoxic, hypotensive and CT demonstrated a perforated duodenum. He was taken emergently to the OR for an exploratory laparotomy, drainage and Gtube placement. There were multiple suspicious lesions on the liver which were biopsied. He was transfered to the SICU intubated, sedated, on multiple pressors, broad spectrum antibiotics, with an open abdomen. His pressors were weaned off over the course of 3 days. He was taken back to the OR on [3-11] for a washout. The perforated area of the duodenum was still difficult to access and he was left with a drain in place and an open abdomen and VAC placement. The patient was extubated on [3-13]. Palliative care was consulted to help guide the discussion with the patient and family regarding palliation and hospice care. The patient was made DNR and they decided to ultimately get the patient through his acute illness with the goal to discharge to hospice. The VAC was changed on [3-14] at the bedside in the SICU. On [2014-3-15], Mr. [Known lastname 100481] was diuresed and TPN was continued in the SICU. He was transfered to the floor on [3-17] in stable condition. On [3-18], he was taken back to the OR for closure of the abdomen with vicryl mesh. After the operation, the patient was transferred on the floor. He remained afebrile and hymodynamically stable. The patient was continued on TPN, his G-tube was clamped on [2104-3-19] and he tolerated well. The patient was started on clear liquid diet on [2104-3-20], his diet was advanced to fulls on [2104-3-21] which patient tolerated well. Before discharge on [3-25], the VAC dressing was removed and changed to a wet to dry for transport. Patient was having intermittent diarrhea during his admission and pancreatic exocrine insufficiency should be considered if this persists. Medications on Admission: verapamil 480mg daily, metformin 1000mg [Hospital1 ], actos 45mg daily, lisinopril 40mg daily, humulin N 30units QAM and QPM, HCTZ (dose unknown) Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) mg Injection Q15MIN () as needed for hypoglycemia protocol. 2. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty Six (36) units Subcutaneous QAM and QPM. 3. insulin regular human 100 unit/mL Solution Sig: see scale units Injection every six (6) hours: 0-70 mg/dL [Hospital1 ] with hypoglycemia protocol, 71-100 mg/dL give 0 Units, 101-120 mg/dL give 2 Units, 121-140 mg/dL give 4 Units, 141-160 mg/dL give 6 Units, 161-180 mg/dL give 8 Units, 181-200 mg/dL give 10 Units, 201-220 mg/dL give 12 Units, 221-240 mg/dL give 14 Units 241-260 mg/dL give 16 Units, 261-280 mg/dL give 18 Units, > 280 mg/dL Notify M.D. . 4. verapamil 240 mg Tablet Extended Release Sig: Four Hundred Eighty (480) mg PO Q24H (every 24 hours): hold if HR < 60, SBP < 100; extended release formulation. 5. lisinopril 20 mg Tablet Sig: Forty (40) mg PO DAILY (Daily): Hold if SBP < 100. 6. pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous Q12H (every 12 hours). 7. sodium chloride 0.9 % 0.9 % Piggyback Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 8. DiphenhydrAMINE 25 mg IV HS insomnia 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. HYDROmorphone (Dilaudid) 0.5 mg IV ONCE PRN vac change 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: 1. Locally metastatic pancreatic adenocarcinoma 2. Duodenal ulcer 3. Duodenal perforation Discharge Condition: A&O x3, ambulating with assistance, VAC dressing over abdomen (whitefoam sponge), pain well controlled, tolerated 1000cc/day full liquids in addition to his TPN. Cholecystostomy tube with 300-400cc/day bilious output, JP with ~35cc/day serosanguinous output, gastrostomy tube with no output, having normal bowel movements. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-6] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: VAC dressing would be changed Q72H by [Month/Year (2) 269] nurses, using whitefoam sponges, -125mmHg continuous pressure. If VAC is not available, a normal saline wet to dry dressing [Hospital1 ] may be used. Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [Hospital1 269] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PTC Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [Hospital1 269] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PICC Line: Please monitor the site regularly, and [Name6 (MD) 138] your MD, nurse practitioner, or [Name6 (MD) 269] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [Name6 (MD) ] your MD [First Name (Titles) ] [Last Name (Titles) 10836] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [Name2 (NI) 269] Nurse if the dressing comes undone or is significantly soiled for further instructions. G-tube Care: Keep capped Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2104-4-2] 2:00 Provider: [First Name8 (NamePattern2) ] [Name8 (MD) 4322], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2104-4-2] 2:00 [Hospital Ward Name 23] 9, [Hospital Ward Name ] . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2104-4-11] 10:30 [Hospital Ward Name 23] 3, [Hospital Ward Name ] . Please follow up with your PCP [Last Name (NamePattern4) ] [1-31] weeks after discharge from Rehab Completed by:[2104-3-25]	[ "V15.82", "V58.67", "511.9", "567.21", "707.21", "197.7", "518.81", "584.9", "250.00", "568.0", "V49.86", "785.52", "V12.72", "V12.54", "196.2", "532.60", "275.03", "537.0", "574.20", "995.92", "272.0", "401.9", "577.0", "707.03", "038.9", "070.54", "577.1", "157.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "52.11", "52.12", "54.62", "99.15", "43.19", "51.03", "96.71", "38.93", "40.11", "50.12", "54.59" ]	icd9pcs	[ [ [] ] ]	13506, 13642	8595, 11764	312, 762	13776, 14102	3514, 8572	18013, 18702	2863, 2993		11964, 13483		13663, 13755	11790, 11941			14126, 14704							14719, 17990			3008, 3008																			3022, 3495									264, 274										790, 2544																2566, 2664	2680, 2847
18,838	100,146	54437	Discharge summary	report	Admission Date: [2115-1-20] Discharge Date: [2115-1-31] Service: NEUROLOGY Allergies: Percocet / Penicillins / Atropine / Keflex / Bactrim / Inderal / Levaquin / Reglan / Ciprofloxacin Hcl / Doxycycline / Azithromycin Attending:[Doctor Last Name 15044] Chief Complaint: prolonged R sided shaking Major Surgical or Invasive Procedure: intubation History of Present Illness: Briefly, pt is a [Age over 90 ] year old woman with PMH notable for breast CT in [2081] (s/p R mastectomy), pancreatic CA [2094] (s/p whipple's), colon CA d/c'ed [1-2], s/p total colectomy, who is transferred from the ICU after presenting in partial status epilepticus. According to the daughter, after her recent colectomy she has had complications of post-operative ileus, overall decreased po's and weight loss. She was in her nursing home and was relatively stable until the day prior to admission when she was more tired and not taking in any po's. That night her nursing aid noted that she had L face, arm, and leg twitching, unclear if true LOC associated with it. The twitching began around midnight and continued through the morning and she was brought to [Hospital1 18] for further evaluation. IN ED she was noted to be talking coherently through the twitching, with O2 sats down to the low 90's on 2L NC. She was given a total of 4 mg ativan and then 1 gm dilantin bolus that stopped the shaking, however she became so sedated that she required intubation. She was admitted to the ICU for further management. Past Medical History: 1. pancreatic cancer status post Whipple procedure [2094] 2. Multiple duodenal strictures and ulcers 3. Adhesions status post lysis from radiation to pancreas. 4. Status post transverse colectomy for radiation-induced injury to colon. 5. Status post appendectomy [2041]. 6. Status post cholecystectomy for gangrenous cholecystitis [2105] 7. Status post gastrojejunostomy. 8. Macular degeneration reportedly legally blind in left eye 9. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 10. Breast cancer status post modified radical mastectomy in [2081] 11. Hypertension. 12. History of Methicillin resistant Staphylococcus aureus infection. 13. Multiple falls. 14. status post ileocolectomy for colon cancer [1-2] 15. osteoarthritis 16. reported history of hepatitis A in [2064] 17. status post partial hysterectomy [2061] 18. status post ventral incision hernia repair [2095] Social History: nursing home resident, formerly a lawyer, per daughter cognitively at baseline very intact, was writing her life memoir until her recent surgery, which left her quite ill. Family History: Noncontributory Physical Exam: Exam on admission to the floor (from ICU) very limited by pt's mental status. Gen: sleeping, arousable but not following commands, breathing comfortably, heart RRR with 2/6 SEM at LSB, lungs with crackles on L mid and base anteriorly, abd soft, non distended, incision site C/D/I. Peripheral pulses easily palpable Neuro: follows no commands, but does intermittently wiggle toes, unclear if to command CN: R pupil 3--2, L pupil surgical, +OC's but no purposeful EOM's, face symmetric, tongue midline, +gag M: moves all 4 extremities vigorously to mild painful stimuli, but moves LUE less than others. S: localizes to pain in all 4 R: RUE and LUE 1+ throughout, patellae 1+ bilaterally, 5 beats of ankle clonus non sustained bilaterally, toes up bilaterally, +jaw jerk, -[Doctor Last Name ] Pertinent Results: [2115-1-20] 11:54AM TYPE-ART TIDAL VOL-500 O2-100 PO2-437* PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 AADO2-252 REQ O2-49 INTUBATED-INTUBATED [2115-1-20] 11:54AM O2 SAT-100 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) PROTEIN-49* GLUCOSE-64 LD(LDH)-50 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1550* POLYS-73 LYMPHS-26 MONOS-1 [2115-1-20] 09:51AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-2550* POLYS-67 LYMPHS-30 MONOS-3 [2115-1-20] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2115-1-20] 08:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2115-1-20] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2115-1-20] 07:38AM TYPE-ART PO2-301* PCO2-39 PH-7.42 TOTAL CO2-26 BASE XS-1 INTUBATED-NOT INTUBA [2115-1-20] 07:38AM GLUCOSE-112* LACTATE-3.3* NA+-131* K+-4.4 CL--99* [2115-1-20] 07:38AM HGB-11.5* calcHCT-35 O2 SAT-99 CARBOXYHB-0.4 MET HGB-0.7 [2115-1-20] 07:38AM freeCa-1.10* [2115-1-20] 07:20AM GLUCOSE-93 UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [2115-1-20] 07:20AM ALT(SGPT)-9 AST(SGOT)-31 AMYLASE-141* TOT BILI-0.5 [2115-1-20] 07:20AM WBC-7.8 RBC-3.95# HGB-11.8# HCT-36.7 MCV-93 MCH-30.0 MCHC-32.3 RDW-14.1 [2115-1-20] 07:20AM NEUTS-82.0* LYMPHS-14.9* MONOS-2.7 EOS-0.3 BASOS-0.2 [2115-1-20] 07:20AM PLT COUNT-472# Brief Hospital Course: ICU/Floor course by system: Neuro: 1. First time seizures - This episode was thought to be focal status, and once stopped she never had a recurrent of seizure-like activity. It was thought that perhaps her seizure was secondary to severe electrolyte abnormalities in the setting of poor nutrition post operatively. She was continued on dilantin, initially 100 mg IV TID, but her levels were persistently supratherapeutic and upon transfer to the floor the dilantin was held each day while levels were checked. On [1-29] the level was finally within low-therapeutic range (4.4, when corrected for albumin was approximately 9) and she was restarted on 100 mg qday. It was thought that has intrinsic slow clearance of dilantin, as none of her other medications are known to decrease dilantin clearance. Upon discharge her level was 3.7. Her levels should be followed 2x/week. Further neurologic workup for seizure included LP that was unremarkable and MRI that showed no enhancing lesions, one small area of DWI right thalamus without FLAIR correleate of unclear significance. Radiology reported diffuse meningeal uptake, but this was likely s/p LP effects. No EEG was performed. 2. Encephalopathy - Pt was initially very encephalopathic, thought to be due to infection as well as dilantin toxicity. As her pneumonia was treated and her dilatnin level was reduced, she became markedly awake and lucid, and by discharge was conversant and easily following commands. ID: 1. Aspiration pneumonia - She had a LLL infiltrate on CXR, leukocytosis to 13K, low grade temp (98.8 ax), she was started on levofloxacin and flagyl and completed a 10 day course. Her wbc was 6 upon discharge and her lung exam was much improved. Her blood and urine cultures were negative to date. Pulm: She was intubated on [1-20] for airway protection after the multiple sedating medications she received for her seizure. She was easily extubated at 6pm on [1-21]. On [1-24] she had an episode of acute respiratory distress, her CXR and lung exam were consistent with pulmonary edema and she was given IV lasix with excellent response. She was started on a maintenance dose of lasix for the remainder of her stay and this was discontinued upon discharge. Heme: On admission, hct dropped from 36->29, repeat was 32 She does not appear to be iron deficiency or anemia of chronic disease, she does however have borderline low B12 and folate. Stool guiaic's were negative. Her hct stayed around 28-29 for the remainder of her stay. Pain: Continued fentanyl patch (for OA) to prevent withdraw, prn tylenol. FEN: Pt was not PO'ing due to encephalopathy. Upon transfer, nutrition consulted and plan for PICC placement for TPN made. PICC was placed but it was only able to be placed peripherally, therefore she was started on [Month/Year (2) 32813]. Electrolytes were followed daily and her initial hyponatremia resolved. She also initially had hypomagnesemia, hypocalcemia, and hypokalemia, all of which were stabilized with her [Month/Year (2) 32813]. On [1-28] she passed her speech/swallow evaluation and an oral diet was started. She tolerated this well and upon discharge her [Month/Day (4) 32813] was discontinued with plans to augment her oral nutrition as well as possible. Her daughter met with the medial nutrition group prior to discharge. Her electrolytes should be followed weekly. She also should be restarted on pancrease once she is eating a more full diet. PPx: for stroke ppx, was initially given ASA, but due to decreasing hct and recent surgery, upon transfer the ASA was d/c'ed. As DVT prophylaxis she was receive heparin in her [Last Name (LF) 32813], [First Name3 (LF) ] was not given SC heparin, but was started back on SC heparin upon discharge. For GI prophylaxis she was receiving pepcid, and was switched back to her home regimen of protonix upon discharge. Code: She was intially DNR but not DNI, after much discussion with her daughter and her PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] the decision was made to make her DNR/DNI. Dispo: She was transferred back to her nursing home in much improved condition on [2115-1-31]. Medications on Admission: 1. Zestril 10mg daily 2. Protonix 40mg daily 3. Pancrease 3 packets per meal 4. Fentanyl patch 25mcg/hr every 72 hours. 5. Ocuvite twice daily Discharge Medications: 1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s)* Refills:2 2. Ocuvite Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1) Injection three times a day. Disp:qs Refills:2 4. Dilantin 100 mg qday 5. Protonix 40 mg qday 6. Fentanyl patch 7. Zestril 10 mg qday 8. Multivitamin Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Partial seizure Pneumonia Discharge Condition: improved Discharge Instructions: Please return to ED if pt develops worsening respiratory distress or seizure-like activity. Once she is taking a more complete diet she should be restarted on her pancrease Her dilantin level and electrolytes should be followed weekly. CHeck an albumin with the dilantin level. Followup Instructions: Dr. [Name (NI) ], pt will schedule	[ "276.1", "285.9", "507.0", "276.8", "V10.3", "401.9", "780.39", "V10.05", "428.0", "V10.09" ]	icd9cm	[ [ [] ] ]	[ "96.04", "03.31", "38.93", "96.71", "99.15" ]	icd9pcs	[ [ [] ] ]	9875, 9965	5067, 9260	367, 380	10035, 10045	3569, 5044	10372, 10414	2722, 2739		9454, 9852		9986, 10014	9286, 9431			10069, 10349										2754, 3550																												302, 329										408, 1552																1574, 2516	2532, 2706
60,666	117,218	6931	Discharge summary	report	Admission Date: [2165-9-24] Discharge Date: [2165-9-29] Date of Birth: [2107-8-7] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 158] Chief Complaint: Rectal cancer Major Surgical or Invasive Procedure: Low anterior resection with takedown of splenic flexure, diverting ileostomy, resection of Meckel diverticulum, rigid sigmoidoscopy [9-24] History of Present Illness: Mr. [Known lastname 26075] is a 58 year-old male with a history of NSCLC s/p lobectomy, rectal adenocarcinoma s/p chemoradiation with 5FU and last dose of radiation on [2165-7-29], catheter-related MSSA bacteremia treated with four week course completed with oxacillin on [2165-7-31]; he presented to [Hospital1 18] for elective LAR and diverting ileostomy status-post neo-adjuvant chemoradiation. Past Medical History: Lung cancer status post right lobectomy 4 years ago COPD Hypertension Type 2 diabetes mellitus Rectal adenocarcinoma diagnosed one month ago Social History: He is married and lives with his wife and two dogs. Has two healthy children. Golfer. - Tobacco: 25PY, quit [2161] - Alcohol: 3 drinks/wk, has been abstaining during chemo Family History: Mother had lung cancer in her 60s. Maternal grandfather also had a lung cancer and also was smoker. Maternal aunt also had a lung cancer and was a smoker. Physical Exam: Physical Exam on Discharge: Vitals: T 99.2 HR 95 BP 128/96 O2sat 94% 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: obese, appropriately tender to palpation at midline incision, staple line clean, dry and intact. GU: no foley Ext: warm, well perfused Pertinent Results: Labs during Admission: . [2165-9-24] 09:39AM HGB-13.6* calcHCT-41 O2 SAT-97 [2165-9-24] 09:39AM GLUCOSE-206* LACTATE-2.5* NA+-137 K+-4.6 CL--102 [2165-9-24] 09:39AM TYPE-ART PO2-128* PCO2-50* PH-7.35 TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [2165-9-27] 04:35AM BLOOD WBC-8.8 RBC-2.93* Hgb-10.1* Hct-28.5* MCV-97 MCH-34.5* MCHC-35.5* RDW-12.6 Plt Ct-100* [2165-9-28] 08:00AM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-138 K-3.3 Cl-98 HCO3-28 AnGap-15 [2165-9-26] 05:56AM BLOOD ALT-47* AST-32 AlkPhos-70 TotBili-1.2. Imaging TTE [9-24]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Small, hypertrophied left ventricle with hyperdynamic biventricular systolic function. . CXR [9-24]: FINDINGS: ET tube to be 6.5 cm above the carina; retrocardiac opacity likely represents atelectasis. No pneumothorax . CXR [9-26]: post-extubation FINDINGS: bilateral atelectasis that is unchanged in extent. Mild fluid overload might be present, no larger pleural effusions. Unchanged borderline size of the cardiac silhouette. . CTA chest [9-24]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Status post right upper lobectomy for non-small cell lung cancer. Moderate emphysema in the left upper lobe. 3. Stellate opacity in the left upper lobe may represent sequela of chronic change, however, focal lesion cannot be entirely excluded given history. Recommend correlation with prior exams once available and short-term followup if prior exams are not available. 4. Bibasilar dependent atelectasis, left greater than right. Concurrent infection in the left lower lobe cannot be entirely excluded in the appropriate clinical setting. . Brief Hospital Course: Mr. [Known lastname 26075] is a 58 y/o M with newly diagnosed rectal cancer s/p low anterior resection with end ileostomy whose intraoperative course was complicated by hypotension requiring continued intubation and care in the ICU. He was reliant on pressors overnight but was weaned successfully and was maintaining good blood pressures within the next post-operative day. He was also successfully weaned to extubate this same day, and was tolerating a sips before transitioning to floor bed status. An intra-operative ECHO at the time showed no pericardial effusion, embolus or other significant abnormality; EF was preserved at 75%. A CT-angiogram of the chest also did not show any acute changes, including that of pulmonary embolus or other etiology to explain his intraoperative hypotension. By system: Neuro: Post-operatively, the patient received Dilaudid IV/PCA, TAP blocks (Pain service), and ativan with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: As mentioned earlier, the patient developed intraoperative hypotension requiring pressors and 5L of crystalloid and 1L of albumin but was weaned off them soon thereafter with some residual tachycardia with normal blood pressure that resolved with beta-blockade. As noted earlier, his ECHO demonstrated no clear etiology to his hypotension. The patient was placed back on his metoprolol and while on the floor the subsequent few days, was stable from a cardiovascular standpoint with a HR in the 80s-90s and SBP within normal range. His vital signs were routinely monitored via telemetry. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. As cited, his chest CT-angiogram was negative for pulmonary embolus. He was extubated POD#1, and maintained good oxygen saturations on nasal cannula in the upper 90's as well as without additional O2 requirement upon discharge. His vital signs were monitored routinely. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He initially experienced some lower urine output POD #3 but responded soon afterwards with a combination of auto-diuresis and a one-time dose of furosemide. His foley was removed on POD#4, with no retention issues. Intake and output were closely monitored. He was discharged on flomax daily and to continue it unless otherwise directed at clinic follow-up or subsequent future appointments. Endo: The patient's blood glucose was initially in the 300s on POD#1, at which point he was started on lantus in the evening alongside his sliding scale of insulin. His sugars normalized to the mid 100s prior to discharge on both lantus and sliding scale insulin. He was discharged home on his oral diabetic medications. ID: The patient's temperature was closely watched for signs of infection, no post-operative antibiotics were required. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. Other: given the nodularity of the patient's liver intra-operatively as well as his post-operative tachycardia, alcohol dependence and withdrawal was entertained as a factor. However, the patient did not score significantly on his CIWA scale; he did not require any additional ativan besides that for his pain throughout his admission for withdrawal symptoms. At the time of discharge on POD#5, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: - Glipizide, Metformin, Omeprazole, Lopressor, 5-FU. Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:90 Capsule, Ext Release 24 hr(s) Refills:2 2. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 7 days. Disp:40 Tablet(s) Refills:0 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Please take while using narcotics to avoid constipation. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Rectal cancer Discharge Condition: Mental status: alert, oriented. Cooperative with plan of care Ambulatory status: ambulating independently without assistance Discharge Instructions: You were admitted to the hospital for a resection of your colon for a previously known rectal cancer. You underwent a resection of your colon as well as creation of an ileostomy to allow your bowel to heal. You initially had lower blood pressures than your normal pressures, which required some higher-level care and medications, but these were managed well. Within a few days, you were transferred to the floor where you continued your ostomy instruction care and did well with walking, and eating a regular diet. Before discharge, you were also able to urinate successfully without a catheter in your bladder. You were also able to manage your pain with oral pain medications. Regarding bowel function and wound care: You have a vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [Last Name (STitle) 1120] or Dr. [Last Name (STitle) ]. You may gradually increase your activity as tolerated but clear heavy exercise for at least 3-4 weeks. You will be prescribed a small amount of the pain medication dilaudid. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Ileostomy: You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a modified regular diet with your new ileostomy. However it is a good idea to avoid Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic in a few days after surgery. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. Currently your ileostomy is allowing the surgery in your large intestine to heal, which does take some time. You will come back to the hospital for reversal of this ileostomy at a time decided on Dr. [Last Name (STitle) 1120] or [Doctor Last Name ] that is safe to do so. You will follow-up in the clinic, and the surgeon will decide when will be the best time for your second surgery. Until this time there is healthy intestine that is still functioning as it normally would and it will produce mucus and some may leak or you may feel as though you need to have a bowel movment and you may sit on the toilet and empty this mucus, it is normal. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. You may call his clinic at ([Telephone/Fax (1) 3378] to schedule an appointment. Completed by:[2165-9-29]	[ "V10.11", "751.0", "154.1", "V15.82", "V15.3", "799.02", "V87.41", "530.81", "401.9", "278.00", "997.39", "V64.41", "568.0", "E878.3", "458.29", "496", "250.00" ]	icd9cm	[ [ [] ] ]	[ "46.01", "00.17", "48.63", "45.33", "45.24", "96.71" ]	icd9pcs	[ [ [] ] ]	8489, 8547	4106, 7801	316, 460	8605, 8605	1954, 4083	13744, 13924	1277, 1434		7904, 8466		8568, 8584	7827, 7881			8756, 9466										1449, 1449																	1477, 1935											262, 278									9479, 13721	488, 903									8620, 8732							925, 1067	1083, 1261
11,244	195,556	19171	Discharge summary	report	Admission Date: [2103-8-25] Discharge Date: [2103-9-3] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 82 year old male with a past medical history of coronary artery disease status post coronary artery bypass graft in [2085], hypertension and diabetes mellitus type 2, found in [Hospital1 6687] Bay on [2103-8-25], unresponsive, floating in the water supine, motionless. The patient was spotted by lifeguards who pulled him from the water and initiated CPR. An AED Device was attached; the patient was noted to be in ventricular fibrillation and underwent defibrillation times two. The patient was presumed to have ventricular fibrillation arrest and was shocked into third degree AV block with slow ventricular escape beats. He was placed on external transcutaneous pacing. He remained hypotensive, unresponsive, hypothermic, with a core body temperature of 94.0 F. He was taken to [Hospital3 22439] where he was intubated and received epinephrine times five and one dose of atropine. Due to an episode of hypotension, he transiently required dopamine. Dopamine was weaned down as the patient's blood pressure stabilized with external pacing. While at [Hospital3 22439], he required another defibrillation. He was started on a lidocaine drip and received a right subclavian central venous line. He was then transferred on [2103-8-25] to [Hospital1 188] via [Location (un) ]. On arrival, temperature was noted to be 92.0 F.; pulse 70; blood pressure 146/69; respiratory rate 16 on assisted control ventilation with total volume of 700, 100% FIO2 with PEEP of 5. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2085]. 2. Hypertension. 3. Diabetes mellitus type 2. 4. Status post hip replacement. 5. Status post total knee replacement. ALLERGIES: The patient with no known drug allergies. MEDICATIONS PRIOR TO ADMISSION: Initially the patient's medications were unknown, however, after contacting his wife, we were able to obtain the following medication list. 1. Novolin N 17 to 20 units q. a.m. 2. Novolin N 17 to 20 units q. p.m. 3. Novalog 8 units q. 6 p.m. 4. Trimethyl glycine 750 mg q. day. 5. Fish Oil 250 mg q. day. 6. Magnesium 64 mg q. day. 7. B12 vitamin, 100 mg q. day. 8. Coenzyme Q 20 mg p.o. q. day. 9. Vitamin B6 200 mg q. day. 10. Aspirin 325 mg q. day. 11. Isosorbide 120 mg p.o. q. day. 12. Folic acid 5 mg p.o. twice a day. 13. Zestril 20 mg p.o. q. day. 14. Niacin [2100] mg p.o. q. day. 15. Metoprolol 25 mg p.o. q. day. SOCIAL HISTORY: On initial arrival, the patient was [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] without any identification; however, on hospital day number two, his wife was located and notified. She travelled to [Hospital1 69] from the patient's home in Tenafly, [State 760]. The patient and his wife have been married for quite some years. He has two grown children. The patient's wife serves as his durable Power of Attorney and Health Care Proxy. PHYSICAL EXAMINATION: Upon admission, temperature 98.2 F.; pulse 70; blood pressure 146/69; [Location (un) 2611] Coma Scale 3, on assist control ventilation with total volume 700, respiratory rate 16, 100% FIO2, PEEP of 5. General appearance: Obtunded, nonresponsive. HEENT: Normocephalic, atraumatic. Pupils nonreactive. No evidence of facial trauma. Neck: C-collar neck stabilizer in place. Lungs: Decreased bibasilar breath sounds. Bronchial breath sounds anteriorly with coarse crackles throughout. Cardiovascular is regular rate and rhythm. Externally paced to a rate of 70 beats per minute. Well healed sternotomy scar present. Abdomen: Soft, nontender, nondistended. Rectal examination was guaiac negative, no rectal tone noted. Back: No spine step off. No evidence of spinal trauma. Extremities cool, one plus dorsalis pedis, posterior tibialis pulses. Neurological: [Location (un) 2611] Coma Scale 3, paralyzed. LABORATORY: Labs available from [Hospital3 22439] prior to transfer demonstrated complete blood cell count with white blood cell count of 9.5, hematocrit 37.1, platelet count 141. Serum chemistry demonstrated a sodium of 146, potassium 5.1, chloride 116, bicarbonate 18, BUN 45, creatinine 1.9, glucose 131, calcium 9.5. Coagulation profile showed PT 13.8, PTT 41.7, INR 1.26. Liver function tests showed a total bilirubin of 1.0, albumin 4.2, total protein 7.2, alkaline phosphatase 189, ALT 130, AST 164, LDH 1330. Cardiac enzymes showed a CK of 452, MB 49, MB index 11%, troponin 0.28. Arterial blood gases on arrival to [Hospital3 22439] showed pH of 6.96, Carbon dioxide 47, O2 88. Repeat laboratory studies done at [Hospital1 190] after transfer showed white blood cell count 19.8, hematocrit 33.1, platelet count 103. Serum chemistry at [Hospital1 69] was sodium of 143, potassium 5.1, chloride 114, bicarbonate 16, BUN 50, creatinine 1.8, glucose 162. Coagulation profile showed PT 15.4, PTT 37.5, INR 1.6, fibrinogen 242. Urinalysis showed specific gravity of 1.015, large blood, 30 protein, greater than 50 red blood cells, zero to two white blood cells, few bacteria. Urine toxicology screen was negative. Serum toxicology screen was negative. Chest x-ray on [2103-8-25], demonstrated cardiomegaly with moderate pulmonary edema. CT scan of the head without contrast on [2103-8-25], showed no intracranial hemorrhage or mass effect. Fluid within the sinuses likely related to the patient's recent prolonged submersion in water. Recommendation is if neurological symptoms persist, a follow-up CT scan or MRI may be performed within 12 to 24 hours. CT scan of the cervical spine without contrast; CT scan reconstruction demonstrated extensive degenerative changes throughout the cervical spine. There was fusion of C5, C6 and C7. There is disc space narrowing at C7 and T1. There is reversal of the normal cervical spine curvature in the region of fusion centered on C6. There are areas of spinal canal stenosis, most prominent at the C6 to C7 level, where there is new bone formation from the fusion. There is no prevertebral soft tissue swelling. Additionally seen is fusion of multiple spinous processes and ossification of the nuchal ligament. The patient is intubated. There is consolidation dependently within the lung apices. No asymmetric soft tissue densities are seen within the neck. There is calcification of the carotid arteries. The patient also has an nasogastric tube. Echocardiogram on [2103-8-26], was a limited study. The left atrium was normal in size. The left ventricular cavity size was normal. Overall left ventricular systolic function is severely depressed with left ventricular ejection fraction estimated at 15 to 20%. Akinesis of the basal and mid inferior, and inferolateral walls. Hypokinesis of the remainder of the ventricle. Regional wall motion assessment is limited; however, the basal and mid to lateral walls appear relatively better preserved. Left ventricular chamber size was normal. There is abnormal septal motion. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. There is linear echogenic structure in the right ventricle consistent with a pacemaker wire / catheter. Echocardiogram on [2103-8-27] with left ventricular ejection fraction of 20 to 25%. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with a relative preservation of the base of the lateral and septal walls. Overall left ventricular systolic function is severely depressed. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is mildly dilated. The aortic valve leaflets (three) appear structurally normal with good leaflet excursion. The aortic valve leaflets are moderately thickened. No aortic regurgitation is seen. Mitral valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the findings of the prior report of [2103-8-26], no significant change was noted. EEG on [2103-8-26], with impression that this was an abnormal EEG due to the monotonous theta range diffuse slowing seen throughout the record. Infrequent bursts of suppression were also observed. In addition, the amplitudes of the wave form were increased frontally as compared to posteriorly which is a poor prognostic factor. The fact that there was little response to verbal or physical stimulation is also indicative of a poor prognosis. This record is consistent with severe encephalopathy. The record is not consistent with brain death. In order to further prognosticate, it may be helpful to repeat the EEG. MRI of the cervical spine on [2103-8-30], showed there is bony fusion of C5, C6, and 7. A normal vertebral body height and signal intensity are preserved. The spinal canal is patent throughout and the spinal cord is of normal signal. The cranial cervical junction is within normal limits. There is no increased signal on the STIR images to indicate an acute soft tissue injury. At the C3, C4 levels, there are posterior spondylotic ridges resulting in moderate bilateral neural foraminal narrowing. At C5-6, there is a right paracentral disc osteophyte complex resulting in mild impression upon the ventral subarachnoid, with no significant neural foraminal or spinal stenosis. At the C6-7 level, there is a left posterior spondylotic ridge resulting in mild left neural foraminal narrowing. No other significant abnormalities are identified. Impression was that there was no evidence of increased ST IR signals to indicate acute bony or ligamentous injury. MRI of the head without contrast on [2103-8-30], showed that several of the sequences are limited due to excessive motion artifact. Allowing for this limitation, the brain appears morphologically normal. There is no mass affect of shift of the normally midline structures. The ventricles and sulci are prominent but symmetric, compatible with involutional change. There are few discrete foci of T2 flare hyperintensity within the subcortical white matter, compatible with chronic microvascular ischemia. There is no increased susceptibility artifact to indicate the presence of blood products. In addition, there is no restricted diffusion to indicate an ischemic event. Normal vascular flow voids are preserved. Visualized soft tissues are notable for fluid within the mastoid air cells bilaterally, likely resulting from the patient's recent drowning event. Impression was that there were no acute intracranial abnormalities identified. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit status post presumed ventricular fibrillation with arrest. 1. CARDIOVASCULAR: On arrival, the patient demonstrated a slow ventricular escape rhythm. A temporary ventricular pacing wire was placed in his right subclavian central venous line. Overnight from [2103-8-25] until [2103-8-26], he was ventricularly paced at a rate of 80 beats per minute. The following morning of [2103-8-26], the pacer rate was decreased to 60 beats per minute as the patient was noted to have his own intrinsic rhythm in the 70s. The patient was able to maintain his own intrinsic rhythm without need for pacing. The pacer wire was discontinued on [2103-8-27]. After discontinuation of the pacer, the patient was able to maintain his own normal sinus rhythm. He had only occasional episodes of ventricular ectopy on Telemetry monitoring. Telemetry was discontinued on [2103-8-31]. As it was unclear on admission if a primary cardiac event was the etiology of the patient's near drowning, his cardiac enzymes were cycled. He had a peak creatinine kinase of 1618, peak troponin T of 1.57. Please note, however, these values were obviously drawn after the patient received multiple defibrillations. As the patient did not exhibit any evidence of ischemic changes on serial electrocardiograms or ectopy on Telemetry monitoring, it was felt that a primary cardiac event was unlikely to be the etiology of his downing. An echocardiogram was obtained to evaluate the patient's overall cardiac function. Echocardiogram on [2103-8-26], showed left ventricular ejection fraction of 20 to 25% with severe global hypokinesis. That evening, the patient had an episode of hypotension requiring transient dopamine and NeoFed pressor support. It was questionable whether his hypotension was due to distributive sepsis versus cardiogenic shock. Therefore, a Swan-Ganz catheter was placed on [2103-8-27] for better hemodynamic monitoring and assessment. Initially, values from the Swan Ganz catheter showed values consistent with early sepsis, with cardiac output of 6.7, systemic vascular resistance of 8 to 96; however, over the next two days, the patient's cardiac function normalized. Prior to discontinuation of the Swan on [2103-8-30], the patient's cardiac output was noted to be 4.8, cardiac index 2.42, with systemic vascular resistance of 1417. Throughout the remainder of his hospital course, the patient maintained hemodynamic stability without pressor support. As the patient has a history of coronary artery disease, he was initiated on his outpatient medications of aspirin, Zestril and Metoprolol. Particularly, the Zestril and Metoprolol were utilized for better blood pressure control. The patient tolerated this regimen well and, as above, was hemodynamically stable at the time of discharge. 2. NEUROLOGICAL: On arrival, the patient was obtunded with [Location (un) 2611] Coma Scale score of three. He was felt to have global hypoxic brain injury in the setting of presumed ventricular fibrillatory arrest, with an unknown period of hypoxia. Initially, the patient was without corneal reflexes; pupils were nonreactive and he was unresponsive to verbal or noxious stimuli. He did not demonstrate any spontaneous movements or pain induced movements. On initial Neurological consultation, hyperventilation over and above ventilatory settings was the only sign of central nervous system function. An EEG was done to assess the patient's level of cortical function. The EEG demonstrated severe encephalopathy. On [2103-8-26], the patient was noted to open his eyes spontaneously and grimace to pain. On [2103-8-27], he demonstrated withdrawal movements with sternal rub and other noxious stimuli. He also had a positive gag reflex at this time. In order to assess for diffuse ischemic injury, an MRI of the head was done without contrast on [2103-8-31]. It was felt that having this information would help with prognostication in terms of the patient's long term neurological prognosis as well as provide the family with additional information that could be used in making further health care decisions on the patient's behalf. An MRI demonstrated no acute intracranial abnormality. The family decided to pursue further care of the patient at a facility closer to their home in [State 760]; namely the patient will be transferred to [Hospital ] [Hospital 25757] Medical Center for further neurological evaluation and treatment. At the time of discharge on [2103-9-3], the patient was noted to open eyes spontaneously. His eyes did not track stimuli. He did demonstrate spontaneous movements, particularly of his upper extremities; however, it was unclear whether these movements were simply reflex or were purposeful in response to stimuli. He did withdrawn his extremities to pain. He did have a positive gag reflex. He demonstrated facial movement and grimacing to pain. He was not able to follow simple commands. 3. PULMONARY: The patient arrived to [Hospital1 190] intubated and sedated. He was placed on Midazolam and Fentanyl intravenous drips as he was dramatically over breathing his ventilatory settings. Chest x-ray showed a questionable adult respiratory distress syndrome like picture. Therefore, initially, ventilation settings were optimized with low PEEP, low volume and high rate settings. Staff experienced difficulty sedating the patient as blood pressure would drop dramatically with Propofol. With withdrawal of paralytic agents, the patient became increasing tachypneic, desynchronous and difficult to ventilate. Therefore, a Pulmonary consultation was obtained in order to assist with appropriate ventilation settings. The Pulmonary staff recommended low tidal volumes, EG500 to 600 cc, with tolerance of increased rate as needed by the patient to compensate for his underlying metabolic acidosis. It was felt that this acidosis was likely secondary to his prolonged arrest and hypoxia. The patient tolerated these ventilation settings and continued to breath over the ventilator. On [2103-8-28], he underwent a trial of pressor support and tolerated this well. He was ultimately extubated on [2103-8-28] and started on four liters of nasal cannula O2. He was able to maintain oxygen saturation levels in the high 90s on the four liters nasal cannula O2. Therefore, over the course of the next several days, he was weaned off of oxygen altogether and at the time of discharge had oxygen saturation levels ranging from 95 to 99% on room air. 4. INFECTIOUS DISEASE: Overnight on hospital day number one, the patient spiked a temperature to 101.2 F. Additionally, a repeat white blood cell count showed white blood cell count level dropped to 1.0 from 10.8. We were concerned regarding possible aspiration of seawater versus gastric contents during the patient's drowning event. Therefore, he was started on Vancomycin one gram intravenous q. 24 hours and Zosyn 2.25 grams q. six hours for presumed sepsis. Please note that these were renally dosed medications. Blood cultures were drawn from his arterial line after his temperature spike and eventually grew out four out of four cultures with positive alpha Streptococci, vancomycin sensitive. After this culture resolved, Zosyn was discontinued on [2103-8-29]. Surveillance cultures drawn on [2103-8-28], demonstrated no growth. It was unclear whether the patient actually had alpha Streptococcus bacteremia or if blood cultures drawn on [2103-8-26] were contaminated; however, the decision was made to continue a total Vancomycin course of two weeks. At the time of discharge on [2103-9-3], the patient will be on Vancomycin day number nine. The patient also had questionable evidence of pulmonary infiltrates on his original chest x-ray examination; therefore a sputum sample was sent. The sputum grew out four plus Gram positive cocci on Gram stain; however, final culture demonstrated only moderate growth of flora consistent with oropharyngeal bacteria. 5. RENAL: Upon admission, the patient's BUN and creatinine were elevated; this was felt to be secondary to hypoxemia and poor renal blood flow during his drowning event, leading to acute tubular necrosis; therefore, he was aggressively rehydrated with intravenous fluids. Additionally, all of his medications were renally dosed in order to decrease any further renal insult. The aggressive hydration led to a progressive decline in his BUN and creatinine values. At the time of discharge, his BUN and creatinine were stable at BUN 37, creatinine 1.0. 6. HYPOTHERMIA: On arrival to [Hospital1 188], the patient's core body temperature was 92.0 F. After arrival in the Coronary Care Unit, he was rewarmed slowly back to normal core temperature with rewarming blankets and warm intravenous fluids. 7. QUESTIONABLE CERVICAL / SPINAL CORD INJURY: A ligamentous injury to the patient's cervical spine could not be ruled out. According to Trauma Surgery consultation, MRI needed to be done within 48 hours of the patient's initial injury; however this was not able to be obtained because the patient had a pacer wire in place. The MRI was done on [2103-8-30], after the 48 hour window. This demonstrated no evidence of ligamentous injury. In order to fully clear the patient's cervical spine, Trauma Surgery consultation team recommended flexion and extension cervical spine films; however, the patient was unable to follow command for this purpose. Therefore, they recommended maintaining cervical spine immobilization with cervical collar for the next four weeks, or until such time as the patient can undergo flexion and extension x-rays. 8. ENDOCRINE: For the patient's history of diabetes mellitus type 2, he was initially monitored with four times a day fingerstick blood glucose testing. Blood glucose levels in the Coronary Care Unit were initially 80s to 150s. The patient was covered with Regular insulin sliding scale. On [2103-8-31], the patient's outpatient NPH was added to his medication regimen. The patient was then transferred to the Floor on [2103-8-31], at which point it seemed that his blood glucose levels became very elevated with sugars on the floor ranging between 250 to 400. Therefore, his NPH dosing was increased to 35 units q. a.m. and 30 units q. p.m. With these elevated blood glucose levels, the patient was also noted to have a relative increase in his urine output. Therefore, a repeat urinalysis was obtained on [2103-9-2] that demonstrated small blood, trace protein, 100 glucose; negative for ketones, bilirubin, leukocyte esterase or nitrite. After initiation of tube feedings, the patient's sodium level progressively elevated. It peaked at a level of 149. At this point, it was felt that the patient was likely suffering from a total body water deficit; therefore, free water boluses of 250 cc of free water q. six hours were initiated. As this produced on a modest decrease in his sodium level, free water boluses were increased to 250 cc q. four hours. On the day prior to discharge, his sodium level was 140. As we were concerned about the possibility of diabetes insipidus in light of his history of neurological injury status post hypoxia, urine studies were sent which demonstrated urine osmolality of 780, urine creatinine 63, urine sodium 151, urine chloride 101. These values seemed to refute the diagnosis of diabetes insipidus. Therefore, we postulated that the patient's polyuria was likely secondary to glycosuria. Now that his sodium level was normalized at 140, the decision was made to just continue with free water boluses q. six hours for relative maintenance of his sodium level. 9. FLUIDS, ELECTROLYTES AND NUTRITION: Nutritional consultation was obtained early on in the [Hospital 228] hospital course. The patient was started on tube feedings with ProMod with fiber at a rate of 70 cc per hour with frequent residual checks. This was initially given via an OG tube secondary to concern for sinusitis status post the patient's drowning event as the head CT scan noted fluid in the patient's maxillary spaces. On [2103-8-31], the OG tube was switched to a Dobbhoff tube for patient's comfort. Throughout his course, the patient was maintained on aspiration precautions. As noted above, the patient was noted to have a free water deficit and therefore was given 250 cc boluses of free water q. six hours initially, increased to q. four hours after his sodium level failed to decline initially. At the time of discharge, he had reached his nutritional goal for his tube feedings on ProMod with fiber at a rate of 70 cc per hour with residual checks q. four hours, free water boluses of 250 cc H2O q. four hours. 10. ACTIVITY: The patient underwent a Physical Therapy consultation on [2103-8-31]. Assessment was that the patient had impaired balance, functional mobility, motor function, cognition, endurance. Impression was that he would require extensive rehabilitation upon discharge; however, it was felt that his rehabilitation potential was good given his high baseline and good support system in place, namely his prognosis will depend mainly on his neurological recovery. Additionally, a Speech and Swallow evaluation was obtained, also on [2103-8-31]. The impression was that the patient was demonstrating overt signs and symptoms of aspiration with thin liquids as well as puree consistency. The patient likely had increasing pharyngeal residue over multiple boluses, placing him at high risk for aspiration. While he did demonstrate appropriate responses to p.o. attempts, he was not felt to be ready at this time for p.o. initiation or for a video swallow study. Therefore, recommendation is that the patient remain n.p.o. at this time. Nasogastric tube feedings were continued for nutrition and hydration. Oral care attempts were to be continued as possible avoiding biting behavior. The patient was to have a follow-up reassessment of his swallow function within one week, likely with a video swallow study if deemed appropriate. 11. CODE STATUS: Discussion with the patient's durable power of attorney and wife, [Name (NI) 31250] [Name (NI) 52293], and the patient's son on [2103-8-31], took place regarding the patient's code status. The patient's wife and son clearly and explicitly expressed their desire that the patient be made "Do Not Resuscitate", "Do Not Intubate". CONDITION ON DISCHARGE: Guarded. DISCHARGE STATUS: The patient is being discharged transferred to [Hospital ] [Hospital 25757] Hospital in [State 531]. Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] will take over primary responsibility for the patient's care. DISCHARGE DIAGNOSES: 1. Status post drowning with anoxic brain injury. 2. Coronary artery disease status post coronary artery bypass graft. 3. Diabetes mellitus type 2. 4. Hypertension. 5. Hypernatremia. 6. Acute renal failure. DISCHARGE MEDICATIONS: 1. NPH insulin 35 units q. a.m. and 30 units q. p.m. 2. Regular insulin sliding scale. 3. Colace liquid 100 mg p.o. twice a day. 4. Metoprolol 25 mg p.o. twice a day. 5. Lisinopril 20 mg p.o. q. day. 6. Aspirin 325 mg p.o. q. day. 7. Pantoprazole 40 mg p.o. q. 24 hours. 8. Acetaminophen 650 mg p.r. q. six hours p.r.n. fever. 9. Vancomycin 1 gram intravenously q. 24 hours; please note that on [2103-9-3], will be day number nine. DISCHARGE INSTRUCTIONS: 1. The patient is being transferred to [Hospital ] [Hospital 25757] Medical Center in [State 531]. There, Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] will assume responsibility for his care. 2. The patient is being transferred for further neurological evaluation and neurological care. Additionally, his family wanted the patient transferred to a location closer to their home in [State 760]. 3. The patient will be transferred on [2103-9-3]. Transportation will occur via air ambulance. 4. The patient's wife, Mrs. [First Name4 (NamePattern1) 31250] [Known lastname 52293] will continue to serve as the patient's power of attorney and health care proxy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 23649] Dictated By:[Last Name (NamePattern1) 41068] MEDQUIST36 D: [2103-9-2] 15:23 T: [2103-9-2] 15:52 JOB#: [Job Number 52294] cc:[Last Name (NamePattern4) 52295]	[ "038.0", "427.41", "584.5", "276.0", "707.0", "348.1", "250.00", "427.5", "994.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "89.64", "96.71" ]	icd9pcs	[ [ [] ] ]								25865, 26079	26102, 26548						26572, 27595																					10983, 25553	1956, 2593				3134, 10953																						118, 1640																1662, 1924	2611, 3110	25579, 25844
8,665	162,657	43484	Discharge summary	report	Admission Date: [2117-8-23] Discharge Date: [2117-8-27] Date of Birth: [2041-10-14] Sex: M Service: MEDICINE Allergies: Nitroglyn / Penicillins Attending:[First Name3 (LF) 2186] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: 75 year old man with MDS, transfusion dependent q4wks, AF on coumadin, CHF with severe MR, p/w presyncope since [8-19], found to have hct 15 and melena today on anoscopy in ED. Reported only one formed tarry black stool this am, none recently. No recent h/o EtOH or NSAID use. Has h/o multiple falls recently and reports LH and clumsiness last few days; hit head this am. In ED hemodynamically stable (hypertensive, not tachycardic), but hct 15. Head CT negative for bleed. He was NGL with a small amount of bile return, no bleeding noted. Started 1u prbc in ED. . ROS: +Weight loss 40 lbs/last 3 mos, + night sweats x 2 wks. Denies f/c, CP, SOB, DOE, n/v, hematemesis, BRBPR, vertigo, dysuria. Past Medical History: 1. MDS w/ intramedullary hemolysis: (dx 1yr ago, on prednisone) 2. Chronic fatigue syndrome 3. Atrial fibrillation 4. s/p MV annuloplasty [5-23] 5. L post occipital CVA after cardiac cath 6. H/o paroxysmal SVT - s/p cardioversion 7. 1st degree AVB 8. CHF, latest EF 60% by TTE [3-25] 9. HTN 10. Diverticulosis 11. SBO s/p ex lap 12. R inguinal repair 13. GERD 14. GIB in '[10] [12-23] NSAIDS with neg EGD. Nl EGD [1-23]. 15. Esophageal spasms [12-23] achalasia 16. Depression 17. Anxiety 18. Back pain 19. OSA 20. CRI (baseline 1.4-1.8) 21. s/p cholecystectomy [33]. s/p appy Social History: Married, with grown children & grandchildren; worked as an executive in hospital cleaning, stopped in [2097]. History of heavy EtOH use, quit 25 yrs ago; Denies current smoking (past history of smoking; quit 25 years ago),and denies illicit drug use. Lives with wife, who has been ill recently, resulting in poor meal preparation and unintentional weight loss. Family History: father and mother had [Name2 (NI) 499] cancer in their 50s and 60s and also had CAD Physical Exam: VS: T 98.7, BP 154/57, P 83, RR 16, O2 100% RA Gen: NAD, resting in bed wearing sunglasses, pleasant Neck: Supple, no bruits or LAD CV: RRR, Nl S1 and S2, III/VI HSM at apex Lungs: Clear to auscultation bilaterally Abd: NABS, soft, NT/ND, no masses. + superficial scars well-healed Extr: No c/c/e, wwp Neuro: AAO x 3, moves all extremities equally and spontaneously Pertinent Results: ECG: NSR at 83, LAD, RBBB, TWI V2-V5, TW flat in V6 . [2117-8-23] CT head:There is no evidence of acute intracranial hemorrhage, mass effect, shift of normally midline structures, major vascular territorial infarct. [Doctor Last Name ]-white matter differentiation is preserved. There is again noted an area of encephalomalacia in the left occipital lobe, which is unchanged when compared to the prior study. Ventricles are stable in size. The sulci are stable. The visualized portions of the paranasal sinus are normally aerated. CXR: Clear lungs without infiltrate, no cardiomegaly . Colonoscopy: The findings do not explain the anemia or weightloss. Diverticulosis of the whole [Doctor Last Name 499] Grade 1 internal hemorrhoids Otherwise normal colonoscopy to cecum . EGD: No obvious AVMs or other lesions to account for GI bleed. Otherwise normal egd to mid-jejunum . Small bowel follow through: Unremarkable . [3-25] TTE: EF 60%, 2+MR [First Name (Titles) ] [Last Name (Titles) 34486] jet, 1+AI, 2+TR, myxomatous mitral valve leaflets, no MVP, moderate MAC and thickening of mitral valve chordae. [4-23] cardiac cath: [1-22]+ MR, diffusely diseased RCA, AM, Lcx; pHTN, elevated PCW, anterobasal/anterolat HK [2117-8-24] 03:01AM BLOOD WBC-6.0# RBC-2.12# Hgb-6.5# Hct-19.9# MCV-94# MCH-30.8 MCHC-32.9# RDW-24.9 Plt Ct-472* [2117-8-24] 12:00PM BLOOD Hct-24.3* [2117-8-26] 09:54AM BLOOD Hct-30.9* [2117-8-26] 10:10PM BLOOD Hct-32.8* [2117-8-27] 07:10AM BLOOD WBC-6.3 RBC-4.00* Hgb-12.3* Hct-36.9* MCV-92 MCH-30.7 MCHC-33.3 RDW-20.4* Plt Ct-603* [2117-8-23] 05:11PM BLOOD Neuts-85* Bands-1 Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [2117-8-23] 05:11PM BLOOD Plt Smr-VERY HIGH Plt Ct-742* [2117-8-25] 04:00AM BLOOD Plt Ct-452* [2117-8-27] 07:10AM BLOOD Plt Ct-603* [2117-8-23] 05:11PM BLOOD Glucose-152* UreaN-61* Creat-2.1* Na-135 K-4.8 Cl-102 HCO3-17* AnGap-21* [2117-8-25] 04:00AM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-136 K-3.9 Cl-102 HCO3-22 AnGap-16 [2117-8-27] 07:10AM BLOOD Glucose-111* UreaN-22* Creat-1.7* Na-138 K-3.7 Cl-99 HCO3-23 AnGap-20 [2117-8-27] 07:10AM BLOOD LD(LDH)-1713* TotBili-3.0* [2117-8-24] 03:01AM BLOOD Calcium-8.2* Phos-5.0* Mg-1.9 [2117-8-27] 07:10AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.8 [2117-8-24] 03:01AM BLOOD VitB12-855 Folate-11.6 Brief Hospital Course: 75 yo M with multiple medical problems including MDS on transfusions q month and Epogen, AF, CHF, h/o GIB in past with nl EGD [1-23], p/w presyncope and found to have melena and HCT 15 in ED. . 1. GI Bleed: Patient had a normal EGD in [1-23], history of GERD, GIB with NSAIDs, and diverticulosis but no documented colonoscopy in our system. Has family history of [Month/Day (1) 499] cancer, and has been on Coumadin for AF. Had 1 episode of melena the morning before admission, and two while on the first day in [Hospital Unit Name 153]. His hematocrit was 15 on admission. His Coumadin was held and he received a total of 8 units of pRBCS with an appropriate increase in his hematocrit and no further melena or any BRBPR. A colonoscopy and EGD were performed. EGD was negative and colonoscopy revealed extensive diverticula of the whole [Hospital Unit Name 499] and grade 1 internal hemorrhoids but otherwise normal colonoscopy that they do not feel explains weight loss or extensive anemia. Patient had no further episodes of GI bleed and HCT remained stable. A small bowel follow through was performed to rule out any masses in the small bowel which was also negative. He was told to eat a high fiber diet. It was felt that he may have had a transient and minor bleed but that his MDS was a contributor to the extent of his anemia. His hematocrit will be followed weekly as an outpatient. . 2. Myelodysplastic syndrome: Patient has MDS with accelerating need for transfusion over past 2 years, now requiring PRBCs q 4 weeks. His profound anemia may be partially secondary of worsening MDS. His oncologist Dr. [First Name (STitle) ] was contact[Name (NI) ] and she felt that he would not benefit from prednisone as this has not helped in the past, and that it was unlikely that accelerating MDS could cause such profound and sudden anemia but that this much have been in conjunction with GI bleed. He will continue to have weekly HCT checks and will follow up in the hematology/oncology clinic for further treatment/transfusions. He will continue his Epogen injections. . 3. Weight loss: This seems to be due to poor appetite, chronic disease, and lack of preparation of meals. In speaking with the patient's daughter, she seems to think that a big part of this is her father's depression as he sleeps a great deal, is unmotivated to go out and has been staying home with his wife that has also been ill. The possibility of counseling was brought up to the patient but he refused as he says he has no "emotional issues." I encouraged him to take supplements including boost, which he said he has been doing with some weight gain but says that he is not interested in meals-on-wheels. The patient said that he would further discuss his diet with Dr. [First Name (STitle) 216]. . 4. PAF: Patient has been on Coumadin with a goal INR of [12-24]. In the setting of GI bleed, his Coumadin was held and he was given small doses of vitamin K. It was felt that although does have structural heart disease, is at relatively low risk for stroke in his acute setting. He was rate controlled on diltiazem and was restarted on Coumadin as his hematocrit was stable and he had no further episodes of bleeding. Given his history of GI bleed he was continued on Coumadin but with a new goal INR of 1.5-2 and will follow up with Dr. [First Name (STitle) 216] as an outpatient. He will continue to have his INR checked once per week. 5. CAD: Patient has diffuse right and left circumflex disease. Currently only on diltiazem. His EKG in the [Hospital Unit Name 153] showed TWI c/w lateral ischemia which resolved by the next day and was felt to be secondary to demand ischemia. He had no chest pain. He was continued on diltiazem. . 6. CHF: Patient has history of diastolic dysfunction w/ normal EF by echo in [3-25]. He was closely monitored given the numerous transfusions he was given, but he did not have any evidence of failure. Given the pt's 3+ MR, he may benefit from afterload reducing medication, such as ACE-I, when acute issues resolved. . 7. CRI: Slightly higher creatinine than baseline 1.5-1.7 on admission, but corrected with fluid resuscitation. At discharge creatinine back to 1.7. 8. Depression/anxiety: His mood appears to be stable and he denies feeling more depressed. However, his daughter feels that he is depressed and tries to encourage to go to a therapist, but he resists. This issues was addressed this admission but the patient refused. He had no SI or HI. He was continued on nortriptyline and fluoxetine with the addition of zyprexa. 9. HTN: Well controlled with HCTZ and diltiazem at home. These were originally held in the setting of GI bleed, but as the patient was hemodynamically stable, they were restarted. He was continued on the regimen at discharge. . 10. Low back pain: Continued on Tylenol and gabapentin. Medications on Admission: 1. zyprexa 5mg qd 2. nortryptiline 10mg qhs 3. gabapentin 300mg daily 4. fluoxetine 20mg daily 5. HCTZ 25mg daily 6. prednisone 10mg daily 7. diltiazem 60mg tid 8. protonix 40mg 9. MVI 10. tylenol 11. ativan 1mg [Hospital1 ] 12. coumadin 5mg daily 13. epogen 60,000 units weekly Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3 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. Coumadin 5 mg Tablet Sig: One (1) Tablet PO Mon, Wed, Fri. 11. Coumadin 5 mg Tablet Sig: 0.5 Tablet PO Tues., Thurs., Sat., Sun. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary 1. GI bleed of unclear source 2. Anemia 3. MDS with hemolysis Secondary 1. Atrial fibrillation 2. Depression 3. Congestive heart failure 4. Hypertension Discharge Condition: Hematocrit stable, hemodynamically stable, afebrile, no further evidence of GI bleed Discharge Instructions: If you have any dizziness, shortness of breath, chest pain, bloody bowel movements or any other concerning symptoms, call your doctor or come to the emergency room. . 1. Take all your medications as directed 2. Keep all of your follow up appointments 3. Your coumadin dosing has now changed given your recent bleeding and your goal INR is now 1.5-2.0. Followup Instructions: You should continue to have your hematocrit and INR checked once per week. . You have the following appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 51819], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2117-9-10] 8:00 Provider: [First Name4 (NamePattern1) 2747] [Last Name (NamePattern1) 5780], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2117-9-10] 8:30 Provider: [Name Initial (NameIs) 4426] 12 Date/Time:[2117-9-10] 8:30 . You should make an appointment with Dr. [First Name (STitle) 216] [Telephone/Fax (1) 250] in the next 1-2 weeks.	[ "427.31", "285.9", "300.4", "396.3", "585.9", "238.7", "578.9", "398.91", "V58.61", "401.9", "397.0", "562.10" ]	icd9cm	[ [ [] ] ]	[ "45.23", "45.13" ]	icd9pcs	[ [ [] ] ]	11054, 11103	4978, 9868	294, 312	11308, 11395	2559, 2629	11795, 12417	2068, 2157		10201, 11031		11124, 11287	9894, 10178			11419, 11772										2172, 2540																												246, 256										340, 1041			2637, 4955													1063, 1669	1685, 2052
40,526	101,343	18227	Discharge summary	report	Admission Date: [2123-5-31] Discharge Date: [2123-6-6] Date of Birth: [2091-8-18] Sex: F Service: SURGERY Allergies: Codeine / Remicade / Vancomycin Attending:[First Name3 (LF) 3376] Chief Complaint: nausea/vomitting Major Surgical or Invasive Procedure: percutaneous drain placement PICC line placement History of Present Illness: 31 yo w/ crohn's history refractory to medical managment present with nausea and vomiting x 3 days. She was discharged on [2123-5-25] after a month long hospitalization for treatment of intra-abdominal abcesses. Since her dischange she has been tolerating clears but regular food has made her increasingly nauseated. Yesterday she has had several bouts of intractable vomitting and she has been unable to tolerate even clears. She denies f/c. She has only mild abdominal pain controlled with 2mg PO dilaudid x 1. She has had flatus and several watery bowel movements per day. Past Medical History: Crohn's Disease Depression h/o arthritis related to medications Anorexia Nervosa/OCD Past Surgical History s/p Wisdom teeth removal in [2103] LEEP procedure in [2121] Primary Care Physician: [Last Name (NamePattern4) ]. [Last Name (STitle) 5781] GI: Dr. [Last Name (STitle) 2161] Social History: Works at [Hospital3 328] in PR department [11-21] EtOH drinks, ~3 times per week smoked [11-20] ppd X 3-4yrs quit 9 years ago Family History: Cousin with [Name (NI) 4522] Disease Father CAD Physical Exam: GEN: a and o x 3, nad V.S.S CV: rrr, no m/r/g RESP: lscta, bilat ABD: soft, nt, nd, + BS Drain site d/c/i no s/s of infection Ext: no c/c/e Pertinent Results: CT abd- (6cm trans, 4/4cm, 6x2cm, sm midline inc 2x 0.5cm) fluid collections. 3.5 cm LUQ dilated sm (same as [Month (only) ]) likely ileus CXR: A new left PICC tip projects over the mid SVC in good position . IR drainage: Status post successful percutaneous drain placement, with the catheter traversing the anterior lower pelvic collection and coursing posteriorly to terminate within the posterior pelvic collection. A sample of the fluid was sent for laboratory evaluation. The catheter should be flushed and aspirated 2-3 times daily until the aspirate is clear. . [2123-5-31] 06:00PM BLOOD WBC-20.3# RBC-4.38# Hgb-10.5# Hct-32.4# MCV-74 MCH-24.0* MCHC-32.5 RDW-18.1* Plt Ct-900* [2123-6-1] 07:00AM BLOOD WBC-32.8# RBC-4.04 Hgb-9.7* Hct-29.7* MCV-74* MCH-24.1* MCHC-32.8 RDW-18.3* Plt Ct-758* [2123-6-1] 12:54PM BLOOD WBC-36.8* RBC-3.98* Hgb-9.6* Hct-28.7* MCV-72* MCH-24.2* MCHC-33.6 RDW-18.2* Plt Ct-779* [2123-6-2] 04:50AM BLOOD WBC-15.5# RBC-3.33 Hgb-8.1* Hct-24.0* MCV-72* MCH-24.3* MCHC-33.7 RDW-18.2* Plt Ct-549* [2123-6-3] 06:40AM BLOOD WBC-10.8 RBC-3.63* Hgb-8.6* Hct-26.2* MCV-72* MCH-23.8* MCHC-33.0 RDW-18.1* Plt Ct-639* [2123-6-4] 06:01AM BLOOD WBC-9.7 RBC-3.58* Hgb-8.5* Hct-26.2* MCV-73* MCH-23.8* MCHC-32.5 RDW-18.3* Plt Ct-634* [2123-5-31] 06:00PM BLOOD Neuts-91.1* Lymphs-4.7* Monos-3.4 Eos-0.6 Baso-0.2 [2123-6-4] 06:01AM BLOOD Plt Ct-634* [2123-6-2] 04:50AM BLOOD PT-15.0* PTT-33.0 INR(PT)-1.3* [2123-6-4] 06:01AM BLOOD Glucose-103 UreaN-12 Creat-0.7 Na-140 K-3.6 Cl-106 HCO3-23 AnGap-15 [2123-6-4] 06:01AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9 [2123-6-3] 06:40AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-1.9 Iron-42 [2123-6-3] 06:40AM BLOOD calTIBC-192* Ferritn-335* TRF-148* [2123-6-4] 06:01AM BLOOD Triglyc-121 . C-DIFFICILE TOXIN [2123-6-4]: Feces negative Brief Hospital Course: The patient was admitted to the surgical service from the ER. She was maintained NPO with IVF/MEDS/ABX. CT abd/pelvis demonstrated reaccumulation of intraabdominal fluid collections previously drained by pigtails, and a new fluid collection below her incision. Initially treated with Zosyn 4.5gm IV q8h, and received one dose vancomycin 1gm IV. At 7am, she spiked a temp to 101.2. Around noon, the patient triggered on the floor for tachypnea with RR 30-40s, HR 120s, and altered mental status. Labs were notable for WBC 20-->30-->36 over the course of the day. As patient worsened, on [6-1], Zosyn switched to meropenem 500mg IV q8h, and was given one dose Fluconazole 400mg IV. She went to IR where she underwent CT-guided drain placement to drain her pelvic fluid collections, ~75cc purulent drainage was noted at the time of the procedure. Additionally 1L of bilious fluid was drained from an NG tube placed at the time of the procedure. She was intubated for the procedure. She became hypotensive during the procedure in the setting of general anesthesia, requiring neo at one point, however has otherwise been hemodynamically stable throughout this admission. She returned to the floor and was continued to receive TPN/IV abx and maintained as NPO. Her foley was removed and she was started on oral/home medications. Drain teaching/PICC/TPN was provied to the patient and mother. The patient will follow up with Dr. [Last Name (STitle) 1120] in [11-20] weeks. Medications on Admission: Acetaminophen, Citalopram 20', Iron 325 mg, Ciprofloxacin 500'' Pantoprazole 40 mg EC', Budesonide 9 mg SR, Ambien 10 mg qHS. Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Ertapenem 1 gram Recon Soln Sig: One (1) bag Intravenous once a day for 14 days. Disp:14 bag Refills:0 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:28 Tablet(s) Refills:0 8. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection every eight (8) hours: flush with 10 cc and withdraw around the same amount. **If you are unable to withdraw at least 5 cc, please stop flushes*. Disp:60 flushes* Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Therapies Discharge Diagnosis: anterior lower pelvic collection coursing posteriorly to terminate within the posterior pelvic collection. Discharge Condition: Stable. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . TPN: you will continue with home TPN and [Location (un) 511] Home Therapies will assist you with this. Abx: [Location (un) 511] Home Therapies will set up ertapenem at home for you. . PICC: A PICC line was placed for TPN while you were in the hospital. The VNA will assist with dressing changes and care. You may shower but you must cover the PICC and not get it wet. . Pigtail Drain: A drain was placed while you were in the hospital. You should continue to empty and record daily and PRN. Please flush and aspirate drain with 10cc of NS every 8 hrs. If you are unable to aspirate more than 5 cc each time, please stop flushes. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2123-6-15] 3:30 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2163], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2123-6-21] 10:00 NEITHER DICTATED NOR READ BY ME Completed by:[2123-6-7]	[ "555.9", "311", "300.3", "584.9", "307.1", "567.22", "458.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "54.91", "99.15" ]	icd9pcs	[ [ [] ] ]	6163, 6232	3573, 5052	307, 358	6384, 6416	1693, 3550	8245, 8591	1465, 1518		5230, 6140		6253, 6363	5078, 5207			6440, 8222										1533, 1674																												251, 269										386, 968																990, 1293	1309, 1449
45,542	141,983	37703	Discharge summary	report	Admission Date: [2164-11-16] Discharge Date: [2164-11-19] Date of Birth: [2135-8-29] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3376] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 29M with h/o GERD presents with abrupt onset of RUQ/epigastric abdominal pain this morning ([11-16]). He was previously healthy and has never had this pain before. At 4am, he woke up and had an episode of non-bloody diarrhea. He re-awoke at 8am and soon after had onset of [11-10] crampy abdominal pain radiating to the back, constant and with no alleviating factors. He vomited once but denies nausea. He drank 4 beers last pm. . In the ED, initial vitals were 98.9 113 124/87 20 100%RA. He received 4-5L of IVF, 4mg IV morphine, 4mg dilaudid, 4mg zofran, 750mg levofloxacin, 500mg metronidazole, 1mg ativan. CT abd was c/w acute pancreatitis, but otherwise unremarkable. He remained persistently tachycardic up to 130s and then 150s, so was admitted to the ICU for monitoring. . On ROS, he denies CP, SOB, palp, urinary sx, fevers, chills. Further ROS is negative except where noted above. Past Medical History: Pericarditis in [2158] of unknown etiology treated with Indocin GERD Social History: EtOH: [11-12] drinks spaced throughout the week. No tobacco use. Lives with girlfriend, currently unemployed. Did not ask re illicit drugs as family present. Family History: Paternal grandmother with pancreatic CA, gallbladder disease. Physical Exam: Temp 100.4 HR 157 BP 120/64 RR 18, 96% RA Gen: Well appearing male in NAD, sitting up in bed alert and oriented HEENT: Anicteric sclerae, MMM CV: Tachy, reg rhythm, no m/r/g RESP: Slightly diminished at bases, otherwise CTAB ABD: Hypoactive BS. Abdomen mildly distended and firm (not rigid). TTP in epigastrium with no reb/guarding. No [Doctor Last Name 515] sign present. Ext: Distal ext cool, but otherwise WWP. No edema . At Discharge: Vitals: 98, 111, 118/90, 20, 98% on RA GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: soft, ND, appropriately TTP, +BS, +flatus Extrem: no c/c/e Pertinent Results: [2164-11-16] 02:36PM BLOOD WBC-22.9* RBC-4.29* Hgb-14.5 Hct-42.0 MCV-98 MCH-33.8* MCHC-34.5 RDW-14.7 Plt Ct-474* [2164-11-17] 05:15AM BLOOD WBC-12.0* RBC-3.66* Hgb-12.6* Hct-37.0* MCV-101* MCH-34.4* MCHC-33.9 RDW-13.4 Plt Ct-266 [2164-11-18] 06:40AM BLOOD WBC-11.3* RBC-3.51* Hgb-12.1* Hct-35.7* MCV-102* MCH-34.4* MCHC-33.9 RDW-13.4 Plt Ct-240 [2164-11-19] 06:40AM BLOOD Hct-34.1* [2164-11-17] 05:15AM BLOOD PT-13.0 PTT-25.7 INR(PT)-1.1 [2164-11-16] 02:36PM BLOOD Glucose-184* UreaN-10 Creat-0.8 Na-137 K-3.4 Cl-99 HCO3-24 AnGap-17 [2164-11-17] 05:15AM BLOOD Glucose-104 UreaN-3* Creat-0.6 Na-135 K-3.9 Cl-102 HCO3-27 AnGap-10 [2164-11-18] 06:40AM BLOOD Glucose-80 UreaN-4* Creat-0.7 Na-137 K-4.1 Cl-101 HCO3-26 AnGap-14 [2164-11-16] 02:36PM BLOOD ALT-118* AST-93* AlkPhos-186* Amylase-610* TotBili-0.7 [2164-11-17] 05:15AM BLOOD ALT-61* AST-37 AlkPhos-100 Amylase-267* TotBili-0.7 [2164-11-19] 06:40AM BLOOD ALT-34 AST-25 AlkPhos-140* Amylase-89 TotBili-1.2 [2164-11-16] 02:36PM BLOOD Lipase-3740* [2164-11-17] 05:15AM BLOOD Lipase-825* [2164-11-19] 06:40AM BLOOD Lipase-166* [2164-11-16] 02:36PM BLOOD Albumin-4.9* [2164-11-17] 05:15AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.3* Cholest-165 [2164-11-18] 06:40AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 [2164-11-17] 05:15AM BLOOD Triglyc-91 HDL-45 CHOL/HD-3.7 LDLcalc-102 Brief Hospital Course: 29M with h/o GERD presents with acute pancreatitis and admitted to the ICU due to persistent sinus tachycardia. . #. Pancreatitis: Supported by history, exam, labs, and CT scan. Abdomen is somewhat tense, but no peritoneal signs and imaging is reassuring. Has been seen by surgery, who are following. Some recent EtOH, but no binging. [Month (only) 116] have passed a gallstone as has some LFT abnormalities. No h/o hyperlipidemia, no offending meds. Continued supportive care with NPO, IVFs and hydromorphone for pain. RUQ U/S was ordered which did not show any acute findings. Continued to trend LFT's. . #. Tachycardia: Sinus tach on EKG. Up to 150-160 on arrival, but back to 120s with aggressive IVF. Likely combination of volume depletion and SIRS from pancreatitis (also suggested by elevated temp and WBC). Continued to monitor on telemetry and IVF's prn keeing in mind respiratory status. . #. Hypoxia: O2 sat normal on arrival, but decreased to 90% on RA for several minutes. Likely from atelectasis and aggressive fluids, but patient remains asymptomatic. Now back to mid-90s on RA. CXR this AM showed pulmonary edema which is likely secondary to IVFs. Will likely resolve with time and no intervention needed at this time. . #. GERD: stable. continued PPI Patient's HR stabilized with hydration. Hemodynamic status stabilized. Transferred to [Hospital Ward Name 1950] 5 under care of General Surgery. LFT's continued to trend down. Clinical presentation improved, pain decreased. Tolerated clear liquids. Voiding adequate amounts. Denies pain. AM LFT's continued to normalize. Started on Regular low fat diet. Denied pain, N/V. Information regarding Low fat diet given to patient. Advised to continue with this diet until follow-up appointment with Dr. [Last Name (STitle) ]. Advised to follow-up with Dr. [Last Name (STitle) ] in [2-3] weeks to arrange for gall bladder removal. Medications on Admission: omeprazole 20mg daily. Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: gallstone pancreatitis Discharge Condition: Stable Tolerating a low fat regular diet Denies pain Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Diet: LOW FAT: please continue with this diet until your follow-up with Dr.[Last Name (STitle) ]. Please refer to the hand-out provided to your per nursing staff as a guide. Followup Instructions: 1. Please follow-up with Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) ]([Telephone/Fax (1) 55917] on Date/Time:[2164-11-20] 3:30 to arrange for your gall bladder to be removed. Completed by:[2164-11-19]	[ "427.89", "577.0", "518.0", "574.20", "518.4", "305.02", "276.50", "530.81", "799.02", "553.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5793, 5799	3666, 5582	331, 338	5865, 5919	2259, 3643	7027, 7270	1559, 1622		5655, 5770		5820, 5844	5608, 5632			5943, 7004										1637, 2066																		2080, 2240										277, 293										366, 1268																1290, 1364	1380, 1543
63,431	176,567	40444+58376	Discharge summary	report+addendum	Admission Date: [2133-6-21] Discharge Date: [2133-6-25] Date of Birth: [2056-12-2] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Fournier's gangrene Major Surgical or Invasive Procedure: [2133-6-21] Flexible bronchoscopy, scrotal debridement, diagnostic laparoscopy, exploratory laparotomy, diverting colostomy History of Present Illness: Patient is a 76 year old male who was initially admitted to OSH for a right VATS, right upper-lobe wedge resection, upper lobectomy and lymph node dissection performed on [2133-5-28], and found to have NSCLC. Following this operation, he developed increasing subcutaneous emphysema, requiring the re-insertion of chest tubes 2 times. During his hospital stay, he developed urinary retention of [6-2] and was found to have a UTI-Enterococcus on [6-18] that was treated with ampicillin. On [2133-6-18], the patient developed scrotal swelling. He was seen by the OSH Urology Service and there was a concern for some type of cellulitis or mass, and they suggested a scrotal ultrasound that was not done because of the weekend. The OSH hospitalist on call was called on [2133-6-21] at 3am because nursing noted a foul-smelling drainage from his rectum. According to the OSH discharge summary, "the rectal sphincter was open and there was ulceration and induration with necrotic tissue all around the whole perineal area and pus-brown liquid drainage with air bubbles." There was concern for a fistula and for the cellulitic and swollen scrotum. General Surgery at the OSH was concerned for an ulcerated perirectal abscess with probable gangrene and a complex polymicrobial infected whole perineum and recommended trasnfer to [Hospital1 18] for immediate surgery. He was started on Zosyn, Flagyl and vancomycin. The patient reports first noticing pain in his genital/rectal area 5 days ago that he rates as 2 or 3 out of 10 that does not radiate. The patient reports having a cough with [Location (un) 2452] sputum and SOB. He reports very soft stools/diarrhea and urinary frequency and urgency. Past Medical History: Past Medical History: 1. Adenocarcinoma, non-small cell lung cancer 2. recurrent subcutaneous emphysema 3. Hypertension 4. Hypercholesterolemia 5. Benign prostatic hypertrophy s/p urinary retention Past Surgical History: 1. Wedge resection, right upper lobectomy VATS procedure on [2133-5-28] 2. Inguinal hernia repair 3. Hemorrhoidectomy Social History: 20 pack-year history of smoking cigarettes, quit smoking 25 years ago. He denies recreational drug use or alcohol use. Family History: Mother-breast cancer diagnosed in mid-70s Sister-brain aneurysm, died at 42yo Physical Exam: (on admission) Physical Exam: Vitals: 97.3 97.3 76 102/43 18 on 3L GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, with decreased breath sounds on the right. ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses GU: Extremely swollen, erythematous scrotum. Wound: Perirectal ulceration with necrotic tissue surrounding the rectal opening. Pus and brown liquid drainage with foul odor draining from the area of ulceration. The area immediately around the ulcer is erythematous. Ext: Diffuse crepitus felt along both UE and along the chest wall. No LE edema, LE warm and well perfused Pertinent Results: [2133-6-21] 02:04PM BLOOD WBC-13.1* RBC-3.78* Hgb-11.2* Hct-34.6* MCV-92 MCH-29.6 MCHC-32.4 RDW-13.1 Plt Ct-731* [2133-6-22] 01:42AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.0* Hct-30.2* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.5 Plt Ct-615* Brief Hospital Course: He was taken emergently to the operating room on [2133-6-21]. He remained intubated post-op and was admitted to the ICU. He was extubated without issue later in the day on POD1. His scrotum and wounds were serially checked. Some scrotal erythema was present but was stable. Dressing changes were done daily and there was no further drainage. His wound is extensive and requires packing with a dampened normal saline gauze using a sterile Q tip to apply the packing loosely into the wound which tracks approximately 3-4 cm. Dressing changes are best performed with patient lying on his left side with a second person to support his leg for optimal visualization. Cultures were sent and final sensitivities are still pending at time of this dictation. Preliminary data shows mixed bacterial types. Empiric treatment with Vanco and Zosyn were initiated early on; this course will need to continue for another 2 days (stop date [6-27]). He was evaluated for PICC line placement by the IV team who were unsuccessful in their attempts at placing. They in turn recommended PICC placement by Interventional Radiology. At time of this dictation he has a functional peripheral line and given that he only has 2 more days of the antibiotics it was discussed with surgical team that he could be discharged with the peripheral IV and if access is lost he may complete his course with Augmentin for the remaining 2 days. The right chest tube that was placed by Thoracic Surgery following VATS procedure RUL wedge, completion lobectomy, anterior hilar lymph node dissection with persistent subcutaneous emphysema was managed by their service during his entire stay. On [6-24] the chest tube was clamped, two follow up chest xrays were obtained immediately after clamped and again at 4 hour mark. His chest tube was pulled and post pull film did show some evidence of small pneumothorax. Clinically he was stable with oxygen saturations 93% room air, RR 18-20. It should be noted that the subcutaneous emphysema does persist on both upper extremities tracking to his upper chest, neck and ethmoid regions. He will require follow up as an outpatient in Thoracic clinic in the next 1-2 weeks. On POD2 his diet was advanced to a regular diet and his pain, which was initially treated with intermittent IV Dilaudid, was transitioned to oral pain medications. On POD2 he was stable for transfer to the floor. Once transferred to the regular nursing unit he continued to progress. At times he has been noted with intermittent delirium but has been cooperative with care and there have been no behavioral issues. He was evaluated by Physical therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: Atenolol 50, simvastatin 20, tamsulosin 0.4, omeprazole, asa 325, vitamins Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 10. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) GM Intravenous Q 12H (Every 12 Hours) for 2 days: stop date [2133-6-27]. 11. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 GM Intravenous Q8H (every 8 hours) for 2 days. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Fournier's gangrene Subcutnaeous emphysema Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with an infection in your scrotum which required an operation to clear the infection. You were also treated with a course of intravenous antibiotics. During this operation you required that a colostomy be created so that your bowel movements are being eliminated through a bag on your abdomen. Your surgical wounds are extensive and require twice/day dressing changes. You are being recommneded to go to a rehabilitation facility once you leave the hopsital for ongoing wound care and for helping to rebuild your strength and endurance. Followup Instructions: Follow up next week in Acute Care Surgery Clinic for evlaution of your wound. Call [Telephone/Fax (1) 600] for an appointment. Follow up in [1-18] with with Dr. [Last Name (STitle) ], [First Name3 (LF) 1092] Surgery; call ([Telephone/Fax (1) 17398] for an appointment. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2133-6-25] Name: [Known lastname 14080],[Known firstname 126] A. Unit No: [Numeric Identifier 14081] Admission Date: [2133-6-21] Discharge Date: [2133-6-25] Date of Birth: [2056-12-2] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3687] Addendum: The red ruber rod remains in the stoma and will be removed next Tuesday when patient returns for his follow up appointment in Acute Care clinic. Please call [Telephone/Fax (1) 4810] to schedule this follow up for Tuesday [2133-6-30]. Discharge Disposition: Extended Care Facility: [Hospital3 1933] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 3689] Completed by:[2133-6-25]	[ "998.81", "041.04", "682.2", "599.0", "401.9", "608.4", "V64.41", "272.4", "608.83", "V10.11", "566", "568.0", "600.00", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "86.22", "61.3", "49.04", "46.03", "33.24", "54.59", "61.0" ]	icd9pcs	[ [ [] ] ]	9698, 9882	3807, 6523	323, 453	7853, 7853	3551, 3784	8626, 9675	2732, 2812		6648, 7697		7788, 7832	6549, 6625			8030, 8603								2454, 2578		2858, 3532																												263, 285										481, 2210									7868, 8006							2254, 2431	2594, 2716
22,930	134,510	54241	Discharge summary	report	Admission Date: [2191-5-11] Discharge Date: [2191-5-25] Date of Birth: [2138-10-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: nausea and vomiting for 4 days and weak legs x 1 day Major Surgical or Invasive Procedure: EGD History of Present Illness: 52 yo male with PMH significant for alcoholism and hyperglycemia presents from home via EMS for collapse. He has been binge drinking for the last 2 weeks and felt nauseated and vomited blood over the last 4 days. On arrival, EMS found him to be naked on the floor. His initial blood pressure was 74/42 and he was brought to the ED. . ED course: Patient received 9 liters IVF and 2 units PRBCs. One dose of Flagyl and Levofloxacin. Pt underwent NGL, w/ dark red return, unable to clear. GI consulted, pt underwent EGD which revealed, blood in the antrum and body, grade IV severe esophagitis in the whole esophagus, congestion, erythema and erosions in the whole stomach compatible with erosive gastritis. Blood clot in the gastroesophageal junction, bleeding likely secondary to esophagitis and M-W tear. Patient also found to be in DKA w/ initial glucose in 800's, + ketones in urine and pH of 7.11. Insulin drip was started, and fluids continued. He was transferred to the MICU. . Currently the patient still has some nausea. He complains of falls over the last few days. He also has had nausea and vomiting with blood. He reports some nonproductive cough over the last few days. He has abdominal pain. He complains of a headache currently. He feels slightly shaky currently. He has been eating only Ensure over the last few days. Past Medical History: 1. Alcohol abuse, history of withdraw seizures, DTs, and alcoholic and starvation ketoacidosis. 2.Chronic pancreatitis. 3.History of polysubstance abuse (cocaine, heroin, amphetamines, benzodiazepines). 4.History of pancytopenia secondary to chronic alcohol abuse. 5.Left gynecomastia with negative mammogram in the past. 6.Genital herpes. 7.Depression. 8.Right clavicular fracture in [2185-4-6]. 9.Peptic ulcer disease w/ UGIB 10.Left ulnar neuropathy entrapment syndrome 11. Bipolar disorder 12. lower back pain Social History: The patient has been divorced since [2176]. He has one daughter and two step-daughters. [Name (NI) ] sells art and antiques and is now retired. Smoked until 2 years ago, 1 PPD at the most, for 30 pack years. Has used cocaine and valium 3-4 years ago. Drinks alcohol to excess over last 20 years, was sober for 6 years once. Family History: Alcoholism in his parents and brother; father died secondary to cerebrovascular accident. Mother has [Name (NI) 2481] disease. Father and 2 paternal aunts with adult onset diabetes. Physical Exam: vitals: T98.9 BP 150/93 P112 R18 98% 2L NC GEN: no apparent distress. Conversant. Somehwat dishevelled HEENT: PERRLA. MM very dry. NECK: No LVD. right EJ in place. CV: RRR nl s1s2 no MGR LUNGS: clear to auscultation bilaterally ABDOMEN: Soft, diffusely tender to palpation. no rebound/guarding EXT: no edema. traumatic left knee, abrasion on abdomen NEURO: CN 2-12 intact. Strength 5/5 UE/LE. FTN intact. Pertinent Results: CXR [5-12]: No evidence of acute cardiopulmonary process. . Knee XR [5-12]: Normal alignment. No fractures or joint effusion. The joint spaces are preserved on this nonstanding view. . TTE [5-20]: 1. The LA is normal in size. The left atrium is elongated. 2. LV wall thicknesses are normal. The LV cavity size is normal. Regional left ventricular wall motion is normal. Overall LV systolic function is normal (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal LV filling pressure. 3. RV chamber size is normal. RV systolic function is normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is a trivial/physiologic pericardial effusion. . CDiff [5-20]: neg urine cx [5-21]: neg . Abd US [5-20]: 1. No ascites. 2. Echogenic coarse hepatic echotexture suggestive of intrinsic liver disease; however, the portal vein is patent with appropriate hepatopetal flow. 3. 2.8 x 2.7 x 1.7 cm cystic focus in the pancreatic head. This could represent a pseudocyst or cystic pancreatic neoplasm. Further evaluation with contrast-enhanced MR [First Name (Titles) ] [Last Name (Titles) ] is recommended. . CT Abd/Pelvis [5-21]: 1. Cystic lesion measuring 3.5 x 2.6 x 3.0 cm in the pancreatic head, confirming the finding on the recent ultrasound and which has developed compared to the more remote CT scan. Note is made of _____ worrisome features identified. The differential diagnosis could again include a pancreatic pseudocyst, particularly given the background of chronic pancreatitis, or a cystic pancreatic neoplasm. If further evaluation with EUS or MRI is not contemplated then followup evaluation in three to six months would be recommended. 2. Small amount of nonspecific free fluid in the pelvis. 3. Changes consistent with chronic pancreatitis with development of mild dilatation of the main pancreatic duct. . CXR [5-21]: Early left lower lobe pneumonia and effusion since [2191-5-12]. Brief Hospital Course: The patient was scoped in the ED, found to have grade IV esophagitis, possible [Doctor First Name ]-[Doctor Last Name ] tear, started on [Hospital1 ] PPI and Sucralfate per GI recs. His hematocrit was monitored for q 6 hours while he was initially kept NPO. His diet was then advanced to a regular diabetic diet, with his hct remaining stable and no further evidence of bleeding. . He was continued on an insulin drip and IVF per DKA protocol in the ICU. Once his gap closed, he was transitioned to SC insulin. However, his gap redeveloped and he was placed back on the insulin drip and IVF. [Last Name (un) ] was consulted, thought that his diabetes was most likely a combination of impaired pancreatic function from ETOH abuse as well as a significant component of an insulin resistance given the high amounts he was requiring. He was started on Lantus and Humalog sliding scale once he gap closed for a second time. On the floor his insulin sliding scale was titrated by [Last Name (un) ] consultants daily. The nurses dedicated much time to diabetes instruction. The patient had a difficult time grasping fingerstick monitoring and drawing up his own insulin. He was hypoglycemic on the floor and was changed over to pranding tid and this regmine worked well for him. For his ETOH abuse, he was closely monitored on a CIWA scale and treated with Valium as needed. Social work and addiction nurse consults were placed to help provide the patient with resources for treatment, as he was indicating that he would like to seek rehab/detox. Physical Therapy worked with him daily. He is being discharged to long term detox. Given the significant amount of knee pain and his history of falls, x-rays were obtained to rule out fractures. The films were negative, and he was given MS contin for pain relief. His elevated CK was thought to be secondary to his falls, and trended down. The morphine was stopped and the patient tolerated this well. Pancreatic mass - noted to have a small mass on abdominal ultrasound and confirmed by CT scan. GI service was reconsulted and recommended repeat CT scan in [7-14] weeks. Patient will also follow up with GI after discharge. Medications on Admission: (gets from CVS on Chestnut St in [Location (un) ]) celexa 40 mg QD trazodone 150 po qd neurontin 800 po QID seroquel 25 mg QID depakote 250 po QID Aspirin 1000 mg po qd lamictal 100 po qd prilosec 20 mg po qd tylenol "very frequently" occasional ibuprofen Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:90 Capsule(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QID (4 times a day). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed: If your glucose is greater than 140, you should take an extra 5 mg of glyburide. . 13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Discharge Disposition: Home with Service Discharge Diagnosis: UGIB EtOH withdrawal Uncontrolled Diabetes Discharge Condition: stable, ambulating with PT Discharge Instructions: Please return if you experience chest pain, shortness of breath, bloody vomit, lightheadedness, increased urination, increased tremors, or any other worrisome symptoms. Please take all medications as directed. You have been started on diabetes medications. You should measure your fingerstick glucose twice a day. If your glucose is greater than 140, you should take an extra 5 mg of glyburide. If your glucose is greater than 400, you should take the extra 5 mg of glyburide and call your doctor. You have been given 3 doses of valium to complete your detoxification from alcohol. You have been arranged follow-up appointments in [Hospital 191] Clinic and [Hospital ] Clinic. Your name is on the waiting list for an appointment at the [Last Name (un) ] Diabetes Center; you can call [Telephone/Fax (1) ] for an appointment. You will also need to follow-up with a psychiatrist at Mac [Hospital ] Hospital. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 1954] or [Telephone/Fax (1) 2422] Date/Time:[2191-6-8] 2:00 . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7869], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2191-6-23] 3:00 . Your name is on the waiting list for an appointment at the [Last Name (un) ] Diabetes Center; you can call [Telephone/Fax (1) ] for an appointment. . You will also need to follow-up with a psychiatrist at Mac [Hospital ] Hospital. Completed by:[2191-6-8]	[ "577.2", "530.7", "303.01", "250.12", "486", "263.0", "291.81", "577.1" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]	9519, 9538	5546, 7757	367, 372	9625, 9654	3280, 5523	10638, 11262	2650, 2839		8068, 9496		9559, 9604	7783, 8045			9678, 10615										2854, 3261																												275, 329										400, 1740																1762, 2283	2299, 2634
2,298	170,681	48207	Discharge summary	report	Admission Date: [2105-1-14] Discharge Date: [2105-1-21] Date of Birth: [2036-12-16] Sex: F Service: MEDICINE Allergies: Aspirin / Niacin / Tape Attending:[First Name3 (LF) 4654] Chief Complaint: dyspnea, bradycardia, hypotension. Major Surgical or Invasive Procedure: none. History of Present Illness: Ms. [Known lastname 101609] is a 68 year old female with a history of dilated cardiomyopathy with resolution on recent ECHO, htn, DM2 who presents with SOB. She states that her SOB started acutely last night at ~ 8 pm and was associated with lightheadedness. It began after going to the mailbox to get the mail and did not begin until she sat down. She also had an episode of prolonged coughing which was minimally productive of greenish sputum at the same time. She denies any prior SOB or DOE although she does note chronic orthopnea. She does note increased LE swelling over the last month. She notes her regular weight it 215 lbs and her weight on ICU admission is 240 lbs (she was 212 lbs on [2104-12-19] sleep visit). She denies any significant cough prior to last night. She denies fevers but does note chills for the last month. She also notes urinary frequency for the last month but denies dysuria. Last night, her SOB improved after 30 minutes of rest. She felt better this am but then had dyspnea while going through her mail and her HHA felt she looked SOB when she got to the house so she hit her medic alert necklace and was brought to the ED. She also notes bilateral calf pain, R worse than L. . In the ED, 97.9, 72, 127/85, 20, 93% RA. Labs remarkable for normal WBC count, Hct at 33 within recent baseline, electrolytes were normal with exception of BUN/Cr 26/1.1 (BL Cr 0.9-1.0, CEs were negative x 1. Lactate was 2.4. CXR showed possible L hilar consolidation. U/A consistent with UTI. She received 1 gram of ceftriaxone and 750 mg of levofloxacin. Her BPs transiently dropped to SBPs in 80s which resolved to 1 L of NS with increase in SBPs to 110s. She received an additional L of NS following this drop. At the time of transfer to the ICU, her SBP was in the 120s. Also of note, her ECG showed weinkeboch at a rate in the 50s which was new compared to prior. Cardiology was consulted with the ED and did not think any further intervention was required. . On arrival to the ICU, patient is in NAD. She feels comfortable. She denies any significant SOB. She denies any current or recent chest pain. She does note calf pain bilaterally which has been chronic. As above she denies fevers but does not chills x 1 month. Denies any nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria. She does note urinary frequency. Past Medical History: --Dilated cardiomyopathy diagnosed [2103-2-2] following spine surgery, with subsequently normalized cardiac function --Hypertension --Diabetes Melitis II (HgA1C 7.3 [2103-2-13], with peripheral neuropathy) --Obstructive sleep apnea (uses CPAP) --Gastroesophageal reflux disease --Anemia (baseline Hct = 30-35) --osteoarthritis --Sciatica --Lumbar spondylosis and disk degeneration s/p laminectomy and fusion [1-/2101] --Right knee replacement --Cervical stenosis --Restless leg syndrome --Cataracts s/p surgery in left eye Social History: Divorced with four children, several grandchildren, and great-grandchildren. She used to work as a special education bus monitor. She lives alone in [Location (un) 686], with some assistance from her daughter. She gets meals on wheels. Denies current and past smoke, alcohol, and IVDU. Family History: Significant for diabetes and coronary artery disease. Multiple family members affected. Mother had DVT following knee surgery. Physical Exam: VS: 96.5 96.5 54 94/62 21 100% obese MMM thick neck, cannot appreciate JVP Fine crackles at bases. RRR. No murmurs Obese. NABS. S/NT 4+ LE edema to thighs. No erythema. Calves minimally tender to palpation bilaterally. A+Ox3. CNs [3-11] intact. 4+/5 strength throughout. Pertinent Results: [2105-1-14] 03:13PM URINE WBCCLUMP-MOD [2105-1-14] 03:13PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [2105-1-14] 03:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2105-1-14] 03:13PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.012 [2105-1-14] 03:13PM URINE GR HOLD-HOLD [2105-1-14] 03:13PM URINE HOURS-RANDOM [2105-1-14] 03:58PM LACTATE-2.4* [2105-1-14] 04:05PM PT-13.8* PTT-26.6 INR(PT)-1.2* [2105-1-14] 04:05PM PLT COUNT-212 [2105-1-14] 04:05PM NEUTS-66.0 LYMPHS-25.7 MONOS-5.0 EOS-2.9 BASOS-0.5 [2105-1-14] 04:05PM WBC-8.1 RBC-3.85* HGB-11.0* HCT-33.2* MCV-86 MCH-28.5 MCHC-33.1 RDW-13.6 [2105-1-14] 04:05PM CK-MB-NotDone proBNP-1340* [2105-1-14] 04:05PM cTropnT-0.02* [2105-1-14] 04:05PM CK(CPK)-57 [2105-1-14] 04:05PM estGFR-Using this [2105-1-14] 04:05PM GLUCOSE-237* UREA N-26* CREAT-1.1 SODIUM-142 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 [2105-1-14] 11:54PM URINE WBCCLUMP-MANY [2105-1-14] 11:54PM URINE AMORPH-MOD [2105-1-14] 11:54PM URINE RBC-33* WBC->1000* BACTERIA-FEW YEAST-NONE EPI-6 [2105-1-14] 11:54PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [2105-1-14] 11:54PM URINE COLOR-Straw APPEAR-Cloudy SP [Last Name (un) 155]-1.015 . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2105-1-21] 06:01AM 11.6* 3.16* 9.0* 27.0* 86 28.5 33.4 13.3 233 Source: Line-PICC [2105-1-20] 08:08AM 10.6 3.17* 8.9* 27.1* 85 28.1 33.0 13.3 215 Source: Line-PICC [2105-1-19] 03:54AM 11.1* 3.43* 9.5* 28.9* 84 27.7 32.9 13.2 196 Source: Line-aline [2105-1-18] 02:17AM 14.1* 3.25* 9.6* 27.3* 84 29.7 35.3* 13.7 175 Source: Line-aline [2105-1-17] 05:49AM 12.8* 3.38* 9.6* 28.4* 84 28.5 33.9 13.4 174 [2105-1-16] 11:15PM 13.9* 3.46* 10.2* 29.3* 85 29.4 34.8 13.7 173 [2105-1-16] 05:00AM 11.4* 3.40* 9.9* 29.2* 86 29.1 33.9 13.6 179 [2105-1-15] 05:05AM 9.6 3.30* 9.6* 28.2* 86 29.1 34.0 13.5 177 [2105-1-14] 04:05PM 8.1 3.85* 11.0* 33.2* 86 28.5 33.1 13.6 212 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2105-1-19] 03:54AM 70.9* 20.9 3.8 4.0 0.4 Source: Line-aline BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2105-1-21] 06:01AM 233 Source: Line-PICC [2105-1-21] 06:01AM 14.2* 60.2* 1.2* Source: Line-PICC Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2105-1-21] 06:01AM 143* 15 0.9 138 4.4 103 26 13 Source: Line-PICC [2105-1-20] 08:08AM 157* 15 0.9 137 4.4 104 25 12 Source: Line-PICC [2105-1-19] 03:54AM 154* 17 0.9 138 3.5 106 27 9 Source: Line-aline [2105-1-18] 10:34PM 265* 16 1.0 138 4.0 104 25 13 Source: Line-aline [2105-1-18] 02:17AM 272* 13 1.2* 138 3.8 103 25 14 Source: Line-aline [2105-1-17] 05:49AM 214* 14 0.9 138 4.2 104 22 16 TEST ADDED ON @1319 [2105-1-16] 11:15PM 231* 15 1.0 138 4.2 105 23 14 [2105-1-16] 05:00AM 238* 18 1.1 138 4.5 107 25 11 [2105-1-15] 05:05AM 126* 21* 0.9 140 3.9 107 26 11 CHEMS ADDED 9:55AM [2105-1-14] 04:05PM 237* 26* 1.1 142 3.8 104 26 16 ESTIMATED GFR (MDRD CALCULATION) estGFR [2105-1-14] 04:05PM Using this1 . ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2105-1-17] 05:49AM 33 27 249 79 0.2 TEST ADDED ON @1319 [2105-1-16] 11:15PM 83 [2105-1-15] 05:05AM 43 CHEMS ADDED 9:55AM [2105-1-15] 12:08AM 53 [2105-1-14] 04:05PM 57 . . [1-14] CXR: Area of increased density superimposed on the left hilum most likely represents pneumonic consolidation. Please ensure followup to clearance. . Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Diastolic function could not be assessed due to arrhythmia. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [2104-5-13], the findings are similar with normal biventricular systolic function. Diastolic function could not be assessed due to arrhythmia. . LE USN: IMPRESSION: Findings consistent with deep venous thrombosis in the short segment of a right popliteal vein, chronic . CTA chest: FINDINGS: Significant burden of acute pulmonary embolus resides in the right main pulmonary artery extending to the lobar and segmental branches. The left main pulmonary artery as well as its lobar and segmental branches is clear. Right heart strain is manifested by paradoxical bowing of the interventricular septum and reflux of contrast into the hepatic veins. Both lungs are clear without areas of infarction. Prominent mediastinal lymph nodes including a 14-mm right paratracheal lymph node, are not significantly changed. The aorta is unremarkable. No pleural or pericardial effusions. The airways are patent. . While the study is not designed for subdiaphragmatic evaluation, there is diffuse fatty infiltration of the liver. . IMPRESSION: Acute occlusive pulmonary embolus in the right main pulmonary artery extending into lobar and segmental branches with evidence of right heart strain. . CT abd/pelvis: IMPRESSION: 1. No evidence for IVC or other venous clot. 2. Trace pericholecystic fluid without evidence for cholecystitis. 3. Simple left renal cyst. 4. Bilateral transpedicular screws at L3, L4, L5 with laminectomy performed at the same level. No evidence for hardware failure or fracture. . . [2105-1-19] CXR: PICC line in place and ready for use. Brief Hospital Course: 68F with a history of dilated cardiomyopathy s/p resolution, HTN, DM2 who presented to the ED with increased dyspnea with exertion. . # dyspnea: initial CXR concerning for early pneumonia, for which pt was treated with ceftriaxone and azithromycin. LE USN and CTA was subsequently obtained after she was noted to have R>L LE edema, which revealed presence of R DVT and R pulmonary embolism, for which pt was started on heparin gtt and coumadin on [1-16]. TTE was without RV strain. She was transferred to the medical floor on [1-16]. Upon arrival to the ICU her O2 requirement was gradually weaned from 5L to 2-3L. . Upon arrival to the floor, she was noted to have an episode of recurrent coughing in the setting of eating chicken soup. She was noted to have desats to 90% on 4L -> 100% on NRB, with RR 40s, and ABG 7.49/32/52, with fever to 102, raising concern for aspiration pneumonia. She was started on clindamycin and taken back to the ICU where it was felt that her CXR was more consistent with hospital acquire pneumonia and she was started on an 8 day course of zosyn and vancomycin on [2105-1-19]. . She was transferred back to the medical floor on [1-19]. Attempts were made to obtain sputum culture which were contaminated flora. She was evaluated by physica ltherapy and found to saturate 99% on 3L and 88% on RA. She was switched to lovenox injections twice daily on [1-21], and discharged home with plan to discontinue lovenox once her INR is between [3-2]. . With regard to her pneumonia, a PICC line was placed, and she is being discharged to a sub-acute facility to complete an 8 day course (day 1 [2105-1-19]) of vancomycin and zosyn. . given her DVT/PE, her raloxifene was discontinued as this can increase risk of VTE (1%). . # dilated cardiomyopathy - resolved on most recent echocardiogram after treatment with beta blockade and ace-inhibitor, no evidence of CHF on CXR. she did receive a single dose of 40 mg iv lasix x 1 on [1-17] [3-1] concern that she may have been mildly volume overloaded. her lasix was discontinued at time of discharge given that she appeared clinically euvolemic, and concern for reducing pre-load excessively in the setting of PE. . # bradycardia/heart block: pt found to have new second degree type 1 (weinkeboch) block on admission EKG in ED, previously know to have first degree block. her dyspnea was felt [3-1] her PE/PNA, therefore her dysrythmia was felt to be asymptomatic. Her nodal [Doctor Last Name 360] (metoprolol) was discontinued, she had been on this for HTN, though it may have been used given her history of dilated cardiomyopathy. Her Amitriptyline was also discontinued as it has been noted to cause (Atrioventricular conduction pattern - finding, Cardiac dysrhythmia, Cardiac dysrhythmia.) . She should be followed by her cardiologist (Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437]), within 1-2 months to discuss utility of restarting beta blockade. . # hypotension: pt noted to be hypotnesive upon arrival to the ICU (systolic 80s-90s), which was felt likely [3-1] volume depletion vs sepsis from UTI or PNA with some contribution likely from her PE. he did not require pressors, his BP meds were held, and he was treated with IVF boluses with improvement of his BP to 120s. . . # UTI: pt with equivocal UA and culture negative on admission. She was initially covered with CTX for PNA which would cover UTI if present. It was susequently felt not. . # ARF: on arrival, cre mildly elevated at 1.1, felt component of post-obstructive component given 600cc residual w/foley placement. Improved with hydration as above, and down to 0.9 at time of discharge. Pt urinating without difficult without foley at time of discharge. . # Diabetes Mellitis: pt covered with SSI while inpatient, then converted back to home regimen of glypizide and januvia at time of discharge. . # Obstructive sleep apnea: pt has been noncompliant in past with CPAP due to poorly fitting mask. She was restarted on CPAP during inpatient hospitalizatin, and encouarged to continue this at home. . # GERD: patient conitnued on omeprazole [Hospital1 ]. . # Anemia: baseline appears to be ~30, down to 27 during this admission but stable at 27. stools guaic negative, INR subtherapeutic, thus felt likely compnent of dilution given volume repletion. . # Restless legs: pt continued on mirapex, lyrica. . # Osteoarthritis: pt continued on calcium, vitamin D. . # h/o anterior cervical decompression and fusion/lumbar spondlosis - continued on ultram. . # oxybutinin - pt denied urinary sx this admission, thus this medication was discontinued. . # Hypertension - pt was noted to be hypotnesive on admission as above, treated with IVF boluses. Her metoprolol was discontinued [3-1] her AV block as above. Her lisinopril was continued. . # FEN: pt maintained on diabetic, low salt (<3g) diet. She was started on aspiration precautions [3-1] concern for aspiration event as above. However, given her negative video swallowing study, it is unlikely that she is aspirating, and if supervised meals reveal no frank evidence of aspiration, this can be discontinued. . # PPX: heparin and coumadin. PPI. bowel regimen . # CODE: patient was FULL CODE during this admission. . # COMMUNICATION: [Name (NI) ] (brother) [Telephone/Fax (1) 101611], [Name (NI) ] (sister) [Telephone/Fax (3) 101612] . # Disposition - pt was discharged to acute care facility with instructions to follow-up with her primary care physician and cardiologist. she will continue lovenox injections until her INR is therapeutic on coumadin. She will complete 8 day course of zosyn and vancomycin. Medications on Admission: Evista 60mg QDaily Lisinopril 10mg Qdaily (recently decreased [3-1] hypotension) Toprol XL 100mg Qdaily Lasix 40mg Qdaily Lyrica 50mg TID Glyburide 10mg QAM/5mg QPM Amitriptyline 100 mg Qhs Prilosec 20mg [Hospital1 ] Oxybutinin 5mg Qdaily Januvia 100mg Qdaily Clortrimazole 1% topical prn Mirapex 0.5mg po qhs Tylenol prn vit C 1000 mg daily Calcium MVI CPAP 11 cm H2O Discharge Medications: 1. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO QAM: pt takes 10mg QAM and 5MG QHS. 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QHS. 3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2) Nasal once a day as needed. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO qhs (). 7. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 10. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 12. Calcium 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for R leg pain. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 19. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every 4 hours) as needed for cough. 20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): adjust as needed for goal INR [3-2]. 21. Outpatient Lab Work please check daily PT/INR, and adjust coumadin dose for goal INR [3-2]. 22. Piperacillin-Tazobactam 3.375 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 6 days: total 8 day course (day 1 [2105-1-19]). 23. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 6 days: total 8 day course (day [2105-1-19]). . 24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 25. 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. 26. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day: continue until patients' INR is between 2 and 3. Discharge Disposition: Extended Care Facility: [Last Name (un) ] house Discharge Diagnosis: primary: pulmonary embolism right deep vein thrombosis hospital acquire pneumonia Discharge Condition: 98% on 3L, breathing comfortably. Discharge Instructions: you were admitted to the hospital with shortness of breath. you were found to have a blood clot in your lungs and right leg. you were also found to have pneumonia. . the following changes were made to your medications: 1. you were started on lovenox, a blood thinner, which you will take until your INR is therapeutic. 2. you were started on coumadin, a blood thinner. 3. your evista was discontinued as this can cause blood clots to form. 4. your metoprolol was discontinued as you were found to have a slow heart rate, which was aysmptomatic. you should discuss restarting this with your cardiologist. 5. your amitriptyline was discontinued as this can contribute to the slow heart rythym seen above. 6. you were started on two antibiotics, vancomycin, and zosyn which you will need to take for a total of 8 days (day 1 was [2105-1-19]). . if you have recurrent symptoms of worsening shortness of breath, chest dicomfort, fevers, worsening cough, or other worrisome symptoms please contact your primary care physician or the emergency department. Followup Instructions: upon arriving home please contact your primary care physician and arrange to be seen within 3-4 weeks. [Last Name (LF) 7021],[First Name3 (LF) ] L. [Telephone/Fax (1) 3581] . upon arriving home, please contact your cardiologist, and arrange to be seen within 4-6 weeks. [First Name8 (NamePattern2) ] [Doctor Last Name ] ([Telephone/Fax (1) 3942]. . please keep your previously scheduled appointments: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2105-2-9] 11:40 Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2105-5-19] 3:00 Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Phone:[Telephone/Fax (1) 11262] Date/Time:[2105-6-10] 11:45 [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658]	[ "425.4", "357.2", "507.0", "530.81", "721.3", "250.60", "401.1", "482.9", "453.41", "285.9", "426.13", "584.9", "327.23", "415.19" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	18966, 19020	10106, 15833	320, 328	19146, 19182	4050, 10083	20285, 21371	3602, 3733		16261, 18943		19041, 19125	15859, 16238			19206, 20262										3748, 4031																												246, 282										356, 2716																2738, 3274	3290, 3586
27,837	116,256	17631	Discharge summary	report	Admission Date: [2167-2-26] Discharge Date: [2167-3-7] Date of Birth: [2138-8-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: palpitations Major Surgical or Invasive Procedure: repair Sinus of Valsalva aneurysm rupture([3-3]) History of Present Illness: 28 yo M who 2 days PTA felt a racing heart rate, presented to ED and was found to be in sinus tach. Cardiac cath at OSH showed a large defect in the right sinus of valsalva with left to right shunt from the aorta to the right atrium. Transferred for surgery. Past Medical History: childhood murmur, palpitations Social History: works in operations for BJs denies toabcco, etoh Family History: NC Physical Exam: NAD Lungs CTAB Heart RRR, tachycardic, [5-17] HSM loudest at apex, heard t/o precordium Abdomen Benign Extrem warm, No edema, 2+ pulses t/o Pertinent Results: [2167-3-7] 07:20AM BLOOD WBC-5.2 RBC-2.79* Hgb-8.3* Hct-23.9* MCV-86 MCH-29.7 MCHC-34.7 RDW-13.4 Plt Ct-166 [2167-3-7] 07:20AM BLOOD PT-13.5* PTT-27.6 INR(PT)-1.2* RADIOLOGY Preliminary Report CHEST (PA & LAT) [2167-3-6] 2:05 PM CHEST (PA & LAT) Reason: eval pneumothoraces [Hospital 93] MEDICAL CONDITION: 28 year old man s/p repair og sinu of valsalva rupture REASON FOR THIS EXAMINATION: s/p thoracentesis INDICATION: 28-year-old status post repair of sinus of Valsalva rupture, status post thoracentesis. PA AND LATERAL CHEST: Compared to [2167-3-5]. There has been interval decrease in the bilateral pleural effusions which remain moderately large on the left and small on the right, with bibasilar atelectasis. No pneumothorax is seen. Median sternotomy wires are intact in midline. IMPRESSION: Slight decrease in bilateral effusions, moderate on the left and small on the right, with bibasilar atelectasis. No pneumothorax. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 49107] [Hospital1 18] [Numeric Identifier 49108] (Complete) Done [2167-3-3] at 3:59:21 PM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2138-8-11] Age (years): 28 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Congenital heart disease. Left ventricular function. Preoperative assessment. Right ventricular function. ICD-9 Codes: 441.2 Test Information Date/Time: [2167-3-3] at 15:59 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 168], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW33-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 6.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: 3.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Low normal LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Sinus of Valsalva aneurysm. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque.There is a right coronary sinus of Valsalva aneurysm. A [Location (un) 49109] appears in the RA and there is left to right shunt. It is uncertain if there is involvement of the TV. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. POSTBYPASS: Right ventricular function remains preserved. Left ventricular function remains borderline normal. The tricuspid valve appears normal and there is trace TR. The defect in the right coronary sinus is no longer visualized and there is no longer left to right shunting on color flow Doppler. The remaining study is unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [Last Name (NamePattern4) ] [2167-3-3] 17:38 Brief Hospital Course: Mr. [Known lastname ] was admitted under cardiac surgery. His creatinine was elevated, PO fluids were encouraged, with improvement in renal function. He remained tachycardic, and his beta blockers were titrated accordingly. On [2167-3-3] he underwent primary closure of sinus of valsalva aneurysm rupture. For surgical details, please see seperate dictated operative note. Following the operation, he was transferred to the ICU in stable condition. He was given 48 hours of Vanocmycin as he was in the hospital preoperatively. He awoke neurologically intact and was extubated later that same day. He was transferred to the floor on POD #1. He went in to rapid atrial fibrillation and was treated with increased beta blockade and Amiodarone. He was also transfused for a hematocrit of 22%. Within 24 hours, he converted back into a normal sinus rhythm. Over the next several days, he continued to make clinical improvements with diuresis. He remained in a normal sinus rhythm without further episodes of atrial fibrillation. He had a moderate L effusion which was tapped on POD#3 for a bloody effusion. His CXR still revealed a mild effusion and he will return for f/u with Dr. [Last Name (STitle) 1290] for a repeat CXR in 1.5 weeks. He was discharged to home in stable condition on POD#4. Medications on Admission: MVI Discharge Medications: 1. 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 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Decrease dose to 400 mg PO daily for 7 days after [Hospital1 ] dose completed. Then decrease dose to 200 mg PO daily after 400 mg dose completed. Disp:50 Tablet(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:50 Tablet(s) Refills:0 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed: Take with food. Disp:90 Tablet(s) Refills:0 10. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Sinus of valsalva Aneurysm Rupture - s/p surgical repair Postoperative Atrial Fibrillation History childhood murmur Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon or while taking pain medicine. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 1290] for Thurs. [3-19] in [Location (un) 47] and have a repeat chest xray. Call [Telephone/Fax (1) ] to arrange appointment. Dr. [Last Name (STitle) 20222] 2 weeks - call for appt Completed by:[2167-3-7]	[ "424.2", "E878.4", "997.1", "747.29", "427.31", "511.9" ]	icd9cm	[ [ [] ] ]	[ "35.39", "39.61", "34.91" ]	icd9pcs	[ [ [] ] ]	8926, 8960	5984, 7289	333, 388	9120, 9128	996, 1289	9477, 9758	813, 817		7343, 8903	1326, 1381	8981, 9099	7315, 7320			9152, 9454										832, 977																												281, 295	1410, 5961									416, 676																698, 730	746, 797
31,723	190,313	27940	Discharge summary	report	Admission Date: [2142-10-3] Discharge Date: [2142-10-11] Date of Birth: [2066-4-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 76 yo woman with rheumatoid arthritis on prednisone and methotrexate who presents with several days of fatigue/lethargy and was found in the ED to be in septic shock. She has been in [Country 4754] for the past several months and during this visit she had a hospitalization about 3-4 weeks ago for a diverticular bleed. She recovered from her illness but in the past several days prior to her arrival she had been more fatigued that usual, taking many day-time naps. ROS positive for occasional cough productive of brownish sputum, but no chest pain, shortness of breath, abdominal pain, N/V, fevers, joint effusions, or any other problems. [Name (NI) ] daughter went to [Name (NI) 4754] to accompany her home as scheduled and on the plane 1-day prior to arrival she was noted to be progressively lethargic. She went to her PCP directly from the airport who evidently drew labs which were suggestive of infection and he started her on augmentin for a presumed respiratory infection. Ms. [Known lastname ] returned home and her daughter noted that her mental status progressively worsened until 1am when she was barely responsive and non-communicative. . At that point she was taken by EMS to [Hospital1 18] ED. Her presenting vitas were T 100.7, HR 110, BP 80/palp with RR 20 and 89% on RA. Her BP improved with 3L NS, but she then spiked a fever to 103.0 and her blood pressure dipped into the mid 80's with hypoxia on a few L nasal canula. CXR was interpreted by the ED staff as RLL and possibly LLL pneumonia so she was given a dose of vancomycin, levofloxacin, and metronidazole. A precept RIJ catheter was placed and she was started on levophed with improvement in mentation and blood pressure. . On questioning at arrival to the ICU she stated that she felt well, did endorse occasional brown sputum, denied SOB, abdominal pain. She did endorse arthritis pain but could not articulate the location of the pain. Her mental status has waxed and waned since being here. . Past Medical History: 1. Rheumatoid arthritis diagnosed in [2136], on MTX and prednisone since that time. complicated by the need for B total knee replacements and single hip replacement. Also with B hand atrophy and Rt shoulder deformity. 2. Steroid-induced diabetes (started on metformin 3 months ago) 3. Diverticular bleed Social History: Emmigrated from [Country 4754] at the age of 70 to live with her daughter. Widowed with 9 children, 2 in [Location (un) 86]. Has smoked 1 PPD since the age of 20. No EtOH. Family History: Sister with stroke, brother died of MI, father died of old age, Mother died in child-birth Physical Exam: T 96.8 BP 104/54 HR 80 RR 20, 98% on 4L NC, CVP 12-15 Gen: Ill-appearing, MM very dry, initially answered questions slowly but appropriately, oriented x 3, but later was somnolent and not answering questions appropriately CV: RRR no m/r/g Lungs: diffusely wheezy and ronchorous with prolonged expiration; diffuse crackles, most prominent at Rt base and Left base. Abd: soft, non-distended, non-tender, no RUQ TTP, negative [Doctor Last Name ] sign Ext: cool, palpable pulses, delayed capillary refill. No edema. Pertinent Results: Admit labs: [2142-10-3] 01:52AM BLOOD WBC-25.7* RBC-3.99* Hgb-11.1* Hct-35.8* MCV-90 MCH-27.8 MCHC-30.9* RDW-17.2* Plt Ct-493* [2142-10-3] 01:52AM BLOOD Neuts-87* Bands-0 Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [2142-10-3] 01:52AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [2142-10-3] 01:52AM BLOOD PT-17.0* PTT-29.6 INR(PT)-1.5* [2142-10-3] 01:52AM BLOOD Glucose-183* UreaN-37* Creat-1.0 Na-138 K-4.7 Cl-97 HCO3-28 AnGap-18 [2142-10-3] 01:52AM BLOOD ALT-643* AST-739* LD(LDH)-1557* CK(CPK)-25* AlkPhos-132* Amylase-22 TotBili-0.3 [2142-10-3] 01:52AM BLOOD Lipase-10 [2142-10-3] 01:52AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1 [2142-10-3] 02:18AM BLOOD Lactate-4.4* [2142-10-3] 06:22AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2142-10-3] 03:27PM BLOOD Acetmnp-NEG [2142-10-3] 01:52AM BLOOD cTropnT-0.01 [2142-10-3] 03:27PM BLOOD CK-MB-2 cTropnT-<0.01 [2142-10-3] 06:22AM BLOOD proBNP-2808* . EKG: sinus tachycardia. No ischaemic signs. . CT chest [10-3]: 1) Extensive centrilobular nodules, tree-in-[Male First Name (un) 239] nodules suggesting tree-in-[Male First Name (un) 239] and discrete nodules as described. Differential diagnosis would include infectious process such as viral infection or mycoplasma. Tuberculosis is less likely. The interstitial lung disease due to methotrexate Treatment is unlikely. No evidence of lung fibrosis to suggest chronic interstitial lung disease. 2) Areas of ground-glass most likely representing a similar process. 3) Status post cholecystectomy with aerobilia most likely post-surgical. 4) Bronchomalacia especially in the right middle and right lower lobe. Bronchial wall thickening and peribronchial inflammation most likely representing the same process as described. . CT head w/o contrast [10-3]: 1. No evidence of intracranial hemorrhage. 2. Focal hypoattenuation within the left frontal lobe that could represent a chronic ischemic event given the fact that there is no sulci effacement and mild dilatation of the ipsilateral frontal [Doctor Last Name 534] of the lateral ventricle suggestive of volume loss. However, in view of patient's symptoms, gadolinium-enhanced MRI with diffusion imaging is recommended for further characterization. 3. Confluent hypodensities in the periventricular and deep white matter, nonspecific, likely represents chronic ischemic changes. Brief Hospital Course: 1. Community acquired pneumonia with septic shock: Initially admitted to [Hospital Unit Name 153] with pressor support. No source identified with negative Pneumocystis jirovecii, Legionella, and blood cultures negative. CT chest showed atypical linear infiltates consistent with a viral or atypical process. Improved gradually on IV vancomycin and cefipime. Respiratory status remained tenuous with CO2 retention even after transfer to the floor. She was converted to oral abx. with cefpodoxime and azitromycin. She required oxygen throughout the hospitalization. Pulmonary consultation was obtained as pt. was noted to have digital clubbing, a lengthy smoking history, and with rheumatoid arthritis, the question of chronic underlying lung disease was entertained. Pulmonary felt o2 requirement explained by pneumonia - no evidence of underlying lung disease on CT. Recommended continued oxygen at home (arranged) and outpatient follow up within three weeks. . 2. Altered mental status: possibly delirium from sepsis. Improved to baseline prior to tranfer to floor. . 3. Adrenal insufficiency: long term steroid use for rheumatoid arthritis. Hypotension on admission could have been sepsis or adrenal insufficiency in the setting of stress from viral illness. She was initiated on stress dose steroids, and these were weaned prior to discharge towards a baseline maintenance level of 10 mg daily. She was put on PCP prophylaxis with bactrim. 4. Rhuematoid arthritis: Methotrexate was held in the setting of acute infection and stress dose steroids as above. She was dishcharged on 10 mg daily prednisone with instructions to follow up with her PCP and [Name9 (PRE) 68053] as an outpatient regarding adjustment of her prednisone and re: possible re-institution of methotrexate. 5. Hyperglycemia/steroid induced diabetes (insulin resistance) - pt. was taking metformin as outpatient, was covered by SSI while getting steroids, as above. Resumed metformin on discharge. 6. SVT - one episode of PAF in ICU, did not recur on telemetry. No anticoagulation inititated as this was likely solitary event and pt. had severe recent LGIB in [Country 4754] per family. Was noted to have one run of SVT in the 120-140 bpm range, c/w common AVNRT. Was started on labetolol (selective [Doctor Last Name 360] given pulmonary issues) without recurrence. 7. Transaminitis - felt due to hypotension/shock in initial presentation. Transaminases trended down with control/improvement in BP. HAV ab (IgG) pos, but acute hepatitis of viral etiology felt not consistent with presentation, so this was not pursued further. Medications on Admission: Methotrexate and steroids for Rheumatoid arthritis Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day) as needed for constipation. [Doctor Last Name ]:120 mL Refills:0 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). [Doctor Last Name ]:90 Capsule(s) Refills:0 3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. [Doctor Last Name ]:60 ML(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. [Doctor Last Name ]:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Doctor Last Name ]:60 Tablet(s) Refills:0 6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. [Doctor Last Name ]:16 Tablet(s) Refills:0 7. Prednisone 10 mg Tablet Sig: as written below Tablet PO once a day: two tablets per day on: [10-12] and [10-13]; THEN: one tablet daily, ongoing. DO NOT STOP THIS MEDICATION WITHOUT CONSULTING YOU PRIMARY DOCTOR. [Last Name (Titles) ]:32 Tablet(s) Refills:1 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMWF (): AS PJP PROPHYLAXIS WHILE ON BACTRIM; DO NOT STOP WITHOUT CONSULTING YOUR PRIMARY DOCTOR. [Last Name (Titles) ]:10 Tablet(s) Refills:1 9. Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. [Last Name (Titles) ]:30 Tablet(s) Refills:0 10. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. [Last Name (Titles) ]:1 inhaler Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Pneumonia with resultant hypoxia and septic shock requiring IV antibiotics, oxygen, vasopressor medications AVNRT Rhematoid Arthritis Discharge Condition: Stable, requires 4 LPM of oxygen via nasal cannula at all times. Discharge Instructions: Take all medications as prescribed. Return to the [Hospital1 18] Emergency Department for: Fevers Shortness of breath Followup Instructions: Call your primary doctor for a follow up appointment for within two weeks of leaving the hospital: [Last Name (LF) 68054],[First Name3 (LF) ] [Telephone/Fax (1) 68055] Call your rheumatologist and make a follow up appointment for within two to four weeks of leaving the hospital. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11622] from the Pulmonary Department here will be calling you to arrange a follow up visit here in the Pulmonary (Lung) division for within three weeks of leaving the hospital. If you have not heard from her within one week, call: ([Telephone/Fax (1) 514] Provider: [First Name11 (Name Pattern1) 8122] [Last Name (NamePattern4) 8123], M.D. Phone:[Telephone/Fax (1) 2977] Date/Time:[2142-11-28] 1:30	[ "038.9", "792.1", "250.00", "785.52", "401.9", "276.0", "V17.3", "V43.64", "709.9", "293.0", "486", "714.0", "276.8", "995.92", "570", "426.89", "255.41", "V43.65" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10577, 10635	6134, 7118	338, 345	10813, 10880	3609, 6111	11052, 11833	2964, 3056		8872, 10554		10656, 10792	8796, 8849			10904, 11029										3071, 3590																												277, 300										373, 2412									7133, 8770							2434, 2747	2763, 2948
20,804	195,836	45630	Discharge summary	report	Admission Date: [2171-3-6] Discharge Date: [2171-3-11] Service: MEDICINE Allergies: Penicillins / Levofloxacin / Phenazopyridine Attending:[First Name3 (LF) 425] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Intubation Extubation History of Present Illness: [Age over 90 ] y/o M with PMHx significant for mild diastolic heart failure, COPD, atrial fibrillation sent from [Hospital 100] Rehab for respiratory distress, with O2 sats in the 70s. Reportedly, he received 240 mg PO lasix as well as 4 mg SL morphine at the NH. He was on BiPAP on arrival. ECG in the ED was difficult to interpret, showing demand pacing with intermittent a.fib with concerning changes laterally (no R waves in V4-V6). On arrival to the ED, the patient's VS were T= 98.2; BP= 115/89; HR= 80s; RR= 30s; O2 sat= 100% on BiPAP 100%. He was given 40 mg IV lasix and put out 30-40 cc of urine. He was given vanc/cefepime for possible PNA on CXR. Also, of note, he was tried on a nitro gtt, which initially caused some hypotension. . On arrival to the floor, the patient's VS were T= 97.6; BP= 123/63; HR= 90; RR= 27; O2 sat= 98% on BiPAP. He was somnolent and was not able to give a history. He did indicate by nodding that he was short of breath. NH records indicated that he was experiencing lightheadedness, SOB, DOE, orthopnea, poor appetite, mild nausea, and fatigue. Per NH records, he was not experiencing chest pain, palpitations, or abdominal pain. Past Medical History: 1. CARDIAC RISK FACTORS: + Hypertension, ? Dyslipidemia, - Diabetes 2. OTHER PAST MEDICAL HISTORY: DDD Pacemaker placed [7-9] for second degree AV block Coronary Artery Disease Congestive Heart Failure Obstructive Sleep Apnea Hypertension Gout Lichen Simplex Chronicus, on zyrtec Incisional hernia Chronic skin ulcers Iron-deficiency anemia s/p prostatectomy s/p appy Ventral hernia Obesity H/o DVT, on coumadin completed 6m course [2166] Hypothyroidism Chronic Renal Insufficiency (1.3 - 1.6) Basal bronchiectasis ?COPD Social History: Per old records, lives at [Hospital 100] Rehab, denies ever smoking. Family History: Not able to obtain. Physical Exam: VS: T= 97.6; BP= 123/63; HR= 90; RR= 27; O2 sat= 98% on BiPAP GENERAL: Somnolent; Responds to verbal stimuli at times. HEENT: NC/AT. Sclera anicteric. NECK: JVP of [10-15] cm. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Decreased air movement; scattered slight crackles throughout on the back. ABDOMEN: Obese. Soft, NTND. No masses noted. Ventral hernia present. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission labs: [2171-3-6] WBC-6.8 RBC-4.55* Hgb-13.2* Hct-43.3 MCV-95 MCH-29.1 MCHC-30.6* RDW-14.5 Plt Ct-319 [2171-3-6] Neuts-63.7 Lymphs-28.9 Monos-5.2 Eos-1.5 Baso-0.7 [2171-3-6] Glucose-115* UreaN-39* Creat-1.9* Na-144 K-4.4 Cl-97 HCO3-42* AnGap-9 . Cardiac biomarkers: [2171-3-7] 12:48PM BLOOD CK(CPK)-52 CK-MB-NotDone cTropnT-0.09* [2171-3-7] 03:39AM BLOOD CK(CPK)-47 CK-MB-NotDone cTropnT-0.09* [2171-3-6] 07:20PM BLOOD CK(CPK)-63 CK-MB-NotDone cTropnT-0.09* . Urine: [2171-3-6] URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2171-3-6] URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2171-3-6] URINE RBC-0-2 WBC-[6-13]* Bacteri-FEW Yeast-NONE Epi-0-2 [2171-3-7] URINE Hours-RANDOM UreaN-362 Creat-54 Na-50 Osmolal-324 . Microbiology: . [2171-3-6] Urine culture Site: CATHETER KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML. _______________________________________________________ AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [2171-3-6] Blood cultures x 2: PND . [2171-3-6]: Sputum Gram stain: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. Culture: RARE GROWTH Commensal Respiratory Flora. . [2171-3-7]: MRSA screen - positive . EKG [2171-3-6]: Ventricular paced rhythm with underlying atrial fibrillation versus irregular supraventricular tachycardia. Compared to the previous tracing there is no diagnostic change. . Echocardiogram, transthoracic [2171-3-7]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2168-5-25], moderate pulm hypertension is now detected. . CXR (portable AP) [2171-3-6]: Pulmonary edema with left pleural effusion. Brief Hospital Course: [Age over 90 ] y/o M with history of CHF, ?COPD who was sent to the ED from [Hospital 100] Rehab for respiratory distress. . # Respiratory failure - The patient's respiratory failure was thought to be multifactorial, related to congestive heart failure and likely also COPD. Pneumonia was also considered in the initial differential diagnosis. The patient was treated with nitroglycerin, morphine, oxygen, Lasix, nebulizers, vancomycin, cefepime, and Bipap. However, he developed progressive hypercarbia, requiring intubation on [2171-3-7]. The patient was extubated on [2171-3-8], after about 30 hours of mechanical ventillation. Vancomycin and cefepime were narrowed to cefpodoxime on [2171-3-9] (to treat urinary tract infection, as pneumonia was thought to be unlikely). On the morning of [2171-3-10], the patient became increasingly hypoxemic and tachypneic. A family meeting was held, and the decision was made to treat the patient with medications, and, if necessary, Bipap, but not intubation. The patient's symptoms improved with diuresis and nebulizers, and he was discharged on [2171-3-11], with a plan for more comfort-oriented care. Patient needs Q4H monitoring of oxygen saturations.He is on a 10 day steroid taper for his COPD during which time he will also be on sliding scale insulin. . # Acute diastolic congestive heart failure: The patient presented in respiratory distress. Echocardiogram showed LVEF >75%, with new pulmonary hypertension, but was otherwise baseline. MI was ruled out with serial cardiac enzymes. The patient was treated with vasodilators, diuresis, and mechanical ventillation, as explained above. The patient was discharged on Lasix 80 mg PO BID. . # RHYTHM: The patient presented in a demand-paced rhythm with underlying atrial fibrillation. He also had a supraventricular tachycardia that was thought to be AVNRT, and a wide-complex tachycardia (with rate around 100) that was thought to be an accelerated idioventricular rhythm versus slow ventricular tachycardia. The patient is on Coumadin for atrial fibrillation. This was briefly held in the setting of supratherapeutic INRs, for the the patient received vitamin K. Coumadin was restarted on [2171-3-10]. The patient will need to have his INR followed after discharge. . # Hypotension: The patient briefly required a dopamine infusino for hemodynamic support. . # Hypothyroidism: Continued levothyroxine. TSH was within normal limits. . # COPD: Pt with reported history of COPD. Initially treated with bronchodilators alone, then with bronchodilators, plus prednisone taper. . # Acute on Chronic Renal Insufficiency: On admission, the patient's creatinine was 1.9, from baseline 1.4. The patient's creatinine ranged from 1.7 to 2.1 during this admission. The etiology of the patient's acute on chronic renal failure was thought to be prerenal, related to the patient's heart failure. He also had a UTI which he is being treated with cefpodoxime for a 7 day course # Urinary Stricture: He has a history of urethral stricture for which he is s/p dilation. He was seen by urology post dilation, with recommendation for intermittent catheterization with a 16 fr catheter if he has difficulty voiding. . # Code status: The patient was full code on admission. He was admitted to the CCU, where he was intubated and briefly required pressors. On [2171-3-11], a meeting was held with the patient and his family. At that time, the patient decided to change his code status to DNR/DNI, no pressors. Medications on Admission: Morphine Oral Concentrate - Dexacidin/Maxitrol Eye Ointment - Warfarin 5-6 mg daily - Artificial Tears - Furosemide 80 mg PO BID - Lorazepam 0.75 mg PO q4 PRN - Nystatin topical qAM - Levothyroxine 75 mcg daily - Cholecalciferol 1000 units daily - Senna 8.6 mg [Hospital1 ] PRN - Acetaminophen 650 mg q4 PRN - Tropicamide 1 drop to each eye per shift - Albuterol - Ipratropium - Calcium carbonate 1300 mg daily - Guaifenesin - Bacitracin Topical Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Artificial Tears Ophthalmic 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for wheezing/dyspnea. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 8. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 12. Nystatin 100,000 unit/g Powder Sig: One (1) spray Topical twice a day: to affected areas. 13. Bacitracin 500 unit/g Packet Sig: [1-5] packet Topical at bedtime: apply to each eye at bedtime. . 14. Tropicamide 1 % Drops Sig: One (1) drop Ophthalmic twice a day: to both eyes. 15. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Tablet(s) 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please check INR on Wednesday [3-13] and call results to provider. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection twice a day. 18. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 19. Calcium 500 500 mg (1,250 mg) Tablet Sig: Two (2) Tablet PO at bedtime. 20. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please give while pt receiving prednisone only. 21. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day: Please taper by 10 mg every 2 days. Total of 10 day course, first day [3-10], last day [3-19]. . Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary - Acute on chronic diastolic heart failure Hypercarbic respiratory failure Klebsiella urinary tract infection Secondary - Chronic kidney disease Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital due to difficulty breathing. You required help breathing briefly and were placed briefly on a ventilator. You were given medications to help remove fluid and improve your respiratory status. We are treating you for a urinary tract infection with antibiotics. We have restarted your warfarin at your previous dose. 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. Medication changes: 1. You are being treated for a urinary tract infection with cefpodixime. . Followup Instructions: Follow up with your primary care doctor at your rehabilitation center. [Last Name (LF) ],[First Name3 (LF) 177] J. [Telephone/Fax (1) 97292] . Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] and Dr. [First Name (STitle) 37342] [Name (STitle) 37343] Phone: [Telephone/Fax (1) 62] Date/time: Monday [5-6] at 8:40 am.	[ "707.19", "V12.51", "E934.2", "274.9", "599.0", "518.81", "494.0", "278.00", "698.3", "496", "244.9", "403.90", "414.01", "428.0", "V12.04", "327.23", "585.9", "790.92", "428.33", "280.9", "V45.01", "598.9", "553.21", "427.31", "041.3" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	11949, 12015	5828, 9353	271, 295	12228, 12228	2742, 2742	12992, 13375	2161, 2182		9853, 11926		12036, 12207	9379, 9830			12403, 12872										2197, 2723																									12892, 12969			211, 233										323, 1503					2758, 5805				12243, 12379							1624, 2055	2071, 2145
25,178	168,972	12705	Discharge summary	report	Admission Date: [2150-12-26] [Month/Day/Year ] Date: [2150-12-31] Date of Birth: [2085-5-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1185] Chief Complaint: transferred from [Hospital3 ] for concern for sepsis Major Surgical or Invasive Procedure: PICC placement Trans-esophageal echocardiogram History of Present Illness: 65 yo M with DM, HTN, CAD s/p PCI and CABG, ischemic cardiomyopathy, h/o VT arrest s/p [Hospital1 ]-V ICD, h/o C. diff, initially presenting to [Hospital3 ] on [2150-12-24] with nausea, vomiting, and diarrhea. Symptoms started on [2150-12-23] with onset of violent nausea/vomiting/diarrhea. + fevers, chills, diaphoresis. + abdominal pain, diffuse, constant with throbbing. stool non-bloody, no foul odor, not like c.diff stool in past. stool soft and loose, not watery. also felt lightheaded and lost balance and fell onto his back on a clothing rack - did not lose consciousness. no new foods, no sick contacts. ROS + for SOB usually with activity at baseline, no orthopnea, sleeps on 2 pillows, no cough day or night. no cp. admits to muscle and joint aches for several months in shoulders, knees, elbows, hands. has pain in back on transfer to floor. blood sugars 250-350 at home. At OSH His initialy labs were notable for glucose 467, INR 1.51, lactate 5.9. U/A showed hematuria but no pyuria, negative ketones. He was found to be in DKA, treated with insulin gtt. The patient's abdominal was markedly distended, but KUB was normal. Blood cultures grew GPCs in clusters, later speciated as Staph aureus (culture from [2150-12-24]). The patient became hypotensive, treated with fluids and neo gtt, which was quickly weaned off. Currently, the patient is satting well on 2L NC. He has a RIJ for access. Lactate trended down to 3.3 this AM. Troponins rising at the time of [Month/Day/Year ] (0.20 -> 0.32 -> pending) OSH RECORD REVIEW: [2150-12-26] supine abd film: stomach significantly distended with air, moderate air in colon; no pneumatosis. [2150-12-26] CXR: mild CHF unchanged, no pleural fluid or pneumothorax. [2150-12-25] CXR: perihilar pulm edema, mild worsening of congestion [2150-12-25] CXR: no definite PNA, pulm edema, or pleural effusion [2150-12-24] non-con CT A/P: GU unremarkable. possible hepatic cirrhosis. tiny ascites. cholelithiasis. extensive ASVD. [2150-12-24] CXR: unremarkable. [2150-12-24] Blood CX: staph aureus [2150-12-25] C. diff PCR: pending [2150-12-25] blood cx x 2: pending On arrival to the MICU, 97.8, 157/82, 85, 96% RA. Review of systems: (+) Per HPI Past Medical History: 1) CAD s/p MI [2131] with LAD angioplasty and PTCA 6 mo later for restenosis; s/p DES in LCx [2142]; s/p CABG x2 (LIMA-->LAD and SVG-->OM [12/2142]) 2) HTN 3) HL 4) IDDM 5) Complete heart block and VTach arrest s/p ICD ([1-/2148]) 6) CHF 7) C. Dif [12/2141] 8) Asthma 9) GERD 10) Vestibular dynsfunction 11) Depression 12) Obesity 13) s/p appendectomy 14) s/p tonsillectomy 15) s/p bilateral cataract surgery [55]) left peripheric abscess [5-/2149], drained on [2149-6-26]: Oxacillin-sensitive Staph aureus 17) Generalized tonic-clonic seizure - Per neuro note [7-/2149], last time occurred when he was 12 years old as well as staring spells, also last time occurred in childhood. He has never been on any medications for these. Social History: -Tobacco history: [3-6] pk/day x decades before quitting in [2131] -ETOH: social -Illicit drugs: none -retired tool maker for [Location (un) ] and [Location (un) ] Family History: Brothers hep C, DM, and CAD. Physical Exam: ADMISSION EXAM: Vitals: T: 97.8 BP: 157/82 P: 85 O2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, TTP in upper quadrants, hyperactive BS, tympanitic to percussion Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation [Location (un) 894] EXAM: Unchanged from admission except abdominal exam is wnl. BG on day of [Location (un) ]: 0800 223 (40U Lantus + 4U Humalog) 1130 259 (6U Humalog) 1600 185 (2U Humalog) 2130 296 (2U Humalog) Pertinent Results: ADMISSION LABS: [2150-12-26] 09:00PM BLOOD WBC-8.8# RBC-4.49* Hgb-13.2* Hct-37.2* MCV-83# MCH-29.5 MCHC-35.5# RDW-13.9 Plt Ct-60# [2150-12-26] 09:00PM BLOOD Neuts-90.8* Lymphs-5.3* Monos-3.5 Eos-0.2 Baso-0.1 [2150-12-26] 09:00PM BLOOD PT-13.6* PTT-33.4 INR(PT)-1.3* [2150-12-26] 09:00PM BLOOD Glucose-214* UreaN-10 Creat-0.6 Na-133 K-3.6 Cl-101 HCO3-24 AnGap-12 [2150-12-26] 09:00PM BLOOD ALT-111* AST-104* CK(CPK)-135 AlkPhos-60 TotBili-1.0 [2150-12-26] 09:00PM BLOOD Lipase-16 [2150-12-26] 09:00PM BLOOD CK-MB-4 cTropnT-<0.01 [2150-12-26] 09:00PM BLOOD Calcium-8.0* Phos-1.6# Mg-1.8 [2150-12-26] 09:21PM BLOOD Type-CENTRAL VE Temp-36.6 pH-7.41 [2150-12-26] 09:21PM BLOOD Lactate-1.6 [2150-12-26] 09:21PM BLOOD O2 Sat-93 [2150-12-26] 09:21PM BLOOD freeCa-1.10 URINE: [2150-12-27] 03:36AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.048* [2150-12-27] 03:36AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2150-12-27] 03:36AM URINE RBC-40* WBC-0 Bacteri-NONE Yeast-MANY Epi-0 [2150-12-27] 03:36AM URINE Mucous-RARE OTHER PERTINENT LABS: [2150-12-27] 03:36AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2150-12-27] 03:36AM BLOOD HCV Ab-NEGATIVE OSH MICRO: [2150-12-24] BCx: Staph aureus [2150-12-25] BCx: Staph aureus Sensitivities - Sensitive to Amp/Sulbactam, Cefazolin, Clindamycin, Erythromycin, Gentamicin, Levofloxacin, Oxacillin, Tetracycline, Trim/Sulfa, Vancomycin Resistant to PCN [Hospital1 18] MICRO: [2150-12-30] BCx: *PENDING [2150-12-29] Cdiff: NEGATIVE [2150-12-29] BCx: * PENDING [2150-12-28] Stool culture: *PENDING [2150-12-28] Cdiff: NEGATIVE [2150-12-28] BCx: * PENDING [2150-12-27] UCx: Yeast [2150-12-27] BCx: *PENDING [2150-12-26] BCx: PENDING STUDIES: [2150-12-26] EKG: Sinus rhythm with ventricular pacing, probably biventricular. Since the previous tracing of [2148-1-20] the rate is faster [2150-12-26] CXR: As compared to the previous radiograph, there is unchanged evidence of a left pectoral pacemaker with unchanged course of the leads. Sternal wires after sternotomy. The patient now has a nasogastric tube with normal course and a right internal jugular vein catheter. This catheter projects with its tip over the upper SVC. The course of the catheter is unremarkable, there is no evidence of complications, notably no pneumothorax. As compared to the previous exam, the lung volumes are decreased and there is a mild increase in diameter of the pulmonary vasculature, potentially indicative of mild fluid overload. No pleural effusions. No focal parenchymal opacity suggesting pneumonia. [2150-12-27] CT abd/pelvis: 1. New wall thickening of the cecum and possibly terminal ileum, likely infectious or inflammatory. Ischemia and typhlitis are considered less likely, given patient history. 2. Mild ascites and small pleural effusions. No evidence of abscess or drainable fluid collections. 3. Cirrhosis, splenomegaly, and varices. 4. Cholelithiasis. 5. Foley balloon inflated in prostatic urethra. Please deflate and advance into the urinary bladder. [2150-12-28] Abd XRAY: There is borderline diameter of the cecum and the transverse colon, unchanged to the CT examination from yesterday. However, no distention is visible. In the left lateral decubitus view, several smaller colonic air-fluid levels become evident. No free air, single calcified gallstone. [2150-12-28] LLE U/S: No DVT in the left lower extremity. [2150-12-29] CXR: Right PICC 2 cm beyond the superior cavoatrial junction. Pulled back 2cm by PICC team [2150-12-30] CXR Right PICC line ends at mid SVC. Small bibasilar atelectasis is unchanged. [2150-12-30] TTECHO: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with global hypokinesis and akinesis of the septum, anterior wall and apex. RV with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2148-1-9], no change. IMPRESSION: No valvular vegetations seen. Severely depressed LVEF [2150-12-31]: TEE: No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). with normal free wall contractility. There are simple atheroma in the ascending aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. Pacemaker wire seen in the RA and RV. No mass or vegetation is seen on the wire. IMPRESSION: No evidence of endocarditis on valves or pacemaker wire. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [Name10 (NameIs) 894] LABS: [2150-12-31] 05:41AM BLOOD WBC-5.9 RBC-4.20* Hgb-12.2* Hct-35.7* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.2 Plt Ct-152 [2150-12-31] 05:41AM BLOOD Glucose-192* UreaN-7 Creat-0.7 Na-140 K-3.4 Cl-104 HCO3-31 AnGap-8 [2150-12-30] 06:25AM BLOOD ALT-39 AST-25 AlkPhos-74 TotBili-1.2 [2150-12-31] 05:41AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.9 Brief Hospital Course: Mr. [Known lastname 7228] is a 65 year old man with h/o CAD (s/p PCI in [2138] and [2142], 2V CABG [2142]), IDDM, CHB, VT arrest s/p ICD [1-11], HTN, CHF (EF 20-30% [1-11]), Cdiff [12-4], MSSA perinephric abscess in [5-12], who was admitted to [Hospital3 ] on [2150-12-24] with N/V/D, [Hospital 39217] transferred to [Hospital1 18] MICU for management of sepsis/hypotension, Staph bacteremia. #. Sepsis: Patient with hypotension to the 70s, likely [2-4] to MSSA bacteremia with component of hypovolemia from N/V/D. Briefly on Neo gtt at OSH and received IVF. Septic physiology resolved prior to transfer to [Hospital1 18]. #. MSSA bacteremia: Patient with MSSA bacteremia with 2 positive cultures at OSH. Surveillance cultures negative to date. Does have prior h/o MSSA perinephric abscess in [2149], but no e/o abscess on current CTs, so etiology/source still unclear. [Name2 (NI) ] with septic physiology on transfer from OSH, but resolved by the time he was admitted to [Hospital1 18]. Patient initially on Vancomycin, switched to Nafcillin when sensitivities returned. ECHO showed no vegetations. Plan for 4 week course of antibiotics per ID consult team. He will require ID follow up, weekly follow up labs faxed to ID offices. His abx course will be completed [2151-1-28]. #. N/V/D: Likely viral gastroenteritis. Patient with NGT from OSH for decompression, which helped symptoms. CT abd/pelvis with possible inflammation in the terminal ileum/cecum. Cdiff toxin negative x2. Patient was advanced to regular diet. Symptoms resolved with conservative management. #. IDDM: Poorly controlled as outpatient, A1C 11.8. Patient with DKA on admission to OSH, initially treated with insulin gtt and IVF. Gap closed prior to transfer to [Hospital1 18]. Patient was restarted on lower dose of Lantus given decreased PO intake in the setting of N/V. Dose titrated back up as diet was advanced. Home Lantus 70units qAM (initially on 40units qAM, discharged with 50U qam and directions to uptitrate per discussion with PCP) . #. sCHF: Patient with EF 20-30%, but was hypovolemic on admission. Tolerated gentle IVF and lightheadedness resolved. Holding diuresis in the setting of recent sepsis and hypotension. Continued on ACEi. Weight 241 lbs on [12-27]. #. cirrhosis: Patient with e/o cirrhosis on CT, low platelets, elevated INR, and elevated liver enzymes. No prior history of cirrhosis, but patient endorses elevated liver enzymes in the past. Suspect NASH given co-morbidities and obesity vs EtOH cirrhosis. LFTs trended down and were WNL prior to [Month/Year (2) ]. Hepatitis B/C serologies were negative. Recommend outpatient liver follow-up. #. CAD: Patient with troponin elevation at OSH, but no EKG changes. CE were negative here. Continued on home ASA and ACEi. #. HTN: Lisinopril held in the setting of hypotension on admission, restarted at home dose during hospitalization. #. Asthma: No wheezing or exacerbation. Patient was satting well on RA. Continued on home advair, albuterol, singulair TRANSITIONAL ISSUES: - f/u BCx - labs x1 while on IV Abx - outpatient EGD to eval cirrhosis and follow up with hepatology as outpatient FULL CODE COMMUNICATION wife [Telephone/Fax (1) 39218] Medications on Admission: glargine 70 units daily Humalog with meals albuterol nebs Q4H PRN montelukast 10 mg daily Advair lisinopril 20 mg daily Zetia 10 mg daily citalopram 20 mg daily metformin 1000 mg [Hospital1 ] aspirin 81 mg daily [Hospital1 ] Medications: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Advair Diskus Inhalation 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. insulin glargine 100 unit/mL Solution Sig: 50U Subcutaneous qam. 9. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous qachs: per sliding scale . 10. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 16 days: day 1 [2150-12-26], will complete course [2150-1-16]. Disp:qs Refills:0 11. Outpatient Lab Work Patient needs lab draw on [2151-1-6] OR [2151-1-7] Please draw CBC with differential, basic metabolic panel, ESR, CRP, AST, ALT, Total Bilirubin, alk phos. Fax results to Dr. [Last Name (STitle) 10543] at [Telephone/Fax (1) 29683] [Telephone/Fax (1) ] Disposition: Home [Telephone/Fax (1) ] Diagnosis: Primary Diagnosis: Methicillin Sensitive Staph Aureus Bacteremia Viral gastroenteritis Secondary Diagnosis: Diabetes Mellitus Congestive Heart Failure [Telephone/Fax (1) ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [Telephone/Fax (1) ] Instructions: Dear Mr. [Known lastname 7228], You were transferred to [Hospital1 ] Hospital with an infection in your blood. You were treated with intravenous antibiotics. You had an echocardiogram, which showed no infection in your heart. You will need to be on intravenous antibiotics for a total of 3 weeks. You will need to get labs done once while you are on this medication, the results will be faxed to your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 10543], and you can discuss the results with him. You also had nausea, vomiting, and diarrhea, which was likely caused by a virus. Your symptoms resolved, and you were treated with intravenous fluids. You were tolerating a regular diet prior to [Last Name (STitle) ]. The following changes were made to your medications: #. START Nafcillin 2grams IV every 4 hours from [Date range (1) 39219] (3weeks total) #. STOP Zetia #. DECREASE Lantus to 50U, as we discussed, please discuss the management of your diabetes and your lantus dose with your PCP and, if you wish, your endocrinologist. Please continue the remainder of your medications as directed. Please discuss these medication changes with your physician. If you take tylenol, limit to less than 2 grams per day. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. It was a pleasure meeting you and taking part in your care. Followup Instructions: Department: LIVER CENTER When: WEDNESDAY [2151-2-3] at 1 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: FRIDAY [2151-8-6] at 10:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 31415] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) 3689], [First Name3 (LF) ], PA Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Appointment: THURSDAY [1-7] AT 11AM [Name6 (MD) ] [Name8 (MD) ] MD [Doctor Last Name 1189]	[ "995.92", "428.0", "530.81", "250.00", "428.22", "038.11", "287.5", "008.8", "493.90", "571.5", "V45.81", "V45.02", "414.00", "401.9", "584.9" ]	icd9cm	[ [ [] ] ]	[ "88.72", "38.93" ]	icd9pcs	[ [ [] ] ]		10754, 13851	375, 424		4560, 4560	17349, 18395	3714, 3744					14073, 14290													3759, 4541																					13872, 14047			2699, 2712				279, 337			14320, 15566							452, 2680				15675, 15756	4576, 5717	15585, 15654	5739, 10731		15771, 17326							2734, 3501	3517, 3698
12,215	100,658	19609	Discharge summary	report	Admission Date: [2186-2-7] Discharge Date: [2186-2-14] Service: MICU HOSPITAL SUMMARY: The patient was initially admitted to the hospital on [2186-2-7] for hypothermia, hypotension, and sepsis protocol. The patient was brought to the hospital by her son because she had had a slurring of her speech which had resolved by the time she arrived at the hospital. In the hospital the patient was fluid resuscitated initially, and her blood pressure improved. However, she became hypotensive again and required intermittent pressors for blood pressure support. The patient had an echocardiogram which revealed severe pulmonary hypertension with RV dysfunction. In the setting of fluid resuscitation, she developed bilateral pleural effusions. The patient had a diagnostic and therapeutic thoracentesis on [2186-2-8] which was complicated by a pneumothorax requiring a right anterior chest tube. She had a bronchoscopy which showed a large amount of mucus plugs. She was diuresed under the guidance of a Swan Ganz catheter, and she underwent a trial of vasodilators with nitric oxide and Viagra for pulmonary hypertension. However, she did not respond, and she was felt not to be a candidate for ............ therapy. She was extubated on [2186-2-10], transferred out of the Medical Intensive Care Unit on [2186-2-11] in stable condition. She was on the floor until [2186-2-13] when she was found to be hypoxic, hypotensive, and tachycardiac. Chest x-ray was done at that time which showed left lung collapse secondary to mucus plugging. The patient initially on hospital admission was "Do Not Resuscitate"/"Do Not Intubate," but her family had reversed her code status. At the time of worsening medical deterioration on [2186-2-13], discussions were held with the family about her code status and whether or not they would want her to be rebronched, and the patient and the family decided on [2186-2-14] that they did not want any further intervention, so the patient was not bronched. The hypotension at that time responded to fluid boluses. However, on [2186-2-14] at 9 p.m. the patient became unresponsive, her heart rate decreased to the 40s, and she had no blood pressure. The patient had fixed and dilated pupils, no breath sounds, no pulse, no heart sounds. Time of death was 8:54 p.m. Her sons were notified. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Name8 (MD) 8736] MEDQUIST36 D: [2186-3-27] 15:56 T: [2186-3-29] 21:56 JOB#: [Job Number 53151]	[ "518.81", "038.9", "280.0", "416.0", "276.4", "427.5", "512.1", "511.9", "710.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.04", "33.23", "98.14", "99.04", "89.64", "34.91", "96.71", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]
1,233	107,110	15052+56599+56600	Discharge summary	report+addendum+addendum	Admission Date: [2178-8-5] Discharge Date: [2178-8-10] Service: CCU CHIEF COMPLAINT: Transfer for high-risk cardiac intervention. HISTORY OF PRESENT ILLNESS: The patient is an 86 year old male with a history of coronary artery disease, severe chronic obstructive pulmonary disease, diabetes mellitus and hypertension, who was in his usual state of health until 2 a.m. the morning of [2178-8-2], when he awoke with shortness of breath and diaphoresis. At that time, he took Combivent without help and went back to sleep. He then again awoke at 04:00 a.m. with worsening dyspnea that was not responsive to his Albuterol and Atrovent nebulizers. At that time, he then went to [Hospital3 1280] Hospital where he was treated for chronic obstructive pulmonary disease exacerbation with Solu-Medrol, Albuterol/Atrovent nebulizers and antibiotics. While at [Hospital3 1280], he had an episode of acute shortness of breath and at that time it was felt that that he was in flash pulmonary edema. An EKG on [2178-8-3], showed transient anterior ST elevations and T wave inversions. At this time, his cardiac enzymes were positive with a peak creatinine kinase of 202 on [2178-8-4]. Cardiac catheterization at this time revealed the following: Left main with 80% stenosis; right coronary artery 70% ostial lesion; patent ductus arteriosus 80% lesion; diffuse left anterior descending and left circumflex disease. The patient was then transferred to [Hospital1 1444] for possible PCI versus coronary artery bypass graft surgery. The patient was then evaluated by Cardiac Surgery and they felt that he was a poor surgical candidate given his history of severe chronic obstructive pulmonary disease; thus, the management of these lesions were those of undergoing a PCI of the right coronary artery and left main. The patient's post catheterization course had also been complicated by a right groin hematoma. A subsequent ultrasound was negative for pseudo-aneurysm, and a CT scan of the abdomen was also negative for retroperitoneal bleed. The patient was then transferred to the Coronary Care Unit Team for which he actually went to the Medical Intensive Care Unit for further monitoring in anticipation of high risk left main coronary artery intervention on [2178-8-6]. Upon transfer to the Floor, the patient continued to experience shortness of breath and was given Albuterol and Atrovent nebulizers with minimal relief. The patient was then given 40 mg intravenously of Lasix and had minimal urine output. The patient was then stared on Bi-PAP on 14/9 with improvement of dyspnea and O2 saturation of 96%. Upon initial evaluation by the Coronary Care Unit team the patient was resting comfortably on Bi-PAP mask and denying any chest pain. Of note, prior to this hospitalization, the patient had noticed a recent increase in his lower extremity swelling and a productive cough. PAST MEDICAL HISTORY: 1. Coronary artery disease: Cardiac catheterization on [2178-8-4], please see HPI for findings. 2. Chronic obstructive pulmonary disease: The patient has pulmonary function test as of [2178-7-14], revealed an FEV1 of 0.78. 3. Asthma. 4. Diabetes mellitus of unknown age and complications unknown. 5. Hypertension. PAST SURGICAL HISTORY: 1. Status post carotid endarterectomy on the right in [2164]. 2. Status post femoral popliteal bypass on the left. MEDICATIONS AT HOME: 1. Procardia XL 90. 2. Lasix 40 mg p.o. q. day. 3. Losartan 150. 4. Aspirin 81 mg p.o. q. day. 5. Imdur 60 mg p.o. q. day. 6. Albuterol and Atrovent nebulizers q. four hours. MEDICATIONS AT TRANSFER: 1. Nitroglycerin drip. 2. Aspirin 325 mg p.o. q. day. 3. Cozaar 50 mg p.o. q. day. 4. Verapamil 240 mg p.o. q. day. 5. Albuterol and Atrovent nebulizers q. four hours. 6. Solu-Medrol 60 mg three times a day. 7. Doxycycline 100 mg p.o. twice a day. 8. Protonix 40 mg p.o. q. day. 9. Regular insulin sliding scale. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient lives at home with wife. The patient is a reformed smoker with a 40 pack year smoking history. The patient denies any ETOH use; the patient denies any intravenous drug use. PHYSICAL EXAMINATION: Vital signs on admission, temperature 97.0 F.; pulse rate 82; blood pressure 119/53; respiratory rate 17; oxygen saturation 94% on four liters. In general, the patient is an elderly Italian male in mild respiratory distress. HEENT examination: Mucous membranes dry; oropharynx clear. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Neck is notable for a jugular venous distention up to 7 centimeters at a 30 degree angle, supple, no lymphadenopathy. Chest: Diffuse wheezing bilaterally, prolonged expiratory phase, use of accessory muscles. Heart: Distant heart sounds; regular rate, no rubs or gallops appreciated. Normal S1, S2, no S3, S4. Abdomen soft, nontender, nondistended, positive bowel sounds in all four quadrants. Extremities with trace one plus edema bilaterally, Doppler-able pulses bilaterally of the lower extremities. Groin, of note, on the right, from the anterior iliac spine down through the scrotum has diffuse ecchymoses and resolving hematoma. Neurological: The patient is alert and oriented times three with normal speech, moving all extremities, without any focal deficits. LABORATORY: On admission, sodium 140, potassium 4.4, chloride 97, bicarbonate 32, BUN 74, creatinine 1.7, glucose 153, white blood cell count was 15.7, hematocrit 35.1, platelets 150. Creatinine kinase was trended at 41, repeat was 42. EKG was a normal sinus rhythm at 82, normal axis, normal intervals, early R wave progression, diffuse T wave flattening. No ST elevations or depressions. Chest x-ray notable for flat diaphragms, mild cephalization, no pneumonia. CT scan of the abdomen with no retroperitoneal bleed, right groin hematoma. Femoral ultrasound with no pseudo-aneurysm, no arteriovenous fistula. ASSESSMENT AND PLAN: On admission, the patient is an 86 year old male with known three-vessel coronary artery disease including left main disease, severe chronic obstructive pulmonary disease, diabetes mellitus, hypertension, peripheral vascular disease, who was admitted for high-risk cardiac catheterization. HOSPITAL COURSE: 1. Cardiovascular: Upon admission, the patient was continued on aspirin, Captopril, nifedipine and Lipitor. The patient was weaned off of the Nitroglycerin drip. Beta blockers were held secondary to chronic obstructive pulmonary disease and the GTB3A inhibitors were held secondary to his right groin hematoma. His cardiac enzymes were cycled and remained flat and there was no evidence of acute ischemia on his repeat electrocardiograms. On hospital day number two, the patient was taken to the Cardiac Catheterization Laboratory and stents were placed to his left main, 4.5 centimeters; right coronary artery (4.5 millimeters to 13 millimeters) and posterior descending artery (2.5 millimeters by 18 millimeters). The patient was then continued on Integrilin for the next 18 hours. Of note, the patient was switched from nifedipine to Diltiazem 240 mg p.o. q. day. The patient then continued to remain chest pain free throughout the remainder of his hospital course and was chest pain free up to the projected discharge date. Myocardium: The patient's ejection fraction at the outside hospital showed a 60% preserved ejection fraction and his ACE inhibitors were titrated up throughout this hospital stay as tolerated. Rhythm: The patient had no rhythm issues throughout the majority of his hospital stay. However, of note, the two nights prior to discharge, the patient had a 13 beat run of nonsustaining ventricular tachycardia. The patient was asymptomatic at the time, with stable vital signs and it occurred while the patient was sleeping. The patient continued to be monitored rigorously on Telemetry for signs of any further episodes of ventricular tachycardia. 2. Pulmonary: The patient had severe chronic obstructive pulmonary disease with FEV1 of less than 1. The patient was continued on his Albuterol and Atrovent nebulizers q. six hours with Albuterol and Atrovent inhalers q. four hours as needed p.r.n. The patient was also continued on Bi-PAP overnight as needed, and a Prednisone taper was begun at the time of admission. The patient reported remaining slightly below or near his baseline as far as his subjective symptoms of dyspnea throughout the hospital course, and will be discharged on his current outpatient regimen. 3. Renal: The patient was admitted with mild renal insufficiency with a creatinine of 1.1. His creatinine was monitored throughout the course of his hospital stay and his kidney function actually improved status post myocardial infarction with improvement in his hemodynamics. 4. Endocrine: The patient has diabetes mellitus of unknown duration with complications at this time unknown. He was continued on four times a day fingersticks and on a Regular insulin sliding scale throughout his hospital stay, with excellent control of his blood pressures throughout the hospital course. 5. Hematology: As per HPI the patient was admitted with a resolving hematoma of his right groin area that was negative for pseudo-aneurysm or retroperitoneal bleed. The patient's hematocrits were followed throughout the majority of his hospital stay and remained stable throughout that time. At the time of discharge, the hematoma is resolving and hematocrits are stable. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE DIAGNOSES: 1. Myocardial infarction. 2. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Lisinopril 20 mg p.o. q. day. 3. Lipitor 10 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day times 30 days. 5. Albuterol and Atrovent inhalers, two puffs q. four to six hours p.r.n. 6. Albuterol and Atrovent nebulizers q. four hours. 7. Prednisone 50 mg p.o. q. day times two days, then Prednisone 40 mg q. day times three days; then 30 mg q. day times three days; then 20 mg q. day times three days, then 10 mg times three days then 5 mg times three days. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with Cardiology, with potential catheterization in three months. A Cardiologist and appointment time for follow-up will be noted on the Page one referral form. 2. The patient will also undergo Physical Therapy and rehabilitation as per plan of rehabilitation facility. DR.[First Name (STitle) ],[First Name3 (LF) ] 11-691 Dictated By:[Last Name (NamePattern1) 33696] MEDQUIST36 D: [2178-8-9] 16:12 T: [2178-8-9] 16:32 JOB#: [Job Number 44003] Name: [Known lastname 8002], [Known firstname 8003] Unit No: [Numeric Identifier 8004] Admission Date: [2178-8-5] Discharge Date: [2178-8-13] Date of Birth: [2091-10-2] Sex: M Service: This is an addendum to the previously dictated discharge summary dictated on [2178-8-9]. Prior to discharge, the patient experienced of multiple episodes of bilious emesis. Estimated to about 900 cc. Radiograph imaging was consistent with small bowel obstruction, and nasogastric tube was placed approximately 700 cc of brown bilious drainage was suctioned from nasogastric tube. General Surgery was consulted for evaluation for possible surgical intervention. Given that the KUB showed dilated loops of small bowel diffuse and air down to the rectum. The patient was switched to NPO, given nasogastric tube, and hydrated with intravenous fluids, as well as with Dulcolax enemas. Outpatient cardiac and pulmonary medications are ................. two IV in the interim. Given the patient's right groin hematoma, CT scan of the abdomen was obtained to evaluate for underlying etiology for this small bowel obstruction with a question of retroperitoneal hematoma. A CT scan at this time showed a normal small bowel with no evidence of obstruction, dilated sigmoid colon, no free air, no free fluid, and no evidence of volvulus, and no retroperitoneal bleed. Within 48 hours of this presentation of partial bowel obstruction, the patient did have a bowel movement. Subsequent the nasogastric tube was clamped with low residual volume, and then was discontinued later that evening. The patient tolerated a clear liquid diet and was advanced to a full regular diet with improvement of all symptoms. Prior to discharge, the patient was tolerating a regular diet with no nausea, vomiting, or other abdominal complaints. During this time, the patient had two episodes of nonsustained V-tach that lasted seven beats and eight beats respectively. Given patient's recent MRI with unknown ejection fraction, EP was contact[Name (NI) ] with regards to .................. possible ................ placement given risk factors. Upon discussion, EP recommended starting patient on low dose beta blocker, metoprolol 25 [Hospital1 ] despite patient's severe history of congestive obstructive pulmonary disease. Patient was monitored closely after receiving beta blocker with no complaints of any respiratory systems or changes in difficulty breathing. The patient otherwise remained stable throughout the hospital stay. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is to be discharged to rehabilitation facility with services as per page one. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease status post stent to left main, right coronary artery, posterior descending coronary artery. 2. Congestive obstructive pulmonary disease. 3. Hematoma. 4. Resolved small bowel obstruction. DISCHARGE MEDICATIONS: 1. ASA 325 mg po q day. 2. Lisinopril 20 mg po q day. 3. Lipitor 10 mg po q day. 4. Plavix 75 mg po x21 days. 5. Albuterol/Atrovent nebulizers q4 hours. 6. Albuterol/Atrovent inhalers two puffs q4-6 hours prn. 7. Metoprolol 25 mg po bid. 8. Prednisone 30 mg po q day x2 days with taper accordingly. FOLLOW-UP PLANS: 1. The patient is to followup with Dr. [First Name (STitle) ] within two weeks. 2. The patient is to return to [Hospital1 1943] for a repeat catheterization. 3. Physical therapy as per patient. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1095] Dictated By:[Last Name (NamePattern1) 8005] MEDQUIST36 D: [2178-8-13] 14:47 T: [2178-8-14] 05:50 JOB#: [Job Number 8006] Name: [Known lastname 8002], [Known firstname 8003] Unit No: [Numeric Identifier 8004] Admission Date: [2178-8-5] Discharge Date: [2178-8-13] Date of Birth: [2091-10-2] Sex: M Service: This is an addendum to the previously dictated discharge summary dictated on [2178-8-9]. Prior to discharge, the patient experienced of multiple episodes of bilious emesis. Estimated to about 900 cc. Radiograph imaging was consistent with small bowel obstruction, and nasogastric tube was placed approximately 700 cc of brown bilious drainage was suctioned from nasogastric tube. General Surgery was consulted for evaluation for possible surgical intervention. Given that the KUB showed dilated loops of small bowel diffuse and air down to the rectum. The patient was switched to NPO, given nasogastric tube, and hydrated with intravenous fluids, as well as with Dulcolax enemas. Outpatient cardiac and pulmonary medications are ................. two IV in the interim. Given the patient's right groin hematoma, CT scan of the abdomen was obtained to evaluate for underlying etiology for this small bowel obstruction with a question of retroperitoneal hematoma. A CT scan at this time showed a normal small bowel with no evidence of obstruction, dilated sigmoid colon, no free air, no free fluid, and no evidence of volvulus, and no retroperitoneal bleed. Within 48 hours of this presentation of partial bowel obstruction, the patient did have a bowel movement. Subsequent the nasogastric tube was clamped with low residual volume, and then was discontinued later that evening. The patient tolerated a clear liquid diet and was advanced to a full regular diet with improvement of all symptoms. Prior to discharge, the patient was tolerating a regular diet with no nausea, vomiting, or other abdominal complaints. During this time, the patient had two episodes of nonsustained V-tach that lasted seven beats and eight beats respectively. Given patient's recent MRI with unknown ejection fraction, EP was contact[Name (NI) ] with regards to .................. possible ................ placement given risk factors. Upon discussion, EP recommended starting patient on low dose beta blocker, metoprolol 25 [Hospital1 ] despite patient's severe history of congestive obstructive pulmonary disease. Patient was monitored closely after receiving beta blocker with no complaints of any respiratory systems or changes in difficulty breathing. The patient otherwise remained stable throughout the hospital stay. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is to be discharged to rehabilitation facility with services as per page one. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease status post stent to left main, right coronary artery, posterior descending coronary artery. 2. Congestive obstructive pulmonary disease. 3. Hematoma. 4. Resolved small bowel obstruction. DISCHARGE MEDICATIONS: 1. ASA 325 mg po q day. 2. Lisinopril 20 mg po q day. 3. Lipitor 10 mg po q day. 4. Plavix 75 mg po x21 days. 5. Albuterol/Atrovent nebulizers q4 hours. 6. Albuterol/Atrovent inhalers two puffs q4-6 hours prn. 7. Metoprolol 25 mg po bid. 8. Prednisone 30 mg po q day x2 days with taper accordingly. FOLLOW-UP PLANS: 1. The patient is to followup with Dr. [First Name (STitle) ] within two weeks. 2. The patient is to return to [Hospital1 1943] for a repeat catheterization. 3. Physical therapy as per patient. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1095] Dictated By:[Last Name (NamePattern1) 8005] MEDQUIST36 D: [2178-8-13] 14:47 T: [2178-8-14] 05:50 JOB#: [Job Number 8006]	[ "428.0", "593.9", "998.12", "560.9", "250.00", "410.71", "427.1", "496", "443.9" ]	icd9cm	[ [ [] ] ]	[ "36.05", "36.06", "96.07", "93.90", "37.22", "88.56" ]	icd9pcs	[ [ [] ] ]							4045, 4063	17432, 17661	17684, 17984				6389, 9622		10339, 13449						3458, 4027		3315, 3437																		4293, 6372						18001, 18510						107, 153										183, 2940																2962, 3292	4081, 4269	17294, 17411
32,184	126,653	8886	Discharge summary	report	Admission Date: [2105-5-10] Discharge Date: [2105-5-23] Date of Birth: [2024-8-14] Sex: M Service: MEDICINE Allergies: Shellfish / Iodine; Iodine Containing Attending:[First Name3 (LF) 458] Chief Complaint: Status post arrest at home. Major Surgical or Invasive Procedure: - ICD placement [2105-5-22]. - Placement and removal of right internal jugular central venous line. - Placement and removal for right-sided PICC line through interventional radiology. - Placement and removal of left radial arterial line. History of Present Illness: Patient is an 80 year old man with history of coronary artery disease status post CABG and stent, systolic congestive heart failure, and stage 4 chronic renal insufficiency who was admitted to the cardiac intensive care unit after presenting to the emergency room after cardiac arrest. He was at home today when his wife heard a loud thump, and he was found down unresponsive in the kitchen with the refrigerator door open with his Procrit in his hand. The wife [Name (NI) 653] 911 and then called her daughter who lives close by. His daughter is CPR certified and arrived within 5-10 minutes and started CPR. EMS arrived a few minutes later. The patient was pulseless, and leads attached demonstrated monomorphic VT. He was cardio-verted with a shock, with return of a pulse. He was intubated in the field and lidocaine drip was started. A systolic blood pressure in the 70's was recorded. . In the emergency room he was initiated on the Arctic Sun cooling protocol. A right internal juglar central venous line was placed. He was hypotensive with a systolic pressure in the 70's, and dopamine 5mcg/kg/min was started. He was reportedly minimally responsive with some movement at that time. Past Medical History: # DM Type 2 - dxed [2071]; insulin since [2081]. # Coronary Artery Disease s/p CABG [2087], PCI [1-/2097], [1-/2097] # Congestive heart failure # Chronic kidney disease, stage 4 # Hyperlipidemia # Anemia of Chronic Illness - on procrit # Urinary Retention, Bladder Neck Obstruction s/p TURP [2105-1-6] # Secondary Hyperparathyroidism . Cardiac History: CABG ([2087]) with anatomy: LIMA --> LAD, SVG --> OM2, SVG --> OM3, SVG to mid-RCA jump to PDA . Percutaneous coronary intervention: [2097-1-8]: BMS x 1 --> SVG to PDA [2097-2-14]: BMS x 3 --> distal anastamotic site SVG to PDA, prox PDA, mid PDA [2105-1-14] - cath without intervention . Social History: Per his wife, patient does not use tobacco or alcohol. He lives at home with wife. Family History: Non-contributory Physical Exam: On transport from ED: SBP 113, 34.2, HR 80, RR 18, 100% VS: 93.4 103 afib 122/66 100% ventilated GEN: intubated and sedated, paralyzed HEENT: normocephalic CV: irregular, s1, s2, no M/G/R RESP: CTA laterally ABD: soft, NT/ND, no masses EXT: cool, + pulses . Pertinent Results: LABORATORIES ON ADMISSION [2105-5-10] 03:34PM SODIUM-138 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 UREA N-62 CREAT-2.9 GLUCOSE-168 CALCIUM-8.2 MAGNESIUM-2.4 PHOSPHATE-4.6 [2105-5-10] 01:24PM WBC-3.8 HGB-8.0 HCT-24.6 MCV-89 PLT COUNT-126 [2105-5-10] 01:24PM PT-31.3 PTT-31.5 INR(PT)-3.2 [2105-5-10] 01:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2105-5-10] 01:24PM AMYLASE-52 [2105-5-10] 01:41PM ABG: GLUCOSE-177 LACTATE-3.2 NA+-135 K+-3.5 CL--99* TCO2-25 HGB-8.4 calcHCT-25 O2 SAT-96 . CARDIAC ENZYMES [2105-5-10] 01:24PM CK(CPK)-50 cTropnT-0.03 CK-MB-4 [2105-5-10] 05:12PM CK-MB-7 cTropnT-0.08 [2105-5-10] 08:02PM CK-MB-8 [2105-5-10] 11:18PM CK(CPK)-110 CK-MB-9 cTropnT-0.10 . LABORATORIES UPON DISCHARGE [2105-5-23] 10:45AM WBC-6.4 Hgb-7.7 Hct-24.5 MCV-91 Plt Ct-135 [2105-5-23] 10:45AM Na-137 K-3.9 Cl-104 HCO3-22 UreaN-81 Creat-4.3 Glucose-147 Calcium-8.2 Mg-2.7 Phos-4.2 [2105-5-23] 10:45AM PT-16.0 PTT-33.2 INR(PT)-1.4 [2105-5-23] 10:45AM BLOOD ALT-154 AST-65 LD(LDH)-287 AlkPhos-95 TotBili-0.8 [2105-5-23] 10:45AM BLOOD Albumin-3.1 [2105-5-19] 03:15AM BLOOD TSH-3.0 [2105-5-16] 05:45AM BLOOD C3-67 C4-16 [2105-5-19] 03:15AM BLOOD calTIBC-315 Hapto-20 Ferritn-214 TRF-242 . EKG/TELEMETRY ON ADMISSION: atrial fibrillation. Telemetry strip from EMS shows VT, post shock there is a period of asystole, followed by a slow wide complex rhythym (approximately 40), followed by an accelerated wide complex rhythym, which then converts to Atrial Fibrillation with a narrow QRS complex. . [2105-5-12]: Transthoracic Echo: Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30-40 %). There is no ventricular septal defect. Right ventricular chamber size is normal. with depressed free wall contractility. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-3]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2105-1-13], the left ventricular ejection fraction is slightly lower. . [2105-5-14]: CT C-Spine without contrast IMPRESSION: Moderately severe DJD. No definite fracture. If there is concern for ligamentous injury, MRI is recommended. There is a 6.6-mm possible nodule in the left lung apex which is only seen on one image. Recommend further evaluation with CT of the chest. . [2105-5-16] Renal Ultrasound: RENAL SON[Name (NI) ]: The right kidney measures 10.4 cm. The left kidney measures 11.0 cm. No stone, hydronephrosis, or mass is identified. There is a simple cyst within the lower pole of the left kidney measuring approximately 1.5 cm, not significantly changed from [2105-1-15]. IMPRESSION: No evidence of hydronephrosis . [2105-5-21] Chest X-Ray IMPRESSION: 1. Cardiomegaly and upper zone redistribution but no overt pulmonary edema. 2. Apparent elevation of right hemidiaphragm, probably due to subpulmonic right effusion, but right lateral decubitus chest radiograph may be considered for confirmation if warranted clinically. Persistent small left effusion. . [2105-5-23] CHEST PA AND LATERAL Pacer/ICD device has been placed with leads terminating in the right atrium and right ventricle, and no pneumothorax. Right PICC line has been withdrawn, and now terminates in the superior right axillary region lateral to the right second rib. Cardiac silhouette remains enlarged, and a moderate-sized right pleural effusion appears slightly larger. Small left pleural effusion is unchanged. Upper zone vascular redistribution is present, but no overt pulmonary edema is evident. Atelectatic changes persist in the right mid and both lower lung zones. . Sputum Culture [2105-5-12]: GRAM STAIN (Final [2105-5-12]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2105-5-15]): 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. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 252-7541M ([2105-5-12]). GRAM NEGATIVE ROD(S). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. . Urine culture [2105-5-10], [2105-5-16], [2105-5-17]: No growth final Urine culture [2105-5-22]: No growth at time of discharge, final results pending. Blood culture [2105-5-10]: No growth final Brief Hospital Course: # Ventricular tachycardia, cardiac arrest: Patient was without spontaneous circulation for approximately 10 minutes, possibly longer. CPR was started within 5-10 minutes after his daughter arrived. It is unclear if the patient was in a perfusing rhythm prior to the arrival of assistance. His [Location (un) 2611] Coma scale on arrival to the emergency department was 5, and the Arctic Sun Cooling protocl initiated. It is difficult to exclude an acute ischemic event but the monomorphic ventricular tachycarida on rhythm strip and known history of coronary artery disease was suggestive of a scar-mediated arrhythmic sudden cardiac death. . Patient tolerated the Arctic Sun Cooling protocol well. Paralytics were used only for induction of the cooling, and he appeared comfortable on sedation for the 24 hours of cooling. Electrolytes, CK, lactate, coagulation studies, and serial arterial blood gases were monitored while he was cooled. . As he was warmed after completing the cooling protocol, he demonstrated purposeful movements and responded appropriately to commands by moving all extremities. He was able to be successfully extubated on [2105-5-13]. His C-spine was cleared and his hard collar was removed. . Patient initally demonstrated some cognitive deficits, especially in short term memory, however these improved greatly during his stay. Physical and occupational therapy worked with the patient, and he was eventually felt to be safe for discharge home with continued home physical therapy. . In regards to his arrhythmia, he did have another episode of ventricular tachycardia on evening after he was extubated for approximately 2 1/2 minutes. During this time he was asymptomatic and his blood pressure remained stable. He was started on intravenous amiodarone at that time and transitioned to an oral regimen. Three days after starting amiodarone, it was noted that his liver function tests (AST, ALT, LDH and total bilirubin) had markedly increased; this was felt to be secondary to initiation of amiodarone, so it was discontinued. His liver function tests trended downward immediately after cessation of the amiodarone. . Based on his presentation, low ejection fraction, and event noted on telemetry, decision was made to place a defibrillator (ICD) to protect against any further events. ICD placement was deferred until the patient's renal function demonstrated improvement, and was ultimately placed on [2105-5-22]. He will complete a short course of prophylatic antibiotics and follow up in device clinic in one week, as well as in one month to check the device. . # Respiratory Failure: Patient was intubated in the field. It was initially it was felt that the patient had evidence of congestive heart failure, however on [2105-5-12] he had an episode of hypoxia. A chest x-ray at that time revealed RUL/RML collapse secondary to mucous plugging which likely caused the acute hypoxic event, which was responsive to suction. He was started on broad spectrum antibiotic coverage (Vancomycin and Zosyn) given concerns over possible pneumonia based on imaging studies and hypotension. His hypoxia resolved and patient was successfully extubated. Initially he was diuresed, however appeared euvolemic during the remainder of his stay without need for further diuresis. He completed a course of antibiotic treatment for pneumonia, with sputum cultures ultimately demonstrating stenotrophomonas maltophilia. He had no further respiratory complaints and continued to have a normal oxygen saturation on room air. . # Coronary artery disease: It was not suspected that inciting event was ischemic in nature. His cardiac enzymes were followed and remained flat (peak 0.10 troponin, CK 175). His EKGs were consistent with his prior EKGs, without any findings concerning for acute ischemia. He had no symptoms of ischemia during his stay. His home medications of metoprolol (although at a lower dose) and aspirin were continued. His statin was also re-started, however this was held due to the increase his liver function tests. * His statin can likely be re-started at his outpatient follow-up visit with his primary care physician, [Name10 (NameIs) ] cardiologist, provided that his liver function tests have returned to baseline. . # Atrial Fibrillation: Patient has a history of atrial fibrillation and is on chronic anticoagulation for this. During his stay, his rhythm alternated mainly between atrial fibrillation and a junctional rhythm. His coumadin was initially held given a supratherapeutic INR. He was given vitamin K for an increasing INR while undergoing cooling protocol. He was kept on a heparin drip during his stay while decisions were being made regarding placement of a defibrillator or other interventions. After his defibrillator was placed, he was re-started on his home doses of coumadin (2.5 mg all days except 5 mg on Tuesday). Rate control was acheived by metoprolol 25 mg twice a day (decreased from home dose of 100 mg [Hospital1 ]. * He will need an INR/PT/PTT check on Tuesday, [5-26], to follow his INR (followed by his primary care physician [Last Name (NamePattern4) ]. [First Name (STitle) 1395]. He will then resume his usual INR checks per his primary provdier. . # Hypotension: Patient initially presented with hypotension after his arrest and required pressor support. He was kept on a dopamine drip, started in the emergency room, until he was able to be weaned 1-2 days later. It was felt his hypotension may have been secondary to his arrest. He had no evidence of adrenal insufficiency. He was treated with antibiotics for his pneumonia as well. His home medication of metoprolol was re-started and his blood pressure was at goal at time of discharge. . # Chronic Systolic Congestive Heart Failure: Patient, per report from family and outpatient cardiologist, was functioning well prior to his cardiac arrest. He was initially diuresed prior to extubation, as he had received a large amount of intravenous fluids while in the emergency room. During his stay, he continued to appear euvolemic. His home diuretics (torsemide and chlorothiazide) were held during his stay for this reason, as well as his renal insufficiency and initially poor urine output. He was autodiuresing prior to discharge. The 24 hours prior to discharge he was negative 1 liter; he was asymptomatic and saturating >97% on room air. Given the increasing size of the right pleural effusion upon discharge, he will likely need diuresis soon; however, the administration of diuretics must be delicately balanced with his renal insufficiency until his renal function returns to baseline (Creatinine ~3). He was instructed to weigh himself daily, limit his sodium intake to 2 grams daily, and to monitor for signs of heart failure (dyspnea, peripheral edema, etc.). A VNA was also arranged to go to his home and measure daily oxygen saturations and weights. He was instructed to contact his physician if he became symptomatic prior to reporting to Dr. [First Name (STitle) 805] for his appointment on [6-25] for renal followup; his VNA was also his oxygen saturation decreased below 93%. . # Diabetes Mellitus: Patient was treated with lantus and a humalog sliding scale. He will need continued titration of his regimen on an outpatient basis. . # Renal Failure: Patient has chronic stage 4 renal insufficiency. His creatinine was initially at baseline during his first few days, however his creatinine then began to rise while he concurrently became oliguric. The renal team was consulted, and it was suspected that the patient had ATN secondary to his circulatory arrest and hypotension. His urine sediment further supported this. His creatinine peaked at 5.5, and was trending downward at time of discharge. It was felt that his renal function would continue to improve, and that he had no indications for dialysis. A renal ultrasound was unremarkable. Patient will need basic electrolyte panel, including BUN and creatinine, checked on Tuesday [5-26], to be followed by his outpatient nephrologist. He will be closely followed after discharge by his outpatient renal team. . # Anemia: Patient has history of chronic anemia and is on Procrit as an outpatient. He was given one unit of packed red blood cells during his stay to help replete volume and improve his hematocrit. His hematocrit remained stable during his stay, ranging mainly in the 24-26 range. While on the heparin drip, he had mild epistaxis and bruising, but otherwise had no evidence of bleeding. . # Code: Patient remained full code during his admission. . # Disposition: Physical therapy and occupational therapy both felt patient was safe for discharge home, where he could continue to work towards returning to his baseline with home physical therapy. Discussions were held with the family to stress the importance of continued activity upon return home. Patient will have close follow up with his nephrologist, primary care physician, [Name10 (NameIs) ] cardiologist, all of whom were aware of patient's hospitalization. Medications on Admission: - Rosuvastatin 20 mg - Metoprolol Tartrate 100 mg [Hospital1 ] - Plavix 75 mg - ASA 325 mg - Tamsulosin 0.4 mg QHS - Senna 1 tablet [Hospital1 ] PRN - Colace 100 mg [Hospital1 ] PRN - Insulin: Lispro Sliding scale QID - Protonix 40 mg daily - Warfarin 5 mg Tuesday, 2.5 mg M,W,Th,F,[Last Name (LF) ],[First Name3 (LF) ] - Torsemide 40 mg [Hospital1 ] - Vitamin D 1 mcg capsule - Chlorothiazide 125 mg 30 minutes prior to Torsemide M/W/F - Klor-con powder packest 20 mEq's daily - Procrit 4,000 u/mL 1 mL 2x/week . Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) Injection QMOWEFR (Monday -Wednesday-Friday): Continue outpatient regimen. 4. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days. Disp:6 Capsule(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO TUESDAY (). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO M, W, TH, F, SAT, SUN (). 8. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous QHS. 9. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale as directed Subcutaneous As directed. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO BID PRN. 11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO BID PRN. 12. Vitamin D Oral 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 14. Outpatient Lab Work Please have INR/PT/PTT, basic electrolyte panel (including BUN/Creatinine), and liver function tests (AST, ALT, Alk Phos, LDH, T. Bili) checked on Tuesday, [2105-5-26]. Please fax results to Dr.[Name (NI) 5329] office (phone [Telephone/Fax (1) 6803]) and Dr.[Name (NI) 17897] office (phone [Telephone/Fax (1) 817]). 15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnosis: - Cardiac Arrest Secondary diagnoses: - ICD placement - Ventricular tachycardia - Chronic renal insufficiency - Anoxic brain injury - Diabetes mellitus - Systolic congestive heart failure - Anemia - Coronary artery disease - Chronic stage 4-5 renal insufficiency Discharge Condition: Stable, ambulating with assistance of walker. Discharge Instructions: You were admitted to the cardiac intensive care unit after having a cardiac arrest at home. You were cooled under the Arctic Sun Protocol and initially intubated. You did well post extubation, with some cognitive deficits and worsening renal function. Upon discharge, you were functioning mentally near baseline, and your renal function was improving. A defibrillator was placed to prevent further dangerous continued arrhythmias. . Please weigh yourself every morning, and call Dr. [Last Name (STitle) ] or Dr. [First Name (STitle) 1395] if you note a weight gain of more than 3 lbs. Please call Dr. [Last Name (STitle) ], Dr. [First Name (STitle) 1395], or go to the emergency room if you experience any chest pain, palpitations, difficulty breathing, bleeding, swelling or redness at site of defibrillator insertion, firing of your defibrillator, decreased or no urination, or other concerning symptoms. Please follow a low salt diet, with no more salt than 2 grams daily. . Please continue to work with physical therapy and ambulate frequently, at least several times a day to maintain your strength. . A few medication changes have been made: - Torsemide has been stopped. This medication has been stopped due to your renal function being worse than your baseline. As you renal function recovers, it will be important to restart this medication after discussing this with your physician. [Name10 (NameIs) ] is important to understand that this medication helps rid your body of excess fluid due to chronic systolic congestive heart failure, or decreased pumping ability of your heart. If you develop symptoms of shortness of breath, inability to lie flat due to shortness of breath, swelling in your feet or ankles, or shortness of breath with exertion, please contact your physician as these are signs of excess fluid which may be affecting your lungs and other organs. You will see Dr. [First Name (STitle) 805] (your kidney doctor) on Thursday, [5-28]. It is also recommended that you followup with your PCP prior to this, if possible, so he can monitor your volume status as well. Also, please weigh yourself daily as described above and notify your physician if you gain >3 pounds in one day as this may be a sign of fluid gain/overload. - Rouvastatin has been stopped, this can likely be re-started at follow up once your liver function tests are checked. - Metoprolol has been decreased to 25 mg twice a day. - Glargine (also called Lantus) has been decreased to 12 units daily. - Chlorothiazide has been stopped. - Potassium (Klor-con powder) has been stopped due to your worsened renal failure. - Continue Keflex antibiotics as prescribed to complete a 3 day course after your pacemaker was placed. . Please follow up with your cardiologist, Dr. [Last Name (STitle) ], at the following appointment: [2105-6-15] at 9:40 AM. The number for his office is ([Telephone/Fax (1) 5909]. You have an echocardiogram scheduled for that morning at 8:00 AM; the number for the echocardiogram lab is ([Telephone/Fax (1) 2037]. . Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 1395], within one week of discharge. His office is aware you have been hospitalized and will be calling you with an appointment. . Please follow up with your kidney doctor, Dr. [First Name8 (NamePattern2) ] [Name (STitle) 30922], at an appointment made for you on Thursday, [5-28], at 3:00 PM. You will need your labs drawn on Tuesday, [5-26], to check your kidney function. The results will need to be sent to Dr. [Name (NI) 30923] office (office phone ([Telephone/Fax (1) 817])). . You will also need to follow up in device clinic in one week as directed to have your ICD checked. Their phone number is ([Telephone/Fax (1) 30924]. Followup Instructions: Please follow up with your cardiologist, Dr. [Last Name (STitle) ], at the following appointment: [2105-6-15] at 9:40 AM. The number for his office is ([Telephone/Fax (1) 5909]. You have an echocardiogram scheduled for that morning at 8:00 AM; the number for the echocardiogram lab is ([Telephone/Fax (1) 2037]. . Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 1395], within one week of discharge. His office is aware you have been hospitalized and will be calling you with an appointment. . Please follow up with your kidney doctor, Dr. [First Name8 (NamePattern2) ] [Name (STitle) 30922], at an appointment made for you on Thursday, [5-28], at 3:00 PM. You will need your labs drawn on Tuesday, [5-26], to check your kidney function. The results will need to be sent to Dr. [Name (NI) 30923] office (office phone ([Telephone/Fax (1) 817])). . You will also need to follow up in device clinic in one week as directed to have your ICD checked. The device clinic will call you for an appointment; you will also need to follow up in one month to have your device checked at that time. Their # is ([Telephone/Fax (1) 2361].	[ "403.90", "285.21", "933.1", "427.1", "458.9", "585.4", "427.31", "428.22", "518.81", "348.1", "584.5", "250.00", "573.8", "427.5", "999.9", "428.0", "482.83", "414.01" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.93", "96.72", "37.94" ]	icd9pcs	[ [ [] ] ]	19481, 19539	8262, 17346	325, 569	19865, 19913	2933, 4255	23813, 25044	2621, 2639		17935, 19458		19560, 19560	17372, 17912			19937, 23790										2654, 2914			19617, 19844																									258, 287										597, 1796						19579, 19596		4269, 8239								1818, 2504	2520, 2605
72,942	100,935	39185	Discharge summary	report	Admission Date: [2201-4-15] Discharge Date: [2201-4-17] Service: SURGERY Allergies: Nitrofurantoin Attending:[First Name3 (LF) 1234] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] year old female transferred from [Hospital ] with a ruptured AAA. She had a known AAA and was being followed by serial US exams. She has refused surgery in the past. On [2201-4-15] she complained of abdominal pain and had a syncopal episode. She presented to [Hospital6 17183] where a CT abdomen was performed and found a 7.1 cm AAA with retroperitoneal rupture. Patient was transferred here because she wanted to consider operative interventions. Past Medical History: Depression AAA Chronic renal insufficiency CAD Social History: Lives alone. Husband died 5 months ago Family History: n/a Physical Exam: Physical Exam on Admission Vital Signs: RR: 13 Pulse: 61 BP: 157/56 Neuro/Psych: Oriented x3, Affect Normal. Neck: No right carotid bruit, No left carotid bruit. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear. Gastrointestinal: Mildly distended, No masses, prominent pulsation, tender to palpation. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. DP: P. PT: P. LLE Femoral: P. DP: P. PT: P. Pertinent Results: [2201-4-15] 07:05AM BLOOD WBC-6.1 RBC-3.58* Hgb-10.7* Hct-33.4* MCV-93 MCH-29.9 MCHC-32.0 RDW-14.7 Plt Ct-89* [2201-4-15] 07:05AM BLOOD Glucose-116* UreaN-30* Creat-1.6* Na-142 K-4.7 Cl-114* HCO3-24 AnGap-9 [2201-4-15] 07:05AM BLOOD Calcium-7.0* Phos-3.9 Mg-1.4* [2201-4-15] 07:14AM BLOOD Glucose-109* Lactate-1.4 Na-141 K-4.7 Cl-111 calHCO3-21 CT Scan OSH: [2201-4-15] 03:30 Juxtarenal AAA with rupture. Brief Hospital Course: Mrs. [Known lastname 86771] was admitted to the cardiovascular intensive care unit after transfer from [Hospital3 15402]. On review of her CT scan it was found that her AAA was juxtarenal and therefore not amenable to an endovascular stent graft for rupture. Discussions of an open repair were held with the patient and her family and the decision was made not to surgically repair. She was treated with strict blood pressure control to avoid hypertension with the knowledge that this likely would be fatal without surgery. Her pain was controlled with minimal pain medication requirement and she actively participated in discussions of her care. Over the course of the first day the patient did quite well. Her blood pressure was controlled initially with a nitroglycerin drip. The nitro was stopped at 10PM on HD#1 and her systolic blood pressures were stable at 110-120. The following morning however her blood pressure dropped precipitously to 60s systolic and she began to become more lethargic. Given this change in her course, discussions were held with the family and per the patients prior wishes she was made comfort measures only. Over the course of HD#2 her blood pressure rebounded somewhat however she became aneuric. She remained lethargic but was arousable and responded to questions and denied pain. Overnight she became more somnolent and obtunded with minimal responses. She began moaning with movement and morphine was given for comfort. She was noted to expire at 9:25AM. Her niece was at her bedside. Autopsy was denied. Medications on Admission: Aspirin 81mg qdaily; Clonazepam 0.5mg qdaily; Esmoprezole 40mg qdaily; Lopressor 25 mg [Hospital1 ]; Pravastatin 20mg qdaily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Ruptured abdominal aortic aneurysm Discharge Condition: Expired Discharge Instructions: Patient expired Followup Instructions: n/a	[ "441.3", "414.00", "V45.81", "403.90", "585.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	3746, 3755	1972, 3538	236, 243	3834, 3844	1520, 1949	3908, 3915	894, 899		3718, 3723		3776, 3813	3564, 3695			3868, 3885										914, 1501																												182, 198										271, 751																773, 821	837, 878
26,958	168,975	3810	Discharge summary	report	Admission Date: [2117-9-4] Discharge Date: [2117-9-4] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Found down Major Surgical or Invasive Procedure: na History of Present Illness: 88 year old female admitted to [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] [2117-5-14] with diagnosis of atrial fibrillation, CAD, CVA, dementia, depression fell out of bed. She was found this morning cold and clammy. She was in rapid atrial fibrillation and cardioverted X 2 with success. She was intubated in the field and had a femoral line placed and pressors started for SBP 80s. She was given levo/vanc/flagyl in the ED and was initially continued on levophed. . PCP saw patient in ED and confirmed DNR/DNI and spoke at length with the family. Pressors were discontinued and patient started on morphine drip and sent to the MICU for extubation. CT scan abdomen demonstrated occlusive thrombus at origin of SMA with extensive pneumatosis. Past Medical History: 1. Dementia 2. Coronary artery disease: stress MIBI + in past (not in this system). Also reportedly has had CT or MRI of heart which showed prior MI 3. Hypertension 4. Atrial fibrillation: No coumadin due to falls 5. Depression 6. Frequent falls 7. s/p caratarct surfery 8. AAA: no other details known 9. h/o pulm nodule (suspicious for malignancy but no further workup planned) Social History: Pt currently resides in [Hospital3 ]. Former tobacco use for many years. No ETOH use. Uses a walker. Has meals on wheels ans is not allowed to use stove. Family helps will all IADLS including bills. Family History: NC. Physical Exam: T: BP: 122/78 P: 84 RR: 27 O2 sats:82% Gen: elderly female, intubated, not following commands HEENT: Neck: CV: Irreg, no murmur Resp: coarse BS bilaterally Abd: s/nt/nd/nabs Ext: cool, purple hue Pertinent Results: [2117-9-4] 09:52AM PT-13.3* PTT-62.8* INR(PT)-1.2* [2117-9-4] 09:52AM PLT COUNT-484* [2117-9-4] 09:52AM NEUTS-68 BANDS-16* LYMPHS-8* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* [2117-9-4] 09:52AM WBC-16.2* RBC-3.91* HGB-12.0 HCT-36.2 MCV-92 MCH-30.6 MCHC-33.2 RDW-15.6* [2117-9-4] 09:52AM CALCIUM-10.0 PHOSPHATE-5.6# MAGNESIUM-2.9 [2117-9-4] 09:52AM CK-MB-15* MB INDX-2.2 cTropnT-0.12* [2117-9-4] 09:52AM LIPASE-70* [2117-9-4] 09:52AM ALT(SGPT)-47* AST(SGOT)-68* CK(CPK)-681* ALK PHOS-108 AMYLASE-261* TOT BILI-0.9 [2117-9-4] 09:52AM estGFR-Using this [2117-9-4] 09:52AM GLUCOSE-106* UREA N-59* CREAT-1.9* SODIUM-147* POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-17* ANION GAP-24* [2117-9-4] 09:57AM LACTATE-7.9* Brief Hospital Course: Ms [Known lastname 10936] was transferred to the ICU and extubated. She passed away on a morphine drip and family at her bedside. Medications on Admission: unknown Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Sepsis Ischemic colitis SMA thrombus CAD dementia AAA Discharge Condition: na Discharge Instructions: NA Followup Instructions: na	[ "427.31", "V15.88", "038.9", "458.9", "414.01", "557.0", "780.09", "162.9", "438.9", "995.92", "V66.7", "441.4", "294.8", "311" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	2991, 3000	2769, 2904	271, 276	3098, 3103	1966, 2746	3154, 3160	1724, 1730		2962, 2968		3021, 3077	2930, 2939			3127, 3131										1745, 1947																												221, 233										305, 1084																1106, 1487	1503, 1708
4,765	154,020	45533	Discharge summary	report	Admission Date: [2177-4-6] Discharge Date: [2177-4-11] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4980] Chief Complaint: Coffee ground emesis and melena Major Surgical or Invasive Procedure: EGD PEG tube placement History of Present Illness: [Age over 90 ] yo F w/ h/o dementia, hemorrhagic cva, aspiration pneumonia, and UGIB who was transferred from [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] to [Hospital1 18] ED for coffee ground emesis and melena x 1 day. In [Name (NI) ], pt's HR=94, BP=100/p, and O2 sat=88% RA. NG lavage was positive for coffee grounds, which cleared after 1 liter. Black, guaiac positive stool. She received Protonix 40 mg IV, Vit K 10 mg, 2 units FFP, 1 unit PRBCs and was transferred to the MICU for further TLC. In the MICU, she remained HD stable, requiring one additional unit of PRBC to maintain admission HCT of ~29. Past Medical History: 1) Left hemorrhagic CA [2169] w/ residual left-sided paralysis 2) Multiple prior aspiration pneumonias on pureeed solids at nursing home 3) UGI bleed [2174], managed conservatively 4) h/o rectal bleeding 5) h/o C. diff colitis 6) h/o diverticulitis 7) dementia 8) severe constipation requiring multiple admissions for LBO/disimpaction 9) CHF: [2163-11-2] TTE: hyperdynamic LV, mild-mod MR 10) GERD 11) Atrial Fibrillation ?? 12) Eye implant Social History: Lives at [Hospital1 8218] Health and Rehab Center; wheelchair bound. No EtOH, tobacco, or other drug use. PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 97129] [Telephone/Fax (1) 60586]. Family History: NC Physical Exam: 97 82 96/36 22 97% 3LNC Elderly female in NAD Noncommunicative, does not follow commands PERRL, poor dentition, would not open mouth for examination No JVD clear to auscultation anteriorly RRR, [2-23] hsm S/diffusely tender to palpation/ND/BS+ 2+ dependent edema Pertinent Results: [2177-4-6] 08:20AM PT-14.7* PTT-34.0 INR(PT)-1.4 [2177-4-6] 08:20AM PLT COUNT-201# [2177-4-6] 08:20AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-2+ [2177-4-6] 08:20AM NEUTS-85.1* BANDS-0 LYMPHS-11.5* MONOS-2.8 EOS-0.5 BASOS-0.1 [2177-4-6] 08:20AM WBC-9.0 RBC-3.03# HGB-9.7# HCT-28.2# MCV-93 MCH-31.9 MCHC-34.4 RDW-15.7 [2177-4-6] 08:20AM MAGNESIUM-1.6 [2177-4-6] 08:20AM LIPASE-12 [2177-4-6] 08:20AM ALT(SGPT)-11 AST(SGOT)-19 ALK PHOS-139* AMYLASE-27 TOT BILI-0.5 [2177-4-6] 08:20AM GLUCOSE-122* UREA N-11 CREAT-0.4 SODIUM-139 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12 [2177-4-6] 11:54AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-[5-30] [2177-4-6] 11:54AM URINE BLOOD-TR NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2177-4-6] 11:54AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 [2177-4-6] 03:40PM HCT-30.5* [2177-4-6] 08:00PM PT-14.2* PTT-31.9 INR(PT)-1.3 [2177-4-6] 08:00PM HCT-30.9* [2177-4-6] 08:00PM CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-1.7 [2177-4-6] 08:00PM GLUCOSE-97 UREA N-10 CREAT-0.5 SODIUM-138 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11 Brief Hospital Course: 1. GIB - stablilized hct between ED and MICU as above. Pt subsequently underwent EGD which revealed 2 cratered ulcerations that were not bleeding. She continued to have melanotic stools on day of discharge. However her HCT remained stable. It was decided that the patient would no longer be hospitalized and that further procedures were not in keeping with her wishes so no action was taken. 2. FTT - son has [Name2 (NI) 97133] PEG tube for route of administration of tube feedings should she not tolerate oral feedings at home as planned. PEG tube placed by GI without complication. However, on day of discharge, there was some oozing around the site of the tube. This was stopped with application of silver nitrate. 3. FEN - Was fluid overloaded with pulmonary edema after aggressive resuscitation on presentation for hemodynamic stabilization. Responded very well to lasix, diuresing over the last 2 days of the hospitalization. Lytes were repleted prn. After placement of the PEG tube, she was started on free water boluses of 250 cc q 4 hours for fluid maintenance at a restriction of 1.5 L given her recent pulmonary edema. No tubefeedings were started after the PEG tube was placed since her son was hoping to encourage PO intake. After several meetings with the palliative care service, the patient went home with her son and [Name (NI) 269] care. A decision had been made to avoid further hospitalizations and procedures since the patient would not want aggressive interventions in the face of her end stage dementia. Medications on Admission: Omeprozole, Nectar thickened liquids, Bowel regimen. Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 2. Colace 60 mg/15 mL Syrup Sig: Thirty (30) ml PO twice a day. Disp:1 bottle Refills:2 3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO twice a day. Disp:1 month supply Refills:2 4. Probalance Liquid Sig: Fifty Five (55) ml PO qhour. Disp:1 month supply Refills:2 5. Silver Nitrate 0.5 % Solution Sig: One (1) Topical as needed as needed for bleeding at G tube. Disp:45 QS Refills:0 6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q2 as needed. Disp:120 Tablet(s) Refills:3 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal once a day. Disp:30 QS Refills:2 9. Morphine Sulfate 10 mg/5 mL Solution Sig: 1/2-1 teaspoon PO four times a day as needed for pain: increase as needed for patient comfort. Disp:QS QS Refills:3 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:QS ML(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: GI bleed a-fib Aspiration Pneumonia CHF h/o CVA Dementia GERD Constipation Discharge Condition: Fair Discharge Instructions: Please continue medications as listed. The narcotics and benzodiazepines can be increased as needed in order to make the patient comfortable. Followup Instructions: Provider: [Name10 (NameIs) 97134] [Name11 (NameIs) 97135], MD Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2177-4-14] 3:30	[ "530.81", "294.8", "532.90", "507.0", "438.20", "V66.7", "427.31", "276.8", "514", "564.00", "428.0", "599.0", "535.51" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13", "96.07", "43.11" ]	icd9pcs	[ [ [] ] ]	6131, 6189	3347, 4891	293, 318	6308, 6314	2026, 3324	6504, 6684	1716, 1720		4994, 6108		6210, 6287	4917, 4971			6338, 6481										1735, 2007																												222, 255										346, 997																1019, 1474	1490, 1700
5,241	133,167	19561+19562+57065	Discharge summary	report+report+addendum	Admission Date: [2109-2-1] Discharge Date: [2109-2-15] Service: ADDENDUM: This is a discharge summary addendum from the time that the patient was on the Medicine Service from [2109-2-12] to [2109-2-15]. In brief, this is an 83-year-old man with a history of CAD who was initially admitted on [2109-1-31] after being found on the highway with facial trauma. He was ultimately diagnosed with a small subarachnoid hemorrhage and multiple comminuted fractures of the right orbital floor, maxillary sinus, zygomatic arch, and medial and lateral walls of the orbit. He had been recovering well except for failing his swallow studies. On the day prior to transfer from the Trauma Surgery Service, the patient was adverse to aspirate and subsequently had a chest film that showed bibasilar consolidations consistent with aspiration pneumonitis and ultimately pneumonia. The patient was not initially started on antibiotics. Subsequently, he was found to have bandemia and transferred to Medicine. On transfer, the patient's T maximum was 104.8, T current 99.9, pulse 80, BP 115/80, respiratory rate 24, saturating at 95% on room air. Generally, he is an Mandarin-speaking man who is lethargic looking up to the sun. Neck had no jugular venous distention. Lungs had bronchial breath sounds at the right bases. Heart examination was regular without murmurs, rubs, or gallops. Abdomen was soft, nontender, nondistended with active bowel sounds. Extremities showed no cyanosis, clubbing, or edema. He had a white count of 19.3 with 60 polys, 26 bands, 10% lymphs, hematocrit 37.2, and platelets 357,000. He had a sputum sample that showed 4+ gram-negative rods. 1. ASPIRATION PNEUMONIA: The patient had a significant leukocytosis with a left shift. Given the chest wall findings and the fever, this was all consistent with an aspiration pneumonitis. The patient was in the hospital for over two weeks and was considered to have a nosocomial infection. He was started on piperacillin/tazobactam antibiotic pending sensitivities of the bug. His fever curve improved during the course of his admission and ultimately his sputum grew out pan sensitive E. coli. His white count continued to normalize. He was changed over to levofloxacin. He will continue a 14 day course of this medication. 2. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was initially on just pureed solid foods. He had a video swallow study that was surprisingly good with mild dysphagia and aspiration. His diet was upgraded to thin liquids and pureed as well as the patient must be sitting upright in a chair while eating. This was his diet by discharge. 3. DISPOSITION: The medical opinion of the treating team was strongly pursuing the idea of a rehabilitation facility with the family and with the patient given the fact that he was severely deconditioned as well as having significant medical problems including significant aspiration and aspiration pneumonia it was the medical opinion that the patient would do best at rehabilitation and that he would not be able to be cared for at home. However, the patient's son, who is the health care proxy, was insistent that the patient go home and so since the patient was clinically stable he was discharged to home with services. Multiple conversations about disposition were had with the family and son. However, he was still insisting on this course. 4. DEMENTIA: The patient was kept on low-dose Aricept. 5. CODE: The patient is a full code. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSIS: 1. Subarachnoid hemorrhage. 2. Facial fractures. 3. Aspiration pneumonia. DISCHARGE MEDICATIONS: 1. Aspirin enteric coated 325 mg p.o. q.d. 2. Aricept 1.25 mg p.o. q.d. 3. Levaquin 250 mg p.o. q.d. times ten days. FOLLOW-UP PLANS: The patient will follow-up with his PCP later this week. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 53061] Dictated By:[Last Name (NamePattern1) 7693] MEDQUIST36 D: [2109-2-15] 06:11 T: [2109-2-16] 08:17 JOB#: [Job Number 53062] cc:[Numeric Identifier 53063] Admission Date: [2109-2-1] Discharge Date: [2109-2-15] Service: TRAUMA [Last Name (un) ] DATE OF SERVICE ON TRAUMA, [2109-2-1] UNTIL [2109-2-12] WHEN TRANSFERRED TO MEDICINE CHIEF COMPLAINT: Status post pedestrian struck. HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old male status post pedestrian struck found on the street by police and brought to an outside hospital for treatment. Patient was transferred to [Hospital6 256] Emergency Department with obvious facial trauma. Patient is Chinese speaking only. Now presented hemodynamically stable with [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 13. PAST MEDICAL HISTORY AS PER THE SON: 1. Coronary artery disease. 2. Status post myocardial infarction. 3. Status post coronary artery bypass graft in [2095]. 4. Dementia. 5. Benign prostatic hypertrophy. HOME MEDICATIONS: 1. Aricept 1.25 q. day. 2. Aspirin 325 q. day. PAST SURGICAL HISTORY: Status post coronary artery bypass graft in [2095]. SOCIAL HISTORY: The patient lives alone with frequent visits by his son for care. No tobacco. No ETOH. ALLERGIES: Patient has no known drug allergies. PHYSICAL EXAMINATION: Patient's heart rate is 80, blood pressure 180/60 on admission, respirations 22, satting at 97 on room air. On physical examination the patient has a right ecchymotic and swollen orbit. Pupils: On the right patient is unable to open right eye secondary to swelling, and on the left pupil is reactive 4 to 2 with positive corneal reflex. Exam is also positive for a right facial laceration. Tympanic membranes are clear. Oropharynx is clear. Regular rate and rhythm. Clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended. Pelvis is stable. Flanks: No costovertebral angle tenderness or deformities, CTLS sign, deformities, or step offs. Guaiac negative; good rectal tone. Extremities: Positive for old ecchymosis of the right lower extremity; +2 palpable pulses throughout with 5/5 strength. LABORATORY DATA: White count is 12.6, hematocrit is 41.5, electrolytes and coags were within normal limits. Lactate was 1.5 and amylase was slightly elevated at 132. Patient's chest x-ray and pelvis at [Hospital3 ] are within normal limits. CT of the head showed a small left subarachnoid hemorrhage and right orbital fracture. CT of the abdomen done at [Hospital3 9717] was negative, as well. Patient had repeat head CTs times two which showed stable and decrease of the right small subarachnoid hemorrhage. CT of the face: Fine cuts were done on [2109-2-1] which showed fractures of the right maxillary sinus, right orbital floor, right lateral orbital floor, and right zygomatic arch. As mentioned, ophthalmology recommended conservative, non-operative management. Oral maxillary and Facial was consulted on right eye contusion and nasal fracture and recommended conservative management as ophthalmological exam was within normal limits. Patient was transferred to the Intensive Care Unit for close monitoring of hypertension, and an A-line was placed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9325], M.D. [MD Number(1) 10637] Dictated By:[Last Name (NamePattern1) 27744] MEDQUIST36 D: [2109-2-21] 11:33 T: [2109-2-21] 14:49 JOB#: [Job Number 53064] Name: [Known lastname ], [Known firstname 9861] Unit No: [Numeric Identifier 9862] Admission Date: [2109-2-1] Discharge Date: [2109-2-15] Date of Birth: [2025-9-3] Sex: M Service: ADDENDUM: This is a continuation of the Discharge Summary. SUMMARY OF HOSPITAL COURSE (CONTINUED): The patient was transferred to the Unit for close monitoring of blood pressure, and an arterial line was placed. The patient was placed on a nicardipine drip for management of blood pressure. The patient's Intensive Care Unit course was unremarkable. The patient's blood pressure was well controlled and was weaned off the drip. Plastic Surgery, Oral Maxillofacial, and Ophthalmology all concluded nonoperative management for the orbital fractures. The patient was transferred to the floor in a stable condition on post trauma day three. The patient's cervical spine was cleared, and a swallowing evaluation was obtained. The patient failed the swallowing study, and tube feeds were started. The [Hospital 1325] hospital course was remarkable for an additional head computed tomography which showed an interval improvement in the right subarachnoid hemorrhage. Throughout the hospital course, the patient had nutritional issues, and aspiration precautions were made. The patient was not motivated to follow commands or swallowing studies, and the patient was kept nothing by mouth for this reason. Each day the patient was more and more alert, and the patient was unable to pass a bedside swallow evaluation times two. All these issues were discussed with the patient's son, who insisted that the patient should attempt oral intake as he did prior to admission. The risks of aspiration pneumonia were told to the patient's son, and the patient's agreed to accept these risks and wanted his father to try oral intake. In addition, the possibility of percutaneous endoscopic gastrostomy tube placement was discussed with the son who adamantly refused this. The patient discontinued his own feeding tubes on post trauma day six. As per the son, the patient was started on thick liquids for a trial of oral intake. A Geriatric consultation was obtained to comment on management of by mouth status. They recommended attempts at oral intake with the son's recommendations. On post trauma day eleven, the patient developed a temperature of 101.4. A urinalysis was sent, which was negative. White blood cell count was 13.6, and a chest x-ray showed new right lower lobe infiltrate. A sputum culture was sent, and blood cultures were sent. The Geriatric fellow who was following the patient suggested transfer to Medicine at this time. A sputum culture grew out gram-negative and gram-positive rods, and the patient was started on Zosyn. At this time hospital course dictated by medical resident should be continued as well as discharge instructions and medications. [Name6 (MD) ] [Name8 (MD) 5407], M.D. [MD Number(2) 3608] Dictated By:[Last Name (NamePattern1) 7275] MEDQUIST36 D: [2109-2-21] 11:43 T: [2109-2-21] 14:58 JOB#: [Job Number 9863]	[ "600.00", "507.0", "802.6", "414.01", "401.9", "290.0", "V45.81", "852.00", "802.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]									3726, 3847		3625, 3703												5194, 5251							5120, 5170											5431, 10803						3865, 4407						4425, 4457										4486, 5102																	5268, 5408	3554, 3604
29,496	102,918	30215	Discharge summary	report	Admission Date: [2185-11-29] Discharge Date: [2185-12-13] Date of Birth: [2117-5-22] Sex: M Service: ORTHOPAEDICS Allergies: Morphine Sulfate / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 11415] Chief Complaint: Left hip infection Major Surgical or Invasive Procedure: [2185-11-30]: I&D Left hip with VAC placement [2185-12-2]: I&D Left hip with VAC placement [2185-12-3]: PICC placement [2185-12-6]: I&D Left hip with primary closure and incisional VAC placement [2185-12-9]: VAC change at bedside [2185-12-13]: VAC change at bedside History of Present Illness: Mr. [Known lastname ] is a 68 year old man who underwent a girdlestone of his left hip [10-23] due to infection. He was placed on Nafcillin per Infectious Disease. He presented to the orthopaedic surgery clinic in follow up and was found to have purulent drainage from his left hip. He was then admitted for further care. Past Medical History: CVA [2180] with L hemiparesis LLE DVT [2180] CAD s/p stents X3 10yrs ago with MI HTN Hypercholesterolemia LLE venous stasis Left hip ORIF [3-/2185] Left hip girdleston [10/2185] Social History: From rehab Family History: n/a Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: LLE staples intact, +draiage, + odor, sensation intact to LLE Pertinent Results: [2185-12-13] 04:37AM BLOOD WBC-5.4 RBC-3.33* Hgb-9.9* Hct-30.1* MCV-90 MCH-29.7 MCHC-32.9 RDW-16.4* Plt Ct-645* [2185-12-10] 04:39AM BLOOD Hct-29.5* [2185-12-9] 10:20AM BLOOD WBC-4.4 RBC-3.22* Hgb-9.8* Hct-29.6* MCV-92 MCH-30.3 MCHC-32.9 RDW-17.2* Plt Ct-525* [2185-12-8] 06:16PM BLOOD Hct-24.5* [2185-12-8] 04:01AM BLOOD WBC-6.1 RBC-2.67* Hgb-8.3* Hct-24.9* MCV-93 MCH-31.0 MCHC-33.2 RDW-17.6* Plt Ct-527* [2185-12-8] 12:45AM BLOOD WBC-5.8 RBC-2.86* Hgb-8.9* Hct-26.8* MCV-94 MCH-31.2 MCHC-33.3 RDW-17.5* Plt Ct-500* [2185-12-7] 07:00AM BLOOD WBC-4.7 RBC-3.10* Hgb-9.3* Hct-28.7* MCV-93 MCH-30.1 MCHC-32.4 RDW-17.7* Plt Ct-479* [2185-12-6] 02:54PM BLOOD WBC-4.2 RBC-3.23* Hgb-10.0* Hct-30.1* MCV-93 MCH-30.9 MCHC-33.1 RDW-17.7* Plt Ct-432 [2185-12-6] 05:57AM BLOOD WBC-7.1 RBC-3.12* Hgb-9.5* Hct-28.8* MCV-92 MCH-30.6 MCHC-33.2 RDW-17.8* Plt Ct-424 [2185-12-5] 03:18AM BLOOD WBC-5.3 RBC-3.09* Hgb-9.4* Hct-28.9* MCV-94 MCH-30.6 MCHC-32.7 RDW-18.4* Plt Ct-487* [2185-12-4] 07:30AM BLOOD WBC-6.9 RBC-3.15* Hgb-9.9* Hct-29.8* MCV-95 MCH-31.6 MCHC-33.4 RDW-18.4* Plt Ct-409 [2185-12-3] 05:11AM BLOOD WBC-8.5 RBC-3.13* Hgb-9.7* Hct-28.4* MCV-91 MCH-31.2 MCHC-34.3 RDW-18.9* Plt Ct-411 [2185-12-2] 04:18PM BLOOD WBC-7.3 RBC-3.27* Hgb-10.2* Hct-30.1* MCV-92 MCH-31.1 MCHC-33.8 RDW-19.3* Plt Ct-441* [2185-12-2] 05:04AM BLOOD Hct-29.6* [2185-12-2] 12:46AM BLOOD WBC-6.7 RBC-3.42# Hgb-10.5 Hct-30.5* MCV-89 MCH-30.7 MCHC-34.5 RDW-19.5* Plt Ct-386 [2185-12-1] 11:55AM BLOOD Hct-28.9* [2185-12-1] 11:55AM BLOOD Hct-28.9* [2185-12-1] 07:55AM BLOOD Hct-27.8* [2185-12-1] 03:46AM BLOOD WBC-8.0 RBC-2.73# Hgb-8.4# Hct-25.2* MCV-92# MCH-30.9 MCHC-33.5# RDW-20.2* Plt Ct-480* [2185-12-1] 12:37AM BLOOD Hct-23.2* [2185-11-30] 08:50PM BLOOD WBC-10.0# RBC-2.18# Hgb-6.5# Hct-21.7# MCV-99 MCH-29.8 MCHC-30.0* RDW-21.3* Plt Ct-777* [2185-11-30] 05:37PM BLOOD WBC-6.4 RBC-3.23* Hgb-9.9* Hct-31.7* MCV-98 MCH-30.7 MCHC-31.2 RDW-20.4* Plt Ct-650* [2185-11-30] 09:51AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.7* Hct-27.7* MCV-97# MCH-30.5 MCHC-31.3 RDW-21.3* Plt Ct-698# [2185-11-30] 08:50PM BLOOD Neuts-60.7 Lymphs-25.3 Monos-5.5 Eos-8.4 Baso-0.1 [2185-11-30] 09:51AM BLOOD Neuts-63.1 Lymphs-19.1 Monos-4.8 Eos-12.7* Baso-0.3 [2185-12-13] 04:37AM BLOOD Plt Ct-645* [2185-12-9] 10:20AM BLOOD Plt Ct-525* [2185-12-8] 04:01AM BLOOD Plt Ct-527* [2185-12-8] 12:45AM BLOOD Plt Ct-500* [2185-12-6] 02:54PM BLOOD Plt Ct-432 [2185-12-6] 05:57AM BLOOD Plt Ct-424 [2185-12-6] 05:57AM BLOOD PT-13.7* PTT-33.3 INR(PT)-1.2* [2185-12-5] 03:18AM BLOOD Plt Ct-487* [2185-12-2] 12:46AM BLOOD PT-14.2* PTT-29.6 INR(PT)-1.2* [2185-11-30] 08:50PM BLOOD Plt Smr-VERY HIGH Plt Ct-777* [2185-11-30] 05:37PM BLOOD Plt Ct-650* [2185-11-30] 09:51AM BLOOD PT-14.1* PTT-31.3 INR(PT)-1.2* [2185-12-13] 04:37AM BLOOD ESR-65* [2185-12-13] 04:37AM BLOOD UreaN-7 Creat-0.8 K-3.6 [2185-12-12] 04:04AM BLOOD K-3.5 [2185-12-11] 08:36AM BLOOD K-3.2* [2185-12-10] 04:39AM BLOOD K-3.3 [2185-12-9] 10:20AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-137 K-4.2 Cl-105 HCO3-25 AnGap-11 [2185-12-8] 06:16PM BLOOD K-3.6 [2185-12-8] 04:01AM BLOOD Glucose-96 UreaN-6 Creat-0.7 Na-135 K-2.8* Cl-101 HCO3-26 AnGap-11 [2185-12-6] 05:57AM BLOOD Glucose-79 UreaN-6 Creat-0.8 Na-139 K-3.3 Cl-104 HCO3-26 AnGap-12 [2185-12-6] 05:57AM BLOOD Glucose-79 UreaN-6 Creat-0.8 Na-139 K-3.3 Cl-104 HCO3-26 AnGap-12 [2185-12-6] 01:59AM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-137 K-3.5 Cl-104 HCO3-25 AnGap-12 [2185-12-4] 07:30AM BLOOD Glucose-85 UreaN-5* Creat-0.8 Na-137 K-3.2* Cl-105 HCO3-22 AnGap-13 [2185-12-3] 05:11AM BLOOD Glucose-109* UreaN-5* Creat-0.8 Na-136 K-3.5 Cl-105 HCO3-24 AnGap-11 [2185-12-2] 12:46AM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-139 K-3.5 Cl-108 HCO3-24 AnGap-11 [2185-12-1] 06:23PM BLOOD K-3.5 [2185-12-1] 07:55AM BLOOD K-3.7 [2185-12-1] 03:46AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-141 K-3.7 Cl-108 HCO3-24 AnGap-13 [2185-12-1] 04:46AM BLOOD CK(CPK)-93 [2185-11-30] 08:50PM BLOOD ALT-5 AST-12 LD(LDH)-312* CK(CPK)-51 AlkPhos-106 Amylase-51 TotBili-0.5 [2185-11-30] 09:51AM BLOOD ALT-5 AST-14 AlkPhos-127* TotBili-0.4 [2185-12-1] 11:55AM BLOOD CK-MB-4 cTropnT-0.03* [2185-12-1] 04:46AM BLOOD CK-MB-NotDone [2185-11-30] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.02* [2185-12-13] 04:37AM BLOOD Albumin-2.4* [2185-12-8] 12:45AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8 [2185-12-7] 07:00AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9 [2185-12-6] 05:57AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 [2185-12-3] 05:11AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8 [2185-12-2] 04:18PM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0 [2185-12-2] 12:46AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2 [2185-12-1] 11:55AM BLOOD Mg-2.4 [2185-12-1] 03:46AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.8 [2185-11-30] 05:37PM BLOOD Calcium-9.1 Mg-2.3 [2185-12-13] 04:37AM BLOOD CRP-91.4* [2185-11-30] 09:51AM BLOOD CRP-35.3* [2185-11-30] 08:50PM BLOOD EDTA Ho-HOLD Brief Hospital Course: Mr. [Known lastname ] presented to the [Hospital1 18] on [2185-11-29] via direct admit from orthopaedic clinic due to a left hip infection. He was admitted, prepped, and consented for surgery. On [2185-11-30] he went to the operating room for an I&D of his left hip with VAC placement. He tolerated the procedure well, was extubated, transferred to the recovery room and then to the floor. On the floor he became poorly responsive with systolic blood pressure in the 80's, and his VAC with a large amount of bloody drainage. He was transfused with 2 units of packed red blood cells due to acute post operative anemia. He was given narcan with some response, but a code was called. He was transferred to the ICU for further care. On [2185-12-1] he was again transfused with 3units of packed red blood cells due to acute post operative anemia. On [2185-12-2] he was started on Cipro in addition to Nafcillin due to gram negative rods for the OR culture. On [2185-12-3] a new PICC line was placed for long term antibiotics. On [2185-12-6] he again returned to the operating room for an I&D with wound closure and placement of an incisional VAC. On [2185-12-8] he was transfused with 2 units of packed red blood cells due to acute post operative anemia. On [2185-12-9] he had his VAC changed at the bedside. On [2185-12-13] his VAC was again changed at the bedside.on day of dc his wound was seen by dr [Last Name (STitle) ] and felt it looked good Throughout his stay his potassium had to be repleated due to low levels. He was started on daily dose of potassium. Physical therapy follow throughout his hospital stay to improve his strength and mobility. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits, and his pain controlled. He is being discharged today in stable condition. Medications on Admission: [Last Name (un) 1724]: atenolol 100'', Fioricet prn, Diovan 80'', [Doctor First Name ] 60'', Flonase 0.05% [Hospital1 ], Lasix 20'', Hydral 50 QID, Lipitor 40', Norvasc 5'', Plavix 75', Darvocet 100 prn, Triamcinolone [Hospital1 ] rashes (cream only) Discharge Medications: 1. Outpatient Lab Work Please draw weekly CBC, BUN/Cr, LFT's, and fax results to Dr. [First Name (STitle) 1075] at [Telephone/Fax (1) 432]. 2. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) 2gm Intravenous Q4H (every 4 hours) for 2 weeks: End date [2185-12-20]. 3. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) 400mg Intravenous Q24H (every 24 hours) for 6 weeks: Start date [2185-12-2] end date [2186-1-13]. 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 15. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 17. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain, temps. 20. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 22. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 23. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea/vomiting. 24. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for pain. 25. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Left hip infection Acute post operative anemia Discharge Condition: Stable Discharge Instructions: Continue activity as tolerated WBAT left leg Continue your medications as prescribed by your doctor You may apply a dry sterile dressing daily or as needed for drainage or comfort If you notice any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. You were started on daily KCL as your potassium was quite low. Continue to have your Postassium checked frequently Physical Therapy: Activity: As tolerated Left lower extremity: Full weight bearing Treatments Frequency: Staples/Sutures may be removed 14 days after surgery or at follow up appointment VAC change every 3 days. VAC is an incisional VAC Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2185-12-16] 9:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2185-12-13]	[ "276.8", "V43.64", "412", "401.9", "285.1", "998.59", "V45.82", "458.29", "E879.9", "V58.62", "414.01", "272.4", "438.20", "V12.51", "459.81" ]	icd9cm	[ [ [] ] ]	[ "83.32", "38.93", "93.59", "99.05", "99.04", "80.15" ]	icd9pcs	[ [ [] ] ]	11318, 11359	6634, 8528	326, 624	11450, 11459	1501, 6611	12215, 12634	1248, 1253		8845, 11295		11380, 11429	8554, 8822			11483, 11950										1268, 1482	11968, 12036	12058, 12192																										268, 288										652, 986																1008, 1203	1219, 1232
54,527	155,458	28905	Discharge summary	report	Admission Date: [2137-9-26] Discharge Date: [2137-9-30] Date of Birth: [2086-8-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Painless rectal bleeding . HPI: 51 year old male with history of diverticulosis s/p sigmoid resection in [2134] now presenting with 3 episodes of painless rectal bleeding that started today. Patient was in his usual state of health until approximately 2pm today, when he developed bloating, nausea and mild crampy abdominal pain. He had the desire to empty his bowel and had a significant amt of dark red blood in the toilet bowl ("blood just poured out"). He had three such episodes. No clots. No nausea or vomiting or fevers/chills. Had lunch (tuna [Location (un) 6002] and french fries) at around 12:30pm. Has been having normal daily BM. No melena or BRBPR in the past. Took one Alleve this am but otherwise no NSAID use. No SOB/CP. . h/o episode of diverticulitis in [2134]. Had sigmoid resection. Has not had a colonoscopy. . In the ER his vitals were 98.8 94 167/109 22 97% RA. No external hemorrhoids seen. NGL was negative. 2 large bore IVs were put in. 1L NS bolus, 40mg IV protonix, 1mg ativan, 4mg IV morphine and 4mg of Zofran were given. . On admission to the floor, pt complaining of [8-1] crampy abdominal pain. Had another episode of rectal bleeding. Feeling mildly lightheaded upon standing up. . ROS positive for right hip pain (being evaluated for hip pain) and fatigue. . PMH: diverticulitis - episode [3-27], sigmoid resection at [Hospital3 ] Right total hip replacement - [10-29] - now complicated by pain. question of loosening of prosthesis. Left total hip replacement - [7-/2129] distal radius fracture - last surgery [2136-5-31]. depression subclinical hypothyroidism h/o hep C infection, cleared [2133] h/o chest pain - ETT mibi [6-29] wnl subclinical hypothyroidism obestiy . MEDS (per patient): Bupropion 450mg qd Keflex PRN fpr dental procedures Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs q4 PRN MVI . ALLERGIES: NKDA . SH:Lives with wife in [Name (NI) 6930]. Works as a project manager for [Hospital1 ]. Avg [6-29] drinks during the week. Stopped smoking approximately 1 yr ago. Smoked for 10 years approximately [3-26] packs/week. No recreational drug use. . FH: Father died of CHF at 66. Also had diabetes. Mother with HBP died of renal complications. Brother has history of "polyps, not cancer." Pt unclear about exact diagnosis. . PE Vitals: 97.9 113/68 94 18 97% RA General: NAD, AAO X3 HEENT: PERRL, EOMI, OP clear, MM dry Neck: no LAD, supple. No carotid bruits. Heart: RRR no m/r/g Lungs: CTAB no wheezes, crackles, rhochi Abd: Hyperactive bowel sounds. Distended. Non-tender to palpation. Soft. Ext: no edema. WWP. Cap refil <2 seconds. Neuro: CN II-XII intact. Extremities 5/5 strength bilaterally, sensation intact to light touch. Psych: appropriate Skin: no rashes. Warm. . LABS: see below . A/P: 51 yo male with history of diverticulitis s/p sigmoid resection now presenting with painless rectal bleeding X4 episodes. . # Rectal bleeding - Upper GI bleed unlikely given negative NG lavage. Given patient's history, diverticulosis high on the differential. Angiodysplasia also a possibility. Unlikely to be hemorrhoids given large amt of blood and lack of history. Patient hemodynamically stable at the moment. [Name2 (NI) ] has been typed and screened. 2 large bore IVs. - IV fluids - 1L NS bolus - Repeat hematocrit. Will assess need for transfusion if significant drop in hct noted. - Will consult GI - Continue to monitor hemodynamic status - NPO for now . # Right hip pain - s/p THR in [2136]. Recent pain thought to be due to loosening of prosthesis. Being followed by orthopedics. . # Depression - continue bupropion. . # FEN/GI - NPO for now. electrolyte repletion prn . # PPx - hold off on hep sc, bowel regimen for now . # Code - full . # Dispo - pending evaluation and resolution of symptoms Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: HPI: 51 year old male with history of diverticulosis s/p sigmoid resection in [2134] now presenting with 3 episodes of painless rectal bleeding that started today. Patient was in his usual state of health until approximately 2pm on day of admission, when he developed bloating, nausea and mild crampy abdominal pain. He had the desire to empty his bowel and had a significant amt of dark red blood in the toilet bowl ("blood just poured out"). He had three such episodes. No clots. No nausea or vomiting or fevers/chills. Had lunch (tuna [Location (un) 6002] and french fries) at around 12:30pm. Has been having normal daily BM. No melena or BRBPR in the past. Took one Alleve am of admission but otherwise no NSAID use. No SOB/CP. . h/o episode of diverticulitis in [2134]. Had sigmoid resection. Has not had a colonoscopy. . In the ER his vitals were 98.8 94 167/109 22 97% RA. No external hemorrhoids seen. NGL was negative. 2 large bore IVs were put in. 1L NS bolus, 40mg IV protonix, 1mg ativan, 4mg IV morphine and 4mg of Zofran were given. . On admission to the floor, pt complaining of [8-1] crampy abdominal pain. Had another episode of rectal bleeding. Feeling mildly lightheaded upon standing up. . ROS positive for right hip pain (being evaluated for hip pain) and fatigue. Past Medical History: diverticulitis - episode [3-27], sigmoid resection at [Hospital3 ] Right total hip replacement - [10-29] - now complicated by pain. question of loosening of prosthesis. Left total hip replacement - [7-/2129] distal radius fracture - last surgery [2136-5-31]. depression subclinical hypothyroidism h/o hep C infection, cleared [2133] h/o chest pain - ETT mibi [6-29] wnl subclinical hypothyroidism obestiy Social History: Lives with wife in [Name (NI) 6930]. Works as a project manager for [Hospital1 ]. Avg [6-29] drinks during the week. Stopped smoking approximately 1 yr ago. Smoked for 10 years approximately 3-4 packs/week. No recreational drug use. Family History: Father died of CHF at 66. Also had diabetes. Mother with HBP died of renal complications. Brother has history of "polyps, not cancer." Pt unclear about exact diagnosis. Physical Exam: Vitals: 97.9 113/68 94 18 97% RA General: NAD, AAO X3 HEENT: PERRL, EOMI, OP clear, MM dry Neck: no LAD, supple. No carotid bruits. Heart: RRR no m/r/g Lungs: CTAB no wheezes, crackles, rhochi Abd: Hyperactive bowel sounds. Distended. Non-tender to palpation. Soft. Ext: no edema. WWP. Cap refil <2 seconds. Neuro: CN II-XII intact. Extremities 5/5 strength bilaterally, sensation intact to light touch. Psych: appropriate Skin: no rashes. Warm. Pertinent Results: [2137-9-26] 03:10PM PT-12.5 PTT-23.1 INR(PT)-1.1 [2137-9-26] 03:10PM PLT COUNT-437 [2137-9-26] 03:10PM NEUTS-52.4 LYMPHS-39.3 MONOS-4.8 EOS-3.2 BASOS-0.3 [2137-9-26] 03:10PM WBC-9.9 RBC-4.32* HGB-13.8* HCT-39.3* MCV-91 MCH-32.1* MCHC-35.2* RDW-14.1 [2137-9-26] 03:10PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.2 [2137-9-26] 03:10PM CK-MB-3 [2137-9-26] 03:10PM cTropnT-<0.01 [2137-9-26] 03:10PM ALT(SGPT)-20 AST(SGOT)-43* CK(CPK)-153 ALK PHOS-89 TOT BILI-0.2 [2137-9-26] 03:10PM estGFR-Using this [2137-9-26] 03:10PM GLUCOSE-117* UREA N-14 CREAT-1.0 SODIUM-141 POTASSIUM-6.1* CHLORIDE-109* TOTAL CO2-22 ANION GAP-16 [2137-9-26] 03:15PM HGB-14.8 calcHCT-44 [2137-9-26] 03:15PM GLUCOSE-110* LACTATE-2.0 NA+-145 K+-5.9* CL--107 TCO2-22 [2137-9-26] 05:38PM K+-4.3 [2137-9-26] 07:45PM HCT-29.4# [2137-9-26] 11:51PM HCT-31.4 [2137-9-26] 11:51PM POTASSIUM-4.3 Bleeding study [9-27]: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images show normal radiotracer distribution. Dynamic blood pool images show normal radiotracer distribution. There is no evidence of GI bleed after 90 minutes. IMPRESSION: No evidence of GI bleed. Colonoscopy [9-30]: Findings: Lumen: Evidence of a previous [Last Name (un) ]-colonic anastomosis was seen at the sigmoid colon. Excavated Lesions Multiple diverticula with mixed openings were seen in the sigmoid colon, descending colon, transverse colon and ascending colon. Diverticulosis appeared to be of moderate severity. Impression: Previous [Last Name (un) ]-colonic anastomosis of the sigmoid colon Diverticulosis of the sigmoid colon, descending colon, transverse colon and ascending colon Otherwise normal colonoscopy to cecum Brief Hospital Course: 51 yo male with history of diverticulitis s/p sigmoid resection presenting with painless rectal bleeding. . 1. Rectal bleeding - Patient had negative nasogastric lavage in the ER. His hct in the ER was 39. Patient was admitted to the floor, when he had 2 more episodes of rectal bleeding. A repeat hematocrit 5 hours later was 29. A transfusion was started and patient was transferred to the MICU. He received a total of 4 untils of PRBC during his hospitalization. Patient remained hemodynamically stable throughout his hospitalization. He was observed in the MICU for 2 days and underwent a tagged RBC scan which was negative. His HCT remained stable after his transfusions for >72 hours. The GI service followed the patient through his hospital course. A colonoscopy was performed, which showed previous [Last Name (un) ]-colonic anastomosis of the sigmoid colon, diverticulosis of the sigmoid colon, descending colon, transverse colon and ascending colon. Otherwise normal colonoscopy to cecum. No signs of active bleeding. It is likely that this was a diverticular bleed that stabilized. He was instructed to eat a high fiber diet and follow up with his PCP. [Name10 (NameIs) ] time of discharge, his hematocrit had been stable X 2 days and he had not had any rectal bleeding X3 days. 2. Right hip pain - s/p THR in [2136]. Recent pain thought to be due to loosening of prosthesis. Being followed by orthopedics. Pain was controlled with PRN Percocet. 3. Depression - bupropion was continued through his hospital stay. Medications on Admission: Bupropion 450mg qd Keflex PRN fpr dental procedures Oxycodone-Acetaminophen 5 mg-325 mg 1-2 tabs q4 PRN MVI Discharge Medications: 1. Bupropion 75 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Primary: Diverticulosis Secondary: Chronic right hip pain (? loose prosthesis) Discharge Condition: All vital signs stable. No rectal bleeding. Hematocrit stable for 2 days. No abdominal pain, nausea or vomiting. Discharge Instructions: You were admitted to the hospital for lower intestinal bleeding. Your hematocrit (blood count) was low and we gave you 4 units of blood after which it stabilized. Your bleeding was likely from a diverticula which appears to have stopped. You had a colonoscopy done which showed some continued diverticulosis. You should eat a diet high in fiber. At time of discharge, you had not had any bleeding for 3 days. Your blood count is stable. Please restart your home medications. Follow up with your PCP as scheduled below. If you develop rectal bleeding, abdominal pain, nausea/vomiting, fevers/chills, chest pain, trouble breathing or any other symptoms that concern you please call your doctor or go to the emergency room. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2137-10-15] 8:20 Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2137-10-28] 7:25 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2137-10-28] 7:45	[ "327.23", "996.41", "562.12", "E878.1", "278.00", "V43.64", "790.01", "311", "244.9", "V12.09", "276.7" ]	icd9cm	[ [ [] ] ]	[ "45.23", "99.04" ]	icd9pcs	[ [ [] ] ]	10772, 10778	8889, 10430	4134, 4148	10901, 11016	6872, 8866	11788, 12212	6219, 6390		10588, 10749		10799, 10880	10456, 10565			11040, 11765										6405, 6853																												274, 4096										4176, 5482																5504, 5939	5955, 6203
43,827	149,950	36596	Discharge summary	report	Admission Date: [2176-7-14] Discharge Date: [2176-7-18] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7333] Chief Complaint: jaw pain and shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization [7-15] History of Present Illness: [Age over 90 ] yo F w/ PMH of AS, AF p/w inferior MI from OSH for cath. Pt. awoke at 0500 on friday and walked to the bathroom. She walked back to bed and then began noticing jaw pain and mild heartburn. She took some xantac which did not relieve the pain and then decided to call 911, but was unable [1-15] inability to see the buttons on the phone. She called 611 and 411 and then decided to call a friend who called EMS. EMS arrived and intial EKG showed 1mm STE's in II, III, aVF and STD's in aVL. She was taken to [Hospital3 4107] where ekg showed resolution of STE's, her chest pain continued and she was treated with nitro. Her chest pain resolved around 1200. She was admitted to the ICU for pulmonary edema and successfully diuresed. She initially refused cath, but then her niece was talked her into having the procedure. She remained pain free until 0200 on [7-14] when she again had jaw pain and shortness of breath. She was treated with nitro and lasix and her pain improved after about 1 hour. Her CK peaked at 860 w/ Trop of 16 on [7-13], BNP was 278. She was transferred to [Hospital1 18] for cardiac catheterization. She states that over the past several months she has had progressive DOE, stating that she has had to stop on her way to the trash room. She has also noticed a general sense of fatigue and daytime somnolence over the past month. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On admission, initial vitals were HR 73, BP 123/77, RR 14, SPO2 97% on NC Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (-)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: History of atrial fibrillation not anticoagulated, aortic stenosis -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Rib fractures Pelvic/acetabular Fx s/p [2176] Breast CA s/p mastectomy [2170] Endometrial CA s/p hysterectomy [2166] Basal cell CA s/p Mohs surgery SCC s/p excision Insomnia Macular degeneration GERD Social History: Lives in [Hospital3 ]. -Tobacco history: 1 cigarrette in life -ETOH: None -Illicit drugs: None Family History: 2 brothers with MI in their 60s, MS in sister, CAD in sister in her 70s. Physical Exam: VS: BP=123/77 HR= 77 RR=.14O2 sat= 97% NC GENERAL: Conversant, appropriate. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP below clavicle CARDIAC: irregularly irregular rhythm, normal S1, S2. Harsh III/VI murmur radiating to carotids. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased BS in bases bilaterally w/ scant crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Popliteal 2+ DP 2+ PT 1+ Left: Carotid 2+ Popliteal 2+ DP 2+ PT 1+ Pertinent Results: [2176-7-14] 11:12PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2176-7-14] 11:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-TR [2176-7-14] 11:12PM URINE RBC->50 WBC-[2-15] BACTERIA-RARE YEAST-NONE EPI-0 [2176-7-14] 01:44PM GLUCOSE-121* UREA N-13 CREAT-0.9 SODIUM-136 POTASSIUM-3.4 CHLORIDE-94* TOTAL CO2-34* ANION GAP-11 [2176-7-14] 01:44PM ALT(SGPT)-43* AST(SGOT)-92* CK(CPK)-586* ALK PHOS-59 TOT BILI-0.9 [2176-7-14] 01:44PM CK-MB-17* MB INDX-2.9 cTropnT-0.95* [2176-7-14] 01:44PM CALCIUM-9.7 PHOSPHATE-3.0 MAGNESIUM-2.0 [2176-7-14] 01:44PM WBC-7.1 RBC-4.14* HGB-13.7 HCT-39.0 MCV-94 MCH-33.2* MCHC-35.2* RDW-13.6 [2176-7-14] 01:44PM NEUTS-76.8* LYMPHS-13.4* MONOS-7.6 EOS-1.4 BASOS-0.7 Cardiac cath [7-15]: 1. Coronary angiography of this right dominant system demonstrated 3 vessel coronary artery disease. The LMCA had no angiographically apparent flow-limiting disease. The LAD had heavy calcifications with 80% stenoses between two aneurysmal segments in the mid-vessel. The LCX was occluded in the distal vessel. The LPL branches filled faintly by left-to-left collaterals. The RCA had a distal 90% stenosis prior to the bifurcation of the PDA. 2. Resting hemodynamics revealed elevated right and left sided filling pressures with a RVEDP of 25 mmHg and a LVEDP of 28 mmHg. There was severe pulmonary arterial hypertension with a PA pressure of 61/31 mmHg. There was moderate systemic arterial hypertension with a central aortic pressure of 163/79 mmHg. The cardiac index was normal at 2.7 L/min/m2. The mean gradient across the aortic valve was 16 mmHg. The calculated [Location (un) 109] was 1.1 cm2. 3. Successful PTCA and placement of overlapping (proximal-to-distal) 3.0x23mm Vision, 3.0x18mm Driver, and 2.5x12mm Micro Driver bare-metal stents were performed in the mid-distal RCA. Final angiography showed normal flow, resolution of the dissection, and no residual stenosis. (See PTCA comments.) FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Severe pulmonary arterial hypertension. 4. Moderate systemic arterial hypertension. 5. Biventricular diastolic dysfunction. 6. Placement of bare-metal stents in the mid-distal RCA. ECHO [7-16]: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-15]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate aortic stenosis. Mild to moderate mitral regurgitation. Moderate tricuspid regurgitation. Mild pulmonary hypertension. Brief Hospital Course: This is a [Age over 90 ] year old female with PMH of moderate AS and atrial fibrillation p/w inferior STEMI from OSH, had cardiac catheterization [7-15] with 3 bare metal stents placed in the mid RCA. . # CORONARIES: Patient initially with STEs on ekg by EMS, but they resolved upon arrival. She only had one episode of jaw pain the morning of transfer prior to her catheterization. Catheterization on [7-15] revealed three vessel coronary artery disease, moderate aortic stenosis, severe pulmonary arterial hypertension, moderate systemic arterial hypertension, and biventricular diastolic dysfunction. Three bare metal stents were placed in the mid-distal RCA. She tolerated the procedure well. The patient is likely not a candidate for CABG given her age. She will continue her home ASA and was started on Plavix and Lipitor. She did not have any more jaw pain at rest or with exertion after the catheterization. . # PUMP: Patient with report of flash pulmonary edema in OSH with CP which resolved with diuresis. She was euvolemic during this hospitalization and required only a 250cc bolus after catheterization because of low urine output. . # RHYTHM: The patient was in atrial fibrillation which was rate controlled as an outpatient on atenolol. Her CHADS2 score was 3. She was started on metoprolol for rate control and was started on warfarin after catheterization. Her INR will be followed by her PCP as an outpatient. . # Hypertension: The patient actually had low blood pressures in the 80s-90s systolic after catheterization. She was titrated to metoprolol 25mg three times daily and converted to toprol XL prior to discharge. The metoprolol dose was kept at three times daily because the patient would have a HR up to the 140s with exertion on lower doses. ACE inhibitor was not restarted given her low blood pressures and may need to be added on as an outpatient. . # GERD: Patient was on ranitidine at home and it was continued given the interaction of pantoprazole with clopidogrel. . # Macular Degneration: Her home prednisolone 1% eye drops were continued. Medications on Admission: Atenolol-Chlorthalidone 50 mg-25 mg Tablet one Tablet(s) by mouth daily Aspirin [Enteric Coated Aspirin] 81 mg Tablet, Delayed Release (E.C.) one Tablet(s) by mouth daily Diphenhydramine-Acetaminophen 500 mg-25 mg Tablet 1 Tablet(s) by mouth at bedtime as needed for insomnia Zantac 150 mg twice daily Prednisolone eye drops Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop taking unless Dr. [Last Name (STitle) 10543] tells you to. Disp:30 Tablet(s) Refills:11 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 7. Outpatient Lab Work Please draw INR on Saturday [7-20] and call results to Dr. [First Name8 (NamePattern2) ] [Known lastname 1356] at [Telephone/Fax (1) 40833] 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Inferior wall St Elevation Myocardial Infarction Secondary diagnoses: -moderate aortic stenosis -atrial fibrillation with rapid ventricular response -Rib fractures -Pelvic/acetabular Fx s/p [2176] -Breast CA s/p mastectomy [2170] -Endometrial CA s/p hysterectomy [2166] -Basal cell CA s/p Mohs surgery -SCC s/p excision -Insomnia -Macular degeneration -GERD Discharge Condition: Stable, afebrile, ambulatory Discharge Instructions: You were admitted to [Hospital1 69] from [Hospital3 ] for jaw pain and shortness of breath. You were found to have an inferior wall heart attack and were taken to cardiac catheterization where 3 bare metal stents were placed in your right coronary artery. You tolerated the procedure well and have been pain free since. You will need to take Plavix and aspirin every day for one month and possibly longer. Do not stop taking Plavix unless Dr. [Last Name (STitle) 10543] tells you to. Your heart rate has been high and we have started you on metoprolol three times a day to keep your heart rate in the 80's range. You were also started on coumadin to prevent a stroke. It is important that you take the dose prescribed by Dr.[Name (NI) 60978] office. You may experience some easy bruising, minor nosebleeds and bleeding gums. This is expected on coumadin. Please call Dr. [Known lastname 1356] if you have any dark or bloody stools, vomit blood or have bleeding that dose not stop promptly. The VNA will send a INR on Saturday [7-18] and Dr. [Known lastname 1356] will tell you how much coumadin to take. Your goal coumadin level is between 2.0 and 3.0. The following changes have been made to your home medication regimen: -You will take Coumadin daily for your atrial fibrillation -You will take metoprolol once daily to control your heart rate -You will take Lipitor 80mg at bedtime for your cholesterol -You will take Plavix 75mg daily to keep your new stents open -You will no longer take atenolol/chlorthalidone Please follow-up with all of your outpatient medical appointments listed below. Please seek medical care for any concerning symptoms such as jaw pain, chest pain, shortness of breath, nausea, sweating, lightheadedness, or dizziness. Followup Instructions: Primary Care: Dr. [First Name8 (NamePattern2) ] [Known lastname 1356] Phone: [Telephone/Fax (1) 40833] Date/Time: [7-25] at 11:30am. Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10543] Phone: ([Street Address(2) 82816] [Apartment Address(1) ] [Hospital1 ], [Numeric Identifier ] [8-8] at 10:30am. Please call the office to confirm this appt.	[ "424.1", "285.9", "414.01", "410.41", "530.81", "V10.3", "427.31", "416.0", "V88.01", "428.0", "401.9", "428.32", "362.50", "V45.71" ]	icd9cm	[ [ [] ] ]	[ "36.06", "00.47", "00.66", "88.56", "00.40", "37.23" ]	icd9pcs	[ [ [] ] ]	10798, 10849	7288, 9384	252, 289	11264, 11295	3910, 5976	13126, 13542	2954, 3029		9763, 10775		10870, 10920	9410, 9740		5993, 7265	11319, 13103										3044, 3891			10941, 11243	2431, 2575																								180, 214										317, 2316												2606, 2820				2338, 2410	2836, 2938
21,255	191,769	43095	Discharge summary	report	Admission Date: [2153-10-8] Discharge Date: [2153-10-12] Date of Birth: [2078-6-1] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) / Tetracyclines / Benadryl / Erythromycin Base / Aztreonam / Diatrizoate Meglumine Attending:[First Name3 (LF) 974] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: open cholecystectomy intraoperatie cholangiogram History of Present Illness: 75 F c/ myleoproliferative disease on steroids x 16 yrs c/ onset of RUQ abdominal pain last Friday night. The pain resolved on its own. This AM, the pain started again and got worse throughout the day. In the ED, the patient had n/v, fever to 103, and chills. Past Medical History: 1. Myeloproliferative disease - essential thrombocythemia 2. p-ANCA associated vasculitis 3. history of LGIB - diverticulosis ([8-22]) 4. Hypertension 5. PMR (Polymyalgia Rheumatica) 6. Hypothyroidism 7. Chronic renal insufficiency 8. CAD s/p angioplasty 9. Cataract L. eye Social History: School teacher; lives in [Location ] with partner, [Name (NI) 2048] who is very supportive She has not had alcohol in years. Never smoked. Family History: HTN (brother, mother) MI (mother)- died at 88 Physical Exam: T= 102.9 HR=114 BP=148/58 RR=22 100 4L GEN: NAD, AAOx3 HEENT: dry mucous membranes HEART: tachy, regular rhythm CHEST: CTA B/L ABD: soft, +distended, +RUQ and epigastric tenderness, + guarding RECTAL: deferred EXT: warm SKIN: fragile, eccymoses Pertinent Results: [2153-10-7] 06:45PM PT-12.2 PTT-23.2 INR(PT)-1.0 [2153-10-7] 06:45PM PLT COUNT-507* [2153-10-7] 06:45PM NEUTS-82* BANDS-13* LYMPHS-4* MONOS-0* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [2153-10-7] 06:45PM WBC-4.3 RBC-4.03* HGB-11.1* HCT-34.0* MCV-84 MCH-27.7 MCHC-32.8 RDW-19.1* [2153-10-7] 06:45PM TOT PROT-6.6 ALBUMIN-4.4 GLOBULIN-2.2 CALCIUM-9.0 PHOSPHATE-4.4 MAGNESIUM-2.3 [2153-10-7] 06:45PM LIPASE-36 [2153-10-7] 06:45PM ALT(SGPT)-116* AST(SGOT)-215* CK(CPK)-30 ALK PHOS-253* AMYLASE-48 TOT BILI-1.1 [2153-10-7] 06:45PM GLUCOSE-132* UREA N-60* CREAT-1.8* SODIUM-142 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-22 ANION GAP-24* [2153-10-7] 07:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [2153-10-7] 07:29PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2153-10-7] 08:08PM LACTATE-2.7* [10-7] Urine: E. coli (pan sensitive) [10-7] Blood: E. coli (pan sensitive) [10-8] Gallbladder: enterococcus (amp, penicillin, vanco) [10-7] ABD X-RAY: IMPRESSION: Somewhat limited study. Predominantly gasless abdomen. Dilated loop of small bowel in the left upper quadrant measuring up to 4.0 cm. Clinical correlation with symptoms is recommended, and if necessary, repeat supine and upright abdominal radiographs [10-7] RUQ U/S: RIGHT UPPER QUADRANT ULTRASOUND: There is diffuse distention of the gallbladder with 11 mm of wall thickening. Within the gallbladder lumen is seen a 4-cm hypoechoic rounded focus that does not demonstrate internal color blood flow. There is a mild son[Name (NI) 493] [Name2 (NI) 515] sign. There is no biliary ductal dilatation. The common bile duct measures 4 mm, which is normal. No pericholecystic fluid is identified. IMPRESSION: Findings are consistent with acute cholecystitis. These findings were relayed to the Emergency Department dashboard at the immediate conclusion of the examination as well as discussed in person with the surgical team caring for the patient. [10-7] CT ABD/PELVIS CT ABDOMEN WITH ORAL, WITHOUT IV CONTRAST: The lung bases are clear. Imaging of the abdomen is limited by the lack of intravenous contrast. Allowing for this, the liver parenchyma is normal in attenuation. The gallbladder is distended measuring 3.8 cm transversely, with a moderate amount of pericholecystic fluid. No intraluminal stones are identified. The common bile duct is not distended. The pancreas is somewhat atrophic. A stable 1.5 x 1.1 cm cystic lesion anterior to the body of the pancreas is unchanged since the prior study. The spleen is not enlarged. The adrenal glands are unremarkable. There is moderate renal cortical atrophy without hydronephrosis. Mild perinephric stranding is unchanged since the prior study. The abdominal loops of large and small bowel are normal in caliber and contour. There are scattered diverticula along the transverse colon. CT PELVIS WITH ORAL, WITHOUT INTRAVENOUS CONTRAST: Oral contrast does not extend into the pelvis. A Foley catheter is seen within a collapsed bladder. There is a small amount of intrapelvic free fluid. The sigmoid, rectum, uterus and adnexa are unremarkable. There is no inguinal or pelvic lymphadenopathy. There is no free air. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous abnormalities. Diffuse degenerative changes are noted along the lumbar spine. Old, healed fractures are incidentally noted in the right ischium, pubic symphysis and left inferior rib. IMPRESSION: 1. Findings consistent with cholecystitis. Correlation with ultrasound is recommended. 2. Cystic lesion adjacent to pancreatic body is unchanged since [2151-8-14]. 3. Diverticulosis. 4. Stable small amount of free fluid within the pelvis. This is a nonspecific finding but is unlikely to be physiologic given patient age. [10-7] CXR: PORTABLE AP CHEST RADIOGRAPH: Comparison is made to the prior chest radiograph dated [2153-5-25]. Cardiac and mediastinal contours are unchanged compared to the prior study. There is no consolidation or effusion. There is no evidence of pneumothorax. No evidence of free air below the diaphragm. [10-12] Pathology: Gallbladder: Chronic cholecystitis. No calculi in specimen. Brief Hospital Course: The patient presented to the ED with RUQ and epigastric abdominal pain, n/v, fever to 102.9, and chills. In the ED, the patient was hypotensive with a SBP in the 90's. RUQ u/s was consistent with acute cholecystitis and a possible mass within the gallbladder. Patient was made NPO, IVF were started, and the patient was begun on Levo/Flagyl. The patient was admitted to the SICU for more intensive monitoring and was pre-op'ed for exploratory laparotomy/open cholecystectomy. Due to the patient's MPD and chronic dose of steriods and immune suppression, Dr. [First Name (STitle) 1557] was consulted on HD2. Cellcept and hydroxyurea were held in addition to starting the patient on a stress dose of 100mg hydrocortisone q8. The patient was brought to the OR for an exploratory laparotomy with open cholecystectomy and intraoperative cholangiogram. There were no surgical complications and the patient was transferred back to the SICU postoperatively. The patient was extubated in the SICU. On POD1, the patient was started on sips. Stress dose of steroids were continued. The patient's blood culture was positive for gram neg. rods. The patient remained hemodynamically stable and was transferred to the floor. Steroids were tapered to PO prednisone 10 mg [Hospital1 ], Cellcept was restarted, and hydroxyurea was to be used if platelets increased greater than 500,000. The patient complained of difficulty breathing on POD2 and CXR revealed small infiltrate/atelectasis of the left lung base. Blood cultures came back postive for E. Coli and bile culture was positive for enterococcus. The E. coli was susceptible to the levofloxacin. On POD3, the patient remained afebrile, tolerating clears, and ambulating. The patient was advanced to a regular diet. However, PO Dilaudid caused nausea overnight. On POD4, the patient was tolerating a regular diet, continued to ambulate and had adequate pain control with PO Vicodin. PT briefly assessed the patient and determined the patient stable to d/c home when medically cleared. On POD4, the patient was d/c'ed home on levofloxacin and vicodin for pain control. Medications on Admission: lisinopril 20 mg qd toprol 100mg [Hospital1 ] catapress qweek cellcept [Pager number ] TID hydroxyurea 500TIW lasix 20mg qd lipitor 10mg qd pred 10mg qd bicitra qd allopurinol 200mg qd mvi tums aranesp per heme/onc synthroid 50mcg qd asa 81mg qd Protonix 40mg [Hospital1 ] Discharge Medications: 1. Home medications Resume your preadmission medications, except for your hydroxyurea & aranesp (Dr [First Name (STitle) 1557] will restart these for you). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 3. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:20 Tablet(s) Refills:0 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: cholecystitis e coli UTI e coli bacteremia ANCA vasculitis myeloproliferative disorder essential thrombocytopenia PMR CAD sp PTA [9-22] h/o diverticulosis & GI bleed hypothyroidism hypertension CRI (creat 1.5) gastritis Discharge Condition: good Discharge Instructions: Diet as tolerated. No strenuous activity, no bathing (showers okay - pat wound dry, and no driving while taking narcotics. Contact your MD if you develop increasing abdominal pain, fevers>101, persistent nausea or vomiting, redness or drainage about your wounds, or if you have any questions or concerns. Followup Instructions: Contact Dr.[Name (NI) 18535] office at ([Telephone/Fax (1) 376] to arrange an appointment in [12-22] weeks. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5386], MD Phone:[Telephone/Fax (1) 2977] Date/Time:[2153-10-16] 2:10 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D., PH.D.[MD Number(3) 708]:[Telephone/Fax (1) 435] Date/Time:[2153-10-22] 2:30 Provider: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern1) 13280], MD Phone:[Telephone/Fax (1) 2309] Date/Time:[2153-12-10] 9:30	[ "414.00", "575.12", "V45.82", "403.90", "287.30", "585.9", "244.9", "599.0", "458.9", "238.79", "790.7", "535.50", "041.4", "447.6" ]	icd9cm	[ [ [] ] ]	[ "87.53", "51.22" ]	icd9pcs	[ [ [] ] ]	8997, 9003	5869, 8005	391, 442	9271, 9278	1552, 5846	9633, 10255	1225, 1272		8340, 8974		9024, 9250	8031, 8317			9302, 9610										1287, 1533																												337, 353										470, 734																756, 1044	1060, 1209
3,575	106,038	46145	Discharge summary	report	Admission Date: [2129-4-20] Discharge Date: [2129-4-23] Date of Birth: [2072-5-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1115] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 56 yo W with ESRD on HD (MWF), HTN (last sBPs in 150s), HCV cirrhosis, Hypothyroidism, Anxiety, chronic back pain on methadone, presenting with systolic BPs in the 60s prior to and during [Hospital 58910] transferred to [Hospital Unit Name 153] for evaluation and management of hypotension. . She reports 1 month of increasing fatigue, weakness, and occasional falls (knee buckling). Occasional cough with brown sputum and chronic loose stools, but no fevers, chills, sweats, dyspnea, nausea, vomiting, black or bloody stools. Regarding her complaints, she reports that her BP medications have been adjusted, but this has not helped. She has also experienced intermittent L-sided sharp chest pains that worsen with arm movement, and was prescribed nitroglycerin that she ended up taking daily instead of on a PRN basis. . In the ED, initial vs were: T 97.4 P 69 BP 64/53 R 14 97% O2 sat on RA. Per report, she was mentating appropriately. A triple lumen femoral CVC was placed. She was bolused 500 cc, given Vancomycin and Zosyn, and started on Levophed at 0.06. CXR was unremarkable. CT C/A/P were obtained and prelim only significant for a right adenexal cyst (present since [Month (only) 404]). . On the floor, the patient was appropriate and comfortable. She was placed on a Nicom. CI and SVI improved with leg raise so Pt was given 250 cc, then on repeat given additional 250 cc. Levophed was weaned off. . Review of sytems: per HPI, otherwise negative Past Medical History: -HTN -ESRD on hemodialysis -HCV cirrhosis -spinal stenosis with back pain -seizure disorder -depression -hypothyroidism -substance abuse -Lumbar laminectomy -status post failed renal transplant -cholecystectomy -thyroidectomy Social History: Retired special education teacher. Widowed, lives at home with sister, who is primary caregiver. [Name (NI) ] one son, who is healthy. # Tobacco: 3 packs per week since teenager # Alcohol: Denies # Drugs: Past IVDU, but not in several years Family History: Father: ESRD and hypertension Mother: lung cancer Physical Exam: VS: 97.6, 63, 133/86, 98% on RA General: alert, oriented, no acute distress HEENT: muddy sclera, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, +BS, TTP in RUQ with mild voluntary guarding GU: no foley Ext: warm, well perfused, symmetric pulses, no clubbing, cyanosis or edema, R hallux with nail bed removed, crusted blood, no erythema or fluctuance, no purulence Neuro: face symmetric, moves all extremities, sensation intact, gait not observed Brief Hospital Course: 56 yo W with Hx of ESRD on HD, HCV cirrhosis, HTN, Hypothyroidism, and chronic pain on methadone presenting from HD with hypotension to systolic BPs, initially admitted to ICU, quickly transferred to medical floor. . # Hypotension: Appears to have been developing subacutely, over the last month. Hypotension is likely secondary to a too aggressive antihypertensive regimen, current medication misuse, or possibly over-diuresis at HD (with need for reassessment of dry weight). Supporting a possible over beta-blockade is a HR that has consistently remained in the 60s despite BPs in the 60s. Additionally she was started on nitroglycerin and had been taking it daily rather than on a PRN basis. She is responsible for her medications, yet unable to correctly remember dosing regimen. Other etiologies to consider given the chronicity include endocrine causes such untreated hypothyroidism (pill bottle not in bag) or adrenal insufficiency. Received a total of 1.5 L of volume resuscitation. Levophed weaned off. Outpt Nephrologist reports dry weight as 74kg. She was started initially on road spectrum antibiotics which were quickly discontinued when all cultures were negative. . TSH, free T4, and AM Cortisol obtained and pt restarted home levothyroxine dose for significant hypothyroidism. CT abd/pelvis was unremarkable except for stable adnexal cyst. Blood pressures remained stable while patient was off her anti-hypertensives. After chart review she had been started on these during an admission for chest pain at which time a cath revealed clean coronary arteries. Therefore it is felt she does not need these medications and they were stopped. She will continue on simvastatin for her cholesterol management and ASA to reduce her risk of stroke. She will follow up with her PCP or in [Name9 (PRE) 1944] clinic for a BP check off of her medications and will have VNA checking her BPs at home as well. Her PCP can titrate medications as necessary . # Elevated bicarbonate: Likely [2-16] recent HD session, as well as contraction from intravascular depletion. Supporting this is a Hct above baseline likely reflecting hemoconcentration. Pt is on advair without documented hx of COPD. CXR not reflective of this and bicarb not chronically elevated. . # Hyperkalemia: Likely [2-16] ESRD. No evidence of peaked T waves on EKG. She was given insulin, kayexelate overnight and repeated insulin per renal recs prior to dialysis this AM. K was noted to be wnl on follow up AM labs. . # Prolonged PT/PTT: INR mildly elevated likely [2-16] underlying poor synthetic liver function from cirrhosis. Also may have a nutritional component as well. Prolonged PTT likely [2-16] heparin received at HD. No evidence to support bleeding. PTT resolved off heparin. . # Thrombocytopenia: Chronic issue, likely [2-16] cirrhosis. Platelets were stable and did not require transfusion. . # Anemia: [2-16] ESRD. BL Hct around 31. On EPO as outpt. Hct was trended and stable; pt did not require transfusion of blood components during her ICU stay. . # CAD: No evidence to suggest acute ischemia. EKG consistent with prior. Trop at 0.05, likely [2-16] demand in setting of CKI. CK and CKMB added on and non-concerning for ACS. Pt asymptomatic. She was continued on asa 81mg, simvastatin 20mg. BBlocker and ACEi held for observation of hemodynamic stability given admission complaint. . # Hypothyroidism: TSH grossly elevated with very low T4. Levothyroxine was not in her pill bag, in discussion with her pharmacy this prescription had not been filled in many months. Pt was started on Levothyroxine 188mcg daily, will need repeat TFT's in [4-20] weeks. [Month (only) 116] be contributing to hypotension, fatigue and depression. Arranged for her pills to be delivered in a bubble pack to help with med compliance in the future. . # Seizure Disorder: Continued on Keppra 250 mg [Hospital1 ]. . # Depression/Anxiety: SHe has severe depression, uncontrolled. No SI/HI. Restarted home clonazepam (held on admission given hypotention), social work consulted, fluoxitine increased from 40 to 60 mg daily. She is interested in outpt therapy, to arranged by her PCP at follow up. . # Chronic Pain: On Gabapentin and methadone dose was confirmed with [Doctor Last Name 7594] Op Co to be 44mg daily. . # Given prior hx of renal nodule seen on CT scan, pt was ordered for MRI to be completed during her stay given concern for poor outpt followup. MRI renal wo contrast was performed; read was pending at time of d/c and needs to be followed up by outpatient providers (either Dr. [First Name (STitle) 805] or PCP) . # Right adnexal Cyst: Patient was told to follow up with pelvic ultrasound for right adnexal cyst seen on CT scan. PCP [Name Initial (PRE) ]/or [Hospital 1944] clinic will help her coordinate this study. . Contact: sister [Name2 (NI) ] at [Telephone/Fax (1) 98152] # Transitions of care: - Right adnexal cyst needs transvaginal ultrasound for further evaluation. To be coordinated with PCP's help - Blood cultures pending at time of discharge and need to be followed up at [Hospital 1944] clinic - Patient had MRI of abdomen to evaluate a renal cyst. Final read pending at discharge and needs to be followed up through outpatient providers either at [Hospital 1944] clinic or with Dr. [First Name (STitle) 805] - Patient seemed depressed and her fluoxetine was increased from 40mg to 60mg daily. Denied SI. At her [Hospital 1944] clinic please assess her mood and help arrange outpt therapy. - Patient's BP meds were held given hypotension. Post-D/c clinic will check her BP to ensure stable off meds still. - Patient had a low blood count (and chronically low plts) which should be repeated at her post-discharge follow up appt Medications on Admission: -Metoprolol succinate 25 daily -Nitrostat PRN -Simvastatin 20 daily -ASA 81 daily -Fluoxetine 40 daily -Gabapentin 300 daily -Lisinopril 2.5 daily -Keppra 250 [Hospital1 ] -Folic acid 1 mg daily -Sensipar 30 mg PRN -Trazadone 50 qhs -Omeprazole 20 daily Discharge Medications: 1. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day: With the 100mcg tab. Disp:30 Tablet(s) Refills:2 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). Disp:30 Capsule(s) Refills:2 6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. methadone 10 mg/mL Concentrate Sig: Forty Four (44) mg PO DAILY (Daily). 8. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:90 Capsule(s) Refills:2 9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Capsule(s) Refills:2 10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 15. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Cargroup Home Care Discharge Diagnosis: Hypotension secondary to medications and dialysis Hypothyroidism Right adnexal cyst Renal Cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with low blood pressure. This was probably a combination of having dialysis and taking blood pressure medications. We have stopped your blood pressure medications as you don't need them. We looked for infections (which can cause your blood pressure to be low) but could not find any. Please take your medications exactly as prescribed. You also had a CT scan which showed a cyst on your right ovary. You need an ultrasound of your ovary to evaluate this. You should coordinate this study with your primary care provider. [Name10 (NameIs) 2172] CT scan also showed a cyst on your kidney. You had an MRI to evaluate this. The read on the MRI is pending at this point and you should follow up with your primary doctor to find out if there is anything else that needs to be done about this. . Medication Changes: START: Calcium acetate 667 TID with meals (to keep your calium higher and your phosphorous lower) START: Levothyroxine 200mcg daily STOP: Lisinopril STOP: Metoprolol STOP: Nitroglycerin CHANGE: Fluoxetine to 60mg daily Followup Instructions: You will be receiving a call with an appointment for next week to come to the clinic and have your blood pressure checked and go over your imaging tests. You will receive a call with this appointment and if you do not you should call the clinic at [Telephone/Fax (1) 250] to make an appointment. Department: RADIOLOGY When: MONDAY [2129-4-25] at 9:30 AM With: RADIOLOGY [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: HEMODIALYSIS When: MONDAY [2129-4-25] at 7:30 AM Completed by:[2129-4-23]	[ "305.1", "287.5", "458.29", "300.4", "585.6", "493.90", "304.01", "E942.6", "458.21", "790.92", "V15.81", "285.21", "304.83", "786.50", "E878.0", "724.5", "345.90", "620.2", "593.9", "244.9", "996.81", "403.91", "E934.2", "338.29" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.93" ]	icd9pcs	[ [ [] ] ]	10916, 10965	3069, 7998	315, 321	11104, 11104		12347, 12968	2350, 2402		9187, 10893		10986, 11083	8904, 9164			11255, 12084										2417, 3046																									12104, 12324			264, 277					1791, 1821					349, 1773									11119, 11231	8019, 8878						1843, 2071	2087, 2334
2,902	188,351	3929	Discharge summary	report	Admission Date: [2137-7-16] Discharge Date: [2137-7-18] Date of Birth: [2056-9-23] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 425] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p cath (Left circumflex ostial ramus branch stented with cypher stent) History of Present Illness: 80 year old female with DM, HTN, and non-hodgkin's lymphoma treated with radiation 14 years ago but with recurrences requiring chemotherapy as recently as [Month (only) ], who presented to the ED with chest pain x 12 hours. She denies any radiation of the pain, or associated dyspnea, diaphoresis, N/V/D. In ED, VSS, found to have lateral ST elevations. ASA, Plavix loaded, heparin and nitro gtt started. In cath lab found to have a 90% stenosis of the ostium of a large branching ramus, thought to be the culprit lesion, and stented with a cypher stent. She additionally had 20% ostial LMCA, duffuse 40% stenoses of the proximal and mid-LAD, and 50% proximal/70% mid RCA stenoses that were unintervened upon. Filling pressures were mildly elevated bilaterally (PCWP 13, PA 38/15), with preserved CO/CI (7/3.8), and evidence of biventricular diastolic dysfunction. She was transported to the CCU in stable condition. Past Medical History: 1) DM2 2) HTN 3) Non-hodgkin's lymphoma, presented as bilateral breast masses, treated with chest radiation 11 and 14 years ago, as well as chemo as recently as [8-13]. Has known intraabdominal and intrathoracic disease. Followed by oncologist at [Hospital1 2025]. ALLERGIES: Reported as having cough with ACE-I, however patient doesn't recall this. Social History: SOCIAL HISTORY: No smoking, IVDU, etoh. Lives with husband, active. Family History: FAMILY HISTORY: +CAD Physical Exam: 98.0, 69, 155/75, 18, 97% on RA GENERAL: Comfortable appearing female, laying supine in bed. NECK: No carotid bruits, no JVD. COR: RR, distant heart sounds, no murmurs/rubs/gallops. LUNGS: Clear anteriorly. ABD: Normoactive bowel sounds, soft, no masses, no hepatosplenomegaly. EXTR: Non-palpable distal pulses, non-dopplerable. No edema. Groin without mass. Pertinent Results: Admission Labs: . [2137-7-16] 08:10AM PT-12.3 PTT-25.3 INR(PT)-1.1 [2137-7-16] 08:10AM PLT COUNT-122* [2137-7-16] 08:10AM WBC-11.8* RBC-4.23 HGB-12.1 HCT-34.6* MCV-82 MCH-28.6 MCHC-34.9 RDW-15.2 [2137-7-16] 08:10AM NEUTS-84.9* LYMPHS-6.5* MONOS-6.6 EOS-1.4 BASOS-0.6 [2137-7-16] 08:10AM cTropnT-<0.01 [2137-7-16] 08:10AM CK-MB-NotDone [2137-7-16] 08:10AM GLUCOSE-148* UREA N-51* CREAT-1.5* SODIUM-140 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16 [2137-7-16] 08:10AM CK(CPK)-51 [2137-7-16] 11:16AM HCT-30.4* . Cardiac cath ([2137-7-16]): 1. Selective coronary angiography of this right dominant system revealed multivessel CAD. The LMCA had a 20% ostial stenosis. The LAD had a 40% proximal and mid vessel stenosis. The ramus had a 90% ostial stenosis. The LCX had no angiographically apparent flow limiting lesions. The RCA was a dominant vessel with a 50% proximal stenosis and a 70% mid vessel stenosis. 2.Resting hemodynamics revealed mildly elevated left and right sided filling pressures with preserved cardiac index. There was mild pulmonary hypertension. 3.Left ventriculography was deferred. 4. Successful stenting of the median ramus with a 2.5 x 18 Cypher DES. Final angiography showed TIMI III flow, no dissection, no embolization and no peforation. (See PTCA comments) . ECG ([2137-7-16]): NSR, nl intervals, nl axis, ST elevation in I, aVL, V4-V6 ST depression in aVR; TWI in III . Echo ([2137-7-16]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mild basal septal hypokinesis. Overall left ventricular systolic function is mildly depressed. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial pericardial effusion. . Arterial doppler of lower extremity ([2137-7-17]): On the right, there is a significant aortoiliac or proximal femoral artery occlusive disease. In addition, there is a multisegmental component likely in the SFA and tibial segment. On the left, there is mild-to-moderate tibial artery occlusive disease. . Other Labs: . [2137-7-16] 08:10AM BLOOD cTropnT-<0.01 [2137-7-17] 06:00AM BLOOD CK-MB-6 [2137-7-17] 03:35PM BLOOD CK-MB-5 [2137-7-18] 06:52AM BLOOD CK-MB-3 . Discharge Labs: . [2137-7-18] 06:52AM BLOOD WBC-9.1 RBC-3.57* Hgb-9.9* Hct-29.4* MCV-82 MCH-27.6 MCHC-33.6 RDW-15.6* Plt Ct-127* [2137-7-18] 06:52AM BLOOD Plt Ct-127* [2137-7-18] 06:52AM BLOOD Glucose-104 UreaN-43* Creat-1.7* Na-144 K-4.5 Cl-112* HCO3-23 AnGap-14 [2137-7-18] 06:52AM BLOOD ALT-15 AST-18 LD(LDH)-175 CK(CPK)-164* AlkPhos-60 TotBili-0.6 [2137-7-18] 06:52AM BLOOD CK-MB-3 [2137-7-18] 06:52AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2 Brief Hospital Course: 80 year old female with DM2, HTN, presenting with chest pain, found to have an ST elevation MI although negative tropinin, with a 90% ramus occlusion, now status post drug eluting stent. Her hospital course for this admission is as follows: . 1) ? STEMI: LCx presumed culprit lesion, cypher stented [7-16], but initial tropinin <0.01. Mild CP post-cath likely distal embolization and possibly vessel wall stretch. Routine post-cath measures with: ASA 325mg PO qday, Plavix 75mg PO qday, increased atorvastatin to 80 mg (from 10) initially, but went back to her initial home dose given her low cholesterol and LDL, initially on integrillin, the d/c'ed integrillin as patient developed thrombocytopenia the afternoon post cath (plt 120 to 97); we initially started metoprolol and titrate up as needed; change back to atenolol 50mg PO qday on d/c; her [Last Name (un) ] and HCTZ was held given increased Cr, and she was instructed to check with her PCP and cardiologist for recheck of her Cr and discuss whether to restart [Last Name (un) ] and HCTZ . 2) HTN: Hold HCTZ and [Last Name (un) ] while creatinine elevated. Titrate up BB, and was discharged on atenolo 50mg Po qday . 3) DM2: FS QID, RISS. Her blood sugar was well controlled in the hospital. She was told to follow up with her PCP for further management of DM2, currently continue diet control . 4) Anemia, thrombocytopenia: Unclear baseline. Plt drop likely secondary to integrillin which has now been d/c'ed. In terms of underlying etiology, if chronic suspect MDS which can be worked up as outpatient. Iron studies consistent with anemia of chronic disease. No drinking history. Repeat hct later after sheath pull to assess stability. Check HIT antibody which was negative. Her Hct and platlet counts remained [Last Name (un) 2677] after sheath pulled. . 5) Creatinine elevation: Associated BUN elevation c/w pre-renal etiology. Getting post-cath hydration with NS x 2 liters. Both [Last Name (un) ] and HCTZ were held, and she was instructed to check her Cr after discharge at her PCPs to discuss whether to restart HCTZ and [Last Name (un) ]. . 6) Non-dopplerable pulses: Patient complains of pain in her legs with ambulation, but ascribes this to arthritis. Non-dopplerable pulses, therefore will check ABIs which showed significant aortoiliac or proximal femoral artery occlusive disease on the right, mild-to-moderate tibial artery occlusive disease on the left. patient was scheduled to have her MRA of her lower extremity done as an outpatient and to follow up the results with her PCPs. . 7) FEN: Cardiac diet. . 8) PPx: multivitamin, and Ca, bowel regimen, pneumoboots for DVTs . 9) Code: full code Medications on Admission: Atenolol 50 mg daily, HCTZ 25 mg daily, Valsartan 360 mg daily, ASA 325 mg daily, Atorvastatin 10 mg daily, MVI, calcium. Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: CAD (90% stenosis of ostium of ramus of Left circumflex - s/p cypher stent) Question of STEMI - but had negative cardiac enzymes (vs. early repol or pericarditis) Thrombocytopenia (presumed [1-10] integrillin - resolved) Acute on chronic renal failure . Secondary: HTN DM Hyperlipidemia Discharge Condition: Stable, chest pain free, ambulating Discharge Instructions: You were found to have a blockage in one of your heart arteries, which was opened up with a stent. It is unclear if you actually had a heart attack, since your blood work did not indicate any evidence of heart damage. You have been started in plavix and aspirin. You MUST take these two medications without fail. If you stop taking these medications even for one day, you are at high risk for having your stent close off and causing a heart attack. We held your blood pressure medication valsartan because your kidney function was not at its usual level. You should re-start this medication when you are instructed to by your primary care doctor. We also held your Hydrochlorothiazide (blood pressure medication). Please restart this medication when instructed by your PCP. Please have an MRA of your pelvis and both legs performed as an outpatient in order to look for blockages in your lower extremities. Please have your cholesterol panel repeated by your PCP. Followup Instructions: Follow up with your primary care doctor within 1 week of discharge. You have an appointment with [Name6 (MD) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2137-7-26] 2:00 Please have your primary care doctor follow up on the following issues: 1. Restart ACEi 2. Restart HCTZ 3. MRA of pelvis and lower extremities 4. Recheck lipid panel 5. Recheck creatinine Please have your MRI of your lower extremity performed on [Last Name (LF) 2974], [8-2] at 1pm. Do not drink or eat anything 4 hours before the procedure. You can call [Telephone/Fax (1) 327] to reschedule your appointment Please follow up with your cardiologist Dr. [Last Name (STitle) ] within 2 weeks of discharge. Call ([Telephone/Fax (1) 5909] to schedule an appointment. Completed by:[2137-7-19]	[ "V10.79", "287.4", "410.91", "250.00", "E934.8", "403.91", "440.20", "584.9", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.45", "99.20", "36.07", "00.66", "00.40", "37.21" ]	icd9pcs	[ [ [] ] ]	8740, 8746	5200, 7922	285, 360	9091, 9129	2232, 2232	10147, 10968	1824, 1830		8094, 8717		8767, 9070	7948, 8071			9153, 10124			4728, 5177							1845, 2213																												235, 247										388, 1318					2248, 4538											1340, 1704	1737, 1792		4550, 4712
22,067	100,566	26234	Discharge summary	report	Admission Date: [2128-1-17] Discharge Date: [2128-2-6] Date of Birth: [2047-6-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5880] Chief Complaint: 80 M s/p unwitnessed fall on ice in driveway ? [Hospital ] transfer to [Hospital ] Hospital, initially c/o bilateral upper extremity weakness. Major Surgical or Invasive Procedure: [2128-1-21] Anterior Cervical Discectomy and Fusion/Posteriror Cervical Laminectomy and Fusion [2128-2-3] Tracheostomy & Percutaneous Gastrostomy Tube Placement History of Present Illness: 80 M s/p unwitnessed fall on ice in driveway ? [Hospital ] transfer to [Hospital ] Hospital, initially c/o bilateral upper extremity weakness. Past Medical History: MI [2127-3-4] -> cath, occluded RCA treated medically s/p pacemaker DDD HTN Hypercholesterolemia s/p Appy Family History: Non-contributory Physical Exam: VS upon admission to trauma bay: 148/92 81 16 O2 Sats 96% on NRB mask GCS 15 HEENT: No lacerations, EOMI Neck: collared, no pain Chest: CTA bilat Cor: RRR S1S2, No m/r/g Abd: soft, NT/ND Rectum: Normal tone, guaiac negative Pelvis: Stable Extr: strength 4/5 except for LUE [4-4] Pertinent Results: [2128-1-17] 02:00PM URINE RBC-[4-4]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2128-1-17] 12:58PM GLUCOSE-138* LACTATE-2.5* NA+-146 K+-4.4 CL--101 TCO2-25 [2128-1-17] 12:55PM WBC-21.2* RBC-5.13 HGB-16.5 HCT-46.3 MCV-90 MCH-32.1* MCHC-35.6* RDW-13.3 [2128-1-17] 12:55PM PLT COUNT-221 [2128-1-17] 12:55PM PT-12.8 PTT-20.6* INR(PT)-1.1 [2128-1-17] 12:55PM FIBRINOGE-283 CT C-SPINE W/O CONTRAST [2128-1-17] 1:07 PM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Reason: fract [Hospital 93] MEDICAL CONDITION: 80 year old man with s/p fall REASON FOR THIS EXAMINATION: fract CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 80-year-old man status post fall. He has new upper extremity weakness and cord contusion is strongly suspected clinically. COMPARISONS: None. TECHNIQUE: Axial non-contrast CT images of the cervical spine were obtained, and sagittal and coronal reaffirmations were performed. FINDINGS: There is prevertebral soft tissue swelling as well as soft tissue density in the nasopharynx, which could represent vomitus or blood, but the appearance is nonspecific. There is no definite fracture, but there are severe multilevel degenerative changes. These include large osteophytes which are partly fragmented along the anterior aspect of C2, particularly C3 as well, there is a huge osteophyte along C4 extending upwards. This may have represented an anterior flowing osteophyte, which extends from C3 through C6. There is slight retrolisthesis and exaggerated lordosis at the C3-C4 level. There are posterior disc protrusions at C3-C4 and C5-C6 with severe spinal stenosis at these levels, and the neural foramina are also very narrow at C3- C4. The thecal contents are difficult to evaluate with CT, but limited view shows impression on the thecal sac at C3-C4 and C5-C6. It is difficult to assess for contusion or hematoma. IMPRESSION: 1. Prevertebral soft tissue swelling. 2. No definite fracture. 3. Severe spinal stenosis particularly at C3-C4. 4. Given severe degenerative changes and ankylosing osteophytes, MRI would be helpful in excluding ligamentous injury. The patient is being treated for presumed cord contusion clinically. C-SPINE NON-TRAUMA [3-5] VIEWS IN O.R. [2128-1-21] 11:13 AM C-SPINE NON-TRAUMA [3-5] VIEWS I Reason: ANTERIOR CERVICAL FUSION HISTORY: Anterior cervical fusion. Three lateral views of the cervical spine were obtained. One view labeled 11:05 demonstrates a surgical device overlying the anterior aspect of the C3/4 disc, which is wider anteriorly. There is minimal C3/4 retrolisthesis. A second view, not labeled as to time, demonstrates anterior plate and screws and intervening fusion plug at C3/4, with minimal retrolisthesis of C3/4 and widening laterally. A third view labelled at 12:30 shows anterior plate and screws in place with a surgical device pointing towards the C5 spinous process. There is severe background osteopenia. CHEST (PORTABLE AP) [2128-2-3] 6:41 PM CHEST (PORTABLE AP) Reason: eval trach position [Hospital 93] MEDICAL CONDITION: 80 year old man s/p fall, cardiac history SOB REASON FOR THIS EXAMINATION: eval trach position INDICATION: Status post fall, cardiac history and shortness of breath. Evaluate tracheostomy position. COMPARISON: [2128-2-1]. SUPINE AP CHEST: In the interim since the prior study, the endotracheal tube has been removed and a tracheostomy tube has been placed. The tracheostomy tube tip is positioned at the thoracic inlet. A pacemaker overlies the left chest, the leads overlie the right atrium and right ventricle. Cardiac and mediastinal contours are unchanged. The lungs are clear. No pneumothorax or pleural effusion. Brief Hospital Course: Patient admitted to the trauma service. Neurosurgery was consulted who recommended frequent neurologic checks and Orthopedic Spine Surgery consult for Central Cord Syndrome. Steroid drip initiated at referring facility and was continued. After discussion with patient by Orthopedic Spine Surgery the decision was made to proceed with posterior cervical laminectomy C3-5 and anteriror fusion C3-4; patient to OR on [1-20] for this procedure. [1-21]- Patient reintubated in PACU and transferred to TSICU [1-26]- Patient extubated [1-27]- transferred to floor, dobhoff placed post pyloric, fell out overnight [1-28]- urinary retention foley placed, s/p fall OOB and c/o hip and knee pain; films of pelvis and R knee negative, bowel regimen, tightened SSI, sent sputum. [1-29]- void trial Sat, started flomax. increased Lopressor. sitter at night for pt safety. PT following patient. [1-30] dobhoff d/c'd b/c clogged, PPN written, IV lopressor and protonix written, sundowned and gave haldol, IR to place new dobhoff. Pt sundowned requiring Haldol c/b copius secretions and inability to protect airway caused desat's -> required re-intubation and transferred back to T-SICU [2-1] CE's negative [2-3]: Patient underwent trach/PEG [2-5]: Transferred to floor. [2-6]: G-tube study in Radiology secondary to high residuals Medications on Admission: [Last Name (LF) ], [First Name3 (LF) ], Plavix, Atenolol Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain: Give per G-tube. 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for HR <60 & SBP <110. Give per G-tube. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Docusate Sodium 50 mg/15 mL Syrup Sig: Two (2) PO twice a day: Give via G-tube. 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): Give via G-tube. 10. Insulin Sliding Scale Sig: One (1) four times a day: See attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: s/p Fall Cervical Spine Stenosis C3 C4 Central Cord Syndrome Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedic Spine and Trauma in [4-3] weeks. Follow up with your Primary Doctor after your discharge from rehab. Followup Instructions: Follow up with Dr. [Last Name (STitle) 363], Orthopedic Spine Surgery in [4-3] weeks, call [Telephone/Fax (1) 3573] for an appointment. Follow up in Trauma Clinic in [4-3] weeks, call [Telephone/Fax (1) 6439] for an appointment. Completed by:[2128-2-6]	[ "719.41", "412", "518.5", "E885.9", "850.11", "293.0", "721.0", "V53.31", "401.9", "599.0", "599.7", "788.20", "806.03" ]	icd9cm	[ [ [] ] ]	[ "81.02", "84.51", "43.11", "81.03", "99.15", "96.04", "81.62", "31.1", "96.6", "96.72", "03.53" ]	icd9pcs	[ [ [] ] ]	7552, 7632	5054, 6415	464, 636	7737, 7746	1305, 1820	7925, 8205	966, 984		6530, 7529	4404, 4450	7653, 7716	6441, 6507			7770, 7902										999, 1286																												274, 426	4479, 5031									664, 817																839, 950
48,982	116,280	38229	Discharge summary	report	Admission Date: [2121-5-20] Discharge Date: [2121-5-24] Date of Birth: [2064-1-4] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Demerol / Latex / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2121-5-20] - Aortic Valve Replacement (21mm St. [Male First Name (un) 923] Mechanical Valve) History of Present Illness: 57 year old female with shortness of breath and chest tightness on exertion. She reports an episode of syncope after climbing one flight of stairs at a quick pace and occasional paroxysmal nocturnal dyspnea, orthopnea and a sensation of palpitations while lying in bed. She completed an ECHO on [2121-2-24] revealing left atrial enlargement with mild MR, severe AS with moderate AI and a globally preserved LV function of 60-65%. Past Medical History: Hypertension Asthma Depression Gastric esophageal reflux disease Aortic Stenosis Hypothyroid Fatigue Neuropathy Irritable bowel syndrome C6-C7 and L4-L5 back surgery Social History: Last Dental Exam: > 1 year will set up outpatient appointment Lives with: son Occupation: works as rehab specialist with work placement Tobacco: denies ETOH: denies Family History: brother s/p AVR, other brother s/p CABG mother s/p stents Physical Exam: Pulse: 89 Resp: 16 O2 sat: 100% RA B/P Right: 153/80 Left: 149/74 Height: 5'7" Weight: 68kg General:no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anterior Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: multiple spider veins bilateral lower extremities Neuro: alert and oriented x3 non focal Pulses: Femoral Right: cath site - mynx closure Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: murmur Left: murmur Pertinent Results: [2121-5-20] ECHO: Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal(LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([12-21]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. There is a well-seated bileaflet mechanical prosthesis in the aortic position with good leaflet excursion. There are two small transvalvular regurgitant jets consistent with washing jets. There is no paravalvular regurgitation. The mean transvalvular gradient is 5 mm Hg. Biventricular systolic function is preserved and all other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings discussed with the surgeon intraoperatively. [2121-5-21] CXR: As compared to the previous radiograph, all monitoring and support devices have been removed, except for the right-sided jugular vein catheter. There is no visible pneumothorax. Unchanged appearance of the lung parenchyma, unchanged minimal retrocardiac atelectasis. No pleural effusions. No overhydration, no pneumonia. Normal size of the cardiac silhouette. [2121-5-20] 01:26PM BLOOD WBC-7.1# RBC-2.63# Hgb-8.3# Hct-24.3# MCV-93 MCH-31.5 MCHC-34.0 RDW-12.7 Plt Ct-161 [2121-5-23] 05:08AM BLOOD WBC-8.0 RBC-2.43 Hgb-7.6* Hct-22.6* MCV-93 MCH-31.3 MCHC-33.6 RDW-12.9 Plt Ct-155 [2121-5-20] 01:26PM BLOOD PT-15.3* PTT-33.8 INR(PT)-1.3* [2121-5-22] 08:44AM BLOOD PT-18.7* PTT-31.0 INR(PT)-1.7* [2121-5-23] 05:08AM BLOOD PT-26.9* INR(PT)-2.6* [2121-5-20] 02:56PM BLOOD UreaN-11 Creat-0.6 Cl-110* HCO3-26 [2121-5-23] 05:08AM BLOOD Glucose-103* UreaN-13 Creat-0.5 Na-135 K-3.5 Cl-98 HCO3-30 AnGap-11 [2121-5-22] 04:23AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 Brief Hospital Course: Ms. [Known lastname 85213] was admitted to the [Hospital1 18] on [2121-5-20] for surgical management of her aortic valve disease. She was taken directly to the operating room where she underwent an aortic valve replacement using a 21mm St. [Male First Name (un) 923] 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. On postoperative day two, she transferred to the step down unit for further recovery. Coumadin was started for anticoagulation for her aortic valve. She was gently diuresed towards her preoperative weight. Chest tubes and epicardial pacing wires were removed per protocol. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She continued to improve will awaiting INR to be in therapeutic range (2.5-3.5). On post-op day four she appeared suitable for discharge home with VNA services and the appropriate medications and follow-up appointments. She was cleared for discharge by Dr. [Last Name (STitle) ] for Dr. [Last Name (STitle) ]. Coumadin with be followed by PCP [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] with goal INR 2.5-3.5. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 puffs four times per day as needed BUPROPION HCL [WELLBUTRIN XL] - (Prescribed by Other Provider) - 300 mg Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - (Prescribed by Other Provider) - 50 mg-325 mg-40 mg Tablet - one Tablet(s) by mouth daily as needed for migraines DIPHENOXYLATE-ATROPINE [LOMOTIL] - (Prescribed by Other Provider) - 2.5 mg-0.025 mg Tablet - one Tablet(s) by mouth daily as needed for IBS ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 50,000 unit Capsule - one Capsule(s) by mouth weekly GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - one Tablet(s) by mouth three times a day HYDROXYZINE HCL - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth daily as needed for itch LEVOTHYROXINE [LEVOXYL] - (Prescribed by Other Provider) - 100 mcg Tablet - one Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - one Tablet(s) by mouth up to three times a day as needed METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth as needed for migraines with nausea MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth daily NORTRIPTYLINE - (Prescribed by Other Provider) - 10 mg Capsule - one Capsule(s) by mouth daily at bedtime OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily TRIAMTERENE-HYDROCHLOROTHIAZID - (Prescribed by Other Provider) - 50 mg-25 mg Capsule - one Capsule(s) by mouth daily VERAPAMIL - (Prescribed by Other Provider) - 240 mg Cap,24 hr Sust Release Pellets - one Cap(s) by mouth daily ZOLMITRIPTAN [ZOMIG] - (Prescribed by Other Provider) - 5 mg Tablet - one Tablet(s) by mouth daily as needed for migraines CALCIUM CARBONATE [CALCIUM 600] - (Prescribed by Other Provider) - 600 mg (1,500 mg) Tablet - one Tablet(s) by mouth daily CYANOCOBALAMIN - (Prescribed by Other Provider) - 1,000 mcg Tablet, Sublingual - 1 tab sublingually qam Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:1 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:1 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:60 Tablet Sustained Release(s) Refills:1 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). Disp:1 Refills:2 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Indication: Mechanical Aortic Valve Goal INR 2.5-3.5 PCP: [First Name8 (NamePattern2) 1494] [Last Name (NamePattern1) 1492] will follow INR and adjust dose accordingly. Disp:60 Tablet(s) Refills:2 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO sunday [2121-5-25] for 1 doses. Discharge Disposition: Home With Service Facility: VNA Carenetwork Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement Past medical history: Neuropathy Hypertension Gastroesophageal reflux Depression Irritable bowel syndrome Hypothyroidism Asthma s/p cervical laminectomy s/p lumbar laminectomy Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema: trace LE edema Discharge Instructions: 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. 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 of sternal wound. Please call cardiac surgery office with any questions or concerns ([Telephone/Fax (1) 170]). Answering service will contact on call person during off hours. Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [6-19] at 1PM Please call to schedule appointments with: Primary Care: Dr. [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] ([0-0-]) [6-3] at 1215 PM Cardiologist: Dr. [Last Name (STitle) ] [Name (STitle) 4922] in [12-21] 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 ?????? for mechanical aortic valve Goal INR: 2.5-3.5 First draw: [2121-5-26] Results to: PCP, [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] (spoke with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22771]) phone: [0-0-] fax: [Telephone/Fax (1) 85214] Last several Coumadin doses and INR: [5-24]: Dose 2mg INR 2.3 [5-23]: Dose 1mg INR 2.6 [5-22]: Dose 2.5mg INR 1.7 [5-21]: Dose 2.5mg INR not drawn Completed by:[2121-5-24]	[ "530.81", "244.9", "424.1", "493.20", "355.9", "401.9", "564.1", "311" ]	icd9cm	[ [ [] ] ]	[ "35.22", "39.61" ]	icd9pcs	[ [ [] ] ]	10378, 10424	4738, 6089	371, 474	10688, 10880	2197, 4715	11734, 12903	1324, 1383		8309, 10355		10445, 10490	6115, 8286			10904, 11711										1398, 2178																												312, 333										502, 937																10512, 10667	1142, 1308
29,699	120,058	32823	Discharge summary	report	Admission Date: [2185-12-31] Discharge Date: [2186-1-5] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2518] Chief Complaint: ICH Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 87 yo R-handed man, on Coumadin for his heart but not sure exactly why, no priro cardiac surgeries, who at 6 pm suddenly felt like his R leg was "asleep"/heavy such that he couldn't walk. He denies headache, neck pain, paresthesias, bowel/bladder dysfunction, change in mentation or speech, no visual changes. He was brought to [Hospital 27217] Hospital. He said on his way there he had some mild chest pain and SOB, which he attributed to being anxious about coming to the hospital. Remainder of ROS negative including fever, hearing changes, nausea, vomiting, abdominal pain. Past Medical History: -HTN -prosthetic R eye -CAD -[2182-9-6] Multiple bilateral PE -95% stenosis of the right carotid artery -Prostate cancer Most recent PSA 19 Patient has not had chemotherapy, radiation or surgery (per Dr. [Last Name (STitle) 30106] -Chronic renal insufficiency Cr 1.8 in [2185-7-6] Cr 1.7 in [2180-1-7] -[2181] Cardiac catheterization Diffuse CAD Social History: lives with his wife, no tobacco/EtOH/recreational drugs Family History: NA Physical Exam: T 97.7 po HR 73 BP 192/78 (117) RR 21 sO2 98% 2L GEN: HEENT: mmm NECK: no LAD; no carotid bruits; full range neck movements LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema SKULL AND SPINE: no bruits. MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, but said [2184]. Attention: DOWbw. Language: fluent; Naming intact to high and low-frequency objects; Comprehension intact; no dysarthria, no paraphasic errors. Prosody: normal. No Neglect. CRANIAL NERVES: II: pupils equally round and reactive to light both directly and consensually, 3-->2 mm bilaterally. III, IV, VI: Extraocular movements intact without nystagmus. No ptosis. V: Facial sensation intact to light touch and pinprick. VII: Facial movement symmetrical; no facial droop. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious movements, no tremor, no asterixis. D T B WF WE FiF [Last Name (un) ] IP Gl Q H AF AE TF TE Right 5 5 5 5 5 5 5 5- 5- 5- 5 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 No pronator drift. No rebound. REFLEXES: 2+ and symmetric, R plantar upgoing, L downgoing SENSORY SYSTEM: Sensation intact to light touch COORDINATION: Normal FNF GAIT: not tested Pertinent Results: [2185-12-31] 12:50AM BLOOD WBC-6.0 RBC-3.46* Hgb-10.9* Hct-31.5* MCV-91 MCH-31.5 MCHC-34.7 RDW-15.0 Plt Ct-170 [2186-1-2] 04:37AM BLOOD WBC-6.3 RBC-3.46* Hgb-11.1* Hct-31.7* MCV-92 MCH-32.1* MCHC-35.0 RDW-15.5 Plt Ct-136* [2185-12-31] 12:50AM BLOOD PT-33.2* PTT-31.2 INR(PT)-3.5* [2186-1-2] 04:37AM BLOOD PT-14.6* PTT-24.1 INR(PT)-1.3* [2185-12-31] 12:50AM BLOOD CK-MB-10 MB Indx-5.2 cTropnT-0.05* [2185-12-31] 06:10AM BLOOD cTropnT-0.27* [2185-12-31] 01:30PM BLOOD CK-MB-15* MB Indx-5.7 cTropnT-0.26* [2185-12-31] 08:58PM BLOOD CK-MB-12* MB Indx-4.7 cTropnT-0.27* [2186-1-1] 03:30AM BLOOD CK-MB-10 MB Indx-4.0 cTropnT-0.31* [2186-1-1] 04:19PM BLOOD CK-MB-10 MB Indx-3.4 cTropnT-0.25* MRI/MRA: Demonstration of known left posterior frontal hemorrhage, and possible second small hemorrhagic residuum adjacent to it. Given the patient's advanced age and peripheral location of the hemorrhages, amyloid angiopathy would be the most reasonable diagnostic consideration. The location is most unlikely to be associated with an aneurysmal hemorrhage. Please note that the MR angiogram did not encompass the entire area of the hemorrhage, nor was gadolinium enhancement employed at this time. Perhaps when the hemorrhage regresses, the gadolinium study would be of greater benefit in excluding an underlying mass lesion. Brief Hospital Course: Mr. [Known lastname ] was admitted to the ICU for closer monitoring. His hospital course by problem is as follows: 1) Left parietal hemorrhage- This was likely in the setting of supratherapeutic coumadin level. There was some concern for possible underlying amyloid angiopathy, but MRI evaluation was not strongly supportive of this diagnosis. There was no AVM visualized by MRA. An MRI with contrast was deffered given his renal insufficiency. He was admitted to the neuro ICU for close neurologic and hemodynamic monitoring. He was given proplex to reverse his anticoagulation, followed by 2 units of FFP. His INR normalized to 1.4. His neurologic exam remained stable with slight right pronator drift. Right facial droop. He was transferred to the neurology floor for further care. He developed an acute episode of chest pain treated with nitrates, morphine and beta blocked. Cardiac troponins peaked at 0.85. (further description of NSTEMI below). His neurologic exam was stable. Serial CT scans revealed stable size of hemorrhage. He was restarted on full dose aspirin therapy for coronary and stroke prevention. There is a risk of recurrent hemorrhage with the use of anticoagulation in the future especially if this is amyloid, but this needs to be weighted against his risk of thrombotic complication. He should not be anticoagulated for now but there will need to be a discussion regarding the risks and benefits in the future. 2) NSTEMI: In the ICU, After receiving the proplex, he developed a bump in his troponins which peaked at .31. He was started on metoprolol but aspirin was not given as he had a large ICH. He was started on a statin and his FLP was checked. His BP was maintained between 120 and 140 with a MAP of less than 130. Second episode of chest pain on the floors managed medically with full dose atorvastatin, metoprolol, nitrates, and aspirin. Cardiology was consulted on admission and followed the patient during his hospital stay. He likely has unstable coronary plaque with need for PCI, but cannot undergo intervention given his cerebral hemorrhage. Maximum medical management, with narrow BP goals SBP 110-120 should be achieved. The patient should follow up with either his primary cardiologist while at rehab or return for a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] and Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] at [Hospital1 18] for further evaluation in four weeks. 3) HEME: Given his recent history if PE's, he was slowly restared on SQ heparin. He should not re-start anticoagulation at this time. 4) Bilateral Carotid Artery Stnnosis- Carotid US revealed 70-70% stenosis bilaterally. This was not thought to be related to his presenting condition. He should remain on aspirin therapy. He was not symptomatic from this but should be followed for any symptoms and with carotid U/S q6months-1 year. Medications on Admission: -Coumadin -Lisinopril -Isosorbide -Ranexa -ASA -Ferrous sulfate -?Zetia -NTG PRN -Atenolol Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection every six (6) hours. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day. 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Isosorbide Mononitrate 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: Fifteen (15) ML PO QID (4 times a day) as needed for indigestion. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Left parietal intracranial hemorrhage Non ST elevation myocardial infarction Hypertension Hypercholesterolemia Systolic heart dysfunction Discharge Condition: Slight right facial droop. Right eye prosthesis. Slight right arm pronator drift. Discharge Instructions: You were admitted for hemorrage around your brain that was likely related to a high coumadin level. You also had a heart attack while in the hospital. You should avoid further coumadin use and take all medications only as prescribed. Please call your doctor or 911 if you experience any new onset of chest pain, shortness of breath, new headache, tingling, numbness, weakness, difficulty speaking or any other concerning symptoms. Followup Instructions: Close monitoring of your blood pressure and heart rate at rehab will be essential to prevent another heart attack. Please see Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] for follow up in the Stroke [Hospital 878] Clinic in [3-12] weeks. Call [Telephone/Fax (1) 2574] to make an appointment. Please see your cardiologist Dr. [Last Name (STitle) 31101] or Call ([Telephone/Fax (1) 2037] to make an appointment at the [Hospital1 18] department of cardiology with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] and Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] (they saw you here in the hospital and can consider performing a heart catheterization once they see you in clinic). The appointment should be made within the next 4 weeks if possible. Follow up with your primary care doctor within 1 week of discharge from rehab. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2533]	[ "585.9", "431", "185", "V45.78", "414.01", "E934.2", "403.90", "272.0", "V58.61", "410.71", "272.4", "433.31", "433.11", "V12.51", "530.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8712, 8784	4454, 7385	267, 273	8966, 9050	3075, 4431	9531, 10535	1395, 1399		7526, 8689		8805, 8945	7411, 7503			9074, 9508										1414, 1805																												224, 229										301, 902	2112, 3056								1820, 2096							924, 1305	1321, 1379
7,241	163,199	24249	Discharge summary	report	Admission Date: [2177-1-4] Discharge Date: [2177-1-13] Date of Birth: [2139-9-13] Sex: M Service: MEDICINE Allergies: Betadine Viscous Gauze / Lisinopril / Valsartan Attending:[First Name3 (LF) 1257] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [2177-1-7] Time: 06:40 Mr. [Known lastname ] is a 37 YOM with a PMH sig for hypertension, Chronic renal insufficiency, type B aortic dissection, anxiety, and medication noncompliance who presented because of three days of worsening dyspnea with exertion. Of note, the patient was recently hospitalized in [Month (only) 359] with hypertensive urgency requiring ICU admission in the setting of medication noncompliance. He was discharged on labetalol 800 mg TID, but patient self-decreased it to labetalol 800 mg [Hospital1 ] because of side effects of medications. He normally does not take his medications regularly because he forgets in the setting of significant life stresses. Three days ago he noted worsening SOB after climbing a flight of stairs. He also c/o sneezing, chills, head and chest congestion during this time. He denies sick contacts, headache, chest pain, ear or throat pain. This morning he woke up and felt so short of breath and other symptoms had progressed that he presented to ED. In the ED, patient was noted to be hypertensive to 251/163 and HR 97. He was SOB with RR 22 and O2 sat 100% RA. CXR looked like there was vascular congestion. A bnp was elevated at 2790 which is slightly higher than his BNP when he presented in [Month (only) 359] in hypertensive urgency/CHF where it was 2333. His Cr was 3.5 which is similar to his Cr at last discharge, but this is higher than his baseline 2.5-3.0. He was given labetalol 20 mg IV x 2, asa, combivent nebs. His BP remained elevated so he was started on nitro gtt for bp control. BP was 179/106 after uptitrtating nitro, with HR 90, satting 97% 2 L nc. In the ICU, he was started on IV labetolol. On [1-5], he was diruesed with IV Furosamide 40mg with good effect. His home HCTZ and Amlodipin were restarted. He was then switch to PO Furosemide and Spironolactone, started PO Labetalol at 400mg TID (half home dose), weaned IV labetolol. In the PM SBP in the 170's increased PO labetolol to 800mg TID patient subsequently became hypotensive to the 90's, Labetolol was reduced to 600mg TID. He received IV furosamide 40mg at 15:00, put out 1200L following but I/O balance remained positive, repeated IV Furosamide 40mg at 20:00. Started Fluid restriction to 2L per day. SW was consulted and discussed housing options. Requested that week-day Social Worker see him and continue managment. [Month/Day (4) 7473] (Renal consult) recommened re-starting home dose meds. On [2177-1-6], Labetalol changed to 600mg PO TID and clonidine patch was started. His 6pm Is/Os revealed -1.1 L. On [2177-1-7] at 6:30 am, he was transfered to the floor. On the floor, he was assymptomatic. He denied CP, SOB, headache, diarrhea or pain. . . Allergies: Betadine - rash Lisinopril - cough ?[Last Name (un) ] . FH: multiple relatives - HTN mother - DM, CAD s/p CABG, obesity grandfather - CVA, 2 bypasses . SH: manager of a bar in [Hospital1 8], also bartends at House of Blues. Eats as healthy as he can with what he makes. Smokes [12-1] pk a day, trying to cut down. Drinks 2x/wk at most, usually has 2 bourbons. No drug use. Sexually active occassionally, with female partners that he is not worried about STDs in. Single, not in a relationship. . . Physical Exam: VS: Temp: BP: 98.6 168/119 HR: 88 RR:13 O2sat 97% GEN: appears in pain, eyes closed HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, jvd difficult to assess RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: obese, +b/s, soft, nt EXT: 1+ pretibial edema SKIN: exzemetous rashes on anterior legs, dorsum feet NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. . Labs: see below Trop-T: 0.04 . 141 105 45 ------------<118 4.3 24 3.5 . proBNP: 2790 . . 12.2 MCV 90 11.8 ∆>--< 212 35.7 N:77.6 L:9.9 M:4.0 E:7.9 Bas:0.6 . PT: 12.2 PTT: 27.9 INR: 1.0 . . EKG: NSR, 87 bpm, leads I and avL reversed? PR prolongation 204, no QRS prolongation, ST elevation in V1-V3 with tombstoning? V3, TWI in V4-V6. . Imaging: CXR: increased vascular congestion, tortuous enlarged aorta that appears stable from prior . Upon review of OMR . In ER: VS: Studies: Fluids given: Meds given: Consults called: VS prior to transfer to the floor: Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain or tightness, palpitations, orthopnea, dyspnea on exertion. Denies cough, shortness of breath, wheezes or pleuritic pain. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - chronic type B aortic dissection - poorly controlled HTN - chronic renal insufficiency, baseline Cr 2.5 -3 - Acute disseminated encephalomyelitis - group B streptococcal bactremia - eczema - childhood asthma - allergic rhinitis - rotator cuff injury - G6PD deficiency Social History: currently employed as a bartender - tobacco: smokes [12-1] ppd - ETOH: [1-2] drinks/ week Denies illicit drugs Family History: Mother w/ CAD in her forties as well as DM and HTN. Maternal grandfather with DM and maternal grandmother w/ HTN. Aunt w/ breast cancer in her late 40's. Physical Exam: VS: 96.4 157/113 78 20 99%RA, 0/10 pain GEN: Alert and oriented to person, place and situation; no apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: CN II-XII intact, [4-3] motor function globally DERM: no lesions appreciated Pertinent Results: [2177-1-4] 08:03PM CK(CPK)-370* [2177-1-4] 08:03PM CK-MB-10 MB INDX-2.7 cTropnT-0.04* [2177-1-4] 01:29PM GLUCOSE-127* UREA N-43* CREAT-3.3* SODIUM-141 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 [2177-1-4] 01:29PM CK(CPK)-448* [2177-1-4] 01:29PM CK-MB-12* MB INDX-2.7 cTropnT-0.04* [2177-1-4] 01:29PM CALCIUM-9.3 PHOSPHATE-4.1 MAGNESIUM-2.2 [2177-1-4] 06:51AM URINE HOURS-RANDOM CREAT-100 SODIUM-74 POTASSIUM-42 CHLORIDE-64 [2177-1-4] 06:51AM URINE OSMOLAL-458 [2177-1-4] 06:00AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2177-1-4] 06:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2177-1-4] 06:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2177-1-4] 04:24AM COMMENTS-GREEN TOP [2177-1-4] 04:24AM LACTATE-0.8 [2177-1-4] 04:19AM GLUCOSE-118* UREA N-45* CREAT-3.5* SODIUM-141 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16 [2177-1-4] 04:19AM estGFR-Using this [2177-1-4] 04:19AM cTropnT-0.04* [2177-1-4] 04:19AM proBNP-2790* [2177-1-4] 04:19AM WBC-11.8# RBC-3.98 HGB-12.2* HCT-35.7* MCV-90 MCH-30.7 MCHC-34.2 RDW-13.3 [2177-1-4] 04:19AM NEUTS-77.6* LYMPHS-9.9* MONOS-4.0 EOS-7.9* BASOS-0.6 [2177-1-4] 04:19AM PLT COUNT-212 [2177-1-4] 04:19AM PT-12.2 PTT-27.9 INR(PT)-1.0 ECG: Rate PR QRS QT/QTc P QRS T 101 186 102 368/439 61 39 63 CXR PA/LAT: FINDINGS: There is no pneumonia. There are trace bilateral pleural effusions. No pneumothorax is seen. There is a similar prominence and tortuosity of thoracic aorta in keeping with known type B aortic dissection. There is stable moderate cardiomegaly. IMPRESSION: 1. No pneumonia. 2. Moderate cardiomegaly. 3. Similar appearance of tortous and prominent thoracic aorta in keeping with known type B dissection, better evaluated on recent MRI chest [2176-9-20]. The study and the report were reviewed by the staff radiologist. ECHO: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets 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 a very small pericardial effusion. IMPRESSION: Moderately dilated left ventricle with moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction with elevated filling pressures. No pathologic valvular abnormality regurgitation seen. Small circumferential pericardial effusion. Compared with the prior study (images reviewed) of [2173-8-14], the findings are similar. pCXR: Portable AP chest radiograph was compared to [2177-1-4]. Heart size is normal. Tortuous aorta is unchanged. Lungs are essentially clear with no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: This is a 37 year old man with hypertension, CKD, stable type B aortic dissection, and a previous hypertensive urgency who presented with dyspnea and hypertensive emergency. He was initially started on a labetalol gtt and diuresed to stabilize his blood pressures. His home medications were also added on at this point to overlap with the more rapid onset of the drip to maintain better long-term control once the drip was discontinued. He was initially given a clonidine patch to improve compliance but this was discontinued later. His blood pressure was titrated to a goal of systolic blood pressures of 150s-160s. He was then seen by his renal specialist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4883] who helped in formulating a new medication regimen: labetalol 600 mg po tid, Norvasc 10mg po daily, Minoxidil 5mg po. His blood pressure was very well controlled on this triple drug regimen. Since medication noncompliance contributed to this hospitalization and hypertensive emergency, psychiatry and social work were consulted in his care and recommended a stay at a facility upon discharge that would help with administration of medication (such as [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] house) and a low-dose antidepressant. He was not approved for [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] and then he was discharged to [Company 3596]. Acute cardiogenic causes were ruled out with cardiac enzymes and an echocardiogram showing diastolic dysfunction, unchanged from prior. He also had an evidence of acute renal failure and proteinuria likely from malignant hypertension. Previously and during current admission he was evaluated for renal artery dissection by US with Doppler. The renal arteries were patent on both studies. His [Last Name (un) ] improved but we had discussion about worsening CKD and potential need for hemodialysis soon. He is scheduled to see vascular surgery in [Month (only) ] and he will see his nephrologist in 6 weeks for further discussions about renal replacement therapy. The patient has a questionable history of obstructive sleep apnea but not on home CPAP. He occasionally used CPAP during this admission. He was asked to see his PCP to reschedule [Name Initial (PRE) ] sleep study and offer CPAP at home is study is positive. He was educated about the risk of untreated hypertension several times. total discharge time 39 minutes. Medications on Admission: Medications at home: (Active Medication list as of [2176-11-28]): AMLODIPINE 10 mg Q day SPIRONOLACTONE [ALDACTONE] - 50 mg Q day LABETALOL - 800 mg [Hospital1 ] FUROSEMIDE - 40 mg [Hospital1 ] CLONAZEPAM - 0.5 mg Tablet [Hospital1 ] ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Q week CALCITRIOL - 0.25 mcg 3 x week CLINDAMYCIN PHOSPHATE - 1 % Lotion PRN CLOBETASOL - 0.05 % Cream [Hospital1 ] CLOBETASOL - 0.05 % Ointment [Hospital1 ] HYDROCORTISONE - 2.5 % Ointment [Hospital1 ] MUPIROCIN - 2 % Ointment [Hospital1 ] TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - [Hospital1 ] CHOLECALCIFEROL 800 unit Q day LORATADINE 10 mg Q day NICOTINE patch Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:20 Tablet(s) Refills:0 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:14 Patch 24 hr(s) Refills:2 4. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 5. labetalol 300 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:180 Tablet(s) Refills:2 6. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. calcitriol 0.25 mcg Capsule Sig: Three (3) Capsule PO once a week. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Emergency Acute Kidney Injury on Chronic Kidney disease Type B aortic dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a very high blood pressure. Your blood pressure medications were adjusted. Please take your medications as prescribed and make your follow up appointments with your PCP [Last Name (NamePattern4) ] [12-1] weeks and your nephrologist in 6 weeks. Followup Instructions: Call your PCP [Name9 (PRE) ], [Name9 (PRE) 2259] [Name9 (PRE) 12048] MD for an appointment Call your nephrologist Dr. [Last Name (STitle) ],[Name8 (MD) ] MD for an appointment Department: PSYCHIATRY When: THURSDAY [2177-1-9] at 2:00 PM With: [Name6 (MD) 247] SHU, MD [Telephone/Fax (1) 1387] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 551] Campus: EAST Best Parking: Main Garage Department: RADIOLOGY When: WEDNESDAY [2177-5-21] at 10:15 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: VASCULAR SURGERY When: WEDNESDAY [2177-5-21] at 11:00 AM With: [Name6 (MD) 251] [Last Name (NamePattern4) 1490], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "493.00", "V17.3", "585.4", "327.23", "404.01", "305.1", "428.31", "428.0", "296.32", "305.00", "282.2", "300.00", "441.01", "584.9", "288.60", "692.9", "278.00", "V15.81", "268.9", "V60.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14267, 14273	10242, 12716	327, 333	14429, 14429	6752, 10219	14895, 15961	5993, 6150		13447, 14244		14294, 14294	12742, 12742			14579, 14872						12764, 13424				6165, 6733																								4851, 5546				268, 289										361, 3684						14313, 14408			14444, 14555							5568, 5840	5856, 5977
22,853	116,411	6563	Discharge summary	report	Admission Date: [2155-10-15] Discharge Date: [2155-10-25] Date of Birth: [2081-7-29] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman with a history significant for coronary artery disease, status post CABG times four in [2147], status post DDD, pacemaker placement in [2155-7-27], negative Persantine mibi test in [2155-7-27] and recent catheterization of his heart on [2155-10-8] showing an EF of 38%, three vessel disease, moderate aortic stenosis, moderate mitral regurgitation and moderate [Date Range 16631] and diastolic ventricular dysfunction, CHF, insulin dependent diabetes mellitus, hypertension, hypercholesterolemia and GI bleed with a recent admission between [10-4] and [10-9] for shortness of breath. The patient was discharged home on Lasix and now returns with increasing shortness of breath on exertion, greater than right, no chest pain, no nausea, vomiting, some abdominal pain, some lightheadedness and fatigue, no orthopnea, no PND, slight headache and decreased appetite. Patient's stools are chronically dark. In the Emergency Room the patient was found to be guaiac positive and with a blood pressure of 74/39, pulse of 80. He was started on Dopamine drip and given one liter of IV fluids. His urine output was 1.2 liters in 6 hours. The Dopamine was started at 5 mcg/kg/min. and then decreased to 2.5 mcg/kg/min. and then stopped, but his blood pressure did not tolerate this and dropped to 68/49 so he was restarted on the drip at 5 mcg/kg/minute. After he was transferred to the unit, right radial A line was placed, PA catheter was floated through his right IJ and initial pressures were CVP of 14, RV of 78/20, PA 60/25, wedge pressure of 33, PVR was calculated 3.3. Cardiac index 3.03, cardiac output 7, SVR between 500 to 800 on Dopamine drip. The patient was started on Dobutamine drip in the CCU on the night of admission but his blood pressure dropped within 20 minutes and this was stopped and he remained on only the Dopamine drip. He was also given two units of packed red blood cells on the night of admission with Lasix after each unit. PAST MEDICAL HISTORY: 1) Coronary artery disease status post CABG times four in [2147], status post DDD pacemaker placement [2155-7-27], Persantine mibi in [2155-7-27] showing no perfusion defects, EF of 56%, history of AS and possible prior MI catheterization in [2155-12-27] showing LVEF of 38%, anterolateral hypokinesis, apical dyskinesis, inferior akinesis, 3+ mitral regurgitation and aortic calcification. 2) CHF stage II. Echocardiogram in [2155-5-27] showed EF of 55% with regional wall motion abnormalities, moderate AS and moderate to severe mitral regurgitation. An echocardiogram in [9-27] showed septal and apical inferoapical hypokinesis, moderate MR, TR and 45% EF with moderate AS. 3) Insulin dependent diabetes mellitus diagnosed in [2132]. 4) Recurrent gastrointestinal bleed with extensive work-up including colonoscopy in [2155-5-27] and [2155-7-27] showing sigmoid diverticulosis and GI hemorrhoids. He is H. pylori negative. EGD in [2155-5-27] and [2155-9-27] showed Barrett's esophagus and mild gastritis. Abdominal CT in [2155-7-27] showed vascular calcifications and he recently had admission on [9-27] through [2155-10-1] for GI bleed leading to orthostasis. He also has a possible history of porcelain gallbladder. 5) Atrial fibrillation on Coumadin in the past, now with pacemaker in place and on Amiodarone. 6) Hypertension. 7) Hypercholesterolemia. 8) Peptic ulcer disease. 9) Iron deficiency anemia. 10) Cholelithiasis. 11) Peripheral vascular disease with neuropathy. MEDICATIONS: At home, Insulin NPH 34 units q a.m., 24 units q p.m., Insulin regular 10 units q a.m., Amiodarone 200 mg q d, Aspirin 81 mg q d, Cimetidine 400 mg q d, Lipitor 40 mg q d, Reglan 10 mg tid, Univasc 30 mg q d, Iron 65 mg tid, Lasix 40 mg q d, Imdur 30 mg q d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Mother passed away from a brain tumor, no history of coronary artery disease or diabetes. SOCIAL HISTORY: The patient is a widow since [2146]. Patient did have a daughter who died in a train accident many years ago. He lives alone in [Location (un) 2251]. He has a brother and sister-in-law who he is in contact with and he does have a girlfriend. [Name (NI) ] is an ex-smoker, quit smoking many years ago. He has a 60 pack year history and he does not drink alcohol. PHYSICAL EXAMINATION: Vital signs, temperature 96.8, blood pressure 80/45, pulse 80 and regular, respiratory rate 18, O2 saturation 99% on three liters nasal cannula. General, elderly gentleman in no apparent distress. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Oropharynx clear. Dry mucus membranes. Neck, no lymphadenopathy, jugulovenous distension to 14 cm. Cardiovascular, regular rate and rhythm, [4-1] late peaking [Month/Day (4) 16631] ejection murmur at left sternal border radiating to the aorta, [3-4] holosystolic murmur at the apex. Pulmonary, bilateral sided basilar crackles [1-29] to [1-28] way up. Abdomen, soft, non distended, nontender, normoactive bowel sounds, no hepatosplenomegaly. Rectal, guaiac positive. Extremities cool, 2+ pitting edema to upper calves, left dorsalis pedis 1+, right dorsalis pedis 2+. Neuro, alert and oriented times three, non focal exam. LABORATORY DATA: White blood cell count 8.5, hematocrit 25.8, platelet count 227,000, PT 13.2, PTT 26.9, INR 1.1, differential with 82% neutrophils, 11% lymphocytes, 4.5% monocytes, 1.8% eosinophils, .7% basophils. Sodium 135, potassium 4.5, chloride 99, CO2 24, BUN 34, creatinine 1.4, glucose 168, anion gap 17, calcium 8.7, magnesium 2. TSH from [10-7] 1.8, cholesterol panel from [2155-5-27], total cholesterol 21, HDL 24, LDL 76, triglycerides 107, troponin less than .3. CK #1 48, CK #2 39, CK #3 34. Urinalysis negative. Urine culture negative. ABG, PH 7.43, PCO2 36, PO2 73, 96% on four liters nasal cannula. Laboratory data from [2155-9-27], iron 46, ferritin 141, haptoglobin 287, LDH 187, retic count 3.5, TIBC 261. Chest x-ray, worsening CHF, satisfactory position of PA cath. Chest x-ray [9-27], mild CHF, small bilateral pleural effusions. EKG, AV paced at 80, left bundle branch block pattern. Catheterization [2155-10-8], right dominant three vessel coronary artery disease (RCA/CO middle segment, LAD proximal 60% and mid 70%, circumflex proximal 60%, mid 100%, distal 100%), patent grafts (LVMA to LAD, SVG to D1, OM1, PDA) moderate AS, moderate MR, moderate [Month/Day/Year 16631] and diastolic ventricular dysfunction, EF 38% (increased right sided intracardiac pressures, increased LVED pressure 21), aortic valve area .9 cm sq going to 1.2 cm sq with Dobutamine infusion, mean gradient 27 mmHg going to 39 mmHg with Dobutamine infusion and cardiac index 2.5 liters per minute per meter sq going to 3.7 liters per minute per meter sq with Dobutamine infusion. Catheterization pressures, right atrium 16/12 with a mean of 15, RV pressure 39/14, PA pressure 39/28 with a mean of 31. Pulmonary wedge pressure 22/23 with a mean of 29. LV pressure 134/17 and 169/20 and aortic pressure 103/57 with mean of 77 and 120/50 with a mean of 73. IMPRESSION: 74-year-old gentleman with a history of CAD, CHF, diabetes mellitus, hypertension, hypercholesterolemia and recurrent GI bleed with recent catheterization on [2155-10-8] showing patent graft, moderate severe AS, moderate MR [First Name (Titles) ] [Last Name (Titles) 16631] and diastolic left ventricular dysfunction with an EF of 38% with improvement in AV area mean gradient and cardiac index with Dobutamine infusion, admitted with progressive dyspnea refractory to Lasix and guaiac positive stool. HOSPITAL COURSE: 1. Cardiovascular: A) Coronary artery disease - patient with patent graft on catheterization. He ruled out on this admission for a myocardial infarction with negative enzymes. The patient was continued on Aspirin and Lipitor. B) Contractility - a) Preload, patient has a complicated clinical picture with the aim to maintain preload for the aortic stenosis but at the same time avoiding fluid overload. The patient was transfused two units of packed red blood cells for hematocrit of 26. Each unit was followed by Lasix 40 mg IV. IT was decided to diurese him gently with Lasix with prn IV doses. His O2 sats and urine output were followed and improved. His goal net fluid balance initially was negative 500 to negative 1 liter. He had decreased requirement of oxygen over time, eventually being on room air on discharge. The patient was started on Aldactone during this admission. On [10-19] he was started on Lasix 40 mg po q d with addition of prn Lasix IV for maintaining his goal urine output. This was changed to 40 mg [Hospital1 ] the following day. On [8-21] this was changed to 40 mg IV bid with prn Lasix in addition and then on [10-23] it was changed to 60 mg po q d and then finally upon discharge was changed to 60 mg po qid as a maintenance dose. Closer to discharge his Lasix dose was changed to lower equivalent dose of po Lasix because his BUN and creatinine bumped a little bit, giving us the impression that he had reached his threshold for Lasix diuresis. b) Inotropic - the patient was initially on a Dobutamine drip to maintain a map of greater than 55 and heart rate of less than 120. This was started because it had been shown to improve his aortic stenosis on his recent catheterization, however, his blood pressure did not tolerate Dobutamine drip and dropped dramatically so this was stopped and he was instead maintained on the Dopamine drip. This was weaned off by hospital day #2. On [10-17] the patient had a TEE to evaluate his valves and this showed LVEF of 45-50% mildly depressed LV [Month/Year (2) 16631] function, RV function normal, simple atheroma in the descending thoracic aorta, aortic valve heavily calcified with restricted motion, mild AS, trace AR, severe 4+ mitral regurgitation, no pericardial effusion. It was decided that his mitral regurgitation was most likely the most significant cause behind his CHF. On [10-19] the patient was started on Digoxin .125 mg q d. His PA catheter was removed and he was transferred to the floor on [8-18]. On [8-22] his Digoxin level was .6 and his Digoxin was therefore increased to .25 mg q d. c) Afterload - patient also had a complicated balance between decreasing his afterload to improve his mitral regurgitation without decreasing it too much because of his aortic stenosis. His home afterload reducers were held off initially. He had a low SVR and sepsis was ruled out with blood cultures. His a.m. Cortisol level was also normal. His low SVR could also be due to diabetic autonomic dysfunction. TSH on recent testing was also within normal limits. Urine culture was negative. Sputum culture was negative. LFTs were within normal limits. The patient did have a low grade fever on [8-15] with an increase in white blood cell count. Differential was added without bands. The patient's SVR came up by itself on [10-17], even off of the Dopamine drip. His hypotension was thought also to perhaps be due to his increased ACE inhibitor dose at home. On [10-18] the patient was restarted on ACE inhibitor, he was started on Captopril 12.5 mg tid. This was further increased to 25 mg tid on [8-18]. C) Conduction - patient is AV paced. His lytes were followed. He did not have any arrhythmias on the Dopamine or Dobutamine drip. The possibility for the future may be to decrease the rate of his AV pacemaker to less than its present setting of 80. He was continued on his regular dose of Amiodarone throughout his hospital stay. D) Valves - On admission it was decided that once the patient was hemodynamically stable and the source of the GI bleed elucidated, that perhaps surgery with mitral valve and aortic valve replacement would be an option. On echocardiogram on [8-16] TEE showed severe mitral regurgitation, mild to moderate aortic stenosis. It was felt that he may still benefit from at least mitral valve replacement, however, his mortality and morbidity risks from the surgery were extremely high given his comorbid state up to 20% mortality. This was discussed with the patient and he was willing to undergo CT surgery evaluation. On [10-18] CT surgery fellow evaluated the patient and indicated that they would be willing to operate on the patient if his cardiologist approved and despite his GI bleed. It was decided by Dr. [Last Name (STitle) ], the patient's primary cardiologist, that he should be medically treated, first given the high risks of operation and at that time aggressive diuresis was implemented. The patient had a PT and social services consult. 2. Pulmonary: On admission the patient was in CHF by exam, PA catheter numbers and chest x-ray showing failure. Initially he was gently diuresed with prn Lasix and his O2 sats were followed as well as his urine output and both improved over time. When the question of sepsis came up, the question of pneumonia also was brought up. Sputum culture was negative. In addition, there was a low suspicion for a PE in the patient. There was no evidence of pneumonia on chest x-ray. 3. GI: The patient has a history of chronic recurrent GI bleed. He was guaiac positive on admission with a hematocrit dropped to 24 from 30 a few days previously as an outpatient. He was transfused two units on his first night and it was decided to maintain his hematocrit above or equal to 27. His hematocrit was initially checked every 8 hours. Given the possibility of CT surgery for valvular replacement, a valvuloplasty, a GI consult was requested despite his recent extensive negative GI work-up including colonoscopy, EGD and small bowel follow through showing small lesions which could be intermittently bleeding but not explaining his anemia. His hematocrit had a good response to the transfusions. He was started on Protonix. The iron was briefly discontinued for one day because of the thought that GI might want to evaluate him but then restarted once it was clear that GI would not do anymore procedure to evaluate his GI bleed. On [8-15] the GI team commented on the patient's GI bleed, that there was no more work-up to be done for him and that the next step would be an outpatient small bowel capsule enteroscopy. They believe that the source of his bleeding is probably a small bowel source and believe that his GI bleed does not preclude him from having CT surgery although he may bleed with Heparinization. The patient required one unit of transfusion also on the second day of admission. The patient did have small elevation in his total bilirubin of 1.7 with direct being .4 and indirect being 1.3. This was probably thought to be due to his chronic cholelithiasis. The history of porcelain gallbladder may be precancerous and this should be reviewed on ultrasound if and when he should go to surgery. On [8-17] his total bilirubin was rechecked and was within normal limits. The patient was initially constipated but this was resolved with Dulcolax suppositories. He was guaiac positive. On [8-21] the patient did complain of some nausea and he was started back on his Reglan home regimen. 4. Heme: The patient's hematocrit was initially checked q 8 hours and he was transfused to maintain hematocrit of greater or equal than 27. He required a total of 3 units of packed red blood cells with good response. Despite his guaiac positive stools, his stable hematocrit indicated that he was probably not actively bleeding. 5. Infectious Disease: On the second day of admission the patient had an increase in his white blood cell count and low grade temperature. Differential was added which showed no bands. He had clammy, diaphoretic skin, feeling cool to the touch. The question of sepsis came up with a low SVR and his hypotension and blood culture, urine culture, sputum culture and chest x-ray as well as urinalysis were all negative. It was felt maybe to start empiric antibiotics but initially this was held off. He did not require antibiotics throughout this admission. On the third day of admission he became afebrile, his white blood cell count came down and sepsis seemed an unlikely explanation for his hypotension and low SVR. 6. Endocrine: The patient was continued on his home regimen of NPH and regular insulin with sliding scale of regular insulin for back-up. His fingerstick blood glucoses were checked qid. Recent TSH on [10-7] was 1.8, within normal limits. On [10-17], because of the patient's poor po intake, it was decided to have his NPH and regular insulin dose. On [10-22], because of his improved appetite and increased po intake, his regular insulin NPH doses were increased back to his preadmission doses. His blood glucose remained stable throughout his hospital stay. 7. Renal: The patient was admitted with an increased BUN and creatinine of 34 and 1.4. This was thought to be prerenal azotemia secondary to his CHF with a component of increased BUN secondary to his GI bleed. It was decided to gently diurese him on admission, to follow his urine output. His BUN and creatinine continued to improve and resolved within a few days. Aggressive diuresis was started once it was decided to treat him medically rather than surgically. The [Initials (NamePattern4) 228] [Last Name (NamePattern4) ] was calculated at 2%. This is in the setting of Lasix so this was deemed not to be accurate. 8. Fluids, Electrolytes & Nutrition: The patient was gently diuresed initially and this became aggressive diuresis once medical management was chosen. Fluid balance initially was negative 500 to negative 1 liter. His electrolytes were followed carefully. He was placed on a diabetic and cardiac diet. His initial PA catheter goal for wedge pressure was 20-25. When the patient was being aggressively diuresed with Lasix, his goal fluid balance was negative two liters and he met this well with successful response to aggressive Lasix. 9. Psychiatry: On [10-17] the patient was started on Celexa 20 mg po q d after it was noted that this is what he had been on for the last four days at home. The patient did appear depressed while in the hospital, especially given his status of living alone and dealing with his medical problems and frequent hospital stays. On [10-22] the patient had a psychiatry consult who recommended that he be continued on the same dose as Celexa given the delay in its effectiveness being felt by patient may take up to weeks. 10. Code: Full. The patient was transferred to the floor on [10-19] and did well. Physical therapy saw him and ambulated with him and recommended that he go to rehab center short-term after being discharged from the hospital. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To [Hospital3 ] Center. DISCHARGE INSTRUCTIONS: 1. Please check BUN, creatinine and potassium three times a week and adjust Lasix and Aldactone accordingly. 2. Please weigh patient every day and aim to maintain current weight and adjust Lasix accordingly. 3. Please check qid fingerstick blood glucose. 4. Consider changing Captopril to Zestril 10 mg q day if patient is stable. 5. Please check Digoxin level three days after discharge and change the medication accordingly. 6. [Doctor First Name ] cardiac diet q day physical therapy. 7. Please have patient follow-up with his cardiologist, Dr. [Last Name (STitle) ], [Telephone/Fax (1) 25135] within 1-2 weeks after discharge. DISCHARGE MEDICATIONS: Lasix 60 mg po bid, Digoxin .25 mg po q d, Regular insulin 10 units subcu q a.m., NPH 34 units q a.m., 24 units q p.m., enteric coated Aspirin 325 mg po q d, Captopril 25 mg po tid, Reglan 10 mg po tid, Colace 100 mg po bid, Iron Sulfate 325 mg po tid, Aldactone 25 mg po q d, Celexa 20 mg po q d, Amiodarone 200 mg po q d, Lipitor 40 mg po q h.s. and Protonix 40 mg po q d. DISCHARGE DIAGNOSIS: 1. Congestive heart failure. 2. Coronary artery disease. 3. Aortic stenosis. 4. Mitral regurgitation. 5. GI bleed. 6. Diabetes mellitus. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 4786] Dictated By:[Last Name (NamePattern1) 7069] MEDQUIST36 D: [2155-10-24] 14:38 T: [2155-10-24] 15:45 JOB#: [Job Number 25136] cc:[Hospital6 25137]	[ "578.9", "401.9", "272.0", "428.0", "396.2", "250.00", "V45.81", "285.9", "414.01" ]	icd9cm	[ [ [] ] ]	[ "42.23", "88.72" ]	icd9pcs	[ [ [] ] ]							4079, 4170		19945, 20321		20342, 20819		7986, 19164		19270, 19921																										4589, 7969																						162, 2178																2201, 4062	4187, 4566	19189, 19246
25,340	131,208	11232	Discharge summary	report	Admission Date: [2147-11-22] Discharge Date: [2147-12-4] Date of Birth: [2073-1-27] Sex: M Service: CARDIOTHORACIC CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old man with cardiac risk factors including hypercholesterolemia, hypertension, and a previous myocardial infarction who was referred to [Hospital6 2018] for CABG following catheterization done on the day of admission at [Hospital ] Hospital. The patient's workup was initiated after the patient developed exertional angina and presented with chest heaviness after mowing his lawn. PAST MEDICAL HISTORY: The past medical history is significant for hypertension, hypercholesterolemia, coronary artery disease status post myocardial infarction in [2124], AML status post x-ray therapy in [2126]--whole body radiation done at [Hospital6 1708], status post colonic polyp removal in [2146], and status post melanoma with an excision from his chest wall five years ago. MEDICATIONS PRIOR TO ADMISSION: Atenolol 25 mg q.d., aspirin q.d., Maxzide 25 mg q.d. FAMILY MEDICAL HISTORY: The family history is significant for a father who died from myocardial infarction in his 80s and a mother who also died of myocardial infarction in her 80s. SOCIAL HISTORY: The patient works as a quality assurance [Doctor Last Name 360]. He is married. He has a remote tobacco history, quit in [2124], and has rare alcohol use. ALLERGIES: No known drug allergies. Catheterization done at [Hospital ] Hospital showed a right dominant circulation with 50% left main stenosis, 90% LAD stenosis, normal circumflex, and an RCA with severe diffuse disease of the entire vessel. His ejection fraction was estimated to be 45%. An echocardiogram done on [2147-11-14] was stopped because of ST depressions in the lateral leads. It showed hypokinesis of the basilar inferior septal region and anterior septal region, and borderline dilated aortic root. LABORATORY DATA: Laboratory data from the outside hospital revealed PT 12.4, PTT 20.7, INR 1.0, white blood cell count 7.9, hematocrit 36.5, platelets 133,000, sodium 135, potassium 4.8, chloride 107, CO2 24, BUN 23, creatinine 1.4, glucose 101, calcium 8.6. PHYSICAL EXAMINATION ON ADMISSION: In general, the patient was comfortable and in no acute distress. Mental status was alert and oriented times three with appropriate affect. HEENT examination revealed pupils equal, afferent nerves to left pupil did not function, efferent nerves do function, extraocular movements intact, no carotid bruits, and no lymphadenopathy. Oropharynx revealed moist mucous membranes with no lesions. Pulmonary examination was clear to auscultation bilaterally. Cardiovascular examination revealed regular rate and rhythm with no murmur. The abdomen was soft, nontender, and nondistended. The extremities were warm with no edema. There were 2+ dorsalis pedis and posterior tibial pulses. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic Service. On the day after admission, he went for carotid duplex studies. Carotid duplex studies showed no evidence of stenosis in the right or left carotid arteries. On hospital day #2, he was brought to the Operating Room where he underwent coronary artery bypass grafting times three. Please see the operative report for full details. In summary, the patient had CABG times three with LIMA to the LAD, vein graft to the OM, and vein graft to the RCA. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had an arterial line, Swan-Ganz catheter, ventricular and atrial pacing wires, and two mediastinal and left pleural chest tubes. His mean arterial pressure was 75, CVP 5. He was A-paced at 90 beats per minute and he had a Propofol infusion at that time. The patient did well in the immediate postoperative period. However during the course of the late afternoon, he required increasing amounts of pressors and by early evening he had increased the amount of chest tube drainage with a drop in his hematocrit to 25. Later that evening, the patient was returned to the Operating Room for cardiac tamponade. His chest was re-explored and they found a bleeder in his chest wall which was cauterized and an intra-aortic balloon pump was placed. The patient tolerated this re-exploration well and was transferred again from the Operating Room to the Cardiothoracic Intensive Care Unit at which time he was hemodynamically stable. On postoperative day #1, the patient remained intubated and sedated. He remained hemodynamically stable on Dopamine, Neo-Synephrine, and intra-aortic balloon pump at 1:1. The decision was made to keep him ventilated and to allow him to rest through the day with the assistance of the intra-aortic balloon pump. On postoperative day #2, his Dopamine was weaned to off and his balloon pump was discontinued. All sedation was also discontinued, however, the patient was a little slow to awaken from his sedation. He was weaned from the ventilator to CPAP and he had good blood gases on CPAP, however, it was questionable whether he would be able to protect his airway and he remained intubated throughout postoperative day #2. On postoperative day #3, the patient was felt to be awake enough to protect his own airway and he was extubated at that time. On postoperative day #4, the patient spiked a fever. Chest x-ray revealed small pleural effusion and a questionable right upper lobe infiltrate for which he was started on Levofloxacin. In addition to that, the patient began to have a small amount of drainage from the lower pole of his sternal incision and for that reason Vancomycin was continued. On postoperative day #5, the patient remained hemodynamically stable. He was afebrile and he was transferred from the Intensive Care Unit to Fahr Six for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient continued slow progress in his activity schedule. He remained hemodynamically stable although he did experience intermittent episodes of atrial fibrillation for which he was started on Amiodarone and his Lopressor dose was increased for rate control. The patient's respiratory status continued to improve and on postoperative day #10, the patient was felt stable and ready for transfer to rehabilitation for continuing postoperative care and cardiac rehabilitation to increase and improve his strength and endurance. At the time of transfer, the patient's status was stable. His physical examination at that time revealed vital signs of temperature 98, heart rate 64 and sinus rhythm, blood pressure 143/73, respiratory rate 22, O2 saturation 97% on room air. His weight preoperative was 97.7 kg and at discharge was 105.2 kg. Laboratory data revealed white blood cell count 9.5, hematocrit 29.3, platelets 189,000, sodium 142, potassium 4.1, chloride 108, CO2 24, BUN 20, creatinine 1.4, glucose 98. Physical examination revealed the patient to be alert and oriented times three, moves all extremities, and follows commands. On pulmonary examination, breath sounds were clear to auscultation bilaterally. Cardiovascular examination revealed regular rate and rhythm, S1 and S2, sternum stable, incision with staples, open to air, and clean and dry with no drainage. The abdomen was soft, nontender, and nondistended with normoactive bowel sounds. The extremities were warm and well perfused. There was 1+ pedal edema bilaterally. DISCHARGE DIAGNOSES: Coronary artery disease status post coronary artery bypass grafting times three with left internal mammary artery to the left anterior descending artery, saphenous vein graft to OM, and saphenous vein graft to right coronary artery; hypertension; hypercholesterolemia; AML status post x-ray therapy; status post colonic polyp removal; status post melanoma excision of the chest wall. DISCHARGE MEDICATIONS: Levaquin 500 mg q.d. through [2147-12-9], aspirin 81 mg q.d., Lasix 20 mg b.i.d. x 2 weeks, potassium chloride 20 mEq b.i.d. x 2 weeks, Colace 100 mg b.i.d., Ranitidine 150 mg b.i.d., Amiodarone 400 mg t.i.d. until [2147-11-5] then b.i.d. x 7 days then q.d. thereafter, Lopressor 100 mg b.i.d., Ibuprofen 400 mg q. 6 hours p.r.n. DI[Last Name (STitle) 408]E STATUS: The patient is to be discharged to rehabilitation. He is to have followup with Dr. [Last Name (Prefixes) ] in one month and followup with his primary care provider two to three weeks after discharge from rehabilitation. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2147-12-4] 10:56 T: [2147-12-4] 10:59 JOB#: [Job Number ]	[ "423.9", "401.9", "414.01", "413.9", "V10.82", "272.0", "427.31", "997.1", "998.11" ]	icd9cm	[ [ [] ] ]	[ "36.12", "39.61", "36.15", "34.1", "38.93", "96.71", "37.61" ]	icd9pcs	[ [ [] ] ]								7613, 7998	8022, 8874				2994, 7591																								1043, 1282																										193, 610								2290, 2976								633, 1010	1299, 2275
65,698	154,434	10218	Discharge summary	report	Admission Date: [2154-5-17] Discharge Date: [2154-5-20] Date of Birth: [2105-12-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2009] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: 49 y/o with Hep C, IVDA, presents unresponsive. Friend called EMS after pt found unresponsive. Empty bottle of oxycotin and oxycodone and empty syringe found by his side. Pt received 4 mg of narcan in the field with minimal responsiveness. BP 120, 80% RA in the field. Vomitting noted in the field after narcan. ON arrival to the [Name (NI) ] pt was minimally responsive, GCS of [4-15]. FS on arrival 64, improved to 92 after glucose administration. Pt was protecting his airway, therefore intubation was avoided. Initial vs were: T 97.9 P 95 BP 84/60 R [4-20] O2 sat 92 4L. Pt BP remained in 80s to 90s, HR in 90s, EKG was normal. CT head was negative. While in the CT scanner the pt awoke and complained on burning in his eyes. Eye pH was 7, no foreign objects noted in his eyes. After the CT scan an LP was performed given his MS changes. Afterwards, 2mg of narcan administered with improvement in MS and the pt became combative and was noted to vomit small amount of blood tinged fluid. He was given 4-5L IVF in the ED wtih UO of 300cc. Oxygen sat intermittantly deterioated and briefly required non-rebreather. Prior to transfer VS 95/80, 85, 18, 100% on 4L? . On the floor, pt was lethargic but arousable, oriented to place. He denied any memory of the events leading to hospitalization but denied any illict or presciption drug use. He complained only of burning in his eyes BL. The patient's Mother briefly arrived and voiced concern of a suicide attempt. The night prior, the pt told his mom he was the only one who loved him in a way which seemed in preperation for saying goodbye. . Of note pt was seen in B+W ED [5-16] for right foot pain, d/ced with Rx for oxycodone. Past Medical History: -Hep C -Hep B -latent TB with treatment with INH for months (AFB neg x 3 in [11-19]) -IVDA, with known cocain and heroin use -right fifth metatarsal fracture, treated at B+W [5-16], dischanged on oxycodone. -Undefined psychiatric disorder Social History: Homeless. IVDA, known heroin and cocaine abuse in the past. Recently incarcerated. Per previous notes, used to smoke, denied Etoh use. Family History: Per records. Notable for psychiatric disturbance in his mother. The patient reports his father died of possible cardiac disease. Physical Exam: Vitals: afebrile, BP:95/80 P:85 R:18 O2: 100% on 4L General: Lethargic, oriented x 2 (not time) HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 6-8 cm above clavicle at 45 degrees, 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: foley Ext: BL track marks. cold fingers > feet, 2+ pulses, no clubbing, cyanosis or edema neuro: pupils constricted but responsive. CN grossly intact. moving all 4 ext. Pertinent Results: [2154-5-17] 09:44PM TYPE-[Last Name (un) ] PO2-33* PCO2-45 PH-7.35 TOTAL CO2-26 BASE XS-0 COMMENTS-GREEN TOP [2154-5-17] 10:05AM LACTATE-5.5* NA+-147 K+-4.6 CL--99* [2154-5-17] 01:27PM LACTATE-4.9* [2154-5-17] 03:40PM LACTATE-3.1* [2154-5-17] 03:40PM TYPE-ART O2-93 PO2-64* PCO2-35 PH-7.36 TOTAL CO2-21 BASE XS--4 AADO2-578 REQ O2-93 [2154-5-17] 07:10PM GLUCOSE-122* UREA N-28* CREAT-1.2 SODIUM-138 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 [2154-5-17] 07:10PM ALT(SGPT)-64* AST(SGOT)-61* ALK PHOS-55 TOT BILI-0.5 [2154-5-17] 07:10PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-2.4# MAGNESIUM-1.6 [2154-5-17] 09:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2154-5-17] 09:50AM WBC-27.6 RBC-4.71 HGB-13.9* HCT-44.1 MCV-94 MCH-29.6 MCHC-31.6 RDW-15.8* . CXR [5-17]: FINDINGS: Heart size and pulmonary vascularity remain normal. Previously described ground-glass opacity has progressed in the left lower lobe with consolidative appearance in the retrocardiac region. Additionally, there is a new area of air space consolidation involving the right lower lobe. The bibasilar distribution and rapid changes favor aspiration but differential diagnosis includes evolving infection, pulmonary hemorrhage, and less likely asymmetrical non-cardiogenic pulmonary edema. No pleural effusion or pneumothorax is evident. R foot films: Fracture at the base of the right fifth metatarsal extending to the edge of the tarsometatarsal joint, with slight distraction . CT head [5-17]: FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses, mass effect or infarction. The [Doctor Last Name 352]-white matter differentiation is well preserved. No fractures or soft tissue abnormalities are identified. IMPRESSION: No acute intracranial process. ECHO [5-20]: The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion (<0.5 cm) located adjacent to the right atrial free wall. . IMPRESSION: Normal global and regional biventricular systolic function. Normal diastolic function. Mild mitral regurgitation in a structurally normal valve. Very small pericardial effusion adjacent to right atrium. . Discharge labs from [5-20]: WBC-6.1# RBC-3.90* Hgb-12.0* Hct-35.4* MCV-91 MCH-30.7 MCHC-33.8 RDW-15.2 Plt Ct-189 Neuts-63.2 Lymphs-28.0 Monos-6.1 Eos-2.1 Baso-0.6 Glucose-99 UreaN-17 Creat-0.9 Na-143 K-3.9 Cl-109* HCO3-27 AnGap-11 ALT-40 AST-27 LD(LDH)-189 AlkPhos-47 TotBili-0.4 Calcium-8.7 Phos-3.5 Mg-1.7 . Imaging Final CXR [5-18]: FINDINGS: The study is somewhat limited as the right costophrenic angle has not been included. The opacity of right lower lobe and left lower lobe have slightly improved. No pleural effusion or pneumothorax is detected. The cardiomediastinal silhouette and hilar contours are normal. UE ultrasound [5-20]: PRELIMINARY - superficial thrombophlebitis. No DVT. Brief Hospital Course: This is a 48 year old with hepatitis C + B and known IVDA who presented unresponsive. # Acute toxic metabolic encephalopathy in setting of drug overdose: Multiple contributing factors. Positive opoid screen, empty oxycodone / oxycontin bottles, and response to narcan suggestive of acute opiod overdose. Inital VBG with CO2 of 90 also suggests hypercarbia as a cause, perhaps as a results of hypoventilation from the opiods. LP performed in ED without evidence of infection and CSF cultures negative to date. On transfer to the floor, mental status improved and per family at his baseline. # Hypotension with elevated lactate on arrival. Elevated JVP on exam, but extremities cold and clammy, likely related to hypovolemia Pressures improved with IV therapy provided in ER. TTE revealed normal function with small pericardial effusion. Blood, urine cultures are negative. # Polysubstance abuse/Opiod overdose - On further questioning, pt denied suicidal ideations, but later stated that he didn't remember if he did it as a suicide attempt. On transfer to the floor he denied current suicidal ideations and was interested in inpatient drug rehab. The psychiatry consult service met with him and suggested that he may be appropriate for a dual diagnosis program and outpatient neuropsychological testing. SW also met with him in order to help get admitted to an inpatient drug rehab program. # Aspiration pneumonia: BL infiltrates on CXR, appear posterior inferior lobes, consistent with aspiration. Given hypotension, bandemia he was started on clindamycin for aspiration pneumonia. His oxygenation improved over the course of the hospitalization. At the time of discharge he was discharged on clindamycin for another 6 days to complete a 1 week course. # Demand ischemia: On admssion, EKG without evidence of acute ST-T wave changes. Initial troponin was 0.08 and rose to 0.1. Was likely elevated in the setting of recent hypotension, opiod overdose, acute renal failure and cocaine use. He remained asymptomatic without chest pain. ECHO revealed normal function with small pericardial effusion. # Acute renal failure: Thought pre renal given elevated BUN/CR. With IV fluids, returned to baseline. # Hepatitis C: Per patient, has not been followed by a hepatologist as an outpatient. Will ultimately need outpatient follow up. # R 5th metatarsal fracture - Had recently been discharged from [Hospital1 112] ED with a cast. Xrays here confirmed this fracture. He was instructed to wear a hard soled shoe follow up with ortho in 2 weeks. # Superficial thrombophlebitis: Ultrasound on day of discharge revealed distal superficial thrombophlebitis. He was treated with warm compresses and elevation. This will likely resolve on its own. FULL CODE Medications on Admission: oxycodone issued at BW [2154-5-16] viagra Discharge Disposition: Extended Care Facility: [Hospital6 ] Crisis Stabilization unit Discharge Diagnosis: Acute encephalopathy related to overdose Myocardial ischemia Foot fracture Aspiration pneumonitis Superficial thrombophlebitis Possible depression Polysubstance abuse. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ( (crutches) Discharge Instructions: You were admitted after a likely overdose. You were admitted to the ICU, and had some damage to your heart from the overdose, and a possible pneumonia. You also had an inflamed superficial vein in your left arm. . You were seen by psychiatry and discharged Keep your left arm elevated, and use warm compresses on the part of your arm that is uncomfortable. . New medications: Complete the course of clindamycin for pneumonia for another 5 days. . Follow up with the orthopedic doctors here and with Dr. [Last Name (STitle) ] for primary care after you leave the psychiatric hospital. Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2154-6-25] at 2:35 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: MONDAY [2154-6-3] at 1 PM With: [Name6 (MD) 13978] [Name8 (MD) ], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "276.52", "507.0", "070.30", "451.82", "070.70", "V60.0", "E980.0", "349.82", "304.00", "785.50", "965.00", "584.9", "414.8", "276.4" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	9794, 9863	6922, 9698	335, 341	10075, 10075	3306, 6899	10867, 11451	2506, 2636				9884, 10054	9724, 9771			10253, 10844										2651, 3287																												277, 297										369, 2068									10090, 10229							2090, 2338	2354, 2490
21,376	150,772	18312	Discharge summary	report	Admission Date: [2180-10-3] Discharge Date: [2180-10-9] Date of Birth: Sex: M Service: Neurosurgery NOTE: This is a brief death note. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old gentleman with a history of hypertension, hypothyroidism, and major depression who was noted to be somnolent with a left-sided facial droop and left-sided weakness while at a psychiatric hospital. By report, the patient was confused. He had limited comprehension and slurred speech. A head computed tomography at the outside hospital showed a subarachnoid hemorrhage and subdural hematoma. The patient was transferred to [Hospital1 1444] from the psychiatric [Hospital1 ] at [Hospital6 2561]. An angiogram was performed, and a coiling of the aneurysm was done on [2180-10-3]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. Chronic renal insufficiency. 4. Depression. ALLERGIES: PENICILLIN. MEDICATIONS ON ADMISSION: Aspirin, methimazole, quetiapine, Neurontin, Klonopin, Norvasc, colace, multivitamin, Tylenol, Senokot, and Metamucil. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission revealed the patient's temperature was 97.2 degrees Fahrenheit, his blood pressure was 128/39, his heart rate was 53, his respiratory rate was 17, and his oxygen saturation was 100%. In general, the patient was drowsy. He followed simple commands. He was moving all extremities. The lungs were clear bilaterally. Cardiovascular examination revealed a regular rate and rhythm. The abdomen was soft and nontender. The bowel sounds were present. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's white blood cell count was 11.7, his hematocrit was 30.6, and his platelets were 363. The patient's prothrombin time was 15.6, his partial thromboplastin time was 150, and his INR was 1.6 (after his angiogram). The patient's sodium was 140, potassium was 4, chloride was 113, bicarbonate was 19, blood urea nitrogen was 19, his creatinine was 1.2, and his blood sugar was 153. BRIEF SUMMARY OF HOSPITAL COURSE: On [2180-10-3] (as previously mentioned), the patient underwent a cerebral angiogram. Status post he had a GDC embolization of a ruptured right A12 junction aneurysm. Complications with the patient having a small impingement by the coil mass at A12. He had good flow. Postoperatively, he was kept on heparin and aspirin for one to two days to keep his partial thromboplastin time at a goal of 60 to 70 overnight. Postoperative, the patient's vital signs revealed his blood pressure was 131/45, his heart rate was 60, his respiratory rate was 13, and his oxygen saturation was 98%. The patient's temperature was 97.2 degrees Fahrenheit. The patient was extubated. He was awake and followed commands. He was nonverbal. He was able to lift his arms off the bed, but the patient was unable to hold up. Pronator drift. The pupils were equal and sluggish, reactive to 2 mm to 1.5 mm. He moved both legs off the bed (right greater than left). His biceps and triceps in the both the right and left arms were [4-21]. His iliopsoas on the right was 4. He was antigravity on the left for his lower extremities. His smile was symmetric. His postoperative hematocrit without 30.6. His partial thromboplastin time was 150. His INR was 1.6. The patient continued to be monitored in the Intensive Care Unit. Neurologically, his neurologic status was checked every one hour. His heparin was kept at 800 units per hour to keep his goal partial thromboplastin time between 60 and 80, and these levels were checked every four hours. Intravenous fluids at 125. His systolic blood pressure was in the 150 range. On the morning postoperatively (on [2180-10-4]), the patient's temperature was 98.4 degrees Fahrenheit, his blood pressure was 127 to 174/40s to 50s, his respiratory rate was 20, and his oxygen saturation was 96%. 24 hours overnight he was positive 116 for his fluid balance. His heparin was 800 an hour, and Nipride was at 3. His white blood cell count was 15.9, his hematocrit was 33.6, and his platelets were 422. His partial thromboplastin time was 81.8. The patient was very lethargic on examination in the morning. He did not open his eyes; only to deep painful stimulation. He had minimal withdrawal. A STAT head computed tomography showed a very large bifrontal hemorrhage which extended through the corpus callosum which faced the frontal [Doctor Last Name 534], lateral ventricles, and sulci of the frontal lobes. There was blood within the subarachnoid space and within the ventricles. There was diffuse narrowing of the cerebral sulci and dilation of the atria and temporal [Doctor Last Name 534] of the lateral ventricles. Basal cistern spaces seemed narrowed. The patient immediately had a ventriculostomy drain placed. Intracranial pressures were in the 12 to 13 range. A follow-up head computed tomography was completed. A central line was placed in the patient. On [10-5], the patient's pupils were reactive 2 mm to 1 mm. He extended the bilaterally upper extremities. He withdrew the lower extremities. The toes were downgoing in both feet. His blood pressure was kept below 140. He was receiving mannitol. He had a second head computed tomography which was stable from the previous head computed tomography. No further hemorrhage. We continued to keep his blood pressure less than 140 using mannitol as needed. The vent drain was kept at 12. On [10-6], the patient opened his eyes to stimulation. He did not follow commands. Faint upper extremity movement. He had triple flexion bilaterally. The right pupil was 4 mm to 3 mm. The left pupil was 2.5 mm to 2 mm. The patient was considered to have a very poor neurologic examination. On [10-8], the patient was found to have dilated pupils at 5 mm and nonreactive. No dolls eyes. No corneal reflexes. No gag reflex. No response to painful stimuli. No plantar flexor or extensor response. However, he was over breathing the ventilator. The family was contact[Name (NI) ]. They were aware of the patient's critical condition and were making the patient comfort measures only. On [10-8], it was felt that the patient's examination had been unchanged. He was only breathing the vent. A further brain death examination was done on 11:30 on [10-8]. Again, the patient was unresponsive to deep painful stimuli. His pupils were fixed and dilated. No corneal reflex. No gag reflex. The patient was not breathing over the ventilator. Oculovestibular testing was performed. No eye movements were noted. The patient met the criteria of brain death. Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132] came in and also examined the patient and discussed his condition with the family. Later on in the evening of [10-8] at approximately 2100, additional family members of the patient came in who claimed they had not been (one son in particular) notified of the patient's hospitalization until that day. He wanted to ask if the patient could remain on the ventilator until further family members came and a further discussion of the circumstances around his father's death could be discussed. Members of the Neurosurgery team and the Neurology Intensive Care Unit team met with both sons, both [Name (NI) ] [Name (NI) 50473] and his brother [Name (NI) 50474] [Name (NI) 50473], met in a meeting and both these sons would not speak to one another. The hospital attorneys were consulted, and Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132] was also consulted. It was explained to them that prolonging the patient's life once declared brain dead in order for additional family members to come, by [State 350] law, that the patient was declared brain dead and no further interventions would be leg, and the patient should be made as comfortable as possible. A discussion again was in the presence of [First Name5 (NamePattern1) ] [Known lastname 50473] and [First Name5 (NamePattern1) 50474] [Known lastname 50473] in the presence of Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and [First Name8 (NamePattern2) 3065] [Last Name (NamePattern1) 3903] (nurse practitioner). Both sons were [Name2 (NI) 50475] and agreed to have some private time/closure with their father. Again, the case was discussed with the [Hospital1 69] legal staff ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 122]) who advised [State 350] brain death law. Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1132] was aware of this discussion. At 2315 brain death testing was performed per protocol, and check was completed. Support was discontinued. The patient died at 0031 on [2180-10-9]. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern4) ] MEDQUIST36 D: [2180-12-28] 12:20 T: [2180-12-30] 06:50 JOB#: [Job Number 50476]	[ "348.4", "443.9", "401.9", "430", "242.20", "593.9", "296.30" ]	icd9cm	[ [ [] ] ]	[ "39.72", "38.91", "96.71", "38.93", "02.2", "88.41", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]												989, 2070																								2100, 9192																											200, 827																849, 962
7,334	147,622	19543	Discharge summary	report	Admission Date: [2153-1-24] Discharge Date: [2153-1-27] Date of Birth: [2100-5-7] Sex: F Service: CARD CARE HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old woman with past medical history significant for hypertension, hyperlipidemia, previous tobacco use, family history of coronary artery disease who was referred to elective coronary catheterization after presenting to her primary care physician with exertional chest pain. Outpatient exercise treadmill test on [2153-1-20] was stopped for chest pain and ST depressions. Patient underwent elective coronary catheterization on [2153-1-24] which showed right coronary artery obstruction status post stent placement. Following catheterization, which the patient tolerated well, the patient had a vagal response to the femoral sheath pull with bradycardia and hypotension for which she received Atropine, intravenous fluids, and was started on Dopamine. Patient's systolic blood pressure initially responded appropriately up to systolic blood pressure of 140. However, the patient was agitated, combative, and interfering with right femoral artery pressure. For this agitation the patient was given Versed and then Fentanyl with adequate sedation level. However, as the Dopamine was being weaned to off patient's systolic blood pressure dropped to the 60s and pulse oximetry dropped to undetectable. Narcan was administered and Dopamine and fluids were given wide open. Anesthesia was called and intubated the patient. A stat echocardiogram in the Coronary Catheterization Lab also was performed and was negative for pericardial fluid. Decision was made to bring the patient back to the Catheterization Lab emergently to evaluate for a retroperitoneal bleed. Angiography in the Catheterization Lab showed extravasation of thigh and to the retroperitoneal area from the external iliac artery above the inguinal ligament. Angiography was otherwise normal. Dye remained to extravasate into the retroperitoneal area despite two inflations of 20 minutes with balloon tamponade in the Catheterization Lab. Therefore, covered stents times two were placed over the area of extravasation and hemostasis was achieved. Patient's Integrilin, which had been started shortly after stent placement, was stopped. Patient was transferred to the Coronary Care Unit for close monitoring and as she was intubated. Vascular Surgery was also consulted in the case and recommended medical management given hemostasis that was achieved at the Catheterization Lab. Upon arrival to the Coronary Care Unit the patient was sedated and intubated and unable to answer questions. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. SOCIAL HISTORY: Previous tobacco use. Patient works as a paralegal. FAMILY HISTORY: Patient with reportedly family history of coronary artery disease. ALLERGIES: Penicillin, unknown reaction. HOME MEDICATIONS: 1. Estradiol Patch. 2. Zestril 25 once a day. 3. Hydrochlorothiazide 25 once a day. 4. Aspirin 81 once a day. 5. Diltiazem unknown dose. REVIEW OF SYSTEMS: Notable for two-pillow orthopnea. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.0, heart rate 80, respiratory rate 26 on the ventilator, blood pressure 127/74, height 5'4", weight 150 pounds. On physical exam endotracheal tube is in place. Lungs are clear to auscultation bilaterally anteriorly. Skin is notable for slow capillary refill, right flank ecchymosis, mottled appearance, and purple discoloration all four distal extremities. Heart exam with S1, S2, regular rate and rhythm, no murmurs appreciated. Neurologically, the patient is stated. Pulses upon transfer were trace in the bilateral lower extremities, dorsalis pedis pulses, as well as posterior tibial pulses. No edema. 1+ pulses in the bilateral upper extremities. DIAGNOSTIC DATA ON ADMISSION: White blood count 24, hematocrit 54 while receiving packed red blood cells, INR 1.5. Chemistry is notable for potassium of 2.7 and normal BUN, creatinine and a magnesium of 1.2. Arterial blood gas upon transfer was pH of 7.16, CO2 of 44, oxygen of 208, and a free calcium of 0.93. SUMMARY OF HOSPITAL COURSE: 1. Retroperitoneal bleed and intraperitoneal bleed: Patient's extravasation of thigh seen on angiography into the retroperitoneum was stable upon exit from the Coronary Catheterization Unit. The patient had a large right groin hematoma as well as firmness in the right abdominal area. Due to these findings patient underwent CAT scan of the abdomen and pelvis on [2153-1-24] which showed a large right groin hematoma as well as retroperitoneal and intraperitoneal hematoma that was extensive, including perihepatic. Patient was followed with serial hematocrits which trended slowly down from her hemoconcentrated value of 54 upon transfer. The slow down trend was likely equilibration with her extravascular volume. Patient's hematoma remained stable, and her abdominal firmness slowly improved throughout her hospital stay. The patient, after extubation, was complaining of mild soreness in her abdomen, right greater than left, as well as at the femoral site. 2. Coronary artery disease status post right coronary artery stent: Patient continuing with aspirin, Plavix, Lipitor. Patient was on Diltiazem at home. This was changed to Toprol on [2153-1-26] and titrated. 3. Hemodynamics: Patient was hypotensive with intravenous fluids and on Dopamine upon arrival at the CCU but on extubation was hypertensive and continued on nitroglycerin drip. Upon transfer to the CCU the patient was extremely peripherally vasoconstricted likely related to her large loss of blood and to retroperitoneum. Patient was started on a nitroglycerin drip to promote peripheral vasodilation. Patient's blood pressure became hypertensive and she was restarted on her home medications with adequate blood pressure control by the time of discharge. 4. Pump: Ejection fraction estimated at approximately 70% at catheterization. Patient's Lisinopril was restarted and increased dosage to 40 q.d. at the time of discharge for better blood pressure control. Patient did not appear fluid overloaded despite the large volume expansion on the day of her retroperitoneal bleed. Patient autodiuresed well. 5. Rhythm: Patient in normal sinus rhythm throughout her hospital stay as seen on telemetry. 6. Pulmonary: Patient was intubated for airway protection on [2153-1-24] and extubated successfully the next day. Patient's oxygen saturation was titrated down, and she was breathing comfortably on room air even with ambulation upon discharge. 7. Neurology: Patient with questionable visual changes post coronary catheterization but prior to her hypotensive episode requiring intubation. Patient with no neurological deficits on physical exam. Head CT on [2153-1-25] did show hypoattenuation in the right parietal and bilateral frontal lobes. However, the patient refused MRI/MRA to further evaluate this. Patient did agree to bilateral carotid Dopplers which, by preliminary report, did not show significant stenosis. Neurology followed the patient throughout her hospital stay. However, the patient refused any further workup and deferred further workup to outpatient. 8. Fluid, electrolytes, nutrition: Patient's electrolytes were repleted aggressively, especially her calcium, as she received eight units of packed red blood cells. Patient upon extubation tolerated cardiac diet well. 9. Hematology: Patient's hematocrit was stable at the time of discharge in the high 30s. Patient's platelets were also stable at the time of discharge but had decreased from her initial labs likely due to the large volume of packed red blood cells that she received without receiving platelets. However, the patient did not have any signs or symptoms of active bleeding and, therefore, platelets were not transfused. Platelets remained above 100,000 throughout her hospital stay. 10. Prophylaxis: Patient maintained on a proton pump inhibitor as well as Pneumoboots in the Cardiac Care Unit. Patient was then ambulated. Communication daily with the patient as well as the patient's daughter. DISCHARGE CONDITION: Stable; ambulating and tolerating POs. DISPOSITION: To home with close follow up. DISCHARGE DIAGNOSES: 1. Coronary artery disease with symptoms and stent placement. 2. Retroperitoneal and intraperitoneal hematomas requiring eight units of packed red blood cells. 3. Hypertension. DISCHARGE MEDICATIONS: 1. Aspirin 325 once a day. 2. Plavix 75 once a day. 3. Hydrochlorothiazide 25 once a day. 4. Lipitor 20 once a day. 5. Lisinopril 40 once a day. 6. Toprol XL 200 once a day. DISCHARGE INSTRUCTIONS: 1. Patient to follow up with her primary care physician or Dr. [Last Name (STitle) 11493] on the next business day after the weekend for a vital signs check as well as laboratory tests, specifically hematocrit and platelets. 2. Patient to follow up with her primary care physician and Dr. [Last Name (STitle) 11493] as scheduled. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Name8 (MD) 6906] MEDQUIST36 D: [2153-1-27] 22:16 T: [2153-1-28] 19:49 JOB#: [Job Number 53012]	[ "998.2", "998.11", "E879.0", "458.29", "902.53", "785.0", "414.01", "997.1", "998.12" ]	icd9cm	[ [ [] ] ]	[ "96.71", "88.53", "37.22", "88.72", "99.04", "99.20", "37.21", "88.56", "36.01", "96.04", "39.90", "39.50", "88.42", "36.07" ]	icd9pcs	[ [ [] ] ]				8225, 8310			2806, 2917	8331, 8512	8535, 8716						8740, 9359															2935, 3078						4188, 8203													3098, 3154														166, 2657								3876, 4160								2679, 2718	2735, 2789
653	110,516	11128	Discharge summary	report	Admission Date: [2117-7-5] Discharge Date: [2117-7-15] Date of Birth: [2040-3-14] Sex: M Service: MEDICINE Allergies: Angiotensin Receptor Antagonist / Ace Inhibitors Attending:[First Name3 (LF) 783] Chief Complaint: dyspnea, IVIG-mediated ATN Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 77 year-old r handed male with PMHx significant for CAD s/p MI x3 w/ stent, HTN, afib admitted for IVIG therapy related to recently diagnosed motor neuropathy. . - Following history adapted from neuromuscular fellow note of [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] - . Pt states that for a couple of years, he has had some difficulty reaching things on high shelves. He began to have to use both his hands to lift anything as heavy as a plate from a high shelf. He did not notice any other problems at that time. In [Month (only) 1096] [2115], he was diagnosed with atrial fibrillation. In [Month (only) 404] of this year, he began to notice some dyspnea on exertion while lifting his paraplegic wife. At the end of [Month (only) 404] he noticed he could no longer breathe while lying flat. He went to [State 108] in [Month (only) 956] and shortly afterward developed severe shortness of breath and lower extremity edema. He was hospitalized in [State 108] and given a diagnosis of a left lower lobe infiltrate and started on diuretics and antibiotics. . After discharge his symptoms did not improve. He returned to [Location 86] and was admitted to [Hospital1 18] with worsening orthopnea, pitting edema and shortness of breath. He was given a diagnosis of diastolic heart failure with an elevated BNP. There was no evidence of MI. He was cardioverted during admission and aggressively diuresed in the CCU. Amiodarone was added. He continued to be hypoxic and require supplemental oxygen. TTE showed EF 50%. . He was discharged to rehabilitation. Since then, he has continued to need supplemental oxygen. He has continued orthopnea and dyspnea on exertion and always sleeps in a chair. He walks with a walker now to carry his oxygen tank and provide a chair if he needs to rest. He can walk around his house without the walker, and admits he often dosen't use the nasal cannula at home. He has been unable to get a chest CT due to the inability to lay flat. . In addition to the breathing problems, a couple of months ago he also developed paresthesias and numbness in the fourth and fifth digits of his left hand. This included the palm and the dorsal surface of the fourth and fifth digits. He also notes weakness of the left hand, particulary his grip. His fourth and fifth fingers "feel big," and when touched feel as though something is between his fingers and the stimulus. He denies neck, wrist and elbow pain. . He denies weakness in the lower extremities. He also denies numbness and paresthesias in the lower extremities. He has not noticed any rippling muscles or twitching. He has had chronic lower extremity cramps at night for years, but this is unchanged. He denies trouble speaking or swallowing, and denies double vision or increased weakness at the end of the day. . A few weeks ago, he had PFTs, which showed an FVC 29% predicted, FEV1 32% predicted. The FEV1/FVC ratio was 111% predicted, which is elevated. The test was consistent with a restrictive lung process. He also had a moderately reduced DLCO. . There is no history of fevers, chills, chest pain, rashes abdominal pain, nausea, vomiting, incoordination, change in vision, change in speech and swallowing. Past Medical History: CAD, s/p stenting of RCA in [2113] TTE at OSH: EF=60% as above Atrial fibrillation, diagnosed [11-14] s/p cardioversion, on coumadin HTN Hypercholesterolemia Gout s/p Spinal fusion Benign tumor of Left breatst 6 yrs ago Left knee replacement Benign tumor of spine Appendectomy OSA carpal tunnel release bilaterally, [2089] rib removal for ? thoracic outlet syndrome bilaterally car accident [2075] with head trauma Social History: He has a ninth grade education. He was in the military, then he worked in a machine shop. In the shop, he says the air was constantly thick with smoke from the materials they were using. He lives with his wife. She was paralyzed from the waist down by a spinal cord infacrtion about 15 years ago. He is her primary caretaker. Family History: His father died at age 72 from heart disease. His mother died at age [Age over 90 ] from heart disease. He has a living brother and a living sister. His other sister died from breast cancer at age 45. There is no history of neurological problems in the family. Physical Exam: GEN: Sitting in chair, NAD HEENT: NC/AT, MMM, o/p clear, neck supple, no carotid bruits, CV:RRR S1/S2 no m/r/g RESP:CTA b/l ABD: soft NT ND + BS EXT: no c/c/e . NEURO EXAM: oriented to person, place and time, patient repeating intact, naming intact, language fluent with normal comprehension. Able to spell WORLD backwards. [Location (un) ] inact. [2-11] registration. [12-14] recall after 3 minutes, [2-11] with prompting. . CN: PERRL, EOMI, face symmetric, normal sensation, no hearing on left ear, sternocleidomastoid intact, palate symmetric, tongue midline. . MOTOR: He has full strength of neck flexion and extension. There is no pronator drift. Tone is normal. Right deltoid [4-15], Left deltoid 4+/5. Right biceps strength is [4-15]; left biceps strength is 4+/5. Right triceps [4-15], left triceps 4+/5. Wrist extension strength is 4+/5 bilaterally. Wrist flexion is full strength bilaterally. Right finger flexion [4-15]. Left 1st, 2nd, and rd digit finger flexion [3-16]. Left 4th and 5th digit flexion 4-/5. There is mild 4+/5 weakness of the iliopsoas muscles bilaterally. Dorsiflexion and plantar flexion are also full strength bilaterally. There was mild weakness of toe extension bilaterally. . SENSATION: Decreased sensation to cold temperature from hands to elbows bilaterally. Decreased vibration on toes bilaterally. . DTR: absent throughout. Toes dowgoing bilaterally. . COORDINATION: Finger nose finger without dysmetria, [Doctor First Name ] normal . GAIT: normal stride and arm swing Pertinent Results: [Doctor First Name 2841] - electrophysiologic findigs most c/w multifocal motor neuropathy w/ conduction block, affecting bilateral median nerves and ulnar nerve. Brief Hospital Course: This is a 77 yo man with multifocal motor neuropathy, CAD, HTN, OSA, s/p PCI, hyperlipidemia, restrictive lung disease (diagnosed [2117-6-25] with FVC of 34% predicted)who initially presented with slowly progressive dyspnea and orthopnea over six months. The patient also reported weakness of his left hand over the last year. On exam the patient was found to have proximal muscle weakness in his upper and lower extremities. He was also noted to have a numbness from his elbows to his finger tips bilaterally with weakness of his left 4th and 5th digits. He also had largely absent reflexes. The patient's [Month/Day/Year 2841] study from [2117-6-15] suggested his defecits are from a multifocal motor neuropathy with conduction block. He also seems to have an ulnar neuropathy. The pt was admitted for an elective 5 day course of IVIG for this motor neuropathy. After administration of the IVIG, the pts creatinine increased from 0.9 on [7-6] to 1.4 on [7-8], to 5.4 on [7-10], and to a peak of 7.4 on [7-11]. The pt was transferred to the MICU on [7-11] for this worsening renal function thought to be secondary to IVIG-mediated ATN, oliguria, and increasing SOB with a mild increase in O2 requirement. In the MICU, the pt was followed by renal. His Bumex was D/C'd, Aspirin and Indomethecin were also D/C'd. Renal US and CXR were obtained. Renal US showed no obstruction. CXR show no pulmonary congestion. Prior to transfer to the floor, the pt was given Lasix 120 mg IV x1 and chlorothiazide 500 mg IV x1. The pt diuresed 2L in response to these doses, and then he further autodiuresed 3-4 L each day subsequently. It was felt the pt had entered into the diuresis phase of ATN prior to discharge. The pt frequently required potassium repletion (K often 3.1-3.4) likely secondary to tubulopathy and inability for K reabsorption during the recovery phase of ATN. Indomethacin was held as was his allopurinol, but prior to discharge his allopurinol was restarted at a lower dose of 100 mg qod. The pts coumadin for his PAF was initially held given the possible need for hemodialysis, but this was restarted at 2.5 mg qhs and titrated up to 5 mg qhs with an INR prior to discharge of 1.6. The pt developed a hyponatremia of 128 on [7-12] which improved to 137 prior to discharge after he had been placed on fluid restriction and diuresed. Prior to and after discharge, po intake was encouraged as the pt was in the regeneration phase of his tubules and at risk of dehydration secondary to loss of tubular concentrating capacity. . The pts shortness of breath improved over his stay. The etiology was likely multifactorial including ARF in the setting of diastolic dysfunction and baseline CHF as well as restrictive lung disease. The pt continued on his home BIPAP machine at night. As the pt is on amiodarone IPF is also possible, but the pt is unable to lie flat for a CT. . Prior to discharge the pt began to c/o intense L hand swelling, throbbing, and numbnbess. This was more than at his usual ulnar neuropathy baseline. Venous US on [7-15] ruled out venous thrombus. The pt was started on a 6 day outpatient prednisone taper as he has a history of gout and his recent ARF/diuresis was a likely trigger (and his allopurinol had initially been held). Medications on Admission: lopressor 12.5 mg [Hospital1 ] bumex 2 mg [Hospital1 ] aspirin 81 mg daily KCL 10 meq daily indomethacin 50 mg [Hospital1 ] allopurinol 300 mg daily warfarin 2.5 mg daily amiodarone 200 mg daily mevacor 40 mg qhs butalbital prn stool softener combivent BIPAP at night supplemental oxygen Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [Hospital1 ]:90 Tablet(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [Hospital1 ]:30 Tablet(s) Refills:2 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [Hospital1 ]:30 Tablet, Chewable(s) Refills:2 6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [Hospital1 ]:30 Tablet(s) Refills:2 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). [Hospital1 ]:15 Tablet(s) Refills:2 8. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day for 5 days: take till potassium checked clinic on [2117-7-19]-then take more potassium if indicated by your primary care physician. [Name Initial (NameIs) ]:10 packets Refills:0 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: start with this dose. [Name Initial (NameIs) ]:6 Tablet(s) Refills:0 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: take after done with 60mg dose . [Name Initial (NameIs) ]:4 Tablet(s) Refills:0 11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: start after done with 40mg dose. [Name Initial (NameIs) ]:2 Tablet(s) Refills:0 12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO use as directed for 6 days: Take 3 tablets for 2 days, take 2 tablets for 2 days, and take 1 tablet for 2 days. [Name Initial (NameIs) ]:12 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: ulnar neuropathy multifocal motor neuropathy w/ conduction block Acute Renal Failure Obstructive Sleep Apnea Atrial Fibrillation Discharge Condition: stable Discharge Instructions: Please call your neurologist or return to the ED if you experience increased shortness of breath, weakness, numbness, decreased urine output. Please do not take Cholchicine till further notice. Please continue to maintain adequate fluid intake. Please keep all follow up appointments. Followup Instructions: Provider: [Last Name (NamePattern4) 35872]/[Last Name (NamePattern4) 35873], MD Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 44] Date/Time:[2117-7-16] 11:00 . Provider: [Name Initial (NameIs) 9484]CC2 PULMONARY LAB-CC2 Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2117-7-20] 8:30 . Provider: [Name10 (NameIs) 2841] LABORATORY Where: CLINICAL CTR-[Location (un) 35874]-NEUROLOGY DEPT Date/Time:[2117-7-20] 10:00 Dr. [Last Name (STitle) ]/[First Name8 (NamePattern2) 5627] [Last Name (NamePattern1) ]-PCP-[Telephone/Fax (1) 3183]-[2117-07-19] at 1:20PM-Please have your K, Cr and Chem panel checked. Your Cr. at time of discharge had decreased from 7.4 to 3.2 [Hospital ] CLINIC-[Hospital 35875] CLINIC WILL CALL YOU by [2117-7-16] with a follow up appointment. If you do not hear from the clinic by [2117-7-16]-please call them immeditaly to schedule a follow up appointment. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "276.1", "427.31", "428.32", "V45.82", "V58.61", "412", "401.9", "414.01", "272.0", "428.0", "E879.8", "274.9", "584.5", "354.2" ]	icd9cm	[ [ [] ] ]	[ "99.14" ]	icd9pcs	[ [ [] ] ]	12007, 12013	6510, 9830	334, 340	12186, 12194	6319, 6487	12528, 13676	4452, 4721		10180, 11984		12034, 12165	9856, 10157			12218, 12505										4736, 6300																												268, 296										368, 3636																3658, 4090	4106, 4436
4,264	148,786	729	Discharge summary	report	Admission Date: [2107-12-17] Discharge Date: [2107-12-24] Service: MICU CHIEF COMPLAINT: Hypotension times one day. HISTORY OF PRESENT ILLNESS: The patient is an 89 year old African-American female admitted in [7-1] after v-fib arrest. The patient was defibrillated in the field which was complicated by anoxic encephalopathy and the patient has remained vent dependent with PEG at JMR since. The patient had a large occiput decub debrided on day prior to admission and was subsequently noted to have persistent hypotension with IVF at 75 cc per hour and atrial fibrillation at a rate greater than 100. Today labs returned showing white blood cell count of 50, hematocrit 17, platelets 42 with a systolic blood pressure in the 80s. Temperature was 98.4, heart rate 76, respiratory rate 19. The patient was started on dopamine and was not given vanc/ceftaz 1 gm which had been ordered, but not given. The patient was transferred to [Hospital1 18] for further management. In the emergency room blood pressure was 99/49, heart rate 142, temperature 100.6 rectally. The patient's blood pressure then dropped to 40/palp and heart rate was 130. EKG at that time showed a-fib with rapid ventricular rate. The patient was cardioverted into a slower rate, but still with a-fib. The patient's blood pressure returned to 120/60. The patient was started on Neo-Synephrine in the emergency room as well. There were several central line attempts made in the left subclavian, right groin, then left groin with success. The patient was given 2 liters of normal saline and then transferred to the MICU. PAST MEDICAL HISTORY: Significant for v-fib arrest complicated by anoxic encephalopathy and vent dependent since [7-1]. Seizures status post status epilepticus in the past. Anemia. A-fib with CHF. Status post PEG. Chronic renal insufficiency. GI bleed/gastric AVM. Severe PHTN. Thrombocytopenia. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Amiodarone 200 mg p.o. q.day, Neurontin 600 mg t.i.d., Flagyl 500 mg p.o. t.i.d., omeprazole 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., captopril 25 mg p.o. t.i.d., Lopressor 12.5 mg p.o. b.i.d., multivitamin, Tylenol, Darvocet, Klonopin. SOCIAL HISTORY: The patient previously lived with family. Now the patient is vent dependent at JMR. No tobacco in the past. Social ETOH. PHYSICAL EXAMINATION: The patient was an obese, African-American female, trached, unresponsive, in decerebrate positioning, in no apparent respiratory distress. Vital signs were temperature 98.4, heart rate 70, blood pressure 115/40. Vent setting AC tidal volume 600, respiratory rate 15, PEEP 5, FiO2 50%. The patient was sating 100%. HEENT: 4 to 5 cm occiput decub to skull about 8 mm deep. Pupils nonreactive, left about 5 mm, right approximately 3 mm, fixed. Anicteric. Positive pallor. Neck trached, no lymphadenopathy, JVP not seen secondary to habitus. Difficult range of motion, but not meningitic. Chest symmetrical, good air exchange and minimal expiratory wheezes bilaterally. CV irregularly irregular heart rate, normal S1, S2, no murmurs, rubs or gallops. Abdomen: decreased bowel sounds, moderately distended with reproducible umbilical hernia. OB positive. Extremities had no clubbing cyanosis, positive 2 to 3+ edema, no splinter hemorrhages. Sacral decub to muscle. Neuro comatose, decerebrate, positive corneal reflex/gag, decreased tone in lower extremities, upgoing toe on right, equivocal on left. No biceps or patellar deep tendon reflexes elicited. LABORATORY DATA: White blood cell count 58, hematocrit 20, platelets 47, MCV 107. Chest x-ray within normal limits. KUB no pneumoperitoneum. HOSPITAL COURSE: The patient's hypotension was treated with Levophed which had been changed from Neo-Synephrine. The patient also had head CT and was started on ceftriaxone and vancomycin. The patient was also started on Cipro. Multiple blood cultures, urine cultures and fecal cultures were taken. Swabs of the occipital decub and sacral decub were taken. Head CT was negative for any acute intracranial process. There was new pansinusitis. There was evidence of a decubitus ulcer to bony calvarium. There was cerebral atrophy. There was old right frontal lucency which may be chronic epidural hematoma. Neurology was consulted who commented on the patient's prognosis. They concluded that her exam currently was consistent with only minimal brain function and that she had lost most of her brainstem function also. The patient had an EEG done that showed no seizure activity. The patient was noted to have facial twitching which was felt to be myoclonus which is not uncommon after anoxic brain injury. Although the patient did not meet criteria for brain death, her prognosis was very poor and there was very little chance of significant functional recovery, given the severity of her injury and the long period of time for recovery that she had already declared herself. A family meeting was set up with Dr. [Last Name (STitle) 5361] who the MICU team had consulted from the ethics committee. The patient had six sons and daughters, five of whom were present during this meeting. It was agreed during this meeting to make the patient DNR/DNI and that she would not want to be continued to be sustained through life support if there was no chance of meaningful recovery. It was decided at the end of the meeting that the missing sibling would be contact[Name (NI) ] and if she was in agreement with the rest of the siblings, the patient would be made CMO. After several days, all siblings agreed to make the patient CMO. On [2107-12-24] at approximately 10:00 p.m. Levophed was discontinued. Morphine drip was started. The patient was taken off the ventilator and put on a trach collar. The patient expired at approximately 2:55 a.m. on [2107-12-24]. There were no heart sounds on exam. There were no spontaneous respirations. Pupils were fixed and dilated. The patient's family was present and refused autopsy at this time. FINAL DIAGNOSIS: Pulmonary arrest. CONDITION ON DISCHARGE: Deceased. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2108-2-9] 08:52 T: [2108-2-11] 18:00 JOB#: [Job Number 5362]	[ "286.6", "707.0", "730.08", "348.1", "785.59", "427.31", "038.8", "519.01", "536.41" ]	icd9cm	[ [ [] ] ]	[ "96.6", "99.62" ]	icd9pcs	[ [ [] ] ]													3734, 6084	6102, 6121																											2408, 3716												108, 136										165, 1629															2001, 2244	1652, 1975	2261, 2385	6146, 6397
59,494	195,595	48406	Discharge summary	report	Admission Date: [2128-5-24] Discharge Date: [2128-5-28] Date of Birth: [2067-4-2] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: [2128-5-24]: 1. Coronary artery bypass graft x4, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: This 60-year-old patient with recent onset chest symptoms was investigated and was found to have severe 3-vessel disease with preserved left ventricular function and was referred for coronary artery bypass grafting. His medical history was significant for morbid obesity, weighing more than 400 pounds, and initially he elected to try to lose some weight before coming for the surgery and he manage to lose about 10 to 15 pounds but he was still well over 400 pounds. He was admitted for elective coronary artery bypass grafting. Past Medical History: Coronary Artery Disease Mobitz type 1 second degree heart block Hypertension Type II diabetes Morbid Obesity Varicose Veins with chronic venous stasis OSA- Recently placed on CPAP Hyperlipidemia History of Kidney stones MVA [2104] with right leg injury and chronic ankle edema up to [12-9] of right calf Hypothyroidism Gout Social History: Mr. [Known lastname 3748] lives alone. He works as a security officer at [Hospital1 3278] [Hospital1 336] but presently not working due to health issues. He does not smoke cigarettes, but does smoke 4 cigars weekly. He stopped smoking cigars 3 months ago. He drinks 2-7 drinks per week. Family History: Denies premature coronary artery disease Physical Exam: Admission Pulse: 96 Resp: 20 O2 sat: 96/RA BP (R) 138/75 (L) 130/76 Height:5'9" Weight:400 lbs General: Alert and oriented x3. No acute distress. Skin: Significant chronic venous stasis bilaterally HEENT: OP benign Neck: Supple, full ROM Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, distant heart sounds. No murmur appreciated. Abdomen: Morbidly obese with significant pannus. Otherwise soft, non-distended, non-tender, with normoactive bowel sounds Extremities: Warm with 1+ Edema Varicosities: Left GSV has significant varicosities above and below knee. Right GSV appears OK. Very difficult to assess on standing. Chronic venous stasis changes to skin. Neuro: Grossly intact Pulses: Femoral Right: non-palp due to obesity Left: non-palp due to obesity DP Right: palp Left: palp PT [Name (NI) 167]: palp Left: palp Radial Right: palp Left: palp R radial art puncture site c/d/i, no bleed/hematoma Carotid Bruit Right: none Left: none Pertinent Results: [2128-5-24] Intra-op TEE: Conclusions PRE-CPB: 1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Lipomatous septum. 2.Overall left ventricular systolic function is mildly depressed (LVEF= 50%). 3. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with mild global free wall hypokinesis. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is no pericardial effusion. POST-CPB: On infusion of epinephrine, phenylephrine. AV pacing, then apacing for slow sinus rhythm. Preserved lv systolic function with post cpb ef= 55%. The right ventricular systolic function is improved on inotropic support. TR, MR remain trace. The aortic contour is normal . [2128-5-28] 05:07AM BLOOD WBC-13.5* RBC-2.45* Hgb-7.8* Hct-24.0* MCV-98 MCH-31.8 MCHC-32.5 RDW-14.0 Plt Ct-186 [2128-5-27] 05:17AM BLOOD WBC-15.1* RBC-2.52* Hgb-7.8* Hct-24.3* MCV-96 MCH-31.1 MCHC-32.3 RDW-13.5 Plt Ct-128* [2128-5-28] 05:07AM BLOOD Glucose-112* UreaN-23* Creat-0.8 Na-137 K-4.0 Cl-99 HCO3-30 AnGap-12 [2128-5-27] 05:17AM BLOOD Glucose-118* UreaN-22* Creat-0.9 Na-134 K-4.3 Cl-99 HCO3-30 AnGap-9 Brief Hospital Course: The patient was brought to the operating room on [2128-5-24] where the patient underwent Coronary artery bypass graft x4, left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal, obtuse marginal and posterior descending arteries. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Respiratory: He remained intubated secondary to airway difficulty and body habitus. He was successfully extubated on POD1. Aggressive pulmonary toilet, incentive spirometer, ambulation and good pain control continued and his oxygenation improved. Cardiac: Hemodynamically stable in SR with 1st degree AVB 80-90's. Beta-blockers were intiated POD1 and titrated as needed. Atorvastatin and low dose aspirin were restarted. GI: obese. benign. GU: He was seen by urology for difficult foley insertion. He was found to have a false passage of urethra requiring placement of a 16 French council with cystoscopic assistance. Foley to remain inplace for 1-2 weeks with voiding trial at home. Renal: He was gently diuresed. Renal function remained within normal range. Electrolytes were repleted as needed. Endocrine: Levothyroxine was restarted. Insulin sliding scale was continued to maintain blood sugars <150. Disposition: The patient was evaluated by the physical therapy service for assistance with strength and mobility. They recommended rehab for continued strength training. He continued to make steady progress and was discharged to [Hospital ] HealthCare on POD 4. Medications on Admission: 1. Allopurinol 300 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Potassium Chloride 20 mEq PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Indomethacin 50 mg PO DAILY 7. Levothyroxine Sodium 200 mcg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO DAILY 2. Levothyroxine Sodium 200 mcg PO DAILY 3. Acetaminophen 650 mg PO Q4H:PRN pain/fever 4. Aspirin EC 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Allopurinol 300 mg PO DAILY 8. Furosemide 40 mg PO BID Duration: 7 Days 9. Furosemide 20 mg PO DAILY resume home dose of 20mg daily after 1 week course of 40mg [Hospital1 ] 10. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > 11. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. 12. Oxycodone-Acetaminophen (5mg-325mg) [12-8] TAB PO Q4H:PRN pain RX Endocet 5 mg-325 mg [12-8] Tablet(s) by mouth q4-6 Disp #40 Tablet Refills:0 13. Indomethacin 50 mg PO DAILY 14. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Discharge Diagnosis: Coronary Artery Disease Mobitz type 1 second degree heart block Hypertension Hyperlipidemia Hypothyroidism Type II diabetes Morbid Obesity Possible OSA recently placed on CPAP History of Kidney stones Gout MVA [2104] w/right leg injury and chronic ankle edema up to [12-9] of right calf Varicose Veins with chronic venous stasis PSH: Right knee arthroscopy/meniscus repair [2119] Discharge Condition: Alert and oriented x3 nonfocal deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: 2+ 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] WOUND CARE NURSE Phone:[Telephone/Fax (1) 170] Date/Time:[2128-6-8] 10:15 Surgeon Dr. [Last Name (STitle) ] [2128-6-29] at 2:00pm [Telephone/Fax (1) 170] Cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [2128-7-6] at 10:00 Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 28549], [First Name3 (LF) ] in [3-11] weeks ([Telephone/Fax (1) 101928] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2128-5-28]	[ "250.00", "272.4", "454.9", "276.2", "401.9", "414.01", "274.9", "426.13", "327.23", "276.69", "V85.43", "414.2", "244.9", "V13.01", "278.01", "459.81", "305.1", "599.4" ]	icd9cm	[ [ [] ] ]	[ "36.13", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	7560, 7613	4606, 6375	326, 600	8050, 8206	2944, 4583	8924, 9770	1851, 1893		6739, 7537		7634, 8029	6401, 6716			8230, 8901										1908, 2925																												269, 288										628, 1161																1183, 1517	1533, 1835
73,979	110,096	30659	Discharge summary	report	Admission Date: [2184-9-20] Discharge Date: [2184-9-27] Date of Birth: [2119-12-26] Sex: M Service: SURGERY Allergies: Keflex Attending:[First Name3 (LF) 668] Chief Complaint: renal transplant Major Surgical or Invasive Procedure: Renal transplant right iliac fossa. History of Present Illness: 64M with DM and HTN with ESRD and on dialysis for approximately 1 year presents for renal transplantation. Overall feels well, denies fevers, chills, nausea, vomiting, diarrhea, recent illness, travel or sick contacts. Past Medical History: PMH: ESRD (most likely secondary to DM nephropathy, T/Th/Sat HD), DM, HTN, now resolved SDH after fall, actinic keratosis PSH: RUE AV fistula creation Social History: married, lives with wife, no smoking or alcohol use Family History: HTN Physical Exam: Discharge physical NAD no murmurs ctab abd protubertant, incision c/d/i, closed with staples, some surrounding ecchymosis, no rebound or guarding no LE edema Pertinent Results: On Admission: [2184-9-20] WBC-4.4 RBC-3.41* Hgb-11.7* Hct-37.0* MCV-108# MCH-34.3# MCHC-31.7 RDW-16.2* Plt Ct-160 PT-12.5 PTT-25.5 INR(PT)-1.1 UreaN-54* Creat-4.9# Na-140 K-4.3 Cl-97 HCO3-29 AnGap-18 ALT-12 AST-27 Albumin-4.4 Calcium-9.3 Phos-4.5 Mg-2.4 At Discharge [2184-9-27] WBC-7.7 RBC-2.79 Hgb-9.3* Hct-28.9* MCV-104* MCH-33.3* MCHC-32.1 RDW-15.6* Plt Ct-175 Glucose-112* UreaN-62* Creat-3.7* Na-136 K-3.4 Cl-98 HCO3-29 AnGap-12 ALT-13 AST-27 AlkPhos-54 TotBili-0.6 Albumin-3.0* Calcium-8.4 Phos-3.3 Mg-2.3 tacroFK-9.0 Brief Hospital Course: This is a 64 yo M w/ ESRD likely secondary to diabetes who was admitted to the hospital for a renal transplantation. He was taken to the OR with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and underwent transplant without complications. On the night of POD#0, the patient had acute change in mental status. Was given Narcan 1.6 mg, will little change. NC Head CT did not show acute changes, and he was transferred to SICU, and returned to baseline without further intervention. Transferred back to floor on POD#1 with no further events. #RENAL Was dialyzed as needed, he was not dialyzed day of discharge as his creatinine was slightly decreased and renal was recommending watching for now. Received ATG doses x 4 and received intra-op solumedrol with routine taper, cellcept per protocol as well as starting prograf on the evening of POD 0. Levels have been monitored daily with dosing adjusted per level. On day of discharge pt and staff felt safe to discharge pt to rehab with close follow up. Medications on Admission: erythropoietin on HD, felodipine 5', nortriptyline 75', furosemide 40'', neurontin 300''', toprol XL 50'(non-HD days), actos 45', allopurinol 100', calcium acetate 2 pills with meals, simvastatin 20', tricor 145', fish oil Discharge Medications: 1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection every six (6) hours. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for Pain. 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Total dose 3.5 mg [Hospital1 ]. 17. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day: Total dose 3.5. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Hospital1 8] Discharge Diagnosis: ESRD now s/p kidney transplant 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 the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, incisional redness, drainage or bleeding, increased pain over the graft site, inability to tolerate food, fluids or medications, decreased urine output. Labs to be drawn daily initially, and send results to the transplant clinic, fax # [Telephone/Fax (1) 697], as nephrologists will determine need for further hemodialysis. Once stable, the labs may be drawn every Monday and Thursday. Please do not adjust medications without consultation with the transplant clinic Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2184-9-30] 3:20, [Hospital ] clinic, [Street Address(2) ], [Hospital Unit Name ], [Location (un) ], [Location (un) 86], MA Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2088], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2184-10-12] 9:50 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2184-10-12] 11:00 Completed by:[2184-9-27]	[ "996.81", "788.5", "E878.0", "585.6", "403.91", "780.62", "250.40", "583.81" ]	icd9cm	[ [ [] ] ]	[ "00.93", "55.69", "39.95" ]	icd9pcs	[ [ [] ] ]	4365, 4426	1590, 2616	283, 320	4501, 4501	1029, 1029	5305, 5878	831, 836		2890, 4342		4447, 4480	2642, 2867			4684, 5282										851, 1010																												227, 245										348, 569								1043, 1567	4516, 4660							591, 745	761, 815
24,800	109,340	17832	Discharge summary	report	Admission Date: [2139-4-17] Discharge Date: [2139-4-20] Date of Birth: [2059-4-12] Sex: F Service: NEUROLOGY Allergies: Cardizem / Plavix / Prozac / Accupril / Crestor / Topiramate / Norvasc / Demerol / Bextra / Lescol / Famvir Attending:[First Name3 (LF) 5868] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: none History of Present Illness: History of Present Illness: The patient is an 80 year old woman with multiple vascular risk factors now presenting with acute onset left sided weakness and slurred speech. She was in her usual state of health until around 9 am today when the son noticed that her left face was drooping and she wasn't moving her left side. He says she got up around 8 am and was initially fine. She had her brought to [Hospital3 7571]Hospital where her symptoms initially seemed to resolve. About 1 hour later (after CT scan), she acutely re-developed the left facial droop, "flaccid paralysis" on left arm and dysarthria. She was started on heparin and transferred to [Hospital1 18] ED for further care. She had a recent colonscopy where colon CA was discovered. She underwent a partial colectomy and was admitted to [Location (un) ] from [4-7] to [4-15]. During this time, her warfarin was held. She was restarted on upon discharge. Past Medical History: Past Medical History: -high blood pressure -atrial fibrillation -colon ca s/p resection -high cholesterol -CAD s/p pacer -s/p cataract surgeries -anxiety -copd -gerd Social History: Social History: -lives with daughter -no smoking or drinking Family History: Family History: -non-contributory Physical Exam: Physical Exam Vitals: 98.6 140/80 88 irreg 16 General: older woman, nad Neck: supple Lungs: clear to auscultation CV: irregular rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, trace edema Neurologic Examination: awake, alert, neglecting left side, answering questions but somewhat dysarthric, able to repeat, naming impaired, following simple commands; perrl 2 to 1 mm, eyes moving all about, left facial droop, tone decreased on left side, seems full strength on the right, [2-1] UMN weakness on left arm and leg, reflexes brisks and symmetric, toe up on left; responds to pain x4, less so on left; gait exam deferred Pertinent Results: [2139-4-17] 05:52PM %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE [2139-4-17] 03:47PM GLUCOSE-126* UREA N-12 CREAT-0.8 SODIUM-144 POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-30 ANION GAP-15 [2139-4-17] 03:47PM ALT(SGPT)-79* AST(SGOT)-37 LD(LDH)-363* CK(CPK)-64 ALK PHOS-103 AMYLASE-46 TOT BILI-0.7 [2139-4-17] 03:47PM LIPASE-38 [2139-4-17] 03:47PM CK-MB-NotDone [2139-4-17] 03:47PM ALBUMIN-3.6 URIC ACID-6.2* [2139-4-17] 03:47PM CRP-62.5* [2139-4-17] 03:47PM PT-17.2* PTT-32.4 INR(PT)-1.6* [2139-4-17] 02:10PM cTropnT-0.01 [2139-4-17] 02:10PM CHOLEST-73 [2139-4-17] 02:10PM TRIGLYCER-103 HDL CHOL-29 CHOL/HDL-2.5 LDL(CALC)-23 [2139-4-17] 02:10PM TSH-3.6 [2139-4-17] 02:10PM WBC-9.9 RBC-3.43* HGB-10.6* HCT-31.8* MCV-93 MCH-30.9 MCHC-33.4 RDW-15.8* [2139-4-17] 02:10PM NEUTS-81.3* LYMPHS-13.3* MONOS-5.0 EOS-0.4 BASOS-0.1 [2139-4-17] 02:10PM MACROCYT-1+ [2139-4-17] 02:10PM PLT COUNT-193 [2139-4-17] 02:10PM SED RATE-22* [2139-4-20] 03:41AM BLOOD WBC-23.7* RBC-3.81* Hgb-11.9* Hct-34.9* MCV-92 MCH-31.1 MCHC-34.0 RDW-15.3 Plt Ct-219 [2139-4-20] 11:50AM BLOOD PT-40.6* PTT-110.9* INR(PT)-4.6* [2139-4-20] 03:41AM BLOOD Fibrino-330 [2139-4-17] 02:10PM BLOOD ESR-22* [2139-4-20] 03:41AM BLOOD Glucose-125* UreaN-23* Creat-1.6* Na-131* K-5.1 Cl-95* HCO3-15* AnGap-26* [2139-4-20] 08:31AM BLOOD CK(CPK)-181* [2139-4-20] 03:41AM BLOOD ALT-3233* AST-3967* LD(LDH)-2087* CK(CPK)-179* AlkPhos-133* Amylase-58 TotBili-1.8* [2139-4-20] 08:31AM BLOOD CK-MB-11* MB Indx-6.1* [2139-4-20] 03:41AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.0 [2139-4-19] 12:53PM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.9 Mg-2.0 [2139-4-17] 05:52PM BLOOD %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE [2139-4-17] 02:10PM BLOOD Triglyc-103 HDL-29 CHOL/HD-2.5 LDLcalc-23 [2139-4-20] 08:31AM BLOOD TSH-1.2 [2139-4-20] 08:31AM BLOOD Free T4-1.6 [2139-4-17] 03:47PM BLOOD CRP-62.5* [2139-4-20] 12:04PM BLOOD Type-ART pO2-134* pCO2-22* pH-7.29* calTCO2-11* Base XS--13 [2139-4-20] 12:04PM BLOOD Lactate-14.4* [2139-4-20] 12:39PM BLOOD Hgb-12.0 calcHCT-36 O2 Sat-79 [2139-4-20] 12:04PM BLOOD freeCa-0.96* [2139-4-20] 12:04PM BLOOD freeCa-0.96* Brief Hospital Course: Assessment and Plan: The patient is an 80 year old woman with multiple vascular risk factors now presenting with acute onset left sided weakness. Her exam shows a left neglect, dysarthria, left sided weakness. She appears to have a significant territory right MCA stroke, probably embolic given her subtherapeutic INR. We will admit her to neurology and do the following: 1. d/c heparin as her risk of bleeding is high 2. start dopamine and achieve SBP 160-200 3. obtain stat head cta 4. obtain carotid US 5. will check lipid profile * * * Ms. [Known lastname ] had a non-contrast Head CT that revealed hypodensity in the right subcortical and insular white matter consistent with infarct. CTA of the head revealed calcifications of the carotid bifurcations, left greater than right, without significant stenosis, but otherwise the major tributaries of the circle of [Location (un) 431] were patent. She was admitted to the intensive care unit due to her need for pressors. While there she began to exhibit septic physiology, with a WBC up to 24, evidence of DIC, and lactate as high as 14. She was placed on broad-spectrum antibiotics but her condition did not improve. She had an echocardiogram on [4-20] that revealed left ventricular cavity enlargement with severe regional systolic dysfunction c/w multivessel CAD, right ventricular hypokinesis, and moderate mitral regurgitation. A chest CTA on [4-19] revealed a pulmonary embolism within a left upper lobe segmental pulmonary artery and bilateral pleural effusions. As her overall condition continued to deteriorate, a family meeting was held. Ms. [Known lastname 49482] siblings asserted that she would never want to be dependent on others, even if it was for a few months. Given her stroke, this was almost a certainty, and it could not be said that she would ever recover her independence fully. This fact, taken together with her deteriorating overall condition, brought her family to decide that in accordance with her previously expressed wishes, care would be withdrawn. Hence on [4-20] care was withdrawn and Ms. [Known lastname ] [Last Name (Titles) ]. Medications on Admission: Medications: -asa 81 -warfarin -avapro -imdur -metformin -spiriva -clonazepam -lasix -zetia -lipitor -fish oil -nifedipine -toprol xl Discharge Medications: None Discharge Disposition: [Last Name (Titles) ] Discharge Diagnosis: Right middle cerebral artery infarct Sepsis Discharge Condition: [Last Name (Titles) ] Discharge Instructions: None Followup Instructions: None	[ "530.81", "415.19", "041.04", "038.9", "272.0", "V45.01", "599.0", "785.52", "V10.05", "995.92", "V66.7", "401.9", "518.82", "434.11", "427.31" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	7036, 7063	4652, 6822	389, 395	7150, 7177	2384, 4629	7230, 7237	1673, 1692		7007, 7013		7084, 7129	6848, 6984			7201, 7207										1707, 1928																												330, 351										451, 1372														1952, 2365		1416, 1562	1594, 1641
24,753	172,375	52554	Discharge summary	report	Admission Date: [2163-6-15] Discharge Date: [2163-6-21] Date of Birth: [2091-7-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Angina Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to Diag) [2163-6-17] History of Present Illness: 71 y/o male with exertional angina and postive stress test. Referred for cardiac cath which revealed three vessel disease. Past Medical History: Hypertension, Benign Prostatic Hypertrophy, Cerebrovascular Accident [4-13], Colon Cancer s/p colectomy & XRT, s/p hernia repair, s/p tonsillectomy Social History: Professor. [First Name (Titles) ] [Last Name (Titles) ] tob 20 yrs ago after 70ppyhx. Drank beers/day until 6 months ago. Family History: Brother with MI x 2 in his 50's Physical Exam: VS: 53 18 160/79 5'9" 90.7kg General: WD/WN male in NAD HEENT: EOMI, PERRL, OP benign, submandibular fullness Neck: Supple, FROM, -JVD, R Carotid Bruit Lungs: CTAB -w/r/r Heart: RRR, +S1S2, -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema or varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Headt CT [6-14]: Old left occipital infarct. Dense calcifications noted within the carotid siphons. Carotid U/S [6-14]: No significant ICA or CCA stenosis bilaterally. Cardiac Cath [6-14]: Selective coronary angiography showed a left dominant system with three vessel disease. The LMCA was severely calcified with no flow limiting stenoses. The LAD had an ostial ulcerated 30-40% stenosis, a mid 80% stenosis and a apical 80% stenosis. The proximal and mid LAD was heavily calcified and the vessel wrapped around the apex. The D1 had an ostial 60% stenosis and the D2 had a mid 60-70% stenosis. The LCX was heavily calcified with an ostial 90% stenosis. The OM1 had a proximal 80% stenosis. The distal LCX was diffusely diseased and there was a small LPDA. The RCA was a small non-dominant vessel and diffusely diseased with subtotal occlusion in the mid segment. Left ventriculography showed mild hypokinesis of the basal posterobasal wall. The calculated contrast jection fraction was 57%. There was trace mitral regurgitation. Echo [6-16]: The left atrium is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. CXR [6-20]: No evidence of pneumothorax. Postoperative changes with residual left pleural effusion and bibasilar atelectasis. [2163-6-14] 09:15AM BLOOD WBC-6.9 RBC-4.38* Hgb-13.5* Hct-37.8* MCV-86 MCH-30.9 MCHC-35.9* RDW-12.9 Plt Ct-192 [2163-6-20] 08:05AM BLOOD WBC-12.0* RBC-3.53* Hgb-10.7* Hct-31.1* MCV-88 MCH-30.2 MCHC-34.3 RDW-13.1 Plt Ct-143* [2163-6-14] 09:15AM BLOOD PT-12.4 PTT-25.6 INR(PT)-1.1 [2163-6-20] 08:05AM BLOOD PT-12.5 PTT-24.1 INR(PT)-1.1 [2163-6-14] 09:15AM BLOOD Glucose-147* UreaN-12 Creat-0.8 Na-137 K-4.1 Cl-106 HCO3-24 AnGap-11 [2163-6-20] 08:05AM BLOOD Glucose-205* UreaN-14 Creat-0.9 Na-134 K-4.2 HCO3-27 [2163-6-20] 08:05AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.9 [2163-6-14] 09:15AM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE [2163-6-14] 12:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2163-6-14] 12:10PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]->1.035 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] [Last Name (Titles) 1834] a cardiac cath which revealed three vessel disease. He was admitted and worked-up for coronary bypass surgery. He [Last Name (Titles) 1834] usual pre-operative work-up as well as a head CT and carotid U/S (please see pertinent results). He consented to surgery and was brought to the operating room on [2163-6-17] where he [Date Range 1834] a coronary artery bypass graft x 3. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one his chest tubes were removed. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. He was then transferred to the cardiac surgery step down floor on post-op day one. Epicardial pacing wires were removed on post-op day three. Beta blockers were titrated for maximum BP and HR control. Physical therapy followed patient during entire post-op course for strength and mobility. He continued to improve without any complications post-operatively. He was discharged home on post-op day four in good condition with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin 81mg qd, Flomax 0.4mg qd, Proscar 5mg qd, Toprol 50mg qd, Folic Acid 400mg qd plavix pre-cath [6-14] dose Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:1 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:40 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Hypertension, Benign Prostatic Hypertrophy, Cerebrovascular Accident [4-13], Colon Cancer s/p colectomy & XRT, s/p hernia repair, s/p tonsillectomy Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you develop a fever or notice redness or drainage from incisions, please contact office immediately. Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks Dr. [Last Name (STitle) ] in [2-11] weeks Dr. [Last Name (STitle) 12816] in [1-10] weeks Completed by:[2163-7-11]	[ "600.00", "V10.05", "411.1", "414.01", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.12", "39.61" ]	icd9pcs	[ [ [] ] ]	6720, 6803	3798, 5146	327, 415	7064, 7070	1273, 3775	7457, 7636	905, 938		5316, 6697		6824, 7043	5172, 5293			7094, 7434										953, 1254																												281, 289										443, 567																589, 742	758, 889
9,358	156,369	4304	Discharge summary	report	Admission Date: [2134-7-6] Discharge Date: [2134-7-7] Date of Birth: [2087-9-20] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 46 year-old male with a history of dilated cardiomyopathy thought secondary to chronic Lyme disease versus chronic alcohol use with an ejection fraction of approximately 10% with clean coronaries by recent cardiac catheterization, recently discharged from the Cardiology Service following admission with decompensated congestive heart failure who now returns on [7-6] with cardiogenic shock. The patient described a four to five day history of worsening fatigue, dyspnea on exertion and increasing chest pain. On presentation to the outside hospital on [Hospital3 ] the patient was hypotensive and tachycardic complaining of 10 out of 10 chest pain. He subsequently became more hypotensive with administration of nitroglycerin. He did not respond to morphine. Electrocardiogram showed a left bundle branch block, which was old. Laboratory studies were notable for worsening creatinine, hyperkalemia and acidosis. He was treated for a question of an acute coronary syndrome at the outside hospital with a heparin drip, Plavix and intravenous Lopressor. The patient apparently refused an intrafat balloon pump and placement of a central venous line at the outside hospital. He was subsequently transferred to the [Hospital1 69] that evening where he had his care in the past. On admission the patient was tachycardic and hypotensive again complaining of chest pain. He had minimal urine output throughout the day. He was noted to be hyperkalemic to 7.0 and acidotic consistent with a metabolic acidosis. His liver function tests and CKs were elevated consistent with multi-organ failure in the setting of shock. Venous access was obtained through a left femoral line. The patient was started on inotropic support with Dobutamine and pressor support with Dopamine. The patient was given Kayexalate bicarbonate, insulin and calcium gluconate for hyperkalemia. Heparin drip was discontinued given the patient's persistently elevated INR. The patient was given one dose of intravenous vitamin K. We decided not to pursue a internal jugular line and Swan-Ganz placement given his coagulopathy. The following morning the patient did receive one unit of fresh frozen platelets and was taken urgently to the catheterization laboratory where a PA catheter was placed revealing elevated biventricular pressures, clean coronary arteries and a depressed cardiac index consistent with severe cardiogenic shock. The patient returned from the catheterization laboratory on max dose of three pressors. The patient remained hypotensive to the 60s with maps in the 40s despite the addition of a fourth pressor at max dose. The patient subsequently experienced asystolic arrest on the floor from which he was revived with medications and transcutaneous pacing. The patient subsequently arrested again after being made DNR/DNI by his family. The time of death was approximately 2:00 p.m. on [2134-7-7]. [Last Name (LF) ],[Name8 (MD) 2064] M.D.12-ABZ Dictated By:[Last Name (NamePattern4) 4689] MEDQUIST36 D: [2134-7-9] 12:29 T: [2134-7-14] 08:37 JOB#: [Job Number 18638]	[ "276.7", "785.51", "998.12", "425.4", "428.0", "570", "584.9", "427.1", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "88.53", "37.61", "37.23", "96.04", "88.56" ]	icd9pcs	[ [ [] ] ]																																																															154, 3321
53,269	149,298	44395+58710	Discharge summary	report+addendum	Admission Date: [2125-1-4] Discharge Date: [2125-1-23] Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 4748] Chief Complaint: bilateral foot pain with weight bearing and bloody drainage rt. toe #2 Major Surgical or Invasive Procedure: [1-8] angiogram diagnostic [1-10] Right Fem-peroneal bypass [1-16] Right 2nd toe amputation History of Present Illness: bilateral foot pain with weight bearing and bloody drainage rt. toe #2 HPI: [Age over 90 ]y/o male with multiple medical problems [Name (NI) 95177] to his gerntologist [2124-12-4] with c/o right foot pain. Foot exam demonstrated calicies and smal ulceration of right plantar heel. Recommendation at that time was to followup with his podiatrist for shoe fitting and possible new shoes prior to leaving to [State 108] for vacation. Did well in [State 108] but upon return to [Location (un) 86] [2123-12-25] noted increasing foot pain bilaterally. Wife noted yesterday when changing his socks bleeding on the sock. Saw his podiatrist today who did a foot film per wife which showed osteo. Patient refered to Dr. [Last Name (STitle) 1391]. Seen in office and now admitted for antibiotics and vascular evaluation. Of note patient previously underwent left SFA-peroneal bpg with right arm vein by Dr. [Last Name (STitle) 1391]. Patient has also had right CEA [8-/2112] staged with his CABG's. Ultrasound at the time of CEA showed bilateral carotid stenosis right > left. Past Medical History: 1. DM2 -latest A1C 6.1% 2. CAD s/p CABG x4 in [2111], SVG to post and lat circ, svg to OM, LIMA to LAD 3. s/p MI (15 years ago) 4. chronic systolic CHF, EF 20% 9/08 5. h/o afib -per chart. Patient denies this. 6. CKD -baseline Cr 2.3 7. Peripheral neuropathy 8. Hypertension 9. PVD s/p fem-[Doctor Last Name ] bypass in [2115] 10. Hypercholesterolemia 11. Depression 12. Memory loss 13. CVA [2109] 14. Left intertrochanteric fracture s/p ORIF [2124-8-10] 15. Recent PE in early [7-21], on coumadin 16. History of R CEA Social History: Lives at home with wife of 60 years. Just d/c'ed from [Hospital1 ]. Ambulates with cane. Denies tobacco, illicit drugs. Occasional EtOH use. Import Social History Family History: non-contributory Physical Exam: VS: 98.8 98.2 67 183/80 18 99%RA Gen : oriented x 3, no acute distress HEENT: no JVD, carotid 1+palp bilat. no bruits Lungs: CTA Heart: RRR, no mumur,gallop or rub ABD. soft nontender, bs active no bruits or masses EXT: left foot cool rubrous , no ulcers rt. foot cool, #2 tore with abraded tip to bone and cynotic toe Pulses: RIGHT: fem/[Doctor Last Name ]/dp/pt: palp/palp/dopp-mono,/dopp-mono LEFT: fem/[Doctor Last Name ]/dp/pt :palp/0/dopp-mono/palp Neuro:AAOx3, nonfocal Pertinent Results: [2125-1-4] 09:14PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2125-1-4] 09:14PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2125-1-4] 09:14PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 [2125-1-4] 08:00PM GLUCOSE-182* UREA N-69* CREAT-3.3* SODIUM-135 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-22 ANION GAP-18 [2125-1-4] 08:00PM estGFR-Using this [2125-1-4] 08:00PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.9 [2125-1-4] 08:00PM TSH-76* [2125-1-4] 08:00PM T4-2.2* FREE T4-0.35* [2125-1-4] 08:00PM WBC-12.4# RBC-3.76 HGB-11.4* HCT-32.5* MCV-86 MCH-30.3 MCHC-35.1* RDW-14.3 [2125-1-4] 08:00PM PLT COUNT-339 CXR:Moderate to severe cardiomegaly unchanged. No pulmonary edema or appreciable pulmonary vascular abnormality, no pleural effusion. The patient has had median sternotomy and coronary bypass grafting. [2125-1-4] 08:00PM PT-27.2* PTT-35.2* [Month/Day/Year 263](PT)-2.7* Brief Hospital Course: [2125-1-4] Admitted. c/s sent of rt.#2 toe,Renally dose ATBX began and Vanco levels monetered. [2125-1-5] Vein mapping and arterial studies completed. Will need and angio. Scheduled for Monday [1-8] thydroid function studies demonstrate thypothyroidism.discussed with patient geritrician, will began low dose of syntyhroid 25mcg daily. 1/24-25/09 No acute events, scheduled for lower extremity angiogram [2125-1-8]. [2125-1-8] Underwent Ultrasound-guided puncture of left common femoral artery. 2. Contralateral third-order catheterization of right superficial femoral artery. 3. Abdominal aortogram with pelvic angiogram. 4. Right lower extremity angiogram. Unable to revascularize, scheduled for right fem-peroneal bypass on [2125-1-10]. Continues on Heparin drip. [2125-1-9] No acute events, angio access benign. Pre-op and consented for lower extremity bypass in am. Continues on Heparin drip. [2125-1-10] Taken to OR and underwent right fem-peroneal bypass and transfered to PACU intubated secondary to intraoperative hypotension, patient was not extubated and transfered to CTICU for vent support. serial troponins were done inital 0.56 peaked 0.66. Cardiology was consulted postoperatively. [2125-1-11] POD#1 CTICU D2 Remains intubated on vent. PA-line, art line remain. [2125-1-12] POD #2 CTICU D3 possible vent wean and extubate today if ABG's satifactory and mental status continues to improve. A-line and PA-line remain. Creatinine rising, admission 3.3-> 3.8 today, ruled in for NSTEMI. Continue to cycle cardiac enzymes. Cardiology following- recs BP control-on Nitro gtt and Hydralazine IV prn, beta blocker. PA line d/c'd. [2125-1-13] POD#3 CTICU D4 Extubated. Remains on Nitro drip and Hydralazine prn for BP control. Trop today .75 from <-.66<-.56. [2125-1-14] POD#4 Transferred to [Hospital Ward Name 121] 5/VICU, oral meds resumed. Weaned off Nitro drip. [2125-1-15] POD#5 No acute events. Vanco trough elevated 24.2, Vanco d/c'd. Remains on Cipro and Flagyl. Checking daily Vanco random levels. Pre-op and consented for right 2nd toe amputation. [2125-1-16] POD #6 Taken to OR, underwent right 2nd toe amputation, tolerated procedure well, recovered in PACU, then transferred back to [Hospital Ward Name 121] 5. Vanco level 18.8. [2125-1-17] POD#[6-13] No acute events. Physical therapy consult for discharge planning- out of bed w/ 2 person assit. vanco level 17.4, creatinine slowly coming down today 3.5 (admission 3.2). Foley catheter d/c'd. [Date range (1) 95178] POD#8-9/2-3 No acute events. Physical therapy following. Remains on Heparin drip- Coumadin bridge, [Date range (1) 263] 1.3. [Date range (1) 95179] POD#10-11/4-5 No acute events. Physical therapy strongly recommends short term rehab, patient and family amenable. Continued heparin drip, [Date range (1) 263] 1.8. [2125-1-22] POD#[11-18] Patient screened for rehab. Heparin drip continued, [Month/Day (4) 263] nearly to [Month/Day (4) ] at 1.9 ([Month/Day (4) ] [1-16]). Plan to d/c to rehab when bed available and d/c heparin drip at that time. [2125-1-23] Discharged to [Hospital3 ] Hospital in stable condition, will FU w/ Dr. [Last Name (STitle) 1391] in 2 weeks. Staples will come out at rehab in 1 week. [Last Name (STitle) 263] today is 1.9, will continue w/ daily dosing of Coumadin till [Last Name (STitle) ] is reached and stable. Medications on Admission: coreg 3.125 mg [Hospital1 ] aricept 10 mg qd lasix 40 mg qd hydralazine 10 mg [Hospital1 ] imdur 30 mg qd omeprazole 20 mg qd simvastatin 10 mg qd aldactone 12.5 mg [Hospital1 ] flomax 0.4 mg qd effexor xr 75 mg qd coumadin 2 mg qd (held since [2125-1-3]) colace 100 mg [Hospital1 ] Novolin [Hospital1 ] MVI . Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Four (24) Units Subcutaneous qAM. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) Units Subcutaneous at bedtime. 17. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) Units Injection with meals: REGULAR INSULIN SLIDING SCALE AS FOLLOWS: 121-160 2Units 161-200 4Units 201-241 6Units 241-280 8Units >280 Notify MD. 18. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please have [Hospital1 263] checked and adjust coumadin dose as per protocol. [Hospital1 18303] [Hospital1 263] [1-16]. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: rt. # 2 toe ischemic changes, gangrene history of DM2, insuin dependant with neuropathy history of perpheral vascular disease s/p left fem-peroneal BPG [8-/2116] history of c6-7 radiculopathy with C4-5 spinal canal stenosis history of CVA,s/p rt.CEA history of coriinary disease s/p CABG"s x4, MI 96w CHF,NSTEMI [1-15] GI bleed [9-20] history of AF, anticoagulated history of DVT, recurrent PEx2, anticoagulated history of dyslipdemia history of macular degeneration history of dyslipdemia history of GI bleed, transfused history of cardiac arrest [1-15] SVT w aberancy with GI bleed [9-20] history of ileus [1-15] narcotics. postoperative NSTEMI acute on chronic renal failure Discharge Condition: stable Discharge Instructions: Lower Extremity Bypass Discharge Instructions Have [Month/Day (2) 263] checked as arranged by your rehab facility, adjust coumadin dose as directed by your doctor. [First Name (Titles) 18303] [Last Name (Titles) 263] [1-16]. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to <2 gm sodium diet. - ambulate essential distances untill FU with Dr. [Last Name (STitle) 1391] - Ace wrap leg from foot-knee when ambulating - Elevate leg when sitting - may shower, no tub baths - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Continue all medications as directed - Keep all follow-up appointments - You have an appointment with Dr. [Last Name (STitle) 1391] scheduled at 9:30AM on WEDNESDAY, [2-7]. Please call [Telephone/Fax (1) 1393] if you need to reschedule. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) 1391] scheduled at 9:30AM on WEDNESDAY, [2-7]. Please call [Telephone/Fax (1) 1393] if you need to reschedule. Completed by:[2125-1-23] Name: [Known lastname ],[Known firstname ] Unit No: [Numeric Identifier 15053] Admission Date: [2125-1-4] Discharge Date: [2125-1-23] Date of Birth: [2033-9-24] Sex: M Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 231] Addendum: Note: Upon final med reconciliation, 2 corrections were made to D/C medication list prior to discharge: Hydralazine is 10mg PO TID (instead of 25mg PO TID as previously listed) Insulin sliding scale is HUMALOG (instead of regular as previously listed) Discharge Disposition: Extended Care Facility: [Hospital6 41] - [Location (un) 42] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2125-1-23]	[ "424.0", "997.1", "440.24", "V45.81", "E878.2", "250.60", "428.0", "428.22", "403.90", "707.14", "250.50", "584.9", "V58.67", "250.40", "707.15", "410.71", "357.2", "362.01", "362.50", "414.00", "583.81", "585.4" ]	icd9cm	[ [ [] ] ]	[ "88.48", "88.42", "39.29", "96.71", "84.11" ]	icd9pcs	[ [ [] ] ]	12198, 12425	3896, 7360	286, 392	10426, 10435	2846, 3873	11372, 12175	2296, 2314		7745, 9586		9700, 10405	7386, 7722			10459, 11349										2329, 2827																												175, 248										420, 1529																1551, 2095	2111, 2280
29,329	192,064	50462	Discharge summary	report	Admission Date: [2188-7-8] Discharge Date: [2188-7-16] Date of Birth: [2106-10-17] Sex: M Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2569] Chief Complaint: Code Stroke, aphasia, right sided weakness Major Surgical or Invasive Procedure: Intubation Cerebral angiography with stent placement at M1 segment of left MCA History of Present Illness: Pt. is an 81 y/o with a hx of alzheimer's type dementia (at baseline speaks short sentence and follows commands, but dependant for all ADLs, including dressing, feeding, and bathing) who presents as a Code Stroke for aphasia and right sided weakness. Per NH report pt was seen well this morning around 8:00. Staff helped him dress and eat breakfast and felt that he was himself at that time. Then at 8:30 he suddenly would not respond to them when they asked him questions. They noticed that his right hand was flaccid and the right side of his face was drooping. They immediately called EMS and he was transported here. Code Stroke was called at 10:04, and Neurology was at the bedside at 10:06. On initial evaluation NIHSS was 10 (2 for LOC questions, 2 for LOC commands, 1 for facial palsy, 3 for best language, and 2 for dysarthria) CT with CTA and perfusion showed an area of stenosis or occlusion at the left M1 segment, which correlated with his symptoms. Therefore IVtPA was given, with the bolus at 11:00, and the drip started at 11:02. Dr. [First Name (STitle) ] from Neurosurgery was [Name (NI) 653], and plan is to take pt. for angiogram and possible IAtPA. Past Medical History: Dementia Hard of Hearing Seborrheic dermatitis L hernia repair Social History: previously living in [Location (un) ] nursing home in the alzheimer's unit Family History: NC Physical Exam: Afebrile BP 134/83 P 58 R 18 02 96% Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, moans when pinched, does not say his name when asked, does not follow any commands (stick out tongue, close eyes, squeeze hands) No spontaneous speech. Cranial Nerves: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Blinks to threat bilaterally. Extraocular movements intact bilaterally, no nystagmus. ? L gaze preference, but will regard examiner on the right side of the bed and track to right side. + R NLF flattening. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. Holds both arms up for 10 seconds with encouragement (does quickly distract or will put arms behind head because he does not understand the command, but with miming will hold both arms up x 10 sec) Seems to have some distal hand weakness on the right (wrist drop) but cannot get him to participate with formal exam. Withdraws both legs briskly and anti-gravity to pain, L more briskly than R. Sensation: grimaces with pinch in all 4 extremities Reflexes: +2 and symmetric throughout. Toes mute bilaterally Coordination: not able to assess Gait: not able to assess Pertinent Results: Labs on admission: 143 104 19 ------------< 121 4.2 29 1.6 WBC 6.8 Hgb 13.6 Plt 288 Hct 40.6 MCV 92 N:61.8 L:30.1 M:5.7 E:2.0 Bas:0.4 PT: 12.4 PTT: 24.3 INR: 1.1 Other labs: Chol 199 TG 312 HDL 41 LDL 96 A1C 5.9 WBC 9.5 and Cr 1.3 on day of discharge Microbiology [2188-7-11] 4:52 pm CATHETER TIP-IV Source: L fem CVL. FINAL REPORT [2188-7-15] WOUND CULTURE (Final [2188-7-15]): KLEBSIELLA PNEUMONIAE. >15 colonies. PSEUDOMONAS AERUGINOSA. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| PSEUDOMONAS AERUGINOSA \| \| AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S 4 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging NON-CONTRAST CT HEAD: There is no acute intracranial hemorrhage or obvious parenchymal hypodensity. There is mild-to-moderate dilation of the ventricles as well as extra-axial CSF spaces, likely related to age-appropriate parenchymal volume loss. The ventricular white matter hypodensities are noted, likely relating to sequela of chronic small vessel occlusive disease. CT PERFUSION: CT perfusion was performed through the MCA territory, selected by the stroke physician. There is a large area of reversible ischemia in the left middle cerebral artery territory, with elevated mean transit time and normal blood volume. In addition, there is a small area of irreversible, acute infarction in the left temporal lobe anteriorly, with elevated transit time and low blood volume. CT ANGIOGRAM OF THE HEAD: There is a short segment of near total versus complete occlusion, at the origin of the left middle cerebral artery, ((series 4, image 239; series 210, image 11,802),with attenuation of the caliber of the remainder of the M1 segment of the left MCA, with decreased enhancement of the M2 and the M3 branches. Marked atherosclerotic calcifications are noted in the cavernous carotid segments, on both sides. The distal vertebral, basilar, the posterior cerebral arteries are patent. The P1 segment of right PCA, is small in caliber and likely hypoplastic, related to fetal PCA pattern. The right anterior and middle cerebral arteries, the anterior communicating artery, and the left anterior cerebral arteries are patent. The A1 segment of the left anterior cerebral artery is small in caliber, related to hypoplasia. CT ANGIOGRAM OF THE NECK: Atherosclerotic calcifications are noted in the aortic arch as well as at the origin of the left common carotid and the left subclavian arteries as well as in the brachiocephalic trunk. The right common carotid artery a small foci of atherosclerotic calcification at the bifurcation, without flow limiting stenosis. Similarly, atherosclerotic calcifications are noted in the left common carotid artery bifurcation, without flow limiting stenosis. The vertebral arteries are patent throughout their course. The visualized portions of the thyroid are unremarkable. No obvious abnormally enlarged nodes are noted in the visualized portions of the neck. Multilevel mild degenerative changes are noted in the cervical spine, most prominent at C4-5, C5-6 and C6-7 levels, not adequately evaluated on the present study. Small areas of increased attenuation in the lung apices, likely represent scarring. However, this is not completely assessed on the present study. IMPRESSION: 1. Short segment of near total versus complete occlusion, at the origin of the left middle cerebral artery, related to atherosclerotic disease or less likely a filling defect, related to clot. Attenuation of the remainder of the M1 segment, and decreased enhancement of the M2 and the M3 branches. 2. Small area of irreversible perfusion deficit representing acute infarction in the left temporal lobe anteriorly, with a large area of surrounding reversible ischemia, in the left middle cerebral artery territory. HEAD CT WITHOUT IV CONTRAST [2188-7-8]: In comparison to the non-contrast head CT from seven hours prior, there is now a hyperdense focus in the left parietooccipital region (2:24), and the left frontal lobe (2:23). Because IV contrast was administered both for CTA head, as well as during the angiographic procedure, these may represent infarct enhancement, versus small foci of hemorrhage. There has been interval placement of a left MCA stent (2:16). No edema, mass effect, or shift of normally midline structures is identified. Prominence of ventricles and sulci as well as extra-axial CSF spaces is likely related to age-appropriate parenchymal volume loss. Periventricular white matter hypodensities are related to chronic small vessel ischemic disease. The ethmoid and sphenoid sinuses are newly opaciified, due to recent intubation. No fracture is identified. IMPRESSION: 1. New left MCA stent. 2. New hyperdensities in the left parietal-occipital and left frontal regions indicate either infarct enhancement or small foci of hemorrhage. 3. No mass effect, edema, or midline shift. CT head/CT perfusion [2188-7-9]: CT HEAD: The patient is status post placement of a left MCA stent. Hypodensity in the left basal ganglia is slightly more conspicuous than on prior studies, consistent with continued evolution of a small region of infarct. There is no evidence of new intracranial hemorrhage. Regions of hyperdensities that were seen in the most recent CT head study have resolved, consistent with resolution of infarct enhancement. Again prominence of the ventricles and extra-axial CSF spaces is consistent with age-appropriate involutional change. Periventricular and subcortical hypodensities likely relate to chronic small vessel ischemic disease. Vascular calcifications are noted in the cavernous carotid arteries. Again ethmoid air cells and sphenoid sinuses are partially opacified, likely related to recent intubation. ET tube and OG tube are noted to be in place on the scout images. CT PERFUSION: No diffusion abnormalities are seen on today's study. Compared to [2188-7-8], this represents interval resolution of a large region demonstrating delayed transit time in the left MCA distribution. IMPRESSION: 1. Continued evolution of left basal ganglia infarct. Improved perfusion is seen on today's study, status post stenting of left MCA. 2. Interval resolution of regions of infarct enhancement seen on the most recent prior study. No new hemorrhage seen. ECHO (TTE) [2188-7-9]: The left atrium is moderately dilated. The right atrium is moderately dilated. 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 root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No cardiac source of embolism seen. No significant valvular abnormality seen. Preserved global biventricular function. Right femoral vascular ultrasound [2188-7-8]: Multiple [Doctor Last Name 352]-scale and color Doppler images of the right groin were obtained. The study demonstrates patent common femoral artery and veins. There is no evidence of pseudoaneurysm. No measurable hematomas are identified. IMPRESSION: No evidence for a pseudoaneurysm or focal hematoma. Repeat right femoral vascular ultrasound [2188-7-9]: FINDINGS: Multiple Grayscale and color Doppler images of the right groin were obtained. The study demonstrated patent right common femoral artery and right common femoral veins. There is no evidence of pseudoaneurysm or hematoma. IMPRESSION: No evidence of pseudoaneurysm or focal hematoma. INDICATION: 81-year-old male with recent stroke, status post stent, noted to have right scrotal mass. FINDINGS: Comparison made to CT from [2187-4-21]. Scrotal ultrasound [2188-7-12]: The right testicle measures 3.8 x 3.0 x 2.6 cm. The left testicle measures 3.9 x 3.6 x 2.3 cm. There is a prominent ductal ectasia seen within the left testicle, and to a slightly lesser degree in the right testicle. There is no focal intratesticular mass. There are small bilateral hydroceles. There is a large fat-containing right inguinal hernia. This appears largely unchanged when compared to CT of [2187-4-21] allowing for differences in modality. Color Doppler evaluation of the testes shows normal flow and vascularity bilaterally. IMPRESSION: 1. Unchanged large fat-containing right inguinal hernia. 2. Prominent bilateral ductal ectasia, left greater than right. 3. Small bilateral hydroceles. CXR [2188-7-11]: There is a small left pleural effusion new since prior study. There is also worsening retrocardiac density and likely dependent atelectasis. There are no new focal consolidations or infiltrates. There is no cardiomegaly. Pulmonary vasculature is normal. IMPRESSION: New small left pleural effusion and retrocardiac opacity likely indicating atelectasis. Brief Hospital Course: 81 y/o with a hx of Alzheimer's dementia, verbal and ambulatory at baseline, who presented as a Code Stroke for acute onset of aphasia and R arm weakness. On initial exam he was globally aphasic, and does not produce any spontaneous speech or follow any commands. He had a R NLF flattening. He seemed to have some distal weakness in his right hand (cannot participate with formal testing) but actually does hold the right arm anti-gravity x 10 seconds; NIHSS 10. On CTA, he had a cutoff of the M1 segment on the left, consistent with his deficits. On CT perfusion there is a small area that appeared to be completed infarct but with a large penumbra of potentially viable tissue. He had no contraindications to tPA and was within the window, so IV tPA was administered. He was then taken up to the angiography suite for L M1 intraarterial angioplasty and subsequent stenting. During angiography, his course was complicated by extremely labile HTN with SBP from 75-275 abruptly, as well as bleeding from R groin puncture site. Repeat imaging after the procedure and at 24 hrs afterward revealed infarction consistent with the occluded vascular territory (left MCA), with stable perfusion and no hemorrhage. The patient was started on ASA 325 daily, as well as Plavix 75 mg daily for the stent. He was extubated shortly after the procedure without complication. Neurologically, his examination improved and the patient was able to speak and answer some questions appropriately, likely consistent with his prior dementia. He was eventually able to move both sides spontaneuosly and anti-gravity, though he appeared to have a preference for use of his right side. His blood pressure began to trend low, and was started on intravenous fluids and neosynephrine to maintain SBP > 100 for perfusion purposes. However, he was successfully transitioned to and ultimately maintained on midodrine with a systolic blood pressure greater than 100 mmHg. He was ruled out for MI, and troponins were stable at 0.02 x 3. ECHO revealed no evidence of a cardioembolic etiology. His hematocrit dropped to as low as 25 post-procedure on [7-9], but rebounded nicely after a 2 unit PRBC transfusion that evening. Groin site and distal pulses were stable. Right groin dopplers post-procedure and at 24 hrs did not reveal evidence of pseudoaneurysm or hematoma. His hematocrit was stable at 30 on the day of discharge. Scrotal ultrasound (prior hernia) was also examined on [7-12], and appeared stable compared to prior imaging. He was evaluated by speech and swallow and started on a diet on [2188-7-14]. Of note, he presented with renal insufficency (Cr 1.7) and was given mucomist for exposure to contrast dye; his creatinine remained stable with intravenous fluid hydration and was 1.3 on day of discharge. Additionally, the patient had a an initially WBC that rose to nearly 24 K on [7-9]. However, he remained afebrile throughout the hospitalization, and his WBC declined to 9.5 on day of discharge. Please be aware that a catheter tip (left femoral CVL) culture from [7-11] grew both pseudomonas and klebsiella species (see results section); final results did not return until [7-15]. Because the patient did not reveal evidence of infection (afebrile, normal WBC, no clinical findings), the decision was made to defer on antibiotic therapy. Code status was discussed with the patient's daughter during the hospitalization and he was made DNR for his stay. Medications on Admission: MEDS: Aricept 10 mg QD Senna Calcium Cabonate 600 mg [Hospital1 ] Vitamin D 400 IU QD Trazodone 25 mg in the morning and afternoon Actonel 35 mg QSunday ALL: PCN, sulfa Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for for rash. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Midodrine 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Can slowly titrate off as blood pressure allows. Goal systolic blood pressure is between 100 and 140. Tablet(s) 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Calcium Carbonate 600 mg (1.5 gram) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 15. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 16. Actonel 35 mg Tablet Sig: One (1) Tablet PO q Sunday. 17. Trazodone 50 mg Tablet Sig: one -half Tablet PO twice a day: in morning and afternoon. Discharge Disposition: Extended Care Facility: [Location (un) 10140] - [Location (un) 10059] Discharge Diagnosis: left MCA infarct Discharge Condition: Stable, moving right side spontaneously and anti-gravity, though a bit less frequently than left side. Spontaneous speech has returned. Discharge Instructions: Please administer medications as prescribed and follow up with appointments as scheduled. The patient has had a stroke. Should he experience any new, worsening, or concerning signs or symptoms, such as weakness, speech or language difficulties, and vision change, please call the patient's PCP, [Name10 (NameIs) ] neurologist at [Hospital1 18] ([First Name8 (NamePattern2) 2530] [Doctor Last Name ] at [Telephone/Fax (1) 7394] or the on-call neurologist at [Telephone/Fax (1) 22727]), or head to the nearest emergency room. Followup Instructions: You have the following appointment scheduled with your neurolgist, Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ]: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2188-8-19] 10:00 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "331.0", "294.10", "585.9", "434.91", "998.11", "403.90" ]	icd9cm	[ [ [] ] ]	[ "99.10", "38.93", "96.04", "00.40", "88.41", "00.65", "38.91", "96.71", "00.62", "00.45" ]	icd9pcs	[ [ [] ] ]	18483, 18563	13215, 16703	339, 420	18624, 18763	3319, 3324	19360, 19744	1837, 1841		16928, 18460		18584, 18603	16729, 16905			18787, 19337										1856, 2148																												257, 301										448, 1638	2374, 3300		8933, 13192					3338, 3491	2187, 2358					2172, 2172		1660, 1724	1740, 1821		3503, 4654
43,787	129,526	8565	Discharge summary	report	Admission Date: [2111-9-12] Discharge Date: [2111-9-19] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Right SDH Major Surgical or Invasive Procedure: R burr holes for evacuation of R SDH History of Present Illness: This patient is a 89 year old male who complains of SDH. The patient is transferred from outside hospital. He has had increasing lethargy and fell 2 weeks prior to today not worked up at that time. Son in law found him earlier today with unusual affect and slight confusion.At the outside hospital a CT showed a right subdural hematoma with 14 mm of shift and significant/severe mass effect. The INR was 2.8 (coumadin for afib). Vitamin K was given and the patient was intubated for transfer. At the outside hospital the patient was awake and had a nonfocal neurologic examination. Past Medical History: afib gerd hypercholesterolemia COPD htn CABG UTI CVA Social History: tobacco Family History: unknown Physical Exam: On Admission: O: T:97.8 BP:100/62 HR:89 R 12 intubated on 100% FiO2 Gen: intubated HEENT: Pupils: PERRL 2mm bilat EOMs couldn't assess Neck: Supple. Lungs: CTA bilaterally. Cardiac: regular Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated not sedated Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light withdraws to pain in bilateral lower ext. moving all 4 spontaneously, minimal response to pain in bilateral upper ext. Toes downgoing bilaterally On Discharge: eyes open, answers simple questions, follows simple commands Pertinent Results: CT HEAD W/O CONTRAST [2111-9-12] 1. Right frontal burr pole with evacuation of right subdural hemorrhage with overall decrease in size and mass effect, though with persistent layering high attenuation components and mass effect with midline shift by 9 mm. 2. In addition, stable foci of left-sided subarachnoid hemorrhage and a small amount of layering intraventricular hemorrhage in the left occipital [Doctor Last Name 534]. 3. Sequelae of remote left-sided MCA distribution infarction with associated ex vacuo dilatation of the left lateral ventricle. CXR [2111-9-12]: ET tube is in standard position. The lungs are hyperinflated. There is no evidence of pneumothorax or large pleural effusion, the right lateral CP angle was not included on the film. Mild cardiomegaly and tortuous aorta are unchanged. Aside from left lower lobe retrocardiac atelectasis, the lungs are grossly clear. There are old healed rib fractures on the right. Sternal wires are aligned. Patient is status post CABG. No interval changes. Brief Hospital Course: This is an 89 year old man who presented to an OSH with increasing lethargy s/p fall 2 weeks prior to presentation. CT head showed large R SDH with significant shift. He was given FFP and vitamin K at the OSH hospital and was transferred to [Hospital1 18] for further neurosurgical intervention. Patient was taken to the OR on [9-12] for Right burr hole for evacuation of Right SDH with Dr. [Last Name (STitle) ]. Post operatively, patient was more responsive, he opened eyes to voice and was moving all extremities spontaneously. He was extubated and post op head CT was stable. On [9-14], exam continued to improve and he was transferred to the floor. PT/OT and speech and swallow evaluations were ordered. Speech and swallow cleared patient for pureed solids and thick nectar on [9-15]. He was being screened for rehab. He was transferred on [2111-9-19]. Medications on Admission: coumadin, spiriva, amilodipine, atorvastatin, omeprazole, albuterol, oxybutynin Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: Two (2) units Injection ASDIR (AS DIRECTED). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain . 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours) as needed for high bp: keep sbp 100-140. 11. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg Intravenous Q6H (every 6 hours): hold for MAP <70 HR <60. Discharge Disposition: Extended Care Facility: [Hospital 4542] Rehabilitation and Nursing of [Location (un) 38] Discharge Diagnosis: Right SubDural Hematoma 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: ?????? Have your incision checked daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. If your rehab fscility finds that you have Aflutter, your Coumadin could be used, otherwise, this should not be used for one month from surgery. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week at the rehab fascility. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ?????? Please have your staples/sutures on or about [2111-9-28] at rehab. ?????? Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast. Completed by:[2111-9-19]	[ "530.81", "272.0", "401.9", "V45.81", "E888.9", "V58.61", "852.21", "348.4", "427.31", "V12.54", "496" ]	icd9cm	[ [ [] ] ]	[ "01.31" ]	icd9pcs	[ [ [] ] ]	4813, 4912	2756, 3640	276, 315	4979, 4979	1699, 2733	6349, 6689	1046, 1055		3771, 4790		4933, 4958	3666, 3748			5155, 6326										1070, 1070																			1617, 1680									227, 238										343, 928	1393, 1603							1085, 1339	4994, 5131							950, 1005	1021, 1030

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