Split (1)

train · 26.9k rows

subject_id int64 12 100k	_id int64 100k 200k	note_id stringlengths 1 41	note_type stringclasses 4 values	note_subtype stringclasses 35 values	text stringlengths 449 78.2k	diagnosis_codes listlengths 1 39	diagnosis_code_type stringclasses 1 value	diagnosis_code_spans listlengths 1 21	procedure_codes listlengths 0 35	procedure_code_type stringclasses 1 value	procedure_code_spans listlengths 1 5	Discharge Disposition: stringlengths 0 12	Brief Hospital Course: stringlengths 0 12	Major Surgical or Invasive Procedure: stringlengths 0 12	Discharge Condition: stringlengths 0 12	Pertinent Results: stringlengths 0 12	Followup Instructions: stringlengths 0 12	Family History: stringlengths 0 12	DISCHARGE DIAGNOSES: stringlengths 0 12	DISCHARGE MEDICATIONS: stringlengths 0 12	[Hospital 93] MEDICAL CONDITION: stringlengths 0 12	DISCHARGE DIAGNOSIS: stringlengths 0 12	MEDICATIONS ON DISCHARGE: stringclasses 983 values	MEDICATIONS ON ADMISSION: stringlengths 0 12	HOSPITAL COURSE: stringlengths 0 12	FINAL DIAGNOSIS: stringclasses 974 values	CARE RECOMMENDATIONS: stringclasses 32 values	DISCHARGE INSTRUCTIONS: stringlengths 0 12	What to report to office: stringclasses 286 values	Discharge labs: stringlengths 0 12	-Cranial Nerves: stringclasses 297 values	Incision Care: stringclasses 388 values	Past Surgical History: stringlengths 0 12	PHYSICAL EXAM: stringlengths 0 12	Physical Therapy: stringclasses 313 values	Treatments Frequency: stringclasses 226 values	SECONDARY DIAGNOSES: stringlengths 0 12	2. CARDIAC HISTORY: stringclasses 715 values	HOME MEDICATIONS: stringclasses 441 values	ACID FAST CULTURE (Preliminary): stringclasses 214 values	Blood Culture, Routine (Preliminary): stringclasses 146 values	Discharge exam: stringclasses 736 values	CLINICAL IMPLICATIONS: stringclasses 128 values	FUNGAL CULTURE (Preliminary): stringclasses 365 values	PREOPERATIVE MEDICATIONS: stringclasses 71 values	SUMMARY OF HOSPITAL COURSE: stringclasses 286 values	PHYSICAL EXAMINATION: stringlengths 0 12	At discharge: stringlengths 0 12	ON DISCHARGE: stringlengths 0 12	Transitional issues: stringclasses 965 values	FOLLOW-UP PLANS: stringclasses 188 values	Changes to your medications: stringclasses 809 values	REVIEW OF SYSTEMS: stringlengths 0 12	Cardiac enzymes: stringclasses 361 values	Medication Changes: stringclasses 665 values	CHIEF COMPLAINT: stringlengths 0 12	REASON FOR THIS EXAMINATION: stringlengths 0 12	Active Issues: stringclasses 353 values	WOUND CULTURE (Preliminary): stringclasses 63 values	LABS ON DISCHARGE: stringclasses 566 values	URINE CULTURE (Preliminary): stringclasses 70 values	Immunizations recommended: stringclasses 34 values	Upon Discharge: stringclasses 230 values	HISTORY OF PRESENT ILLNESS: stringlengths 0 12	CRANIAL NERVES: stringlengths 0 12	CT Head: stringclasses 955 values	secondary diagnosis: stringlengths 0 12	Head CT: stringclasses 601 values	INACTIVE ISSUES: stringclasses 124 values	ADMISSION LABS: stringlengths 0 12	PRIMARY DIAGNOSIS: stringlengths 0 12	On admission: stringlengths 0 12	ANAEROBIC CULTURE (Preliminary): stringclasses 227 values	MENTAL STATUS: stringlengths 0 12	3. OTHER PAST MEDICAL HISTORY: stringclasses 667 values	Chronic Issues: stringclasses 245 values	NEUROLOGIC EXAMINATION: stringclasses 339 values	Medications on transfer: stringclasses 568 values	Past medical history: stringlengths 0 12	SOCIAL HISTORY: stringlengths 0 12	CONDITION ON DISCHARGE: stringlengths 0 12	FLUID CULTURE (Preliminary): stringclasses 112 values	Meds on transfer: stringclasses 242 values	Other labs: stringclasses 142 values	Discharge physical exam: stringclasses 473 values
56,714	173,051	4143	Discharge summary	report	Admission Date: [2132-4-25] Discharge Date: [2132-4-30] Date of Birth: [2084-2-2] Sex: M Service: MEDICINE Allergies: Metoclopramide / Bupropion Attending:[First Name3 (LF) 2108] Chief Complaint: vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 48-year-old male with history of type I DM c/b DKA, gastroparesis, neuropathy and retinopathy who presents from outside hospital with nausea and vomiting x3 days. . Per outside hospital records, he was in his ususal state of health until a recent admission at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5678] Hospital for uncontrolled hyperglycemia. He was admitted for 3 days and then left against medical advice. An unclear amount of time passed and he represented to the outside hospital with 3 days of nausea and vomiting. He also noted he felt dehydrated. At that time he denied atypical pain, fever, cough, dyspnea, headache, dizziness, weakenss, rash, diarrhea, constipation or dysuria. Labs on presentation were glucose 1101, Na 114 (not corrected), K 5.7, Cl 72, HCO3 14, BUN/Cr 50/2.0, AG 28. CE were normal. VBG 7.22 and acetone was 90. He was given 3L IVF, insulin bolus and started on insulin gtt. Since no ICU beds were available at AJH he was transferred to [Hospital1 18]. . In the EW, EMS from AJH, who know patient well, note that he is acting "goofy". In the EW he was AOx1. His initial vitals were: T 99.4, P 109, BP 172/104, R 20, SaO2 99% on RA. Labs showed glucose 597, AG 18, Corrected Na 137, K 4.4, BUN/Cr 48/1.9, WBC 13.1, lactate 2.2. VBG of 7.35/40/63. Serum tox pending, urine tox negative except for opiates. UA with ketones, no evidence of infection. EKG with wide QRS, new by report. CXR without evidence of consolidation. CT head without acute intracranial process. He was diagnosed with hyperglycemia, ?DKA and started on 3L IVF, KCl and insulin gtt. A femoral CVL was placed in a sterile fashion. He was admitted to ICU for further evaluation and management. . Currently, he complains of thirst and wants "medications". He often repeats "I need water" and "Can I have some medications?" in response to questions. He states that he has been compliant with his medications (although shortly after he told RN that he has not been taking medications). He endorses chills. He denies fevers, night sweats, recent nausea, vomiting, diarrhea, cough, abdominal pain, chest pain, shortness of breath, headache, neck pain, photophobia or phonophobia. Past Medical History: - type I DM: c/b gastroparesis, history of DKA, neuropathy and retinopathy - chronic pain: epigastric and retrosternal, recent negative ETT, dependent on narcotics - depression - s/p laparoscopic cholecystectomy - hypertension - s/p myocardial infection - "kidney trouble" Social History: He patient lives with mother and son. [Name (NI) ] is currently on disability. - Tobacco: denies - Alcohol: denies - Illicits: denies Family History: Mother has adult onset diabetes mellitus. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 99.3, BP: 175/91, P: 106, R: 14, SaO2: 100% General: Alert, oriented x1, no acute distress, grinding teeth HEENT: Sclera anicteric, dry MM, small lesion on oropharynx, no thrush, no phono- or photo-phobia, teeth worn down from grinding. Neck: supple, JVD low. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi. Normal to percussion. Cardiovascular: Regular rhythm, normal rate, S1, S2, no murmurs, rubs, gallops. Abdomen: soft, voluntary guarding, liver difficult to assess secondary to voluntary guarding, he denies pain and does not show pain with palpation to epigastric area or right upper quadrant area, no masses appreciated. GU: foley to gravity Ext: warm, well perfused, limited pulses, no edema, bilateral 1st digit amputations lower extremities Neuro: AOx1, conversant but perseverates on "I want water" and "I need medications", limited exam as not fully participatory, CNII-XII grossly intact, moves [5-5] extremities. Pertinent Results: [2132-4-25] 05:55AM BLOOD WBC-13.1# RBC-3.86 Hgb-11.5* Hct-32.6* MCV-84 MCH-29.9# MCHC-35.4* RDW-12.8 Plt Ct-448* [2132-4-25] 05:55AM BLOOD Neuts-85.4* Lymphs-11.3* Monos-3.0 Eos-0 Baso-0.2 [2132-4-25] 05:55AM BLOOD PT-11.0 PTT-21.6* INR(PT)-0.9 [2132-4-25] 05:55AM BLOOD Glucose-597* UreaN-48* Creat-1.9* Na-129* K-4.4 Cl-90* HCO3-21* AnGap-22* [2132-4-25] 09:28AM BLOOD ALT-36 AST-19 LD(LDH)-181 CK(CPK)-72 AlkPhos-225* TotBili-0.2 [2132-4-25] 09:28AM BLOOD CK-MB-3 cTropnT-<0.01 [2132-4-25] 07:16PM BLOOD CK-MB-3 cTropnT-<0.01 [2132-4-25] 05:55AM BLOOD Calcium-9.5 Phos-2.1* Mg-2.4 [2132-4-25] 09:28AM BLOOD TSH-0.94 [2132-4-25] 05:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2132-4-25] 05:55AM BLOOD Lactate-2.8* K-4.5 [2132-4-25] 07:40PM BLOOD Lactate-0.6 [2132-4-25] 05:55AM BLOOD freeCa-1.19 [2132-4-27] 03:10AM BLOOD WBC-7.0 RBC-3.30* Hgb-10.2* Hct-28.6* MCV-87 MCH-29.3 MCHC-33.8 RDW-12.8 Plt Ct-266 [2132-4-30] 07:15AM BLOOD Glucose-190* UreaN-35* Creat-1.3* Na-135 K-5.3* Cl-98 HCO3-31 AnGap-11 [2132-4-30] 07:15AM BLOOD Calcium-9.9 Phos-4.3 Mg-2.1 [2132-4-28] 07:20AM BLOOD %HbA1c-12.7* eAG-318* IMAGING: CT HEAD W/OUT CONTRAST [2132-4-24]: FINDINGS: No acute hemorrhage, large vascular territory infarct, shift of midline structures or mass effect is present. The ventricles and sulci are normal in size and configuration. The visible paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial process. CXR [2132-4-25]: TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours and pleural surfaces are normal. No pleural effusions or pneumothorax is present. A needle is noted in the posterior soft tissues near the thoracolumbar junction on the lateral view. Healed rib fractures are noted on the left. IMPRESSION: No acute intrathoracic process. A needle is noted in the posterior subcutaneous tissues at the thoracolumbar junction. Brief Hospital Course: 48-year-old male with history of type I DM c/b DKA, gastroparesis, neuropathy and retinopathy who presents with DKA. DIABETIC KETOACIDOSIS, TYPE I DIABETES UNCONTROLLED WITH COMPLICATIONS: admitted to ICU and started on an insulin drip. Rehydrated and ACUTE ON CHRONIC RENAL FAILURE improved. He was seen by [Last Name (un) ] consult and insulin was transitioned to sc and adjusted. His A1c was noted to be 12.7%. He was discharged home on an increased dose of insulin and adjustments to his sliding scale, and will f/u with his endocrinologist. ALTERED MENTAL STATUS: secondary to DKA, improved with treatment above. DEPRESSION WITH PSYCHOTIC FEATURES: he saw psychiatry inpatient who intially recommended voluntary inpatient psychiatry, after his DKA improved his mood and psychotic features did as well; psychiatry re-evaluated and stated that outpatient follow up should be adequate. DKA: The patient had labs at the OSH which were consistent with diabetic ketoacidosis. Given his high blood sugars he may have had a HONC picture as well. The trigger for this event is not entirely clear, although most likely is medication non-compliance. Other etiology could be secodnary to gastroparesis exacerbation. No clear evidence of infection including in lungs, urine, bowel or blood. Negative tox screens. Appeared hypovolemic on admission and continued to have elevated blood sugars throughout admission even after AG closed and transitioned to SQ heparin. LFT Elevation: Unclear etiology. Alk phos elevated out of degree of tbili, ALT or AST with possible source other than liver. No RUQ symptoms. Monitored throughout admission and suggest outpatient work up. OTITIS MEDIA: started on amoxicillin for a 7 day course. No external ear involvement, no mastoid involvement. Medications on Admission: per OSH records - metoprolol 100mg PO daily - lisinopril 20mg PO daily - MS contin 65mg PO TID prn - demerol 100mg PO Q4H - insulin lantus 15u SC qAM, 12u SC qHS - insulin humalog sliding scale - nitroglycerin prn - omeprazole 20mg PO daily - Zetia 10mg PO QHS - ondansetron 4mg PO daily prn - Celexa 60mg PO daily - Levoxyl 50mcg PO daily - Thorazine 50mg PO BID Discharge Medications: 1. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 2. amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:12 Tablet(s) Refills:0 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q8H (every 8 hours). 5. Demerol 100 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. chlorpromazine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. insulin glargine 100 unit/mL Solution Sig: as directed units Subcutaneous twice a day: 20 units before breakfast, 12 units at bedtime. 13. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous before meals and at bedtime: please follow the sliding scale provided to you. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic ketoacidosis Diabetes Type I uncontrolled with complications Otitis media 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 elevated blood sugar level and "DKA" which is a diabetic emergency. You were treated with an insulin drip in the ICU and your insulin regimen was adjusted. You were also found to have an ear infection. Please take your medications as prescribed and make your follow up appointments. Please use your new sliding scale and insulin doses that were provided to you. Followup Instructions: Please follow up with your endocrinologist (Diabetes specialist) within 2 weeks of your discharge from the hospital. Please follow up with your primary care physician [Name Initial (PRE) 176] 1 month of your discharge from the hospital. Please follow up with your psychologist within 1 week of your discharge from the hospital.	[ "584.9", "382.9", "250.53", "536.3", "296.24", "V58.67", "357.2", "403.90", "250.13", "585.9", "362.01", "276.1", "250.63" ]	icd9cm	[ [ [] ] ]	[ "86.09" ]	icd9pcs	[ [ [] ] ]	9633, 9639	6146, 6709	295, 301	9785, 9785	4066, 6123	10371, 10708	2999, 3042		8348, 9610		9660, 9660		7960, 8325				9936, 10348						3082, 4047																						247, 257								329, 2532							9679, 9764			9800, 9912					2554, 2828	2844, 2983
75,525	121,651	13250	Discharge summary	report	Admission Date: [2122-11-19] Discharge Date: [2122-11-23] Date of Birth: [2071-10-17] Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[First Name3 (LF) 1115] Chief Complaint: flu like symptoms & hypertension Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 51 year-old man with a history of asthma, hypertension, and cocaine use who presented to the [Hospital1 18] ED on [2122-11-19] with a non-productive cough, chest pain, and DOE. Patient states tht the symptoms began on the morning of [11-19], when he woke up. Described [10-17] substernal chest pain, radiating to L arm, mildy associated with exertion, not associated w/ position. He does not have a history of an 'anginal equivalent', but had negative atypical CP work-up at [Hospital1 112] in [2120] including stress test. He reports nausea, vomiting, and subjective fevers at home (although he did not take his temperature). He also reports a headache ([10-17], involving whole head, +photosensitivity). Denies neck stiffness, vision loss, confusion, or seizures. States that he takes 4 anti-hypertensive medications at home, but does not know the name of his medications. He denies sick contacts. . In ED, initial VS were 100.8 96 191/102 20 100% on RA. Patient had CXR negative for pneumonia, negative cardiac enzymes, and a normal D Dimer. EKG with J point elevation in V1-V3, unchanged from previous EKG of [2-/2120] from [Hospital1 112] (with exception of resolved sinus bradycardia). Head CT without evidence of bleed, but with changes concerning for PRES. Chest pain resolved w/ SL nitro, nitro paste, morphine 12 mg IV, and combivent nebs. SBP was noted to be 191/102, and due to headache and chest pain, labetolol gtt was initiated due to concern for hypertensive emergency, and patient was admitted to MICU. . During MICU course, labetolol gtt was weaned and patient was placed back on home meds of oral labetolol 100 mg PO BID, hctz 25 mg PO daily, amlodipine 10 mg PO daily, and valsartan 80 mg PO daily (confirmed w/ physician at [Hospital1 ], but are about a year old). SBPs decreased to 160s/90s with oral medication. Nasopharyngeal aspirates returned + for influenza A. Patient also with dirty U/A (6-10 WBCs), but he is does not have dysuria. Prostate exam reveals no tenderness. Tox screen + only for opiates, neg for cocaine, but received morphine in the ED. D-dimer low, and CEs neg x2. Patient called out to medicine floor for further treatment. . Review of systems: (+) Per HPI (-) Denies recent weight loss or gain, chest pain or pressure, palpitations, myalgias, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria, seizures or confusion. . Past Medical History: -Atypical CP with negative workup from [Hospital1 112] [2120] (echo, nuclear stress) -Asthma -HTN -Gunshot wound s/p ex-lap [2101] -Hepatitis C -Sleep Apnea -Depression Social History: Patient lives in JP with his wife. [Name (NI) ] has 7 children and works a truck driver. 10 ppy smoking history, current smoker (5 cigarettes per day). Denies EtOH use. +marijuana use (smokes daily), but denies any recent cocaine use (states that he has not used cocaine in years). History of cocaine use and incarceration. Family History: -Mother - died of breast cancer -Siblings - healthy -No history of cardiac problems, lung problems, DM, or cancer (other than breast cancer in mother) -No history of dementia. Physical Exam: Admission Exam: T= 100.4 BP= 168/100 HR= 77 RR=26 O2= 98% 3L . . PHYSICAL EXAM GENERAL: Pleasant gentleman, uncomfortable appearing, vomiting during the interview HEENT: MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: S1 & S2 regular without murmur. No elevated JVP. LUNGS: Coughing on deep inspiration, wheezes. ABDOMEN: Nontender or distended EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact except for pinpoint pupils. Preserved sensation throughout. 5/5 strength throughout. [1-9]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission labs: LABS: [2122-11-19] D-Dimer: 367 . Trop-T: <0.01 . [Age over 90 2239] \|103\| 12 -------------< 118 3.4 \| 26\| 0.8 CK: 142 MB: 2 proBNP: 499 MCV 90 14.4 3.6 >-------< 190 42.6 N:80.9 L:13.8 M:3.5 E:1.5 Bas:0.5 PT: 14.3 PTT: 33.1 INR: 1.2 [2122-11-23] 06:50AM BLOOD WBC-3.1* RBC-4.41* Hgb-14.0 Hct-39.9* MCV-90 MCH-31.8 MCHC-35.2* RDW-12.9 Plt Ct-197 [2122-11-23] 06:50AM BLOOD Glucose-92 UreaN-15 Creat-1.1 Na-142 K-3.0* Cl-102 HCO3-31 AnGap-12 [2122-11-23] 12:45PM BLOOD K-3.7 [2122-11-20] 01:59AM BLOOD ALT-26 AST-28 LD(LDH)-194 CK(CPK)-138 AlkPhos-80 TotBili-0.6 [2122-11-20] 01:59AM BLOOD CK-MB-2 cTropnT-<0.01 [2122-11-23] 06:50AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7 [2122-11-19] 03:28PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [2122-11-23]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [2122-11-23]): Negative for Neisseria Gonorrhoeae by PCR. FINAL REPORT [2122-11-24] DIRECT INFLUENZA A ANTIGEN TEST (Final [2122-11-24]): REPORTED BY PHONE TO [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ON [2122-11-20] AT 1126. POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. Positive for Swine-like Influenza A (H1N1) virus by RT-PCR at State Lab. REPORTED BY PHONE TO DR [First Name (STitle) ] [Doctor Last Name 3689] 11:35AM [2122-11-24]. DIRECT INFLUENZA B ANTIGEN TEST (Final [2122-11-20]): Negative for Influenza B. . CXR - [11-19]: FINDINGS: The lungs are clear. There is no pneumonia. There is no pleural effusion or pneumothorax. Hilar, mediastinal, and cardiac silhouettes are within normal limits. IMPRESSION: No pneumonia. . Head CT - [11-19]: FINDINGS: There is no evidence of acute hemorrhage, large acute territory infarction, or large masses. There are bilateral patchy non-confluent hypodense foci, predominantly in subcortical white matter distribution, could be due to chronic small vessel ischemic changes; however, it could also be manifestation of acute hypertensive encephalopathy (Posterior Reversible Encephalopathy Syndrome [PRES]). Ventricles and sulci are normal in size and configuration. There is no shift of midline structures. Visualized portion of the paranasal sinuses and mastoid air cells are within normal limits. IMPRESSION: 1. No bleed. 2. Subcortical bilateral white matter foci of hypodensity, in a patchy pattern, which could be due to chronic small vessel ischemic changes, or manifestation of acute hypertensive encephalopathy, PRES. MR [Name13 (STitle) 430]: IMPRESSION: 1. No definite evidence of acute intracranial process. 2. Though the extensive multifocal white matter abnormalities in both the supra- and infratentorial compartments are highly nonspecific, they are most consistent with chronic microvascular infarction, particularly in setting of poorly-controlled hypertension. Given the extent of involvement, the relative asymmetry and the sparing of the posterior parietooccipital subcortical white matter would militate against PRES, though this entity cannot be completely excluded. Arguing in favor of chronic hypertensive small vessel disease are the likely chronic hemorrhagic lacune in the right cerebellar hemisphere, and at least one "microbleed" elsewhere. 3. The involvement of the subcortical white matter of the anterior temporal poles, bilaterally, as well as the very peripheral extensive subcortical white matter abnormality, elsewhere, raises the possibility of underlying CADASIL. This should be correlated with any history of chronic episodic headaches and dementia in this patient, as well as in any first-degree family member. Brief Hospital Course: Mr. [Known lastname 40366] is a 51 year old gentleman with asthma and hypertension who presented with a hypertensive emergency and Influenza A. #. Hypertension: Initial head CT showed changes concerning for PRES. He was started on a labetalol drip in the MICU. Eventually, he was transitioned to his home medication regimen. Blood pressures slowly decreased and were in the 150-160's when patient arrived on the floor. The home medication regimen was confirmed with his PCP's office. The patient could not remember the names of his medications. He also stated that he had missed several doses because the medications were too expensive. A new, affordable blood pressure regimen was designed that was available for a total copay of $16 per month. This regimen included: Triamterene-HCTZ, Hydralazine, Isosorbide Mononitrate, and Metoprolol. He had some elevated blood pressures when transitioning to this new regimen, but was well controlled once it was started. He was given instructions to follow up with his PCP later in the week for BP and lab check. . # Brain Imaging: MR of the head final report was consistent with chronic hypertension and raised the possibility of CADASIL. The patient denied any history of dementia in his family. He and his family have not noticed any changes in baseline mental status. A final report was not available at the time of discharge. It was mailed to him once it became available. He was going to follow up with his PCP to determine what further workup should be performed. . # Chest Pain: Mr. [Known lastname ] presented with chest pain. Patient had CXR negative for pneumonia, negative cardiac enzymes, and a normal D Dimer. EKG showed J point elevation in V1-V3, unchanged from previous EKG of [2-/2120] from [Hospital1 112] (with exception of resolved sinus bradycardia). His SBP was noted to be 191/102. Chest pain resolved with SL nitro, nitro paste, morphine 12 mg IV, and combivent nebs. As his blood pressure improved, he had no more episodes of chest pain. He was discharged on a more affordable antihypertensive regimen, as above, to try to prevent future episodes. . #. Influenza A: The patient's DFA was positive for Influenza A. He was started on oseltamivir x 5 days. His WBC was noted to be low likely secondary to the viral infection. . #. Asthma: The patient was maintained on nebulized bronchodilators. #. Pyuria: He had 2 U/A's positive for WBC's. However, his cultures, gonorrhea, and chlamydia were negative. A prostate exam showed no tenderness. He was to follow up with his PCP for another urinalysis. . #. Nicotine: Patient received a nicotine patch. He stated this helped resolve his headache. He wasnted a prescription at discharge to help him quit smoking. . # Prophylaxis: He was placed on subcutaneous heparin, but refused most injections. He had a bowel regimen with docusate and senna. . #. Code Status: Patient was a full code during this hospitalization. Medications on Admission: Albuterol 2 PUFF INH QID Amlodipine 10mg PO daily Atenolol 12.5mg PO daily Tricor 48mg PO daily HCTZ 25mg PO Daily Irbesartan 300mg PO Daily Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 Inhaler Refills:0 2. Oseltamivir 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 4 doses. Disp:4 Capsule(s) Refills:0 3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 4 weeks: Do not use while actively smoking. Disp:28 Patch 24 hr(s) Refills:0 4. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:84 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:28 Tablet Sustained Release 24 hr(s) Refills:0 7. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:28 Cap(s) Refills:0 8. Outpatient Lab Work Please perform a CBC, Chem 7, and urinalysis. Fax results to Dr. [Last Name (STitle) 30186] of [Last Name (un) 10526] [Hospital1 ] at ([Telephone/Fax (1) 40367]. 9. Please provide patient with automatic blood pressure cuff. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Influenza A Hypertensive Emergency Secondary Diagnosis: Asthma Hepatitis C Sleep Apnea Discharge Condition: Stable. Afebrile, Blood pressure 148/70 , O2 saturation 100% on room air. Discharge Instructions: You were admitted with fever, headache, nausea, cough, chest pain, and a blood pressure of 240/130. You were found to have influenza A and and a dangerously elevated blood pressure. You were taken to the intensive care unit where you were given intravenous medication to lower your blood pressure. You were switched to oral anit-hypertensive medications and moved to the floor. You were also treated with Tamiflu for influenza. During your admission, your anti-hypertensive regimen was changed to a more affordable combination of medications. Your blood pressure was stabalized on these medications prior to discharge. You were also found to have white blood cells in your urine. Testing here did not reveal infection. A urinalysis should be performed by your primary doctor to ensure that this clears. The MRI of your brain which was done was concerning for changes in your brain due to high blood pressure. These changes can sometimes also be seen in syndromes of inherited early dementia. A copy of the final report will be mailed to you when available. Please discuss the results with your primary doctor. We made the following changes to your medications: -Your blood pressure medications were changed as follows. Each one can be purchased from [Company ] for $4 per month. It is extremely important that you take these medications regularly and do not miss doses. Please check your blood pressure at home and call your primary doctor if your blood pressure is greater than 180/100. 1. Hydralazine 10 mg Tablet, One (1) Tablet every 8 hours. 2. Metoprolol Tartrate 25 mg Tablet, 0.5 Tablet 2 times a day. 3. Isosorbide Mononitrate 30 mg Tablet Sustained Release, One (1) Tablet Daily. 4. Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule, One (1) Cap Daily. -You were also started on Tamiflu for influenza. Continue Oseltamivir 75 mg Capsule, One (1) Capsule 2 times a day for 4 doses. - You were started on a Nicotine patch for smoking cessation. Continue Nicotine 14 mg/24 hr Patch, One (1) Patch 24 hr Transdermal Daily for 4 weeks: Do not use while actively smoking. Discuss with your primary doctor further need for this patch. Please call your primary care physician or go to the emergency department if you experience headache, fever, cough, chest pain, blood pressure greater than 180/100, or any other concerning symptom. Followup Instructions: Please follow-up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 30186] at [Hospital1 ], ([Telephone/Fax (1) 40368]. The following appointments have been scheduled for you: 1. Friday, [2122-11-27] at 10:30pm - BP and lab check/follow-up appointment. 2. Wednesday, [2122-12-9] at 10:40am - Follow-up appointment.	[ "070.70", "276.8", "784.0", "401.9", "791.9", "305.1", "780.57", "250.00", "493.90", "584.9", "288.50", "487.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12646, 12652	8233, 11184	318, 324	12803, 12880	4338, 4338	15292, 15667	3372, 3549		11376, 12623		12673, 12673		11210, 11353				12904, 14049						3564, 4319																		14078, 15269	2603, 2806			246, 280								352, 2584			12749, 12782			4354, 8210	12692, 12728								2828, 3010	3026, 3356
15,472	148,372	20	Discharge summary	report	Admission Date: [2178-11-15] Discharge Date: [2178-12-2] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[First Name3 (LF) 281] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Tracheostomy Placement [First Name3 (LF) 282] tube placement History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, COPD, mini-trach to manage secretions, on home O2 who presents c/o 4 days progressively worsening SOB. Need to increase home O2 from 2 to 3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically his baseline). Given combivent, solumedrol, clinda, and azithro for presumed COPD exacerbation. Initially admitted to MICU for close monitoring, started on Azithromycin and CTX, switched to Ceftaz given past history of Pseudomonas. Transferred to floor on [11-17], stable and at baseline. On floor, patient had repeated episodes of desaturation, with tachypnea. Became SOB on [11-18] in AM, given Ativan 1, Morphine 2 and Valium 5, with some initial improvement. Then found to be lethargic, and ABG with PCO2 102, pH 7.22. Brought to the ICU for further management. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts Social History: He lives with his wife. [Name (NI) ] has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: Upon Discharge: Gen: Alert, NAD, cooperative, well appearing HEENT: PERRLA, [Year (4 digits) ] MMM/clear, trach in place CV: irreg rhythym, reg rate, no m/r/JVD Pulm: coarse BS on the left, transmitted BS on R Ab: s/nd/[Last Name (LF) ], [First Name3 (LF) 282] in place Ext: no LE edema, 2+DPPBL Pertinent Results: [2178-11-15] 11:21PM TYPE-ART PO2-172* PCO2-59* PH-7.34* TOTAL CO2-33* BASE XS-4 [2178-11-15] 09:04PM TYPE-ART PO2-163* PCO2-62* PH-7.39 TOTAL CO2-39* BASE XS-10 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2178-12-1] 04:00AM 9.3 2.83* 8.4* 26.9* 95 29.7 31.2 14.4 284 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2178-12-2] 04:11AM 17.6* 2.0 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2178-12-1] 04:00AM 133* 20 0.8 147* 5.0 107 36* 9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili [2178-12-2] 04:11AM 46* 20 219 128* 18 0.4 OTHER ENZYMES & BILIRUBINS Lipase [2178-12-2] 04:11AM 19 CHEMISTRY TotProt Albumin [2178-12-2] 04:11AM 2.8* Blood Gas BLOOD GASES Type Rates Tidal V PEEP FiO2 pO2 pCO2 pH calHCO3 [2178-12-1] 04:32AM 18 500-600 5 0.50 92 68.1 7.42 46 Brief Hospital Course: 1) Respiratory distress: Improved with face mask. Serial ABGs showed hypercarbic failure, improved with face mask. Switched to nasal cannula in PM [11-18], but ABGs with ongoing hypercarbia in the 80s. At night, patient had sub-acute worsening respiratory status, with desaturation and tachypnea, along with agitation and confusion. pH with PCO2 in 90s. Placed on CPAP, unsuccessfully. Repeat ABG with PaCO2 87, pH 7.29. Patient intubated. Arterial line finally placed successfully. Extubated on [11-19] but extremely anxious and hypertensive and hypercarbic. Placed on BIPAP and reintubated. [2178-11-23] trach placed. Pt was stable with the trach and venitilator support. Pt has been maintaining stable oxygenation and ventilation on pressure controlled ventilation with PS 3, PEEP 5, Fi02 0.5, PIP 22, TV 500-600, RR18. He benefited from albuterol/atrovent nebs, suction, steroids. At the time of discharge he was on day 4 of prednisone taper. Pt was also on Zosyn for GNR, has h/o pseudomonas. No further abx at the time of discharge. 2) [Name (NI) 283] Pt was placed on amiodarone for afib, but this was discontinued when he developed persistent bradycardia to the 30's-40's on [2177-11-29]. Pt was also anticoagulated on a heparin drip and on [11-24] began coumadin loading. 3)bradycardia- likely [12-30] amiodarone; resolved after holding this med ([2178-11-30]). pt will follow up with Dr [Last Name (STitle) 284] and will likely need a Holter Monitor as an outpt. TFT's pending at time of discharge. 4) agitation: likely due to hypercarbic reso drive, controlled with haldol and then resolved completely when respiratory status stabilized. 5) DM: controlled on RISS with standing dose of NPH. 6) FEN: [Last Name (STitle) 282] tube placed on [2177-11-29] without complication. Tubefeeds started through the [Date Range 282] on [2177-11-30]. Discharge Medications: 1)Praoxetine 20mg QD 2)Ferrous Sulfate 3)Colace 100mg [Hospital1 ] 4)MVI 5)Atorvastatin 10mg QD 6)B12 7)Combivent neb q2-4 hr 8)Senna 1tab [Hospital1 ] 9)Coumadin 5mg QD titrate to INR 10)Insulin SS + NPH fixed dose 11)Prednisone taper (starting [12-3] as 20,20,10,10,5,5, off) 12)Ambien 10mg qhs prn insomnia Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Hypercarbic respiratory Failure s/p trach placement Discharge Condition: Stable Discharge Instructions: 1)Trach care as per rehab facility protocol. 2)[Location (un) 282] tube care and use as per rehab facility protocol. 3)Titrate INR to 1.5 for a fib. 4)Wean ventilator as tolerated. Followup Instructions: 1)Follow up with Dr [Last Name (STitle) 284] ([Telephone/Fax (1) 285]) later this week for further evaluation of your atrial fibrillation, bradycardia. 2)Follow up for weekly INR checks and titrate for a fib to INR >1.5 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 286]	[ "250.00", "300.00", "276.2", "V10.11", "593.9", "787.2", "285.9", "518.81", "276.0", "276.3", "V58.61", "491.21", "788.29", "428.0", "401.9", "V12.51", "427.31", "427.89" ]	icd9cm	[ [ [] ] ]	[ "88.43", "38.91", "43.11", "96.04", "96.72", "97.23", "96.6", "96.05", "57.94" ]	icd9pcs	[ [ [] ] ]	5435, 5506	3154, 5066	314, 380	5601, 5609	2132, 3130	5843, 6165	1750, 1789		5089, 5412		5527, 5580						5633, 5820						1804, 1804																						255, 276							1820, 2113	408, 1230															1252, 1538	1554, 1734
11,715	120,195	12137+12138+12139	Discharge summary	report+report+report	Admission Date: [2191-2-5] Discharge Date: [2191-2-24] Date of Birth: [2191-2-5] Sex: M Service: HISTORY OF PRESENT ILLNESS: Baby [Known lastname 916] [Known lastname 8389] is a Twin #1, born with a birth weight of 1365 gm at 27 3/7 weeks gestation with problems of surfactant deficiency progressing to bronchopulmonary dysplasia, adductus arteriosus which has been closed with Indocin as well as some feeding intolerance. Pregnancy was remarkable for a 29 year old gravida 3, para 1 to 3 mom. Prenatal screens revealed 0 positive, hepatitis B negative, RPR nonreactive, Rubella immune. Pregnancy was followed at [Hospital3 7362]. Pregnancy was remarkable for twin gestation thought to be monozygotic but in two sacs. Pregnancy was complicated by premature prolonged rupture of membranes on [2190-12-31] at 22 2/7 weeks gestation of Twin #2. Mom was seen at [Hospital3 7362] where betamethasone was given. At that time Mom was released to home until the age if viability. The Mom was readmitted to [Hospital6 38031] Hospital and remained there on the Antepartum Service for about five weeks with serial fetal surveillance. Prolonged rupture of membranes in lead Twin A who later emerged as Twin #2, the sibling of this infant. This infant had an intact sac throughout pregnancy. DELIVERY HISTORY: On the day of admission there was acute onset of maternal fever. Due to no available Newborn Intensive Care Unit beds at [Hospital6 ] at the time and the urgent need for delivery, maternal transfer from [Hospital6 26457] Hospital to [Hospital6 256] was arranged. Upon arrival to [Hospital6 2018] there was an urgent cesarean section due to maternal fever and concern for fetal distress. Intraoperative antibiotics were given. This twin emerged first, however, was the Twin B on prenatal surveillance. The infant gasped, cried weakly but had a good heartrate and was given blow-by oxygen, escalating to positive pressure ventilation. Apgars were 5 and 7 at one and ten minutes respectively. Decision to intubate by about six to eight minutes because of work of breathing and sustained high need for oxygen. The infant was subsequently brought to the Neonatal Intensive Care Unit for further management of prematurity and respiratory distress. PHYSICAL EXAMINATION ON ADMISSION: Weight was 1,365 gm, 90th percentile, length 36.5 cm, 50th percentile. Head circumference 27 cm 75th percentile, heartrate 160, respiratory rate 52, temperature 98.6, blood pressure 71/41 with a mean arterial pressure of 58. Dextrose sticks were between 78 and 50. This was a pink baby with adequate perfusion, low activity, normal facies and soft anterior fontanelle, normal ears, intact palate. Lungs were tight and coarse to auscultation bilaterally. Cardiac examination revealed a tapping quality with good rate and rhythm, no murmurs. Abdomen was soft with some gurgles. Pulses were initially faint. Scrotum was well developed. Testicles were apparently descended. Normal hips and spine were noted. There were otherwise normal extremities and grossly normal tone. HOSPITAL COURSE: 1. Respiratory -Chest x-ray showed significant bilateral hazy density consistent with Surfactant deficiency and the infant received three doses of Survanta with some improvement in ventilatory requirements but not enough to result in extubation. The infant had some blood tinged excretions on day of life #2 with some evidence of adductus arteriosus on examination which was closed with Indocin and will be outlined in the cardiovascular part of this dictation. There was no other evidence of pulmonary hemorrhage. On day of life #8 through 12, chest x-rays did show evidence of pulmonary edema. The etiology was unknown, however, the infant did require escalating peak inspiratory pressures and positive end-expiratory pressure. There were periods of time where the infant also had blood-tinged bright red secretions from the endotracheal tube. The infant self-extubated several times and required reintubation with an oral airway, however, now has a nasal airway which has been in past for the past five days. Respiratory settings have actually been improving over the past three days with current settings of 22/6 times 16 with an FIO2 of 25%. These have been some of the best settings the infant has had since his hospitalization and we anticipate that if he continues to improve, he may approach extubation to CPAP next week. Discussion has been made with the family regarding the progression of bronchopulmonary dysplasia in both of these infants and the possibility that they may need prolonged intubation. We have not started diuretics on either of these infants since they seem to be progressing well without the need for longterm diuretics. This infant has received intermittent doses of Lasix from time to time especially when chest x-rays were consistent with pulmonary edema. He has not received any Lasix over the past three days. 2. Cardiovascular - The infant had a murmur on day of life #2 which was treated with one course of Indomethacin. The murmur subsequently resolved. He also had a hyperactive precordium with widened pulse pressure at the time of Indomethacin administration which subsequently resolved. He had a large heart on chest x-ray with evidence of pulmonary edema on day of life 8 through 10. He has had two subsequently echocardiogram which have shown no evidence of adductus arteriosus with good biventricular function. His edema issues resolved. It is also worth mentioning that the infant had transient expected hypotension the first two days of life with Dopamine infusion rate which was maximum at 7 mcg/kg/hour on day of life #2. He was off of Dopamine by day of life #4. 3. Fluids, electrolytes and nutrition - Due to Indomethacin treatment and Dopamine requirements the infant was not sat initially and kept NPO on parenteral nutrition. Feedings were started on day of life #6 and were advanced by 10 cc/kg b.i.d. over the course of one week. He obtained full feeds. He is currently receiving 26 calorie mother's milk or preemie Enfamil along with some ProMod. He is also receiving supplemental Vitamin E and iron. There has been some spittiness noted with feeds so they are being given q. 2 to 2?????? hours. His total fluids are at 140 cc/kg/day due to spittiness as well. He has been having reasonably good weight gain on this regimen, however. Abdominal films have been unremarkable. His abdomen is nontender. He stools once every other day or so. 4. Hematology - The infant has been on phototherapy due to prolonged hyperbilirubinemia, likely due to increased enterohepatic circulation and infrequent stooling. There has been no frank evidence of hemolysis. Most recent serum bilirubin was 5.5. He will continue on phototherapy and have a bilirubin rechecked tomorrow. If it is normal, his phototherapy could potentially be discontinued with rebound to be checked the day after. The infant has received blood transfusion following complication during umbilical arterial catheter removal where he had some blood out estimated at approximately 20 to 30 cc. He received 30/kg of packed cells following this incident. He did not show significant signs of hemodynamic instability during or after the episode. Due to the presence of significant blood-out it was difficult to estimate the total blood losses at this time. This may have been a contributing factor towards his fluid retention and some interstitial edema on chest x-ray. These issues as mentioned above have resolved. His most recent hematocrit was 33.7 which was obtained on [2-18], or day of life #13. 5. Infectious disease - The infant was initially treated with ampicillin and gentamicin for 48 hours. This infant did not have prolonged rupture of membrane and did not receive lumbar puncture. Initial complete blood count showed a white blood cell count of 12 with 19% polys, 1% bands and 70% lymphs and a platelet count of 143,000. On day of life #13 the infant was showing demonstrated temperature instability with no other signs of sepsis. After looking for potential environmental etiologies including shutting off his isolette the infant still showed elevated temperature as high as 101.4??????. This was in an off-isolette with the windows opened. Due to significant temperature instability and fevers the infant had sepsis evaluation which showed a white blood cell count of 16.8 with 43% polys, 2% bands. The presence of fever increased our suspicion for possible viral infection. Lumbar puncture was done showing 570 red cells, 1 white cell, protein of 106 and glucose of 55. Urine culture was done as well. The infant was started on Vancomycin, gentamicin and acyclovir. HSV, PCR was sent as well. The infant stayed on Vancomycin and gentamicin for 48 hours with subsequent blood cultures found to be negative. The infant remained on acyclovir until HSV, PCR results were negative. The infant is currently not on any antibiotics or antivirals. 6. Neurology - The infant has had head ultrasound which has shown no evidence of intraventricular hemorrhage. He should have a head ultrasound at 30 days of age as well. 7. Psychosocial - We have had two meetings with the family, both Mom and Dad are actively involved in the infant's care and would like to be updated on a weekly basis. The parents are kangarooing the infant on a daily basis. Mom is now starting to express some degree of anxiety and sadness over having the babies in the Intensive Care Unit but seems to feel well-informed about their progress and their clinical picture. Primary pediatrician is identified as Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 38032]. This doctor is at [Hospital 1121] Hospital. When the infants are extubated and off of CPAP and stable for transfer to level 2 nursery, they will be candidates for transfer over to [Hospital 38033] Hospital. DISCHARGE DIAGNOSIS: 1. 27 Week premature infant, Twin #1 2. Surfactant deficiency, treated 3. Bronchopulmonary dysplasia 4. Sepsis evaluation times two, completed 5. Patent ductus arteriosus medically closed with Indomethacin 6. Feeding intolerance 7. Hyperbilirubinemia [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Name8 (MD) 38034] MEDQUIST36 D: [2191-2-24] 18:09 T: [2191-2-24] 19:24 JOB#: [Job Number 38035] Admission Date: [2191-2-5] Discharge Date: [2191-3-30] Date of Birth: [2191-2-5] Sex: M Service: NEONATOLOGY Please note that this is an interim summary from the date of [2-28] to [3-29]. Please refer to previous summaries dictated from the period of [2191-2-5] to [2191-2-26]. HISTORY OF PRESENT ILLNESS: Briefly, this is a 27 [2-3] week twin number one boy with a birth weight of 1365 that was delivered to a 29 year-old gravida 3 para [12-2] mother with unremarkable prenatal screens. The mother was originally admitted to [Hospital6 1708], but was transferred to the [Hospital1 69] on the day of delivery secondary to bed shortage. HOSPITAL COURSE: The baby was initially intubated with a diagnosis of Surfactant deficiency. He received three doses of Surfactant with some improvement. Of note, earlier in his hospital course he was noted to have episodes of red secretions from the endotracheal tube that resolved. These episodes were short lived, mild and was not considered to be evidence of a pulmonary hemorrhage. He had remained intubated weaning slowly on his settings and was actually extubated to CPAP during the late part of [Month (only) 958]. He remained intubated with for most of the first few weeks of life and made slow improvement on his ventilatory requirements. He was transitioned to CPAP at [3-8] at day of life 31 successfully. His FIO2 requirements at the time remained at about 22 to 40% with some mild retractions noted. However,he appeared comfortably and was attempted on nasal cannula shortly thereafter. His oxygen flow slowly started to escalate to 400 cc during that time and because of due to increased work of breathing he was put back on MP-CPAP on [3-18] at day of life 41. This resulted in a satisfactory decrease in apnea and bradycardia episode. He has been maximized on caffeine as well. He remained stable with decreasing oxygen requirements to about 21 to 30% on CPAP and eventually was weaned to room air CPAP of 5. He was again trialed on nasal cannula at 200 cc flow on day of life 47 and has remained stable since. He does have occasional drifts and periodic breathing that resolves with mild stimulation and suctioning. At day of life 51 he was tried off caffeine and has remained stable with minimal spells since. From a cardiovascular standpoint, briefly the baby had been treated with one course of indomethacin for a clinically evident PDA. Subsequent echocardiogram showed no evidence of a persistent patent ductus arteriosus and good biventricular function. It is also noted that initially the patient had a transient hypotension in the first few days of life with dopamine requirements. He was off of dopamine by day of life four. Fluids, electrolytes and nutrition, fluids were initially due to Indomethacin Dopamine requirements the baby was kept NPO on parenteral nutrition. Feedings were started on day of life 6 and was advanced by 10 cc b.i.d. over the course of the next few weeks. He has also been on supplemental vitamin E and iron. He has occasional spits with feeds that require the feeds to be given over an hour to an hour and forty five minutes. That is also slowly resolving. Currently he is total fluids at 140 cc per kilo per day on PE-26 without ProMod. He is showing nice weight gain and growth. On the day of this dictation his formula was changed to PE-24 and we will be following his weight gain closely. Hematology, the patient was briefly on phototherapy due to prolonged hyperbilirubinemia. He has also tolerated a few blood transfusions during his early hospital course without any complications. Infectious disease, the baby was initially treated with ampicillin and gentamicin for 48 hours. His initial CBC was unremarkable for sepsis. It is of note, however, that his platelet count was initially 143,000. He did receive a sepsis evaluation on day of life 13 secondary to temperature instability. This evaluation was unremarkable (including an LP). He did receive 48 hours of vancomycin and gentamicin. Acyclovir was started, but was discontinued when the PCR/HSV results were negative. Neurology, the infant has had head ultrasounds, which showed no evidence of intraventricular hemorrhage. This was a head ultrasound within the first week of life as well as a head ultrasound at 30 days of age. Psycho/social, primary pediatrician is Dr. [Last Name (STitle) 38032] at [Hospital 38033] Hospital. We have had multiple meetings with the parents. Both mom and dad are actively involved in the infant's care and would like to be updated on a regular basis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Last Name (NamePattern1) 38036] MEDQUIST36 D: [2191-3-30] 11:50 T: [2191-3-30] 11:59 JOB#: [Job Number 38037] Admission Date: [2191-2-5] Discharge Date: [2191-4-29] Date of Birth: [2191-2-5] Sex: M This is a final discharge summary for patient, Boy [Known lastname 8389], from the Neonatal Intensive Care Unit at the [Hospital1 346]. Please refer to earlier interim dictations dated [2191-2-24] and [2191-3-30] for details of earlier HISTORY: Baby [Name (NI) ] [Known lastname 916] [Known lastname 8389] is twin #1, born with a birth weight of 1365 gm at 27 3/7 weeks gestation to a 29-year-old gravida 3, para [12-2] mother. Pregnancy was remarkable for monozygotic diamniotic twin gestation followed at [Hospital3 7900]. Prenatal screens notable for blood type O+, hepatitis B negative, RPR non reactive and rubella immune. membranes on [2190-12-31] at 22 2/7 weeks gestation. Mother was treated with Betamethasone and was subsequently admitted to [Hospital1 69] for monitoring. Of note, rupture of membranes occurred in twin #2; membranes for this twin were intact throughout pregnancy. Mother was monitored until the day of admission when there was acute onset of maternal fever. Due to concerns for infection and fetal distress, an urgent cesarean section was performed at 27 3/7 weeks gestation. Boy [Known lastname 916] [Known lastname 8389], twin #1, emerged with a weak cry and was resuscitated with a positive pressure ventilation. Apgars were 5 and 7, and the infant was intubated in the delivery room secondary to respiratory distress. At the time of birth, weight was 1,365 gm, 90th percentile, length was 36.5 cm or 50th percentile and head circumference was 27 cm, 75th percentile. HOSPITAL COURSE: 1. Respiratory: The infant exhibited moderate to severe hyaline membrane disease and received three doses of Surfactant with some improvement. The infant did experience a possible mild pulmonary hemorrhage on day of life [1-2] associated with a patent ductus arteriosus. This subsequently improved with treatment of the ductus. The infant subsequently developed a significant chronic lung disease and was very gradually weaned from the ventilator. He was eventually extubated to C-pap successfully on day of life #31. Several attempts to transitioning to nasal cannula failed; with good growth the patient's lung disease did improve and he was eventually transitioned nasal cannula on day of life #47. Patient was treated with caffeine for apnea of prematurity but was not treated with diuretics. Lung disease continued to improve and by day of life #60, [2191-4-6], the patient was transitioned to room air. Since that time the patient has been stable on room air, initially with occasional desats but subsequently these had also resolved. The patient did not have significant apnea of prematurity recently and was taken off the caffeine on day of life #62, [2191-4-8]. By the time of discharge, the patient has been stable from a respiratory standpoint, breathing comfortably on room air for 1-2 weeks without any significant episodes of desaturation or apnea or bradycardic spells for over one week. 2. Cardiovascular: The patient did have clinical evidence of a patent ductus arteriosus on day of life #[12-1] and was treated with a course of Indomethacin. The clinical symptoms including a murmur resolved. During the first two weeks of life, due to varying pulmonary course and concerns for pulmonary edema, the patient did undergo two subsequent echocardiograms, both of which showed good biventricular function without evidence of patent ductus arteriosus. The patient did have transient hypotension on the first two days of life treated with Dopamine to a max of 7 mcg/kg/min. This was consistent with the diagnosis of respiratory distress syndrome and the patient has remained hemodynamically stable since that time. The patient has not had any significant cardiovascular issues for the remainder of the hospitalization. Last echocardiogram was on [2-18], day of life #14, which was normal. 3. Fluids, Electrolytes & Nutrition: The patient was initially maintained on IV fluids and parenteral nutrition. The infant was begun on enteral feeds on day of life #[5-6] and gradually advanced. He was advanced to a max of 26 calories per oz and exhibited good weight gain on this regimen. Over the course of hospitalization his formula was gradually transitioned to Enfamil 24. He did receive Vitamin E supplementation as well as iron. At the time of discharge the patient continues on Enfamil 24, taken on a po ad lib basis with good weight gain. He also is continued on iron therapy. The patient has been eating entirely po without need for supplemental gavage feedings for approximately one week at the time of discharge. 4. Hematology: The patient did receive phototherapy for transient hyperbilirubinemia of prematurity. The patient did receive several blood cell transfusions during admission. Last hematocrit was measured [4-12], day of life #66 and was found to be 28.1 with reticulocyte count of 3.6. 5. Infectious Disease: The patient was treated with Ampicillin, Gentamycin for the first 48 hours of life while undergoing a sepsis evaluation. These were discontinued on day of life #2. Another sepsis evaluation treated with Vancomycin, Gentamycin and Acyclovir for 48 hours was performed on day of life #13 to 15 secondary to temperature instability. All cultures were negative and the antimicrobials were discontinued. 6. GI: The patient had no significant gastrointestinal issues throughout the hospitalization. The patient was begun on prune juice for mild constipation with good effect. 7. Neurology: A head ultrasound within the first week of life and again on day #32 of life were normal. A final head ultrasound performed on [4-28], day of life #82 was also within normal limits. Ophthalmologic screening revealed immature eyes initially, they were found to be mature on day of life #60, [2191-4-6]. Hearing screen was passed on [2191-4-27], day of life #81. 8. Other: On exam, the patient was noted to develop a small umbilical hernia as well as a right hydrocele. These will be followed as an outpatient. CONDITION ON DISCHARGE: The patient, at the time of discharge, is hemodynamically stable, breathing comfortably on room air. The patient is feeding Enfamil 24 with good volumes and good weight gain. The patient has appropriate urine output and appropriate stool output on prune juice. Weight on [2191-4-28] was 3575 gm. DISCHARGE DISPOSITION: The patient is being discharged to home with family. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 38032] at [Hospital 1121] Hospital. CARE RECOMMENDATIONS: A) Feeds: Enfamil 24 on an ad lib basis. B) Medications: Fer-in-[Male First Name (un) ] .35 cc po q day. C) Car seat: Car seat test was passed on [2191-4-25]. D) State newborn screening status: Last newborn screen was sent on [2191-3-21] and was normal. A repeat newborn screen will be sent on [2191-4-29], day of discharge. E) Immunizations: The patient received first doses of IPV and HIB on [2191-4-6], first doses of DTAP and PCV on [2191-4-7] and first dose of hepatitis B vaccine on [2191-4-7]. F) Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for those infants who are born at less than 32 weeks. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach 6 months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. G) Follow-Up: The infant will follow-up with primary pediatrician three days after discharge. In addition, referrals will be made to early intervention, VNA and the infant follow-up program at [Hospital3 1810]. DISCHARGE DIAGNOSIS: 1. Twin gestation. 2. Prematurity at 27 3/7 weeks. 3. Respiratory distress syndrome. 4. Chronic lung disease. 5. Patent ductus arteriosus. 6. Sepsis evaluation. 7. Feeding immaturity resolved. 8. Hyperbilirubinemia of prematurity resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Doctor Last Name 38038] MEDQUIST36 D: [2191-4-29] 07:43 T: [2191-4-29] 07:56 JOB#: [Job Number 38039]	[ "V29.0", "765.05", "770.7", "747.0", "V30.01", "553.1", "514", "779.3", "774.6" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.72", "03.31", "96.04" ]	icd9pcs	[ [ [] ] ]	22101, 22287										23551, 24074			17227, 21749		22309, 22853																																			22880, 23530		10927, 11275								2367, 3148									21774, 22077
13,490	107,881	27091	Discharge summary	report	Admission Date: [2131-4-16] Discharge Date: [2131-4-20] Date of Birth: [2070-1-22] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1561] Chief Complaint: tracheobronchial malacia Major Surgical or Invasive Procedure: bronch tracheobronchial malacia History of Present Illness: Ms. [Known lastname ] is a 61-year-old woman with severe tracheobronchomalacia. She has had improvement after a stent trial. Past Medical History: 100pkyr hx, s/p Nissen [2-7], Y-stent placed [2-6] removed [3-9], COPD, hypertension, osteoporosis, depression, gout, hyperlipidemia TBM w/ stent trial Social History: 100 pk year smoker Family History: non-contributory Pertinent Results: [2131-4-19] CXR : ONE VIEW. Comparison with [2131-4-18]. A right chest tube has been removed. No pneumothorax is identified. Streaky density consistent with subsegmental atelectasis or scarring persist. Mediastinal structures are unchanged. Right rib fractures and underlying pleural thickening, loculated pleural fluid or extrapleural hematoma are again demonstrated. IMPRESSION: No significant change post-removal of right chest tube. Brief Hospital Course: pt was admitted and taken to the OR on [2131-4-16] for Tracheoplasty with mesh, right main-stem bronchoplasty with mesh, left mainstem bronchoplasty with mesh, flexible bronchoscopy. an epsiural was placed pre-op for pain control w/ good effect. Two right chest tubes were placed in the OR and placed to sxn w/o no evidence of air leak. Post-op -extubated and admitted to the ICU for post-op management. On POD#0 -required IVB for low BP and low u/o-responded approp'ly. O2 sats 94% on 4LNP. Bronch'd on POD#2 pt was bronched - edema was seen in the upper airway and at right mainstem; secretions were aspirated from the left lower lobe. POD#3 chest tube removed and [Doctor Last Name ] placed to bulb sxn. Ambulating, [Last Name (un) 1815] po's and po pain med. d/'d to home on POD#4 w/ home oxygen as PTA. Medications on Admission: Advair 50/500'', combivent 4'''', prevacid 30', prozac 40', HCTZ 25', trazadone 50 qhs, zocor 40', zantac 150', MVI' . Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-5] Puffs Inhalation Q6H (every 6 hours). 2. Fluoxetine 10 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:75 Tablet(s) Refills:0 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Hospital6 ] of saco me Discharge Diagnosis: tracheobronchial malacia s/p tracheoplasty Discharge Condition: good-oxygen dependent at baseline Discharge Instructions: call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] if you develop chest pain, shortness of breath, fever, chills, redness or drainage from your surgical incision.The steri-strips on the incisison will fall off in time. You may shower on saturday. After showering, remove the chest tube site dressings and cover the site w/ a clean bandaid or gauze daily until healed. Do not drive while taking pain medication. Take a mild laxative to prevent constipation while taking pain medication. Followup Instructions: Call Dr.[Name (NI) 1816] office [Telephone/Fax (1) 170] for a follow up appointment Completed by:[2131-4-23]	[ "272.4", "496", "401.9", "305.1", "519.19", "715.90", "458.29", "311", "274.9", "518.5", "530.81" ]	icd9cm	[ [ [] ] ]	[ "96.05", "33.48", "33.22", "31.79" ]	icd9pcs	[ [ [] ] ]	3140, 3198	1294, 2117	354, 388	3285, 3321	823, 1271	3868, 3991	786, 804		2287, 3117		3219, 3264		2143, 2264				3345, 3845																												290, 316								416, 547															569, 734	750, 770
18,970	199,656	29803	Discharge summary	report	Admission Date: [2159-1-19] Discharge Date: [2159-2-19] Date of Birth: [2085-12-31] Sex: F Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[First Name3 (LF) 2698] Chief Complaint: cardiogenic shock (transfer from [Hospital 47] [Hospital 1281] Hospital) Major Surgical or Invasive Procedure: operative IABP placement ([2159-1-19]) Cardiac catheterization, tracheostomy tube placement, PEG tube placement. History of Present Illness: 73 yoF with PMH HTN, hypothyroid who has been complaining of "indigestion" since [9-/2158] and has been treated with a ppi without relief. She reports this as a 15-30 min non-radiating burning sensation, unrelated to exertion. She reportedly had a "normal" stress test at [Hospital1 2177] on [2159-1-12]. On the night prior to admission, she had complained of intermittent epigastric pain which became persistent around 6 PM. . Around 5 AM on [2159-1-16], she reported to an OSH ED c/o 11 hrs of epigastric pain. She had a BP of 191/120, HR 102, Sat 91% on ra (98% on 2L n.c.), and was afebrile. An ECG (performed 90 minutes after arrival to ED) showed Q-waves and ST elevations in V1-V5, she had elevated cardiac enzymes (troponin peak 135, CK peak 3508) and was taken to an emergent cardiac cath. [Date Range ]-cath, she was found to have a R-dominant system, received a BMS to her proximally-occluded LAD (with resultant TIMI-3 flow) and also was found to have ostial RCA (90% stenosis) and LCx disease (50% stenosis in OM1 and OM2) which were not intervened upon at the time. . Post-cath, had some episodes of hypoxia and hypotension to 70s. A post-cath echo showed an EF of [10-1]% with anterior/septal/apical akinesis. Also of note, she had persistent tachycardia and "did not tolerate" Lopressor. She received digoxin for "inotropic support". She was assessed to be "on the cusp of cardiogenic shock" and was transferred to [Hospital1 18] for operative placement of LVAD vs IABP placement. . [Hospital1 ]-op, her Swan numbers showed a CVP 20, PAD 25, [Doctor First Name 1052] 28, CO 3.1; she had an IABP placed. An [Doctor First Name ]-op TEE showed an LVEF of 20-25% with 1+ MR. On arrival to the CSRU, she had MAP 80, CVP 20, PAD 25, [Doctor First Name 1052] 28, CO 3.1. Past Medical History: HTN hypothyroid osteoporosis fibromyalgia asthma L total knee replacement R femur fx s/p rod placement Social History: No tobacco/alcohol. Ambulates with cane at baseline. Family History: both parents died of MIs in their 50s Physical Exam: T 98.6 BP 134/67 HR 95 PAP 33/21 CVP 14 RR 12 Sat 100% on vent Gen: sedated, intubated HEENT: (+) ETT, (+)OG tube Chest: ronchorous breath sounds throughout (ant/lat exam only) CV: regular rate/rhythm, no m/r/g heard Abd: soft, NTND, nl BS, no masses Extr: cool, 1+ PT pulses, trace bipedal edema Neuro: sedated Pertinent Results: CXR: [2-19] CXR Tracheostomy tube and left PICC line are in standard position. Cardiac and mediastinal contours are unchanged. There are worsening bilateral alveolar opacities most prominent in the central portions of the lungs with relative sparing of the apices and extreme periphery. This is most likely due to pulmonary edema particularly given waxing and [Doctor Last Name 688] course over serial prior radiographs. . TEE: [2-7] ECHO MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.4 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 40% (nl >=55%) INTERPRETATION: Findings: This study was compared to the prior study of [2159-1-31]. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Apical LV aneurysm. No LV mass/thrombus. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. PERICARDIUM: No pericardial effusion. Conclusions: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is an apical left ventricular aneurysm. No masses or thrombi are seen in the left ventricle (echo contrast given to exclude). Overall left ventricular systolic function is mildly depressed. Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2159-1-31], no change. IMPRESSION: No LV thrombus seen. . [2-15] ECG: Sinus tachycardia. Prior anteroseptal myocardial infarction. Compared to the previous tracing of [2159-2-14] the rate has slowed and anterolateral ST segment elevation persist. Otherwise, no diagnostic interim change. . [2-7] MRA head IMPRESSION: Severely limited study demonstrating absence of flow signal in the distal left vertebral artery and small basilar artery which could be secondary to fetal posterior cerebral arteries. No evidence of vascular occlusion seen in the anterior circulation. Left posterior cerebral artery is not well visualized. . [1-26] Cardiac Cath COMMENTS: 1. Coronary angiography in this right dominant system demonstrated two vessel disease. The LMCA had no angiographically apparent disease. The LAD was mildly calcified and had mild luminal irregularities in the proximal section, followed by a widely patent stent; diffuse disease and attenuation of the LAD distally. The Cx had 40-50% stenosis in OM1 and OM2.The RCA had an ostial 90% lesion and there was diffuse disease in the mid to distal segments of the RCA. 2. [Name (NI) 9927] PTCA and stenting of the Right coronary artery with aa 2.5 Cypher DES, post dilated with a 3.0 NC [Name (NI) 71306] at the ostium; three 2.5 Cypher DES in the mid vessel and two 2.0 BMS in the mid to distal segment. The final angiogram demonstrated no residual stenosis with no angiographic evidence of dissection, embolization or perforation with TIMI III flow in the distal vessel. (See PTCA comments) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. [Name (NI) 9927] multi-stent PCI of the RCA. Brief Hospital Course: A/P: 73 yo woman with recent anterior MI transferred for cardiogenic shock, now s/p IABP removal on [2159-1-21], s/p stents to RCA [2159-1-26] with VAP s/p trach placement [2-2], PEG [2-4] and new acute CVA x2in the setting of hypotensive episodes and L carotid stenosis. . This 73 year old woman was transferred from [Hospital1 ] after acute MI initially out of concern for LVAD placement for cardiogenic shock. On arrival she was found to have intraoperative CVP 20, PAD 25, [Doctor First Name 1052] 28, CO 3.1 so had IABP placed. LVEF 20-25% with 1+ MR. [First Name (Titles) ] [Last Name (Titles) 71306] pump was weaned and removed. Repeat TTE showed improved LVEF 40%. She was initially attempted to be extubated however shortly afterwards became stridorous and was reintubated. She was found to have pseudomonas and MRSA in her sputum and treated with vanco, ciprofloxacin, and aztreonam. She did not have rapid improvement and continued to have pseudomonas in her sputum so was desensitized to meropenem (given allergy to penicillin) and treated with that for her VAP. Given difficulty extubating and high RSBI's, she had trach and PEG placed for longterm vent weaning. For her CAD she underwent cardiac cath on [2159-1-26] which showed 90% RCA lesion that was stented with 2 drug eluting stents and 4 bare metal stents. Given her allergy to aspirin she was maintained on 150mg daily of plavix but was desensitized to aspirin and maintained on 325mg daily with 75mg plavix daily for her stents. . ## Pump- Cardiogenic shock on admission; LVEF 40% on re-evaluation. - IABP d/c'ed on [2159-1-21]; weaned off pressors readily though blood pressure quite labile and intermittantly requires pressors for MAP's 40-50 - TEE showed EF 20-25% when rate-controlled; recheck TTE much improved with LVEF 40%, hypokinesis so heparin d/c'd. Repeat TTE with echocontrast is negative for mural thrombus however she did have evidence of apical LV aneurysm which would be an indication for anticoagulation for 3-6 months. However, given her bleeding while on heparin (into her eye, her mouth, and requiring blood transfusion, we will hold of on starting anticoagulation until the patient is more stable). - beta blocker for am only given labile BP and propensity for hypotension at night; d/c'ed captopril d/t hypotensive episodes - continue furosemide 40 mg po daily . ## CAD- s/p 1 BMS to LAD for large anterior MI at OSH (CK peak 3508 at OSH); known severe (90%) ostial RCA disease and 50% stenoses of OM1, OM2 so 2 DES/4 BMS to RCA here [1-26] - desensitized to aspirin on [2159-1-28]; now tolerating aspirin 325mg daily - clopidogrel to 75 mg po qd; cont statin - BB restarted in am . ## Rhythm- HR elevated with aggitation, but remains in sinus rhythm, on BB . ## Valves- 1+ MR [First Name (Titles) ] [Last Name (Titles) ]-op TEE . ## Labile blood pressure: Intermittently hypotensive (MAP's 40's-50's) and hypertensive (SBP 200). Initially thought [1-19] volume depletion from diuresis plus blood loss from trach but swings without clear etiology. Also noted to occasionally be brady to 50's with hypertension. ? Central etiology given recent CVA though time course not likely to be [1-19] cerebral edema and location of CVA not characteristic for autonomic dysregulation though CVA may have progressed to involve insula. [Last Name (un) ] stim appropriate. Infection/sepsis is another possible cause for her hypotension, however s/p abx for known VAP. Labile BP may also be [1-19] CO2 narcosis, however VBG pCO2 during hypotensive episode did was not high enough to be concerning for CO2 narcosis, no improvement with forced MV. Additionally, decreasing sedation did not prevent the events. Intermittent levophed required for hypotension earlier in hospital course. Midodrine titrated up to 10mg po qhs. She continues to have occasional episodes of SBP as low as 70s but these are transient and she appears to be asymptomatic. Neurology recommends an EEG if this persists. - If SBP < 80, re-check in 15 minutes, will likely resolve. If persists for more than 1/2 hour to one hour, consider other etiologies. . ## L frontal stroke. Was initially on heparin gtt but this was stopped as it was thought to be a [1-19] watershed from low blood pressure - continue ASA/plavix - ideally keep SBP 120-170 - PT and [Hospital ] rehab . ## Respiratory failure- likely [1-19] VAP (pseudamonas, MRSA) and pulmonary eduema but both improved. Now s/p trach which will make weaning from ventilator easier for pt to tolerate. Failed extubation on [2159-1-23]. Sputum cx with continued pseudomonas. ID consulted and patient underwent meropenem desensitization. - may have had flash edema during failed extubation +/- further stress on cardiac function - albuterol and ipratropium MDIs for wheezing - wean ventilator as tolerated, appreciate Pulm recs who state that vent weaning may take several weeks of pulmonary rehab . ## VAP; Pseudomonas and S. aureus growing in sputum cx, with pseudomonas cont. despite treatment. s/p meropenem desensitization - tolerated meropenem desensitization; course of meropenem now complete on [2-12] - Pseudomonas coverage, d/c aztreonam and cipro - Sputum Cx growing pseudomonas but per ID likely colonized and will hold on further antibiotics unless spikes or clinical change . ## ARF: Now resolved. likely etiology is contrast nephropathy given the large dye load she got in cath on [2159-1-26] - follow cr as outpatient . ## Ophtho: Improved subconjunctival hemorrhage [1-19] heparin. No evidence of ulcer or infection. Also with increased IOP. - cont. cosopt 1gtt OU [Hospital1 ], lacrilube [12-21]" OU TID . ## Hypothyroidism: repeat TSH, free T4 WNL [2-10] - cont Levoxyl . ## Access: PICC placed [2-6] . ## Full Code . ## Contact: HCP [Name (NI) 39829] [Initials (NamePattern4) ] [Name (NI) ] (husband; [Telephone/Fax (1) 71307] or [Telephone/Fax (1) 71308]); alternative Shahnaz Imam ([Telephone/Fax (1) 71309] or [Telephone/Fax (1) 71310]) . ## Dispo: to trach-rehab. Medications on Admission: Flagyl (15 d course for H. pylori +) Clarithromycin (15 d for H. pylori +) Toprol XL 100mg daily levoxyl 125mcg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet [Telephone/Fax (1) ]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Levothyroxine 125 mcg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol [Telephone/Fax (1) ]: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 5. Clopidogrel 75 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol [Telephone/Fax (1) ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 7. Aspirin 325 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 8. Dorzolamide-Timolol 2-0.5 % Drops [Telephone/Fax (1) ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. Artificial Tear with Lanolin 0.1-0.1 % Ointment [Hospital1 ]: One (1) Appl Ophthalmic TID (3 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 12. Therapeutic Multivitamin Liquid [Hospital1 ]: Five (5) ML PO DAILY (Daily). 13. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Hospital1 ]: One (1) ML Intravenous DAILY (Daily) as needed. 15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QAM. 17. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: Two (2) PO Q4-6H (every 4 to 6 hours) as needed for fever, pain, agitation. 19. Ibuprofen 100 mg/5 mL Suspension [Last Name (STitle) ]: One (1) PO Q8H (every 8 hours) as needed for pain. 20. Midodrine 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO QHS (once a day (at bedtime)). 21. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 22. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) injection Injection TID (3 times a day). 23. Erythromycin 5 mg/g Ointment [Last Name (STitle) ]: One (1) cm Ophthalmic TID (3 times a day) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Coronary artery disease, hypertension, cerebrovascular accident, ventilator associated pneumonia, respiratory failure requiring tracheostomy placement and PEG tube placement, hypothyroidism, osteoporosis, fibromyalgia. Discharge Condition: Stable on vent Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [Last Name (STitle) ] or return to the emergency department if you experience chest pain, chest pressure, shortness of breath, dizziness, nausea, vomitting, weakness, numbness, or any symptoms that concern you. Followup Instructions: Please follow-up with your cardiologist, Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 1295] ([Telephone/Fax (1) 20259] within 2 weeks of discharge. . Please follow-up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] at [Hospital3 9947] within 2 weeks of discharge.	[ "244.9", "434.91", "785.51", "285.1", "482.41", "428.0", "790.7", "573.0", "433.10", "584.9", "401.9", "518.81", "V43.65", "493.90", "414.01", "733.00", "482.1", "372.72", "410.11", "729.1", "V09.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "43.11", "38.91", "89.64", "00.17", "99.04", "99.20", "00.66", "36.06", "31.1", "88.56", "00.48", "37.61", "88.72", "96.72", "00.40", "96.6", "36.07", "97.44" ]	icd9pcs	[ [ [] ] ]	15054, 15129	6135, 12279	364, 483	15392, 15409	2954, 6002	15800, 16126	2560, 2600		12447, 15031		15150, 15371		12305, 12424		6019, 6112		15433, 15777						2615, 2935																						244, 326								511, 2346															2368, 2473	2489, 2544
27,020	199,397	2405	Discharge summary	report	Admission Date: [2196-1-8] Discharge Date: [2196-1-19] Service: MEDICINE Allergies: Erythromycin Base / Benzodiazepines Attending:[First Name3 (LF) 458] Chief Complaint: ICD firing Major Surgical or Invasive Procedure: ablation of atrial flutter History of Present Illness: 84 year-old male with history of CAD s/p CABG in [2186], VT with ICD in [2186], systolic dysfunction with EF 50% with recent admission for VT storm mid [Month (only) ]/[2194] who is transfer from OSH after ICD fired. . Patient reports that his ICD fired this am. He was watching TV and he felt mild SOB and then his ICD fired. He denied chest pain, palpitations, lightheadeness prior to the episode. He has SOB with minimal activities including shower, and moving around the house. He does report a + cough for about 2 weeks. + Yellow flegms. No fevers, chills or URI symptoms. He sleeps with 3 pillows. + ankle edema over the last 2 months. . He was taken to [Hospital ] hospital, Vs on arrival 97.7, P 134, RR 24 Sat 100% 3 L. Past Medical History: CAD s/p CABG x 4v in [2183], h/o MI in [2170] CHF with EF 50% [2195-11-14] h/o VT s/p [Company 1543] ICD placement in [2186] upgraded to a dual chamber PPM [11-4] s/p VT ablation after EP study showed inducible monomorphic ventricular tachycardia in the RV outflow tract and apex HTN [11-4] Dyslipidemia Aortic Stenosis - mild s/p endovascular AAA repair in [2195-2-26] h/o bowel obstruction with cecum perforation s/p resection [2186] Hypertension Social History: Social history is significant for the absence of current tobacco use. He quit smoking 20 years ago; 32 pack-year history. There is no history of alcohol abuse. Family History: There is a family history of sudden death in his brother at age 40. Physical Exam: VS: T 98.6, BP 137/86, HR 68, RR 16, O2 98% on 3L NC Gen: non apparent distress HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, JVP up to the ear lobe. CV: RRR, distant heart sounds, soft eyection murmur RUSB, Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. bibasilar crackles + Abd: obese,+ ventral hernia. BS +, soft, non tender, non distended. Ext: 2+ edema. Pulses: Right: Carotid 2+ ; Femoral 2+; 2+ DP Left: Carotid 2+ ; Femoral 2+; 2+ DP Brief Hospital Course: . ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: 84 yo male with CAD s/p CABG in [2183], VT with ICD placement in [2186], CHF with EF of 50%, transferred from OSH after ICD fired. . # Rhythym: pacer interrogated and showwed that he had atrial flutter/afib that conducted 1 to 1 to the ventricle and he was shocked. No evidence of VT. He was started on anticoagulation during last admission given afib/aflutter on telemetry. Underwent successful ablation of atrial flutter. Continued on betablocker and amiodarone for rate and rhythm control and monitored on telemetry with no further events post intervetnion. Restarted on warfarin . * CAD: h/o CAD with CABG, no recent catheterization. No clinical signs of ischemia. Continued on ASA, statin and beta blocker. . * Pump: EF 50%, on recent echocardiogram. chest x ray on OSH no pulmonary edema. Continued on ACE and bblocker for comorbidity of CAD. . * Chronic kidney disease: Relatively stable since admission but elevated since [Month (only) ]. Per urine lytes appears to be intrinsic renal failure with elevated prot/cr ratio; likely chronic kidney disease from long standing hypertension . * GERD: continue PPI . * h/o Gout: continue allopurinol . * Code: FULL . * Comm: [Name (NI) 717] [Name (NI) 12412], daughter, [Telephone/Fax (1) 12413] . Medications on Admission: Allopurinol 100 qod Senna 8.6 tab [Hospital1 ] Aspirin 81 Amlodipine 10 daily Simvastatin 20 mg qhs Pantoprazole 40 [Hospital1 ] Cyanocobalamin 0.5 mg day Warfarin Lasix 40 daily Amiodaron 400mg daily Metoprolol. 12.5 mg Daily. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [Hospital1 ]:60 Tablet(s) Refills:2 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). [Hospital1 ]:45 Tablet Sustained Release 24 hr(s) Refills:2 9. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). [Hospital1 ]:180 Tablet(s) Refills:2 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO three times a day. [Hospital1 ]:90 Tablet(s) Refills:2 11. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs puffs Inhalation four times a day. [Hospital1 ]:1 inhaler Refills:2 12. Outpatient Lab Work Please draw PT/PTT/INR and have results faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12416] at ([Telephone/Fax (1) 12417]. 13. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please start this on [1-20], and then follow directions from your PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary: Atrial fibrillation/flutter with RVR Secondary: Congestive heart failure Discharge Condition: Good, vital signs stable, V-paced. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . You were admitted to the hospital with an abnormal heart rhythm. You had a procedure called an ablation to prevent this from happening again. . Please follow up with Dr. [Last Name (STitle) ] in Cardiology on [1-29]. . Changes were made to your medications which include: Toprol XL 75 mg daily Captopril 25 mg three times a day Lasix 80mg three times a day Discontinue amlodipine Coumadin: start tomorrow ([1-20]) at 2mg daily Please call your doctor or return to the emergency room if you develop worrisome symptoms such as chest pain, shortness of breath, lightheadedness, dizziness, passing out, etc. Followup Instructions: Follow up with electrophysiology (Division of Cardiology) with: Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2196-1-29] 10:20 at [Location (un) 830], [Hospital Ward Name 23] building [Location (un) 436]. . You should have your blood drawn on Thursday [2196-1-19] and the results faxed to your primary care doctor.	[ "V45.81", "427.31", "428.30", "V45.02", "403.90", "518.0", "530.81", "585.9", "428.0", "272.4", "427.1", "511.9", "427.32" ]	icd9cm	[ [ [] ] ]	[ "37.34" ]	icd9pcs	[ [ [] ] ]	5651, 5722	2442, 3801	252, 280	5848, 5885		6651, 7133	1765, 1834		4088, 5628		5743, 5827		3827, 4065				5909, 6628						1849, 2419																						202, 214								308, 1059															1081, 1569	1585, 1749
81,543	177,374	44754	Discharge summary	report	Admission Date: [2141-11-20] Discharge Date: [2141-11-27] Date of Birth: [2092-4-6] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / Bactrim Attending:[First Name3 (LF) 1384] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: 49yM s/p recent Kidney transplant [10-6] c/b drug induced interstitial nephritis likely secondary to bactrim and/or PPI, also c/b upper GI bleed managed medically, and Renal AV fistula likely secondary to kidney biopsy. Now presents with three days of increasing lethargy, dizziness, and suprapubic pain. Pt says he lost his blood sugar monitor under the bed and has not been checking his sugars for days. Because of that he is only taking small doses of insulin because he was afraid of becoming hypoglycemic. He admits to some mild tenderness that is suprapubic. No dysuria or hematuria. Denies any bleeding per rectum, melena, or hemeatemesis. He has had some N/V for past few days. No diarrhea, fevers, or chills. Past Medical History: 1. CAD s/p [Month/Year (2) ] to OM1 in [9-2] and [Month/Day (1) ] to RCA in [5-5] 2. End-stage renal disease, on HD since [6-3] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [2137-3-29]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Kidney transplant, right iliac fossa [2141-10-14]. Social History: The patient lives with his wife and 2 sons in [Name (NI) 669]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [Last Name (un) 95749]-[Doctor Last Name 3532] disease. Physical Exam: T 97.7 HR 74 BP 146/65 RR 20 O2 sat 100 Gen-mild distress, diaphoretic Heent-anicteric, no jaundice CV-RRR Pulm-CTA b/l Abd-soft, non-distended, graft palp RLQ, no tenderness. Some suprapubic TTP Ext-no edema or cyanosis, palp pulses Pertinent Results: On Admission: [2141-11-20] WBC-12.7# RBC-4.98 Hgb-13.9 Hct-44.3 MCV-89 MCH-27.8 MCHC-31.3 RDW-15.8* Plt Ct-285 PT-11.2 PTT-27.4 INR(PT)-0.9 Glucose-720* UreaN-54* Creat-2.1* Na-129* K-6.6* Cl-96 HCO3-12* AnGap-28* Calcium-10.0 Phos-2.0* Mg-2.0 [2141-11-23] VitB12-424 Folate-8.8 On Discharge: [2141-11-27] WBC-5.7 RBC-3.27* Hgb-9.3* Hct-28.5* MCV-87 MCH-28.4 MCHC-32.7 RDW-16.7* Plt Ct-182 Glucose-161* UreaN-26* Creat-1.3* Na-138 K-4.8 Cl-112* HCO3-21* AnGap-10 Calcium-9.5 Phos-1.9* Mg-1.5* tacroFK-7.3 Brief Hospital Course: 49 y/o male s/p kidney transplant [2141-10-14] who returns with complaint of dizziness at home and found to be in DKA when admitted. He was started on an insulin drip and sugars very slowly improved but have not yet normalized. He was found in interview to have been unable to manage blood sugars at home. Blood pressure medications were adjusted and he was found to be orthostatic and having some dizziness. With decreased blood pressure meds the dizziness seems to be improved but needs orthostatic signs daily until meds have been adjusted appropriately. A neuro consult was obtained for patient complaint of hand numbness, and they recommended outpatient [Month/Day/Year 2841] as previously scheduled. Also, the patient may be switched to Rapamycin as an outpatient due to Prograf neurotoxic effects. Medications on Admission: Valcyte 450', insulin, cellcept [Pager number ]'''', hydral prn, Isosorbide mononitrate ER 60', nifedipine 180', percocet prn, trazadone 50 prn, ranitidine 150', metoprolol succ ER 200'', Tacro [10-7] . Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Nifedical XL 60 mg Tablet Extended Rel 24 hr Sig: Two (2) Tablet Extended Rel 24 hr PO once a day. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a day): Hold for SBP < 110 or HR < 60. 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty Two (32) units Subcutaneous twice a day: AM and PM doses and continue humalog sliding scale. 10. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [Location (un) 86] Center - [Location (un) 2312] Discharge Diagnosis: Hyperglycemia Hypertension S/p renal transplant [2141-10-14] LV diastolic dysfunction per [10-6] Echo Discharge Condition: Stable/good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, increased dizziness/lightheadedness, drops in orthostatic blood pressure inability to take food, fluids or medications Labs q Monday and Thursday with results faxed to transplant clinic at [Telephone/Fax (1) 697]: CBC, Chem 7, Ca, Mg Phos, Trough Prograf Monitor Blood sugars and give insulin accordingly Orthostatic BP checks daily. Please call if consistently drops to the [Hospital 95754] clinic at [Telephone/Fax (1) 673] [Telephone/Fax (1) 2841] as outypatient, previously scheduled Followup Instructions: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-12-1] 9:10 BONE DENSITY TESTING Phone:[Telephone/Fax (1) 4586] Date/Time:[2141-12-1] 10:40 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7167], RD Phone:[Telephone/Fax (1) 3681] Date/Time:[2141-12-5] 10:30 Completed by:[2141-11-27]	[ "V15.81", "250.43", "357.2", "401.9", "V42.0", "250.13", "070.32", "327.23", "429.9", "V49.72", "250.63", "272.4", "271.0", "362.01", "707.19", "V58.67", "250.53", "414.01" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5300, 5383	3120, 3934	306, 313	5537, 5551	2577, 2577	6205, 6607	1934, 2303		4196, 5277		5404, 5516		3960, 4173				5575, 6182						2318, 2558															2880, 3097							257, 268								341, 1072								2591, 2866							1094, 1737	1753, 1918
61,527	199,757	36216	Discharge summary	report	Admission Date: [2106-3-31] Discharge Date: [2106-4-22] Date of Birth: [2068-11-26] Sex: M Service: CARDIOTHORACIC Allergies: Vancomycin / Zosyn Attending:[First Name3 (LF) 165] Chief Complaint: transfer from [Hospital6 33] with known aortic Type A dissection. Awake and c/o throat pain at time of transfer Cheif complaint at [Hospital1 34]: throat pain and chest heaviness Major Surgical or Invasive Procedure: [2106-3-31] 1. Emergent repair of type A aortic dissection with Aortic Root Replacement, Bentall procedure with size 29 St. [Male First Name (un) 923] mechanical Valsalva composite graft. 2. Hemiarch replacement with a size 30 Gelweave graft. 3. Right axillary artery cannulation. [2106-4-1] 1. Exploration of left subclavian artery followed by brachial embolectomy after cutdown. 2. Stent of axillary and subclavian arteries. 3. Arteriography. [2106-4-2] 1. Prophylactic left forearm fasciotomy. 2. Prophylactic left hand fasciotomy. 3. Left open carpal tunnel release. 4. Layered closure, medial arm wound. History of Present Illness: 37 yo man without significant past medical history awoke morning of admission with sudden onset of cough followed by pain in his throat. Past Medical History: none Social History: works as telecommunication technitian tob quit 1.5 years ago, 10 pack year history ETOH denies drug use denies Family History: Uncle passed away after dissection Physical Exam: deferred due to emergent nature of case Pertinent Results: [2106-3-31] 03:40PM PT-13.2 PTT-26.1 INR(PT)-1.1 [2106-3-31] 03:40PM PLT COUNT-346 [2106-3-31] 03:40PM WBC-16.7* RBC-5.18 HGB-16.9 HCT-47.2 MCV-91 MCH-32.6* MCHC-35.7* RDW-13.3 [2106-3-31] 03:40PM CK-MB-4 [2106-3-31] 03:40PM cTropnT-<0.01 [2106-3-31] 03:40PM ALT(SGPT)-31 AST(SGOT)-23 CK(CPK)-177* ALK PHOS-66 TOT BILI-1.1 [2106-3-31] 03:40PM GLUCOSE-157* UREA N-26* CREAT-1.3* SODIUM-138 POTASSIUM-5.4* CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [2106-3-31] 03:44PM GLUCOSE-149* LACTATE-3.1* NA+-144 K+-5.4* CL--104 TCO2-22 [2106-4-22] 04:15AM BLOOD WBC-6.3 RBC-2.89* Hgb-8.8* Hct-26.8* MCV-93 MCH-30.5 MCHC-32.9 RDW-17.3* Plt Ct-514* [2106-4-22] 04:15AM BLOOD Plt Ct-514* [2106-4-22] 04:15AM BLOOD PT-31.2* PTT-40.2* INR(PT)-3.2* [2106-4-21] 05:46AM BLOOD Glucose-100 UreaN-24* Creat-1.0 Na-139 K-4.5 Cl-101 HCO3-29 AnGap-14 [2106-4-18] 03:12AM BLOOD ALT-1 AST-19 LD(LDH)-303* AlkPhos-61 Amylase-31 TotBili-0.4 ======================================== [Known lastname 13613],[Known firstname ] [Medical Record Number 82107] M 37 [2068-11-26] Radiology Report MR HEAD W/O CONTRAST Study Date of [2106-4-18] 7:30 PM Reason: visual changes in right eye r/o stroke no focal deificts [Hospital 93] MEDICAL CONDITION: 37 year old man with s/p asc aorta replacement with mechanical AVR REASON FOR THIS EXAMINATION:visual changes in right eye r/o stroke no focal deificts Final Report MRI OF THE BRAIN WITHOUT GADOLINIUM. MRA OF THE BRAIN USING 3D TIME-OF-FLIGHT TECHNIQUE. HISTORY: Status post aortic surgery with visual changes, rule out stroke. There are no comparison studies. FINDINGS: There is no evidence for acute transcortical ischemia. There is a questionable focus of increased DWI signal within the left cerebellum with no associated mass effect or edema. This could represent a tiny focus of acute ischemia. This is too small to characterize on the ADC maps. No supratentorial evidence for acute ischemia is seen. There is no mass effect or midline shift. Intracranial flow voids are maintained. Bilateral mastoid opacification and under-pneumatization is seen. There is mucosal thickening in the left sphenoid sinus. MRA of the circle of [Location (un) 431] is motion-degraded. There is apparent prominence of the left ophthalmic artery origin which may be artifactual. Recommend correlation with CTA for further evaluation. IMPRESSION: Questionable tiny focus of possible acute ischemia in the left inferior cerebellum, without associated mass effect or edema. Markedly degraded MRA. Questionable prominence at the origin of the left ophthalmic artery. Recommend correlation with CTA. DR. [First Name (STitle) ] [Name (STitle) 12563] =========================================== [Known lastname 13613],[Known firstname ] [Medical Record Number 82107] M 37 [2068-11-26] Radiology Report CHEST (PORTABLE AP) Study Date of [2106-4-18] 4:39 PM [Hospital 93] MEDICAL CONDITION: 37 year old man with s/p asc aorta replacement and avr REASON FOR THIS EXAMINATION: evaluate left lower lobe ? effusion Final Report REASON FOR EXAM: SP ascending aorta replacement and AVR. Followup left lower lobe opacity. Comparison is made with prior study [2106-4-13]. Left lower lobe opacity has improved, but not completely resolved. The right lung is grossly clear. There are no large pleural effusions or pneumothorax. Mild-to-moderate cardiomegaly is stable. Mediastinal widening has improved. Mild interstitial edema has improved. Left displacement of the distal external wire is unchanged from prior study, new from [4-10]. IMPRESSION: Improved, but not complete resolution of left lower lobe atelectasis. Left central venous catheter tip is in the SVC. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] ============================================== [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 13613], [Known firstname ] [Hospital1 18] [Numeric Identifier 82108]Portable TEE (Complete) Done [2106-4-2] at 11:34:03 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] 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: [2068-11-26] Age (years): 37 M Hgt (in): 70 BP (mm Hg): 115/65 Wgt (lb): 300 HR (bpm): 113 BSA (m2): 2.48 m2 Indication: Aortic dissection. H/O cardiac surgery. Left ventricular function. Prosthetic valve function ICD-9 Codes: 441.00, V43.3 Test Information Date/Time: [2106-4-2] at 11:34 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: Portable TEE (Complete) Son[Name (NI) 930]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2009W000-0:00 Machine: Vivid i-3 Sedation: Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings LEFT ATRIUM: No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Aortic arch intimal flap/dissection. Descending aorta intimal flap/aortic dissection. Flow in false lumen. AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). Normal AVR leaflets. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse in [Last Name (Titles) 9833] throughout the procedure. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Conclusions 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 normal (LVEF=55%). Right ventricular chamber size and free wall motion are normal. A mobile density is seen in the aortic arch and descending aorta consistent with an intimal flap/aortic dissection. There is flow in the false lumen. A mechanical aortic valve prosthesis is present. The prosthetic aortic valve leaflets appear normal. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Normal biventricular contractile function and normal appearance of the prosthetic mechanical aortic valve were visualized. There was no pericardial effusion. The the dissection in the aortic arch and descending aorta was visualized. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2106-4-2] 12:02 ================================================ Brief Hospital Course: 37 year old male med flighted in from outside hospital, went directly to operating room for type A dissection repair. See operative report for further details. [Year (4 digits) ] surgery was consulted for left arm due to left subclavian dissection. He was hemodynamically stable with nitroglycerin and fluid resuscitation. He returned to the operating room for exploration of left subclavian artery and angioplasty by [Year (4 digits) 1106] surgery on postoperative day one. See operative report for further details. Due to prolonged ischemia he underwent fasciotomy of left arm. See operative report for further details. Over the first few days postoperative days he remained intubated requiring increased PEEP for hypoxia and supportive care. On postoperative day three he had decreased urine output however myoglobin was decreasing from admission and CK decreasing from peak of 55,950 and receiving fluid. He continued with oliguria and was treated with diuretics but no response. Renal was consulted and he was started on ultrafiltrate for volume removal on [2106-4-4]. He remained intubated and sedated due to volume overload however hemodynamically stable on heparin for mechanical aortic valve with resolving rhabdomylosis. He continued with ultrafiltrate for fluid removal, and intubated. On [4-6] due to increased white blood cell count he was started on antibiotics to cover sputum that had gram negative and gram positive, and lines were changed. He developed a rash on vancomycin and zosyn, the vancomycin was stopped and the zosyn was changed to meropenum. The rash progressively resolved, and the meropenum was discontinued after course completed. He continued on ultrafiltrate with aggressive fluid removal until [2106-4-8], and he was monitored for the next few days but restarted ultrafiltrate due to increased ventilatory requirements. After volume was removed he was weaned from the ventilator and extubated on [4-12], however due respiratory difficulty and hypoxia he was reintubated. He was aggressively diuresed for several additional days. On [4-15] he was again extubated, he remained in the ICU for several additional days for pulmonary toilet and hemodynamic monitoring. On [4-20] he was transferred from the ICU to the step down floor where he continued to progress. He was noted to have two episodes of bradycardia while off oxygen, resolving when oxygen was replaced. Therefore, he may benefit from an outpatient sleep study. On [4-22] he was transferred to rehabilitation at [Hospital 38] Rehabilitation Center. Medications on Admission: MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 1 mg Tablet Sig: adjust dose to target INR 2.5-3.0 Tablets PO DAILY (Daily): Target INR 2.5-3.0. 8. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day. 9. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous Q AC&HS. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 14. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for anxiety. 15. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 19. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 20. Hydromorphone 2 mg Tablet Sig: 4-6 mg PO Q4H (every 4 hours) as needed for pain. 21. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) as needed for congestion. 22. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO Q12H (every 12 hours). 23. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold SBP<110. 24. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 25. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once for 1 days: [4-22] dose. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Type A Aortic Dissection, s/p repair Marfans Syndrome Obesity Postop Ischemic Left Arm, s/p repair Acute Renal Failure secondary to Rhabdomylosis Postop Pneumonia Postop Right Eye Visual Deficits Discharge Condition: Good Discharge Instructions: Take medications as directed in discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 pounds for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Do not use lotions, powders, or creams on wounds. Call our office for sternal drainage, redness, temperature >101.5. Followup Instructions: - Dr. [Last Name (STitle) ](Cardiac Surgery) in one month, call for appt - Dr. [Last Name (STitle) 23606](Plastic Surgery Resident Clinic) on [2106-4-30] - please call [Telephone/Fax (1) 4652] for an appointment time - Dr. [Last Name (STitle) ](PCP), call for appt Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] ([Doctor First Name ]) [Doctor First Name ] LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2106-6-3] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2106-6-3] 3:45 Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital3 1810] for Genetic Counseling [Telephone/Fax (1) 54211] Sleep study for sleep apnea as outpatient is recommended [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2106-4-22]	[ "427.89", "E930.0", "424.1", "584.5", "E878.1", "486", "441.01", "E878.8", "278.00", "E930.8", "378.10", "444.21", "443.29", "368.40", "435.2", "693.0", "276.0", "276.6", "728.88", "759.82", "997.39", "276.52" ]	icd9cm	[ [ [] ] ]	[ "00.40", "39.50", "00.46", "83.14", "04.43", "38.03", "88.72", "39.64", "38.91", "35.21", "38.45", "39.90", "88.49" ]	icd9pcs	[ [ [] ] ]	14148, 14245	9233, 11837	472, 1099	14485, 14491	1548, 2820	14848, 15801	1437, 1473		11891, 14125	4565, 4620	14266, 14464		11863, 11868				14515, 14825						1488, 1529																						246, 434	4649, 9210							1127, 1265															1287, 1293	1309, 1421
76,508	127,570	2108	Discharge summary	report	Admission Date: [2137-6-30] Discharge Date: [2137-7-16] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 5129] Chief Complaint: Nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: ERCP and sphincterotomy Percutaneous biliary drain s/p removal History of Present Illness: Mrs. [Known lastname 6680] is a [Age over 90 ] yo F with a history of COPD, depression, TIA, GERD, left CEA, HTN, macular degeneration, who was referred to [Hospital1 18] ED for further management of abdominal pain and elevated liver enzymes. She was in her usual state of health yesterday before developing sudden onset of severe right upper quadrant pain at 7pm, which was constant, nonradiating, and accompanied by multiple episodes of vomiting over the course of the night. She was diaphoretic and reported a pressure sensation extending essentially from neck to her lower abdomen. She denies previous similar episodes, and has no history of biliary disease though two daughters are s/p cholecystectomy. She subsequently presented to OSH ED this morning, where a CT abdomen revealed a thickened gallbladder wall without evidence of stones. She was given ciprofloxacin and flagyl, and was transferred to [Hospital1 18] ED for further management. In the ED, her initial vitals were 99.6 84 124/69 16 96%/2L. She was intermittently tachycardic to >100, and a note was made of a transiently low BP to 80s systolic, however subsequent pressures were normal. Her abdominal exam revealed some guarding. Her RUQ U/S revealed gallbladder wall thickening with gallstones, but no evidence of CBD dilation. Her transaminases and AP were strikingly elevated. Her troponin was elevated to 0.2, trending up to 0.55 prior to transfer with a CKMB elevation to 15. She received aspirin at the OSH this morning. While her EKG was not available on arrival to floor, note was made of ST depressions laterally. Surgery was consulted and recommended perc-bili drain due to poor surgical candidacy. ERCP also notified of case. On the ICU floor, her VS were HR77, BP135/110, RR21, Sat 100%3LNC. She was comfortable and denies any further abdominal pain. She is hungry. No current chest pain. On review of systems, she denies shortness of breath, cough, sore throat, current nausea or vomiting, jaundice, current fevers or chills, rigors, hematuria, diarrhea, melena, hematochezia. Past Medical History: -COPD -TIA (x2) -GERD -Schatzki Ring s/p dilation with persisting dysphagia -macular degeneration -carotid stenosis s/p CEA -Hypertension -previous tobacco use -hypercholesterolemia -early Alzheimers -urge incontinence Social History: Patient lives alone in [Location (un) ], requiring increasing help from daughters to accomplish ADLS/IADLs. Previous 20PY history of smoking, quit 30 years ago. No alcohol. Recently lost her husband a few months ago. Family History: Mulitple siblings with MI/CAD Sister CVA, daughter epilepsy Physical Exam: Vitals: Temp 97.7 HR77, BP135/110, RR21, Sat 100%3LNC General: Alert, oriented x2, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Quiet breath sounds but otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mild tenderness to palpation in the right upper quadrant but no [Doctor Last Name ] sign. No diffuse abdominal pain, guarding, or rebound tenderness. No hepatosplenomegaly. +BS. GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII intact, strength 5/5 throuhgout, no sensory deficits Pertinent Results: 1. Labs on admission: [2137-6-30] 06:45AM BLOOD WBC-11.5# RBC-4.05 Hgb-10.3* Hct-32.6* MCV-81* MCH-25.4* MCHC-31.5 RDW-15.3 Plt Ct-100* [2137-6-30] 06:45AM BLOOD Neuts-81* Bands-3 Lymphs-4* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2137-6-30] 03:12PM BLOOD PT-16.5* PTT-31.8 INR(PT)-1.5* [2137-6-30] 06:45AM BLOOD Glucose-230* UreaN-18 Creat-1.6* Na-134 K-2.9* Cl-99 HCO3-24 AnGap-14 [2137-6-30] 06:45AM BLOOD ALT-377* AST-723* LD(LDH)-714* CK(CPK)-151 AlkPhos-262* TotBili-2.0* DirBili-1.6* IndBili-0.4 [2137-6-30] 06:45AM BLOOD Lipase-27 [2137-6-30] 06:45AM BLOOD CK-MB-15* MB Indx-9.9* [2137-6-30] 06:45AM BLOOD cTropnT-0.20* [2137-6-30] 12:15PM BLOOD cTropnT-0.55* [2137-6-30] 08:43PM BLOOD CK-MB-32* MB Indx-7.9* cTropnT-0.99* [2137-6-30] 06:45AM BLOOD Albumin-4.0 Calcium-8.0* Phos-1.0# Mg-1.6 [2137-6-30] 07:04AM BLOOD Lactate-2.1 . 2. Labs on discharge: 3. Imaging/diagnostics: [2137-6-30] - Liver/gallbladder u/s: 1. Gallbladder wall edema and cholelithiasis; non-specific findings, cannot exclude acute cholecystitis; if clinical concern, HIDA can be considered. 2. No intra- or extra-hepatic biliary duct dilatation. 3. Main portal vein patent. [7-11] CXR:IMPRESSION: 1. No pneumonia. Mild bibasilar atelectasis. 2. Mild pulmonary edema and small bilateral pleural effusions. [7-11] UE US: IMPRESSION: No evidence of deep vein thrombus in the left upper extremity. Brief Hospital Course: [Age over 90 ] yo F with a history of depression, COPD c/b pulmonary HTN not on home O2, HTN, HLD, GERD, h/o TIA, who presented with clinical and radiographic evidence of cholecystitis/cholangitis. Her course has been notable for/complicated by ICU admission, sepsis related NSTEMI, volume overload, PAF, and poor oral intake. Hospital Course by Issue: # CHOLECYSTITIS/CHOLANGITIS: Patient presented with RUQ pain, nausea, and vomiting with radiographic evidence of gallbladder wall thickening and gallstones. She also had dramatic elevations in alk phosphatase, direct bilirubin, and transaminitis. Surgery declined cholecystectomy based on high surgical risk, thus a percetaneous cholecystostomy tube was placed for decompression. Patient was started on ciprofloxacin, metronidazole, and vancomycin for emperic coverage (given PCN allergy) for plan of a total 14 day course. Bile fluid culture revealed Clostridium perfringens. Percutaneous tube was self discontinued accidentally and attempt was made to replace but there was no longer biliary dilatation. ERCP was performed with sphincterotomy and patient remained clinically stable on antibiotics. She completed >2 weeks of triple antibiotics prior to discharge. She had a slight rise in her alkaline phosphatase during admission but this decreased on discharge. She was discharged pain free. # NSTEMI: Patient had elevated troponin which trended up from 0.20 -> 0.97 and MB 15 -> 32 - >23. Patient has multiple risk factors. MB peaked at 32. It was unclear whether this was a demand event vs. an acute plaque rupture coronary syndrome. Echo showed mild focal hypertrophy of the basal septum with mild regional LV systolic dysfunction. Initially patient received heparin but was later stopped in anticipation for ERCP. Patient was started on medical therapy for CAD with aspirin, beta blocker, low dose ACEI, and high dose statin. ASA was held for ERCP and should be restarted [2137-7-16]. # COPD: Echo showed evidence of pulmonary hypertension and RV dilation with systolic dysfunction as well as severe TR likely [2-13] COPD. She was started on Spiriva as she was not on any medical therapy for her COPD prior to admission. However, it is unclear whether pulmonary HTN is due solely to COPD as patient has not been hypoxic. . #CHF, acute on chronic, R>L sided sxs, preserved LVEF w diastolic dysfunction: She has diastolic dysfcuntion based on [2134] TTE. Her volume was managed with prn Lasix based on symptoms of dyspnea and orthopnea. # DEPRESSION: This seems to have worsened over the course of her hospitalization. Fluoxetine was continued. # PAROXYSMAL ATRIAL FIBRILLATION: Given rhythm abnormality and history of TIA patient was started on aspirin and warfarn after discussion with family based on high CHADS2 score. These were then held around the time of ERCP. Her rates have been well controlled on BB and she has been intermittently in sinus rhythm. She is at significant risk of stroke due to the A.Fib, and was started on Pradaxa for stroke prophylaxis. Please monitor for bleeding. #Delirium: Patient had mild delirium not requiring medical intervention during hospital course thought to be related to her infection that resolved at the time of discharge. This resolved. Please note she is very hard of hearing and has poor vision so communication is challenging. #Anemia: Pt presented with Hct 30s that went as low as 22's. She refused blood transfusion during admission. I reviewed this with her again on the day of discharge, when her Hct was 22.1, and she once again refuses blood transfusion, stating she "feels fine" without it. #CODE/Goals Of Care: Pt was DNR/DNI except for procedures. Regarding nutrition she was not taking adequate nutrition during end of hospitalization felt to be due to depression. Discussed options for PEG tube and patient (corroborated by daughters) said that she did not want to have an invasive nutritional support. They were counseled that poor nutrition could lead to dehydration. They are pondering possible "Do Not Hospitalize" status upon discharge. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs four times a day as needed for wheeze FLUOXETINE - 20 mg Tablet - 1 Tablet(s) by mouth once a day OXYBUTYNIN CHLORIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath. 3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multiple Vitamins Daily Tablet Sig: One (1) ML PO ONCE (Once) for 1 doses. 7. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily) as needed for COPD. 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Cholangitis and sepsis from biliary obstruction, most likely from a stone - now s/p percutaneous drainage then ERCP Sepsis induced NSTEMI 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 for cholangitis (infection of your galbladder and biliary tract) and required admission to the ICU. You were given antibiotics and improved. You also had an ERCP with sphincterotomy. Followup Instructions: You should follow up with your primary care doctor in the next 2-4 weeks.	[ "V14.0", "995.91", "038.9", "410.71", "530.81", "414.01", "331.0", "V46.2", "V49.86", "787.20", "416.9", "576.1", "V12.54", "783.0", "348.31", "788.30", "263.1", "496", "585.4", "286.9", "275.2", "311", "V15.82", "276.51", "276.8", "424.2", "403.90", "272.0", "428.0", "574.01", "428.33", "427.31", "284.1", "584.9", "294.10" ]	icd9cm	[ [ [] ] ]	[ "51.01", "38.93", "51.85" ]	icd9pcs	[ [ [] ] ]	10791, 10885	5227, 9317	252, 317	11067, 11067	3749, 3757	11470, 11547	2941, 3002		9654, 10768		10906, 11046		9343, 9631				11245, 11447						3017, 3730																						180, 214				4671, 5204				345, 2442								3771, 4651		11082, 11221					2464, 2684	2700, 2925
28,640	165,709	26952	Discharge summary	report	Admission Date: [2127-10-19] Discharge Date: [2127-10-20] Date of Birth: [2107-11-19] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1666] Chief Complaint: Intentional overdose of tizanidine Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Per MICU, psychiatry and outside chart notes, and brief history from pt, this is a 19 yo F with PMH of chronic back pain presents after overdose. She reportedly took 45-60 Tabs (each 4mg) of tizanidine (approx. 160 mg) around 11 am on [2127-10-19] after a breakup with her boyfriend. . She was prescribed tizanidine earlier this year for back pain and biofeedback was recommended, which she evidently has not been impressed with, feeling that her pain has a physiologic origin. To the original admitting team, she stated that she deals with chronic pain for years and wanted all her pain to go away. She also told the ED team she might do it again. She said that she took the pills and then called her mother to say goodbye. She says she did not want help, she just wanted to say goodbye. . Per prior notes, in the ED, her vitals initially were T96.2, BP 140/88, HR 56, RR 16, O2sat 97% RA. She was given charcoal in the ED (no vomiting afterwards). She was also given 0.4mg narcan with no effect, and then given 2mg narcan which brought her HR up from 50 to 88 and her BP down from systolic 140 to 110s. Toxicology was consulted in the ED and said she would be at risk for bradycardia, hypertension and AV block along with respiratory depression. She was admitted to the MICU for close monitoring. Overnight there were no events, and she is transferred to the medicine floor pending admission to [Hospital1 ] 4 for inpatient psychiatric treatment. . On our exam in the MICU prior to transfer to the medicine floor, she was minimally communicative, but said she simply felt "stupid." She did not affirm any type of discomfort or pain or other symptoms. She denied current suicidal ideation and said that she had not had suicide attempts prior, though she did have prior feelings of "wanting it all to go away." Besides her back pain she denied any other significant medical history. Past Medical History: asthma -exercise induced seasonal allergies lactose intolerance ovarian cysts being worked up for ? arthritis . Social History: She is a student of nutrition at [University/College ], a nonsmoker, rare drinker. She has a boyfriend of four years, who she told psych service has been her "best friend"; they have had recent problems. She is a high academic achiever relative to her family. Family History: father with emphysema, grandfather with CAD and MI Physical Exam: On admission to MICU: vitals: afebrile, BP 114/66, HR 68, RR 20, O2sat 100% on RA general: depressed affect, lying in bed fetal position HEENT: PERRL, EOMI, MMM, anicteric sclera, non-injected conjunctiva CV: RRR no m/r/g Lungs: CTAB no w/r/r Abdomen: +BS, soft, NDNT, navel ring Ext: no e/c/c Neuro: alert and oriented to person, place and time. Depressed affect. CN III-XII in tact, strength full throughout, sensation intact . On transfer to medical floor [10-20]: vitals: afebrile, BP 133/67, HR 78, RR 18, O2sat 98% on RA general: sitting up in bed, talking to sitter when we arrived; on our exam avoided eye contact, very flat affect, slow and quiet speech with minimal responses. HEENT: PERRL, EOMI, MMM, anicteric sclera, non-injected conjunctiva CV: RRR no m/r/g Lungs: CTAB no w/r/r Abdomen: +BS, soft, NDNT, navel ring in place without erythema Ext: no edema, WWP Derm: no rashes; no cuts or scars appreciated in limited exam Neuro: Alert and oriented grossly. Depressed affect. . Pertinent Results: [2127-10-20] 03:49AM BLOOD WBC-5.6 RBC-4.15* Hgb-13.6 Hct-39.8 MCV-96 MCH-32.7* MCHC-34.1 RDW-12.5 Plt Ct-291 [2127-10-20] 03:49AM BLOOD Glucose-91 UreaN-10 Creat-1.0 Na-142 K-4.3 Cl-107 HCO3-29 AnGap-10 [2127-10-19] 12:00PM BLOOD ALT-13 AST-20 AlkPhos-46 TotBili-0.6 [2127-10-20] 03:49AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.5* [2127-10-19] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2127-10-19] 02:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: A/P: 19 yo F with PMH of chronic back pain is admitted to the MICU with tizanidine overdose and suicide attempt. . # Overdose/suicide attempt: OD of tizanidine. The patient was monitored for bradycardia and AV block overnight, did not emerge, judged to be past danger phase from a toxicologic and medical point of view. She was cleared from a medical point of view to enter [Hospital1 ] 4 for inpatient treatment. Pending the discharge she was assigned a 1:1 sitter and put on suicide precautions. . # Chronic back pain: In MICU, team used acetaminophen for pain control and warm packs. She had been followed by pain clinic and neurosurgery prior to admission. Tizanidine was held as drug washed out. If pain breakthrough beyond acetaminophen and warm packs, would hesitate to add narcotics; could increase anti-inflammatories. . # Asthma: Exercise induced, was not a problem currently. She uses albuterol and [Doctor First Name 130] at home. This can be added to patient's medicine list as needed. . # FEN: Pt was advanced to regular diet. . # PPX: Heparin SC while she was not ambulating, but as long as she is ambulating on psych floor she should not need this. Bowel regimen prn. . # Access: 2 large bore PIV were placed on admission. These were discontinued prior to discharge to [Hospital1 ] 4. . # Code: Full. . # Dispo: To [Hospital1 ] 4 inpatient psychiatry unit with an involuntary committment. . Medications on Admission: Excedrin prn Trivora OCP albuterol prn [Doctor First Name ] prn tizanidine for back pain Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Tizanidine overdose secondary to suicide attempt . Secondary Back pain Depression Discharge Condition: Medical discharge condition: good. Discharge Instructions: You took an overdose of tizanidine. From a medical point of view, you now appear to be doing well. We remain concerned about you, however, which is why you are now being sent to a psychiatric facility for further treatment and monitoring. Followup Instructions: [Hospital1 ] 4 followed by intensive outpatient psychiatric treatment as determined by psychiatry team. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673]	[ "271.3", "E950.4", "E849.0", "338.29", "311", "975.2", "493.90", "724.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6158, 6173	4324, 5750	307, 313	6335, 6342	3757, 4300	6629, 6868	2674, 2726		5895, 6135		6194, 6285		5777, 5872				6366, 6606						2741, 3738																						233, 269								342, 2240															2263, 2377	2393, 2658
58,414	142,885	36360	Discharge summary	report	Admission Date: [2192-9-20] Discharge Date: [2192-9-23] Service: MEDICINE Allergies: Ace Inhibitors / Norvasc Attending:[First Name3 (LF) 30] Chief Complaint: GI Bleeding Major Surgical or Invasive Procedure: Upper Endoscopy with biopsies pending History of Present Illness: 87 yo M with PMHx HTN, Afib, PVD, s/p PM for CHB and duodenal AVM [4-28] who has had ongoing transfusion dependent GI bleeds transferred from OSH for anemia and fatigue. His GI history dates back to [2-27] where started having GI bleeds and underwent a workup in Flordia. They had found mild gastric erosions on EGD/[Last Name (un) ] at that point. Subsequently he was admitted [3-29] to [Hospital3 ] hospital for syncope for which a PM was placed for CHB and found to be anemic again. He was scoped at that admission but there are is no documention but report of EGD/[Last Name (un) ] - gastric erosions - with ?avms in upper GI tract. Also per report he had a capsule study which did not show evidence of bleeding. He was admitted in [4-28] to [Hospital1 18] for anemia found to to have duodenal AVM on endoscopy. Since then he has required 14 units of packed RBCs and has had ongoing dark stools. At OSH today his hct was found to be 20. He was given 2 units at OSH and a protonix gtt. EKG showed paced rhythm but no STTW. Trop 0.28. . In ED, 80 150/60 20 98 %RA. Per GI given history no need for NGL. Hct 23.9. Cr up. Ordered for another unit of blood that he had not recieved. Got 1/2-1L fluid. 3PIV, 1 20 and 2 18G. Protonix gtt. 98.8 68 135/55 16 98% on RA. GI consulted and will staff in am. . Currently, patient reports some abdominal cramps that he has had after each meal. Reported fatigue but no lightheadness or LOC. He denied nausea but reported dark tarry diarrhea. Denied CP, SOB, cough, fever, chills. Has chronic lower extremity swelling but denies orthopnea or PND. No recent NSAID use. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: GI Bleed Anemia from GI Bleed AFib Complete Heart Block s/p pacemaker BPH HTN PVD Right CEA DJD Social History: Currently a resident of [Hospital3 ] Pavilion ([Hospital1 1501] associated with [Hospital3 ] Hospital) - [Telephone/Fax (1) 82406]. Tobacco: No ETOH: Heavy drinker [5-29] scoth drinks per day, last drink was 6 wks back. Family History: Mother: had cancer (pt does not know the type) Physical Exam: Tmax: 36.2 ??????C (97.2 ??????F) Tcurrent: 36.2 ??????C (97.2 ??????F) HR: 65 (65 - 76) bpm BP: 135/51(70) {133/51(70) - 135/58(76)} mmHg RR: 9 (8 - 14) insp/min SpO2: 96% Heart rhythm: V Paced Height: 65 Inch General Appearance: Well nourished Eyes / Conjunctiva: PERRL HEENT: pale conjunctiva Chest: Regular HS, Lungs CTAB Abd: soft, no tenderness elicited, no rebounding or guarding Ext: [1-24]+ pitting edema b/l to knees Skin: Not assessed Neurologic: Oriented and appropriate. Pertinent Results: EGD [2192-9-20] Normal mucosa in the duodenum Normal mucosa in the esophagus Angioectasias in the stomach body Ulcer in the stomach body (biopsy) Otherwise normal EGD to third part of the duodenum [2192-9-20] 03:55AM BLOOD WBC-4.8 RBC-2.73* Hgb-7.8* Hct-23.9* MCV-88 MCH-28.8 MCHC-32.8 RDW-16.7* Plt Ct-294 [2192-9-20] 12:24PM BLOOD Hct-24.1* [2192-9-20] 05:36PM BLOOD Hct-31.0# [2192-9-20] 11:34PM BLOOD Hct-27.3 [2192-9-21] 04:39AM BLOOD WBC-5.0 RBC-3.22* Hgb-9.5* Hct-28.5* MCV-89 MCH-29.6 MCHC-33.4 RDW-17.4* Plt Ct-268 [2192-9-21] 05:01PM BLOOD WBC-5.8 RBC-3.53* Hgb-10.2* Hct-31.3* MCV-89 MCH-28.8 MCHC-32.5 RDW-17.2* Plt Ct-296 [2192-9-22] 01:15AM BLOOD Hct-28.7* [2192-9-22] 05:10AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.1* Hct-30.4* MCV-91 MCH-30.1 MCHC-33.2 RDW-17.0* Plt Ct-280 [2192-9-22] 05:30PM BLOOD Hct-30.6* [2192-9-20] 03:55AM BLOOD Neuts-71.6* Lymphs-19.2 Monos-7.0 Eos-1.9 Baso-0.4 [2192-9-20] 03:55AM BLOOD PT-12.0 PTT-24.1 INR(PT)-1.0 [2192-9-22] 05:10AM BLOOD PT-12.5 PTT-25.1 INR(PT)-1.1 [2192-9-22] 05:10AM BLOOD Plt Ct-280 [2192-9-20] 03:55AM BLOOD Glucose-110* UreaN-85* Creat-2.5# Na-139 K-4.2 Cl-101 HCO3-26 AnGap-16 [2192-9-20] 05:36PM BLOOD Glucose-156 UreaN-67* Creat-2.1* Na-140 K-4.4 Cl-104 HCO3-24 AnGap-16 [2192-9-21] 04:39AM BLOOD Glucose-92 UreaN-56* Creat-1.8* Na-142 K-4.0 Cl-107 HCO3-27 AnGap-12 [2192-9-22] 05:10AM BLOOD Glucose-94 UreaN-37* Creat-1.4* Na-143 K-3.7 Cl-108 HCO3-29 AnGap-10 [2192-9-20] 03:55AM BLOOD CK(CPK)-29* [2192-9-20] 12:24PM BLOOD CK(CPK)-16* [2192-9-20] 03:55AM BLOOD CK-MB-NotDone cTropnT-0.13* proBNP-4085* [2192-9-20] 12:24PM BLOOD CK-MB-NotDone cTropnT-0.10* [2192-9-21] 04:39AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9 [2192-9-22] 05:10AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 Chest x-ray ([9-21])- 1. Small bilateral pleural effusion and pulmonary vascular congestion compatible with mild fluid overload. 2. Asymmetrically enlarged and dense right hilus which could be due to vascular congestion, however oblique radiographs are recommended for further evaluation. 3. Severe atherosclerosis. Chest x-ray (PA, lateral, obliques)- [9-22]- Small bilateral pleural effusions and generalized pulmonary vascular engorgement persists. Heart is slightly larger. Multiple views of both hila show that their enlargement is probably due to dilated pulmonary arteries. Transvenous right atrial and right ventricular pacer leads are in place. Thoracic aorta is extremely heavily calcified, but not dilated. No pneumonia EKG- [9-21]- Sinus rhythm with marked first degree A-V block and ventricular electronic pacing. Compared to the previous tracing of [2192-5-5] the P-R interval has lengthened Stomach biopsies- pending Brief Hospital Course: MICU COURSE: The patient was transferred to [Hospital1 18] for further management of his upper GI bleeding, and was admitted directly to the medical intensive care unit. He had a prior enteroscopy with Dr. [First Name (STitle) ] [Name (STitle) ] in [Hospital1 18] in [2192-4-20]. EGD in the MICU revealed multiple linear 2-3cm ulcers were found along the gastric folds in the stomach body. Blood clot suggested recent bleeding. The folds around the ulcer was induated and edematous. This appearance might be compatible with gastric lymphoma. Cold forceps biopsies were performed for histology at the stomach body. He was transfused 2 units while at [Hospital1 18], but has remained hemodynamiclly stable. He was treated with intravenous PPI. He remained fully alert and oriented throughout his MICU stay. FLOOR COURSE: Patient transferred to the floor on the evening of [2192-9-21]. He was stable and did well while in the MICU. Upon transfer to the floor, the patient had two non-bloody bowel movements. His Hct was closely monitored- trended from 31.3 to 28.7 overnight. Up to 30.4 upon discharge (was ~20 on admission). He did not require any transfusions while on the floor and tolerated oral intake well. His blood pressure medications were held and his finesteride was restarted. BP returned to SBP of 130s-140s. Patient instructed to resume home blood pressure medications now that bleed has resolved and he has no signs of hypovolemia on exam or on vital signs. Upon discharge, the patient was stable and comfortable. Medications on Admission: Cardura 4mg po qHS Digoxin 0.125 mg daily Lasix 40mg PO daily Fenestrate 5mg PO daily colace 100mg po bid hydralazine 50mg po tid omeprazole 40mg po daily ferrous sulfate 325mg po daily toprol xl 75mg po daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 4. Cardura 4 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 10. Outpatient Lab Work Please check CBC, Chem-7 prior to [2192-9-26] and fax results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 82407] at [Telephone/Fax (1) 82408] 11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - Acute GI bleed resolved - Multiple 2-3cm ulcers in the stomach body - Acute renal failure; resolved - Non-thrombotic troponin elevation - Dense right hilus secondary to enlarged pulmonary artery. Secondary: - Atrial fibrillation - Heart block, s/p pacemaker - CKD Stage III - Benign prostatic hypertrophy - Hypertension - Duodenal AVMs - Peripheral vascular disease S/P iliac stent - S/P right carotid endarterectomy - S/P appendectomy - Macular degeneration, blind in the right eye Discharge Condition: Good. Vital signs stable. No sign of active GI bleed. Discharge Instructions: You were transferred to [Hospital1 18] for GI bleed management. When you arrived here, you were fatigued with a low hematocrit (a measure of your blood count). You were transfused 3 total units of blood and responded very well. The GI team saw you and performed an EGD. They found stomach ulcer and believe that is the cause of your bleed. They took samples from the ulcer for analysis- those results are still pending. Your bleed has now resolved and you have been hemodynamically stable. Upon discharge, you had no signs of active GI bleed. Your blood pressure medications were held while you were in the hospital. Please resume all home medications at this time. Please do not take any blood thinning medications (coumadin, lovenox) The following medication changes were made: 1. Stop taking your omeprazole and start taking pantoprazole 40mg by mouth twice a day. If you experience another GI bleed, fevers, chest pain, shortness of breath, light-headedness, severe abdominal pain or any other medically concerning symptoms, please contact your primary care physician or go to the emergency department immediately. Followup Instructions: Please follow-up with your primary care physician ([Last Name (LF) ],[First Name3 (LF) 2747] S [Telephone/Fax (1) 82409]) next week. Call Dr. [Name (NI) 82410] office on Monday [9-24] to make an appointment for next week. Please get your blood drawn by [2192-9-26] so your primary care physician can have the results by the time you see her. The GI doctors here [Name5 (PTitle) ] [Name5 (PTitle) 138] you at [Telephone/Fax (1) 82411] to schedule a follow-up appointment in the next week. Completed by:[2192-9-23]	[ "403.90", "V45.01", "285.1", "600.00", "531.40", "585.3", "584.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "45.16" ]	icd9pcs	[ [ [] ] ]	8876, 8882	5942, 7510	242, 281	9421, 9479	3134, 5919	10662, 11220	2560, 2609		7770, 8853		8903, 9400		7536, 7747				9503, 10639						2624, 3115																						191, 204								309, 2165															2187, 2285	2301, 2544
80,185	103,031	29078	Discharge summary	report	Admission Date: [2100-11-5] Discharge Date: [2100-11-9] Date of Birth: [2027-9-18] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: rigors Major Surgical or Invasive Procedure: [2100-11-6] CT-guided aspiration of right hepatic abscess History of Present Illness: 73 year-old Cantonese-speaking-only man s/p cholecystectomy on [2100-10-17] presents after syncopal episode. He was noted on post-op day #1 to be unsteady on his feet and complaining of dizziness but was not orthostatic, and physical therapy consult cleared him on post-op day #2 to go home without any assistance, despite oxygen desaturation to mid 80s without dyspnea. He now has 2-3 days of subjective fever, chills, night sweats, shaking, malaise, poor PO intake, and diffuse abdominal ache. At the time of consultation he had a prodrome of lightheadedness and syncope in the morning. There was brief loss of consciousness, and he was incontinent of stool. He has no history of previous syncope or seizures. He had stopped taking tramadol on [2100-11-2] because his PCP said it might be affecting his appetite. CT scan performed in the ED showed a fluid collection in the gallbladder fossa and an additional fluid collection (likely abscess) in the liver parenchyma. Past Medical History: Past Medical History: hypertension, GERD, H. Pylori, symptomatic cholelithiasis Past Surgical History: laparoscopic cholecystectomy Social History: Denies alcohol/drug use Denies tobacco use Cantonese-speaking Lives alone Family History: notable for a family history of TB. otherwise non-contributory Physical Exam: On admission: Vitals: T 97.1, HR 88, BP 118/63, RR 16, 98% 2L NC GEN: A&O, 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, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused On discharge: Vitals: 99.2 70 140/70 18 94% RA GEN: A&O, 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, nondistended, nontender, no rebound or guarding, no palpable masses Ext: No LE edema, LE warm and well perfused, + pedal pulses Pertinent Results: 17.7>12.9/39.6<344 N 95.0, L 3.4, M 1.3, E 0.1, B 0.2 . 136/98/20 ---------<134 4.1/26/1.5 . Lactate 2.7 PT 13.5, PTT 26.8, INR 1.3 ALT 47, AST 45, AP 61, Lip 19, Tbili 0.7 [11-4] CXR: Stable moderate right pleural effusion and resolution of previously noted left pleural effusion. Bibasilar airspace opacities likely reflect atelectasis, though infection cannot be completely excluded. [2100-11-4] CT abdomen/pelvis 1. Post-surgical changes related to recent cholecystectomy. There is fluid collection within the resection bed, which may represent a biloma, hemorrhage, or alternatively an abscess formation. Just superior to the resection bed within segment [Doctor First Name 690]/b, there is a multicystic lesion involving the liver parenchyma, most compatible with an abscess formation. This lesion appears new from [2100-10-17] ultrasound exam. There is apparent hyperemia surrounding the lesion. Dilated tubular structures within the resection bed likely represent residual cystic ducts. 2. Multiple liver cysts or hamartomas. 3. Right lung base consolidation may represent aspiration, infection in the appropriate setting, or atelectasis with adjacent small pleural effusion. [2100-11-4] Blood culuture results: KLEBSIELLA PNEUMONIAE Brief Hospital Course: Mr. [Known lastname ] was admitted on [2100-11-5] with fevers, rigors s/p syncope on [2100-11-4]. Labs and imaging were concerning for peri-hepatic abscess. He was admitted to the floor and started on zosyn and IV fluids for hydration. While on the floor he had persistent fevers and rigors, with oxygen desaturation and tachycardia, so was transferred to the ICU. In the ICU he remained stable and underwent CT guided drainage of intra-abdominal abscess: drained 18cc of purulent fluid, no drain left in place. The intrahepatic collection not amenable to perc drainage. He was subsequently transferred back to the floor, where he remained hemodynamically stable with a heart rate in the 70s-80's. His oxygen was weaned at his O2 sats remained in the mid 90's on room air. He had minimal low grade temps, not above 100.0. ON [11-8] his blood cultures (which grew kleibsiella pneumoniae) came back as sensitive to ciprofloxacin, and his antibiotic regimen was changed to PO cipro. On [2100-11-9], he remained afebrile and hemodynamically stable on oral antibiotics. His respiratory status remained uncompromised. He denied further syncopal episodes or abdominal pain. He was tolerating a regular diet and out of bed ambulating indepdendently with a steady gait. He felt well and was discharged to home with VNA services and scheduled follow up in [Hospital 2536] clinic. Medications on Admission: MEDS at previous discharge: - sertraline 50 mg qd - omeprazole 20 mg qd - acetaminophen 1000 mg tid - oxycodone 5 mg Q4H PRN - docusate sodium 100 mg [Hospital1 ] - bisacodyl 10 mg qd PRN - magnesium hydroxide PRN - senna 8.6 mg [Hospital1 ] PRN - atenolol 50 mg - vitamin D3 [2088] IU qd - alendronate 70mg 1x/wk - vitamin D [Numeric Identifier 1871] IU 1x/wk Discharge Medications: 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:9 Tablet(s) Refills:0 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. Bacteremia 2. Intraabdominal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with fevers, chills and a report of a syncopal episode. On CT scan, you were found to have a fluid collection near the area where your gallbladder was removed on your previous hospital admission. You were also found to have bacteria in your blood. You were given IV antiotics, and are not being discharged home with a prescription for oral antibiotics. It is important that you take the entire course of antibiotics as prescribed, even if you are feeling better. You may resume a regular diet. You should resume all of your regular home medications that you were taking prior to coming to the hospital. You are being given a prescription for narcotic pain medication. Take the medication as need, but do not take it more frequently than prescribed. You may also take tylenol as needed for pain, but do not take more than 4 grams (4,000 mg) of tylenol in 24 hours. Narcotic medications can cause constipation so be sure to drink plenty of fluids to avoid this. You may take an over the counter stool softener such as colace or milk of magnesia if needed to prevent constipation. Do not drink alcohol or drive/operate heavy machinery while taking narcotics. Please call your doctor or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Completed by:[2100-11-9]	[ "790.7", "567.22", "572.0", "998.59", "530.81", "401.9", "041.85", "E878.6" ]	icd9cm	[ [ [] ] ]	[ "50.91" ]	icd9pcs	[ [ [] ] ]	6096, 6153	3659, 5056	277, 341	6237, 6237	2369, 3636		1619, 1684		5484, 6073		6174, 6216		5082, 5461				6388, 8412					1480, 1511	1699, 1699															2053, 2350							231, 239								369, 1354								1714, 2038		6252, 6364					1398, 1457	1527, 1603
57,737	172,619	54760+59630	Discharge summary	report+addendum	Admission Date: [2183-8-1] Discharge Date: [2183-8-7] Date of Birth: [2157-9-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 15397] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 25F with polysubstance abuse presents with altered mental status and found to be febrile and hyponatremic. Per report, patient was in her USOH on the morning of [7-30]. She then was reported to have undertaken EtOH binge throughout the evening of the 4th into the 5th. The afternoon of [7-31], she was found to be confused and agitated in her room covered with bloody vomit. Four empty vodka bottles were found in her room along with a juice bottle smelling of 'rubbing alcohol'. EMS was activated, and on arrival to scene patient was AAOx1, anxious, and 'easily spooked'. VS were P96, BP 128/78, RR 14 and blood glucose 138. She admitted to alcohol, prescription medicine abuse, and may have voiced suicidal ideas. There was also report of possible heroin and cocaine use. She was brought to [Hospital1 ] where she was noted to be uncooperative, responsive to painful stimuli, with incomprehensible speech. Temperature was reported to be 104, but only documented temperature was 98.2. Initial labs were notable for Na of 124, PCO2 of 35, and negative urine tox and serum EtOH. NCHCT showed no acute process and EKG was unremarkable. She received 5mg haldol, 2mg ativan, naloxone, and 2L NS. Hypertonic saline was started prior to transfer to [Hospital1 18]. In the ED, initial vitals were 98.8 101 104/74 24 100%. Patient was noted to be clammy and agitated on arrival, oriented x 1 requiring total Ativan 6 mg IV and soft restraints. Temperature was measured at 102F, and patient was given tylenol 650 mg PO x 1. CBC showed white blood cell count of 12.8K with 88% neutrophils, no bands. Sodium was 131, and hypertonic saline was stopped. Serum osmolality was 268. Lithium level was normal. Serum and urine toxicology screens were negative. AST was mildly elevated at 64. Lactate was 2.7. Urinalysis was unremarkable. Blood cultures were sent. Patient was treated empirically with vancomycin/ceftriaxone for possible bacterial meningitis and received 100mg thiamine. Lumbar puncture was performed and showed 0 WBCs, 1 RBC, protein 29, glucose 81. Foley was placed with 2 liters urine output. Vitals prior to transfer were 101.4 (ax), P: 89, RR: 17, BP: 110/75. On arrival to the MICU, patient is initially awake, but lethargic with incomprehensible speech. On re-evaluation, patient is awake and conversant and has no complaints other than fatigue. She denies recent substance use and is unclear of the events leading up to her hospitalization. She denies any suicidal thoughts. Past Medical History: -Polysubstance abuse -anxiety/depression Social History: Lives in a group home sober house for 3 years. History of alcohol abuse. Inconsistent reports of cocaine, heroin, prescription medicine abuse as well. Per report, is a smoker. Family History: Unable to be obtained Physical Exam: Admission Physical Exam: General: Lethargic, but awake, oriented to person only. Intermittently follows commands and answers simple questions. HEENT: Sclera anicteric, dry MM with abrasions over anterior tongue,, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Nonlabored on room air. Intermittent soft expirtory wheeze. Somewhat distant breath sounds. Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Awake, lethargic, oriented to person. PERLL, EOMI, symettric face and tongue. Moving all extremities. No asterixis noted. Discharge Physical Exam: Vitals- 98.4 121/84 60 18 100RA I/O 1610/2400 General- Alert, oriented, no acute distress, pleasnt, cooperative, responding appropriately to questions HEENT- Sclera anicteric, MMM, oropharynx clear Skin-bruising on left arm in two areas from IVs. Scattered minor bruising and cuts on legs. No large hematomas noted. Small bruise on abd at Lovenox injection site. Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: [2183-8-1] 08:40AM SODIUM-133 POTASSIUM-3.4 CHLORIDE-103 [2183-8-1] 08:40AM CK(CPK)-4573* [2183-8-1] 05:20AM CEREBROSPINAL FLUID (CSF) PROTEIN-29 GLUCOSE-81 [2183-8-1] 05:20AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* POLYS-79 LYMPHS-14 MONOS-7 [2183-8-1] 01:59AM LACTATE-2.7* [2183-8-1] 01:50AM GLUCOSE-112* UREA N-5* CREAT-0.6 SODIUM-131* POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16 [2183-8-1] 01:50AM estGFR-Using this [2183-8-1] 01:50AM ALT(SGPT)-20 AST(SGOT)-64* ALK PHOS-63 TOT BILI-0.7 [2183-8-1] 01:50AM ALBUMIN-4.6 [2183-8-1] 01:50AM OSMOLAL-268* [2183-8-1] 01:50AM TSH-1.3 [2183-8-1] 01:50AM LITHIUM-LESS THAN [2183-8-1] 01:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2183-8-1] 01:50AM URINE HOURS-RANDOM UREA N-206 CREAT-54 SODIUM-175 POTASSIUM-48 CHLORIDE-221 [2183-8-1] 01:50AM URINE HOURS-RANDOM [2183-8-1] 01:50AM URINE OSMOLAL-517 [2183-8-1] 01:50AM URINE UHOLD-HOLD [2183-8-1] 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2183-8-1] 01:50AM WBC-12.8* RBC-3.99* HGB-12.7 HCT-37.7 MCV-94 MCH-31.8 MCHC-33.7 RDW-13.0 [2183-8-1] 01:50AM NEUTS-88.5* LYMPHS-5.6* MONOS-5.6 EOS-0.2 BASOS-0.1 [2183-8-1] 01:50AM PLT COUNT-207 [2183-8-1] 01:50AM PT-10.1 PTT-24.8* INR(PT)-0.9 [2183-8-1] 01:50AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 [2183-8-1] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2183-8-3] 07:15AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.9* Hct-36.1 MCV-96 MCH-31.6 MCHC-32.9 RDW-13.1 Plt Ct-117* [2183-8-1] 01:50AM BLOOD Neuts-88.5* Lymphs-5.6* Monos-5.6 Eos-0.2 Baso-0.1 [2183-8-3] 07:15AM BLOOD Plt Ct-117* [2183-8-6] 07:14AM BLOOD Glucose-86 UreaN-4* Creat-0.5 Na-140 K-4.2 Cl-107 HCO3-23 AnGap-14 [2183-8-6] 07:14AM BLOOD CK(CPK)-6152* EKG 7/6/2012Sinus tachycardia. Slightly delayed R wave progression. No previous tracing available for comparison. CXR [2183-8-2] IMPRESSION: Vague right basal opacity may be present though study is limited and repeat evaluation, preferably with conventional PA and Lateral views is recommended. CXR [2183-8-2] IMPRESSION: Equivocal retrocardiac opacity. Otherwise, no focal infiltrate Brief Hospital Course: 25F with polysubstance abuse presents with delirium and found to be febrile and hyponatremic, and elevated CK to 30,000. Delirium resolved; given fluids, hyponatremia resolved, aggressive hydration for elevated CK which resolved as well. Creatinine remained stable throughout. # Toxic metabolic encephalopathy secondary to ingestion: She was delirious in the setting of ingestion, however, tox screen were negative. Infectious work up including LP was negative. With hydration and time the delirium completely resolved. She was alter, oriented and clear (normal mental status) at the time of discharge. # Rhabdomyolysis: The CK was elevated to [Numeric Identifier ]. She was given IV fluid hydration and monitored closely while the CKs decreased to 3000. She did not have any evidence of kidney injury throughout her state. She did have sore thighs, however, those resolved and she did not have muscle aches at the time of discharge. # Polysubstance abuse: She was seen by social work and is committed to being sober. She will be discharged home and will be going to [First Name9 (NamePattern2) 86953] [Doctor Last Name ] Discovery Program outpatient therapy. She will also see her therapist. She ultimately plans to re-enter living at a Sober House. # Psychiatric history: She was on Zoloft. She denies suicidal ideation during the admission or previously. # Hyponatremia: Recorded at 123 at OSH, received normal saline which corrected her to normal. Transitional Issues: -f/u electrolytes and CK with PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2433] next week -follow up with [Hospital3 10310] Discovery Program -follow up with outpatient therapist Medications on Admission: None - not taking medications for several weeks Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Altered Mental Status Rhabdomyolysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Last Name (Titles) 111949], You were admitted to the hospital because you were found down in your sober house. You were admitted to the Intensive Care Unit where you were found to have a very low sodium level and you were very confused. You were given fluids and your sodium level normalized and you became less confused, and you were then transferred to the medical floor. You were also found to have a very high CK level, a product of muscle breakdown. You were given lots of fluids to wash these products out of your body and we monitered your kidney function, which was normal. Please continue to drink 8 glasses of water daily for the next few days to continue to wash these products out. You were seen by social work to discuss new accomodations for sober living. You stated that you were planning to work on sobriety support plan with your parents. You discussed with us your plans to go to [Hospital3 10310] "The Discovery Program", an outpatient program, as well as your plans to see your therapist in the next few days to plan to move to a new sober house. You agreed that if you were unable to secure placement at a sober house which is the best plan, you will contact [Doctor First Name 1191] at [Name (NI) 32568] contacts. In the meantime, your plan as discussed with us is that you will return home with your parents. It was a please caring for you. Followup Instructions: Please follow up with: PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2433] [Telephone/Fax (1) 41132] Tuesday, [8-12] at 2:00pm Please follow up with the program at [Hospital3 10310] Completed by:[2183-8-7] Name: [Known lastname 18390],[Known firstname ] Unit No: [Numeric Identifier 18391] Admission Date: [2183-8-1] Discharge Date: [2183-8-7] Date of Birth: [2157-9-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 18392] Addendum: Thrombocytopenia: No clear etiology. No evidence of petechiae, clot, bleeding or other problems. [Name (NI) ] known prior heparin exposure and very early decline so unlikely secondary to HIT. Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 18393] MD [MD Number(2) 18394] Completed by:[2183-8-7]	[ "300.4", "349.82", "305.90", "305.00", "728.88", "919.0", "305.1", "276.1", "E928.8" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	11599, 11763	7207, 8677	325, 332	9154, 9154	4798, 7184	10725, 11576	3150, 3173		9038, 9044		9094, 9133		8966, 9015				9305, 10702						3213, 3960																8698, 8940						263, 287								360, 2875										9169, 9281					2897, 2940	2956, 3134					3985, 4779
9,457	186,416	47168	Discharge summary	report	Admission Date: [2194-7-13] Discharge Date: [2194-7-17] Date of Birth: [2133-3-7] Sex: F Service: MED Allergies: Iodine; Iodine Containing / Vantin Attending:[First Name3 (LF) 898] Chief Complaint: chills Major Surgical or Invasive Procedure: none History of Present Illness: 61 year old female with PMH of gastric bypass in [2193-11-25] complicated by gastoparesis, decreased PO intake and TPN supplementation since [1-29] who was admitted to the [Hospital1 18] [Hospital Unit Name 153] on [2194-7-13] for fever, chills, tachypnea, and hypotension. She was recently admitted at [Hospital6 ] [7-6] for Right PICC infection. During that admission the PICC was removed and a new one was reinserted in the Right arm and Levofloxacin was administered x 3 days. The patient was discarged to home on [7-9]. On the day of admission she noted chills/ rigors and right flank pain. She called her PMD who told her to come to the ED. In the ED, the patient was tachypneic (RR 40), oxygen sat 89% RA, Temp 101.3, BP 98/36, CVP - 5, EKG with sinus tachycardia, CXR with RLL infiltrate (possibly old) and Lactate 4.1. The sepsis protocol was initiated. Her Right PICC was pulled and a RIJ was placed. The patient received normal saline bolus x 4, Levo/Flagyl/ vanco. Her RR and lactate trended down while in the ED. While in the unit, the patients Tmax trended down to 99.0, RR decreased to 20, BP increased to 112/86 s/p IVFs, CVP increased from [5-6]. The patient denies fever, headache, chestpain, dysuria, rash. SHe also notes a decrease in her baseline nausea and emesis from 12 to 2-3 times/day. She also notes an increase in her baseline nonproductive cough approximately 3 weeks ago. Pt notes cough worst when lying down. Past Medical History: PAST MEDICAL HISTORY: 1. Phen Phen induced valvular disease, aortic insufficiency, mitral regurgitation. 2. Left ureteral stone with stent placement. 3. Hypothyroid. 4. Depression. 5. Hypertension. PAST SURGICAL HISTORY: Laparoscopic roux-en y gastric bypass [2193-12-3]- postop course complicated by pneumonia and gastroparesis. Since original surgery, patient has had 3 further operations at [Hospital6 ] to evaluate for blockage, in [1-29] she had a lysis of adhesions and a revision of the J to J anastomosis and a gastric emptying study that reported delayed emptying in small in testine and continued blockage. She has been tried on several prokinetic agents including Zelnorm and Reglan. She has been on TPN since [1-29]. Social History: The patient lives alone [Street Address(1) ]. She does all of her own PICC line and TPN care. The patient denies tobacco, alcohol, illicit drug use. Family History: noncontributory Physical Exam: Tempcurrent 99.2 Temp max 100.3 BP 117/43, 95/42-122/58 Pulse 81, 67-86 Resp 20 O2 sat 97% RA Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - supple, no JVD, no cervical lymphadenopathy Chest - bilateral basilar crackles- R>L, otherwise clear to auscultation CV - Normal S1/S2, RRR, +II/VI holosystolic murmur at LSB; RIJ site -nontender; no erythema, tenderness at site Abd - Soft,nondistended, with decreased bowel sounds, minimal LLQ tenderness to palpation Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis (+)1+ edema. 2+ DP pulses bilaterally ; old R PICC site-some redness; nontender, no erythema Neuro - Alert and oriented x 3, cranial nerves [2-6] intact, upper and lower extremity strength 5/5 bilaterally Skin - No rash Pertinent Results: [2194-7-13] 08:30AM PT-13.0 PTT-25.4 INR(PT)-1.1 [2194-7-13] 08:30AM WBC-9.6 RBC-4.21# HGB-12.4# HCT-35.9* MCV-85 MCH-29.5 MCHC-34.6 RDW-14.4 PLT - 275 NEUTS-91.6* BANDS-0 LYMPHS-5.9* MONOS-2.0 EOS-0.2 BASOS-0.2 [2194-7-13] 02:35PM WBC-12.5* RBC-3.41* HGB-9.9* HCT-29.5* MCV-87 MCH-29.0 MCHC-33.5 RDW-14.6 NEUTS-70 BANDS-20* LYMPHS-5* MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 PLT COUNT-228 [2194-7-13] 08:30AM CRP-7.16* [2194-7-13] 08:30AM CORTISOL-41.7* [2194-7-13] 02:35PM TSH-1.1 [2194-7-13] 08:30AM GLUCOSE-144* UREA N-24* CREAT-0.9 SODIUM-143 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-19 CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-1.8 [2194-7-13] 08:46AM LACTATE-4.1* [2194-7-13] 10:33AM LACTATE-3.2* [2194-7-13] 11:47AM LACTATE-3.0* [2194-7-13] 12:37PM LACTATE-3.8* [2194-7-13] 01:31PM LACTATE-3.6* [2194-7-13] 02:47PM LACTATE-2.4* [2194-7-13] 03:49PM LACTATE-1.8 [2194-7-13] 1 set -BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE [7-14], [7-15] - Blood Cultures - no growth [7-15] - fungal culture of blood - no growth [2194-7-16] TTE: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but not stenotic. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No definite valvular vegetations identified. Compared with the findings of the prior study (tape reviewed) of [2193-12-31], no definite change is evident. [7-13] CXR IMPRESSION: . Consolidations are again seen in the right lung and in the left mid lung zone. 1) The central line tip is in the right atrium. The line should be pulled back by 5-6 cm. 2) Right lung consolidation compatible with pneumonia. Follow-up after treatment is recommended to ascertain resolution. 3) Atelectasis or early consolidation in the left mid lung zone. Brief Hospital Course: A/P 61 year old female with history of gastric bypass with recent PICC line infection s/p levo x 3 days, currently with chill/rigors, dry cough; blood cultures + for gram positive cocci in pairs and clusters; 1. Fevers/Leukocytosis with Bandemia - The patient was admitted to the ICU with fevers to 101 and with 20% of her increased white blood cell count being made up of bands. She was started empirically on Vancomycin for a presumed line infection and her left PICC line was pulled. A chest x-ray was taken which showed a multifocal pneumonia and the patient was started on levofloxacin for presumed community acquired pneumonia. The fevers and bandemia resolved within 1 day of hospital admission. On the day of admission, 2 sets of blood cultures were sent and one set was positive for gram positive cocci in pairs and cluster; micro came back positive for coag negative staph aureus; patient was continued on vancomycin and will remain on vancomycin for 2 weeks s/p first negative blood culture on [7-14]. A urine culture was also sent on admission which was negative. After the first day of admission in the ICU, the patient did well with no fevers, chills, hypotension, tachycardia. 2. Increased lactate - on admission the patient's lactate was 4.1 and she was hypotensive and febrile; it was thought that she might have sepsis, so the sepsis protocol was initiated. The lactate decreased and her blood pressure increased after the patient received one dose of vanco/flagy/several liters of normal saline boluses. The patients blood pressures remained stable after this initial fluid bolus. 3. ST depressions in V4-V6- on admission the patient was tachycardic to 135 beats per minute. During this time, an ekg was done which showed ST depressions in V4-V6. Two days later, the patient was afebrile without tachycardia and another EKG was done which no longer showed these depressions. Three sets of cardac enzymes were also negative making ischemia less likely. 4. Nutrition-the patient is on chronic TPN; she was continued on her home regimen of TPN throughout the admission with clears as tolerated. Her blood sugars, triglycerides and electrolytes were within normal limits on the TPN. 5. Hypotension - Her SBPs were 80s-90s on admission to the ICU. It increased to 110-120s with IVFs and antibiotics. To evaluate for adrenal insufficiency as a source of her hypotension a cortisol level was checked. Her cortisol was 41.7 on admission, which was appropriate for a time of stress making adrenal insufficiency an unlikely diagnosis. Her systolic blood pressures remained 110-130s while on the floor. 6. Gastroparesis - The patient noted decreased episodes of nausea and vomiting since restarting Zelnorm on Wednesday, so the zelnorm was continued. She also took compazine for nausea which she said decreased the nausea substantially. She notes few bowel movements since the gastric bypass in [11-28]; she was started on colace and offered a dulcolax suppository which she refused. The patient demanded to speak with "her surgeon" Dr. [Last Name (STitle) ] throughout the admission. His office was contact[Name (NI) ] twice and he did not come to see the patient. On the day of discharge, the house officer spoke to dr.[Doctor Last Name ] secretary and she said that the patient was discharged from Dr. [Name (NI) 74681] care. 7. Chronic cough - possible secondary to GERD vs recurrent aspiration; patient was maintained on protonix throughout the admission. She was also given tensolon pearls and cepaclor with improvement in her daytime cough, but little improvement of the cough when she was lying down. Speech and swallow saw the patient and found that she had no oropharyngeal aphasia, but suggested a video swallow study. The patient refused secondary to not being able to tolerate the barium without emesis. She was advised to follow up for a video study when she tolerating liquids as an o/p. 6. Microscopic Hematuria - Two UAs were positive for large amounts of blood. The patient denies gross hematuria or dark colored urine or history of being told there was blood in her urine. On the day of admission, the patient did complain of flank pain, so it is possible that she had passed a stone, which was contributing to both the pain and hematuria. 7. Normocytic Anemia - The patient has had a normocytic anemia since her gastric bypass surgery. Iron studies were sent to evaluate for possible contibuting factors such as iron deficiency, B12, and folate deficiency in the setting of poor nutrition and decreased absorption. 8. Hypothyroid - TSH 1.1; the patient was continued on IV synthroid at home dose (not tolerating PO synthroid per pt, so is maintained on IV synthroid at home) 9. Prophylaxis - for DVT prophylaxis heparin was put in the patient's TPN. Medications on Admission: Zelnorm (restarted on [7-5]) Synthroid 65mcg IV Levofloxacin -3 days TPN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Tegaserod Hydrogen Maleate 6 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:90 Tablet(s) Refills:2 4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:90 Tablet(s) Refills:1 5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous QD (once a day) as needed. Disp:3000 ML(s) Refills:0 7. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 5 days. Disp:2500 mg Refills:0 8. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 10 days. Disp:20 Recon Soln(s) Refills:0 9. Levothyroxine Sodium 62.5 mcg IV QD Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: PICC line infection Discharge Condition: stable Discharge Instructions: please notify your primary care physician if you have increasing fevers, chills, night sweats, nausea, vomiting. also notify if your PICC line site looks red or is painful. -please continue the vancomycin for a total of 2 weeks so for 10 more days after discharge. -please continue the levofloxacin for 5 more days after discharge -please continue the TPN on your home Regimen and cycle for 12 hours per day. -please have Dr. [First Name (STitle) ] follow up on iron studies, folate, and B12. -it is also suggested that you have a video swallow study as an outpatient. Followup Instructions: please follow up with your primary care physician [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ], MD [First Name (Titles) ] [2194-8-11] at 1 pm. Please call Dr.[Name (NI) 17074] office for follow up-[Telephone/Fax (1) 17075]. The secretary also has your phone number and will call you as soon as there is an opening. Provider: [First Name11 (Name Pattern1) 1409] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], RD Where: RA [Hospital Unit Name ] ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) NUTRITION Phone:[Telephone/Fax (1) 3681] Date/Time:[2194-7-24] 2:00	[ "996.62", "V45.3", "486", "536.3", "038.11", "995.91", "401.9", "244.9", "599.7" ]	icd9cm	[ [ [] ] ]	[ "99.15" ]	icd9pcs	[ [ [] ] ]	12180, 12232	6105, 10919	295, 301	12296, 12304	3646, 6082	12926, 13582	2769, 2786		11046, 12157		12253, 12275		10945, 11023				12328, 12903					2057, 2582	2801, 3627																						249, 257								329, 1807															1851, 2033	2598, 2753
48,023	124,676	39609+58308	Discharge summary	report+addendum	Admission Date: [2129-11-14] Discharge Date: [2129-11-19] Date of Birth: [2083-7-29] Sex: F Service: CARDIOTHORACIC Allergies: Peanut Attending:[First Name3 (LF) 922] Chief Complaint: Ascending aortic aneurysm Major Surgical or Invasive Procedure: [2129-11-14] Bentall Procedure(25mm [Company 1543] Freestyle) with Hemiarch Replacment(26mm Gelweave Graft) with circulatory arrest. History of Present Illness: This is a 46 year old female with a longstanding heart murmur and a known bicuspid aortic valve. She has been followed with serial echocardiograms over the years with her most recent showing mild aortic stenosis and an ascending aorta of 4.7cm. She has been referred for surgery and is now admitted for same. Past Medical History: Bicuspid aortic valve Aortic stenosis/Aortic insufficiency ascending aortic aneurysm gastroesophageal reflux Social History: Last Dental Exam: recently-has dental clearance Lives with: Alone Occupation: Archivist WGBH Tobacco: Denies ETOH: [5-3] glasses wine/wk Family History: Family History: Half-sister with HOCM. Father died of MI at 71. Mother died in her 40's - cause unknown. Physical Exam: admission: Pulse: 67 Resp: 16 O2 sat: 100% B/P Right: 150/93 Left: 127/85 Height:5'4" Weight: 168 General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [xc] Full ROM []no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- [5-3] harsh SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact;MAE [6-1] strengths;nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit: murmur radiates softly to B carotids Pertinent Results: [2129-11-14] Intraop TEE: PREBYPASS The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve is bicuspid. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([1-29]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. POSTBYPASS The patient is A-paced and is on no inotropes. Cardiac output is 5.2 L/min. There is a new bioprosthetic aortic valve which appears to be wellseated without evidence of paravalvular leak. Peak/mean gradients across the valve are 11/7 mmHg respectively. There is no aortic insufficiency. The thoracic aorta is intact. Trace mitral valve regurgitation persists. Left ventricular systolic function continues to be normal (LVEF>55%). [2129-11-16] 05:10PM BLOOD WBC-16.1* RBC-3.92* Hgb-11.9* Hct-35.3* MCV-90 MCH-30.3 MCHC-33.7 RDW-15.3 Plt Ct-172 [2129-11-14] 12:39PM BLOOD WBC-13.3# RBC-2.62# Hgb-8.5# Hct-23.5# MCV-90 MCH-32.6* MCHC-36.3* RDW-14.1 Plt Ct-206 [2129-11-16] 05:10PM BLOOD Glucose-123* UreaN-19 Creat-0.9 Na-138 K-4.6 Cl-102 HCO3-29 AnGap-12 [2129-11-14] 01:45PM BLOOD UreaN-9 Creat-0.5 Na-142 K-3.9 Cl-111* HCO3-23 AnGap-12 [2129-11-16] 02:16AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1 Brief Hospital Course: Mrs. [Known lastname 87397] was admitted and underwent a Bentall procedure by Dr. [Last Name (STitle) 914]. For surgical details, please see operative note. Following the operation, she was brought to the CVICU for invasive monitoring on Propofol alone. Shortly after arrival to the CVICU, she experienced a brief episode of VT/VF and cardiac arrest. She was quickly resuscitated and remained hemodynamically stable. Within 24 hours of the operation, she awoke neurologically intact and was extubated without incident. On postoperative day two, she transferred to the floor. She remained in a normal sinus rhythm. CTs and pacing wires were removed in a timely fashion according to protocol. Physical Therapy worked with her for strength and mobility. She was begun on beat blockers, her BP was well controlled. She was also diuresed to her preoperative weight. Wounds were clean and healing well at discharge and she was independently ambulatory. Arrangements were made for follow up and medications were discussed with her as were postoperative restrictions. Medications on Admission: RANITIDINE HCL 150 mg Tablet - 1 Tablet(s) by mouth once a day CALCIUM CARBONATE - 1 Tablet(s) by mouth prn LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth prn NAPROXEN SODIUM - 220 mg Tablet - 1 Tablet(s) by mouth prn Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Ascending Aortic Aneurysm Bicuspid Aortic Valve Mild Aortic Stenosis/Insufficiency s/p Bentall Procedure gastroesophageal reflux Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema :trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] ([Telephone/Fax (1) 170]) on [2129-12-13] at 2:45 pm Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2129-12-16] at 9:10 am Please call to schedule appointments with your Primary Care Dr. [Known firstname ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 2115]in [5-2] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2129-11-18] Name: [Known lastname 13864],[Known firstname 153] Unit No: [Numeric Identifier 13865] Admission Date: [2129-11-14] Discharge Date: [2129-11-19] Date of Birth: [2083-7-29] Sex: F Service: CARDIOTHORACIC Allergies: Peanut Attending:[First Name3 (LF) 1543] Addendum: Ms.[Known lastname ] was cleared for discharge to home with VNA on POD#5. All follow up appointments were advised. Discharge Disposition: Home With Service Facility: [Location (un) 42] VNA [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2129-11-19]	[ "427.41", "997.1", "530.81", "276.51", "278.00", "441.2", "427.5", "E878.1", "427.1", "424.1", "790.29", "E878.2", "746.4", "401.9", "285.1" ]	icd9cm	[ [ [] ] ]	[ "38.45", "99.62", "38.91", "99.60", "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	8468, 8685	3732, 4806	300, 443	6257, 6420	1988, 3709	7344, 8445	1106, 1197		5076, 6004		6105, 6236		4832, 5053				6444, 7321						1212, 1969																						235, 262								471, 782															804, 915	931, 1074
10,330	158,745	26260	Discharge summary	report	Admission Date: [2194-3-14] Discharge Date: [2194-3-20] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Left sided chronic loculated subdural hematoma with significant mass effect, and right sided acute and chronic septal hematoma with mass effect. Major Surgical or Invasive Procedure: Left sided bur hole evacuation of left sided chronic subdural hematoma, membrane lysis, evacuation of cystic fluid, and right sided bur hole evacuation of acute and chronic subdural hematoma. History of Present Illness: 86yoM with h/o Anemia, Afib off anticoagulation, CAD, bi ventricular CHF (EF 30%), hypothyroidism, transferred from nursing facility. Patient was admitted in [12/2193] with decompensated heart failure, and again in [1-/2194] with a low hematocrit. He has been worked up for hematocrit (presumed GI bleed)however colonscopy did not find a source. He had required near weekly transfusions, now stable on procrit. His family reports a fall approximately 3 weeks ago while on Coumadin. The coumadin has subsequently stopped the coumadin due to low crits and fall risk. Approximately 1 week ago he was noted to have near complete paralysis of his RUE and dragging right leg. His family has noted that it has improved over the last week to the point where he can lift his right arm now. Past Medical History: Atrial fibrillation Biventricular failure (EF 30%) Coronary artery disease (pMIBI [12/2193] with partially reversible lateral and inferior defects) Hypothyroidism Anemia Social History: previously lives alone; transferred from [Hospital1 599] Center Tob: smoked pipe x60yrs, quit 2mos ago EtOH: none Family History: non-contributory Physical Exam: O: T:97.9 BP: 122/66 HR:82 R 15 O2Sats Gen: cachetic ill/ appearing, awake and cooperative HEENT: Pupils: slightly reactive EOMs Neck: Supple. CV: irreg irreg, II/VI SEM at LLSB, PMI nondisplaced Resp: CTA Abd: thin, cachectic, +BS, soft, NT, ND; large right inguinal hernia Ext: no edema, 1+ DP pulses Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [3-21] 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 slightly reactive to light, 3mm 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 decreased IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: B T IP AT [Last Name (un) 938] G R 4- 4- 4- 3 3 4- L 5 5 5 5 5 5 (less than 5 but equal/ full based on age) Profound right sided drift Sensation: Intact to light touch, Reflexes: unable to illicit Toes downgoing bilaterally Pertinent Results: [2194-3-19] 11:45PM BLOOD WBC-9.1 RBC-3.29* Hgb-10.6* Hct-32.6* MCV-99* MCH-32.1* MCHC-32.4 RDW-17.7* Plt Ct-180 [2194-3-19] 11:45PM BLOOD PT-17.0* PTT-63.5* INR(PT)-1.6* [2194-3-19] 11:45PM BLOOD Glucose-348* UreaN-36* Creat-1.2 Na-140 K-4.1 Cl-107 HCO3-23 AnGap-14 [2194-3-19] 11:05PM BLOOD Glucose-192* UreaN-37* Creat-0.6 Na-142 K-5.2* Cl-109* HCO3-21* AnGap-17 [2194-3-19] 11:45PM BLOOD CK-MB-7 cTropnT-0.07* [2194-3-19] 06:20AM BLOOD Phenyto-9.4* [2194-3-19] 11:49PM BLOOD Type-ART pO2-297* pCO2-56* pH-7.18* calHCO3-22 Base XS--7 Brief Hospital Course: The patient was admitted to [Hospital1 18] on [2194-3-14] for bilateral subdural hematomas. A CT of his head from that date confirmed the presence of large bilateral subdural hematomas, with chronic and acute components. A carotid ultrasound deomnstrated less than 40% bilateral carotid stenosis. A medicine consult was obtained on HD 2 because of his significant comorbidities. They declared him at is at low-moderate risk of developing cardiovascular complications during his anticipated surgery and recommended continuing current care. The following day, the patient underwent a left sided bur hole evacuation of left sided chronic subdural hematoma, membrane lysis, evacuation of cystic fluid. In addition, he also had a right sided bur hole evacuation of acute and chronic subdural hematoma. The operation was performed by Dr. [Last Name (STitle) ] and it went well with no complictions (please see operative note for details). A post-operative CT demonstrated stable appearance of bilateral subdural hematomas with chronic and acute components causing flattening of both cerebral hemispheres. It also showed interval development of moderate pneumocephalus, most prominently seen at the frontal lobes with increasing mass effect. After reviewing this scan, the patient was given 100% FiO2 and kept flat for 48 hours. He was given perioperative ancef as well as morphine for pain. He was also give dilantin 100mg TID. He was transferred to step down in stable condition on POD 1. On POD 2, he was noted to be alert and oriented to self, but not totally cooperative. His pupils were reactive but sluggish. He was able to follow commands. He was transfused one unit of RBCs for blood loss anemia. His 100% O2 was discontinued. On POD 3, he was still not quite strong enough to be discharged back to his rehabilitation center. His metoprolol was increased for tachycardia. That night, he sustained sudden and unexpected cardiopulmonary arrest. His nurse found him unresponsive and not breathing. She proceeded to call a "code blue." Several physicians responded and proceeded to resuscitate the patient. He was intubated emergently and treated with epinepherine, atropine, chest compressions, and ultimately cardioversion. We were able to obtain a sinus rhythum. A right groin line was placed for access. He was transferred to the ICU for further monitoring. Due to the extremely grave nature of his prognosis, his daughter subsequently decided to declare him DNR. He was treated with a morphine drip for comfort and died at 3:30am on POD 4. Medications on Admission: metoprolol XL, folic acid, MVI, atorvastatin, levothyroxine, colace, albuterol/atrovent Discharge Disposition: Expired Discharge Diagnosis: bilateral subdural hematomas, CHF, A-fib, blood loss anemia Discharge Condition: dead Discharge Instructions: none Followup Instructions: none Completed by:[2194-3-20]	[ "401.9", "V66.7", "427.31", "244.9", "427.41", "298.9", "285.1", "414.01", "997.1", "348.8", "E888.9", "428.0", "852.20", "427.5" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.62", "99.04", "99.60", "96.04", "01.31" ]	icd9pcs	[ [ [] ] ]	6484, 6493	3762, 6346	412, 606	6597, 6603	3173, 3739	6656, 6691	1783, 1801				6514, 6576		6372, 6461				6627, 6633						1816, 2149																						227, 374								634, 1431	2442, 3154									2164, 2426					1453, 1629	1645, 1767
29,378	164,381	48982	Discharge summary	report	Admission Date: [2162-7-19] Discharge Date: [2162-8-17] Date of Birth: [2095-10-11] Sex: F Service: SURGERY Allergies: Penicillins / Cipro / Aspirin / Nsaids / Dicloxacillin / Aldomet / Motrin / Lisinopril / Vioxx / Keflex Attending:[First Name3 (LF) 974] Chief Complaint: Coffee ground emesis Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname ] is a 66 yo woman with hx of OSA, discoid lupus, GERD, HTN, and DM who initially presented to the ED with left calf pain and some shortness of breath. She had no EKG changes, her vitals were stable, and left LENI negative. Those symptoms all resolved in the ED, but when PT saw her, she was unstable. She was in observation in the ED and planned to go to rehab when she developed nausea and vomitting. This was intially kept at bay with antiemetics, but then the emesis became coffee ground. It was guaiac posistive. NG lavage was done and showed more coffee ground emesis. Her Hct was stable at 39. Of note, she has a history of nausea and vomitting, which is being worked up as an outpatient currently. She has had an EGD that showed retained food and a gastric emptying study that showed delayed empting. In the ED, her SBP was in the 140s-160s, Hr 70-80, T 98.9 and setting high 90s on RA, RR 18. Past Medical History: 1. Non-insulin dependent diabetes mellitus 2. Gastroesophageal reflux disease 3. Coronary artery disease. Dobutamine MIBI in [2156]: No Dobutamine-induced perfusion abnormalities identified. Ejection fraction of 46%. 4. Hypertension 5. History of SVT 6. History of Congestive heart failure (felt to be diastolic dysfunction). ECHO in [2156]: Overall left ventricular systolic function is normal (LVEF>55%). Mild to moderate ([12-30]+) mitral regurgitation is seen. Borderline pulmonary artery systolic hypertension. 7. Schizo-affective disorder 8. Depression 9. History of CVA with MRI in [2156] with here are moderate microvascular changes in the cerebral white matter, which appear to have progressed slightly compared to the proton-density images from [2153-12-5]. 10. History of seziures 11. History of right lower extremity deep venous thrombosis 12. Discoid lupus erythematosus 13. Chronic obstructive pulmonary disease 14. History of acute renal failure 15. History of cellulitis 16. s/p total abdominal hysterectomy. 17. History of partial small bowel obstruction in [4-2] Social History: Discharge Summary Social History Signed [Last Name (LF) ],[First Name8 (NamePattern2) 734] [Last Name (NamePattern1) ] WED [7-4],[2158] 8:08 PM She lives in an apartment adjacent to her daughter. -Tobacco: 1ppd x 35 yrs ~ 35 pack-years. Currently smokes 1 pack per day. -History of cocaine abuse in the past, most recently 30 years ago. -EtOH: History of heavy EtOH use, none currently. Drank up to "a fifth" or a quart of "[First Name4 (NamePattern1) 4884] [Last Name (NamePattern1) 4886]" at the most in one night. Family History: Father died of MI less than 50 years of age. Mother diagnosed with breast CA for 4 years Notes that mother has history of mental illness, but does not know what kind. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 99.7 BP: 179/80 P: 88 RR: 22 O2Sat: 97% 2L Gen: nauseated, vomitting HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, obese. some pain to palpation, no guarding EXT: trace edema LLE SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [12-30]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: AMDISSION LABS: [2162-7-19] 10:25AM GLUCOSE-139* UREA N-16 CREAT-1.2* SODIUM-140 POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [2162-7-19] 10:25AM CALCIUM-9.7 PHOSPHATE-3.6 MAGNESIUM-2.0 [2162-7-19] 10:25AM WBC-9.1 RBC-4.61 HGB-11.5* HCT-36.2 MCV-79* MCH-25.0* MCHC-31.8 RDW-16.8* [2162-7-19] 10:25AM NEUTS-62.8 LYMPHS-30.1 MONOS-3.4 EOS-2.9 BASOS-0.8 [2162-7-19] 10:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2162-7-19]: Lt LENI: IMPRESSION: No evidence of DVT involving the left lower extremity. [2162-7-19] CXR: IMPRESSION: Limited study due to low lung volumes with no evidence of pneumonia or pulmonary edema. Mild cardiomegaly however could be related in part to AP projection. [2162-7-21] EGD: Erythema, erosion and granularity in the whole stomach compatible with gastritis (biopsy) Nodule in the antrum (biopsy) Duodenum with significant retained fluid, possibly secondary to poor motility or distal obstruction. Normal mucosa in the esophagus Otherwise normal EGD to third part of the duodenum CT Abdomen/Pelvis [2162-7-21]: Small bowel obstruction, with a transition point in the mid- pelvis, without an identifiable cause for the obstruction. No secondary findings to suggest associated bowel ischemia. URINE STUDIES: [2162-7-22] 12:28PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.030 [2162-7-22] 12:28PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [2162-7-22] 12:28PM URINE URINE CULTURE (Final [2162-7-24]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 66F admitted for partial SBO. She was managed conservatively with NGT decompression, IVF and NPO. She was followed closely by the GI and surgery services. On [7-25], her NG tube was pulled w/o complication, and she was started on a clear diet. However, she began to have vomiting on the evening of [7-27], her NGT was replaced on [7-28] and she was again made NPO. She underwent ex lap, small bowel resection, LOA on [7-30]. Patient tolerated the procedure well and was briefly taken to PACU prior to be transferred to the surgical floor. Patient's systolic BP was 185-190. Patient was given IV Lopressor and hydralazine. On POD2 patient became tachycardic with pulse 155-185. EKG showed narrow complex tachycardia SVT vs afib/flutter. Patient was transferred to ICU for CV management. Patient was loaded with esmolol drip at rate of 100mc/kg/min, IV lopressor. Then the patient rhythm became sinus. Esmolol drip was continued and lopressor was titrated up. POD3: Patient was weaned off esmolol drip and placed on home dose of BP meds. Lopressor IV was used PRN for HR>110. POD4 ([8-12]) # UTI: Urine cultures showed greater than 100,000 E.Coli. She completed a 3-day course ending [2162-7-26]. . # Hypertension: Clonidine patch, IV metoprolol, IV Hydralzine while NPO; home doses of diltiazem, atenolol, and PO clonidine were restarted [ ] . # Diabetes Mellitus II: well-controlled on sliding scale during admission. . # CAD: cont. lipitor, B-blocker; plavix was held as indication unclear, especially peri-operatively. . # Schizoaffective disorder: continued Clozapine 100mg and Wellbutrin SR Medications on Admission: Atenolol 50mg qam and 25mg qpm Wellbutrin SR 300 mg daily clonidine 0.2mg twice daily Plavix 75mg daily Clozapine 100mg qHS Combivent as needed Diltiazem 360mg daily fluticasone (flovent) 1 puff daily Lasix 40mg daily K-lor 10 Lipitor 10mg nightly metformin 1gm twice daily Zofran 4mg as needed Protonix 40mg EC Calcium 500mg TID docusate 100mg twice daily vitamin 400mg daily iron 325mg daily MVP Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: Small Bowel Obstruction Upper GI Bleed UTI Secondary: Hypertension Discharge Condition: Fair. Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. Your nurse may wash you, however, do not shower until your wound has closed. If there is clear drainage from your incisions, cover with a dry dressing. Please have your nurse pack your wound with moist sterile dressing three times per day. Activity: No heavy lifting of items [10-13] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: Please follow-up with your pcp [Last Name (NamePattern4) ] 1 week: Dr. [Last Name (STitle) ],[First Name3 (LF) ] S. [Telephone/Fax (1) 250]. Please call Dr.[Name (NI) 18535] office regarding you follow up appointment [Telephone/Fax (1) 2359]. Completed by:[2162-8-16]	[ "295.72", "401.1", "327.23", "276.52", "998.59", "428.32", "530.81", "535.50", "041.4", "337.1", "428.0", "427.89", "560.81", "V12.54", "695.4", "496", "578.9", "250.62", "536.8", "599.0", "518.89", "276.2", "276.0", "E878.6", "311", "349.82" ]	icd9cm	[ [ [] ] ]	[ "54.59", "45.16", "38.93", "45.62", "99.15" ]	icd9pcs	[ [ [] ] ]	8115, 8185	6035, 7667	384, 391	8306, 8314	3859, 6012	9290, 9588	3055, 3223				8206, 8285		7693, 8092				8338, 9267						3263, 3840																						324, 346								419, 1348															1370, 2477	2493, 3039
80,849	188,119	36860	Discharge summary	report	Admission Date: [2126-11-30] Discharge Date: [2126-12-2] Date of Birth: [2096-4-12] Sex: M Service: MEDICINE Allergies: Optiray 300 Attending:[First Name3 (LF) 3984] Chief Complaint: CC: BLE pain Reason for MICU transfer: septic shock PCP: [Name10 (NameIs) 83255], [Name11 (NameIs) ] [Name Initial (NameIs) ]. ([Telephone/Fax (1) 83256]) Major Surgical or Invasive Procedure: None History of Present Illness: 30yoM with h/o HepB and metastatic HCC (Dx in [5-/2125], s/p 14cm mass resection in [6-/2125], with several different cycles of chemotherapy), several admissions recently, and per reports with significant increase in multiple pulmonary nodules who presented to ED with severe bilateral crampy leg pain and swelling that started acutely Friday am. His wife called the covering oncologist, then called 911 due to pain severity. He originally presented to ED early am [11-29] but unable to go to ED due to bed availability. Initial ED vitals: 100.8 128 114/70 16 97%. Through his stay in the ED the originally just swollen BLE's then began to appear hemorrhagic. He had bilateral LENI's which did not show DVT. He had RUQ u/s which was consistent with known hepatic disease and with apparently patent portal vein but with "low, to-and-fro flow" which was different from the previously hepatopetal flow. Finally, had CT abd pelvis showing some possible disease progression, moderate ascites, areas of bowel wall thickening called as edema vs infection, and mass effect of enlarged liver compressing the IVC and ? distending the stomach, and pulm nodules at the L base as previously seen. His labs in the ED were significant for [3-17] BCx's with GNR's, WBC count 3.0 with 12% bandemia, thrombocytopenia of 41 which is within baseline, newly elevated INR to 2.1 from 1.2, AG to 17, BUN/Cr 47/1.1, elevated LFT's which appears to have been uptrending, lactate 7.1. Finally, pt had a Dx paracentesis which showed WBC's 27.6k (92% polys) and 22k RBC's, no organisms on GStain and culture pending. In the ED he received: 2g IV Cefepime x2, 1g IV Vancomycin x2, 7L NS, 8mg IV Dilaudid, and 4mg IV Zofran. He put out 450 cc's of UOP recorded. Vitals before transfer: 116 96% on RA 92/60. He has a portacath, no central line, and no pressors had been started. Of note, there was a recent discussion on [11-25] with Dr. [Last Name (STitle) ] re: hospice vs. further chemotherapy and code status is now DNR/DNI per that discussion, and referring physician recommended strong consideration of palliative care/hospice consult. Review of her recent notes indicates that the plan was to try palliative Doxorubicin to see if any effect, with clear understanding of the risk for life threatening side effects. Currently ROS is only positive for BLE pain, and negative for all other systems. He is feeling better after getting pain meds. Past Medical History: Past Oncologic History: - [4-21] abdominal pain, u/s demonstrated a large hepatic mass - [5-22] biopsy at [Location (un) 745] showed hepatocellular carcinoma - [6-21] one week of sorafenib (prescribed by oncology at [Hospital1 2025]) - [2125-6-21] right hepatic trisegmentectomy and cholecystectomy in a wedge resection of left lateral segment nodules x2. Path showed grade III poorly differentiated hepatocellular carcinoma. Post op course complicated by fluid collections and need for abx. - [2125-8-15] MRI abdomen: multiple focal liver masses c/w HCC - [2125-8-27] started sorafenib 400 mg [Hospital1 ] with stabilization of AFP - [2125-10-12] sorafenib 200mg [Hospital1 ] b/c hand foot syndrome - [10-22] sorafenib 400 mg qam, 200 mg qpm --> significant hand blisters. AFP with significant rise and imaging with progression. Sorafenib held. - [2125-11-23] - Started first cycle of gemcitabine & oxaliplatin (GEMOX) (without avastin). Course complicated by prolonged thrombocytopenia. No evidence of immediate response. Completed 1+ cycles -- initial AFP response, but unable to continue b/c of prolonged thrombocytopenia about 50 [2126-1-22]: started xeloda and progressed within 6 weeks on imaging and AFP. plts improved to 70 range 04/10: started avastin/erlotinib. Course complicated by facial rash. However, with immediate decrease in AFP [6-22]: Erlotinib held [5-/2126] for patient's wedding. Resumed end of [5-/2126] in combination for bevacizumab [2126-7-31]: Erlotinib/bevacizumab discontinued due to disease progression - [2126-9-7]: Started on everolimus, discontinued on [2126-11-1] due to rising AFP . Other Past Medical History: 1. Hepatitis B. 2. History of nephrolithiasis in [2119]. Social History: - Tobacco: prior social tobacco, stopped 1 year ago at the time of diagnosis - etOH: prior social alcohol use, stopped at the time of diagnosis - Illicits: occasional marijuana to stimulate appetite, denies current or prior IV drug use. Lives with wife, no children. Is currently working as an systems administrator for the NEJM. Family History: Reports that his mother and brother both have HBV. mother and father who are both age 57 and healthy grandparents died of unknown causes. He has siblings who are healthy. Physical Exam: 97.2 p115-122 80/62 to 98/62 96% on RA Thin, tired appearing Asian male, no distress but appears very till, with jaundice and scleral icterus, eyes half shut but conversational, wife at bedside Mouth very dry CTAB anteriorly, no w/c/r/r, has well placed port on R chest does not appear infected RRR no m/g but hyperdynamic Abd distended but not tight, but surprisingly not tender to palpation, BS+ BLE with gross pitting edema to just below knees, with gross petechiae and confluent dark ecchymoses, hemorrhagic bullae on RLE dorsal foot CN2-12 intact, no focal neuro deficits, clear and lucid conversation Pertinent Results: [2126-12-2] 05:30AM BLOOD WBC-9.2# RBC-3.50* Hgb-9.9* Hct-28.2* MCV-81* MCH-28.2 MCHC-35.0 RDW-27.7* Plt Ct-16* [2126-12-1] 10:20AM BLOOD WBC-5.5 RBC-3.71* Hgb-10.3* Hct-31.7* MCV-85 MCH-27.8 MCHC-32.6 RDW-27.6* Plt Ct-17* [2126-12-1] 04:55AM BLOOD WBC-4.8 RBC-3.65* Hgb-10.2* Hct-30.5* MCV-83 MCH-28.0 MCHC-33.6 RDW-27.4* Plt Ct-17* [2126-11-30] 05:00PM BLOOD WBC-4.7# RBC-4.49* Hgb-12.3* Hct-37.8* MCV-84 MCH-27.5 MCHC-32.6 RDW-27.4* Plt Ct-29* [2126-11-30] 12:50AM BLOOD WBC-3.0# RBC-5.12 Hgb-13.6 Hct-42.4 MCV-83 MCH-26.6* MCHC-32.2 RDW-27.4* Plt Ct-41* [2126-11-30] 05:00PM BLOOD Neuts-40* Bands-0 Lymphs-51* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-16* [2126-11-30] 12:50AM BLOOD Neuts-50 Bands-12* Lymphs-26 Monos-2 Eos-0 Baso-0 Atyps-3* Metas-6* Myelos-1* NRBC-6* [2126-11-30] 05:00PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-2+ Polychr-1+ Spheroc-1+ Target-1+ Schisto-1+ Burr-1+ [2126-11-30] 12:50AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-1+ Macrocy-1+ Microcy-3+ Polychr-1+ Spheroc-2+ Target-3+ Schisto-1+ [2126-11-30] 05:00PM BLOOD PT-26.1* PTT-45.1* INR(PT)-2.5* [2126-11-30] 01:15AM BLOOD PT-22.3* PTT-31.9 INR(PT)-2.1* [2126-12-2] 05:30AM BLOOD Glucose-106* UreaN-98* Creat-2.4* Na-138 K-5.2* Cl-105 HCO3-17* AnGap-21* [2126-12-1] 04:55AM BLOOD Glucose-71 UreaN-71* Creat-1.5* Na-137 K-5.0 Cl-104 HCO3-17* AnGap-21* [2126-11-30] 05:00PM BLOOD Glucose-99 UreaN-60* Creat-1.6* Na-136 K-4.6 Cl-106 HCO3-15* AnGap-20 [2126-11-30] 12:50AM BLOOD Glucose-127* UreaN-47* Creat-1.1 Na-136 K-4.5 Cl-100 HCO3-19* AnGap-22* [2126-12-2] 05:30AM BLOOD ALT-310* AST-465* LD(LDH)-359* AlkPhos-110 TotBili-29.9* [2126-11-30] 05:00PM BLOOD ALT-508* AST-789* LD(LDH)-377* AlkPhos-169* TotBili-21.9* [2126-11-30] 08:40AM BLOOD DirBili-17.4* [2126-11-30] 12:50AM BLOOD ALT-295* AST-397* AlkPhos-219* TotBili-22.5* [2126-11-30] 12:50AM BLOOD cTropnT-<0.01 [2126-12-2] 05:30AM BLOOD Calcium-8.7 Phos-5.4* Mg-2.4 [2126-12-1] 04:55AM BLOOD Calcium-8.3* Phos-6.7* Mg-2.2 [2126-11-30] 05:00PM BLOOD Calcium-7.6* Phos-5.8# Mg-1.9 [2126-11-30] 04:56PM BLOOD Type-MIX pO2-48 pCO2-38 pH-7.26* calTCO2-18* Base XS--9 [2126-11-30] 04:56PM BLOOD Lactate-4.8* [2126-11-30] 06:39AM BLOOD Lactate-5.4* [2126-11-30] 01:05AM BLOOD Lactate-7.1* [2126-11-30] 08:15AM URINE Color-Amber Appear-Hazy Sp [Last Name (un) ]-1.024 [2126-11-30] 08:15AM URINE Blood-SM Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-LG Urobiln-4* pH-6.5 Leuks-NEG [2126-11-30] 08:15AM URINE CastWBC-[2-15]* [2126-11-30] 04:27AM OTHER BODY FLUID WBC-[Numeric Identifier 28124]* RBC-[Numeric Identifier ]* Polys-92* Lymphs-1* Monos-4* Mesothe-3* Time Taken Not Noted Log-In Date/Time: [2126-11-30] 4:31 am PERITONEAL FLUID GRAM STAIN (Final [2126-11-30]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] . GRAM NEGATIVE ROD(S). Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. [2126-11-30] 1:15 am BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) \| AMIKACIN-------------- S AMPICILLIN------------ R AMPICILLIN/SULBACTAM-- R CEFEPIME-------------- S CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- S GENTAMICIN------------ S MEROPENEM------------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ R Anaerobic Bottle Gram Stain (Final [2126-11-30]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] #[Numeric Identifier 83257] [2126-11-30] 1245. Aerobic Bottle Gram Stain (Final [2126-11-30]): GRAM NEGATIVE ROD(S). [2126-11-30] 12:50 am BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 312-4127K [2126-11-30]. Aerobic Bottle Gram Stain (Final [2126-11-30]): GRAM NEGATIVE ROD(S). [11-30] CT abd pelvis FINDINGS: Within the lung bases, a 1.6 x 1.5 cm lesion at the left base (2:6) appears grossly similar to the prior MRI examination. An 8 x 8 mm lesion (2:1) also appears unchanged. There are small pleural effusions, right greater than left. Within the abdomen, the liver is markedly enlarged and heterogeneous compatible with multifocal hepatocellular carcinoma. Direct comparison with MRI is limited, however, there may have been some progression. For instance, a lesion in the left hepatic lobe measuring 5.0 x 4.9 cm (2:15) measured approximately 4.8 x 4.4 cm previously. A lesion in the right lobe measuring 4.4 x 4.0 cm (2:24) previously measured 3.9 x 3.8 cm. There is mass effect including compression of the IVC, though patency is not assessed on this non-contrast examination. The stomach is distended and may also be due to mass effect. There is moderate ascites. Some nodularity in the peritoneal fat posterior to the right lobe is present. Diffuse colonic wall thickening is seen in the ascending colon, descending colon, sigmoid and rectum. The non-contrast appearance of the pancreas, spleen, adrenal glands, and kidneys are grossly within normal limits. No free air is identified. There is diffuse subcutaneous anasarca. The bladder is collapsed around a Foley catheter. The prostate gland appears grossly unremarkable. No concerning osseous lesion is seen. IMPRESSION: 1. Multifocal liver lesions compatible with known hepatocellular carcinoma. Though direct comparison with MRI is limited, there does appear to have been some progression. 2. Moderate ascites; the presence of infection is not assessed on this examination. Additionally, diffuse areas of large bowel wall thickening may be related to edema/ascites, however, infection would appear similar by CT. Nodularity posterior to the liver could be seen with peritoneal carcinomatosis. 3. Mass effect due to enlarged liver including compression of the IVC. Distention of the stomach may also be secondary to obstruction from mass effect. Assessment of patency of the veins is not performed on this non-contrast examination. 4. Pulmonary nodules at the left base as previously seen. RUQ u/s FINDINGS: The liver is diffusely heterogeneous and enlarged, compatible with multifocal HCC replacing much of the liver parenchyma. The portal vein appears patent, however, demonstrates low, to-and-fro flow. Of note, the patient is status-post right lobe resection (trisegmentectomy), causing some distortion of anatomy and the image labelled main portal vein may representleft portal. A moderate amount of ascites is present. The spleen is enlarged measuring up to 15.5 cm. The gallbladder is surgically absent. IMPRESSION: 1. Enlarged, heterogeneous liver compatible with multifocal hepatocellular carcinoma. 2. Low, to-and-fro flow within the main/left portal vein, new from the prior examination when flow was hepatopetal. LENI FINDINGS: Grayscale and Doppler son[Name (NI) 1417] of the bilateral common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. There is normal compressibility, flow and augmentation. In the region of the lower calf bilaterally, subcutaneous edema is noted. IMPRESSION: No evidence of deep venous thrombosis. Brief Hospital Course: 30yoM with h/o HepB, metastatic HCC with extensive disease in his liver and pulmonary mets who presents with BLE edema and subcutaneous hemorrhage and found to have SBP, GNR bactermia, hypotension, consistent with severe sepsis. He was treated with ABx, IVF's, pressors and was ultimately discharged to [Hospital 12914] Hospice facility given his end stage malignancy. Between his family and him, their goals were for him to hopefully survive until [Holiday ] (5 days from now). 1. SBP/GNR bacteremia: Paracentesis with 27k WBC's. Pt had Gram negative rods grow from cultures from his peritoneal fluid and blood and was treated with several days of IV Ceftazadime before switching to PO Cipro on discharge to hospice. He also received albumin on days 1 and 3. Speciation was not complete by discharge, but sensitivities were done and bacteria was sensitive to Cipro. Plan for 14d course of PO Cipro from day of discharge. Pt did not have any abdominal pain from the SBP. 2. Hypotension: SBP's 80-90's on admission. Most likely septic shock in the setting of SBP/bactermia. Was bolused IVF's through his R sided port and was on Dopamine which was weaned and pt's BP's stabilized to systolics in the 110's by discharge. Pt with elevated lactate, worsening renal and liver failure as evidence of end organ ischemia; but mental status was very clear through admission. Pt was tachycardic on admission to 110-120's which remained elevated 100-110's by discharge. 3. BLE edema and subcutaneous hemorrhage: Likely due to low albumin, hepatic disease, compression of his IVC due to hepatic mass. Legs were kept elevated, but pt was NOT diuresed. SubQ hemorrhage due to thrombocytopenia. Pain was controlled with IV and PO Dilaudid and started on MS Contin by discharge. 4. Thrombocytopenia: Due to liver disease. Notable because the pt had gross hemorrhage into his legs, and also he developed rapid bilateral scleral hemorrhage through admission. He was given 2u platelets through admission. 5. Hepatitis B/HCC: Pt with end stage hepatocellular carcinoma s/p resection and numerous cycles of chemotherapy, most recently palliative Doxorubicin after having discussed with his Oncologist the risk for life threatening infection. 6. Dispo: Pt is DNR/DNI and being transferred to [Hospital 1121] Hospice. No further escalation of care. Medications on Admission: confirmed with pt 1. Dexamethasone 4mg tablet; 2 tablets PO qd for days [11-28], [11-29], and [11-30]; pt's wife states is taking [12-15] tablet now 2. Furosemide 20 mg tablet; [12-15] PO bid 3. Lamivudine 100 PO qd 4. Morphine prn unclear dosage, wife states taking [Name (NI) 68177] and Contin 5. Zofran 8mg PO q8 prn Discharge Medications: 1. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:28 Tablet(s) Refills:0 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: Titrate to comfort at hospice. Disp:180 Tablet(s) Refills:2 5. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 6. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Disp:180 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: The [Hospital1 656] Family Hospice Discharge Diagnosis: Hepatitis B Hepatocellular Carcinoma Spontaneous bacterial peritonitis Gram negative bacteremia Acute Renal Failure Thrombocytopenia Liver failure with coagulopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: [Hospital 83258] Hospice level care Discharge Instructions: You were admitted to [Hospital1 18] with bilateral lower extremity pain and hemorrhage and were found to have spontaneous bacterial peritonitis, bacterial infection in your blood, low blood pressure, worsening kidney function, low platelets, and worsening liver function. You were treated with antibiotics, medicine to maintain your blood pressure (from which you were weaned), and IV fluids. You are being discharged to [Hospital 1121] Hospice with a prescription for 2 weeks of Ciprofloxacin, an antibiotic that will treat your infection. Followup Instructions: The following appointments were previously scheduled: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2126-12-3] at 11:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2502], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2126-12-3] at 11:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2126-12-3] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "459.81", "584.9", "729.92", "038.49", "V66.7", "567.23", "197.0", "V58.69", "372.72", "338.3", "155.0", "729.5", "286.9", "V13.01", "789.59", "070.32", "V15.82", "287.5", "995.92", "V49.86", "785.52", "276.2" ]	icd9cm	[ [ [] ] ]	[ "54.91" ]	icd9pcs	[ [ [] ] ]	17610, 17675	14089, 16433	449, 456	17884, 17884	5945, 8940	18624, 19760	5125, 5298		16829, 17587		17696, 17863		16459, 16806				18049, 18601						5313, 5926							10567, 14066															234, 411								484, 2940									9224, 9300	17899, 18025					4693, 4757	4773, 5109		8975, 9188
10,515	187,982	48306+48307	Discharge summary	report+report	Admission Date: [2160-7-1] Discharge Date: [2160-7-7] Date of Birth: [2110-9-29] Sex: F Service: VSU CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: This 49-year-old female was admitted to the [Year (4 digits) 1106] service on [2160-7-1], and discharged on [2160-7-7]. The patient was initially evaluated in the emergency room. This 49-year-old African American with end stage renal disease status post renal transplant with chronic DVT who complains of fever starting on Saturday ranging from 101 to 103.7 and then on Sunday to 98. On the day prior to admission the patient did experience chills about 3 a.m. She denies cough or any sick contacts, any abdominal pain. Work up in the emergency room included an ultrasound of the left leg which showed no fluid collection or DVT. Blood cultures were obtained which were finalized and no growth. Urine culture obtained but was contaminated specimen and it was not repeated. The patient was given a dose of vancomycin 1 gram, levofloxacin 500 IV. [Year (4 digits) ] service was consulted and the patient was admitted to the [Year (4 digits) 1106] service for continued care. Medications on admission included: 1. CellCept [Pager number ] mg b.i.d. 2. Prednisone 10 mg q.d. 3. Protonix 40 mg q.d. 4. Calcitrol 0.5 mg q.d. 5. Sodium bicarbonate [2105] mg b.i.d. 6. Moprolol 25 mg b.i.d. 7. Lisinopril 5 mg daily. 8. Neoral 75 mg b.i.d. 9. Folic acid 4 mg b.i.d. 10. Bactrim single strength 400 mg 3 times a week. 11. TUMS after meals. 12. Percocet p.r.n. for pain. 13. Morphine p.r.n. for pain. 14. Neurontin 600 mg t.i.d. 15. Aranesp 40 mg q 2 weeks. 16. Vitamin E daily. 17. Multivitamin tablets daily. PAST MEDICAL HISTORY: Significant for end stage renal disease status post renal transplant, peripheral [Year (4 digits) 1106] disease, osteoarthritis, osteoporosis, coronary artery disease, history of Methicillin-Resistant Staphylococcus Aureus, history of SLE, history of chronic DVTs on the right, dilated cardiomyopathy with an ejection fraction of 40 to 45 percent, hypothyroidism, anemia of chronic disease, coronary artery disease with a history of myocardial infarction. PAST SURGICAL HISTORY: Right first toe amputation, bilateral femoral popliteal bypass [Last Name (LF) ], [First Name3 (LF) ] fistula, colectomy with ileostomy secondary to bowel perforation, history of coronary artery disease status post MI. SOCIAL HISTORY: The patient lives with her husband. She denies tobacco or alcohol use. PHYSICAL EXAMINATION: VITAL SIGNS: 103.1, 94, 16, 92/49, oxygen saturations 94%. GENERAL APPEARANCE: Alert, cooperative female in no acute distress. HEENT: Negative for carotid bruits. CHEST: Regular rate and rhythm with a 3/6 systolic ejection murmur at the base. LUNGS: Clear to auscultation. ABDOMINAL: Unremarkable. The stoma was pink and working. The left leg was warm with erythema. No obvious wounds. The left groin with a mass 1 cm. No induration or fluctuants. The pulse examination - palpable femorals bilaterally. Popliteals 2+ on the right and 1+ on the left. The DV on the right was monophasic signal, on the left it was triphasic signal. The PT on the right was a triphasic signal and on the left a monophasic signal. NEUROLOGIC: Unremarkable. HOSPITAL COURSE: The patient was admitted to the ICU, placed on sepsis protocol, broad spectrum antibiotics were begun with vanco, levo and Flagyl. Renal service followed the patient during her hospitalization. Admitting white count was 12.2 with a hematocrit of 30.8, platelets 2110, BUN 66, creatinine 2.4, baseline 1.5. Ultrasound of the left lower extremity was obtained which was negative for DVT or fluid collection. A CT was obtained of the leg which was negative for abscess. There were questionable bony changes in the foot. A regular x-ray was obtained and this was questionable osteomyelitis. There was also presence of fasciitis that could not be determined by the CT study. An MRA was recommended. The patient DNR, DNI was continued. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2160-7-7] 18:56:55 T: [2160-7-8] 09:03:38 Job#: [Job Number 101761] Admission Date: [2160-7-1] Discharge Date: [2160-7-7] Date of Birth: [2110-9-29] Sex: F Service: VSU This is continuation of dictation. Work No. [Serial Number 101761]. HOSPITAL COURSE: ID was consulted on [2160-7-1]. The patient remained in the surgical intensive care unit. RECOMMENDATIONS: To continue current antibiotic therapy and monitor cultures. Monitor left ankle for tenderness and pain. The patient was transferred to regular nursing floor on [2160-7-2]. She continues to be followed by renal. Her immune suppression medications did not require adjusting. Her temperature defervesced and her white count continued to show progressive improvement. Rheumatology was requested to see the patient because of her history of lupus and concern that she may have reactivation of her lupus. They saw the patient on [2160-7-4]. They felt there were no acute issues regarding her lupus and that her ankle should just be monitored and if it did not improve consider other imaging studies. The patient continues to show steady improvement. She was finally able to undergo a diagnostic MR of the foot and ankle to determine whether the bone findings were secondary to osteopenia or whether there was active osteomyelitis. The formal results were discussed with the senior resident. The patient was discharged to home improved on ___________. She is to follow up with Dr. [Last Name (STitle) 1391] as directed. She is to continue all her pre admission medications. DISCHARGE DIAGNOSES: Fever of unknown etiology, status post renal transplant on immune suppression. History of SLE. Anemia of chronic disease status post ileostomy, history of DVT, history of dilated cardiomyopathy by echocardiogram with an EF of 40 to 45%, history of hypothyroidism, history of peripheral [Last Name (STitle) 1106] disease status post right first toe amputation and bilateral femoral popliteal bypasses, history of osteoarthritis status post left total hip replacement, status post multiple AV fistula revisions, status post colectomy for perforated ischemic transverse colon with end ileostomy, history of coronary artery disease with perioperative myocardial infarction, history of Methicillin- Resistant Staphylococcus Aureus, history of hepatitic C positive, history of hemochromatosis secondary to multiple transfusions, history of neuropathy. DISCHARGE MEDICATIONS: 1. CellCept [Pager number ] mg b.i.d. 2. Prednisone 10 mg q.d. 3. Protonix 40 mg q.d. 4. Calcitrol 0.5 mg q.d. 5. Sodium bicarbonate [2105] mg b.i.d. 6. Moprolol 25 mg b.i.d. 7. Lisinopril 5 mg q.d. 8. Neoral 75 mg b.i.d. 9. Folic acid 4 mg b.i.d. 10. Bactrim 400 mg 3 times a week. 11. TUMS after meals. 12. Percocet p.r.n. for pain. 13. Morphine p.r.n. for pain. 14. Neurontin 600 mg t.i.d. 15. Aranesp 40 mg q 2 weeks. Last dose was on [2160-5-6]. 16. Vitamin E 400 IU daily. 17. Multivitamin tablet daily. 18. _____________ 600 mg b.i.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2160-7-7] 19:20:21 T: [2160-7-8] 09:38:42 Job#: [Job Number 101762]	[ "V42.0", "582.81", "584.9", "414.01", "710.0", "275.0", "682.6", "070.70", "780.6" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								5919, 6770	6793, 7664					4603, 5897								2274, 2502														2614, 3353									152, 160								189, 1766															1789, 2250	2519, 2591
52,861	171,985	38950+58253	Discharge summary	report+addendum	Admission Date: [2105-4-16] Discharge Date: [2105-4-25] Date of Birth: [2030-7-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2105-4-16] 1. Aortic valve replacement with a size 25-mm St. [Male First Name (un) 923] Epic tissue valve. 2. Coronary artery bypass graft x1, saphenous vein graft to diagonal. History of Present Illness: This is a 74 y.o. white male with past medical history of hypertension, CRI, AS, and second-degree AV block. He presently has increasing shortness of breath suggestive of worsening aortic stenosis. His symptoms have been progressive for the last 6 months. He also has significant COPD with most recent PFT's revealing moderate to severe obstructive disease. He also has CRI with a creatinine of 1.9 and will require prehydration overnight prior to the catheterization. He reports shortness of breath with minimal activity. He is audibly short of breath with conversation and mild wheezing can be heard. Past Medical History: Aortic Stenosis Chronic Renal Insufficiency (1.9) Hydronephrosis Chronic Obbstructive Pulmonary Disease Hypertension Wenckebach second degree AV block Prostate CA S/P radical prostatectomy S/P urethral stricture dilatation Hyperlipidemia Gout Gastroesophageal reflux disease Fracture right hand Mild Arthritis Social History: Race:Caucaisian Last Dental Exam: edentulous Lives with: wife [Name (NI) ] (home) [Telephone/Fax (1) 86394]. Occupation:retired dpw worker Tobacco: cigars quit 12 yrs ago ETOH: 3-5 drinks/wk Family History: Mother died of heart disease at age 60 Father died of heart disease at age 62 Physical Exam: VS: 97.1, 133/98, 66, 20, 97% RA Height:6'0" Weight: 250 lbs General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact, non focal, A&Ox3 Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: Left: Radial Right: 2+ Left: 2+ Carotid Bruit bilat Right: 2+ Left: 2+ Pertinent Results: [2105-4-16] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. There is mild to moderate global left ventricular hypokinesis (LVEF = 40 %). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.9-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS: LV systolic function is slightly improved (LVEF~45%). RV systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The study is otherwise unchanged from the prebypass study. [2105-4-23] 06:30AM BLOOD WBC-11.8* RBC-2.99* Hgb-8.8* Hct-27.5* MCV-92 MCH-29.5 MCHC-32.0 RDW-14.1 Plt Ct-284 [2105-4-16] 12:06PM BLOOD WBC-15.6# RBC-3.20 Hgb-10.0* Hct-29.3# MCV-92 MCH-31.3 MCHC-34.2 RDW-14.5 Plt Ct-228 [2105-4-23] 06:30AM BLOOD PT-12.7 INR(PT)-1.1 [2105-4-16] 11:07AM BLOOD PT-17.1 PTT-38.5* INR(PT)-1.5* [2105-4-23] 06:30AM BLOOD Glucose-84 UreaN-63* Creat-3.5* Na-130* K-4.2 Cl-94* HCO3-24 AnGap-16 [2105-4-17] 03:10AM BLOOD Glucose-107* UreaN-16 Creat-2.0* Na-136 K-5.5* Cl-106 HCO3-27 AnGap-9 [2105-4-23] 06:30AM BLOOD ALT-7 AST-38 LD(LDH)-277* AlkPhos-164* Amylase-133* TotBili-0.9 [2105-4-23] 06:30AM BLOOD Albumin-2.9* Mg-3.0* Brief Hospital Course: Mr. [Known lastname 56442] was a same day admit after undergoing all preoperative work-up following his cardiac cath on [2105-4-9]. On [4-16] he was brought directly to the operating room where he underwent an aortic valve replacement and coronary artery bypass graft x 1. Please see operative report for surgical details. He tolerated the procedure well and was transferred in critical but stable condition to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He subsequently developed rhythm issues with Nonsustained VTach, A Fib, and AV nodal disease. EP was consulted and he is rate-controlled with beta blockade. Anticoagulation was initiated with Coumadin,INR goal of 2.0-2.5 for atrial fibrillation. he remained in the CVICU for closer observation of his rhythm as well as postoperative ATN. Renal was consulted. Diuresis was limited. Mr.[Known lastname 86395] BUN/Cr continued to trend down without any intervention. POD# 5 his INR increased to 13 after 2 doses of Coumadin (5mg/2mg) having been bolused with Amio. He was reversed with Vitamin K/FFP. POD# 6 he was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. His rhythm remained stable in paroxysmal AFib. He continued to progress. POD# 7 he was cleared by Dr.[Last Name (STitle) ] for discharge to Life care Rehabilitation in [Location (un) 86396]. All follow up appointments were advised. Medications on Admission: ALLOPURINOL 100 mg once a day AMLODIPINE 2.5 mg once a day CLONIDINE 0.1 mg once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] 500 mcg-50 mcg/1 puff twice a day NILUTAMIDE [NILANDRON]150 mg once a day OMEPRAZOLE 20 mg twice a day SIMVASTATIN 20 mg once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER]18 mcg Capsule, w/Inhalation Device once a day ASPIRIN 81 mg [Location (un) 8426] once a day IBUPROFEN 200 mg twice a day Discharge Medications: 1. Aspirin 81 mg [Location (un) 8426], Delayed Release (E.C.) Sig: One (1) [Location (un) 8426], Delayed Release (E.C.) PO DAILY (Daily). 2. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 3. Acetaminophen 325 mg [Location (un) 8426] Sig: Two (2) [Location (un) 8426] PO Q4H (every 4 hours) as needed for pain/fever. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Tramadol 50 mg [Location (un) 8426] Sig: One (1) [Location (un) 8426] PO Q4H (every 4 hours) as needed for pain. 7. Amlodipine 5 mg [Location (un) 8426] Sig: Two (2) [Location (un) 8426] PO DAILY (Daily). 8. Warfarin 1 mg [Location (un) 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] DAILY (Daily). 9. Warfarin 1 mg [Last Name (Titles) 8426] Sig: 0.5 [Last Name (Titles) 8426] PO ONCE (Once) for 1 doses. 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 11. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Simvastatin 10 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO DAILY (Daily). 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 15. Allopurinol 100 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg [Hospital1 8426] Sig: 0.25 [Hospital1 8426] PO BID (2 times a day). 17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for SBP>140. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: Life Care Center of [Location 15289] Discharge Diagnosis: Aortic Stenosis/Coronary artery Disease s/p Aortic valve replacement/Coronary artery bypass graft x 1 Past medical history: Chronic Renal Insufficiency (1.9) Hydronephrosis Chronic Obbstructive Pulmonary Disease Hypertension Wenckebach second degree AV block Prostate CA S/P radical prostatectomy S/P urethral stricture dilatation Hyperlipidemia Gout Gastroesophageal reflux disease Fracture right hand Mild Arthritis postop A Fib/V tach/complete heart block postop ileus Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] *daily PT/INR checks for Coumadin dosing. INR goal=2.0-2.5 (atrial fibrillation) Followup Instructions: Surgeon Dr. [First Name (STitle) ] [5-18] at 1:15 pm [Telephone/Fax (1) 170] Please call to schedule appointments: Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [12-27] weeks Cardiologist Dr. [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) ] in [12-27] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2105-4-23] Name: [Known lastname 13691],[Known firstname ] J Unit No: [Numeric Identifier 13692] Admission Date: [2105-4-16] Discharge Date: [2105-4-25] Date of Birth: [2030-7-27] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: Of note, Mr. [Known lastname ] had episdoes of non-sustained ventricular tacycardia throughout his hospital course of decreasing duration. He remained asymptomatic and hemodynamically [Last Name (un) 13693] during the episodes. electrophysiology was consulted and recommended increasing his lopressor as tolerated. His hear rate was 45-50 at rest with BP 130-140/60. His betablocker was unable to be increased due to bradycardia and his lisinopril was increased for BP control. Electrophysiology was not of the opinion that a pacer was indicated at ths time. Discharge Disposition: Extended Care Facility: Life Care Center of [Location 2075] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2105-4-25**]	[ "997.1", "424.1", "491.21", "E878.2", "414.01", "530.81", "403.90", "427.32", "427.31", "585.9", "V10.46", "426.0", "274.9", "584.5", "427.1", "426.13", "272.4" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21", "36.11" ]	icd9pcs	[ [ [] ] ]	10987, 11173	4084, 5617	340, 527	8707, 8802	2474, 4061	9425, 10964	1725, 1804		6103, 8102		8213, 8315		5643, 6080				8826, 9402						1819, 2455																						281, 302								555, 1160															8337, 8686	1509, 1709
13,668	125,474	49200	Discharge summary	report	Admission Date: [2198-2-14] Discharge Date: [2198-4-2] Date of Birth: [2157-12-9] Sex: F Service: PRINCIPAL DIAGNOSIS: Status epilepticus. SECONDARY DIAGNOSES: Respiratory failure, adult respiratory distress syndrome. woman with left perinatal stroke, intractable seizures, cognitive impairment and right hemiparesis. She is well known to the neurology service. She was admitted [2198-2-14] for medication adjustment for her seizure disorder. Her seizures consisted mainly of right arm extension at the elbow and forward flexion of the deltoid with left arm extension at the elbow and abduction of the shoulder followed by a head time and she was having two to three per day, months prior to admission. The therapy, prior to admission, included a vagal-nerve stimulator, as well as multiple medications. MEDICATIONS ON ADMISSION: 1. Neurontin. 2. Trileptal. 3. Zonegran. 4. Ativan. SOCIAL HISTORY: She is living with her sister and attending a day program. She was admitted on [2-14] for adjustment of her medications. She had a complicated medical course, which included the development of status epilepticus, which required the induction of a phenobarbital coma. This course was complicated by respiratory failure and ARDS and further adjustment of her medications. HOSPITAL COURSE: The patient was admitted, as stated before, for adjustment of her antiepileptic medications. She was found to be in status epilepticus. Multiple EEGs were performed and early in the course she had an EEG, which showed repetitive spikes of two to three hertz bilateral parasagittal region with a slow disorganized background, which was worse on the left most likely due to her perinatal insult. She was induced into a pentobarbital coma. The pentobarbital was discontinued on [2-24]. The patient was slow to awaken. She had multiple adjustments made to her anti-seizure medications. Currently the anti-seizure medications include the following: Ativan, Dilantin, Valproic acid, and Topamax. She has had good control of her seizures, although occasionally had breakthrough seizures, which correlated with low Dilantin or Valproic acid levels. These responded to adjustments of her medications. The last EEG on [2198-3-19] showed a mildly slow background with asymmetric voltage (lower voltage on the left side with no seizures noted on her EEG). The last Dilantin level was 7.0. Valproic acid was 60; this was on the [3-4]. Goal for her to have a Dilantin level around 10 and the valproic acid around 75. These levels were treated with additional boluses of medications. Full medications list will be at the end of this dictation. RESPIRATORY: Her course was complicated by respiratory failure and ARDS, as stated below. She had a tracheostomy tube in place on [2198-3-16]. She currently is on an 8.0 size tube and she is on ventilated tracheostomy settings with CPAP and pressure support. She has been doing well with that. INFECTIOUS DISEASE: She has had multiple episodes of pneumonia and urinary tract infection. The most recent cultures include urine culture from [2198-3-28], which showed a klebsiella urinary tract infection specimen sensitive to Levofloxacin and sputum culture from [2198-3-26] showing Staphylococcus aureus, which was coagulase positive, also sensitive to Levofloxacin. The last blood cultures are from [3-26], which had been negative. She currently is on Amoxicillin and Levofloxacin for treatment of her infections. Levofloxacin was started on [3-27], and the Oxacillin on [3-30]. GASTROINTESTINAL: She had a PEG placed on [3-30]. She is currently tolerating her feeds of Promote with fiber through her PEG tube. Access: She has a PICC line placed in her right upper extremity on [2198-3-21]. She also, as stated before, has a tracheostomy tube and a PEG tube. MEDICATIONS: 1. Ativan 1 mg IV q.8. 2. Dilantin 200 mg IV q.8. 3. Depakene 1250/1000/1250/1000. 4. Topamax 100 mg PT, b.i.d. 5. Zantac 150 mg b.i.d. 6. Flovent, Atrovent, Albuterol nebs. 7. Colace 100 mg b.i.d. 8. Motrin 600 mg q.8h.p.r.n. 9. Tylenol 650 mg p.r.n. 10. Oxacillin 2 gram IV q.6h. started on [3-30]. 11. Levofloxacin 500 mg q.d., started [3-27]. 12. Epogen q 4000 units q. Monday and Thursday. 13. Folate 1 mg q.d. 14. Magnesium oxide 400 mg b.i.d. 15. Insulin sliding scale b.i.d. PSYCHIATRIC: During the hospitalization she stated that she felt very depressed. She will have a psychiatrist at her rehabilitation hospital; further outpatient psychiatric care within the Behavioral Neurology Unit here will be implemented upon her discharge from the rehab hospital. The primary neurologist is Dr. [Last Name (STitle) 851] at [Hospital1 346]. The patient's primary care physician has been following her closely while in the hospital. The primary care physician is [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Phone #: [Telephone/Fax (1) 608]. [First Name8 (NamePattern2) 7495] [Name8 (MD) ], M.D. [MD Number(1) 7496] Dictated By:[Last Name (NamePattern4) 103179] MEDQUIST36 D: [2198-4-2] 09:09 T: [2198-4-2] 09:49 JOB#: [Job Number ]	[ "345.11", "E937.0", "518.82", "041.3", "780.09", "507.0", "438.22", "599.0", "V58.83" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.72", "96.6", "96.56", "99.15", "46.32", "31.1", "38.93" ]	icd9pcs	[ [ [] ] ]													874, 931	1343, 5311												194, 848																																											948, 1325
1,113	128,609	46377	Discharge summary	report	Admission Date: [2106-12-7] Discharge Date: [2107-3-3] Date of Birth: [2060-11-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: Shortness of breath and fatigue Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to LAD Endotracheal intubation Central venous line placement PICC line placement PEG tube placement [2107-1-13] Intubation Axillary lymph node biopsy History of Present Illness: Mr. [Known lastname 1968] is a 46 year-old man with a PMHx significant for HIV (dx'd [2089], CD4 260 in [7-/2106], last VL [2104] was [Numeric Identifier ], self d/c'd HARRT in mid [2105] [12-22] financial difficulty, no history of opportunistic infections) in USOH until one month prior to presentation when he began to develop myalgias, fevers, chills, progressive DOE, PND, and eventually orthopnea. Over this month he also had multiple episodes of vomiting and weight loss. He saw his PCP two weeks prior to presentation regarding these symptoms. A CXR showed an upper lobe infiltrate, and he was treated with a Z-Pac, without symptomatic improvement. He was referred to the ED for further evaluation on [2106-12-7]. In the ED, EKG revealed ST elevation in the anterior leads. A CXR showed diffuse bilateral infiltrates. Past Medical History: 1. HIV, diagnosed in [2089]. Discontinued HAART in mid-[2105] [12-22] financial struggle. No history of opportunistic infections. Last CD4 260, VL [Numeric Identifier ] in [2104]. 2. Hyperlipidemia Social History: Mr. [Known lastname 1968] works at a zoo. Multiple animal exposures. Ex-smoker. Family History: N/A Physical Exam: Physical examination in ED (per records): VITALS: T 97.7, HR 117, BP 101/77, RR 16, Sat 100% on room air. HEENT: PERRLA NECK: Supple, no LAD, no JVD. RESP: CTA bilaterally. No wheezing. CVS: Normal S1, S2. No S3, S4. No murmur or rub. GI: No flank or pelvic pain. INTEGUMENT: No suspicious lesions. NEURO: Alert and oriented X 3. Pertinent Results: Relevant studies in hospital: Labs on admission: WBC-7.7 RBC-4.28* HGB-11.8* HCT-36.6* MCV-85 MCH-27.6 MCHC-32.3 RDW-14.3 NEUTS-67.8 LYMPHS-28.1 MONOS-3.6 EOS-0.2 BASOS-0.3 PLT COUNT-235 CK(CPK)-117 CK-MB-2 cTropnT-0.08* GLUCOSE-106* UREA N-19 CREAT-1.1 SODIUM-132* POTASSIUM-5.8* CHLORIDE-99 TOTAL CO2-23 ANION GAP-16 ALBUMIN-3.1* CALCIUM-7.9* PHOSPHATE-4.6* MAGNESIUM-1.9 LIPASE-24 ALT(SGPT)-24 AST(SGOT)-33 LD(LDH)-347* ALK PHOS-142* AMYLASE-33 TOT BILI-0.4 [2106-12-7] CARDIAC CATHETERIZATION: 1. Selective coronary angiography demonstrated a right dominant system with a ramus branch and one vessel CAD. The left main was a long vessel with mild plaquing. The LAD had an ostial subtotal occlusion and a proximal total occlusion. The distal LAD filled faintly by left to left collaterals. The LCx was modest AV groove vessel with small OM branches. The ramus intermedius was large with a 30% mid vessel lesion. The RCA had diffuse plaquing to 30% proximally. There were some septals providing collateral flow to the LAD. 2. Resting hemodynamics demonstrated cardiogenic shock. Right sided filling pressures were markedly elevated with a mean RA pressure 18 mm Hg. Left sided filling pressures were also elevated with a mean PCW pressure of 24 mm Hg and LVEDP of 23 mm Hg. Cardiac index was markedly depressed at 1.0 L/min/m2, based on an assumed oxygen consumption index. There was no evidenc of a gradient across the aortic valve on pullback of the pigtail catheter from the left ventricle. Moderate pulmonary hypertension was present. 3. An 8 French 40 cc intra-aortic balloon pump was placed via the right common femoral artery. There was appropriate augmentation of the diastolic pressure and unloading of the ventricle. After balloon augmentation, the cardiac index rose to 1.8 L/min/m2. 4. Successful PCI of the proximal LAD with a 2.0 x 18 mm Pixel stent, post-dilated with a 2.5 mm balloon at 18 atm (see PTCA comments). 5. Abdominal aortography was performed with a 4 French Tennis Racquet catheter using 30 cc of contrast at 15 cc/second. There was adequate runoff with mild diffuse plaquing in the bilateral iliac and right common femoral arteries despite the presence of the IABP sheath. FINAL DIAGNOSIS: 1. One vessel CAD. 2. Cardiogenic shock. 3. Successfl PCI of the LAD for acute anterior myocardial infarction. [2106-12-8] ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. A patent foramen ovale is present. The inferior vena cava is dilated (>2.5 cm). The left ventricular cavity is moderately dilated. There is severe global LV hypokinesis with distal septal and apical dyskinesis. The basal to middle septum is thinned and akinetic. A large, non-mobile thrombus is seen in the left ventriclar apex (2.0 x 3.0 cm) extending down the distal septum. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-21]+) mitral regurgitation is seen. There is no pericardial effusion. [2106-12-14] CT OF THE CHEST WITH IV CONTRAST: Bilateral axillary, left internal mammary, precarinal, and subcarinal lymphadenopathy is again noted, unchanged since the prior study. Left subclavian approach Swan-Ganz catheter terminates within the left main pulmonary artery. A focal area of soft tissue within the left ventricular cavity presumably represents the patient's known thrombus. The heart is enlarged but there is no pericardial effusion. The appearance of the lungs is unchanged since the prior study. Again, seen are multifocal areas of parenchymal opacification in a peribronchovascular distribution as well as smaller nodular opacities. Peripheral left basilar opacities are again identified associated with a small amount of pleural fluid. The airways remain patent to the level of the subsegmental bronchi bilaterally. CT OF THE ABDOMEN WITH IV CONTRAST: Oblong hypodensity extending from the splenic hilum to the posterior aspect of the spleen likely represents a splenic infarct. A smaller area of decreased attenuation is identified as well. The splenic vein and artery appear patent. The liver, gallbladder, pancreas, adrenal glands, and right kidney appear grossly normal. There is a peripheral area of hypodensity involving the left kidney in a single image, possib ly representing a renal infarct. Left kidney otherwise enhances and excretes contrast. Stomach and visualized loops of small and large bowel are unremarkable. The aorta and its major intra- abdominal branches appear patent. There is no free fluid within the abdomen. CT OF THE PELVIS WITH IV CONTRAST: A small focus of gas within the urinary bladder, presumably related to prior instrumentation. The distal ureters, seminal vesicles, and pelvic loops of bowel appear grossly normal. There is no free fluid within the pelvis. BONE WINDOWS: No suspicious lytic or blastic lesions are identified. IMPRESSION: 1) Unchanged appearance of bilateral peribronchovascular airspace opacities as well as multiple peripheral poorly defined nodular opacities. Differential diagnosis remains unchanged and includes infection, septic emboli, cryptogenic organizing pneumonia, and vasculitis. 2) Stable appearance of mediastinal and axillary lymphadenopathy. 3) Findings consistent with splenic infarcts involving the posterior aspect of the spleen. 4) Focal area of hyperperfusion within the lateral mid pole of the left kidney possibly an infarct. 5) Ill-defined soft tissue within the left ventricle presumably represents the patient's known left ventricular thrombus. [2106-12-17] CT HEAD W/O CONTRAST: There is no evidence of intracranial hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct. [Doctor Last Name ]-white matter differentiation is preserved. Note is made of a mucosal retention cyst in the left maxillary sinus. Osseous and soft-tissue structures are otherwise unremarkable. IMPRESSION: No evidence of intracranial hemorrhage or other acute intracranial pathology. [2106-12-18] EEG: This is a discontinuous bedside EEG telemetry from [12-17]-29 that was abnormal due to the presence of a low voltage background rhythm with occasional low voltage periods of delta and alpha frequency activity. These findings suggest deep, midline subcortical dysfunction and are likely a medication effect due to Propafol. As the record progressed, higher voltage, [11-21] Hz delta frequency activity was seen. This also suggests deep, midline subcortical dysfunction and is consistent with an encephalopathy that, again, may be due to a medication effect. During the recording, intermittent arm twitching and upper body fasciculations were noted and there was no evidence of seizure activity. No lateralizing abnormalities were seen. Sinus tachycardia was noted. [2106-12-23]: RIGHT UPPER QUADRANT ULTRASOUND: Comparison is made to a CT scan dated [2106-12-18]. Liver demonstrates no focal or textural abnormalities. There is no intrahepatic or extrahepatic ductal dilatation. The common bile duct measures 2.2 mm in diameter. The portal vein is patent with flow in the appropriate direction. There is mild distention of a sludge containing gallbladder. The pancreas is normal in appearance. There is a small amount of pericholecystic fluid as well as focal wall edema. Small amount of ascites is present adjacent to the right lobe of the liver. There is a small right pleural effusion. IMPRESSION: Mildly distended sludge containing gallbladder, small amount of pericholecystic fluid and focal wall edema as above. These findings are concerning for, but not diagnostic of, cholecystitis. If there is continued clinical concern for cholecystitis, a HIDA scan is recommended. [2106-12-23] HIDA: Negative [2106-12-27] Right axillary lymph node biopsy: HIV-associated adenopathy with follicular involution, lymphocyte depletion, follicular dendritic cell hyperplasia and histiocytic hyperplasia see note. [2107-1-6] CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: In comparison with the previous examination, there has been marked interval progression of bilateral patchy and nodular pulmonary parenchymal opacity consistent with multifocal pneumonia. There is a new large right-sided pleural effusion and interval increase in size of a moderate left pleural effusion. The visualized portions of the heart and pericardium appear unchanged. Visualization of the mediastinal structures is limited due to lack of IV contrast. The airways are patent to the level of the segmental bronchi bilaterally. Limited images of the upper abdomen, including limited images of the liver, spleen, and stomach, appear unremarkable. BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or sclerotic osseous lesions. There is significant motion during image acquisition, which limits visualization of fine osseous detail within the ribs, particularly on the right. IMPRESSION: Significant interval progression of bilateral pulmonary parenchymal consolidation consistent with multifocal pneumonia. Interval increase in bilateral pleural effusions. MICROBIOLOGY/SEROLOGY WORK-UP: Urine legionella negative DFA negative for influenza on admission Induced sputum negative for PCP, [Name10 (NameIs) 11381] Cryptococcal antigen negative EBV serology negative CMV viral load negative Galactomannan antigen positive on first assay (false positive on Zosyn), then negative on repeat testing. Bartonella serology negative Monospot ngative Toxoplasma serology negative [2106-12-21] Stool positive for C. difficile. -> C. diff negative x3 s/p treatment (last test on [2107-3-1] neg). [2107-2-16] Wound swab from PEG site: pseudomonas but thought to be colonization by ID. No signs of abscess or deeper infection on abd CT. [2107-2-22] Urine culture: pseudomonas thought to be colonization by ID. UA neg x2. ID recommends against treatment. [2107-3-2] Sputum gram stain: gram neg rods and gram positive cocci in pairs and clusters. NGTD [2107-3-2] UA: clear; Uctx: NGTD All blood cultures NGTD Brief Hospital Course: A/P: 46 year-old male with HIV previously on HAART, admitted with 1 month of DOE, CHF symptoms, found to have anterior ST elevations on EKG in ED and total occlusion of LAD in cath lab, status post stent placement (bare metal stent) on [2106-12-7], also with bilateral pulmonary infiltrate on CXR. His hospital course will be reviewed by problems as it was complicated by multiple issues. . 1) CV: A). CAD: As mentionned above, Mr. [Known lastname 1968] was taken to the cath lab on [2106-12-7] where he was found to have total occlusion of the LAD and received a bare metal stent. Right heart catheterization showed elevated PCWP of 26 and MVO2 sat of 24%, with CI of 1.0. An IABP was placed with improvement in CI to 1.8, and dopamine was initiated. He was subsequently transferred to the CCU for further care. It was felt that the MI was not acute given the low enzyme levels (troponin 0.08, flat MB on [2106-12-7]) but most likely represented an event a couple weeks old. Of note, Plavix was held in anticipation for invasive diagnostic procedures for his pulmonary process. He had a heparin coated bare metal stent placed on [2106-12-7], and Plavix was stopped despite such a short course. It was not restarted due to persistent bleeding from epistaxis. . B). Pump: An echo on [2106-12-8] revealed an EF 10-15% and an apical LV thrombus, and Mr. [Known lastname 1968] was started on Heparin IV. During his course in the CCU, he was switched to Milrinone for inotropic support, and diuresis was initiated given elevated filling pressures and poor EF. Lasix and Milrinone therapy were tailored to increase his cardiac index by following PAP values. During this part of the hospital course he had several episodes of SVT responsive to Lopressor, and later had NSVT for which milrinone wean was accelerated. As tolerated by good cardiac index, he was weaned off the IABP and started on ACE-inhibitor, and weaned off Milrinone. Digoxin was also started and Coreg was added. . He was transferred to the floor on [2106-12-16], stable on ACE inhibitor and BB. On the second day on the floor, he became hypotensive and developed a fever to 102.5. He was given fluids and placed on Dopamine out of concern for sepsis and possible cardiogenic shock, and transferred back to the CCU. Over that night he was switched to Levophed as he was too tachycardic on Dopamine. A swan was again placed and the numbers were consistent with cardiogenic shock and superimposed sepsis. Pressors were changed to Milrinone. . He has remained on Milrinone since his transfer back to the CCU, and has been on intermittent ACE inhibitor therapy (held in the setting of hypotension and rising creatinine). We were eventually able to titrate Lisinopril to 5 mg PO QD. Therapy was tailored to the patient's BP and urine output once the PA line was out. Few attempts to wean Milrinone have been unsuccessful because of hypotension. The CHF service was consulted, with recommendations to start Digoxin for inotropic support, and transfuse to keep hematocrit > 30, both of which were done. Of note, while in the CCU, Mr. [Known lastname 1968] had recurrent episodes of complete heart block, and Digoxin was discontinued. He was also diuresed with Lasix boluses prn for goal daily even to negative fluid balance. At some point he was so fluid overloaded, he required lasix gtt with additional boluses to attain euvolemia. . However, the patient's congestive heart failure continue to worsen throughout his course. At first, the patient wished to be DNR/DNI with continued measures to save his life including milrinone. The swan was discontinued with persistently low cardiac indexes in the 1.4 range on milrinone. However, the patient then reversed his code status as he was given the hope that he might recover. Despite this hope, the patient's congestive heart failure worsened to the point that recovery is slim and he will remain dependent on milrinone for the rest of his life. Meanwhile, he would occasionally drop his pressures and require levophed. On dobutamine, he developed ectopy and this was stopped. At the patient's family's request, Dr. [Last Name (STitle) 10910] from [Hospital1 336], a heart failure expert, came to evaluate the patient and agreed that the patient would not be a candidate for a left ventricular assist device or heart transplant as the patient has no intrinsicly preserved heart function to support such a thing. Furthermore, his pulmonary status is so poor that he would not tolerate a heart transplant. In addition, Dr. [Last Name (STitle) 98552] from the Brighham also offered a second opinion in which he at first suggested repeating a CT scan of his chest, improving his nutritional status and repeating an echocardiogram to assess the patient's improvement and consider LVAD. However, a repeat CT scan showed minimal improvement of the patient's BOOP on prednisone, a repeat echo showed decreased systolic function and although he is at goal TPN, his nutritional status will not further improve. Therefore, the patient has been denied by the [Hospital1 756] for further intervention as well. . The patient continued to be dependent on milrinone and levophed for inotropy and pressure support. Multiple attempts were made to wean down the levophed dose in an attempt to discharge/transfer pt to home/floor, however this proved very difficult due to repeated episodes of hypotension. On the last days of his hospitalization, his hypotensive episodes became worse most likely secondary to sepsis and he required higher and higher doses of leveophed to maintain pressures. At some point, the levophed was not able to support his blood pressure and max dose milrinone was unable to generate sufficient forward flow to maintain tissue perfusion. . C). Rhythm: The patient had been tachycardic to 140-160s since admission but was started on Amiodarone on [2107-2-11] and had shown signs of better nodal control. The patient only had occasional episodes of tachycardia after wards. He was therefore continued on Amiodarone at 100mg once daily dose (lower than normal dose due to history of significant bradycardia with full dose amiodarone). The patient was continued to be observed on telemetry as well during his hospitalization. . . 2) Pulmonary: A). Pulmonary infiltrates/BOOP: Given his initial CXR with bilateral patchy infiltrates, Mr. [Known lastname 1968] was started on Levoquin for coverage of atypicals and CAP organisms. ID was consulted. He was placed on isolation out of concern for possible TB, and Bactrim was added pending rule out PCP. [Name Initial (NameIs) 227] CD4>200 and negative induced sputum X2, Bactrim was discontinued. Vancomycin was added for gram positive coverage. A CT chest was eventually performed to further characterize his pulmonary lesions, and revealed bilateral conglomerated central peri-bronchovascular opacity with air bronchograms as well as multiple peripheral scattered poorly defined nodular opacities and foci of ground-glass opacity and lymphadenopathy. The differential diagnosis included atypical infection, cryptogenic organizing pneumonia, atypical vasculitis, sarcoidosis, and neoplastic processes such as Kaposi sarcoma and lymphoma. An extensive non-invasive work-up including induced sputum for PCP, [Name10 (NameIs) 11381], legionella, as well as blood cultures, sputum cultures, cryptococcal antigen, chlamydia psitacci, histoplasmosis, coccidioidomycosis, chlamydia pneumonia, Bartonella titers, was non-revealing. He also did not respond to broad-spectrum antibiotics. . Pulmonary was consulted, along with ID and a tissue diagnosis was recommended. A VATS was felt to be the best diagnostic procedure. However, thoracic surgery declined VATS given the patient's tenuous respiratory and cardiac status. Attempt was made to perform a bronchoscopy with biopsy on [2106-12-23] but was aborted given the patient's tenuous hemodynamics. The yield of such a procedure was also anticipated to be low, and the risk/benefit ratio of elective intubation was not favorable. Given his generalized lymphadenopahy, he underwent a right axillary lymph node biopsy on [2106-12-27]. Initial pathology reports were suggestive of an atypical tumor. However, further evaluation was felt consistent with HIV adenopathy with non-specific histiocytic proliferation, and the biopsy turned out to be non-diagnostic. Special stains and immunophenotyping were also unrevealing. . Given the above, Mr. [Known lastname 1968] was started on empiric steroid and antifungal therapy on [2106-12-29]. Heme was also consulted, who felt that his pulmonary process was unlikely to be lymphoma. In the differential were KS, COP (BOOP), lymphoma (unlikely), infection (unlikely). On [2106-12-31], a Galactomannan antigen came back positive at 0.79 (drawn on [2106-12-24]). Given this positive result, Caspofungin was changed to Voriconazole, and steroids were D/C'd. A repeat Galactomannan was sent on [2106-12-31]. The patient was on Zosyn at the time of the first sample, which can cause false positive results. The repeat Galactomannan eventually came back negative. Given this negative result as well as lack of clinical and radiographic improvement, antifungal therapy was discontinued after completion of a 7-day course. . A repeat chest CT was performed on [2107-1-6], which revealed stable pulmonary infiltrates. After discussion with pulmonary and ID services, empiric steroid therapy was reinitiated on [2107-1-7]. A repeat CT chest performed on [2107-1-14] showed slight radiographic improvement, and Methylprednisolone was changed to Prednisone 60 mg PO QD. He will need at least 6 months of therapy for presumed BOOP (COP). Of note, Bactrim prophylaxis was also initiated given repeat CD4 186 and steroid therapy. . The patient was treated empirically for BOOP on prednisone which has been tapered to 50 mg from 60 mg, with a slow taper over 6 months. A repeat CT scan after at least a month of steroids showed minimal improvement. He continued to have a rapid respiratory rate but expressed his wish to be intubated if needed. Pulmonary no longer followed the patient and we continued steroids and bactrim prophylaxis. Furthermore, we discussed the patient with ID who recommended no additional HIV prophylaxis. . B). Respiratory Failure: This is most likely secondary to volume overload from end stage heart failure. The patient was intubated for severe respiratory distress with tachypnea to 60s, SaO2 of 80% on NRB and ABG of 7.4/34/43 on NRB. The patient remained tachypneic and was overbreathing the vent, possibly due to the sepsis or other metabolic derangement. The sedation was increased sequentially in attempts to better control his respiratory status. He was unable to be extubated prior to expiration. . . 3) ID: Please see above for work-up of pulmonary infiltrates. As mentioned above, Mr. [Known lastname 1968] was started on Levaquin on admission for coverage of CAP and atypicals. Vancomycin was eventually added for improved gram positive coverage, and he completed a 7-day course of both antibiotics. . On [2106-12-17], he became hypotensive and developed a recurrent fever to 102.5. Vancomycin and Levofloxacin were restarted, and Zosyn was added to broaden GN coverage. He continued to spike fever despite broad spectrum antibiotic coverage. An extensive infectious work-up, including induced sputum for PCP, [Name10 (NameIs) 11381], legionella, as well as blood cultures, sputum cultures, cryptococcal antigen, chlamydia psitacci, histoplasmosis, coccidioidomycosis, chlamydia pneumonia, Bartonella titers, was non-revealing. He had a positive femoral catheter tip culture on [2106-12-18] positive for Enteroccus, felt a likely contaminant. All antibiotics were D/C'd on [2106-12-20]. Stool cultures were positive for C. diff on [2106-12-21], and Flagyl was started. Oral vancomycin was eventually added on [2106-12-30] given ongoing diarrhea. Vancomycin was D/C'd on [1-4] and Flagyl was D/C'd on [2107-1-8]. He has been afebrile since [2106-12-30]. . A PEG tube was placed on [2107-1-13], complicated by significant pneumoperitoneum. Hence, broad spectrum antibiotherapy was reinitiated with Vancomycin, Levofloxacin and Flagyl. The patient completed this course of antibiotics without difficulty and remained symptom free until [2107-2-11] when his white count began to rise. This was felt to be no surprise as the nursing staff reported seeing the patient self-contaminate himself on many occasions by touching his stool and then touching his nose and mouth with the same hand. On [2107-2-13], the patient's white count rose to 17 and although he had not yet spiked, he was pancultured and placed on vanco/levo/flagyl empirically for a [5-29] day course without ever manifesting any sx, the vanc/levo/falgyl course was completed. . The patient complained of significant hoarseness and dysphaga in his throat. He was initially treated symptomatically with viscous lidocaine and improved oral hygiene. In addition, he was started on fluconazole for treatment of oral thrush which was thought to be the causative organism. CMV viral load in [Month (only) 956] was negative, however repeat viral load on [2107-3-1] was 6200. ID was consulted regarding treatment for CMV esophagitis, however they did Not recommend treatment without a tissue diagnosis given the multiple toxicities of Gancyclovir. A tissue diagnosis could not be obtained due to the fragile nature of the patient's cardiopulmonary status which may have led to earlier respiratory failure and intubation. . The pt spiked a temperature to 101 again on [2107-3-1] (3days post intubation) at which point he was started on vancomycine for presumed MRSA VAP. Gram positive cocci were found in the sputum gram stain. On day 4 of intubation, the patient spiked a temperture to 104 and ultimately reuquired a cooling blanket and around the clock tylenol to defervese. The patient was started on levofloxacin and flagyl in addition to the vancomycin. He subsequently dropped his pressures requiring inc. doses of levophed suggesting he was in severe sepsis. A repeat sputum gram stain showed gram postivie cocci as well as gram negative rods suggesting the causative organism were most likely MRSA and pseudomonas. Antibiotics were continued, however he expired from overwhelming sepsis and multi organ failure refractory to two max dose pressors. . During the course of his admission, the patient was found to have a low CD4 count and the decision regarding re-starting HIV med was deferred from ID to PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] who has been following his HIV care. Ultimately his HIV meds were not re-started due to the signfiicant side effects of the medication given the patient's many complications and acutely ill state. . . 3) Neuro: On [2106-12-18], in the setting of recent hypotension and high fever, Mr. [Known lastname 1968] had a seizure and required intubation for airway protection. Neurology was consulted. CT with and without contrast showed no bleed/mass, electrolytes were essentially unchanged, and LP was without infection (although it was remarkable for an elevated total protein). EEG was consistent with diffuse encephalopathy, possibly medication-related. Given negative work-up, his seizure was felt most likely in the setting of fever. Per neurology, he was started on Dilantin for seizure prophylaxis. The latter was eventually changed to Keppra in the setting of elevated LFT's. He has had no recurrence of his seizure, but has been intermittently confused with poor short-term memory. The possibility of a thalamic stroke was raised by neurology, but he subsequently improved and further work-up was not pursued. . Given his ongoing tachypnea and [Last Name (un) 6055]-[Doctor Last Name ] breathing despite radiographic improvement and fair CHF control, the possibility of a central process was again raised. Attempt was made to obtain a head MRI on [2107-1-15] which was aborted given patient agitation and inability to lay still. . He remained on Keppra 1gm PO BID which was discontinued early in [Month (only) 958] as it was felt that this medication was not necessary to prevent further seizures. This was discussed and agreed with by neuro. . . 4) Renal: Pt developed ATN (muddy brown casts in urine) most likely secondary to transient ischemic insult from hypotension. Duration of oliguria was very short < 24hours followed by extensiv diuresis (post ATN diuresis) despite cessation of diuretics. This was complicated by frequent episodes of metabolic alkalosis: Given his significant diuresis as well as the inc. bicarb, the patient was thought to be in contraction alkalosis. as well as fluid over load. These fluid balances were managed with differing levels of diuretics including lasix bolus to gtt as well as acetazolamide, natrecor and renal dosed dopamine gtt. His fluid balances remaiend difficult to manage throughout his stay. In addition, the patient had frequent electrolyte imbalances which were also difficult to manage due to their wide fluctuations. This ranged from signficnt hyponatremia to hyperkalemia as well as hyperkalemia which were all managed clinically. . . 5) GI: A). Elevated LFT's: On [2106-12-23], Mr. [Known lastname 1968] was noted to have elevated LFT's. Interestingly, he had elevated ALP + GGT>>>> AST and ALT. Peak ALP 1457, AST 271 and ALT 128 on [2106-12-23] with normal bilirubin. A RUQ ultrasound was performed on [2106-12-23] which revealed a mildly distended sludge containing gallbladder with a small amount of pericholecystic fluid and focal wall edema. Given theses results, a HIDA scan was performed, which was normal. Hepatology was consulted on [2106-12-26] with an impression of drug-induced liver disease versus infiltrative process (infection or lymphoma), although the latter was felt unlikely. Dilantin was felt to be the possible culprit, and was weaned to off. He was transitioned to Keppra for seizure prophylaxis, with parallel improvement in his LFT's. However, as Kepra affects LFTS, this was discontinued without further issues. His LFTS continued to trend down and were felt to be elevated secondary to hepatic congestion. . B). Pancreatitis: The patient developed acute RUQ pain with elevated amylase and lipase. The RUQ US showed sludge in CBD suggesting possible pancreatitis due to sludge from chronic TPN. Pt was placed on bowel rest and TG were taken out of TPN. Although ERCP or MRCP would have been ideal to ascertain and possibly treat the ongoing GI process, GI believed he would most likely not tolerate either procedure. Therefore a decision was made in conjunction with the GI team to persue a conservative management as above. The Amylase and Lipase did decrease slowly almost normalized prior to expiration. . . 6) Apical Thrombus: The patient has a large left ventricular apical thrombus secondary to poor LV function. As a result, he was bridged to coumadin. However, during the week of [1-31], the patient's INR rose suddenly to as high as 9.5 and he developed spontaneous epistaxis that required 4 blood transfusions and 4 units of FFP. ENT was asked to evaluate the patient and placed nasal packings to prevent further epistaxis. They placed the patient empirically on cefazolin while the packing remains in place. His coumadin was held in the setting of these nosebleeds. Once the packing were removed and the patient was able to maintain appropriate Hct, he was started on loevenox 30mg [Hospital1 ] for two weeks followed by heparin gtt for treatment o his apical thrombus. . . 7) FEN: Poor PO intake in the setting of tachypnea and critical illness. He refused NG tube and Dob Hoff placement, and was started on TPN on [2106-12-30]. He finally underwent PEG tube placement on [2107-1-13] at the bedside with GI and Anesthesia present. Post-procedure, incidental note was made of significant abdominal free air on CT chest. He also complained of ongoing abdominal pain. An erect CXR revealed significant free air, and surgery was consulted. A gastrograffin CT abdomen was performed on [2107-1-15] which showed no extravasation of contrast indicating a leak. . The PEG tube was used initially with high residuals and increased abdominal pain. Repeat films showed persistent air in the peritoneum a month after the PEG placement which was felt not to be unusual. It was felt that by using the PEG, the patient's abdominal pain was significantly worse than if he received TPN through a PICC. Therefore, we have continued to provide him TPN nutrition and disontinued the PEG tube. The patient was encouraged to continue on a fluid-restricted, BRAT-like diet. However the patient was known to eat sardines and Chinese food which exacerbated his congestive heart failure and precipitated a sharp decline in his function and caused increased abdominal pain. Multiple discussions regarding moving the PEG tube to PEJ tubes were undertaken during his hospital course, however neither GI, IR, or IP was willing to perform the procedure given the patient's significant comorbidities and high risk of intubation. The patient was continued on TPN until his expiration. . . 8) Code status: The patient has significant heart disease with severe LV dysfunction (EF of 10%). As such, he was unable to create any forward flow without max dose milrinone and additional pressure support with levophed. As per our transplant service (and two other independent cardiologists from outside institutions), he was Not a candidate for heart transplant or LVAD secondary to pulmonary hypertension and significant RHF. In addition, he has had significant complications including BOOP, LV thrombus formation with significant epistaxis secondary to supratherapeutic INR, worsening immunosuppression from HIV, with CMV infection and ATN. Throughout his hospital course, we had multiple discussions with the family regarding goals of care. Over the last several days of his hospitalization, he developed severe sepsis from what appears to be GPC and GNR of unclear origin. Given his underlying heart condition and all of these complications, his prognosis was poor. During the last days of his hospitalizations we had multiple discussions with the HCP, the family, ethics service as well as palliative care service daily to address goals of care. The HCP communicated to the team her desires to stop any additional treatments. She was interested in taking treatment regimens away with the understanding that we will Not re-start them. On the last day of his hospitalization, he was unable to maintain pressures despite max dose milrinone and levophed and he was having high fevers despite multiple antibiotics. Given the rapid and what appeared to be fatal progression of his many illness, the HCP made the patient DNR and DNI. The patient expired later that afternoon. Medications on Admission: None. Discharge Medications: None. Discharge Disposition: Extended Care Discharge Diagnosis: Pneumonia Sepsis. Cardiomyopathy with Congestive Heart Failure. Coronary Artery Disease. BOOP. Acute Renal Failure. Discharge Condition: Pt. Expired. Discharge Instructions: Pt. Expired. Followup Instructions: Pt Expired. Completed by:[2107-3-12]	[ "444.89", "042", "536.49", "428.0", "784.7", "403.91", "516.8", "707.03", "512.1", "078.5", "429.0", "518.84", "584.5", "995.92", "577.0", "414.01", "008.69", "112.0", "008.45", "425.4", "038.8", "785.51", "410.11", "780.39" ]	icd9cm	[ [ [] ] ]	[ "21.02", "89.64", "96.6", "37.61", "99.15", "43.11", "37.23", "31.42", "34.91", "97.44", "88.42", "00.13", "38.93", "40.11", "88.56", "00.17", "36.06", "03.31", "36.01" ]	icd9pcs	[ [ [] ] ]	35742, 35757	12538, 35656	347, 548	35917, 35931	2164, 2200	35992, 36035	1793, 1798		35712, 35719		35778, 35896		35682, 35689		4406, 12515		35955, 35969						1813, 2145																						276, 309								576, 1435								2214, 4389							1457, 1676	1692, 1777
27,800	172,399	46353	Discharge summary	report	Admission Date: [2159-10-3] Discharge Date: [2159-10-6] Date of Birth: [2096-5-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4654] Chief Complaint: Tachycardia, Tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 63 y/o M with PMHx of COPD on home 1.5-2L O2 started after recent admission for PNA/COPD exacerbation s/p intubation was admitted with tachycardia and tachypnea. After prompting by home nurse, pt was persuaded to come to ED for respiratory distress. Pt had been recently admitted [2159-9-17] for subacute worsening hypoxia (70's% at rest and 60's% with minimal exertion) [3-10] RLL PNA. He was started on azithromycin and ceftriaxone for a presumed COPD exacerbation; and developed hypercarbic respiratory failure requiring intubation on HD [3-11] with successful extubation HD 4. He was given pulse dose steroids, nebulizers and received a 5 day course of levofloxacin, and was due to finish a prednisone taper starting at 60mg with a planned 14 day taper, on the day of this admission. Of note, despite improvement, he had persistent episodes of desaturation to the 70s% with ambulation. He denied fevers/CP/N/V/D, but endorsed ongoing productive non-bloody cough and difficulty clearing secretions. He denied any lower extremity swelling, palpitations, chest pain, diaphresis, and lightheadedness. Of note, pending discharge for most previous hospitalization, pt was able to maintain an ambulatory oxygen saturation of 90% but was sent home with home oxygen nevertheless. He was using 1.5-2L at rest and for ambulation on presentation. . On arrival to the ED, his VS were T 97.4 HR 126 BP 123/72 RR 28 Sats 88% on RA, and 98% on 2L. Pt received solumedrol 125mg IV, Albuterol/Ipratropium Nebs, Vancomcyin 1gram, Levofloxacin 750mg, Magnesium 2grams IV. CXR showed improvement in RLL infiltrate since last admission. Urine/blood Cx were sent. Due to concern for hypercarbic respiratory failure, pt was admitted to the ICU for overnight monitoring for need for intubation. . Past Medical History: Severe COPD: FEV/FVC 60% in [2150] (no recent PFts available), on home 1.5-2L O2 Secondary severe Pulmonary Hypertension (noted in prior ECHO) Schizophrenia Social History: Lives in [Location ] with brother and brother-in-law. On disability since [2149] for mental health issues. Visiting nurse twice daily. Ongoing tobacco use, in the past as much as 4 packs/day. Denies ongoing EtOH or drug use. Family History: Non-contributory Physical Exam: PE: T 96.8 HR 83 BP 134/89 RR 26 Sats 95% on 4L Gen: tachypneic with mild resp distress, completing short sentences, alert & oriented. HEENT: NCAT, EOMI, PERRLA, MMM CV: RRR no apprec m/r/g Pulm: crackles at RLL base, moving air well in upper air [Last Name (un) 18100], scattered expiraotry wheezes, not moving air well at LLL base Abd: soft, NT/ND, NABS, no rebound/guarding Ext: warm, no c/c/e, +DP/PT Neuro: CN 2-12 grossly intact, alert & oriented, mentating at baseline, moving all 4 extremities well Pertinent Results: [2159-10-3]: Na 138, K 3.8, Cl 97, Bicarb 30, BUN/Cr 23/0.9, glucose 146, WBC 25.1 (87% N, 8.7% L), Hct 46.5, platelets 354. . [2159-10-3]: CK 32, MB not done, Trop T<0.01 CK 20, MB not done, Trop T <0.01 . [2159-10-3]: ALT: 28 AP: 52 Tbili: 0.9 AST: 16 LDH: 214 [Doctor First Name ]: 49 Lip: 18 . [2159-10-3]: UA +Gluc 1000, otherwise negative Serum/Urine tox -negative . [2159-10-3]: Lactate 1.2 . [2159-10-3]: ABG 7.31/58/127, O2 Sat 96 . EKG: 7am [2159-10-3] sinus tach at 124 with peaked P waves and pseudonormalization of inferior ST segments (inverted at baseline). . EKG: 1pm [2159-10-3] NSR with rate of 72, TWI noted inferior leads II,III & AVF and biphasic t waves in lateral leads. All these are consistent with baseline EKGs. . Micro: Blood culture ([2159-10-3]): no growth at time of d/c (72 hours). Imaging: CXR ([2159-10-3]): Hyperexpanded lung fields. Resolving right lower lobe opacity. Otherwise clear lung fields. TTE ([2159-9-18]): moderate RVH and RV dilation w/ global free wall hypokinesis. Severe pulmonary artery systolic hypertension. normal EF no diastolic dysfunction. PFT's ([2150-9-10]): FVC 90%, FEV1 55%, FEV1/FVC 60% . Brief Hospital Course: A/P: 63 y/o M with severe COPD presents with hypercarbic respiratory distress c/w COPD exacerbation. As above, pt initially admitted to ICU for observation, did not require invasive or non-invasive resp support, sx resolved with steroids/abx/Neb tx as above. Pt with 95%o2 sat on 0.5L NC at time of d/c, sx at baseline per pt. <br> # Hypercapnic respiratory distress [3-10] c/w COPD exacerbation with contributions from secondary pulmonary hypertension from COPD and resolving RLL PNA. Ruled out for MI. Tachycardia resolved with steriods and antibiotics, making PE less likely. New PNA unlikely given absence of new infiltrate on CXR and clinical signs of cough/fever. - ambulatory sats day prior to d/c did not drop below 90% - pt continued on prednisone 60mg QD, Rx 2 [2-7] week taper given severity of baseline COPD and recent history, though pt with sig sx improvement - resume home COPD meds incuding albut/ipratropium inhalers, advair, and tiotropium - Azithromycin 500mg day [4-11] at time of d/c, Rx 2 more days - maintain on home O2 2L by NC, wean as tolerated for goal O2sats 90-95% -Pt's PCP fu appt has been moved up to next week, pt to f/u. <br> # Leukocytosis: [3-10] to underlying COPD flare/resolving PNA; steroid use. Infection was ruled out given normal lactate 1.9 wnl on admission; stable and improving RLL process on CXR; LFTs/amylase/lipase were all WNL. - Blood/UA neg, no diarrhea - likely [3-10] steroids, afebrile, leukocytosis improving at time of d/c at 13.3 from 19.3, PCP to [Name Initial (PRE) ]/u. - Azithro for COPD exacerbation as above <br> # Tachycardia: Resolved on admission to ICU, likely secondary to primary respiratory distress. Unlikely to represent a PE given that tachycardia resolved with nebulizers and steroid treatment. <br> # CAD: ECHO preported prior basolateral hypokinesis but ECG on admission shows no ST changes, and Ruled out for MI. - continued aspirin <br> # Schizophrenia: Severe psychiatric disease which has been a barrier to medical care in the past when the patient has refused to come to the hospital. ECG X3 negative for QTc prolongation - Continue olanzapine 5mg qd, outpt f/u as per routine with changes per PCP <br> # History of inpatient fall on admission [2159-9-17]. - Fall precautions while in-house, no events - Pt c/s for gait stability <br> # Prophylaxis: Heparin sc TID, bowel regimen, PPI while on steriods, Rx 3 week course at time of d/c with steroids above, chest PT, [Name (NI) ] while on steriods (while in-house), PT c/s Medications on Admission: - Olanzapine 5 mg Daily - Aspirin 81 mg Daily - Prednisone 20 mg Daily for 10 days - Albuterol Inh 1 Puff every 4 hours - Tiotropium Bromide 18 mcg Capsule Inhalation Daily - Fluticasone-Salmeterol 500-50 mcg 1 Inhalation 2 times a day - Ipratropium Bromide 17 mcg 2 Inhalations every 6 hours as needed Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 days. Disp:4 Tablet(s) Refills:0 7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day: Please take 6 tabs for qdaily for 2 days, then take 5 tabs for next 3 days, then 4 tabs for next 3 days, 3 tabs for next 3 days, then 2 tabs for next 3 days, followed by 1 tab for the last 3 days then you can stop. Disp:57 Tablet(s) Refills:0 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 21 days: to be taken while on your steroids (and your home aspirin). Disp:21 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home With Service Facility: Nizhoni health system Discharge Diagnosis: Primary diagnosis: COPD exacerbation Secondary: Schizophrenia Discharge Condition: Good Discharge Instructions: Resume your old medications as previously prescribed plus the antibiotics and steroids as newly prescribed today. Please assure to see your PCP within the next couple weeks for follow-up care. If your breathing worsens signficantly please contact your PCP or return to the emergency room. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN, CS Phone:[Telephone/Fax (1) 250] Date/Time:[2159-10-9] 10:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2159-11-20] 11:40 [First Name8 (NamePattern2) ] [Name8 (MD) 474] MD [MD Number(2) 4658] Completed by:[2159-10-6]	[ "491.21", "288.60", "V46.2", "276.2", "785.0", "416.8", "295.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8809, 8861	4413, 6963	337, 343	8968, 8975	3181, 4390	9314, 9762	2617, 2635		7316, 8786		8882, 8882		6989, 7293				8999, 9291						2650, 3162																						275, 299								371, 2163							8901, 8947								2185, 2350	2366, 2601
14,172	136,585	24783	Discharge summary	report	Admission Date: [2123-1-29] Discharge Date: [2123-2-3] Date of Birth: [2045-2-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Thoracic ultrasound of L pleura. Transthoracic echocardiography. History of Present Illness: 77M with h/o COPD with home O2 qhs and lung cancer (T2Nx NSCLC) who presented to clinic today to receive his first radiation treatment with CyberKnife. He reports increased SOB x 1wk, cough productive of white/brown sputum x few weeks, and increased swelling of lower extremities x few weeks. Patient diagnosed with URI last week by PCP and completed [Name Initial (PRE) ] 6 day course of an antibiotic (does not know which) one day prior to admission with minimal improvement. Per daughter patient has been increasingly lethargic at home x 1 week, getting out of bed only to go to the bathroom. Patient also has been using oxygen all day instead of just at night. In clinic he was found to be tachypneic (RR40), dyspneic, and mildly hypoxic (O2sat 88-93%) and with an irregular pulse. Patient was sent to the ED for further evaluation. ROS: Denies chest pain, abd pain, dysuria, abnormal bowel habits. Has stable 2 pillow orthopnea, denied PND. Appetite has been good. ED course: T 97.1 BP 132/79 HR 91 RR24 Sat 99% 5L (93% RA) Patient noted to be lethargic, sleepy on presentation but had just taken 0.5mg Ativan and 4mg Dexamethasone (for radiation treatment). Received Atrovent/Albuterol nebs, Solu-medrol 125mg iv x1, CTX/Azithro and Kayexalate for hyperkalemia. Patient found to be somnolent with ABG 7.28/78/86. BiPAP initiated. RT later decreased FiO2 to decrease O2sat with improved mentation. Patient admitted to ICU on 2L NC for further management. Past Medical History: COPD- FEV1 0.75 (32 %pred) FVC 1.67 (46% pred), FEV1/FVC 45 (69%pred) Lung Cancer (T2Nx NSCLC, squamous cell carcinoma) Dx [4-28] s/p Mediastinoscopy [9-28]- negative paratracheal LN s/p fiducial seed placement in RML lesion [12-28] Atrial Fibrillation BPH status post TURP status post remote appendectomy Hard of hearing right foot drop secondary to pinched peripheral nerve. Social History: He works managing [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 62442] store. He lives with his wife [Name (NI) 382]. He has two daughters. [Name (NI) ] has smoked two packs per day for approximately 60-65 years. He is trying to quit, but he is still smoking at least half a pack per day. No alcohol. No IVDA. Family History: Non-contributory Physical Exam: T98.6 BP105/67 HR130 RR34 O2sat 92% 2L Gen: elderly gentleman, NAD HEENT: PERRL, EOMI, OP-clear, MMM neck supple, no LAD Lungs: poor inspiratory effort, decreased breath sounds at R base. crackles R base, diffuse expiratory wheezes bilaterally. + ronchi CV: irreg irreg. no murmurs abd: soft, NT, ND. normoactive bowel sounds ext: 2+ pitting edema to knees bilaterally. Neuro: grossly intact Pertinent Results: [2123-1-29] 11:55AM WBC-19.2# HGB-10.3 HCT-32.2* MCV-95 PLT COUNT-534* NEUTS-95.2* LYMPHS-3.2* MONOS-1.3* EOS-0.1 BASOS-0.1 SODIUM-138 POTASSIUM-6.4* CHLORIDE-97 TOTAL CO2-34* UREA N-25* CREAT-1.4* GLUCOSE-101 ANION GAP-7 CK-MB-NotDone cTropnT-<0.01 URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG LACTATE-1.3 K+-6.1* TYPE-ART PH-7.28* PCO2-78* PO2-86 TOTAL CO2-38* BASE XS-6 [2123-1-29] Sputum culture RESPIRATORY CULTURE (Final [2123-2-1]): HEAVY GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. [2118-6-29] Urine culture negative. [2123-1-29] Blood culture with no growth to date. EKG: AFib at 127. no acute ischemic changes. Studies: EKG: AFib at 127. no acute ischemic changes. . CXR [2123-1-29]: Atelectasis and moderate sized pleural effusion seen in the area of the known right middle lobe mass. No evidence of pneumothorax. . CTA [2123-1-29]: Again noted is an obstructing mass in the right middle lobe with a similar appearance. As noted on the very recent prior CT, the mass encases the hilar vessels in the right middle lobe, and there is distal partial collapse of the right middle lobe. There is a similar appearance of a right-sided pleural effusion, with peribronchial thickening in the right lower lobe. Again noted are multiple small mediastinal lymph nodes, which do not meet CT criteria for pathologic enlargement. There is no evidence of pulmonary embolism, and the heart and pericardium are unremarkable. There is no pericardial effusion. . [2123-2-1] Echocardiography: Suboptimal image quality.The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets are moderately thickened. There is probably at least mild aortic valve stenosis. The mitral valve leaflets are mildly thickened. At least trace mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2122-10-5], the degree of pulmonary hypertension detected has increased. [2123-2-1] Chest X-ray: AP chest compared to [1-29] and [1-5]: Small right pleural effusion has increased since [1-29] collecting along the diaphragmatic and lower costal surface of the right lung adjacent to consolidation surrounding a right middle lobe mass demonstrated on plain chest films from [1-5]. Right middle lobe is probably collapsed. Left lung is clear. The heart is normal size. Thoracic aorta is tortuous and heavily calcified, but unchanged in overall caliber. There is no pneumothorax. Laboratories: [2123-2-3] 06:50AM BLOOD WBC-13.6* RBC-3.03* Hgb-9.7* Hct-29.5* MCV-97 MCH-32.1* MCHC-33.0 RDW-18.1* Plt Ct-523* [2123-2-3] 06:50AM BLOOD Glucose-78 UreaN-41* Creat-1.2 Na-138 K-4.8 Cl-96 HCO3-36* AnGap-11 Brief Hospital Course: This is a 77 year old gentleman with COPD (on home O2), atrial fibrillation, smoking, and recently diagnosed lung cancer (T2Nx NSCLC). He initially presented to clinic on [2123-1-29] for his first radiation treatment with CyberKnife. He had been feeling more dyspneic for about a month. The day of admission he noted this was getting worse and he required more frequent O2 requirement (all day vs qhs), along with productive cough, lethargy, and increased LE edema. Of note, the patient had taken Ativan prior to his schedule radiation treatment. He had recently recently treated for a URI with a 6 day course of ABX. In the [Name (NI) ], pt received Atrovent/Albuterol nebulizers, Solu-medrol 125mg iv x1, Ceftriaxone/Azithromycin and Kayexalate for hyperkalemia. Patient noted to be somnolent with ABG 7.28/78/86. BiPAP was initiated. Mentation improved with downward adjustment of FiO2. Upon admission to [Hospital Ward Name 332] Intensive Care Unit ([Hospital Unit Name 153]) he was saturation 2L NC. He did not require intubation. In [Name (NI) 153] pt was noted to be volume overloaded by exam with signifcant LE swelling and JVD. Pt was also noted to be in atrial fibrillation by telemetry. CXR notable for new R pleural effusion as well as for previously seen RML mass. He was diuresed with IV lasix and his fluid balance was approximately -700 mL for LOS in [Hospital Unit Name 153]. He was continued on prednisone for presumed COPD exacerbation, and continued empirically on levofloxacin for presumed pneumonia. He reverted to sinus rhythm. On HD3 he was transferred to the floor. By this time he had continued to be mentating appropriately and had been afebrile for 48 h. His oxygen was roughly 93% on 2L. He was somewhat tachypneic but has otherwise been hemodynamically stable. Per pt and wife, they felt his LE edema had gone down. A transthoracic echocardiogram revealed diastolic congestive heart failure. Diuresis was continued first with IV, then with PO lasix. Interventional Pulmonary service was consulted for possible thoracentesis and stenting given his lung cancer. Amt of fluid was found by ultrasound to be too small for thoracentesis and prior bronchoscopy revealed no evidence he would benefit from stenting. The patients respiratory status steadily improved and he was saturating at 97% on 2L by discharge. He was seen by radiation oncology and he was rescheduled for Cyberknife radiation therapyi for his non-small cell lung cancer. Pt was discharged on HD6 afebrile, breathing at his baseline, and hemodynamically stable. He was to complete his seven day course of levofloxacin and one more day of prednisone. He was also to attend Cyberknife therapy 2 days after admission and to follow up with this oncologists, Dr. [Last Name (STitle) 5565] and Dr. [Last Name (STitle) ]. In summmary, this is a 77 yo gentleman with COPD on home O2 and recently diagnosed squamous cell lung cancer who was admitted to intensive care unit with increasing SOB, cough and LE edema, elevated WBC, and a R pleural effusion on CXR. Differential for this presentation includes diastolic CHF, pneumonia, COPD exacerbation, obstruction related to his non-SCLC and oversedation from Ativan. All of these may have factors may have contributed to his respiratory distress, but given his findings of LE edema, increased creatinine, most important factors were likely exacerbation of diastolic CHF and respiratory depression with Ativan. He was successfully treated with diuresis for CHF, antibiotics for possible pneumonia, steroids for CHF exacerbation. He is to follow up for radiation therapy and, possibly, chemotherapy for treatment of his non small cell lung cancer. Issues and plan from this hospitalization: . 1. Dyspnea, pts resp status is now back to baseline. Differential of presentation includes, CHF exacerbation, COPD exacerbation, post-obstructive PNA, CAP, vs progression of lung cancer. - Pt to continue home oxygen - Pt to continue albuterol/atrovent nebulizers - only 1 day of prednisone post discharge for possible COPD exacerbation. He is to start radiation therapy soon and therefore is stopping prednisone day after discharge. - continue Levofloxacin for empiric treatment of PNA for two days, pneumonia appears less likely given hosp course and lack of CXR changes - Supplemental O2 to keep O2 sats >93% - Per IP no indication for stenting, R pleural effusion to small for thoracentesis. - Robitussin, Tessalon pearls as needed for cough . 2. Lung Cancer - scheduled for Cyberknife on [2123-2-5] - to follow up with Dr. [Last Name (STitle) 5565] and Dr. [Last Name (STitle) ] of Oncology, may undergo chemotherapy if radiation therapy tolerated. . 4.Cardiovascular issues: has evidence of diastolic CHF as seen on TTE. A) Perfusion: possible he that has new CHF secondary to ischemic event. -will restart aspirin -continue [Last Name (un) 62443] -pt will need outpt cardiology follow up. B) Pump -Diastolic CHF, impaired relaxation seen on echo -Pt to continue Lasix -volume status appeared euvolemic by discharge and creatinine normalized by discharge C) Rhythm Atrial Fibrillation- Patient rate controlled with diltiazem, initially was a. fib. this admission than converted to sinus after 1x IV 10 mg diltiazem. - continue home regimen of Dilt 120 [Hospital1 ]. . 5. Hyperkalemia- [Month (only) 116] be related to spironolactone. No evidence of EKG changes. - Continue to hold spironolactone . 6. Leukocytosis- most likely [2-25] PNA trended downward but still high. Likely from steroid therapy at this point -continue to monitor. . 7. CRI- Improved by discharge. Creatinine at 1.2, likely renal insufficiency was in part secondary to heart failure. . 8. FEN- cardiac healthy diet. . 9 [Name (NI) ] pt maintained on nicotine patch. Encouraged to quit and prescribed nicotine patches. . 10. Prophylaxis included Heparin SQ, bowel regimen. no h/o GERD. Will start . 11. Communication: wife [Name (NI) ] [Telephone/Fax (1) 62444], [Name2 (NI) ]er [Name (NI) ] [Telephone/Fax (1) 62445]. . 12. Code status remains full. Confirmed with daughter. Medications on Admission: Spironolactone 25mg po qday Cartia XT 120mg po bid Iron 55mg po qday ASA 325mg po qday Albuterol nebs QID Albuterol MDI [Hospital1 ]-qid prn Atrovent MDI [Hospital1 ]-qid prn Home O2 2L qhs Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days. Disp:1 Tablet(s) Refills:0 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q4 (). 4. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:0 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary diagnoses. Diastolic congestive heart failure. Pneumonia. COPD exacerbation. Non small cell lung cancer. Hypercarbic respiratory failure secondary to oversedation with benzodiazepine. Discharge Condition: Good. Breathing back to baseline status with oxygen saturation in 95-97 range on 2L nasal cannula. Able to ambulate. Tolerating heart healthy diet. Discharge Instructions: Please weigh yourself every morning Please limit salt in your diet (2 g daily) Please return to hospital if you develop worsening shortness of breath, increased swelling in hand and feet. Please note we have written a prescription for Lasix 40 mg PO daily, please continue this medication. Do not continue spironolactone or bumetenide until consultation with your doctor Please note you will take levofloxacin for two more days only. Please note you will take prednisone for one more day only. We encourage you to stop smoking, we have provided a nicotine patch prescription if you would like to try. Please do not smoke and use the patch at the same time. Please do not use any benzodiazepine medications including Ativan, Librium, or Valium Please consult your doctor before using any type of sedative medication. Followup Instructions: Please follow up with your oncologists within 2 weeks, Dr. [Last Name (STitle) 5565] and Dr. [Last Name (STitle) ], their number is [Telephone/Fax (1) 62446]. Please keep your appointment with the Radiation Oncology service to undergo your first Cyberknife therapy. Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]; ([Telephone/Fax (1) 62447]. Please make follow up appointment with a cardiologist. You can make an appointment to see the [Hospital1 18] Cardiology service at ([Telephone/Fax (1) 3942].	[ "E932.0", "585.9", "162.4", "518.84", "511.9", "491.21", "600.00", "428.0", "427.31", "486", "276.7", "428.33" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13913, 13968	6325, 12513	333, 399	14204, 14355	3168, 6302	15229, 15823	2719, 2737		12762, 13890		13989, 14183		12539, 12739				14379, 15206						2752, 3149																						274, 295								427, 1903															1925, 2317	2333, 2703
62,722	173,667	36967	Discharge summary	report	Admission Date: [2194-9-27] Discharge Date: [2194-10-1] Date of Birth: [2131-7-17] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1271] Chief Complaint: headache and mild ataxia Major Surgical or Invasive Procedure: [2194-9-29]: Suboccipital Craniotomy and Mass resection History of Present Illness: This is a 63 year old male with chief complaint of headache and ataxia and a history of RCC, who presented with a new metastasis to the cerebellum. The patient was diagnosed with RCC in [2191] and is s/p left nephrectomy. He also has metastatic disease to the lung, s/p IL2 therapy cycle 1 in [2192-7-25] and cycle 2 in [2192-11-25]. He developed an obstructive right upper lobe lesion in [2193-4-25] and is s/p tumor debridement by rigid bronchoscopy and photodynamic therapy, as well as cyberknife to the right upper lobe lesion. . The patient was doing well after that and at the end of last year even traveled to [Location (un) ]. However over the last 2 weeks he developed a headache that was worsening and over the last week it was associated with ataxia especially when in the dark. He reports "bumping into things" and "almost falling over". The patient went to [Hospital ] Hospital at [State 1727] today where a MRI revealed a cerebellar mass with associated shift. He did received Decadron 10 mg IV. He was transferred here for further oncology care. He currently reports already feeling much improved. . In the ED, the neurological exam was benign except for some mild unsteadiness of the gait. Neurosurgery eval was requested due reported mass effect seen on MRI and q4 neuro checks + dexamethasone was recommended. No indication for surgery currently. . Review of Systems: (+) Per HPI as well as bloating and nausea of last few days, now resolved; also + weight loss of 25lbs recently (per patient due to hard physical labor) (-) Review of Systems: GEN: No fever, chills, night sweats. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: [2191-3-26] Left radical nephrectomy; grade II clear cell carcinoma staged as T2NxMx. CT scan showed 6-mm noncalcified nodule in the anterior right middle lobe and a possible second nodule slightly more inferior; bone scan negative; PET CT showed activity in left kidney tumor but no abnormal FDG uptake in the lungs. A single focus of increased activity in the left lobe of the thyroid was noted and a thyroid ultrasound was recommended. [2192-5-25] surveillance CT scan showed multiple new pulmonary nodules and enlargement of previously noted nodules. The largest of the nodules measured 1 cm. Referred for high-dose IL-2 treatment at [Hospital1 18] [2192-6-25] Multiple R lung wedge resections; RML path shows RCC mets [2192-7-25] IL2 Therapy at [Hospital1 18] [2192-11-25] IL2 Therapy [Date range (1) 83379]; [2111-5-15]: chest CT with post-obstructive consolidation, concerning for endobronchial lesion causing obstruction. [2193-6-14]: Flexible bronchoscopy with obstructing RUL endobronchial lesion and nonobstructing RLL endobronchial lesion. [2193-6-17]: rigid bronchoscopy with mechanical and argon plasma coagulation tumor debridement. Biopsy revealed clear cell carcinoma. [2193-7-5]: bronchoscopy and photodynamic therapy to RUL and RLL endobronchial lesions [2193-7-8]: rigid bronchoscopy with mechanical tumor debridement [2193-8-25]: Cyberknife to right upper lobe lesion; [2194-5-10] CT torso with 1. Slight interval increase in size of the dominant right upper lobe nodule with adjacent increased soft tissue density surrounding the right upper lobe bronchus, concerning for new adenopathy versus tumor extension. 2. Increase in size of a nodule along the right middle lobe scar, now measuring 6 x 9 mm, previously barely visible. Stable size of multiple other small pulmonary nodules as described above. Asymptomatic. . Past Medical History: - Arthroscopic repair of the right shoulder and right knee, three years ago. - Spine surgery about 20 years ago. - Hypertension, resolved with weight loss after IL2 Social History: Married, has three healthy sons. Does not smoke, drinks only occasionally. Lives in [Location ], [State 1727], where he works as a farmer. His wife is a school principal. Regular Marijuana consumption Family History: Negative for cancer. Physical Exam: VS: 97.4 155/97 72 18 95RA GEN: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising; extensive callus and cracks on hands Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). Gait WNL. Romberg normal. Tandem gait with instability to both directions Upon discharge: Stable Pertinent Results: Labs: not reported from OSH (records were not brought to the floor from the ED; I called at 4am and asked for them to be courriered over) . Imaging: not reported from OSH (records were not brought to the floor from the ED; I called at 4am and asked for them to be courriered over) [2194-9-29] CT Head: Expected post-op changes. [2194-9-29] MRI Brain with and without contrast: expected postop changes Brief Hospital Course: ASSESSMENT AND PLAN: 63 yo M with metastatic RCC presenting with HA, ataxia and new cerebellar lesion, likely due to metastatic RCC. . # Brain lesion: - continue Dexamethasone 4mg Q6h (RSS and H2blocker with steroids) - will request neurosurgery consult given mass effect - Q4h neuro exam - review OSH records once available - obtain baseline labs as OSH not available . # Nausea resolved; ? due to brain lesion as well vs stress induced vs other - H2blocker while on high dose steroids . # FEN: Regular diet # PPx: - DVT PPx: encourage ambulation; will neeed to consider pneumoboots; no Hep sq given RCC mets in the brain # Access: PIV # Comm: patient # [Name2 (NI) 7092]: FULL # Dispo: pending above On [9-28] the patient was transferred to the [Hospital Ward Name ] to the neurosurgery service. He remained in the PACU overnight in anticipation of surgery in the morning. On [9-29] he underwent a suboccipital craniotomy and resection of left cerebellar mass. Surgery was without complication and he was extubated and transferred to the ICU post op. CT head was obtained which revealed expected post-op changes. He was kept in the Neuro ICU for monitoring. On [9-30] an MRI was done which showed expected postoperative changes. He was transferred to the regular floor and his diet was advanced. Neurooncology and radiation oncology were consulted and he will followup with Dr. [Last Name (STitle) 724] in Brain tumor clinic. He was seen and evaluated by physical therapy who felt that he was safe to return home. At the time of discharge he is tolerating a regulat diet, ambulating without difficuty, afebrile with stable vital signs. Medications on Admission: none Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(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. sod phos,di & mono-K phos mono 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for muscle spasm. Disp:90 Tablet(s) Refills:0 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 6. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every six (6) hours: Take 2 tabs Q6 on [10-1] tabs Q12 hrs on [10-2] and [10-3] then tabe 1 tab Q12 hrs ongoing. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cerebellar lesion Cerebral edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair after your staples are removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days (from your date of surgery) for removal of your staples. This appointment can be made by calling [Telephone/Fax (1) 1272]. ??????You have an appointment in the Brain [Hospital 341] Clinic on :[2194-10-6] 11:30. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. You will see a rdaition specialist at that time. Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2194-10-6] 11:30 [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2194-10-1]	[ "348.5", "198.3", "585.9", "V10.52", "403.90", "197.0" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]	8645, 8651	6108, 7778	334, 396	8728, 8728	5672, 5971	10115, 11063	4944, 4967		7833, 8622		8672, 8707		7804, 7810				8879, 10092						4982, 5629																			2015, 2587			269, 296							5645, 5653	424, 1820		5980, 6085								8743, 8855					4531, 4698	4714, 4928
52,344	169,737	47760+59027	Discharge summary	report+addendum	Admission Date: [2107-12-3] Discharge Date: [2107-12-12] Date of Birth: [2029-1-8] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[Doctor First Name 2080] Chief Complaint: RLE weakness, fever Major Surgical or Invasive Procedure: [2107-12-4] 1. Bilateral T12 laminotomy. 2. Laminectomy, L1, L2. 3. Bilateral L3 laminotomy. 4. Open bone biopsy, deep. [2107-12-12] -PICC placement History of Present Illness: The patient is a 78 yoM with h/o DM2, HTN, CKD (Cr was 2.4 on [2107-11-26] on last admission), CAD s/p MI on [2107-11-26], who presents with 3 days of lumbar back pain and F/C/rigors. The day prior to admission, the patient went to [Hospital1 ] [Location (un) 620] for acute on chronic lower extremity weakness without trauma (he normally uses two canes to ambulate, which is thought to be due to spinal stenosis). He was found to be febrile to 104 with progressive right leg weakness and decreased rectal tone. At [Hospital1 ] [Location (un) 620], C/T/L spine MRI was concerning for epidural abscess though it was a poor quality film as they did not use gadolinium given CRI. He was also found to have a UTI (has a urosomy bag) and was started on vanco/cipro prior to transfer for the UTI, possible leg cellulitis and epidural abscess. He was transferred for surgery evaluation. On admission to [Hospital1 18], [Hospital1 ] [Location (un) 620] called to report he was growing GPC in [3-19] blood culture bottles from [12-2]. . In the ED, he also received acetaminophen x2, zosyn, atorvastatin 80 mg, Carvedilol 25 mg, and isosorbide mononitrate (Extended Release) 30mg. . Of note, on [2107-11-26], he was admitted for c/f STEMI, though ultimately did not have a cath b/c it was felt his case was atypical for STEMI. He was managed medically with asa, plavix 600 mg, heparin gtt, nitro gtt. He subsequently underwent an ECHO with limited views which revealed hypokinesis of the distal septum, apex and distal anterior and inferior walls with an EF of 45% and no prior ECHO for comparison. Patient requested transfer to [Hospital 1268] [Hospital6 ] for insurance issues and was transferred shortly thereafter. Initial TnT was 0.1 and rose to 1.3 prior to transfer. CK rose to 250 with MB 18. It is unclear exactly what happened at [Last Name (un) ] VA and he was discharged on [2107-11-29]. Past Medical History: # Diabetes 20 years, neuropathy, nephropathy, ?charcot foot # Dyslipidemia # HTN # CAD s/p recent MI 6 days ago - h/o silent MI, ?PCI in past # CKD # PMR on prednisone # Bladder CA s/p urostomy # Depression # s/p Appendectomy Social History: Lives alone in [Location (un) ] with his girlfriend. Korean [Name2 (NI) ] veteran. 90 pack year smoking history, quit 40 years ago. Denies tobacco or illicit drug use. Family History: Doesn't know family history Physical Exam: VS on arrival to the ED: T 104.4, BP 214/82, HR 86, 20, 95% on RA VS on arrival to the ICU: T 98.2 (post Tylenol), BP 113/55, HR 63, 20, 94% on RA Gen: elderly man, comfortable in bed HEENT: poor dentition, OP clear, nml sclera NECK: JVD to midneck CV: RR, no m/r/g appreciated LUNGS: CTA b/l, no w/c ABD: somewhat obese, soft, NTND, + BS, no fluid wave; RLW ostomy bag with clean healthy-looking stump EXT: 2+ LE edema NEURO: AAOx3, CN II-XII in tact, 2-3/5 strength on LE b/l, [3-20] strength on upper extremities b/l, 2+ patellar & ankle reflexes b/l symmetric, down-going Babinski, normal sensation on legs throughout DRE: deferrred on arrival to ICU (decreased tone per ED and ortho spine) Pertinent Results: ADMISSION LABS: . [2107-12-2] 10:36PM LACTATE-2.1* [2107-12-2] 10:20PM GLUCOSE-179* UREA N-59* CREAT-2.9* SODIUM-137 POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [2107-12-2] 10:20PM CK(CPK)-110 [2107-12-2] 10:20PM CK-MB-2 cTropnT-0.71* [2107-12-2] 10:20PM CRP-78.8* [2107-12-2] 10:20PM WBC-9.9 RBC-3.58* HGB-10.8* HCT-32.2* MCV-90 MCH-30.3 MCHC-33.7 RDW-16.3* [2107-12-2] 10:20PM NEUTS-84.4* LYMPHS-10.5* MONOS-3.4 EOS-1.4 BASOS-0.3 [2107-12-2] 10:20PM PLT COUNT-149* [2107-12-2] 10:20PM PT-12.8 PTT-30.5 INR(PT)-1.1 [2107-12-2] 10:20PM SED RATE-90* . PERTINENT LABS/STUDIES: . Hct: 27.8 ([12-3]) -> 26.1 ([12-7]) -> 24.7 ([12-12]) INR: 1.2 ESR: 66 CRP: 125.8 Cr: 3.1 ([12-3]) -> 4.8 ([12-7]) -> 3.1 ([12-12]) BUN: 62 -> 71 K: 5.0 ([12-3]) -> 5.6 ([12-12]) . Troponin: 0.70 ([12-3]) -> 0.32 -> 0.30 ([12-5]) . TIBC: 172 Vit B12: 509 Folate: 10.1 Ferritin: 582 TRF: 132 . Vanco trough: 25.8 ([12-12]). . Urine eosinophils: positive ([12-6]) . MICROBIOLOGY: [2107-12-2] 10:20 pm BLOOD CULTURE FINAL REPORT [2107-12-5] Blood Culture, Routine (Final [2107-12-5]): STAPH AUREUS COAG +. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [2107-12-3]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Numeric Identifier 100825] AT 1814 ON [2107-12-3]. Anaerobic Bottle Gram Stain (Final [2107-12-3]): GRAM POSITIVE COCCI IN CLUSTERS. === [12-3], [12-4] No growth blood cultures === [2107-12-3] 1:00 am URINE CULTURE (Final [2107-12-4]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. === [2107-12-7] 12:55 pm URINE CULTURE (Final [2107-12-8]): NO GROWTH. . ADMISSION EKG: sinus @ 71. RBBB. RAD. Inferior QWs. Compared to prior, little diagnostic change. . TRANSTHORACIC ECHOCARDIOGRAM [2107-11-28](@WXVA): Nl RV. Moderating thickened AV w/o AS. Trace AI. Mild MAC. No MS. [Name13 (STitle) ] MR. [First Name (Titles) ] [Last Name (Titles) ]. EF 55%. Moderate concentric LVH. No regional WMA. Grade I diastolic dysfunction. . TRANSTHORACIC ECHOCARDIOGRAM [2107-11-26]: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal septum, apex and distal anterior and inferior walls. Not all of the remaining segments are visualized, but most appear to contract normally (LVEF = 45%). The aortic valve is not well seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. . [2107-12-3] MRI C/T/L SPINE w/o CONTRAST (prelim read): At L1-2, there is moderate spinal stenosis seen secondary to disc and facet degenerative changes. At L2-3, mild-to-moderate spinal stenosis with moderate right subarticular recess narrowing seen. From L3-4 to L5-S1 level, degenerative disc disease and mild bulging identified. No spinal stenosis seen. There is no discitis, osteomyelitis, or epidural abscess. No paraspinal abscess identified. IMPRESSION: Degenerative changes with moderate spinal stenosis at L1-2 and mild-to-moderate spinal stenosis at L2-3 level. No evidence of discitis, osteomyelitis, or epidural abscess. . 12/21 Persantine Stress Test: No anginal symtoms or ischemic ST segment changes. Appropriate hemodynamic response to the Persantine infusion. Nuclear report sent separately. MPRESSION: Normal myocardial perfusion. Moderately enlarged left ventricular cavity size with mild global hypokinesis. Calculated left ventricular ejection fraction is 44%. . [12-6] ECHO TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No 2D echocardiographic evidence of endocarditis. . [12-7] CT Head: 1. Study limited by lack of contrast administration. Within this limitation, no evidence of septic emboli. 2. There is no evidence of acute hemorrhage, edema, large mass, mass effect or infarction. 3. Sequelae of chronic microvascular infarction noted. . [12-7] RENAL ULTRASOUND: FINDINGS: The right kidney measures 12.2 cm. The left kidney measures 11.2 cm. There is no hydronephrosis bilaterally. Although son[Name (NI) 493] penetration is difficult, no obvious renal mass or calculi are seen bilaterally. IMPRESSION: No hydronephrosis . [12-9] LEFT UPPER EXTREMITY ULTRASOUND FINDINGS: Grayscale and Doppler evaluation of left internal jugular, subclavian, axillary, brachial, and basilic veins demonstrate normal compressibility, flow, response to augmentation wherever applicable. The right internal jugular waveforms are demonstrate normal respiratory phasicity and asymmetric. There is an intraluminal thrombus distending the left cephalic vein with lack of compressibility of the left cephalic vein consistent with left cephalic thrombosis. There is no color flow within the thrombosed vein suggesting a nearly occlusive thrombus. IMPRESSION: Nearly occlusive left cephalic vein thrombus. No evidence of deep venous thrombosis in the left upper extremity. . . DISCHARGE LABS: . WBC: 7.9, Hgb 8.2, Hct 24.7, Plt 292 PT 13.6, PTT 36.6, INR: 1.2 Glucose: 102 Na: 142 K: 5.6 Cl: 112 HCO3: 23 BUN: 71 Cr: 3.1 . Vancomycin trough: 24.5 Brief Hospital Course: 78 year old male with sig vascular risk factors, admitted with suspected spontaneous epidural abscess and cauda equina syndrome. #. CAUDA EQUINA SYNDROME: On presentation, the patient clinically had cauda equina syndrome with decreased rectal tone and progressive RLE weakness. MRI on admission did not demonstrate epidural abscess, though it was concerning for epidural lipomatosis, per ortho spine. The patient underwent a laminectomy of T12-L3 on [12-4] for spinal canal stenosis. After discussion with both cardiology and ortho spine, the patient's home dose of ASA was restarted on POD1, given his recent MI. The patient's Plavix was held until [12-11]. Per ortho spine, the patient could continue activity as tolerated. He was seen by PT on [2107-12-12], who recommended discharge to a rehab facility. #. MSSA BACTEREMIA: [3-19] OSH bcx bottles grew GPC; [12-19] aerobic bottle here grew GPC, speciated as MSSA. Patient was initially on Vanc/Zosyn on [2107-12-3] for broad spectrum coverage, and which was subsequently switched to Nafcillin following speciation per ID recs. TTE and TEE showed no evidence of endocarditis. Patient was switched from Nafcillin to Vancomycin due to Allergic Intersitial Nephritis with Renal Failure. His Vancomycin was renally dosed, and troughs were checked daily. The patient should complete a 4 week course of Vancomycin, per infectious disease, which will end [2108-1-3]. The patient's most recent Vancomycin trough on 1000 mg Vancomycin daily was supratherapeutic at 25.5. Thus, we would recommend decreasing this dose to 750 mg and checking a Vancomycin trough on [12-14]. #. UTI: Cx at OSH with > 100,000 E Cloacae, Klebsiella in urine sensitive to ciprofloxacin, has urostomy. Was started on Ciprofloxacin per ID recs on [2107-12-3]. Repeat urine culture was negative. Patient had evidence of delirium, so given negative repeat urine culture ciprofloxacin was stopped after a 3 day antibiotic course and patient was monitored. . #. CAD, native vessel: High risk for surgery given recent medically managed STEMI [2107-11-26]. Was continued on Carvedilol, Imdur, Aspirin. Atorvastatin was initiated. Plavix was held pre-op and was restarted on [12-11]. We continued to hold his Lisinopril, given his CKI, and his Lasix was restarted at 20 mg PO daily on [12-11]. Patient had TTE for pre-op evaluation, and had p-MIBI performed following his procedure, given the fact that he had TWI laterally on EKG (no CP, VSS) the night following his procedure. Cardiac enzymes showed troponin leak and p-MIBI showed normal myocardial perfusion. Troponin leak was felt to be both demand in setting infection, due to increasing renal failure and perhaps resolving enzymes from STEMI. The patient reportedly already has an appointment scheduled with his outpatient cardiologist at the VA. . #. CKD stage IV: unclear baseline although on admission was in the mid-2s and trended up to mid-3's post-op. Urine lytes were sent and revealed allergic interstitial nephritis due to eosinophils and FeNa 1.5%. Naficillin was stopped and patient was transitioned to vancomyin with improvement in renal function. The patient's renal fucntion improved to 3.1 and he was restarted on Lasix 20 mg daily on [12-11]. . #. HTN, benign: The patient had borderline low BPs when started on cardiac meds including beta-blocker & imdur per cards recs pre-op. Amlodipine, Lasix, and Lisinopril were held for surgery. He then became hypertensive to SBPs of 180s on [12-10] and [12-11]. Lasix was restarted on [12-11] and Amlodipine was restarted on [12-12]. His Lisinopril was held given his CKI. . #. SUPERFICIAL LEFT UPPER EXTREMITY CLOT: The patient developed swelling of his left arm on [11-30] in the setting of refusing SC heparin. LUE U/S demonstrated nearly occlusive left cephalic vein thrombosis but no evidence of DVT. He agreed to SC heparin and was restarted on his home dose of Plavix, warm compresses, and left arm elevation. . #. Altered Mental Status: Post-operative patient developed waxing and [Doctor Last Name 688] mental status attributed to multifactorial delirium: post-operative, bacteremia, urinary tract infection, pain management with morphine post-operatively, elderly. CT head showed no acute event. No other infections identified. Patient's opioids, ambien and ciprofloxacin were stopped with improvement in patient's mental status. At discharge the patient was alert and oriented x3. . #. ANEMIA of CHRONIC DISEASE: HCT 32 on admission. Given 2 units pRBCs [12-3] prior to surgery. Patient HCT was lower post surgery at HCT 24-27. Slight drift downward attributed to poor nutrition with delirium and blood draws. Iron and B12, Folate studies revealed anemia of chronic disease. The patient's Hct on discharge was 24.7. . #. PMR: Has h/o PMR and is on chronic prednisone. Checked with ID - no need for prophylaxis as dose not high enough. Continued Prednisone #. DM2, poorly controlled with complications: Glargine/ HISS, follow BGs . #. NEUROPATHIC PAIN: The patient was continued on his home dose of Gabapentin 600mg QHS . #. DEPRESSION: The patient was continued on his home doses of Venlafaxine and Citalopram #. FEN/PPx: The patient was maintained on a cardiac, diabetic diet. He refused sc heparin until [12-10] when told about the superficial upper extremity clot, then agreed to sc heparin. The patient was FULL CODE during this admission. #. COMMUNICATION: Patient and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 100826] [Telephone/Fax (1) 100827] Medications on Admission: HOME MEDICATIONS (per cards per recent d/c paperwork at WXVA): prednisone 7.5mg daily amlodipine 10mg daily gabapentin 600mg qhs carvedilol 12.5 mg [Hospital1 ] lasix 20mg daily insulin NPH 12units qAM, 12units qPM citalopram 20 mg daily plavix 75 mg daily asa 81 mg daily Imdur 30 mg daily lisinopril 5 mg daily simvastatin 40 mg daily venlafaxine 75 mg qam, 150 mg qpm Discharge Medications: 1. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO qam. 15. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO qPM. 16. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 19. Vancomycin 1g based on level Discharge Disposition: Extended Care Facility: [Location 1268] VA Discharge Diagnosis: Cauda equina syndrome, MSSA bacteremia, UTI, acute on chronic kidney injury Secondary diagnoses: -CAD s/p STEMI [2107-11-26] (medically managed) -IDDM -dyslipidemia -HTN -CKI -polymyalgia rheumatica -bladder cancer s/p urostomy -depression Discharge Condition: Mental Status:Clear and coherent, sometimes confused Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to [Hospital1 ] Hospital for evaluation of lower back pain associated with fevers, chills, and rigors. You were diagnosed with cauda equina syndrome which occurs when there is compression of your spinal cord. In order to relieve the compression, you required an operation called a laminectomy which you tolerated well. You were also found to have an infection in your blood with a bacteria called MSSA. You were treated with nafcillin, which unfortunately worsened your kidney function due to a process called allergic interstitial nephritis. Luckily, your kidney function returned to its baseline when this medication was stopped and replaced with vancomycin. You will require a total of 4 weeks of treatment with vancomycin and for that reason, a more permanent IV called a PICC was placed before your discharge to the VA. You also developed a urinary tract infection which responded well to treatment with ciprofloxacin. The following changes have been made to your home medications: - Your home carvedilol dose has been increased to 25mg twice daily - Your home lisinopril dose has been held for now and may be restarted at the discretion of the VA - Your home simvastatin was changed to Lipitor 80mg daily - You were started on Senna, docusate, and Miralax to help move your bowels - You will use Tylenol as needed for your pain Please follow-up with all of your outpatient medical appointments listed below. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below: 1. Infectious disease, Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2108-1-6] 9:00 2. Ortho/Spine, Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007], MD (Orthopedics). Date/Time: [2108-1-25] at 1:30 PM. Location: [Hospital Ward Name 23] [Location (un) ]. 3. Please follow-up with your previously scheduled VA kidney, VA cardiologist, and VA primary care physician. Name: [Known lastname 16192],[Known firstname 126] Unit No: [Numeric Identifier 16193] Admission Date: [2107-12-3] Discharge Date: [2107-12-12] Date of Birth: [2029-1-8] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[Doctor First Name 1299] Addendum: The patient should actually continue on vancomycin IV until he follows up in [Hospital ] clinic on [1-6] at which point the decision will be made to continue or stop the antibiotic course. Discharge Disposition: Extended Care Facility: [Location 205] VA [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1300] MD [MD Number(2) 1301] Completed by:[2107-12-12]	[ "272.4", "713.5", "725", "344.60", "722.52", "995.92", "428.0", "250.40", "293.0", "311", "403.10", "250.60", "276.7", "250.50", "584.9", "357.2", "599.0", "451.82", "428.32", "038.11", "412", "580.89", "V58.65", "214.8", "362.01", "410.92", "414.01", "V44.50", "V10.51", "585.4" ]	icd9cm	[ [ [] ] ]	[ "03.09", "38.93", "77.49", "88.72" ]	icd9pcs	[ [ [] ] ]	21153, 21359	10467, 14521	291, 450	18346, 18346	3662, 3662	20003, 21130	2899, 2928		16524, 17985		18078, 18155		16125, 16501				18536, 19533		10288, 10444				2943, 3643			18176, 18325		19551, 19980																	232, 253								478, 2441		8989, 10272				3678, 8980				18360, 18512					2463, 2690	2706, 2883
24,712	185,749	2430	Discharge summary	report	Admission Date: [2142-3-6] Discharge Date: [2142-4-27] Date of Birth: [2100-9-5] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: He is a 41-year-old, with history of HIV. CD-4 was 238 in [12-20]. Hepatitis B virus, end stage liver disease. He was awaiting hepatorenal transplant. Prior to admission, he had a three day history of fever. He was recently discharged to home. He did well for 5 days prior to the current admission. The patient's partner noticed that the patient was complaining of feeling hot and took his temperature and found to have a temperature of 101.0 orally and for that reason subsequently asked for admission. The patient was brought in. He denied abdominal pain, shortness of breath, chest pain, nausea or vomiting. He denied URI symptoms. He did report that he was recently admitted for feeding tube placement and post pyloric and had admission to the ICU after the patient then developed fevers and hypotension following a therapeutic paracentesis, requiring volume resuscitation. At that point in time, no source was discovered and the patient remained afebrile, off of antibiotics but then returned for the current admission. PAST MEDICAL HISTORY: Significant for HIV, hepatitis B, end stage liver disease, chronic renal insufficiency, anemia, neuropathy. The patient had a tonsillectomy in the past. He has had multiple paracentesis in the past. He has pulmonary hypertension and heart murmur. He works in real-estate, smokes 2 to 3 cigarettes per day, 25 pack year history. No ETOH. No drugs. He is from [Country 4194] and lives with his partner. FAMILY HISTORY: Significant for a mom with diabetes. PHYSICAL EXAMINATION ON ADMISSION: According to medical intern, temperature was 97.7, blood pressure 118/70, pulse 74, rate 20, 97 percent on room air. Pupils equal, round, reactive to light, anicteric. Oropharynx was clear. No cervical lymphadenopathy. Regular S1-S2. 2 out of 6 systolic ejection murmur, loudest at the apex. Lungs: Clear to auscultation bilaterally. Positive distention, positive fluid wave. Positive shifting dullness on the abdominal examination. Trace lower extremity edema. White count was 4.7, hematocrit was 24. Platelets were 58 on admission. Sodium 137 over 5.3, 104 over 23, 70 over 3.9, blood sugar of 139. Calcium, mag and phos were 7.6, 3.9 and 5.8 respectively. Peritoneal fluid ascites was 50. Active issues were a fever of unclear etiology, acute on chronic renal failure, hyperkalemia, end-stage liver disease, anemia, HIV on heart, FEN. Those were his active issues upon admission. The patient was admitted to the medical service, after a paracentesis. Renal service was consulted for acute on chronic renal failure. Peritoneal fluid was sent multiple times. Echocardiogram was performed. No evidence of endocarditis was noted. The patient continued to have fevers and was treated for peritonitis. The patient remained on the medical service and on the Friday before discharge, he was transferred to the surgical service because there were nursing issues on the floor as to being able to have the level of care the patient was requiring. Therefore, the patient was transferred to surgical ICU and transferred services from the medical service to the surgical ICU team and followed by the transplant team as per the rule that pretransplant patient's were transferred from medical service over to surgical service. At that point in time was the first time that I had begun to take care of this patient and on initial examination he was somebody who obviously had suffered from longstanding liver disease and had extensive ascites, requiring tap every 48 hours in order for patient's comfort. His bilirubin hovered around the rate of 63 and he was quite icteric. The patient was then admitted to the surgical ICU in anticipation of potential liver, kidney donation and subsequent transplantation. By systems, the patient was neurologically intact. Conversationally confused at times but was definitely cohesive in his thoughts and understood and was oriented to time, place and person. Pulmonary: The patient had coarse breath sounds at the bases and was actually doing quite well from a pulmonary perspective. From a cardiovascular perspective, the murmur had been noted and echocardiogram had previously been worked up in order to evaluate this patient. All of that was found to be within normal limits and the patient's pulmonary hypertension was once again reestablished. However, the patient did not suffer any abnormal rhythms during his stay in the ICU nor did he manifest any cardiac disease. From a GI perspective, the patient was on tube feeds at goal, meeting goal protein needs. However, he had the ability to reaccumulate fluid and was in a cycle where he needed to be tapped at least q. 48 to 72 hours requiring potentially 5 liters of fluid to be taken off as ascites. His LFTs were consistent with end-stage liver disease with his bilirubin hovering in the mid 60 range. From a GU perspective, the patient made minimal urine and had a Foley catheter that was placed and was able to irrigate the bladder out with Amphotericin for fungal infection of the bladder. This was carried out for several days and this was then stopped. The patient remained in the surgical service for approximately 3 days while waiting potential liver and renal transplant. He was evaluated by all of the transplant service on a continual basis and extensive discussions were taken with family and with Dr. [Last Name (STitle) 497] and his team. The transplant attendings rounded on the patient and decided that he was a poor candidate for surgery. At this point in time, the patient was delisted and the family members decided that the patient would be discharged to home and he was discharged to home/hospice care. He was deemed unfortunately, not a suitable candidate for transplant. Therefore, the patient was discharged in tenuous condition with end-stage liver disease, end-stage renal disease, in need of a transplant. However, he was unfortunately to ill to be transplanted. Therefore, he was discharged to hospice. The patient was discharged on [2142-4-27] to home in tenuous condition. DISCHARGE DIAGNOSES: 1. End-stage liver disease, subsequent to hepatitis B. 2. Advanced HIV. 3. Chronic renal insufficiency. 4. Acute renal failure. 5. Anemia. 6. Neuropathy. 7. Pulmonary hypertension. 8. Hepatorenal syndrome. 9. Cachexia. 10. Hyperkalemia. 11. Coagulopathy. 12. Failure to thrive. 13. Ascites. 14. History of bleeding esophageal varices. 15. History of bleeding rectal varices. The patient was discharged to home. Subsequently, the patient by report passed away several days after discharge to home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD [MD Number(2) 12497] Dictated By:[Last Name (NamePattern1) 7823] MEDQUIST36 D: [2142-4-30] 11:50:17 T: [2142-5-2] 20:35:22 Job#: [Job Number 12498]	[ "599.0", "585", "070.30", "372.00", "785.6", "572.2", "112.2", "416.8", "455.6", "E879.8", "285.29", "995.91", "996.75", "584.9", "284.8", "078.19", "569.3", "572.3", "042", "571.1", "571.5", "511.9", "038.9", "459.81", "041.4", "286.6", "482.82", "567.2", "456.0", "572.8", "355.9", "286.9", "466.0" ]	icd9cm	[ [ [] ] ]	[ "45.25", "99.07", "40.24", "41.31", "38.95", "45.13", "39.95", "33.24", "99.04", "45.16", "54.91" ]	icd9pcs	[ [ [] ] ]							1673, 1732	6293, 7092																																													181, 1220								1747, 6272							1243, 1656
7,310	148,664	2141	Discharge summary	report	Admission Date: [2173-9-14] Discharge Date: [2173-9-14] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Ativan Attending:[Last Name (NamePattern4) 290] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: This is an 87 year-old female with a history of metastatic non-small cell lung cancer on hospice brought in by her family for altered mental status. Patient unable to give me any information regarding her symptoms. She was able to shake her head that she was not in any pain. Family is divided in the type of care they think their mother should receive. I spoke with the HCP, [Name (NI) 717], who is the patient's daughter. She confirmed that her mother would not want to be intubated or rescusitated. She reports that over the last week she has been more lethargic. She is mostly sedentary and has not walked in the last week but was previously walking. She was noted to have a fever friday and the son was concerned that she was developing a pna. Per pcp notes, plan was to have her come into the office if possible for an xray. No sob, cough or increased oxygen requirement. Pt is on 2 liters nc at home. She was noted to have no appetite and was barely eating. Her family gave her solids yesterday and she had an incident of coughing/choking with that per HCP. HCP left her mother the night of admission and reports she was sleeping comfortably. Her other daughter and son came over and thought the patient looked worse and brought her into the ED. She was also just started on thorazine for "terminal agitation". It was making her very lethargic so the dose was decreased from 50 mg tid to 25 mg tid. Last dose just prior to coming to the ED. Pt on fentanyl 200 mcg q 72 and oxyfast at her usual doses. Past Medical History: Squamous cell lung carcinoma, s/p resection in 10/[2171]. No chemotherapy or radiation. Marginal Zone Lymphoma, s/p fludarabine and rituxan in [2168]-[2169] Auto-immune hemolytic anemia dx [6-20]. S/p splenectomy [12-21] GERD COPD (emphysema) Osteopenia Oral HSV H/o asbestos exposure with bilateral calcified pleural plaques History of DVT S/p cholescystectomy H/o Pulmonary mycobacterium kansasii infection Social History: Tobacco: smoked 1ppd x 50 years, quit [2152]. Occasional etoh. No illicit drugs. Widowed, lives alone. Has 6 children, 23 grandkids. Family History: Son: throat cancer Mother: colon cancer Father: unknown cancer Physical Exam: Vitals: T 96, 112/60, 129, RR 26, O2 sat 86% 100% NRB GEN: frail, lethargic, tacchypneic, pale HEENT: NCAT, EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MM dry, OP Clear NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RR, tacchycardic, no M/G/R, normal S1 S2, radial pulses +2 PULM: diffuse exp wheezing throughout, decreased at right base ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: moving all extremities, follows command to squeeze my hands but not to move feet, unable to assess cranial nerves, DTRs +1 throughout, negative babinski. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2173-9-14] 06:34AM BLOOD WBC-9.5 RBC-3.26* Hgb-11.4* Hct-35.0* MCV-108* MCH-34.9* MCHC-32.5 RDW-11.8 Plt Ct-116* [2173-9-14] 06:34AM BLOOD Neuts-64 Bands-29* Lymphs-1* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-1* [2173-9-14] 06:34AM BLOOD PT-17.1* PTT-29.9 INR(PT)-1.5* [2173-9-14] 06:34AM BLOOD Ret Aut-1.1* [2173-9-14] 06:34AM BLOOD Glucose-117* UreaN-58* Creat-0.7 Na-147* K-3.6 Cl-115* HCO3-23 AnGap-13 [2173-9-14] 06:34AM BLOOD Albumin-2.5* Calcium-7.7* Phos-3.2 Mg-1.9 [2173-9-14] 06:34AM BLOOD Hapto-289* [2173-9-14] 06:46AM BLOOD Type-ART Temp-35.7 FiO2-100 pO2-55* pCO2-49* pH-7.32* calTCO2-26 Base XS--1 AADO2-611 REQ O2-99 Intubat-NOT INTUBA Comment-NON-REBREA [2173-9-14] 03:47AM BLOOD Lactate-1.5 [2173-9-14] 12:29AM BLOOD Lactate-2.2* CXR: Interval increase in right pleural effusion. Right lower lobe opacity is likely due to pneumonic consolidation. Asymmetric interstitial prominence probably due to edema. CTH: No evidence of acute intracranial abnormalities. No change from [2173-4-30]. Please note that MRI with gadolinium would be significantly more sensitive for metastatic disease. Brief Hospital Course: Mrs. [Known lastname 11480] is an 87 year-old female with a history of metastatic non-small cell lung cancer on hospice who presents with altered mental status, fever, and leukocytosis likely secondary to aspiration pneumonia. Patient was DNR/DNI on admission, and intially received IV antibiotics and NIPPV while goals of care were discussed with family. After discussion with her family, the patient was transitioned to NRB. Patient became progressively hypotensive and hypoxic and expired shortly thereafter. 1.Altered mental status: Patient has underlying vascular dementia. Given her fever and tacchycardia with CXR demonstrating a focal infiltrate, likely secondary to pneumonia. Other possibilities include medications including her narcotics but patient did not respond to narcan or thorazine which was just started this week. Pt is also volume depleted which can contribute. Head CT negative for midline shift, hemorrhage or metastatic disease. Neuro exam not suggestive of acute stroke. No e/o seizure. Hypercarbia is only mild. Patient was started on clindamycin and levofloxacin for presumed aspiration pneumonia. Patient was also initially provided with NIPPV, which was transitioned to a NRB upon discussion with her family. 2. Sepsis: Patient meets SIRS criteria with fever, tacchycardia, and hypotension. Likely source was penumonia. CXR concerning for worsening pleural effusion/infiltrate on right side. Patient given levoflxoacin and clindamycin presumed aspiration pna given her mental status. She was also aggresively volume repleted. 3. Hypoxia: Patient uses supplemental oxygen at home due to her underlying lung disease (lung cancer and copd). Likely worse in setting of pneumonia. Received systemic steroids and nebulizers doing hospitalization. 4. Acute renal failure: In setting of infection and poor oral intake, likely pre-renal. This is further supported by elevated BUN and hematocrit well above her baseline. Patient received aggresive fluid rescucitation during admission. 5. History of marginal zone lymphoma treated with fludarabine/Rituxan [2168]-[2169]. No active issues at this time. 6. History of hemolytic anemia status post splenectomy in [2171]. Per notes, vaccine status unclear. 7. COPD: Treated with atrovent and albuterol nebs as well as systemic steroids. 8. GERD: Continued on PPI during admission. 9. PPx: Patient received heparin SQ and PPI during admission. 10. Code status: Patient on presentation was DNR/DNI. Family expressed clear wishes that patient was not to be intubated and that central access, other invasive procedure, or pressors were not to be initiated. Medications on Admission: thorazine 25 mg tid oxyfast 25-50 mg prn fentanyl 200 mcg q72 hrs vitamin d 400 IU [Hospital1 ] folic acid 1 mg qd senna colace bisacodyl omeprazole 20 mg qd Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2173-9-14]	[ "584.9", "V10.79", "492.8", "799.02", "V10.11", "995.92", "507.0", "038.9", "530.81", "198.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7305, 7314	4409, 4937	280, 286	7366, 7376	3228, 4386	7433, 7608	2454, 2518		7272, 7282		7335, 7345		7086, 7249				7400, 7410						2533, 3209																						219, 242								314, 1827										4952, 7060					1849, 2283	2299, 2438
27,394	174,983	34293	Discharge summary	report	Admission Date: [2101-7-17] Discharge Date: [2101-7-20] Date of Birth: [2079-6-6] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: s/p motor vehicle collision Major Surgical or Invasive Procedure: [7-17]: 1. Exploratory laparotomy. 2. Packing of liver. 3. Diagnostic peritoneal lavage. 4. Right femoral vein cordis catheter. [7-18]: 1. Left hemicraniectomy. 2. Placement of right ICP monitor. 3. Abdominal wound exploration 4. Placement of Kentuck patch silastic abdominal dressing History of Present Illness: This patient is a 22 year old female who was on her way home from a [Doctor Last Name ] concert on the night of [2101-7-17] when she was involved in a motor vehicle [Last Name (un) 8886]. She was ejected from the vehicle and found 70 feet away in a tree. In the scene, she had a GCS of 3 with fixed and dilated pupils. She was emergently transported to [Hospital1 18] via helicopter for continued care. Past Medical History: None Social History: The patient works as a PCA at [Hospital 24759] Rehab. (+) h/o ETOH use, unknown history of tobacco or drug use. Family History: Unknown Physical Exam: VS: HR 58 BP 150/50 -> 80/P RR 18 SpO2 100% on ventillator PE: Neuro: GCS 3, pupils 5mm fixed and dilated bilaterally, (+) decorticate posturing HEENT: (+) blood in right ear CV: RRR Lungs: Coarse breath sounds bilaterally Abdomen: Unable to assess Pelvis: Stable FAST: (-) in trauma bay DPL: Grossly positive for blood in trauma bay Brief Hospital Course: The patient was brought to the [Hospital1 18] via [Location (un) ] on [7-17]. On arrival she was noted to be hypotensive, which initially responded to crystalloid and then 5 units of packed blood. Given ongoing hypotension, a diagnostic peritoneal lavage was performed and found to be grossly positive. A right femoral vein central venous catheter was placed for access and the patient was then transferred to the operating room for surgical treatment. Intraoperatively, the patient was found to have massive hemoperitoneum with extensive fracture of the right liver. An intracranial monitoring device was also placed for ICP monitoring. Following this, the patient's abdomen was left open with packs placed to control bleeding. A sterile dressing was placed over the open abdomen, and the patient was transported to the trauma ICU in critical condition. The remainder of the discharge summary will be dictated by system. Neuro: The patient was kept intubated and sedated following initial surgery with close monitoring of the ICP. She was also kept on pressor to maintain a CPP of 60-70. ICPs remained labile for the initial 24 hours of the patient's postoperative course, and were noted to be as high as 44 on occasion. IV mannitol was initiated and serum osmolality was closely followed to direct therapy, and the patient was taken for an emergent left frontal craniectomy on [7-18]. Post-craniectomy, ICPs were noted to be stable, Following stabilization, a CT of the c-spine demonstrated a buckle fracture of C4. She was left in a cervical collar for traction. On [7-18], the patient was noted to have some movement of the right upper and left lower extremities though there were not noted again. Pupillary reflexes were noted to be briskly present until the morning of [7-20], when the pupils were suddely noted to be fixed and dilated. An emergent CT head was performed, which showed slight re-expansion of the third ventricles and lateral ventricles compared to prior examination. No new areas of hemorrhage were identified, nor was there evidence for herniation. There was noted persistence of diffuse cerebral edema as well as hemorrhagic contusions. In addition, a brain perfusion scan did not show any signs of a lack of blood flow. Despite these findings, the patient remained nurologically unresponsive with fixed and dilated pupils. After a family meeting was held and the family was appraised of the patient's grim prognosis, a change in the code status was made to comfort measures only. Cardiovascular: The patient was kept on vasopressor for 72 hours after admission and slowly weaned to keep CPP>60. The patient's blood pressure remained stable until a brief period of the morning of [7-20] when her blood pressure dipped to a SBP of 90. This was in close proximity in time to the acute change in mental status. Following this, vasopressor was restarted and maintained until the patient's code status was changed and the patient was declared deceased. Pulmonary: The patient was maintained on a ventillator for the duration of the hospital stay. The patient's oxygenation and ventillation was adequate until the code status was readdressed on [7-20]. GI: The patient had a fractured liver secondary to her injuries. Nasoenteric suctioning was maintained to provide for decompression of the bowel for the duration of the hospital course. Following the initial surgery on [7-17], the patient was taken back to the operating room on [7-18]. At the time of reoperation, there was seen to be no active bleeding from the liver desipte severe damage being noted to the parenchyma. The gastrointestinal tract was run from the ligament of Treitz all the way around to the peritoneal reflection and no hollow viscus injury was encountered. The spleen was likewise examined and there was no splenic laceration evident. A silastic [State 19827] patch was placed over the abdomen, as the fascia was not able to be re-approximated. GU: The patient developed neurogenic diabetes insipidus acutely after injury, which corrected on hospital day #2. The urine output remained adequate throughout the hospital course. Heme: The patient's hematocrit remained stable after initial resuscitation. The white blood cell count declined slowly from 12.3 on [7-18] to 3.6 on [7-19] and finally 1.6 on [7-20]. Platelet count also declined slowly from 127k on [7-17] to 67k on [7-20]. A HIT panel was sent and was pending at the time of death. ID: The patient was started on IV Ancef for prophylaxis after bolt placement. Wound swabs taken on [7-18] were found to be negative. Medications on Admission: Unknown Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiac death after declaration of CMO status Traumatic brain injury Loss of cortical function Traumatic liver injury Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None	[ "807.09", "348.5", "868.03", "801.25", "E812.0", "805.04", "958.4", "864.04" ]	icd9cm	[ [ [] ] ]	[ "01.25", "01.10", "54.11", "54.25", "96.71", "54.63", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	6373, 6382	1649, 6286	341, 636	6544, 6554		6607, 6614	1261, 1270		6344, 6350		6403, 6523		6312, 6321				6578, 6584						1285, 1626																						274, 303								664, 1084															1106, 1112	1128, 1245
75,251	101,864	37527	Discharge summary	report	Admission Date: [2189-11-20] Discharge Date: [2189-11-30] Date of Birth: [2114-4-27] Sex: M Service: MEDICINE Allergies: Levaquin / Shellfish Derived / Latex / Aranesp Attending:[First Name3 (LF) 9002] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Lumbar Puncture Paracentesis History of Present Illness: 75 yo M hx CAD s/p NSTEMI, a. fib not on Coumadin with 1 day hx generalized fatigue, weakness, poor PO, decreased UOP. Patient was in his USOF on Weds when he saw his new PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. On [Holiday ] Eve, his daughter brought him to dinner at her house and noticed that after walking down the stairs that he was having difficulty walking. His daughter also notes that he just seemed "off" that night. He did not sleep well that night, and today he felt lethargic, but otherwise denied fevers, abdominal pain, dysuria, headaches, neck pain and diarrhea. Decreased urine output was noted today. In the ED, patient's altered mental status improved and he did not receive CT head. CXR revealed pleural effusions but no obvious consolidation. FAST was positive for fluid in ruq and luq. Troponin was elevated but consistent with prior falues. EKG was paced without ischemic changes. UA was clean. Saturating was 80% according to EMS, but 100% on 4 l in the ED. He was hypotensive to the 80s/50s in the ED and responded to 3 L NS. Cardiology was consulted and advised Medicine bed. When bed was assigned, patient became hypotensive with MAP of 58. He was initially started on dobutamine which was later transitioned to levphed. He received Vanco and Zosyn in the ED. He has had 2 recent hospital stays this month. The first at [Hospital1 18] was from [10-29] through [11-4] was for NSTEMI which was felt to be related to demand ischemia in the setting of afib with RVR. He was not started on anticoagulation given prior GI bleeding. Failure to thrive workup was not pursued given that he had a recent colonoscopy/egd, CT head and chest at [Hospital 6451] hospital within the past year. The second hospital stay was from [11-6] to [11-8] for hypotension in the setting poor po intake. He was thought to have food poisoning. Po intake improved with zofran and fluids. The patient's hypotension was not symptomatic, wht SBP ranging from 90 to 100. Right pleural effusion was noted in the setting of smoking history, and thoracentesis was deferred until patient could follow up as an outpatient. In the ICU, Mr. [Known lastname 64592] is feeling well and has no specific complaints. He says that his neck feels stiff but that this is chronic. He has [Last Name ] problem with neck ROM. ROS was otherwise essentially negative. The pt denied recent fevers, night sweats, chills, headaches, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: 1) CAD (cath in [2161] showed 3-vessel disease, patient states he had MI [09] years ago), presented with NSTEMI believed to be secondary to demand 2) Atrial fibrillation (not on Coumadin given h/o GI bleeding) 3) [Company 1543] Kappa KDR701 dual-chamber placement 4) Cirrhosis (classified as cryptogenic although patient has history of heavy EtOH use 35 years ago) 5) chronic kidney disease with baseline Cr 2.7 6) angiodysplasia of stomach and small intestine with serial endoscopic cauterization ([2186]) 7) GI bleeding chronic anemia (multifactorial, thought to be [12-29] kidney disease + GI bleeding) 8) prior TIA ([4-3], ? [8-5]) 9) melanoma, right forearm 10) multiple BCCs 11) Diverticulosis 12) Colon polyps 13) Left carotid stenosis with stent ([2184]) 14) BPH ([3-4]) 15) Gout 16) Pneumonia ([12-3]) 17) portal gastropathy 18) low grade esophageal varices 19) remote appendectomy Social History: Lives independently, across the street from daughter. Smoked 1.5 packs/day x 15 years, quitting 35 years ago. Former heavy EtOH use, sober x 35 years. No drugs. Pt previously worked as a letter carrier for the United States Postal Service. Family History: Notable for MI. Both parents lived to be >[Age over 90 ] years old. Physical Exam: Vitals: T: 92.1 BP: 132/98 P: 76 R: 20 SaO2: 100% RA General: Awake, alert, NAD, Oriented x3 HEENT: NCAT, PERRL, EOMI, pale conjunctivae, no scleral icterus, MMM, no lesions noted in OP Neck: supple, JVP at clavicle Pulmonary: decreased breath sounds at right base, otherwise CTA Cardiac: distant HS, RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted, no shifting dullness Extremities: 1+ RLE edema, no LLE edema Skin: mild erythema at left foot Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. [3-1] quadriceps and gastroc bilaterally. Grip [3-31]. Sensation intact to gross tough throughout. Pertinent Results: [2189-11-24] 04:41AM BLOOD WBC-7.2 RBC-2.28* Hgb-8.1* Hct-24.8* MCV-109* MCH-35.6* MCHC-32.6 RDW-19.0* Plt Ct-52* [2189-11-20] 04:40PM BLOOD WBC-2.5* RBC-2.84* Hgb-9.6* Hct-31.1* MCV-110* MCH-33.9* MCHC-30.9* RDW-18.4* Plt Ct-77* [2189-11-24] 04:41AM BLOOD Neuts-94.4* Lymphs-3.9* Monos-1.6* Eos-0.1 Baso-0 [2189-11-20] 04:40PM BLOOD Neuts-73.6* Lymphs-15.3* Monos-8.8 Eos-1.9 Baso-0.3 [2189-11-24] 04:41AM BLOOD Plt Ct-52* [2189-11-24] 04:41AM BLOOD PT-15.3* PTT-44.7* INR(PT)-1.3* [2189-11-20] 04:40PM BLOOD PT-13.4 PTT-45.2* INR(PT)-1.1 [2189-11-24] 04:49PM BLOOD Glucose-168* UreaN-86* Creat-3.2* Na-147* K-3.2* Cl-119* HCO3-16* AnGap-15 [2189-11-24] 04:41AM BLOOD Glucose-110* UreaN-85* Creat-3.5* Na-148* K-3.5 Cl-118* HCO3-16* AnGap-18 [2189-11-20] 04:40PM BLOOD Glucose-110* UreaN-82* Creat-3.1* Na-142 K-4.6 Cl-111* HCO3-20* AnGap-16 [2189-11-23] 04:09AM BLOOD ALT-54* AST-48* LD(LDH)-271* AlkPhos-170* TotBili-0.9 [2189-11-21] 02:42AM BLOOD ALT-68* AST-74* LD(LDH)-282* CK(CPK)-72 AlkPhos-241* TotBili-1.0 DirBili-0.5* IndBili-0.5 [2189-11-21] 02:42AM BLOOD CK-MB-NotDone cTropnT-0.30* [2189-11-20] 11:33PM BLOOD CK-MB-NotDone cTropnT-0.28* [2189-11-20] 04:40PM BLOOD cTropnT-0.32* [2189-11-24] 04:41AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3 UricAcd-8.4* [2189-11-23] 04:09AM BLOOD Albumin-3.1* Calcium-8.8 Phos-4.7* Mg-2.1 [2189-11-21] 09:11AM BLOOD Ammonia-75* [2189-11-20] 11:33PM BLOOD TSH-15* [2189-11-21] 02:42AM BLOOD T4-5.3 [2189-11-20] 04:40PM BLOOD CRP-33.4* [2189-11-21] 03:36PM BLOOD Cortsol-19.3 [2189-11-22] 05:12PM BLOOD HIV Ab-NEGATIVE [2189-11-24] 04:41AM BLOOD Vanco-24.8* [2189-11-22] 03:27AM BLOOD Vanco-8.3* [2189-11-22] 03:38AM BLOOD Type-ART Temp-36.1 pO2-168* pCO2-27* pH-7.38 calTCO2-17* Base XS--7 [2189-11-20] 09:58PM BLOOD Type-ART Temp-32.7 FiO2-21 O2 Flow-15 pO2-511* pCO2-27* pH-7.40 calTCO2-17* Base XS--5 Intubat-NOT INTUBA Comment-NON-REBREA [2189-11-20] 09:58PM BLOOD Glucose-105 Lactate-0.9 Na-140 K-4.4 Cl-116* calHCO3-17* [2189-11-21] 09:55AM BLOOD O2 Sat-68 [2189-11-24] RENAL ULTRASOUND: Small echogenic right kidney, with normal-appearing left kidney. No hydronephrosis. ULTRASOUND (ABD) [2189-11-22]: Moderate ascites with appropriate spot for paracentesis marked in the right lower quadrant. [2189-11-23] LENI: No evidence of DVT in bilateral lower extremity. [2189-11-21] CT HEAD W/O CONTRAST: No acute intracranial hemorrhage or mass effect. Hypodense white matter changes- current CT is significantly limtied due to motion. Pt. appears to have pacemaker on concurrent PXR Chest, whick precludes MR study. Hence, a close follow up with motion elimination when the pt. is cooperative, can be onsidered for better assessment for any intracranial abnormality. [2189-11-25]: ECHO - The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2189-10-30], there is no significant change. As noted in the prior study, there is evidence of plaque in the descending thoracic aorta. [2189-11-26]: Duplex/Doppler Hepatic US - FINDINGS: The liver is shrunken and has a coarse echotexture and an irregular outline in keeping with liver cirrhosis. No focal liver lesions are seen. There is extensive ascites, and a right-sided pleural effusion. The common bile duct is not dilated, and there is no intrahepatic bile duct dilatation. The main portal vein, left, and right portal veins are patent with hepatopetal flow. The main, right, and left hepatic veins are patent. The IVC is patent and demonstrates normal flow. The gallbladder contains gallstones, however, there is no evidence of acute cholecystitis. The spleen measures 9.8 cm longitudinally, and there is no focal abnormalities. Brief Hospital Course: # Systemic Inflammatory Response Syndrome: No obvious source for infection but leukopenic and hypothermic on admission. (WBC 1.8, T 92.1). Both have improved w/ empiric antibiotcs (vanc/zosyn). The patient underwent a paracentesis which was negative for SBP, although had been on antibiotics for 3 days prior to paracentesis, so it is feasible that the infection had already been partially treated. He further underwent an LP which was negative for infection, blood cultures that did not reveal a source, and urinalysis/urine culture that was also not revealing. CXR was performed that revealed bilateral pleural effusions but no pneumonia. Possible partially treated SBP is the most likely source for infection in this patient, especially given the non specific symptoms of fatigue and the presentation including confusion. The patient was treated with an empiric course of vanc/zosyn for 6 days given no clear etiology. After antibiotics were discontinued, the patient did not develop any further signs or symptoms of SIRS. The patient was initially admitted to the medical intensive care unit because of hypotension and he transiently received levophed(low doses), discontinued at 6 a.m. on [11-24]. Please note that the patient's systolic blood pressure appears to range between 95-110 mmHg. The patient further received stress dose steroids after a cortisol stim test that tapered to completion on [2189-11-26]. # End Stage Liver Disease: Cirrhosis, labeled as cryptogenic but patient with previous history of heavy alcohol use. Lactulose as needed for confusion has been somewhat effective. Liver team was consulted and the patient was followed by Dr. [Last Name (STitle) 497] and his time while an inpatient. The patient had a duplex/doppler ultrasound that showed patent hepatic veins and braches as well as moderate ascites. # Pancytopenia: Leukopenia has resolved and likely related to infection. Thrombocytopenia is possibly related to liver disease, however, his platelets drifted to a nadir of 31. We monitored his fibrinogen, FDP, and LDH for concern of developing disseminated intravascular coagulopathy. The patient's anemia was likely due to his chronic kidney injury. The patient's platelets have risen for the past several days, now at 89. During this time, the patient's fibrinogen also continued to rise. His platelets began to recover after antibiotics were discontinued. It is possible that the antibiotic administration contributed to his worsening of thrombocytopenia. The patient appears to have a baseline hematocrit around 29-30. On [2189-11-25] patient was found to have a hematocrit of 23.9 and was transfused 2 units of pRBCs. His hematocrit bumped appropriately to 28.5 and has remained stable around 28. HCT on discharge was 29.2. # Hypoxia Patient was transiently hypoxic upon presentation, though this promptly resolved. The patient has bilateral pleural effusions but his oxygenation improved w/o intervention. Possibly as MS improved he had some atelectasis that resolved. # Altered Mental Status: Patient presented with altered mental status. He was evaluated by neurology and they believed his altered mental status to be due to a toxic-metabolic abnormality. With the improvement in mental status with lactulose treatment and the elevated ammonia level, his altered mental status was likely due to hepatic encephalopathy. We would recommend continuing lactulose 30gm PO TID prn for confusion. # Acute on Chronic Renal Injury: Baseline creatinine appears to be 2.7, though we have limited data from [2189-10-27] only. The patient was admitted with a creatinine of 3.1, reached a peak of 3.5. Initially thought to be related to pre-renal vs. hepatorenal although creatinine did not improve w/ fluid resuscitation. Renal ultrasound w/ small right kidney but no hydroneprhosis. Uric acid slightly elevated. Renal was consulted and followed the patient during his hospitalization. As the patient's overall condition improved, his creatinine also returned to baseline. Upon discharge, his creatinine was 2.1. Initially, the patient's lasix, nadolol, spironolactone, and finasteride were held due to renal failure. His lasix was able to be added back on but at half of his usual home dose. The patient will start sodium bicarb tablets 650mg PO BID. # Coronary Artery Disease: NSTEMI earlier in [2189-10-27] with medical management. No signs of ischemia on EKG upon presentation. The patient underwent transthoracic echo with preserved systolic function early in his hospitalization and had a second echo towards the conclusion of his hospitalization - both showed preserved LV EF of 55-60% and borderline diastolic heart failure. Patient initially presented on aspirin and a statin. Due to his decreasing platelet level, his aspirin was discontinued as was all heparin products. Due to patient's blood pressure around 100 mm Hg, beta blocker was not restarted during hospitalization. We would recommend that both aspirin and beta blocker be restarted as tolerated. #Atrial Fibrillation: Not on coumadin given history of GI bleed and presence of melena. Patient has remained rate controlled and intermittently paced. # Hypernatremia: Patient initially was not taking much oral food or liquid given his mental status, but is now tolerating a regular diet. Hypernatremia is likely from the initial restriction of free water. He had a free H2O deficit is 2.7 liters. Patient was given D5W and had slow correction of his hypernatremia. Of note, patient reports that he drinks 32 water bottles per week (1 pint bottles) in addition to other fluids. # Hypothermia: Throughout the hospitalization the patient was hypothermic. He initially had rectal temperatures around 32.7 degrees celcius while in the intensive care unit. He initially was treated with the use of a Bair hugger while in the intensive care unit as well as on the medical floor. As the patient's condition improved, his temperature moderately improved. He remained with temperature between 95-96 degrees fairenheight, though rectal temperatures were 97. The patient was always warm and well perfused with temperatures of 94-95 PO farenheit. We would recommend obtaining rectal temperatures for a true core temperature. # FEN/GI: Initially recommended soft (dysphagia); Nectar prethickened liquids per speech and swallor recommendations, however, as his condition improved he was transitioned to thin liquids and regular solids. Medications on Admission: - ATORVASTATIN 40 mg po daily - ESOMEPRAZOLE MAGNESIUM 40 mg po daily - FINASTERIDE 5 mg po daily - FUROSEMIDE 40 mg po BID - LEVOTHYROXINE 25 mcg po daily - NADOLOL 20 mg po daily - SPIRONOLACTONE 50 mg [Hospital1 ] - ASPIRIN 81 mg po daily - CHOLECALCIFEROL (VITAMIN D3) 800 units po daily - FERROUS SULFATE 325 mg po daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Lactulose 10 gram/15 mL Solution Sig: Forty Five (45) ML PO Q8H (every 8 hours) as needed for confusion. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 13. Hydrocortisone 2.5 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for pruritis. 14. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Altered Mental Status Systemic Inflammatory Response Syndrome End Stage Liver Disease Acute on Chronic Kidney Injury Pancytopenia Hypoxia Hypernatremia Discharge Condition: Mental Status: Alert, sometimes confused Ambulatory Status: out of bed to chair with assist Discharge Instructions: You presented to the hospital with low blood pressure, fatigue, confusion, and weakness. Because your blood pressure was so low, you were initially admitted to the intensive care unit where you received antibiotics. You began to improve, and there was suspicion that you may have had an infection in your abdomen. Fluid was taken from your abdomen, but did not show any infection. As you were already on antibiotics, we cannot be sure if there was initially an infection causing your symptoms. Your liver function was noted to be worsening, and you were seen by Dr. [Last Name (STitle) 497], the hepatologist (liver doctor), while you were in the hospital. Your kidney function also was more impaired than usual when you arrived to the hospital. With the help of the kidney doctors, your kidney function returned better than its baseline. You were taken off of antibiotics and were stable without fever or other signs of infection. Your confusion may have been due to an infection in your abdomen, or your confusion may have been due to a build up of ammonia that your liver could not break down. You should continue to take the medicine lactulose if you are found to be confused. We discontinued several of your medicines while you were in the hospital: (1) Aspirin 81mg by mouth daily (2) Nadolol 20mg by mouth daily (3) spironolactone 50mg by mouth twice daily (4) finasteride 5mg by mouth daily Some of these medicines will be slowly reintroduced into your regimen by Dr. [Last Name (STitle) 497]. We also introduced new medications while you were in the hospital: (1) hydrocortisone 2.5% topical cream, apply to affected areas [Hospital1 ] (2) clotrimazole cream, apply to affected area over buttocks and back [Hospital1 ] (3) sarna lotion, apply to topical area QID prn itch. (4) lactulose 30 gm PO TID prn confusion The following medications were changed while you were in the hospital: (1) Lasix 20 mg PO BID Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9001], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2189-12-3] 7:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2189-12-11] 2:20 Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2189-12-21] 10:20 Completed by:[2189-11-30]	[ "995.92", "511.9", "584.9", "403.90", "427.31", "038.9", "799.02", "995.93", "285.9", "V10.82", "585.9", "567.23", "333.94", "303.90", "785.52", "284.1", "276.0", "410.72", "571.2", "V45.01", "416.8" ]	icd9cm	[ [ [] ] ]	[ "38.91", "54.91", "38.93", "03.31" ]	icd9pcs	[ [ [] ] ]	18014, 18111	9806, 12870	318, 349	18307, 18307	5397, 9783	20395, 20860	4544, 4617		16692, 17991		18132, 18286		16337, 16669				18425, 20372						4632, 5378																						270, 280								377, 3316										18322, 18401					3338, 4271	4287, 4528
66,825	129,103	36875	Discharge summary	report	Admission Date: [2120-12-24] Discharge Date: [2121-1-16] Date of Birth: [2059-9-21] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3021] Chief Complaint: Acute renal failure and hyperkalemia. Major Surgical or Invasive Procedure: Right Internal Jugular Venous Line Placement. Right radial arterial line placement. [2120-12-3] Temporary dialysis catheter placement. [2120-12-8] Tunnelled dialysis catheter placement. History of Present Illness: A 61-year-old male with a new diagnosis of metastatic renal cell carcinoma, unknown subtype, with metastatic disease in the right frontal lobe, pulmonary nodules and marked adenopathy presented with acute renal failure and hyperkalemia when he did a routine blood works for debulking nephrectomy. . The patient had been in his usual state of health until today when he underwent a pre-op blood works. He was found to have ARF and hyperkalemia. He stated that in the last week, he had mild diarrhea that he attributed to stool softeners. At that time, he had mild lower abd cramps associated with diarrhea. After he hold stool softeners, he experienced constipation now. His last BM was 2-3 days ago. He also reported that his PO intake significant decreased due to the lack of appetite. He denied weight loss. He denied lightheadedness, headache, dizziness, blurry vision, dry mouth, CP, SOB, chest pressure, N/V, abd pain, hematuria, BRBPR, or melena. However, over the past a few weeks, he noticed his urine output had decreased. . In our ED, he received Calcium Gluconate and Insulin and Dextrose. . Review of Systems: (+) Per HPI. (-) Denies fever, chills, night sweats. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting,, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: Oncology history: -metastatic renal cell carcinoma, unknown subtype, with metastatic disease in the right frontal lobe, pulmonary nodules and marked adenopathy. - s/p CyberKnife to CNS. - Scheduled [2121-1-7] to have lapascopic nephrectomy and IVC thrombectomy for tumor thrombus in the IVC. . Other PMH: - Chronic renal insufficiency, recent creatinine 1.7 - Enlarged prostate, found a few days ago, found at time varicocele being worked up by urology - Peripheral neuropathy, prior to diagnosis of diabetes, likely about 15 years ago - Diabetes II, 8 years ago - GERD - Cataract surgery to right eye, pseudophakia - varicocele - hypertension - hypercholesterolemia Social History: Smoking: Stopped [2080], one pack per day prior for about five years. Alcohol: No - prior "more than just social use", but not for 25 years. Drugs: No. Living Situation: Lives with mother, he helps care for her - difficulty walking, CAD, OA, legally blind, PPM - he is primary care provider. [Name10 (NameIs) 382] not determined yet. Education and Language: English, graduate, works as attorney -insurance defence law. Functional Baseline: Independent. Other: No military service, no toxic exposures, in [Country 6171] for four days, eight years ago. Family History: Mother - childhood disorder affected one eye, AION the other, CAD, OA, irregular heart beat/block. Father - died in 40s from MVA. Siblings - one sister died of breast cancer, another sister well. [Name2 (NI) 83278] - MGM CAD, MGF stroke. PGP's - PGM CAD, PGF CAD. An aunt (father's sister) with breast cancer. Physical Exam: Admission Physical Exam: Vitals - T:98.8 P 110 BP 88/53 R 18 SaO2 98% RA GENERAL: NAD, lying comfortably on bed with nasal canula SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent nares, MMM, nontender supple neck, no LAD, no JVD. CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: 5/5 strength bilaterally throughout. Sensation intact and symmetric throughout. EOMI. Pertinent Results: ADMISSION LABS: LACTATE-2.2* cTropnT-0.01 PT-12.8* PTT-23.8* INR(PT)-1.2* UREA N-98* CREAT-2.9# SODIUM-134 POTASSIUM-6.1 CHLORIDE-97 TOTAL CO2-25 ANION GAP-18 WBC-5.3# RBC-3.50* HGB-9.6* HCT-28.1* MCV-81* MCH-27.4 MCHC-34.0 RDW-16.8* Trop-T- negative x 3 Albumin 3.3 TSH 2.0 Lactate ([2120-12-25])- 1.8 . IMAGING: [2120-12-24] CXR: IMPRESSION: 1. Possible new intrathoracic lymphadenopathy, which could be better evaluated by CT if clinically warranted. 2. Increased left lower lobe atelectasis. 3. Unchanged pulmonary metastases. . [2120-12-24] RENAL U/S: IMPRESSION: Left renal mass compatible with known renal cell carcinoma, without hydronephrosis in either kidney. . [2120-12-25] ECHO: Left atrium moderately dilated. Mild LVH. EF>75%. Cardiac index is high (>4.0L/min/m2). Normal PCWP<12mmHg. RV cavity mildly dilated. Aortic root mildly dilated. Ascending aorta mildly dilated. . [2120-12-25] CT C/A/P: IMPRESSION: 1. Slight enlargement of left RCC tumor with stable necrosis and no evidence to suggest acute infection of the tumor. 2. Progression of mediastinal, hilar, and retroperitoneal lymphadenopathy. 3. Enlargement of the known pulmonary metastases with several new sub-4 mm nodules. 4. Bilateral pleural effusions, greater on the left than the right. Small consolidation in the left base which may represent atelectasis or possibly early infection. 5. Progression of lytic [Month/Day/Year 500] metastases as described above. . [2120-12-26] CXR: IMPRESSION: Mild-to-moderate pulmonary edema is new. Moderate cardiomegaly is worsened and there is now a new small pleural effusion. Extensive pulmonary metastasis is only partially visible. Interval increase in mediastinal caliber is probably due to venous engorgement, baseline widening due to extensive fat deposition and some lymph node enlargement. Right jugular line ends low in the SVC. No pneumothorax. . [2120-12-27] ECHO: Left atrium mildly dilated. LVEF >55%. Aortic root mildly dilated. Ascending aorta mildly dilated. . [2120-12-30] LE DOPPLER U/S: IMPRESSION: No evidence of deep vein thrombosis. . [2120-12-30] V/Q SCAN: IMPRESSION: Very low likelihood ratio for recent pulmonary embolism. Focal left upper lobe perfusion/ventilation defect corresponds to a known metastatic nodule in that region. . [2120-12-31] CXR: FINDINGS: In comparison with study of [12-27], the overall cardiac size is within normal limits and there is no definite pulmonary vascular congestion. Left pleural effusion and small right effusion persists. Multiple nodular metastases are seen as well as extensive prominence of the mediastinum caliber that could reflect venous engorgement, lymphadenopathy, or both. Central catheter has been removed. . [2121-1-1] RENAL U/S: IMPRESSION: 1. Heterogeneous and hypervascular left renal mass, without frank hydronephrosis. Elevated resistive indices and decreased diastolic flow, compatible with known partial renal vein thrombosis. 2. Mildly elevated right renal resistive indices. . [2121-1-7] CT HEAD: IMPRESSION: Right frontal lobe lesions again seen. The surrounding vasogenic edema has decreased in severity. No post traumatic abnormalities are seen. . [2121-1-7] CT C-SPINE: IMPRESSION: 1. No evidence of fracture or malalignment of the cervical spine. 2. Multiple hypodense thyroid nodules measuring up to 8 mm in diameter. Please correlate with any prior history of ultrasound examinations for thyroid disease. 3. Left pleural effusion. . [2121-1-7] X-RAY LEFT HUMERUS/SHOULDER: IMPRESSION: Angulated displaced fracture of the left proximal humerus and humeral neck. Underlying pathologic fracture is not excluded. . [2121-1-7] X-RAY HIP/FEMUR: IMPRESSION: 1) Mild endosteal undulation in the left proximal/mid femoral diaphysis (<50% cortical thickness). The possibility of a subtle lytic lesion cannot be excluded. Otherwise, no focal lytic or sclerotic lesion is detected radiographically. 2) Right greater than left hip degenerative changes. Sclerosis left femoral head, ? related to degenerative spurring. . DISCHARGE LABS: [2121-1-16]: WBC 3.3, Hb 10.7, HCT 33.2, MCV 87, PLT 253. [2121-1-8]: PT 14.5, PT 26.3, INR 1.4. [2120-12-29]: Retic 1.9. [2121-1-16]: GLU 118, BUN 42, CREAT 5.9, Na 141, K 5.1, CL 97, CO2 28. [2121-1-16]: ALT 16, AST 36, LDH 460, ALP 84, T BILI 0.3. [2121-1-16]: Ca 8.7, PHOS 6.1, MG 2.4. [2121-1-15]: URIC ACID 3.4. [2121-1-29]: BNP 941. [2121-1-9]: ALBUMIN 2.4. [2120-12-26]: IRON 30, TIBC 139, FERRITIN 1273. [2120-12-25]: TSH 2.0. [2121-1-15]: PTH 43. [2120-12-26]: AM CORTISOL 23.4. [2121-1-3]: HBsAg negative, HBsAb negative, HBcAb negative, HCV Ab negative. [2120-12-25]: MRSA SCREEN POSITIVE. Brief Hospital Course: 61yo man with a recently diagnosed metastatic renal cell CA to brain s/p cyberknife, lung, and [Month/Day/Year 500] admitted for acute on chronic renal failure and hyperkalemia found on pre-op labs prior to debulking nephrectomy. Hospital Day #1, he was transferred to the ICU for hypotension and rapid afib. He was given 6L IV fluids, pip/tazo, and vancomycin for possible sepsis. CT suggested a LLL infiltrate with effusion. Afib converted to NSR with metoprolol. Because of hypoxia, heparin, then enoxaparin, were started for a possible PE, but CTA could not be done due to ARF. Echo did not show right heart strain. Transferred out of ICU. LE doppler U/S and V/Q scan were negative for clots, so enoxaparin was stopped. Furosemide given for pulmonary edema and hypoxia, but then creatinine worsened, Nephrology consulted, and dialysis started [2121-1-3]. Drowsiness and confusion waxing and [Doctor Last Name 688]. Fell and broke left humerus [2121-1-7] (pathologic), then received XRT to left humerus. Generalized weakness/fatigue slowly improving. . # Left humerus pathological fracture: Fell [2121-1-7]. Othopedics recommended conservative management given co-morbidities. Fell again [2121-1-9]. Started XRT [2121-1-8], plan for 5 fractions, held [2121-1-10] due to weakness, restarted [2121-1-14], finished [2121-1-16]. Changed MSContin 15mg [Hospital1 ] with PRN morphine to oxycodone PRN to avoid high plasma concentrations due to kidney failure per Nephrology and Pharmacy. . # Acute on chronic renal failure: Initially improved with IV fluids and resolution of hypotension. U/S did not show hydronephrosis. Returned back to baseline creatinine 1.8, but on the floor started to rise again after furosemide given for pulmonary edema. Nephrology consulted. Repeat renal U/S did not show hydronephrosis. Repeat U/A negative. Urine eosinophils negative. Temporary dialysis cath placed [2121-1-2]. Hemodialysis started [2121-1-3]. Tunnelled cath placed [2121-1-10]. Started dialysis, nephrocaps, low-phos diet. Calcium acetate for hyperphosphatemia. - Continue dialysis 3x per week. . # Hyperkalemia: Initially resolved with insulin/D50 and sodium polystyrene sulfonate. Now treated with regular dialysis. . # Mucositis: Possibly due to sunitinib, but Mr. [Known lastname 3142] states this started prior to sunitinib. Started viscous lidocaine PRN. Started artificial saliva (Gelclair) TID. Continued nystatin. - [Month (only) 116] need to hold sunitinib if mucositis worsens. . # Altered mental status: Likely metabolic encephalopathy/acute delirium due to hypoxia and medications (lorazepam/narcotics). Stopped lorazepam. CT head showed improved cerebral edema. Neuro-onc consulted. - EEG [2121-1-9] results pending. . # Hypotension: Developed 1st night of admission, seemingly not related to afib. Required pressors in ICU. Modestly improved with IV fluids, antibiotics, and resolution of afib. AM cortisol x2 adequate. Cardiac enzymes negative. Blood and urine cultures negative. Recurred after dialysis line placed [2121-1-2] (trigger for BP 78/47) and improved again with IV fluids. Tamsulosin stopped for anuria. Continued metoprolol 12.5mg [Hospital1 ]. Amiodarone started for afib. . # Pneumonia: Cefepime for possible sepsis changed to pip/tazo and vancomycin, and continued for LLL infiltrate. Although no leukocytosis, he did have a fever to 100.6F in the ICU. Completed pip/tazo [Date range (3) 83279], vancomycin [Date range (3) 83280]. . # Atrial fibrillation with RVR: Able to only tolerate low doses of metoprolol due to hypotension. Echo unremarkable. Normal TSH. Cardiology consulted. Started amiodarone loading [2121-1-8]. Continued metoprolol 12.5mg PO BID. Continued amiodarone loading 400mg [Hospital1 ] x2-3 weeks, then 200-400mg daily. Started low-dose aspirin (high risk for fall, therefore not a candidate for anticoagulation). - Needs thyroid function tests and CXR in 2-3wks for amiodarone monitoring. - EKG weekly x2 to follow QT interval while on amiodarone and sunitinib. . # Hypoxia: Likely causes include acute pulmonary edema and pneumonia, both seen on imaging as well as RCC. Emperically started on heparin gtt, then enoxaparin. No right heart strain on echo. BNP 941. LE doppler U/S negative. V/Q scan very low probability for PE. Given V/Q, LE doppler U/S, and echo findings, enoxaparin stopped. Avoided CTA with acute on chronic kidney failure. Furosemide 40mg IV x1 given [2120-12-31] with ensuing ARF. Completed course of antibiotics for pneumonia. O2 support as needed. . # Metastatic renal cell CA: s/p CNS cyberknife. Scheduled [2121-1-7] for debulking nephrectomy, but cancelled given events of this admission. Continued levetiracetam 500mg PO BID seizure prophylaxis with extra half dose after dialysis. Started sunitinb [2121-1-10], following QT closely. Plan sunitinib 4wks on, 2wks off, unless needing to stop early for side-effects. . # Microcytic anemia: Likely anemia of CKD and inflammation as based on iron studies, low retic index. Transfused 1U pRBC [2120-12-25], 1U [2121-1-3], 2U [2121-1-7], and 2U [2121-1-9]. . # Hypertension: Lisinopril held due to hypotension and ARF. Metoprolol started for rapid afib. . # Hyperlipidemia: Continued outpatient statin. . # DM: Glipizide held due to ARF, but as ARF resolved, glipizide was restarted, then stopped again with recurrent ARF. D/C'd finger sticks given reasonable glucose control with diet. . # BPH: Stopped tamsulosin given low BP and anuria. . # Anxiety: Consulted Psychiatry. Stopped quetiapine and citalopram. Started mirtazapine. Low-dose quetiapine if needed. . # GERD: Continued outpatient PPI. . # FEN: Regular cardiac low-K+ diet. Hyperphosphatemia due to renal failure. Hyperkalemia treated by 3x/wk dialysis. . # Pain (humerus, abdomen): MSContin 15mg [Hospital1 ] + morphine PRN changed to oxycodone PRN only to avoid rising plasma concentrations in kidney failure per Nephrology and Pharmacy. . # GI PPx: PPI and bowel regimen. . # DVT PPx: Heparin SC. . # Precautions: Fall, MRSA (screen positive). . # Lines: Dialysis central line. . # CODE: DNR/DNI. Medications on Admission: tamsulosin ER 0.4 mg 24 hr Cap 1 Capsule(s) by mouth HS levetiracetam 500 mg PO BID for seizure prevention pantoprazole 40 mg PO q24HR hydrocodone-acetaminophen 5mg-500mg PO q6hrs morphine 15-30mg PO q3HR PRN pain lisinopril 10 mg PO DAILY dexamethasone 4 mg PO once a day, Decrease to 2 mg a day on [12-21] x4d, then on [12-25] decrease to 1 mg a day x4d. Stop on [12-29]. simvastatin 10mg PO DAILY glipizide 5mg PO once a day multivitamin,tx-minerals PO DAILY Discharge Medications: 1. levetiracetam 500 mg PO BIDExtra 250mg to be given after dialysis. 2. levetiracetam 250 mg PO ASDIR (AS DIRECTED): This is an additional dose to be given after each dialysis session. 3. pantoprazole 40 mg PO Q24H. 4. simvastatin 10 mg PO DAILY. 5. B complex-vitamin C-folic acid 1 mg 1 TAB PO DAILY: Nephrocap. 6. sodium chloride 0.65 % Aerosol, Spray Sig: [1-13] Sprays Nasal QID PRN dry nose. 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID. 8. oral wound care products Gel in Packet Sig: 15 ML Mucous membrane TID. 9. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane QID PRN Pain. 10. oxycodone 5-10mg PO Q3H PRN Pain. 11. docusate sodium 100 mg PO BID. 12. senna 8.6 mg PO BID PRN Constipation. 13. aspirin 81 mg PO DAILY. 14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS. 15. sunitinib 50 mg PO DAILY: 4 weeks on, 2 weeks off. 16. metoprolol tartrate 12.5 mg PO BID: Hold for SBP <100. 17. amiodarone 200 mg Tablet Sig: 400mg PO BID x2 weeks, then 400mg PO daily. Check EKG weekly x2 weeks. 18. mirtazapine 7.5 mg PO HS. 19. heparin (porcine) 5,000 unit/mL Solution Sig: 1mL SC TID. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: 1. Acute on chronic kidney failure. 2. Hyperkalemia (high potassium). 3. Hypotension (low blood pressure). 4. Atrial fibrillation (fast irregular heart arrhythmia). 5. Hypoxia (low oxygen level). 6. Pneumonia. 7. Pulmonary edema (fluid on the lungs). 8. Acute delirium (confusion). 9. Metastatic kidney cancer. 10. Anemia. 11. Hypertension (high blood pressure). 12. Diabetes. 13. Left humeral pathological fracture (broken left arm due to cancer in the [Hospital1 500]). 14. Mucositis (inflammation of the mucosa in the mouth/throat). 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 acute kidney failure and hyperkalemia (high potassium level). This was found on pre-op blood work in preparation for a nephrectomy for metastatic kidney cancer. You were given medication to correct the high potassium level. However, your blood pressure became dangerously low and your heart developed an abnormal fast rhythm called atrial fibrillation. For these reasons, you were transferred to the ICU and given a large volume of IV fluids as well as metoprolol, which controlled the heart arrhythmia and returned it to normal. Your kidney function returned to your baseline and blood pressure modestly improved. However, you were requiring more oxygen and CT of the chest suggested pneumonia, for which you were given a course of antibiotics. V/Q (nuclear) lung scan and ultrasound of the legs were negative for blood clots, so blood thinners were stopped. Chest x-ray showed fluid on the lungs (pulmonary edema). For this, you were given furosemide, a diuretic, which temporarily improved your oxygen levels, but your kidneys did not tolerate this and worsened. The kidney specialists were consulted and a dialysis line was placed. Immediately after the dialysis line was placed, your blood pressure became dangerously low again, but this time it improved quickly with IV fluids. You had a period of time on [2121-1-2] when you were lethargic/drowsy and confused. This may have been due to very low oxygen levels and lorazepam, a medication given the night before for sleep/anxiety. You started dialysis [2121-1-3] and were given a red blood cell transfusion the same day for severe anemia (low red blood cell count). From all these medical problems, you have become very weak and will need physical therapy/rehab. Twice while in the hospital, you fell, one time fracturing the left humerus (arm [Month/Day/Year 500]). Orthopedic surgeons were consulted. They felt you would not benefit from surgery. The fracture was partially caused by cancer in that [Last Name (LF) 500], [First Name3 (LF) ] radiation therapy to the left arm was done. The arm will remain in a cuff and collar sling until adequately healed. You still require oxygen and prior to hospital discharge your pain regimen was changed in an effort to avoid morphine which can build up in your body when your kidneys are not working. Morphine was changed to oxycodone only as needed. Although oxycodone can also build up in the body, this is not as much as morphine. The pain regimen may need to be adjusted in the future. Persistent high potassium levels and high phosphorous levels will be treated primarily by dialysis. You were also started on viscous lidocaine to numb the mouth and artificial saliva (Gelclair) for mucositis. The cause of mucositis is not clear, but chemotherapy (sunitinib) may be contributing. Treatment for diabetes has been stopped because of controlled sugar levels by diet. . MEDICATION CHANGES: 1. Metoprolol 25mg 2x a day for atrial fibrillation. 2. Amiodarone 2x a day x2 weeks, then once daily for atrial fibrillation. 3. Nephrocaps, vitamin, once daily. 4. Oxycodone 5-10mg as needed for pain. 5. Levetiracetam (Keppra) 2x a day, dose varies on day of dialysis: 500mg 2x a day with an extra 250mg after each dialysis session. 6. Sunitinib (Sutent) 50mg by mouth once daily, 4 weeks on, 2 weeks off (chemotherapy). 7. Stop tamsulosin (Flomax) because your kidneys no longer make urine. 8. Stop lisinopril due to kidney disease. 9. Stop glipizide due to kidney disease. 10. Aspirin started for atrial fibrillation. You are unable to have a stronger blood thinner because of your risk for falling/bleeding. 11. Calcium acetate to treat high phosphorous levels. Followup Instructions: Department: RADIOLOGY When: MONDAY [2121-1-20] at 7:55 AM With: RADIOLOGY MRI [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2121-1-20] at 1:30 PM With: DR. [First Name8 (NamePattern2) 610] [Last Name (NamePattern1) ] [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2121-1-20] at 1:30 PM With: DRS. [Name5 (PTitle) ]/[Doctor Last Name ] [Telephone/Fax (1) 13016] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "458.21", "300.00", "197.0", "518.4", "528.09", "486", "189.0", "293.0", "458.9", "584.5", "198.89", "585.6", "275.3", "198.3", "250.00", "600.00", "403.91", "198.5", "196.2", "427.31", "356.9", "427.32", "276.7", "348.5", "733.11" ]	icd9cm	[ [ [] ] ]	[ "39.95", "92.29", "38.95" ]	icd9pcs	[ [ [] ] ]	17299, 17374	9334, 11919	343, 538	17957, 17957	4544, 4544	21899, 22756	3529, 3844		16129, 17276		17395, 17936		15631, 16106				18132, 21087		8648, 9311				3884, 4525																			1695, 2239		21107, 21876	266, 305								566, 1676		7602, 8632				4560, 7593				17972, 18108					2261, 2933	2949, 3513
74,618	124,798	6174+55736	Discharge summary	report+addendum	Admission Date: [2169-5-31] Discharge Date: [2169-6-9] Date of Birth: [2091-11-21] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1835] Chief Complaint: tumor resection Major Surgical or Invasive Procedure: [5-31]: Right parietal craniotomy and resection of lesion [6-1]: Right craniotomy evacuation of epidural hematoma History of Present Illness: 77 year old woman followed as an outpatient with complaint of right upper extremity pain and burning. Initially she was being seen for a right parietal convexity meningioma that was found incidentally in [2166] while being seen in the ER at an OSH. Upon examination she was noted to have symptoms likely from a cervical pathology. She subsequently underwent a C4-5 Anterior Cervical Discectomy and Fusion on [2168-12-1]. She has recovered well from this and now electively presents for a craniotomy and resection of her meningioma. Past Medical History: Type II DM Hyperlipidemia HTN Right parietal convexity meningioma Social History: Patient lives with her daughter, [Name (NI) 24095] in [Name (NI) 392]. Patient is from [Country 3587] and does not speak English. Family History: Brother - DM Physical Exam: At discharge: She is awake, and alert. She speaks in 1 word answers in English, apeaks to family in Portuguese Creole. Improving left hemineglect. She follows simple commands. On cranial nerve examination, pupils are equal and reactive, EOMI. Slight left N-L fold flattening. On motor examination, patient has full strength on right side. She is now moving the left hand. Left toes wiggle. Left hyperreflexia with upgoing left toe. Pertinent Results: [5-31] MRI Brain: 1. Extra-axial, dural-based mass lesion measuring 15 (CC) x 25 (transverse) x 31 (AP) dimensions within the right parietal region of the vertex with homogenous enhancement shows no significant change from the prior examination allowing for positioning and technique. 2. Stable size of the small dural-based lesion in the right temporal region lateral to Meckel's cave. 3. Paranasal Sinus disease [5-31] CT Head: Expected post-operative changes, after recent right frontovertex craniotomy with resection of the known frontal meningioma. There is moderate bilateral prefrontal pneumocephalus and minimal blood products in the surgical bed. [6-1] MRI Brain: New convex epidural fluid collection with contrast extravasation, highly concerning for epidural hematoma and active bleeding. CT HEAD W/O CONTRAST [2169-6-1] 1. Status post evacuation of a right frontoparietal epidural hematoma, with evolving right frontoparietal white matter hypodensities likely representing edema. 2. No new intracranial hemorrhage. 3. Moderate amount of pneumocephalus and expected post-surgical changes [6-1] CT head - 1. Status post evacuation of a right frontoparietal epidural hematoma, with evolving right frontoparietal white matter hypodensities likely representing edema. 2. No new intracranial hemorrhage. 3. Moderate amount of pneumocephalus and expected post-surgical changes EEG [6-1] This telemetry captured one pushbutton activation. It showed some rhythmic left arm jerking of low amplitude 5 video, but there was no clear electrographic seizure at the time. There was some rhythmic delta activity in the right frontal area then and, at other times, some brief but rhythmic sharp activity in the right central region. These findings suggest areas of potential epileptogenisis likely related to the clinical observations. They indicate a potential for more seizures at other times. Otherwise, the most prominent finding was the lower voltage and slow activity in the left occipital area. Finally, most of the more rapid rhythmic background suggested medication effect. [6-2]: IMPRESSION: This telemetry captured 3 pushbutton activations. The event at 7:30 on the morning of [5-31] showed video and EEG evidence of a seizure. The focus was not completely clear by EEG as there was irregular slowing in the right central region and also left temporal area, both with sharp and spike features. At other times, the spikes and sharp waves were evident but did not appear to lead to clinical or electrographic seizures. The background remained slow and encephalopathic throughout. [6-3]: This telemetry captured no pushbutton activations. The telemetry showed a mildly slow background throughout. After the first hour or so, right central sharp waves and focal slowing were less prominent. Also, the mildly slow, often 7 Hz, background while generally improved from the previous day, did not change much after that first hour. There were no electrographic seizures. [6-4]: IMPRESSION: This telemetry captured no pushbutton activations. The background remained moderately slow, at a [4-17] Hz maximum in most areas, throughout the recording. This indicates a widespread encephalopathy. In addition, there was minimal slowing and occasional sharp wave in the right central region, but there were no repetitive discharges or electrographic seizures. [6-5]: MPRESSION: This is an abnormal continuous ICU monitoring study because of attenuation of faster frequencies and background rhythmicity over the right hemisphere particularly in the right parasagittal area. These findings are indicative of a mild to moderate diffuse right hemispheric dysfunction more prominently seen in the parasagittal region. The background activity over the left hemisphere reaches 8-8.5 Hz with admixed excess theta. In addition, there are brief runs of bifrontal intermittent rhythmic delta activity (FIRDA). These findings are indicative of a mild to moderate diffuse encephalopathy of nonspecific etiology. No epileptiform discharges or electrographic seizures are present. Compared to the prior day's recording, there is improvement as faster background rhythms are present in this recording. [6-6]: pendinf [6-7]: pending [6-2] CT head - 1. No significant change in the appearance of the post-surgical resection bed in comparison to exam obtained 15 hours prior. Again seen is a small amount of pneumocephalus, trace residual blood products, and [Doctor Last Name 352] matter hypodensities, most consistent with edema. [6-4] Ct Head - With the exception of the resolution of the minimal pneumocephalus previously seen, there has been no significant change in the appearance of the right [Last Name (un) 24096]-frontal post-surgical resection bed, including trace residual blood products and [Doctor Last Name 352] matter hypodensities, most consistent with edema. [6-5] EEG: Findings are indicative of a mild to moderate diffuse encephalopathy of nonspecific etiology. No epileptiform discharges or electrographic seizures are present. Compared to the prior day's recording, there is improvement. Brief Hospital Course: Pt electively presented and underwent a right parietal craniotomy and resection of her meningioma. Surgery was without complication and she tolerated it well. She was extubated and transferred to the ICU for neurological monitoring. On post operative exam it was noted that she was not moving her left leg as well. Post op Head CT revealed no hemorrhage, + pneumocephalus therefore she was placed on a non-rebreather. She was stable overnight but in the morning she was noted to be more agitated/confused and had significant left sided weakness. This was thought to be due to post operative edema. She was continued on steroids at 4mg q6hr. Post operative MRI was performed which revealed new convex epidural fluid collection with contrast extravasation. She remained in the ICU for close neurological monitoring. Head CT was obtained which showed acute hemorrhage in the R frontoparietal region. She was taken to the OR immediately for R craniotomy for evacuation of clot. Post operatively, patient was lethargic and confused, no movement of LLE. She was full on the R side. Post op head CT showed good resection of clot with no acute hemorrhage. Overnight, she was seen to have twitching of her LUE which was continuous. She recieved 2 doses of ativan before it resolved. EEG leads were placed and keppra was increased to 1000mg [Hospital1 ]. On [6-2], on exam, patient had no EO and did not follow commands. Her RUE moves antigravity spontaneously, with no movement on the left. EEG showed seizure activity in the R central region and her keppra was increased to 1500mg [Hospital1 ] and dilatin was added. A repeat head CT was done which was stable. [6-3], Patient's TFs were held and she was extubated without incident. She was given 1 unit of PRBC for Hct 23.9 in setting on low UOP. Post hematocrit [Last Name (un) 24097] 29.2%. [6-5] Speech and swallow eval and he was deemed an aspiration risk. As a result, she remained NPO. Additionally, AM Lantus was increased to 20mg from 15mg; re-started SQH. On [6-6], she was without seizure activity. The EEG leads were DC'ed on [6-7]. She was neurologically stable and orders for floor trasnfer were made. She was being screened for rehab. Speech/swallow re-evaluated the patient and cleared her for a diet given her improved mental status. At the time of discharge on [6-9] she was tolerating a pureed (dysphagia) diet with thin liquids, afebrile with stable vital signs. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Lisinopril 40 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Metoprolol Tartrate 50 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 500 mg PO BID 9. Docusate Sodium 100 mg PO BID 10. Multivitamins 1 TAB PO DAILY 11. 70/30 30 Units Breakfast 70/30 2 Units Dinner Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. LeVETiracetam Oral Solution 1500 mg PO BID 7. Phenytoin (Suspension) 100 mg PO Q8H 8. Dexamethasone 2 mg PO Q12H 9. Famotidine 20 mg PO Q12H 10. Calcium Carbonate 500 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Metoprolol Tartrate 50 mg PO BID 14. 70/30 30 Units Breakfast 70/30 2 Units Dinner Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: right parietal lesion right epidural hematoma seizures postop anemia dysphagia malnutrition 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: Craniotomy for tumor Dr. [Last Name (STitle) 14354] [Name (STitle) ] ?????? Have a caretaker check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You were on a medication Aspirin, prior to your injury, please wait until you are seen in follow up prior to restarting this medicine. ?????? You have been discharged on Keppra (Levetiracetam) and Dilantin (Phenytoin) for anti-seizure medicines, please take as prescribed and follow up with laboratory blood drawing in one week to measure the phenytoin level. This can be drawn at rehab or your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: ??????You have an appointment in the Brain [Hospital 341] Clinic: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12567] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2169-6-12] 1:30. Wound check will be done at that time. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. Completed by:[2169-6-9] Name: [Known lastname ],[Known firstname 4113] Unit No: [Numeric Identifier 4114] Admission Date: [2169-5-31] Discharge Date: [2169-6-9] Date of Birth: [2091-11-21] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 599] Addendum: Medication changed Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. LeVETiracetam Oral Solution 1500 mg PO BID 7. Phenytoin (Suspension) 100 mg PO Q8H 8. Dexamethasone 2 mg PO Q12H 9. Famotidine 20 mg PO Q12H 10. Calcium Carbonate 500 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Metoprolol Tartrate 50 mg PO BID 14. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 7 Days 15. Glargine 10 Units Bedtime NPH 20 Units Breakfast NPH 15 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [Hospital6 41] - [Location (un) 42] [Name6 (MD) ] [Last Name (NamePattern4) 603] MD [MD Number(2) 604] Completed by:[2169-6-9**]	[ "V58.67", "342.92", "E878.8", "276.0", "401.9", "787.20", "432.0", "272.4", "362.01", "225.2", "E849.7", "997.02", "285.9", "250.50", "263.9", "780.39" ]	icd9cm	[ [ [] ] ]	[ "01.59", "01.23", "96.71", "96.6" ]	icd9pcs	[ [ [] ] ]	14060, 14266	6970, 9439	324, 448	10700, 10700	1765, 2196	12368, 13380	1283, 1297		13403, 14037		10585, 10679		9465, 9944				10878, 12345						1312, 1312														1327, 1746								269, 286								476, 1018		2205, 6947								10715, 10854					1040, 1107	1123, 1267
62,528	130,949	53968	Discharge summary	report	Admission Date: [2179-6-22] [Month/Day/Year ] Date: [2179-7-16] Date of Birth: [2150-4-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 613] Chief Complaint: headaches --> brain mass Major Surgical or Invasive Procedure: PICC Line placement Ganciclovir implant placed in L eye on [7-1] to treat CMV History of Present Illness: Mr. [Known lastname ] is a 29 yo man with a PMH of HIV/AIDS (last CD4 3, viral load > 1,000,000) complicated by poor compliance with HAART medications, diarrhea and esophageal candidiasis, IV drug use (heroin and crack), and Hep. C who initially presented to OSH with fever, headache x 4days, N/V, decreased po intake and lethargy requiring intubation for airway protection. The patient was subsequently found to have a right frontal lesion with vasogenic edema and 9mm midline shift. He was transferred from OSH to [Hospital1 18] on [2179-6-22] given intracranial mass lesion. . In brief, Mr.[Known lastname ] was initially treated in the Neuro ICU with mannitol and dexamethasone taper for cerebral edema. He was continued on empiric toxoplasmosis treatment with pyrimethamine (200mg PO x 1) 50mg PO daily, sulfadiazine 1000mg PO Q6, and leucovorin 10mg PO daily. Also shortly after admission ([6-24]), Mr. [Known lastname ] was started on a HAART regimen of truvada, ritonavir and darunavir. He had a ganciclovir implant placed in L eye on [7-1] for CMV retinitis. There was also question of RLL pneumonia, which was covered by empiric vancomycin and ceftriaxone course initially. Other medications include azithromycin, fluconazole and valganciclovir. He was extubated on [6-23] with improvement in mental status. Overall, his toxoplasmosis is getting better with treatment, and repeat imaging reveals that midline shift has improved. His hospital course has been complicated by hyponatremia, fevers, tachycardia, and diarrhea. Renal was consulted for his hyponatremia that has been poorly responsive to fluid restrictions (now on 750 mL/day). ID has also been consulted for his spiking fevers and persistent tachycardia, which they believe can be attributed to [Doctor First Name ]. GI was consulted for his diarrhea ([7-15] BMs per day) that began after hospital admission, and the patient underwent a flexible sigmoidoscopy with negative work-up. The diarrhea has since improved, and the patient currently reports only one BM per day. . On transfer to the medicine floor, the patient was stable and able to converse. He had no complaints of headaches. Past Medical History: - HIV/AIDS, CD4 3, VL > 1,000,000 (poor medical compliance, now on HAART therapy) - Hepatitis C - CMV colitis and retinopathy - Esophageal candidiasis - h/o MRSA - polysubstance abuse- cocaine, heroin, crack - thrombocytopenia Social History: Patient lives in [Hospital1 487], MA and has a [Name (NI) 45534] girlfriend (sometimes referred to as his wife) and four step-children. He is originally from [Male First Name (un) 1056] and came to the US in [2164]. (Patient speaks both English and Spanish.) He has a history of IV drug use with heroin and cocaine days prior to admission and reports reusing needles. He currently smokes but denies any alcohol use. Family History: He denies any recent exposure to TB. Physical Exam: At admission: Vitals: T: 97.3 P: 67 BP: 135/113 vent CMV General: intubated, sedated, appears cachectic HEENT: ET tube in place Pulmonary: lcta anteriorly b/l Cardiac: RRR, S1S2 Abdomen: soft, +BS Extremities: warm, well perfused Neurologic: no eye opening. no commands. pupils 1 mm and non-reactive to light. Eyes in midline; unable to elicit Dolls eyes. No corneals. No cough/gag. Decreased muscle bulk throughout. No spontaneous movements. No withdrawal to noxious stimuli in any extremity. No grimmace to noxious stimuli. Biceps reflex 1+ and symmetric, unable to elicit any other reflexes. Extensor plantar response on the left, mute on the right. ************* At [Year (4 digits) ]: Vitals: Tc 98.1 BP 107/62 HR 86 RR 18 SaO2 98% on RA Gen: Young man sitting in bed eating breakfast, NAD, oriented x3, good attention HEENT: dilated L surgical pupil, both pupils mildly reactive to light, mildly dry, OP clear Neck: no JVD, bilateral tender lymphadenopathy (right submandibular nodes palpable and firm, left>right) CV: RRR, [3-15] late peaking systolic murmur at LUSB Resp: CTAB, with decreased breath sounds at R lower base with faint crackles GI: soft, nontender, nondistended +normactive BS Ext: trace bilateral lower extremity edema, 2+ DP pulses Neuro: CN II-XII intact, [6-12] strenght in UE and LE bilaterally, reflexes 2+ patellar, biceps, triceps bilaterally Psych: A&OX3, appropriate SKIN: left elbow birthmark Pertinent Results: FINAL REPORT [2179-6-22] TOXOPLASMA IgG ANTIBODY (Final [2179-6-22]): POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. >300 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [2179-6-22]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with Toxoplasma once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [3-12] weeks. . FINAL REPORT [2179-6-22] CRYPTOCOCCAL ANTIGEN (Final [2179-6-22]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. . FINAL REPORT [2179-6-23] Legionella Urinary Antigen (Final [2179-6-23]): 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. . FINAL REPORT [2179-6-24] RAPID PLASMA REAGIN TEST (Final [2179-6-24]): NONREACTIVE. Reference Range: Non-Reactive. . MRI head with and without contrast ([2179-6-22]): IMPRESSION: 2.1 x 2.3 cm rim-enhancing lesion with irregular walls, centered in the right gangliocapsular region with mass effect over the right lateral ventricle and 1 cm midline shift to the left. This lesion demonstrates an area of slow diffusion, which is not present in the center of this lesion. Findings may represent lymphoma or an infectious process such as toxoplasmosis or TB. . TTE ([2179-6-23]): Conclusions 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%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild pulmonary artery hypertension. Mild right ventricular cavity enlargement with low normal systolic function. Normal left ventricular cavity size and regional/global systolic function. . Tallium SPECT brain ([2179-6-25]): IMPRESSION: 1. There is a relatively low level thallium uptake in the lesion in the right cerebral hemisphere with less activity than scalp. Given the differential of toxoplasmosis versus lymphoma, findings are more concerning for toxoplasmosis. 2. Similar degree of vasogenic edema and leftward shift of normally midline structures. . CT HEAD W/O CONTRAST ([2179-7-6]) FINDINGS: Since the previous study, the mass effect on the right lateral ventricle and edema in the right basal ganglia region has decreased. Hypodensity persists in the periventricular white matter extending to the basal ganglia region. No hemorrhage is seen. There is no midline shift or hydrocephalus. Mild-to-moderate brain atrophy is noted as before. IMPRESSION: Decrease in edema in the right basal ganglia since the prior CT. No new areas of abnormalities or hemorrhage seen. Brain atrophy. . LABS . ADMISSION [2179-6-21*] 10:05PM GLUCOSE-99 UREA N-13 CREAT-0.8 SODIUM-126 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-16* ANION GAP-18 [2179-6-21] 10:05PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.0 [2179-6-22] 01:55AM ALT(SGPT)-31 AST(SGOT)-38 ALK PHOS-62 TOT BILI-0.3 [2179-6-21] 10:05PM WBC-5.0 RBC-3.85* HGB-10.9* HCT-34.8* MCV-90 MCH-28.3 MCHC-31.4 RDW-16.1* . [7-6] (hyponatremia) RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2179-7-6] 04:06 991 10 0.7 1186 4.9 88 19* 16 URINE CHEMISTRY UreaN Creat Na K Cl [2179-7-6] 04:05 33 98 49 83 . [7-8] (anemia) COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2179-7-8] 04:28 6.6 2.20* 6.8* 20.6* 94 30.8 32.9 20.8* 211 . [Year (4 digits) 894] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2179-7-15] 21:59 3.3* 2.63* 7.6* 24.5* 93 28.9 31.0 18.9* 308 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2179-7-15] 21:59 86 7 0.6 133 4.5 101 23 14 Brief Hospital Course: Mr.[Known lastname ] is a 29 yo man with HIV/AIDS (last CD4 3, viral load > 1,000,000) complicated by poor compliance with HAART medications, IV drug use (heroin and crack), and Hep. C who initially presented to OSH with fevers and headaches x 4days and was found to have a contrast-enhancing R-sided lesion with significant edema. He was empirically treated for presumed CNS toxoplasmosis (no biopsy, diagnosed by IgG) and subsequently developed multiple complications during his hospital course including hyponatremia, diarrhea, fevers, and tachycardia. He was initially admitted to the neuro ICU at [Hospital1 18] ([2179-6-22] - [2179-6-24]) transferred to the neuro floor ([2179-6-24] - [2179-7-6]) and finally to the medicine floor for management of his complications ([2179-7-7] - [2179-7-16]). . Active Issues: #Toxoplasmosis: He was initially admitted to the ICU where he was continued on Mannitol 25 mg q6h with Na and Dexamethasone 4 mg q6h. Neurosurgical biopsy was planned to confirm pathological diagnosis of the lesion but a positive IgG Toxo prompted empiric treatment of toxoplasmosis. MRI w/ contrast confirmed that there was a single large contrast-enhancing R-sided lesion with significant edema. Given the extent of the swelling, LP was deferred. Brain thallium scan was ordered to help differentiate lymphoma from other etiologies (eg. toxo). Brain bx was defered during empiric Toxo treatment period. A repeat imaging on [7-6] showed decreased swelling. On the medicine floor, we continued his toxo regimen of pyrimethiomine, sulfadiazine, and leucovorin with planned duration of at least 4 weeks and re-imaging of head after if no improvement. . #HIV/AIDS: He initially presented with a CD4 of 3 and viral load >1 million. The infectious disease team was consulted and closely followed the patient throughout his hospital course. He was started on HAART treatment on [2179-6-24] with plans to be followed by an ID doctor [First Name (Titles) ] [Last Name (Titles) ]. . #Hyponatremia: His serum Na reached a low of 118 on [7-6] and began trending up with fluid administration (NS). His current sodium on [Month/Year (2) ] was 129. The renal team was consulted and closely followed the patient. Based on his serum and urine lytes, the etiology of his was SIADH vs. cerebral salt wasting. Mr.[Known lastname ] was started on a fluid restriction of 1500 mL to limit his free water intake and put on a high salt and high protein diet. He was also started on 2 mg sodium tablets TID. We monitored his volume status clinically and measured orthostatics. Morning cortisol levels were normal. Fluids seemed to help improve his serum Na values, and he was given IV fluids of 500 mL NS boluses intermittently. . #Fever: Has had intermittent low grade fevers reaching a maximum temperature of 102-103. He has recently been reinitiated on HAART ([6-24]), so his fevers are thought to be secondary to immune reconstitution inflammatory syndrome ([Doctor First Name ]). He currently had no focal signs of infection. His diarrhea had improved, and he does not have new respiratory or urinary symptoms or abdominal pain. Blood cultures NGTD. Negative UA/urine culture. Cryptococcal negative. PPD negative. Per ID, he had no shortness of breath, headache, vision change or bulky LAD that pointed toward clinically significant [Doctor First Name ] that would require treatment with steroids. CXR, LENIs, and TTE were all normal. . #Anemia, normocytic: Reached a low hct of 20.6 on [2179-7-8] and was given 1 unit of packed RBCs (irradiated given HIV status). His hct on [Date Range ] was 24.7 and stable. Based on his labs (low Fe, high ferritin), this is likely due to anemia of chronic disease. -We closely monitored his hct. . #Sinus Tachycardia: He had frequent episodes of tachycardia to the 140s-160s. During these episodes, he was given IV fluids (500 mL bolus) and responded well. . #Acid/Base Disturbances: Has evidence metabolic acidosis, likely [3-11] proximal tubule RTA. He was started on sodium bicarbonate TID. . #CMV retinitis: The patient was diagnosed with CMV retinitis and is s/p ganciclovir implant placed in L eye on [7-1]. He was started on oral vangancyclovir to prevent CMV retinitis in contralateral eye. He will likely remain on the vangancyclovir for 3 weeks after [Month/Year (2) ]. Mr.[Known lastname ] has been scheduled for a follow-up appointment in eye clinic with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 253] in one month. . #Substance abuse: The patient has a history of IV drug use, including heroin and cocaine. On initial presentation, he was monitored for withdrawal symptoms and given both clonidine and lorezepam. These medications were discontinued on the medicine floor. for him to go to a dual diagnosis program for substance abuse following [Telephone/Fax (1) ]. . #Nutrition: Patient appeared frail and weak with initial weight 41.7 kg. Nutrition closely followed him, and suggested a high protein and high salt diet with supplements at each meal. The patient reported a decreased appetite, so tube feeds recommended as well as consideration of appetite stimulants. The patient declined the tube feed option. . #Insomnia: Mr. [Known lastname ] has had some difficulty sleeping for many nights and was given a trial of Ambien. This was switched to Seroquel after patient reported using this in the past to aid with sleep. . Inactive Issues: #Diarrhea: Mr.[Known lastname ] experienced a brief period of diarrhea that began after admission. resolved. His Lipase and ALT slightly elevated, possibly related to re-feeding syndrome. Other electrolytes improving. The etiology of his diarrhea is likely multifactorial: heroin withdrawal, re-feeding syndrome, magnesium replacement. His C. diff was negative and CMV from biopsy is negative. The GI team was consulted and he was started on loperamide. He was continued on electrolyte replacement and [Hospital1 ] lytes for refeeding syndrome. His diarrhea gradually resolved without further treatment. . #Thrombocytopenia: His platelet count briefly decreased to 123 on [7-2] 10days after being on heparin. The HIT antibody was negative and thrombocytopenia gradually resolved. He was restarted on heparin. . #Sinus bradycardia: He presented with sinus bradycardia, TTE was normal and EKG showed slightly prolonged but stable Qtc ~480 ms. [Name13 (STitle) 227] his cocaine abuse prior to admission, this was considered to be a possible sign of cocaine withdrawal. He was given glycopyrrolate 1X on the first night of admssion but his rhythm normalized thereafter without intervention. . #Intubation: Mr.[Known lastname ] presented with severe lethargy to the OSH per ICU team with uncomplicated extubation on [2179-6-23]. His sats were high on RA at time of transfer. . Transition Issues: - Follow-up with ID regarding toxo regimen and consider head re-imaging after completion if no improvment. - Continue HAART regimen and follow-up with ID/new HIV physician. [Name Initial (NameIs) ] Continue salt tabs and limit free water (<1500 mL ideally) intake until toxoplasmosis infection resolves. Will need to follow-up with renal in a few weeks. - Continue taking bicarbonate until metabolic acidosis resolves. Follow-up with renal in a few weeks. - Closely monitored and given acetaminophen 1000 mg PO/NG Q6H:PRN fever. (Fevers likely [3-11] [Doctor First Name ].) - Ensure volume replete to limit tachycardia. - Continue taking vangancyclovir for 3 weeks after [Doctor First Name ] for CMV retinitis and follow-up with ophthalmology regarding implant. - Encourage high protein and high salt diet with protein supplement shakes. - Continue Seroquel PRN insomnia and encourage full night's sleep. - Continue treatment for substance abuse while in rehab. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Pharmacy. 1. Dapsone 100 mg PO DAILY 2. Ethambutol HCl 400 mg PO BID 3. Pantoprazole 40 mg PO Q12H 4. Multivitamins 1 TAB PO DAILY 5. Fluconazole 100 mg PO Q24H 6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 7. RiTONAvir 100 mg PO DAILY 8. Clarithromycin 500 mg PO Q12H 9. Vitamin D 50,000 UNIT PO 1X/WEEK ([Doctor First Name ]) Duration: 8 Weeks 10. Leucovorin Calcium 25 mg PO 1X/WEEK (TH) 11. Dabigatran Etexilate 400 mg PO BID 12. Rifabutin 150 mg PO BID 13. Pyrimethamine 25 mg PO 1X/WEEK (TH) [Doctor First Name ] Medications: 1. RiTONAvir 100 mg PO DAILY RX Norvir 100 mg once a day Disp #30 Capsule Refills:3 2. Pyrimethamine 50 mg PO DAILY RX Daraprim 25 mg once a day Disp #60 Tablet Refills:3 3. Multivitamins 1 TAB PO DAILY RX Daily Multi-Vitamin once a day Disp #30 Tablet Refills:3 4. Leucovorin Calcium 25 mg PO DAILY RX leucovorin calcium 25 mg once a day Disp #30 Tablet Refills:3 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY RX Truvada 200 mg-300 mg once a day Disp #30 Tablet Refills:3 6. Acetaminophen 1000 mg PO Q6H:PRN fever, pain RX acetaminophen 650 mg every six (6) hours Disp #90 Tablet Refills:3 7. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl LEFT EYE [Hospital1 ] RX bacitracin-polymyxin B 500 unit-[Unit Number ],000 unit/gram twice a day Disp #2 Tube Refills:1 8. Darunavir 800 mg PO DAILY RX Prezista 400 mg daily Disp #60 Tablet Refills:3 9. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg once a day Disp #30 Tablet Refills:3 10. Nicotine Patch 21 mg TD DAILY RX nicotine 21 mg/24 hour once a day Disp #14 Pack Refills:3 11. ValGANCIclovir 900 mg PO DAILY RX Valcyte 450 mg once a day Disp #60 Tablet Refills:3 12. SulfADIAzine 1000 mg PO Q6H RX sulfadiazine 500 mg every six (6) hours Disp #60 Tablet Refills:3 13. Sodium Chloride 1 gm PO TID RX sodium chloride 1 gram three times a day Disp #42 Tablet Refills:3 14. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg once a day Disp #14 Capsule Refills:3 15. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg once a day Disp #14 Tablet Refills:3 16. Phosphorus 500 mg PO BID RX Phospha 250 Neutral 250 mg twice a day Disp #28 Tablet Refills:3 17. Sodium Bicarbonate 650 mg PO TID RX sodium bicarbonate 650 mg three times a day Disp #42 Tablet Refills:3 18. Azithromycin 1200 mg PO 1X/WEEK (TH) RX azithromycin 600 mg weekly on Thursday Disp #24 Tablet Refills:3 [Unit Number ] Disposition: Home [Unit Number ] Diagnosis: Primary diagnosis: toxoplasmosis encephalopathy Secondary diagnosis: HIV - AIDS, CMV retinitis, immune reconstitution inflammatory syndrome, hyponatremia, likely secondary to SIADH +/- cerebral salt wasting, renal tubular acidosis, anemia of chronic disease, polysubstance abuse [Unit Number ] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [Unit Number ] Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital for headaches and found to have a brain mass causing swelling. We believe this mass is most likely due to an infection called toxoplasmosis. We have started you on medications for this. Please continue to take them until further recommendations from the infectious disease clinic. While hospitalized, we also monitored your labs in your blood. Be sure to stay hydrated and take acetominophen if you develop a fever. You are to follow-up with both your primary care physician (Dr.[Last Name (STitle) 110662]) and in [Hospital ] clinic. We also restarted you on HIV HAART medications. Your CD4 count is extremely low and this likely contributed to your development of the toxoplasmosis. We also started you on weekly azithromycin prophylaxis in hopes of protecting you from further infections. It is EXTREMELY important that you continue on these medicines and follow up in [Hospital3 6616]. Moreover please consider strongly avoiding drug use of all kinds as this will not only increase your infection risk, decrease your likelihood of taking you medication, but also will eventually kill you. Followup Instructions: PCP [Name Initial (PRE) 7274]: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. Appt: [7-21] at 11am Location: [Hospital ] Medical Group Address: [Apartment Address(1) 110663], [Hospital1 ],[Numeric Identifier 59034] Phone: [Telephone/Fax (1) 110664] . Department: [Hospital3 1935] CENTER When: MONDAY [2179-7-26] at 1:15 PM With: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . RENAL Department: WEST [Hospital 2002] CLINIC When: MONDAY [2179-8-16] at 2:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage . INFECTIOUS DISEASE/HIV Dr. [Last Name (STitle) 72851] Appt: [2179-9-7] at 1PM [Apartment Address(1) 110665] [Hospital1 189], [Numeric Identifier 41087] Office phone: [Telephone/Fax (1) 67306] Appointment line: [Telephone/Fax (1) 110666] [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2179-7-16]	[ "363.20", "287.49", "070.54", "276.4", "995.90", "486", "042", "285.29", "305.50", "588.89", "427.89", "305.1", "253.6", "288.60", "292.0", "780.52", "348.39", "112.84", "305.60", "348.5", "V15.81", "078.5", "130.0", "518.81", "787.91" ]	icd9cm	[ [ [] ] ]	[ "14.79", "45.25", "99.29", "96.71", "38.93" ]	icd9pcs	[ [ [] ] ]		10010, 10847	340, 424		4935, 9987	22226, 23642	3380, 3418						17972, 20558										3433, 4888																						276, 302		10862, 15528						452, 2663			20627, 20869		15545, 17946		20577, 20606			20884, 22203					2685, 2913	2929, 3364
42,583	194,413	24602	Discharge summary	report	Admission Date: [2164-2-3] Discharge Date: [2164-2-7] Date of Birth: [2118-5-26] Sex: M Service: CARDIOTHORACIC Allergies: Pollen/Hayfever Attending:[First Name3 (LF) 5790] Chief Complaint: Right upper lobe nodule Major Surgical or Invasive Procedure: [2164-2-3] Right video-assisted thoracoscopic surgery, pneumolysis, and lung biopsy. History of Present Illness: Mr. [Known lastname 62107] is a 45 year old Caucasian male with history of stage III esophageal cancer s/p MIE by Dr. [Last Name (STitle) ] on [2162-11-5] after adjuvant chemoradiation therapy. He had local recurrence and was/p chemo and radiation by [2161-1-29]. On CT chest from [2163-11-3] he was found to have a new 1.8 x 1.0 cm nodule within the right lung apex, which was FDG avid by PET CT on [2164-1-5] with SUV max of 15.9. He had MRI brain on [2164-1-15] with negative brain metastasis but a C4 lesion not completely visualized in the neck, with recommended MRI cspine for further imaging. PET CT did not reveal any neck avididity. The patient denies shortness of breath or any other issues. He is scheduled to follow up with his cardiologist for his dilated aorta. Past Medical History: Stage III esophageal cancer s/p MIE [2162-11-5] after adjuvant chemoradiation therapy. Diverticulitis w/ colovesicle fistula s/p repair, Ventral Hernia, Dilated aortic root Marfans Traits Tonsil and adenoidectomy Social History: lives with wife and 2 daughters. Employed by [Company 33655] Family History: Maternal grandfather died of squamous cell esophageal cancer at age [Age over 90 ]. Maternal aunt had breast cancer. His mother has melanoma. His paternal uncle and a paternal grandmother had [Name2 (NI) 499] cancer. His eldest daughter has a [Name (NI) 62108] syndrome and [Last Name (un) 62109] syndrome. She was initially found to have aortic root dilation and carried the FBN1 gene, which lead to identification of these problems in Mr. [Known lastname 62107] as well. Physical Exam: VS: afebrile HR SR 80's BP 130/70 Sats 96% RA General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR Resp: decreased breath sounds on right faint crackles at base. left clear GI: bowel sounds positive, soft non-tender large ventral hernia Incision: Right VATs site clean dry intact Neuro: Non-focal Pertinent Results: [2164-2-5] WBC-6.5 RBC-3.75* Hgb-10.9* Hct-33.1 Plt Ct-211 [2164-2-3] WBC-11.9# RBC-4.39 Hgb-13.5* Hct-38.8 Plt Ct-252 [2164-2-5] Glucose-99 UreaN-12 Creat-0.9 Na-134 K-4.2 Cl-101 HCO3-27 [2164-2-4] Glucose-138* UreaN-18 Creat-1.1 Na-136 K-4.7 Cl-102 HCO3-23 [2164-2-3] Glucose-164* UreaN-22* Creat-1.1 Na-135 K-5.3* Cl-102 HCO3-24 [2164-2-7] Calcium-8.8 Phos-4.5# Mg-1.8 [2164-2-5] Calcium-8.5 Phos-2.7 Mg-1.8 Chest xray: [2074-2-6] Status post chest tube removal. Pleural effusions are stable. Small locules of air at the right apex and linearly at the right base laterally, at the site of chest tube entry, likely reflect small locules of pleural air. No large pneumothorax. [2164-2-6] There is no change in the right apical opacity as well as in the position of the two right chest tubes. The left subclavian line tip is at the level of superior SVC. Lungs are essentially clear. Small bilateral pleural effusions are present. 3/7/10Two right apical chest tubes are present. Since the patient has gone to water seal, there has been mildly increased right apical pneumothorax with fluid at the right apex. There is increased density in the right lung with possible mild volume loss. The left lung is relatively clear. Left subclavian catheter terminates at the superior vena cava. There is a small left-sided pleural effusion with left lower lobe atelectasis. There is minimal atelectasis at the right lung base as well. Heart and mediastinum are within normal limits. Brief Hospital Course: Mr. [Known lastname 62107] was admitted on [2164-2-3] where he was taken to the operating room on [2164-2-3] for right upper lobe wedge resection. Due to right upper lobe apical wall invasion, a biopsy was performed. His chest tube remained water-seal for a right apical pneumothorax which resolved. The chest tube was removed and [2164-2-7]. He was discharged to home and will follow-up with Dr. [Last Name (STitle) 3274] 0n [2164-2-14]. Medications on Admission: nexium 40mg po daily, atenolol 50mg po daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 4. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Right upper lobe mass invading right apical chest wall. Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Call Dr. [Last Name (STitle) 62110] office [Telephone/Fax (1) 2348] if you experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Incision develops drainage -Chest tube dressing remove Wednesday cover site with a bandaid. -You may shower on Wednesday. No tub bathing or swimming for 2 weeks -No driving while taking narcotics Followup Instructions: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[0-0-] Date/Time:[2164-2-14] 1:30 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 24]. Completed by:[2164-2-7]	[ "198.89", "327.23", "759.82", "562.10", "V10.03", "E878.8", "519.19", "197.0", "530.81", "553.20", "512.1", "493.90", "511.0" ]	icd9cm	[ [ [] ] ]	[ "33.99", "33.20" ]	icd9pcs	[ [ [] ] ]	5017, 5023	3980, 4446	304, 395	5123, 5123	2443, 3957	5671, 5927	1568, 2065		4541, 4994		5044, 5102		4472, 4518				5271, 5648						2080, 2424																						241, 266								423, 1229										5138, 5247					1251, 1469	1485, 1552
5,136	151,912	238+55197	Discharge summary	report+addendum	Admission Date: [2189-12-1] Discharge Date: [2189-12-11] Date of Birth: [2123-2-13] Sex: M Service: VSU CHIEF COMPLAINT: Chronic right ankle infection with unstable joint. HISTORY OF PRESENT ILLNESS: This is a 66-year-old male with a nonhealing right malleolar wound and fracture for the last 2 years who underwent a right ankle traction and open reduction internal fixation. The patient has had multiple admissions for wound infections and multiple IV antibiotic courses. Most recent admission was [2189-9-28], for a wound infection. The patient recently complained of a temperature elevation on [2189-11-30], and now is to be admitted to Dr.[Name (NI) 1392] service for continued IV antibiotics. The patient initially was discharged on daptomycin and followed by VNA. PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, endstage renal disease secondary to diabetes, status post cadaver transplant in [2182], history of coronary artery disease, status post CABG in [2178], history of peripheral vascular disease, right ankle fracture in [2188-6-6], with an open reduction internal fixation, status post hardware removal, chronic osteomyelitis. ALLERGIES: No known drug allergies. MEDICATIONS: Percocet, dicloxacillin 100 mg twice a day, gabapentin 1600 mg twice a day, Lasix 20 mg twice a day, Sensipar 30 mg daily, metoprolol 25 mg daily, ranitidine 150 mg daily. There are two other medications that the patient is on, of which the handwriting is not decipherable at this time. SOCIAL HISTORY: The patient is a nonsmoker, is married and lives with his spouse. PHYSICAL EXAMINATION: Vital signs 94.6, 94, 18, blood pressure 144/88, oxygen saturation 93% in room air. Blood sugar fingerstick was 291 on admission. General appearance: Alert, cooperative white male in no acute distress. HEENT exam: Mild right eye ptosis. Neck is supple without lymphadenopathy or carotid bruits. Lungs are clear to auscultation bilaterally. Chest is with a well healed median sternotomy incision. Heart is a regular rate and rhythm with a systolic ejection murmur II/VI, nonradiating. Abdomen is soft, nontender, obese. Extremities: Right malleolus with punctate lesion with draining and surrounding erythema. Pulse exam shows palpable radial pulses, femoral pulses bilaterally. The right DP and PT are dopplerable signals. The left DP and PT are dopplerable signs. Neurological exam is nonfocal. HOSPITAL COURSE: The patient was admitted to the vascular service. His dicloxacillin was continued. Vancomycin and Flagyl were instituted. He was continued on his preadmission medications. He was seen by Dr. [Last Name (STitle) 1391] and advisement was made for him to undergo a below the knee amputation. The patient accepted the recommendation. Transplant nephrology was consulted to follow the patient during his hospitalization. [Last Name (un) ] was consulted for hyperglycemic management. Daily SK5 levels were obtained. He required minimal adjustment in his immunosuppression. He continued on his Lantus with a Humalog sliding scale with improvement in his glycemic control. On [2189-12-3], he underwent a right BKA without incident. He was transferred to the PACU in stable condition. At the end of his surgical procedure intraoperatively, the patient became hypotensive with systolic blood pressure in the 60s and he was given Neo 200 mcg x2 and epinephrine 5 mg x2. The patient went into a monomorphic VT 4 minutes at a rate of 130. He was given lidocaine 100 mg IV bolus and amiodarone 125 mg over 15 minutes. The patient converted to sinus rhythm. An intraoperative TEE showed severe biventricular failure. Dopamine was started at 5 mcg/kg/minute. Blood pressure improved. He was transferred to the PACU and then to the ICU for continued care. Serial enzymes were obtained. Repeat echo was obtained on the 28th which demonstrated left ventricular wall thickness and cavity dimensions were obtained by 2-D images. He has severely depressed left ventricular ejection fraction. He had multiple regional wall motion abnormalities. His aortic valve was moderately thickened leaflets. There were no masses or vegetations on the aortic valve. No aortic insufficiency. The mitral valve, tricuspid valve were normal with trivial MR [First Name (Titles) ] [Last Name (Titles) ]. The pulmonic valve and artery were unremarkable. The pericardium showed no pleural effusion. Aortic valve area was calculated at 1.3 cm squared, normal is 3 cm squared. Gradient peak was 32 mm. There was no intracardiac thrombus noted on the primary or the secondary echo. The ejection fraction was calculated at 30% to 40%. IV heparin was begun to maintain a goal PTT between 40 and 60. The patient's Dobutamine was weaned with hopes to extubate. Pulse exam remained unchanged. The right amputation site was clean dry dressing. He remained on bedrest in the SICU. Cardiac enzymes: Base was 20, peaked at 96 for the CK. CK MBs were not obtained. His troponins were 0.01 and 0.03. The patient's Swan was converted to a CVL on [2189-12-4]. The patient continued on heparin, was extubated and transferred to the VICU for continued monitoring and care on [2189-12-5]. Cardiology was requested to see the patient on [2189-12-6], who felt the patient was hemodynamically stable and his atrial fibrillation was rate controlled. We should continue the heparin while his INR is less than 2 and his goal INR should be [1-9], and recommend metoprolol tartrate twice a day versus single dosing. They recommended aspirin 81 mg and simvastatin 20 mg daily. Hyperglycemia control remained relatively good. He did not require adjustment in his Lantus. His premeal coverage was adjusted. Vancomycin, ciprofloxacin and Flagyl were discontinued on [2189-12-7]. The patient remained afebrile. Foley was discontinued. Peripheral line was placed and the central line was discontinued. The patient had been advanced to a regular diet and ambulation to chair was begun. On [2189-12-8], postoperative day 5, the patient continues on IV heparin/Coumadinization conversion. Serial coags were monitored. Physical therapy will see the patient and make recommendations regarding disposition planning, being a new amputation if he will go to rehabilitation. Will talk to infectious disease, Dr. [Last Name (STitle) 2379], regarding discontinue the doxycycline. The remaining hospital course, the patient will be discharged when medically stable and bed available at rehabilitation. At the time of discharge, discharge medication instructions will be dictated. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2189-12-8] 11:23:20 T: [2189-12-8] 14:38:59 Job#: [Job Number 2383] Name: [Known lastname 229],[Known firstname ] F. Unit No: [Numeric Identifier 230] Admission Date: [2189-12-1] Discharge Date: [2189-12-10] Date of Birth: [2123-2-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 231] Addendum: [Date range (1) 232]/07 continued to progress. dicloxcilllin dicontinued. antibiotics distontinued. glycemic control required multiple adjustments to insulin dosing. current regment patient's controll much improved. d/c to rehab. stable. wounds clean dry and intact. Medications on Admission: same except for new meds: amidarone quinepate Discharge Medications: 1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 11. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 16. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day. 19. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 20. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS PRN () as needed for agitation. 21. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 22. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime: 40 units. 23. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: AC scale: glucoses <120 / no insulin glucoses 121-160/10u glucoses 161-200/12u glucoses 201-240/14u glucoses 241-280/16u glucoses 281-320/18u glucoses 321-360/20u glucoses > 320 [Name8 (MD) 233] Md [First Name (Titles) 234] [Last Name (Titles) 235]: glucoses < 200 no insulin glucoses 201-240/2u glucoses 241-280/4u glucoses 281-320/6u glucoses 321-360/8u glucoses >360 [Name8 (MD) 233] Md. Discharge Disposition: Extended Care Facility: [Hospital6 41] - [Location (un) 42] Discharge Diagnosis: aortic stensois by ECHO chronic unstable infected rt. ankle joint postop ventricular tacycardia with hypotnesion requiring vassopressor and inotropic support, converted to NSR with amidarone and lidocaine history of PVD histroy of HTN history of DM2 with neuropathy history of ESRD ,s/p cadveric renal transplant history of coronary artery disease with,s/p CABG's [2178] Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 233] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: SBE prophlaxsis for dental procedure or invasive tests no stump shrinkers Followup Instructions: 3-4 weeks Dr. [Last Name (STitle) ]. call for appointment [Telephone/Fax (1) 236] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2189-12-10]	[ "731.8", "250.80", "424.1", "357.2", "730.17", "250.60", "250.50", "427.31", "583.81", "362.01", "250.40", "427.1", "458.29", "997.1", "V42.0" ]	icd9cm	[ [ [] ] ]	[ "84.15", "88.72" ]	icd9pcs	[ [ [] ] ]	9760, 9830			10248, 10257		10498, 10748			7638, 9737		9851, 10227		7568, 7615	2472, 4921			10281, 10475																			1657, 2454							4938, 7542		155, 207								236, 819															842, 1550	1567, 1634
12,706	124,795	11060	Discharge summary	report	Admission Date: [2112-9-25] Discharge Date: [2112-10-19] Date of Birth: [2049-9-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5368] Chief Complaint: Syncopal episode Major Surgical or Invasive Procedure: Tunnelled Cath [First Name3 (LF) ] Line placement History of Present Illness: 62 yo F w/ h/o DM w/ past admissions for DKA, CAD s/p 5 V CABG, ESRD on HD, and h/o MRSA UTI ([8-30]) admitted s/p syncopal episode, found to be in DKA. Patient reports she underwent HD today and then fell asleep. When she awoke she syncopized upon standing up. No preceding sx but she has been c/o SSCP since arrival of EMS and it is now constant. She got no relief w/ 2 SL NTG + [Month/Year (2) ] in the ED. Her EKG was remarkable for [Street Address(2) 4793] dep in V4-6. She has a h/o MI but cannot tell me if this pain is similar to her MI in the past. She reports the CP is exertionally related but is a poor historian. Of note, she has been N/V, not taking po, and not taking her insulin for the past 2 days. She reports F 101 at home. She does feel worse at HD and reports rigors w/ HD lately. She has a tunneled line in her right chest but doesn't know when that was placed. She also reports h/o foul smelling urine w/o dysuria. She only makes about 4 oz urine/day. On further ROS she reports + LH recently. No sick contacts. (+) nonproductive cough x mos. (+) diarrhea x 1 month - w/ cramps but no blood. No h/o antibx w/in past 3 months. Past Medical History: 1. s/p banding of AV fistula [10-30] 2. s/p EGD [8-29] mild duodonitis, gastritis, esophageal candidiasis, [Doctor First Name 329] [Doctor Last Name ] tear 3. IDDM 25yrs, hx DKA/ neuropathy/ nephropathy 4. ESRD on HD 5. CAD s/p 5v CABG [2103]- cath [8-30] sever native 2v CAD presumed total occl of SVG-D1- echo [8-30] EF 55% 1+MR- PMIBI [2-29] no rev defects 6. diastolic CHF EF 55% 7. HTN 8. hyperchosterolemia (no statin [12-30] lft abn) 9. fibroids 10. PVD s/p L CEA 11. pubic ramus fx [12-30] 12. hx MRSA UTI 13. s/p CCY 14. hx pleural effusions tapped [12/2110] after rll pulm mass seen on CT- negative serologies 15. h/o pancreatitis [7-31] Social History: She has a 100 pack year smoking history, and continues to use tobacco. She only drinks alcohol occasionally. She lived with mother who died this past [Name (NI) 547]. She has 2 children, but is divorced. Family History: Father died of myocardial infarction at the age of 65. Her mother had a heart attack and had cardiac surgery in [2101]. No history of cancer, strokes or liver or kidney disease. Physical Exam: On admit to hospital: T:96.9 80 159/52 22 99% on 2L NC Gen: Ill appearing, weak, vomitting 200cc brown fluid during exam HEENT: PERRLA (3 to 2mm), sclera anicteric, dry MM Neck: no jvd CVS: RRR, no m/r/g Pulm: R tunneled cath, crackles at left base, some diffuse expiratory wheeze Abd: +BS, tender RLQ and RUQ, NR/gaurding, No mass/[Last Name (un) ] Ext: no c/c/e neuro: a&ox3, maew Pertinent Results: [2112-9-24] 09:24PM PT-12.2 PTT-25.4 INR(PT)-1.0 [2112-9-24] 09:24PM WBC-12.6# RBC-3.96 HGB-13.6 HCT-44.3 MCV-112# MCH-34.2 MCHC-30.6* RDW-14.7 [2112-9-25] 12:14AM ACETONE-LARGE [2112-9-25] 12:14AM ALBUMIN-3.6 CALCIUM-7.6* MAGNESIUM-2.3 [2112-9-25] 12:14AM CK-MB-NotDone cTropnT-0.21* [2112-9-25] 12:14AM ALT(SGPT)-15 AST(SGOT)-15 CK(CPK)-67 ALK PHOS-207* AMYLASE-52 TOT BILI-0.4 [2112-9-25] 12:14AM GLUCOSE-1214* UREA N-50* CREAT-3.5# SODIUM-128 POTASSIUM-6.2* CHLORIDE-77* TOTAL CO2-5* ANION GAP-52* [2112-9-25] 01:04AM GLUCOSE-ABOVE ASSA LACTATE-4.0* [2112-9-25] 01:31AM K+-5.4* [2112-9-25] 01:31AM PO2-138* PCO2-18* PH-7.14* TOTAL CO2-6* BASE XS--21 COMMENTS-NONE SPECI [2112-9-25] 03:07AM CALCIUM-7.3* PHOSPHATE-7.0# MAGNESIUM-2.1 [2112-9-25] 03:07AM GLUCOSE-951 UREA N-55* CREAT-3.9* SODIUM-133 POTASSIUM-4.4 CHLORIDE-84* TOTAL CO2-11* ANION GAP-42* [2112-9-25] 03:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2112-9-25] 06:00AM OSMOLAL-338* [2112-9-25] 07:55AM OSMOLAL-320* [2112-9-25] 06:00AM GLUCOSE-650* UREA N-48* CREAT-3.7* SODIUM-138 POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-15* ANION GAP-33* [2112-9-25] 07:55AM GLUCOSE-404* UREA N-47* CREAT-3.7* SODIUM-140 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-19* ANION GAP-28* [2112-9-25] 10:33AM GLUCOSE-156* UREA N-46* CREAT-3.9* SODIUM-141 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-23* [2112-9-25] 12:20PM GLUCOSE-49* UREA N-47* CREAT-4.0* SODIUM-142 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20 [2112-9-25] 05:01PM GLUCOSE-129* UREA N-49* CREAT-4.2* SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-21* [2112-9-25] 07:55AM LIPASE-517* CHEST PORT. LINE PLACEMENT [2112-9-25] 1:52 AM CHEST PORT. LINE PLACEMENT Reason: confirm line placement [Hospital 93] MEDICAL CONDITION: 62 year old woman with chest pain, SOB, N/V. Please r/o infiltrate. REASON FOR THIS EXAMINATION: confirm line placement HISTORY: Chest pain, shortness of breath, nausea and vomiting. Confirm line placement. COMPARISON: [2112-9-24]. UPRIGHT AP VIEW OF THE CHEST: There has been interval placement of a left subclavian central venous catheter with tip in the superior vena cava. No pneumothorax is demonstrated. Cardiac and mediastinal contours are unchanged. The patient is status post median sternotomy and CABG. Right subclavian central venous catheter remains in stable position. The lungs are clear. The pulmonary vascularity is normal. There are no effusions. Stable biapical pleural thickening is again seen. Fracture of the right sixth posterior rib is again noted. IMPRESSION: Satisfactory placement of left subclavian central venous catheter without evidence of pneumothorax. RADIOLOGY Final Report PORTABLE ABDOMEN [2112-9-28] 2:40 AM PORTABLE ABDOMEN Reason: Eval please for free air, obstructive pattern [Hospital 93] MEDICAL CONDITION: 62 year old female with DM, ESRD, HD dependent, admitted with DKA, now with worsening abdominal pain REASON FOR THIS EXAMINATION: Eval please for free air, obstructive pattern INDICATION: 62-year-old woman with diabetes and worsening abdominal pain. Evaluate for free air. ABDOMEN SINGLE VIEW: There is no free air. There is normal bowel gas pattern. The patient is status post cholecystectomy. A feeding tube is in place. RADIOLOGY Final Report MR RECONSTRUCTION IMAGING [2112-10-2] 3:17 PM MRCP (MR ABD W&W/OC); MR CONTRAST GADOLIN Reason: eval for etiology of pancreatitis Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 63 year old woman with resolving DKA, pancreatitis of unknown etiology REASON FOR THIS EXAMINATION: eval for etiology of pancreatitis MRI FO THE ABDOMEN WITH AND WITHOUT CONTRAST (MRCP PROTOCOL), DATED [2112-10-2] CLINICAL HISTORY: 63-year-old woman with resolving BKA, pancreatitis of unknown etiology. TECHNIQUE: In- and out-of-phase T1, HASTE, 2D time-of-flight, and pre- and post-gadolinium dynamic sequences were performed at 1.5 Tesla using a non- breath-hold technique. Images were reformatted on a separate workstation. COMPARISON: Comparison is made to prior abdominal MRI dated [2111-2-22]. FINDINGS: Study is somewhat limited due to non-breath-hold technique. The intra- and extrahepatic biliary ducts are normal in diameter, without evidence for filling defect. Normal pancreatic duct anatomy is identified and there is no duct dilatation. The pancreas is normal in signal without evidence of a focal mass. Both the liver and spleen are decreased in signal on long TE sequences suggesting iron deposition. No focal liver lesions are identified. The patient is status post cholecystectomy. The spleen is normal in size. Adrenal glands are normal. There are several bilateral simple cysts, measuring up to 2.8 cm in diameter. Note is made of a 1.4 cm hemorrhagic cyst in the left kidney. The visualized bowel is normal. IMPRESSION: 1. Normal-appearing pancreas and pancreatic duct. No intra- or extrahepatic biliary dilatation. 2. Iron deposition within the spleen and liver. Question if patient has received multiple transfusions in the past. [2112-10-8] CHEST (PA & LAT) Reason: ? pneumonia vs edema [Hospital 93] MEDICAL CONDITION: 62 year old woman with diastolic HF N/V, SOB, worsening cough cough and O2 requirement, with increasing WBC REASON FOR THIS EXAMINATION: ? pneumonia vs edema CHEST TWO VIEWS, PA AND LATERAL History of shortness of breath with worsening cough and oxygen requirement. Status post CABG. Double-lumen right CV line is in distal SVC and at cavoatrial junction. No pneumothorax. Heart size is normal. Lungs are clear and there are no pleural effusions. IMPRESSION: No evidence for CHF or pneumonia. No pneumothorax. DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Approved: SUN [2112-10-9] 7:34 AM [2112-10-11] RADIOLOGY Final Report CHEST (PORTABLE AP) [2112-10-11] 6:51 PM CHEST (PORTABLE AP) Reason: need CXR now [Hospital 93] MEDICAL CONDITION: 62 year old woman with coffee ground emesis--unresponsive REASON FOR THIS EXAMINATION: need CXR now INDICATION: History of coffee-ground emesis and unresponsive. Evaluate for abnormality. COMPARISON: Study from [2112-10-8]. PORTABLE AP CHEST RADIOGRAPH: The lung fields are clear. The heart size and mediastinal contours are stable in appearance. Again seen is a double-lumen central venous catheter, with the tip positioned in the right atrium, unchanged from prior study. No pneumothorax or pleural effusions are seen. The soft tissue and osseous structures are stable. IMPRESSION: No interval change. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 5650] [Name (STitle) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 2601] Approved: TUE [2112-10-11] 10:38 PM [2112-10-11] EKG Sinus tachycardia Left ventricular hypertrophy with ST-T abnormalities Precordial T waves are peaked - clinical correlation is suggested for possible hyperkalemia Since previous tracing of the same date, sinus tachycardia rate faster and further ST-T wave changes present [2112-10-17] Echo Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include lateral wall hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [2112-10-21] Tunnelled Cath placement by IR IMPRESSION: Successful placement of 14.5 French 23 cm cuff to tip tunneled [Month/Day/Year 2286] catheter via right IJ access with tip in the right atrium. The line is ready for use. Brief Hospital Course: #. DKA - Patient was admitted to MICU with blood glucose 0f 1214 and anion gap of 46, consistent with severe DKA. On presentation, precipitating factor was initially unknown. The patient was known to be non-compliant with her home medications, which was the most likely inciting factor for her decompensation. However, initial concern on presentation as well for infection as well as cardiac ischemia given chest pain on presentation. The patient did have a mild leukocytosis to 12.6 on admission but no obvious locus of infection. The patient did however have a troponin leak which continued to rise over a number of days with an elevated CK-MB fraction as well, making cardiac ischemia a potential precipitating factor (in addition to medical non-compliance). The patient was started on an insulin drip and hyrated aggressively with electrolyte repletion as needed. However, as the patient is ESRD on HD, hydration was discontinued as per [Month/Day/Year ]'s recs after volume replacement. Over the course of a few days the patient's gap has narrowed to as low as 12. The patient has a persistent small gap attributable likely to her organic acidosis given her [Month/Day/Year ] failure. The patient historically has had poor glucose control. Currently, she is receiving sliding scale insulin with am and pm NPH with adequte but imperfect glucose control and will require ongoing titration of diabetes meds. . On arrival to the floor the pt had a persistent AG but no ketones in the urine. This gap was attributed to her [Month/Day/Year ] failure. She was noted to have a delta delta with her alkalosis attributable to vomiting. She also had poor sugar control throughout her stay. After being transferred from the MICU she was placed back on her home regimen of daily lantus. Her sugars continued to be erratic. This was partially due to inherent problems but also iatrogenic problems created by her highly variable BS. The pt was given IVF containing glucose [12-30] hypogelcemia and as a result ran hyperglycemic on several occassions. She also had her lantus held on one occassion [12-30] hypoglycemia and this resulted in her being hyperglycemic the following day. The pt was followed by [Last Name (un) ] throughout her stay, and they increased her lantus to 12U qhs and maintained her on SS humalog. [Last Name (un) ] recently stated that postprandial hyperglycemia should be treated with bedtime insulin dosing because pt. has tendency to stack insulin and experience delayed hypoglycemia. Once her diet was advanced, her sugar control improved on this regimen. . On [2112-10-15] the pt was found to have a BG of 623, but no gap. The pt was managed aggressively on the floor, with care taken to avoid stacking insulin doses which has caused subsequent overshoot and hypoglycemic episodes in the past. The pt received Q2hr fingersticks throughout the night and responded well to humolog and glargine dosing with normalized blood glucose levels. . #. N/V - On presentation patient reported abdominal pain and had an elevated lipase. Over the course of a few days her amylase and lipase continued to rise and she reported ongoing abdominal pain and nausea for which she was kept NPO, hydrated cautiously as above and monitored. In the MICU these signs symptoms were attributed to acute pancreatitis. The patient had a Doboff feeding tube placed post-pyloric by IR and feeding was initiated. The patient tolerated jejunal feeding without increased abdominal pain or bump in enzymes. Her amylase and lipase have since peaked and subsequently began trending down. . However, when her diet was advanced to clears her N/V returned, and her A/L increased. A KUB showed no evidence of obstruction or performation. With bowel rest, the pt's A/L again trended downward and several attempts were made to advance her diet. These were unsuccessful as the pt continued to experience N/V and abdominal pain despite resolution of her abdominal pain. At this time a MRCP was performed to identify any ongoing inflammation of the pancreas. It showed no evidence of pancreatitis, and therefore the GI service was consulted to help identify the source of the pt's N/V. They indicated that the elevated A/L were likely [12-30] the pt's DKA and not an episode of pancreatitis. They also recommended resuming her standing reglan to help with her gastroparesis. This medication had been held in the MICU [12-30] the pt's ongoing diarrhea. Upon resumption of IV reglan, the pt's symptoms improved. Her diet was advanced to clears. After tolerating this for several days, she received a swallow study that showed no signs of aspiration. Therefore, her diet was advanced further to regular consistency foods. On [2112-10-11] the pt. had an acute episode of 60cc coffee ground emesis. The medical team was called to the bedside and within 30 sec of arrival, the pt was unconscious and unresponsive. The pt was noted to be markedly hypoxic at 73% on NRB, tachy at 104, resps at 24 and BP at 180/70. The pt was noted to have rales half way up bilaterally, but CXR revealed no consolidations. Approximately 500cc coffee ground emesis, clots and BRB were suctioned through NGT. Pt slowly regained consciousness and after suctioning, the pt's O2 sats climbed to 100% on NRB. EKG showed nl sinus tach at 140 and ? ST 1mm elevation in v1-v3 and depression v5-6. With this event, the pt's hx of [Doctor First Name ]-[Doctor Last Name ] tear and the pt's NSTEMI toward the beginning of this hospital course, the pt. was transferred to the MICU. GI was also consulted but felt no emergent need for EGD at this time considering there was no fresh blood on NG lavage. . The pt was subsequently placed on Protonix [Hospital1 ] and had her hct followed closely to be kept above 30. The pt. also had a cortisol stim test and passed. The patient remained stable throughout her time in the MICU with no further evidence of GI bleeding. The pt' also ruled out for having an MI during her [Doctor First Name ]-[Doctor Last Name ] tear event. The pt. was therefore deemed stable enough for transfer back to the floor on [2113-10-13]. . #. NSTEMI - On admission, patient had troponin of .21 which increased to 2.07, consistent with cardiac ischemia although difficult to interpret in setting of HD dependent [Date Range ] failure. However, the patient's CK-MB fraction also was elevated peaking at 12.1, now resolving, consistent with NSTEMI. The patient was medically managed and therapy with Aspirin, 325mg po qd and metoprolol was started. Patient was seen by Cardiology who recommended , restarting her ACE inhibitor prior to transfer. During her stay the pt c/o intermitent nonradiating CP, not assoc c SOB/N/V/diaphoresis. EKGs showed no ischemic changes. She was given nitro sl c relief of her chest pain. During the next week of her stay, her chest pain did not return. . On [2112-10-11], the pt was noted to have new EKG changes with lateral depressions during her event of hematemesis. Her CE's were followed and were all negative except for a seemingly down-trending troponin from previous elevation. The pt. was therefore felt to have had a transient event of demand ischemia in the setting of her [Doctor First Name ]-[Doctor Last Name ] tear creating the new lateral ST depressions seen on her EKG. #. ID - On admission, the patient had a mild leukocytosis and fever, which in the setting of DKA, was concerning for an ongoing infectious process. The patient was initially covered with Vancomycin and ciprofloxacin although patient was without definite locus of infection. Blood and urine cultures were sent. Chest film did not demonstrate any obvious cardiopulmonary disease and although the patient reported RUQ pain, the patient is s/p cholecystectomy, thus ruling out any gallbladder pathology. Antibiotics were discontinued as the patient remained afebrile without a source of infection. However, ampicillin was temporarily started with report of gram positive rods growing from blood culture. However, as only 1 bottle of 6 grew any bacteria, it was thought likey that the growth reflected contamination than bacteremia and amp was discontinued. Speciation and sensitivity of the GPR is currently pending. The patient reports she has had ongoing diarrhea as well, but denies that it is cramping or painful in nature. Stool C. Diff was negative times one. She was briefly started on IV flagyl as empiric cocverage for C diff. However, the pt's diarrhea resolved after several days and so further C diff studies were not sent and flagyl administration was discontinued. . The pt's leukocytosis improved and then returned after one week. The pt remained afebrile and hemodynamically stable. There was no obvious source for infection. There was concern for aspiration pna and so several CXRs were performed. None of these showed evidence of pna. Blood cultures were without growth. A UA was obtained that showed multiple bacteria and WBCs. The pt has h/o of 2 past MRSA UTIs, but initial culture was negative with a second culture collected this morning ([10-10]). ID fellow was consulted and an extended course of cipro was begun and is to be continued pending repeat culture growth--pt. has been asymptomatic and afebrile. If culture grows organism not covered by cipro, antibiotic regimen should be modified. On [2112-10-11], pt was noted to have low grade fever and rigors at [Date Range 2286]. The pt. was started on vanco and ctx for concerns of possible line sepsis. The pt. was cultered and 6/6 bottles grew out gram positive cocci, so the transplant surgery team was asked to remove the pt's HD permacath and place a temprorary femoral cath. The blood cultures eventually showed MRSA bacteremia, and therefore here catheter was pulled and a temporary catheter was placed. The pt was continued on the proper dosing of vanco by monitored trough levels. The pt. resumed HD after 72 hours of negative survallence blood cx's. Eventually, a permenant tunnelled catheter was placed. . #. CHF - Patient with history of diastolic heart dysfunction. Patient with evidence occasionally of mild fluid overload as evidenced by rales on pulmonary exam although peripherally she did not demonstrate edema. Patient's volume status was controlled predominantly by [Date Range ] team via [Date Range 2286]. Patientis is without large O2 requirements. Patient is received metoprolol and lisinopril with diuresis performed by hemodialysis. . #. ESRD - Patient receives hemodialysis on Tuesday, Thursday, Saturday. Patient has been receiving HD during admission with careful attention towards electrolyte status and volume status. . See above section of ID for discussion of pt's subsequent MRSA becteremia from line infection, subsequent permacath removal, vanco treatment, temprorary catheter placement and eventual tunnelled cath placement by IR after survaillence cultures were persistantly negative for an adequate amount of time. . #[Name (NI) 8407] Pt noted constant NP[MD Number(3) ] throughout her hospital stay. Multiple CXRs showed no evidence of pna. She was started on sugar free guafenisen c good relief of her symptoms. . #[Name (NI) 3674] Pt's Hct slightly below baseline. However, she was not transfused [12-30] concern for iron overload given her elevated ferritin. . #Depression - Pt noted to be very frustrated with her care. SW consulted and states that pt will benefit from emotional and coping support. Pt continued to appear aggressive, combative and depressed toward the ending of her hospital course, requesting to be discharged without any further procedures, including any procedure for perminant [Month/Day (2) 2286] access. Pt offerred anti-depressants to assist with her declining mental state, but refused. Pt was seen and evaluated by psychiatry who feel she does not have capacity to make her own decision to leave the hospital, and was therefore placed on a 1:1 sitter for her own safety. . On [2112-10-18], Dr. [Last Name (STitle) ] determined that the pt. could leave AMA after a legnthy assessment of the pt., including weighing risks and benefits of different options for aftercare. On [2112-10-19], the pt was deemed unsafe for home by PT as she is a high fall risk. The pt. insisted upon leaving at this time and was seen by the resident, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], who determined that the pt was currently cooperative and demonstrated good understanding of her condition. The pt. was able to state clearly the reason why the medical team feels it is unsafe for her to leave, the fact that she could fall and harm herself leading to bleeding/fracture/death, and the pt. continued to refuse acute rehab and persistantly insist on being discharged. HD was arranged per her normal outpt schedule, psychiatrist contact[Name (NI) ] and stated pt. competent for discharge AMA per his last eval. Pt therefore signed all discharged AMA forms, and [Name (NI) 269] PT was attempted to be set up, but [Name (NI) 269] refused as pt had already been deemed as unsafe for d/c home. Pt. subsequently left the hospital for home AMA. #Code [Name (NI) 13115] The pt communicated to her PCP her desire to be DNR/DNI in the event of a cardiac arrest. Medications on Admission: [Name (NI) ] 81mg QD Renagel 800 TID Isosorbide mononitrate 10mg TID Nephrocaps Protonix 40mg QD Lipitor 10mg QD Toprol 50mg QD Clonidine 0.2mg Qfriday Hydralazine 25mg po QD Colace 100mg [Hospital1 ] Glargine 10U QHS Humalog SS Albuterol PRN Lisinopril 80mg po QD Wellbutrin 150mg [Hospital1 ] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (): 12 hours on, 12 hours off. Disp:20 Adhesive Patch, Medicated(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:0 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED). Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Gastroparesis Anemia Cardiac Ischemia Congestive Heart Failure End Stage [Hospital1 2793] Disease Hypertension Diabetes MRSA bacteremia Discharge Condition: Improved. Pt leaving AMA. Discharge Instructions: Call your doctor if: You have shaking chills or a temperature over 101F. You see blood in your urine. Your symptoms do not improve in 3 days. You have nausea (upset stomach), are vomiting (throwing up), have diarrhea (loose watery bowel movements), or a rash. You have any new symptoms which may be caused by your medicine. Your UTI symptoms return after you finish taking your antibiotics. SEEK CARE IMMEDIATELY IF: You are vomiting (throwing up) so much that you cannot keep down any fluids or your medicine. You are so weak that you cannot stand up. You have signs of water loss from your body (dehydration). Not urinating as much as usual. More thirsty than usual. Dry skin and mouth. Feeling dizzy or light-headed. Your blood sugar is higher than 350. You have ketones in your urine. You have been vomiting for more than 1 hour and cannot keep liquids down. You have symptoms of DKA, like fruity-smelling breath, breathing faster or slower, or are very sleepy. You have chest pain. You have shortness of breath. You have trouble thinking clearly. You are too weak to stand up. Your chest discomfort does not go away after resting and taking your chest pain medicine as directed. You have new or worsening chest pain, tightness, or discomfort that lasts longer than 15 to 20 minutes. You have chest discomfort and feel lightheaded, dizzy, weak, or faint. You have chest discomfort and suddenly start sweating for no reason that you know of. You have nausea or vomiting with your chest discomfort. You have new or worsening trouble breathing. You lose feeling or movement in your face, arms, or legs, or suddenly feel weak. You suddenly have trouble thinking clearly, seeing, or speaking. You cough or vomit blood. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in the next 5 days. Call him at [Telephone/Fax (1) 250] to make an appointment.	[ "250.41", "530.7", "599.0", "585.6", "428.0", "414.01", "995.91", "403.91", "276.2", "410.71", "038.11", "V09.0", "250.11", "276.7", "428.30", "996.62", "577.0", "285.29", "583.81" ]	icd9cm	[ [ [] ] ]	[ "99.04", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	26484, 26490	11423, 24753	333, 389	26696, 26724	3152, 5078	28520, 28652	2546, 2730		25111, 26461	9302, 9360	26511, 26675		24779, 25088				26748, 28497						2745, 3133																						277, 295	9389, 11400							417, 1580															1602, 2301	2317, 2530
23,946	197,173	4541	Discharge summary	report	Admission Date: [2148-7-1] Discharge Date: [2148-7-8] Date of Birth: [2079-4-21] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 69-year-old woman with a past medical history of myopathy and restrictive lung disease requiring nightly BIPAP and multiple intubations in the past. The last admission was in [Month (only) 547] of this year for pneumonia and hypercarbic respiratory failure. She has a history of CO2 retention. According to her daughter, the patient presents with four to five days of confusion and fatigue with slurred speech consistent with the patient's past presentation for hypercarbia. Over the past 24 hours prior to admission the nursing home where she lives ([Hospital3 15416]) noted that her O2 saturations were lower than baseline. She was confused and having low grade temperatures. She also by report had systolic blood pressures to the 80s and had new onset atrial fibrillation where she was given Diltiazem in the field and converted to normal sinus rhythm. In the Emergency Department, she was noted to have a temperature of 101 degrees Farenheit with a blood pressure of 140/64, heart rate in the 80s to 100s, O2 saturation 90-92% on 100% non-rebreather. Her initial arterial blood gas was 7.25/135/65. She was started on BIPAP but her systolic blood pressure dropped to 65/21. She received 2 liter normal saline bolus with her systolic blood pressure going up to 99. Repeat arterial blood gas was 7.24/123/96. She was intubated and transferred to the MICU for further care. Of note, the patient had been on Cipro for a urinary tract infection for three days prior to admission. The patient's daughter reports she had not complained of pain, chest pain, shortness of breath, increased cough from her baseline or change from her baseline, or clear sputum production. There has been no nausea, vomiting, diarrhea, or headaches. PAST MEDICAL HISTORY: The past medical history revealed steroid-dependent myopathy diagnosed in [2145], possibly inclusion body myositis with restrictive lung disease. Her last pulmonary function tests in [2147-4-15] revealed an FVC of 65%, FEV1 71%, 1.29 liters, with a ratio of 109%. DLCO was slightly decreased which was felt to be consistent with a mild restrictive picture. Her baseline bicarbonate is 30-40 with baseline pCO2 probably in the 60s. She is on home O2 as well as evening BIPAP. The patient has a history of diabetes, hypertension, hypercholesterolemia, liver hemangioma, depression, and gastrointestinal bleed. SOCIAL HISTORY: There is no alcohol and no tobacco use reported. She lives in an [Hospital3 ] facility, [Hospital3 15416]. ALLERGIES: The patient has no reported drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature 96.8 degrees Farenheit, blood pressure 97/76, heart rate 106, O2 saturation 89-99%. In general, this is a sedated intubated woman in no apparent distress otherwise. HEENT was anicteric, PERLA. The neck was supple. JVD could not be assessed as she was lying flat. Chest examination revealed coarse breath sounds with rhonchi bilaterally auscultated anteriorly. Cardiac examination revealed irregularly irregular with no murmurs, rubs, or gallops appreciated, tachycardiac. The abdomen was soft, nontender, and nondistended with normal bowel sounds. The extremities revealed no cyanosis, clubbing, or edema. On neurologic examination, the patient was sedated. The toes were down-going bilaterally. She was moving all four extremities spontaneously. LABORATORY DATA ON ADMISSION: White blood cell count was 17.3 with hematocrit 39.5 and platelets 140,000 with 89 polys, 8 lymphocytes, 2 monocytes. Sodium was 140, potassium 3.4, chloride 94, bicarbonate greater than 45, BUN 22, creatinine 0.6, blood sugar 151. Urinalysis revealed 1.017, trace protein, 500 glucose, no red blood cells or white blood cells. Chest x-ray #1 showed a new basilar left lower lobe consolidation with no effusion. EKG #1 showed atrial fibrillation at 108 with left axis deviation, no Qs, no ST or T wave changes. EKG #2 revealed normal sinus rhythm at 86, left axis deviation with no ST or T wave changes. MEDICATIONS ON ADMISSION: Evista 60 mg p.o. q. day, Lasix 20 mg p.o. q. day, Mysoline 200 mg p.o. q. day, Neurontin 600 mg b.i.d. and 300 mg q. afternoon, Prednisone 30 mg p.o. q.o.d., Prilosec 40 mg p.o. q. day, Prinivil 10 mg p.o. q. day, Valium 2 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Effexor 75 mg p.o. b.i.d., calcium chloride 500 mg p.o. t.i.d., Combivent 3 puffs q.i.d., Tylenol p.r.n., Milk of Magnesia p.r.n., Artifical Tears 2 drops in each b.i.d. p.r.n., Trazodone 150 mg p.o. q.h.s., Cipro 250 mg p.o. b.i.d. x 3 days, Duragesic patch 50 mcg q. 72 hours, iron 325 mg three times a week, Bactrim double strength one tablet three times a week, aspirin 81 mg p.o. q. day, Atenolol 50 mg p.o. q. day, Imuran 250 mg p.o. q. day, Claritin 10 mg p.o. q. day. HOSPITAL COURSE Pulmonary: The patient was intubated for hypercarbic respiratory distress. On [2148-7-5], she was extubated with an arterial blood gas of 7.39/79/83 and kept on BIPAP at night. Her respiratory status at the time of discharge revealed no respiratory distress and she was saturating 94% on 2 liters by nasal cannula. Infectious disease: The initial chest x-ray was suggestive of a left lower lobe pneumonia and she was treated initially with Levofloxacin and Flagyl for both a community acquired pneumonia and a possible aspiration pneumonia. Vancomycin was added to this regimen as well. Her Vancomycin and Flagyl were discontinued after hospital day #5 and she was continued on p.o. Levofloxacin to complete a 7 day course again for presumed left lower lobe pneumonia. Cardiovascular: The patient had one EKG during her hospitalization which revealed atrial fibrillation but since has been in normal sinus rhythm with occasional atrial ectopy. As she became hemodynamically stable, her antihypertensives were restarted. She continued to have some mild ectopy by telemetry but remained in normal sinus rhythm. She had elevated CPKs as high as 489 with normal MB fraction but had a troponin of 3.6. At the time of discharge, her troponin was less than 0.3. Her cardiovascular issues will be worked up further as an outpatient. Neurology: The patient has a history of steroid-dependent myositis, possibly inclusion body myositis. Her neurologist, Dr. [Last Name (STitle) 557], was helping with the management of her neurologic issues. The patient was restarted on her Imuran as at some point it had been discontinued and was initially on stress dose steroids during her hypotensive episode but was put back on Prednisone and will have her Prednisone tapered at rate as determined by Dr. [Last Name (STitle) 557]. DISCHARGE MEDICATIONS: Effexor 75 mg p.o. q. day, Neurontin 600 mg p.o. q.a.m. and q.h.s., Neurontin 300 mg p.o. at 2:00 p.m., aspirin 325 mg p.o. q. day, Tums 500 mg p.o. t.i.d., iron sulfate 325 mg TIW, Colace 100 mg p.o. b.i.d., Neutra-Phos 2 packets q.i.d., Prinivil 10 mg p.o. q. day, Evista 60 mg p.o. q. day, regular insulin sliding scale, Dulcolax 10 mg p.o. q. day p.r.n., Protonix 10 mg p.o. q. day, Lopressor 25 mg p.o. b.i.d., Levaquin 250 mg p.o. q. day x 7 days--the last dose should be on [2148-7-8], Imuran 250 mg p.o. q. day, Prednisone 60 mg every other day q. Monday, Wednesday, Friday, and Sunday, then Prednisone 40 mg every other day starting next week Tuesday, Thursday, Saturday, and Monday, followed by Prednisone 60 mg every other day q. Monday, Wednesday, Friday, and Saturday in an alternating fashion. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4263] Dictated By:[Last Name (NamePattern1) 19359] MEDQUIST36 D: [2148-7-8] 09:49 T: [2148-7-8] 11:05 JOB#: [Job Number ]	[ "427.31", "250.00", "458.0", "E932.0", "710.4", "285.9", "517.8", "518.82", "486" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.04", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]									6874, 7956				4251, 6850																																								158, 1917								3614, 4224							1940, 2562	2579, 3599
45,985	137,386	18995	Discharge summary	report	Admission Date: [2148-10-6] Discharge Date: [2148-10-11] Date of Birth: [2077-10-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: - Laryngoscopy History of Present Illness: Mr. [Known lastname 51902] is a 70 year old man with a long history of marginal zone lymphoma s/p auto SCT [2140], s/p four cycles of bendamustine and Rituxan ([7-/2148]) but with progression of disease noted on interval PET scan, course c/b mycobacterium chelonae cutaneous infection on abdomen (recently initiated for treatment with clarithromycin with noted resolution of symptoms), recently admitted [Date range (1) 51905] with disease progression during which he was started on RIME (Ifosfamide, Mitoxantrone, Etoposide), also with history of kidney cancer s/p nephrectomy [2139]; CAD s/p CABG, bronchopulmonary aspirgillus s/p treatment with voriconazole, who presents with fevers at home in the setting of neutropenia with an outpatient sputem sample growing pansensitive pseudomonas. He was discharged [10-1] to home where he reports having done well for several days. He was seen by ID on [10-2] at which time he mentioned a cough and a sputem sample was sent. He has a cough at baseline (x3 years) however this has become productive of brownish sputem over the last few weeks. He has also noticed a sore throat for the last few days. Over the last 2-3 days he has also felt overall weakness. The day of admission he had a temperature of 102.9 at home. He called his oncologist who requested that he be evaluated in the ED. He presented to [Hospital3 417] Hospital, where his white blood count was found to be 0.2. He received 2 g of cefepime prior to transfer to [Hospital1 18]. No acute process on OSH Hospital CXR. Denies nausea/vomiting/dysuria/diarrhea. Denies chest pain/headache. Denies worsening of his abdominal wound infection. In the ED, initial VS were 99.1 76 121/64 16 99%. Labs were notable for leukopenia with WBC count 0.2 (34% PMNs). Blood cultures were sent. He received Cefepime 2g IV at [Hospital3 ], Vancomycin 1g at [Hospital1 18], and Roxicet for a sore throat. His pressures fell to 89/52. He was given a total of 3L of NS and admitted to the [Hospital Unit Name 153] for further workup and management. On arrival to the MICU, patient's VS were 98.2 91 110/59 14. He denied any specific complaints. Past Medical History: ONCOLOGIC TREATMENT HISTORY: - Status post eight cycles of R-CHOP chemotherapy from [4-/2139] to 08/[2139]. - Status post left nephrectomy in [12/2139] with clear cell carcinoma of the kidney with stage limited to kidney only with no lymph node involvement. - Status post Zevalin treatment in 02/[2140]. - Status post autologous stem cell transplant in 05/[2140]. - Status post radiation to the right supraclavicular area following his autologous transplant. - Noted recurrence of his disease in [12/2141] with initiation of treatment on the bendamustine study, status post five cycles of therapy, which was then put on hold as of [2142-3-27] due to development of hemolytic anemia. - Status post Rituxan x 3 for noted paraspinal lesion then received XRT to the area, completed [2143-1-2]. - CT scan in [1-/2143] showed wall thickening with 4-cm segment of sigmoid colon; follow up colonoscopy with noted focal prominent atypical B-cell infiltrate with immunoperoxidase studies revealing CD20 + B cells with co-expression of CD5. - Initiated treatment with R-CEP, first cycle given on [2-/2143], supported with Neulasta; the second cycle given on [2143-3-13] with only day one of Cytoxan and day two of VP16 due to travel; resumed cycle three of CEP on [2143-4-10]; cycle four of RCEP on [2143-5-8] with follow up CT scan showing stable disease; cycle five of RCEP on [2143-6-5]. - Maintenance Rituxan with one dose given on [2143-7-3], [2143-8-19], and [2143-9-18], two doses then given in 01/[2144]. - Rituxan on hold as CT scan in [3-/2144] showed no evidence for lymphoma, but notable gallbladder soft tissue nodule confirmed on ultrasound on [2144-5-20]. Cholecystectomy and liver biopsy on [2144-7-24] by Dr. [Last Name (STitle) 1924]. Biopsy revealed the gallbladder with adenomyoma and mild chronic cholecystitis with no gallstones present. Liver core biopsy showed no definitive fibrosis with features consistent with toxic/metabolic injury. - Persistent anemia with some dysplastic features noted on his differential which was followed over time and advised to decrease/stop drinking, which he has successfully done since [42]/[2144]. Bone marrow aspirate and biopsy on [2144-10-14] showed a normal cellular erythroid dominant marrow with maturing trilineage hematopoiesis, although with numerous mononuclear megakaryocytes and Pelger-Huet neutrophils. His counts have normalized with no further immature cells in his differential. - [2145-1-27], surgical replacement of aortic valve and coronary artery bypass surgery to correct coronary artery disease. Cardiac catherization had shown 80% blockage of LAD with single vessel coronary artery disease. - Persistent abdominal cramping and change of bowel pattern. CT scan in [8-/2145] showed no increased adenopathy but noted large sigmoid polyp; biopsy from [2145-9-8] revealed non-Hodgkin lymphoma with more aggressive phenotype with Mib fraction about 70%, initiated treatment with bendamustine and Rituxan on [2145-10-12] and status post four cycles of therapy completed on [2146-1-4]. - FDG tumor imaging on [2145-12-6] following three cycles of therapy showed no evidence for FDG-avid lymphoma with no adenopathy noted within the bowel in particular. - Colonoscopy on [2146-2-1] showed no abnormalities noted on the sigmoid biopsy. - Status post three doses of Rituximab in [2146-3-7]. - Status post right hip replacement on [2146-4-8]. - Admitted to OSH for pneumonia treated with antibiotics with resolution after a period of time. CT scan done noted nodule in right lung which was new from prior images. Repeat CT scan at [Hospital1 18] on [2146-8-2] showed the previously described left upper lobe nodule has decreased in size and become less round with two new lung nodules, measuring 13 mm in the right upper lobe, and measuring 5 mm in the right lower lobe corresponding to areas on CT from OSH. - VATS with right upper lobe wedge resection for biopsy of nodule on [2146-9-9] which revealed extranodal marginal zone lymphoma(MALT). Positive for CD20 and CD79a, but do not co-express CD5, CD10 or CD43. MIB-1 proliferative is 30% overall. - Persistent sinus symptoms with CT scan showing significant sinus disease. Received prolonged course of antibiotics with plan for possible sinus surgery. Received monthly IVIG to improve immune functioning. - PET scan on [2147-1-31] showed progression of his lymphoma in the head and neck area including cervical nodes, left temporalis muscle, and likely left parotid involvement as well as within the left rectus muscle and left mesenteric external iliac nodes. Core biopsy of the rectus abdominal muscle on [2147-2-13] showed involvement by his non-Hodgkin's lymphoma marginal zone. MIB-1 staining showed a proliferation fraction to be approximately 40%. - Dose of Rituxan given on [2147-2-22], followed by 5 cycles of Rituxan/Bendamustine from [2147-3-1] to [2147-5-31]. - CT scan of the chest from [2147-9-29] showed new diffuse peribronchovascular ground-glass opacities predominantly in the upper lobes, most suggestive of an infectious etiology. Evaluated by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] and felt to have bronchopulmonary aspergillosis and treated with Voriconazole with improvement in ground glass opacities. Completed 5 weeks of treatment on [2147-11-8]. Continues on monthly IVIG at low dosing. - CT of the chest abdomen and pelvis on [2147-12-15] showed no evidence for lymphomatous disease. Improved ground-glass opacities in bilateral lungs compatible with improving infection. Stable 3-mm nodule in the right lower lobe. Sigmoid diverticulosis without diverticulitis. - Sinus surgery on [2148-2-1], due to persistent sinus symptoms and receiving IVIG monthly due to hypogammaglobulinemia. - In [3-/2148], noted for an enlarging lymph node in the left lower cervical and supraclavicular area; PET imaging on [2148-3-29], showed new bilateral cervical lymph nodes, left supraclavicular lymph node peritoneal nodules and numerous musculoskeletal foci with FDG uptake consistent with recurrence. - Treated with a course of Rituxan from [4-12] to [2148-5-3] with no change to probable increase in supraclavicular node. - Initiated treatment with Bendamustine on [5-14] and [2148-5-15]. Rituxan not given as he had just received course. - 2nd cycle of Bendamustine and Rituxan on [6-4] and [2148-6-5]. - 3rd cycle of Bendamustine and Rituxan on [7-2] and [2148-7-3]. - 4th cycle of Bendamustine and Rituxan on [7-23] and [2148-7-24]. Other notable past medical history: - Non-Hodgkins Lymphoma (marginal zone)as above - Right hip replacement - CAD s/p AVR (bovine graft) and 3V CABG - History of hemolytic anemia - Nonalcoholic fatty liver disease - Open appendectomy - Lap cholecystectomy - Hyperlipidemia - Stage I left renal carcinoma, status post left radical nephrectomy, adrenalectomy, and regional lymphadenectomy by Dr. [Last Name (STitle) ] in [2139-12-7]. - Prostate carcinoma, s/p radical prostatectomy [2132]. - Obstructive sleep apnea. - Status post right ulnar neurolysis as management for an ulnar neuropathy by (Dr. [Last Name (STitle) ] in [2143-8-7]) Social History: The patient is married and lives in [Location ] MA. He is an avid soccer fan. He denies IVDU /illicit drug hx, but admits to prior severe alcoholism up until [2137] when he stopped drinking ETOH after diagnosis of NHL. He states he now drinks 1-2 drinks every few months at holidays. He has a remote smoking history of 8 pack-years and was exposed to asbestos at home and radiation in the military. Family History: He states he has 6 siblings and all of them have been diagnosed with high cholesterol but none have had NSTEMI/MIs or CVAs. One brother with recent stent placed. Father with lung cancer and mother had CVA at age 84 and HTN. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, unable to adequately visualize oropharynx, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic regular, normal S1 + S2, no murmurs, rubs, gallops Lungs: sparse scattered and bibasilar rales but otherwise clear Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, circular brownish-red discoloration to right of umbilicus without surrounding erythema, warmth, tenderness of discharge 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, gait deferred. DISCHARGE EXAM: VITALS - Tm 98.5, Tc 98.3, 118/73, 90, 20, 98%CPAP GENERAL - comfortable, appropriate and in NAD HEENT - NC/AT, sclerae anicteric, MMM, OP clear without lesions NECK - supple LUNGS - CTAB, moving air well and symmetrically, resp unlabored, no accessory muscle use HEART - RRR, S1-S2 clear and of good quality without murmurs, rubs or gallops ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, 2cm diameter brownish scar to the right of the umbilicus NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS: [2148-10-7] 03:49AM BLOOD WBC-0.4# RBC-2.51 Hgb-7.7* Hct-23.1* MCV-92 MCH-30.8 MCHC-33.5 RDW-14.7 Plt Ct-39* [2148-10-7] 03:49AM BLOOD Glucose-103* UreaN-21* Creat-1.4* Na-137 K-4.2 Cl-107 HCO3-21* AnGap-13 [2148-10-7] 03:49AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.8 [2148-10-7] 03:49AM BLOOD IgG-282L IgA-7L IgM-49 [2148-10-6] 04:38PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [2148-10-6] 04:38PM BLOOD B-GLUCAN-PND [2148-10-6] 04:38PM BLOOD B-GLUCAN-Test [2148-10-6] 04:38PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test IMAGING: CT CHEST w/o contrast [2148-10-6] IMPRESSION: 1. New focal consolidation in the right upper lobe with smaller opacity in left upper lobe concerning for pneumonia. 2. 5mm Nodular opacity in the right lower lobe is most likely also part of the same infectious process. Attention on follow-up. 3. Increased lobulated left pleural effusion and new small right pleural effusion. 4. Stable left axillary lymphadenopathy. 5. Significant coronary artery and aortic valve calcifications. CT SINUS [2148-10-6] IMPRESSION: Interval worsening of sinus disease compared to [2148-9-24] with near-complete opacification of the maxillary, sphenoid and ethmoid air cells. Mucosal thickening of the left frontal sinus. NOTE ADDED AT ATTENDING REVIEW: I agree with the above and note that the patient has undergone bilateral fiber optic endoscopic surgery with creation of nasal anstrostomies and extensive ethmoidectomies. The ehtmoid roof is markedly thinnned and in some places evidently discontinuous. If there is concern of intracranial extension then an MR examination may be helpful. DISCHARGE LABS: [2148-10-11] 06:00AM BLOOD WBC-11.4* RBC-2.75* Hgb-8.5* Hct-25.1* MCV-91 MCH-30.9 MCHC-33.8 RDW-15.5 Plt Ct-127* [2148-10-11] 06:00AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1* [2148-10-11] 06:00AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Stipple-OCCASIONAL [2148-10-11] 06:00AM BLOOD Plt Smr-LOW Plt Ct-127* [2148-10-6] 02:56PM BLOOD Thrombn-15.1 [2148-10-11] 06:00AM BLOOD Glucose-104* UreaN-16 Creat-1.3* Na-140 K-4.3 Cl-106 HCO3-25 AnGap-13 [2148-10-11] 06:00AM BLOOD ALT-103* AST-52* LD(LDH)-393* AlkPhos-137* TotBili-0.3 [2148-10-11] 06:00AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.9 Brief Hospital Course: Brief Course: Mr. [Known lastname 51902] is a 70M marginal zone lymphoma s/p SCT and now s/p 4 cycles of BR with recent admission for disease progression now on RIME admitted with neutropenic septic shock with concern for pseudomonal vs. fungal PNA. # Septic Shock: SBPs 90s in ED which have which responded fluid resuscitation. He was admitted to the ICU, but did not require pressors. Most likely pulmonary source with sputum [10-2] with pan-sensitive pseudomonas. Notably worsening cough with purulent sputum production. No clear e/o PNA on CXR however possible retrocardiac process. Other possible sources include a retropharyngeal abscess or less likely dissemination or his cutaneous M chelonae infection. UA negative. Lactate 0.8. Port site good. He was placed on Cefepime and Vancomycin. Considered fungal coverage and sent off beta-glucan and galactomannan per ID recs (both were negative). Repeat CT chest showed new infiltrate and CT sinus showed worsening opacifications. He underwent laryngoscopy by ENT, which did not reveal any evidence of sinus infection, but showed some laryngitis of unclear etiology. He was started on nystatin and anti-fungal coverage was added with micafungin. His BP improved and he remained afebrile. He was transitioned to ciprofloxacin for 14 additional days. Prior to starting cipro, and then 24 hours after the first dose QTc interval was checked, and was not prolonged. He was instructed to have an additional EKG checked at his appointment on [10-15] with Dr. [First Name (STitle) ]. # Sinusitis/Pharyngitis: Pt with few days of sore throat. Unable to effectively visualize in our exam. Given history, concern for retropharyngeal abscess or fungal infection. CT sinuses showed evidence of worsening opacifications. ENT was consulted, as above, and they did note laryngitis. He was discharged on nystatin for # Wound Infection: Abdominal would infected with M chelonae. He was continued on clarithromycin per ID recs. # Marginal Zone Lymphoma: He has had marked progression of disease in the last few months, as seen on recent PET scan and was admitted for 1st cycle of RIME [Date range (1) 51905] Immunoglobulins were sent and showed low IgG and IgA. He was given an IVIg transfusion, which was not well tolerated. Approximately half-way through the infusion he developed rigors, which were treated with demerol, benadryl, and tylenol, and stopping the infusion. His symptoms improved, and he was not given any additional IVIg. Additionally, he was continued on valcyclovir & bactrim for prophylaxis. # Pancytopenia: Most likely [2-8] recent chemotherapy. He was continued on neupogen until he was no longer pancytopenic. CHRONIC ISSUES: # Chronic renal insufficiency: Baseline creatinine ~1.5 with one kidney. The patient has a history of stage I left renal carcinoma, status post left radical nephrectomy, adrenalectomy, and regional lymphadenectomy by Dr. [Last Name (STitle) ] in [2139-12-7]. # CAD s/p AVR (bovine graft) and 3V CABG: No acitive issues on this admission. He was maintained on aspirin and statin during this admission. # Chronic pain due to sciatica: No acitive issues on this admission. He was maintained on his home dose of gabapentin. # Nonalcoholic fatty liver disease: No acitive issues on this admission. His LFT's were trended daily. # Hyperglycemia: Sugars were elevated intermittently on this admission. A HgbA1C was checked, and was found to be 6.9. TRANSITIONAL ISSUES: - HgbA1C was elevated to 6.9 - Blood cultures from [10-9] pending Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Albuterol-Ipratropium [1-8] PUFF IH [Hospital1 ] shortness of breath 2. Clarithromycin 500 mg PO Q12H 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 1 SPRY NU QHS 5. FoLIC Acid 1600 mcg PO DAILY 6. Gabapentin 300 mg PO QAM 7. Gabapentin 600 mg PO QPM 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. ValACYclovir 500 mg PO Q12H 12. Rosuvastatin Calcium 20 mg PO DAILY 13. Filgrastim 480 mcg SC Q24H Duration: 14 Days 14. Aspirin 81 mg PO DAILY 15. Levothyroxine Sodium 25 mcg PO DAILY 16. Sulfameth/Trimethoprim DS 1 TAB PO MWF Discharge Medications: 1. Albuterol-Ipratropium [1-8] PUFF IH [Hospital1 ] shortness of breath 2. Clarithromycin 500 mg PO Q12H 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Fluticasone Propionate NASAL 1 SPRY NU QHS 5. FoLIC Acid 1600 mcg PO DAILY 6. Gabapentin 300 mg PO QAM 7. Gabapentin 600 mg PO QPM 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES DAILY 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Rosuvastatin Calcium 20 mg PO DAILY 13. Sulfameth/Trimethoprim DS 1 TAB PO MWF 14. Miconazole Powder 2% 1 Appl TP TID Apply to axilla RX miconazole nitrate [Anti-Fungal] 2 % 1 application three times a day Disp #1 Bottle Refills:0 15. Nystatin Oral Suspension 5 mL PO TID RX nystatin 100,000 unit/mL 5 mL by mouth three times a day Disp #1 Bottle Refills:0 16. Ciprofloxacin HCl 750 mg PO Q12H RX ciprofloxacin 750 mg 1 tablet(s) by mouth every twelve (12) hours Disp #17 Tablet Refills:0 17. Aspirin 81 mg PO DAILY 18. ValACYclovir 500 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary: Sepsis with pulmonary source Neutropenic fever Acute on chronic renal injury Marginal zone lymphoma Laryngitis Anemia Secondary: HTN CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 51902], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for treatement of your neutropenic fever and sepsis. You were initially admitted to the ICU because your blood pressure was low. You were determined to have an infection in your lungs which was likely contributing to your low blood pressure. You were treated with antibiotics and IV fluids, and you improved. You were able to leave the ICU and continued to improve while on the regular oncology floor. Prior to leaving the ICU you underwent evaluation of your sinuses and larynx by the ENT doctors. They saw that you have an infection in your larynx, which was also treated with antimicrobial agents. While you were admitted you were found to have low levels of IgG and IgA. As treatment for this, you were given an infusion of IVIg. During this infusion you had a reaction (rigors) despite pre-medication. The infusion was stopped, and your symptoms were treated with medications including benadryl, hydrocortisone and demerol. Your symptoms improved. Additionally, while you were here you were transfused a unit of packed red blood cells to treat your anemia. Following this transfusion your hematocrit rose appropriately. You tolerated this transfusion without any issues. You stopped having fevers, and you no longer became neutropenic. You were transitioned to an oral antibiotic (Ciprofloxacin) which you should take through [2148-10-19]. Followup Instructions: Department: HEMATOLOGY/BMT When: TUESDAY [2148-10-15] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4380], MD [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage * You will need an EKG checked during this appointment Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2148-10-23] at 2:15 PM With: CHECKIN HEM ONC CC7 [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: WEDNESDAY [2148-10-23] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD [Telephone/Fax (1) 457] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2148-10-14**]	[ "403.90", "724.3", "584.9", "V42.82", "995.92", "V45.73", "585.9", "571.8", "327.23", "200.30", "780.61", "288.00", "E933.1", "464.00", "286.9", "284.11", "V42.2", "482.1", "V10.46", "031.1", "785.52", "V10.52", "038.43", "473.9", "V45.81", "428.0", "414.00" ]	icd9cm	[ [ [] ] ]	[ "99.14", "31.42" ]	icd9pcs	[ [ [] ] ]	19890, 19896	14438, 17137	333, 350	20162, 20162	12000, 12000	21805, 22810	10489, 10714		18821, 19867		19917, 20141		18026, 18798				20313, 21782		13690, 14415				10729, 11448								11464, 11981								17929, 18000						275, 295								378, 2566						12016, 13674				20177, 20289		17153, 17908			9426, 10048	10064, 10473
18,300	194,940	19861	Discharge summary	report	Admission Date: [2100-9-28] Discharge Date: [2100-10-2] Date of Birth: [2025-2-12] Sex: F Service: MEDICINE/BLUMGARDT HISTORY OF PRESENT ILLNESS: This is a 75-year-old woman, with no significant past medical history, who presented to an outside hospital initially with acute onset of shortness of breath and acute onset of high anxiety. These symptoms came on 2 hours prior to presentation while the patient was sitting down and eating lunch. She denied any pain. She denied any chest pain, fevers, chills, nausea or vomiting. Her vital signs at the outside hospital showed her to be afebrile with the heart rate in the 120s. She was tachypneic to 28 with an oxygen saturation of 87% on room air. A CT scan was done which showed bilateral pulmonary emboli. She was transferred to this hospital for continued care. On further history, the patient denies any periods of immobilization or any leg swelling. She is active and walks up to 40 minutes a day. She has had minimal weight loss in the past. She does admit to wrist fracture approximately 3 months ago, in [2100-4-25], and states that she also had back surgery. She is not on hormone replacement therapy. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Left wrist fracture, [2100-4-25]. 4. Back surgery, specifics unknown, in [2100-4-25]. 5. Anxiety. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Zocor 10 mg qd. 2. Fosamax 70 mg q Sunday. 3. Hydrochlorothiazide, dose unknown. 4. Celexa 20 mg. SOCIAL HISTORY: The patient lives alone. She is close to her family members. She denies tobacco or alcohol use. She is active and walks daily. PHYSICAL EXAMINATION ON ADMISSION: Vital signs - she is afebrile with a blood pressure of 110/69, heart rate 104, respiratory rate 28. She is satting 95% on 6 liters nasal cannula. This was increased to 100% on a nonrebreather. She is a well-appearing, elderly female, speaking in choppy sentences. She is alert and oriented x 3. Her head is normocephalic, atraumatic. She has no scleral icterus. Her pupils are equal and reactive to light. She has full extraocular movements. Her heart has a regular rhythm and is tachy. There are no murmurs, rubs or gallops. Her lungs are clear to auscultation bilaterally. She has fine left basilar rales. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. No right upper quadrant tenderness. Her extremities show no clubbing, cyanosis or edema. There are no palpable cords. There are 2+ DP pulses. Calves are symmetric. Neuro exam - she is alert and oriented. There are no focal deficits. LABS ON ADMISSION: White blood cell count 15.4, hematocrit 47.2, platelets 224. Her chem-7 was within normal limits. Her INR was 1.2. Total protein 7.7, albumin 4.5, total bilirubin 0.5. LFTs were slightly elevated with an AST of 112, ALT 98, alk phos 121. A first set of cardiac enzymes showed a troponin of 0.6 and a CPK of 88. Two ABGs were drawn at the outside hospital. The first one had a pH of 7.44, carbon dioxide 34, oxygen 45. Five hours later, a second one was drawn which showed a pH of 7.46, carbon dioxide 33, oxygen 39. RADIOGRAPHIC DATA: A CTA was performed which showed a left main pulmonary artery embolus, as well as a right segmental artery embolus. A chest x-ray showed left lower lobe atelectasis. EKG at the outside hospital showed sinus tach with typical S1, Q3, T3. HOSPITAL COURSE - 1) BILATERAL PULMONARY EMBOLI: The patient was initially admitted to the MICU overnight for close observation of her oxygen status. She was started on a heparin drip. Her PTTs were monitored, and the drip was titrated. She did well overnight. Her oxygen requirement changed from a nonrebreather mask to nasal cannula, satting approximately 94% on 3 liters. She was called out of the MICU the following day and transferred to the floor. There, the heparin drip was continued and Coumadin was started. An ultrasound was performed which showed left-sided DVTs, one in the deep femoral vein, and another in the superficial femoral vein. An echo was also performed which showed an ejection fraction of greater than 55%. However, it did show a dilated right ventricle with moderate global right ventricular free wall hypokinesis. There was mild pulmonary artery systolic hypertension. The etiology of Ms. [Known lastname 46272] pulmonary emboli and DVTs are deferred for work-up as an outpatient. Her hospitalization was discussed with her primary care doctor, Dr. [Last Name (STitle) 51132], of [Hospital 1263] Hospital who will be following her. Malignancy is a great concern, considering the unexpected presentation of pulmonary embolus and no other risk factors per patient. She has not had colonoscopy. She has had mammography as recently as a year ago which she reports was negative. It is unlikely that a hypocoagulability state would present for the first time this late in life. However, she also needs to have further work-up for this. Her distant history of a right wrist fracture with rehabilitation 3 months ago is a mild risk factor, but not convincing in these circumstances. 2) CARDIOLOGY: On admission, the patient had an elevated troponin of 0.37. This subsequently fell in the 3 following sets. It was felt that this was a troponin leak secondary to right heart strain and some myocardial injury. This was confirmed with an echo. 3) EARLY DEMENTIA/MUSICAL HALLUCINATION: Per PCP, [Name10 (NameIs) ] patient has a history of musical hallucinations which were treated with Celexa. Dr. [Last Name (STitle) 51132], her primary care doctor, also states that she has early signs of dementia, but has not yet acknowledged her situation. The musical hallucinations were discussed with the patient. She said that they were a symptom of the past but not currently, but was amenable to continuing Celexa while in-house. The diagnosis of early dementia was not discussed with the patient, and no signs of it were evident on exam here. DISCHARGE: Ms. [Known lastname ] will be discharged in fair condition. She will be going to the [Hospital6 ] [Hospital ] Hospital. She continues to have an oxygen requirement, satting 92-94% on 2 liters nasal cannula. She will be discharged with Lovenox shots [Hospital1 ]. She will continue taking Coumadin 5 mg at night. The goal INR is between 2.5-3.5. Once this INR is reached, Lovenox and Coumadin will be overlapped for the following 48 hours, at which point Lovenox will be discontinued. Ms. [Known lastname ] will have follow-up with her primary care doctor, Dr. [Last Name (STitle) 51132], to continue her dosage of Coumadin, and to track her INR. He will also follow her for the work-up of her hypocoagulability state. DISCHARGE DIAGNOSES: 1. Bilateral pulmonary emboli. 2. Deep vein thrombosis x 2. 3. Right ventricular strain with myocardial injury. 4. Status post left wrist fracture. 5. Anxiety. DISCHARGE MEDICATIONS: 1. Coumadin 5 mg po q hs. 2. Senna tabs 1 tablet [Hospital1 ] prn. 3. Ativan 0.5 mg po q 4-6 h prn. 4. Acetaminophen 325 mg 1-2 tablets q 4-6 h prn. 5. Celexa 20 mg 1 tablet po qd. 6. Zocor 10 mg po qd. 7. Fosamax 70 mg q Sunday. 8. Lovenox 40 mg subcu q am, Lovenox 60 mg subcu q hs. Ms. [Known lastname ] will follow-up with her primary care doctor, Dr. [Last Name (STitle) 51132]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Last Name (NamePattern1) 37631] MEDQUIST36 D: [2100-10-1] 14:07 T: [2100-10-1] 14:34 JOB#: [Job Number 53672]	[ "415.19", "410.71", "300.00", "789.04", "294.8", "453.8", "272.0", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								6859, 7020	7043, 7715				1448, 1550																																								180, 1210								2687, 6838							1232, 1422	1567, 1719
54,405	106,836	33623	Discharge summary	report	Admission Date: [2200-2-27] Discharge Date: [2200-2-28] Date of Birth: [2143-10-11] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[First Name3 (LF) 5893] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION AND TRIGGER NOTE . Date: [2200-2-27] Time: 2100 _ ________________________________________________________________ PCP: [Name10 (NameIs) ] info(fax and phone), confirmed with patient, last saw PCP [Last Name (NamePattern4) ] .[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17474] [Location (un) 796] _ ________________________________________________________________ HPI: 56 y/o M with tobacco and ETOH abuse who presets with stage 4 pancreatic cancer diagnosed in [2200-1-31] when he presented with abdominal pain and weight loss. He presented with biliary obstruction and is transferred from an OSH after a failed ERCP attempt with Dr. [First Name (STitle) ]. Pt underwent PTC in [2200-1-31]. The wire traversed the gallbladder and reached the duodenum. The wire could be seen in the duodenum fluroscopically but could not be reached by endoscope due to diffuse duodenal edema and tumor growth. He was transferred her for palliative stent placement to relieve his biliary obstruction as without this, he will not be a candidtate for chemotherapy. He has been having nausea and vomiting non-bilious, non bloody. Upon arrival to floor he had an episode of diarrhea. Of note the patient reports that he was diagnosed with a blood clot in his L leg but the left leg "blew up" overnight and is worse. He reports a cold R foot with increasing pain and numbness, worse over the past 24 hours which he attributes to the ambulance ride. . PAIN SCALE: [7-20] RUQ ________________________________________________________________ REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative" CONSTITUTIONAL: [] All Normal [ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [X ] ____30_ lbs. weight loss/gain over __6___ weeks Eyes [] All Normal [ ] Blurred vision [ ] Loss of vision [] Diplopia [ ] Photophobia ENT [ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [] All Normal [+] Shortness of breath [+ ] Dyspnea on exertion which I witnessed but he does not report this [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [- ] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [] All Normal [ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling [ ] Diarrhea [ ] Constipation [ ] Hematemesis [- ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [] All Normal [ ] Rash [ ] Pruritus [+] jaundice MS: [x] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [x] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy [ +] jaundice HEME/LYMPH: [] All Normal [+ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: ALLERGY: [ x]Medication allergies [ ] Seasonal allergies [X]all other systems negative except as noted above Past Medical History: Metastatic pancreatic cancer with liver mets and regional adenopathy- s/p percutaneous drain on [2200-1-31]. He has had 4 attempted ERCPs. Rectal abscess and L hirdradenitis incision and drainage. Per report LLE DVT but no imaging report available HTN Colonic polyps Gout Folic acid deficiency Alcohol abuse Lyme disease Tobacco PVD ----------- Social History: He lives with his wife. [Name (NI) ] smokes 2.5 packs per day for ? 30 years. He denied alcohol abuse to me but per the d/c summary he has a history of alcohol abuse. Social history is very limited because he does not want to talk as he is tired. Wife: [Name (NI) ]: [Telephone/Fax (1) 77883] Family History: Father died at age 60 with cirrhosis, HTN, CAD. Mother died at age 53 with a CVA. [3-15] sisters with HTN. Physical Exam: 1. VS Tm T P 90 BP RR 18 O2Sat on _95 RA___ liters O2 Wt, ht, BMI GENERAL: thin, ill appearing male sitting on the toilet. Nourishment : at risk Grooming : ok Mentation 2. Eyes: [] WNL + jaundice PERRL, EOMI without nystagmus, Conjunctiva: clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP 3. ENT [x] WNL [] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [] WNL [X] Regular [] Tachy [x] S1 [x] S2 [] Systolic Murmur /6, Location: [] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [] Edema RLE None, Neither DPP nor PT pulse could be appreciated by doppler. L DPP and L PT could be appreciated by doppler [] Bruit(s), Location: [] LLE None 3+ up to the middle of the thigh [] Vascular access [x] Peripheral [] Central site: 5. Respiratory [ ] [x] CTA bilaterally [ ] Rales [ ] Diminshed [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [ ] WNL [x] Soft PTC drain site C/D/I [] Rebound [] No hepatomegaly [x] Non-tender [] Tender [] No splenomegaly [] Non distended [] distended [] bowel sounds Yes/No [] guiac: positive/negative 7. Musculoskeletal-Extremities [] WNL [ ] Tone WNL [x ]Upper extremity strength 5/5 and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength 5/5 and symmetrica [ ] Other: [x] Normal gait - able to walk to BR unassisted []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [] WNL [x ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [] WNL jaundiced R foot 10. Psychiatric [] WNL [] Appropriate [x] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic [] Combative [Doctor First Name ] [] No inguinal [Doctor First Name ] [] Thyroid WNL [] Other: 12. Genitourinary [X] WNL [ ] Catheter present [] Normal genitalia [ ] Other: TRACH: []present [x]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I . Discharge Physical: VS - Afebrile, HR108, BP95/68, RR17, 91% on 5L NC. General: Alert, oriented, no acute distress, jaundiced, chronically ill appearing HEENT: Sclera icteric, MMM, oropharynx clear Neck: Soft, 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, mild discomfort to deep palpation in RUQ, perc drain site clean/intact - covered, with significant serous drainage. Green bile, no blood or pus in drain. GU: Foley in place Ext: Warm, well perfused bilateral upper extremities, no clubbing of bilateral lower extremities, [2-10]+ pitting edema bilaterally with L>R, dopplerable pulses, warm bilaterally with good capillary refill on left but purplish, mottled right toes (big, second/third toes especially) with significant TTP Pertinent Results: [2200-2-27] 10:30PM WBC-18.8* RBC-3.42* HGB-11.8* HCT-37.0* MCV-108* MCH-34.4* MCHC-31.8 RDW-15.6* [2200-2-27] 10:30PM PLT COUNT-131* . SR: 95 bpm. No acute changes. . [2200-2-27] 11:42PM ALT(SGPT)-35 AST(SGOT)-57* CK(CPK)-43* ALK PHOS-252* TOT BILI-5.0* [2200-2-27] 11:42PM CK-MB-2 cTropnT-<0.01 [2200-2-27] 11:42PM CALCIUM-6.9* PHOSPHATE-1.9* MAGNESIUM-1.6 [2200-2-27] 11:42PM PT-18.3* PTT-29.0 INR(PT)-1.7* [2200-2-27] 10:30PM NEUTS-86.4* LYMPHS-6.9* MONOS-5.8 EOS-0.6 BASOS-0.4 [2200-2-27] 10:30PM NEUTS-86.4* LYMPHS-6.9* MONOS-5.8 EOS-0.6 BASOS-0.4 . CT [2200-1-31] Locally advanced pancreatic malignancy with obstruction of the CBD, liver metastases and regional adneopathy. Tumor abuts the proximal superior mesenteric artery, superior mesenteric vein and the portal vein. ERCP [2200-1-31] Friable mass in the second portion of the duodenum. Stricture with conscioius villing. Pancreatic duct accesses but the CBD could not be accessed. . Path from bx demonstrated pancreatic adenocarcinoma. . CT torso [2200-2-28]: IMPRESSION: Preliminary Report1. Extensive pulmonary embolism involving the right main, lobar and segmental Preliminary Reportarteries of the right lower lobe and segmental arteries of the left lower Preliminary Reportlobe. No right heart strain. Preliminary Report2. Multifocal consolidation in both lungs, predominantly involving both upper Preliminary Reportlobes and the right middle lobe, concerning for multifocal pneumonia. Preliminary ReportBilateral small pleural effusions. Preliminary Report3. Known pancreatic malignancy, is not well assessed in this study. Bulky Preliminary Reportpancreatic head may represent the known mass. Metastatic disease in the Preliminary Reportabdomen including multifocal liver metastasis, enlarged Preliminary Reportgastrohepatic/retroperitoneal adenopathy, and thickened left adrenal gland. Preliminary Report4. Diffuse thickening of the gastric and colonic walls could be reactive Preliminary Reportchanges versus third spacing. Moderate amount of abdominal ascites. Preliminary Report5. Percutaneous cholecystostomy tube and duodenal stent are in place. Preliminary Report6. Extensive atherosclerotic disease of the iliac arteries. Preliminary ReportRIGHT: Long segment occlusion of the right external iliac and the common Preliminary Reportfemoral artery, with reconstitution at the level of distal CFA. Multifocal Preliminary Reportstenosis of the right SFA and popliteal arteries, with absent flow in the Preliminary Reportright anterior tibial and peroneal at the distal third of the leg. Preliminary ReportLEFT: Multiple areas of high-grade stenosis and short segment near-complete Preliminary Reportocclusion of the left external iliac artery, with multiple areas of high-grade Preliminary Reportstenosis in the femoral, popliteal arteries of the left lower extremity. Preliminary ReportAbsent flow in the anterior tibial and peroneal distal to the ankle. Preliminary ReportPatent posterior tibials bilaterally. Preliminary ReportThe above findings were discussed via telephone with Dr.[Last Name (STitle) ] at 8:30 A.M on Preliminary Report1/20/12. . TTE: Conclusions Poor image quality. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size is normal with normal free wall contractility. Interventricular septal motion is normal. There is no pericardial effusion. IMPRESSION: No clear evidence of RV strain. Brief Hospital Course: Brief Course: Pt is a 56 year old male with history of hypertension, peripheral vascular disease, tobacco abuse, previous alcohol abuse, LLE DVT, and recently diagnosed metastatic stage 4 pancreatic cancer with gastric outlet/biliary obstruction who presented s/p ERCP at [Hospital1 18] for duodenal/biliary stent placement, found to have bilateral PE's, now transferred to the medical ICU with acute hypotension and dyspnea on exertion/hypoxemia. After arrival of his family in the ICU, decision was made to make patient CMO. He was discharged to hospice. . # Goals of care: On arrival to the ICU, pt's family, including his Wife, [Name (NI) ] (HCP), arrived. Per discussion with the patient and his wife, pt desired comfort and no more aggressive treatment. Decision was made for comfort measures only. Heparin gtt for PE's, and antibiotics were discontinued. He was continued on pain medications. He was discharged to hospice on [2200-2-28]. . # Hypotension: Likely multifactorial from bilateral PE's, possible hypovolemia, and concern for developing sepsis. Pt had CTA torso on the medical floors prior to transfer to the ICU, and was found to have bilateral PE's. TTE showed no evidence of right heart strain. He had a mild drop in hematocrit, but no obvious signs of bleeding, and the Hct on recheck was stable. Infiltrates were seen on CT, with concern for developing infection, though he remained afebrile. Given goals of care as discussed above, pt was made CMO and antibiotics in addition to heparin gtt were discontinued. . # Right foot/toe ischemia and peripheral vascular disease: Currently no plans for intervention. Improved overnight. CTA suggests chronic problem with intermittent ischemia. As above, heparin gtt was discontinued. He was given pain medication as needed for vomfort. . # LLE DVT: Per report and patient was previously on lovenox which was stopped ~ 7 days prior to admission to [Hospital 794] Hospital on [2200-2-24] for planned ERCP with stenting. As above, heparin gtt was stopped. . # Non-anion gap metabolic acidosis: Differential includes hyperalimentation (TPN was started previously?) vs. diarrhea vs. pancreatic fisuli (alkali lossfrom pancreas). Most likely due to his pancreatic cancer and known fisultas/obstructions. No more labs were checked given goals of care. . # Metastatic Pancreatic Cancer: Complicated by biliary/duodenal obstruction with difficult to intervent anatomy. The patient is s/p PTC drain and was transferred for another attempt at biliary stent placement vs. new PTC drain placement via EUS. ?role of chemotherapy and what the plans were for this. As above, given goals of care discussion, he was given morphine for pain control. . Transitional care: 1. CODE: comfort measures only 2. Contact: wife 3. Discharged to hospice care Medications on Admission: Allopurinol 300 mg po qd Polyethylene Glycol 17 gm Morphine sulfate 15 mg ER [Hospital1 ] Morphine 15 mg po q 4 hours Discharge Medications: 1. morphine 30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 3. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. metastatic pancreatic cancer 2. pulmonary emboli Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 35962], You were admitted to the hospital for ERCP. However, your blood pressure was low, and you were admitted to the ICU. You were found to have pulmonary emboli, and possible infection in your lungs. After discussion with you further, you and your family decided that you would like to pursue comfort. You were discharged to hospice. Please stop all medications you were taking at home prior to this. Please start the following medications: - Morphine IR 30mg orally every 4 hours as needed for pain - Tylenol as needed for pain or fevers - Ondansetron 4mg IV or ODT as needed for nausea every 8 hours Followup Instructions: Please follow-up with the hospice care team. Completed by:[2200-3-1]	[ "285.9", "443.9", "415.19", "157.9", "787.91", "787.01", "V66.7", "576.2", "995.91", "453.42", "537.3", "458.9", "274.9", "276.2", "401.9", "197.7", "486", "038.9" ]	icd9cm	[ [ [] ] ]	[ "46.86" ]	icd9pcs	[ [ [] ] ]	15147, 15162	11838, 14653	296, 303	15267, 15267	8191, 11815	16113, 16188	4761, 4875		14825, 15124		15183, 15246		14679, 14802				15452, 16090						4890, 8172																			1978, 4050			242, 258								331, 1959										15282, 15428					4072, 4423	4439, 4745
6,878	121,907	26487	Discharge summary	report	Admission Date: [2112-1-24] Discharge Date: [2112-2-13] Date of Birth: [2052-10-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2112-1-25] Redo Sternotomy, Redo Mitral Valve Replacement with a [Street Address(2) 65440]. [Male First Name (un) 923] mechanical valve, Tricuspid Valve Repair with 32 millimeter CE ring History of Present Illness: Mr. [Known lastname 1968] is a pleasant 59 year old male who underwent a porcine mitral valve replacement in [2107-12-3] for mitral valve prolapse/regurgitation. He started to develop dyspnea on exertion about two years after his operation. His dyspnea on exertion has recently worsened and his exercise tolerance has dramatically diminished. Over years, there has been evidence of increasing transvalvular gradients. An echocardiogram in [2111-12-3] was notable for a mean gradient of 16mmHg across the mitral valve. There was moderate tricuspid regurgitation and his LVEF was estimated at 60-65%. Subsequent cardiac catheterization in [2111-12-3] confirmed mitral stenosis with a gradient of 15mmHg and valve area of 0.9 square centimeters. His coronary arteries were clean and his LVEF was normal at 60%. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Bioprosthetic Mitral Stenosis, Tricuspid Regurgitation, History of MVP/mitral regurgitation - s/p Porcine Mitral Valve Replacement in [2107], s/p Permanent Pacemaker in [2110], Hypertension, Pulmonary hypertension, Obstructive Sleep Apnea - on CPAP, BPH, GERD, Gout, Obesity, Osteoarthritis, Depression/Anxiety, History of Postop Atrial Fibrillation, History of Urosepsis Social History: -smokes [2-5] three cigarettes per day (last [2-5] mo) -H/o [1-4] PPD for 20years -ETOH: 0.5 pint per month -Works for Youth Development Council -Divorced w/ 2 grown children -admits to past cocaine use, none recent Family History: -Father: died of cerebral hemorrhage ([2-4] aneurysm)in his 60's, h/o stroke -No history of premature arthrosclerotic CVD or sudden cardiac death -Mother: HTN Physical Exam: Vitals: T 96.3, BP 136/78, HR 70's, RR 16, SAT 99% on room air General: over weight male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD Heart: regular rate, normal s1 with split s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2112-1-24] 03:45PM BLOOD WBC-5.9 RBC-5.26 Hgb-11.3* Hct-35.6* MCV-68* MCH-21.4* MCHC-31.7 RDW-15.9* Plt Ct-168 [2112-1-24] 03:45PM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2 [2112-1-24] 03:45PM BLOOD Glucose-109* UreaN-22* Creat-1.4* Na-143 K-4.0 Cl-104 HCO3-29 AnGap-14 Brief Hospital Course: Mr. [Known lastname 1968] was admitted on [2112-1-24]. The following day, Dr. [Last Name (STitle) 1290] performed a redo sternotomy, redo mitral valve replacement and tricuspid valve repair. The operation was uneventful and he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He was started on Amiodarone for episodes of rapid atrial fibrillation. His renal function acutely declined with creatinine peaking to 2.7 on postoperative day two. He did not become oliguric. His acute renal insufficiency was attributed to hypotension and NSAIDs. With avoidance of nephrotoxic agents and adequate hemodynamics, his renal function gradually improved over several days. The Electrophysiology service was consulted regarding PPM interogation, showed good capture and function. PPM changed to DDD mode. The physical therapy service was consulted for assistance with postoperative strengthening and conditioning. Over the next several days he made steady progress in his ability to ambulate. Beta blockade and aspirin were resumed. He was gently diuresed towards his preoperative weight. Coumadin and heparin were started with a target INR of 3.0-3.5. Initially he did not respond to coumadin and the Heme/Onc service was consulted. Serum protein electrophoresis was conducted and pending at time of discharge to determine the presence of alpha thalassemia. Mr. [Known lastname 1968] was placed on his outpatient regimen of coumadin 40mg q day. On postoperative day 18 Mr. [Known lastname 1968] was at his preop weight with good exercise tolerance, no SOB, or Chest pain. His blood pressure was stable. His sternotomy incision was clean, dry, and intact without evidence of infection. His staples were removed. He was discharged home on POD 18 in good condition, cardiac diet, sternal precautions, and instructed to follow up with his PCP and cardiologist in [1-4] weeks. He will follow up with Dr. [Last Name (STitle) 1290] in four weeks. His PCP will draw his INR at 10AM on [2112-2-15] and assume management of his anticoagulation. Medications on Admission: Lasix 120 mg qd, KCL, Lisinopril 40 qd, Toprol XL 75 mg qd, Terazosin, Protonix, Aspirin 325 mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:2 5. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Warfarin 5 mg Tablet Sig: Eight (8) Tablet PO ONCE (once) for 2 doses. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bioprosthetic Mitral Stenosis, Tricuspid Regurgitation, History of MVP/mitral regurgitation - s/p Porcine Mitral Valve Replacement in [2107], s/p Permanent Pacemaker in [2110], Hypertension, Pulmonary hypertension, Obstructive Sleep Apnea - on CPAP, BPH, GERD, Gout, Obesity, Osteoarthritis, Depression/Anxiety, History of Urosepsis, Postop Atrial Fibrillation, Postoperative Acute Renal Insufficiency Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [4-6] weeks. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [2-5] weeks. Local cardiologist, Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] in [2-5] weeks. Completed by:[2112-2-13]	[ "305.1", "584.9", "600.00", "427.31", "327.23", "397.0", "V53.31", "282.49", "416.8", "V58.61", "428.0", "458.29", "996.02" ]	icd9cm	[ [ [] ] ]	[ "39.61", "93.90", "88.72", "00.17", "35.24", "00.13", "35.14", "99.04" ]	icd9pcs	[ [ [] ] ]	6335, 6341	3024, 5165	342, 544	6795, 6802	2723, 3001	7121, 7429	2142, 2307		5314, 6312		6362, 6774		5191, 5291				6826, 7098						2322, 2704																						283, 304								572, 1476															1498, 1880	1896, 2126
3,319	159,001	65+66	Discharge summary	report+report	Admission Date: [2157-3-21] Discharge Date: [2157-3-27] Date of Birth: [2093-2-22] Sex: F Service: HISTORY OF PRESENT ILLNESS: 64-year-old woman with history of right parietal occipital hemorrhage in [10/2156] with an admission to the Neurology service. She presented with headaches and unsteadiness the last two weeks. Headaches are unclear duration. Very forgetful since [54]/[2156]. She has been slowing down as per her family. Being forgetful, positive chills, no fevers, positive nausea, no vomiting, positive diarrhea over last two to three days, cough positive last three days. PAST MEDICAL HISTORY: 1. Hypertension. 2. Anxiety. 3. Hepatitis C. 4. Right parietal-occipital hemorrhage in 09/[2156]. 5. Normal stress test in 11/[2156]. MEDICATIONS: 1. Keppra. 2. Metoprolol. 3. Epogen. ALLERGIES: 1. Penicillin. 2. Codeine. SOCIAL HISTORY: Lives alone; completed eighth-grade education. PHYSICAL EXAMINATION: Temperature maximum 97.8, 134/65, 80, 16, 98% on room air. Generally sleepy; in no acute distress. Mucous membranes moist. Normocephalic, atraumatic. Lungs: Clear to auscultation bilaterally. Regular rate and rhythm; no murmurs, rubs, or gallops appreciated. Skin: No obvious lesions. Abdomen: Soft, nontender, no masses. Extremities: Without edema; moving all extremities. Neuro: Arousable to voice but falls back asleep. Speech is sparse. Left visual space neglect. Left - lot of motor impersistence; does not consistently follow commands. Cranial nerve, fundi, tongue midline. Motor: Moves all extremities well. Biceps and triceps [5-9], IP at best [5-9], bilateral gastrocnemius [6-8] bilaterally, deep tendon reflexes 3, toes equivocal. LABORATORY DATA: Patient's white count on admission was 8.1, hematocrit 39, platelets 248, sodium 140, potassium 4.0, 101 chloride, 30 CO2, BUN 16, creatinine 0.4, glucose 137. IMAGING: CT of the head: Right parietal temporal mass; right to left midline shift; compression of right lateral ventricle; right lateral ventricle dilated. MR of the head was pending. HOSPITAL COURSE: 64 year old, likely primary brain tumor, now with some headache, visual spatial defects,quick neurologic deterioration non-attentiveness admitted to Neurosurgery on [2157-3-21]. Steroids and tilt biopsy. Keppra was continued NPO at midnight. The patient continued to deteriorate and remained significantly more difficult to arouse. At this point, after further examining the patient, MRI was obtained which again further delineated the primary brain tumor. It would be most appropriate to perform the excision of the mass. Patient was taken urgently to the Operating Room early the next morning for craniotomy and the mass was removed from the temporal parietal area. Patient tolerated the procedure well. Please see operative dictation. Continued to improve. Patient was seen on [2157-3-23] by Neuro-Oncology and Dr. [Last Name (STitle) 724] and was given instructions to follow up as per prognosis with patient. On [2157-3-24] dressing was removed. Patient was hemodynamically stable. Diet was increased. Patient was seen by Endocrine on [2157-3-24], as well, who recommended repeat thyroid function tests in two weeks to check for residual endocrine abnormality but no other recommendations prior to that. It was decided that patient met criteria and needed to be seen acutely in rehab. Endocrine came back and re-evaluated and maintained again in hypopituitary access, said there was no evidence of hypothalamic versus pituitary abnormality. On [2157-3-25] patient remained neurologically stable. Rehab planning was begun. Psychiatry evaluated patient. Their impression was dementia due to organic process glioblastoma. Psychiatry recommended Haldol 0.5 mg p.o. b.i.d. standing and 0.5 mg p.o. intravenously b.i.d. p.r.n. agitation and avoiding benzodiazepines and anticholinergics. Patient, on [2157-3-26], was offered sitters and, for greater than 24 hours, it was decided that patient, on [2157-3-27], would be able to be discharged to [Hospital1 ] when bed became available. Patient needed to be screened, and insurance issues prevented her to be discharged on [2157-3-27]. However, this was planned for [2157-3-28]. DISCHARGE CONDITION: Stable status post removal of glioblastoma. DISCHARGE INSTRUCTIONS: 1. Patient is to follow up with Dr. [Last Name (STitle) 724] regarding glioblastoma and long-term prognosis in two weeks' time. 2. Follow up with Dr. [Last Name (STitle) 739] in two weeks' time. DISCHARGE DIAGNOSIS: Brain tumor. SECONDARY DIAGNOSIS: Change in mental status. TERTIARY DIAGNOSES: 1. Endocrine abnormality. 2. Dementia. DR.[Last Name (STitle) ],EFSTATHI 14-AAA Dictated By:[Last Name (NamePattern1) 740] MEDQUIST36 D: [2157-3-27] 11:33 T: [2157-3-27] 14:48 JOB#: [Job Number 741] Admission Date: [2157-3-20] Discharge Date: [2157-3-30] Date of Birth: [2093-2-22] Sex: F Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman with a history of right parietal occipital hemorrhage in [2156-10-4]. She was admitted at that time to the Neurology Service. She presented with headaches and unsteadiness for the last two weeks. Headaches were of unclear duration, as she has become very forgetful since [2156-2-4]. She has been getting lost in the grocery store, has had no fever, positive nausea, no vomiting, positive diarrhea for the last 2-3 days. She has had positive chest pain on and off, but none over the last two days prior to admission. No cough over the last two days prior to admission. PHYSICAL EXAMINATION: Vital signs: Temperature 97.8??????, blood pressure 134/65, heart rate 80, respirations 16, oxygen saturation 98% on room air. General: She was sleepy but in no acute distress. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. Nonicteric. Lungs: Clear to auscultation. Cardiovascular: Regular rhythm. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. Extremities: No clubbing, cyanosis, or edema. Skin: No obvious lesions. Neurological: She was arousable to voice but then fell back to sleep. Speech: Sparse. Repetition intact. She had a left visual space neglect. She was impersistent with motor exam testing. She did not consistently follow commands. Her pupils were 4 down to 3 mm bilaterally. Her face was symmetric. Tongue midline. She moved all extremities well. Triceps and biceps were 4+ out of 5 bilaterally. IP at least 3 out of 5 bilaterally. Gastrocs 5 out of 5. Deep tendon reflexes 3+ in the upper extremities, 3 at the patella, and 2 at the Achilles. Toes were equivocal. IMAGING: The patient had a head CT that showed right parietal temporal mass with right-to-left midline shift and depression of the right lateral ventricle with left lateral ventricle slightly dilated. HOSPITAL COURSE: The patient was admitted to the Neurosurgery Service. She received an MRI. The patient's mental status deteriorated. She became unresponsive with a blown right pupil. The patient was taken to the Operating Room emergently for craniotomy for excision and biopsy of the tumor. The patient underwent a right parietal temporal craniotomy for excision of tumor without intraoperative complications. Postoperatively the patient was monitored in the Recovery Room over night. Her vital signs were stable. She awakened easily to voice, saying her name. Pupils were 6 down to 5 mm bilaterally to ambient light. She withdrew briskly in her upper and lower extremities. On postoperative day #1, she was awake and alert. Pupils were 5 down to 4 mm. She had a left neglect visually. Strength was symmetric. Finger flexors and IPs bilaterally. She was improved and was much more awake and alert. The patient was seen by Neuro-oncology who recommended Radiation/Oncology and possible chemotherapy. She was transferred to the regular floor on postoperative day #1. She was out of bed and ambulating. She was assessed by Physical Therapy and Occupational Therapy and found to require a short rehabilitation stay prior to discharge to home. She was also seen by Endocrine due to the mass near her hyperthalamus. TSH was slightly decreased with a normal T4. Endocrine recommended follow-up on PFTs in two weeks. The patient was therefore prepared for rehabilitation and discharged to rehabilitation on [2157-3-30], with follow-up in the Brain [Hospital 341] Clinic on Monday for staple removal. DISCHARGE MEDICATIONS: ................... 10 mg p.o. q.d., Decadron 4 mg p.o. q.12 to be weaned to 2 mg p.o. q.12 and stay at that dose, Hydralazine 10 mg p.o. q.6 hours to be weaned off as tolerated, .................. 40 mg p.o. q.24 hours, Heparin 5000 U subcue q.12 hours, Colace 100 mg p.o. b.i.d., Metoprolol 25 mg p.o. b.i.d., ................. 500 mg p.o. b.i.d. CONDITION ON DISCHARGE: Stable a the time of discharge. FOLLOW-UP: She will follow-up in the Brain [Hospital 341] Clinic on Monday, [4-4]. [Name6 (MD) 742] [Name8 (MD) ], M.D. [MD Number(1) 743] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2157-3-29] 17:53 T: [2157-3-29] 18:40 JOB#: [Job Number 744]	[ "401.9", "294.8", "191.9", "070.54", "300.00" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]				4355, 4400					8732, 9082		4652, 4666			7104, 8708			4424, 4630																			5814, 7086																	5173, 5791			4688, 5144												654, 897	914, 962	9107, 9474
11,098	192,287	49072	Discharge summary	report	Admission Date: [2170-12-24] Discharge Date: [2170-12-30] Date of Birth: [2110-1-10] Sex: F Service: ORTHOPAEDICS Allergies: Hydrocodone Attending:[First Name3 (LF) 3190] Chief Complaint: Hardware failure Major Surgical or Invasive Procedure: Scoliosis fusion T3-S1 History of Present Illness: Ms. [Known lastname 1968] [Known lastname ] had a previous scoliosis fusion with instrumentation which has unfortunately failed. She now presents for surgical intervention. Past Medical History: gastric bypass bilateral hip replacements scoliosis fusion Social History: Denies Family History: N/C Physical Exam: NAD RRR CTA B Abd soft NT/ND + palpable deformity midspine BUE- good strength at biceps, triceps, wrist extension and flexion, finger extension and flexion and intrinsics; sensation intact in all dermatomes; reflexes intact at biceps, triceps and brachioradialis BLE- good strength at hip flexion and extension/abduction/adduction, knee flexion and extension, ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation intact distally; reflexes intact at quads and Achilles Pertinent Results: [2170-12-28] 05:50AM BLOOD Hct-29.8* [2170-12-27] 05:02AM BLOOD Hct-26.9* [2170-12-26] 07:16AM BLOOD WBC-9.2 RBC-2.74* Hgb-8.3* Hct-24.5* MCV-89 MCH-30.4 MCHC-34.0 RDW-14.9 Plt Ct-90* [2170-12-25] 01:46AM BLOOD WBC-7.0 RBC-2.60* Hgb-7.9* Hct-22.8* MCV-88 MCH-30.4 MCHC-34.6 RDW-15.0 Plt Ct-136* [2170-12-26] 07:16AM BLOOD Glucose-112* UreaN-16 Creat-1.5* Na-139 K-4.2 Cl-108 HCO3-26 AnGap-9 [2170-12-25] 01:46AM BLOOD Glucose-160* UreaN-17 Creat-1.3* Na-139 K-5.2* Cl-111* HCO3-23 AnGap-10 [2170-12-24] 04:52PM BLOOD Glucose-175* UreaN-16 Creat-1.2* Na-142 K-4.8 Cl-115* HCO3-24 AnGap-8 Brief Hospital Course: Ms. [Known lastname 1968] [Known lastname ] was admitted to the service of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363] for a revision scoliosis fusion T3-S1. She was informed and consented for the procedure and elected to proceed. Please see Operative Note for procedure in detail. She was transferred to the T/SICU for volumne maintenance and did well. Post-operatively she was administed pain medication and antibiotics. She spiked a fever post-operatively and incentive spirometer was encouraged. No further action was needed. Her hematocrit was closely monitered and she was given three units of PRBCs post-operatively. Her hematocrit responded accordingly. The remainder of her hospital course was unremarkable. She was able to work with physical therapy and made improvemetns in strength and balance. She was given a brace which she was encouraged to wear at all [Last Name (un) 80859]. She will follow up in clinic during her previously scheduled appointments. She was discharged in good condition. Medications on Admission: See list Discharge Medications: 1. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release 12HR(s) Refills:0 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:100 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q 8H (Every 8 Hours) as needed for chronic pain and post surgical pain. Disp:90 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Scoliosis fusion revision Post-operative anemia Post-operative fever Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic if you notice any redness or discharge from the incision site. Call the clinic for any additional concerns. Followup Instructions: Please follow up in the Orthopedic Spine clinic during your previously scheduled appointments. Please follow up in the Hemetology/[Hospital ] clinic. Call [Telephone/Fax (1) 11624] and schedule an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6160] Completed by:[2171-1-3]	[ "327.23", "V45.86", "997.3", "996.49", "V43.64", "737.30", "285.1", "518.0" ]	icd9cm	[ [ [] ] ]	[ "77.79", "99.04", "81.38", "81.64" ]	icd9pcs	[ [ [] ] ]	3531, 3589	1829, 2888	295, 320	3702, 3709	1190, 1806	3963, 4291	654, 659		2947, 3508		3610, 3681		2914, 2924				3733, 3940						674, 1171																						239, 257								348, 531															553, 613	629, 638
30,139	191,230	33352	Discharge summary	report	Admission Date: [2130-1-29] Discharge Date: [2130-3-6] Date of Birth: [2051-1-3] Sex: F Service: MEDICINE Allergies: Heparin Agents / Succinylcholine Attending:[Last Name (NamePattern1) 495] Chief Complaint: Respiratory failure & oliguric renal failure Major Surgical or Invasive Procedure: Endotracheal intubation s/p trach on [2-7] PEG placement History of Present Illness: 79 F h/o asthma, CAD, CRI, initially presented to OSH [2129-12-7] with cough/sob, felt likely [12-24] PNA with reactive airway disease. She was started on a course of levaquin, nebs, and decadron, but failed to improve. CT CHEST on [12-14] revealed bilateral lower lobe infiltrates, and pt underwent bronchoscopy on [2129-12-23] which revealed old blood clot in both bronchi, BAL +[Female First Name (un) ] and +hsv per report, for which she was treated with courses of diflucan and acyclovir. . Pt's O2 requirement gradually increased despite broadening abx, until on [1-1] she was on NRB. Repeat bronchoscopy on [1-3] again showed blood clots in bilateral airways. p-anca, c-anca, and [Doctor First Name ] were negative. She improved slightly, but returned to the ICU on [1-10] for hypoxia, with sats 80%9L, at which time pt was felt to have component of CHF, which improved somewhat with lasix and intermittent bipap. for her pnuemonia, her abx course was broadened to include at various points zosyn, vancomycin, linezolid, primaxin, azithromycin and voriconazole. . On [12-26] pt developed afib with rvr, which resolved by [12-27]. on [12-20], pt was found to have a rectus sheath hematoma in the setting of inr 3.8. she was on coumadin for h/o HITT ~1y ago per notes. Her coumadin was d/c'd, as were her aspirin and plavix in consultation with cardiology (stents placed in [2127]). she was evaluated by general surgery who felt no intervention was necessary. . on [1-11] renal consult was obtained [12-24] rising creatinine (cre 1.7 on admit, 2.8 on [12-10], renal usn with some asymetry, lasix held, down to 1.3 on [12-24] so was restarted on diuresis for CHF), and declining UOP. ddx included intravascular depletion vs ATN [12-24] "hemodynamic stresses" vs AIN [12-24] multiple abx. because of worsening oliguria, she was ultimately started on CVVH on [1-15]. Her course was then c/b +cdiff on [1-9], started flagyl on [1-8]. . on [1-15] pt was felt to have worsening respiratory acidosis in the setting of progressive fluid overload. ABG=7.17/60/61 on 12L, thus pt was intubated with plan to start CVVHD [12-24] low BPs (90s). she continued solumedrol, iv flagyl, po vanco. Pt bronch'd again on [1-16] which again showed bilateral blood clots, GPC clusters, yeast. Her flagyl iv is d/c'd, solumedrol is weaned as was team "doubted vasculitis," pt was started on vfend 400mg po bid for [Female First Name (un) ] [1-17]. she continued to spike low grade temps, 101-102. CVVH stoped on [1-19] as pt felt dry. On [12/2050], pt noted to have some vomitting on vent, ?aspiration. UOP again declined thus HD restarted on [1-21]. . Pt restarted IV vanco [1-19]. restarted HD [12-24] oliguria, on [1-21]. alk phos starts to rise (282, ast and alt 70s, plt 20s, wbc 2.3). on [1-22] started on cefepime for fevers (102), bcx still unremarkable. BP 80/30s on [1-24], improved with 2U PRBCs and IVF. unclear if pt ever required pressors, but never documented. on [1-26], cbc with 27% bands. on [1-27] HITT ab sent and was negative. . in the setting of ongoing respiratory failure, and ARF, decision made to pursue transfer to [Hospital1 18]. . Past Medical History: -Hypertension -Hyperlipidemia -CAD - s/p MI [6-28], s/p stents x 3 @ [Hospital1 ] -Hypothyroid -RA -Gout -CRI (baseline cre 1.6-1.8) - etiology unclear, felt to develop after [2127] cath requiring dialysis, in [10-29] left kidney 7cm, right kidney 10cm. -Anemia [12-24] CKD - on epo -DM2 - on insulin -Asthma - not on home o2 -Pseudocholinesterase insufficiency -H/o HITT ([2127] [Hospital1 2025]) -H/o hemoptysis on heparin ([2127] [Hospital1 2025]) -H/o UGIB on heparin ([2127] [Hospital1 2025]) Social History: Denies tobacco, IVDU, ETOH Family History: non contributory Physical Exam: 99.1 111 122/67 24 95% on AC 380x16 60% peep 5. GEN: NAD, gross anasarca. HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no carotid bruits. CV: regular, nl s1, s2, no m/r/g. PULM: coarse breath sounds bilaterally, +rales/wheeze. ABD: distended, soft, NT, ND, + BS, no HSM. subcutaneous edema. EXT: warm, 2+ dp/radial pulses BL. 2+ LE edema. NEURO: responds to voice & tracks, PERRLA. Pertinent Results: [2130-1-29] 05:02PM BLOOD WBC-8.3 RBC-3.69* Hgb-10.9* Hct-33.4* MCV-90 MCH-29.4 MCHC-32.6 RDW-20.2* Plt Ct-105* [2130-2-6] 06:09AM BLOOD WBC-37.7* RBC-3.20* Hgb-9.1* Hct-28.0* MCV-88 MCH-28.5 MCHC-32.5 RDW-22.2* Plt Ct-162 [2130-2-10] 04:05AM BLOOD WBC-33.5* RBC-2.65* Hgb-7.4* Hct-23.5* MCV-89 MCH-27.9 MCHC-31.4 RDW-24.2* Plt Ct-152 [2130-1-30] 05:45AM BLOOD Neuts-75* Bands-8* Lymphs-4* Monos-4 Eos-0 Baso-0 Atyps-3* Metas-5* Myelos-1* NRBC-8* [2130-2-4] 05:05AM BLOOD Neuts-64 Bands-4 Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-9* Myelos-15* NRBC-6* [2130-2-8] 04:06AM BLOOD Neuts-65 Bands-2 Lymphs-9* Monos-12* Eos-0 Baso-2 Atyps-3* Metas-0 Myelos-5* Promyel-2* NRBC-8* [2130-1-29] 05:02PM BLOOD Glucose-166* UreaN-23* Creat-2.1* Na-139 K-4.6 Cl-101 HCO3-29 AnGap-14 [2130-2-10] 04:00PM BLOOD Glucose-65* UreaN-8 Creat-0.4 Na-141 K-4.4 Cl-108 HCO3-23 AnGap-14 [2130-1-29] 05:02PM BLOOD ALT-60* AST-67* LD(LDH)-725* CK(CPK)-16* AlkPhos-905* Amylase-19 TotBili-0.7 [2130-2-3] 05:28AM BLOOD ALT-48* AST-53* LD(LDH)-1231* AlkPhos-1054* TotBili-0.8 [2130-2-10] 04:05AM BLOOD ALT-42* AST-47* AlkPhos-755* TotBili-0.6 [2130-1-30] 05:45AM BLOOD GGT-818* [2130-1-29] 05:02PM BLOOD CK-MB-4 cTropnT-0.36* proBNP-7356* [2130-2-9] 05:25AM BLOOD VitB12-[2072]* Folate-8.4 [2130-1-30] 05:45AM BLOOD T4-1.8* T3-32* calcTBG-1.23 TUptake-0.81 T4Index-1.5* Free T4-0.18* [2130-1-31] 10:18PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2130-1-30] 05:45AM BLOOD ANCA-NEGATIVE B [2130-2-1] 11:08AM BLOOD PEP-TRACE ABNO IgG-720 IgA-89 IgM-545* IFE-TRACE MONO [2130-2-12] 05:31AM BLOOD WBC-27.7* RBC-2.73* Hgb-8.1* Hct-24.1* MCV-88 MCH-29.6 MCHC-33.6 RDW-22.8* Plt Ct-157 [2130-2-14] 04:36AM BLOOD WBC-20.2* RBC-2.93* Hgb-8.9* Hct-26.2* MCV-89 MCH-30.5 MCHC-34.1 RDW-23.3* Plt Ct-124* [2130-2-16] 04:05AM BLOOD WBC-27.3* RBC-2.70* Hgb-8.2* Hct-25.3* MCV-94 MCH-30.5 MCHC-32.5 RDW-24.5* Plt Ct-151 [2130-2-17] 04:52AM BLOOD WBC-26.0* RBC-2.73* Hgb-8.4* Hct-24.3* MCV-89 MCH-30.6 MCHC-34.4 RDW-23.8* Plt Ct-138* [2130-2-17] 06:59PM BLOOD WBC-25.5* RBC-2.75* Hgb-8.4* Hct-24.3* MCV-89 MCH-30.4 MCHC-34.4 RDW-23.8* Plt Ct-140* [2130-2-19] 04:57AM BLOOD WBC-23.3* RBC-2.59* Hgb-8.0* Hct-23.5* MCV-91 MCH-30.8 MCHC-33.9 RDW-24.3* Plt Ct-191 [2130-2-21] 06:26AM BLOOD WBC-14.9* RBC-2.39* Hgb-7.2* Hct-22.4* MCV-94 MCH-30.3 MCHC-32.4 RDW-23.8* Plt Ct-279 [2130-2-23] 04:44AM BLOOD WBC-15.4* RBC-2.65* Hgb-7.9* Hct-25.0* MCV-94 MCH-29.7 MCHC-31.5 RDW-22.3* Plt Ct-566* [2130-2-25] 05:36AM BLOOD WBC-11.7* RBC-2.54* Hgb-7.3* Hct-24.1* MCV-95 MCH-28.8 MCHC-30.5* RDW-21.7* Plt Ct-591* [2130-3-1] 12:30AM BLOOD WBC-15.1* RBC-2.83# Hgb-8.5 Hct-26.3* MCV-93 MCH-30.0 MCHC-32.2 RDW-21.6* Plt Ct-381 [2130-3-3] 04:11AM BLOOD WBC-15.1* RBC-2.95* Hgb-8.6* Hct-27.1* MCV-92 MCH-29.1 MCHC-31.7 RDW-21.8* Plt Ct-424 [2130-3-5] 02:33AM BLOOD WBC-18.6* RBC-3.09* Hgb-8.8* Hct-29.8* MCV-96 MCH-28.6 MCHC-29.7* RDW-22.2* Plt Ct-383 [2130-3-6] 03:52AM BLOOD WBC-17.6* RBC-2.99* Hgb-8.8* Hct-28.6* MCV-96 MCH-29.3 MCHC-30.7* RDW-23.0* Plt Ct-367 [2130-2-13] 05:40AM BLOOD Neuts-69 Bands-7* Lymphs-3* Monos-14* Eos-0 Baso-2 Atyps-2* Metas-0 Myelos-3* NRBC-5* [2130-2-16] 04:05AM BLOOD Neuts-68.8 Bands-2.1 Lymphs-2.1* Monos-9.4 Eos-0 Baso-0 Atyps-3.1* Metas-4.2* Myelos-4.2* Promyel-6.3* NRBC-5* [2130-2-21] 06:26AM BLOOD Neuts-82* Bands-4 Lymphs-6* Monos-3 Eos-1 Baso-1 Atyps-1* Metas-2* Myelos-0 NRBC-1* [2130-3-5] 02:33AM BLOOD Neuts-70 Bands-3 Lymphs-11* Monos-11 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-5* NRBC-9* [2130-3-4] 11:22AM BLOOD PT-13.2 PTT-39.1* INR(PT)-1.1 [2130-3-5] 02:33AM BLOOD PT-13.4 PTT-45.9* INR(PT)-1.2* [2130-1-30] 05:45AM BLOOD Fibrino-586* [2130-1-30] 05:45AM BLOOD FDP-0-10 [2130-2-1] 05:29AM BLOOD Fibrino-348# [2130-2-3] 05:57AM BLOOD FDP-10-40 [2130-1-29] 05:02PM BLOOD Gran Ct-5830 [2130-2-10] 04:05AM BLOOD LAP-195* [2130-2-10] 04:05AM BLOOD ESR-96* [2130-1-30] 05:45AM BLOOD Ret Aut-1.6 [2130-2-17] 04:52AM BLOOD Glucose-163* UreaN-42* Creat-1.5* Na-139 K-3.9 Cl-104 HCO3-24 AnGap-15 [2130-2-19] 04:57AM BLOOD Glucose-159* Creat-1.4* Na-141 K-4.1 Cl-107 HCO3-26 AnGap-12 [2130-2-21] 06:26AM BLOOD Glucose-161* UreaN-66* Creat-2.4* Na-141 K-5.0 Cl-108 HCO3-23 AnGap-15 [2130-2-23] 04:44AM BLOOD Glucose-81 UreaN-41* Creat-2.0* Na-144 K-4.9 Cl-109* HCO3-23 AnGap-17 [2130-2-25] 05:36AM BLOOD Glucose-74 UreaN-30* Creat-1.8* Na-148* K-3.9 Cl-111* HCO3-24 AnGap-17 [2130-3-1] 12:30AM BLOOD Glucose-87 UreaN-16 Creat-1.2* Na-140 K-4.3 Cl-103 HCO3-27 AnGap-14 [2130-3-3] 04:11AM BLOOD Glucose-115* UreaN-16 Creat-1.4* Na-144 K-3.9 Cl-106 HCO3-27 AnGap-15 [2130-3-5] 02:33AM BLOOD Glucose-78 UreaN-19 Creat-1.5* Na-143 K-4.2 Cl-104 HCO3-29 AnGap-14 [2130-3-6] 03:52AM BLOOD Glucose-107* UreaN-36* Creat-2.2* Na-142 K-4.3 Cl-101 HCO3-28 AnGap-17 [2130-2-12] 05:31AM BLOOD ALT-38 AST-38 LD(LDH)-657* AlkPhos-631* TotBili-0.5 [2130-2-14] 04:36AM BLOOD ALT-33 AST-34 LD(LDH)-619* AlkPhos-653* TotBili-0.5 [2130-2-15] 05:32AM BLOOD ALT-32 AST-32 LD(LDH)-531* AlkPhos-636* TotBili-0.4 [2130-2-16] 04:05AM BLOOD ALT-30 AST-33 LD(LDH)-512* AlkPhos-650* TotBili-0.5 [2130-2-17] 04:52AM BLOOD ALT-30 AST-36 AlkPhos-559* TotBili-0.4 [2130-2-19] 04:57AM BLOOD ALT-32 AST-40 LD(LDH)-512* AlkPhos-582* TotBili-0.5 [2130-2-26] 04:57AM BLOOD ALT-22 AST-31 AlkPhos-540* TotBili-0.3 [2130-1-29] 05:02PM BLOOD CK-MB-4 cTropnT-0.36* proBNP-7356* [2130-1-30] 05:36PM BLOOD CK-MB-4 cTropnT-0.30* [2130-2-21] 06:26AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0 [2130-2-23] 04:44AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.1 [2130-2-25] 05:36AM BLOOD Calcium-8.3* Phos-2.2# Mg-1.9 [2130-2-27] 03:46AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.6 [2130-3-1] 12:30AM BLOOD Calcium-8.1 Phos-1.6* Mg-1.9 [2130-3-3] 04:11AM BLOOD Calcium-8.6 Phos-1.3* Mg-2.0 [2130-3-5] 02:33AM BLOOD Calcium-8.5 Phos-1.0* Mg-2.0 [2130-3-6] 03:52AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.2 [2130-2-16] 04:05AM BLOOD calTIBC-173* Ferritn-450* TRF-133* [2130-2-20] 04:22AM BLOOD TSH-10* [2130-2-27] 03:46AM BLOOD TSH-5.0* [2130-2-27] 03:46AM BLOOD T4-7.9 calcTBG-1.12 TUptake-0.89 T4Index-7.0 Free T4-1.0 [2130-1-29] 05:02PM BLOOD Cortsol-27.0* [2130-1-29] 08:48PM BLOOD Cortsol-29.0* [2130-1-29] 09:25PM BLOOD Cortsol-31.8* [2130-2-6] 06:09AM BLOOD Cortsol-27.1* [2130-1-31] 10:18PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2130-2-20] 04:22AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2130-1-30] 05:45AM BLOOD ANCA-NEGATIVE B [2130-2-2] 12:10PM BLOOD AFP-3.3 [2130-2-10] 04:05AM BLOOD CRP-177.1* [2130-1-30] 05:45AM BLOOD [Doctor First Name ]-NEGATIVE [2130-2-19] 05:23AM BLOOD freeCa-1.09* [2130-2-21] 06:38AM BLOOD freeCa-1.06* [2130-2-23] 12:07PM BLOOD freeCa-1.05* [2130-2-24] 06:31AM BLOOD freeCa-1.18 [2130-2-24] 05:12PM BLOOD freeCa-1.09* [2130-2-25] 08:28PM BLOOD freeCa-1.10* [2130-1-30] 05:45AM BLOOD B-GLUCAN-Test [2130-1-30] 05:45AM BLOOD ANTI-GBM-PND [2130-1-30] 05:45AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST Imaging: [1-30] CT CHEST/ABD/PELV IMPRESSION: 1. Right rectus sheath hematoma. 2. Bilateral pleural effusions and pulmonary edema compatible with congestive failure. Atrophic left kidney. Small amount of perihepatic and right paracolic ascites. Fluid-filled colon may represent colitis. Soft tissue anasarca. 3. Endotracheal tube positioned at the carina, oriented towards the right main stem bronchus. [1-31] ECHO: 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 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-23]+) 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 [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: hyperdynamic, hypertrophic left ventricle with small cavity dimension; atrial fibrillation [2-1] RUQ U/S IMPRESSION: Portable ultrasound performed in the ICU. Images are limited given significant subcutaneous edema from patient's anasarcic state. The gallbladder is distended possibly secondary to NPO status. No intraluminal stone or sludge is detected. No secondary signs are identified to suggest acute cholecystitis. [1-30]: CT HEAD IMPRESSION: No acute intracranial pathology including no hemorrhage. [2-3] TEE: 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 normal (LVEF>55%). There are complex, nonmobile (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are moderately thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets and chorda tendinae are mildly thickened with a characteristic rheumatic deformity of the valve. The posterior mitral leaflet is thickened and largely immobilized. There is, however, no mitral stenosis. No mass or vegetation is seen on the mitral valve. Mild-to-moderate ([11-23]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no vegetation of the tricuspid valve. IMPRESSION: No endocarditis. Mild rheumatic valvular disease. Complex and extensive aortic atheroma. . [2-6] Chest CT: IMPRESSION: 1. Widespread ground-glass opacities with dependent consolidation. The findings are consistent with the given history of ARDS. Given additional septal thickening and pleural effusions and anasarca, an element of superimposed hydrostatic edema is suspected. A superimposed infection cannot be excluded in the setting of widespread parenchymal abnormality. 2. Colon wall thickening at the splenic flexure suggestive of colitis as previously described on the CT of [2130-1-30] with apparent progression. Dedicated abdominal CT may be considered for more complete assessment, if warranted clinically. 3. Appropriate position of endotracheal tube. 4. Stable right adrenal adenoma. 5. Diffuse enlargement of the thyroid gland. Correlate with biochemical markers. . TTE [2-7] No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-23]+) 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 [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2130-2-3], no change. . CTA [2-16] IMPRESSION: 1. No central pulmonary embolism. The study is markedly limited by motion, and therefore more distal emboli cannot be definitely excluded. 2. Diffuse ground-glass and patchy opacities which appear slightly worsened, as described above. 3. Increase in the left pleural effusion and new small right pleural effusion with associated lower lobe atelectasis, worst in the left base. . [2-20] Tunneled HD line placement IMPRESSION: Successful placement of a 15.5 Fr double-lumen tunneled hemodialysis catheter measuring 27 cm in length, with the tip positioned within the right atrium. The line is ready for use. [2-17] LIVER OR GALLBLADDER US (SINGL Reason: please evaluate for acalculous cholecystitis [Hospital 93] MEDICAL CONDITION: 79 year old woman with increasing fever and rising alk phos. REASON FOR THIS EXAMINATION: please evaluate for acalculous cholecystitis HISTORY: 79-year-old female ICU patient with increasing fever and rising alkaline phosphatase. COMPARISON: CT torso of [2130-1-30], right upper quadrant ultrasound on [2130-2-1]. PORTABLE GALLBLADDER ULTRASOUND: Sludge is seen within a distended gallbladder. The gallbladder wall is not thickened. The appearance of the gallbladder is overall similar to that seen on the ultrasound of [2130-2-1] and the CT of [2130-1-30]. A small amount of fluid is seen around the gallbladder, consistent with the ascites that was seen on the CT. The common duct measures 9 mm. IMPRESSION: Sludge within distended gallbladder without wall thickening. Cannot rule out cholecystitis based on the current study. CHEST (PORTABLE AP) [2130-3-1] 5:17 AM CHEST (PORTABLE AP) Reason: eval for interval change [Hospital 93] MEDICAL CONDITION: 79 year old woman with ventilator associated pneumonia REASON FOR THIS EXAMINATION: eval for interval change HISTORY: Ventilator associated pneumonia, to assess for change. FINDINGS: In comparison with study of [2-27], there has been some decrease in the bilateral pulmonary opacifications. This is consistent with improvement in the pulmonary vascular congestion. Pleural effusions appear to persist bilaterally. Tubes remain in place. Micro: [2130-1-29] 5:15 pm BLOOD CULTURE FINAL REPORT [2130-2-4] Blood Culture, Routine (Final [2130-2-4]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. Daptomycin AND TETRACYCLINE Sensitivity testing per DR. [First Name (STitle) ] PAGER [Numeric Identifier 1097] [2130-1-31]. Daptomycin 2MCG/ML SENSITIVE. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R Anaerobic Bottle Gram Stain (Final [2130-1-30]): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. [2130-1-29] 5:02 pm URINE Source: Catheter. FINAL REPORT [2130-1-31] URINE CULTURE (Final [2130-1-31]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R [2130-1-30] 5:36 pm Immunology (CMV) Source: Line-RIJ. FINAL REPORT [2130-2-1] CMV Viral Load (Final [2130-2-1]): 46,200 copies/ml. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. [2130-1-30] 8:31 pm CATHETER TIP-IV Source: RIJ. FINAL REPORT [2130-2-2] WOUND CULTURE (Final [2130-2-2]): ENTEROCOCCUS SP.. >15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R [2130-1-31] 4:27 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2130-1-31]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [2130-2-2]): SPARSE GROWTH OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Final [2130-2-7]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Final [2130-2-13]): YEAST. ACID FAST SMEAR (Final [2130-2-1]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2130-1-31]): NEGATIVE for Pneumocystis jirvovecii (carinii). [2130-2-3] 9:40 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2130-2-3] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2130-2-3]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [2130-2-6] 2:56 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2130-2-7] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2130-2-7]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [2130-2-9] 9:12 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2130-2-9] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2130-2-9]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. [2130-2-9] 12:39 pm Immunology (CMV) Source: Line-art. FINAL REPORT [2130-2-11] CMV Viral Load (Final [2130-2-11]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. [2130-2-10] 9:20 am SWAB LIP LESION. FINAL REPORT [2130-2-17] VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [2130-2-17]): NO VIRUS ISOLATED. [2130-2-11] 12:24 pm SPUTUM Source: Endotracheal. FINAL REPORT [2130-2-13] GRAM STAIN (Final [2130-2-11]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [2130-2-13]): SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. [2130-2-17] 3:53 am SPUTUM Source: Endotracheal. FINAL REPORT [2130-2-24] GRAM STAIN (Final [2130-2-17]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2130-2-24]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. YEAST. RARE GROWTH. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| AMIKACIN-------------- 16 S CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 8 I =>16 R MEROPENEM------------- 2 S 4 S PIPERACILLIN---------- 64 S =>128 R PIPERACILLIN/TAZO----- 8 S R TOBRAMYCIN------------ 4 S =>16 R [2130-2-22] 4:29 am Immunology (CMV) Source: Line-right radial. FINAL REPORT [2130-2-23] CMV Viral Load (Final [2130-2-23]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. [2130-2-26] 3:29 pm SPUTUM Source: Endotracheal. FINAL REPORT [2130-3-3] GRAM STAIN (Final [2130-2-26]): [9-16] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2130-3-3]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH OF THREE COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. YEAST. MODERATE GROWTH. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| NON-FERMENTER, NOT PSEUDOMONAS AERUGIN \| \| AMIKACIN-------------- 4 S R CEFEPIME-------------- 4 S 16 I CEFTAZIDIME----------- 2 S <=2 S CEFTRIAXONE----------- =>32 R CIPROFLOXACIN--------- =>4 R 2 I GENTAMICIN------------ =>16 R =>8 R IMIPENEM-------------- 2 S LEVOFLOXACIN---------- S MEROPENEM------------- 1 S S PIPERACILLIN---------- =>128 R <=8 S PIPERACILLIN/TAZO----- R <=8 S TOBRAMYCIN------------ =>16 R =>8 R TRIMETHOPRIM/SULFA---- <=2 S [2130-2-27] 6:53 pm BLOOD CULTURE Source: Line-HD line. FINAL REPORT [2130-3-5] Blood Culture, Routine (Final [2130-3-5]): NO GROWTH. Brief Hospital Course: 79F h/o F with respiratory failure/ARDS, oliguric renal failure, massive volume overload, VRE bacteremia & CMV viremia on admission. # Hypoxia: Pt was transferred from OSH after being intubated for over 2wks unable to wean off high PEEPs with a CT c/w ARDS and massive volume overload. Pt was aggressively diuresed with CVVH and weaned down to a PEEP of 5. Trach was placed on [2-7] and pt transitioned to trach collar. During admission, sputum Cx were negative for signficant growth despite VRE bacteremia. Unfortunately, the patient developed progressive hypoxemia again on [2-16]. CTA was performed which did not show PE. She was placed back on mechanical ventilation. Sputum cultures grew mixed resistance pseudomonas. She was treated for an 8 day course of ceftazadime. Her respiratory status improved and she was weaned on the ventilator. She then developed increased WBC and sputum, and her sputum was recultured growing mixed colonies of pseudomonas, also ceftazidime sensitive. She was treated with a repeat course of ceftazidime to complete a 14 day course. Prior to discharge, patient was weaned to trach mask and then tolerated PMV trial. She had not been on the ventilator for greater than 5 days prior to discharge. Her trach was downsized to a 7mm portex on [3-6], she was fitteed with a PMV and passed a speech and swallow evaluation with speech language pathology. # Hypotension/Sepsis??????Pt was admitted with hypotension & found to have VRE bacteremia. RIJ line tip was +VRE, blood & urine were also +VRE. RIJ & Left PICC were pulled and replaced, pt was treated with a 14 day course of Linezolid. All repeat blood Cx were neg for growth. CT scan revealed no abscesses or fluid collections. Both TEE & TTE were negative for vegetations. Pt did require minimal amounts of levophed during first week of CVVH and etiology was thought more likely due to intravascular volume depletion than ongoing sepsis. Pt was also continued on PO vanco for h/o C.diff from OSH, it was d/c'd after 5 C. Diff toxins returned negative. Pt was noted to have a CMV viremia on adm and was started on Gangcyclovir, which was stopped on [2-18]. Untreated hypothryoidism on admission may also have contributed to the hypotension and pt was treated with increased dose of levothyroxine per endocrine. Patient continued to maintain blood pressures during admission with transient drops during CVVH and HD. No further pressors were required. #GI: Pt has a h/o GIB in [2127]. EGD performed on [2-1] confirmed gastritis, no [Month/Year (2) ] bleeding. Pt was noted to have guaic positive stools & also produced bloody oral secretions that resolved after extubation. Pt was treated with PPI [Hospital1 ] & was transfused for a slowly dropping hct thought to be multifactorial including hemolysis via CVVH, phlebotomy & guaic positive stools due to ongoing colitis. Pt did not experience any acute hct drop while in hospital. She received a total of 4 packed RBC transfusions during admission. # Elev Alk Phos/LDH: Etiology of elevated AP & LDH was unclear. It may have been due to CMV virus as these trended down in house with Gangcyclovir treatment. Pt had an occult malignancy work up that was essentially negative including a normal AFP. Pan-CT scan showed no e/o lymphadenopathy. SPEP was essentially normal. Pt was noted to have a predominance of immature cells on peripheral smear with a persistently elevated WBC ct. Hem/Onc was consulted and felt this was most likely consistent with acute infection. LAP was elevated, consistent w/ inflammation. No further work up was initiated. # ARF/CRI -Pt was admitted in massive volume overload with ARF and remained dialysis dependant & oliguric while in house. Pt had successful volume removal with CVVH which allowed for vent weaning & ultimate transition to trach collar with toleration of trach mask with PMV. Pt was transitioned from CVVH to HD over [2-11] and will need to continue with HD as outpt. She is currently on a Tues, Thurs, Saturday HD schedule. # HEME/[Name (NI) 77417] Pt has a h/o HITT Ab + from OSH and was noted to be profoundly thrombocytopenic at OSH which recovered after transfer. Pt was started on Epo per renal & received transfusions as needed in house. There was no e/o active hemolysis & no acute GI bleed. Hem/Onc was consulted for predominance of immature cells on smear, CMV viremia & question of immunosuppression from primary hem malignancy who felt this was likely due to sepsis/acute infection. Platelets were at their nadir of 105 on transfer peaked to >700 and have been stable aroun 300-400 for 6 days prior to discharge. # CV: Pt with h/o CAD s/p stenting in ??????06. ASA & Plavix had been held in setting of pulm hemorrhage & guaic + stools at OSH. Pt was in persistent A.Fib throughout hospitalization. Amiodarone was bolused for an episode A.fib with RVR, but pt acheived best rate control with low dose Metoprolol 12.5mg TID. Pt was treated with ASA 81mg for CAD/stroke prevention due to high risk of bleeding & guaic + stools. Her rate remained high on metoprolol so she was transitioned to diltiazem, which better controlled her heart rate. In addition, she was started on digoxin with little improvement in rate. A combination of metoprolol with prn ativan maintained heart rates until 100, and she was continued on this regimen for the remainder of her hospitalization. #DM2: Pt with type II DM and h/o poorly controlled BS. Endocrine was consulted and assisted with BS management in house. She is on an agressive insulin regimen due to persistently elevated blood sugars. This can continue to be reevaluated as she is being transitioned to PO in addition to tube feeds just prior to discharge. # [Name (NI) 13488] Pt was not continued on home regimen of Synthroid per OSH records & presented with elevated TSH & depressed T3/T4 levels. Pt was started back on Levothyroxine replacement & endocrine was consulted to assist with persistent hypotension, profoundly depressed thyroid function & poor controlled blood sugars. Pt did well on Levothyroxine 75mcg IV daily & was transitioned to po Levothyroxine 150 mcg daily. TSH, FT4, T3 Uptake were followed weekly and continued to improve. # Wounds-Pt was noted to have multiple areas of superficial skin breakdown over sacrum & face on admission, no [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 77418]. Wound care team was consulted and pt received daily wound care treatment. Sacral wounds granulating well with no evidence of purulence, facial wounds healing. On day of discharge patient was afebrile with stable vital signs. She was pain free and tolerating PO intake. She will be discharged to a rehab facility to complete a 14 day course of antibiotics for her pneumonia Medications on Admission: Medications upon TRANSFER: levemir 8U QAM, SSI epo [Numeric Identifier 31034] UNITS Q28Days sucralfate 1000mg tid metoclopramide 5mg po q8hrs ipratropium/albuterol 4 puffs q4hrs nystatin powder toppically tid cefepime 1g q24hrs (last dose 0130 [2130-1-29]) vitamin a&d topical to buttocks q2hrs neutra phos 2pkt qid lisinopril 10mg po qdaily diltiazem 10mg/hr gtt zofran 2mg iv prn relgan 5mg iv q4hr prn prochlorperazine 25mg pr q12hr prn ativan 0.5 mg ngt q8hr prn ipratropium/albuterol 8 puffs q2h prn midazolam 2-4mg iv q1hr prn tylenol 650 q6hr prn morphine 2-4mg iv q1hr prn (increased respiratory rate) . Discharge Medications: 1. Ceftazidime 2 gram Recon Soln [Month/Day/Year ]: One (1) Recon Soln Injection QHD (each hemodialysis) for 7 days: To complete a 14 day course, last day, [3-13]. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Year (2) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid [Month/Year (2) ]: 50-100 mg PO BID (2 times a day) as needed. 4. Senna 8.6 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO BID (2 times a day) as needed. 5. Miconazole Nitrate 2 % Powder [Month/Year (2) ]: One (1) Appl Topical TID (3 times a day) as needed. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol [Month/Year (2) ]: Six (6) Puff Inhalation Q4H (every 4 hours). 7. Aspirin 81 mg Tablet, Chewable [Month/Year (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Month/Year (2) ]: [11-23] Drops Ophthalmic PRN (as needed). 9. Artificial Tear with Lanolin 0.1-0.1 % Ointment [Month/Day (2) ]: One (1) Appl Ophthalmic PRN (as needed). 10. Lidocaine HCl 2 % Solution [Month/Day (2) ]: Twenty (20) ML Mucous membrane TID (3 times a day) as needed. 11. Levothyroxine 75 mcg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 13. Epoetin Alfa 10,000 unit/mL Solution [Last Name (STitle) ]: 10,000 units Injection QHD: Dose with dialysis. 14. Diltiazem HCl 90 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QID (4 times a day): Hold for SBP <100. 15. Oxycodone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) as needed: Hold for sedation, RR <10. 16. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 17. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 18. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: Six (6) Units Injection QACHS: 6 units regular to be given with meals and at bedtime, also to be given Q6 hours per sliding scale: 0-60: [11-23] amp D50 61-100: none 101-140: 2 units ...increase by one unit for each increment of 40. . 19. Insulin NPH Human Recomb 100 unit/mL Suspension [Month/Day (2) ]: Seven (7) Units Subcutaneous twice a day: At breakfast and at bedtime. 20. Acetaminophen 500 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Hospital Discharge Diagnosis: Respiratory Failure s/p Trach placement Oliguric Renal Failure ARDS s/p trach & PEG placement Renal failure on HD VRE bacteremia CMV viremia Pseudomonas VAP with recurrence Discharge Condition: Stable Discharge Instructions: You were transferred from an outside hospital intubated with respiratory failure & renal failure. You have had aggressive volume removal & have been extubated with trach placement. You were treated for a blood infection, viremia, and pneumonia. Please continue your antibiotics for another 6 days which will be given with dialysis. You should continue your insulin as per recommended by the [Hospital ] clinic. It is very important that you continue your diltiazem and thyroid replacement medication as well. You have been started on hemodialysis that you will likely continue to require as your kidneys are not working well. You are scheduled to have hemodialysis on Tuesday, Thursday, and Saturday, and as per the Nephrologist's recommendations. Please do not miss [First Name (Titles) 9278] [Last Name (Titles) 4314]. Followup Instructions: You will need to call Dr. [Last Name (STitle) 18741] and set up a follow up appointment after discharge	[ "584.9", "518.81", "287.4", "414.01", "428.0", "535.50", "427.31", "999.9", "790.5", "412", "482.1", "459.0", "276.0", "995.92", "255.41", "008.45", "038.0", "428.32", "V45.82", "250.00", "493.90", "244.9", "078.5", "593.9" ]	icd9cm	[ [ [] ] ]	[ "96.6", "39.95", "88.72", "38.93", "00.14", "96.72", "45.13", "43.11", "31.1", "38.95", "99.04" ]	icd9pcs	[ [ [] ] ]	37550, 37611	27453, 34279	343, 406	37829, 37837	4843, 17385	38726, 38837	4383, 4401		34950, 37527	18405, 18460	37632, 37808		34305, 34927				37861, 38703						4416, 4824						22124, 27430																259, 305	18489, 22088							434, 3757															3779, 4323	4339, 4367
30,782	179,345	25407	Discharge summary	report	Admission Date: [2195-8-19] Discharge Date: [2195-8-24] Date of Birth: [2156-6-30] Sex: F Service: MEDICINE Allergies: Reglan Attending:[First Name3 (LF) 2817] Chief Complaint: Metatstatic osteogenic sarcoma; SVC syndrome Major Surgical or Invasive Procedure: None History of Present Illness: ONCOLOGIC HISTORY. T cell lymphoblastic leukemia/lymphoma over 20 years ago, treated and cured with radiation and chemotherapy. Radiation included mediastinum and chest. Diagnosed with primary MFH (malignant fibrous histocytoma) of the bone (left tibia) in [2193-6-24]. Received neoadjuvant chemotherapy with cisplatin/adriamycin (AP), and had definitive resection in [2193-11-24]. Operative specimen showed suboptimal necrosis (only 5% necrosis) and her postoperative chemotherapy was switched to AP alternating with IE (ifosfamide/etoposide). Finished chemotherapy in [2194-2-22]. She was treated by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 18]. Her chemotherapy course was complicated by profound myelosuppression and mucositis/esophagitis. HPI. Presents with worsening dyspnea (particularly on exertion), fatigue, and upper body/facial edema over the last several days. The patient was followed in Buffalo, NY, since she finished chemotherapy. She apparently was noted to have small lung nodule or nodules in early [2194] by imaging. This was followed by observation and in [2195-5-24] one of the nodules became very large (over 10 cm) and began to cause symptoms. She had a telephone discussion with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and she decided to pursue options including possible surgery in Buffalo [Location (un) 63519] Institute. However, the symptoms got quickly worse, and one of the lesions, apparently mediastinal in location, began to cause SVC type symptoms. She was treated with palliative XRT to the mediastinal mass to 18 [Doctor Last Name ], finished on or around [8-3]. She was also started on gemcitabine/docetaxel as 3rd line sarcoma therapy. Due to extensive prior chemotherapy for her hematologic malignancy and osteosarcoma and previous serious myelosuppression with AP and IE, she was started on a 50% dose of gemcitabine and did NOT receive docetaxel for her 1st cycle. She receive day 1 of her 2nd cycle last Saturday ([8-15]) and was scheduled to receive day 8 (gemcitabine and docetaxel) next Saturday in Buffalo. She has received neulasta even with gemcitabine out of fear for myelosuppression. She decided to transfer her care back to [Hospital1 18]. She feels that her shortness of breath, particularly when she tries to ambulate is worse, and that her face and left arm have begun to swell up over the last 2 days. She is reasonably comfortable at rest, but uses oxygen 6-8 hours every day for the last few days. Seen in clinic today and was admitted to the hospital for aggressive palliative treatment of her progressive symptoms. Upon arrival to the floor, the patient states that she also has some increased chest pain in the midsternal area over the past 2 days. Not pleuritic in nature. Does not describe any acute worsening of her respiratory status, though is tachypneic at rest. She additionally describes worsening fatigue, with more difficulty with movement. Past Medical History: --T cell lymphoblastic lymphoma 20 years ago treated with chemo and mediastinal irradiation --Osteosarcoma of the proximal left tibia s/p 2 cycles of Adriamycin and Cisplatin in [9-28] and [10-28], complicated by febrile neutropenia, espophagitis, s/p radical resection on [2193-12-23] --Cecal volvulus s/p right partial colectomy --Thyroidectomy [12-26] thyroid nodules ([12-26] mediastinal radiation) --ARF, pre-renal, resolved --UE DVT [12-26] PICC Social History: Works as rad tech. Now not working. Lives in [Hospital1 ] with a friend. [Name (NI) ] tobacco, alcohol or drugs. Married, but her husband is living in [Name (NI) 531] (her state of residence.) Mother is local, and very involved in her care. Family History: Significant for HTN. No coagulopathy. Hx of cancer in two maternal aunts of unknown type. No sarcomas. Physical Exam: Vitals BP107/68 Pulse 124 Temp afebrile RR 23 O2 no pulsus sats 99% on 2L. Facial edema. No jaundice, no skin rash. Tongue coated with some green/whie exudate. No lymphadenopathy. Lungs, clear,with reduced breath sounds on right Heart regular, but tachycardic. no m/r/g Abdomen, soft non tender. Extremeties: Left upper: edema from the elbow down. No leg edema, well healed surgical scar in left tibia. Pertinent Results: ON ADMISSION: [2195-8-19] 06:35PM WBC-5.7 RBC-3.18* HGB-9.1* HCT-27.9* MCV-88# MCH-28.5 MCHC-32.6 RDW-19.7* [2195-8-19] 06:35PM PLT COUNT-165 [2195-8-19] 10:30PM BLOOD PT-14.1* PTT-22.1 INR(PT)-1.3* [2195-8-19] 06:35PM BLOOD Gran Ct-5070 [2195-8-19] 10:30PM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-132* K-4.9 Cl-97 HCO3-22 AnGap-18 [2195-8-19] 10:30PM BLOOD ALT-74* AST-69* LD(LDH)-521* CK(CPK)-47 AlkPhos-126* TotBili-0.9 [2195-8-19] 10:30PM BLOOD Albumin-2.5* Calcium-7.4* Phos-2.6* Mg-2.1 . STUDIES: CT CHEST with CONTRAST IMPRESSION [8-20]: 1) 16 x 15 x 10cm, new prevascular mediastinal mass occluding a long segment of the superior vena cava, severely compromising the right bronchial tree and right lung pulmonary circulation invading the pericardium, accompanied by new and/or enlarging right lung nodules and bilateral pleural effusions. 2) Well-developed collateral venous circulation reflecting superior vena cava syndrome. 3) Segmental pulmonary embolus, left lower lobe. . ECHO [8-20]:The left and right atria appear compressed by an extrinsic mass. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Mitral regurgitation is present but cannot be quantified. There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2193-12-20], the atria now appear compressed by an extrinsic mass. . INTERVENTIONAL RADIOLOGY VISUALIZATION OF VEINS IMPRESSION [8-21]: 1) Recent thrombosis of the left and right subclavian and brachiocephalic veins, due to severe encasement of the SVC. 2)A 12 mm x 8 cm stent was placed in the SVC and extended with a 10 mm x 6 cm stent into the left brachiocephalic vein with good angiographic results. . [8-20] Bilateral LENIs: negative . CXR [8-23]: Markedly increased bilateral basal consolidations are seen accompanied by bilateral increase in pleural effusion. This consolidations might be either due to bibasilar atelectasis or massive aspiration. Mild pulmonary edema is seen. There is no change in the position of the right central venous line. Unchanged position of the central venous stent. . HOSPITAL LABS: [2195-8-23] 09:45AM BLOOD WBC-10.4 RBC-3.60* Hgb-10.5* Hct-31.3* MCV-87 MCH-29.0 MCHC-33.4 RDW-19.5* Plt Ct-82* [2195-8-20] 12:15PM BLOOD Neuts-89.3* Bands-0 Lymphs-7.7* Monos-1.2* Eos-1.7 Baso-0.1 [2195-8-23] 09:45AM BLOOD PT-13.3* PTT-21.8* INR(PT)-1.2* [2195-8-23] 09:45AM BLOOD Glucose-152* UreaN-12 Creat-0.7 Na-134 K-4.5 Cl-102 HCO3-21* AnGap-16 [2195-8-21] 06:14AM BLOOD ALT-74* AST-37 LD(LDH)-276* AlkPhos-125* TotBili-1.2 [2195-8-23] 09:45AM BLOOD Calcium-7.3* Phos-3.0 Mg-2.1 [2195-8-22] 12:33PM BLOOD Type-ART Temp-38.0 pO2-127* pCO2-25* pH-7.42 calTCO2-17* Base XS--5 Intubat-NOT INTUBA [2195-8-21] 07:21PM BLOOD Glucose-118* Lactate-1.5 Na-131* K-3.7 Cl-105 Brief Hospital Course: 39 year old female with NHL at age 19 treated with chemo/XRT later developed tibia osteosarcoma with metastasis to the lung/mediastinum admitted to OMED for progressive shortness of breath, fatigue, found to have SVC syndrome, subsegmental pulmonary embolism and right and left atrial compression. . 1) Mediastinal Mass/SVC syndrome: Patient has developed a large medistinal mass compressing right upper lobe bronchus, shifting mediastinum to left and compressing right and left atria seen on CT scan. ECHO done confirming left and right atrial compression, but only physiologic effusion. Thoracic surgery consulted for surgical consideration, however, given extensive vascular invasion of mass, felt to not be a surgical candidate. Not a candidate for XRT per Rad-Onc given already has received maximal doses. . She was admitted to Oncology service on [8-19] as patient was considering chemotherapy options, although disease has progressed despite chemo/XRT. She is currently on 3rd line therapy, so prognosis is poor. Patient aware of prognisos. After CT scan was ordered showing SVC syndrome, right upper lobe lung compression, subsegmental PE, possible pericardial invasion and compression of right and left atria on Echo, she was transferred to the [Hospital Unit Name 153] on [8-20] for closer monitoring. . She was monitored overnight in the [Hospital Unit Name 153] without any overnight events. She remained tachycardic 120-130's (although has been for 1 month) and bp stayed 95-110 systolic (also stable for a month). Pulmonary performed thoracentesis of L pleural effusion. Sent for cell count/diff, LDH, total protein, cultures and cytology. Given the plan for IR SVC stent and possible Interventional Pulmonary stent, she was transferred to MICU West for plan to monitor for 24-48 hours. Oncology was notified prior to transfer. . On the [Hospital Ward Name 517] MICU [Location (un) 2452]. [6-20] Bronchoscopy left airways patent. Right Main Stem narrowed secondary to external compression. Bronchus intermedius collapsed. Balloon dilatation of right main stem, and bronchus intermedius. Covered stent placed in the bronchus intermedius, and Y stent placed (trachea-LMS-RMS). Returned from Interventional Pulmonary intubated, sedated, hypotensive on neo. Changed to fentanyl/versed. Pt was seen by IR, stent was placed with femoral line and sheath in arm for access. Pt was given 4 liters of fluid and 1 unit PRBC for procedure. Fluid overloaded by report and sedated; therefore pt was not extubated overnight. Pt alert and transfered to [Hospital Unit Name 153] [8-22] for extubation. For [8-22] patient was extubated, with improved aeration of right lung. Over the day, night patient developed increased sputum production and increasing opacity in left lower lobe. . On [2195-8-23] started on Acapella therapy, maximum ventilation via shovel mask/O2 via NC; still with dyspnea and poor saturation. Patient requiested code status change to DNR/DNI. Started on morphine IV for comfort/decreased dyspnea ---> changed to morphine gtt on [2195-8-24]. Added scopolamine for secretion management [8-24] and ativan prn for agitation. . Patient's respiratory status continued to decline. One the afternoon of [8-24] the patient began to take agonal breaths and PEA was noted on the cardiac monitor. Physician exam revealed patient had died. Time of Death 1553 on [2195-8-24]. Family was by patient's bedside. . 2) Tachycardia - Likely secondary to atrial irritation/compression with intermittent hypoxia. Taking poor po intake, additionally hypovolemic. Patient heart rhythm alternated tachy-brady until PEA. . 3) Thrombocytopenia- Improved, still low. Consider heavy heparin products and HIT especially in light of rapid drop. No further lab draws as of [8-24] given comfort measures status. . 4) PE- subsegmental, diagnosed on Chest CT. Not likely causing her symptomatology. Anticoagulation contraindicated given bleeding risk and invasion into pericardium. No further intervention given comfort measures status. . 5) LLL opacity- concerning for pneumonia. Possible evolving infarct from PE or new thrombus. No further intervention/CXR given comfort measures status. . 6) Non anion gap acidosis- consistent with persistent hyperventilation. No diarrhea or ATN noted. Continue to monitor. No further lab draws given comfort measures status. . 7) Anemia- patient has myelosupression secondary to chemotherapy. No further lab draws given comfort measures status. . 8) Hypothyroid - No further lab draws given comfort measures status. . 9)FEN: No further lab draws given comfort measures status. . 10)Contact: [Name (NI) 21206] [Name2 (NI) 52711] [Telephone/Fax (1) 63520]. She is currently at the bedside. . 11)IV access: Port . 12)DNR/DNI: discussed with patient & family . 13)Dispo: To Morgue and then Funeral Home as family wishes Medications on Admission: levothyroxine colace/senna Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Osteosarcoma Cardiac Arrest Discharge Condition: Death Discharge Instructions: N/A Followup Instructions: N/A	[ "276.2", "V10.69", "V15.3", "V10.81", "E934.2", "415.19", "287.4", "197.0", "E933.1", "486", "197.1", "459.2", "511.9", "285.8" ]	icd9cm	[ [ [] ] ]	[ "33.91", "96.05", "34.91", "99.04" ]	icd9pcs	[ [ [] ] ]	12831, 12840	7797, 12726	312, 318	12911, 12918	4719, 4719	12970, 12976	4174, 4278		12803, 12808		12861, 12890		12752, 12780				12942, 12947						4293, 4700																						228, 274								346, 3388								4733, 7774							3410, 3887	3903, 4158
53,294	167,263	22929	Discharge summary	report	Admission Date: [2189-1-2] Discharge Date: [2189-1-10] Date of Birth: [2109-7-27] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: Mesenteric tumor Major Surgical or Invasive Procedure: s/p small bowel resection, resection of metastatic tumor of mesentery, common bile duct exploration and operative cholangiography History of Present Illness: 79M found to have a mesenteric mass on the previous admission for cholangitis due to gallstone([12-22]). Patient underwent ERCP, stent placement and presented for tumor excision and common bile duct exploration. Past Medical History: Hypothyroidism Hypercholesterolemia Panhypopituitarism- secondary to pituitary tumor resection. CCY approx 5 yr ago CAD s/p MI in [2172]- cardiologist Dr. [Last Name (STitle) 40149] Social History: Lives with wife, no tobacco, occasional [Name (NI) ] 1 glass wine over holidays, no illicit drugs, no IVDU, no Hx of blood x-fusions. Family History: Mom- [Name (NI) 3730], died of MI Dad- died of MI at age 59 No Hx of leukemia or liver problems Physical Exam: On admission, patient was Afebril with stable vital signs. Patient was alert and oriented, regular rate and rhythm, chest was CTAb, abdomen was soft, NT, ND. Brief Hospital Course: After the operation, patient was on neo gtt for pressure support which was weened in ICU. His pain was controlled with epidural, kept NPO with IVF. He was hypotensive with epidural and his pain medication was changed to dilaudid PCA. On POD 1, his pain was well controlled with good UOP. On POD2, patient continued to do well. He was kept NPO with IVF. His swan ganz cathether was changed to triple lumen. Patinet continue to do well. He was transferred to the floor. On POD5, he had low output from the NGT, passed gas and his abdomen was soft, NT and ND. His NGT was removed and he was started on clear liquid diet. Patient was seen by oncology service. On POD6, his diet was advanced to regular. He also developed wound infection at the surgical site, which was I&D. Dressing changes were started on the wound. On POD8. Patient was tolerating PO and doing well. He was discharged home in good condition. Medications on Admission: Gemfibrozil 600" Prednisone 5' Simvastatin 10' Lisinopril 5' Atenolol 100' Ranitidine 150" ASA 81' Vit B12 Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Hypothyroid Hypercholesterolemia Panhypopituitarism Pituitary tumor resection Coronary artery disease Myocardial infarction Mesenteric mass Discharge Condition: Good Discharge Instructions: Dressing changes twice a day Keep T-tube capped Call with fever, chills, abdominal pain No driving while taking pain med Followup Instructions: Please followup with Dr. [First Name (STitle) ] Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2189-1-30] 2:00 Please call Dr.[Name (NI) 18535] office for a followup appointment Completed by:[2189-1-10]	[ "998.59", "253.7", "196.2", "272.0", "E878.6", "244.9", "197.6", "574.50", "152.8", "276.5" ]	icd9cm	[ [ [] ] ]	[ "45.62", "87.53", "51.41", "51.11", "54.4" ]	icd9pcs	[ [ [] ] ]	3402, 3473	1392, 2315	329, 461	3657, 3663		3832, 4157	1092, 1195		2472, 3379		3494, 3636		2341, 2449				3687, 3809						1210, 1369																						273, 291								489, 707															729, 921	937, 1076
61,711	164,762	5354	Discharge summary	report	Admission Date: [2135-7-31] Discharge Date: [2135-8-5] Date of Birth: [2062-7-9] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 1973] Chief Complaint: Altered mental status and fever Major Surgical or Invasive Procedure: none History of Present Illness: 73 year old Male with a PMH significant for Alzheimer's dementia, Type 1 Diabetes, and CAD s/p CABG admitted for bilateral pyelonephritis with septicemia due to urinary obstruction. The patient developed altered mental status, fever to 103, and blood glucose of 500 at his nursing home on the day of admission, for which he was brought into the [Hospital1 18] ED. In the [Hospital1 18] ED, VS 98.3 157/72 86 18 98%RA. He received levofloxacin and flagyl as he as noted to have a distended abdomen. A foley catheter was placed and was noted to drain 2 liters of urine. Given his altered mental status and fever, the patient also received CNS dosing ceftriaxone for possible meningitis, although LP was deferred after CTAP demonstrated bilateral perinephric stranding and hydronephrosis concerning for bilateral pyelonephritis. The patient received 2L IVF and was transferred to the [Hospital Unit Name 153] for further management. The patient proceeded to improve steadily, and was transferred out to the floor. It was also noted that the patient had not had a bowel movement in many days, and the patient was given mirilax, along with an agressive bowel regimen, and the patient proceeded to have multiple massive BM's with additional improvement in mental status. Past Medical History: 1. Alzheimer's disease: Diagnosed approximately a year ago by Dr. [Last Name (STitle) ] after extensive neuropsychiatry testing. He has not ever received any therapy for symptoms and is not followed by Neurology despite referral in past. There is a head CAT scan on record. 2. Diabetes type 1: Diagnosis 47 years ago, currently maintained on an insulin pump. No known complications, per patient's wife. [Name (NI) ] history of DKA. 3. Coronary artery disease: Status post 2 prior heart attacks and a bypass surgery. 4. Hyperlipidemia. 5. Hypothyroidism. 6. Hyperkalemia. 7. Basal cell cancer followed by Dermatology last seen in [10-18]. 8. History of colon adenomatous polyps, last colonoscopy in [2131-3-13]. Follow-up in five years recommended. 9. Hyperhomocystinemia on folic acid. Social History: He has been married to [Doctor First Name 4489] for the last 50 years. They have four children together, 3 boys and 1 girl, [Doctor First Name 4489] is his healthcare proxy. [Name (NI) ] worked for [Location (un) 86] [Male First Name (un) 17703] for many years before retiring. He graduated from [University/College 5130] and lives in [Location 86]. He is not a smoker. Family History: Mother died at age [Age over 90 ]. Father is also deceased. He had two sisters both deceased. One died at 50 with a heart attack and one had alcoholism. He had one brother who died of complications of coronary artery disease at 74. He is the only surviving sibling. He has four children, a son aged 49, a son aged 47, a daughter aged 46 and a son aged 44. [Name2 (NI) ] are healthy with no known medical problems. Physical Exam: VS: 98.8 84 157/66 22 97% RA Gen: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Nl S1+S2, no m/r//g Pulm: CTAB Abd: Non-tender/non-distended, +bs. -CVAT Ext: No c/c/e. +bs Neuro: Oriented to person. CN II-XII grossly intact. Pertinent Results: [2135-8-4] 06:05AM BLOOD WBC-10.8 RBC-3.53* Hgb-10.6* Hct-31.0* MCV-88 MCH-30.1 MCHC-34.3 RDW-16.4* Plt Ct-281 [2135-8-2] 04:16AM BLOOD WBC-20.4* RBC-3.96* Hgb-12.2* Hct-35.5* MCV-90 MCH-30.7 MCHC-34.3 RDW-16.4* Plt Ct-192 [2135-8-1] 07:25PM BLOOD WBC-20.2* RBC-3.98* Hgb-12.1* Hct-35.9* MCV-90 MCH-30.4 MCHC-33.7 RDW-16.5* Plt Ct-200 [2135-8-1] 02:24AM BLOOD WBC-26.8* RBC-4.26* Hgb-13.0* Hct-37.2* MCV-87 MCH-30.5 MCHC-34.9 RDW-16.5* Plt Ct-192 [2135-7-31] 02:45PM BLOOD WBC-31.4# RBC-3.83 Hgb-11.7* Hct-33.5* MCV-88 MCH-30.6 MCHC-35.0 RDW-16.0* Plt Ct-219 [2135-7-31] 02:45PM BLOOD Neuts-93.7* Bands-0 Lymphs-2.8* Monos-2.9 Eos-0.2 Baso-0.4 [2135-8-1] 07:25PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-3+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-1+ Burr-2+ Ellipto-OCCASIONAL [2135-8-2] 04:16AM BLOOD PT-16.9* PTT-37.5* INR(PT)-1.5* [2135-8-1] 12:43PM BLOOD PT-18.2* PTT-34.4 INR(PT)-1.6* [2135-8-1] 02:24AM BLOOD PT-17.7* PTT-32.5 INR(PT)-1.6* [2135-7-31] 02:45PM BLOOD PT-14.0* PTT-29.3 INR(PT)-1.2* [2135-8-5] 06:05AM BLOOD Glucose-134* UreaN-10 Creat-0.8 Na-133 K-3.9 Cl-100 HCO3-25 AnGap-12 [2135-8-1] 06:52PM BLOOD UreaN-22* Creat-1.0 Na-128* K-3.8 Cl-95* HCO3-23 AnGap-14 [2135-8-1] 12:43PM BLOOD UreaN-27* Creat-1.3* Na-127* K-4.0 Cl-95* HCO3-24 AnGap-12 [2135-8-1] 02:24AM BLOOD Glucose-215* UreaN-40* Creat-2.2* Na-125* K-4.4 Cl-97 HCO3-16* AnGap-16 [2135-7-31] 09:25PM BLOOD Glucose-244* UreaN-47* Creat-3.2# Na-125 K-4.4 Cl-93* HCO3-21* AnGap-15 [2135-7-31] 02:45PM BLOOD Glucose-188* UreaN-64* Creat-5.8# Na-120 K-5.0 Cl-88* HCO3-15* AnGap-22* [2135-7-31] 02:45PM BLOOD ALT-35 AST-34 CK(CPK)-480* AlkPhos-102 Amylase-36 TotBili-0.9 [2135-7-31] 02:45PM BLOOD cTropnT-0.01 [2135-7-31] 02:45PM BLOOD CK-MB-13* MB Indx-2.7 [2135-8-5] 06:05AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.0 [2135-8-1] 02:24AM BLOOD PSA-1.2 [2135-8-1] 02:36AM BLOOD Type-[Last Name (un) ] Temp-36.8 Comment-GREEN TOP [2135-8-1] 02:36AM BLOOD Lactate-1.4 [2135-7-31] 02:57PM BLOOD Glucose-184* Lactate-2.6* [2135-8-1] 07:26PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2135-8-1] 04:12AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.012 [2135-7-31] 09:00PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.017 [2135-7-31] 03:00PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2135-8-1] 07:26PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [2135-8-1] 04:12AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose->1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2135-7-31] 09:00PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2135-7-31] 03:00PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2135-8-1] 07:26PM URINE RBC-432* WBC-9* Bacteri-NONE Yeast-NONE Epi-0 [2135-8-1] 04:12AM URINE RBC-13* WBC-13* Bacteri-NONE Yeast-NONE Epi-<1 [2135-7-31] 09:00PM URINE RBC-[6-22]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [2135-7-31] 03:00PM URINE RBC-[6-22]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0 [2135-7-31] 3:00 pm URINE Site: CLEAN CATCH FINAL REPORT [2135-8-1] URINE CULTURE (Final [2135-8-1]): NO GROWTH. [2135-8-1] 2:30 am MRSA SCREEN NASAL SWAB. FINAL REPORT [2135-8-3] MRSA SCREEN (Final [2135-8-3]): No MRSA isolated. ECG Study Date of [2135-7-31] 11:57:52 PM Sinus rhythm. Occasional premature atrial contractions. Compared to the previous tracing of [2133-5-12] ventricular premature beats have resolved. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 138 90 356/394 47 -1 58 CHEST (PA & LAT) Study Date of [2135-7-31] 3:44 PM IMPRESSION: Mild interstitial pulmonary edema. CT HEAD W/O CONTRAST Study Date of [2135-7-31] 5:57 PM IMPRESSION: No intracranial hemorrhage or edema. RENAL U.S. Study Date of [2135-8-1] 1:18 PM IMPRESSION: Little overall change to bilateral mild to moderate hydronephrosis. No perinephric abscess identified. PORTABLE ABDOMEN Study Date of [2135-8-2] 4:46 AM IMPRESSION: Stool mixed with contrast is noted throughout the colon. Brief Hospital Course: Mr. [Known lastname 11060] is a 73 year old gentleman with a PMH significant for Alzheimer's dementia, DM 1, and CAD s/p CABG admitted for bilateral pyelonephritis. 1. Septicemia due to pyelonephritis: - Patient with CTAP demonstrating bilateral perinephric fat stranding and hydronephrosis. That said, patient has had two UA's in the ED that were negative for pyuria, which is atypical for pyelonephritis, suggesting that a non-infectious post-obstructive uropathy leading to hydronephrosis may be causing his symptoms, although given fever and leukocytosis and prior dose of antibiotics this may be a culture with no growth due to antibiotics. Discussed with Urology, who recommended to start flomax, check PSA, f/u with urology as outpt (Dr. [Last Name (STitle) ] as below, discharge with catheter in place, the patient was discharged on ciprofloxacin. 2. Constipation: KUB showed large amts of stool in bowel. Pt had one BM overnight. Also noted previous days to have some scrotal edema, which is now improved. No need for scrotal u/s at this time. We continued bowel regimen and enema to relieve constipation, and finally mirilax with good effect. 3. Acute renal failure: Likely secondary to post-obstructive uropathy. Appears to be resolved, Cr now 0.8, after IVF. 4. Hyponatremia: Most likely etiology is intravascular volume depletion. Has resolved at time of discharge. 5. Anion gap acidosis: Likely secondary to lactic acidosis given lactate of 2.6. Patient without ketones on UA, although was noted to have a blood glucose of 500 at his NH. Anion gap closed at 10. We continued her insulin sliding scale. 6. CAD Bypass Vessle, Benign Hypertension: We increased his home metoprolol to 25 [Hospital1 ], and started his home isosorbide. Continued home atorvastatin and ASA 81 mg daily. 7. Type 1 Diabetes: Continued home basal lantus and HISS. 8. Dementia and Acute Delerium: Held home namenda until delerium resolved, and then it was restarted. 9. Hyperlipidemia: Continued home atorvastatin 10. Hypothyroid: Continue home levothyroxine. Code: DNR/DNI (form in chart) Medications on Admission: Atorvastatin 20 mg daily Lantus 22 units QAM Lispro ISS Isosorbide mononitrate 30 mg daily Levothyroxine 112 mcg daily Lorazepam 0.5 mg po tid Memantine 10 mg po bid Toprol XL 12.5 mg daily ASA 325 mg daily Folate 0.4 mg po bid Vitamin B6 . Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). units 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily): Hold for loose stools. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Acetaminophen 160 mg/5 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for Fever. 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26) units Subcutaneous once a day. 12. Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-75 mg/dL [1-14] amp D50 [1-14] amp D50 [1-14] amp D50 [1-14] amp D50 76-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units Instructons for NPO Patients: 1/2 dose if NPO 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 14. Memantine 5 mg Tablet Sig: Two (2) Tablet PO Daily (). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] - [Location (un) 2498] Discharge Diagnosis: Septicemia Pyelonephritis Urinary Obstruction Hyponatremia Acute Delerium Alzheimer's Dementia Benign Hypertension CAD Native Vessle Hypothyroidism Discharge Condition: Good Discharge Instructions: Return to the hospital with fever, chills, nausea, vomitting, diahrea. The patient is being discharged with an indwelling foley catheter, which must stay in until he is seen by urology on [8-15]. It can be changed (normal foley) but he will obstruct if he does not have a foley. Please give daily mirilax as directed and only hold for loose stools, as he becomes very constipated. Followup Instructions: Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2135-8-15] 1:30 [Hospital Ward Name 23] Bldg [Location (un) ]	[ "272.4", "590.10", "294.10", "V58.67", "995.91", "331.0", "244.9", "038.9", "401.1", "584.9", "414.00", "591", "250.01", "276.1", "276.2", "V45.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12335, 12457	8092, 10195	301, 307	12648, 12654	3651, 8069	13089, 13309	2889, 3312		10487, 12312		12478, 12627		10221, 10464				12678, 13066						3327, 3632																						230, 263								335, 1615															1637, 2457	2473, 2873
29,918	132,527	8468	Discharge summary	report	Admission Date: [2198-1-9] Discharge Date: [2198-1-21] Date of Birth: [2125-8-10] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2817] Chief Complaint: R sided weakness Major Surgical or Invasive Procedure: angiogram History of Present Illness: Patient is a 72y man sent from [Hospital3 ] with new R sided weakness, suspected stroke after recent d/c from [Hospital1 18] on [2197-12-31] following R sided intraparenchymal hemorrhage (x2) likely secondary to fall and presumed underlying amyloid angioopathy. His background also includes IHD s/p bypass surgery in [2189], right bundle branch block, hypertension, hyperlipidemia. During last admission platelets replaced for thrombocytpenia, aspirin ceased. Some confusion assoc with UTI. Since d/c has had very limited L arm and leg weakness. He was noted at 9.30am to be having incr difficulty eating with R hand. At that time VS BP144/77 HR 67 temp 98.2. Hand grip was [3-3], able to raise hand to mouth. Also complained of R forearm tingling. . Since that time weakness has progressed to involve both arm and leg. No speech or swallowing problems. [Name (NI) ] [Name2 (NI) ], dizzyness, visual change. Otherwise has been well. Treated with 7d ciprofloxacin from [12-31] for UTI.He has been getting heparin DVT prophylaxis. Past Medical History: PMHx: Recent right hip replacement (within the past month), coronary disease with bypass surgery in [2189], hypertension, hyperlipidemia, family with a history of heart disease, right bundle branch block, severe back pain, BPH, DJD, postoperative anemia Social History: Social Hx: lives with wife; works as a mechanic and welder; pipe smoking intermittently Family History: Family Hx: non-contributory Physical Exam: T:97.3 BP:161/76 HR:60 RR:18 O2Sats: 99% RA Gen: WD/WN, comfortable, NAD. Fingernails onycholytic/tar stained on L. HEENT: Pupils: PERRL EOMs-sl limitation bilat abduction Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused, nail changes. Neuro: Mental status: Awake and alert, cooperative with exam then quiet not answering questions, appropr concerned. Orientation: Oriented to person, place, not date. Language: Speech fluent with good comprehension. No answering naming Qs. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to finger counting. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial L weakness. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid ok and trapezius weak bilaterally ?effort. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. [Doctor First Name ] Tri [Hospital1 ] WF WE FE FF R 0 1 4- 4 3 3 4 L 0 0 0 4 0 1 4 Legs-nil R, L small movements of toes and adduction. Sensation: Intact to light touch bilaterally. Toes upgoing bilaterally Pertinent Results: Labs on admission: [2198-1-9] 01:01PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2198-1-9] 01:01PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2198-1-9] 12:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2198-1-9] 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2198-1-9] 11:15AM GLUCOSE-143* UREA N-26* CREAT-0.9 SODIUM-137 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-30 ANION GAP-10 [2198-1-9] 11:15AM WBC-12.0* RBC-4.44* HGB-14.2 HCT-41.4 MCV-93 MCH-32.0 MCHC-34.4 RDW-13.7 [2198-1-9] 11:15AM NEUTS-77.6* LYMPHS-17.6* MONOS-3.5 EOS-0.8 BASOS-0.4 [2198-1-9] 11:15AM PT-12.3 PTT-24.5 INR(PT)-1.0 Labs at time of expiration: [2198-1-20] 11:00AM BLOOD WBC-52.1* RBC-4.97 Hgb-15.6 Hct-46.8 MCV-94 MCH-31.3 MCHC-33.2 RDW-13.3 Plt Ct-137* [2198-1-20] 11:00AM BLOOD Neuts-90* Bands-0 Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2198-1-20] 11:00AM BLOOD Plt Smr-LOW Plt Ct-137* [2198-1-20] 11:00AM BLOOD PT-15.1* PTT-27.7 INR(PT)-1.3* [2198-1-20] 11:00AM BLOOD Glucose-199* UreaN-133* Creat-6.3# Na-138 K-5.9 Cl-102 HCO3-10* AnGap-32* [2198-1-19] 05:15AM BLOOD ALT-37 AST-43* LD(LDH)-634* AlkPhos-161* Amylase-68 TotBili-0.3 [2198-1-20] 11:00AM BLOOD Calcium-8.2* Phos-12.4# Mg-2.8 [2198-1-10] 01:45AM BLOOD CRP-10.2* [2198-1-20] 11:21AM BLOOD Type-ART Temp-35.6 FiO2-95 pO2-108* pCO2-31* pH-7.19* calTCO2-12* Base XS--15 AADO2-554 REQ O2-90 Intubat-NOT INTUBA [2198-1-20] 11:21AM BLOOD Lactate-3.1* Microbiology: Urine cx [1-13] - coag positive staph [2198-1-16] Stool cx - + c diff Blood cx [Date range (1) 29831] - negative Brief Hospital Course: Mr. [Known lastname ] is a 72 year old man sent from [Hospital3 ] initially with new R sided weakness and suspected stroke after recent d/c from [Hospital1 18] on [2197-12-31] following R sided intraparenchymal hemorrhage (x2) likely secondary to fall and presumed underlying amyloid angioopathy. His background also includes IHD s/p bypass surgery in [2189], right bundle branch block, hypertension, hyperlipidemia. He had a quite extensive hosptial course, initially in the neurological ICU for a new head bleed that was noted on admission CT scan. With this new head bleed, he now had had 3 recent intracranial hemorrhages, and was felt to likely have an underlying amyloid angiopathy per neurology, as the etiology of his symptoms. He was transiently on dexamethasone for question of vasculitis as the etiology of his bleeds, but this was eventually discontinued as this was felt not to be the etiology. He was eventually stable enough for transfer to the neurological floor, where he was noted to have waxing and [Doctor Last Name 688] mental status. His floor course was complicated by a number of factors, including waxing and [Doctor Last Name 688] mental status (as mentioned), intermittent fever spikes where work up demonstrated a UTI and c diff colitis (for which he was appropriately treated with antibiotics), a right femoral vein thrombosis for which he had an IVC filter placed (could not be anticoagulated due to his intra-cranial hemorrhage), renal failure, metabolic acidosis (felt to be due to the renal failure). Throughout his floor course he progressively declined, and was eventually transferred to the medical ICU when we was noted to be somnolent, tachypnic with an increasing oxygen requirement, and decreasing blood pressure. On transfer to the medical ICU he was noted to be extremely ill with decreasing blood pressures, increasing oxygen requirement. His renal function was also noted to be worsening (likely causing some fluid in the lungs, contributing to his poor pulmonary status, along with likley aspiration event from his poor mental status) and he was approaching anuria with need for dialsys. His other laboratory data indicated worsening in his condition with his white blood cell count increasing, and lactate level increasing. Given the impending need for intubation given his poor mental status and poor respiratory status, central line placement for pressors for blood pressure support, initiation of dialysis and ?intra-abdominal pathology (concern for ischemic gut given his climbing WBC and elevated lactate), code status and goals of care were addressed with the family. Within 24 hours of the [Hospital 228] transfer to the medical ICU, his family deemed him comfort measures only and he expired shortly thereafter. Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Intracranial hemorrhage Renal failure C diff colitis Urinary tract infection Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA	[ "600.00", "276.51", "995.92", "V45.81", "038.3", "287.5", "414.00", "702.19", "599.0", "431", "401.9", "342.90", "453.40", "V43.64", "272.4", "593.2", "584.9", "277.39" ]	icd9cm	[ [ [] ] ]	[ "38.7", "88.41" ]	icd9pcs	[ [ [] ] ]	8910, 8919	5063, 7869	297, 308	9039, 9048	3229, 3234	9099, 9104	1812, 1842		8883, 8887		8940, 9018		7895, 8860				9072, 9076						1857, 2181																						241, 259								336, 1408	2466, 3210							3248, 5040		2196, 2450					1430, 1690	1706, 1796
75,248	130,187	44636	Discharge summary	report	Admission Date: [2200-9-20] Discharge Date: [2200-9-28] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: Patient presented with nausea, vomiting and abdominal pain Major Surgical or Invasive Procedure: 1)Exploratory laparotomy with extensive lysis of adhesions 2) Small bowel resection 3) Enteroenterostomy 4) Transgastric feeding jejunostomy History of Present Illness: Patient is an 88y.o. Male who resides in a nursing home. Patient has had abd pain for 2 days. A kub obtained at a imaging facility revealed ileus vs small bowel obstruction. Pt began vomiting was brought to the ED. He is alert and orientated but is unable to give a good history. Past Medical History: 1. Type II diabetes. 2. Chronic renal insufficiency. 3. Sick sinus syndrome, status post pacemaker placement. 4. Ventricular tachycardia (no details), status post AICD. 5. Severe cardiomyopathy with an EF of [10-30]%. Social History: He lives in [State 108]. His family is here. He receives most of his care at the West Palm Beach VA. No tobacco. Occasional ETOH. Family History: No family history, per the patient. Physical Exam: Vitals:T-96.3 HR-62 BP-150/70 RR20 97%RA Exam: Awake, Oriented, NAD Lungs: Bilateral basilar crackles, Bilateral breath sounds Heart: irregularly irregular Abd: soft, nondistended, nontender, lower midline incision x2, no pulsatile masses, GJ tube in place Extremities: LE trace edema bilaterally, w/ hyperpigmentation and alopecia over B lower legs Brief Hospital Course: [Known firstname 95533] is a very pleasant 88-year-old gentleman with a history of small bowel obstruction and previous surgery who presented with nausea, vomiting, abdominal pain. He had a CT scan that demonstrated a small bowel obstruction. A nasogastric tube was placed. Plain films and repeat CT scan demonstrated no resolution of the bowel obstruction. The patient was admitted to the General Surgical Service for evaluation and treatment. Through the son, a consent was obtained for exploratory laparotomy. Pt went to the OR [2200-9-20] for Exploratory laparotomy with extensive lysis of adhesions, small bowel resection, enteroenterostomy and transgastric feeding jejunostomy. Patient was admitted to the ICU postoperatively for close monitoring. In the ICU, patient with AICD, demand pacer (intermittently firing), beta blocked, sepsis cath with SVV now downtrending with improved CVP suggest better hemodynamics with fluid resusitation. Patient transferred to the regular nursing floor once stable. The patient arrived on the floor NPO, on IV fluids with a foley catheter, and dilauded for pain control. The patient was hemodynamically stable. Neuro: The patient received dilauded with good effect and adequate pain control. Patient received very little dilauded and is discharged with out the need for narcotics. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. NPO, G-J tube in place. Patient started on Tube feeds and advanced to goal. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating tube feeds at goal, and pain was well controlled. Medications on Admission: 1. Coumadin 5 mg one p.o. q.d. 2. Lasix 40 mg one p.o. q.d. 3. Senna p.r.n. 4. Imdur 30 q.d. 5. Glyburide 2.5 mg one p.o. q.d. 6. Digoxin 0.125 mg one p.o. q.d. 7. Monopril 20 mg one p.o. q.d. 8. Coreg 3.125 mg one p.o. b.i.d. 9. Trazodone 27 mg one p.o. q.h.s. p.r.n. 10. Levaquin 250 mg one p.o. q.d. 11. Colace p.r.n. 12. Multivitamin daily. 13. Vitamin C daily. 14. Cytotec 200 b.i.d. 15. Niacin 500 b.i.d. 16. Duo-Nebs. 17. Temazepam 15 p.o. q.h.s. p.r.n. 18. Voltaren 500 t.i.d. Discharge Medications: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Insulin SC (per Insulin Flowsheet) Sliding Scale Digoxin 0.125 mg PO DAILY Patient may resume all medications upon discharge. Patient's coumadin was held due to fall risk and may be started as per physicians at Care Facility. Patient's lasix held due to hypernatremia and may be started as per physicians at Care Facility. Discharge Disposition: Extended Care Facility: Bear [Doctor Last Name ] Nursing Center Discharge Diagnosis: Closed loop complete bowl obstruction Acute on chronic renal failure Cardiomyopathy with severe systolic dysfunction Discharge Condition: Stable Discharge Instructions: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-25] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. Followup Instructions: Please follow up with Dr. [First Name (STitle) 2819] in three weeks in clinic. Please call ([Telephone/Fax (1) 6347*] to schedule an appointment.	[ "427.81", "585.9", "E870.8", "584.9", "276.0", "425.4", "250.00", "428.0", "441.4", "998.2", "560.2", "293.0", "V45.02", "428.21", "560.81" ]	icd9cm	[ [ [] ] ]	[ "45.91", "46.39", "96.07", "46.73", "45.62", "96.71", "54.59" ]	icd9pcs	[ [ [] ] ]	5031, 5101	1627, 4082	320, 463	5262, 5271		7053, 7210	1198, 1236		4627, 5008		5122, 5241		4108, 4604				5295, 6642				6658, 7030		1251, 1604																						222, 282								491, 776															798, 1027	1043, 1182
13,924	143,031	13106	Discharge summary	report	Admission Date: [2133-6-23] Discharge Date: [2133-7-1] Service: MEDICINE Allergies: Betalactams Attending:[First Name3 (LF) 297] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: transfer to unit, line placed History of Present Illness: 80M CAD s/p CABG [2120] (LIMA to LAD, SVG to RCA, SVG to LCX), ischemic CM/CHF with EF 35%, chronic afib (on coumadin) s/p PPM (infected wire [2120], revised and reinserted on left in [2122]), initially admitted to OSH [2-4] for LLL PNA, treated with levofloxacin. He was readmitted [3-7] with ? cellulitis RUE related to IV site and found to have MSSA bacteremia, treated with IV PCN x 4 weeks. He did well until [2133-6-14] when he developed F/C at home. Outpt Blood Cx + for MSSA --> admitted to OSH for IV ceftriaxone, zosyn and levofloxacin. Few days later changed to nafcillin and then PCN. He continues to have positive blood cultures despite treatment. TEE report from [2133-6-18] showed increased echogenicity on 2 pacer wires without vegetations, EF 35%. He was transferred to [Hospital1 18] [2133-6-23] for persistent staph aureus bacteremia after receiving IV abx since readmission on [2133-6-12], concern for PPM infection, and acute renal failure occurring while receiving abx at OSH. In CCU, patient remained hemodynamically stable. ID, Renal, and CT surgery consultants are following. Patient currently on IV ceftriaxone and oxacillin. Past Medical History: CAD s/p CABG [2120] (LIMA to LAD, SVG to RCA, SVG to LCX) Ischemic CM and CHF, LVEF 35% History of PE on Coumadin PPM placed [2120], c/b infection, with replacement [2122] or [2132] Moderate to severe TR Chronic afib COPD GERD GOUT Social History: Lives alone and cares for himself. NOK are his 2 nieces. Family History: Not discussed Physical Exam: T 97.0, 93/50, 80, 18, 96% on RA GEN - NAD, A&Ox3, sitting up in bed eating HEENT - PERRL, EOMI, OP clear, MMM NECK - no JVD, no LAD HEART - nl s1s2, RRR, III/VI HSM at RUSB LUNGS - CTAB, poor air movement ABD - soft, NT/ND, NABS, no hsm, no masses EXT - no edema Pertinent Results: [6-23] INR 21.4 [6-23] urine eos negative [6-23] creatinine 4.9 OSH micro - Blood cx [6-20], [6-20] and [6-23] NGTD for staph Blood cx [6-20] + for Cornybacterium EKG [2133-6-23]: NSR at 86 bpm, TW flattening I, L, V6 CXR [2133-6-23]: No CHF or infiltrates, flattened diaphragms, dual-pacer, s/p CAB Renal U/S [2133-6-24]: no hydro, no stones, no masses in kidneys, prostate enlarged, small echogenic kidneys Brief Hospital Course: 1) MSSA Bacteremia: Patient received Nafcillin and PCN at OSH and last + BCx was [6-19]. He then developed ARF likely [3-4] AIN (white cell casts seen in urine despite lack of urine eosonophils). He was then switched to vancomycin and placed on prednisone. EP was planning on removing pacer wires at a later time. In the setting of his renal failure, his lasix, ACEI and allopurinol were held. * 2) CARDIAC: . A) CAD: s/p CABG in [2120]. No evidence of ischemia on EKG. Continued ASA, statin, BB (holding ACE-I [3-4] ARF). Patient had a h/o CHF: EF 35%. No evidence of failure on admission. Pt takes lasix 80mg QOD even days, 40mg QOD odd days as OP. Held and ace. He was started on low dose BB, titrate up as tolerated . C) Atrial fibrillation: History of chronic afib. OP Coumadin dose 1.25mg M-Sat; 2.5mg QSun. INR 21 on admission, 12 today. He was then given some vitamin K * 3) COPD: No evidence of exacerbation. --Continued on atrovent, albuterol PRN Patient was doing much better, until he developed the acute onset of SOB requiring intubation and transfer to MICU. Given his h/o of PE, there was concern for repeat PE. Given his renal failure, CTA was difficult and given his COPD, a V/Q scan was not feasible as well. He was started on heparin drip. He also became hypotensive refractory to triple pressor support. An echo was done which showed a severe EF depression (less than 10%) with RV dilation and seevre global RV hypokinesis. EKG has no ischemic changes and first set of enzymes was negative. Concern was still for a massive PE and there was a question as to whether lytics sould be started. However, patient was oozing blood from his line site and decision was to only start lytics if a PE was definite. He was too unstable to go for CTA, and decison was to take the patient to cath to better define his HD. He continued to clinically decline and was started on broad spectrum abx, including vanco, levo, [Doctor Last Name ] gent. A pulmonary angiogram was done, and showed no evidence of PE. In addition, his blood cultures grew [5-4] gram negative rods, and patient continued to decline clinially and seemed in septic shock with limited cardaic reserve. His family was contact[Name (NI) ] and the case was discussed. Patient passed away shortly thereafter. Medications on Admission: (On admission to [Hospital3 ]): Lisinopril 20mg daily, Lanoxin 0.25mg daily, Lasix 80mg QOD, Allopurinol 200mg daily, Ecotrin 81mg daily, Coumadin (dose not listed), Omeprazole 20mg daily, Lescol 80 daily, Floredil, Atrovent. Discharge Medications: patient expired Discharge Disposition: Home with Service Discharge Diagnosis: patient expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2133-7-1]	[ "V09.0", "584.5", "V12.51", "996.61", "580.89", "785.52", "995.92", "285.9", "424.2", "428.0", "274.9", "790.92", "496", "V45.81", "414.8", "038.11", "427.31", "V45.01", "785.51", "530.81" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.71", "96.04", "37.21", "88.43", "38.93" ]	icd9pcs	[ [ [] ] ]	5284, 5303	2646, 4964	228, 259	5362, 5371	2169, 2623	5427, 5464	1854, 1869		5244, 5261		5324, 5341		4990, 5221				5395, 5404						1884, 2150																						178, 190								287, 1492															1514, 1763	1779, 1838
21,090	185,350	45189	Discharge summary	report	Admission Date: [2120-1-2] Discharge Date: [2120-2-2] Date of Birth: [2043-8-28] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides / Bactrim / Vancomycin Attending:[First Name3 (LF) 2763] Chief Complaint: COPD, PEA Arrest, T11 Fracture Major Surgical or Invasive Procedure: Intubation Ortho Spine [2120-1-11]: Posterior approach and attempted reduction of fracture dislocation, Fusion T6 to L4, Laminectomy T12, L1, L2, Repair of dura spinal cord injury. Ortho Spine [2120-1-19]: OR wash out. PICC Line Arterial Line x 2 History of Present Illness: This is a 76 year old female with a history of COPD on home oxygen, moderate to severe aortic stenosis and diastolic heart failure who presented to [Location (un) 620] on [2119-12-30] with progressive dyspnea on exertion and cough productive of clear sputum. She was initially treated for presumed COPD exacerbation with IV solumedrol, levofloxacin and nebulizers. She initially refused non-invasive and invasive ventilation. She developed progressive hypercarbia despite ultimate initiation of non-invasive ventilation and suffered PEA arrest on [2120-1-1]. ABG during her arrest was 7.07/113/172 and she was intubated. She required one round of epinephrine and atropine as well as CPR and regained spontaneous circulation. She did not require defibrilation. She had a femoral line placed after her arrest as well as an arterial line. After the arrest she underwent CT torso which was negative for pulmonary embolism but showed an unstable T11 fracture with evidence of hemorrhage. She also underwent CT head which showed no acute signs of hemorrhage. She initially was started on lovenox given concern for possible pulmonary embolism and elevated troponin after the arrest but developed bleeding from her right ear as well as from her OGT and this was discontinued. Prior to transfer her antibiotic regimen was switched to ceftriaxone from levofloxacin for ciprofloxacin resistent e. coli in her urine. She also transiently required levophed after her cardiac arrest but this was discontinued on the morning of the day of transfer. She is transferred for orthopedic evaluation of her unstable T11 fracture. . On arrival to the ICU she is intubated and sedated. Review of systems unable to be obtained. Past Medical History: pmhx: 1.COPD - GOLD Stage III with FEV1 32% predicted on PFTs in [2115], on home O2 2.Moderate-to-severe aortic stenosis - valve area 0.9 cm, Mean gradient 29mmHg, peak velocity 3.4 on echo in [8-/2117] 3.Diastolic CHF 4.Obstructive sleep apnea - No formal sleep study and not on CPAP 5.Achalasia, s/p pneumatic dilatation and botulinum toxin injection of LES 6.Morbid obesity 7.Chronic lower extremity edema 8.S/P cholecystectomy: [2102] 9.Chronic low-back pain Social History: She lives in a skilled nursing facility. She ambulates minimally and uses a wheelchair. She is dependent for the majority of her activities of daily living. Remote history of tobacco use, no alcohol or illicit drug use. Family History: Mother deceased at age 72, [2-6] to trauma. Daughter died at age 47 of cancer. 4 children. One adult daughter is deceased at age 47, [2-6] to cancer, the remaining daughers are alive. Previously at [Hospital 100] Rehab, now lives at home. Physical Exam: Vitals: T: 95.4 BP: 110/67 P: 80 R: 24 O2: 100% (AC 400 x 24, PEEP 10, FiO2 40%) General: Intubated, sedated, no distress HEENT: Sclera anicteric, MMM, OGT with dried blood, right ear with dried blood in external canal. Neck: obese, unable to appreciate JVP Lungs: Coarse breath sounds bilaterally, no wheezes, rales, ronchi CV: Distant heart sounds, regular, s1 and s2, II/VI SEM at RUSB, no rubs or gallops Abdomen: obese, mildly distended, faint bowel sounds, no rebound tenderness or guarding GU: foley with clear yellow urine Ext: Warm, well perfused, trace pedal pulses, trace radial warm, no clubbing, cyanosis. Erythema in the lower extremities bilaterally without warmth. 2+ edema bilaterally to knees. Femoral line in place, left arterial line in place. Neurologic: PERRL, EOMI, corneal reflexes intact, withdraws upper extremities to painful stimuli, does not withdraw lower extremities, toes equivocal bilaterally in lower extremities, trace patellar reflexes bilaterally, unable to elicit ankle reflexes, present biceps, triceps reflexes. Pertinent Results: Labs on Admission: Labs on Discharge: Microbiology: [2120-1-14] 3:00 pm CATHETER TIP-IV Source: right IJ central line. WOUND CULTURE (Final [2120-1-17]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxcillin 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. Please contact the Microbiology Laboratory ([7-/2416]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML ______________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S [2120-1-17] 3:32 pm BLOOD CULTURE Source: Line-picc. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. [2120-1-20] 4:49 pm BLOOD CULTURE Source: Line-PICC line #2. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [2120-1-22]): GRAM POSITIVE COCCI IN CLUSTERS. [2120-1-14] 3:48 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [2120-1-14]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2120-1-17]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. 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. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 0.5 S CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 1 S OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S [2120-1-19] 3:15 pm SWAB Site: SPLEEN SPINE. GRAM STAIN (Final [2120-1-19]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". DR. [Last Name (STitle) 20570] #[Numeric Identifier 21634] REQUESTED TETRACYCLINE , DOXYCYCLINE AND DORIPENEM SENSITIVITIES [2120-1-22]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX \| AMPICILLIN/SULBACTAM-- 4 S CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I IMIPENEM-------------- 8 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Studies: ECHO ([1-2]): The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is at least moderate aortic stenosis but Doppler data are technically suboptimal for estimation of aortic valve area. 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 a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2117-12-22], the aortic valve gradient is now higher. Shoulder Xray ([1-3]): Dislocated left shoulder. Brief Hospital Course: 76 yo F history of COPD on home oxygen, moderate to severe aortic stenosis and dCHF who presented to [Location (un) 620] on [2119-12-30] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after PEA arrest with evidence of unstable T11 fracture now s/p fusion T6 to L4, laminectomy T12-L2. . Outside Hospital Course (Hypercarbic Respiratory Failure/PEA Arrest/T11 Fracture): She was initially treated for presumed COPD exacerbation with IV solumedrol, levofloxacin and nebulizers at the outside hospital. She initially refused non-invasive and invasive ventilation. She developed progressive hypercarbia despite ultimate initiation of non-invasive ventilation and suffered PEA arrest on [2120-1-1]. ABG during her arrest was 7.07/113/172 and she was intubated. She required one round of epinephrine and atropine as well as CPR and regained spontaneous circulation. She did not require defibrilation. She had a femoral line placed after her arrest as well as an arterial line. After the arrest she underwent CT torso which was negative for pulmonary embolism but showed an unstable T11 fracture with evidence of hemorrhage. She also underwent CT head which showed no acute signs of hemorrhage. She initially was started on lovenox given concern for possible pulmonary embolism and elevated troponin after the arrest but developed bleeding from her right ear as well as from her OGT and this was discontinued. Prior to transfer her antibiotic regimen was switched to ceftriaxone from levofloxacin for ciprofloxacin resistent e. coli in her urine. She also transiently required levophed after her cardiac arrest but this was discontinued on the morning of the day of transfer. She is transferred for orthopedic evaluation of her unstable T11 fracture. . Hypercarbic Respiratory Failure: Patient presented from outside hospital intubated as above. Broadly patient was treated for MRSA/Pseudomonas pneumonia with Linezolid and Cefepime for 14 days. Linezolid was continued in the perioperative period. Patient was continued on steroids and albuterol/ipratroprium nebs. Further patient was diuresed in the perioperative period on a lasix gtt given borderline low blood pressures while on sedation. Patient was weaned and [Date Range 8337] pressure support without difficulty. After stabilization of the patient spine in the OR patient was extubated and did rather well for multiple days on first oxygen via facemask then Nasal Canula. During this time patient refused non invasive ventilation. Because of continued drainage from the patients surgical site patient went back to the OR for wash out. After the procedure the patient was eventually extubated again. This time patient continued to be hypercarbic and was reintubated at approx. 24 hours. After extensive family discussion it was decided to place tracheostomy and PEG tube. Tracheostomy and PEG tube were placed however the patient continued to have respiratory difficulty. She had episodes of continued tachycardia, hypotension and poor oxygenation even on high PEEP and FiO2. Daughters decided to continue to make her comfortable. She expired shortly after that decision secondary to respiratory failure. . Unastable T11 Fracture/Spinal Cord Injury: On transfer pt was stabilized. Spinal cord was protected with log roll precautions. Pt had no sensation or movement in her lower extremity. Ortho Spine was consulted and stabilized fracture with T6 to L4 fusion, T12-L2 laminectomy. The operation was uneventul. The post operative course was complicated by continued drainage from the wound. Eventually the patient was taken to the OR for washout. The washout was complicated by an episode of hypotension and ST depression in lateral leads. Hypotension resolved initially with pressures. EKG was later repeated without ST-T wave depression or elevation. Cardiac Cardiac enzymes were flat. During the procedure a seroma was identified. Wound cultures grew acintobactor. SP post washout patient was continued initially on empiric linezolid. Once cultures returned with acintobactor antibiotics, she was started on broad spectrum antibiotics including Tobramycin and Tigecycline. Drainage eventually decreased and the drain was pulled. . Pain control: Throughout the [Hospital 228] hospital course patient's pain was assessed and controled. Initially patient reguired IV fentanyl drip for her T11 fracture. IV fentanyl was tranisitioned to fentanyl and lidocaine patch. Lidocaine patch was started specifically for pain secondary to left anterior should dislocation. Likely post-op. Also has history of left shoulder dislocation. IV fentanyl was eventually weaned off. . Hypotension: Throughout the hospitalization patient had periods of hypotension reguiring pressor support with neosynephrine. On admission episodes of hypotension were thought to be secondary to sedative effect (propofol/fentanyl). Later in the hospitalization as sedatives were weaned pressors were also weaned. Sepsis was also considered as a cause of the patients hypotension given patients multiple infections. During the hospital course patient was continued on a steroid taper and stress dose steroids were provided during surgical procedures. . Bacteremia: Patient found to have a coag negative staph from multiple blood cultures drawn from PICC line. Given the inability to attain peripheral access in this patient the desicion was made to treat through the infection. Patient was treated with linezolid and then when tobramycin was started linezolid was held given tobramycins coverage. Eventually blood cultures were negative. . Anemia: Over the course of the hospitalization and specifically the perioperative period patient reguired 10 Units pRBCs . Transfusion goal of >25 was continued during the post arrest period. . Left shoulder dislocation: Patients left shoulder was found to be dislocated anteriorly on admission. Orthopaedics reduced shoulder. Shoulder xray confirmed position. Multiple times during admission patients should dislocated and was reduced by Ortho. Lidocaine patch was used to control pain. s/p PEA arrest: Patient appeared to have escaped serious cardiac damage. ECHO sp arrest was without significant myocardial dysfunction. EF was >60%. . UTI: On presentation patient with evidence of urinary tract infection which was covered by cefepime. Later cultures during the hospitalization were negative for infection. . DM: During hospital course patient was covered with ISS. Medications on Admission: Albuterol Inhaler 6 PUFF IH Q6H Albuterol Inhaler 6 PUFF IH Q2H:PRN wheezing CefePIME 2 g IV Q24H Day 1 [1-2], dc on [1-17] for 14 day course Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [Hospital1 ] Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 ] Fentanyl Citrate 25-300 mcg/hr IV DRIP INFUSION Ipratropium Bromide MDI 6 PUFF IH QID Lidocaine 5% Patch 1 PTCH TD DAILY Linezolid 600 mg IV Q12H till [1-17] Olanzapine 5 mg PO HS:PRN Pantoprazole 40 mg IV Q24H Phenylephrine 0.5 mcg/kg/min IV DRIP TITRATE TO MAP greater than 65 Polyethylene Glycol 17 g PO/NG DAILY:PRN Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Senna 1 TAB PO/NG [Hospital1 ] Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2120-2-4]	[ "424.1", "482.1", "998.51", "785.52", "278.01", "458.29", "041.4", "733.00", "E879.8", "E878.8", "806.25", "737.43", "491.21", "428.0", "482.42", "718.31", "428.32", "518.81", "599.0", "999.31", "584.5", "995.92", "038.9" ]	icd9cm	[ [ [] ] ]	[ "45.13", "00.14", "81.05", "81.64", "33.22", "03.53", "31.1", "84.52", "43.11", "38.93", "03.59", "81.62", "79.71", "96.72", "81.35" ]	icd9pcs	[ [ [] ] ]	17179, 17188	9907, 16411	339, 596	17239, 17248	4452, 4457	17304, 17433	3108, 3360		17147, 17156		17209, 17218		16437, 17124				17272, 17281						3375, 4433							5990, 7883															269, 301			7918, 8808	4492, 5715				624, 2353								4472, 4472	8844, 9884						2375, 2853	2869, 3092
19,826	129,118	12114	Discharge summary	report	Admission Date: [2120-3-10] Discharge Date: [2120-3-14] Date of Birth: [2087-4-11] Sex: F Service: [Hospital1 212] CHIEF COMPLAINT: Suicidal attempt with overdose of Tylenol and Benadryl. PHYSICAL EXAMINATION: The patient is feeling much better from a physical standpoint this morning, [2120-3-14]. The patient does complain of some urinary frequency, denies any dysuria. The patient also has a slight cough, which has been improving over the last several days. The cough is dry and there is no productive sputum. The patient's appetite is also improving. Mentally, the patient is afraid of inpatient psychiatry. The patient's vital signs are 98.4 temperature maximum, 122/80 blood pressure, heart rate 104, respiratory rate 18, and saturation 97% on room. GENERAL: The patient is in no acute distress. CARDIOVASCULAR: Slightly tachycardiac rate, regular rhythm, no murmurs, gallops or rubs. LUNGS: Lungs were clear to auscultation bilaterally. There were no wheezes, rhonchi, or rales. ABDOMEN: Abdomen was soft, nontender, and nondistended, positive bowel sounds in all four quadrants. EXTREMITIES: Extremities revealed no signs of clubbing, cyanosis or edema. NEUROLOGICAL: Examination was normal, cranial nerves II to XII grossly intact. She was awake, alert, and oriented times three. LABORATORY DATA: Currently, the labs revealed the following: white count 7.9, hemoglobin and hematocrit of 10.4 and 30.0. Platelet count 141,000, sodium 145, potassium 3.4, chloride 109, bicarbonate 27, BUN 4, creatinine .6 and glucose 90. Chest x-ray was done, which showed consolidation in the left lower lobe. Urinalysis was done on [2120-3-13], positive for urinary tract infection. SUMMARY OF HOSPITAL COURSE: The patient arrived in the emergency department on [2120-3-10] after the ingesting approximately 850 tablets of Tylenol and unknown amounts of Benadryl. The patient had decreased mental status, but was arousable. The patient was intubated in the emergency department for protection of her airway. It was noted that the patient did vomit several times prior to arriving to the emergency department. Once the patient was intubated in the emergency department, she was treated for her overdose. She was then admitted to the medical ICU. While in the medical ICU she remained stable. As her mental status improved, she became extubated, which was on [2120-3-11]. On [2120-3-12], she was transferred to a regular nursing floor. On the nursing floor, she did develop a fever of 102.3. The white count was also elevated to 14.3. At that time, blood cultures were sent as well as the urinalysis was done. Chest x-ray was completed. The chest x-ray did show left lower lobe consolidate and the urinalysis was positive for urinary tract infection and the blood cultures are still pending. The patient was initially placed on Cipro due to the fact that this was completed before the chest x-ray was done. After the chest x-ray was read, the patient was switched from Ciprofloxacin to Levofloxacin 500 mg b.i.d. and Flagyl 500 mg q.i.d. to treat for both the pneumonia and the urinary tract infection. On [2120-3-13] the patient's white count dropped to 11.7. On [2120-3-14] the white count dropped to 7.9. Currently, she is afebrile. White count is back into the normal range. The patient has also been followed by the Department of Psychiatry for her entire admission. Their recommendation is that the patient is to be admitted inpatient psychiatry due to depression and suicidal attempt. During the patient's entire stay, the patient had no signs of continued hepatotoxicity. The alkaline phosphatase, ALT and the AST were within normal range, three days after admission. The patient is medically cleared today to be transferred to a psychiatric unit, whether it be in this hospital or in another bed in the city. The patient understands this and is willing to go on her own [Location (un) ]. DISCHARGE MEDICATIONS: 1. Motrin elixir 400 mg p.o. q. 4 to 6 hours p.r.n. fever. 2. Levaquin 500 mg p.o.b.i.d., which will be continued for ten days. 3. Flagyl 500 mg p.o.q.6h. This should also be continued for ten days. It is unknown of the psychiatric unit where the patient will be going, so, therefore, I am unable to give you the facility name. DR.[First Name (STitle) ],[First Name3 (LF) 734] 12-944 Dictated By:[Last Name (NamePattern1) 37970] MEDQUIST36 D: [2120-3-14] 12:12 T: [2120-3-14] 13:05 JOB#: [Job Number 37971]	[ "E950.0", "787.01", "E950.4", "311", "965.4", "507.0", "963.0", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]									4031, 4605																										1776, 4008	250, 1747									170, 227
5,127	186,788	29862	Discharge summary	report	Admission Date: [2120-1-10] Discharge Date: [2120-1-15] Date of Birth: [2045-10-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1974] Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 71415] is a 74M w/DM on glyburide, renal xplant in [2105] [1-26] hereditary nephritis, lymphoma 9ya s/p RCHOP, SCC scalp excised in [2120-6-23], afib on flecainide, MS, circumcision last week who presented to the ED w/2 days of hypoglycemia, also found to have low BP. . Mr. [Known lastname 71415] is not aware of why he is in the hospital. He is able to describe frequent falls [1-26] MS which increased over [Holiday ] and New Years. He denies vertigo with the falls, but does report decreased streadiness when his blood sugars are low. He takes his own medications and his list is extensive as below. . He presented to [Hospital 882] hospital yesterday with mental status changes, BG18 and hyopthermia. His urinalysis was negative at that time and he was sent home. He returned w/hypoglycemia and was thus transferred to BDIMC. In our ED, his VS were 100.6 104/58 80 98RA w/next BP 86/50. He was given 1L NS, 1/2A D50, D10 drip and levofloxacin. At the time of transfer to the CCU under MICU service, his BP was 89/63 and FS142. . His ROS is notable for the falls, dysphagia to solid foods for years, mild dysphagia, and recent GI ilness (upper and lower) of his wife for a few weeks; he had similar symptoms for several days two weeks ago. While he gives some detailed history, his answers to many questions are tangential and circumstantial, and in response to being asked why he is here, he describes a vacation that he took with his wife to [Name2 (NI) ] five years ago, and her diarrheal ilness. His PCP reports that this is baseline for him. His wife reports that he takes all of his own medications, and does not typically make mistakes. Social History: Lives w/his wife; performs own ADLs, never smoked. Never IVDA. <2 glasses wine per day. Family History: Mother, sister, and father died of CVAs in 60s, 60s, 78 years old, respectively. Two children w/ESRD [1-26] hereditary nephritis. Physical Exam: VS: 97.6 100/78 76 12 98RA Gen: NAD M/O: MMD w/small thrush in posterior oropharynx Lungs: CTAB CV: Nl S1/S2 Abd: Soft, nt, nd, +BS Ext: WWP X 4 w/o c/c/e Skin: Diffuse bruising, wounds on scalp, erythema of penis, open R shoulder wound per pt clearly assoc w/a fall GU: penis head is edematous/erythematous w/ plaque like ulceration. No discharge seen. Neuro: CN2-12 intact, 5/5 strength R side and 4/5 strength on L, sensation intact and symetric to soft touch, reflexes 1+ throughout, toes upgoing bil, responds to year as [2119], date as [1-11], time of day as morning. Responds to reason for being in hospital explaining first his wife's diarrhea ilness, then a trip to [Location (un) ] 5 years ago. Says that five [Last Name (un) 9163] and a dime make 35c and that if he found a stamped adressed envelope on the street, he would mail it. Lymph: No LAD in ant/post cervical chains, submental, pre-auricular, supraclav, axillary, femoral nodes Pertinent Results: ECG: SR w/LAD @ 80 w/LAFB, borderline QT, no ischemic changes . CXR: There is a dual lead left subclavian AV pacemaker. The heart, mediastinum, and hilar regions are otherwise within normal limits. The lungs are clear. . [2120-1-10] 05:15AM DIGOXIN-0.5* . Brief Hospital Course: . 74M w/MMP as above admitted w/hyoglycemia, hypotension, and low-grade fever 13d s/p circumcision. It is not clear if his glyburide was recently increased--this could be a primary contributor to his presentation. He has an evident ballantitis which could also be contributing. . 1) Hypoglycemia- Thought to be most likely [1-26] glyburide in the context of recent illness and polypharmacy. On the evening following admission, his blood glucose levels were maintained at normal levels with D51/2NS gtt titrated to q1 hour fingersticks. Glyburide's half life is 24 hours, and in keeping with this, hypoglycemic effect wore out within 24 hours of admission. Subsequently blood glucose levels were >200 and the dextrose support was discontinued. With the resolution of hypoglycemia, sliding scale insulin was initiated. After transfer from the MICU, the patient had blood sugars > 250. He was started on low dose glipizide prior to discharge. Although Glipizide still has some interaction with voriconazole, it has less interaction that Glyburide. The patient had been on Glyburide and Voriconazole for many years prior to this episode of hypoglycemia and it was not clear why the patient had hypoglycemia. The Glipizide was started back after the patient was found to have blood sugars in the 250 range. He will be seen by his primary care doctor shortly after discharge for further titration of meds. . 2) UTI- The patient was started on IV ceftriaxone which would cover both his UTI and balantitis. Culture results were negative. The patient was discharged on PO Augmentin. . 3) Balantitis- Patient was found to have balanitis after recent circumcision approximately 2 weeks prior to this admission. A swab gram stain negative. The wound culture was found to grown Diptheroids (Corynebacterium) and Coag Negative Staph consistent with skin floral. The patient was continued on a topical antifungal as well as IV Ceftriaxone. Additionally, a DFA was negative for HSV. The patient was discharged on PO Augmentin and will followup with his [Hospital1 2025] Urologist. . 4) Thrombocytopenia: Thought to be [1-26] drug effect of voriconazole vs. ranitidine; however, per PCP at [Name9 (PRE) 2025], he has had baseline thrombocytopenia. Thrombocytopenia has been mentioned as a rare side effect of vori, but per ID's assessment of risks vs. benefits, would not stop Voriconazole. At [Hospital1 18], patient's ranitidine was stopped to see what effect it would have on platelets. Patient's platelets rose from 60s-80s at baseline to 112, making Ranitidine a possible cause of the patient's thrombocytopenia. The patient was instructed not to take Ranitidine anymore. He will followup at [Hospital1 2025] for further monitoring of his thrombocytopenia. . 5) Pulmunary aspergillosis- The patient was continued on lifelong voriconazole therapy for history of pulmonary aspergillosis. . 6) Thrush- Patient was thought to have evidence of oral thrush upon admission to the MICU. He was continued on voriconazole and nystatin S&S was added to his regimen. He had no further evidence of thrush upon transfer to the floor from the MICU. . 7) Afib/SSS- Has PPM but currently native sinus driven. The patient was anticoagulated with warfarin. Flecainide was continued as per his outpatient regimen. . 8) S/P renal xplant- Patient was continued on his immunosupressives, Tacrolimus. He was continued on Bactrim for PCP [Name Initial (PRE) 1102]. He will followup with his renal doctor at [Hospital3 5870] upon discharge. . Medications on Admission: Glyburide 5mg QD Warfarin 5mg QD Azathioprine 50mg QD Digoxin .125mg QD Vfend 200mg [Hospital1 ] Niaspan ER 500 QD Toprol 25mg QD Flecainide 100mg qHS Ranitidine 150mg [Hospital1 ] Docuasate Clonazepam .5mg QHS Discharge Medications: 1. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO M,WED,FRI (). Disp:30 Tablet(s) Refills:0 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 8. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 Refills:2 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -[Hospital1 20212]-Friday). 11. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QD (). 12. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:21 Tablet(s) Refills:0 13. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. Disp:30 Capsule, Sust. Release 24HR(s) Refills:0 14. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Balantitis Hypoglycemia Aspergillosis Thrush UTI Atrial fibrillation Discharge Condition: Stable: - Balanitis improving - No further hypotension - No further episodes of hypoglycemia. Discharge Instructions: . Please take all medications as prescribed. - Please do not take your Coumadin until [Hospital1 20212], [1-17] at which time you should see your primary care doctor for an INR check. Your primary care doctor should tell you when to restart taking your Coumadin. - Please do not take your Toprol until you see your primary care doctor [First Name (Titles) ] [Last Name (Titles) 20212]. Your blood pressure has been low in the hospital and you should not restart this medicine until your blood pressure is rechecked by your primary care doctor. - Please stop taking your Glyburide as it interacts with Voriconazole and was making your hypoglycemia. Please start Glipizide 2.5mg PO daily (Glipizide has less interaction with Voriconazole). - Please stop taking your Ranitidine. It may have been causing low platelets. Your ranitidine was stopped and your platelets have risen to > 100 while at [Hospital1 18]. . Please call your doctor if you experience dizziness, confusion, fevers, chills, nausea or vomiting. . Please attend all followup visits as listed below. . Followup Instructions: . Please followup with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 20212], [1-17]. Please do not take your Coumadin until you see your primary care doctor and get your INR check (your INR upon discharge was high, 3.9). Your primary care doctor should tell you when to restart taking your Coumadin. . Please followup with your urologist at [Hospital1 2025], Dr. [Last Name (STitle) ], for your BPH and to have your balanitis followed. If you are unable to followup with your urologist at [Hospital1 2025], you may set up an appointment with the [Hospital1 18] urologists, Dr. [First Name (STitle) ], for followup at [Telephone/Fax (1) 6317]. . Completed by:[2120-1-24]	[ "E932.3", "117.3", "E943.8", "250.80", "427.81", "202.80", "427.31", "112.2", "V45.01", "287.4", "V42.0", "112.0", "340" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8832, 8838	3632, 7201	328, 334	8950, 9046	3344, 3609	10184, 10921	2203, 2339		7470, 8809		8859, 8929		7227, 7447				9070, 10161						2354, 3325																						276, 290								362, 2081																2097, 2187
29,281	194,660	32479	Discharge summary	report	Admission Date: [2126-10-10] Discharge Date: [2126-10-23] Date of Birth: [2051-11-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: headache, hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 74 yo man with pmhx afib, HTN, hyperlipidemia and recent CVA with ICH who presents with headache from [Hospital ] rehab. In the ED, his initial vs were: T 97.3 P 80 BP 152/91 O2 sat 97 % on RA RR 16. There was concern that he had progression of his bleed and CT scan was repeated which showed evolution of hemorrhage with stable edema, no midline shift and no new intra or extra- axial hemorrhage or infarct. Neurosurg was initially consulted but given no new changes on CT did not feel it was necessary to admit him to neuro ICU. He therefore is admitted to medicine with headache and hypertension with sbps in the 180s. He was given 10 mg IV labetolol and transferred to the ICU. In addition, in the ED, he had periods of apnea with desats to low 90s and high 80s and per family may have sleep apnea which has never been diagnosed. His wife reports that he snores at home and occassionally stops breathing. Respiratory saw him in the ED and started Bipap. His ABG in the ED was pH 7.48 pCO2 38 pO2 92 HCO3 29. . On admission to the ICU, his initial VS were BP 152/71, HR 69, O2 98% on 3 liters R 21. He was sleepy but arousable and had a difficult time communicating his thoughts. His wife reports that he received narcotics at rehab. In a discussion with he and his family, patient eats well, no aspiration events, no cough or fever. Patient himself denies HA currently, chest pain, sob, abd pain, nausea, vomiting, vision changes. . He was controlled with oral medications in the ICU and never required iv meds. . Patient denies HA currently, chest pain, sob, abd pain, nausea, vomiting, vision changes. Past Medical History: Afib - was off coumadin HTN Hyperlipidemia PVD - s/p left fem [Doctor Last Name ] bypass [2119] AAA - 4.2cm in size last u/s [4-14] being followed-- no surgery. Gout CVA with ICH [9-15], thought to be embolic with hemorrhagic conversion Social History: Stopped smoking 20 years ago. Was drinking 1 Glass of wine daily prior to stroke. No IVDU. Patient married, has 4 kids. Currently lives at [Hospital 24759] rehab. Family History: Family Hx:NC Physical Exam: VS T afebrile P 69 BP 152/71 O2 sat 98 % on 3 liters RR 21 Gen- sleepy but arousable, NAD, has periods of apnea HEENT- NCAT, anicteric, pupils are pinpoint and reactive, patient would not cooperate enough to check extra-ocular movements. MMM and no oral lesions. Neck- supple, nt, no masses or LAD, no bruits Cor- irreg irreg, no mgr Pulm-CTA b/l Abd-+bs, soft, nt, nd, no masses of hsm Extrem-no cce, pedal pulses 1+ b/l Neuro- could not assess cranial nerves, strength was [4-13] throughout except grasp was diminished bilaterally, normal sensation and DTRs +1 throughout and symmetrical. Pertinent Results: [2126-10-22] 07:30AM BLOOD WBC-7.2 RBC-4.76 Hgb-14.6 Hct-42.4 MCV-89 MCH-30.6 MCHC-34.3 RDW-13.9 Plt Ct-391 [2126-10-10] 04:35PM BLOOD WBC-8.3 RBC-4.99 Hgb-15.4 Hct-44.3 MCV-89 MCH-30.8 MCHC-34.7 RDW-14.2 Plt Ct-358# [2126-10-23] 07:35AM BLOOD PT-17.9* INR(PT)-1.6* [2126-10-21] 07:45AM BLOOD PT-14.4* PTT-35.1* INR(PT)-1.3* [2126-10-20] 07:15AM BLOOD PT-14.6* PTT-34.7 INR(PT)-1.3* [2126-10-19] 07:40AM BLOOD PT-13.6* PTT-32.8 INR(PT)-1.2* [2126-10-18] 06:55AM BLOOD PT-13.3* PTT-32.8 INR(PT)-1.2* [2126-10-10] 04:35PM BLOOD PT-11.9 PTT-30.0 INR(PT)-1.0 [2126-10-23] 07:35AM BLOOD K-4.7 [2126-10-21] 07:45AM BLOOD Glucose-140* UreaN-20 Creat-1.1 Na-134 K-5.3* Cl-97 HCO3-31 AnGap-11 [2126-10-11] 06:21PM BLOOD Glucose-190* UreaN-23* Creat-1.2 Na-127* K-4.8 Cl-91* HCO3-25 AnGap-16 [2126-10-10] 04:35PM BLOOD Glucose-154* UreaN-15 Creat-0.9 Na-125* K-4.8 Cl-90* HCO3-25 AnGap-15 [2126-10-22] 07:30AM BLOOD UreaN-19 Creat-1.0 Na-136 K-5.2* Cl-100 HCO3-30 AnGap-11 [2126-10-20] 07:15AM BLOOD Lipase-111* GGT-355* [2126-10-23] 07:35AM BLOOD Lipase-102* [2126-10-22] 07:30AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.4 [2126-10-13] 07:35AM BLOOD Osmolal-279 [2126-10-12] 02:57AM BLOOD TSH-1.7 [2126-10-12] 02:57AM BLOOD Cortsol-14.0 [2126-10-15] 07:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2126-10-15] 07:00AM BLOOD Phenyto-3.0* [2126-10-15] 07:00AM BLOOD HCV Ab-NEGATIVE [2126-10-10] 05:56PM BLOOD Type-ART pO2-92 pCO2-38 pH-7.48* calTCO2-29 Base XS-4 Intubat-NOT INTUBA [2126-10-23] 07:35AM BLOOD ALT-134* AST-70* AlkPhos-145* Amylase-102* TotBili-0.4 [2126-10-21] 07:45AM BLOOD ALT-171* AST-90* CK(CPK)-25* AlkPhos-165* Amylase-108* TotBili-0.4 [2126-10-20] 07:15AM BLOOD ALT-156* AST-83* LD(LDH)-162 AlkPhos-149* Amylase-91 TotBili-0.4 [2126-10-19] 07:40AM BLOOD ALT-184* AST-97* LD(LDH)-217 AlkPhos-172* Amylase-103* TotBili-0.5 DirBili-0.2 IndBili-0.3 [2126-10-14] 06:30AM BLOOD ALT-194* AST-123* AlkPhos-155* TotBili-0.5 [2126-10-16] 08:28AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2126-10-16] 08:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2126-10-10] 04:35PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.024 [2126-10-10] 04:35PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2126-10-10] 04:35PM URINE RBC-[5-19]* WBC-[2-11] Bacteri-FEW Yeast-NONE Epi-0-2 [2126-10-16] 08:28AM URINE Hours-RANDOM Creat-99 Na-34 [2126-10-16] 08:28AM URINE Osmolal-548 CXR [2126-10-10]: IMPRESSION: No acute pulmonary process. CT HEAD WITHOUT CONTRAST [2126-10-10]: A large left parietotemporal intraparenchymal hemorrhage is unchanged in size and slightly less hyperdense compared to a few days prior consistent with evolution of hemorrhagic components with stable surrounding edema and mass effect on the occipital [Doctor Last Name 534] of the left lateral ventricle. A tiny amount of dependent blood is noted within the occipital horns bilaterally, less compared to [10-5]. There is no new intra- or extra- axial hemorrhage or evidence of acute major vascular territorial infarct. Periventricular white matter hypodensity and small basal ganglia lacunes are unchanged bilaterally. There is no shift of normally midline structures. The ventricles are unchanged in caliber. Atherosclerotic calcification of the cavernous carotids is noted bilaterally. Imaged portions of the paranasal sinuses and mastoid air cells are well aerated. Surgical clips associated with the right orbit are again observed. IMPRESSION: Further evolution of a large left parietotemporal intraparenchymal hemorrhage with no new intra- or extra-axial hemorrhage identified. Cardiology Report ECG Study Date of [2126-10-10] 4:30:10 PM Atrial fibrillation with moderate ventricular response. Non-diagnostic small Q waves in the inferior leads. Non-specific anterior ST-T wave changes. Compared to tracing of [2126-10-4] there is no significant diagnostic change. Patient was also previously in atrial fibrillation. TRACING #1 Cardiology Report ECG Study Date of [2126-10-10] 10:12:42 PM Atrial fibrillation with moderate ventricular response. Compared to tracing #1 there is no significant diagnostic change. TRACING #2 Read by: [Last Name (LF) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10592] Intervals Axes Rate PR QRS QT/QTc P QRS T 64 0 94 428/435 0 46 13 SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: recent ICH. Comparison is made with prior study performed a day earlier. There are peristent low lung volumes. Mild-to-moderate large cardiac silhouette is unchanged. There are no lung consolidations or overt pulmonary edema. US abdomen: FINDINGS: The liver is normal in echotexture. No mass lesions are identified. There is no intra- or extra-hepatic biliary dilatation. The common bile duct measures 7 mm. The gallbladder appears to be surgically absent. The right kidney measures 10.3 cm and the left kidney measures 12.0 cm. No renal masses, calculi, or hydronephrosis is identified. The spleen is top-normal in size measuring 12.2 cm in length. The pancreas is not well visualized secondary to obscuration by overlying bowel gas. Ectasia/aneurymal change of the aorta is noted in the mid portion. Cross-sectional assessment of this ectatic area demonstrates measurements of 4.2 x 3.9 cm. Atherosclerotic plaque is also noted to narrow the lumen of the aorta at this level. The proximal and distal aorta is normal in caliber. The main portal vein is patent with appropriate direction of flow. IMPRESSION: 1. Unremarkable liver without evidence of intra- or extrahepatic biliary dilatation. Apparent surgical absence of the gallbladder. 2. Ectatic, aneurysmal atherosclerotic abdominal aorta measuring 4.2 x 3.9 cm at the mid-portion of the abdomen, with anterior thrombosed component. Continued surveillance is recommended. [2126-10-21]: MDCT-acquired contiguous axial slices are obtained through the brain without administration of intravenous contrast. FINDINGS: Areas of low attenuation in the periventricular white matter suggestive of chronic microangiopathic ischemic disease are noted. There is no evidence of new bleed or masses. The previously demonstrated left parietotemporal intraparenchymal hemorrhage is again visualized and demonstrates decrease in attenuation consistent with evolution of hemorrhage. There is evidence of low attenuation surrounding the hemorrhage, suggestive of parenchymal edema which causes compression of the left posterior [Doctor Last Name 534] of the lateral ventricle and adjacent sulci, causing a minimal 2.4 mm midline shift to the right. Overall the ventricles appear mildly dilated and the sulci appear prominent. These changes are relatively unchanged compared to prior study and could be related to age-associated involutary changes. Post- surgical clips are noted in the right ethmoid and maxillary sinus wall, underlying type of surgical procedure associated is unclear from the provided history, similar clips have been used for surgical clipping of vessels in epistaxis. There is evidence of left mastoid air cell opacification. The orbits, sinuses, osseous and soft tissue structures are unremarkable. Atherosclerotic calcifications are noted in the cavernous portions of bilateral carotid arteries. IMPRESSION: Changes consistent with hemorrhagic evolution of the left parietotemporal intraparenchymal hemorrhage as described above. No new areas of hemorrhage are identified. ECHO (TTE): Conclusions The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. CLINICAL IMPLICATIONS: Based on [2125] 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: Initialy confusion and somnolence was likely from the low Na levels and narcotic use at rehab. With fluid restriction the Na levels normalized and no narcotics or sedatives were used. The sodium levels will need to be monitored closely. The patient may have an element of obstructive as well as centaal sleep apnea (from the CVA) and is advised to follow up in sleep clinic for a formal evaluation. Did not require CPAP. CT head did not show worsening ICH. He was followed first by neurosurgery. No neurosurgical procedure required as per them. Neurology then consulted regarding the timing of initiation of warfarin for CVA. They recommended warfarin. after a detailed discussion about risks and benefits of the anticoagulation with the family and patient - warfarin was started. INR will require close monitoring at rehab. Target INR is between 2 and 3. Had intermittent headaches with resolution with Tylenol. CT head repeated and again no new events were seen. Neurology and neurosurgery follow up arranged on discharge. Dilantin subsequently stopped based on neurology recommendation due to hepatitis (see below) HTN- Patient hypertensive in the ED. No ekg changes or head CT changes to suggest hypertensive emergency. Improved with po meds. Hyponatremia- Likely due to SIADH. Ultiimately, his sodium corrected with fluid restriction. Afib- continued on metoprolol for rate control. Ultimately, after the period of time when he was out of risk for a bleed, patient and family decided to go ahead with anticoagulation with coumadin given his risk of stroke. Refer to details above. hepatitis: likely drug induced per hepatology consult. slowly improving with discontinuation of statin and dilantin. Weekly LFt recommended at rehab and if worsening or if still abnormal - liver clinic follow up recommended in [1-12] months. Excessive tylenol should be avoided. Patient did not report any abdominal symptoms. Abdominal U/S was done and was negative for hepatobiliary process as above. He had hepatitis panel sent which was negative. Hyperlipidemia: Initially was on statin, however this was stopped as above. He should be placed on a lipid lowering [Doctor Last Name 360] once his transaminitis resolves with very close monitoring of LFT's. Orthostatic hypotension - transiently noted and resolved with stopping lisinopril. Hyperkalemia - transiently noted upto 5.3. resolved with stopping lisinopril. Abdominal aortic aneurysm - should be followed up with PCP for follow up imaging. patient aware. BP controlled. Hematuria - transiently noted. repeat UA with no RBCs. Follow up prn with PCP. Gout- continued on allopurinol Full code. Wife [Name (NI) ] is the health care proxy. Above information communicated to wife on telephone at discharge. Evaluated by PT and OT and recommend acute rehab. Medications on Admission: 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 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). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 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 BID (2 times a day) as needed for constipation. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: Three (3) 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. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Take while on coumadin. Can substitute Prilosec if necessary. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Hyponatremia / Syndrome of Inappropriate ADH secretion Stroke with residual deficits hepatitis, likely drug induced / pancreatitis Inracranial hemorrhage Atrial fibrillation Hypertension Orthostatic hypotension Hyperkalemia Hypoxia, Apnea - resolved Gout Hematuria Abdominal aortic aneurysm Discharge Condition: Stable Discharge Instructions: As you know, you recently had an intracerebral hemorrhage after a stroke. You also had a decrease in your sodium and a condition called SIADH. For this it is recommended that you adhere to less than 1.2 litres of fluid per day. Sodium levels will require monitoring at rehab. You were found to have elevated liver and pancreas enzymes. This could be from some medications eg. phenytoin (dilantin) and the cholesterol. Weekly liver tests are recommended till they return to normal. If the levels are risisng or still high at 2 months, follow up in liver clinic is recommended. You were started on coumadin for atrial fibrillation. You will need the INR levels to be closely monitored while at rehab and thereafter to follow up with your doctor to have your blood level monitored. Being on the warfarin or coumadin you are at an increased risk of bleeding. You should watch for signs of bleeding. You may also bruise more easily on coumadin. if this happens contact your doctors [Name5 (PTitle) 2227]. You should be aware of increase in headache, blurred vision, weakness, change in your speech, or change in your ability to walk. These may be signs of a stroke or a bleed in your head. if you notice any new symptoms of concern to you, contact your doctor. You should return to the emergency room for any significant bleeding or signs of a stroke. A follow up in sleep clinic is recommended to assess if you have sleep apena. You also need follow up urine tests to make sure no blood is noted in urine. Also, a follow up CT abdomen is recommended with your primary doctor [First Name (Titles) ] [Last Name (Titles) 32942] the abdominal aortic aneurysm. Please discuss these issues with Dr [Last Name (STitle) 32285]. Followup Instructions: PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 32285]. [Telephone/Fax (1) 75786]. Please call for a follow up appointment within 1-2 days of leaving rehab. You will need to have your INR level checked (goal [1-12]). You should also discuss further management of your abdominal aortic aneurysm and blood in urine. Sleep study: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 33555] & DR. [First Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2126-11-8] 10:40. Go to [Hospital Ward Name 23] [Location (un) ]. A family member should call the clinic at [Telephone/Fax (1) 612] to complete the registration process in the next 1 to 2 days. Neurosurgery: [Telephone/Fax (1) ] - Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7746], MD Phone:[Telephone/Fax (1) 3666] Date/Time:[2126-11-11] 2:00 Neurology: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2126-12-24] 10:30. A family member should call the clinic at to complete the registration process in the next 1 to 2 days. Liver clinic with Dr [Last Name (STitle) 7033] ([Telephone/Fax (1) 2422]) on wednesday [2127-2-5] at 11AM. At [Hospital1 18] - [Hospital Ward Name ] Bldg at [Hospital1 18]. Provider: [Name10 (NameIs) ] [Name8 (MD) 75787], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2127-2-5] 11:00	[ "276.7", "584.9", "451.82", "E936.1", "599.7", "327.23", "996.62", "272.4", "274.9", "253.6", "427.31", "438.11", "401.1", "577.0", "441.4", "573.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	16481, 16561	11994, 14824	349, 356	16896, 16905	3134, 11711	18692, 20215	2488, 2503		15746, 16458		16582, 16875		14850, 15723				16929, 18669						2518, 3115									11734, 11971													279, 311								384, 2011															2033, 2288	2304, 2472
71,059	111,156	36070	Discharge summary	report	Admission Date: [2156-12-27] Discharge Date: [2157-2-10] Date of Birth: [2103-7-6] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Intracranial hemorrhage Major Surgical or Invasive Procedure: Intubation->Tracheostomy [First Name3 (LF) 5041] placement->VP shunt PEG placement Temporary tarsorrhaphy OS History of Present Illness: 53 year-old man with a possible history of hypertension presents as a transfer to [Hospital1 18] for management of intracranial hemorrhage. The patient apparently presented to [Hospital3 ] late this morning with a left-sided headache associated with dysarthria and right hemiparesis. He reportedly had asked his mother to call emergency services. CBC revealed hyperchromia and macrocytosis without anemia. INR was reportedly normal (thoough not included in transfer documentation). EKG showed sinus tachycardia perhaps with peaked T waves in V2 and V3. CT at [Hospital1 ] revealed a pontine hemorrhage with spread into the 4th ventricle. There was one report that his left pupils was "blown." There was also report of a possible left lower lobe opacity on CXR. He was intubated for "airway protection" then and received an additional dose of versed for some agitation on the ventilator. He also received 5 mg lopressor for blood pressure control. Review of Systems: Unable to provide, given intubation Past Medical History: -Possible hypertension Social History: Lives at home with his mother, for whom he is her primary care giver. Family History: Unknown Physical Exam: Vitals: T 100.5 F BP 166/91 P 64 RR 14 SaO2 100 on vent FIO2 100% General: NAD, not on standing sedation HEENT: NC/AT, sclerae anicteric, orally intubated, NGT in place Neck: supple, no nuchal rigidity, no bruits Lungs: clear ventilated breath sounds CV: regular rate and rhythm, no MMRG Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, no edema, pedal pulses appreciated, onychomycosis Skin: severely dry skin on feet Neurologic Examination: Mental Status: Appears awake, able to follow basic verbal commands, including squeezing of hands and effort at tongue protrusion Cranial Nerves: Fundoscopy limited; no blink to threat bilaterally. Pupils equally round and reactive to light, 2.5 to 2 mm bilaterally. On Doll's maneuver, eyes just able to cross midline bilaterally. Nasal tickle and corneals absent bilaterally. Hearing intact to loud verbal commands. Make a weak effort to protrude tongue. Brisk gag reflex. Sensorimotor: Normal bulk and tone throughout. No tremor or adventitious movement noted. Squeezes hands bilaterally, more strongly on the left. Able to bend left knee, just lifting it off the bed. He is not moving the right voluntarily. He withdraws in all four extremities, left side more briskly than right. Reflexes: B T Br Pa Pl Right 2 2 2 2 0 Left 2 2 2 3 0 Left toe is upgoing and the right is mute. Coordination and gait could not be assessed Brief Hospital Course: 1. Pontine/medullary hemorrhage: The patient is a 53 year-old man with a possible history of hypertension who presented as a transfer to [Hospital1 18] for management of intracranial hemorrhage. The patient apparently presented to [Hospital3 ] with a left-sided headache followed by right hemiparesis. On general examination on admission, he had a low-grade fever (rectal) and was hypertensive. On neurologic examination on admission, off standing sedation, he was able to follow basic appendicular and midline commands, nasal tickle and corneals were difficult to elicit; otherwise brainstem reflexes, including pupillary reflex, appeared preserved. He was not moving the right voluntarily. CTA Head on admission showed hemorrhage in the medulla and pons, subarachnoid hemorrhage in the prepontine and premedullary cisterns, small amount of intraventricular hemorrhage in the posterior [Doctor Last Name 534] of the left lateral ventricle, and slightly dilated lateral ventricles bilaterally. He received Nimodipine for vasospasm x14 days starting on the day of admission. Serum tox showed 78 EtOH, urine tox positive for BZD. Neurosurgery was consulted on admission, and placed an [Doctor Last Name 5041] on [12-27] in the right lateral ventricle. Given that the [Month/Year (2) 5041] was in place, he was started on Dilantin 100 mg TID. Was later stopped prior to transfer and had no seizures. MRI head on admission showed multiple small enhancing foci in the area of hemorrhage in the left side of the pons; extensive left pontine and medullary hemorrhage, intraventricular and subarachnoid hemorrhage; moderate dilatation of the supratentorial ventricular system; and small 1-2 mm infundibulum at the junction of the right distal vertebral artery and the basilar artery. Cerebral angiography was performed on [1-3], which showed possible acute right vertebral artery occlusion, but no AVM or aneurysm. Regardless, this occlusion would not explain his symptoms and he could not be anticoagulated anyway. The patient failed multiple attempts to clamp his [Last Name (LF) 5041], [First Name3 (LF) ] a VP shunt was placed. Neurological course over the hospitalization was stable to slowly improving. He is alert and follows some commands. Near full strength extremities, and minimal movement on right. Also profound left facial weakness. 2. Hypertension: The patient has an unknown past medical history, but possible history of hypertension. He was started on Labetalol 200 PO tid and Lasix 20 mg daily. TTE showed no cardiac source of embolism, hyperdynamic left ventricular systolic function with LVEF >75%. 3. SIADH vs. cerebral salt wasting: His Na was 130 on admission, then normal from [Date range (1) 81836]. However, on [1-6] his Na dropped from 132->125, and nadired at 121. His serum osm was initially 262, and nadired at 256. Renal was consulted who determined that he most likely had SIADH. He received 3% hypertonic saline at 20 cc/hr and initially started Lasix 20 PO bid to decrease urine osms with improvement in his Na to normal. 4. ATN: His Cr increased from 0.8 to 1.4 on [1-8], and peaked at 1.7. Renal determined that this was possibly due to a hypotensive episode along with his Hct drop (see below) causing some ATN. FeNa was 2.3% supporting this. His Lasix and Enalapril were discontinued at that time. Renal ultrasound was a limited portable exam without hydronephrosis or upper abdominal ascites. His Cr slowly improved. 5. ID: The patient continued to spike fevers during the hospitalization, which were thought to be central fevers from his hemorrhage. He was initially on Ancef IV while the [Month/Day (4) 5041] was in place, then changed to Vanc/Cefazolin on [1-4] for WBC (40) out of proportion to RBC (5250) in CSF, which was changed to Vanc/Zosyn which was subsequently discontinued. CSF cultures showed no growth, and eventually the WBC in his CSF was thought to be reactive to the [Month/Year (2) 5041]. He also recevied Fluconazole 200 IV q24 hr for sparse growth yeast in his sputum. Bilateral LENIs showed no DVT of the lower extremities, and CT Torso showed emphysematous changes in the lungs, minimal bronchiolitis in the lingula and bilateral lower lobes, 1.4-cm enhancing lesion in the left lobe of the liver may represent a hemangioma, cholelithiasis. Head CT showed left mastoid opacification. 6. Respiratory: The patient was intubated upon admission, and extubated [12-28] but then required re-intubation. Tracheostomy was placed on [1-4]. Continues to be vented. 7. Hematology: He received 2 U PRBCs on [1-8] for a Hct drop to 23.7. His stool was guaiac negative. 8. Left corneal abrasion/ulceration: Ophthalomology was consulted for his left eye chemosis, and the patient was found to have a left corneal abrasion and ulceration. He is s/p temporary tarsorrhaphy [1-7]. He was placed on Bacitracin/Polymyxin ointment and artificial tears. Eye culture showed no growth. Impriving with ointment and drops. 9. GI/FEN: The patient is s/p PEG placement on [1-4] for tube feeds. He was placed on MVI/thiamine/folate on admission given the positive EtOH on his tox screen. Medications on Admission: -Flonase Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain or fever. 2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q2H EXCEPT AT TIMES WHEN POLYSPORIN OINTMENT IS GIVEN (). 12. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 16. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 18. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding scale Injection four times a day. 19. Metoclopramide 5 mg IV Q8H Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Pontine hemorrhage Discharge Condition: Fair Discharge Instructions: Patient being transferred to vent unit. Follow up as below. Meds as below. Please call or bring pt to ED if any acute neurological changes. Followup Instructions: Patient should follow up with Dr. [Last Name (STitle) 78537]/[Doctor Last Name ] ([Telephone/Fax (1) 15319] on [4-20] 1:30 PM. [Hospital1 ] [Last Name (Titles) 516], [Hospital Ward Name 23] Building [Location (un) ]. Should also follow up with PCP [Name Initial (PRE) 6164] [Telephone/Fax (1) 4475] [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "790.01", "432.9", "253.6", "430", "401.9", "518.81", "997.31", "599.0", "305.00", "511.9", "276.3", "331.4", "518.0", "995.91", "482.0", "584.5", "351.9", "342.90", "434.90", "437.3", "038.9" ]	icd9cm	[ [ [] ] ]	[ "43.11", "38.91", "96.6", "31.1", "33.21", "96.72", "38.93", "96.04", "02.39", "88.41", "99.04" ]	icd9pcs	[ [ [] ] ]	10063, 10135	3129, 8340	339, 453	10198, 10205		10395, 10831	1655, 1664		8400, 10040		10156, 10177		8366, 8377				10229, 10372						1679, 2130																			1469, 1506			276, 301								481, 1450	2300, 3106									2169, 2284			2154, 2154		1528, 1552	1568, 1639
24,581	157,030	5691	Discharge summary	report	Admission Date: [2105-3-6] Discharge Date: [2105-3-9] Service: NEUROLOGY Allergies: Lorazepam / Penicillins / Prednisone / Hydrochlorothiazide / Ceftriaxone / Phenytoin Attending:[First Name3 (LF) 618] Chief Complaint: progressing slowing of mentation and gait difficulties since a week; evaluation for ICH Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 83 yo R-handed man with a history of multiple intracranial hemorrhages during the last few years, pacemaker, hyperlipidemia, arrhythmia who now presents with gradual decline in gait and slowing of mentation over the last week. The patient had a fall about ten days ago, when he was walking the dog. The leash got wrapped around his legs. According to his wife he had a small abrasion on the top of his head, but nothing major. He did not complain about a headache. He was at baseline with respect to his gait (at baseline unsteady, though he refuses to walk with a walker) and his mentation (at baseline difficulties with memory since months; keeps forgetting appointments). Then about a week ago, the patient and his wife noted that his gait became even more unsteady, though he did not fall. He also had difficulties navigating through his apartment, having difficulties finding the fridge for example. They were concerned that the fall might have caused another bleed, as had happened in the past, and this prompted them to come to the ED. No headache, neckpain, nausea, vomiting or focal weakness/numbness. Review of systems: denies any fever, chills, weight loss, visual changes, hearing changes, dysphagia, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. His legs have been feeling weaker, bilaterally since the last week. Past Medical History: 1. Previous interventricular hemorrhages: [6-7] resolved as of repeat head CT one month later, no residual deficits; [2-8]: ICH in 3rd, 4th, and L-lat ventricle; no aneurysm; [6-8]: ICH in R-temporal lobe; question of underlying mass at that time per contrast CT; decided to follow up with serial scans rather than to biopsy 2. pacemaker placement for arrhythmia, Afibb; during last hospitalization episodes of NSVT 3. history of slowness of gait, ?parkinsons? and possibly dementia followed by Dr. [Last Name (STitle) ] ([Location (un) 745] [Location (un) 3678]). Sinemet was stopped during last admission [6-7] as he was thought to NOT have PD. 4. Depression 5. COPD 6. hyperlipidemia 7. bilateral cataract surgery 8. orthostatic hypotension, on midodrine Social History: The pt. is married, independent in ADLS, lives with wife in a retirement community. Significant tobacco history x 40 yrs x 1ppd, quit 20 yrs ago, Reported occassional glass of wine, no illicit drugs He is a retired architect. Wife states that he would NOT want to be recussitated, and that OSH placed ETT before asking her. Family History: no kids, no bleeds or strokes in other family members Physical Exam: Vitals: 96.7 HR60 BP153/52, later 178/85 RR 18T sO298% RA Gen: NAD, in bed HEENT: mmm Neck: no LAD; no carotid bruits; limited range neck movements bilaterally Lungs: Clear to auscultation bilaterally Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs. Abdomen: normal bowel sounds, soft, nontender, nondistended Extremities: no edema; cold feet bilaterally Mental Status: Awake and alert, cooperative with exam, normal affect; facial expression somewhat sparse. Oriented to place and person, not date [2095]. Attention: DOYbw. Memory: Registration: [3-6] items; Recall [3-6] at 5 min. Language: fluent; repetition: intact; Naming intact; Comprehension intact; no dysarthria, no paraphasic errors. [Location (un) ]: intact; 3D-construction: poor, difficulties putting handles in clock; No Apraxia. No Neglect. Unable to do luria. Named 10 animals in 1 minute, no perseveration, but no further animals after 30secs. Cranial Nerves: II: Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 2.5-->2 mm bilaterally. III, IV, VI: Extraocular movements intact with few beats of horizontal endgaze nystagmus. Limited eye movements in upgaze. Fixation and saccades are normal. 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: Decreased bulk throughout; tone normal 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 Left 5 5 5 5 5 5 5 5 5 5 5- 5 5 5 5- No pronator drift. No rebound. Sensory system: Sensation intact to light touch, pin prick, temperature (cold). Decreased vibration in feet and ankles bilaterally, some in knees; proprioception decreased in his feet bilaterally. Reflexes: B T Br Pa Pl Right 2 2 2 1 0 Left 2 2 2 1 0(Less brisk than on R, but exam limited due to cuff) Toes: mute bilaterally; TFL contracted on the L. Coordination: Normal [Last Name (LF) 11140], [First Name3 (LF) ], HTS. No dysmetria or pastpointing. Gait: not tested (later tested and patient markedly unstable on feet) Pertinent Results: [2105-3-6] 10:59PM GLUCOSE-89 [2105-3-6] 10:59PM CK(CPK)-128 [2105-3-6] 10:59PM CK-MB-6 cTropnT-<0.01 [2105-3-6] 04:00PM URINE HOURS-RANDOM [2105-3-6] 04:00PM URINE GR HOLD-HOLD [2105-3-6] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.017 [2105-3-6] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2105-3-6] 02:00PM GLUCOSE-72 UREA N-17 CREAT-0.8 SODIUM-140 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 [2105-3-6] 02:00PM WBC-6.7 RBC-4.53* HGB-14.8 HCT-44.6 MCV-99* MCH-32.8* MCHC-33.3 RDW-12.6 [2105-3-6] 02:00PM NEUTS-65.5 LYMPHS-25.8 MONOS-7.0 EOS-1.4 BASOS-0.2 [2105-3-6] 02:00PM MACROCYT-1+ [2105-3-6] 02:00PM PLT COUNT-213 [2105-3-6] 02:00PM PT-12.3 PTT-24.5 INR(PT)-1.1 CT BRAIN (INITIAL) FINDINGS: There is a 41 x 23 mm area of hyperdensity within the right frontal lobe, with moderate surrounding vasogenic edema (series 2, image 23), compatible with acute intraparenchymal hemorrhage. The chronic encephalomalacic changes at the adjacent right frontal lobe and the right parietal/occipital region remain stable in appearance. There is mild mass effect upon the anterior [Doctor Last Name 534] of the right lateral ventricle. No further intraaxial or extraaxial fluid collections or hematoma are identified. There is no displacement of the normally midline structures, hydrocephalus, or effacement of the basal cisterns at present. Review of bone windows demonstrates no skull bulge or skull base fracture. There is an air/fluid level within the right maxillary sinus - ? acute sinusitis, but acute blood cannot be excluded, in the setting of acute trauma. CONCLUSION: 41 x 23 mm acute intraparenchymal hematoma at the right frontal lobe, causing mild mass effect upon the ipsilateral lateral ventricle, suspicious of hemorrhage secondary to congophilic angiopathy in this age group. Chronic encephalomalacic changes at the right frontal lobe and right parietal/occipital region are unchanged in appearance since [2104-11-4]. REPEAT HEAD CT [3-7]: no significant change from above. EKG: Atrial pacing. Since the previous tracing of [2104-2-21] atrial pacing is a new finding. The electrocardiogram is otherwise, unchanged and continues to [Location (un) 381] voltage in the limb leads and non-specific ST-T wave abnormalities. Read by: [Last Name (LF) ],[First Name3 (LF) ] B. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 188 104 460/460 85 55 75 Brief Hospital Course: The patient is a 83 yo man with a history of past intracranial hemorrhages (most recent [6-8] with R-frontal hemorrhage) who presented with gradually slowing of mentation and increased gait instability since one week. On initial exam the patient was not oriented to time, seemed somewhat slow, and had difficulties generating a list of animals. His cranial nerves and strength were full, and the sensory exam showed mildly decreased vibration and proprioception in both LE, suggesting peripheral neuropathy. A CT was performed in the ED that showed a new significant R-frontal intraparenchymal hemorrhage in the same location as the prior bleed. The patient was seen by both neurology and neurosurgery, and the two teams agreed that the etiology seemed to be related to underlying amyloidosis. During the last admission the question of a mass underlying a hemorrhage in the R-frontal region was raised. The location of the hemorrhage was not felt to be typical for hypertensive bleed (cortical) and it was felt to be unlikely that the recent fall was related to the bleed. The patient could not undergo an MRI due to his pacer. He was admitted to the neurology ICU for closer monitoring and was stable overnight - BP was initially elevated and required a labetalol drip for <24 hours, then stabilized. The goal SBP of <150 was achieved. Coags and UA were checked and were normal. For the question of seizure activity associated with a cortical bleed, he was started prophylactically on Keppra (given questionable allergy to dilantin), at 500 mg [Hospital1 ]; no seizure activity was seen. This medication should be continued as an outpatient at least while the bleed has time to clear up, with planned titration up to 1000 mg [Hospital1 ] on [3-13]. Head CT repeated on [3-7] was unchanged, and the patient remained stable with only very suble focal exam findings (very mild right pronator drift) as well as his persistently poor memory related to dementia. The plan after 24 hours was to transfer him to the floor, but the hospital was full and he never got a bed. Cardiovascularly, lipitor and amiodarone were continued. He could not get an MRI due to his pacemaker. There were no telemetry events, and he ruled out by enzyme. Pulmonlologically, his chest xray was negative and he complained of no breathing problems. Endocrinologically, BG was monitored to improve outcome in ICU setting though he had no history of DM. Of note, Hba1c done [2-9] was slightly elevated ("borderline DM") at 6.3; this was repeated and was still pending on the day of discharge. Ins/outs and electrolytes were monitored and were not abnormal; he was on a bowel regimen, VD boots and PUD prophylaxis with protonix during the admission. Walking was assessed later and the patient was unstable on his feet. PT was asked to see him for this gait problem. [Name (NI) ] felt well and was seen by PT who suggested a rehab/[Hospital1 ] to work on walking with the eventual goal of returning to [Hospital3 ] with his wife when walking improved. Follow-up was arranged with neurosurgery in [5-9] weeks with repeat head ct to be arranged by neurosurgery office to make sure blood has cleared, and if indicated, to look for a possible underlying lesion (although unlikely). Medications on Admission: Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO qod - in [Month (only) 958], should be on odd days. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Mirtazapine 30 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Ocuvite Tablet Sig: One (1) Tablet PO once a day. Artificial Tears Drops Sig: One (1) drop Ophthalmic twice a day: ou. Ensure Liquid Sig: 0.5 to 1 can PO three times a day. Midodrine 10 mg Tablet Sig: 1.5 Tablets PO twice a day: at 8am and noon. Ritalin 5 mg Tablet Sig: see below Tablet PO see below: 1.5 tablets at 10am (7.5mg), 1 tablet 2pm (5mg). Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Guaifenesin 100 mg/5 mL Liquid Sig: [1-5] teaspoons PO every six (6) hours as needed for cold symptoms. Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO qod - in [Month (only) 958], should be on odd days. 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Mirtazapine 30 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): on [3-13], please increase to TWO tablets [Hospital1 ] (1000 mg [Hospital1 ]). 8. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 9. Artificial Tears Drops Sig: One (1) drop Ophthalmic twice a day: ou. 10. Ensure Liquid Sig: 0.5 to 1 can PO three times a day. 11. Midodrine 10 mg Tablet Sig: 1.5 Tablets PO twice a day: at 8am and noon. 12. Ritalin 5 mg Tablet Sig: see below Tablet PO see below: 1.5 tablets at 10am (7.5mg), 1 tablet 2pm (5mg). 13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Guaifenesin 100 mg/5 mL Liquid Sig: [1-5] teaspoons PO every six (6) hours as needed for cold symptoms. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] - [Location (un) ] Discharge Diagnosis: Right sided intraparenchymal cerebral hemorrhage Discharge Condition: Stable - still with difficulty walking, and mental status exam with memory loss c/w dementia, but otherwise no focal weakness. Discharge Instructions: Please [Name8 (MD) 138] MD or return to ED if new symptoms suggestive of stroke or brain hemorrhage including weakness, numbness/tingling, facial droop, visual changes, vertigo, loss of coordination, or worsened problems with walking. Followup Instructions: Please f/u with Dr. [Last Name (STitle) ]/neurosurgery in 6 weeks - patient will receive a call from the neurosurgery office to set up a repeat head CT prior and to schedule this visit. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2105-3-9]	[ "294.8", "496", "427.31", "V45.01", "355.8", "272.4", "431", "458.0", "780.39" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13772, 13887	8201, 11507	379, 386	13980, 14109	5611, 8178	14396, 14708	3030, 3086		12538, 13749		13908, 13959		11533, 12515				14133, 14373						3101, 3497																			1563, 1863			251, 341								414, 1544	4087, 5592									3512, 4071					1885, 2672	2688, 3014
58,834	167,010	48008	Discharge summary	report	Admission Date: [2174-12-19] Discharge Date: [2174-12-27] Date of Birth: [2109-8-1] Sex: F Service: CARDIOTHORACIC Allergies: Keflex / Latex / Lipitor / Zosyn Attending:[First Name3 (LF) 1505] Chief Complaint: febrile x 2 days, acute onset of SOB and mental status changes Major Surgical or Invasive Procedure: NONE History of Present Illness: Mrs [Known lastname ] is well known to the cardiac surgery service. She originally underwent CABG x3 on [2174-11-14]. She was readmitted on [12-1] for sternal wound dehisence and on [12-6] underwent bilaterl pectoral flaps and plating with Dr. [First Name (STitle) ]. She was discharged to rehab on [2174-12-14] on a 6 week course of Vanco and Cipro despite negative OR cultures. Sternal drains placed by plastics remained in place. She was due to f/u with Dr. [First Name (STitle) ] this week to have them removed. Over the past 48hrs she spiked fever and zosyn was added. Today she became acutely SOB and lethargic. She was brought to the ER and was intubated. Head CT was negative (recent hx of stroke after CABG), CTA of chest suggestive OF PE. ALabs, EKG and bedside Echo was unremarkable. During her ER stay she became mildly hypotensive. Central line was placed and she was started on levo. She was admitted cardiac surgery service for further evaluation Past Medical History: Coronary Artery Disease s/p Coronary artery bypass grafting x 3 [2174-11-14] Hypertension insulin dependent Diabetes peripheral vascular disease Hypercholesterolemia Right Breast CA in [2166] s/p lumpectomy and radiation therapy with recurrence in [2170] s/p right breast mastectomy and reconstruction Left great toe to left shin cellulitis s Depression Restless leg syndrome Hypothyroidism h/o deep vein thrombophlebitis s/p appendectomy Social History: Lives with:daughter Occupation:retired meat manager at grocery store Cigarettes: Smoked no [] yes [x] Hx:1ppd for 15 years and quit 25 to 30 years ago Other Tobacco use:denies ETOH: < 1 drink/week [x] [1-17] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: non-contributory Physical Exam: Pulse: 80 SR Resp: 24 O2 sat:100 vented B/P Right:120/89 Left: Height: Weight: Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [] hyperactive bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [x] _+1____ Varicosities: None [x] Neuro: Intubated and sedated Pulses: Femoral Right:+2 Left:+2 DP Right:+1 Left:+1 PT [Name (NI) 167]:+1 Left:+1 Radial Right: +2 Left:+2 Carotid Bruit Right: None Left:None Pertinent Results: ECHO: [2173-12-20] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is at least 15 mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%) with abnormal septal motion and septal hypokinesis. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal study. Low-normal global left ventricular systolic function and hypokinesis of the septum. Mildly dilated right ventricle with mild free wall hypokinesis. [2174-12-26] 05:45AM BLOOD WBC-11.0 RBC-3.41* Hgb-9.3* Hct-28.8* MCV-85 MCH-27.2 MCHC-32.1 RDW-15.4 Plt Ct-246 [2174-12-25] 06:01AM BLOOD WBC-10.0 RBC-3.24* Hgb-9.0* Hct-27.8* MCV-86 MCH-27.7 MCHC-32.2 RDW-15.2 Plt Ct-209 [2174-12-19] 07:20PM BLOOD WBC-13.5* RBC-3.94* Hgb-10.9* Hct-32.9* MCV-84 MCH-27.6 MCHC-33.0 RDW-15.2 Plt Ct-443* [2174-12-26] 05:45AM BLOOD Glucose-76 UreaN-22* Creat-1.0 Na-145 K-4.2 Cl-111* HCO3-29 AnGap-9 [2174-12-25] 06:01AM BLOOD Glucose-99 UreaN-29* Creat-1.1 Na-146* K-3.9 Cl-112* HCO3-27 AnGap-11 Brief Hospital Course: Mrs [Known lastname ] arrived in the ER from rehab after becoming acutely short of breath, lethargic and developing a rash after receiving a one time dose of zosyn for fever. She was also mildly hypotensive and neo was started. She was intubated and sent for a CTA and head CT to r/o PE. Both were negative for acute processes. ECHO was unremarkable. She was admitted to the CVICU, weaned from the vent and extubated on HD#2. She was pan cultured and continued on Vanco, Zosyn, and Cipro. ID was consulted and recommended all antibiotics be discontinued since previous OR cultures were negative and event was thought to be related to a Zosyn reaction. She was seen by Plastic Surgery - Dr. [First Name (STitle) ] and one of two JP drains was removed. The remaining JP will be removed at subsequent follow up visit to Dr. [First Name (STitle) ]. On HD #3 she was transferred to the stepdown unit. Her foley was removed but was re-inserted after failing to void. She continued to progress, remained afebrile with normal WBC. She did have large volumes of loose stool which was negative for c-diff and O+P. It was noted that due to her very poor appetite she was only consuming Glucerna whicih caused diarrhea. She was started on banana flakes with significant improvement. She was noted to have a Stage II pressure ulcer on coccyx and was seen by the wound care specialist and regimen of Criticaide and DXeroform gauze was recommended. She was discharged on [12-27] to [Hospital3 ] with appropriate follow up appointments. Medications on Admission: ciprofloxacin 500 mg q 12hrs, vancomycin 750mg q 24hrs, 81 mg daily, pravastatin 20 mmg DAILY, pantoprazole 40 mg daily, ergocalciferol weekly, levothyroxine 50 mcg daily, heparin sc tid,clopidogrel 75 mg daily, citalopram 20 mg daily, metoprolol 25mg TID, tramadol 50 mg prn,Imdur 60 mg q 24hrs, hydralazine 50 mg q 6hrs, Norvasc 5 mg daily,lomotil prn, lantus 80 units q am Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 12. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for loose stools. 13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. glargine 80 units SQ every morning at breakfast 15. novolin -R dose based on sliding scale fingerstick before meals and at bedtime Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: mental status changes s/p sternal dehiscence, debridement, sternal plating Coronary artery disease s/p coronary artery bypass grafts hypertension insulin dependent Diabetes peripheral vascular disease hyperlipidemia Breast CA in [2166] s/p lumpectomy (radiation therapy with recurrence in [2170]) s/p right breast mastectomy and reconstruction Left great toe to left shin cellulitis problem Depression Hypothyroidism s/p appendectomy Obesity Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait and assist of onw Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Edema 1+ bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Dr. [First Name (STitle) ] Plastics: Dr. [First Name (STitle) ] [Telephone/Fax (1) 1416] JP drains to remain in place until follow up with Dr [First Name (STitle) ] Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) 59223] [Telephone/Fax (1) 6803] after discharged from rehab. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2174-12-27]	[ "707.03", "458.9", "333.94", "V10.3", "438.89", "401.9", "780.60", "311", "438.0", "272.0", "250.00", "V45.71", "440.20", "707.22", "518.52", "V58.67", "244.9", "780.79", "V45.81", "414.00" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	7821, 7891	4493, 6040	364, 372	8385, 8598	2937, 4470	9522, 10100	2172, 2190		6466, 7798		7912, 8364		6066, 6443				8622, 9499						2205, 2918																						261, 326								400, 1394															1416, 1868	1884, 2156
1,498	137,660	14451	Discharge summary	report	Admission Date: [2191-11-17] Discharge Date: [2191-11-25] Date of Birth: [2117-5-21] Sex: M Service: NEUROLOGY Allergies: Indocin / Lipitor / Plavix Attending:[First Name3 (LF) 2518] Chief Complaint: intermittent chest pain -> code stroke Major Surgical or Invasive Procedure: cardiac catheterization angiogram MERCI retrieval History of Present Illness: 74 year-old male w/ h/o CAD s/p MI and multiple PCIs with at least 8 stents, diabetes, HTN, hypercholesterolemia, and + FH who is admitted to cardiology service with unstable angina who was having cardiac catheterization performed when at 3:15 (noted to be at baseline neurologic function). @3:30, noted to cough and to not be moving his left side and to not be able to speak, while only intermittently following commands. Dr. [First Name (STitle) ], stroke fellow, was contact[Name (NI) ] for code stroke. Upon his arrival, pt following simple commands. Pt noted to have forced R gaze (couldn't move eyes past midline), L homonymous hemianopsia, L facial droop, aphasia, [1-31] on UE and LE. Code stroke was called at that time. Pt brought to CT scanner where no hemorrhage was noted. CTA demonstrated filling defect in R MCA. With history of previous cardiac cath/heparin and integralin X 2, decision was made not to give IV tpa. Pt brought to neurointerventional suite. Angio demonstrated cut off in superiof M2 branch on the right. Patient was given local IA tPA and MERCI device was utilized with recovery of flow. repeat CT performed afterwards was without evidence of bleeding. Pt was then admitted to SICU for post tPA care. ROS: upon admission, pt denied associated SOB, N, V, diaphoresis, recent illness. Past Medical History: 1. NIDDM (diet control) 2. CAD s/p MI x2 3. Cardiomyopathy 4. Gout 5. Hypertension 6. Hyperlipidemia 7. Severe lower Back pain 8. ? BPH 9. CRI - baseline ~1.3 10. unstable angina (admitted on [2191-11-17] after 4 episodes of chest pain over a 2 day period with radiation to left arm). Social History: Tob 100 py. Quit 13 y ago. Denies extensive EtOH use. Leaves with wife, has children and grandchildren, but no sick contacts. Family History: F died MI at age 74, son had [Name2 (NI) ] at age 48. Physical Exam: VS - AF BP 128/54 RR17 HR 60 100% on 2LNC Exam per Stroke Fellow Gen: White elderly male in NAD. not speaking, but following simple commands; head turn to right HEENT: NCAT. MMM CV: RRR, no m noted Chest: CTAB Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: No lesions noted Neuro NEUROLOGICAL MS: General: alert, following simple commands, head turn to right. CN: II,[Name2 (NI) 1105]: left homonymous hemianopsia, pupils R 3->2 mm; L 2->1.5. [Name2 (NI) 1105],IV,V: right gaze, not crossing midline. VII: left facial palsy VIII: grossly appears to hear IX,X: palate elevates symmetrically XII: tongue protrudes midline without atrophy or fasciculation Motor: normal bulk, no movement of LUE with some spontaneous movement of LLE. [4-30] in RUE and RLE. 0/5 on LUE. [1-31] in LLE flexors. Reflex: [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 0 0 0 1 1 Flexor R 1 1 1 1 1 Flexor Sensation: intact to LT bilaterally. extinction on left side Coordination: unable on left side, no dysmetria on right Gait: not tested Pertinent Results: [2191-11-17] 07:05PM CK(CPK)-72 [2191-11-17] 07:05PM CK-MB-NotDone cTropnT-<0.01 [2191-11-17] 12:00PM GLUCOSE-92 UREA N-21* CREAT-1.4* SODIUM-142 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16 [2191-11-17] 12:00PM CK(CPK)-95 [2191-11-17] 12:00PM cTropnT-<0.01 [2191-11-17] 12:00PM WBC-7.6 RBC-4.38* HGB-13.6* HCT-37.9* MCV-87 MCH-31.1 MCHC-35.9* RDW-13.8 [2191-11-17] 12:00PM NEUTS-78.6* LYMPHS-12.9* MONOS-5.0 EOS-3.3 BASOS-0.4 [2191-11-17] 12:00PM PT-13.4 PTT-21.7* INR(PT)-1.2* Head CT: No evidence of intracranial hemorrhage or significant mass effect. Mild loss of attenuation involving the right insular ribbon likely represents early change from known right MCA distribution infarct. Cardiac Catheterization: 1. Two vessel coronary artery disease. 2. Normal diastolic left ventricular function MR [Name13 (STitle) ]: Large acute/subacute infarct involving the territory of the superior branch of the right middle cerebral artery. No significant mass effect or shift of the normally midline structures. TTE: The left atrium is normal in size. The left ventricular cavity is dilated. Left ventricular function is severely depressed with septall and apical akinesis. Right ventricular chamber size and free wall motion are normal. The aortic arch 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. Mild to moderate ([12-28]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. No definite apical thrombus seen (cannot definitively exclude); apex is akinetic. Compared with the prior study (images reviewed) of [2191-2-4], left ventricular systolic function appears similar. [2191-11-23] 01:18PM URINE RBC-3* WBC-51* Bacteri-NONE Yeast-NONE Epi-0 [2191-11-22] 08:58AM URINE RBC-21-50* WBC-[11-15]* Bacteri-FEW Yeast-NONE Epi-0 TransE-0-2 [2191-11-22] 08:58AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2191-11-23] 01:18PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2191-11-22] 8:58 am URINE URINE CULTURE (Preliminary): STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. [2191-11-22] 10:17 pm SWAB Source: L antecubital iv site. GRAM STAIN (Final [2191-11-23]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Preliminary): GRAM POSITIVE BACTERIA. SPARSE GROWTH. ? OF TWO COLONIAL MORPHOLOGIES. BLOOD CX [11-22] & 28: NGTD Brief Hospital Course: Mr. [Known lastname 42746] was admitted to the hospital for management of unstable angina. He was sent to cardiac cath when he developed abrupt onset L sided weakness and a L facial droop. A code stroke was called at 3:30. He further hospital course by problem is as follows. Unstable angina: He was transferred from the cardiac cath as a code stroke. He has not had chest pain or ECG changes since the procedure. He was ruled out for an MI. His BP was treated aggressively with metoprolol and his FLP was excellent with an LDL of 75. He was continued on Tricor, Rosuvastatin and a full aspirin. He had a TTE which showed apical akinesis and a severely depressed EF (20-25%). This issue and the role of anticoagulation was discussed with cardiology. As this defect was both old and stable, cardiology did not feel that there would be added benefit in anticoagulation, especially as he is already on 2 antiplatelet agents, which he needs for cardiac stents. Stroke: He was found to have occlusion of the R MCA likely an embolus from the catheterization. As he had received Integrilin and heparin for his cardiac cath, the decision was made not to give IV tPA given the risk for bleeding. Therefore he was treated with IA tPA and MERCI. He had good recovery of flow and no bleeding afterwards. He was transferred to the ICU for post tPA care and then to the floor for further management. His SBP was maintained between 140-185 and the DBP was < 105. He was maintained on Metoprolol 100 mg PO & Imdur ER 90. He was also continued on ASA 325. After his stroke, he remained expressively aphasic, however his comprehension was good. He was evaluated by speech for possible aspiration and started on a modified diet. Despite several re-evaluations, he continued to be a significant aspiration risk, therefore he was referred for rehab with 1:1 supervision during meals. ID: He developed cellulitis prior to discharge at an IV site. He was therefore treated with vancomycin and a PICC was placed. He will complete a 10 day course. He also developed a UTI which grew coag positive staph and will also be treated with the vancomycin. Zosyn was added on the day of discharge for a persistent WBC, however the site appeared to be improving. Medications on Admission: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID PRN (). 2. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 8 days. 9. Zosyn 2.25 gram Recon Soln Sig: One (1) Intravenous three times a day for 7 days. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: 1. NIDDM (diet control) 2. CAD s/p MI x2 3. Cardiomyopathy 4. Gout 5. Hypertension 6. Hyperlipidemia 7. Severe lower Back pain 8. ? BPH 9. CRI - baseline ~1.3 10. unstable angina (admitted on [2191-11-17] after 4 episodes of chest pain over a 2 day period with radiation to left arm). 11. R MCA occlusion s/p MERCI/ IA TPA 12. Cellulitis 13. UTI Discharge Condition: Stable, dysarthria and dysphagia Discharge Instructions: 1. Please call your doctor or come to the closest ED if you have new symptoms 2. Please take all medications as prescribed 3. Please have your swallowing re-evaluated in [1-29] weeks, you may need to schedule a video swallow study Followup Instructions: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2191-12-26] 2:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2533]	[ "412", "250.00", "682.3", "600.00", "274.9", "V45.82", "041.19", "996.62", "599.0", "585.9", "403.90", "272.0", "998.2", "997.02", "411.1", "414.01", "434.11", "E879.0" ]	icd9cm	[ [ [] ] ]	[ "37.22", "39.74", "99.10", "88.52", "88.41", "88.55", "99.20", "00.40" ]	icd9pcs	[ [ [] ] ]	9978, 10060	6334, 8572	329, 380	10454, 10489	3419, 3955	10773, 10993	2221, 2280		9202, 9955		10081, 10433		8598, 9179				10513, 10750						2295, 3400																						251, 291			6194, 6311		5810, 6159			408, 1747				3964, 5775											1769, 2060	2076, 2205
18,722	124,792	45781	Discharge summary	report	Admission Date: [2123-12-16] Discharge Date: [2123-12-17] Date of Birth: [2087-1-19] Sex: F Service: MEDICINE Allergies: Penicillins / Ultram / Codeine Attending:[Last Name (NamePattern4) 290] Chief Complaint: Drug Overdose Major Surgical or Invasive Procedure: Intubation History of Present Illness: 34 yo F with history of overdoses, found unconscious outside of [Hospital3 ]. Intubated, given Thiamine, charcoal, narcan, glucose, and sent to our ED, then transfered to ICU. By report of father possibly [Name (NI) 88916] on [Name (NI) ], trazodone, and ? [Name (NI) 97543]. Tox screen positive for opiates and benzo's. EKG and CXR normal. Pt has history of opioid/cocaine abuse and overdoses. Pt mental status waxing and [Doctor Last Name 688]. When awake, answered questions appropriately and denied pain. Unable to answer any other questions. Past Medical History: Hepatitis C Asthma Nephrolithiasis Depression Bipolar Heroin/Cocaine Abuse (last use 1 year ago according to father) Social History: No Alcohol Former Heroin and Cocaine abuse hx of mult detox unemployed x 8 years Family History: NC Physical Exam: T 95.9 P 57 BP 112/59 AC 500 12 5 40% O2 100 ABG 7.4/40/178/26 Gen - somnolent, waxes and wanes in mental status from completely unresponsive to answering question appropriately HEENT - Pupils 1mm equal round barely reactive to light OGT, ETT in place Cor - RRR Chest - CTA anteriorly Abd - S/NT/ND hyperactive bowel sounds Ext - w/wp, no c/c/e , Cast on L arm Neuro - moves all 4 ext spont Pertinent Results: [2123-12-16] 10:16PM WBC-8.9 RBC-3.90* HGB-12.2 HCT-34.4* MCV-88 MCH-31.3 MCHC-35.4* RDW-12.6 [2123-12-16] 10:16PM NEUTS-73.6* LYMPHS-20.6 MONOS-3.3 EOS-1.9 BASOS-0.5 [2123-12-16] 10:16PM PLT COUNT-167 [2123-12-16] 10:16PM PT-13.5 PTT-29.2 INR(PT)-1.2 [2123-12-16] 10:16PM HCG-<5 [2123-12-16] 10:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2123-12-16] 10:55PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2123-12-16] 10:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2123-12-16] 10:55PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2123-12-16] 10:57PM TYPE-ART PO2-178* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 [2123-12-16] 10:16PM GLUCOSE-99 UREA N-8 CREAT-0.9 SODIUM-139 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [2123-12-16] 10:16PM ALT(SGPT)-26 AST(SGOT)-33 CK(CPK)-97 ALK PHOS-68 AMYLASE-44 TOT BILI-0.3 [2123-12-16] 10:16PM LIPASE-18 [2123-12-16] 10:16PM CK-MB-NotDone cTropnT-<0.01 [2123-12-16] 10:16PM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-1.6* MAGNESIUM-2.0 EKG - NSR, nl axis, nl int, no ischemic changes CXR - no acut cardiopulm disease, ETT 2 cm too high Brief Hospital Course: 36 yo female who presents with likely overdose on trazodone, [Month/Day/Year ], and [Month/Day/Year ]. 1) Drug Overdose - [Month/Day/Year 3755] - Patient had no signs of withdrawl. Trazodone - Patient had no seizure or increased QTC. [Name (NI) 97543] - pt reacted well to narcan in ED. Psychiatry and [First Name8 (NamePattern2) 2411] [Last Name (NamePattern1) 2412] saw the patient in the unit and set up psychiatry follow up. . 2) Respiratory Distress - Unable to wean pt upon arrival to ICU secondary to sedation. Propofol stopped. Patient was extubated the morning of discharge with no complications. After extubation she was able to oxygenate well on room air. . 3) Psych History - pt has history of bipolar disorder and depression - Sent home on her outpatient psych meds. Medications on Admission: By report of father: Depakote [Name (NI) 3755] Trazodone for sleep can verify at [Doctor First Name ] Pharmacy in [Hospital1 ] in AM Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: [2-5] neb Inhalation Q6H (every 6 hours) as needed. 2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 3. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 4. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO three times a day. 5. [Month/Day (2) 3755] 1 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Trazodone HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Overdose Discharge Condition: Good Discharge Instructions: Please take all of your medications Please follow up with all of your doctors. Please follow up with AA. If you feel any urge to abuse any substance again, please call either your sponsor or your psychiatrist. Followup Instructions: Please follow up with your PCP within two weeks of discharge. The psychiatry case manager, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 32355] RN, will call you with a referral for a psychiatry follow up. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "E850.0", "518.81", "311", "969.4", "296.80", "300.3", "V15.81", "070.70", "965.01", "305.90", "493.90" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	4669, 4675	2978, 3787	314, 326	4728, 4734	1632, 2955	4993, 5357	1187, 1191		3983, 4646		4696, 4707		3813, 3960				4758, 4970						1206, 1613																						261, 276								354, 932															954, 1072	1088, 1171
71,726	138,577	5308	Discharge summary	report	Admission Date: [2157-11-11] Discharge Date: [2157-11-16] Service: MEDICINE Allergies: Penicillins / Aspirin Attending:[First Name3 (LF) 5119] Chief Complaint: Leg Pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: Initial H & P is as per the admitting ICU team. . Most of HPI and PMH obtained via granddaughter's translation, pieced together with her conferring with mother over the phone as pt. is a poor historian. This is a 84 year-old woman with a history of atrial fibrillation who has had R leg pain since monday, evaluated multiple times as outpt. over the week, including Xray that was negative. Family reports pain was in front of her leg, shin area, sharp, intermittent. Of note 2 weeks ago, saw her PCP for bilateral LE swelling and was given furosemide 20mg po x 4 days with resolution of edema. She denies calf pain, shortness of breath, but does report some vague weakness, ? lightheadedness/dizziness per granddaughter (though denied by pt currently) with 1 near fall. She also denies melena, BRBPR, hematuria. She has developed diffuse ecchymoses over her arms and legs over the last 24 hours. Of note family notes that INR has been up and down a lot recently with many changes in dose, and report there may have been some confusion over proper dose. In ED, Initial BP 77/40, but increased to 104/39 on next measurement without intervention. She had head CT that was negative for acute process and was found to have hct 27, Cr 1.6 from normal baseline, and PT/PTT >150, INR >21.8. In addition, had Na 130 down to 127 on repeat with normal potassium. She was noted to have hematuria in ED as well. Rectal guaiac negative in ED. She had abdominal CT to evaluate for RP bleed and which showed dilated CBD duct with ?Hemorrhage/inflammation surrounding duodenum with small amount of blood in pelvis. ED was concerned with giving contrast in setting of ARF, so had U/S which showed marked CBD and mild pancreatic duct dilation, with recommendation to perform MRCP or contrast study to evaluate for mass. Surgery was consulted and felt pelvic bleeding likely [1-8] elevated INR, and given minimal blood no surgical intervention was necessary. She received FFP x2 and 10mg IV vitamin K in ED. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, vision changes. She does report h/o chronic headache, but does not have one currently. She denies leg pain. Past Medical History: - Atrial fibrillation on amiodarone and dig - HTN: on amlodipine/benazepril 2.5/10 - chronic cough with symmetric biapical scarring with multilobar bronchiectasis - h/o enlarged thyroid Social History: lives with daughter, granddaughter, grandson. no smoking, drinking, ETOH Family History: not assessed Physical Exam: Vitals: T: 96.8 BP: 126/46 HR: 89 RR: O2Sat: 18/97%RA GEN: thin, tan woman, NAD, pleasant, answering ?'s with a smile in spanish HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, MM sl. dry, dentures in place NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: irregular rhythm, regular rate, no MRGs, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no wheezes, rales ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords. no TTP on either leg, no calf tenderness. no erythema, warmth, joint swelling. NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. diffuse ecchymoses over legs and arms bilaterally Pertinent Results: [2157-11-11] 06:00PM ALT(SGPT)-15 AST(SGOT)-27 LD(LDH)-399* ALK PHOS-104 TOT BILI-1.2 [2157-11-11] 06:00PM LIPASE-31 [2157-11-11] 06:00PM PT-150* PTT-150* INR(PT)->21.8 [2157-11-11] 06:00PM WBC-9.4# RBC-3.10# HGB-9.7# HCT-26.9# MCV-87 MCH-31.3 MCHC-36.1 RDW-17.2* CT HEAD W/O CONTRAST Study Date of [2157-11-11] 6:24 PM Preliminary Report !! WET READ !! No acute hemorrhage. One hypodense focus in right high frontal lobe - does not apparently correlate with patient's neurologic exam. No acute left-sided territorial infarct. CT PELVIS W/O CONTRAST Study Date of [2157-11-11] 7:03 PM Preliminary Report !! WET READ !! ?Hemorrhage/inflammation surrounding duodenum with small amount of blood in pelvis. Dilated CBD and intrahepatic bile ducts - recc. contrast enhanced scan when possible to eval for mass. LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [2157-11-11] 7:53 PM Preliminary Report !! WET READ !! Gallstones in a distended gallbladder. No evidence of cholecystitis. Marked CBD and mild panc duct dilation - again contrast enhanced scan, or MRCP is recc. when feasibile. Brief Hospital Course: This is an 84 year-old woman with atrial fibrillation on warfarin with hct drop and bleeding from various sites including skin, pelvis and urine. repeat INR here is 1.8 with Cr 1.0 and Hct 22.8. . Plan: # Elevated INR/anemia: likely some error with initial result given drop in INR from >220 to 1.8 with only 2 units FFP and IV insulin within hours. No clear interacting changes in medication such as abx., change in doses. Stolls were guaiac negative. CT abd/pel was done and was negative for retroperitoneal bleed . # CBD dilitation: This was an incidental finding on CT scan. LFTs were essentially normal except for a slightly elevated T bili. MRCP was done which showed mild common bile duct dilatation. ERCP was done and a periampulary diverticulum was noted along with benign papillary stenosis. A stent was placed into the CBD. The patient will need a repeat ERCP in 4 weeks for stent removeal. The GI team was going to arrange this. . # Atrial fibrillation: The patient was continued on her home regimen of digoxin and amiodarone. COumadin was initially held for concren of elevated INR and for ERCP. It was restarted at discharge. VNA service was going to monitor the pts INR at home and report the values to her PCP. . # HTN: The patients BSP were on the low normal sign while in the hospital. Her benazepril/amlodipine was held. She was instructed to not take this medication at discharge and follow up with her PCP to determine if she needed the medication or not. . # Code: FULL CODE, confirmed with daughter # Dispo: The patient was cleared for discharge home with home services and home PT. # Comm: daughter [Name (NI) ] [Name (NI) 21648](daughter) [Telephone/Fax (1) 21649] ; [Telephone/Fax (1) 21650] Medications on Admission: - amiodarone 200mg 5x week - amlodipine/benazepril 2.5/10mg qdaily - warfarin ? dose - digoxin 250mcg qdaily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Supratherapeutic INR 2. Chronic anemia 3. Biliary duct dilitation secondary to benign papillary stenosis. Discharge Condition: Good Discharge Instructions: -Take coumadin at a LOWER dose 4mg. -VNA should follow your INR levels. -Follow up at the [Hospital ] clinic next week. -DO NOT take your blood pressure medication for now as your blood pressure has been running on the low normal side. Have PCP determine if you need to be restarted on this medication at a later -Return to ED if you experience fever/chills, nausea/vomiting, abdominal pain or any other worrisome signs/symptoms. Followup Instructions: -Follow up with your PCP at [Name9 (PRE) ] next week. -The GI team will contact you to schedule a follow up procedure to remove the stent that was placed into you bile duct. Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2158-2-16] 9:20 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2157-11-20]	[ "401.9", "584.9", "276.1", "E934.2", "285.1", "576.2", "458.29", "562.00", "V58.61", "427.31", "790.92", "728.89" ]	icd9cm	[ [ [] ] ]	[ "51.85", "99.04", "51.87", "99.07" ]	icd9pcs	[ [ [] ] ]	7309, 7367	5155, 6903	240, 247	7520, 7527	4000, 5132	8010, 8570	3003, 3017		7062, 7286		7388, 7499		6929, 7039				7551, 7987						3032, 3981																						192, 202								275, 2686															2708, 2896	2912, 2987
32,763	160,695	31343	Discharge summary	report	Admission Date: [2124-6-8] Discharge Date: [2124-7-12] Date of Birth: [2045-4-13] Sex: M Service: MEDICINE Allergies: Shellfish / Latex / Ivp Dye, Iodine Containing Attending:[First Name3 (LF) 2297] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 79 y/o male with PMHx significant for CABG and porcine AVR in [2116] who presented to [Hospital3 4107] with cough, fever, and shortness of breath. Patient states that shortness of breath was the primary symptom where he could not even take a few steps without getting short of breath. At [Hospital3 4107] it was felt that he had a RLL pneumonia and started on ceftriaxone and azithromycin. During his hospital stay he suddenly became nauseous and had episodes of dry heaves x 5; denies any emesis. After the episode of dry heaves patient developed chest tightness which he states was relieved with aspirin. His nausea resolved after getting anti-emetics. His cardiac enzymes became positive and peaked with TropI of 1.48 and CK of 103. He was diagnosed with an NSTEMI and transferred to [Hospital1 18] for possible cath. . Upon arrival it was noted that patient INR was 2.2 and family not aware patient transferred for cath. It was decided to defer cath until further workup. . On review of symptoms, patient states that he needs [12-22] pillows at home. He denies any PND. Last time he had CP was months ago. Also rather tightness than pain. Associated with anxiety/stress. Never had CP during the time of his CABG (was just found to have an old MI on stress test). He has a dry cough with occasional sputum production (clear). Sick contacts significant for his daughter who had similar symptoms two weeks ago and was treated with abx. No urinary symptoms. No recent changes in his bowel movements. Past Medical History: . Cardiac History: CABG, in [2123] anatomy as follows: will need to get records Porcine AVR Cardiomyopathy with LVEF of 20% per report from echo in [2120] . Other Past History: DM type 2, diet controlled per patient Hyperlipidemia HTN H/O nephrolithiasis H/O VRE H/O C. diff TIA in [2116] after CABG operation Social History: Significant Asbestos exposure in Navy. Remote cigar use for 15 years. H/o significant alcohol abuse (up to ten beers and multiple liquour at times). Mother and father with heart disease. Mother with [Name2 (NI) 499] cancer. Family History: Mother and father with heart disease. Mother with [Name2 (NI) 499] cancer. Physical Exam: VS: T 101, BP 113/98, HR 99, RR 24, O2 93% 3L, FS 189 Gen: WDWN middle aged male in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple. CV: RR, normal S1, loud S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Mild crackles at bases, no wheezes or rhonchi. Abd: Soft, NTND. Abdominal wall hernia. Ext: No c/c/e. 1+ pulses. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2124-6-8] 04:00PM WBC-7.6 RBC-3.53* HGB-10.8* HCT-30.2* MCV-86 MCH-30.5 MCHC-35.7* RDW-14.5 [2124-6-8] 04:00PM GLUCOSE-136* UREA N-35* CREAT-1.4* SODIUM-133 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-24 ANION GAP-16 [2124-6-8] 06:45AM ALT(SGPT)-176* AST(SGOT)-210* LD(LDH)-310* CK(CPK)-102 ALK PHOS-143* TOT BILI-0.8 . EKG at OSH demonstrated NSR, LBBB pattern with diffuse ST changes but no change compared to an EKG from 3/13 per EKG report at OSH. . EKG at [Hospital1 18] showed similar findings (LBBB). . Nuclear stress test at OSH on [2124-3-3] showed large, moderately severe, fixed defect in lateral wall and large, severe, fixed defect in inferior wall. Also severe hypokinesis with LVEF of 24%. . Cardiomyopathy with LVEF of 20% per report from echo in [2120]. . CXR [2124-6-8]: 1. Left-sided pleural thickening may represent malignant or nonmalignant (loculated effusion) pleural based disease and not fully characterized. 2. Ovoid opacity along the major fissure likely represents fluid. Right lung base opacities not fully characterized. Comparison with prior studies (chest radiographs or CTs) is recommended and/or a baseline CT scan with IV contrast for further characterization. 3. Status post CABG and aortic valve replacement. . Echo [2124-6-9]: Left ventricular hypertrophy with cavity enlargement and extensive regional and global biventricular systolic function c/w multivessel CAD or other diffuse process. Normal functioning aortic valve bioprosthesis. Pulmonary artery systolic hypertension. At least mild-moderate mitral regurgitation. . CT chest w/o contrast [2124-6-9]: 1. No evidence of lobar pneumonia. 2. Bilateral partially loculated pleural effusions in the upper portion of the chest and bilateral areas of smoothly marginated pleural thickening in the lower portions of the chest. Evaluation of pleural disease is limited in the absence of intravenous contrast. Diffuse pleural thickening can be seen as a sequela of prior asbestos exposure, and at least one calcified pleural plaque is identified. Malignant pleural disease is more typically unilateral than bilateral but a malignant etiology cannot be excluded. 3. Extensive mediastinal lymphadenopathy with additional nodes in the supraclavicular and retrocrural region. Etiology is uncertain. If the patient has experienced recent CHF in a setting of the history of myocardial infarction, the nodes could potentially be related to this condition. However, short-term followup CT in [3-24] weeks may be helpful to ensure resolution and to exclude a neoplastic cause such as lymphoma or metastatic disease. 4. Diffuse ground-glass opacities with mild septal thickening. Although non-specific, this is very likely due to hydrostatic edema. 5. Incompletely imaged 8.5 cm left renal cystic lesion. Dedicated renal ultrasound could be performed for complete characterization if warranted clinically. CXR ([2124-7-11]) IMPRESSION: AP chest compared to [6-29] through 16. Moderate right pleural effusion has changed in distribution, still substantially fissural, but not in overall volume. The smaller left pleural effusion is stable. The portions of the lungs not obscured by pleural abnormality are grossly clear. ET tube, nasogastric tube, and left subclavian line are in standard placement. Right PIC line ends in the lower SVC. No pneumothorax. Brief Hospital Course: 79 year old gentleman with CAD s/p CABG, ischemic cardiomyopathy, diabetes originally admitted to OSH with severe dyspnea where he was treated for presumed pneumonia, transferred for cardiac catheterization which was deferred secondary to ongoing pneumonia and decompensated CHF.Pt was intubated on the floor for hypoxic respiratory [Hospital 73895] transferred to the MICU. Pt had a long MICU course complicated by FUO along with rash which resolved secondary to discontinuation of zosyn which was being given empirically for presumed pna. Pt. failed extubation secondary to pulmonary edema in the context of pt's extremely low EF. Pt's HD status remained tenous throughout with daily episodes of transient hypotension mostly responsive to fluid boluses and later responsive to transient pressors as attempts were being made to diurese patient for immienent hypotension. Pt. also treated for psuedomonas VAP with tobramycin and ceftazadime. After agressive treatment, patient continued to deteriorate in clinical condition, requiring continuous mechanical ventilation and pressors. Renal function worsened and multi-system failure ensued. After many family discussions regarding prognosis, we were asked to not attempt resusitation in the event of cardiac arrest. With further worsening, family requested pressors to be stopped and to begin comfort measures. Patient expired on [2124-7-12] shortly after stopping pressors. Family member was at the bedside. Medications on Admission: HOME MEDICATIONS: ASA 81mg Lisinopril 5mg Vitamin E Vitamin D Fish Oil Co EnzymeQ 10 Note: Patient stopped Zetia 10 qd, Coreg 10 qd, Plavix 75 qd, Lasix 20 qd at home by himself several weeks ago. . MEDICATION ON TRANSFER: Tylenol ASA 81 Lisinopril 5 Nitropast prn Lovenox [Hospital1 ] Azithromycin 500 qd Ceftriaxone 1gm qd Discharge Medications: Patient deceased Discharge Disposition: Expired Discharge Diagnosis: Patient deceased. Discharge Condition: Patient expired Discharge Instructions: Patient deceased Followup Instructions: Patient deceased	[ "584.9", "V15.84", "553.20", "786.8", "425.4", "250.00", "286.9", "V42.2", "401.9", "V45.81", "482.1", "272.0", "573.0", "518.81", "785.51", "486", "428.0", "410.71", "038.9", "995.92", "785.52", "427.31" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "45.13", "96.04", "38.93", "96.72", "00.17", "88.72", "99.04" ]	icd9pcs	[ [ [] ] ]	8432, 8441	6543, 8011	317, 341	8502, 8520	3126, 6520	8586, 8605	2505, 2587		8391, 8409		8462, 8481		8037, 8037				8544, 8563						2602, 3107					8055, 8368																	267, 279								369, 1898															1920, 2244	2260, 2489
4,329	154,157	45174	Discharge summary	report	Admission Date: [2144-1-19] Discharge Date: [2144-1-24] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 898] Chief Complaint: decreased po, confusion Major Surgical or Invasive Procedure: None History of Present Illness: 83y/o F with recent hospitalization (D/C [1-10]) for LLL pneumonia and diverticulitis presented to ED after home caregiver [First Name (Titles) 8706] [Last Name (Titles) 96552] po intake and confusion x24 hours. After D/C, pt completed 10 day course of levo/flagyl (day 10 [1-14]). No abd pain, CP, fever, or chills. Pt does report diarrhea over the last few days - cannot quantify how many BMs/day. Vomited x1, no blood or coffee ground emesis. +SOB. Baseline mentation good per husband and care-giver (per [Name (NI) ] report). . In the [Name (NI) ], pt was afebrile, disoriented, mildly hypoxic (92% on RA, 96% on 2L NC), EKG w/ no acute changes. Rec'd ceftriaxone 1g, azithromycin, and vancomycin 1g. Pt was ready to be admitted to the floor but became hypotensive to the 70s and minimally responsive. She responded well to 1 1/2 L IVF, with rise in SBP to 100s and improved mental status. ABG was 7.4/43/129 on O2, lactate decreased from 2.8 to 1.4. Past Medical History: DM type 2 CAD s/p 2 vessel CABG and PCI to LIMA-LAD in '[23] Carotid stenosis s/p stent to L ICA in '[36] Atrial septal defect TIA/CVA Chronic kidney disease, baseline cr 1.6-2.1 Stroke Induced Seizures HTN Hyperlipidemia Cervical Spondylosis Lumbar Radiculopathy Depression CHF EF 20% 8/04, mildly dil LA, small ASD w/ L->R flow, mild LVH, near akinesis distal [1-17] ventricle, mildly hypokinetic basal anterior septal and inferolatral walls. Mild global RV free wall hypokinesis. trace AR, 1+ MR, 3+ TR. Mild pulmonary artery systolic hypertension . PSH: S/p cataract repair s/p LUE fx repair s/p CABG '[23] Social History: Retired math professor [First Name (Titles) ] [Last Name (Titles) ], married and lives with husband. [Name (NI) ] is health care proxy. Denies present or past tobacco, no EtoH. Pt has 24h home health aid and states that she ambulates without a walker, though previous [Last Name (un) ] notes indicate she is wheelchair bound and needs a walker for assistance. States that does all of her own cooking. Son- [Name (NI) ] phone # [Telephone/Fax (1) 96553]; Nurse [First Name8 (NamePattern2) ] [Last Name (Titles) 1356] #[Telephone/Fax (1) 96554] Family History: Non- contributory Physical Exam: Tc 96.5 109/51 73 12 97% 3L NC Gen: Lying in bed in NAD, appropriate, cooperative HEENT: anicteric, pale conjunctiva, MM dry, OP clear Neck: supple, no LAD, JVP ~ 8 cm Cardiac: RRR, soft S1/S2, II/VI SM at apex Pulm: crackles on L side - entire lung field posteriorly, no crackles anteriorly; R base clear, no wheezes Abd: Soft, NT, minimally distended, +BS Ext: no pitting edema, warm, 2+ DP bilaterally, L calf scar from CABG, intact to light touch Neuro: A&Ox1 (to person; not to city, fact that in a hospital, not to year/month/day), CN II/XII intact Pertinent Results: [2144-1-19] 05:15PM BLOOD WBC-12.3* RBC-4.14* Hgb-11.9* Hct-36.0 MCV-87 MCH-28.7 MCHC-33.0 RDW-14.9 Plt Ct-408# [2144-1-20] 04:16AM BLOOD WBC-7.8 RBC-3.37* Hgb-9.8* Hct-29.5* MCV-88 MCH-29.2 MCHC-33.3 RDW-14.3 Plt Ct-292 [2144-1-20] 01:04PM BLOOD WBC-7.0 RBC-3.14* Hgb-9.1* Hct-27.3* MCV-87 MCH-29.0 MCHC-33.4 RDW-14.2 Plt Ct-263 [2144-1-20] 06:12PM BLOOD Hct-29.6* [2144-1-21] 04:10AM BLOOD WBC-7.1 RBC-3.30* Hgb-9.9* Hct-28.7* MCV-87 MCH-30.1 MCHC-34.7 RDW-15.0 Plt Ct-331 [2144-1-22] 05:30AM BLOOD WBC-7.9 RBC-3.63* Hgb-10.4* Hct-31.2* MCV-86 MCH-28.8 MCHC-33.5 RDW-14.1 Plt Ct-322 [2144-1-24] 06:00AM BLOOD WBC-6.5 RBC-3.34* Hgb-9.7* Hct-28.7* MCV-86 MCH-29.0 MCHC-33.7 RDW-14.2 Plt Ct-336 [2144-1-19] 05:15PM BLOOD Glucose-129* UreaN-37* Creat-1.8* Na-133 K-8.3* Cl-99 HCO3-22 AnGap-20 [2144-1-20] 04:16AM BLOOD Glucose-48* UreaN-35* Creat-1.6* Na-141 K-4.8 Cl-109* HCO3-24 AnGap-13 [2144-1-20] 01:04PM BLOOD Glucose-77 UreaN-32* Creat-1.5* Na-138 K-4.7 Cl-109* HCO3-23 AnGap-11 [2144-1-21] 04:10AM BLOOD Glucose-79 UreaN-31* Creat-1.4* Na-139 K-4.7 Cl-105 HCO3-25 AnGap-14 [2144-1-22] 05:30AM BLOOD Glucose-109* UreaN-28* Creat-1.3* Na-137 K-4.8 Cl-103 HCO3-25 AnGap-14 [2144-1-24] 06:00AM BLOOD Glucose-86 UreaN-23* Creat-1.1 Na-137 K-4.2 Cl-102 HCO3-26 AnGap-13 . CXR [2144-1-21] - Portable AP chest film was performed and compared with the portable AP chest film from [2144-1-19]. The patient is status post median sternotomy and CABG. Cardiomegaly is present with no significant change in comparison to the previous study. There is no evidence of pulmonary edema. There is slight improvement in the left lower lobe consolidation and slight decrease in small left pleural effusion is also noted. IMPRESSION: Slight improvement in the left lower lobe pneumonia. Brief Hospital Course: This is an 83 y/o female with PMH significant for depression, CHF, CAD, s/p recent admission for PNA, now presenting with confusion, poor po intake. 1. Mental status changes - likely multifactorial [1-16] infection, dehydration, renal failure, back to baseline per husband and family after gentle hydration. She also appears depressed, and will benefit from a psychiatry consult at rehab. Likely underlying dementia as well. No underlying signs of infection given negative cultures. She should continue to follow with behavioral neurology as well . 2. Hypotension - briefly hypotensive on admission to 70's SBP. This resolved rapidly with gentle hydration. This hypotension was likely [1-16] to dehydration, and her lactate also normalized with fluids. Her anti-hypertensives were restarted and her BP is stable in the 120's-130's. . 3. Pneumonia - covered transiently for possible hospital-acquired with Zosyn. Urine legionella pending, never produced sputum for culture. As no sign of infectious process, Zosyn d/c'ed after 2 days. CXR on [2144-1-21] showed resolving PNA. . 4. Acute renal failure - likely prerenal in setting of decreased po intake, infection. Resolved back to baseline with gently hydration with Cr 1.0-1.1 . 5. CHF - EF of 20% - Was monitored off medications for first 2 days, restarted on BB and ACEI once creatinine normalized and BPs climbed to 160s. No current symptoms of volume overload. Continue strict I/O's and daily weights and she may need lasix prn depending on symptoms. She was on 20 mg of lasix daily at home. . 6. CAD - As above, transiently held ACEI and BB, restarted before leaving ICU. Stable, no active symptoms. - no evidence of acute ischemic issues - Monitored on tele with no evidence of arrhythmias. . 7. Hx CVA/ Seizures - contued depakote for seizure ppx as per outpt regimen. No active symptoms. . 8. DM2 - held glyburide in setting of renal failure as is renally cleared and could precipitate hypoglycemia. Also as she is eating less, would continue insulin sliding until she is eating more and sugars are stable. Continue diabetic diet. . 9. Depression - on sertraline and olanzapine. Due to oversedation, olanzapine was d/c'd on [2144-1-23]. She needs a psychiatric evaluation at rehab as she appears more depressed and her poor po intake may be secondary to that. . 10. Anemia - baseline 27-30, secondary to ACD. Stable Hct. [Month (only) 116] benefit from checking SPEP/UPEP in future as outpatient to r/o other processes. Medications on Admission: aspirin 81mg po qday prilosec 40mg po qday lasix 20mg po qday lisinopril 10mg po qday atenolol 50mg po qday olanzapine 2.5mg po BID atrovent inh albuterol inh divalproex 125mg [Hospital1 ] glyburide 5mg/day 70/30 insulin 6U-8U/day (based on sliding scale) zoloft 25mg/day Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 6. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED): See attached flow sheet. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Primary - mental status changes, brief hypotension due to dehydration, resolving pneumonia Secondayr - diarrhea (resolved, currently, c diff negative x 1); CHF (EF 20%), CAD, h/o CVA/seizures, NIDDM, ARF (resolved, baseline Cr 1.0-1.1) Discharge Condition: Stable, 96%/2L Discharge Instructions: -please continue with all medications as directed - strict I/O and weights daily -> goal I/O even, may need lasix prn to reach goal or depending on symptoms (shortness of breath, hypoxia, peripheral edema, etc) - low salt diet - less than 2 g daily - if symptoms of shortness of breath, chest pain, dizziness/lightheadededness, severe nausea/vomiting, diarrhea or any other concerning symptoms occur, please see your PCP immediately or come to the ED Followup Instructions: Please see your PCP [Name Initial (PRE) 176] 1-2 weeks after discharge from rehab. Completed by:[2144-1-28]	[ "311", "294.8", "414.00", "428.0", "584.9", "276.51", "401.9", "250.00", "276.7", "799.02", "272.4", "585.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8862, 8934	5005, 7510	242, 249	9215, 9232	3148, 4982	9731, 9849	2531, 2550		7836, 8839		8955, 9194		7536, 7813				9256, 9708						2565, 3129																						179, 204								277, 1267															1289, 1918	1934, 2515
20,504	144,585	5040	Discharge summary	report	Admission Date: [2179-5-13] Discharge Date: [2179-5-18] Date of Birth: [2102-8-31] Sex: F Service: [Company 191] EAST HISTORY OF PRESENT ILLNESS: The patient is a 76 year old female transferred from [Hospital3 417] Hospital with the diagnosis of gastrointestinal bleed and pneumonia. The patient was admitted to the outlying hospital on [5-5], with an upper gastrointestinal bleed by report, as had been taking Aleve about five per day, for musculoskeletal pains. The patient had increase in nausea, abdominal pain, fatigue and over the 24 hours, had black stool in addition to hematemesis. At the outlying hospital, the patient had endoscopic examination which revealed [Doctor First Name ]-[Doctor Last Name ] tears, distal esophageal ulcer and several gastric ulcers. She was placed on intravenous Protonix and intravenous Octreotide for 24 hours and she was started on liquid diet and placed on a medical floor. She required blood transfusions times 12. The patient also, at the outlying hospital, was considered to have possibly a left mid lung pneumonia and was started on Ceftriaxone. The patient was transferred to [Hospital1 346] for further evaluation. REVIEW OF SYSTEMS: She currently feels well on admission. Denied any emesis, although continued to have black tarry stools with some red blood mixed in. She denied any cough, chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. Colon cancer about 20 years ago status post resection, radiation therapy and chemotherapy. 2. History of hypertension. 3. Left total knee replacement. 4. Right total hip replacement. 5. Rotator cuff tear. 6. Breast cancer about seven years ago status post radiation and chemotherapy and resection. MEDICATIONS ON TRANSFER: 1. Iron sulfate 325 mg p.o. twice a day with Vitamin C 500 mg p.o. twice a day. 2. Ceftriaxone 1 gram intravenously q. 12. 3. Compazine. 4. Protonix 40 mg intravenously once a day. 5. Lopressor 12.5 mg twice a day. At home, the patient had been on Captopril and Hydrochlorothiazide. ALLERGIES: Allergies included erythromycin from which she would vomit. SOCIAL HISTORY: She lives with her husband of 54 years; two children. No tobacco history. she drinks about two drinks a day and positive for non-steroidal anti-inflammatory drug use. PHYSICAL EXAMINATION: On admission, temperature 99.4 F.; blood pressure 150/70; pulse 76; O2 was 95% on room air. She was 125 pounds. In general, she was a female lying in bed, feeling low, in no acute distress. HEENT: Normal conjunctivae, anicteric and oropharynx was clear. Chest with some coarse rales at the bases and otherwise clear to auscultation. Cardiovascular is regular rate and rhythm, no murmurs, rubs or gallops. Abdomen obese, soft, nontender, nondistended. Extremities thin with no edema. LABORATORY: On admission, sodium 141, potassium 4.4, chloride 108, bicarbonate 28, BUN 8, creatinine 1.1, glucose 111. White blood cell count of 9.6, hematocrit 30.6, platelets 739. The patient had already tested Helicobacter pylori negative. PT on arrival was 13.4, INR 1.2, PTT 24. EKG was sinus with occasional PACs, normal axis and normal intervals. No ischemic changes. HOSPITAL COURSE: The patient was admitted to the floor and was being monitored for large melenic stools or for a drop with serial hematocrits. On the day of admission, the patient's hematocrit dropped from 28.3 at 1 a.m. to 23.8 by 10 a.m., so the patient was scheduled to go to the GI Laboratory for endoscopy. During endoscopy, they found evidence of gastritis and a Dieulafoy lesion which they cauterized and treated. At the end to the scope, the patient was no longer bleeding as they pulled out. The patient was then transferred to the Unit for further monitoring. The patient received a total of two units of O positive blood in the afternoon of that day and the next day received two units of A positive blood. The patient remained stable and hematocrits were serially monitored, and then the patient was transferred to the floor where her hematocrits remained stable and started to elevate from 34, 35 to 38.0 on discharge. The patient was restarted on her anti-hypertensive of Lopressor 12.5 mg twice a day and Captopril 25 mg three times a day. The patient was doing well, ambulating, without assistance through the hallways, and the patient was advanced slowly on her diet from liquids to full liquids to a regular diet. The patient tolerated all of this well and with a hematocrit of 38.0 on the morning of discharge, she was deemed in condition appropriate for discharge. CONDITION ON DISCHARGE: Good. DISPOSITION: The patient was discharged to home with her son and daughter-in-law. DISCHARGE MEDICATIONS: To resume home medicines: 1. Captopril. 2. Hydrochlorothiazide. 3. To continue pantoprazole 40 mg by mouth twice a day. DISCHARGE INSTRUCTIONS: 1. The patient was given instructions to avoid non-steroidal anti-inflammatory medicines. 2. She is to be wary of large melenic stools. 3. Return and see her primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007], in one week. 4. To see her Gastrointestinal physician, [Last Name (NamePattern4) ]. [First Name (STitle) 572] in one to two weeks to adjust TPI therapy as needed. DIAGNOSES: 1. ACUTE UPPER GI BLEED/ ACUTE GASTRITIS 2.ANEMIA DUE TO BLOOD LOSS 3.HYPERTENSION 4. OSTEOARTHRITIS [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1019] Dictated By:[Name8 (MD) 20804] MEDQUIST36 D: [2179-5-19] 11:23 T: [2179-5-23] 14:20 JOB#: [Job Number 20805]	[ "486", "535.50", "285.1", "V10.05", "537.84", "401.9", "V10.3" ]	icd9cm	[ [ [] ] ]	[ "45.13", "44.43" ]	icd9pcs	[ [ [] ] ]									4784, 4908					3263, 4641			4932, 5809																			2370, 3244						1246, 1439											181, 1226														1794, 2158	1461, 1769	2176, 2346	4667, 4759
29,054	173,691	49321	Discharge summary	report	Admission Date: [2147-4-24] Discharge Date: [2147-4-27] Date of Birth: [2097-8-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: abdominal pain, hypotension, fever Major Surgical or Invasive Procedure: peritoneal dialysis History of Present Illness: 49 yo female with metastatic colon cancer on chemotherapy and s/p renal transplant on peritoneal dialysis was admitted from the ED with fever to 10 and hypotension to 80. Patient reports that 2 days ago ([2147-4-22]) she awoke with pain in her left lower quadrant, which she describes as a "hurting" pain, no radiations, worse with touching and movement, and with no known relievers. Associated symptoms include the following: - nausea - vomiting: nonbloody, nonbilious - [2-19] stools per day: loose, nonbloody, watery but mixed with stool - inability to tolerate solid or liquid POs - an episode of shaking chills on Saturday [2147-4-22] - productive cough with nonbloody but yellow-colored sputum She otherwise denies dysuria, back pain, headache, or neck pain. She also reports that she has had difficulty tolerating her oral medications the last 2-3 days. Of note, patient was previously admitted to the MICU in [2-24] after being hypotensive in the IR suite. Her hypotension was thought most likely secondary to hypovolemia given that her symptoms improved rapidly with fluid resuscitation alone. Upon admission to the ED, vital signs were 98.4, HR 124, BP 133/102 and follow-up BP 86/64, and 100% RA. While in the ED, her blood pressure declined to as low as 80/49. She received 2.3L NS, tylenol 650mg PR, zofran 2mg x 1, vancomycin 1 g x 1, and ceftriaxone 1g x 1. Past Medical History: 1. Metastatic Colon Cancer Patient initially presented with bowel obstruction in [2143] and underwent resection, which revealed a stage III colon adenocarcinoma with lymphovascular, venous, and perineural invasion. She underwent treatment with FOLFOX. Then in [Month (only) 216] [2146], she was undergoing evaluation for a third renal transplant, when she was found to have a mass on CXR. Follow-up PET scan demonstrated FDG-avid right upper lobe mass and left adrenal gland. Pathology was consistent with metastatic colon adenocarcinoma. She underwent 3 cycles of capecitabine and oxaliplatin. her course has been complicated by hypotension and patient was recommended to increase her salt intake. 2. ESRD Patient is now s/p two failed renal transplants (first transplant from sister in [2118] and second transplant in [2140]) and has restarted peritoneal dialysis in late [2146]/early [2147]. Now undergoes peritoneal dialysis 3 times per day 3. s/p stroke in 8/98 with no residual deficit 4. Hyperlipidemia 5. Dyspepsia 6. SLE Diagnosed as a teenager and was maintained on chronic steroids 7. Osteoporosis 8. Mitral Regurgitation Social History: Home: lives alone in [Location (un) 3844] Occupation: was employed until [1-24] as a file clerk at a local hospital EtOH: denies Drugs: denies Tobacco: denies Family History: Multiple relatives with cancer, including GM with stomach cancer and grandfather with unknown type of cancer. Physical Exam: T 98.8 / HR 100 / BP 97/67 / RR 23 / Pulse ox 99% RA Gen: resting comfortably in bed, tired appearing but in no acute distress HEENT: Clear OP, dry mucous membranes, mild right-sided facial droop with flattening of the right nasolabial fold NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: + BS, soft, tender to soft palpation in LLQ with positive guarding and rebound. PD catheter insertion site clean and without evidence of drainage or discharge EXT: trace edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. Preserved sensation throughout. [5-22] strength throughout. Normal coordination. Gait assessment deferred. slight right-sided facial droop with flattening of nasolabial fold PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2147-4-24] CT ABDOMEN/PELVIS: IMPRESSION: 1. New evidence of thickened bowel loop in the left lower quadrant, which has a broad differential and may be due to low albumin or compression from other adjacent structures, or even serosal implants. 2. No significant change in the pelvic mass size. 3. Mild enlargement in the left adrenal lesion. 4. Moderate ascites and free fluid in the pelvis. [2147-4-25] CXR: No free subdiaphragmatic gas or appreciable intestinal distention in the upper abdomen is present. Lung volumes are low, previous pulmonary vascular engorgement has improved. Right juxtahilar mass has been growing since [2147-1-17]. Lungs are otherwise grossly clear. Heart size top normal. Mediastinal vascular engorgement improved. = = = = = = = = = = ================================================================ laboratory results on admission: URINE: COLOR-Brown APPEAR-Cloudy SP [Last Name (un) 155]-1.015 BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-250 KETONE-40 BILIRUBIN-LG UROBILNGN->8 PH-9.0* LEUK-LG RBC-0-2 WBC-[12-7]* BACTERIA-MANY YEAST-NONE EPI-[3-22] AMORPH-FEW ASCITES WBC-21* RBC-9* POLYS-7* LYMPHS-39* MONOS-0 MESOTHELI-1* MACROPHAG-53* blood: GLUCOSE-82 UREA N-42* CREAT-8.0* SODIUM-141 POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 ALT(SGPT)-30 AST(SGOT)-57* ALK PHOS-102 TOT BILI-0.9 CALCIUM-6.1* PHOSPHATE-2.9 MAGNESIUM-1.4* PT-14.9* PTT-27.3 INR(PT)-1.3* LACTATE-1.6 K+-3.2* UREA N-41* CREAT-7.8# SODIUM-139 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 estGFR-Using this PHOSPHATE-3.0 MAGNESIUM-1.6 WBC-29.1# RBC-3.31* HGB-9.8* HCT-30.1* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.5 NEUTS-93* BANDS-2 LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 PLT COUNT-232 GRAN CT-[Numeric Identifier ]* Stool: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA Brief Hospital Course: 49 yo female with history of metastatic colon adenocarcinoma, SLE, ESRD on peritoneal dialysis s/p 2 failed transplants, and history of previous stroke was admitted to the [Hospital Unit Name 153] with sepsis secondary to c.diff colitis. She was treated with oral Vancomycin and metronidazole IV. Her diarrhea improved over the course and so did her hemodynamic instability. She did not require pressor therapy during the course of her ICU stay and was transferred to the floor with stable vital signs. Her diet was advanced to regular without intolerance. IV Flagyl was discontinued and she received prescription for oral vancomycin to finish a total course of 2 weeks. With regard to her ESRD, she was followed by renal inpatient service and continued on PD per protocol. Given her immunosuppressed state and the complete failure of her renal graft, decision was made by renal service that she should discontinue Sirolimus given risk/benefit profile. She should continue with low dose prednisone with Bactrim prophylaxis. For her continues hypokalemia she was instructed to add 8 mEq KCL to her PD bags which she uses every 8 hours. Her SLE was stable and not active. Metastatic Colon Adenocarcinoma: s/p adjuvant therapy with folfox in [2143] s/p irinotecan X2 doses, dc'd d/t intractable diarrhea. On CapOX every 21 days Xeloda 500 mg [Hospital1 ] D1-D14 and oxaliplatin every 21 days now s/p C4 (D1: [2147-4-17]) Will hold further chemotherapy until full resolution of infection. Medications on Admission: 1. Prednisone 5mg PO daily 2. Compazine 10mg PO q8h prn 3. Sirolimus 2mg PO daily 4. Bactrim 400-80 qMWF 5. Tylenol prn 6. Aspirin 81mg PO daily 7. Calcium Carbonate Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days: last day to take this medication [2147-5-8]. Disp:48 Capsule(s) Refills:0 6. Potassium Chloride 2 mEq/mL Syringe Sig: Four (4) ml (of 2mEq/ml Syringe) Intravenous Q 8H (Every 8 Hours): TO BE INJECTED INTO DIALYSIS BAG (4 SYRINGES EVERY 8 HOURS) - NO FOR INTRAVENOUSE OR ORAL USE!!! . Disp:360 ml (of 2mEq/ml Syringe) Refills:6 7. Needle (Disp) 18 G 18 x 1 [1-18] Needle Sig: Four (4) NEEDLE Miscellaneous once a day. Disp:360 Refills:5 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: C diff colitis end stage renal disease colon cancer systemic lupus Discharge Condition: Good, no diarrhea, good po intake Discharge Instructions: You were admitted to the intesive care unit as you had severe infectiouse diarrhea caused by clostridium difficile. You were treated with an antibiotic which you have to continue takintg as instructed. It is very important to follow this instructions and call your doctor or come to emergency department if you experience any recurrence of diarrhea or loose stools after finishing your course of antibiotic. YOU SHOULD NOT CONTINUE TAKING SIROLUIMUS as discussed with your kidney doctors. You also should call your doctor or 911 if you have any abdominal pain, bloody stools, nausea vomiting or any other health concer Followup Instructions: Provider: [Name10 (NameIs) ] FELT, RN Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-1] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-10] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 26384], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-10] 9:00	[ "458.9", "585.6", "V10.05", "584.9", "272.4", "710.0", "V45.1", "197.0", "285.21", "427.89", "V58.66", "424.0", "198.89", "729.5", "438.89", "198.7", "996.81", "345.90", "008.45", "582.81" ]	icd9cm	[ [ [] ] ]	[ "54.98" ]	icd9pcs	[ [ [] ] ]	8743, 8749	6019, 7525	350, 372	8860, 8896	4163, 5024	9563, 9971	3178, 3289		7742, 8720		8770, 8839		7551, 7719				8920, 9540						3304, 4144																						276, 312								400, 1793								5039, 5996							1815, 2978	2994, 3162
30,579	184,564	34678	Discharge summary	report	Admission Date: [2142-7-18] Discharge Date: [2142-8-27] Date of Birth: [2078-1-27] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline / Meropenem / Metoprolol Attending:[Last Name (NamePattern4) 290] Chief Complaint: pancreatic necrosis, sepsis, respiratory failure Major Surgical or Invasive Procedure: # Intubation # Tracheostomy # Paracentesis # IR drains x 2 (pseudocyst, peritoneal) # Endoscopic dobhoff placement and re-placement # Arterial line placement # Central venous catheter placement # PICC placement History of Present Illness: Mr. [Known lastname ] is a 64M with DM, HTN, CAD, necrotizing pancreatitis ([5-7]) c/b shock, respiratory failure, bacteremia, VAP. More recently admitted to an OSH [2142-7-13] with hypotension. Transferred to [Hospital1 112] [2142-7-17], where he was intubated, started on 2 pressors, on Dapto/Flagyl/Aztreonam, and found to have troponin leak. Transferred to [Hospital1 18] on [2142-7-18] at the request of the family. . The patient was admitted [Date range (1) 79523] at [Hospital1 18] with necrotizing pancreatitis, unknown trigger (no etoh, visualized gallstone last admit), complicated by shock, respiratory failure, CoNS and VSE bacteremia, acinetobacter VAP and bacteremia. In the interim, he was discharged home from rehab and had his trach removed in [6-7]. He was admitted to [Hospital ] Hospital on [2142-7-13] after his VNA noted hypotension. At the time, he was c/o mild diarrhea and abdominal pain. He had no fevers or any other complaints. At the OSH, he was started on Tobramycin and Flagyl. He was also noted to have ARF (Cr 2.3 on admission), which resolved to 0.9 prior to transfer. He had two abdominal CT scans at the OSH, which showed multiple pseudocysts. On [2142-7-17], he became acutely tachypneic and tachycardic and required transfer to an ICU. There were no beds available at [Hospital1 18], so he was transferred to [Hospital1 112]. . At [Hospital1 112], the patient was intubated shortly after arrival [1-30] to hypoxis respiratory distress. He was tachypneic (RR 40s) and satting mid80s on 100%NRB. He was initially treated with Daptomycin/Flagyl/Tobramycin, but Tobra was switched to Aztreonam on [2142-7-18]. He became more hypotensive and was not responsive to aggressive IVF resuscitation, so he was started on Levophed and Vasopressin. While at [Hospital1 112], the patient was noted to have ischemic EKG changes - ST elevation in the inferior leads, attributed to demand. Given ASA PR. He was also noted to have a troponin leak, but with resolution of the EKG changes. He had an ECHO today that showed preserved LV function (EF 60-65%) and mild global RV systloic function. . Culture data at Caritas and [Hospital1 112] have remained negative to date. Cdiff negative x2 at Caritas and pending at [Hospital1 112]. Pancreatic enzymes and LFTs remained WNL. . On arrival to the [Hospital Unit Name 153], the patient was intubated but awake. He noted abdominal pain, but denied other complaints. . Full ROS was unable to be conducted prior to sedation. Past Medical History: CABG [2139] Tracheostomy [2141] - removed [6-7] DM II with neuropathy CHF (EF 35-40% [8-5] TTE) HTN hyperlipidemia PNA - [5-5] treated at [Hospital6 19155] MSSA epidural abscess s/p laminectomy - [2133] Social History: Divorced, lives alone in [Location (un) ], MA. Retired high school english teacher. Former cigar smoker, [12-30] cigars/day, quit 8 years ago. Rare ETOH use, no illicits. Family History: Dad passed away from complications of CAD (MI in 60s) and CHF. Mother had an MI in her 50s. Sister with obesity, DM. Physical Exam: GEN: on arrival - intubated, awake, moving all extremities, interacting appropriately, now sedated VS: T 100.4 P 139 BP 109/68 RR 34 O2sat 96% on PS 15 / PEEP 10 HEENT: MMM, unable to assess JVP, neck is supple, no cervical, supraclavicular, or axillary LAD, RIJ in place CV: tachycardic, S1S2, no m/r/g appreciated PULM: CTAB anteriorly ABD: diminished bowel sounds, soft, distended, TTP throughout, no masses or HSM LIMBS: 2+ LE edema, wwp SKIN: No rashes or skin breakdown NEURO: moving all extremities and interacting appropriately prior to sedation Pertinent Results: <b>Labs on Admission:</b> [2142-7-18] 10:44PM URINE HOURS-RANDOM UREA N-418 CREAT-195 SODIUM-24 POTASSIUM-62 CHLORIDE-60 [2142-7-18] 09:46PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.043* [2142-7-18] 09:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-10 BILIRUBIN-SM UROBILNGN-2* PH-5.5 LEUK-MOD [2142-7-18] 09:46PM URINE RBC-23* WBC-18* BACTERIA-FEW YEAST-NONE EPI-0 [2142-7-18] 09:46PM URINE GRANULAR-18* HYALINE-4* [2142-7-18] 09:46PM URINE MUCOUS-RARE [2142-7-18] 09:46PM URINE EOS-NEGATIVE [2142-7-18] 09:21PM PO2-91 PCO2-27* PH-7.37 TOTAL CO2-16* BASE XS--7 [2142-7-18] 09:21PM LACTATE-1.9 [2142-7-18] 09:06PM GLUCOSE-187* UREA N-23* CREAT-1.2 SODIUM-141 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-15* ANION GAP-20 [2142-7-18] 09:06PM estGFR-Using this [2142-7-18] 09:06PM ALT(SGPT)-6 AST(SGOT)-16 LD(LDH)-229 CK(CPK)-54 ALK PHOS-43 AMYLASE-51 TOT BILI-0.4 [2142-7-18] 09:06PM LIPASE-19 [2142-7-18] 09:06PM CK-MB-10 MB INDX-18.5* cTropnT-0.41* [2142-7-18] 09:06PM ALBUMIN-2.2* CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-2.0 [2142-7-18] 09:06PM WBC-25.8# RBC-4.05# HGB-11.5# HCT-37.1# MCV-91 MCH-28.4 MCHC-31.0 RDW-15.9* [2142-7-18] 09:06PM PLT COUNT-479* [2142-7-18] 09:06PM PT-16.2* PTT-29.6 INR(PT)-1.4* . <b>Selected Radiographic studies:</b> [7-18] CXR Portable: FINDINGS: The endotracheal tube has been changed. The newly inserted ETT now projects approximately 3 cm above the carina. Right central venous access line in correct position. Normal course of the nasogastric tube. Small lung volumes, newly appeared bilateral small pleural effusions. Newly appeared retrocardiac atelectasis, the size of the cardiac silhouette is at the upper range of normal but no evidence of pulmonary edema is present. . [7-20] US Ab: 1. 11 cm fluid collection consistent with pseudocyst in the left abdomen with overlying collapsed stomach and possible overlying collapsed colon. CT-guided drainage recommended as a safer approach. 2. Moderate amount of ascites. . [7-20] CT-Guided Drainage: IMPRESSION: Technically successful CT-guided drainage of a presumed pancreatic pseudocyst. Samples sent to microbiology for gram stain and culture. Second sample sent to biochemistry for an amylase level. . [7-24] CT sinus/mandible: IMPRESSION: Mild mucosal thickening involving all of the paranasal sinuses without evidence of acute sinusitis . [7-24] CT Ab/Pelvis/CTPA: IMPRESSION: 1. Left basal pleural effusion and atelectasis. 2. Decreasing size of pancreatic pseudocyst in caudate lobe and body and tail of pancreas. 3. Residual pseudocyst left flank with pigtail catheter in situ. 4. Ascites stable. 5. Central venous catheter via the left internal jugular vein, with the tip in the azygos vein. . [7-25] CXR Portable: IMPRESSION: No significant interval change. . [7-28] Liver/GB US: IMPRESSION: No evidence of cholecystitis. Small abdominal ascites. . [7-28] Abdomen Portable: Single frontal radiograph shows OJ tube tip projecting towards the right of the midline, could be in the antrum or first portion of the duodenum. The second OG tube is coiled in the stomach. . [7-31] CT-Torso: 1. Left large pleural effusion with adjacent atelectasis, with mild interval increase in size compared to prior. Right lung base atelectasis. 2. Similar size of pancreatic pseudocyst in the body of pancreas. 3. Residual pseudocyst in the left flank area with pigtail catheter in situ, and interval decrease in size. 4. Fluid collection along the left flank just inferior to the main pseudocyst, with interval decrease in size. 5. Stable ascites. 6. Moderate anasarca similar to prior. . [7-31] CT-Guided Needle/Paracentesis: IMPRESSION: Technically successful insertion of a drainage catheter into ascites in the left lower quadrant. No immediate post- procedural complications. . [8-2] CXR Portable: FINDINGS: As compared to the previous radiograph, the right atelectasis has completely resolved. Otherwise, the lung parenchyma shows no change. Presence of a left-sided pleural effusion cannot be excluded. Relatively extensive retrocardiac atelectasis. No newly appeared focal parenchymal opacities suggesting pneumonia. Unchanged course of the nasogastric tube. A second new tube has been placed. The course of the tube is unremarkable, the tip is not visualized on today's image. No evidence of complications. . [8-8] Abdomen Portable: 1. Dobhoff tube tip curled in the stomach. This finding was reported to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17595] at 1510 on [2142-8-8]. 2. Moderately dilated loops of small and large bowel. 3. Ascites is present. Consider ultrasound to further assess the ascites. . [8-8] CT Ab/Pelvis without contrast: 1. Pleural effusion and bibasilar atelectasis, stable. 2. Pancreatic pseudocysts as described above, unchanged to decreased in size. 3. Multiple indwelling catheters. Loculated fluid in the left lower quadrant is slightly smaller in size. No new fluid collections identified. 4. Mildly loculated central ascites is extensive but fairly stable, not definitely communicating to the more peripheral collection which was recently drained. Continued consultation with the abdominal interventional service is suggested. 5. Mild dilatation of the small bowel loops likely ileus or inflammatory reaction secondary to primary pancreatitis. Partial or early obstruction seems less likely, but if suspected serial radiographs could be considered. 6. Renal hypodensities, incompletely characterized, but stable when compared to prior exams. 7. Diffuse anasarca. . [8-10] CXR Portable: FINDINGS: Indwelling devices are unchanged in position, and cardiomediastinal contours are stable in appearance, and a moderate left pleural effusion with adjacent left basilar atelectasis is again demonstrated, and not appreciably changed allowing for positional differences of the patient. No new areas of lung or pleural abnormality are detected. . [8-13] CXR Portable: FINDINGS: In comparison with the study of [8-12], there are continued low lung volumes with a substantial left pleural effusion and bibasilar atelectasis. Monitoring and support devices remain in place. . [8-14] Abdomen Portable: FINDINGS: [Last Name (un) 1372]-intestinal tube is seen traversing the stomach and small bowel with distal tip within the jejunum. There is what appears to be retrocardiac opacity that is better evaluated on chest radiograph. There are air-filled non-dilated loops of small and large bowel noted. IMPRESSION: Dobbhoff tube with tip in the jejunum. . [8-15] PICC: IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 4 French Power PICC line. Final internal length is 42 cm, with the tip positioned in the SVC. The line is ready to use. . [8-20] CT-Ab/Pelvis: IMPRESSION: 1. Increase in size of the pancreatic body pseudocyst. 2. Decrease in size of the pancreatic tail pseudocyst with collapse of the fluid collection around the drain catheter. 3. Slight decrease in size of the pelvic fluid collection with catheter in place. 4. Interval resolution of small bowel dilation with enteral tube ending in the jejunum. 5. Narrowing of the splenic and superior mesenteric veins, unchanged. 6. Splenomegaly. 7. Stable left pleural effusion. <b>Labs on Discharge:</b> CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2142-8-26] 03:19 13.2* 2.90* 8.4* 25.8* 89 29.1 32.7 16.5* 288 DIF Neuts Bands Lymphs Monos Eos Baso [2142-8-26] 03:19 71.8* 12.4* 5.8 9.5* 0.4 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2142-8-26] 03:19 1161 40 1.3* 136 4.1 97 30 13 Ca Mg Ph 8.5 3.5 2.0 Brief Hospital Course: Mr. [Known lastname ] is a 64 year old man with h/o DM, HTN, CAD s/p CABG, recent ICU stay for necrotizing pancreatitis ([Date range (1) 79524]), which was complicated by respiratory failure requiring tracheostomy, fevers, bacteremia (CNS, enterococcus), prolonged ileus, [Last Name (un) ] and drug reactions, transferred to [Hospital Unit Name 153] on [2142-7-18] from [Hospital1 112] at family??????s request with septic shock requiring pressors, hypoxic respiratory failure requiring intubation, [Last Name (un) ], and cardiac ischemia. # Sepsis/Necrotizing Pancreatitis: Over the course of the hospitalization, necrotizing pancreatitis and the associated inflammatory and [Last Name (un) 1083] cascades were presumed to be the primary pathophysiologic etiology of the patient's presentation and clinical course. Was managed with aggressive fluid resuscitation and pressor support in line with early goal directed therapy. Source control with broad spectrum antibiotics as outlined below was instituted, tailoring antimicrobial coverage to cultures accordingly and progressively discontinuing antibiotics as the patient stabilized in a step-wise fashion once surveillance cultures were persistently negative. Once the septic picture showed signs of resolving, the patient was aggressively diuresed with Lasix GTT and transitioned to Lasix IV boluses; over the course of diuresis his respiratory function steadily improved. . # Fever / leukocytosis / [Last Name (un) 1083] source control: ID was consulted on admission and followed throughout the hospitalization course. Was covered initially very broadly with a combination of colistin/aztreonam/flagyl/vancomycin PO/daptomycin/fluconazole, with daptomycin started in response to enterococcus species. Aztreonam/amikacin/colistin/vancomycin PO were promptly discontinued and the patient was transitioned to amikacin, desensitized to cefepime and started started on cefepime. Amikacin was then discontinued and a regimen of daptomycin/cefepime/metronidazole/fluconazole was continued for about 3 weeks until the patient began to stabilize and cultures were negative at which point fluconazole was discontinued, followed by metronidazole, followed by daptomycin, and finally cefepime. Other than a gram negative species that grew out of the left pseudocyst in late [Month (only) 205] and the entrococcus species already mentioned, which was thought to likely be a contaminant by ID, all other cultures were negative, including cultures of catheter tips and ascitic fluid. Leukocytosis showed a general trend toward improvement with intermittent lability as did the patient's temperature; cultures taken at the time of spikes were repeatedly negative. The etiology of the spikes remained unclear but it was hypothesized that inflammatory mediators from a sterile cyst could be triggering febrile episodes; it could also not be ruled out that the untapped midline cyst may be infected and transiently seeding the blood. Drug reaction, in particulary to cefepime and lasix was also considered. . # Pancreatic pseudocysts: IR successfully placed a catheter in the patient's lateral pseudocyst; culture data as above. Serial imaging showed some slight decrease in size in the cyst but no significant change. The midline cyst was not amenable to IR drainage; GI consult was obtained for endoscopic drainage, but intervention was deferred given the potential risks and complications in an otherwise critical patient. General surgery was also consulted for the duration of the hospitalization; surgery was deferred and the recommendation was made to continue the drains until follow-up with outpatient General Surgery [1-31] weeks after discharge to rehab, but upon repeat CT imaging immediately prior to discharge, the recommendation was made to pull the lateral pancreatic cyst in light of it being smaller in size and to continue the LLQ ascitic drain; the LLQ drain was subsequently discontinued prior to discharge. The patient was scheduled for a repeat CT and follow-up with Dr. [Last Name (STitle) ] in late [Month (only) ] prior to discharge; he was also scheduled for a follow-up with Dr. [Last Name (STitle) 174] of GI. #. Respiratory Failure / Tracheostomy: Intubated at an outside hospital for hypoxic respiratory failure. CMV/AC was maintained and titrated to ABGs per the usual ICU protocol in conjunction with appropriate IV sedation. Given the patient's anticipated protracted ventilator dependence and difficult weaning course, the decision was made to place a tracheostomy, which was performed by thoracic surgery without complication circa [7-27], as dated by his thoracic surgery pre-op note. The cuff initially leaked intermittently, but after minor repositioning at the bedside functioned appropriately without further issues. The patient was progressively weaned to PS and ventilator mask as tolerated as his respiratory status improved in conjunction with his overall clinical improvement as a result of the interventions detailed above. Prior to discharge he was breathing comfortably on trach mask 24 hours a day. He had an episode of delerium late in his hospitalization the weekend prior to discharge which resulted in him pulling out his tracheostomy, but it was replaced without complication at the bedside and he subsequently had no further episodes. Speach and swallow consulted late in the hospitalization to fit a Passy-Muir valve, but was unsuccessful and it was thought that this was due to the transient inflammation caused by the aforementioned episode of removing and replacing his tracheostomy. Of note, he was phonating the day of discharge without the Passy-Muir valve. He will likely benefit from downsizing of his cuff once in rehab. #. Left Sided Pleural Effusion: Noted early in the hospitalization that the patient had a left sided pleural effusion. This effusion was not tapped in the setting acute instability and subsequently managed conservatively without tapping as the patient stabilized from a respiratory perspective with the hypothesis that it would progressively shrink with diuresis. The etiology was thought to be trans-diaphagramatic ascites. # Anasarca / Volume overload: Iatrogoenic from fluid resuscitation and steadily improved with Lasix GTT followed by Lasix Bolus IV which was then transitioned to PO in conjunction with the patient's autodiuresis. Diuresis was titrated to remain within the patient's hemodynamic limits during the period of labile hypotensive episodes and then titrated to Cr when the patient was more hemodynamically unstable. On discharge he was NEGATIVE 21 LITERS from admission and 96KG from 128KG on admission. In the days prior to discharge, was transitioned from Lasix to PO Torsemide, which was titrated to 30mg daily. # Ascites: Paracentesis fluid consistent with exudative process likely due to necrotizing pancreatitis. Underwent paracentesis with drain placement. The drain was discontinued prior to discharge and the patient was scheduled for follow-up with Dr. [Last Name (STitle) ]. # HYPO-tensive episodes, Labile blood pressures part 1 of 2: Multifactorial, initially due in large part to septic physiology, but also complicated by a borderline abdominal-compartment syndrome in the setting of pancreatitis. Hypotension was responsive to aggressive fluid resuscitation and source control in conjunction with pressors but SBP remained labile into the 80s-90s until the abdomen became less tense, with peak bladder pressures ranging in the 30s. Abdominal compartment syndrome resolved with paracentesis and drain placement as well as diuresis. In turn, hypotensive episodes also resolved. # HYPER-tensive episodes, Labile blood pressures part 2 of 2: Coincident with hypotensive episodes, also had hypertensive episodes especially in the setting of agitation. Agitation was addressed with IV sedatives in the early interval of the hospitalization and antipsychotics as detailed below in the latter interval. Hypertensive medications were started and titrated to address the hypertensive spikes - metoprolol and enalaprilat - in conjunction with prn labetalol and hydralazine. Once the hypertensive episodes were less frequent and lower in amplitude (peaking into the 190s at times), the patient was transitioned onto a metoprolol 75 TID and enalaprilat was discontinued. Metoprolol was discontinued [8-23] because it was suspected as a cause of his eosinophilia. # Sinus Tachycardia: Rate controlled with metoprolol as described above, which was then discontinued because it was suspected to be causing his eosinophilia. Metoprolol was discontinued and Diltiazem was started then titrated to 120 mg PO/NG QID. # DM2 / Hyperglycemia: Blood sugars were controlled with an ISS and when running, TPN insulin to keep BS <150. Patient was started on a low dose of Glargine after TPN was dc'ed as blood sugars ran above 200 with the tube feeds. Glargine was titrated up to 45 U QHS prior to discharge. # Agitation/Delirium: Once sedation was weaned, the patient had intermittent episodes of agitation and delerium, which were treated with zyprexa 5 qAM & 10mg qPM and prn haldol. This regimen was discontinued late in the hospitalization because it was thought to not be helping the patient's underlying problem, which was insomnia. Prior to discharge he was started on prn 50mg Trazodone QHS, which was effective in inducing and maintaining sleep. # Anemia of chronic disease: Iron studies were suggestive of ACD; patient was transfused as needed to maintain Hct > 22. # Rash: Developed a diffuse macular rash over the extremities with few weapy bullae at the peak of volume overload; dermatology was consulted and ruled out [Month/Year (2) 1083] processes; rash progressively improved with diuresis. # [Last Name (un) ] / Hypernatremia due to low ECV: Normalized with IVF resuscitation. # Coagulopathy on admission due to malnutrition: Resolved with vitamin K; coag labs remained stable over the course of the hospitalization without signs suggestive of DIC. # Difficult Foley Change / Yeast UTI: One UC positive with yeast with a corresponding bland UA. He has a history of difficult foley changes and during the hospitalization, foley exchange was deferred despite the positive culture in the setting of diffuse anasarca and benefit of foley to daily aggressive diuresis. Foley was successfully changed [8-22] and subsequent UA showed 68 WBC with few bacteria and few yeast; he was asymptomatic. Foley was subsequently discontinued; he was spontaneously voiding upon discharge. Anti-fungals were not started under the premise that he would likely clear the infection spontaneously. # s/p NSTEMI on admission with dynamic EKG changes likely due to demand ischemia. Maintained on ASA 300mg PR daily. # Diarrhea on admission: C.Dif negative x 2. # Eosinopilia: Had eosinophilia to 12% on [8-23]. Was initially thought to be due to Cefepime, which he was desensitized to, as well as Lasix; however, eosinophilia persisted after discontinuing these medications. Metoprolol was discontinued because it was thought to be a potential cause and eosinophilia subsequently started to downtrend. It was thought that Metoprolol was the allergen and that Lasix was not. Eosinophilia persisted despite discontinuing Metoprolol; the cause remains unclear upon discharge. Medications on Admission: ON TRANSFER: - Aztreonam 2g IV q8h - Daptomycin 600mg IV q24h - Flagyl 500mg IV q8h - Fentanyl 50-100mcg IV q2h prn pain - Fentanyl 0-100mcg IV gtt - Versed 1-2mg IV q1h prn anxiety - Levophed 0-20mcg/min IV gtt - Vasopressin 0-0.04 units/min IV gtt - Peridex mouthwash 15mL [Hospital1 ] - Famotidine 20mg IV daily - Heparin 5000 units SC TID - Insulin gtt . HOME MEDS (from OSH admission note): - MVI daily - Prevacid 30mg PO daily - Symbicort 1puff [Hospital1 ] - Pancrease enzymes 3capsules TID - Citalopram 20mg PO daily - Toprol XL 200mg daily - Lisinopril 5mg PO daily - Levemir 16 units qhs Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): Hold for loose stool. 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB IH Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH Inhalation Q6H (every 6 hours) as needed for wheezing. 9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 10. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush. 11. Dextrose 50% in Water (D50W) Syringe Sig: 12.5 gm Intravenous PRN (as needed) as needed for hypoglycemia protocol. 12. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for agitation: hold for rr < 12, sedation. 13. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 14. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous every six (6) hours as needed for hyperglycemia: 0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0 Units 101-150 mg/dL 8 Units 151-200 mg/dL 11 Units 201-250 mg/dL 14 Units 251-300 mg/dL 17 Units 301-350 mg/dL 20 Units 351-400 mg/dL 23 Units > 400 mg/dL 26 Units . 15. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times a day: Please hold for SBP < 90 or HR < 60. 16. Torsemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 8957] Discharge Diagnosis: # Necrotizing pancreatitis # Septic shock # Respiratory failure 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: It was a privilege to take care of you as your physician in the ICU. . You were hospitalized for necrotizing pancreatitis, septic shock, and respiratory failure. Your necrotizing pancreatitis and septic shock were treated with aggressive IVF, medicines to raise your blood pressure, and antibiotics as well as a pancreatic and lower abdominal drain; both drains were removed prior to your discharge. Your respiratory failure was treated with ventilator support and a tracheostomy; support was provided until you were able to breath on your own. Your condition improved over the course of 40 days in the ICU with the above interventions as well as others that were instituted over the course of your hospitalization in response to secondary issues as they arose, including diarrhea, anemia of chronic inflammation, nutrition with a dobhoff feeding tube, high and low blood pressure, fast heart rate, and skin rash. . You were started on a number of new medications. Please take your medications as prescribed in the list attached. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 1231] Date/Time:[2142-9-21] 9:30 . Provider: [Name10 (NameIs) ] [Name11 (NameIs) 79525] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2142-9-24] 3:25 . Provider: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2142-10-3] 10:30 . Provider: [Name10 (NameIs) ] DISEASE. Phone:[Telephone/Fax (1) 79526] Please Schedule an appointment with DR. [Last Name (STitle) ]. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "995.92", "787.91", "782.1", "401.9", "789.59", "584.9", "285.29", "427.89", "518.84", "038.42", "250.00", "V58.66", "V45.81", "263.9", "414.01", "112.2", "288.3", "785.52", "293.0", "272.4", "286.9", "577.0", "577.2", "276.0", "511.9" ]	icd9cm	[ [ [] ] ]	[ "31.1", "96.6", "54.91", "38.93", "96.72", "52.01" ]	icd9pcs	[ [ [] ] ]	26428, 26502	12211, 23058	404, 617	26610, 26610	4396, 4404	27842, 28582	3689, 3807		24266, 26405		26523, 26589		23636, 24243				26788, 27819						3822, 4377																						316, 366				11843, 12188				645, 3223								23072, 23610		26625, 26764					3245, 3477	3493, 3673
10,624	150,114	17093	Discharge summary	report	Admission Date: [2142-11-28] Discharge Date: [2142-12-26] Date of Birth: [2093-4-16] Sex: M Service: MEDICINE Allergies: Pseudoephedrine / Sulfa (Sulfonamides) / Ativan Attending:[First Name3 (LF) 6169] Chief Complaint: Mouth pain Major Surgical or Invasive Procedure: CT guide biopsy of R pleural abscess Thoracetesis History of Present Illness: HPI: Mr. [Known lastname 48043] is a 49 year old male with CLL, followed by Dr. [First Name (STitle) 1557], s/p allo-[First Name (STitle) 3242] in [2-16], who has been on campath since [7-20], complicated by mucositis/oral lesions. He has had recurrent oral ulcers since his transplant, treated with famvir for biopsy proven HSV-2 in the past. Recently was hospitalized for oral ulcers and treated with foscarnet for resistent HSV. He was discharged on valcylovir on [2142-11-21]. Recently he was seen in clinic and given a does of erythropoetin and IVIG on [2142-11-26]. He recieved a dose of rituximab today. He has been able to take only liquids and has had trouble recently taking oral medications. He feels like he has been unable to keep up his required oral intake and is losing wieght. His also reports increased mouth pain. . ROS (+)mouth and throat pain, emesis with pills, confusion since starting scopolamine patch for secretions. (-)headache, photophobia, fever, [Date Range ], SOB, chest pain, abdominal pain, constipation (last BM [11-27]), dysuria Past Medical History: Oncologic history: CLL, diagnosed in [2137] when incidentally noted to have elevated WBC count. Treated with fludarabine then relapsed and required four cycles of PCR and then again had five cycles of PCR, but had persistent disease. He underwent reduced intensity allo-[Year (4 digits) 3242] from his brother in [2-16] that was relatively uncomplicated, though he did have grade I skin and hepatic GVHD, and febrile neutropenia. In [7-19] his CLL relapsed and he underwent DLI in [9-18] and [10-19]. in [7-20] his WBC rose and he developed lyphadenopathy. It was decided to start campath. He has suffered from oral lesions, and has been on famvir. . Other Medical History: -HTN -Klebsiella sepsis -C. Diff -2nd degree, Mobitz I, heart block. -s/p inguinal hernia repair -Cardiomyopathy: Moderate pericardial effusion and markedly reduced EF (20%) noted on echo in [9-19], presumed viral vs. chemotherapy induced. Followed by cardiology. Social History: married to a nurse, with 3 sons. Worked as a software engineer and math teacher. no tob, no etoh Family History: NC Physical Exam: PE: 98.9 110/74 100 16 94%RA Gen: Cachectic appearing male, resting comfortably in bed. Wife at bedside HEENT: PERRL. Sclera white. MMM. +desquamation in multiple areas of buccal mucosa, hard palate, with surrounding erythema. Notably tender. +aphthous ulceration on lower lip. Vesicular rash on chin. Left submandibular adenopathy Neck: Supple Cor: RR, tachycardic, with laterally displaced PMI and hyperdynamic precordium. S4. Lungs: Crackles at Right base otherwise clear.. Abd: NABS, soft, NT/ND. Extr: No c/c/e. Skin: No rash. Neuro: AOX3 non-focal Pertinent Results: [2142-11-28] 09:10AM GLUCOSE-115* UREA N-17 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-12 [2142-11-28] 09:10AM ALT(SGPT)-90* AST(SGOT)-41* LD(LDH)-160 ALK PHOS-119* TOT BILI-0.4 [2142-11-28] 09:10AM ALBUMIN-3.0* CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-1.9 [2142-11-28] 09:10AM WBC-1.0* RBC-3.17* HGB-10.6* HCT-29.3* MCV-92 MCH-33.3* MCHC-36.1* RDW-23.0* [2142-11-28] 09:10AM NEUTS-58 BANDS-2 LYMPHS-36 MONOS-0 EOS-0 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 NUC RBCS-2* [2142-11-28] 09:10AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ [2142-11-28] 09:10AM PLT SMR-VERY LOW PLT COUNT-47* [2142-11-28] 09:10AM GRAN CT-650* _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-11-29] 6:11 pm SWAB WOUND. WOUND CULTURE (Final [2142-12-1]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD(S). MODERATE GROWTH. BEING ISOLATED. VIRIDANS STREPTOCOCCI. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. FUNGAL CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. SACCHAROMYCES CEREVISIAE. _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-12-3] 8:02 pm BLOOD CULTURE 2. FINAL REPORT [2142-12-6] AEROBIC BOTTLE (Final [2142-12-6]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (un) ] AT 1705.. ENTEROBACTER CLOACAE. FINAL SENSITIVITIES. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 16 S TOBRAMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [2142-12-6]): GRAM NEGATIVE ROD(S). IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-11-14] 09:20AM MISCELLANEOUS TESTING Test Result Unit Reference Range ---- ------ ------ ---------------- HSV Acyclovir Resistance (1) >50.0 ug/ml Sensitive: <2.0 Resistant: >1.9 HSV Ganciclovir Resistance (1) >50.0 ug/ml Sensitive: <2.0 Resistant: >1.9 The concentration of drug which results in a 50% reduction in plaque formation induced by viral cytopathic effect (CPE) versus the no-drug control established the inhibitory Dose 50 (ID 50) drug concentration. the range of drug concentration tested varies with respect to the type of drug. This test was developed and its characteristics determined by ViroMed Laboratories.It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or research. Test performed at: ViroMed Laboratories Minnetonka, [Numeric Identifier 48044] Complete report on file in Laboratory. Comment: ACYCLOVIR + GANCYCLOVIR (SOURCE: THROAT) Ordering Provider [Name9 (PRE) ],[Name9 (PRE) 1730] [Name Initial (PRE) ]. ICD-9 Diagnosis 204.10 _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-12-6] 8:43 am SPUTUM Site: INDUCED QUANTITY NOT SUFFICIENT FOR ALL OTHER TESTING PNEUMOCYSTIS CARINII HAS BEEN GIVEN PRIORITY AND WILL BE PERFORMED. FINAL REPORT [2142-12-6] IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [2142-12-6]): PNEUMOCYSTIS CARINII NOT SEEN. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report CT CHEST W&W/O C [2142-12-4] 1:08 PM CT CHEST W&W/O C ; CT 100CC NON IONIC CONTRAST Reason: infection, pulmonary edema Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 49 year old man with CLL s/p [Hospital 3242] with neutropenia. Hypoxia, new b/l infiltrates on CXR suggesting fungal infection. Also has cardiomyopathy with CHF on clinical exam. REASON FOR THIS EXAMINATION: infection, pulmonary edema INDICATION: CLL status post bone marrow transplantation with neutropenia. Cardiomyopathy with CHF on clinical examination. TECHNIQUE: Axial CT imaging of the chest without and with intravenous contrast. Comparison made to CT of the chest from [2142-9-5]. FINDINGS: Multiple enlarged mediastinal lymph nodes are present (up to 3.1 x 1.2 cm in the right paratracheal station). A large pericardial effusion has increased compared to [2142-9-5]. Polychamber cardiomyopathy is present. A dilated esophagus with distal mural thickening is filled with debris. A 5.3 x 3.5 cm (5:37) rim-enhancing fluid collection along the anterior medial margin of the right chest abuts pleura and pericardium and crosses the plane of the minor fissure, adjacent to a previous pneumonia; whether is a lung or pleural abscess is uncertain. Enlarging, moderate volume, nonhemorrhagic, layering pleural effusions have some pleural enhancement suggesting exudation (5:35). New multiple foci of ground-glass opacity and parenchymal consolidation occur in both upper lobes and the superior segment of the right lower lobe. No bone lesions worrisome for malignancy are seen. In the imaged upper abdomen, marked splenomegaly and enlargement of a patent portal vein are unchanged compared to [2142-9-5]. The imaged liver, kidneys, and pancreas are normal. Enlarged lymph nodes are present adjacent to the renal vessels and the celiac axis. IMPRESSION: 1. A new 5.3 x 3.5 cm abscess in the anteromedial right chest could be pleural or pulmonary, abutting an enlarging pericardial effusion. 2. Multifocal consolidation and ground-glass opacity suggest pneumonia. Alternative diagnostic considerations include pulmonary hemorrhage or unexplained pulmonary edema. 4. Polychamber cardiomegaly. 5. Dilated debris-filled esophagus with wall thickening. 6. Mediastinal adenopathy. 7. Enlarging pericardial and bilateral pleural effusion (right greater than left), likely exudative. 8. Stable splenomegaly and enlargement of the patent portal vein. These findings were discussed at length with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11182] at 2 p.m. on [2142-12-4]. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] K. [Doctor Last Name 34865] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: [Doctor First Name ] [2142-12-6] 11:51 AM _ _ _ ________________________________________________________________ [12-6] Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, lymphocytes, neutrophils, red blood cells and macrophages. _ _ _ ________________________________________________________________ [2142-12-19] CXR IMPRESSION: AP chest compared to [2066-12-10], and 31: Right pleural effusion has almost disappeared since [12-15]. Small bilateral pleural effusions remain. There is, however, more that perihilar opacification in both upper lungs. Given patient's recent history of rapid waxing and [Doctor Last Name 688] of asymmetric pulmonary edema, this may represent recurrence of edema alone, but since there has been five-day interval since the last chest film, the rapidity of onset is really indeterminate and pneumonia or pulmonary hemorrhage cannot be excluded. Mild cardiac enlargement is unchanged. There is no pneumothorax. Tip of right PIC catheter projects over the SVC. No pneumothorax. _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-12-23] Tissue 1. Skin, chin: Necrotic material with bacterial colonies and isolated fungal spores. 2. Skin, chin: Necrotic material with bacterial colonies and isolated fungal spores (see note). _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2142-12-11] BAL GRAM STAIN (Final [2142-12-11]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2142-12-18]): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. ENTEROBACTER CLOACAE. ~3000/ML. WORKUP REQUESTED BY DR. [First Name (STitle) 8495] TAN ([2142-12-13]). This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ASPERGILLUS FUMIGATUS. 1 COLONY ON 1 PLATE. IDENTIFICATION REQUESTED BY DR [Last Name (STitle) ] ([Numeric Identifier 30694]) [2142-12-14]. Brief Hospital Course: 49 year old male with CLL on campath, history of HSV-2 oral ulcers, presents with severe mucositis and oral ulcerations with concern for viral infection. . #) Mucositis: HSV resistant to acylovir and gancyclovir. Treated with foscarnet and monitored daily for hypocalcemia, hypomagnesemia, and renal function. Started voriconazole for ? resistant oral [Female First Name (un) ], but oral culutres grew out SACCHAROMYCES CEREVISIAE. Fungal coverage then changed to ambisome and patient was treated for 5 days and changed back to voriconazole. Continued to improve and went from requiring frequent IV dilaudid to no pain medications to no oral pain whatsoever. Patient had significant lesion in right lower molar area and anterior to lower gums. Eventually the latter area eroded through his chin and formed on orocutaneous fistula. ENT was consulted and did not recommend any change in management, and advised the patient to keep the area open and draining (no bandage as this would become saturated and a breeding ground for infection). A sample of tissue was sent to pathology and microbiology and showed oropharyngeal flora, small amount of yeast, and small amount of fungal spores. Pathology demonstrated necrotic tissue. The lesions slowly improved and the patient was changes from foscarnet to valacyclovir as he no longer had evidence of active infection. Continued on TPN during the majority of his admission for nutritional support, but this was stopped prior to discharge. . #)Pulmonary infection - CT scan, xrays w/ right sided effusion, bilateral ground glass opacities most consistent with CHF. Biopsy of R chest wall collection unrevealing but micro specimen misplaced was misplaced. Treated with zosyn for broad coverage. Got pentamidine for PCP [Name Initial (PRE) 1102]. Tapped R sided pleural effusion and sent for culture and cytology which were both negative. Reaccumulated on [12-10] and repeat CT w/ re-accum of effusion and persistent infiltrates. The patient had a diagnostic BAL performed, but this resulted in dyspnea, hypoxia, and tachypnea, and the patient was sent to the ICU. After a fairly uneventful course in the ICU, with one episode of desaturation thought to be secondary to sedation, the patient returned to the floor. BAL showed enterobacter, sensitive to zosyn, and he was continued on this antibiotic. Also had apergillosis fumigata, and he was continued on voriconazole at an increased dose of 300 mg PO BID, decreased to 200 mg by discharge. Effusion was tapped for a second time for symptomatic improvement of DOE, and this was successful. Will be continued on voriconazole as outpt. Zosyn stopped and patient changed changed to neutropenia prophylaxis with augmentin and cipro, the former discontinued prior to discharge d/t diarrhea. . #) CLL: Patient with borderline neutrophil count and pancytopenia, which remained stable throughout hospital course. Started rituximab [11-27]. Continued prednisone for mild GVHD. Transfused pRBC to goal of 25. Plan for Q3-4 wk IVIG and count support. No acute issues while in hospital. . #) Cardiomyopathy: Depressed EF of 22%. Was well-compensated with no clinical CHF until [12-10]. Underlying cause thought secondary to viral infection vs. chemo. Followed by Cardiology ([Doctor Last Name 437]) as outpatient. Patient had CHF exacerbation (d/t TPN and IV foscarnet and abx) with hypoxia, increased RR, tachycardia, which required ICU care. Patient was diureses and sent to the [Doctor Last Name 3242] floor. While on [Doctor Last Name 3242], CHF management was optimized, taking low BP into account. By discharge the patient was on Toprol XL 50 mg PO QD and 37.5 mg PO TID of captopril, as well as 40 mg PO lasix QD, and maintained a relatively even fluid balance. The patient was tapped by IP x 2 for a large right pleural effusion while trying to get to optimal CHF regimen. Repeat echo was unchanged. . #) FEN: Closely monitored lytes while on Foscarnet. Liquid diet given mucositis. Started and maintained on TPN for majority of hospitalization. . #) Deconditioning: The patient is severely weak and deconditioned. Encouraged daily ambulation. Did not qualify for acute rehab, but will get VNA and PT at home. Medications on Admission: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:8 Capsule(s) Refills:4 4. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Tablet(s) 5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 10. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 11. Hydromorphone 2 mg Tablet Sig: 1-4 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:180 Tablet(s) Refills:0 12. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: do not exceed 4 tablets a day. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Two (2) ML Intravenous PRN (as needed): for PICC line care. Disp:2 week supply Refills:2 16. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection as needed: for PICC line care. Disp:2 week supply Refills:2 17. Valtrex 500 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 18 Scopolamine patch Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 4. Heparin Flush 10 unit/mL Kit Sig: Two (2) cc Intravenous once a day as needed for flush: For PICC. Disp:QS QS Refills:0 5. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection once a day as needed for as needed to flush PICC. Disp:QS QS Refills:0 6. Change PICC DSG QWeek 7. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:600 ML(s) Refills:2 9. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:QS QS Refills:0 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for PRN. Disp:30 Tablet(s) Refills:0 11. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 14. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. Disp:QS QS Refills:0 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: Mucositis (resistant HSV) CHF exacerbation Aspergillus fumigata on BAL Orocutaneous fistula Malnutrition Discharge Condition: Stable. The patient is not SOB and is able to ambulate around the [Last Name (un) 3242] unit without minimal difficulty. Orocutaneous fistula on chin remains, but has been followed by ENT who recommend no further intervention at this time. Has cardiology and CLL follow up arranged. Discharge Instructions: 1) Please take all of your medications as prescribed 2) Please call your PCP or return to the ED if you have SOB, chest pain, dizziness, increasing edema, mouth pain, or any other symptoms that are worrisome to you. 3) Please weigh yourself daily and call your PCP if your weight increases more than 3 pounds 4) Please fluid restrict to 1.5 L/day 5) Please limit salt intake 6) Eat a high caloric healthy diet Followup Instructions: 1)[First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 3512] Date/Time:[2143-1-2] 9:30 2)Please follow up appt with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] on Friday, [2142-12-28]. Please call his clinic to find out the exact time of this appointment.	[ "425.4", "996.85", "518.82", "401.9", "054.2", "528.3", "117.3", "790.7", "484.6", "204.10", "426.13", "428.41", "511.9", "261", "117.9", "284.8", "423.9" ]	icd9cm	[ [ [] ] ]	[ "33.24", "86.11", "34.24", "99.05", "99.15", "99.04", "34.91", "38.93" ]	icd9pcs	[ [ [] ] ]	21311, 21367	13413, 17665	321, 372	21516, 21807	3221, 4557	22265, 22627	2627, 2631		19452, 21288	8152, 8335	21388, 21495		17691, 19429				21831, 22242						2646, 3202										4593, 8115												271, 283	8364, 13390							400, 1502															1524, 2496	2512, 2611
41,934	160,055	13422	Discharge summary	report	Admission Date: [2159-3-2] Discharge Date: [2159-3-7] Date of Birth: [2082-2-10] Sex: M Service: CARDIOTHORACIC Allergies: Accupril / Iodine-Iodine Containing Attending:[First Name3 (LF) 1505] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: [2159-3-2] Redo-Sternotomy, Aortic Valve Replacement (23mm Porcine) History of Present Illness: 76 year old male with prior coronary artery grafts in [2142] at the [Hospital ] Hospital, who has known severe aortic stenosis which was being followed by serial echocardiograms. Given worsening dyspnea on exertion and exertional angina, he has been referred for a redo sternotomy and aortic valve replacement. Past Medical History: Aortic Stenosis Coronary artery disease s/p coronary artery bypass graft x3 [2142] Dr. [Last Name (STitle) 1774] at [Hospital ] [First Name (Titles) ] [Last Name (Titles) 40724]a Bilateral lower extremity claudication Peripheral vascular disease Diabetes Mellitus Inflammatory Arthritis Glaucoma CABG x 3 [2142] ( LIMA to LAD, SVG to OM1, SVG to OM2) Bilateral femoral endarterectomies [9-29] Tonsillectomy Left vitrectomy [2128]'s Social History: Occupation: Retired teacher Last Dental Exam: 6 months ago Lives with wife in [Name (NI) ], MA Tobacco: Brief use while in college ETOH: denies Family History: no premature coronary artery disease Physical Exam: BP: 133/63 Pulse:77 Resp: 20 O2 sat: 98% RA Height: 65" Weight: 135 lb General: WDWN elderly gentleman in NAD Skin: Warm, dry and intact. No C/C. Well healed bilateral groin incisions. Well healed sternotomy. Well healed R leg saphenectomy incision. HEENT: NCAT, PERRLA, EOMI, Anicteric sclera, OP benign Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2 +S4, III/VI SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Trace Edema Mildly thickened digits. Varicosities: Right GSV surgically absent. Left appears suitable if needed. Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 No bruit bilaterally DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit Transmitted murmur to (B) carotids Pertinent Results: [2159-3-6] 02:52AM BLOOD WBC-10.7 RBC-3.79* Hgb-11.5* Hct-34.4* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.0 Plt Ct-116* [2159-3-2] 01:37PM BLOOD WBC-20.0# RBC-3.13 Hgb-9.8* Hct-29.3* MCV-94 MCH-31.5 MCHC-33.6 RDW-13.4 Plt Ct-165 [2159-3-6] 02:52AM BLOOD Plt Ct-116* [2159-3-2] 12:39PM BLOOD PT-16.1* PTT-48.6* INR(PT)-1.4* [2159-3-2] 12:39PM BLOOD Plt Ct-131* [2159-3-7] 07:55AM BLOOD UreaN-27* Creat-1.3* Na-138 K-4.8 Cl-99 HCO3-32 AnGap-12 [2159-3-2] 01:37PM BLOOD UreaN-21* Creat-0.9 Cl-113* HCO3-24 [2159-3-6] 02:52AM BLOOD Mg-2.5 [Known lastname 40725],[Known firstname ] F [Medical Record Number 40726] M 77 [2082-2-10] Cardiology Report ECG Study Date of [2159-3-6] 8:13:48 AM Sinus rhythm with sinus arrhythmia. Possible left atrial enlargement. Possible inferior myocardial infarction of indeterminate age. Non-specific ST-T wave abnormalities. Compared to tracing #1 sinus rhythm has replaced atrial flutter. ST-T wave abnormalities are less marked. Clinical correlation is suggested. TRACING #2 Read by: [Last Name (LF) 10516],[First Name3 (LF) ] Intervals Axes Rate PR QRS QT/QTc P QRS T 84 180 94 364/406 47 73 31 [Known lastname 40725],[Known firstname ] F [Medical Record Number 40726] M 77 [2082-2-10] Radiology Report CHEST (PA & LAT) Study Date of [2159-3-5] 3:01 PM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG FA6A [2159-3-5] 3:01 PM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 40727] Reason: ? effusions [Hospital 93] MEDICAL CONDITION: 77 year old man with AVR REASON FOR THIS EXAMINATION: ? effusions Final Report PA AND LATERAL CHEST, [3-5] HISTORY: AVR, question effusions. IMPRESSION: PA and lateral chest compared to [3-4]: Small right pleural effusion and mild left lower lobe atelectasis is unchanged. More severe right lower lobe atelectasis has worsened. No pneumothorax. Stable postoperative appearance to cardiomediastinal silhouette. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: MON [2159-3-5] 8:43 PM [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 40725], [Known firstname ] [Hospital1 18] [Numeric Identifier 40728] (Complete) Done [2159-3-2] at 11:29:12 AM PRELIMINARY 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: [2082-2-10] Age (years): 77 M Hgt (in): 65 BP (mm Hg): 124/73 Wgt (lb): 133 HR (bpm): 63 BSA (m2): 1.66 m2 Indication: Aortic valve disease. Shortness of breath. ICD-9 Codes: 786.05, 424.1, 424.2 Test Information Date/Time: [2159-3-2] 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) ], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: IE33 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 5.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.5 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.9 cm <= 5.0 cm Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.1 cm <= 3.0 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: 5.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 101 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 0.6 cm2 >= 3.0 cm2 Aortic Valve - Pressure Half Time: 334 ms Findings LEFT ATRIUM: Moderate LA enlargement. Elongated LA. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-bypass: The left atrium is normal in 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 thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Post-bypass: I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 40729],[Known firstname ] F [2082-2-10] 77 Male [Numeric Identifier 40730] [Numeric Identifier ] Report to: DR. [Last Name (STitle) ]. [Doctor Last Name ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mtd SPECIMEN SUBMITTED: Aortic Valve. Procedure date Tissue received Report Date Diagnosed by [2159-3-2] [2159-3-2] [2159-3-6] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/vf DIAGNOSIS: Aortic valve: Valvular tissue with calcification, fibrosis and myxoid degeneration. Clinical: Aortic stenosis. Gross: The specimen is received in saline in a container labeled with the patient's name, "[Known lastname ], [Known firstname 1528]", the medical record number and additionally labeled "aortic valve tissue". It consists of three separate heavily calcified valve leaflets which measure 1.6 x 1 cm, 1.8 x 1 cm, 1.6 x 1.1 cm. Representative sections are submitted in cassette A for decalcification. Brief Hospital Course: He was admitted and brought to preoperative holding area, and brought to the operating room where he underwent a redo-sternotomy and aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes and epicardial pacing wires were removed per protocol. He was diuresed towards his preoperative weight and beta blockers were begun. Physical Therapy worked with him for mobility and strength. He had a brief episode of atrial fibrillation after transfer and the beta blocker dose was increased. Arrangements were made for outpatient follow up. Medications, restrictions and precautions were discussed prior to discharge. He was readyu for discharge home on post operative day five with plan for lab drawn [3-9]. Medications on Admission: Prednisone 10 qd Plaquenil 200 qd ASA 81 mg daily Avapro 150 mg daily Fish oil Simvastatin 40 mg daily Timolol ophthalmic 0.5% one gtt daily Lantus insulin 20 units qAM Humalog SSI insulin MVI/minerals daily Trazodone 100 qhs Ambien 10 qhs prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:90 Tablet(s) Refills:0 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:qs qs Refills:0 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: sliding scale as prior to admission . Disp:qs qs Refills:0 12. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 14. Outpatient Lab Work please check potassium, cr on friday [3-9] with results to Dr [Last Name (STitle) ] office phone # [Telephone/Fax (1) 170] Discharge Disposition: Home With Service Facility: [Hospital1 1376] [Hospital3 ] Discharge Diagnosis: Aortic Stenosis s/p AVR Coronary artery disease s/p coronary artery bypass graft Rheumatoid arthritis peripheral vascular disease s/p bilateral femoral endarterectomies Diabetes mellitus type 2 Hyperlipidemia Bilateral lower extremity claudication Peripheral vascular disease Diabetes Mellitus DJD/Inflammatory Arthritis, currently on steroids and Plaquenil Glaucoma CABG x 3 [2142] ( LIMA to LAD, SVG to OM1, SVG to OM2) Bilateral femoral endarterectomies [9-29] Tonsillectomy Left vitrectomy MEEI [2128]'s OD Laser surgery Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2159-4-5] 1:30 Please call to schedule appointments Primary Care: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 40731] ([Telephone/Fax (1) 40732]in [12-23] weeks Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 14890] in [12-23] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Outpatient Lab Work please check potassium, cr on friday [3-9] with results to Dr [Last Name (STitle) ] office phone # [Telephone/Fax (1) 170] Completed by:[2159-3-7]	[ "V58.67", "V45.81", "427.31", "250.01", "424.1", "272.4", "V58.65", "714.0", "782.3" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	12888, 12956	9971, 10876	316, 390	13537, 13634	2377, 3922	14174, 14870	1408, 1446		11170, 12865	3962, 3987	12977, 13516		10902, 11147				13658, 14151						1461, 2358																						261, 278	4019, 9948							418, 738															760, 1227	1243, 1392
77,478	160,698	39048	Discharge summary	report	Admission Date: [2137-4-1] Discharge Date: [2137-4-9] Date of Birth: [2069-9-8] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: EKG changes, coronary stenosis Major Surgical or Invasive Procedure: catheterization with Bare metal stent to Left circumflex artery History of Present Illness: 67 F with hx CAD s/p RCA and LCx stents, PVD s/p aortobifem bypass and R CEA (with 99% restenosis), CHF,ischemic cardiomyopathy s/p ICD (previous EF 25%, now 50 %), s/p ICD who initially presented to [Hospital ] med ctr in [Month (only) 956] with diarrhea and found to have ischemic colitis s/p 2 colectomy with 2 colostomies. Sent to [Hospital3 ] on [3-22] and refused by that rehab due to TWI V2-V4 on ECG done by EMS enroute, unclear why. Sent to LGH and where she had a trop T 0.18 and flat CKs without any symptoms. Was noted to have Course complicated by flash pulmonary edema with transfer to CCU. She was subsequently underwent diagnostic cath on [3-27] showing 80% LCx 80-90% stenosis proximal to previous stents and total occlusion RCA with L to R collaterals. She has now been transferred to [Hospital1 18] for interventional cath. . 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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On arrival to the CCU HR 80s, BP 110-130s, has TLC. She continued to be chest pain free. EKG showed LVH, diffuse TWI and old QW in inferior leads. On arrival she was hypotensive with MAPs to 64 howevr was asymptomatic. She noted to have nitropaste on, presumably to control BP/aferload reduce given recent flash. Past Medical History: CAD h/o NSTEMI x2 including inferior infarct and stents to circumflex diag and RCA. Aorto-bifem bypass s/p left leg thrombosis requiring thrombectomy from graft. ischemic Cardiomyopathy s/p ICD and PPM with EF 25% several months ago but 55% on repeat echo. ischemic colitis c/b post op ileus now on TPN Right CEA- now occluded? COPD Smoker HTN CKD baseline Cr 1.3-1.4 Chronic back pain Anemia Social History: Tobacco history: 40 ppy, quit. Has daughter. -ETOH:none -Illicit drugs:none . Tobacco history: 40 ppy, quit. Has daughter. -ETOH:none -Illicit drugs:none Family History: FAMILY HISTORY: Father died of MI at 35 follow cardiac disease. Physical Exam: VS: T=99.8 BP= 95/52 HR= 84 RR=17 O2 sat=94% 3L GENERAL: comfortable, AOX 3 Neck: supple, no JVP, no carotid bruit CVS: RRR, S1 S2 clear, I/VI SEM heard best at RUSB, abdominal bruit/pulsation radiating to femorals. Lungs: CTA-B, no wheeze, rales, ronchi. Abd: +bs, soft, nt, nd colostomy bag site no erythema, tenderness, swelling, staples in place with some granulation tissue/? drainage Venous stasis ulcer. . Ext: WWP, no edema, 2+ DP/PT Pertinent Results: [2137-4-1] 05:23PM ALT(SGPT)-179* AST(SGOT)-266* CK(CPK)-17* ALK PHOS-451* TOT BILI-0.7 [2137-4-1] 05:23PM GLUCOSE-84 UREA N-36* CREAT-1.1 SODIUM-135 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-14 [2137-4-1] 05:23PM ALT(SGPT)-179* AST(SGOT)-266* CK(CPK)-17* ALK PHOS-451* TOT BILI-0.7 [2137-4-1] 05:23PM CK-MB-NotDone cTropnT-0.10* [2137-4-1] 05:23PM ALBUMIN-3.1* CALCIUM-8.4 PHOSPHATE-4.8* MAGNESIUM-1.7 [2137-4-1] 05:23PM WBC-9.4 RBC-4.49 HGB-11.8* HCT-35.8* MCV-80* MCH-26.3* MCHC-33.0 RDW-21.8* [2137-4-1] 05:23PM NEUTS-80.2* LYMPHS-11.1* MONOS-7.5 EOS-1.1 BASOS-0.1 [2137-4-1] 05:23PM PLT COUNT-346 [2137-4-1] 05:23PM PT-13.9* PTT-30.1 INR(PT)-1.2* . [2137-4-7]- right femoral US Large 2.8 x 2.2cm pseudoaneurysm involving the right common femoral vein with active flow noted within it. Adjacent right sided hematoma. . [2137-4-2]- Cardiac catheterization One vessel coronary artery disease. 2. Placement of a bare-metal stent in the proximal LCX. [2137-4-8] ultrasound guided thrombin injection right femoral pseudoaneurysm. -final report not available per viewing. Per report procedure successful with plan for out patient follow up. Brief Hospital Course: ASSESSMENT AND PLAN:67 F with hx CAD s/p RCA and LCx stents, PVD s/p aortobifem bypass and R CEA (with 99% restenosis), CHF (previous EF 25%, now 50 %) admitted for interventional cath following diagnostic cath at OSH who continues to be asymptomatic. . # CORONARIES:The patient has a 90% stenosis of left circumflex as well as total occlusion of her RCA with collaterals. Her troponin had been elevated to 0.18 at OSH but continued to trend downwards and she remained chest pain free. She underwent interventional cardiac catheterization during which a bare metal stent was placed in her left circumflex artery proximal to her pre-existing lesion. She was continued on aspirin, low dose statin given transaminitis, and metoprolol. She did develop a right femoral vein pseudoaneurysm and hematoma as a complication of her cardiac catheterization and underwent ultrasound guided thrombin injection which was successful. She will have a follow up ultrasound as an outpatient as well as an evaluation with [Month/Day/Year 1106] surgery. . # PUMP: She had a hx of CHF with most recent Echo showing EF 50%, improved from 25 % previously. She had experienced flash pulmonary edema at an outside hospital but was euvolemic on admission to the CCU here. Given this her spironolactone and lisinopriol were held. She will follow up with Dr [Last Name (STitle) 23097], her outpatient cardiologist, to determine when these medications will be restarted. . # RHYTHM:She remained in sinus as determined by telemetry. . # Ischemic colitis: s/p cholectomy with dual colostomies. She had been on TPN at the OSH and had developed transaminitis. Her TPN was dc'd at [Hospital1 18] and surgery and nutrition consults recommended enteral feeding with nutritional supplements. Wound care consult service provided ostomy care. She has a PICC line placed while she took TPN to supplement her p.o intake, however she was able to take adequate p.o by calorie count and the TPN and PICC were discontinued. She should continue to have oral intake with supplements for adequate nutrition. . # Anemia: Admitted [3-11] to All saints with bloody diarrhea with crit drop to 22 with ischemic colitis ,with subsequent x-lap, colostomy and blood transfusions. Also has known iron deficiency with IV iron given [3-18]. HCT had been in mid 30s this admission,guaic stools have been negative. She also had prolonged bleeding at the site of her PICC placement which eventually stopped with application of pressure and reinforcement as well as right femoral vein hematoma and pseudoaneurysm. After these events, her Hct drifted down to 23-24 but was stable over last 5 days. Her labs did not indicate a coagulopathy. She will need to check a CBC after discharge. . # Weakness: thought secondary to deconditioning. PT evaluated, recommended rehab. . # Back pain: this has been ongoing since the patient's mobility has been limited and she has been in bed. She required oxycodone for pain control, warm compresses and physical therapy. Medications on Admission: Home Meds: lipitor 80mg daily spironolactone 25mg daily lisinopril 40mg daily metoprolol 25mg daily Aspirin 81mg daily fish oil . Meds on Transfer: aspirin 81 daily Atorvastatin 80mg p.o daily lovenox 30mcg sq q 24 Iron sulphate 325mg p.o daily lasix 40 IV q 12 metoprolol 25 p.o [Hospital1 ] morphine 2mg IV q 3 hours PRN nitroglycerin 1 inch topically q 8 hours nyastatin 100,000 units powder topically applied [Hospital1 ] protonix 40mg daily potassium chloride 40mEQ p.o [Hospital1 ] tylenol 650mg p.o q4 PRN colace 100mg p.o [Hospital1 ] as needed nitroglycerin 0.4 mg sublingual prn q 5 minutes zofran 4mg IV Q8 hr PRN percocet 1 tab p.o q 4 PRN . Allergies: IV dye contrast -vomits 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. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 0.5-1.0 Tablet PO Q4H (every 4 hours) as needed for back pain. 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: Life Care Center of [Hospital3 ] - [Location 55315] Discharge Diagnosis: Coronary Atery Disease Ischemic coliltis requiring colectomy and colostomies x2. Chronic Diastolic congestive Heart Failure Acute Blood Loss anemia Chronic Low back pain Transaminitis 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 because you had blockage in the blood vessels supplying your heart. You had a cardiac catheterization and a stent was placed. It is extremely important that you take Plavix and Aspirin 325 mg every day for at least 1 month and probably longer. Do not stop taking Plavix or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) 86571] tells you to. You developed a hematoma and pseudoaneurysm around the site where the catheterization was done.Thrombin was injected at the site.If you have increasing pain, bruising or redness in the next 1-2 weeks, please call [Hospital1 18] at [Telephone/Fax (1) 13471] and ask to have the interventional fellow on call paged if this happens. A PICC line was placed for intravenous feeding. However, you were able to eat normally and the PICC line was discontinued before you were transferred. Medication changes: Dr [Last Name (STitle) 23097] will tell you when to restart your spironolactone and lisinopril Lipitor 80mg changed to simvastatin 20mg daily. Added plavix 75mg daily Increased to Aspirin 325mg daily. Weigh yourself every morning, call Dr. [Last Name (STitle) 86571] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Primary Care: Pt does not have one, please ask Dr. [Last Name (STitle) 23097] to recommend one . Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23097], MD [Last Name (Titles) ]Cardlgy 27 [Location (un) 61259] [Location (un) 15749], [Numeric Identifier 86572] Phone: ([Telephone/Fax (1) 86573] Date/Time: [5-2] at 4:45pm. . Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] ([Doctor First Name ]) [Doctor First Name ] LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2137-4-24] 11:00 Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2137-4-24] 11:45 Completed by:[2137-4-10]	[ "412", "428.0", "997.2", "790.4", "585.9", "428.32", "496", "285.1", "403.90", "458.29", "560.1", "E879.0", "724.2", "998.12", "V44.3", "414.2", "414.01", "443.9", "414.8", "V45.72", "V45.02", "442.3" ]	icd9cm	[ [ [] ] ]	[ "88.55", "00.66", "36.06", "99.29", "38.93", "99.15", "00.40", "37.22", "00.45" ]	icd9pcs	[ [ [] ] ]	9086, 9172	4542, 7557	342, 407	9400, 9400	3305, 4519	10879, 11628	2776, 2827		8313, 9063		9193, 9379		7583, 7713				9573, 10491						2842, 3286																					10511, 10856	272, 304								435, 2154										9415, 9549					2176, 2571	2587, 2744			7731, 8290
29,425	131,086	33199	Discharge summary	report	Admission Date: [2168-8-25] Discharge Date: [2168-8-30] Date of Birth: [2121-9-19] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: AVM with R visual field deficits Major Surgical or Invasive Procedure: angiogram/embolization History of Present Illness: Mr. [Known lastname ] is a 47-year-old right-handed Vietnamese gentleman with a very large AVM involving his left occipital area, which is fed by multiple vessels. Based on his angiogram and CT angiogram, the plan was made to proceed with embolization followed by radiosurgery after reducing the nidus size on the day of admission. His visual field on the right has already been affected (incongruous right-sided homonymous hemianopsia). Past Medical History: none significant. lac behind ear sutured as a child Social History: The patient is divorced and works in hardwood floor maintenance. He has a 25-year history of smoking half a pack of cigarettes per day. Family History: Not significant for any vascular problems. Not significant for any brain aneurysms, AVMs, or vascular problems. Physical Exam: T 98.6 BP 104/40 HR 56 RR 11 Sat on room air Gen: comfortable HEENT: AT/NC Chest: CTA b/l CV: rrr, nl s1s2, no m/r/g Abd:s/NT/ND Extr: no edema, 1+ PT pulses Neuro: A&O x3, PERRL, CN 2-12 intact, 5/5 strength throughout, no pronator drift. Pertinent Results: [2168-8-25] 02:08PM GLUCOSE-92 UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-23 ANION GAP-8 [2168-8-25] 02:08PM CALCIUM-6.9* PHOSPHATE-2.4* MAGNESIUM-1.7 [2168-8-25] 02:08PM WBC-5.8 RBC-3.78* HGB-12.0# HCT-35.0 MCV-93 MCH-31.8 MCHC-34.4 RDW-13.2 [2168-8-25] 02:08PM PLT COUNT-224 [2168-8-25] 02:08PM PT-13.8* PTT-31.5 INR(PT)-1.2* Brief Hospital Course: Pt was admitted in anticipation AVM embolization. He underwent his procedure without complications. Approximately 30% of the lesion was embolized. He was brought the SICU for observation, and the was to maintain an SBP under 100 for the AVM. He was started on metoprolol, hydralazine, nicardipine and nitroprusside drips to accomplish this, and remained in the SICU for BP control. He underwent a head CT POD #1 which was a limited exam due to artifact from embolization, however, no definite new hemorrhage seen. Also showed left hemispheric mass effect unchanged. Subfalcine herniation with rightward midline shift is roughly stable from the preoperative exam. On POD 2, he developed some dizziness with head movement, and it was thought that this could be in part due to starting all the HTN meds. We attempted to wean him off his nitro and nicardipine drips, and his SBP requirement was increased to <140. By POD 3, he had been weaned off the drips, and his SBP was in decent control. He was started on dexamethasone and Keppra, and continued to do well. The following day, he continued to do well, and was sent home on metoprolol 25 [Hospital1 ], along with a steroid wean and anti-convulsant. He will follow-up with Dr. [First Name (STitle) ] in 2 weeks to discuss further embolization. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): use if taking Percocet for pain. Disp:30 Capsule(s) Refills:1 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Dexamethasone 1.5 mg Tablet Sig: 1-2 Tablets PO 2 tabs tid X2 days; 2 tabs [Hospital1 ] X 2 days; 1 tab [Hospital1 ] X2 days then stop. Disp:30 Tablet(s) Refills:0 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:25 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: AVM L occipital lobe Discharge Condition: stable Discharge Instructions: You have had partial embolization of an AVM What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F -Swelling in groin or coolness in right leg Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[First Name (STitle) ] to be seen in 2 weeks so you can have your procedure in 3 weeks call [Telephone/Fax (1) 1669]. Completed by:[2168-8-30]	[ "368.46", "780.4", "305.1", "747.81", "348.4" ]	icd9cm	[ [ [] ] ]	[ "39.72" ]	icd9pcs	[ [ [] ] ]	3922, 3928	1897, 3201	350, 375	3993, 4002	1487, 1874	6174, 6403	1093, 1208		3256, 3899		3949, 3972		3227, 3233				4026, 4767	4793, 6151					1223, 1468																						278, 312								403, 847															869, 922	938, 1077
32,321	100,825	31977	Discharge summary	report	Admission Date: [2121-10-15] Discharge Date: [2121-10-22] Date of Birth: [2043-5-15] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [2121-10-15] cabg x4 (LIMA to LAD, SVG to OM, SVG to RCA, SVG to PDA) [2121-10-15] med. re-exploration History of Present Illness: 78 yo female with abnormal EKG and ETT done as pre-op workup for abdominal hernia repair.Referred for cath which revealed three vessel disease, and then referred for CABG. Past Medical History: IDDM HTN elev. lipids glaucoma GERD CRI LE neuropathy uterine Ca macular degeneration abdominal hernia Social History: retired no tobacco use or ETOH use divorced, lives with daughter Family History: mother died of MI at 61 Physical Exam: HR 64 RR 16 right 176/53 left 187/59 NAD , flat after cath skin/HEENT unremarkable neck supple, full ROM, no carotid bruits CTAB anterolaterally RRR, no murmur sift, NT, ND, + BS, large ventral hernia extrems warm, well-perfused, no edema left calf varicosities, difficult to assess while flat neuro grossly intact 2+ bil. fem/DP/PT/radials Pertinent Results: CHEST (PA & LAT) [2121-10-20] 10:06 AM PA and lateral upright chest radiographs compared to [2121-10-16]. The patient was extubated in the meantime interval with removing of the NG tube, Swan-Ganz catheter, mediastinal drain, and left chest tube. The heart size is stable. Mediastinal position, contour, and width are unremarkable. The sternotomy wires are intact. Small left apical pneumothorax is noted, new. The bibasal atelectasis accompanied by small bilateral pleural effusion are demonstrated, markedly improved compared to the previous study. New fracture of second right rib is demonstrated with no adjacent pneumothorax. IMPRESSION: 1. Small new left apical pneumothorax. 2. New fracture of second right rib. 3. Decrease in bilateral pleural effusions and adjacent atelectasis. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Date/Time: [2121-10-15] at 19:26 LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. 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. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. [2121-10-20] 06:30AM BLOOD WBC-6.9 RBC-3.42* Hgb-10.5* Hct-30.9* MCV-90 MCH-30.6 MCHC-33.9 RDW-14.5 Plt Ct-92* [2121-10-20] 06:30AM BLOOD Plt Ct-92* [2121-10-18] 03:41AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1 [2121-10-21] 06:15AM BLOOD Glucose-82 UreaN-41* Creat-1.4* Na-143 K-3.6 Cl-108 HCO3-30 AnGap-9 [2121-10-20] 06:30AM BLOOD Glucose-87 UreaN-44* Creat-1.5* Na-143 K-3.6 Cl-110* HCO3-29 AnGap-8 [2121-10-19] 05:05AM BLOOD Glucose-131* UreaN-44* Creat-1.7* Na-144 K-4.4 Cl-113* HCO3-21* AnGap-14 Brief Hospital Course: Admitted [10-15] and underwent cabg x4 with Dr. [First Name (STitle) ]. Transferred to the CSRU in stable condition on a titrated propofol drip. Returned to the OR later that evening for a mediastinal re-exploration for bleeding after acute hypotension in the CSRU. Transfered back to the CSRU in stable condition on nitroglycerin and propofol drips. Extubated on POD #2 and swallow eval. done to assess aspiration risk with no signs of aspiration seen. Transferred to the floor on POD #3 to begin increasing her activity level. Chest tubes and pacing wires removed without incident. She progressed well and was ready for discharge to home on POD #7. Medications on Admission: humulin N 16 units QAM humulin N 6 units QPM metoprolol 25 mg [Hospital1 ] plavix 600 mg (SINGLE dose 10/3) vasotec 2.5 mg daily protonix 40 mg daily ASA 81 mg daily metamucil one cap daily MVI daily macular protect one tab [Hospital1 ] Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 16 in AM/6 in PM units Subcutaneous twice a day. Disp:QS 1 month Refills:0 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: s/p cabg x4 s/p mediastinal re-exploration for bleeding\nIDDM HTN elev. chol. glaucoma GERD CRI postop A fib Discharge Condition: good Discharge Instructions: SHOWER DAILY , pat incisions dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage home physical therapy Followup Instructions: see Dr. [Last Name (STitle) 11559] in [1-7] weeks see Dr. [Last Name (STitle) 11493] in [2-8] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2121-10-22]	[ "518.0", "553.20", "807.01", "285.9", "530.81", "585.9", "512.8", "V10.42", "458.29", "424.0", "403.90", "276.2", "998.89", "414.01", "272.4", "365.9", "427.5", "427.31", "E928.8", "E849.9", "357.2", "V58.66", "362.50", "E878.8", "998.11", "V58.67", "250.60" ]	icd9cm	[ [ [] ] ]	[ "99.05", "36.15", "96.04", "39.61", "36.13", "99.07", "34.03", "96.71" ]	icd9pcs	[ [ [] ] ]	6214, 6263	4136, 4797	335, 448	6415, 6422	1280, 4113	6699, 7013	873, 898		5092, 6191		6284, 6394		4823, 5069				6446, 6676						913, 1261																						283, 297								476, 649															671, 775	791, 857
8,770	100,557	12133	Discharge summary	report	Admission Date: [2174-11-25] Discharge Date: [2174-12-5] Service: MEDICINE Allergies: Nsaids / Ace Inhibitors Attending:[First Name3 (LF) 7934] Chief Complaint: shortness of breath and hemoptysis Major Surgical or Invasive Procedure: - History of Present Illness: This a [Age over 90 ]y/o female with a history of COPD, hypertension, gastroespohageal reflux who presented with shortness of breath and dyspnea on exertion X 3 days. Per nursing home records, the patient was reported to have had 10cc of hemoptysis. O2 sat was 92%. Patient reports substernal chest pain radiating to the back, lasting seconds. By history the pain is pleuritic, because coughing makes it worse. . On presentation peak flow was 140; improved to 240 after 1st neb in the ED. Chest X-ray showed multilobular consolidation. CT-A showed no PE or obstructive bronchial lesion, but central bilateral consolidation secondary to pneumonia and CHF was noted. An EKG showed TWI in I and avL, and in V4-V6, unchanged from previous. Trop was 0.10 in the setting of renal insufficiency. Past Medical History: COPD Rash back of neck GERD HTN Social History: Lives in [Hospital 100] Rehab Denies alcohol and ciggarette smokine Family History: Non-contributory Physical Exam: VS t98.8, hr82, bp, r26, 99%on2lNC Gen elderly petite Caucasian female sitting upright in stretcher, in mod distress, using accessory muscles to breath HEENT MMM, OP, -JVD, bruits Heart nl rate, S1S2, unable to assess due to breathing Lungs coarse, rhonchorous breath sounds Abdomen round, soft, nt, nd, +bs Extremities [1-2]+pitting edema, posterior aspect of legs bilaterally Neuro: A&O X3, II-XII grossly intact Pertinent Results: Labs on Admission [2174-11-25] 11:30AM BLOOD WBC-17.1# RBC-3.86 Hgb-11.2* Hct-34.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-14.0 Plt Ct-290 [2174-11-25] 11:30AM BLOOD Plt Ct-290 [2174-11-25] 11:30AM BLOOD Glucose-119* UreaN-47* Creat-1.9* Na-142 K-4.4 Cl-101 HCO3-31 AnGap-14 [2174-11-25] 11:30AM BLOOD CK(CPK)-48 [2174-11-25] 11:30AM BLOOD CK-MB-3 cTropnT-0.10* . Chest X-ray [2174-11-25] 1. Multilobar consolidation, which could reflect asymmetrical edema and/or multilobar pneumonia. A postobstructive process in the right middle lobe cannot be excluded. By report, the patient is scheduled to undergo CTA, which will be helpful for more complete characterization of these findings. 2. Bilateral pleural effusions, right greater than left. . CT-A [2174-11-25] 1. No parenchymal mass lesion or mediastinal lymphadenopathy. No acute pulmonary embolus. 2. Central bilateral consolidation mainly along the inferior hilar regions with patchy areas of consolidation in the upper and lower lobes. Enlargement of the central arterial pulmonary vasculature and mild cardiac enlargement suggestive of background pulmonary hypertension. Small bibasilar pleural effusions. These findings may all be due to cardiac failure with pulmonary hypertension. Infective consolidation should be also considered depending on the current clinical correlation. Interval followup post-treatment initially with chest x-ray is advised. Brief Hospital Course: 1. Pneumonia The patient was initially maintained on ceftriaxone and azithromycin for community acquired pneumonia. Because the patient came from rehabilitation, the decision was made to change the antibiotic coverage to Levaquin. Her treatment also consisted of Q2 nebulizer treatments, oxygen and her home dose of prednisone. On the morning of HD #2, the patient's course was complicated by transient desaturation to 88% on 6L NC and a shovel mask. On exam the patient had rhonchorous breath sounds, difficulty mobilizing her secretions. O2 sats improved with coughing to 91%. Despite improvement in her O2 sats, the patient continued to have labored breathing. She received 10 of IV lasix and nebulizer treatments. O2sats improved to 95-99% on the same amount of O2. Respiratory therapy recommmended humidified air to help loosen the secretions. Patient course deteriorated on the morning of HD #3. 02sats were initially stable in the 90s. The patient became tachypneic breathing at an average rate of 30. Antibiotic coverage was changed to Ceftazadine because prelim sputum cultures grew gram negative rods. Despite lasix, morphine and frequent nebulizer treatments, patient's O2sats decreased to 86% on 6LNC and 100%NRB. The decision was made to transfer her to the [Hospital Unit Name 153] for further management. . In the [Hospital Unit Name 153], the pt continued to desaturate to the 80s on NC and FM. She had one episode of desaturation to the 80s which did not resolve after one minute. CXR showed mucus plugging of the entire left lung. Pt was placed on her right side and had rigorous chest PT, and saturations improved to low 90s. Family was called in. After several days of pt's respiratory status not improving, pt's status was discussed with family, who decided to make her CMO. Pt was placed on morphine gtt and died on [2174-12-5] am surrounded by her family. . 2. Leukocytosis: Pt's leukocytosis was likely [2-2] to pneumonia and UTI. Pt was afebrile throughout admission. Pt was placed on levaquin, and blood cultures were negative. . 3. Hemoptysis: Pt had episodes of hemoptysis on the floor, but not in the [Hospital Unit Name 153]. This was likely [2-2] pneumonia. Pt's Hct stayed stable, and stool was guaiac negative. . 4. Chest pain: Pt had episodes of fleeting, pleuritic chest pain on the floor, with Trop 0.10, which was likely due to renal insufficiency. The family and patient agreed not to have any intervention for any possible cardiac issues. . 5. Acute renal failure: Pt's acute renal failure was likely due to a dye load with the CT. Cr improved with fluids. . 6. HTN: Pt was continued on Isordil and norvasc. . 7. CHF: Pt had evidence of CHF on CXR, with trace edema on the posterior aspect of her legs. She was continued on daily lasix prn. Medications on Admission: Acetaminophen Aluminum Hydroxide Suspension Albuterol 0.083% Neb Soln Amlodipine Bicitra Calcium Carbonate Cyanocobalamin Fexofenadine Fluticasone-Salmeterol (250/50) Furosemide Hydrocortisone Cream 1% Hyoscyamine Ipratropium Bromide Neb Isosorbide Dinitrate Pantoprazole Prednisone Simethicone Sorbitol Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: pneumonia non ST elevation myocardial infarction congestive heart failure, EF 15-20% COPD Secondary Diagnoses: Hypertension GERD Discharge Condition: expired Discharge Instructions: None. Followup Instructions: None Completed by:[2175-3-26]	[ "293.0", "410.71", "584.9", "491.21", "786.3", "518.81", "599.0", "403.90", "486", "416.8", "787.91", "428.0", "511.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6388, 6397	3188, 6004	267, 270	6590, 6600	1731, 3165	6654, 6690	1258, 1276		6359, 6365		6418, 6528		6030, 6336				6624, 6631						1291, 1712			6549, 6569																			193, 229								298, 1096															1118, 1152	1168, 1242
222	145,243	48541	Discharge summary	report	Admission Date: [2137-7-15] Discharge Date: [2137-7-18] Date of Birth: [2073-7-25] Sex: F Service: CCU CHIEF COMPLAINT: Left carotid stenosis. HISTORY OF PRESENT ILLNESS: This is a 63 year old female with coronary artery disease status post catheterization with stent of the mid left anterior descending on [2137-6-18], who presented on [2137-7-15], for elective carotid catheterization. In the past, the patient has had a series of flashing lights in her left and right eyes which were possibly attributed to carotid disease. A duplex of the carotids was obtained on [2137-5-29], which showed significant plaque of 80 to 99% in the left. A stenosis of 40 to 59% was identified in the right. The lesion in the left internal carotid artery was stented this morning. The final residual was 20% with normal flow. The patient did have some mid segment spasm of the internal carotid artery that improved with TNG through the sheath. The patient was neurologically intact throughout the case. She was admitted to the Coronary Care Unit for postoperative care. PAST MEDICAL HISTORY: 1. Coronary artery disease status post stent on [2137-6-18], of the mid left anterior descending. 2. Status post coronary artery bypass graft times four in [2118]. 3. Status post myocardial infarction times three in [2106], [2109] and [2118]. 4. Hypertension. 5. Hypercholesterolemia. 6. Diverticulosis status post gastrointestinal bleed. 7. Carpal tunnel syndrome. 8. Trochanteric bursitis. 9. Status post cholecystectomy. ALLERGIES: No known drug allergies. HOME MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Metoprolol 15 mg p.o. q. day. 3. Atorvastatin 10 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day. 5. Multivitamin. 6. Folic acid. FAMILY HISTORY: Early coronary artery disease. PHYSICAL EXAMINATION: Blood pressure 110 to 120 over 50 to 53; heart rate 45 to 50; saturation 99% on room air. In general, alert and oriented in no acute distress. Cardiac: Regular rate and rhythm, normal S1, S2. No murmurs, rubs or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, positive bowel sounds. Groin: Right groin site without hematoma or bruit. Extremities with no cyanosis, clubbing or edema. One plus dorsalis pedis pulses bilaterally. Neurological: Pupils are equal, round and reactive to light, 3 millimeters to 2 millimeters. Extraocular movements intact without nystagmus. Symmetric but normal sensation in all three branches of the trigeminal nerve. Tongue: Midline, clear phonation, elevation of palate is symmetrical. LABORATORY: On admission, white blood cell count 7.9, hemoglobin 11.2, hematocrit 31.6, MCV 87, MCH 30.9, MCHC 35.5, platelets 177. Sodium 139, potassium 3.3, chloride 103, bicarbonate 29, BUN 16, creatinine 0.7. SUMMARY OF HOSPITAL COURSE: 1. Status post left internal carotid catheterization. The patient was neurologically intact and doing well following the procedure. All blood pressure medications were held with a target blood pressure goal of 120 to 170. The patient required a Neo-synephrine drip to maintain her blood pressure near 120. On the evening of [2137-7-15], and during the day on [2137-7-16], multiple attempts were made to wean the patient off the Neo-synephrine drip. When this was done, her systolic blood pressures would drop to around 100. She was also given multiple boluses of normal saline in an attempt to bring up her blood pressure. Throughout this time, the patient was asymptomatic without dizziness or lightheadedness. She was up in a chair and walking around her hospital room. The Neo-synephrine was successfully weaned off at 01:00 a.m. on [2137-7-17]. The patient's blood pressure once weaned off the drip remained between 110 and 115. The patient was continued on aspirin and Plavix throughout the admission. 2. Possible sleep apnea: When asleep, the patient has episodes when she pauses in her breathing and her saturations drop. Saturations return immediately when she takes a deep breath and resumes her normal breathing pattern. Will have her follow-up for this with her primary care physician. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Status post left internal carotid artery catheterization. 2. Coronary artery disease status post stent on [2137-6-18], and mid left anterior descending. 3. Status post coronary artery bypass graft times four vessels in [2118]. 4. Status post myocardial infarction times three. 5. Hypertension. 6. Hypercholesterolemia. 7. Diverticulitis status post gastrointestinal bleed. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [First Name (STitle) ] on [2137-7-19], for a blood pressure check. 2. Dr. [First Name (STitle) ], on [2137-9-10], at 04:00 o'clock. 3. Vascular study at the CC Clinical Center for Radiology on [2137-9-10], at 03:00 o'clock. 4. Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 1250], on [2137-7-29], at 04:00 o'clock. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 5211] Dictated By:[Name8 (MD) 315] MEDQUIST36 D: [2137-7-17] 16:04 T: [2137-7-18] 22:16 JOB#: [Job Number 102139]	[ "401.9", "412", "458.2", "414.01", "V17.3", "433.10", "272.0", "V45.82", "780.57" ]	icd9cm	[ [ [] ] ]	[ "39.90", "39.50" ]	icd9pcs	[ [ [] ] ]							1826, 1858	4341, 4733	4756, 4819								4843, 5513											1641, 1808							2901, 4228	1882, 2873									151, 175								205, 1108															1130, 1623		4254, 4320
14,245	101,072	7991	Discharge summary	report	Admission Date: [2147-6-28] Discharge Date: [2147-7-14] Date of Birth: [2068-2-6] Sex: M Service: MEDICINE Allergies: Ambien Attending:[First Name3 (LF) 2698] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: Angiography of lower limbs History of Present Illness: Mr. [Known lastname 28624] is a 79 year old male with past medical history of congestive heart failure, coronary artery disease, COPD, and diabetes mellitus who was transferred to [Hospital1 18] for further management after being found to have hyperkalemia, worsening renal function, and hypotension. . He presented to [Hospital6 17032] today after being referred there when routine laboratory draw revealed abnormalities. His potassium was found to be 6.1, and creatinine 4.7. Blood pressure there was noted to be 83/42. He was given an albuterol nebulizer, 1 amp of calcium gluconate, 10 units of regular insulin, 1 amp of D50, and 30 mg of kayexalate, as well as 500 cc of normal saline. . In the ED here at [Hospital1 18], initial vital signs were: blood pressure of 91/54, heart rate of 76, respiratory rate of 22, and oxygen saturation of 90%. A right femoral central line was placed for initiation of pressors, and he was started on neo. He was given 1 gram of vancomycin and 4.5 grams of zosyn for possible urinary tract infection. He received 1 gram of calcium gluconate, 1 amp of D5, and 10 units of regular insulin as well for hyperkalemia. Renal and cardiology were consulted. . On the floor, he reports he has to move his bowels, but otherwise denies any shortness of breath or other complaints. Of note, has highly variable BP readings depending on position, alternating in rapid sequence from 70-110's systolic. . Of note, he was recently admitted to [Hospital1 18] cardiology service from [2147-6-10] until [2147-6-16] after being transferred from [Hospital6 27369]. At that time, he had acute on chronic renal insufficiency, as well as hypotension. He was diuresed with a lasix drip, which was switched to torsemide. EP also followed the patient, and his ICD was re-programmed to allow for native conduction, with consideration of up-grade to [Hospital1 ]-ventricular pacer in future, as this was deferred given improvement in his symptoms with diuresis. His blood pressure was noted to be 70-100 systolic during that admission with normal mentation. Elevated creatinine was felt to be secondary to poor forward flow, and LFT elevations secondary to congestion. . He states that since his admission, he has been at rehabilitation. He reports he gained about 10 pounds since discharge, though he's not sure how. On [2147-6-28] he presented to [Hospital6 17032] for hyperkalemia, worsening renal function, and hypotension. Past Medical History: 1. CARDIAC RISK FACTORS: -Coronary Artery Disease (s/p MI x2) -Diabetes (Type 2 insulin-dependant) -Dyslipidemia -Hypertension 2. CARDIAC HISTORY: -CABG: -s/p CABG in [2139] (LIMA->diag, SVG->OM1, SVG->LAD) -PERCUTANEOUS CORONARY INTERVENTIONS: -s/p prior LAD stent and PTCA of diag -s/p [Year (4 digits) ] to RCA in [2146] -PPM/ICD: - Ischemic cardiomyopathy, s/p ICD implantation [2141-7-14] - PPM (unclear when placed) -OTHER CARDIAC HISTORY: - Paroxysmal atrial fibrillation - Nonsustained ventricular tachycardia - Chronic systolic CHF [2-14] ischemic cardiomyopathy(last EF 20%) - Mitral regurgitation - Pulmonary Hypertension 3. OTHER PAST MEDICAL HISTORY: -Chronic Obstructive Pulmonary Disease on 3L home O2 since [2146] -Chronic Renal Insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -Severe Peripheral Vascular Disease, s/p left fem-[Doctor Last Name ] bypass [2137] -Obstructive sleep apnea intolerant to CPAP -GERD -Anxiety -Depression -Post Traumatic Stress Disorder Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [Hospital ] [Hospital6 28623]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: Afebrile, BP 116/53, HR 91, RR 28, Oxygen saturation 98% on 3L General: Male resting in bed, intermittently trying to sit up, then asleep, appearing mildly distressed HEENT: NC/AT, PERRL, EOMI, slightly dry MM Neck: Supple, JVP elevated to ear Lungs: Decreased BS over bases, right > left, no wheezes or rales Cardiac: Irregularly irregular, though regular at times Abd: Soft, NT, ND, +BS Extr: Pitting edema bilaterally, improved from prior, eschar over right heel and right lateral foot below metatarsal. Skin: Fragile skin tears Neuro: Awake, though unable to assess if oriented to place--oriented to self, speech slightly dysarthritic at times, poor attention Able to follow some commands. Occasional myoclonic shaking when awakening. Psych: Agitated. Pertinent Results: Admission Labs: [2147-6-28] 03:30PM BLOOD WBC-10.4 RBC-4.28* Hgb-13.0* Hct-40.8 MCV-95 MCH-30.3 MCHC-31.7 RDW-17.2* Plt Ct-244 [2147-6-28] 03:30PM BLOOD Neuts-79.3* Lymphs-9.6* Monos-9.4 Eos-1.2 Baso-0.5 [2147-6-28] 05:18PM BLOOD PT-25.7* PTT-33.0 INR(PT)-2.5* [2147-6-28] 03:30PM BLOOD Glucose-204* UreaN-77* Creat-4.4# Na-130 K-5.9* Cl-92* HCO3-21* AnGap-23* [2147-6-28] 09:00PM BLOOD ALT-120* AST-250* LD(LDH)-353* CK(CPK)-127 AlkPhos-58 TotBili-1.1 [2147-6-28] 09:00PM BLOOD Albumin-3.6 Calcium-8.6 Phos-7.0# Mg-2.8 Cardiac Biomarkers: [2147-6-28] 03:30PM BLOOD cTropnT-0.07* [2147-6-28] 09:00PM BLOOD CK-MB-9 cTropnT-0.08* [2147-6-29] 04:12AM BLOOD CK-MB-8 cTropnT-0.09* [2147-7-5] 03:14AM BLOOD CK-MB-4 cTropnT-0.05* [2147-6-28] 03:30PM BLOOD proBNP-7763* U/A [2147-6-28] 03:48PM URINE Color-Amber Appear-Hazy Sp [Last Name (un) ]-1.016 [2147-6-28] 03:48PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.5 Leuks-SM [2147-6-28] 03:48PM URINE RBC-[12-2]* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0 [2147-6-28] 03:48PM URINE CastGr-0-2 CastHy-[6-22]* BCx negati x 2 Recent Labs prior to discharge: [2147-7-10] 02:16PM BLOOD WBC-8.9 RBC-4.37* Hgb-12.9* Hct-39.1* MCV-90 MCH-29.5 MCHC-32.9 RDW-16.1* Plt Ct-263 [2147-7-11] 06:14AM BLOOD WBC-9.6 RBC-4.37* Hgb-12.4* Hct-38.4* MCV-88 MCH-28.5 MCHC-32.4 RDW-16.3* Plt Ct-264 [2147-7-12] 05:48AM BLOOD WBC-10.1 RBC-4.30* Hgb-12.5* Hct-37.8* MCV-88 MCH-29.0 MCHC-33.0 RDW-16.1* Plt Ct-246 [2147-7-13] 09:21AM BLOOD WBC-9.5 RBC-4.53* Hgb-12.8* Hct-39.5* MCV-87 MCH-28.3 MCHC-32.4 RDW-16.3* Plt Ct-263 [2147-7-13] 02:43PM BLOOD WBC-9.5 RBC-4.56* Hgb-13.3* Hct-40.0 MCV-88 MCH-29.1 MCHC-33.2 RDW-16.0* Plt Ct-231 [2147-7-14] 05:43AM BLOOD WBC-10.2 RBC-4.48* Hgb-13.2* Hct-39.5* MCV-88 MCH-29.3 MCHC-33.3 RDW-16.2* Plt Ct-242 [2147-7-5] 03:14AM BLOOD Neuts-74.0* Lymphs-13.7* Monos-10.1 Eos-1.9 Baso-0.3 [2147-7-12] 05:48AM BLOOD Neuts-77.3* Lymphs-11.0* Monos-9.4 Eos-1.7 Baso-0.7 [2147-7-13] 09:21AM BLOOD PT-26.5* PTT-33.6 INR(PT)-2.6* [2147-7-13] 09:21AM BLOOD Plt Ct-263 [2147-7-13] 02:43PM BLOOD PT-25.3* PTT-31.0 INR(PT)-2.4* [2147-7-13] 02:43PM BLOOD Plt Ct-231 [2147-7-14] 05:43AM BLOOD PT-27.3* PTT-31.4 INR(PT)-2.7* [2147-7-14] 05:43AM BLOOD Plt Ct-242 [2147-7-8] 02:34PM BLOOD Glucose-196* UreaN-36* Creat-1.7* Na-136 K-4.3 Cl-97 HCO3-29 AnGap-14 [2147-7-9] 05:52AM BLOOD Glucose-101* UreaN-35* Creat-1.7* Na-137 K-3.9 Cl-98 HCO3-31 AnGap-12 [2147-7-9] 02:58PM BLOOD Glucose-246* UreaN-35* Creat-1.7* Na-137 K-4.0 Cl-97 HCO3-29 AnGap-15 [2147-7-10] 02:45AM BLOOD Glucose-142* UreaN-34* Creat-1.8* Na-138 K-3.7 Cl-98 HCO3-32 AnGap-12 [2147-7-10] 02:16PM BLOOD Glucose-171* UreaN-32* Creat-1.6* Na-135 K-4.7 Cl-96 HCO3-33* AnGap-11 [2147-7-11] 06:14AM BLOOD Glucose-150* UreaN-31* Creat-1.8* Na-136 K-3.8 Cl-94* HCO3-34* AnGap-12 [2147-7-12] 05:48AM BLOOD Glucose-103* UreaN-29* Creat-1.9* Na-137 K-4.0 Cl-93* HCO3-33* AnGap-15 [2147-7-12] 02:44PM BLOOD Glucose-250* UreaN-33* Creat-1.9* Na-134 K-3.6 Cl-90* HCO3-34* AnGap-14 [2147-7-13] 09:21AM BLOOD Glucose-164* UreaN-30* Creat-1.8* Na-135 K-3.9 Cl-89* HCO3-37* AnGap-13 [2147-7-13] 02:43PM BLOOD Glucose-195* UreaN-30* Creat-1.9* Na-132* K-3.3 Cl-86* HCO3-37* AnGap-12 [2147-7-14] 05:43AM BLOOD Glucose-198* UreaN-32* Creat-1.9* Na-136 K-2.9* Cl-86* HCO3-38* AnGap-15 [2147-7-11] 06:14AM BLOOD ALT-22 AST-23 AlkPhos-46 TotBili-1.2 [2147-7-5] 03:14AM BLOOD CK-MB-4 cTropnT-0.05* [2147-7-14] 05:43AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9 ART DUP EXT LO UNI;F/U LEFT Preliminary report only. Chest Xray [7-5]: IMPRESSION: AP chest compared to [7-4]. Lateral aspect right lower chest is excluded from the examination. New hazy opacification at the right lung base could be due to either recent aspiration or developing asymmetric edema. Moderate cardiomegaly and mediastinal vascular engorgement have both increased. Small left pleural effusion is unchanged. Right PICC line ends in the SVC and a transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard placements, unchanged. No pneumothorax. Cardiology Report ECG Study Date of [2147-7-5] 12:19:20 AM Atrial paced rhythm with intrinsic A-V conduction, frequent ventricular ectopy and fusion beat. Compared to the previous tracing of [2147-6-29] there is frequent ventricular ectopy. Otherwise, no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 0 132 418/453 0 -29 139 URINE CULTURE (Final [2147-7-9]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| GENTAMICIN------------ 8 I <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN------------- =>4 R <=0.25 S TETRACYCLINE---------- =>16 R 2 S VANCOMYCIN------------ 2 S 1 S Brief Hospital Course: He was transferred to [Hospital1 18] ED where he was triaged as septic, given neosynephrine, vancomycin, zosyn, and treated for hyperkalemia. . In MICU, he was diuresed on lasix drip and noted to have baseline SBPs 70s-80s in acute on chronic systolic congestive heart failure with EF 20%. With diuresis he was able to maintain SBPs off pressors in 80s and his renal function improved. His infectious work-up was negative. He was transferred to cardiology floor on a lasix drip for diuresis. Overnight [Date range (1) 28625], he was reported to be agitated and intermittently hypoxic to 80s after which he would awaken and be startled. He was transferred to the MICU for higher level of nursing care. Assessment there suggested multiple factors including adverse reaction to sleep aide (ambien), high dose ciprofloxacin (for empiric UTI treatment), haldol and hypoxia in setting of known sleep apnea not on BiPAP. With observation and cessation of medications the patient's mental status improved to baseline and he was no longer hypoxic. Ambien was felt to be the primary cause and should not be given again; avoid in the future. . He was seen by vascular surgery and podiatry for his severe peripheral vascular disease and chronic ulcers. No current inpatient managment was felt necessary at that time given CHF exacerbation. However, during agressive diuresis of the patient, Mr. [Known lastname 28624] developed cellulitis of his right lower limb. Due to the edema and poor blood supply to the legs given his vascular disease, the pt developed an infection of the skin and healing ulcers on his feet. He was given broad spectrum IV antibiotics to treat the infection (vancomycin, cipro and flagyl x7days). . In addition, given the development of infection, vascular surgery performed an angiography in an attempt to improve blood flow to in order to facility abx treatment. The legs showed significant blockages which require correction; however, vascular surgery was not able to perform any stenting due to patient movement. Thus, vascular surgery arranged to use general anesthesia for the procudure balloon or stenting of the leg blood vessels; tentatively vascular surgery will perform this on [7-18]. . Although there was as strong preference by all care providers involved that the patient remain at [Hospital1 18] while completing IV antibiotics and awaiting surgery, the patient was adament that he be moved closer to home to [Location (un) 25576] to complete IV antibiotics until the time of the vascular intervention. Arrangements were made and the pt was transferred to [Location (un) 28626]. . PLEASE NOTE THAT AMBIEN HAS BEEN ADDED TO PT'S LIST OF ALLERGIES. Medications on Admission: - Albuterol nebulizer Q2 hours PRN - Amiodarone 100 mg daily - Ascorbic acid 500 mg daily - Aspirin 325 mg - Fenofibrate 145 mg QHS - Fluticasone/Salmeterol 250/50 [Hospital1 ] - Laisx daily--? dose - Humalog mix 50/50 - Levothyroxine 25 mcg - Metoprolol Succinate 25 mg + 50 mg daily - Multiple vitamin - Polyethylene glycol daily - Ranitidine 150 mg daily - Senna [Hospital1 ] - Simvastatin 10 mg - Bactrim DS [Hospital1 ] - Tramadol 50 mg Q8H - Trazodone 50 mg QHS - Valsartan 40 mg daily - Velafaxine ER 75 mg QHS Of note, discharge summary from [2147-6-16] as the following medications listed differently: - Venlafaxine 75 mg--1.5 tablets daily - Torsemide 100 mg daily - Metoprolol Succinate 50 mg daily - Warfarin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze, shortness of breath. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 9. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 4 days: Pt should complete 7 day course to end on [7-18]. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 18. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous ASDIR: See attached sheet. 19. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: Six (6) unit Subcutaneous ASDIR: See attached sheet. 20. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 22. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 23. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 26. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 27. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 28. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 29. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 30. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Congestive Heart Failure Acute renal failure Secondary Diagnosis: Hyperkalemia (high potassium, electrolyte imbalance) Coronary artery disease COPD diabetes mellitus 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 because you had gained 10 pounds and were experiencing with difficult breathing and substantially increased swelling of you lower legs. You were found to have dnagerous electrolyte imbalances, worsening kidney function and very low blood pressure. This was an exacerbation of your chronic heart failure and there was concern for infection. . While in the hospital, your symptoms worsened and you were transferred to the ICU and received antibiotics. Although there was concern for infection, tests were negative. After further investigation it was felt that Ambien (a medication you received) caused significant unexpected adverse side effects in you. We recommend that you never take Ambien again and have listed it as a medication [Location (un) ] in your record. Please be sure to alert you PCP and other doctors of this [Name5 (PTitle) ]. . To treat your heart failure you received medications to remove excess fluid that had accumlated in your body. With the removal of this fluid your symptoms improved. However, due to the edema and poor blood supply to your legs due to vascular disease, you developed an infection of the skin and healing ulcers on your feet. You were given IV antibiotics to treat this infection. You responded well but require continued treatment of the infection with IV antibiotics. . In addition, vascular surgery performed an angiography and other tests of you blood vessels in you legs which showed significant blockages which require correction; if these are not corrected you risk continued life threatening infections of the legs and ampulation. Correction of these blockages was attempted while you were here but was not success in the setting of only partial sedation during the procedure. Thus, vascular surgery will be arranging to use general anesthesia (complete sedation) for the procudure to open the leg blood vessels; you have an appointment with vascular surgery on [7-18] to further address this issue. . Given your strong preference to be closer to your family, you were transferred to an outside care facility ([Location (un) 25576]) once you stablized in order to continue the removal of the remaining fluid you had accumulated and the complete your course of IV antibiotics for the treatment for your infection. . The following changes were made you your medications: - Please CONTINUE taking Furosemide 160mg PO twice daily. - Please CONTINUE taking Metolazone 5mg daily. - Please CONTINUE taking Vancomycin 1000 mg IV Q 24H - Please CONTINUE taking MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q8H - Please CONTINUE taking Ciprofloxacin HCl 500 mg PO/NG Q12H - Please continue to take all of your other home medications as prescribed. . Please be sure to take all medication as prescribed. . Please be sure to weigh yourself daily and record your weight. If you have more than a 3lb increase in your weight, please call you doctor immediately. . Please be sure to keep all follow-up appointments with your PCP and heart doctor. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP and heart doctor. Department: CARDIAC SERVICES When: THURSDAY [2147-7-20] at 9:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . With: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391] Department: Vascular Surgery When: Tuesday [2147-7-18] 10:00AM Location: [Last Name (NamePattern1) 439] [Hospital Unit Name ] [Location (un) ] Suite C, [Location (un) 86] [Numeric Identifier 718] Phone: [Telephone/Fax (1) 1393] Completed by:[2147-7-16**]	[ "250.00", "427.31", "403.90", "530.81", "416.8", "424.0", "414.01", "496", "293.0", "276.1", "707.15", "272.4", "799.02", "309.81", "041.19", "414.8", "V58.67", "440.23", "300.4", "V45.82", "412", "599.0", "790.6", "428.0", "276.7", "V45.81", "585.9", "E937.8", "V45.02", "327.23", "682.7", "584.9", "428.23" ]	icd9cm	[ [ [] ] ]	[ "88.48", "89.49", "88.42", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	16998, 17084	10759, 13465	286, 315	17314, 17314	5048, 5048	20610, 21373	4189, 4257		14255, 16975		17105, 17105		13491, 14232				17497, 20587						4272, 5029				2999, 3526																		227, 248								343, 2826			17191, 17293			5064, 10736	17124, 17170			17329, 17473	3557, 3912				2848, 2979	3928, 4173
16,573	184,418	51955	Discharge summary	report	Admission Date: [2164-9-1] Discharge Date: [2164-9-12] Service: SURGERY Allergies: Codeine / Erythromycin Base / Amoxicillin / Sulfur Attending:[First Name3 (LF) 301] Chief Complaint: acute GI bleeding Major Surgical or Invasive Procedure: subtotal gastrectomy with retrocolic Billroth 2 gastrojejunostomy, [2164-9-2]. History of Present Illness: 83yo female with low-grade lymphone on rituxan felt diaphoretic and weak on the the day prior to presentation, followed by a bloody bowel movement. She presented to an outside hospital with an initial hematocrit of 28 (baseline 40), hypotensive. A femoral central line was placed, transfused two units packed cells, an NGT placed yielded maroon-colored material, and transferred to [Hospital1 18] for further management. Of note, she relates upper abdominal / epigastric pain of 2 weeks duration managed with over-the-counter maalox and rolaids. Past Medical History: CAD s/p CABG [2156] CHF (EF 30% [2158]) AFib HTN lymphoproliferative d/o hemolytic anemia on prednisone CRI depression gout Social History: lives alone, multiple children and close family members. Physical Exam: on arrival: T 97.0, P 86, BP 145/86, RR 20 on surgical consult: T 96.3, P 98, BP 104/32, RR 29, 100% on levophed .033mg/kg/h arousable, alert, ashen anicteric CTAB irreg irreg soft, NT, no r/g cool extremities rectal exam: BRBPR Pertinent Results: [2164-9-1] 02:30AM BLOOD WBC-9.4 RBC-3.37* Hgb-10.4* Hct-31.0* MCV-92 MCH-30.8 MCHC-33.5 RDW-17.0* Plt Ct-91* [2164-9-1] 06:18AM BLOOD WBC-6.5 RBC-2.85* Hgb-8.9* Hct-25.9* MCV-91 MCH-31.3 MCHC-34.5 RDW-17.1* Plt Ct-87* [2164-9-1] 01:22PM BLOOD Hct-19.6* [2164-9-1] 02:30PM BLOOD WBC-10.3# RBC-3.21* Hgb-9.9* Hct-28.5# MCV-89 MCH-30.9 MCHC-34.9 RDW-15.3 Plt Ct-57 [2164-9-1] 05:41PM BLOOD Hct-31.5* [2164-9-1] 11:16PM BLOOD Hct-29.3* [2164-9-2] 05:49AM BLOOD Hct-23.0* [2164-9-2] 05:23PM BLOOD WBC-6.7 RBC-3.59* Hgb-11.1* Hct-30.1# MCV-84 MCH-31.0 MCHC-37.0 RDW-16.1* Plt Ct-73* [2164-9-4] 03:07AM BLOOD WBC-7.7 RBC-3.17* Hgb-9.9* Hct-27.4* MCV-86 MCH-31.1 MCHC-36.0* RDW-16.3* Plt Ct-83* [2164-9-5] 06:03AM BLOOD WBC-6.8 RBC-2.90* Hgb-8.7* Hct-25.9* MCV-90 MCH-30.1 MCHC-33.6 RDW-16.4* Plt Ct-95* [2164-9-5] 08:42AM BLOOD Hct-24.6* [2164-9-6] 03:34AM BLOOD Hct-30.0* [2164-9-9] 05:30AM BLOOD WBC-5.9 RBC-3.38* Hgb-10.4* Hct-30.2* MCV-89 MCH-30.8 MCHC-34.5 RDW-16.3* Plt Ct-166 [2164-9-1] 02:30AM BLOOD PT-16.1* PTT-24.0 INR(PT)-1.8 [2164-9-1] 02:30AM BLOOD Plt Ct-91* [2164-9-1] 02:30PM BLOOD PT-18.8* PTT-36.2* INR(PT)-2.5 [2164-9-2] 02:59AM BLOOD PT-14.5* PTT-30.3 INR(PT)-1.4 [2164-9-2] 02:12PM BLOOD PT-13.6* PTT-27.2 INR(PT)-1.2 [2164-9-12] 04:52AM BLOOD PT-13.5* INR(PT)-1.2 [2164-9-1] 02:30PM BLOOD Fibrino-110* [2164-9-2] 02:59AM BLOOD Fibrino-255# [2164-9-2] 02:12PM BLOOD Fibrino-337 [2164-9-1] 02:30AM BLOOD Glucose-331* UreaN-107* Creat-1.7* Na-136 K-5.1 Cl-98 HCO3-26 AnGap-17 [2164-9-2] 05:23PM BLOOD Glucose-171* UreaN-65* Creat-1.1 Na-143 K-3.9 Cl-112* HCO3-23 AnGap-12 [2164-9-9] 05:30AM BLOOD Glucose-84 UreaN-25* Creat-1.0 Na-139 K-3.9 Cl-99 HCO3-31 AnGap-13 [2164-9-11] 04:31AM BLOOD UreaN-24* Creat-0.9 K-2.9* [2164-9-12] 04:52AM BLOOD K-3.9 [2164-9-1] 06:18AM BLOOD ALT-17 AST-13 LD(LDH)-204 CK(CPK)-34 AlkPhos-48 Amylase-36 TotBili-1.0 [2164-9-1] 06:18AM BLOOD Lipase-20 [2164-9-1] 06:18AM BLOOD CK-MB-4 cTropnT-<0.01 [2164-9-1] 06:18AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9 Brief Hospital Course: 83yo F initially admitted to the [Hospital Unit Name 153] under the medical service for presumtpive upper GI bleed. She was transfused with serial Hcts, received IVF resuscitation, and still required ionotropic support. GI and surgical consults was immediately obtained; a cordis line was placed and she was electively intubated. An EGD found a large bleeding ulcer at the gastric incisura which was injected and electrocautery applied; please see EGD report for details. A protonix drip was begun and the hemodynamics initially improved with no new bleeding noted. Serial Hcts however resumed downtrending the next morning. After receiving since admission in 24 hours a total of 9units of PRBCs, 5units of FFP with successful normalization of INR, 1unit platelets and 1unit cryoprecipitate, she was therefore taken to the OR for resection of the bleeding ulcer; please see operative report for details. A subtotal gastrectomy was performed on [9-2] with a Billroth 2 anastamosis. POst-operatively, the patient was brought to the SICU in intubated condition with stable hemodynamics. Serial Hcts were stable, pressor support was unnecessary, and she was easily extubated. She was begun on lopressor for atrial fibrillation rate control and her home dose of digoxin. The cordis was changed to a triple-lumen and the femoral line removed. The patient was transferred to the floor on POD 2 and begun on stage 1 post-gastrectomy diet with was tolerated and advanced sequentially. PT began to see the patient. The Hct slowly downtrended over the next two days with stable hemodynamics and asymptomatic anemia, likely either dilutional from mobilizing fluid or related to her pre-admission hemolytic anemia. She was seen earlier in the admission by Heme/Onc and was now transfused 2unit PRBCs with lasix. Cardiology was consulted for fluid management given her cardiac history. On POD 4 she developed respiratory distress and tachycardia due to pulmonary edema; pulmonary embolus was ruled out with a Chest CT angiogram. Cardiology was re-consulted and she was brought to the SICU for closer observation. Aggressive diuresis with lasix commenced and she improved without requiring intubation. An echocardiogram was performed showing worsening mitral regurgitation and pulmonary hypertension without wall motion abnormalities. Cardiac enzymes were negative. A diltiazem drip was begun for rate control and was later transitioned to POs. After successful diuresis and rate control, she was returned to the floor on POD 7. Lasix was returned to her home dose, good rate control with diltiazem and digoxin, and PT was re-consulted to mobilize the patient. Post-gastrectomy diet was resumed and advanced and tolerated. The mid-portion of the wound began draining dark serosanguinous fluid and was opened, cultured, and packed with wet-to-dry gauze; kefzol begun. Erythema was minimal and resolved quickly, the wound base was clean and non-purulent, and kefzol discontinued. Her affect was blunted but improved with family visits and better mobility from PT. Hypokalemia was repleted and checked, the central line was removed and PIV placed, and coumadin begun. Upon discharge she was afebrile, tolerating a post-gastrectomy heart-healthy diet, with stable hematocrit, controlled AFib, and a clean wound. Medications on Admission: lasix 40', coumadin 2.5', carvedilol 12.5", digoxin, colchicine, prednisone 40', protonix, insulin, rituxan Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: qs units Injection ASDIR (AS DIRECTED): according to included sliding scale. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO BID (2 times a day). 9. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Hospital ] Nursing Home - [Location (un) 5087] Discharge Diagnosis: gastric ulcer Atrial fibrillation congestive heart failure/pulmonary edema hemolytic anemia gout arthritis depression Discharge Condition: stable Discharge Instructions: [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) ], chills; nausea, vomiting, abdominal pain, or inability to tolerate diet; of in incision develops redness, swelling, or drains pus. Post-gastrectomy diet (soft solids) as tolerated. Continue with wound care to incisional wound. Continue medications as directed. Follow-up with primary care physician for any adjustments to outpatient regimens. Have your INR checked daily and coumadin dosage adjusted accordingly Followup Instructions: Follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], surgeon, in [11-27] weeks. Call [Telephone/Fax (1) 2723] for an appointment. Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], hematology, upon discharge. Call [Telephone/Fax (1) 3237] for an appointment. Follow-up with your outpatient primary care physician and cardiologist upon discharge.	[ "274.9", "427.31", "998.59", "V45.81", "428.0", "414.00", "531.40", "287.5", "285.9", "518.5" ]	icd9cm	[ [ [] ] ]	[ "96.71", "43.7", "38.93", "43.41" ]	icd9pcs	[ [ [] ] ]	7952, 8068	3585, 6930	273, 358	8230, 8239	1433, 3557	8775, 9205			7088, 7929		8089, 8209		6956, 7065				8263, 8752						1184, 1414																						216, 235								386, 939															961, 1095	1111, 1169
7,715	162,032	47059+47060	Discharge summary	report+report	Admission Date: [2176-6-25] Discharge Date: [2176-7-2] Date of Birth: [2121-6-21] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Tetracycline / Darvon Attending:[First Name3 (LF) 1055] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in [10/2174], FVL def and Prot S deficiency on coumadin, presented to an OSH with N/V/coffee ground emesis x1 week, and melena x 3 days. She states that she has been feeling progressively weaker over the past 2 weeks, and developed nausea with coffee ground emesis intermittantly over the past week. She also states that she had black, tarry stools for the past 3 days. She does not know how many BMs she is having per day; last melenic stool was 9am this morning. She was taken to an OSH for further w/u this AM. . At the OSH, her HR was in the 130s with BP in the 80s; initial hct 31 --> 24.6, intial INR 10. Pt received 10mg IM Vit K, PPI, 2u FFP, and 1u pRBC. An NG tube at the OSH showed coffee ground emesis, and she was placed on Protonix gtt and taken to their GI suite where an an EGD performed that saw copious blood in stomach on EGD, ? duodenal angioma, ? duodenal bleeding, although no definitive source found. At that time, due to her coagulopathy, no intervention was performed. Pt was transferred to to [Hospital1 18] post-EGD where she received a 2nd unit of pRBC en route. . In our ED, T98.1, HR 130s, BP130/70 - received 2L NS. Hct here 26.6, INR 2.7. She was admitted to the [Hospital Unit Name 153] for monitoring and transfused an additional pRBC with goal hct >28 given h/o CAD; no active ischemia at this time. Pt had 2 large bore IV's in place at all times and was placed on IV PPI [Hospital1 ]. Her ASA, Plavix and coumadin were held. GI was consulted and on HD#2 due to ongoing melena, with an INR of 5.8, she was transfused 3u FFP prior to having an additional EGD which was unremarkable for any ulcer or bleeding diathesis. Her hct remained stable over the next day, with no further episodes of melena. Her diet was advanced as tolerated. Currently she is s/p 6UPRBCs in total with a stable HCt for >48 hours. Past Medical History: h/o GIB likely from duodenal AVMs as seen on prior capsule endoscopy Multiple Sclerosis IBS with frequent constipation CAD (MI in [2174]), s/p LAD stent [10/2174] +Factor V Leiden (requiring coumadin) Protein S deficiency h/o DVT/PE PTSD L knee arthroscopy Degenerative disc disease treated with steroid injections Asthma Chronic pelvic pain d/t post-herpetic neuralgia Social History: Lives alone, not currently working, on disability. [1-22] ppd tobacco since age 17, past heavy ETOH use, quit 15 years ago. Family History: breast and lung ca Physical Exam: On admission: VS: T98.4 HR85 BP124/65 RR16 o2sat: 100% RA GEN: Thin woman, in NAD. HEENT: Anicteric sclera. PERRL. NECK: No elevated JVP. CV: Regular, nml s1,s2. No murmurs. RESP: CTAB. No c/w/r. ABD: Soft, ND. +BS. Mild epigastric pain EXT: No edema bilat. NEURO: AAOx3. Moves all ext RECTAL: No masses. Melenic stool in the vault, grossly guiaic positive. Transfer to floor: VS: Pertinent Results: EKG: NSR, 95. Nml axis, nml intervals. LAA. <1mm depression in V4-V6, no prior to compare. No Q waves. Brief Hospital Course: Impression: 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in [10/2174], FVL def and Prot S deficiency on coumadin, presented to an OSH with melena and found to have an INR of 10. . Plan: # Melena/Coffee ground emesis Pt with melena and 14 point drop in hct in the context of an INR of 10. Likely UGI source given melena and coagulopathy and previous h/o duodenal AVMs seen on prior capsule endoscopy at OSH. Pt is s/p FFP, Vit K at OSH, INR 2.7 at time of admission. She was admitted to the [Hospital Unit Name 153] for monitoring and transfused an additional pRBC with goal hct >28 given h/o CAD; no active ischemia at this time. Pt had 2 large bore IV's in place at all times and was placed on IV PPI [Hospital1 ]. Her ASA, Plavix and coumadin were held. GI was consulted and on HD#2 due to ongoing melena, with an INR of 5.8, she was transfused 3u FFP prior to having an additional EGD which was unremarkable for any ulcer or bleeding diathesis. Her hct remained stable over the next day, with no further episodes of melena. Her diet was advanced as tolerated. HCT remained stable and she had no episodes of melena or hemetemesis while inpatient. She was maintained on PPI [Hospital1 ]. . # Coagulopathy Pt with a reported INR of 10 at OSH, unclear etiology, but likely due to decreased PO intake over the past 2 weeks with poor follow up of INR levels. She received Vit K at the OSH, and received 1mg Vit K IV as well as 3u FFP as above. Her INR decreased to 1.8. Her OSH hematologist was contact[Name (NI) ] regarding to restarting her anticoagulation in the setting of her GIB, given her hypercoagulable state of +factor V leiden and protein S deficiency. Coumadin was resumed [2176-6-28] at 2mg/day, without lovenox bridge intitially. However, INR continued to fall from 1.8 and her coumadin was increased slowly to 5 mg PO QD and lovenox bridge was started on [2176-7-1]. Her INR will NEED TO BE FOLLOWED CLOSELY as an outpatient, with goal [2-23]. We would recommend holding the coumadin at 5mg and allowing the INR to increase slowly so as not to overshoot and precipitate a GI bleed. Plan to continue lovenox until INR therapeutic. . # hx of CAD s/p LAD stent (last ECHO nromal w. EF 55%. EKG only showed <1mm of ST depressions laterally; 2 sets of CE's were negative. Pt remained completely asymptomatic. Her hct was transfused as needed to maintain hct >28. Her ASA, plavix were held, and her cardiologist was contact[Name (NI) ] due to the fact that patient had been on Plavix >18 months post-stent placement. Her cardiologist (Dr. [First Name (STitle) ] [Name (STitle) 121], formerly at [Last Name (un) 4068]) agreed that Plavix was no longer needed, and to continue ASA once tolerating in regards to her GIB. Her bblocker was initially held and then restarted once her SBP was stable. ASA restarted on discharge. . # Factor V Leiden & Protein S deficiencies Pt with a hypercoagulable state, currently on coumadin and Plavix for anticoagulation. Anticoagulation was initially held in the setting of active GI bleed. After discussion with her cardiologist, Plavix was discontniued indefinitely. Since she has a stent she does require a full dose aspirin which was re-started immediately before discharge, and after consultation with the hematology service, coumadin was restarted at a lower dose than previous. Given the amount of vitamin K she recived at the OSH, it is likely that it will be quite some time before patient is therapeutic and her INR should be watched very closely as an outpatient to allow for the appropriate dose adjustments. . # Chronic Pain: Patient has very complex pain issues and attends an outpatient pain management clinic. Continued topamax, ultram, lidoderm patch, vicodin prn. Nortriptiline was stopped and trazadone was increased to 500mg PO QHS and ambien continued at night. . # Mild asthma - cont albuterol . # Ativan PRN - Started on klonopin during this admission. She was on 0.5 TID, and dose was increased to 1mg [Hospital1 ]. Consider increasing this to 1mg TID as needed. . # PPx - On lovenox, PPI [Hospital1 ] . Medications on Admission: Protonix 40mg Plavix 75mg QHS ASA 325 Toprol 25mg Topamax 75 tid Nortryptiline 100 qhs Trazadone 300mg qhs Valtrex 1gm qD Ultram 100mg TID Lipitor 80 Vicodin [Hospital1 ] Soma 350 TID Coumadin (5 SMTWF, 6 ThSa) Miralax Albuterol prn Advair prn Boniva Lidoderm patch Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Topiramate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Trazodone 100 mg Tablet Sig: Five (5) Tablet PO HS (at bedtime). 5. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 14. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral [Hospital1 ] (2 times a day) as needed. 15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous twice a day. 21. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary: Gastrointestinal Bleed Elevated INR . Secondary h/o GIB likely from duodenal AVMs as seen on prior capsule endoscopy Multiple Sclerosis IBS with frequent constipation CAD (MI in [2174]), s/p LAD stent [10/2174] +Factor V Leiden (requiring coumadin) Protein S deficiency h/o DVT/PE PTSD L knee arthroscopy Degenerative disc disease treated with steroid injections Asthma Chronic pelvic pain d/t post-herpetic neuralgia Discharge Condition: Good. Patient able to sit in chair and ambulate. Hct stable without evidence of ongoing bleeding. Discharge Instructions: Please take all of your medications as prescribed. Please call your PCP or return to the ED if you have shortness of breath, chest pain, fevers, chills, nausea, vomiting, bright red blood per rectum, melena, or other symptoms that are of concern to you. Followup Instructions: Please call your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17103], at [Telephone/Fax (1) 3658] to schedule a follow up appointment 1-2 weeks after you are discharged from the rehabilitation facility. . Please schedule a follow up appointment with your neurologist, Dr. [Last Name (STitle) ], at your earliest convenience. She has been e-mailed and is aware of your recent admission. Admission Date: [2176-6-25] Discharge Date: [2176-7-2] Date of Birth: [2121-6-21] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Tetracycline / Darvon Attending:[First Name3 (LF) 1055] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in [10/2174], FVL def and Prot S deficiency on coumadin, presented to an OSH with N/V/coffee ground emesis x1 week, and melena x 3 days. She states that she has been feeling progressively weaker over the past 2 weeks, and developed nausea with coffee ground emesis intermittantly over the past week. She also states that she had black, tarry stools for the past 3 days. She does not know how many BMs she is having per day; last melenic stool was 9am this morning. She was taken to an OSH for further w/u this AM. . At the OSH, her HR was in the 130s with BP in the 80s; initial hct 31 --> 24.6, intial INR 10. Pt received 10mg IM Vit K, PPI, 2u FFP, and 1u pRBC. An NG tube at the OSH showed coffee ground emesis, and she was placed on Protonix gtt and taken to their GI suite where an an EGD performed that saw copious blood in stomach on EGD, ? duodenal angioma, ? duodenal bleeding, although no definitive source found. At that time, due to her coagulopathy, no intervention was performed. Pt was transferred to to [Hospital1 18] post-EGD where she received a 2nd unit of pRBC en route. . In our ED, T98.1, HR 130s, BP130/70 - received 2L NS. Hct here 26.6, INR 2.7. She was admitted to the [Hospital Unit Name 153] for monitoring and transfused an additional pRBC with goal hct >28 given h/o CAD; no active ischemia at this time. Pt had 2 large bore IV's in place at all times and was placed on IV PPI [Hospital1 ]. Her ASA, Plavix and coumadin were held. GI was consulted and on HD#2 due to ongoing melena, with an INR of 5.8, she was transfused 3u FFP prior to having an additional EGD which was unremarkable for any ulcer or bleeding diathesis. Her hct remained stable over the next day, with no further episodes of melena. Her diet was advanced as tolerated. Currently she is s/p 6UPRBCs in total with a stable HCt for >48 hours. Past Medical History: h/o GIB likely from duodenal AVMs as seen on prior capsule endoscopy Multiple Sclerosis IBS with frequent constipation CAD (MI in [2174]), s/p LAD stent [10/2174] +Factor V Leiden (requiring coumadin) Protein S deficiency h/o DVT/PE PTSD L knee arthroscopy Degenerative disc disease treated with steroid injections Asthma Chronic pelvic pain d/t post-herpetic neuralgia Social History: Lives alone, not currently working, on disability. [1-22] ppd tobacco since age 17, past heavy ETOH use, quit 15 years ago. Family History: breast and lung ca Physical Exam: On admission: VS: T98.4 HR85 BP124/65 RR16 o2sat: 100% RA GEN: Thin woman, in NAD. HEENT: Anicteric sclera. PERRL. NECK: No elevated JVP. CV: Regular, nml s1,s2. No murmurs. RESP: CTAB. No c/w/r. ABD: Soft, ND. +BS. Mild epigastric pain EXT: No edema bilat. NEURO: AAOx3. Moves all ext RECTAL: No masses. Melenic stool in the vault, grossly guiaic positive. Transfer to floor: VS: Pertinent Results: EKG: NSR, 95. Nml axis, nml intervals. LAA. <1mm depression in V4-V6, no prior to compare. No Q waves. Brief Hospital Course: Impression: 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in [10/2174], FVL def and Prot S deficiency on coumadin, presented to an OSH with melena and found to have an INR of 10. . Plan: # Melena/Coffee ground emesis Pt with melena and 14 point drop in hct in the context of an INR of 10. Likely UGI source given melena and coagulopathy and previous h/o duodenal AVMs seen on prior capsule endoscopy at OSH. Pt is s/p FFP, Vit K at OSH, INR 2.7 at time of admission. She was admitted to the [Hospital Unit Name 153] for monitoring and transfused an additional pRBC with goal hct >28 given h/o CAD; no active ischemia at this time. Pt had 2 large bore IV's in place at all times and was placed on IV PPI [Hospital1 ]. Her ASA, Plavix and coumadin were held. GI was consulted and on HD#2 due to ongoing melena, with an INR of 5.8, she was transfused 3u FFP prior to having an additional EGD which was unremarkable for any ulcer or bleeding diathesis. Her hct remained stable over the next day, with no further episodes of melena. Her diet was advanced as tolerated. HCT remained stable and she had no episodes of melena or hemetemesis while inpatient. She was maintained on PPI [Hospital1 ]. . # Coagulopathy Pt with a reported INR of 10 at OSH, unclear etiology, but likely due to decreased PO intake over the past 2 weeks with poor follow up of INR levels. She received Vit K at the OSH, and received 1mg Vit K IV as well as 3u FFP as above. Her INR decreased to 1.8. Her OSH hematologist was contact[Name (NI) ] regarding to restarting her anticoagulation in the setting of her GIB, given her hypercoagulable state of +factor V leiden and protein S deficiency. Coumadin was resumed [2176-6-28] at 2mg/day, without lovenox bridge intitially. However, INR continued to fall from 1.8 and her coumadin was increased slowly to 5 mg PO QD and lovenox bridge was started on [2176-7-1]. Her INR will NEED TO BE FOLLOWED CLOSELY as an outpatient, with goal [2-23]. We would recommend holding the coumadin at 5mg and allowing the INR to increase slowly so as not to overshoot and precipitate a GI bleed. Plan to continue lovenox until INR therapeutic. . # hx of CAD s/p LAD stent (last ECHO nromal w. EF 55%. EKG only showed <1mm of ST depressions laterally; 2 sets of CE's were negative. Pt remained completely asymptomatic. Her hct was transfused as needed to maintain hct >28. Her ASA, plavix were held, and her cardiologist was contact[Name (NI) ] due to the fact that patient had been on Plavix >18 months post-stent placement. Her cardiologist (Dr. [First Name (STitle) ] [Name (STitle) 121], formerly at [Last Name (un) 4068]) agreed that Plavix was no longer needed, and to continue ASA once tolerating in regards to her GIB. Her bblocker was initially held and then restarted once her SBP was stable. ASA restarted on discharge. . # Factor V Leiden & Protein S deficiencies Pt with a hypercoagulable state, currently on coumadin and Plavix for anticoagulation. Anticoagulation was initially held in the setting of active GI bleed. After discussion with her cardiologist, Plavix was discontniued indefinitely. Since she has a stent she does require a full dose aspirin which was re-started immediately before discharge, and after consultation with the hematology service, coumadin was restarted at a lower dose than previous. Given the amount of vitamin K she recived at the OSH, it is likely that it will be quite some time before patient is therapeutic and her INR should be watched very closely as an outpatient to allow for the appropriate dose adjustments. . # Chronic Pain: Patient has very complex pain issues and attends an outpatient pain management clinic. Continued topamax, ultram, lidoderm patch, vicodin prn. Nortriptiline was stopped and trazadone was increased to 500mg PO QHS and ambien continued at night. . # Mild asthma - cont albuterol . # Ativan PRN - Started on klonopin during this admission. She was on 0.5 TID, and dose was increased to 1mg [Hospital1 ]. Consider increasing this to 1mg TID as needed. . # PPx - On lovenox, PPI [Hospital1 ] . Medications on Admission: Protonix 40mg Plavix 75mg QHS ASA 325 Toprol 25mg Topamax 75 tid Nortryptiline 100 qhs Trazadone 300mg qhs Valtrex 1gm qD Ultram 100mg TID Lipitor 80 Vicodin [Hospital1 ] Soma 350 TID Coumadin (5 SMTWF, 6 ThSa) Miralax Albuterol prn Advair prn Boniva Lidoderm patch Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Topiramate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Trazodone 100 mg Tablet Sig: Five (5) Tablet PO HS (at bedtime). 5. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 14. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral [Hospital1 ] (2 times a day) as needed. 15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed. 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous twice a day. 21. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary: Gastrointestinal Bleed Elevated INR . Secondary h/o GIB likely from duodenal AVMs as seen on prior capsule endoscopy Multiple Sclerosis IBS with frequent constipation CAD (MI in [2174]), s/p LAD stent [10/2174] +Factor V Leiden (requiring coumadin) Protein S deficiency h/o DVT/PE PTSD L knee arthroscopy Degenerative disc disease treated with steroid injections Asthma Chronic pelvic pain d/t post-herpetic neuralgia Discharge Condition: Good. Patient able to sit in chair and ambulate. Hct stable without evidence of ongoing bleeding. Discharge Instructions: Please take all of your medications as prescribed. Please call your PCP or return to the ED if you have shortness of breath, chest pain, fevers, chills, nausea, vomiting, bright red blood per rectum, melena, or other symptoms that are of concern to you. Followup Instructions: Please call your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17103], at [Telephone/Fax (1) 3658] to schedule a follow up appointment 1-2 weeks after you are discharged from the rehabilitation facility. . Please schedule a follow up appointment with your neurologist, Dr. [Last Name (STitle) ], at your earliest convenience. She has been e-mailed and is aware of your recent admission.	[ "053.19", "535.50", "305.1", "340", "289.81", "578.1", "280.0", "V58.61", "578.0", "V12.51", "V45.82", "286.3" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13", "99.07" ]	icd9pcs	[ [ [] ] ]	20696, 20768	14480, 18643	11378, 11383	21247, 21348	14350, 14457	21650, 22105	13905, 13925		18963, 20673		20789, 21226		18669, 18940				21372, 21627						13940, 13940																						11332, 11340								11411, 13343								13954, 14331							13365, 13744	13760, 13889
4,431	198,450	13790	Discharge summary	report	Admission Date: [2131-1-25] Discharge Date: [2131-1-30] Date of Birth: [2057-2-8] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 73-year-old gentleman with a known history of coronary artery disease, status post percutaneous transluminal coronary angioplasty of his left anterior descending in [2121] who has been followed and treated medically for stable exertional angina. His angina has been increasing over the past several weeks. He was again referred to [Hospital1 69] for cardiac catheterization. At cardiac catheterization he was found to have a LVEDP of 26, ejection fraction of 50%, 95% distal right coronary artery, 90% mid-LAD, 99% first diagonal, 80% first OM and 95% OM2 lesion. He was referred to Dr. [Last Name (STitle) ] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypercholesterolemia. 3. Noninsulin dependent diabetes mellitus. 4. Benign prostatic hypertrophy. ALLERGIES: Penicillin. PREOPERATIVE MEDICATIONS: 1. Zantac 150 mg p.o. q day. 2. Hytrin 10 mg q day. 3. Ecotrin 325 mg p.o. q day. 4. IFMO 20 mg p.o. twice a day. 5. Lopressor 75 mg p.o. twice a day. 6. Lopid 600 mg p.o. twice a day. 7. Glucophage 500 mg p.o. twice a day. 8. Plavix 75 mg p.o. q day. 9. Nitropatch .2 during the day. PREOPERATIVE LABORATORY DATA: Significant for a creatinine of 1.4. HOSPITAL COURSE: The patient was admitted to [Hospital1 346] on [2131-1-25] and was taken to the operating room with Dr. [Last Name (STitle) ] for a coronary artery bypass graft times three with left internal mammary artery to left anterior descending, SVG to OM and SVG to patent ductus arteriosus. Please see operative note for further details. The patient was transported to the Intensive Care Unit in stable condition on Levophed, Propofol infusion. The patient was weaned and extubated from mechanical ventilation on his first postoperative night. Levophed was weaned off on postop day one. Postoperative day two the patient was started on low dose beta-blocker. The patient's chest tubes remained in for moderate amount of serosanguinous output. It was noted at this time that the patient had significant problems with urinary retention preoperatively therefore a Urology consult was obtained and it was recommended by Urology to continue his Foley catheter while he was in the hospital and discharge the patient to home with instructions the straight catheterization himself as needed as the patient had been straight cathing during the week prior to his surgery. Follow-up with his outpatient Urology Dr. [First Name (STitle) 1356] in [Hospital1 2436]. On postoperative day three, the patient had some short bursts of rapid atrial fibrillation which converted spontaneously. The patient's electrolytes were repleted. Lopressor was increased. Postop day three the patient was transferred from the Intensive Care Unit to the regular part of the hospital and by postop day four the patient had cleared a level five and on postop day five the patient will be cleared for discharge to home. CONDITION ON DISCHARGE: T-max 100.0, pulse 95 in sinus rhythm, blood pressure 117/73, respiratory rate 18. Room air oxygen saturation 96% LABORATORY DATA: White blood cell count 7.6, hematocrit 25.7, platelet count 127. Sodium 134, potassium 4.1, chloride 102, bicarbonate 27, BUN 26, creatinine 1.1, glucose 130. Neurologically the patient is awake, alert and oriented times three. Nonfocal. Heart: Regular rate and rhythm. Positive rub no murmur. Breath sounds are coarse bilaterally. No wheezes or rhonchi. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Distal extremities are warm and well perfused with 1+ pitting edema. Bilateral lower extremity vein harvest sites are clean and dry with no erythema or drainage. Sternum: Staples are intact. There is no erythema or drainage. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q day. 2. Colace 100 mg p.o. twice a day. 3. Percocet 5/325 one to two p.o. q 4 hours p.r.n. 4. Zantac 150 mg p.o. twice a day. 5. Glucophage 500 mg p.o. twice a day. 6. Terazosin 2 mg p.o. q h.s. 7. Lopressor 25 mg p.o. twice a day. 8. Lopid 600 mg p.o. twice a day. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2131-1-29] 16:04 T: [2131-1-29] 18:23 JOB#: [Job Number 41464]	[ "250.00", "600.00", "413.9", "788.20", "414.01", "997.1", "V45.82", "272.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.93", "36.12", "88.72", "38.91", "99.04", "36.15" ]	icd9pcs	[ [ [] ] ]									3969, 4550					1421, 3128																				1039, 1403																			159, 832															854, 1013		3153, 3946
67,216	152,445	25685	Discharge summary	report	Admission Date: [2183-2-19] Discharge Date: [2183-2-24] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: transfer from outside hospital for R leg thrombectomy Major Surgical or Invasive Procedure: Angiogram of Right Superficial Femoral Artery and Right Peroneal Arteries with Partial Thrombectomy History of Present Illness: Ms. [Known lastname 64059] is an 85 year old woman with history of hypertension, PVD presents as tranfer from [Hospital3 ] for superficial femoral artery thrombectomy. She reported that she was about to take a shower the day of her admission to the outside hospital when she experienced dizziness and also pain from her Right ankle to her Right knee associated with some numbness of her Right big toe as well as the 2nd and 3rd digits. She lied down on a bath mat, denied any loss of consciousness or head trauma. The dizziness resolved but then recurred, so her daughters took her to [Hospital3 5365] where she was admitted in complete heart block and noted to have an ischemic Right foot with cyanosis extending to midfoot. She was noted at that time to have 2 episodes of near syncope from near asystole. At [Hospital1 10551], she had emergent placement of temporary pacer wire in her Right IJ with restoration of heart rate. She was then taken to the OR with thrombectomy of R leg and started on a Heparin drip. Later, a permanent pacer was placed. She had an echocardiogram that showed normal EF, mildly dilated RA, mild MR, and moderate TR. She was noted to have elevated troponin-T which trended 0.03, 0.037, 0.03 and was felt to have an NSTEMI. The Right foot was noted to still be cold compared to the Left, so she was referred to [Hospital1 18] for RLE angiogram [2183-2-19] with Dr. [Last Name (STitle) ]. On presentation, pt was resting comfortably, reporting no pain or dizziness. She had a low grade temperature and had the following vitals: T 100.0 BP 164/62 HR 82 RR 22. Review of Systems as above, negative for fevers/chills/nausea, vision changes, has occasional headaches, no neurological signs. Occasional dizziness at baseline, weakness attributed to age. No orthopnea, PND, palpitations, or chest pain. No cough, SOB. No nausea, vomiting, diarrhea, constipation, abdominal pain. No dysuria. No skin/joint changes other than above. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, tobacco use 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: DDD Pacer placed recently at [Hospital1 392] 3. OTHER PAST MEDICAL HISTORY: Hypertension left cheek basal cell carcinoma left eyelid basal cell carcinoma s/p resection s/p appendectomy PVD with arteriogram [6-7] of left leg, followed by Dr. [Last Name (STitle) ] Social History: She lives alone. She has smoked for 60 years, had cut down to 5 cigarettes per day then quit [2182]. Restarted smoking socially recently. Has a daughter that lives nearby. Family History: Significant for a father with COPD and cancer. Physical Exam: Admission Exam: 100.0 164/62 82 22 GEN: Elderly pleasant lady in no distress, rambling tangential conversation but answering appropriately, alert Neck: No jugular venous distention noted, some external jugular pulsations noted around 5cm at 30 degrees. Carotid pulsations palpable. Lungs: Scattered wheezes, light crackles and adventitious sounds are appreciated. CV: S1 and S2 are very faint but regular and no appeciable murmurs are heard ABd: Soft NT ND obese abdomen SKIN: Diffuse senile ecchymoses on bilateral arms EXT: No BLE edema is noted. R foot is cold compared to very warm and well perfused L foot. Tips of all toes bilaterally with some pinkness, but no cyanosis noted. DP's and PT's are not palpable bilaterally. Prior to discharge, the feet were both warm and well perfused with only the Right sided toes feeling cool to touch. The 2nd and 3rd digits on the right foot had decreased sensation. Right posterior tibial pulse was dopplerable, but right dorsalis pedis pulse was not dopplerable. Pertinent Results: [2183-2-20] 12:30AM BLOOD WBC-9.2 RBC-4.19* Hgb-10.3* Hct-32.3* MCV-77* MCH-24.7* MCHC-32.0 RDW-16.8* Plt Ct-252 [2183-2-24] 03:47AM BLOOD WBC-8.2 RBC-3.93* Hgb-9.7* Hct-30.7* MCV-78* MCH-24.7* MCHC-31.6 RDW-16.9* Plt Ct-307 [2183-2-24] 03:47AM BLOOD PT-12.8 PTT-23.0 INR(PT)-1.1 [2183-2-20] 12:30AM BLOOD Glucose-141* UreaN-19 Creat-0.9 Na-141 K-3.9 Cl-106 HCO3-27 AnGap-12 [2183-2-24] 03:47AM BLOOD Glucose-102* UreaN-24* Creat-1.0 Na-141 K-4.3 Cl-107 HCO3-27 AnGap-11 [2183-2-20] 12:30AM BLOOD CK(CPK)-146 [2183-2-20] 12:30AM BLOOD CK-MB-3 cTropnT-0.03* [2183-2-20] 06:05AM BLOOD %HbA1c-5.5 eAG-111 [2183-2-20] 06:05AM BLOOD Triglyc-69 HDL-41 CHOL/HD-3.4 LDLcalc-85 Cardiology Report Cardiac Cath Study Date of [2183-2-21] COMMENTS: 1. Access was obtained in retrograde fashion through the left common femoral artery. 2. A 4F Omniflush catheter was advanced into the lower abdominal aorta. Non selective angiography revealed: - Abodminal aorta: minimal disease - Single patent renal artery bilaterally - Left: patent CIA, IIA, EIA and CFA. - right: patent CIA, IIA, EIA and CFA. 3. An angled glide wire was then crossed over and advanced into the right SFA over which the Omni flush catheter was exchanged for a straight glide catheter that was advanced to the CFA level and selective angiography was performed which demonstrated: - 90% SFA lesion proximally, - patent popliteal artery - patent TPT. - occluded anterior tibial artery - occluded posterial tibial artery - single peroneal artery run off with 100% occlusion at distal calf. 4. Successful PTA and stenting of the right sfa stenosis with a 5.0x40mm Everflex Protege stent that was 5.0mm. Final angiography revealed no residual stenosis, localized perforation and good distal flow (see PTA comments). 5. Unsuccessful PTA of the peroneal artery with 2.0mm and 3.0mm balloons. Final angiography revealed localized perforation and unchanged flow status. FINAL DIAGNOSIS: 1. Peripheral artery disease. 2. [Name (NI) 64060] PTA and stenting of the right SFA. 3. Unsuccessful intervention of the right peroneal artery. 4. Stable localized perforation at the right SFA level as well as the right peroneal artery level. Radiology Report ART EXT (REST ONLY) Study Date of [2183-2-20] 3:47 PM FINDINGS: Doppler waveform analysis, pulse volume recording, and ankle- brachial index were calculated at rest. On the right, there is triphasic waveform within the femoral, superficial femoral, and popliteal distributions with monophasic waveforms in the posterior tibial and dorsalis pedis distribution. Additionally, there is marked loss of amplitude at the level of the ankle and metatarsal on pulse volume recordings. The ankle brachial index is 0.43. On the left, there is a triphasic waveform at the level of the femoral artery, with loss of phasicity at the superficial femoral, popliteal, and posterior tibial and dorsalis pedis distributions, with monophasic waveform seen at levels. The ankle-brachial index measures 0.45. There is significant loss of amplitude at the level of the calf, ankle, and metatarsal levels. IMPRESSION: Findings are consistent with significant right tibial disease, and left disease at the SFA and tibial levels. Brief Hospital Course: Ms [Known lastname 64059] is a 85 year-old female with hypertension, PVD, complete block s/p pacemaker placement, and an ischemic right leg s/p thrombectomy and RLE angiogram complicated by a small perforation transferred to the CCU for monitoring of hematoma formation. . # Ischemic R foot s/p thrombectomy and RLE angiogram with small perforation: Patient had partial thrombectomy at outside hospital and was transferred to [Hospital1 18] for further thrombectomy. During the catheterization, the superficial femoral artery was underwent successful percutaneous transluminal angioplasty. There was diffuse peripheral arterial disease but no intervention was made at the level of the right peroneal artery. The procedure was complicated by localized perforation of the right superficial femoral artery as well as the right peroneal artery. Her anticoagulation with heparin was reversed with protamine. Vascular surgery was consulted with no intervention. Her right foot did become warm and of normal color after the procedure with just the toes feeling cooler to touch. Posterior tibial pulses on both feet were dopplerable; dorsalis pedis pulse was dopplerable on the left foot but not the right foot. The patient was transferred to the CCU for monitoring but was not found to have any signs of compartment syndrome. She had a large anterior hematoma and ecchymoses. Her groin site was tender and continues to have staples upon discharge, which should be removed during her followup appointment with Dr. [Last Name (STitle) ]. She did have one episode of sudden throbbing leg pain which resolved after tylenol and one dose of oxycodone. Ms. [Known lastname 64059] may require another procedure in the near future for her peripheral arterial disease and should follow up with Dr. [Last Name (STitle) ] in two weeks to confirm. She was started on plavix during this hospitalization after placement of the stent. # Coronary Artery Disease: Patient is a current smoker with significant peripheral arterial disease, so she likely has coronary artery disease as well, though she reports no history. She was reported to have elevated cardiac enzymes at the outside hospital; however, her CK here was normal and her trop was stable at 0.03. She has no history of angina, though her peripheral vascular disease puts her at risk for CAD as well. She was started on a beta blocker and aspirin which should be continued as an outpatient. She may require further workup for coronary artery disease as an outpatient. She was counseled on the importance of smoking cessation. # Hypertension: The patient was continued on her home dose of amlodipine during hospitalization and should restart her home lasix upon discharge. # Complete Heart Block: Patient was noted to be in complete heart block at the outside hospital and had a pacemaker placed. EKG showed V-paced rhythm. She was monitored on telemetry. Upon discharge, the visiting nurse will monitor her site of pacemaker placement. # Urinary Tract Infection: Patient was started on Ciprofloxacin 500mg twice daily on [2-24] and should be continued for three days total. # Tobacco Use: Patietn was counseled on smoking cessation. Medications on Admission: Norvasc Lasix Potassium Meds on transfer: Nexium, Morphine, Tylenol, Zofran Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. Disp:5 Tablet(s) Refills:0 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Lasix - dosage unknown 7. Potassium - dosage unknown Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Right Superficial Femoral Artery Thrombosis Secondary Diagnoses: Urinary Tract Infection Hypertension Peripheral Vascular Disease Tobacco Abuse Discharge Condition: Stable. Alert and Oriented x3. Ambulatory. Discharge Instructions: Dear Ms. [Known lastname 64059], You were transferred to [Hospital1 18] from another hospital because you were having right leg pain and needed to have an angiogram and removal of the blood clot in your leg. At the other hospital, you had a pacemaker placed because you had passed out from an abnormal heart rhythm. It also appears that you may have had a small heart attack at the other hospital. It appears that a clot had blocked off an artery in your right leg, so you had a procedure here at [Hospital1 18] to remove the clot. Most of the clot was removed, though you may need to have another procedure to remove the rest at a later time. During the procedure, you experienced a complication in which part of your artery was perforated and blood leaked into your leg. You were monitored for this complication and found to be stable, though you should seek medical attention if you are experiencing increasing leg pain at home. You will need to follow up with Dr. [Last Name (STitle) ] as scheduled below. Please be sure to quit smoking, as it can contribute to heart disease and the Peripheral Vascular Disease in your legs. Because you may have had a small heart attack that caused the abnormal rhythm in your heart at the other hospital, you should be evaluated for Coronary Artery Disease by your primary care physician or cardiologist. You have high risk of heart disease because you have smoked for many years and because you have peripheral vascular disease. You were started on daily aspirin for this reason. The following changes have been made to your medications. - Please start taking aspirin 325mg daily - Please start taking Metoprolol Succinate (or Toprol XL) 50mg daily - Please start taking Clopidogrel (Plavix) 75mg daily until you are told by Dr. [Last Name (STitle) ] that you no longer need it - Please start taking Ciprofloxacin 500mg twice daily for 3 days total for a urinary tract infection Please be sure to keep all of your followup appointments. Please seek medical attention if you begin to experience worsening leg pain, chest pain, sudden shortness of breath, lightheadedness or any other symptoms concerning to you. Followup Instructions: Please be sure to keep all of your followup appointments. Dr. [Location (un) 64061] Office [3-10], at 2pm - At this visit, please be sure to discuss your new medications, including how much longer you should be taking Plavix, and your risk for cardiac disease. You may need a stress test in the future. Also, please be sure to discuss whether or not you will need a followup procedure to remove the rest of the clot in your leg. Please set up an appointment with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5456] at [Telephone/Fax (1) 5457].	[ "998.12", "599.0", "444.22", "414.01", "998.2", "410.71", "305.1", "E878.8", "440.22", "401.9", "V45.01", "426.0" ]	icd9cm	[ [ [] ] ]	[ "00.45", "88.48", "39.50", "88.42", "88.45", "39.90", "00.40" ]	icd9pcs	[ [ [] ] ]	11479, 11485	7503, 10718	316, 418	11693, 11738	4184, 6183	13966, 14607	3088, 3136		10845, 11456		11506, 11506		10744, 10769		6200, 7480		11762, 13943						3151, 4165			11591, 11672	2532, 2649																		223, 278								446, 2439							11525, 11570				2680, 2876				2461, 2512	2892, 3072			10787, 10822
48,780	162,023	42733	Discharge summary	report	Admission Date: [2178-2-21] Discharge Date: [2178-2-26] Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 896] Chief Complaint: Hypotension on pressors Major Surgical or Invasive Procedure: Right internal jugular central line placement History of Present Illness: [Age over 90 ]F with a history of hypertension, CAD s/p MI, atrial fibrillation who presented from [Hospital3 ] facility ([Street Address(1) 92345] in [Hospital1 1559]) with a one day history of fever to 102 and lethargy following several days of feeling unwell with poor PO intake. According to her daughter, she was very well earlier in the week (they went out to lunch on Wednesday and she seemed fine at that time). Of note, she had a recent UTI which was treated with a course of antibiotics, though family is unaware of the name of the medication. She left a blood sample when she saw her doctor at that visit a few weeks back, but unfortunately was unable to produce a urine sample at that time so it sounds as though no culture was obtained. She was taken to [Hospital2 ] [Hospital3 6783] Hospital in [Hospital1 1559] initially, but transferred to [Hospital1 18] given no ICU beds there. At [Hospital2 ] [Hospital3 6783], initial vitals were BP 65/49, HR 154, RR 22, T 99.1, 99% on RA. She was noted to be in ? SVT on arrival with rate to 140s-150s. She has known history of A-fib. This self-resolved -> sinus rhythm following 3L IVF. She remained hypotensive to 77/46 despite IVF, so CVL (right IJ) was placed in sterile fashion and she was started on Levophed. U/A was positive for infection; CXR was clear. Ceftazidime 1g IV and Vancomycin 1g IV administered. In the ED, initial VS were: T 97.6, HR 80, BP 128/90, RR 20, O2 sat 96% on RA. Set of labs were drawn (including repeat U/A and UCx) and CVL placement was confirmed by CXR. Labs notable for lactate is 1.0. She was noted to be alert and oriented x 3 in the ED though with very limited memory of the day's events. BPs were stable on Levophed. Pt in NSR with controlled rate. Got one dose of PR acetaminophen. Vitals on transfer HR 83, BP 133/76 (on Levophed 0.09), RR 20, 100% RA. Just prior to transfer, patient was noted to develop SVT (not A-fib) with rate to 160. She was given 3 mg of adenosine and converted back to NSR with rate in 80s. . On arrival to the MICU, she is somnolent but rousable. She answers many Qs appropriately, but ignores other Qs. Not oriented to hospital/ICU at this time. Inattentive/sleepy. . Review of systems: Reports some pain in her back which is chronic; she is unable to qualify this on numerical pain scale. Denies CP or SOB. Deneis abdominal pain. Remainder of ROS could not be accurately obtained due to somnolence. Past Medical History: - Atrial fibrillation on amiodarone, atenolol - Hypertension - CAD s/p MI per OSH records (per family, no prior MI) - Frequent UTI (completed course of Abx ~ 10 days ago) - Has some ? bladder prolapse and has suffered from recent incontinence (on oxybutinin) - Primary Biliary Cirrhosis on ursodiol (followed by a gastroenterologist) - Anxiety (family reports mirtazepine is for this indication) - Chronic back pain - S/p cholecystectomy - Chronic GERD and atypical chest pain Social History: Has 4 children. Lives alone in [Hospital3 ] ([Street Address(1) 92345] in [Hospital1 1559] [Telephone/Fax (1) 92346]) and is independent with most ADLs (does have assistance with bathing for safety reasons). Uses a walker at baseline. - Tobacco: None - Alcohol: None - Illicits: None Family History: N/C Physical Exam: ADMISSION: General: Resting in bed, rousable but confused. Unable to name hospital. Knows date as [2-20]. Drifting off mid-conversation. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, RIJ in place CV: Regular rate and rhythm, slightly hyperdynamic S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly (patient winces slightly during exam, but denies pain with palpation when asked) GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No gross focal defects noted; full exam deferred due to patient somnolence DISCHARGE PHYSICAL EXAM: Physical Exam: Vitals: 98.4 118/82 74 16 98%2L General: Comfortable, alert and oriented x3, appropriate. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, -m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No gross focal defects noted Pertinent Results: Labs on admission to [Hospital1 18]: Labs from [Hospital2 ] [Hospital3 6783] in [Hospital1 1559]: - WBC 14.4 (91N/3L/6M/0E/0B), Hgb 10.8, Hct 31.4, plt 255 - Troponin T < 0.03, CPK 165, CK-MB 2.9 (MB% 1.8) - INR 1.2, PTT 31.0 - U/A with cloudy appearance, moderate blood and leukocytes, 100 protein - Lactate 1.8 Micro: ([Hospital2 ] [Hospital3 6783]): - Blood culture [2178-2-21]: E. coli (pan-sensitive, see below) ([Hospital1 18]): - Blood culture [2178-2-21]: E.coli 2/2 bottles (pan-sensitive, see below) - Blood culture [2178-2-21]: E.coli 2/2 bottles (pan-sensitive, see below) - Urine culture [2178-2-21]: E.coli (pan-sensitive, see below) ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: CXR [2178-2-21]: IMPRESSION: Right-sided internal jugular venous catheter with tip in the mid SVC. No pnuemothorax. CXR [2178-2-24]: FINDINGS: As compared to the previous radiograph, the right central venous access line has been removed. The right PICC line is in unchanged position. Unchanged bilateral pleural effusions with moderate fluid overload. Unchanged mild cardiomegaly and bilateral areas of atelectasis. No evidence of pneumonia. RENAL U/S [2178-2-22]: IMPRESSION: 1. 2-cm complex left mid pole cystic lesion might represent an abscess. 2. Small amount of right hydronephrosis. [2178-2-21] 03:06AM BLOOD WBC-16.0* RBC-3.10* Hgb-10.4* Hct-30.0* MCV-97 MCH-33.7* MCHC-34.8 RDW-13.2 Plt Ct-226 [2178-2-22] 03:28AM BLOOD WBC-15.6* RBC-2.84* Hgb-9.6* Hct-28.3* MCV-100* MCH-33.8* MCHC-34.0 RDW-13.4 Plt Ct-235 [2178-2-22] 12:55PM BLOOD WBC-16.5* RBC-2.98* Hgb-9.9* Hct-29.2* MCV-98 MCH-33.3* MCHC-34.0 RDW-13.7 Plt Ct-201 [2178-2-23] 03:14AM BLOOD WBC-15.2* RBC-2.77* Hgb-9.2* Hct-27.1* MCV-98 MCH-33.2* MCHC-33.9 RDW-13.8 Plt Ct-200 [2178-2-24] 03:37AM BLOOD WBC-14.0* RBC-2.80* Hgb-9.3* Hct-27.8* MCV-100* MCH-33.2* MCHC-33.3 RDW-13.9 Plt Ct-231 [2178-2-25] 06:13AM BLOOD WBC-12.4* RBC-2.81* Hgb-9.4* Hct-28.1* MCV-100* MCH-33.4* MCHC-33.4 RDW-14.2 Plt Ct-276 [2178-2-26] 06:45AM BLOOD WBC-13.6* RBC-2.94* Hgb-9.7* Hct-28.6* MCV-97 MCH-32.9* MCHC-33.9 RDW-13.7 Plt Ct-302 [2178-2-26] 06:45AM BLOOD Neuts-80.9* Lymphs-11.1* Monos-2.7 Eos-3.3 Baso-2.1* [2178-2-21] 03:06AM BLOOD PT-13.7* PTT-32.1 INR(PT)-1.3* [2178-2-23] 03:14AM BLOOD PT-13.0* PTT-39.1* INR(PT)-1.2* [2178-2-24] 03:37AM BLOOD PT-12.5 PTT-37.3* INR(PT)-1.2* [2178-2-21] 03:06AM BLOOD Glucose-121* UreaN-43* Creat-2.1* Na-129* K-4.2 Cl-97 HCO3-20* AnGap-16 [2178-2-21] 10:36AM BLOOD Glucose-138* UreaN-40* Creat-1.8* Na-132* K-4.0 Cl-103 HCO3-17* AnGap-16 [2178-2-22] 03:28AM BLOOD Glucose-131* UreaN-38* Creat-1.4* Na-132* K-3.4 Cl-105 HCO3-19* AnGap-11 [2178-2-22] 12:55PM BLOOD Glucose-133* UreaN-37* Creat-1.4* Na-134 K-3.4 Cl-106 HCO3-19* AnGap-12 [2178-2-23] 03:14AM BLOOD Glucose-106* UreaN-36* Creat-1.3* Na-137 K-4.4 Cl-110* HCO3-20* AnGap-11 [2178-2-24] 03:37AM BLOOD Glucose-100 UreaN-33* Creat-1.2* Na-136 K-3.6 Cl-109* HCO3-17* AnGap-14 [2178-2-25] 06:13AM BLOOD Glucose-102* UreaN-26* Creat-1.0 Na-139 K-3.5 Cl-109* HCO3-20* AnGap-14 [2178-2-26] 06:45AM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-140 K-2.7* Cl-104 HCO3-24 AnGap-15 [2178-2-26] 01:10PM BLOOD Glucose-130* UreaN-20 Creat-0.9 Na-140 K-3.9 Cl-108 HCO3-24 AnGap-12 [2178-2-24] 03:37AM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.4* Mg-1.9 [2178-2-23] 06:03AM BLOOD Vanco-4.0* [2178-2-22] 03:28AM BLOOD Cortsol-25.7* [2178-2-21] 03:06AM BLOOD Lactate-1.0 [2178-2-21] 11:04AM BLOOD Lactate-1.4 [2178-2-22] 01:08PM BLOOD Lactate-1.3 Brief Hospital Course: HOSPITAL SUMMARY: [Age over 90 ]F with history of atrial fibrillation and frequent UTI who presented to OSH with fever and lethargy found to have septic shock from UTI. OSH course complicated by SVT to 140s-150s (self-resolved after IVF) and hypotension requiring pressors. Overall clinical picture consistent with urosepsis; she was placed on norepinephrine for pressure support and admitted to the medical ICU. She was treated with antibiotics for her urosepsis and episodes of SVT were managed with hydration, amiodarone and adenosine. Vitals stabilized and she was called out to the medical floor on hospital day #4. On the floor, she had sporadic episodes of both AVNRT to rates of 160 that spontaneously resolved and atrial fibrillation with rates of approximately 110 with sporadic bursts to 140. All SVT was hemodynamically stable and asymptomatic. ACTIVE ISSUES: # SEPTIC SHOCK WITH UTI: Patient initially met SIRS criteria with tachycardia, leukocytosis, tachypnea secondary to infection. Source was urine, given history of frequent UTI, +U/A at OSH, and relatively clear CXR and absence of other localizing symptoms. BPs were refractory to IVF so she was initiated on norepinephrine; CVL (RIJ) was placed at OSH. She was treated with vancomycin and Zosyn initially for broad-spectrum coverage; this regimen was narrowed to ceftriaxone when cultures ultimately revealed pan-sensitive E. coli in the blood and urine. She will require 2 weeks of IV ceftriaxone for bacteremia from the first negative culture on [2-22]. She will also require outpatient follow-up with urology for bladder prolapse, which over the past year has caused multiple UTIs. # TACHYARRHYTHMIA: The patient with a known history of atrial fibrillation not on coumadin was noted to be in a supraventricular tachyarrhythmia first at OSH with rate to 140s-150s. This self-resolved after administration of IVF, but recurred in the [Hospital1 18] ED with rate to 160s; this broke with 3 mg adenosine. This SVT was felt to be AVNRT by electrophysiology, which she was not known to have. She had several further episodes during her ICU stay with rates to 150-160, initially associated with hypotension/increasing pressor requirement. These were managed initially with a one-time dose of 150 mg IV amiodarone (then pt was resumed on her home dose of 100 mg PO daily) and 3 mg adenosine PRN. Once blood pressures stabilized, she was started on low-dose metoprolol. On [2-23] had persistent AVNRT (hemodynamically stable) and received adenosine 3mg x2, followed by another 150 mg IV amiodarone which eventually broke her. Cardiology was consulted and recommended increasing her amiodarone to 200 mg daily for seven days and continuing her metoprolol at 12.5 mg [Hospital1 ]. Cards felt that this arrhythmia was likely secondary to increased catecholamine [Doctor First Name ] from septic shock, and would resolve eventually. On the floor, she had few sporadic and self-limiting [10-19] second bursts of AVNRT to 160s, which were asymptomatic and hemodynamically stable. She also had a few episodes of atrial fibrillation at rates of approximately 110 with bursts to 140s, again hemodynamically stable and asymptomatic. Her beta blocker was uptitrated at this point to TID to ensure good rate control when in atrial fibrillation. She is being discharged on 12.5 TID, with plan to convert stable long acting metoprolol when discharged. She is also being discharged on [Hospital1 ] amiodarone 100mg with plan to go back to 100mg qd after 7 days. She should be discharged on amio 100 QD and toprol XL 25-37.5mg with cardiology follow-up. Per cardiology, she tolerates these episodes well and watchful waiting is a good strategy as long as she is hemodynamically stable and without significant symptoms. # Diarrhea: started a few days after antibiotics. Guaiac negative, cdiff toxin negative. She had a leukocytosis that was elevated but stable throughout her hospital course. It was felt that her diarrhea was likely antibiotic associated diarrhea rather than cdiff infection. A cdiff PCR was sent which is pending at time of discharge; if this returns positive, we will contact the rehabilitation facility for plan of [10-18] day course of PO flagyl. At the time of discharge, however, our suspicion for cdiff is low and she is not on flagyl. Her volume status should be monitored closely, and PO fluids strongly encouraged to avoid [Last Name (un) ]. # ACUTE RENAL FAILURE: Creatinine was 2.1 on arrival to [Hospital1 18]; prior baseline was 0.8 per PCP [Name Initial (PRE) 14453]. Medications were renally dosed and nephrotoxins avoided (ibuprofen was held). Urine lytes were consistent with a prerenal/ATN picture likely secondary to sepsis. Creatinine trended down to 0.8 at the time of discharge. Urine output was excellent throughout. # HYPONATREMIA: Na 129 on arrival. Patient appeared euvolemic after 3L IVF, though felt she was still dehydrated. Hyponatremia was likely hypovolemic; this resolved with IVF. INACTIVE ISSUES: # ANEMIA: Hct ~30. Baseline unknown. Normocytic with MCV 94. No evidence of active bleeding. Hct remained stable in-house. # CORONARY ARTERY DISEASE: Has history of MI in records, but per family no known MI. Continued aspirin, started metoprolol. # HYPERTENSION: discontinued home amlodipine due to hypotension initially, then diarrhea at the time of discharge and concern for future hypovolemia. As lopressor was added for rate control, her amlodipine was discontinued at discharge until PCP [Last Name (NamePattern4) 702]. # CHRONIC BACK PAIN: Mild at this time. Oxycodone was continued. Ibuprofen was discontinued due to renal failure, and was discontinued upon discharge. # INCONTINENCE, FREQUENT UTI: oxybutinin was continued. She will need outpatient evaluation by urology for suspected bladder prolapse leading to multiple UTIs. # PRIMARY BILIARY CIRRHOSIS: Details unknown. Followed by outpatient gastroenterologist. She was noted to have mildly elevated alk phos c/w baseline but otherwise normal LFTs. Continued ursodiol. # Prophylaxis: Subcutaneous heparin, home PPI TRANSITIONAL ISSUES: - Code status during this admission DNR/DNI - Contacts: Son [Name (NI) ] [Name (NI) 92347] ([Telephone/Fax (1) 92348] or [Telephone/Fax (1) 92349]), daughter [Name (NI) ] [Name (NI) 92347] (HCP; [Telephone/Fax (1) 92350]). Other contacts are PCP [Name9 (PRE) 92351] [Name9 (PRE) 90965] in [Name (NI) 5700] ([Telephone/Fax (1) 32376]), [Street Address(1) 92345] [Hospital3 ] facility in [Hospital1 1559] [Telephone/Fax (1) 92346], and [Location (un) 91122] in [Hospital1 1559] [Telephone/Fax (1) 92352]. - Will need further urologic evaluation as an outpatient Medications on Admission: (reconcilled with pharmacy) oxycodone 5mg TID PRN mirtazipine 7.5mg qHS amiodarone 100mg daily amlodipine 2.5mg daily lidoderm patch ursodiol 300mg TID tramadol 25mg q8H PRN ibuprofen 400mg q6H PRN oxybutynin 5mg daily omeprazole - stopped aspirin 81mg daily multivitamin daily calcium and vitamin D colace 100mg [Hospital1 ] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Last day [3-2]. 9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day: Start [3-3] and continue indefinitely. 10. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours. 12. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours): Last day [2178-3-8]. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. 14. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Hospital1 1559] Discharge Diagnosis: Septic shock UTI Atrial fibrillation with rapid ventricular rate AV nodal reentry tachycardia Antibiotic associated diarrhea Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [Hospital1 18]. You were transferred to our ICU for septic shock from a urinary tract infection. You were given IV antibiotics and IV fluids as well as medications to increase your blood pressure and you improved. You have an irregular heart rhythm. While you do have a history of atrial fibrillation, you also had a different rhythm called AV nodal reentrant tachycardia. This other rhythm, while occurring a few times per day, was brief at each episode. We increased your metoprolol and your amiodarone to help control your heart rate. You developed diarrhea, likely from the antibiotics used to treat your urinary tract infection. The diarrhea should improve once the antibiotics are finished. We made a few changes to your medications: -INCREASE Amiodarone 100mg by mouth to TWICE per day (increased from once) for one week (last day [2-/2095]), then go back to home dose: 100mg daily -START Metoprolol tartrate 12.5mg by mouth three times per day. This medication can be switched to a long acting version by your rehab when you are ready for discharge. - START ceftriaxone 1g IV every 24 hours, last day [2178-3-8] - STOP tramadol - STOP amlodipine 2.5mg by mouth until you see your primary care doctor (this was stopped because you were started on metoprolol which will help control your blood pressure). - START tylenol as needed for pain - STOP ibuprofen - STOP colace until your diarrhea resolves Followup Instructions: With your primary care doctor 1 week after discharge With your cardiologist 2-4 weeks after discharge	[ "E930.9", "785.52", "584.9", "571.6", "412", "995.92", "276.1", "V49.86", "038.42", "427.89", "300.00", "787.91", "599.0", "799.02", "427.31", "V13.02", "411.89", "788.30", "276.69", "724.2", "276.2", "530.81", "288.60", "414.01", "285.9", "401.9", "618.01" ]	icd9cm	[ [ [] ] ]	[ "38.97", "54.91" ]	icd9pcs	[ [ [] ] ]	17519, 17602	9001, 9865	256, 304	17791, 17791	4931, 8978	19434, 19540	3636, 3641		16203, 17496		17623, 17770		15848, 16180				17942, 18706						4428, 4912																15189, 15822		18735, 19411	2586, 2801			193, 218		9881, 14056						332, 2567					14074, 15168					17806, 17918					2823, 3302	3318, 3620					4413, 4413
6,062	186,821	25728	Discharge summary	report	Admission Date: [2170-7-19] Discharge Date: [2170-7-30] Date of Birth: [2098-2-18] Sex: F Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 2485] Chief Complaint: 1. Shortness of breath 2. Status post PEA arrest 3. Hypotension Major Surgical or Invasive Procedure: 1. Orotracheal intubation 2. Central venous access History of Present Illness: 72-year-old female with a history of CAD who called EMS yesterday for increasing SOB. [Hospital ] transferred to [Hospital1 1474] obtunded, acutely sob, was then noted to be bradycardic and hypotensive after receiving albuterol, atrovent nebs, IV solumedrol 125mg, and morphine 4mg. Patient intubated (SIMV Vt500 R14 Peep 5 PS 5 gas 7.24/51/191) and PEA arrested, CPR performed (2 minutes) and pt received epi, atropine, bicarb. Arrested 2nd time. Pulse restarted and pt was started on dopamine. EKG at OSH showed [Street Address(2) 1766] elevations V1 and V2. Noted to have temp to 100.2. Started on heparin gtt. Transferred to [Hospital1 18] for emergent cath. Patient unable to give history given all of above, but pt's daughter reports that pt felt some "indigestion" and mild epigastric pain two days ago w/ some mild diarrhea-- both resolved yesterday. They had lunch together yesterday, patient felt fine. patient then called her daughter at 4 pm feeling SOB. Daughter lives next door, came right over to find patient doing neb treatment, looking unwell. Nebs w/o effect so patient's daughter called 911. Rest of history as outlined above. Per patient's daughter, pt is very stoic and rarely complains about her health, even when she does not feel well. Patient did not complain about any other sx's over last days. . At [Hospital1 18] [Name (NI) ], pt weaned off dopa. Tachy to 130s -> started on esmolol gtt. Given levo and vanc for ?sepsis, ASA for MI. Bedside echo showed decreased wall motion in bilateral ventricles and septum. L femoral central line placed in ED. Pt became hypotensive again and restarted on dopamine as taken to cath lab. Past Medical History: 1. Coronary artery disease: Acute MI, s/p OM2 stent [1-12]; [2169-2-8] cath [Hospital 1474] Hospital: Emergent cath for acute onset SOB, + troponin. LAD: mild luminal irregularities. LCx: 90% stenosis prox lg OM2, 30% prox circ. RCA: 30% mid. PTCI LCx lesion, s/p Pixel stent. 2. Chronic obstructive pulmonary disease: intubated 1.5 yrs ago 3. Hypertension 4. History of recurrent pneumonias Social History: Was at [Hospital1 ] rehab but lives next door to her daughter and son-in-law. Heavy smoking and etoh use history. Family History: NC Physical Exam: VS: in ICU, HR: 106, BP: 124/74, R: 25 100% Vent: Vt 400 x 25, Fio2 100% x Peep 5 ABG: 7.13/24/69 Gen: intubated, sedated HEENT: pupils 3 mm b/l Neck: laying flat Chest: expiratory wheezes through out ant fields CV: RRR Nl S1 S2, heart sounds obscured by BS Abd: ND, + BS, no rebound/guarding Ext: no edema, cool, 2+ DP and PT b/l. L fem line: CDI. Neuro: sedated Pertinent Results: [2170-7-19] 04:00AM WBC-21.3* RBC-4.27 HGB-13.6 HCT-41.0 MCV-96 MCH-31.8 MCHC-33.1 RDW-13.0 [2170-7-19] 04:00AM NEUTS-84* BANDS-9* LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2170-7-19] 04:00AM PLT SMR-NORMAL PLT COUNT-212 [2170-7-19] 04:00AM PT-24.2* PTT-150* INR(PT)-3.9 [2170-7-19] 04:00AM GLUCOSE-330* UREA N-27* CREAT-1.4* SODIUM-140 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-16* ANION GAP-23 [2170-7-19] 04:00AM CK(CPK)-25* [2170-7-19] 04:00AM CK-MB-NotDone cTropnT-0.58* [2170-7-19] 04:00AM CALCIUM-9.6 PHOSPHATE-1.5* MAGNESIUM-1.8 [2170-7-27] 03:59AM BLOOD WBC-12.5* RBC-3.37* Hgb-10.5* Hct-32.4* MCV-96 MCH-31.2 MCHC-32.5 RDW-13.4 Plt Ct-261 [2170-7-25] 02:19AM BLOOD PT-11.6 PTT-29.3 INR(PT)-0.9 [2170-7-26] 04:03AM BLOOD PT-11.5 PTT-24.6 INR(PT)-0.9 [2170-7-24] 04:36AM BLOOD Glucose-169* UreaN-33* Creat-0.8 Na-147* K-3.9 Cl-111* HCO3-31* AnGap-9 [2170-7-27] 03:59AM BLOOD Glucose-114* UreaN-30* Creat-0.7 Na-147* K-4.0 Cl-101 HCO3-38* AnGap-12 [2170-7-19] 09:42AM BLOOD ALT-113* AST-121* CK(CPK)-153* AlkPhos-87 Amylase-62 TotBili-0.7 [2170-7-23] 03:36AM BLOOD ALT-31 AST-16 AlkPhos-56 TotBili-0.2 [2170-7-24] 04:36AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.8 [2170-7-27] 03:59AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.0 [2170-7-20] 04:31AM BLOOD Type-ART Temp-37.4 Rates-25/1 Tidal V-400 PEEP-10 FiO2-30 pO2-75* pCO2-55* pH-7.24* calHCO3-25 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [2170-7-21] 03:30AM BLOOD Type-ART Temp-37.8 Rates-20/ Tidal V-400 PEEP-10 FiO2-30 pO2-112* pCO2-55* pH-7.28* calHCO3-27 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2170-7-25] 09:23PM BLOOD Type-ART Tidal V-550 PEEP-5 FiO2-30 pO2-87 pCO2-68* pH-7.32* calHCO3-37* Base XS-5 Intubat-NOT INTUBA [2170-7-27] 04:48AM BLOOD Type-ART pO2-63* pCO2-62* pH-7.43 calHCO3-43* Base XS-13 ## Cath [7-19]: 1. Selective coronary arteriography revealed a right dominant system without evidence for acute coronary artery thrombosis. The LMCA and LAD had no angiographic evidence of coronary artery disease. The LCx had a patent stent in the OM with mild in-stent restenosis of 50%. The RCA had a 40% mid-vessel stenosis and a 50% mid PDA stenosis. 2. Hemodynamics revealed elevated left and right heart filling pressures. The patient was hypotensive off pressors and had a high cardiac output with low SVR. However, given the hypokinesis noted on echo, the patient's stroke volume is lower than normal and while she was tachycardic, it is impossible that she could produce the cardiac output calculated. It was felt that she had septic physiology with inability to extract oxygen at the tissue level. 3. Left ventriculography was not performed. ## Echo [7-19]: The left atrium is dilated. The right atrium is dilated. Overall left ventricular systolic function is severely depressed. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen although significant regurgitation cannot be excluded by this study. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is no pericardial effusion. ## CXR [7-25]: Status post extubation. Allowing for differences in technique, no other interval change. No evidence of congestive heart failure or pneumonia. Brief Hospital Course: ## Respiratory failure -- Hypercarbic/hypoxic. Likely secondary to a copd exacerbation. Improved with maximizing PEEP, regular MDI, steroid therapy. Pt also started on tiotropium and salmeterol. Patient required many adjustments to vent as she had significant auto-peep by decreasing inspiration time. Initially extubated after trial of pressure support but had to be reintubated for shortness of breath, anxiety and hypertension. Patient subsequently faired well with pressure support and reextubated. She continued to do well, initially on bipap for long stretches (2hours on, 30min off), but then switched to nocturnal and as needed bipap; however, she rarely required bipap during the day and generally did not require it at night either. She was put on a steroid taper with scheduled MDIs. Patient should be slowly tapered off the steroids over a period of 2 weeks. Her goal O2 sat is 88-92%, not above, as she develops hypercarbia and somnolence with higher O2 sats. ## Hypotension -- Pt did not appear septic (no fever, tachycardia, wbc declined quickly) and had cath without cad. She does have chf with ef 15-20%. Hypotension was likely due to impeded venous return related to significant auto-peep. Pt quickly became normontensive with vent adjustments, had no pressor requirement for the entire admission minus the few hours surrounding her presentation. ## CAD -- Pt has h/o cad s/p stent, and there was concern for another event, though cath without flow-limiting lesions. Her troponins were initially elevated but this was secondary to her severe copd exacerbation, especially given that her ck's were near flat. They trended down rapidly. She was started on aspirin. ## GI bleed -- Pt with coffee-ground in ng-aspirate that rapidly cleared with flushing, however hct remained stable. She was placed in PPI and hct was monitored, and was stable. She had no melena or hematochezia. ## Abdominal distension -- Had KUB [7-20] with no obstruction. Has bowel sounds and low residuals. ## RLE pallor -- Occured after pulling sheath but improved within 48 hours without intervention. Has good pulses, and this was followed closely in house. In addition, ther was a question of a R hand cellulitis. Patient received 4 days of clindamycin with marked improvement, and this was stopped. ## Code -- dnr/dni Medications on Admission: 1. Prevacid 30 QD 2. Toprol XL 50 QD 3. Lipitor 20 QD 4. HCTZ 12.5 QD 5. MVI 1 tab QD 6. Celexa 10 QD 7. FeSO4 300 QD 8. Atrovent MDI 2p QID 9. Darvocet 1 tablet prn 10. Tylenol prn 11. ASA 325 QD 12. Cozaar 50 QD 13. Advair Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB IH Inhalation Q6H (every 6 hours). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Losartan Potassium 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) IH Inhalation [Hospital1 ] (2 times a day). 17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 3 doses. 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 3 doses. 19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 4 doses. 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 21. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed. 22. Morphine 2 mg/mL Syringe Sig: 2-4 mg IV mg Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 700] Discharge Diagnosis: 1. COPD exacerbation Discharge Condition: Good Discharge Instructions: Please call your doctor or come to ED if you develop fevers, chills, shortness of breath, chest pain, nausea/ vomiting. Followup Instructions: Please call Dr. [Last Name (STitle) 17025] at [Telephone/Fax (1) 3183] for a follow up appointment within one week of discharge Completed by:[2170-7-30]	[ "305.1", "682.4", "V45.82", "729.81", "V17.3", "401.9", "412", "458.9", "276.0", "518.81", "428.0", "491.21" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.17", "96.72", "37.23", "96.6", "38.93", "96.04", "93.90" ]	icd9pcs	[ [ [] ] ]	11244, 11290	6679, 8997	331, 383	11354, 11360	3074, 6656	11528, 11695	2670, 2674		9272, 11221		11311, 11333		9023, 9249				11384, 11505						2689, 3055																						228, 293								411, 2090															2112, 2518	2534, 2654
29,631	141,170	34382	Discharge summary	report	Admission Date: [2180-12-4] Discharge Date: [2180-12-13] Date of Birth: [2101-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: arterial line placement History of Present Illness: 79M with CAD s/p recent admission persistent chest pain, ruling in for NSTEMI, 3VD on cath and now s/p in CABG w/[First Name3 (LF) 1291] on [2180-10-5], DMII found unresponsive at NH with a finger stick of 37 and given glucagon x2. he was taken to [Hospital 4068] Hospital and intubated for airway protection. He had a CXR with possible RLL pna and a Head CT that was negative. he was given Levo/Flagyl and transferred to [Hospital1 18]. In our ED his vitals were: 986 60 117/40 16550 PEEP 5 100Fi02 he was given 1 amp dextrose and started on a D5 1/2NS infusion. He had a CXR repeated which confirmed a RLL process vs CHF and CTX was added to his antibiotic regimen. He was also given Lasix 40 IV. He was transferred to the ICU intubated. As per nursing staff, confused this morning, no cough, no fevers documented. Admitted to [Hospital ] Nursing Home on [2180-11-29] with no medication changes since admission. Patient had enterococcus UTI and was given Cipro [2180-12-2]. Patient reportedly was eating well. No documented decreased PO intake and last dose of insulin was given lantus 20 U this morning. 9pm BS last night was 186 and not given any sliding scale. Past Medical History: CAD s/p 3v CABG [2180-10-5] (LIMA to LAD, SVG to OM, SVG to RCA) St. [Initials (NamePattern4) 1525] [Last Name (NamePattern4) 1291] 8/28/8 dCHF (EF 55-60% [2179-4-23] TTE) AS ([Location (un) 109] 1.0 cm2 [2179-4-23] TTE) DMII HTN hyperlipidemia prostate CA s/p prostatectomy Social History: Lives with wife in [Name (NI) ], MA. Retired salesman. Former 3 pack/day smoker, quit >30 years ago. Currently smokes a pipe. Drinks 2-4 ETOH 2-3x/week. Family History: Mother had CVA. Father had bladder CA. No known h/o premature CAD. Physical Exam: Tmax: 35.9 ??????C (96.6 ??????F) Tcurrent: 35.9 ??????C (96.6 ??????F) HR: 58 (58 - 58) bpm BP: 124/106(109) {124/106(109) - 124/106(109)} mmHg RR: 13 (13 - 13) insp/min SpO2: 100% Heart rhythm: SB (Sinus Bradycardia) General Appearance: Overweight / Obese Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), III/VI holosystolic ejection murmurs at apex and base Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : slight crackles @ r base, No(t) Diminished: , Rhonchorous: L base) Abdominal: Soft, Bowel sounds present Extremities: Right: 2+, Left: 2+ Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: LAB RESULTS: [2180-12-13] 07:55AM BLOOD WBC-10.3 RBC-3.92 Hgb-11.0* Hct-34.0* MCV-87 MCH-28.1 MCHC-32.4 RDW-14.8 Plt Ct-308 [2180-12-8] 04:09AM BLOOD Neuts-71.4* Lymphs-16.3* Monos-6.9 Eos-5.3* Baso-0.2 [2180-12-13] 07:55AM BLOOD Plt Ct-308 [2180-12-13] 07:55AM BLOOD Glucose-110* UreaN-17 Creat-1.1 Na-142 K-3.7 Cl-108 HCO3-28 AnGap-10 [2180-12-13] 07:55AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.1 [2180-12-5] 04:28AM BLOOD calTIBC-218* VitB12-1147* Folate-GREATER TH Ferritn-185 TRF-168* [2180-12-9] 11:39AM BLOOD %HbA1c-5.8 [2180-12-5] 04:28AM BLOOD TSH-2.1 [2180-12-6] 03:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [2180-12-6] 03:41AM BLOOD HCV Ab-NEGATIVE Echo [12-6]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %) with global hypokinesis and akinesis of the antero-septum, anterior wall and apex. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. A bileaflet aortic valve prosthesis is present. The prosthetic aortic valve leaflets appear normal The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen. This may be paravalvular and/or eccentric. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2180-10-10], the technical quality of th study has improved. The LVEF is similar. Aortic regurgitation is now detected (was probably present on prior study but difficult to assess). . . CTA CHEST [2180-12-4]: A heterogeneous lobualated left thyroid lobe is enlarged to 3.7 x 2.6 cm. The pulmonary arteries are patent to the subsegmental level. The aorta and great vessels show extensive atherosclerosis . Several borderline enlarged mediastinal nodes include a right paratracheal and an AP window node. Extensive coronary artery calcification as well as post CABG. Cardiomegaly is moderate. There is no pericardial effusion. Bilateral effusions are moderate with left relaxation atelectasis and right atelectasis versus consolidation noted. The imaged upper abdomen including the liver and spleen appear unremarkable except to note a 3 mm gallstone without evidence of cholecystitis. BONE WINDOWS: No concerning lytic or sclerotic lesion is identified. Bilateral healed and healing rib fractures are noted. A nasogastric tube courses through the esophagus to terminate in the upper stomach and may be advanced further. IMPRESSION: 1. No pulmonary embolism. 2. Moderate bilateral effusions and atelectasis. 3. Large lobulated left thyroid. Recommend correlation with ultrasound. 4. Right lower lobe atelectasis versus pneumonia. . . Brief Hospital Course: The patient was admitted to the medical intensive care unit from the referring hospital. He continued to be mechanically ventilated. His hypoglycemia resolved. He had 3 days of spontaneous breathing trials in which he was unable to come of the vent. His hypoxia was thought secondary to decompensated CHF. He was therefore diuresed with a lasix drip and with the help of phenylephrine infusion and showed improvement in blood pressure such that phenylephrine was able to be weaned off easily. He continued to have thick secretions from his ETT tube and was covered with vancomycin and zosyn for healthcare associated pneumonia, but with suspicion for aspiration during his initial event. He was extubated on hospital day five without complication. The patient was transferred to the general medicine floor on hospital day six. His oxygenation continued to improve. He completed a seven day course of antibiotics for his pneumonia. . # Hypoglycemia: The patient is a diabetic, type II. The patient's hypoglycemic episode occurred on regimen of Lantus 20 units qHS, metformin, and an insulin sliding scale. This regimen was likely too aggressive for this patient. His wife reported that the patient was not eating much at the nursing home because he did not like the food. This change in food intake may have contributed to his episode of hypoglycemia. The patient's HbA1c is 5.8. We recommend that the patient follow the following an insulin sliding scale and that you consider transitioning patient to an oral regimen. . # Coronary artery disease/heart failure: Patient is s/p recent CABG/[Month/Day/Year 1291] [9-15] with bioprosthetic valve. The patient does not require anti-coagulation for his bioprosthetic valve. We recommend that the patient continue to take aspirin, pravastatin and his lasix at 20 mg PO BID. We switched the patient's beta-blocker to metoprolol 12.5 mg PO BID. We recommend that the patient start an ACEI as the patient's blood pressure allows. . # renal function: The patient had a worsening in his renal function on hospital day seven, likely related to overdiuresis. The patient's renal function improved with gentle IVF and holding his lasix. Medications on Admission: Aspirin 81 mg Tablet Acetaminophen 325 mg Docusate Sodium 100 mg [Hospital1 ] Albuterol Sulfate prn Ipratropium Bromide 0.02 % prn Folic Acid 1 mg qd Thiamine HCl 100 mg qd Atorvastatin 80 mg qd Atenolol 12.5 mg qd Furosemide 20 mg [Hospital1 ] Insulin Glargine 25U daily Insulin Lispro Sliding Scale Fosamax 70 mg Tablet weekly Metformin 500 mg [Hospital1 ] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Tablet(s) 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. 11. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units Injection ASDIR (AS DIRECTED): as per sliding scale. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: Hypoglycemia, in type II Diabetic on insulin Pneumonia Secondary Diagnoses: Cornoary Artery Disease s/p Aortic Valve Replacement Systolic Heart Failure (EF 30-35%) Diabetes Mellitus, Type II, well controlled, HbA1C 5.8 hypertension hyperlipidemia history of prostate cancer s/p prostatectomy Discharge Condition: stable Discharge Instructions: You were admitted after you were found unresponsive with a very low blood sugar. We think that your insulin regimen was too aggressive for your decreased level of food intake at the nursing home. We recommend that you check you blood sugars [4-11] times a day and adhere to the attached insuling sliding scale. During this admission you were also treated for a pneumonia. We have made the following changes to your medication regimen. We have discontinued your insulin glargine (lantus). We have discontinued your atenolol and instead started metoprolol 12.5 mg tablets, 1 tab by mouth twice daily. We have discontinued your albuterol and ipratropium inhalers. You do not have a history of lung disease. You did not require any inhalers this admission. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please contact your doctor or go to the emergency room if you have any of the following symptoms: feeling shaky, sweating, dizziness, nausea, vomiting, confusion, worsening cough, fever greater that 100.4, chills, shortness of breath or any other concerning symtpoms. Followup Instructions: You have a follow up appointment scheduled with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [1-10], at 2pm. Please call [Telephone/Fax (1) 67509] if you have questions. Please consider adding a ACE inhibitor for his heart failure if his blood pressure will tolerate. We have not started this medication due to systolic blood pressures in the 100-110s. We recommend that the patient get a thyroid ultrasound to follow up on a lobulated left thyroid gland noted incidentally on CTA CHEST on [2180-12-4]. Completed by:[2180-12-13]	[ "428.43", "401.9", "V10.46", "272.4", "250.80", "584.9", "997.31", "599.0", "507.0", "410.72", "518.81", "V42.2", "V45.81", "428.0", "041.4" ]	icd9cm	[ [ [] ] ]	[ "38.93", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	9982, 10096	6304, 8499	328, 353	10433, 10442	3083, 6281	11621, 12238	2102, 2170		8920, 9959		10117, 10173		8525, 8897				10466, 11598						2185, 3064			10194, 10412																			276, 290								381, 1588															1610, 1911	1927, 2086
1,699	168,451	27876	Discharge summary	report	Admission Date: [2170-3-3] Discharge Date: [2170-3-12] Date of Birth: [2101-8-31] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1384] Chief Complaint: Admitted for liver transplant Major Surgical or Invasive Procedure: Orthotopic Liver Transplant [2170-3-3] History of Present Illness: 68 y/o male with PMH of cryptogenic cirrhosis, and hepatocellular carcinoma s/p RFA, with current MELD of 22. Denies fever, chills, sweats, headache, dizziness, chest pain, SOB, N/V, abdominal pain. Only positive complaint on ROS is fatigue. Of note, he has had a prior splenectomy and has partial occlusion of the portal vein. Past Medical History: 1. Hepatocellular carcinoma, diagnosed via CT-guided biopsy [6-28], well-differentiated. Normal AFP 3.4. 2. Cirrhosis, incidentally diagnosed in [2159] following splenectomy for splenic rupture following fall, complicated by varices and ascites. 3. ? Hemochromatosis diagnosed in [2162], but negative HFE, phelobotomies until 1 year ago. Recently told that he did NOT have it. 4. Hypertension 5. DM type 2 6. Known partial portal and SMV thrombosis, first seen on imaging 01/[2168]. 7. Esophageal varices, status post banding on [2169-4-11] and [2169-6-6] 8. Status post splenectomy following traumatic rupture 9. History of TIA 10. Chronic pancreatitis with diffuse duct dilatation, ? IPMN Social History: He lives with his wife. They have 4 children, grown. remote hx smoking, quit >25 years ago. No EtOH. Family History: Mother deceased, age 56, stomach cancer. Father deceased, age 74, diverticulitis, DVT, PE. 2 healthy sisters. Physical Exam: Gen: NAD HEENT: anicteric, PERRLA, EOMI, neck supple, no LAD Neuro: CN II-XII grossly intact Card: RRR Lungs: CTA bilaterally Abd: Soft, non-tender, non-distended Extr: No edema Pertinent Results: On Admission: [2170-3-3] WBC-6.9 RBC-2.77* Hgb-10.3* Hct-31.7* MCV-114* MCH-37.3* MCHC-32.7 RDW-14.2 Plt Ct-253 PT-13.5* PTT-29.6 INR(PT)-1.2 Fibrino-163 Glucose-284* UreaN-20 Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-22 AnGap-17 ALT-28 AST-36 AlkPhos-179* TotBili-1.1 Albumin-2.9* Calcium-9.3 Phos-2.6* Mg-2.0 Brief Hospital Course: 68 y/o male with PMH of cryptogenic cirrhosis, and hepatocellular carcinoma s/p RFA, with current MELD of 22 who presents for OLT. The donor is a 35-year-old donor after cardiac death. The donor is hemodynamically stable but is a high risk donor due to recent IV drug abuse with negative serologies. The recipient is aware of the social history. Please see the operative note for surgical details. Of note the patient had extensive adhesions and the left lobe of the liver was hypertrophied into the splenic bed. The portal vein was thickened and partially occluded, clot was removed, and thrombectomy completed on the recipient portal vein. During course of the hepatectomy, there was constant oozing diffusely and systolic pressures were in the 70-90 range. He also required some pressor support during this time point as well as following reperfusion, which quickly corrected. After about 10 minutes of hepatic artery reperfusion, there was poor flow in the hepatic artery. This appeared to be due to spasm and some topical papaverine was placed on the hepatic artery. The common hepatic artery was mobilized to the GDA and the GDA ligated. Following this, there was excellent flow in the hepatic artery and no further revision was done. The patient overall tolerated the procedure well and by the end of the case had systolic pressures in the 100-110 range. Patient transferred still intubated to the intensive care unit in stable condition. He received immunosuppression intra-op and post-op per transplant protocol. Patient extubated on POD 1, and has required some O2 support via NC. Patient transferred out of the SICU on POD3. PT consult obtained, patient requiring assistive devices (walker, cane) due to feeling unsteady. Patient was placed on insulin drip for elevated blood sugars. On POD 4, NPH and sliding scale implemented with good response. Patient will likely discharge home with insulin. Patient remained on O2. During PT consult, sats dropped to 88% on RA, improved to 91% on 2L. Lasix given IV and IS was encouraged. Lateral JP drain removed on POD 4 as well as Foley. On [3-8] (POD5) late in the afternoon the patient was sitting in a chair and was noted by his wife to be flailing arms, and unable to speak. Patient was transferred to bed by team, briefly lost consciousness and then slowly regained function. Approximately 20 minutes later the patient, who had been speaking with the team, suddenly began making unintelligle sounds, his eyes rolled back and he clenched his jaw. This lasted greater than 1 minute. Received Ativan, once stable underwent head CT and was transferred back to the SICU. He was also evaluated by the neuro team. Head CT showed: 1. No hemorrhage or mass effect. 2. Chronic lacunar infarct in the left cerebellar hemisphere. Patient underwent MR of head and MRA, which showed no evidence of acute infarct, hemorrhage, or enhancing masses to explain patient's current seizures. The MR did show changes from chronic small vessel ischemic disease. MRA was normal with normal appearing Circle of [Location (un) 431]. Patient was transferred back to the surgical floor the following day. There has been no repeat seizure activity noted. Neuro did not feel that any medication should be started at this time. Patient was stable the following two days, liver function tests continued to improve and patient was ready for discharge home with home PT and Nursing. Medications on Admission: Propranolol 10??????, Glyburide 2.5??????, Metformin 500????????????, Lactulose 10g QD & prn, Flomax 0.4??????, Furosemide 40??????, Spironolactone 100?????? Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day: Follow [Hospital 1326] Clinic Taper. 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:30 Tablet(s) Refills:0 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day: Take with breakfast. Disp:qs bottles Refills:2 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous at bedtime. Disp:qs units Refills:2 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: check blood sugar before meals. Administer insulin per sliding scale. Disp:qs bottles Refills:2 14. Insulin Syringe 0.5cc/28G Syringe Sig: One (1) Miscellaneous up to 6 daily: Disp: 1 box Refill: 2. Disp:1 box Refills:2 15. glucometer strips One Touch Ultra Test Strips Disp 2 Bottles Refill: 2 16. Lancets Lancets for Finger stick blood sugars Disp 2 bottles Refill: 2 17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: cryptogenic cirrhosis now s/p Orthotopic Liver Transplant Seizure [2170-3-9] Discharge Condition: Good Discharge Instructions: Please call [Telephone/Fax (1) 673] if you experience fever, chills, nausea, vomiting, diarrhea, inability to take or keep down medications. Monitor incision for redness, drainage or bleeding. Measure and record blood sugars and take insulin as prescribed. Bring this record with you to transplant clinic Do not drive if you are taking narcotic pain medications Labwork to be done every Monday and Thursday: CBC, Chem 10, AST, ALT, T Bili, Alk Phos, Trough Prograf level. Please have results faxed to [Telephone/Fax (1) 697] ([Hospital 1326] Clinic) Followup Instructions: [Name6 (MD) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2170-3-15] 10:40 [Last Name (LF) ],[First Name3 (LF) 156] TRANSPLANT SOCIAL WORK Date/Time:[2170-3-22] 11:00 [Name6 (MD) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2170-3-22] 11:40 Completed by:[2170-3-14]	[ "571.5", "250.00", "275.0", "E849.7", "780.39", "577.1", "572.3", "401.9", "155.0", "E878.8", "998.89" ]	icd9cm	[ [ [] ] ]	[ "99.05", "50.59", "99.04", "00.93" ]	icd9pcs	[ [ [] ] ]	7733, 7795	2242, 5660	309, 353	7920, 7927	1910, 1910	8537, 8928	1584, 1696		5868, 7710		7816, 7899		5686, 5845				7951, 8514						1711, 1891																						240, 271								381, 711								1924, 2219							733, 1449	1465, 1568
22,624	110,498	43871	Discharge summary	report	Admission Date: [2117-3-31] Discharge Date: [2117-4-2] Date of Birth: [2070-8-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 943] Chief Complaint: MICU call out, initial admit for Hematemesis Major Surgical or Invasive Procedure: EGD x2 History of Present Illness: 46 y.o. male with history of alcoholism and Hep. C, complicated by varices, ascites and encephalopathy who presented with hematemesis. . Patient reported continued alcohol use, but less compared to his routine. He notes two recent stressors - pain and a break-up with his girlfriend, which caused him to rely more heavily on alcohol and in doing so, he noticed "dark" emesis evening of admisison around 10 PM, which was persistent, prompting him to call EMS. He denies fevers, chest pain, SOB, but does report some lightheadedness. He denied any BRBPR, but did not increasing dark to black stools. . In the ED, patient was reported to have 700 ccs of coffee ground and bright red blood emesis. However, he remained hemodynamically stable with SBPs ranging from 123-130 and no tachycardia. A hepatology consult was placed and the patient was started on Ceftriaxone and received 3 L of NS before coming to the floor. . Of note, pt. was hospitalized at [Hospital1 18] from [2-24] - [3-10] for encephalopathy and had an EGD revealing 2 cords of grade I - II esophageal varices, which were banded. He was also found to have portal hypertensive gastropathy at this time. . Patient was initially admited to the MICU and underwent EGD which showed varices. Received 1 unit PRBC with originally with no improvement in hct. Had EGD the following day. Banding was not performed during either EGD. In total received 3 units PRBC, 2U FFP. Last transfusion [3-31] at 5PM. . At time of transfer pt has no complaints. Denies any recent vomiting. Continues to have some dark stools. Denies lightheadedness, dizziness, chest pain. Past Medical History: - Etoh cirrhosis, actively drinking, MELD 18 - HCV viral load is 436,000 international units. The patient has not had a liver biopsy nor has the patient had any treatment to date for his hepatitis C followed by Dr. [Last Name (STitle) 497] (last seen [12-9]). - EGD [2115-12-23] revealing varices at the lower third of the esophagus, with two bands placed, and portal gastropathy. - Grade 3 esophageal varices with multiple admissions for GIB, banding in past - Ethanol abuse with history of DTs. - h/o Nephrolithiasis. - MVA [2113-5-4] with two fractured lumbar vertebrae, torn rotator cuff, and humeral head fracture. - h/o coagulopathy, anemia (baseline Hct ~30), thrombocytopenia - foot surgery - facial reconstruction as a child - leg cramps - asthma Social History: The patient is single. Moved to cape and is living with friends. Currently moving. He is actively drinking. Has long hx of etoh abuse (since high school, with 1 6 month period of sobriety) and withdrawl. He smokes 1 pack every 3 days, x 30+ years. He is not working. He used to work as a carpenter. He denies IVDA x last 15 years, has used intranasal drugs within the past year or so, +cocaine/heroin use in past; hx of incarceration in the past. Family History: He does not know much about his family history. He does not know of any liver disease or colon cancer. Physical Exam: Tmax 99 Tc 98.6 BP 131/93 (130-140/80-92) HR 80 RR 14 O2 96%RA I/O (24 hr)3216/1455 . Gen: Young male lying in bad in nad HEENT: PERRL, EOMI, OP clear, poor dentition Neck: Supple, no LAD Lungs: CTAB, no carckles. Heart: S1, S2 nl, no m/r/g appreciated Abd: Soft, nontender, nd Ext: No lower ext edema. Neuro: CN II - XII intact, moves all extremities equally Pertinent Results: EGD [3-31] Varices at the lower third of the esophagus Medium hiatal hernia Blood in the stomach body Erythema, congestion, nodularity and friability in the stomach body and fundus compatible with portal hypertensive gastropathy Blood in the first part of the duodenum and second part of the duodenum There were no gastric varices. Otherwise normal EGD to second part of the duodenum . EGD [4-1] Impression: Esophageal varices Erythema, congestion, nodularity and friability in the stomach body and fundus compatible with portal hypertensive gastropathy Blood in the stomach Otherwise normal EGD to second part of the duodenum Recommendations: Continue once daily PPI. Brief Hospital Course: Pt is a 46 yo M with history of ETOH/HCV cirrhosis with known varices and portal gastropathy admitted with hematemesis. Now being called out of the ICU. . # Hematemesis: Baseline hct 26-30 and patient presented with hct of 22 which then dropped to 19. EGD was performed x2 which showed esophageal varices as likely source of bleed, but no active bleeding from site. He had variceal banding performed recently on [3-8]. EGD this admission also showed gastritis. He received a total of 3U prbcs and 2U FFP and hct at time of discharge was 30 and he was without evidence of any further active bleeding. Nadolol and diuretics were originally held in the setting of unstable blood volume, but were restarted upon his discharge. . # Cirrhosis: Secondary to ETOH and HCV. Multiple complications including variceal bleeding, ascites, encephalopathy, coagulopathy, thrombocytopenia. As above, nadolol, lasix, and spironolactone were originally held, but were restarted for discharge. He was taking pentoxyfilline on admission, but this was discontinued per liver team. . # Alcohol abuse: He continues to actively drink with last drink 1 night PTA. He has history of withdrawal, no seizures. He was placed on CIWA scale with prn valium and was continued on MVI, thiamine and folate. Although addressed with social work and case management, he currently refuses rehab as he states that he has been "detoxed" here. . # Hepatic encephalopathy: He was not encephalopathic during this admission. He was continued on lactulose titrated for goal [4-8] bowel movements daily. . # Ascites: Fluid from previous paracenteses showed SAAG c/w portal HTN. No paracentesis performed during this admission. He was restarted on spironolactone and lasix prior to his discharge. . # Coagulopathy/thrombocytopenia: Secondary to cirrhosis. In the setting of his GI bleed, he received vitamin K and 2U FFP. . # Asthma: During this admission, he had no active pulmonary issues. He was continued on prn albuteral and ipratropium. Medications on Admission: Meds at home: Has not been taking his meds for 5 days. Meds from last d/c summary: 1. Thiamine HCl 100 mg Qday 2. Hexavitamin Qday 3. Gabapentin 300 mg TID 4. Nadolol 40 mg qday 5. Pentoxifylline 400 mg TID 6. Folic Acid 1 mg Qday 7. Furosemide 80 mg [Hospital1 ] 8. Spironolactone 150 mg [Hospital1 ] 9. Lactulose 10 g/15 mL QID 10. Clonidine 0.1 mg [Hospital1 ] 11. Albuterol 90 mcg prn 12. Sucralfate 1 g QID 13. Atrovent prn 14. Omeprazole 20 mg [Hospital1 ] 15. Nicotine 21 mg/24 hr Patch 16. Hydromorphone 2 mg Q8hrs:prn . MEds at transfer: Ciprofloxacin 400 mg IV Q12H Duration: 5 Days Multivitamins 1 CAP PO DAILY Diazepam 10 mg IV Q2H:PRN CIWA>10 Nicotine Patch 21 mg TD DAILY Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Pantoprazole 40 mg IV Q12H Gabapentin 300 mg PO Q8H HYDROmorphone (Dilaudid) 0.5-2 mg IV Q6H:PRN Lactulose 30 ml PO QID Goal [4-8] BM's per day Thiamine HCl 100 mg PO DAILY Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:qs Tablet(s) Refills:2 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:qs Refills:2 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:90 Capsule(s) Refills:0 4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 7. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:90 Tablet(s) Refills:0 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Titrate to [4-8] BMs daily. Disp:qs Refills:0 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 10. Albuterol 90 mcg/Actuation Aerosol Sig: [1-5] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:qs Refills:0 11. Sucralfate 1 g Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:0 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. Disp:qs 1 month supply Refills:2 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:4 Tablet(s) Refills:0 15. Atrovent Inhalation 16. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for pain. Disp:15 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Esophageal varices Cirrhosis Alcohol abuse/dependence . Asthma Recent Left humeral surgical neck fracture Discharge Condition: Stable with stable hematocrit and hemodynamics. Discharge Instructions: Please call your doctor or return to the emergency room if you develop blood in your vomit or stool, fevers/chills, nausea/vomiting, inability to tolerate food/fluid, heavy alcohol consumption, or alcohol withdrawal. . Please avoid alcohol consumption. . Please follow up with your appointments as scheduled below. Please take your medications as prescribed and be sure to complete an addional 2 days of your antibiotics. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 497] on [4-30] at 2:40pm. . Appointments scheduled prior to this admission: 1. Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7676] Phone:[Telephone/Fax (1) 1387] Date/Time:[2117-4-16] 9:40am 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1984], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2117-4-29] 8:20am 3. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2117-4-30] 1:30pm	[ "571.2", "280.0", "553.3", "070.70", "303.91", "572.2", "305.1", "305.93", "456.20", "305.63", "493.90", "572.3", "286.7", "287.4", "592.0", "537.89", "276.1", "535.50" ]	icd9cm	[ [ [] ] ]	[ "99.07", "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]	9209, 9215	4508, 6533	357, 365	9389, 9439	3803, 4485	9909, 10533	3302, 3408		7509, 9186		9236, 9368		6559, 7486				9463, 9886						3423, 3784																						273, 319								393, 2025															2047, 2821	2837, 3286
29,199	126,623	33215	Discharge summary	report	Admission Date: [2154-2-5] Discharge Date: [2154-2-26] Date of Birth: [2079-10-31] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 473] Chief Complaint: Obstructive Painless Jaundice Pancreatic Mass Major Surgical or Invasive Procedure: Total Pancreatectomy History of Present Illness: This is a 74 year old male who presents with lethargy, mild weight loss and painless obstructive jaundice and pruritis. He has a decreased appetite, and he had some diarrhea. He was seen and evaluated by Dr. [Last Name (STitle) ] and had placement of a biliary stent. Past Medical History: A-fib, staging laparoscopy [1-21], ERCP w/stent placement, eye surgery, tonsillectomy Social History: Engaged Retired insurance executive Physical Exam: Gen: Thin, healthy man with profound jaundice and scratching. No peripheral lymphadenopathy CV: Atrial fibrillation Chest: Clear on auscultation Abd: Soft, no massess, nontender Ext: full range of motion, +pulses bilaterally. Pertinent Results: [2154-2-5] 04:34PM BLOOD WBC-9.2 RBC-3.45* Hgb-10.2* Hct-29.9* MCV-87 MCH-29.6 MCHC-34.1 RDW-17.0* Plt Ct-260 [2154-2-7] 02:09AM BLOOD WBC-11.3* RBC-2.96* Hgb-8.9* Hct-26.5* MCV-89 MCH-30.0 MCHC-33.6 RDW-17.1* Plt Ct-209 [2154-2-11] 08:40AM BLOOD WBC-8.9 RBC-3.15* Hgb-9.4* Hct-28.3* MCV-90 MCH-29.9 MCHC-33.3 RDW-17.4* Plt Ct-214 [2154-2-8] 08:22AM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.2* [2154-2-11] 08:40AM BLOOD Plt Ct-214 [2154-2-6] 04:23PM BLOOD Glucose-235* UreaN-28* Creat-1.0 Na-139 K-4.5 Cl-108 HCO3-24 AnGap-12 [2154-2-9] 01:36PM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-145 K-3.2* Cl-105 HCO3-29 AnGap-14 [2154-2-11] 02:44AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-142 K-3.0* Cl-106 HCO3-28 AnGap-11 [2154-2-11] 08:40AM BLOOD CK(CPK)-98 [2154-2-11] 08:40AM BLOOD CK-MB-NotDone cTropnT-0.03* [2154-2-11] 02:44AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.7 . Pathology Examination DIAGNOSIS: I. Gallbladder (A): 1. Chronic cholecystitis. 2. No calculi or tumor. II. Pancreatic neck margin of Whipple specimen (B): 1. Marked atrophy, with fibrosis and chronic inflammation. 2. No tumor. III. Proximal jejunum (C-D): Segment of small intestine: Within normal limits. IV. Whipple specimen, pancreaticoduodenectomy (E-AG): 1. Adenocarcinoma of the head of pancreas, see synoptic report. 2. Obstruction of the common bile duct, due to invasion of the wall by tumor. 3. Marked fibrosis and atrophy of the pancreas. 4. Segment of duodenum: Within normal limits. V. Pancreas body and tail (AH-AV): 1. Separate small adenocarcinoma of the pancreatic body, 1.5 cm in diameter. a. Well differentiated. b. Minimal invasion of the surrounding adipose tissue. c. No tumor at the inked outer margin. 2. Marked fibrosis/atrophy of the pancreas with dilated pancreatic duct. 3. Multiple microscopic foci of pancreatic intraepithelial neoplasia (PanIN), ranging from low to high grade. 4. No lymph nodes in this segment. Note: Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] (for Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 468]) was notified on [2154-2-7]. Pancreas (Exocrine): Resection Synopsis MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, total pancreatectomy. Tumor Site([Doctor Last Name ] tumor): Pancreatic head. Tumor Size Greatest dimension: 4.8 cm. Additional dimensions: 4.5 cm x 3.4 cm. Other organs/Tissues Received: Gallbladder, jejunum.. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G1: Well differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 29. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Margin(s) involved by invasive carcinoma: Posterior retroperitoneal (radial) margin: posterior surface of pancreas. Uncinate process margin (non-peritonealized surface of the uncinate process). Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Additional Pathologic Findings: Pancreatic intraepithelial neoplasia -- highest grade: PanIN: III. . Cardiology Report ECG Study Date of [2154-2-9] 1:27:34 PM Atrial fibrillation with rapid ventricular response. Poor R wave progression suggest prior anteroseptal myocardial infarction. Non-specific ST-T wave changes. Low QRS voltage in the limb leads. Compared to the previous tracing of [2154-1-24] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 113 0 102 344/436 0 29 -16 . CHEST (PORTABLE AP) [2154-2-11] 10:09 AM FINDINGS: In comparison with the study of [2-6], there is little overall change. Some prominence of the cardiac silhouette and interstitial markings is again seen. The increased opacification at the left base is again consistent with some atelectatic change in the retrocardiac region. . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2154-2-12] 05:00AM 12.5* 3.51* 10.5* 31.1* 89 30.0 33.8 17.7* 258 ENZYMES & BILIRUBIN ALT AST CK(CPK) AlkPhos Amylase TotBili [2154-2-11] 06:14PM 68* 73* 125 224* 13 18.4* . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2154-2-16] 12:50 PM CONCLUSION: 1. Large bibasilar effusions with increased interstitial markings and ground glass opacities throughout both lungs suggestive of pulmonary edema from fluid overload or CHF. 2. No central or segmental pulmonary emboli, however, given the extent of effusions and passive atelectasis, subsegmental pulmonary emboli in the lower lobes cannot be excluded. 3. Abdominopelvic ascites with no evidence of abscess. 4. Postoperative changes in the upper abdomen in keeping with recent laparotomy. Stable pneumobilia and intra-hepatic biliary dilatation. 5. Subcentimeter hypodensities in the liver and left kidney likely represent cysts or hemangiomas. . CHEST (PORTABLE AP) [2154-2-18] 9:04 AM IMPRESSION: No significant changes in moderate right and small left pleural effusions. Bilateral parenchymal opacification predominantly apical distribution is atypical for pulmonary edema and pneumonia is another consideration. . TTE (Complete) Done [2154-2-18] at 10:37:50 AM Conclusions The left atrium is dilated. The right atrium is markedly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) 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 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Brief Hospital Course: This is a 74 year old male with painless obstructive jaundice. He went to the OR on [2154-2-5] for: Total Pancreatectomy with Splenic Preservation and Open Cholecystectomy. Pain: He had an epidural for pain control. He was then switched to a PCA and once tolerating clears, was started on PO pain meds. GI/Abd: He was NPO, IVF and a NGT. Per the Whipple pathway, the NGT was removed on POD 3. His diet was slowly advanced along. His incision was C/D/I with staples in place. His abdomen was soft and nontender. He did not have a drain in place. He was on TPn for nutritional support. This was weaned off as he was able to tolerate a regular diet. We encouraged a diet with supplemental shakes. Post-op Hyperglycemia: He was followed by [Last Name (un) ] to blood sugar management. He was getting Lantus qhs and a Humalog sliding scale. Post-op Hypotension/Hypovolemia: The early morning of POD 6, the patient had a fall from standing when getting up to use the bathroom. Later that morning he was found to have a BP of 74/68 and was tachycardic to the 140's. He received several fluid boluses without immediate effect. He was asymptomatic. Cardiology consult was called and they were considering cardioversion. His HR settled out in the 90-100's. His BP gradually improved and his UOP slowly picked up. He received 1 unit PRBC. His HCT was stable and he did not appear to have a bleed. . Post-op Tachycardia: Diltiazem drip. Changed to PO Diltiazem. He was switched to PO Lopressor for rate control. His dose was titrated up as his BP tolerated it. He continued to have elevated HR. POD [10-26], after transfer to the PACU, he was started on a Diltiazem drip. He was then switched to PO Diltiazem and his HR was well rate controlled. . Post-op Orthostasis: On POD 8, when working with PT, he continued to be unsteady and orthostatic with a drop in BP to 80's. At time of discharge he was able to take short walks with supervision. He was still quite deconditioned and will require rehab. . Respiratory: He was started on Cipro on [2-14] for possible pneumonia. . Acute CHF: On POD [10-26], he developed CHF and had some respiratory distress. He was transferred to the PACU, as no ICU beds were available. He was placed on a oxygen face mask and maintained his O2 sats. He also received Lasix for diuresis with good results. He continued to receive aggressive Diuresis with Lasix [Hospital1 ]. At time of discharge he still had significant LE edema, and his weight was near his baseline. We repleated his potassium as needed. . Sepsis: When he decompensated on POD 10, with CHF and possible sepsis, he was started on Vanco, Flagyl and continued on Cipro. Vancomycin and Zosyn were continued for 10 days. Medications on Admission: diltiazem 120', warfarin 7.5', zolpidem 5qhs, vicodin Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold HR<60, BP<100. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): continue for LE edema and pleural effusion. 5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day: continue while taking Lasix. monitor potassium level. 6. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Monitor INR and adjust dose accordingly. 7. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) Subcutaneous at bedtime. Units 8. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous four times a day: see sliding scale. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57850] Healthcare Center - [Location (un) ] Discharge Diagnosis: Pancreatic Cancer Rapid A-fib Post-op blood loss anemia Post-op hypovolemia post-op hypotension post-op orthostasis post-op sepsis post-op malnutrition post-op deconditioning post-op lower extremity edema post-op hypokalemia Discharge Condition: Good Tolerating a diet Able to walk short distances with assistance incision C/D/I pain well controlled Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . 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 skin, or the whites of your eyes become yellow. * 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. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily and work towards daily ambulation. * No heavy lifting (>[10-30] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 468] in 2 weeks. Call [Telephone/Fax (1) 2835] to schedule an appointment. Please follow-up with [Last Name (un) ] for blood glucose control. Call [Telephone/Fax (1) 2378] to schedule an appointment. Completed by:[2154-2-26]	[ "E878.6", "486", "276.52", "E849.7", "575.11", "518.0", "276.8", "157.0", "250.02", "458.29", "427.31", "576.2", "263.9", "038.9", "785.0", "285.1", "157.1", "995.91" ]	icd9cm	[ [ [] ] ]	[ "96.07", "51.22", "38.93", "99.04", "52.6", "99.15" ]	icd9pcs	[ [ [] ] ]	11046, 11184	7289, 10022	359, 382	11453, 11559	1110, 7266	13323, 13616			10126, 11023		11205, 11432		10048, 10103				11583, 11583				11598, 13300		864, 1091																						274, 321								410, 683															705, 796	812, 849
30,208	143,272	51834	Discharge summary	report	Admission Date: [2180-8-4] Discharge Date: [2180-8-7] Date of Birth: [2111-12-2] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Compazine / Benadryl / Sulfonamides / Oxycodone Attending:[First Name3 (LF) 1973] Chief Complaint: Shortness of breath, Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known firstname ] [Known lastname ] is a 68 year old female with history of DM2, HTN, hyperlipidemia who presents with productive cough x 2 days and sudden development of shortness of breath and fever since evening prior to admission. She had been in her usual state of health until 2 days ago when she developed cough. She was unable to bring up any sputum with the cough. She had no other associated symptoms until yesterday evening at 11PM, while lying in bed she developed acute onset of shortness of breath, fevers, chills. She had associated headache, lightheadedness. She had no chest pain, abdominal pain, diarrhea or constipation. . On [7-25] she was seen in dermatology clinic for abdominal rash/nonhealing erosion which was biopsied at that time. Biopsy revealed trauma/excoriation with bacterial superinfection with S. aureus. She was started on topical bactroban and topical triamcinolone which reportedly helped initially, but worsened over the past day. Ms. [Known lastname ] is also followed in [Hospital ] clinic for chronic minocycline suppression for history of recurrent Group B strep cellulitis/bacteremia. . In the ED, T 102.6, Tmax 102.9, BP 154/88, HR 131, RR 16, O2sat 98% on NRB. EKG with ST at 105, nl axis, nl intervals, ST depressions V2, TWI III, V1, V2, TWF avF, V3-V4. Labs were notable for lactate of 4.6, WBC 16.2, 2% bands. First set of cardiac enzymes are negative. CXR showed LLL PNA. UA was negative. She was given one dose of Levaquin 750mg x1. She was given tylenol 500mg x1, Aspirin 325mg x1 and 1L NS. She has 2 PIV in place. She was seen by Dr. [Last Name (STitle) ] of ID in the ED who felt that abdominal rash was expanding compared to prior. . On arrival to the [Hospital Unit Name 153] the patient is on NRB. She notes that her breathing is much more comfortable than on arrival to the ED. She denies chest pain, diaphoresis, abdominal pain, diarrhea, constipation. She continues to have cough but is unable to produce sputum. She also reports dysuria and urinary frequency over the past week. She reports history of food "going down the wrong pipe" and food getting stuck occasionally. Past Medical History: 1. DM2 2. HTN 3. Dyslipidemia 4. Obesity 5. Panic disorder/Depression 6. Personality disorder, NOS 7. Status post R knee replacement 8. Total abdominal hysterectomy-for Ovarian CA in [2158] 9. s/p GI bleed 10. Peptic ulcer disease/GERD 11. Diverticulosis 12. Status post cholecystectomy [85]. Borderline personality 14. B/L Breast reduction c/b L breast cellulitis/abscess 15. UTI completed 7 d course of Cipro [2178-8-15] 16. Osteoarthritis 17. OSA on CPAP at home 18. Sinusitis Social History: Patient lives alone in [Location (un) ] - in a shelter. She attends a psych day facility called [First Name4 (NamePattern1) 1634] [Last Name (NamePattern1) ]. Has 1 child but is estranged from him. Sister [Name (NI) 12074] is HCP. [Name (NI) ] alcohol, tobacco, or drug use. Family History: non-contributory at present. Physical Exam: VS: T 97.6, BP 106/57, HR 89, RR 22, O2 sat 100% NRB GEN: Well appearing elderly, obese female in NAD on NRB. Not using accessory muscles, breathing comfortably. Speaking in full sentences. HEENT: AT, NC, poor dentition, PERRLA, EOMI bilaterally, edema of right eyelid, no conjunctival erythema, anicteric, dry MM Neck: supple, no LAD, no carotid bruits, JVP difficult to assess CV: RRR, nl s1, s2, no m/r/g appreciated. PULM: Distant breath sounds bilaterally with decreased most notably at left base. No wheezing on exam. ABD: Obese, soft, NT, ND, + BS, no HSM. Rash described below. EXT: Varicose veins, warm, dry, +2 distal pulses BL, no femoral bruits, trace edema bilaterally NEURO: Alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. PSYCH: appropriate affect Skin: Erythema, warmth on abdomen extending from site of prior biopsy, no pus able to be expressed from biopsy site. Sutures in place. Area marked. Erythema and papules also appreciated in inguinal folds bilaterally. Pertinent Results: [2180-8-4] 05:15AM WBC-16.5# RBC-4.67 HGB-13.1 HCT-41.5 MCV-89 MCH-28.1 MCHC-31.6 RDW-14.3 [2180-8-4] 05:15AM NEUTS-82 BANDS-2 LYMPHS-13* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2180-8-4] 05:15AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2180-8-4] 05:15AM PLT SMR-NORMAL PLT COUNT-196 [2180-8-4] 05:15AM GLUCOSE-207* UREA N-24* CREAT-1.0 SODIUM-140 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-17 [2180-8-4] 05:20AM LACTATE-4.6* [2180-8-4] 05:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2180-8-4] 05:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . [2180-7-24] 3:12 pm TISSUE Site: SKIN Source: Skin biopsy. GRAM STAIN (Final [2180-7-24]): REPORTED BY PHONE TO [First Name8 (NamePattern2) 6118] [Last Name (NamePattern1) 6119] @ 4PM [2180-7-24]. 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. TISSUE (Final [2180-7-27]): STAPH AUREUS COAG +. SPARSE GROWTH. Please contact the Microbiology Laboratory ([8-/2478]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2180-7-28]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2180-7-25]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): . [7-24] Skin biopsy: Bacterial (Gram positive cocci in clusters on Gram stain) colonies are present within the surface of the ulcer bed. No fungi are seen in PAS - reacted sections. No viral cytopathic changes are seen (multiple levels examined). The findings suggest traumatic injury/excoriation with bacterial superinfection, however a primary impetigo complicated by excoriation is also within the differential diagnosis Brief Hospital Course: # Aspiration Pneumonia: The patient presented with a 2 day history of cough, shortness of breath and found to have LLL PNA on CXR. Tmax 102.9 and WBC count 16.5 with 2% bands on admission. She was started on Levofloxacin and flagyl for community acquired aspiration PNA for planned 10 day course. # Cellulitis - Trunk: On [7-25] the pt was seen in dermatology clinic for abdominal rash/ nonhealing erosion which was biopsied at that time. Biopsy revealed trauma/excoriation with bacterial superinfection with S. aureus. On admission the pt was found to have a worsening abdominal cellulitis. Levaquin was started initially given her multiple antibiotic alleriges however on the evening on admission she developed worsening of her cellulitis and vancomycin was started. Her stitches were removed, no purulence could be expressed for culture. After 3 days of vancomycin, dramatic improvement, well within ink line. Plan for additional 10 days of IV antibiotics. Midline placed. # Hypoxia: Requiring NRB in ED and on arrival to [Hospital Unit Name 153]. Found to have PNA on CXR, known OSA. She was weaned from O2 quickly on arrival to the ICU and was maintained on CPAP overnight for her OSA. PNA treated as above. #Obstructive Sleep Apnea Maintained on CPAP 10cm with good results # Tachycardia: Present on admission to the ED, however resolved upon transfer to ICU. EKG with possibly new TWF in lateral leads. Last stress test [2180-1-14] with no EKG changes or ischemic symptoms during exercise, normal cardiac perfusion. No chest pain this admission. CE negative for ACS. # Type 2 Diabetes Uncontrolled with Complications - The patient was maintained on insulin sliding scale and home dose insulin - Metformin was held due to lactate # Benign Hypertension - - Antihypertensives initially held on admission Metoprolol restarted at lower dose - lisinopril and lasix held due to hypotension # Hyperlipidemia - Continued statin # Panic disorder/depression - Continued outpatient regimen #COMMUNICATION: patient - [Month/Day/Year ] House [Telephone/Fax (1) 107342] - [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]: Nurse [First Name (Titles) ] [Last Name (Titles) ] House [Telephone/Fax (1) 107342] at work, cell phone is [Telephone/Fax (1) 18294] - PCP [Name Initial (PRE) 1266] [Telephone/Fax (1) 608] - Sister [Name (NI) 12074] [Name (NI) ] [Telephone/Fax (1) 107343] (cell) [Hospital3 4262] Group Patient Medications on Admission: Medications: (per list provided from [Hospital3 ] House) Albuterol inh 2 puffs q4-6H PRN Celexa 40mg daily Lipitor 40mg daily Lasix 20mg daily Lisinopril 10mg daily Lactulose 10g/15mL syrup Lamictal 200mg daily Loratadine 10mg daily Metoprolol 25mg hs Mirtazapine 7.5mg daily Minocycline 100mg [Hospital1 ] Metformin SR 500mg daily Nystatin 100,000 unit topical Prilosec 20mg daily Seroquel 400mg hs Temazepam 15mg hs Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 10 days. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection ASDIR (AS DIRECTED). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO HS (at bedtime). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 13. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2 times a day). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 15. Levofloxacin 250 mg Tablet Sig: Two (2) Tablet PO once a day for 5 days. 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 20. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache. 21. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 22. Respiratory CPAP 10cm h20 nightly for obstructive sleep apnea Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Sepsis from Pneumonia (aspiration) Abdominal wall cellulitis sleep apnea, obstructive Discharge Condition: stable Discharge Instructions: You were treated for pneumonia and infection of the abdominal wall skin. Followup Instructions: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 608] Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2180-10-2] 3:10 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 612] Date/Time:[2180-10-2] 3:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2180-10-2] 3:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2180-10-2] 3:30	[ "995.91", "401.1", "682.2", "300.01", "272.4", "250.92", "799.02", "311", "780.57", "038.9", "507.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "93.90" ]	icd9pcs	[ [ [] ] ]	12335, 12408	7380, 9880	367, 373	12537, 12545	4559, 6732	12666, 13328	3437, 3467		10357, 12312		12429, 12516		9906, 10334				12569, 12643						3482, 4540						6923, 7357				6765, 6889												301, 329								401, 2592															2614, 3108	3124, 3421
76,265	158,504	41661	Discharge summary	report	Admission Date: [2187-9-23] Discharge Date: [2187-10-9] Date of Birth: [2135-2-28] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 695] Chief Complaint: Newly diagnosed biliary ductal mass - noted to be consistent with cholangiocarcinoma, initially here for PTC placement Major Surgical or Invasive Procedure: [2187-9-24]: Internal-external drain placement in the right anterior and left intrahepatic biliary system and external drain placement in the right posterior biliary system. [2187-9-25]: Successful uncomplicated coiling of a small bleeding branch of the a left hepatic artery. [2187-10-1]: Exploratory laparotomy, evacuation of intra-abdominal hematoma, cholecystectomy, intraoperative ultrasound. [2187-10-5]: Cholangiogram with internalization of R. posterior PTC History of Present Illness: Per Dr [Last Name (STitle) 4727] note, this is a 52 y/o woman who presented with painless jaundice and pruritus. She was noted to have elevated liver function tests including alkaline phosphatase of 325 and a bilirubin of 19.5. CT scan of the abdomen on [9-7], demonstrated intrahepatic biliary ductal dilatation of the left lobe with abrupt cutoff at the porta hepatis suspicious for cholangiocarcinoma. A followup triphasic CT scan of the abdomen on [9-17], demonstrated invasive tumor in the hilum of the liver suggestive of cholangiocarcinoma. She had a replaced right hepatic artery. She had intrahepatic biliary dilatation that was more severe on the left compared to the right. There was an infiltrating mass measuring 2 cm in extent of the hilum, suspicious for cholangiocarcinoma. There was early branching off the right posterior portal vein which was mildly narrowed by the tumor. More distally, however, the proximal right anterior and left main portal veins were thought to be occluded with more distal reconstitution beyond the hilum. The tumor also involves the origin of the left main hepatic duct and all segmental biliary ducts in the right lobe appear separately occluded by the mass near the hilum. The anterior right segment of the liver, especially segment VIII, are mildly atrophic with prominent intrahepatic biliary ductal dilatation and attenuated in segment portal branches and associated increased compensatory arterial enhancement. There may be tumor infiltration of the central portion of the anterior segments with lesser involvement suspected along the posterior segments. There was no definite tumor involvementin left lobe parenchyma. She did not have adenopathy that was suspicious for metastatic disease. On further review, it appeared there was narrowing of the main left portal vein, but it was not occluded. An ERCP demonstrated a malignant- appearing stricture at the bifurcation extending to the left and right main hepatic ducts with upstream dilatation. She was subsequently admitted to [Hospital1 18] where she underwent percutaneous transhepatic cholangiography. She had placement of transhepatic catheters in the right anterior, right posterior and left hepatic ducts. She appeared to have more extensive involvement on the right side. The involvement of the left hepatic duct was approximately 2-3 mm above the confluence of the left and right hepatic ducts. She had bleeding from a branch of the left hepatic artery after the PTC requiring embolization of a small branch of the left hepatic artery supplying the left lateral segment (segments II and III). She did have a large intra-abdominal hematoma demonstrated on CT scan. She did develop some ischemia of the left lateral segment with a rise in transaminases and also a small infarct demonstrated on CT scan post embolization. Her bilirubin has also increased from a nadir of 10.1 to 22.8. At the same time, her transhepatic catheters were drained of bilious fluid well. The rising bilirubin was thought to either be representative of absorption of the hematoma or compromised liver function post embolization or a combination. Past Medical History: Asthma, chronic, stable Hypothyroidism Elevated fasting glucose EKG abnormalities - unspecified Colonic polyp Migraine headache Tobacco Dependence Social History: 40 pack year tobacco use history, stopped 1 month ago. Denies EtOH use. Lives with her husband. Family History: Negative for biliary or bowel disease and negative for cancer. Physical Exam: GENERAL: Alert and oriented; no acute distress; obviously jaundiced HEENT: Mucous membranes moist and pink; scleral icterus present; no occular or nasal discharge; thyroid without enlargemement or masses CV: Regular rate and rhythm; no murmurs, rubs, or gallops PULMONARY: Clear to auscultation bilaterally ABDOMEN: Soft, non-tender, non-distended, PTC catheters in R. abdomen capped and without leakage; incision along R. costal border clean and with steri strips in place - small amount of serous drainage from pin-point are [2-12] of the way along the incision from the R. with no fluid collection palpated and no fluctuance noted; no surrounding erythema; R. flank ecchymoses extendes to midline of back and resolving EXTREMITIES: No swelling or edema bilaterally Pertinent Results: On Admission: [2187-9-23] WBC-9.0 RBC-3.98* Hgb-12.3 Hct-36.8 MCV-93 MCH-31.0 MCHC-33.4 RDW-15.0 Plt Ct-199 PT-15.7* PTT-25.6 INR(PT)-1.4* Glucose-350* UreaN-7 Creat-0.4 Na-135 K-4.2 Cl-96 HCO3-27 AnGap-16 ALT-39 AST-44* AlkPhos-235* Amylase-520* TotBili-18.8* Lipase-905* Albumin-3.1* Calcium-9.0 Phos-3.1 Mg-2.3 Brief Hospital Course: 52 year old female admitted with jaundice, and status post ERCP demonstrating an intra-hepatic biliary mass concerning for cholangiocarcinoma. Initially her admissison was for placement of percutaneous biliary drains. On [2187-9-24] she went for placement of the drains and she underwent successful placement of internal-external biliary drainage catheters in the right anterior and left hepatic ducts, and external drainage catheter in the right posterior intrahepatic biliary ducts. They were unable to push through the ERCP stent that had been placed earlier. The patient's post-procedure course was complicated by blood noted in her drains and transfer to the ICU for hemodynamic instability (Hct of 23.7) secondary to bleeding from a small branch of the L. hepatic artery (likely trangressed along the course of the L. PTBD catheter). 8 units of PRBCS were transfused as well as 3 units of FFP. The bleeding vessel was localized on angiogram and successfully coil embolized by IR on [2187-9-25]. The L. PTBD catheter was repositioned and shown to be in good position at the end of the procedure. She was extubated the following day, weaned off all pressors, advanced to a clear liquid diet, and transferred out of the ICU back to the floors. The patient continued to do well post-procedure with no further evidence of bleed although she remained visibly jaundiced. She was noted to develop some ischemia of the left lateral segment of her liver with a rise in transaminases, and a small infarct was demonstrated on CT scan ([2187-9-28]) post-embolization. Her bilirubin has also increased from a nadir of 10.1 to 22.8 although her transhepatic catheters were draining bilious fluid well. The rising bilirubin was thought to either be representative of absorption of the intra-abdominal hematoma caused by her L. hepatic artery bleed, possibly secondary to compromised liver function post-embolization or a combination of both. She was advanced to a regular diet on [2187-9-29] (day #4 post-placement of PTCs) and placed on a regimen of 40mg IV Lasix twice daily for lower extremity swelling/edema. On [2187-10-1] (hospital day #7) the patient was taken to the OR for for exploratory laparotomy, evacuation of intra-abdominal hematoma, cholecystectomy, and possible common bile duct excision, possible right hepatic lobectomy, possible Roux-en-Y hepaticojejunostomy, and possible lymph node dissection. Intra-operatively ultrasound demonstrated the mass at the hilum with involvement of the right anterior and right posterior portal veins and with significant involvement of the left portal vein up to the bifurcation into the left lateral and left medial segment veins in the umbilical fissure. Additionally the left lateral segment of he liver was noted to be extremely small (the left lobe was estimated to be 600cc on CT scan but appeared significantly smaller than that intra-operatively). Therefore the tumor was deemed unresectable as it was unlikely that her liver would tolerate a hepatic resection whether a right lobe or trisegmentectomy and no attempts at debulking were made. The patient's post-operative course was complicated by difficulty extubating after transfer from the PACU to ICU. A bronchoscopy was performed on post-op day #1 for a R. mucous plug, after which the patient was successfully extubated. She was started on a clear liquid diet which she tolerated well, and TPN. On post-op day #2 the patient was transfused 1 unit of PRBCs for a Hct of 24 without evidence of active bleed. She responded adequately and remained stable afterwards. She was then transferred out of the ICU to the floors without adverse event. 20mg IV Lasix twice daily was begun to address her continued lower extremity edema. The following day the patient continued to do well, was started on a regular diet, and began Ciprofloxacin 500mg daily prophylactically as her R. posterior PTC and L. hepatic PTC were noted to have decreased output (output from the R. anterior drain remained high)in addition to upward trending serum bilirubin levels (elevated to 20.3). On post-op day #4 the patient returned to IR for a cholangiogram to evaluate the patentcy of the R. anterior/R. posterior and L. biliary PTCs. At the time the R. posterior biliary drain was noted to be displaced, and it was replaced with an 8-french internal-external biliary drain. The R. anterior and L. biliary drains were noted to be in good position and patent. Following the procedure the patient did well, her serum bilirubin began trending down, and her R. posterior and L. biliary drains were capped on post-op days 6 and 7 (respectively). TPN was discontinued on post-op day #4 as she was taking good PO, and the patient was able to ambulate independently. Ursodiol 300mg PO TID was begun on post-op day 7 for her elevated bilirubin levels although through-out her hospital course the patient denied itching or other symptoms of hyperbilirubinemia. By post-op day #8 the patient's pain was under good control, she was taking good PO, ambulating, her serum bilirubin was down-trending, other laboratory values were stable, and her incision was noted to be healing well with a minimal amount of serous drainage from a pin-point spot approx [2-12] of the way along the incision from the right. No fluid collection palpated along the incision. The serous drainage is small in amount with no odor or evidence of purulence. At this point the patient was deemed stable for discharge to home, and her third PTC drain (R. anterior biliary drain) was capped. She will follow-up as an outpatient for permenant metal abdominal stent placements at a future date. Medications on Admission: Levothyroxine 100mg daily Flovent 110mcg 2 puffs Albuterol inhaler PRN Nicotine patch Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:30 Tablet(s) Refills:0 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for asthma attack. 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: cholangio CA hyperglycemia hepatic artery bleeding s/p embolization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [Location (un) 86] Visiting Nurse services have been arranged Please call Dr.[Name (NI) 1369] office [Telephone/Fax (1) 673] if you have any of the following: fever (temperature of 101 or greater), shaking chills, worsening jaundice, nausea, vomiting, increased abdominal pain or distension, biliary drains sites are red or have drainage, incision drainage, diarrhea or constipation. Call if you feel thirsty, dizzy or weight drops 3 pounds. -Please come to [Hospital ] Medical Office Building, [Last Name (NamePattern1) 8028], [Location (un) 86] for blood work on Friday am [10-12] -Please check your blood sugars prior to meals and record. Please make a follow up appointment with your primary care physician to review blood sugars. Call your PCP if your blood sugar is persistently 200 or greater. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2187-10-17] 10:40 [First Name4 (NamePattern1) 698] [Last Name (NamePattern1) 699], RN coordinator for Dr. [Last Name (STitle) ] [Telephone/Fax (1) 17195] will call you with a follow up appointment Please make an appointment with your PCP, [First Name8 (NamePattern2) 4115] [Last Name (NamePattern1) 4011] to review your blood sugars [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2187-10-9]	[ "575.12", "305.1", "782.3", "458.9", "934.1", "346.90", "493.90", "155.1", "E915", "244.9", "285.1", "459.0", "568.81", "V64.3", "E849.8" ]	icd9cm	[ [ [] ] ]	[ "88.49", "51.98", "38.91", "51.22", "87.51", "54.11", "97.55", "33.23", "39.79", "45.13", "88.76" ]	icd9pcs	[ [ [] ] ]	12150, 12207	5614, 11276	421, 906	12319, 12319	5272, 5272	13324, 13994	4400, 4464		11412, 12127		12228, 12298		11302, 11389				12470, 13301						4479, 5253																						263, 383								934, 4100								5286, 5591		12334, 12446					4122, 4270	4286, 4384
6,001	124,521	26073	Discharge summary	report	Admission Date: [2183-11-30] Discharge Date: [2183-12-2] Date of Birth: [2148-9-23] Sex: F Service: OBS HISTORY OF PRESENT ILLNESS: This is a 35-year-old G3, P1-0-1- 1 at 22 weeks and 6 days who has a prior admission to the [Hospital1 ]. Please see a previous dictation. She left against medical advice. She returned to [Hospital3 ] complaining of shortness of breath with an O2 requirement. She had completed a 10-day course of ceftriaxone and azithromycin at home. She states that she was doing well at home when she suddenly developed right lower rib pain and described that pain as being sharp. She became more tachypneic and short of breath. Her saturations were 94% on room air at the outside hospital. At the outside hospital she also had a chest x-ray which showed a right lower lobe infiltrate. There was concern for a pulmonary embolism, so she was started on a heparin drip and transferred over to the [Hospital1 ] for further management. On arrival to the [Hospital1 ], she was saturating at 98% on 2 liters of nasal cannula. She denied any nausea, vomiting, lightheadedness, diaphoresis, and she denied any fevers or chills. PAST MEDICAL HISTORY: Thyroid mass/nodule. PAST OBSTETRIC HISTORY: One vaginal delivery and 1 miscarriage. ALLERGIES: Bactrim. MEDICINES: Completed ceftriaxone and azithromycin on [11-26] and [11-28], respectively. She was taking prenatal vitamins and was taking Zofran occasionally. SOCIAL HISTORY: She works as a chemistry professor [First Name (Titles) ] [Last Name (Titles) 64717]. She denies smoking, alcohol or drug usage. PHYSICAL EXAMINATION: Temperature 99.1, blood pressure 126/68, pulse 80, respiratory rate 30, O2 saturations 98% on 2 liters nasal cannula. In general, she is able to sit up in bed and talk. Neck examination: There is an enlarged thyroid gland on the left which is supple. Lung examination: There are decreased breath sounds at the right base. No wheezes or crackles. Cardiac examination: Regular rate and rhythm. No murmurs, gallops or rubs. Abdominal examination: Gravid, soft, slight tenderness in the right upper quadrant but no rebound or guarding. Negative for [Doctor Last Name ] sign. Extremities: No cyanosis, clubbing, or edema. LABORATORY DATA: Outside hospital labs show white count was 9.8, hematocrit 35, platelets 314, neutrophils 79%, no bandemia. Her Chem-7 was 131, 3.6, 98, 26, 4, 0.5, 74, calcium 7.8. AST 20, ALT 60, alkaline phosphatase 155, fibrinogen 620. Her ABG pH was 7.48, bicarbonate 28. Chest x-ray at the outside hospital showed an opacity of right lower lobe. A CTA was negative for pulmonary embolism and had a right lung consolidation. HOSPITAL COURSE: Pneumonia: Patient was initially admitted for rule out pulmonary embolism and started on a heparin drip per the outside hospital. She had a CT angiogram at the [Hospital1 ] which was consistent with a right lower lobe consolidation with a small pleural effusion. Otherwise, there was no evidence of pulmonary embolism. The heparin drip was stopped. Her symptoms resolved with aggressive pulmonary toilet and physical therapy. Her O2 saturations had improved, and she was saturating between 96% and 97% on room air at the time of her discharge status. She was given O2 nasal cannula periodically to keep her saturations greater than 96%. She was initially admitted to the IC unit for the first few days of her hospital stay and on her 2nd day was discharged out to the floor. She did not have her O2 requirements which she had before. She was not started on antibiotics. Her white blood cell count had dropped down to 6.8 at the time of her discharge status. She remained afebrile. She was not started on any other further antimicrobials or antiretrovirals. Obstetrics: She had a full fetal survey that was done on [11-19] which was within normal limits. She had Doppler tones, all of which were within normal limits. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Pregnancy. 3. Thyroid mass. DISCHARGE FOLLOW-UP PLANS: 1. Will need to follow up with her general obstetrician at [Hospital1 2436] within 1 week following her discharge status. 2. The endocrine clinic for further workup of her thyroid nodule. She will need a fine needle aspiration. 3. Her primary care provider for further attention about her thyroid mass. DISCHARGE MEDICATIONS: Prenatal vitamins. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [MD Number(4) 64718] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2183-12-2] 15:00:18 T: [2183-12-2] 16:02:47 Job#: [Job Number 64719]	[ "648.13", "647.83", "486", "241.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								3990, 4049	4413, 4698					2742, 3969																						1668, 2724				4066, 4389													166, 1190															1213, 1490	1507, 1645
32,219	141,688	1279+1280	Discharge summary	report+report	Admission Date: [2147-2-2] Discharge Date: [2147-2-7] Service: Cardiothoracic CHIEF COMPLAINT: The patient is a postoperative admission and preoperative testing. The patient's chief complaint is increasing dyspnea on exertion with a positive exercise treadmill test. HISTORY OF PRESENT ILLNESS: Status post inferior myocardial infarction in [2141] with a stent to the right coronary artery. Continued to have increasing shortness of breath. A workup revealed worsening aortic stenosis with an aortic valve area of 0.7. PAST MEDICAL HISTORY: (Significant for) 1. Left carotid endarterectomy in [2142]. 2. Status post appendectomy. 3. Non-insulin-dependent diabetes. 4. Hypertension. 5. Status post inferior myocardial infarction in [2141] with a percutaneous transluminal coronary angioplasty of his right coronary artery, also requiring a balloon pump at that time with a resultant injury to his left femoral artery which was also repaired at that time. 6. Gastroesophageal reflux disease. The patient denies any neurological, respiratory or gastrointestinal problems. SOCIAL HISTORY: Alcohol with one drink per day. Smoking history was remote; quit 40 years ago. MEDICATIONS ON ADMISSION: Prilosec 20 mg p.o. b.i.d., Zocor 10 mg p.o. q.d., Synthroid 0.025 mg p.o. q.d., K-Dur 20 mEq p.o. b.i.d., atenolol 25 mg p.o. b.i.d., Zestril 10 mg p.o. b.i.d., Isordil 60 mg p.o. q.d., Glyburide 2.5 mg p.o. q.d., aspirin 325 mg p.o. q.d., Lasix twice a day (unable to recall dose). ALLERGIES: He is allergic to PENICILLIN. RADIOLOGY/TESTING: The patient had an echocardiogram and cardiac catheterization done at [Hospital6 2910] prior to testing. The echocardiogram was done on [12-28], and per telemetry, showed inferior hypokinesis with an ejection fraction of 50%, and an aortic valve area of 0.7 cm2 with trace mitral regurgitation. He also had a catheterization, and catheterization report via telemetry as well, was arteriovenous tightness as new, critical aortic stenosis, ejection fraction was about 40%. No other details available. PHYSICAL EXAMINATION: Vital signs were a heart rate of 56, blood pressure 120/70, respiratory rate 18, height of 67 inches, weight was 216 pounds. Generally, a well-appearing 78-year-old man in no acute distress. Skin was intact. No lesions. HEENT was unremarkable. Neck revealed carotids palpable. Neck was supple. No jugular venous distention. No lymphadenopathy. Chest revealed lungs were clear to auscultation bilaterally. Heart sounds, grade [2-24] holosystolic murmur. The abdomen was soft and nontender, positive bowel sounds. Extremities were warm and well perfused with mild superficial erythema of the right lower extremity. The patient currently taking erythromycin for this presume right lower extremity cellulitis. Neurologically nonfocal, grossly intact. Carotid pulses were 2+ with no bruit, but a radiating murmur bilaterally. Radial pulses were 2+ bilaterally. Femoral were 2+ bilaterally. Dorsalis pedis pulses were 1+. Posterior tibial pulses were unable to palpate. LABORATORY/RADIOLOGY ON ADMISSION: Preoperative chest x-ray showed left ventricular enlargement with no evidence of failure. No radiographic evidence of acute cardiopulmonary process. Electrocardiogram revealed sinus rhythm with a rate of 60, Q waves in III and F. ST depressions in I, II, and aVL as well as V4, V5, and V6. Normal intervals. HOSPITAL COURSE: The patient was admitted on [2-2] and brought to the operating room where he underwent an aortic valve replacement. He tolerated the procedure well. Please see the operative report for full details. He was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, he had an arterial and a Swann-Ganz catheter as well as ventricular and atrial pacing wires, and two mediastinal chest tubes. His mean arterial pressure was 69, his central venous pressure was 9, his heart rate was 73 in a sinus rhythm. He had dobutamine at 5 mc/kg per minute and propofol at 30 mcg/kg per minute. He did very well postoperatively. He was extubated on the day of his surgery, and his dobutamine as well as his propofol were weaned to off. He was hemodynamically stable on postoperative day one. His chest tubes were discontinued. His central line was discontinued, and he was transferred to Far Six for continuing postoperative care and cardiac rehabilitation. The patient was noted to have hematuria postoperatively, for which his catheter was irrigated frequently removing several blood clots. His Foley was discontinued on postoperative day two; however, the patient failed to void within eight hours post removal of his catheter, and the Foley was replaced with an 800-cc return of urine. He was started on Flomax, gently diuresed, and again his Foley was discontinued on postoperative day three. The patient was again unable to void post catheter removal, and urology was consulted. Upon urology's recommendation, the patient's Foley was to remain in place for one week. He was to continue on Flomax and come back in one week for a follow-up appointment. On postoperative day five, the patient remained hemodynamically stable. His activity level had increased throughout the past five days; although, he still had not reached the minimal requirements for discharge to home. Therefore, it was planned to send him to [Hospital 3058] rehabilitation for continuing cardiac rehabilitation and postoperative care. CONDITION AT TRANSFER: At the time of transfer, the patient's condition was stable. His vital signs were as follows. Temperature 99.4, heart rate 66, sinus rhythm, blood pressure 140/68, respiratory rate 20, oxygen saturation 97%, breath sounds were clear to auscultation bilaterally. Heart sounds with a regular rate and rhythm, S1/S2. The sternum was stable. The incision was clean, dry, and open to air. Abdomen was soft, nontender, and nondistended, positive bowel sounds. Extremities were warm and well perfused, 1+ edema bilaterally. The patient's laboratory data as of [2-7] was a hematocrit of 22.6, potassium of 4.5, BUN of 30, creatinine of 1.2, and blood glucose of 78. His preoperative weight was 98.7 kg. His discharge weight was 109.6 kg. MEDICATIONS ON DISCHARGE: 1. Zocor 10 mg p.o. q.h.s. 2. Synthroid 0.025 mg p.o. q.d. 3. Glyburide 2.5 mg p.o. q.d. 4. Prilosec 20 mg p.o. b.i.d. 5. Zestril 10 mg p.o. b.i.d. 6. Flomax 0.4 mg p.o. q.d. 7. Metoprolol 12.5 mg p.o. b.i.d. 8. Lasix 20 mg p.o. b.i.d. 9. Potassium chloride 20 mEq p.o. b.i.d. 10. Colace 100 mg p.o. b.i.d. times two weeks. 11. Aspirin 81 mg p.o. q.d. 12. Neurontin 300 mg p.o. t.i.d. 13. Percocet 5/325 one to two tablets p.o. q.4h. p.r.n. DISCHARGE STATUS: The patient was to be discharged to rehabilitation. FOLLOWUP: He was to have follow up with Dr. [Last Name (STitle) 1537] in one month and follow up with his primary care provider in three to four weeks. DISCHARGE DIAGNOSES: 1. Status post left carotid endarterectomy in [2142]. 2. Status post appendectomy. 3. Non-insulin-dependent diabetes mellitus. 4. Hypertension. 5. Coronary artery disease, status post inferior myocardial infarction in [2141]. 6. Status post left femoral artery repair. 7. Gastroesophageal reflux disease. 8. Hypothyroidism. 9. Status post aortic valve replacement with a #21 bioprosthetic valve. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2147-2-7] 14:15 T: [2147-2-7] 13:35 JOB#: [Job Number 7950] Admission Date: [2147-2-2] Discharge Date: [2147-2-8] Service: Cardiothoracic Surgery ADDENDUM: The patient was not discharged as previously planned on [2-7] due to a low hematocrit of 22.6, which we have attributed to his hematuria which is resolving. The patient has been followed by the urology service and the patient received 1 unit of packed cells yesterday evening the night of [2-7]. His hematocrit this morning was 24.9. He is to receive one more unit of packed red blood cells today and after his transfusion is completed, he may be discharged to a rehabilitation facility. The transfusions are at the request of the patient's primary care provider, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 7951] [Last Name (NamePattern1) ]. The patient remains hemodynamically stable with no contraindication to discharge from the hospital. He is to follow up with urology as previously discussed in one week due to his hematuria and inability to spontaneously void. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2147-2-8] 10:38 T: [2147-2-8] 11:06 JOB#: [Job Number 7952]	[ "401.9", "414.01", "424.1", "788.20", "530.81", "V45.81", "997.5", "599.7", "250.00" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61" ]	icd9pcs	[ [ [] ] ]								7049, 9016				6334, 7028	1238, 2096	3472, 6307																						2119, 3126									114, 288								317, 547								3141, 3454							569, 1113	1130, 1211
22,754	101,703	3241+55454	Discharge summary	report+addendum	Admission Date: [2119-3-31] Discharge Date: [2119-4-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [4-12] Right-sided crani for evac of subdural hematoma History of Present Illness: 81 year-old male with history of CHF, atrial fibrillation, ascending aortic aneurysm and mitral regurgitation who is admitted with dyspnea and failure to thrive. . The patient's daughter reports that the patient has been sick for "a while", particularly since he was admitted in [2119-2-22]. Since his discharge, he was improving and doing better at home until three days ago when he started declining rather rapidly. She reports that he has had shortness of breath, slurred speech and difficulty walking over the last three days. He has also been confused and falling asleep in his chair and falling out of the chair and from his bed. He has been refusing help, but unable to get up. She also reports that her father has had decreased grip strength and things have been falling out of his hands. As a result of his confusion, he has been eating less, though he has been very thirsty and is drinking a lot of fluids. There have been no fevers, chills, night sweats, cough, emesis, diarrhea. She also reports "difficulty with motor planning", as if he had trouble "putting one foot in front of the other". Interestingly, his mental status has been waxing and [Doctor Last Name 688]. Although he has been confused, he was able to have a completely coherent conversation with his sister yesterday. [Name2 (NI) ] was recently on Coumadin but this was held secondary to fall risk. . In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1. . Today, the patient states that his main concern is his shortness of breath. He has been feeling dyspneic over the last several days. Has a mild cough, non-productive. No chest pain or palpitations. Denies edema. Reports orthopnea but no PND. Past Medical History: 1. CHF: [2-27] echo: mild symm LVH, EF 55% but likely overestimation with degree of MR 2. 3+ mitral regurgitation 3. Atrial fibrillation 4. Ascending aortic aneurysm- [11-27] CTA: 5.7 x 5.4 cm stable (pt. currently not interested in surgery) 5. DM2 6. Gout 7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior surgeries or recent flares. 8. Hypertension 9. GERD 10. h/o Asbestosis 11. Recent B12 and Fe def. anemia Social History: Married, lives with wife, no prior [Name (NI) ]/ETOH. Worked as a salesman. h/o asbestosis exposure when in the service (?shipyards). Family History: no Alzhemer's or Parkinson's Physical Exam: Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25 (25-38) 100% 4L General: restless in bed, no spontaneous eye opening, answers questions, follows some commands (aside from eye opening) HEENT: pupils small but reactive, dry mucous membranes Neck: no evidence of JVD Lung: rales at bilateral bases Cor: irregularly irregular, 3/6 systolic murmur loudest at apex Abd: NABS, soft, non-distended, reports some tenderness in RUQ Ext: warm, no edema, pneumoboots in place Neuro: oriented x 2 (hospital, name), follows some commands, somewhat restless Pertinent Results: Head CT ([4-1]): Moderate right subdural hemorrhage with associated subfalcine herniation. . CTA ([4-1]): New CHF with enlarging moderate/large bilateral pleural effusions with concomitant atelectasis. No evidence for pulmonary embolus . Head CT ([4-2]): No significant change from prior study with right-sided pleural hematoma and subfalcine herniation again seen. . EKG ([4-2]): very wavy baseline, largely uninterpretable secondary to motion, afib with HR 100s, no ST changes (but diff to interpret) . Renal US ([4-2]): No evidence of hydronephrosis or stones. . Echo ([4-3]): LVEF>55%. Significant aortic regurgitation is present, but cannot be quantified. The mitral valve leaflets are mildly thickened. At least, moderate (2+) mitral regurgitation is seen. . Head CT ([4-3]): Stable appearance of the right-sided subdural hematoma and stable to mildly improved subfalcine herniation . Abd US ([4-4]): No focal or textural hepatic abnormality is identified. Patent portal vein with hepatopetal flow. Mild splenomegaly. Small amount of ascites. . Head CT ([4-4]): Stable appearance of a large right subdural hematoma . CXR ([4-5]): Cardiomegaly, bilateral effusions, and borderline vascular congestion with little interval change . Head CT [4-14] evacuation of hematoma stable. . Head CT [4-17] hematoma stable. Brief Hospital Course: 1. altered mental status - He was admitted with subacute course of non-specific mental status changes and was found to have a chronic appearing with superimposed acute features subdural hemorrhage. He was followed by neurosurgery, who deferred evacuation on account of the stability of the SDH as well as his concomitant medical issues (liver failure, renal failure, UTI, CHF). . His mental status was poor with marked delirium, but remained stable. Serial head CTs demonstrated stable subdural hemorrhage. Pt was taken to the operating room on [4-12] for a right crani for evacuation of Subdural hematoma. [Name (NI) ] pt was extubated and reintubated within 1 hr. Pt had aggressive pulm toilet and self extubated overnoc on [5-2]. Drain removed [4-13]. Pt currently doing well extubated. Staples to be dc'd [4-21]. . Patient transferred to Neurosurgery service on [2119-4-12] for subdural hematoma evacuation after become medically stable. His INR has been stable under 1.3. His mental status improved over the course of time, as his electrolytes, and coags improved. His initial INR went up as high as 1.8 which stayed around the same level until given factor VIIa on [4-5] then stayed around 1.2-1.3 range per recommendation of Hematology service. His creatinine improved greatly, his creatinine jumped up to 2.5, but now dropped down to 1.5 renal service has been following along. He is cleared by medicine team to be operated on his subdural hematoma. He had a left lower lobe pneumonia which is treated with Levo. He had a hypernatremia Na up to 157 on [4-11], eventually corrected with fluid. . He underwent right craniotomy on [2119-4-12] for evacuation of subdural hematoma and placement of subdural JP drain placement under general anesthesia without complications, he was able to extubated in [Hospital ] transferred to PACU, however 2 hour later he required re-intubation secondary to hypoventilation. He is neurologically moving all extremities, opens his eyes to voice intermittently, squeezes to command. He placed on a beta-blocker [Hospital ] for heart rate control, [Hospital ] ECG remained unchanged, underlying rhythm being atrial fibrillation. His postoperative head CT([4-12]) is revealed residual small amount of hemorrhage mixed with fluid, pneumocephalus and postoperative changes. No further shift of normally midline structures. Repeat head CT on [4-13] remained stable, therefore his right subdural JP removed, patient tolerated procedure well. . Patient will need drain stitch and staples removed on [4-21]. If cant be done at nursing home will need to see Dr. [Last Name (STitle) 739]. Switched from dilantin to keppra. . 2. congestive heart failure - He was worked up for dyspnea and hypoxemia. Final etiology was clearly congestive heart failure. He had a repeat Echo which demonstrated preserved EF and some MR. [Name13 (STitle) ] was maintained on a regimen of hydral/nitro, beta blocker, and cautious diuresis. He was maintained on oxygen by nasal canula. Patient sent out on lasix. . 3. Liver failure/coagulopathy - He had a self limited course of liver failure with associated coagulopathy. This was felt to be secondary to dilantin toxicity. Dilantin was stopped and his liver enzymes ultimately trended down toward normal. Alternative explanation could have been acute hepatic congestion from heart failure. . Re: coagulopathy, he was treated with vitamin K, FFP, and also proplex in acute setting. Thereafter, his INR trended down and he was given po vitamin K. Heme/onc involved in his care; agreed with hepatic synthetic dysfunction as etiology of coagulopathy. . 4. Acute on chronic renal failure - Likely pre-renal exacerbation of chronic kidney disease. Resolving toward baseline. . 5. Atrial fibrillation Continued rate control with bblocker. Held warfarin on account of coagulopathy and SDH. . 6. DM Held oral hypoglycemics; kept RISS. Patient has been having low blood sugars so sliding scale reduced. Patient will need frequent blood sugar. Medications on Admission: levothyroxine 25mcg daily allopurinol 150mg qOD Toprol XL 25mg daily tylenol 325mg q4-6h prn lasix 40mg daily ferrous gluconate 300mg [Hospital1 ] combivent inh [Hospital1 ] celexa 10mg daily glipizide 2.5mg daily lipitor ? dose Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-26] Puffs Inhalation Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): see insulin sliding scale. 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): hold for SBP < 100. 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary diagnoses: 1. Subdural hematoma s/p evacuation 2. Congestive heart failure 3. Pneumonia 4. Urinary Tract infection . Secondary diagnoses: 1. Mitral regurgitation 2. Atrial fibrillation 3. Diabetes Mellitus Discharge Condition: Stable Discharge Instructions: You are discharged to a Rehabilitation facility where you should continue all medications as prescribed. Please alert the physicians at the facility or contact your physician if you experience headache, visual changes, shortness of breath, chest pain, palpitations, or other concerns. You should be weighed every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: You will need a follow-up appointment with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 3649] in [1-27] weeks. Please call [Telephone/Fax (1) 3070] to make that appointment. You will need an appointment with Dr. [Last Name (STitle) 739] 4 weeks after your surgery with a head CT. Please call ([Telephone/Fax (1) 11314] to make that appointment. Right craniotmy drain stitch to be dc'd [4-21]; Craniotomy staples to be dc'd [4-21]. If pt in house this will be done by neurosurgery team; if in rehab they can be dc'd there, otherwise pt to return to Dr.[Name (NI) 4674] office to be dc'd. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Name: [Known lastname ],[Known firstname 2415] Unit No: [Numeric Identifier 2416] Admission Date: [2119-3-31] Discharge Date: [2119-4-19] Date of Birth: [2037-6-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 391] Addendum: Pt developed some mild chest pain on day of discharged over his right nipple. Pain occurred while lifting himself in bed. The chest pain spontaneously resolved without intervention. Vitals signs remained stable and chest X-ray and ECG were unchanged. It was concluded that this was most likely musculoskeletal in nature and the patient was discharged without incident. Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - [Location (un) 1409] [Name6 (MD) 116] [Name8 (MD) 117] MD [MD Number(1) 392] Completed by:[2119-4-19]	[ "403.91", "428.31", "570", "284.8", "E936.1", "584.5", "783.7", "432.1", "250.00", "244.9", "293.0", "427.31", "286.7", "424.0", "599.0", "276.0", "V15.88", "486" ]	icd9cm	[ [ [] ] ]	[ "96.6", "99.07", "01.31", "99.06" ]	icd9pcs	[ [ [] ] ]	12680, 12892	4695, 8772	269, 330	10693, 10702	3305, 4672	11145, 12657	2683, 2713		9059, 10327		10456, 10581		8798, 9036				10726, 11122						2728, 3286			10602, 10672																			222, 231								358, 2054															2076, 2511	2527, 2667
83,224	166,602	35570	Discharge summary	report	Admission Date: [2155-1-14] Discharge Date: [2155-1-27] Date of Birth: [2104-12-10] Sex: F Service: SURGERY Allergies: Lactose Attending:[First Name3 (LF) 2836] Chief Complaint: The patient was transferred from an outside hospital for management of pancreatitis Major [First Name3 (LF) 2947] or Invasive Procedure: Dobbhoff placed [1-15] History of Present Illness: 50F was admitted to OSH on [2155-1-10] for severe abd pain. She has been having pancreatitis for 6 months. Strong history of ETOH use. Pt subsequently developed hypotension to 80s, transferred to ICU for resuscitation and was intubated for respiratory failure. Pt transferred to [Hospital1 18] for further care. Past Medical History: HTN, peptic ulcer, hypelipidemia Social History: Smokes a pack a day, ETOH abuse Family History: non contributory Physical Exam: On transfer from OSH: T100.9 HR106 BP109/49 vent: AC 0.7 450/14 PEEP10 Gen: intubated, sedated HEENT PERRLA Lungs CTAB Heart RRR Abd distended, soft, diffusely tender, non-peritoneal Ext no edema Pertinent Results: [2155-1-14] 05:25PM BLOOD ALT-17 AST-30 LD(LDH)-311* CK(CPK)-35 AlkPhos-111 Amylase-55 TotBili-0.9 [2155-1-14] 05:25PM GLUCOSE-105 UREA N-6 CREAT-0.5 SODIUM-133 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-18* ANION GAP-15 [2155-1-14] 05:25PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-4.3 MAGNESIUM-1.9 [2155-1-14] 05:25PM FERRITIN-1053* [2155-1-14] 05:25PM WBC-7.2 RBC-3.75* HGB-13.1 HCT-38.4 MCV-102* MCH-34.9* MCHC-34.1 RDW-17.1* Brief Hospital Course: The patient was transferred from an OSH for management of pancreatitis. She was transferred intubated and sedated to the ICU for intense monitoring. She remained intubated, sedated, no vasopressors were needed, NG tube and foley catheter in place, no antibiotics were given, and IVF for resuscitation. [1-15] - Nasojejunal tube placed under fluoro, continued IVF, intubated and sedated. [1-16] - enteric tube feeds started, remained on IVF, intubated, sedated [1-17] - [1-18] - successfully extubated, placed in restraints to protect tubes and lines and given haldol prn, continued tube feeds, started clonidine [1-19] - transferred to the [Month/Year (2) ] floor for continued monitoring. She remained NPO, tube feeds to goal, foley catheter in place [1-20] - diet advanced to clears, continued tube feeds [1-21] - diet advanced to regular, continued tube feeds [1-22] - continued regular diet and tube feeds, discontinued foley catheter and she voided without difficulty [1-23] - continued regular diet, cycled tube feeds 70 ml/hr from 6pm to 6am [Date range (1) 80968] - pt continued on a regular diet and calorie counts were done to assess adequacy of PO intake. Her TFs were stopped and her NJ feeding tube was removed immediately prior to discharge. She was discharged to home on [1-27] with VNA services for monitoring. She will return for follow-up imaging and clinic visit with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Medications on Admission: oxycodone 5', norvasc 5', labetalol 100", ferrous sulfate 325", MVI', lisinopril 40' Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Please do not take Tylenol with alcohol. Discharge Disposition: Home With Service Facility: VNA Association of [Hospital3 ] Discharge Diagnosis: Pancreatitis Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2155-2-5] 1:45. Please arrive at CAT SCAN at 12:45 for your appointment ([Hospital Ward Name 452] Bldg, [Hospital Ward Name 516]) and please do not have anything to eat or drink for three hours prior to your appointment. Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SPECIALTIES CC-3 (NHB) Phone:[Telephone/Fax (1) 274] Date/Time:[2155-2-5] 3:00 Completed by:[2155-1-28]	[ "276.2", "281.9", "518.81", "577.0", "787.91", "577.1", "401.9", "272.4", "533.90", "303.90", "291.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "45.13", "93.90", "96.6" ]	icd9pcs	[ [ [] ] ]	3716, 3782	1592, 3115		3839, 3846	1122, 1569	5040, 5604	871, 889		3251, 3693		3803, 3818		3141, 3228				3870, 5017						904, 1103																						229, 400								428, 749															771, 806	822, 855
25,225	103,975	4373	Discharge summary	report	Admission Date: [2177-7-24] Discharge Date: [2177-8-19] Date of Birth: [2147-8-13] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[First Name3 (LF) 8367] Chief Complaint: ?infected hardware Major Surgical or Invasive Procedure: Left Obturator artery pseudoaneurysm embolization History of Present Illness: Ms. [Known lastname 14323] is a 29 year old woman with ESRD on HD s/p failed renal transplant (rejection [2174]) and s/p bilateral nephrectomy, now s/p right tibial IMN on [2177-6-24] who returns from rehab with worsening leg wound and possible infection. She also notes worsening right knee swelling and pain. . Her recent admission was complicated by possible cellulitis, which was treated with vancomycin/Zosyn to complete a 2 week course. She was discharged from [Hospital1 18] on [7-8] and was found hypotensive on [7-12] (blood cultures growing coag negative staph sensitive to vancomycin). She received one dose of gentamicin at that time. She responded well to IVF. The right knee was aspirated on [7-15] and showed gram positive cocci in pairs and clusters but nothing grew in cultures. She had a PICC line catheter tip culture on [7-12] which grew coag negative staph sensitive to vancomycin. She had another catheter tip sent for culture on [7-18] (unclear what line) which did not grow anything. She also underwent a debridement of the right lower extremity wound by vascular surgery. Coumadin and heparin were discontinued (started for DVT prophylaxis after tib/fib surgery) and she was anticoagulated with Lovenox. . She was transferred back to [Hospital1 18] for concern for hardware infection, and non-healing wound. The septic knee reportedly has improved significantly with surgery and antibiotics. . In the ED, vital signs were T99.1, HR 100, BP 99/50, RR 16, sat 95% on room air. She received dilaudid IV for pain, in addition to vancomycin IV x 1 (preceded by Benadryl) and clindamycin IV x 1. She was given 2 L NS for rehydration. . REVIEW OF SYSTEMS: She notes constipation, right lower extremity pain (both at the site of the wound and at the knee), and low grade temperature. She denies abdominal pain, nausea, vomiting, shortness of [Hospital1 1440], dizziness, and vomiting. She has mild numbness of the right lower extremity below the knee. Past Medical History: PAST MEDICAL HISTORY: - SLE diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [2166]. In [2173], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [8-/2175] complicated by rejection and capsule rupture 11/[2174]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [2177-6-24] Social History: No smoking, occasional alcohol, no drug use. Originally from [Country ], now lives in [Location 2268]. used to work at [Hospital1 18]. Family History: Non-contributory Physical Exam: Vitals: T 97.0, BP 92/70, HR 86, RR 18, Sat 100%2L Gen: Chronically ill appearing, no acute distress HEENT: EOMI, OP clear Neck: No lymphadenopathy Cardiac: RRR, normal S1/S2, 1/6 systolic murmur at apex Lungs: CTA bilaterally. No wheezes, rales, or rhonchi. Abd: Soft, but distended, mildly diffusely tender, normal active bowel sounds. No hepatosplenomegaly. Midline and bilateral oblique scars from previous abdominal surgeries. Ext: No clubbing, cyanosis, or edema. [12-10]+ DP pulses bilaterally. Right Knee: swollen and tender to palpation, no erythema, no warmth Right Leg: open wound with no purulence on anterior surface, approximately six inches long and 4 inches wide, 2cm deep, No swelling, no erythema. Skin: No rashes Neuro: A&O x 3 Pertinent Results: . [7-24] CT LLE with contrast: 1. Fluid collection due to an apparent skin defect in the anterolateral distal calf. It may represent seroma. Abscess less likely. 2. Distal calf intermuscular hypoattenuation which should be followed on further series but is likely to represent muscle edema. 3. Recent tibia and fibular fractures. 4. Subcutaneous edema in distal calf and foot. . 8/16 L tib/fib plain film: No definite radiographic evidence for osteomyelitis. Internally fixated tibial fracture and impacted nondisplaced nonangulated fibular fracture as previously described. Significant soft tissue ulceration at the level of the fracture site. . [7-24] R knee plain film: No definite radiographic evidence for osteomyelitis. Internally fixated tibial fracture and impacted nondisplaced nonangulated fibular fracture as previously described. Significant soft tissue ulceration at the level of the fracture site. . Shoulder Plain film 1. Demineralization of the bones associated with a reticular appearance, this may be seen in the setting of renal failure. 2. No erosions identified. 3. No fractures are seen. 4. Diffuse opacities within the visualized lungs, cannot exclude underlying pneumonia. . R LE U/S No evidence of DVT. . Bilateral arterial doppler u/s IMPRESSION: On the right normal arterial Doppler study _____ lower extremity at rest. On the left there appears to be mild tibial artery occlusive disease. . CXR 1. Stable bibasilar opacities may reflect underlying pneumonia with possible associated atelectasis. 2. Findings consistent with pulmonary artery hypertension. 3. Interval removal of left-sided PICC line. . [7-30] CTA Chest with and without contrast 1. Slightly limited study due to patient motion and insufficient contrast -bolus, but no evidence of pulmonary emboli. 2. Stable extensive airspace opacities in both lungs with ground glass opacities with interlobular thickening. Findings are likely related to a combination of left ventricular heart failure superimposed on an underlying chronic process such as COP or lupus pneumonitis. 3. Stable mediastinal and hilar lymphadenopathy. 4. Enlarged pulmonary artery consistent with underlying pulmonary arterial hypertension. . [8-1] Echocardiogram with bubble study. IMPRESSION: No ASD/PFO seen. No evidence of endocarditis. Possible shunting through the pulmonary vasculature. Symmetric LVH with preserved global and regional systolic function. Mildly dilated right ventricle with preserved systolic function. Moderate tricuspid regurgitation. Mild pulmonary hypertension. . Compared with the prior study (images unavailable for review) of [2177-2-10], right ventricular systolic function may have slightly improved. Severity of mitral regurgitation appears less. Discrete mitral valve echodensity is not appreciated on the current study. The other findings are similar. . [8-7] CT abd/ pelvis: IMPRESSION: 1. Interval decrease in size of bilateral renal fossa fluid collections. 2. Interval development of the presumed hematoma in the left obturator internus muscle. 3. There is significant interval change in bibasilar ground-glass opacities, with redemonstration of a right middle lobe pulmonary nodule now measuring 5 mm in size. 4. Stable pelvic lymphadenopathy. . [8-13] CT abd/ pelvis: IMPRESSION: 1. Slightly worsened left lower lobe peribronchial opacity and airspace consolidation. This nonstanding. 2. Interval expansion of the obturator internus presumed hematoma. There is also an avidly enhancing focus here. The findings are highly concerning for pseudoaneurysm. 3. Stable nephrectomy bed postoperative collections. . [8-14] IR embolization: IMPRESSION: Angiographically successful embolization of left obturator artery pseudoaneurysm with microcoils and thrombin. . [2177-7-24] 04:25PM BLOOD WBC-8.6 RBC-2.82* Hgb-8.5* Hct-26.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-20.5* Plt Ct-114# [2177-7-29] 04:32AM BLOOD WBC-6.6 RBC-2.62 Hgb-8.0* Hct-25.0* MCV-95 MCH-30.5 MCHC-31.9 RDW-19.8* Plt Ct-147* [2177-7-31] 12:38PM BLOOD WBC-7.5 RBC-2.81* Hgb-8.4* Hct-26.2* MCV-93 MCH-29.9 MCHC-32.0 RDW-19.5* Plt Ct-100* [2177-8-2] 08:00AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.3* Hct-28.8* MCV-91 MCH-29.6 MCHC-32.4 RDW-19.5* Plt Ct-147* [2177-7-24] 04:25PM BLOOD PT-12.8 PTT-31.3 INR(PT)-1.1 [2177-8-1] 05:00AM BLOOD PT-12.9 PTT-32.3 INR(PT)-1.1 [2177-7-24] 04:25PM BLOOD ESR-115* [2177-7-25] 04:42AM BLOOD Ret Aut-4.3* [2177-7-24] 04:25PM BLOOD Glucose-98 UreaN-23* Creat-7.0# Na-136 K-4.8 Cl-101 HCO3-24 AnGap-16 [2177-8-2] 08:00AM BLOOD Glucose-83 UreaN-24 Creat-7.4* Na-137 K-4.5 Cl-101 HCO3-27 AnGap-14 [2177-7-25] 04:42AM BLOOD ALT-12 AST-19 LD(LDH)-204 AlkPhos-193* TotBili-0.2 DirBili-0.1 IndBili-0.1 [2177-7-25] 04:42AM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.1 Mg-2.3 Iron-59 [2177-7-31] 12:38PM BLOOD Albumin-2.8* Calcium-9.1 Phos-2.6* Mg-2.7* [2177-7-25] 04:42AM BLOOD calTIBC-130* Hapto-77 Ferritn-1223* TRF-100* [2177-7-26] 05:20AM BLOOD PTH-144* [2177-7-29] 08:06AM BLOOD PTH-80* [2177-8-2] 08:30AM BLOOD PTH-153* [2177-7-25] 04:42AM BLOOD CRP-33.6* [2177-7-26] 05:20AM BLOOD PEP-POLYCLONAL IgG-3236* IgA-289 IgM-155 IFE-NO MONOCLO [2177-7-26] 05:20AM BLOOD Vanco-40.4* [2177-7-27] 05:59AM BLOOD Vanco-27.6* [2177-7-28] 04:56AM BLOOD Vanco-26.4* [2177-7-29] 04:32AM BLOOD Vanco-25.3* . Blood cx [7-24] (venipuncture): ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R All subsequent blood cultures are thus far negative. . Swab wound cultures: no growth (final) Brief Hospital Course: A/P: Ms. [Known lastname 14323] is a 29yo female s/p failed renal transplant (rejection [2174]) and s/p bilateral nephrectomy, now s/p right tibial IMN on [2177-6-24] who was transferred from [Hospital ] rehab with bacteremia, worsening RLE, and concern for hardware infection. . #) Bacteremia: The patient was transferred from rehab with positive BCx growing coag negative staph sensitive to vancomycin on [7-12], and grew VRE sensitive to Linezolid in BCx on [7-24]. There was no clear source for the bacteremia ?????? CXR and CT of the chest was not suggestive of PNA. Surgery and orthopedics were not concerned for wound infection or hardware infection as a possible septic source. CT of the abdomen/ pelvis was without evidence of abscess or any other infectious source. Surgery was not concerned for the L obturator hematoma (see below) as potential source for sepsis. The ID service was consulted, and the patient was treated with Linezolid for VRE bacteremia and vancomycin for coag. negative staph. Vancomycin will be dosed at dialysis. It will be continued for an unspecified course, to be determined during outpatient follow-up with Dr. [Last Name (STitle) 4020]. Surveillance cultures remained negative for the remainder of the patient??????s hospital course and the patient was clinically well (afebrile, without leukocytosis, negative blood cultures) upon discharge. . #) Hypotension: On [8-8] while on the floor, the patient was found to be lethargic with desaturation to 85% and SBPs~70's. She had received Dilaudid >10mg IV over the course of the day and had a rapid yet brief improvement in her mental status and BP in response to Narcan. BP was unresponsive to IVF boluses and she was transferred to the MICU for closer management, where she briefly required pressors in addition to multiple fluid boluses. She was started on Linezolid, Aztreonam, and Flagyl for presumed sepsis, with sources likely either hardware or abdomen. She was started on stress dose steroids, which was quickly tapered. Hypotension stabilized while in the MICU and the patient was transferred to the floor in stable condition. As above, subsequent cultures have been negative to date. . #) RLE Ulcer: Upon presentation there was no clear purulent drainage but the wound was exquisitely painful to touch. There was no fever or leukocytosis, and no clear osteomyelitis on right leg films. CT, however, demonstrated small abscess in the anterior subcutaneous tissues near the fixation but no deep abscess. She was started on clindamycin and vancomycin, and plastic surgery and orthopedics were consulted for wound care. She was continued on dry sterile dressing changes during her hospital course. Both services monitored the wound regularly and felt that the wound was healing well by discharge. The patient will see orthopedics as an outpatient to follow-up re: IMR placement and plastic surgery to follow-up progression of wound healing. . #) Abdominal pain: The patient has complained of significant diffuse abdominal pain during admission, up to [9-17]. CT scan of abdomen/pelvis was unremarkable except for an incidental finding of a L obturator hematoma (spontaneous in nature - no history of manipulation or trauma). General surgery did not suspect any acute process that could account for her symptoms. Pain subsequently resolved; however, the patient began experiencing significant LUQ pain different than prior on [8-9]. A repeat CT of the abd/ pelvis showed slight interval expansion of the hematoma, and there was a concern for a pseudoaneurysm. The patient was taken for angiography with placement of 13 coils and thrombin into the pseudoaneurysm with a rapid improvement in pain. LUQ pain was thought by GI and general surgery services to be referred pain from this pseudoaneurysm. The patient was able to tolerate po well subsequently and had much improved pain managed by a fentanyl patch (uptitrated to 200mcg) and oral dilaudid by discharge. . #) S/p nephrectomy: The patient was continued on a Tues, Thurs, Sat schedule for dialysis without any complication. She is to continue as an outpatient on this schedule. . The patient was discharged in stable condition to home. She was afebrile, VSS, tolerating po well, and ambulating with crutches (secondary to RLE wound). She was discharged to home with PT follow-up and VNA for dressing changes. Medications on Admission: Vitamin C 500mg [Hospital1 ] Aspirin 81mg daily Amitryptyline 100mg QHS Calcium Acetate 1334mg TID with meals Senna [Hospital1 ] PRN Dulcolax 10mg daily Lovenox 30mg QPM-->Contraindicated in HD patients? Gabapentin 200mg PO QHS Prednisone 5mg daily Colace 100mg [Hospital1 ] Lactulose 30mg Q8H Acetaminophen 650mg PO Q6H Sevelamer 1600mg TID Silver Sulfadiazine 1% cream applied [Hospital1 ] . ALLERGIES: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril Discharge Medications: 1. Home Oxygen Patient needs oxygen at home 2-3L NC as she has ambulatory desaturations to 88% 2. Comode Please give patient high comode 3. Shower Chair Please give patient shower chair 4. Amitriptyline 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 5. Ascorbic Acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule [Hospital1 ]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Capsule(s) Refills:2 8. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:1 10. Sevelamer 800 mg Tablet [Hospital1 ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Linezolid 600 mg Tablet [Hospital1 ]: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 13. Prednisone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. Gabapentin 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:2 15. Silver Sulfadiazine 1 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:2 16. Hydromorphone 2 mg Tablet [Hospital1 ]: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 17. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO DAILY (Daily) as needed for constipation. Disp:30 units Refills:1 18. Medication during dialysis Vancomycin IV (to be given at hemodialysis per HD protocol) 19. Outpatient Lab Work Please draw 2 sets of blood cultures after patient finishes linezolid on [2177-8-14] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Right lower extremity cellulitis/wound infection Right tibia/fibula fracture Septic right knee bacteremia hypoxia . Secondary: End-stage renal disease on hemodialysis Discharge Condition: Good, pain well-controlled, BP stable 100-130s Discharge Instructions: You were admitted for an infection of your right leg and bloodstream. This was treated with antibiotics, and with evaluation by orthopedics, plastic surgery, and vascular surgery, who felt that the wound had good blood flow and would heal over time. Because of the type of organism and the fact that you have orthopedic hardware in your leg, you need to take 2 antibiotics: the first, linezolid, is an oral medication you should take for 10 more days; the second, vancomycin is an intravenous antibiotic which you should get during dialysis. You will need this for several months. We have arranged followup with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 4020] of infectious disease, please see below for details. You were seen by the pulmonary doctors because [Name5 (PTitle) ] have needed extra oxygen to avoid feeling short of [Name5 (PTitle) 1440]. You should follow-up with them as an outpatient (details below - Dr. [Name (NI) 18849] office will call you with an appointment, but you should have a repeat CT scan of the chest before that. You should also have pulmonary function tests before or on the day of that appointment, Dr.[Name (NI) 18850] office can arrange this). You have been started on several new medications: linezolid, vancomycin, and lactulose. Please return to the emergency room if you experience worsening knee pain, fevers, shortness of [Name (NI) 1440], chest pain, or any other new or concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) 4021] [Name11 (NameIs) ] (infectious disease specialist), MD Phone:[Telephone/Fax (1) 457] Date/Time:[2177-8-28] 11:30 . [2177-9-30] 10:15am Follow-up CT Scan of the chest. Please do not eat anything from 3 hours before study in [Hospital Ward Name 23] clinical center on [Hospital Ward Name ]. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2177-9-30] 10:15. . Dr. [First Name8 (NamePattern2) 4944] [Last Name (NamePattern1) ] of pulmonology and would like to see you as an outpatient in [1-11] months. Her office will call you with an appointment. If you do not hear from them in a few weeks, call ([Telephone/Fax (1) 513] to make an appointment. . Orthopedic followup: Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2177-8-14] 10:10 Provider: [Name10 (NameIs) ] [Name8 (MD) 18851], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2177-8-14] 10:30 . Followup with the [8-21] at 1pm with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in [Hospital Ward Name 23] [Location (un) ] central suite. (she is a nurse practitioner who works with Dr. [Last Name (STitle) ] Followup with Dr. [Last Name (STitle) ] on [10-3] at 10:40am. If she wants to see you sooner, someone from her office will call you.	[ "V45.1", "403.91", "416.9", "V15.2", "442.3", "710.0", "287.5", "282.5", "458.9", "585.6", "682.6", "997.2", "564.09", "996.67", "998.11", "515", "996.81", "790.7" ]	icd9cm	[ [ [] ] ]	[ "88.48", "39.95", "99.04", "38.88" ]	icd9pcs	[ [ [] ] ]	17097, 17155	9922, 14322	362, 414	17375, 17424	4192, 9899	18956, 20393	3388, 3406		14851, 17074		17176, 17354		14348, 14828				17448, 18933						3421, 4173																			2161, 2461			304, 324								442, 2142															2505, 3206	3222, 3372
9,473	125,694	13089	Discharge summary	report	Admission Date: [2103-3-23] Discharge Date: [2103-3-30] Date of Birth: [2036-5-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: CHF exacerbation Major Surgical or Invasive Procedure: Right IJ placement History of Present Illness: 66M with hx of CHF (EF10%), CRF (baseline 2.6), CAD s/p CABG, AAA, bilateral renal artery stenosis s/p stenting and COPD who presents from outside hospital with acute renal failure and CHF exacerbation. Pt initially presented to [Hospital6 5016] on [3-15] with chief complaint of nausea/vomiting and diarrhea associated with fevers. On evaluation, pt was thought to be dehydrated given his history and creatinine of 3.1, up from his baseline of 2.6 so he was given IVF in the ER. The following day, the creatinine had not improved and a CXR showed evidence of CHF so pt was started on lasix. The creatinine continued to rise over his hospital stay and renal was consulted who thought that his renal failure was pre-renal [12-22] his cardiomyopathy and poor forward flow. He was started on a lasix drip which was titrated up. His urine output remained poor and his BUN and creatinine cont to rise, peaking at 5.6. The renal team discussed dialysis with the patient which he was very reluctant to start. Pt was transferred to [Hospital1 18] for further evaluation of his worsening renal function and heart failure . Other issues included fever, bacteremia and elevated liver enzymes. On admission, pt spiked to 101.6 and he was started on rocephin prophylactically. When blood cultures ([2-21]) from admission grew out Enterococcus casseliflavus, he was started on vanc on [3-16] which was changed to ampicillin on [3-19] when sensitivities returned. ID was consulted and recommended TEE to rule out vegetations. TEE showed no evidence of vegetations but did show an EF of [9-3]%.He was found to have an elevated bilirubin and alk phos (to 3.9 and 358 respectively) so the patient had a workup including GI consult, EGD, ERCP and ultrasound. ERCP showed normal CBD with no stones and ultrasound showed enlarged liver and two "suspicious" lesions in the pancreas possibly adenomyoma vs malignancy. An abdomen/pelvis CT was also done which showed moderate ascites and gallstones. . On admission to the CCU, pt denied any chest pain, shortness of breath, fevers, chills. His only complaint is that of constipation. Past Medical History: * ischemic cardiomyopathy (EF 10-15%) * CAD s/p CABG in [2086] (SVG to PLA, LIMA to LAD) * s/p BiV AICD at [Hospital1 18] in [2100] * s/p PEA arrest in [11/2102] * hx of VT during [11/2102] admission now s/p amio load * 100% Right ICA stenosis * Left ICA stenosis s/p CEA * AAA * bilateral renal artery stenosis s/p stenting by [Year (4 digits) ] in [2097] and again to the left in [1-/2103] * Chronic renal failure, baseline 2.6-2.9 * COPD * OA in ankle * bilateral inguinal hernias * s/p appy * hx of remote gastric ulcer Social History: Social history is significant for the absence of current tobacco use. 2PPD previously, quit 20 years ago. There is previous history of alcohol abuse. Family History: NC Physical Exam: Pt was afebrile at 96.1. Blood pressure was 113/51 mm Hg while seated. Pulse was 70 beats/min and regular, respiratory rate was 18 breaths/min and 100% on room air. Weight 65kg on the bedscale. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 14cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were slightly labored and there were no use of accessory muscles. The lungs had crackles at the bases to 1/2way up bilaterally. There were also crackles anteriorly. . Palpation of the heart revealed the PMI was not able to be located. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There was a soft [12-26] early systolic murmur heard best at the LUSB . The abdominal aorta was not able to be palpated. There was no hepatomegaly. The abdomen was soft nontender but moderately distended with a possible fluid wave. The lower extremities had no pallor, cyanosis, clubbing or edema and were both warm. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: EKG demonstrated paced rhythm with occ PVC. No acute changes when compared to EKG from [3-15] . TELEMETRY demonstrated: paced beats . 2D-ECHOCARDIOGRAM performed on [2103-1-16] (at [Hospital1 18]) demonstrated: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. The delay between left ventricular and right ventricular ejection is 62 ms (nl <40ms). Right ventricular systolic function appears depressed. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. . TEE at OSH [2103-3-22]: 1. Mitral annulus is calcified, mild to moderate MR 2. Aortic valve is tricuspid and sclerotic 3. Mild TR with estimated RV systolic pressure of 52mmHg based on estimated RA pressure of 10mmHg suggesting pulm HTN 4. LV enlarged [Last Name (un) ] 6.1cm at end diastole 5. LV is globally hypokinetic with estimated EF of 15% 6. [Name Prefix (Prefixes) ] [Last Name (Prefixes) 40004] at 4.6cm 7. RV enlarged 8. no ASD or PFO 9. no pericardial effusion . no ETT in system . no CARDIAC CATH in system . [2103-3-26]: Renal U/S: 1. Patent main renal arteries bilaterally with good arterial upstrokes. Increased echogenicity within the renal cortical parenchyma is consistent with change related to chronic renal disease. 2. Ascites. . LABORATORY DATA: . 134 96 74 ---\|-------\|------< 92 6.4 >------< 89 (138 on admission) 3.5 20 5.6 29.4 . ALT 135 AST 94 LDH 285 ALK PHOS 347 BILI 2.5 ALB 3.3 . PRO-BNP: [Numeric Identifier ] . Brief Hospital Course: 66M with hx of CAD s/p CABG, ischemic cardiomyopathy (EF 10-15%), BiV pacer and AICD, [Hospital ] transferred from OSH with enterococcal bactermia, unclear source, elevated LFTs, bilirubin, acute on chronic renal failure with oliguria and CHF exacerbation. . 1. CHF: EF known to be 10-15% seen on TEE from OSH. Initially, the patient was thought to be dehydrated in the setting of his viral gastroenteritis and given fluid at the OSH (unclear how much). His BNP on admission was markedly elevated at 23,000 and his JVP is elevated with what appeared to be ascites on exam. However, he had no oxygen requirement and his lower extremities were without edema. These findings pointed towards right heart failure. His beta blocker was held in the setting of acute exacerbation as well as his isordil to give more room for BP. He was started on dobutamine gtt to improve pump function and was titrated to UOP>100cc/hr. The patient autodiuresed without additional lasix. He was placed on a low salt diet, daily weights, 1.5L fluid restriction. Patient had a significant UOP and became >2L negative over his initial stay. He was started on gentle IVF hydration to maintain his fluid status at slightly negative-even. Next, he was weaned off the dobutamine drip leading to less UOP. Dobutamine was restarted later that evening with UOP somewhat improving. UOP remained stable, allowing Dobutamine to be weaned off. . 2. CAD: s/p CABG in [2086]; no stress tests or cardiac caths in our system. There were no signs of active ischemia. He was continued on ASA and lipitor. His BB, nitrate, HCTZ were held as above for more BP room and in setting of acute exacerbation. Given his episode of epistaxis his ASA was switched to qod. His lipitor was then held due to mildly elevated. Upon discharge, lipitor was restarted. . 3. Rhythm: BiV pacer and AICD; hx of VT and PEA arrest. Patient was continued on amiodarone. . 4. Acute on chronic renal failure: Most likely from poor forward flow in setting of volume overload and shift down Starling curve. He was started on dobutamine as above to improve forward flow and MAPs >65. His Cr remained elevated but stable and he had a significant UOP, likely post-ATN diuresis. A renal U/S did not show any signs of obstruction. His renal artery stents were patent. His UOP slowed down after dobutamine drip had been weaned. Dobutamine was restarted and UOP increased to some extent. Dobutamine was weaned again and urine output remained acceptable although low. Renal was consulted and also an outpatient appointment with nephrology was scheduled. . 5. Gap acidosis: likely from renal failure, closed slowly during hospitalization. . 6. Renal Artery stenosis: Patient was continued on ASA, plavix for his renal artery stents. His plavix, however, was briefly held following an episode of epistaxis requiring packing by ENT. An U/S did not reveal any obstruction of his b/l stents. . 7. Enterococcal bacteremia: Diagnosed at OSH. Possible sources include urine (neg cx), biliary system (ERCP and U/S without pathology), GI (hx of diarrhea but stool cx negative), pancreas? (abd CT showed "suspicious" areas of pancreas; could these be abscesses?) S/p 3 days of vanc and 5 days of ampicillin on admission. Patient was continued on ampicillin x 14 day course total (last day [3-29]). He was monitored for fevers. Blood cultures cleared at OSH. They were sent again and were pending upon discharge. Patient remained afebrile and stable throughout remainder of hospital stay. . 8. Elevated LFTs and bili: Initially, a primary bilirubin elevation but now bili has improved and LFTs have trended slightly up. ERCP negative for CBD dilatation, + gallstones. Ultrasound unrevealing. Possibly due to hepatic congestion from RHF thought would expect more of a transaminitis vs a cholestatic picture. Statin was discontinued. LFTs were slowly trending down. Upon discharge, lipitor was restarted. . 9. Questionable pancreatic lesions: see above . 10. Funguria: twice urine culture positive for yeast. Pt was started on fluconazole, renally dose, to be continued for a total of 7 days, i.e. four more days after discharge. . 11. Thrombocytopenia: Chronic. plts of 117,000 on admission to OSH so have not dropped by [11-21]. Platelets remained stable. Heparin products were held. . 12. COPD: continued home regimen of advair, spiria, montelukast; prn atrovent and albuterol nebs . 13. Constipation: bowel regimen . 14. FEN: low salt diet, 1.5L fluid restriction . 15. Ppx: boots, PPI . 16. Access: quad lumen right IJ, placed on [3-23]; PIV x 1 . 17. Code: discussed with patient on admission: he would like to be intubated if the medical team thinks it is a reversible problem but would not like to be intubated for a prolonged time; he is agreeable to shocks esp since he has an ICD in place Medications on Admission: CURRENT MEDICATIONS (on transfer): * Ampicillin 1gm q8hr (on abx since [3-16]) * Lasix gtt 40mg/hr * Coreg 25mg [Hospital1 ] * Amiodarone 200mg [Hospital1 ] * Advair 50/250 [Hospital1 ] * Spiriva 18mcg qd * Levoxyl 25mcg qd * Protonix 40mg qd * Plavix 75mg qd * ASA 325mg qd * Isordil 10mg [Hospital1 ] * Zocor 80mg qd . HOME MEDS: * HCTZ 25mg qd * Lipitor 40mg qd * Isordil 10mg [Hospital1 ] * Lasix 80mg qd * Trental 40mg qd * Flovent 220mcg [Hospital1 ] * Singulari 10mg qd * Plavix 75mg qd * ASA 325mg qd * Coreg 25mg [Hospital1 ] * Amiodarone 200mg [Hospital1 ] * Advair 50/250mcg [Hospital1 ] * Spiriva 18mcg qd * Levoxyl 25mcg qd Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO QOD (). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 4 days. Disp:8 Tablet(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1) puff Inhalation twice a day. 8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Aspirin EC 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. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 14. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day: please take this medication a half hour prior to your morning dose of lasix. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Congestive heart failure Acute renal failure Enterococcal bacteremia Coronary artery disease Renal artery stenosis s/p b/l renal artery stents (patent on US) Elevated LFTs Thrombocytopenia COPD Discharge Condition: Hemodynamically stable. Tolerating POs. Afebrile. Discharge Instructions: Please continue to take your medications as directed. . Please weight yourself every day. If your weight increases by 2 lbs call your health care provider as your lasix dose may need to be adjusted. Please continue to adhere to a low salt diet of no more than 2gm/day. To do this you should avoid processed foods and canned foods as these contain a lot of sodium. You should also restrict your fluid intake to no more than 1.5 liters/day. . take your medications as prescribed. . attend your appointments as listed. . If you experience shortness of breath, chest pain or other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with your nephrologist Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] at the renal unit of the [Hospital ] Clinic (Phone: [Telephone/Fax (1) 3637]) on [4-26] at 12PM. In addition, you have been put on a waiting list. His secretary will call you if she can schedule you an earlier appointment. . Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week. PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ] [Telephone/Fax (1) 34574] . Please follow up with your cardiologist within 2 weeks. [Last Name (LF) ],[First Name3 (LF) ] J. [Telephone/Fax (1) 2394] Completed by:[2103-3-30]	[ "585.9", "440.1", "584.9", "414.8", "112.2", "794.8", "424.0", "428.0", "790.7", "397.0", "V45.81", "V45.02", "276.2", "287.5", "041.04", "496" ]	icd9cm	[ [ [] ] ]	[ "00.17", "38.93" ]	icd9pcs	[ [ [] ] ]	14104, 14187	7061, 11684	332, 352	14425, 14477	4946, 7038	15156, 15859	3300, 3304		12628, 14081		14208, 14404		11926, 12605				14501, 15133						3319, 4927																						276, 294								380, 2536								11698, 11900							2558, 3116	3132, 3284
71,851	145,136	29045	Discharge summary	report	Admission Date: [2137-1-18] Discharge Date: [2137-1-22] Date of Birth: [2104-3-26] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7055] Chief Complaint: Pericardial effusion with early tamponade Major Surgical or Invasive Procedure: Pericardial tap History of Present Illness: Mr [Known lastname 69973] is a 32 year old man without significant past medical history, with recent upper respiratory febrile illness and SOB that started 10 days prior. Recently completed a course of oral antibiotics in mid [Month (only) ] for sinus infection, however he continued to have SOB, productive cough, and fever. He was diagnosed with upper respiratory tract infection and possible pneumonia (?LLL infiltrate), however that diagnosis was in question, and he was treated with moxifloxacin. He presented to OSH on [1-16] with temperature of 103 and worsening pleuritic chest pain and shortness of breath. Cardiac enzymes were negative. He had a negative influenza swab. On bedside echocardiogram was found to have a moderate pericardial effusion 1.2-1.9 cm initially and was treated with Toradol. Echo today noted that it had increased to 2.1cm, mostly posterior, with septal flattening. He was transferred for further evaluation and on arrival was found to have a large pericardial effusion with early signs of tamponade. Pericardiocentesis was performed with opening pressure 21 mmHg and removal of 410 cc serosanguinous fluid that was sent for laboratory evaluation which is pending. Post-drainage pericardial pressure was 3 mmHg. His chest pain is nearly resolved, although continues to have substernal discomfort with deep inspiration. He has a mildly productive cough of pink sputum. His breathing is improved but still limited by chest discomfort. 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 unintended weight loss, chills, or nightsweats. He had no known infectious exposures. He also denies exertional buttock or calf pain. All of the other review of systems were negative except per HPI above. Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: NONE 3. OTHER PAST MEDICAL HISTORY: - frequent sinus infections - nasal polyps removed [4-16] - distant history of ETOH abuse - cocaine/heroin abuse, hx of prior smoking. Social History: Works for internet car sales. Single. -Tobacco history: Denies. -ETOH: Denies. -Illicit drugs: Denies. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T= 100.8 BP= 125/82 HR= 113 regular RR= 34 O2 sat= 92% 6L GENERAL: WDWN tachypnic taking shallow breaths speaking in broken sentences. 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 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Tachycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Pericardial drain in place draining serosanguinous fluid. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS [2137-1-18]: [2137-1-18] 08:45PM WBC-8.4 Hgb-9.0* Hct-27.0* Plt Ct-441* [2137-1-18] 08:45PM Neuts-77.7* Lymphs-15.6* Monos-5.0 Eos-1.2 Baso-0.5 [2137-1-18] 08:45PM PT-15.7* PTT-33.1 INR(PT)-1.4* [2137-1-18] 08:45PM Glucose-171* UreaN-13 Creat-0.9 Na-138 K-4.4 Cl-104 HCO3-24 AnGap-14 [2137-1-18] 08:45PM ALT-126* AST-153* LD(LDH)-342* CK(CPK)-65 AlkPhos-165* TotBili-0.6 [2137-1-18] 08:45PM CK-MB-NotDone cTropnT-<0.01 [2137-1-18] 08:45PM Albumin-3.2* Calcium-7.8* Phos-2.9 Mg-2.1 Iron-11* [2137-1-18] 08:45PM calTIBC-157* Ferritn-1191* TRF-121* [2137-1-18] 08:45PM TSH-0.62 LFT TREND: [2137-1-18] 08:45PM ALT-126* AST-153* LD(LDH)-342* AlkPhos-165* TotBili-0.6 [2137-1-20] 06:28AM ALT-242* AST-124* AlkPhos-163* TotBili-0.5 [2137-1-22] 07:10AM ALT-339* AST-167* AlkPhos-187* MICRO: [2137-1-18] 4:50 pm FLUID,OTHER Site: PERICARDIUM GRAM STAIN (Final [2137-1-18]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2137-1-21]): NO GROWTH. ANAEROBIC CULTURE (Final [2137-1-20]): DUE TO LABORATORY ERROR, UNABLE TO PROCESS. ANAEROBES ARE SCREENED FOR IN THE FLUID CULTURE. TEST CANCELLED, PATIENT CREDITED. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [2137-1-19]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): RESULTS PENDING. [2141-1-18] BCx: NGTD [1-19] Influenza DFA: negative [1-18] Sputum Cx: respiratory flora Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. IMAGING: [1-18] ECHO: 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. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate to large circumferential pericardial effusion with echocardiographic signs of early tamponade. [1-18] REPEAT ECHO: Overall left ventricular systolic function is mildly depressed (LVEF= 50 %), possibly secondary to tachycardia. Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no signs of tamponade. IMPRESSION: Small echodense residual pericardial effusion. Resolution of tamponade physiology. Compared with the prior study (images reviewed) of [2137-1-18], pericardial effusion is smaller and echo signs of tamponade are no longer evident [1-18] CXR: No focal consolidation is identified, but the retrocardiac area is dense and the left hemidiaphragm is indistinct. Pleural fluid or consolidation at the left base cannot be excluded. Further evaluation with lateral view or lateral decubitus views should be considered [1-19] REPEAT ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is abnormal septal motion. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Cine loop #27 demonstrates transient flattening of interventricular septum during inspiration, suggesting ventricular interdependence and analogous to a physical Kussmaul's sign. The echo findings are therefore suggestive of pericardial constriction. No evidence of cardiac tamponade. IMPRESSION: Small residual echodense pericardial effusion. Echocardiographic findings are strongly suggestive of effusive-constrictive physiology. Compared with the prior study (images reviewed) of [2137-1-18], there is evidence of constrictive physiology. The other findings are similar. [1-20] CXR: There is a small bilateral pleural effusion. The lungs are essentially clear with no evidence of consolidation worrisome for infectious process. There is no pneumothorax. [1-21] ECHO: The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion and exaggerated transtricuspid respiratory variation suggestive of pericardial constriction. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. The echo findings are suggestive but not diagnostic of pericardial constriction. Compared with the prior study (images reviewed) of [2137-1-19], the findings are similar (and continue to suggest constriction). DISCHARGE LABS [2137-1-22]: [2137-1-22] 07:10AM WBC-9.0 Hgb-11.6 Hct-35.3 Plt Ct-648 [2137-1-22] 07:10AM Glucose-83 UreaN-14 Creat-0.9 Na-139 K-4.8 Cl-102 HCO3-28 AnGap-14 [2137-1-22] 07:10AM ALT-339 AST-167 AlkPhos-187 Brief Hospital Course: Mr. [Known lastname 69973] is a 32 year old man with no significant medical history who presented with pericardial effusion and early signs of tamponade, now stable status post drainage. # PERICARDIAL EFFUSION: S/P tap and latest ECHO on [1-21] does not show reaccumulation of fluid. Most likely related to viral illness given fevers, myalgias possibly related to flu however swab negative at outside hospital and here. One BC bottle grew coag neg staph, other cultures negative. Staph is likely a contaminant and 2 sets of blood cultures are pending at the time of this summary with NGTD in [4-11] days. No leukocytosis or fevers. Pericaridal pain well controlled on indomethecin and colchicine. Symptoms of pericardial constriction likely r/t inflammation. Started on Omeprazole to prevent stomach irritation from NSAIDS. [Known firstname ] will have an appt with Dr. [Last Name (STitle) 7047] in 1 month for a repeat ECHO and further assessment. # Pneumonia: Noted prior to admission and CXR here showed ? retrocardiac opacity that has since cleared. Pt was on ceftriaxone and Azithromycin for CAP, changed to Azithromycin and Cefpodoxime at discharge for total 7 day course. No further fevers or leukocytosis. Cough with white sputum which cultured negative. Using Flonase and nasal irrigation to treat sinus pressure. # Tachycardia: Sinus, rate 80's-low 100's, related to pain and inflammatory state, and nebs. Treat with analgesics per above. # Increased LFT's: Unknown baseline. Abd exam benign. Pt states he was tested for Hep C in past after IVDA, was negative. AST/ALT 2:1. ? r/t viral illness vs antibiotics. No further IVDA since. No tenderness, enlargement of liver. No pain with eating or nausea. Bili has been nl. -f/u as outpt in 1 month. If still elevated will consider Hepatitis screen and RUQ ultrasound. # Sinus pain: some facial tenderness. Pt states usually treats with nasal irrigation and flonase. - start flonase and nasal irrigation. Medications on Admission: (on transfer) ativan 12noon morphine- last dose of 2mg at 230pm heparin SQ-last dose 6am today Toradol last dose 11am flonase nebs Discharge Medications: 1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 4. SinuCleanse Nasal Wash System 700-2,300 mg Packet Sig: One (1) packet Nasal [Hospital1 ] (2 times a day). 5. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:4 Tablet(s) Refills:0 6. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:4 Tablet(s) Refills:0 7. Outpatient Lab Work Please send CBC and LFT's on Tuesday [1-29] and call results to Dr. [Last Name (STitle) 7047] at [Telephone/Fax (1) 8725] 8. 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 Discharge Disposition: Home Discharge Diagnosis: Pericarditis and pericardial effusion Left lower lobe pneumonia. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had a fluid collection and inflammation around your heart. This was probably because of a viral infection. We drained the fluid around your heart and it has not reaccumulated. You will take 2 medicines to treat the inflammation in your heart. It appears that you have had a pneumonia in the left side of your heart. You have been on antibiotics to treat this pneumonia and we will send you home on an antibiotic pill to complete a 7 day course. Your liver function tests were elevated, this is likely because of a virus but Dr. [Last Name (STitle) 7047] will check them again in 1 week. Please bring the prescription to any lab or office to get your blood drawn. . Medication changes: 1. Start Cefpodoxime to treat pneumonia 2. STart Azithromycin to treat pneumonia 3. Start Colchicine and Indomethecin to treat the inflammation around your heart. 4. Start Flonase and sinus rinse to treat your sinus congestion. . Followup Instructions: Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] Phone: [Telephone/Fax (1) 8725] Date/time: Office will call you an appt at home in one month. Please call the above number to schedule an appt if you don't hear from them. .	[ "794.8", "420.91", "427.89", "423.3", "486" ]	icd9cm	[ [ [] ] ]	[ "37.0" ]	icd9pcs	[ [ [] ] ]	12790, 12796	9613, 11601	314, 332	12905, 12905	3987, 5264	13999, 14266	2848, 2963		11783, 12767		12817, 12884		11627, 11760				13050, 13723						2978, 3968				2533, 2538		5301, 5395				5428, 9590											13743, 13976	233, 276								360, 2419										12919, 13026	2569, 2709				2441, 2512	2725, 2832
17,330	152,853	14954	Discharge summary	report	Admission Date: [2166-4-7] Discharge Date: [2166-4-27] Date of Birth: [2088-1-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Hemodialysis line removal Placement of Temporary Hemodialysis Catheter PICC line placement Placement of Tunneled Hemodialysis Catheter History of Present Illness: HPI: 78W with history of MPD, HTN, DM2, ESRD on HD, depression, and AF on anticoagulation who presented from [Hospital 100] Rehab w/large UGIB but has designated code status as DNR/DNI. The patient was admitted to [Hospital 100] Rehab [2166-3-31] following an admission to [Hospital1 882] for left leg hematoma with INR 19 s/p fasciotomy [2166-2-22] which was c/b DVT in hematoma for which she was restarted on coumadin and underwent repeat surgery [2166-3-24]. Since discharge she had been doing well until this morning when noted to have 200cc bright red emesis with blood clots. She has noted at the Rehab to have poor po intake for days without a bowel movement in five days. In the ED, she dropped her sat sto 84%, was put on high flow O2. [12-26] large amt of hematemesis, she received 2-3L of fluid in the ED. . She says that she has been sick long enough and does not wish escalation of care. She specifically refuses cpr, intubation, EGD, interventional lines, embolization but does want dialysis and blood-products in the short term. If her GIB does not resolve quickly, she wishes to have comfort the main goal of care, including discontinuation of HD and blood products. Two sisters are present at interview who agree, but express concern about the patient's son or husband interfering with her wishes. Past Medical History: Past Medical History: 1. Fasciotomy w/DVT in hematoma s/p fasciotomy [2166-2-22], back to OR [2166-3-24] 2. Afib 3. HTN 4. Type 2 diabetes mellitus 5. ESRD 6. Depression 7. Multifactorial anemia. 8. mpd 9. Echo LVH w/EF60% mod MR+AS 10. Subarrachnoid hemorrhage [2163] 11. Hypothyroidism 12. COPD Social History: Social History: Lived at home w/ husband and daughter before hospitalization. Originally from [Country 5976]. She is now at [Hospital1 100] Senior Life. Past smoker, non-drinker. Family History: NC Physical Exam: Vitals: T 97.8 BP 120-128/37-49 HR 98-102 R 21 Sat 96% NC 2L * PE: G: NAD HEENT: MMM Lungs: Coarse rhonchi BL, occ wheezes Cardiac: Irregular. Distant S1S2. No murmurs appr Abd: Soft, NT, ND. NL BS. Ext: No edema. 2+ DP pulses BL. Back: Stage 2-3 decubitus ulcer along sacral area, no evidence of tracting. Malodorous. Pertinent Results: Admission Labs: . [2166-4-7] 02:11AM LACTATE-1.8 [2166-4-7] 02:15AM PT-17.8* PTT-25.8 INR(PT)-1.7* [2166-4-7] 02:15AM PLT COUNT-621* [2166-4-7] 02:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [2166-4-7] 02:15AM NEUTS-87* BANDS-2 LYMPHS-1* MONOS-6 EOS-2 BASOS-1 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1* [2166-4-7] 02:15AM WBC-32.2# RBC-3.74 HGB-10.5* HCT-33.3* MCV-89 MCH-28.0 MCHC-31.4 RDW-19.4* [2166-4-7] 02:15AM ALT(SGPT)-17 AST(SGOT)-45* ALK PHOS-129* TOT BILI-0.8 [2166-4-7] 02:15AM GLUCOSE-192* UREA N-50* CREAT-5.0# SODIUM-136 POTASSIUM-5.1 CHLORIDE-92 TOTAL CO2-30 ANION GAP-19 [2166-4-7] 03:13AM URINE GRANULAR-0-2 [2166-4-7] 03:13AM URINE RBC-[1-26]* WBC-[5-3]* BACTERIA-MOD YEAST-MANY EPI-[10-13] [2166-4-7] 03:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD [2166-4-7] 03:13AM URINE COLOR-Amber APPEAR-Cloudy SP [Last Name (un) 155]-1.021 [2166-4-7] 04:03AM HGB-9.8* calcHCT-29 [2166-4-7] 04:03AM LACTATE-1.5 K+-3.6 [2166-4-7] 08:36AM FIBRINOGE-689* [2166-4-7] 08:36AM PT-16.8* PTT-26.1 INR(PT)-1.6* [2166-4-7] 08:36AM PLT COUNT-537* [2166-4-7] 08:36AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL [2166-4-7] 08:36AM NEUTS-90* BANDS-1 LYMPHS-4* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2166-4-7] 08:36AM WBC-27.4* RBC-3.64* HGB-10.3* HCT-32.4* MCV-89 MCH-28.4 MCHC-31.9 RDW-18.6* [2166-4-7] 08:36AM T4-3.8* [2166-4-7] 08:36AM TSH-8.3* [2166-4-7] 08:36AM ALBUMIN-2.9* CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-1.9 [2166-4-7] 08:36AM proBNP-[Numeric Identifier 43790]* [2166-4-7] 08:36AM LIPASE-32 [2166-4-7] 08:36AM ALT(SGPT)-13 AST(SGOT)-17 LD(LDH)-320* ALK PHOS-110 AMYLASE-19 TOT BILI-0.8 [2166-4-7] 08:36AM GLUCOSE-138* UREA N-54* CREAT-4.8* SODIUM-137 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-30 ANION GAP-16 [2166-4-7] 09:17AM URINE RBC-34* WBC-134* BACTERIA-OCC YEAST-MANY EPI-2 [2166-4-7] 09:17AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [2166-4-7] 09:17AM URINE COLOR-LtAmb APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2166-4-7] 01:15PM HCT-33.2* [2166-4-7] 10:07PM HCT-29.9* Pertinent Labs/Studies: . Imaging: [2166-4-7]: Portable Chest - 1. No significant change in the upper lung zone pulmonary vascular redistribution and slight perihilar haziness which is consistent with mild congestive heart failure. 2. Mild cardiomegaly. . [2166-4-9]: Portable Chest - IMPRESSION: Resolved pulmonary edema. . [2166-4-11]: Portable Chest - IMPRESSION: Interval intubation and placement of PICC. Atelectasis at the right lung base and right middle lobe. Aspiration cannot be excluded. . [2166-4-11]: RUE US - IMPRESSION: No DVT in right upper extremity. . [2166-4-12]: Portable - IMPRESSION: Possible early failure. . [2166-4-14]: FINDINGS: There has been interval placement of a left-sided dialysis catheter with the tip terminating just below the cavoatrial junction. A left-sided PICC is in stable position. There is no pneumothorax. There is worsened pulmonary edema. There has been development of a right-sided pleural effusion and a tiny left-sided pleural effusion. IMPRESSION: 1. No evidence of pneumothorax. 2. Worsened pulmonary edema with bilateral pleural effusions, greater on the right side. . [2166-4-18]: There is continued mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. There is slight improvement of the bibasilar patchy atelectasis. The left-sided PICC line and left jugular IV catheter remain in place. No pneumothorax is identified. There is continued tortuosity of the thoracic aorta with calcification. . [2166-4-20]: CT lower extremity - There are two large heterogeneous fluid collections with areas of high attenuation involving the anterior and medial thigh consistent with hematomas. The largest collection involving the anterior medial thigh located in or just deep to the sartorius muscle measures 17 x 8 x 5 cm (craniocaudad, transverse, AP). The collection more superiorly centered within the tensor fascia lata measures 6 x 5 x 3 cm. (craniocaudad, transverse, AP). There are no air bubbles in the collection or other specific CT signs to suggest superinfection though this cannot be excluded. Surrounding osseous structures demonstrate no evidence of destruction or secondary signs of osteomyelitis. The bones are normally mineralized. There is mild subcutaneous edema diffusely. Incidental note is made of rectal tube. The visualized pelvic contents are unremarkable with the exception of sigmoid diverticulosis without evidence of diverticulitis. Diffuse vascular calcification is noted. . IMPRESSION: Two large hematomas as described above centered in the left tensor fascia lata and just deep to the sartorius muscle. No air is seen in these collections, however superinfection is not excluded. . [2166-4-23]: Portable Chest - IMPRESSION: No change in pulmonary vascular congestion. . [2166-4-24]: Successful placement of a tunneled dialysis catheter in the left internal jugular vein. The tip is in the right atrium. The line is ready for use. . . Microbiology: . Reports from [Hospital 882] Hospital Reviewed: - Hematoma evacuation [2166-3-24] - gram stain negative, no growth on cultures . Urine: [2166-4-7]: Yeast x 2 . Blood: [2166-4-7]: No growth [2166-4-10]: [2-27] Blood cultures growing E. Coli [2166-4-11]: No growth [2166-4-20]: No growth [2166-4-25]: NGTD . Sputum: [2166-4-11]: 1+ GPC in pairs, cxs - rare OP flora, rare GNRs [2166-4-15]: 4+ GNR, cxs: E. Coli, sensitive to ceftriaxone . Stool: [2166-4-13]: C. Diff+ [2166-4-15]: C. Diff+ . Discharge Labs: . [2166-4-27] 06:00AM BLOOD WBC-PND RBC-3.50* Hgb-10.1* Hct-33.3* MCV-95 MCH-28.8 MCHC-30.3* RDW-23.1* Plt Ct-PND [2166-4-27] 06:00AM BLOOD PT-17.7* PTT-64.4* INR(PT)-1.7* [2166-4-27] 06:00AM BLOOD Glucose-137* UreaN-31* Creat-4.5# Na-134 K-4.6 Cl-99 HCO3-22 AnGap-18 [2166-4-27] 06:00AM BLOOD Calcium-8.6 Phos-6.1# Mg-1.8 Brief Hospital Course: A/P: Patient is a 78 year old female with medical history significant for Myeloproliferative disorder, DMII, ESRD on HD, perm AF, HTN who was recently hospitalized at [Hospital1 882] s/p evacuation on left thigh hematoma x 2 with course complicated by LLE DVT. Patient was transferred to [Hospital1 18] MICU for hematemesis/UGIB in setting of anti-coagulation for DVT as well as permanent afib with course complicated by E. Coli bacteremia, rapid afib, hypotension, and respiratory failure requiring intubation. . #. GI Bleed: On presentation to the ICU the patient was hemodynamically stable maintaining her SBP although tachycardic. GI evaluated the patient in the ICU with assessment that the patient should undergo EGD but that it would be better to defer until her repiratory status stabilized given the patient's bleeding was self-limited and there was no evidence for active bleed at that time. However, upon further conversation with the patient regarding code status and goals of care, the patient reported to the treating team that she did not want invasive procedures including resuscitation, intubation or EGD. Given this EGD was not performed this admission. The patient had no repeat episodes of hematemsis throughout the hospital course and her Hct was stable. In the setting of a supratherapeutic INR the patient did exeprience some bloody discharge from her rectal tube which was self limiting without Hct drop. The patient received a total of 2U of PRBCs ([4-7] and [4-12]) during her hospital course. The patient continued to have guaiac positive stools but no evidence of rapid bleeding. . #. Respiratory Failure - The patient appeared to be relatively stable after initial admission to the MICU and was to be transferred to the floor when she began to develop respiratory distress. Subsequent imaging revealed evidence for volume overload and pulmonary edema. The patient required intubation on [4-10] because of impending respiratory failure. The patient had multiple spontaneous breathing trials with difficult wean, but was eventually extubated on [4-13]. During that time period, the patient had daily HD with removal of multiple liters of fluid. S/p extubation there was some concern for ongoing respiratory insufficiency w/ hypercarbia although the patient was mentating well. As the patient's ABGs on and off Bipap remained similar, it was decided not to continue Bipap. After multiple days of qd hemodialysis, the patient's peripheral O2 saturation began to improve as did her blood gases. The patient was initally put on face mask for transition and eventually weaned to NC. Given patient's history of COPD, her goal O2 sats were maintained for 93-96%. The patient was initially maintained on 2L NC with recent increasing O2 needs to 3L and postional desats. Repeat chest film demonstrated persist pulmonary vascular congestion but no new infiltrates or consolidation. More aggressive volume removal has been limited to date by persistent relative hypotension. . #. ID - The patient was found to have + blood cultures from [2166-4-10], 4/4 bottles growing E. Coli. Initial sensitivities revealed this was sensitive to Zosyn for which treatment was initiated. Subsequent sensitivites revealed however only partial sensitivity to Zosyn for which Abx therapy was tailored to ceftriaxone, dosed with HD. It was initially suspected in the ICU that this was a line related infection for which the patient's dialysis line was pulled on [2166-4-11] although tip culture never grew any bacteria. Of note the patient had negative blood cultures on admission. The patient subsequently had complete ID workup including repeat blood,urine, and sputum cultures. The patient rapidly cleared her cultures with treatment and all surveillance cultures subsequently have been negative. Urine cultures were unrevealing. However, sputum cultures revealed moderate growth E. Coli which was thought more likely to represent colonizer than respiratory pathogen. On admission the patient had a white count of 32.2 with peak at 50 on [2166-4-20]. The patient's elevated white count was initially attributed to her known MDS on admission although on discharge from most recent hospitalization on [2166-1-10] the patient had a white count of only 14.3. The patient was subsequently found to have C. Diff which was thought to most likely account for her elevated white count. The patient was treated with oral Flagyl as well as oral Vancomycin given persistently elevated white count a and is currently on both with planned treatment duration of three weeks. An infectious disease consult was obtained. ID reported additional concern for potential infection of the patient's left thigh hematoma. Review of records from [Hospital1 882] revealed that hematoma aspiration cultures from the patient's second intervention on [2166-3-24] demonstrated negative gram stain and no growth on cultures. A repeat CT of the LLE was performed that demonstrated two hematomas in the medial and anterior thigh, but imaging demonstrated no gas or destructive changes to suggest an active infectious process. Given this, it was felt that most likely the patient's E. Coli bacteremia was iatrogenic during her MICU stay and repeat aspiration of the patient's hematoma was not performed given concern of actual introduction of infection into this space with sampling. Patient additionally has a sacral decubitus ulcer. On transfer to the floor evaluation of sacral decub was not revealing for active infection, there was no purulent drainge or fluctuance associated. However, despite the patient having a rectal tube in place, given intermittent leakage and soiling, this site likely represents the most life threatening source of infection at time of discharge. Instructions have been given to make all efforts to keep sacral debuc site clear of stool. The patient's white count is currently slowly trending downward, most recently 28.5 from peak of 50, likely representing response to therapy with regards to C. Diff infection. . 3. Afib - The patient was admitted with known permanent afib. During the hospital course the patient had episodes of occasional RVR with rates in the 140s. In this setting the patient would develop transient worsening hypotension. The patient's rate control medications were up titrated and she has now been continued throughout her course on Diltiazem 60mg qid as well as metoprolol 12.5 mg po bid with imperfect rate control with heart rate ranging 100-115. Further increases in these agents has been limited by hypotension, often in the setting of post-dialysis. Given history of DVT as well as persistent afib the decision was made to continue anticoagulation but with goal to maintain anti-coagulation at the lower end of therapeutic. The patient was maintained on a Heparin gtt with goal PTT of 60 throughout her hospital course. Since placement of tunneled hemodialysis catheter, the patient has begun transition back to coumadin and should continue of Heparin gtt with gaol PTT 50-70 until a therapeutic INR is achieved. Again, given the history of GI bleeding and thigh hematoma, an INR on the lower range of therapeutic would be recommended, 2.0 to 2.5. As above, the patient was transfused 2U PRBCs in the ICU in the setting of hematemesis but had otherwise stable Hct since transfer to the floor. . #. ESRD: As previous in the setting of volume overload and respiratory failure the patient was receiving qd dialysis for volume removal upon establishment of euvolemia the patient continued to recieve HD as needed. The patient was maintained on nephrocaps. The patient initially developed transient hypotension post-dialysis likely related to volume shifts. The patient was given small boluses as needed and efforts were maintained to control heart rate as above. However, over the hospital course the patient was noted to develop persistent hypotension. This occurred in the setting of poor po intake, increase in rate control meds, and concern for possible impending sepsis. The patient's temporary HD catheter was reported to be functioning imperfectly. As surveillance cultures had remained negative > 48 hours and the patient remained afebrile, her hemodialysis catheter was replaced on [2166-4-24]. . #. DM2 - The patient was maintained with Lantus 5 Units at breakfast with additional ISS with generally tight glycemic control, with most sugars < 180. Over last few days with improving PO intake patient's sugars have been increasing with increase in Glargine to 8 units. . #. Left Leg Hematoma - The patient was admitted with known prior left thigh hematoma s/p fasciotomy and evacuation at [Hospital1 882]. Inital hematoma occured in the setting of INR of 18. Surgery was consulted with assessment that there was no indication for evacuation of hematoma given there were no neurologic or vascular deficits. As above, given concern for potential infectious source repeat LLE CT was performed. This demonstrated two large hematomas centered in the left tensor fascia lata and just deep to the sartorius muscle. No air was seen in these collections, nor were there any destructive changes to the surrounding tissues. Given this as well as concern for actually introducing infection with sampling, decision was made not to aspirate fluid from the hematoma this admission for cultures. The patient's Hct remained stable after transfer from the MICU. . #. Myeloproliferative disorder - The patient was admitted with known diagnosis of a MPD. As previous, the patient had a persistent leukocytosis throughout this hospitalization with question of whether this represented an infectious source or the patient's known MPD. However, on discharge from last hospitalization in [2165-12-25] the patient had a white count of 13K. Heme pathology was asked to prepare a peripheral blood smear for review. It was felt that there was no significant left shift or toxic granulations to suggest infection and that the elevated white count may be consistent with her underlying MPD, although the possibility that an uderlying infection could have caused demargination could not be ruled out. The patient was continued on her outpatient treatmet regimen of Anagrelide for thrombocythemia with platelet counts < 400K. As above, the patient's white count has most recently started to trend downward from peak value of 50 to most recently 28.5. . #. Hypotension - Please note on transfer that patient at baseline has had persistent baseline hypotension with SBP rangin 80-100. The patient has been asymptomatic, mentating well. The patien has received few 250cc boluses as needed but aggressive volume repletion has not been attempted given ESRD and patient's DNR/DNI status with evidence previously for pulmonary edema. The patient's pressures have been decreased in the setting of Diltiazem and metoprolol for rate control which have been likely contributing. The patient should continue to receive these medications although with hold parameters as prescribed, holding for SBP < 90. The patient remains afebrile, with all surveillance cultures negative and slowly resolving white count. . #. Code Status: Code status was discussed with the patient, the patient's family and Dr. [Last Name (STitle) ]. There were many conversations with regards to code status with many reversals throughout the patient's hospitalization. There was concern that the patient did not seem to have the same goals as her family (patient indicated she did not want escalation of care.) Upon admission initially, the patient stated that she had been sick long enough and did not wish escalation of care. She specifically refused CPR, intubation, EGD, interventional lines, embolization but did want dialysis and blood-products in the short term. However, upon conversation with patient's family and patient, this decision was reversed and the patient was acutally intubated this admission for respiratory failure. Post-extubation ongoing conversations regarding code status were performed, ultimately with request for ethics to get involved. After further discussions it was agreed between the patient and her family that most appropriate decision was to be DNR/DNI. The patient further stated she would not want BiPap if necessary. Medications on Admission: Meds: Anagrelide 1mg [Hospital1 ] Calcium acetate 1334mg tid Calcium carbonate 650mg [Hospital1 ] Diltiazem 90mg qid Colace 100mg [Hospital1 ] Ferrous gluconate 324mg tid ECASA 81mg daily Compazine 10mg tid prn Nephro 1 can tid Protonix 40mg daily Lantus 10U QAM, Humalog ISS Fluticasone/Salmeterol 1 puff [Hospital1 ] Combivent 2 puff qid Levothyroxine 50mcg daily Acetaminophen 650mg q4h prn Bisacodyl 10mg daily prn constipation Magnesium Hydroxide 30ml daily prn constipation Oxycodone 10mg q6h prn pain Senna 2 tabs [Hospital1 ] prn constipation Sorbitol 30ml tid prn constipation Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Primary Diagnoses: Upper GI Bleed E. Coli Sepsis Respiratory Failure Left Leg Hematoma Afib with rapid ventricular response ESRD, hemodialysis dependent . Secondary Diagnoses: Myeloproliferative Disease Diabetes Mellitus II DVT Discharge Condition: Fair. Patient with significant medical comorbidities including ESRD on HD, permanenet afib,DVT, DM-II, myeloproliferative disorder with known stable relative hypotension with blood pressures ranging from 80-100, but mentating well. Discharge Instructions: 1. PLease take all medications as previous. . 2. Please keep all outpatient appointments. Please continue care currently as guided by the treating team at the [Hospital 100] Rehab MACU. . 3. Please return to the hospital as appropriate and desired for symptoms of worsening hypotension, dizziness, bleeding, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: 1. Please continue care with the physicians at the [Hospital 100] Rehab MACU . 2. Upon discharge, please call the office of your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 39828] at [Telephone/Fax (1) 13745] to make an appointment to be seen within one to two weeks of discharge	[ "403.91", "453.8", "578.0", "599.0", "008.45", "496", "280.0", "038.42", "250.00", "427.31", "238.7", "286.7", "995.92", "998.12", "707.03", "585.6", "V58.67", "458.21", "428.0", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.6", "86.05", "38.91", "39.95", "99.04", "96.72", "38.95", "99.07", "96.34" ]	icd9pcs	[ [ [] ] ]	22154, 22220	9212, 21498	326, 462	22495, 22729	2758, 2758	23155, 23464	2391, 2395				22241, 22399		21524, 22131				22753, 23132		8847, 9189				2410, 2739			22420, 22474																			275, 288								490, 1839						2774, 8831									1883, 2171	2203, 2375
27,195	106,702	19240	Discharge summary	report	Admission Date: [2146-4-17] Discharge Date: [2146-4-23] Date of Birth: [2095-12-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12174] Chief Complaint: Variceal bleed stabilized at OSH, TIPS occluded and transferred for TIPS revision Major Surgical or Invasive Procedure: Central line placement TIPS revision History of Present Illness: Mr. [Known lastname 52412] is a 50yo man with HCV cirrhosis s/p TIPS in [1-31], TIPS redo by IR in [6-1] at OSH and again [1-1] here. Presented to OSH with hematemesis. Intubated for airway protection. EGD showed gastric bleeding most likely secondary to gastric varices. He was xferred to [Hospital1 ] for further mgmt. He was admitted to the SICU. He was found have TIPS blocked. The TIPS was revised on [4-17]. Pt was started on cotreotide. His HCT remained stable at 25-26. . On ROS, he c/o diarrhea. he says usually he has [3-29] BM/day. he denies N/V/abd pain. he [Last Name (un) 52413] CP, SOb, dizziness, palpitations, dysuria, F/C/C. Past Medical History: - HepC w/ cirrhosis - complicated by variceal bleeds s/p banding. - TIPS placement [1-31] with redo [6-1], another balloon dilation [1-1] - hepatic encephalopathy - carpel tunnel syndrome - h/o recurrent cellulitis - obesity - mild COPD by PFTs - diverticulosis - chronic low back pain [2-26] disk protrusion - depression - h/o substance abuse Social History: Lives with his sister. Previously used to work in bakery but quit in [Month (only) ] as was too tired to work (was lifting 50lb bags of flour, etc). Smokes [1-26] ppd of cigarettes, no EtOH, prior heroin use but reports being sober since [1-31]. Attempting to quit tobacco and feels like this hospitalization may prompt change. Family History: No history of liver problems. Otherwise noncontributory. Physical Exam: 99.2 130/71 80 16 96/3L HEENT: EOMI, PERRL, MMM, no LAD Neck: supple, mo thyromegaly Heart: RRR, no M/R/G, nl S1 S2 Lungs: CTAB Abd: soft, obese, NT/ND, no HSM, BS +, no ascites Extr: 2+ pitting edema b/l, right arm with swelling in hand, forearm and arm TTP, no erythema or warmth Neuro: AAO x 3. no asterixis. no focal neuro deficit Pertinent Results: [4-17] TIPS revision IMPRESSION: 1. Moderate new intimal hyperplasia and stenosis at the hepatic venous end of the TIPS, clearly flow limiting, with a post balloon angioplasty persitent portosystemic gradient of 14 mmHg. Given the persistently elevated gradient and the presence of large varices as well as the moderate but clearly flow-limting proximal stenosis, an additional 10 mm Wallstent was deployed, with subsequent balloon angioplasty of the stent and good angiographic results. The portosystemic gradient was reduced to 10 mmHg post stent deployment. Plan: The bleeding risk should be eliminated at the current time. Careful ultrasonogrphic imaging is recommended, the TIPS is at risk of failure given the presence of multiple stents [4-18] u/s IMPRESSION: 1. In comparison to the last study, there is a marked increase in velocity from 120 to 212 cm/sec with no flow in the left portal. This represents a new baseline with markedly increased TIPS velocity. This study cannot exclude an element of stenosis. 2. Thready flow within the stent, which may be technical. [4-19] u/s IMPRESSION: Limited examination due to body habitus. Patent TIPS with velocities ranging from 132-140 cm/sec d/c labs [2146-4-23] 04:10AM BLOOD WBC-3.2* RBC-2.82* Hgb-8.3* Hct-24.9* MCV-89 MCH-29.4 MCHC-33.2 RDW-15.9* Plt Ct-39* Brief Hospital Course: A/P: 50yo man with HCV cirrhosis s/p TIPS p/w GIB to OSH. Intubated for airway protection. Found to have TIPS occluded. TIPS revised. started on octreotide. HCT stable. . # Variceal bleed due to TIPS occlusion As per OSH d/c summary, most likely from variceal bleed. TIPS was fund to be occluded. TIPS revised on [4-17] with good flow on US. HCT stable for several days, patient discharged with stable hematocrit and no signs of further bleeding. . # HCV Cirrhosis HCV cirrhosis. recent VL [2146-3-24] was 755,000 IU/mL. s/p rx w/ interferon and ribavirin in [2139]. relapsed after that. recent note from Dr [Name (NI) 32282] talks about starting rx w/ pegylated inteferon and ribavirin. COntinued lactulose and rifaximin for encephalopathy. Refractory ascites s/p TIPS with multiple revisions and at high risk for further occlussion given multiple stents placed. Continued lasix and aldactone to manage ascites and peripheral edema. S/p band ligation of varices, h/o recurrent variceal bleeding, restarted nadolol. Will follow up in next 2 weeks with Dr. [Last Name (STitle) 497]. . # Depression: Continued his outpatient Wellbutrin and trazodone at home doses. Medications on Admission: Bupropion 100 mg 1 p.o. b.i.d. Lasix 20 mg once a day lactulose 3 tablespoons by mouth daily Prilosec 40 mg once a day Aldactone 100 mg once a day trazodone 50 mg once a day Discharge Medications: 1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Variceal bleed Secondary: Hep C Cirrhosis COPD Hepatic encephalopathy Discharge Condition: Stable. ambulating well, cleared by PT Discharge Instructions: You were admitted with a variceal bleed requiring TIPS revision for narrowing of the stent. You need to complete 1 more day of antibiotics and you were started on nadolol 20mg daily to help prevent any further episodes of variceal bleeding. You should follow up with Dr. [Last Name (STitle) 497] in [2-28] weeks for follow up, the [Date Range ] coordinator. . If you have any bloody vomit, blood in stool, fainting, shortness of breath, abdominal pain or any worrisome symptoms present to the ER immediately for evaluation. Followup Instructions: Call Dr.[Name (NI) 948] office at ([Telephone/Fax (1) 3618] to schedule an appointment in the next 2-4 weeks, [Telephone/Fax (1) ] coordinator aware . Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 327] Date/Time:[2146-6-22] 10:30 . Provider: [Name10 (NameIs) ] [Hospital 1389] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2146-6-22] 1:00 . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 673] Date/Time:[2146-6-22] 2:00	[ "070.71", "571.5", "496", "996.1", "459.2", "569.3", "789.59", "311", "456.8", "E849.9", "E878.1", "286.9", "578.1", "278.00", "572.3", "578.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "00.40", "39.49", "99.07", "99.05", "39.50" ]	icd9pcs	[ [ [] ] ]	5805, 5811	3694, 4883	399, 439	5935, 5976	2333, 3671	6560, 7096	1903, 1962		5108, 5782		5832, 5914		4909, 5085				6000, 6537						1977, 2314																						278, 361								467, 1145															1167, 1529	1545, 1887
29,545	183,019	3049	Discharge summary	report	Admission Date: [2200-1-3] Discharge Date: [2200-1-14] Date of Birth: [2130-6-6] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 1350] Chief Complaint: 69-year-old male with a one-year history of progressive syndrome consistent with cervical spondylotic myelopathy. Major Surgical or Invasive Procedure: 1. Anterior cervical decompression and fusion C3-C4. 2. Anterior cervical decompression and fusion C5-C6. 3. Anterior cervical corrective osteotomy C5-C6. 4. Anterior cervical arthrodesis with interbody devices. 5. Posterior cervical laminectomy C4-C7. 6. Posterior cervical arthrodesis C3 to T1. 7. Posterior cervical instrumentation C3 to T1. History of Present Illness: [Known firstname 14516] [Known lastname 14517] is a 70-year-old male who has had a one-year history of numbness in both of his arms and both of his legs. He also has had bilateral shoulder pain, right greater than left, which has been resolved to some extent with injections. This is considered to be related to degenerative pathology of his rotator cuff. In terms of his numbness however, he reports that this is most bothersome in his fingertips in the palms of his hands. The numbness in his legs and feet, is also problem[Name (NI) 115]; he reports a sensation of having "[Doctor Last Name 5691]" under foot when he walks. Associated with this numbness, he has also had intermittent burning pain in his arms and also in his right thigh. He also complains that his hands feel "sleepy and heavy." Past Medical History: +PPD from bcg vaccine, polycythemia [Doctor First Name ], PUD, prostate ca, ED, DM diet controlled, OA, depression, neuropathy, OSA (does not tolerate bipap), gout R knee, syphillis Social History: rare etoh, no tob denies HIV risk factor originally from [Country ], married but separated from his wife Family History: NC Physical Exam: Physical examination today in the office, the patient is able to perform fluid gait, but he demonstrates broad-based stance and a broad-based gait with his neck flexed and head stooped in order to watch the ground with his progression. He demonstrates a slow velocity of progression. He does not demonstrate any prolonged stance phase or Trendellenberg. When asked to perform heel-to-toe in line gait, the patient is unable to perform this. He exhibits severe difficulty with balance in attempting to perform an in-line gait. Palpation of the posterior elements of the cervical, thoracic spine are nontender. There is no tenderness of the paraspinal musculature either. There are no skin lesions, changes or scars here. On range of motion testing, the patient is able to flex his cervical spine such that he can nearly touch his chin to his chest. On extension however, he can only extend to approximately 5 to 10 degrees beyond neutral. On lateral bending, he can lateral bend only 20 degrees in either direction and he can rotate 35 degrees in either direction. These does not cause pain or exacerbate his numbness. Lhermitte's test exacerbates his upper extremity numbness. Spurling sign is negative, however. [Doctor Last Name ] sign is positive. He exhibits two beats of clonus bilaterally at the ankle. Babinski is downgoing. Motor muscle testing reveals [4-14] intrinsic strength, [4-14] grip, [3-15] wrist extension, [3-15], wrist flexion bilaterally, [3-15] triceps extension on the right with 5/5 triceps extension on the left, [3-15] biceps on the right [3-15], [4-14] biceps on the left and [4-14] shoulder abduction bilaterally. He exhibits numbness on sensory provocation in bilateral upper and lower extremities, Pertinent Results: [2200-1-3] 08:16PM BLOOD WBC-9.3 RBC-4.36# Hgb-13.3# Hct-38.2# MCV-88 MCH-30.6 MCHC-35.0 RDW-15.2 Plt Ct-178 [2200-1-4] 02:26AM BLOOD WBC-14.4# RBC-4.58* Hgb-13.4* Hct-40.1 MCV-88 MCH-29.2 MCHC-33.4 RDW-14.6 Plt Ct-192 [2200-1-5] 08:40AM BLOOD WBC-15.9* RBC-4.14* Hgb-12.2* Hct-36.5* MCV-88 MCH-29.5 MCHC-33.4 RDW-14.5 Plt Ct-188 [2200-1-6] 12:27AM BLOOD WBC-17.1* RBC-4.09* Hgb-12.1* Hct-37.7* MCV-92 MCH-29.6 MCHC-32.1 RDW-14.1 Plt Ct-260 [2200-1-6] 03:30AM BLOOD WBC-16.8* RBC-4.05* Hgb-12.0* Hct-35.4* MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 Plt Ct-219 [2200-1-6] 03:30AM BLOOD WBC-16.8* RBC-4.05* Hgb-12.0* Hct-35.4* MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 Plt Ct-219 [2200-1-7] 03:26AM BLOOD WBC-10.5 RBC-3.76* Hgb-11.3* Hct-33.1* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.3 Plt Ct-178 [2200-1-8] 02:36AM BLOOD WBC-10.3 RBC-4.28* Hgb-12.8* Hct-37.2* MCV-87 MCH-29.8 MCHC-34.3 RDW-14.3 Plt Ct-239 [2200-1-9] 06:30AM BLOOD WBC-9.4 RBC-4.25* Hgb-12.6* Hct-37.2* MCV-88 MCH-29.6 MCHC-33.8 RDW-14.4 Plt Ct-273 [2200-1-10] 06:10AM BLOOD WBC-9.2 RBC-4.75 Hgb-13.8* Hct-41.7 MCV-88 MCH-29.0 MCHC-33.0 RDW-14.5 Plt Ct-343 [2200-1-6] 03:30AM BLOOD CK-MB-18* MB Indx-10.7* cTropnT-0.03* [2200-1-6] 11:00AM BLOOD CK-MB-4 cTropnT-0.02* [2200-1-9] 04:38PM BLOOD CK-MB-NotDone cTropnT-0.02* [2200-1-9] 09:30PM BLOOD CK-MB-NotDone cTropnT-0.03* [2200-1-10] 09:40AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2200-1-11] 06:15AM BLOOD cTropnT-<0.01 [2200-1-3] 03:02PM BLOOD Type-ART pO2-195* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Intubat-INTUBATED [2200-1-3] 04:34PM BLOOD Type-ART pO2-230* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 Intubat-INTUBATED [2200-1-3] 05:48PM BLOOD Type-ART Rates-/10 Tidal V-600 FiO2-31 pO2-138* pCO2-49* pH-7.32* calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [2200-1-3] 08:38PM BLOOD Type-ART pO2-85 pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [2200-1-6] 12:25AM BLOOD Type-ART pO2-54* pCO2-199* pH-6.90* calTCO2-43* Base XS--1 [2200-1-6] 12:43AM BLOOD Type-ART pO2-154* pCO2-84* pH-7.17* calTCO2-32* Base XS-0 [2200-1-6] 12:25AM BLOOD Type-ART pO2-54* pCO2-199* pH-6.90* calTCO2-43* Base XS--1 [2200-1-6] 12:43AM BLOOD Type-ART pO2-154* pCO2-84* pH-7.17* calTCO2-32* Base XS-0 [2200-1-6] 01:44AM BLOOD Type-ART pO2-156* pCO2-59* pH-7.27* calTCO2-28 Base XS-0 [2200-1-6] 03:10AM BLOOD Type-ART pO2-93 pCO2-40 pH-7.47* calTCO2-30 Base XS-4 [2200-1-6] 04:38AM BLOOD Type-ART pO2-88 pCO2-38 pH-7.45 calTCO2-27 Base XS-2 [2200-1-6] 08:01AM BLOOD Type-ART pO2-154* pCO2-27* pH-7.55* calTCO2-24 Base XS-3 [2200-1-6] 09:25AM BLOOD Type-ART pO2-144* pCO2-45 pH-7.43 calTCO2-31* Base XS-5 [2200-1-6] 11:06AM BLOOD Type-ART pO2-98 pCO2-54* pH-7.41 calTCO2-35* Base XS-7 [2200-1-6] 01:04PM BLOOD Type-ART pO2-121* pCO2-48* pH-7.40 calTCO2-31* Base XS-4 [2200-1-6] 01:04PM BLOOD Type-ART pO2-121* pCO2-48* pH-7.40 calTCO2-31* Base XS-4 [2200-1-6] 02:25PM BLOOD Type-ART pO2-101 pCO2-48* pH-7.40 calTCO2-31* Base XS-3 [2200-1-6] 05:22PM BLOOD Type-ART pO2-104 pCO2-44 pH-7.42 calTCO2-30 Base XS-3 [2200-1-6] 08:43PM BLOOD Type-[Last Name (un) ] pH-7.43 [2200-1-7] 07:16AM BLOOD Type-ART pO2-82* pCO2-45 pH-7.41 calTCO2-30 Base XS-2 [2200-1-7] 07:16AM BLOOD Type-ART pO2-82* pCO2-45 pH-7.41 calTCO2-30 Base XS-2 [2200-1-7] 10:56AM BLOOD Type-ART pO2-118* pCO2-41 pH-7.44 calTCO2-29 Base XS-4 [2200-1-7] 12:29PM BLOOD Type-ART pO2-123* pCO2-52* pH-7.36 calTCO2-31* Base XS-3 Echo [2200-1-10]: 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation in a structurally-normal valve. ECG [2200-1-9]: Atrial flutter with predominantly 4:1 block and a single wide complex beat which is probably ventricular. Since the previous tracing of [2199-1-6] the rate is slower and flutter waves are more apparent. Clinical correlation is suggested. Brief Hospital Course: [Known firstname 14516] [Known lastname 14517] is a 70-year-old male with a one year history of upper and lower extremity numbness with progressive balance difficulty, causing ambulatory dysfunction. He was consented in the office for his anterior and posterior cervical fusion. He tolerated the procedure well and was transfered to the PACU and then to the TSICU while intubated for overnight care. He was then transfered to the floor. On [2200-1-6] Mr. [Known lastname 14517] was found unresponsive on the floor. A code was called and he was transfered to the SICU. Once stabilized in the SICU, he was transfered back to the floor. The rest of his hospital course was unremarkable. He was discharged to home with physical therapy. Medications on Admission: Multivitamin Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breakthrough pain. [Known lastname ]:100 Tablet(s) Refills:0 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Known lastname ]:60 Tablet(s) Refills:2 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Target INR 2.0-3.0 [Hospital ] Clinic, [Company 191], [Doctor First Name ]-[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Last Name (Titles) ]:30 Tablet(s) Refills:0 4. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day). [Hospital1 ]:30 Refills:0 5. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: INR 2.0-3.0 [Hospital ] Clinic, [Company 191]. [Company ]:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: 1. Cervical spondylotic myelopathy. 2. Fixed cervical kyphotic deformity. 3. Atypical Atrial Flutter Discharge Condition: Stable to home with Physical Therapy Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [Telephone/Fax (1) ]. Please resume all home mediciation as prescribed by your primary care physician. [Name10 (NameIs) ] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Physical Therapy: Weight Bearing/Activity as tolerated. Gait training Treatments Frequency: Please continue to change dressings daily with dry gauze. There are no sutures or staples to remove. Followup Instructions: You had a CT scan of the chest during your hospitalization. It showed: '5 mm ground-glass opacity in the right lung along the fissure is slightly more conspicous sine the CT of [2196-3-18], similarly there is a new 2 mm ground glass opacity in the left lower lobe. A chest CT in 6 months is advised to assess stability.' PLEASE SPEAK WITH YOUR PRIMARY CARE DOCTOR to get a follow-up CT scan of your chest in 6 months to make sure these spots are not growing (e.g., are not cancerous). Completed by:[2200-1-21]	[ "427.32", "327.23", "721.1", "997.1", "427.5", "238.4", "784.2", "518.5", "285.1", "276.2", "737.10", "781.2", "250.00" ]	icd9cm	[ [ [] ] ]	[ "81.63", "81.02", "96.04", "93.90", "84.51", "02.94", "96.71", "81.03", "99.60", "80.51" ]	icd9pcs	[ [ [] ] ]	10089, 10172	8400, 9158	431, 778	10317, 10356	3802, 8377	11439, 11962	1980, 1984		9221, 10066		10193, 10296		9184, 9198				10380, 11220						1999, 3783	11238, 11291	11313, 11416																				278, 393								806, 1628															1650, 1837	1853, 1964
29,771	194,913	16640	Discharge summary	report	Admission Date: [2111-6-24] Discharge Date: [2111-6-30] Date of Birth: [2050-10-27] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: hip pain Major Surgical or Invasive Procedure: T12 vertebrectomy & instrumented fusion T10-L2 History of Present Illness: This 61-year-old gentleman had an incidental discovery of a renal cell tumor with metastasis to the T12 vertebral body after continued hip pain s/p hip replacement [3-6]. There was almost complete destruction of the vertebral body. The left-sided pedicle, transverse process, and rib were involved. Past Medical History: [3-6] hip replacement Social History: married never smoked Family History: nc Physical Exam: a0x3, nad ht: rrr lungs: cta abd: nt, flat neuro: motor full sensation intact dtr 2+, no clonus Brief Hospital Course: Pt was admitted was admitted to the hospital and underwent embolization to T12 mass on [6-24]. He tolerated this procedure well. He was readiied for the OR and ON [6-25] under general anesthesia underwent lateral extracavitary left-sided approach for resection of a T12 renal cell metastasis,reconstruction with anterior interbody graft and pedicle screws from T10-L2 with posterolateral fusion. He tolerated this procedure well but post op was kept intubated due to the prone positioning and length of procedure. He tolerated ventilator weaning post op. He had drains which were placed intra-op and output was monitored and they were removed on POD#2. His incision was clean and dry with staples intact. His diet and activity were advanced. His hematocrit was followed and he needed a total of 3 PRBC for blood loss anemia. His crit at discharge was 27. His pain medication was transitioned without difficulty from PCA to PO. He was seen by PT/OT and was recommended for discharge to home with PT. Medications on Admission: percocet prilosec Discharge Medications: 1. Outpatient Physical Therapy OUTPATIENT PHYSICAL THERAPY FOR LEFT HIP STRENGTHENING PLEASE EVALUATE AND TREAT 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 cap Refills:2 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: metastatic renal cancer blood loss anemia Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ remove dressing / begin daily showers [2111-6-30]. ?????? If you have steri-strips in place ?????? keep dry x 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE Spine Center - [Hospital Ward Name 23] 2 Tuesday [7-7] at 11:45am FOR REMOVAL OF YOUR STAPLES PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS and lumbar MRI (please view T10 thru L 2) PRIOR TO YOUR APPOINMENT Completed by:[2111-6-30]	[ "V45.89", "530.81", "198.5", "189.0", "274.9", "716.90", "280.0", "V43.64" ]	icd9cm	[ [ [] ] ]	[ "77.79", "81.62", "99.29", "77.89", "99.79", "81.08", "81.05", "88.49", "84.51" ]	icd9pcs	[ [ [] ] ]	2671, 2729	952, 1968	329, 378	2815, 2839		4320, 4684	813, 817		2036, 2648		2750, 2794		1994, 2013				2863, 4297						832, 929																						281, 291								406, 710															732, 759	775, 797
12,346	186,008	12236	Discharge summary	report	Admission Date: [2170-1-15] Discharge Date: [2170-1-27] Date of Birth: [2086-12-1] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 2569] Chief Complaint: garbled speech, somnolence Major Surgical or Invasive Procedure: PEG placement History of Present Illness: The pt is a 83-year-old man with history of hypertension, hyperlipidemia, Afib on coumadin, RCA occlusion, s/p LCA stent who presents with new onset expressive aphasia found to have left frontal IPH. Per transfer records, he was last seen well at 1:30 pm today with his wife. At 4:30 pm, she noticed that he started speaking gibberish. Therefore, she called 911 and he was taken to [Hospital3 417] Hospital. There initial NIHSS was 6. BP on arrival was 189/119. Head CT was done which showed no acute process. He was transferred to [Hospital1 18] ED for further management. On arrival, his NIHSS was 6 as outlined below. His BP on arrival was 250/120. He was taken immediately for CT scanning. CT scan was notable for L frontal IPH, right ICA occlusion, and patent L ICA stent. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: [2160] RCA stent pre-op for AVR [4-/2161] AVR Last cardiac cath [8-/2165] showed patent RCA stent without significant L coronary dx . OTHER PAST MEDICAL HISTORY: GERD Atrial Fibrillation s/p failed cardioversion [2165] s/p L carotid stent [2-/2162], functionally occluded R carotid hx of lower GIB w/colonoscopy showing colon AVM s/p laser treatment Social History: -Tobacco history: previously smoked for ~20 years, 1 ppd, quit in [2108]. -ETOH: social -Illicit drugs: denies Lives with wife, has 4 children. Former police officer in [Location 9104]. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Sister died of brain cancer, another sister died of rheumatic fever and cardiac complications. Physical Exam: Vitals: BP:250/120 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Patient is awake and oriented. He is not able to make speech sounds. He attempts to move his mouth but no words are spoken. He is able to follow simple command such as to grip or close his eyes. He appears to attend to both sides. -Cranial Nerves: PERRL 3 to 2mm and brisk. + blink to threat. Funduscopic exam revealed no papilledema; EOMI without nystagmus. Right facial droop. Palate elevates symmetrically. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch or pinprick. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Toes mute. -Coordination: not tested -Gait: not tested Pertinent Results: [2170-1-15] 08:50PM BLOOD WBC-6.3 RBC-4.79 Hgb-14.9# Hct-42.5# MCV-89 MCH-31.1# MCHC-35.0# RDW-14.3 Plt Ct-172# [2170-1-15] 08:50PM BLOOD PT-12.6 PTT-26.2 INR(PT)-1.1 [2170-1-15] 08:50PM BLOOD Glucose-98 UreaN-22* Creat-1.5* Na-143 K-3.8 Cl-103 HCO3-28 AnGap-16 [2170-1-17] 03:23AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8 Cholest-143 [2170-1-17] 03:23AM BLOOD Triglyc-99 HDL-41 CHOL/HD-3.5 LDLcalc-82 [2170-1-17] 03:23AM BLOOD %HbA1c-6.0* eAG-126* EKG: Atrial fibrillation with single wider complex beat, more likely ventricular than aberration. Right bundle-branch block. ST-T wave abnormalities. Since the previous tracing of [2169-9-17] atrial fibrillation is new. NONCONTRAST HEAD CT There are two large areas of intraparenchymal hematoma within the left frontal lobe with surrounding hypodensity consistent with extruded serum and edema. The superior intraparenchymal hematoma measures approximately 35 x 22 mm and is adjacent to the frontal convexity. The inferior intraparenchymal hematoma is at the junction of the frontotemporal lobe and measures approximately 26 x 23 mm. There is associated mass effect and minimal midline shift. CTA HEAD/NECK 1. Multifocal left frontal lobe intraparenchymal hematomas as described above. 2. Extensive atherosclerosis in the cervical vasculature with complete occlusion of the right internal carotid artery throughout its cervical course. The intracranial branches of the right internal carotid artery are supplied via the anterior communicating artery from the contralateral ICA branches. 3. Right MCA aneurysm. CXR: Minimal retrocardiac atelectasis. MRI BRAIN 1. Two superficial hematomas in the left frontal lobe and insula. Smaller hemorrhages in the posterior left parietal and temporal lobes. While these are located in the left MCA territory, there is no convincing evidence for an underlying infarct on diffusion-weighted images. The small amount of edema surrounding the larger hemorrhages is also not typical for an infarct. Given the patient's age, amyloid angiopathy should be considered. 2. Patchy contrast enhancement within the two larger hematomas may be reactive, but should be followed to exclude possibility of underlying masses. 3. Occlusion of the right internal carotid artery is again demonstrated. ECHOCARDIOGRAM The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-31]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2168-9-4], LVH has progressed. R ARM XRAY 1. Non-displaced fracture at the sublime tubercle of the ulna at the attachment site of the ulnar collateral ligament. 2. Suspected nondisplaced fracture at the radial neck. 3. Large amount of soft tissue swelling about the elbow Brief Hospital Course: 83 yo RHM with h/o hypertension, hyperlipidemia, Afib on coumadin, RCA occlusion, s/p LCA stent who presents with new onset expressive aphasia found to have left frontal IPH. # INTRACRANIAL HEMORRHAGE: At [Hospital3 417] Hospital, initial NIHSS was 6, and BP on arrival was 189/119. Head CT done at Good Samarital showed no acute process. He was transferred to [Hospital1 18] ED where upon arrival, his NIHSS was 6, and his BP on arrival was 250/120. CT scan showed L frontal IPH, right ICA occlusion, and patent L ICA stent. His exam was significant for expressive aphasia and right facial droop. He was admitted to the neuro ICU for blood pressure control and monitoring. He was intubated for airway protection and hyperventilation to reduce intracranial pressure. He was on nicardipine drip for BP. He received mannitol and hypertonic saline to reduce ICP. On hospital day 5, repeat head CT appeared stable. Patient was extubated and transferred to the neurology floor. On the floor, the patient's mental status gradually improved. He became more alert, interactive, follows commands inconsistently, but remained with expressive more than receptive aphasia. He remained with 4/5 weakness on the right. He was able to ambulate with 2 assist, walker, and safety belt. The etiology of his ICH was felt to be primary lobar hemorrhage due to amyloid angiopathy. Based on this and the risk of additional ICH, he was started on ASA 81 mg, but no further anticoagulation for his atrial fibrillation. He will follow up in stroke clinic. # RIGHT ulnar/radial fracture: nondisplaced proximal ulnar and radial fractures seen on X-ray. Ortho was consulted and recommended no treatment, but will follow up in clinic in [4-4] weeks. # HYPERTENSION Patient remained hypertensive after coming off nicardipine drip, he was started on amlodipine and increased dose of lisinopril. He was continued on metoprolol. # NUTRTION Patient failed swallow evaluation and underwent PEG placement [2170-1-26]. Patient was made DNR but not DNI during this hospitalization per his wife and HCP [Name (NI) ]. Medications on Admission: Prilosec 20 mg daily Metoprolol 50 mg tabs 1.5 tabs [Hospital1 ] Ecotrin 81 mg daily Coumadin 5 mg tabs 1 tab alternating with 1/2 tab daily Lipitor 20 mg QPM Zetia 10 QPM Lisinopril 20/25 daily Discharge Medications: 1. atorvastatin 20 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 2. ezetimibe 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day) as needed for constipation. 4. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 5. dorzolamide 2 % Drops [Hospital1 ]: One (1) Drop Ophthalmic TID (3 times a day). 6. amlodipine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 7. latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 8. brimonidine 0.15 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QID (4 times a day). 11. lisinopril 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 12. senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 15. acetaminophen 325 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever>101F. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: LEFT frontotemporal intraparenchymal hemorrhage amyloid angiopathy hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive at times Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a intracranial hemorrhage. This was likely caused by buildup of abnormal proteins in the blood vessels, which make them more fragile and prone to breaking. Due to the hemorrhage, you needed PEG placement for nutrition and you are discharged to [Hospital 38] Rehab for inpatient physical, occupational and speech therapy. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2170-3-13] 11:30 [Hospital Ward Name 23] Clinical Center [Location (un) ] ORTHOPEDICS [2169-2-13]:40 AM [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 1228] [Hospital Ward Name 23] Clinical Center [Location (un) ] [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2170-1-27]	[ "V42.2", "V58.61", "V49.86", "272.4", "813.08", "431", "331.0", "414.01", "V49.87", "433.10", "263.9", "V45.82", "424.0", "787.20", "401.9", "277.39", "784.3", "348.5", "E885.9", "437.3", "427.31", "V15.82", "781.94" ]	icd9cm	[ [ [] ] ]	[ "96.6", "43.11", "79.02" ]	icd9pcs	[ [ [] ] ]	11138, 11235	7150, 9260	300, 316	11359, 11359	3715, 7127	11917, 12460	1883, 2094		9510, 11115		11256, 11338		9286, 9487				11544, 11894			2870, 3696			2109, 2602				1234, 1431																		234, 262								344, 1140										11374, 11518					1453, 1652	1668, 1867
77,439	110,528	37158	Discharge summary	report	Admission Date: [2148-11-29] Discharge Date: [2148-12-6] Date of Birth: [2077-3-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: s/p arrest Major Surgical or Invasive Procedure: Intubation Multiple defibrillations History of Present Illness: Mr. [Known lastname 52932] is a 71 yo M with PMH significant for CHF (EF: 20-25%), CAD s/p CABG, CKD, a-fib on coumadin, s/p ICD, presents after VF arrest. Per the family the patient had been complaing of dizziness over the last few months. He does have a history of VT per the wife with 2 episodes of syncope in [Month (only) 547]. They also state that he has just not been himself over the last few months since he was cardioverted for his a-fib. He has been having frequent falls and syncopal episodes. He has been closely followed by his cardiologist who had been titrating his medications including d/c spironolactone and decreasing his lisinopril. He reportly underwent cardiac cath 3 months prior that showed occluded grafts, but collateral flow, no intervention was performed. He had been having worsening function and unable to perform daily activities because of dizziness. Today the patient was walking to his bedroom when he had a syncopal episode. His wife heard him fall and raced to his side and called 911. EMS arrived within 5-7 minutes and he was found to be in he was found to be in VF arrest and was shocked twice with return of spontaneous circulation. He was taken to [Hospital1 ]. At [Hospital1 ] ECG showed a LBBB. Cardiac enzymes: MBI 2%, Trop 0.16 and Cr. 6. Patient was intubated and sedated with propofol. He was started on dopamine gtt for hypotension SBP 70-90s and lidocaine gtt. ABG: 7.35/37.8/340/20.8 on Tv:500, RR:14, FiO2:60%, PEEP: 3. The patient was transferred to the [Hospital1 18] ED. In the ED: T: 97.8 BP: 87/62 HR: 118, the dopamine was stopped and he was started on levophed 0.15mcg/kg/min and neo 2.5mcg/kg/min in the ED. He was continued on lidocaine gtt 4mg/min and given 1mg versed and 50mcg of fentanyl. A code STEMI was called and given ASA 325mg and plavix 600mg. Upon review the ECG that showed LBBB and discussion with the family regarding his PMH it was decided that he would not be cathed and would pursue medical management. CE: Trop 0.16 CK: 521 MB: 13 MBI: 2.5. INR 3.9, WBC 15.3, Cr 5.3, Gap 20. He had a CT-head that did not show acute abnormality and CXR that showed pulmonary edema. The patient was transferred to the CCU and cooling protocol was initiated. Unable to obtain ROS. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: CABG -PERCUTANEOUS CORONARY INTERVENTIONS: 3 months prior showed occluded grafts, but collateral flow. No intervetion per wife. - ICD - a-fib on coumadin - CHF (reported EF 20-25%) - h/o VT 3. OTHER PAST MEDICAL HISTORY: CKD Gout Social History: Lives with his wife -[Name (NI) 1139] history: unable to obtain -ETOH: unable to obtain -Illicit drugs: unable to obtain Family History: Unable to obtain Physical Exam: VS: T=95.2...BP=97/77...HR=65...RR=17...O2 sat=92% GENERAL: intubated and sedated HEENT: Sclera anicteric. minimally reactive to light. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP difficult to assess given habitus. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. transmitted vent sounds. CTA anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/ +2 edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: patient sedated with no purposful movement PULSES: Right: Carotid 2+ Femoral 2+ DP dopplerable Left: Carotid 2+ Femoral 2+ DP dopplerable Pertinent Results: ADMISSION LABS [2148-11-29]: [2148-11-29] 12:04AM WBC-15.3* Hgb-11.5* Hct-36.7* Plt Ct-205 [2148-11-29] 12:04AM Neuts-89.3* Lymphs-5.8* Monos-4.6 Eos-0.1 Baso-0.3 [2148-11-29] 12:04AM PT-37.3* PTT-36.9* INR(PT)-3.9* [2148-11-29] 12:04AM Glucose-119* UreaN-98* Creat-5.3* Na-141 K-4.4 Cl-105 HCO3-16* AnGap-24* [2148-11-29] 12:04AM ALT-91* AST-94* LD(LDH)-416* CK(CPK)-521* AlkPhos-292* TotBili-0.6 [2148-11-29] 12:04AM CK-MB-13* MB Indx-2.5 [2148-11-29] 12:04AM cTropnT-0.16* [2148-11-29] 12:04AM Albumin-3.7 Calcium-9.3 Phos-5.9* Mg-2.0 URINE: [2148-11-29] 05:16AM Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.014 [2148-11-29] 05:16AM Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2148-11-29] 05:16AM RBC->50 WBC-[2-22] Bacteri-MOD Yeast-NONE Epi-0-2 [2148-11-29] 05:16AM Hours-RANDOM UreaN-430 Creat-114 Na-10 MICRO: UCx - Staph species, ~1000/ml UCx - Citrobacter BCx - NGTD Sputum Cx - MSSA, mixed flora IMAGING: [11-29] ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is borderline dilated. There is severe regional left ventricular systolic dysfunction with inferior and inferolateral akinesis. There is moderate to severe hypokinesis of the remaining segments (LVEF <20%). The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload, as well as a conduction abnormality or RV apical pacing. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is at least mild pulmonary artery systolic hypertension, athough this may be underestimated given severity of TR. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with severe regional and global systolic dysfunction, c/w prior extensive inferior myocardial infarction and a superimposed process (or multivessel CAD). Markedly dilated right ventricle with severe global systolic dysfunction. Mild aortic regurgitation. Moderate mitral and tricuspid regurgitation. Depressed cardiac index and at least mild pulmonary hypertension. [11-29] CXR: ETT balloon hyperinflated. Low lung volumes, with possible mild vascular congestion. Moderate cardiomegaly. [11-29] CT head: No acute intracranial abnormality. No intracranial hemorrhage or loss of [Doctor Last Name 352]-white matter differentiation. [11-30] CXR: Development of pulmonary edema and left basilar atelectasis or consolidation and possibly pleural fluid [12-2] CT head: 1. No evidence of intracranial hemorrhage, edema, large masses, mass effect, or large vascular territory infarction. 2. Mucosal thickening in bilateral maxillary sinuses and sphenoid sinus. 3. Interval increase in opacification of the right middle ear and mastoid air cells. 4. Lipoma is noted within the right occipital region, unchanged from prior. 5. Coiling of NG tube within the nasopharynx. [12-5] CXR: Moderate cardiomegaly is stable. Left transvenous pacemaker leads terminate in a standard position in the right atrium and right ventricle. Left IJ catheter tip is in unchanged position in the left brachiocephalic vein. Right central catheter tip is in the right atrium. Small bilateral pleural effusions, larger on the left side associated with atelectasis are unchanged. Difference in density in the bases is consistent with difference in redistribution of the pleural effusions. There is mild new pulmonary edema. Right lower lobe opacity could be atelectasis, but pneumonia cannot be excluded. Brief Hospital Course: Mr. [Known lastname 52932] is a 71 yo M with PMH significant for CHF (EF: 20-25%), CAD s/p CABG, CKD, a-fib on coumadin, s/p ICD, who presented after VT arrest. #. VT Arrest: The patient was brought in s/p shock x2 by EMS for VT. The rhythm was unclear at first and thought to be VF, so the patient was initiated on cooling protocol with Arctic Sun. He was intubated and sedated for several days. CT head and EEG were negative for intracranial events. The patient's ICD was interrogated, and it was found that he had several episodes of slow VT during the past few weeks that were below the threshold for pacing by his ICD. His pacer was reset to detect VT as a lower heart rate, but he continued to have episodes of VT despite Amiodarone, Lidocaine, and several shocks by his ICD as well as externally. The patient was made DNR/DNI by his family on [2148-12-5]. He passed away at 10:55am on [2148-12-6] with his family by his bedside. # CORONARIES: The patient was continued on ASA 325mg and Lipitor 20mg. BB and ACEi were held [1-22] to hypotension. # PUMP: Pt with severe CHF. He was dialyzed with CVVH x 2 days. #. Resp Distress: Pt was intubated for airway protection in the setting of VT arrest. Patient likely volume overloaded from CHF and pulm edema on CXR. He also developed VAP and was treated with Vanc/Zosyn/Cipro for 7 days. Medications on Admission: Imdur 30mg daily Coumadin Amiodarone 100mg daily Mexiletine 150mg TID ASA 81mg daily Lisinopril 10mg daily Colchicine 600mcg daily Demadex 50mg daily Lipitor 20mg daily Coreg 25mg [Hospital1 ] Probenecid 500mg [Hospital1 ] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Ventricular Tachycardia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "518.81", "428.0", "V45.02", "E879.8", "274.9", "584.5", "427.1", "427.31", "780.39", "426.3", "428.43", "V58.61", "414.8", "410.01", "785.51", "780.01", "272.0", "997.31", "427.32", "414.02", "787.20", "486", "276.4", "348.31", "585.9" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.95", "39.95", "96.6", "38.93", "99.62" ]	icd9pcs	[ [ [] ] ]	9843, 9852	8172, 9534	327, 365	9920, 9930	4085, 6852	9982, 9989	3144, 3162		9815, 9820		9873, 9899		9560, 9792				9954, 9959						3177, 4066				2755, 2945																1673, 2675		277, 289								393, 1656		7134, 8149									2976, 2986				2697, 2735	3002, 3128
55,962	131,890	32346	Discharge summary	report	Admission Date: [2128-2-20] Discharge Date: [2128-2-24] Date of Birth: [2049-1-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3705] Chief Complaint: transfer from OSH for hematuria Major Surgical or Invasive Procedure: Endotracheal intubation and extubation Mechanical ventilation Central venous line placement (non-sterile code line) and removal History of Present Illness: 79 yo male with a history of prostate cancer txd with XRT/ADT, renal cancer s/p L nephrectomy, cad s/p stenting, htn, acute cholecystitis s/p percutaneous drain placement and 4 cvas most recently in [2127-11-29] in [Country 6962] (now nonverbal baseline) who was seen at [Hospital3 6592] today for hematuria and poorly draining foley. Patient has been residing in a [Hospital1 1501] for the last several weeks. Patient was admitted for acute cholecytitis last week and discharged back to [Hospital1 1501]. He has had intermittent urinary obstruction [12-31] to hematuria this week, and was sent from [Hospital1 1501] to [Hospital3 6592] 3 days ago, and was discharged after clots were removed. Patient did well for the next two days, until this morning when Foley catheter again became obstructed. Patient was transferred again to [Hospital3 6592] this morning. . At [Hospital3 6592], a a 3 way foley was placed with gross hematuria. He received Morphine 4 mg IV, Zofran 4 mg IV, Lewvaquin 750 mg IV and 1 L NS. Labs were notable for a UA with many rbcs, Chem panel with Na 133, K 3.8, CO2 21, Gly 194, Cr 1.5, BUN 25, a CBC with WBC 20.2 ( 86% polys, 1 band), Hct 35, Plt 381. He was transferred to [Hospital1 18] for further care and Urology consultation. Prior to transfer, patient was noted to have scrotal edema and decrease in hct from 35 to 26 . In the ED, urology was consulted and bladder was irrigated for > 1 h with large amoutn of clot removed. CBI was started, and hematuria cleared from frank blood to light pink in color. Patient became hypotensive, and required 1 L NS bolus. Patient received Morphine 4 mg IV x4, Oxybutinin 5 mg po x1, Zofran 4 mg IV x1. Patient was then being cleaned by nursing staff when he became unresponsive and went into PEA arrest. Although patient had previously expressed wishes to be DNR/I, son reversed code status in the [Name (NI) ] when faced with this dire situation. Patient received 1 mg of epi and 1 mg of atropine, and pulse returned to sinus tach. Patient was shocked twice with 200J, and intubated. fentanyl and midazolam drips were started. Nonsterile femoral line access was obtained and patient was started on norepinephrine and phenylephrine. A CT abdomen was obtained that revealed a right sided RP bleed. He was transfused 4 u prbc. He was previously on plavix and fragmin x 4 days, but these were stopped this week. After further discussions with family were held, patient was made DNR/I. On transfer, VS were 113, 165/86, 18, 100% on AC TV 500 PEEP 5 RR 18 and FiO2 100%. . In the ICU patient is intubated and sedated. He appears comfortable. . Review of systems: Limited given patient is intubated and sedated. Past Medical History: # Prostate cancer dxd 12 years ago, s/p XRT and ADT # Renal cancer (unknown subtype) s/p left nephrectomy # CVA x 4, most recently in [Month (only) 404] with baseline now nonverbal and disoriented, unable to attend to ADLs # CAD s/p stent in [2122], on plavix # Htn # Recurrent cholecystitis, with percutaneous drain placement this month # IDDM # DL # Asthma Social History: Born in [Country 2784], and has been living in [Country 6962] until recently immigrated to the US on [1-17] to be closer to his son. nonsmoker, no sig etoh. Former marketing consultant. Speaks [Doctor First Name 533]. Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: T: 99 BP:120/46 P: 117 R: 22 O2: 100% AC TV 500 RR 18 FiO2 100% General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley with gross hematuria and clots Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: Vitals: None, CMO Gen: Alert, responds to commands HEENT: NCAT, dry MMs Pulm: CTAB CV: RRR nml S1/2 no [1-30]/m/r/g Ab: TTP suprapubically; percutaneous cholecystostomy in place draining brown bile GU: Marked scrotal edema; foley; urine yellow Ext: No edema Neuro: Moving 4 extremities spontaneously Pertinent Results: ADMISSION LABS: [2128-2-20] 10:00AM BLOOD WBC-16.6* RBC-2.86* Hgb-9.2* Hct-26.3* MCV-92 MCH-32.1* MCHC-35.0 RDW-13.3 Plt Ct-326 [2128-2-20] 10:00AM BLOOD Neuts-94.8* Lymphs-3.5* Monos-1.6* Eos-0.1 Baso-0.1 [2128-2-20] 10:00AM BLOOD PT-14.4* PTT-25.1 INR(PT)-1.2* [2128-2-20] 10:00AM BLOOD Glucose-168* UreaN-25* Creat-1.9* Na-136 K-4.2 Cl-106 HCO3-18* AnGap-16 [2128-2-20] 10:00AM BLOOD ALT-49* AST-31 AlkPhos-70 TotBili-0.6 [2128-2-20] 10:00AM BLOOD Lipase-23 [2128-2-20] 10:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-1.7 [2128-2-20] 10:40AM BLOOD Glucose-146* Lactate-1.9 Na-138 K-3.4* Cl-113* calHCO3-16* [2128-2-20] 10:40AM BLOOD Hgb-9.8* calcHCT-29 OTHER LABS: [2128-2-20] 03:59PM BLOOD freeCa-1.05* [2128-2-20] 02:45PM BLOOD Albumin-2.5* Calcium-7.3* Phos-6.4# Mg-2.1 [2128-2-20] 02:45PM BLOOD cTropnT-0.02 [2128-2-20] 07:30PM BLOOD CK-MB-12* MB Indx-5.7 cTropnT-1.01* [2128-2-21] 03:12AM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-0.60* [2128-2-20] 07:30PM BLOOD CK(CPK)-212 [2128-2-21] 03:12AM BLOOD CK(CPK)-380* MICRO: [2-20] Blood cultures: pending IMAGING: [2-20] CT Torso: 1. Acute hematoma filling the urinary bladder. No evidence of bladder rupture. The etiology of the bladder hemorrhage is unclear, though given the localization of hemorrhage within the bladder and no associated ureteral/renal abnormality, the possibility of hemorrhagic cystitis is considered. Moderate amount of subacute retroperitoneal bleed; please correlate clinically. Status post left nephrectomy for renal cell cancer, with unremarkable appearance of the right kidney. Cholecystostomy tube within a decompressed gallbladder, which contains multiple stones. No acute findings in the chest. ETT and right femoral CV catheter in place. [2-20] CXR: Frontal radiograph demonstrates lines and tubes in appropriate position. Widened mediastinum may be due to portable technique. Lungs are relatively clear. Brief Hospital Course: 79 yo male with a history of prostate cancer, renal cancer s/p L nephrectomy, cva now nonverbal baseline, cad s/p stenting, htn, acute cholecystitis s/p percutaneous drain placement who presented with worsening hematuria leading to catheter obstruction, and is now s/p PEA arrest in the ED. . # Goals of care: Patient with multiple medical comorbities, and had previously expressed wishes to be DNR/I to his family. In the acute setting of PEA arrest, patient's son asked for CPR, Compression and Shocks. Son felt somewhat uncomfortable that he went against his dad's wishes, and hoped to limit any further interventions which would cause pain. He wanted to continue interventions as they were, which necessitated MICU care. His son returned the following morning with his wife, and decided to limit care. The patient was transferred to the floor for comfort measures only. IV access was discontinued and the patient was discharged on oral analgesics for comfort as detailed under medications. 24h after being made CMO, the patient's clinical status had improved - sitting up and tolerating PO diet. On discharge the patient was stable for transport. . # PEA arrest: Unclear precipitant but likely related to vagal event in the setting of CBI of high volume of urine with clots in the setting of possible RP bleed which may have preceded the code based on the findings on CT abdomen indicating a nonacute bleed. The patient was resuscitated and transferred to the MICU; cooling protocol was deferred in light of goals of care. He was transferred to the floor for management once made CMO. . # Shock: The differential was wide including cardiogenic, hypovolemia due to RP bleed, and possible some component of evolving sepsis in the setting of recent cholecystostomy placement. Patient was initially aggressively fluid resusciated and broadly covered with vanco/zosyn, until the following day, when patient was transferred to the floor for comfort measures only care. . # Cholecystostomy: Patient admitted with cholecystostomy tube in place on amoxicillin and levofloxacin. Antibiotics were stopped when the patient was made CMO. The patient was discharged with the cholecystostomy in place with intructions for inpatient hospice to drain as needed. . # RP bleed: Some findings on CT scan indicated this was a subacute bleed, so femoral line unlikely to be a causative factor. Patient had been on plavix for stenting, and has had repetitive foley trauma. Patient also had percutaneous cholecystostomy tube last week, which could also be a causative factor. No further work-up or intervention was planned once he was made CMO. . # Hematuria: [Month (only) 116] have been related to infection vs worsening prostate malignancy vs radiation induced injury. Urology saw the patient in the ED and started CBI, which was stopped prior to discharge after 36h of no hematuria. He was discharged with instructions for inpatient hospice to perform intermittent irrigation as needed for comfort. . # CAD: His plavix, statin and ace were stopped once made CMO. . # DM: He was covered with an Insulin sliding scale, which was stopped once made CMO. Medications on Admission: HOME: Tylenol 650 mg q4h prn MOM daily prn Dulcolax prn Levaquin 500 mg daily Amoxicillin 500 mg [Hospital1 ] Florastor 250 mg daily Lantus 10 U daily Lisinopril 2.5 mg daily Plavix 75 mg daily Simvastatin 20 mg daily Gatifloxacin 0.3% drops daily Protonix 40 mg daily Fragmin Nystatin Humalog sliding scale Percocet [11-30] tab Q4H Oxybutinin 5 mg daily Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 5-15 mg PO Q2H (every 2 hours) as needed for pain, sob, agitation. Disp:50 ml Refills:2 2. lorazepam 0.5 mg Tablet Sig: 0.5-2 mg PO Q4H (every 4 hours) as needed for anxiety, sob. Disp:100 tablets Refills:2 3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. Disp:30 Tablet, Rapid Dissolve(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital 31356] Healthcare Center - [Location (un) 730] Discharge Diagnosis: Primary: 1. Prostate cancer 2. Renal cell carcinoma 3. Retroperitoneal bleed 4. ST elevation myocardial infarction 5. Pulseless electrical activity arrest Discharge Condition: Stable for transport Discharge Instructions: You were transferred to [Hospital1 18] for urology evaluation after you had blood clots in your bladder. In the emergency department, your heart stopped beating and you were resuscitated. You were transferred to the ICU and the decision was made to focus on comfort as the goal. Non-comfort measures were withdrawn. . Continuous bladder irrigation was started for the blood in your urine and then stopped once the blood cleared. You are being discharged on intermittent bladder flushes as needed. . The following changes were made to your medications: # STOP all previous medications . # START -sublingual concentrated morphine as needed for pain and shortness of breath -Ativan as needed for anxiety and shortness of breath -Senna, colace as needed for constipation -Zydis as needed for agitation (danger to self) if symptoms not relieved with morphine and ativan Followup Instructions: None	[ "568.81", "285.1", "427.5", "V49.86", "403.10", "V10.46", "585.3", "785.59", "575.0", "599.71", "V45.82", "250.00", "410.91", "V10.52", "414.01" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "96.04", "99.60" ]	icd9pcs	[ [ [] ] ]	11094, 11185	6805, 9944	336, 466	11384, 11407	4818, 4818	12324, 12332	3877, 3895		10357, 11071		11206, 11363		9970, 10334				11431, 12301						3910, 4478								4494, 4799											3170, 3219			265, 298								494, 3151						4835, 5503									3241, 3609	3625, 3861				5515, 6782

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.