Split (1)

train · 26.9k rows

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56,572	164,494	36365	Discharge summary	report	Admission Date: [2181-6-22] Discharge Date: [2181-6-28] Date of Birth: [2111-11-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3705] Chief Complaint: Hypotension, hypoxia, narcotic overdose. Major Surgical or Invasive Procedure: Left subclavian central venous line placement PICC line placement History of Present Illness: A 69 year-old woman with history of moderate AS, enterocutaneous fistula on TPN and complicated PMH who presents from [Hospital 100] Rehab after an accidental overdose w/ 40 mg crushed oxycontin instead of 20 mg IR oxycodone. She was given the oxycontin today and was noted to be obtunded w/ bradycardia and hypoxia so was given narcan. After the narcan was given, she became acutely tachycardic and hypertensive to 220/120 with associated dypnea. An ABG done at the time demonstrated 7.24/53/95. Per OSH records, she has also been having high-spiking fevers to 104 over the past couple of days w/ GNR in urine and blood and had been treated with imipenem since day prior to admission. In the emergency department, initial vitals: 16:54 0 102.4 150 190/100 22 100 on NRB (82% on RA). EKG with sinus tach. Received albuterol, combivent nebs, meropenem 500 mg IV, tylenol 650 pr. CXR with ? multifocal PNA. 92/45, 100% on neb mask, HR 120. Has only received 650 cc NS. Guaiac +. On arrival to the ICU, she states she was afraid she was going to die this afternoon. She endorses persistent mild dyspnea and anxiety. She has chronic bilateral hip pain that has been attributed to osteoarthritis. She endorses dysuria and fevers X 1 week. She thinks she has been coughing up thick mucus X 1 day. No sick contacts. Review of systems: (+) Per HPI, + sense of a fast heartrate (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Past Medical History: PAST MEDICAL HISTORY: (per patient and OSH records) COPD/ Asthma High-out Entero-cutaneous fistula (complication of prior abdominal surgery), on long-term tpn for bowel rest and secondary to high output of fistula Gout Cdiff ? MRSA Recurrent bacteremia Depression Anxiety Osteoarthritis GI bleed resulting in partial colectomy HTN DM2 Aortic stenosis Obesity Diverticulitis OSA on CPAP Uterine prolapse Duodenal ulcer Iron deficiency anemia Social History: Has been either in the hospital or in rehab continuously for almost one year. Has been on TPN for many months. + former smoker but quit 3 years ago w/ about a 100 pack year history. Former heavy ETOH use but quit at 50 yrs old. No known liver disease. Family History: Non-contributory. Physical Exam: VITAL SIGNS: T 99.4 BP 93/59 HR 115 RR 24 O2 95% on 4L NC GENERAL: Pleasant, fatigued-appearing, mildly dyspneic, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dry MM w/ blackish substance on her tongue. OP clear. Neck Supple CARDIAC: Reg, tachycardic, IV/VI systolic murmur heard throughout the pre-cordium but heard best at RUSB LUNGS: scant bibasilar crackles, otherwise CTAB w/o rhonchi or wheeze. ABDOMEN: NABS. Soft, NT, fistula w/ drainage bag in place EXTREMITIES: No edema or calf pain, could not palpate pedal pulsesSKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 4/5 strength throughout (limited by pain in LE). Gait assessment deferred PSYCH: Listens and responds to questions appropriately but unclear on the details of her medical history, pleasant Pertinent Results: [2181-6-22] 05:15PM BLOOD WBC-8.4 RBC-4.14* Hgb-9.0* Hct-29.6* MCV-72* MCH-21.7* MCHC-30.3* RDW-19.2* Plt Ct-145* [2181-6-22] 05:15PM BLOOD Neuts-76* Bands-6* Lymphs-15* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [2181-6-22] 05:15PM BLOOD PT-16.3* PTT-30.6 INR(PT)-1.5* [2181-6-23] 05:01AM BLOOD Ret Aut-3.1 [2181-6-22] 05:15PM BLOOD Glucose-93 UreaN-28* Creat-0.9 Na-135 K-4.2 Cl-102 HCO3-22 AnGap-15 [2181-6-22] 05:15PM BLOOD ALT-26 AST-30 LD(LDH)-251* CK(CPK)-87 AlkPhos-223* TotBili-1.5 [2181-6-22] 05:15PM BLOOD cTropnT-<0.01 [2181-6-23] 11:28AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-1649* [2181-6-22] 05:15PM BLOOD Albumin-2.9* [2181-6-23] 03:28AM BLOOD Calcium-6.1* Phos-2.7 Mg-1.6 [2181-6-23] 05:01AM BLOOD Calcium-7.2* Phos-3.1 Mg-2.0 Iron-11* [2181-6-23] 05:01AM BLOOD calTIBC-133* Ferritn-760* TRF-102* [2181-6-22] 05:15PM BLOOD Hapto-348* [2181-6-22] 05:15PM BLOOD TSH-1.4 [2181-6-22] 05:31PM BLOOD Lactate-3.1* [2181-6-22] 07:19PM BLOOD Type-ART pO2-113* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 Intubat-NOT INTUBA [6-22] CXR IMPRESSION: 3. Vague opacity at the right lung base which may represent a focus of scarring, though given the lack of prior studies to assess stability, a CT is recommended to further assess. 2. Prominence of bronchovasculature may be related to chronic lung disease though mild congestion may also be considered. [6-23] ECHO The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve is not well seen. There is severe aortic valve stenosis (valve area likely <1.0cm2 given peak gradient >60mmHg). No definite aortic regurgitation is seen. The mitral valve could not be adequated assessed. The pulmonary artery systolic pressure could not be quantified. There is no definite pericardial effusion. IMPRESSION: Suboptimal image quality. Severe aortic stenosis. Normal left ventricular cavity size with preserved global systolic function. [6-23] LE U/S IMPRESSION: No DVT in the lower extremities. MICRO DATA [2181-6-22] 5:15 pm BLOOD CULTURE #1. FINAL REPORT [2181-6-25] Blood Culture, Routine (Final [2181-6-25]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2181-6-23]): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO DR [First Name (STitle) ],[First Name3 (LF) 9982] AT 0202 [2181-6-23]. Surveillance blood cultures 5/16: negative PICC line tip culture: negative Central line tip culture: negative Stool C dif: negative Brief Hospital Course: A 69 year-old woman with history of moderate AS (now severe on most recent TTE), HTN, COPD, entero-cutaneous fistula after abdominal surgery on TPN, h/o multiple infections presents from rehab with hypoxia and hypotension after accidental overdose of oxycodone. # Sepsis: Blood cultures grew out pan-sensitive E coli. She had been treated for a UTI at rehab with imipenem x1 day prior to admission. She was started on Zosyn but this was switched over to intravenous ciprofloxacin when cultures and sensitivities had returned. The presumed source for the bacteremia is urinary, although GI source must also be considered given her complicated surgical history and enterocutaneous fistula. Her PICC line was removed and a temporary central venous line was placed. Prior to discharge, another PICC has been placed and the left subclavian CVL removed. She can continue to receive TPN through this PICC line. Her antibiotics have been switched to PO ciprofloxacin. She will complete a 14-day course on [7-6]. # Hypotension and blood pressure control: Her hypotension at admission was felt to be due to opioid effect and possible sepsis from GNR bacteremia. On the morning of [6-23] she became hypertensive in the setting of holding her home antihypertensive regimen. At time of transfer from the ICU, she was started back on captopril, metoprolol, and nitroglycerin patch. Captopril has been uptitrated to achieve better BP control. Given the history of diabetes, target blood pressure should be less than 130/85. She is now on maximum dose of captopril at 150 mg tid. Clonidine has been held during this admission due to concern of decreasing preload in the setting of severe aortic stenosis. # Hypoxia: This was thought to be acute respiratory distress in setting of getting a blood transfusion. It may have been a transfusion reaction, or a manifestation of SIRS given her bacteremia. CXR was without overt pulmonary edema though she may still have had flash pulmonary edema or TACO. The hypoxia improved with nitro paste, morphine, lasix and non-invasive ventilation. Echo showed severe AS. She was continued on her home COPD regimen and respiratory status improved. On the floors, her oxygenation has been high 90s on RA. We have not made any changes to her outpatient COPD regimen. # Tachycardia and large volume ostomy output: This was felt to be due to intravascular volume depletion in setting of large-volume ostomy output, infection, pain, and fever. We gave her gentle IVF boluses and treated her infection and the tachycardia resolved. She may need to continue maintenance IV fluids at rehab. In addition to TPN at 75 cc/hr, we have been giving her IV fluid ([2-9] normal saline) at a rate of 100 cc/hr. Our goal is to keep total Is = Os, given the persistent high-volume ostomy output. Of note, C dif toxin during this admission was negative. We held her colchicine due to the high-volume stool output. # Aortic stenosis: A TTE repeated here showed severe AS. As above, she was treated with BB, ACEI, and nitrate (the latter of which she seemed to tolerate). Fluid infusions were given cautiously in order to avoid precipitating acute pulmonary edema. # Anemia: This is a microcytic anemia with known iron-deficiency and guaiac + fistula output. She had an EGD in [Month (only) 404] that showed gastritis. HCT remained stable in the high 20s during this admission. There were no signs of active GI bleed. As above, she received one unit of PRBCs during this admission. # Opioid overdose: She received naloxone 0.4 mg at rehab and 0.2 mg on the first night of admission. She was alert on the first hospital day. There were no further concerns. We continued her home fentanyl patch. # Obstructive sleep apnea: She was kept on CPAP overnight per her outpatient regimen. # Gout: We held her colchicine due to large volume fistula output. # Diabetes mellitus type II: Per history this is diet-controlled. We kept her on humalog sliding scale insulin. Fasting blood sugars were consistently in the 140s-180s. # COPD/Asthma: We continued her home advair and ipratropium nebs. We held the albuterol given her tachycardia. # Prophylaxis: subcutanous heparin, PPI. # Access: Left-sided PICC (placed on [6-26]). # Code status: Full code (confirmed with patient in the ICU) # Disposition: to [Hospital 100] Rehab. Medications on Admission: acetaminophen captopril 37.5 mg po tid clonidine patch 0.2 mg colchicine 0.6 mg [Hospital1 ] fentanyl patch 100 mcg iron 325mg [Hospital1 ] advair 250/50 [Hospital1 ] nystatin swish and swallow omeprazole ondansetron prn oxycodone 20 mg q 4 hrs Eucerin imipenem/cilastatin 500 mg IV ipratroprium inh LR 62.5 ml/hr lido patch lorazapam metop 100 mg po tid mirtazapine 30 mg qhs nitroglycerine patch 0.2 mg/hr daily Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain. 3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Captopril 100 mg Tablet Sig: 1.5 Tablets PO once a day. 5. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 6. Nystatin Oral 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. Ondansetron Oral 9. Oxycodone 5 mg/5 mL Solution Sig: [2-9] PO Q4H (every 4 hours) as needed for pain. 10. Eucerin Cream Topical 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours): Continue through [7-6] for 14-day course. 13. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day. 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: PRIMARY DIAGNOSES: Septicemia with E coli believed secondary to urinary tract infection Narcotic overdose . SECONDARY DIAGNOSES: Chronic obstructive pulmonary disease High-output enterocutaneous fistula Depression and anxiety Osteoarthritis Hypertension Diet-controlled diabetes Severe aortic stenosis Obesity Obstructive sleep apnea on CPAP Iron deficiency anemia Discharge Condition: Vital signs stable. Afebrile. Discharge Instructions: You were admitted to the hospital for altered mental status, fevers, and treatment of urinary tract infection. We believe the altered mental status was due to overdose of pain medicines because the mental status improved with reversal of the pain medicines. The fevers and urinary tract infection were treated with antibiotics. Cultures from the blood grew out a bacteria that likely came from a urinary source. Please complete a 14-day course of antibiotics for this infection to end on [7-6]. . Please take your medicines as prescribed: -we started ciprofloxacin for UTI and bacteremia; please complete a fourteen day course to end on [7-6] -we increased the dose of captopril; please continue to take this dose unless instructed otherwise by your doctor -we stopped clonidine -we stopped colchicine due to high-volume output from the ostomy bag -we decreased the dose of fentanyl . Please call the doctor or return to the emergency room if you have fever, increasing abdominal pain or urinary pain, or any other new concerning symptoms. Followup Instructions: -please follow-up with your primary physician in the next one to two weeks: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 66933]. Completed by:[2181-6-29]	[ "965.09", "799.02", "327.23", "278.00", "E878.8", "514", "250.00", "584.9", "998.6", "300.4", "280.0", "E850.2", "458.9", "274.9", "038.42", "E940.1", "785.0", "995.91", "518.82", "493.20", "599.0", "424.1", "263.0", "287.5", "276.52" ]	icd9cm	[ [ [] ] ]	[ "99.15", "38.93" ]	icd9pcs	[ [ [] ] ]	13513, 13578	7214, 11563	357, 425	13987, 14019	3780, 7191	15115, 15319	2840, 2859		12039, 13490		13599, 13707		11589, 12016			14043, 15092									2874, 3761	13728, 13966																	1789, 2089				276, 319									453, 1770																		2133, 2553	2569, 2824
13,144	151,909	11736	Discharge summary	report	Admission Date: [2201-11-10] Discharge Date: [2201-11-14] Date of Birth: [2137-7-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2181] Chief Complaint: SOB, dizziness, weakness Major Surgical or Invasive Procedure: Large volume paracentesis Hemodialysis History of Present Illness: Briefly, Mr. [Known lastname 32126] is a 64 y/o M with CAD, MI [2-26] to cocaine use, DM, ESRD on HD, polysubstance abuse, and cirrhosis who presented to the ED with severe electrolyte abnormalities in the setting of missing HD x 3 weeks. The patient presented to the ED where he c/o SOB, dizziness, weakness. Had hyperkalemia to 7.4, hyponatremia to 126, BUN 203 and Cr 23.8. Went into wide complex tach and went to ICU where he was emergently dialyzed. Patient also found to have aflutter in the MICU and seen by cards who are planning for ablation. Cardiology and EP was consulted and planned for ablation on Friday. On labetalol and nifedipine for rate control. TTE pending. Myo/pericarditis MB 15 Friday should go for early dialysis and then ablation. ?SBP in ED but no overt signs of infection, abdominal exam benign. Past Medical History: Diabetes- neuropathy, microalbuinuria Alcohol abuse Cocaine abuse- drug free since [2194-1-25] Anemia Back pain- central and right paracentral disc herniation compressing the thecal sac with moderate central canal stenosis and compression right L4. CKD- on dialysis CAD Hyperlipidemia Hypertension Social History: Per psych) recent homelessness leading to living at the [Hospital1 ] homeless shelter, multiple chronic medical problems, living away from his wife and kids, and unemployment. The patient has a remote history of cocaine dependence and alcohol dependence which he refused to elaborate on. The patient was born and raised in [State 5111] by both of his parents. He has 5 brothers, 4 sisters, and 2 children with his wife. Currently, his wife and children reside in [Name (NI) 29530]. Mr. [Known lastname 32126] states that he is religious and that god was the main reason that "I am still here today". He completed the 9th grade and would not reveal any other information about his social history. Family History: One brother with MI at age 54, multiple siblings with DMII. Father died of lung CA in his 60's. Diabetes in his mother, brother, and sisters along with hypertension. No history of renal disease. Physical Exam: ADMISSION EXAM: GEN: NAD, awake, alert VS: T 99.7 BP 162/101 HR 110 RR 18 Sat 96% RA NECK: no JVD CV: RRR, no murmurs, no rub. PULM: crackles at b/l bases ABD: soft, distended, mildly tender to palpation EXT: WWP, no edema BLE DISCHARGE EXAM: 98.3 143/85 95-112 18 97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, Regular rate, normal S1 + S2, II/VI SEM, rubs, gallops Lungs: Bilateral inspiratory rhonchi improved, no wheezes, rales. Abdomen: soft, minimally tender to deep palpation, distended, BS+, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: ADMISSION LABS: [2201-11-10] 12:40PM WBC-8.8 RBC-3.65* HGB-11.2* HCT-33.9* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.8 [2201-11-10] 12:40PM NEUTS-87.7* LYMPHS-7.1* MONOS-4.3 EOS-0.8 BASOS-0.2 [2201-11-10] 12:40PM PLT COUNT-316 [2201-11-10] 12:40PM CK-MB-20* MB INDX-6.3* proBNP-GREATER TH [2201-11-10] 12:40PM cTropnT-0.59* WBC RBC Polys Lymphs Monos Eos Mesothe Macroph Other [2201-11-13] 16:44 186* 36* 10* 3* 0 13* 74* BLOOD CX X 2 FROM [2201-11-11]: NGTD IMAGING: EKG [2201-11-12]: Atrial flutter with 3:1 and 4:1 conduction with a single, likely aberrantly conducted beat versus a ventricular premature beat. Borderline low limb lead QRS amplitude. There are likely diffuse repolarization abnormalities which are distorted and accentuated by the underlying flutter waves. Compared to the previous tracing of [2201-11-10], computed frontal plane axis is no longer rightward. Criteria for left ventricular hypertrophy are no longer fulfilled. T wave inversions in the left precordial leads are unchanged, accounting for differences in electrode placement. An ongoing lateral ischemic process cannot be excluded. Clinical correlation is suggested. Presence of inferior flutter waves makes excluding inferior ischemia difficult. ECHO (TTE) [2201-11-11]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is akinesi and thinning of the basal inferior septum. The remaining segments contract normally. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2201-6-18], pulmonary pressures are higher. Other findings are similar. There is no significant pericardial effusion. DISCHARGE LABS: [2201-11-14] 08:45AM BLOOD WBC-8.2 RBC-2.80* Hgb-8.6* Hct-25.9* MCV-92 MCH-30.5 MCHC-33.1 RDW-14.4 Plt Ct-250 [2201-11-14] 08:45AM BLOOD Plt Ct-250 [2201-11-14] 08:45AM BLOOD Glucose-142* UreaN-38* Creat-5.7# Na-137 K-3.9 Cl-100 HCO3-25 AnGap-16 [2201-11-13] 01:20PM BLOOD PT-12.1 PTT-35.4 INR(PT)-1.1 [2201-11-14] 08:45AM BLOOD Calcium-8.5 Phos-2.7# Mg-1.9 Brief Hospital Course: Mr. [Known lastname 32126] is a 64 year old man with a history of CAD, MI secondary to cocaine use, HTN, hyperlipidemia, DM, ESRD, polysubstance abuse, and cirrhosis who presented to the ED with progressive weakness, dyspnea, and dizziness in the setting of not going to hemodialysis for the past 3 weeks. #Electrolyte abnormalities: On admission, patient with metabolic acidosis with anion gap of 40 in setting of missing dialysis for past 2-3 weeks. Labs notable for hyponatremia (126), hyperkalemia (7.4), BUN of 203, and Cr 23.8. He did have ECG notable for widening QRS on interval studies. He was given 3 amps of calcium gluconate, insulin/dextrose and ECG normalized. He was emergently dialyzed with normalization of electrolytes. He was restarted on his home sevelamer and calcium acetate. He continued to undergo HD daily and his electrolytes slowly improved prior to d/c. He will resume HD at [Hospital1 ] on his normal dialysis schedule upon discharge. #Atrial Flutter: Following first dialysis session, pt was found to be in a-flutter with a HR of 150. He was rate contolled on labetalol. Cardiology consult saw patient and believed he would benefit from ablation. However, because the patient admitted that he may not be able to adhere to AC. If can show compliance by coming to cardiology f/u as outpatient, then Ablation and AC will be considered. His rate control was switched to metoprolol and nifedipine as the patient was hypotensive with the combination of labetalol and nifedipine on the regular floor. #Pericarditis: Pt promotes CP and SOB prior to admission but states it has resolved. Per cardiology consult, he had a pericardial rub in ED and ECG was consistent with pericarditis with ST-segment elevations in V2-V4 and diffuse pr depressions. Given patients elevated BUN of 206, most likely uremic pericarditis. Vital not concerning for tamponade or constrictive physiology. His uremia resolved with dialysis and he did not require NSAIDS for pain. A TTE showed trivial pericardial effusion. # Anemia - Patient had HCT drop overnight from 32.8 -->24.5. No signs of active bleeding on exam today, abdominal exam unchanged from prior. Patient endorses abdominal pain in setting of being hungry but no continued pain after eating. Anemia likely [2-26] to poor nutritional status and and chronic kidney disease with poor epo production. [Month (only) 116] also be [2-26] bone marrow suppression if patient is continuing to consume alcohol although he denies it. He received iron IV and epoietin infusion during dialysis. His HCTs were trended and continued to be stable. #CAD: Pt notes some chest pain and SOB in days prior to admission but pt not complaining of any CP on arrival. Pt does have elevated troponin on admission but believed to be secondary to renal failure. ST elevations in leads V2-5 thought to be secondary to pericarditis. PR depressions and rub on PE coorbarated this diagnosis. He was started on home ASA, valsartan, nifedipine, labatalol. Serial ECGs showed a-flutter with resolution of ST elevations. Cardiac enzymes downtrended from admission. A TTE showed moderately dilated LA/RA, moderate symmetric LVH with EF >55%. There is akinesis and thinning of the basal inferior septum. Mildly dilated RV with borderline normal free wall function. Trivial MR, Moderate AR, moderate pulmonary artery systolic hypertension with dilation of main pulmonary artery, and trivial/physiologic pericardial effusion #Cirrhosis: Pt has cirrhosis most likely [2-26] EtOH. Last theraputic paracentesis in 6/[2201]. RUQ US in [5-/2201] notable of cirrhosis with no potal vein abnormality. Physical exam consistent was consistent with ascities this admission. No fever or elevated WBC to indicate SBP. He underwent therapeutic thoracentesis of 5L with no evidence of SBP on peritoneal fluid analysis. #DM: On admission to MICU, held home NPH and started on humolog sliding scale. #Social Work: Pt has missed several HD sessions in the past and was seen by social work. SW receives return call from [Doctor First Name ], SW on [Hospital1 ] dialysis unit. [Doctor First Name 717] explains that it would be very difficult to change pt. to another shift since that could only happen if he traded slots with another pt. Pt. has a history of non-compliance with dialysis, both at [Hospital1 ] and at prior facility, Da Vita. [Doctor First Name ] is reluctant to work out a trade with another pt. as this will be an inconvenience for this other pt. and may be done in vain if pt. continues to be non-compliant. SW receives return call from D&G Towing ([Telephone/Fax (1) 37137]). They agree to waive some of pt's car's storage fees. They request that pt. come to retrieve his car at discharge which is anticipated for tomorrow. -SW FAX'es a letter to towing company confirming pt's presence in hospital. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Valsartan 320 mg PO DAILY 2. Labetalol 400 mg PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Calcium Acetate 1334 mg PO TID W/MEALS 4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:0 6. Lorazepam 0.5 mg PO HS:PRN Insomnia 7. NIFEdipine CR 90 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL PRN Chest Pain 9. Omeprazole 40 mg PO DAILY 10. Oxycodone-Acetaminophen (5mg-325mg) [1-26] TAB PO Q6H:PRN Pain 11. sevelamer CARBONATE 1600 mg PO TID W/MEALS 12. NPH 15 Units Breakfast 13. Nephrocaps 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: Electrolyte abnormalities ESRD on Dialysis Atrial Flutter Cirrhosis 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: It was a pleasure taking care of you at [Hospital1 18]! You were admitted due to electrolyte abnormalities that happened because of missing your dialysis. You were in the intensive care unit for a number of days being treated for an abnormal heart rhythym. You improved and were transferred to the general medicine floor to continue dialysis. You also had fluid in your abdomen drained. MEDICATION CHANGES: - Please STOP Valsartan. You can discuss re-starting this with your primary care doctor if your blood pressure improves. - Please STOP Labetolol and replace it with Metoprolol You continue to have an abnormal heart rhythym called atrial flutter. We do not believe this is dangerous right now but you need to follow-up with doctors as [Name5 (PTitle) ] outpatient. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Your car is in a lot: DNG Towing [Male First Name (un) 37138] [Location (un) 577] [Numeric Identifier ] ([Telephone/Fax (1) 37139] Followup Instructions: Department: [Hospital1 7975] INTERNAL MEDICINE When: THURSDAY [2201-11-19] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: LIVER CENTER When: TUESDAY [2201-12-1] at 1:20 PM With: DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: THURSDAY [2201-12-3] at 2:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37140], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "585.6", "311", "V45.12", "303.93", "427.32", "588.89", "276.1", "V60.0", "789.59", "453.81", "571.2", "272.4", "V15.82", "414.01", "250.40", "584.9", "275.3", "412", "403.91", "276.7", "423.9" ]	icd9cm	[ [ [] ] ]	[ "54.91", "39.95" ]	icd9pcs	[ [ [] ] ]	12063, 12069	6316, 11224	331, 372	12181, 12181	3381, 3381	13408, 14380	2309, 2506		11417, 12040		12090, 12160		11250, 11394			12364, 12757			5913, 6293						2521, 2749				2765, 3362															12777, 13385			267, 293									400, 1237				3398, 5896				12196, 12340										1259, 1563	1579, 2293
10,429	125,203	19195	Discharge summary	report	Admission Date: [2186-5-25] Discharge Date: [2186-6-21] Date of Birth: [2140-8-4] Sex: M Service: HISTORY OF PRESENT ILLNESS: He is a 50-year-old man involved in a high speed motor vehicle accident and when he rear ended a stopped car. There was a prolonged extrication 45 minutes and the patient was Life Flighted to [Hospital3 ]. Initially, he had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] coma score of 15, but in route desaturated down to the 80s and became confused. Patient initially upon arrival to the Trauma Room had a patent airway, bilateral but decreased breath sounds on the right. A chest tube was placed on the right. There was no rush of air. A trauma line was obtained, and the patient was given rapid crystalloid infusion. He was still persisted to be hypotensive. FAST examination was positive and a subsequent DPL was grossly positive for blood. Initial trauma x-rays showed the patient to have a left pneumothorax, right tube to be in place, fractured ribs on the left side. A second chest tube on the left was then placed, and the patient was paralyzed intubated in preparation, taken directly to the operating room for emergent exploratory laparotomy. PAST MEDICAL HISTORY: 1. Hepatitis B and hepatitis C positive. 2. Status post Intravenous drug abuse. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: Significant for the fact that the patient's home situation is not stable enough to discharge him to. PHYSICAL EXAMINATION: Heart rate of 122, blood pressure of 74 by palp, O2 saturations is 99% by nonrebreather, and he was afebrile. HEENT: Pupils were 3 mm, and equal, and reactive. Tympanic membranes were intact and midface was stable. Trachea is midline in the neck and there was no jugular venous distention. The C spine was protected in the hard collar. The back was without step-off or deformity. He was tachycardic without murmurs. There were breath sounds bilaterally, but decreased on the right prior to the insertion of the right sided chest tube. The abdomen was soft, distended with decreased bowel sounds and the FAST examination was positive for fluid in the abdomen. Pelvic was stable to [Doctor Last Name ], and the rectal showed normal tone. Was heme negative and the prostate was normal. Extremity examination revealed an obvious right knee deformity and distal pulses in all four extremities were thready, but equal. Initial radiology consisted only of a chest x-ray demonstrating a left pneumothorax and a right sided chest tube on the chest x-ray. Initial laboratories are significant for a hematocrit of 29 and many red blood cells in the urine. Serum toxicology was negative. Urine toxicology was positive for benzos and opiates, however, he had received phenylintomodate prior to urinalysis. HOSPITAL COURSE: The patient was taken directly to the OR where exploratory laparotomy showed a liver laceration. Due to the source of the patient's bleeding, splenectomy was performed. Patient was packed and taken to the SICU. He was noted to have continuing bleeding and was taken back again for ligation of a short gastric arterial bleed. He was stabilized and closed at a later date. Also diagnosed upon the workup was a right medial femoral condyle fracture, left tibial plateau fracture, and a left distal ulnar fracture, left clavicle fracture, and left rib fractures. After the patient had been hemodynamically stable, Dr. [Last Name (STitle) 284] from the Orthopedics Department, repaired the patient's right and left leg injuries. The patient's clinical status improved, eventually was extubated and both chest tubes were able to be removed without incident. He remained in the C collar throughout this time. Because of continued pain in the neck had flexion and extension views were obtained, which showed abnormal splaying suggestive of a ligamentous injury, and Dr. [First Name (STitle) 1022] was consulted from Orthopedics regarding this, who recommended the patient should stay in the collar for four weeks after discharge. Plastic Surgery was also consulted as the patient suffered burns to his left number fourth and number fifth digits. They currently recommended Xeroform dressing changes q day. Follow up by them. After lengthy discussion with the Social Work and Case Management, it was felt that patient's home would not be ideal place for him for the remaining three weeks before he is able to enter rehabilitation. He is discharged to a skilled-nursing facility for nonweightbearing rehabilitation to prevent muscle atrophy of his extremities, and then he will be transferred to a rehabilitation facility, where he will gain his original function. FINAL DISCHARGE DIAGNOSES: 1. Status post high speed motor vehicle accident. 2. Ex-lap with splenic lacerations status post splenectomy. 3. Left tibial plateau fracture. 4. Right medial femoral condyle fracture. 5. Gastric arterial bleed status post ligation. 6. Left distal ulnar fracture. 7. Hepatitis B. 8. Hepatitis C. 9. Left clavicular fracture. 10. Left rib fractures. 11. History of intravenous drug use. 12. Abnormal flexion and extension cervical spine films suggestive of a ligamentous injury of the cervical spine. 13. Bilateral pneumothoraces status post chest tubes. 14. Left hand burn numbers four and five digits. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [First Name (STitle) 1022] at [Location (un) 86] Orthopedics in four weeks for re-evaluation of his C spine and also with Dr. [Last Name (STitle) 284] in two weeks for re-evaluation of his leg and arm fractures, and follow up in the Hand Clinic here at [Hospital1 ] for his left hand burns. DISCHARGE MEDICATIONS: 1. Acetaminophen 325 mg 1-2 tablets po q4 prn. 2. Ibuprofen 400 mg one tablet po tid. 3. Famotidine 20 mg one po bid. 4. Glycerin suppository one suppository PR [Hospital1 ] scheduled. 5. Bisacodyl 5 mg tablets two po bid. 6. Docusate sodium 100 mg one po bid. 7. Metoprolol 25 mg po bid. 8. Lovenox 40 mg subcutaneous injection q24h for anticoagulation while the patient is nonweightbearing. 9. Oxycodone 20 mg sustained release tablet one po q12h. 10. Oxycodone/acetaminophen 5/325 mg 1-2 tablets po q4-6h prn pain. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Last Name (NamePattern1) 4791] MEDQUIST36 D: [2186-6-21] 13:20 T: [2186-6-21] 13:22 JOB#: [Job Number 52334]	[ "860.0", "821.21", "070.30", "286.9", "305.90", "070.51", "998.11", "958.4", "865.03" ]	icd9cm	[ [ [] ] ]	[ "89.64", "34.04", "39.30", "41.5", "79.35", "38.91", "79.36", "86.59", "93.57", "38.93", "37.12", "96.72", "39.31" ]	icd9pcs	[ [ [] ] ]									5766, 6568					2865, 4743																							1533, 2847																		4770, 5374	159, 1248															5399, 5743			1270, 1391	1408, 1510
3,841	161,225	10295	Discharge summary	report	Admission Date: [2173-3-20] Discharge Date: [2173-4-10] Date of Birth: [2107-5-12] Sex: Male Service: MICU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 34227] is a 65-year- old male with past medical history significant for coronary artery disease status post coronary artery bypass graft, end- stage renal disease on hemodialysis, multiple episodes of Methicillin-resistant Staphylococcus aureus bacteremia, multiple access issues for hemodialysis with stent stenosis of the left subclavian and right IJ and IVC stents, who was admitted to an outside hospital on [2173-3-8] with an episode of nausea, vomiting, and dehydration. Patient was discharged but had returned to [Hospital6 4620] on [2173-3-19] with chest pain and shortness of breath that developed while in hemodialysis that day. The patient had noted an episode of chest pain one day prior to admission which was relieved with one sublingual nitroglycerin. In the [Hospital3 ] Emergency Department the patient was found to have a blood pressure of 65/47, heart rate 79, temperature 96.8 F. He was emergently intubated for hypoxemia and airway protection. Despite intravenous fluids the patient's blood pressure did not increase and he was initiated on Neo-Synephrine. One set of cardiac enzymes was negative and a CT angiogram of the chest was performed which indicated no pulmonary embolism. An ultrasound of his hemodialysis graft of his left extremity demonstrated no thrombosis or abscess. The patient was transferred to [Hospital1 ] for further management. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis secondary to diabetes mellitus. 2. Diabetes mellitus insulin dependent for 35 years. 3. Coronary artery disease status post four-vessel CABG. 4. 1 to 2 plus mitral regurgitation complex atheroma of the aortic arch, PSO, and a normal EF on recent echocardiogram. 5. Status post stroke with residual left-sided weakness. 6. Atrial fibrillation. 7. Hypertension. 8. AV fistula. 9. History of MRSA infection. 10. Esophagitis. 11. Depression. MEDICATIONS ON TRANSFER: 1. Ciprofloxacin day number two. 2. Linezolid day number two. 3. Renagel 2400 mg p.o. t.i.d. 4. Lipitor 20 mg p.o. q.d. 5. Digoxin 0.125 mg q. Tuesday, Thursday, and Saturday. 6. Calcitrol 0.25 mg p.o. q. day. 7. Diflucan. 8. Isordil 20 mg p.o. t.i.d. 9. Zoloft 25 mg p.o. q.d. 10. Actos 30 mg p.o. q.d. 11. Lopressor 12.5 mg p.o. b.i.d. 12. Nephrocaps. 13. Sublingual nitroglycerin p.r.n. 14. Humulin 70/30, 20 units p.o. b.i.d. 15. Percocet p.r.n. 16. Coumadin 3 mg p.o. h.s. ALLERGIES: 1. Vancomycin. 2. Keflex. 3. Penicillin. SOCIAL HISTORY: Patient is married and was with his wife. [Name (NI) ] has three children; two boys and one girl. No history of tobacco or alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Temperature equals 98 F, heart rate 55, blood pressure 100/47, and vent settings are AC 500, rate 10, PEEP of 5, and an FIO2 of 50 percent. In general, the patient is intubated and sedated. HEENT examination demonstrates conjunctival edema. Cardiovascular exam is irregular irregular, S1 and S2 without murmur. Respiratory examination demonstrates decreased breath sounds at the bases bilaterally, rhonchi on the right side appreciated. Abdomen is obese, soft, nontender, nondistended, normoactive bowel sounds. Extremities demonstrate no lower extremity edema, left AV fistula with mild erythema, positive bruit. The patient's fingers and toes are cyanotic with cool fingers and toes. The patient has a right femoral hemodialysis catheter without erythema or edema. There are three peripheral IVs in place. BRIEF SUMMARY OF HOSPITAL COURSE FROM [2173-3-20] THROUGH THE TIME OF THIS DICTATION, [2173-4-10]: 1. Respiratory failure: Mr. [Known lastname 34227] presented to [Hospital 34228] complaining of chest pain and was emergently intubated secondary to hypoxemia and depressed mental status. A CT angiogram at the outside hospital was negative for an aortic dissection or pulmonary embolism. There were large bilateral pleural effusions noted which, upon thoracentesis, were transudative. Cultures that were drawn at [Hospital6 4620] were negative. A component of the patient's respiratory failure was felt to be secondary to a pneumonia which was clearly demonstrated on chest x-rays. A sputum culture from [2173-2-19] was positive for E. Coli, two different morphologies, multiresistant, but this organism was sensitive to Meropenum, Tobramycin, Bactrim, cefepime, and Gentamicin. The patient's sputum culture from [2173-3-21] also demonstrated MRSA. The patient's antibiotics on transfer included Ciprofloxacin, Linezolid. These were continued until the results of the sputum culture returned. Ciprofloxacin was continued and Gentamicin initiated on [2173-3-25]. Patient finished a seven- day course of Linezolid for the MRSA. Despite treating the underlying pneumonia, the patient was difficult to wean. A repeat thoracentesis was performed on [2173-3-23], which demonstrated a transudative fluid which, upon culture and cytology, was negative. We continued the daily treatment, and appropriate spontaneous breathing trials were performed, but the patient's mental status limited his extubation despite adequate pulmonary esthetics. Hospital course was complicated by a self-extubation that occurred on [2173-3-29] and emergent reintubation. He was successfully extubated on [2173-4-1] and remains so at the time of this dictation. Mr. [Known lastname 34227] continued to do well status post extubation until [2173-4-7] when he developed significant upper chest/neck and upper extremity edema secondary to a worsening SVC syndrome. His breathing became more labored presumably secondary to decreased chest wall compliance secondary to this edema, potential aspirations, and pleural effusion, and a VVD demonstrated hypercarbia on [2173-4-9]. The patient was placed on masked ventilation for six hours and has continued to do well off of ventilatory support. A family meeting was held on [2173-4-9] with the patient's wife [Name (NI) ] and brother [Doctor First Name ] and his three children. However, they agree not to reintubate the patient. This, because the underlying etiology of his respiratory failure would not be quickly reversible; i.e., SVC syndrome secondary to failing collaterals and potential aspiration. 1. Distributive shock: [Known lastname 34227] presented to [Hospital ] hypotensive despite aggressive fluid resuscitation. He was initiated on vasopressors at that time. On transfer the patient had [Initials (NamePattern4) ] [Last Name (NamePattern4) ] stim test to evaluate for potential adrenal insufficiency in the setting of his likely septic shock presentation. His [Last Name (un) ] stim test did demonstrate that he was relatively adrenal insufficient, and hydrocortisone and Fludrocortisone were initiated. The patient's sepsis was treated with broad- spectrum antibiotics initially, including Linezolid and Ciprofloxacin. Blood cultures, urine culture, portal fluid cultures were followed. The patient's sputum culture was positive for MRSA and E. Coli, as above. His antibiotics were changed to Linezolid, Gentamicin on [2173-3-25] to complete a seven-day course of Linezolid for the MRSA in the sputum. Patient's blood cultures from [2173-3-28] returned positive for E. coli and he had intermittent meropenem added to Gentamicin at that time. He completed a five-day course of Gentamicin and continues on meropenem for a 14-day course; last dose to be administered [2173-4-11]. Mr. [Known lastname 34227] continued to require vasopressors intermittently with Levophedrine and Vasopressin until [2173-4-3] and has remained hemodynamically stable throughout to the time of this dictation. The underlying etiology of his continued hypertension was unclear, although it was felt to be secondary to a combination of septic shock, adrenal insufficiency, and relative hypovolemia during sessions of CBDH and hemodialysis. His cardiac function was initially evaluated with transthoracic echocardiogram which demonstrated a left ventricular ejection fraction of 55 percent without significant abdominal aortic compromise or pericardial fluid. Given his protracted hospital course requiring vasopressors, alternate sources for inferior were evaluated despite the lack of evidence of a significant leukocytosis or fever. A TEE was performed on [2173-3-29] which demonstrated no vegetation. An abdominal CT scan on [2173-3-31] without contrast demonstrated a potential ________ tumors, although infection could not be ruled out. Repeat CT scan of the abdomen with contrast on [2173-4-1] demonstrated no enhancement of these areas of concern. Stool cultures were negative for C. difficile. 1. Acute blood loss anemia secondary to gastrointestinal bleeding: Mr. Angiostatin had been maintained on ulcer prophylaxis with a proton pump inhibitor. Despite this he developed hematochezia on [2173-3-30] with a hematocrit that decreased from 29 to 23. The NG tube was aspirated and Gastroccult was negative. Stools were heme positive. A GI consult was obtained and recommended conservative management at that time with close monitoring of serial hematocrits. Since the patient was on Heparin at the time, this was discontinued for several hours and restarted at a lower goal PTT. Patient's Protonix was changed to b.i.d. dosing and he was transfused five units of PRBCs between [2173-3-30] and [2173-3-31]. Serial hematocrits following have remained stable with the low- dose anticoagulation. The Gastroenterology consults recommend an EGD to be performed non-emergently prior to the discharge from the hospital. 1. Peripheral vascular disease with multiple-vessel thromboses: Mr. [Known lastname 34227] was anticoagulated during hospitalization with intravenous Heparin with a goal PTT of 6100. It was difficult to maintain these values given the multiple procedures requiring discontinuation for periods of time. Given his gastrointestinal bleeding the Heparin was changed for a lower goal PTT. Unfortunately, the patient's neck, face, upper chest, and upper extremities began to become increasingly edematous and swollen [2173-4-7]. Interventional Radiology was consulted and agreed to perform an IVC venogram to evaluate for any venacaval thrombus. The prior procedure involved the placement of a left subclavian triple-lumen catheter which demonstrated almost total occlusion of the SVC with chronic thrombus, he had multiple collaterals from the upper extremities which drained into the IVC. The patient's IVC vena gram demonstrated that this was widely patent, and no intervention was performed. Heparin was increased with a higher goal PTT and the patient was dialyzed with aggressive fluid removal goals given his worsening respiratory status secondary to the SVC syndrome. On discussion with the interventional radiologist regarding other means for intervening on this SVC, there was felt to be no procedure likely to provide benefit to the patient's situation. A second opinion is pending at the time of this dictation. With hemodialysis the patient's neck and upper chest edema was slightly improved on [2173-4-10]. 1. Atrial fibrillation: On presentation to [Hospital1 18] Mr. [Known lastname 34227] was noted to have four- to six-second pauses on telemetry requiring Atropine. An Electrophysiology consult on [2173-4-20] recommended holding Digoxin, beta blockers, and drawing Digoxin levels. Some low-dose Dopamine was recommended for chronotrophy, although the patient became tachycardiac with this intervention and it was discontinued. An EP study was recommended at a later date given his acuity of illness. Throughout the hospitalization patient's rate was elevated to 120s to 130s at time requiring initiation of Amiodarone. The patient responded well with heart rates being in the 70s and 80s after being maintained on this medication. 1. End-stage renal disease secondary to diabetes mellitus on hemodialysis: Mr. [Known lastname 34227] was followed by the Renal service throughout his admission and was initiated on CVBH [2173-3-25] secondary to continuing total-body fluid accumulation with decreasing lung compliance while on mechanical ventilation. He continued on CVBH until his hemodynamics stabilized and tolerated hemodialysis. Initially patient's left hemodialysis graft was accessed with no complications for hemodialysis. However, upon initiation of CVBH a right femoral hemodialysis catheter was utilized. Given the concern for continued infection the right femoral hemodialysis catheter was changed over wire on [2173-3-29]. Further hemodialysis sessions were performed from this line secondary concerns for diminished blood flow in the left upper extremity secondary to the SVC syndrome. 1. Adrenal insufficiency: Relatively adrenal insufficient as noted above with a random cortisol level during episode of septic shock of 10.3. He was continued on Fluocortolone and hydrocortisone for seven days and discontinued. He was reinitiated on hydrocortisone the following day as he once again became hypotensive. This, for a seven-day course, and he was tapered 50 percent a day per recommendations of the endocrinologists. Upon taper to hydrocortisone 25 mg p.o. q.d. a repeat [Last Name (un) ] stim test demonstrated a basal cortisol level of 43.4 and a 60- minute post stim value of 52.6. The patient will require stress-dose steroids during any episodes of acute illness or procedures. 1. Code status: The patient was initially DNR with no chest compressions or shocks but will be reintubated if necessary. Based on a family meeting with his wife, brother, children, and [Name2 (NI) ], we agreed upon that the patient would not be reintubated if so required. 1. Insulin-dependent diabetes mellitus: Mr. [Known lastname 34227] was maintained on insulin drip [First Name8 (NamePattern2) ] [Last Name (un) ] protocol for the majority of his ICU stay as his nutrition was not consistent given difficult intravenous and enteral access. A PEG tube was placed on [2173-4-8] and tube feeds were initiated. He was changed to Lantus with sliding scale on [2173-4-10]. His hospital course was complicated by one episode of diabetic ketoacidosis which was promptly recognized and treated. 1. Communication: [Name (NI) 34229], brother-[Name (NI) ], [Name2 (NI) ]-[Doctor First Name 2855]. Patient was very involved in and was updated on a daily basis. DR [Last Name (STitle) ],[First Name3 (LF) 1569] 12.684 Dictated By:[Doctor Last Name 34230] MEDQUIST36 D: [2173-4-10] 14:53:27 T: [2173-4-10] 17:02:39 Job#: [Job Number 34231]	[ "785.52", "482.41", "403.91", "482.82", "995.91", "285.1", "518.81", "453.8", "038.42" ]	icd9cm	[ [ [] ] ]	[ "34.91", "00.14", "96.72", "43.11", "39.95", "38.93", "96.6", "99.04" ]	icd9pcs	[ [ [] ] ]																																																								169, 1594							2907, 15356										2143, 2712	1616, 2118	2729, 2892
80,386	141,441	6270	Discharge summary	report	Admission Date: [2154-1-18] Discharge Date: [2154-1-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1136] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 86 y/o female with h/o dementia presented with acutely worsening altered mental status and fevers. She has a history of a sacral decubitus ulcer x 6 months since she has stopped walking and a UTI in the past month. Yesterday her husband found her slumped in the chair with her head bent over and decided that he should bring her to the ED. LP demonstrated 3400 WBCs and she was given vanc, ampicillin, zosyn, ceftriaxone and acyclovir. CT abd prior to LP demonstrated a fistulous tract between her decubitus ulcer and her spinal canal. In the ED, temp was 102.6. She was following simple commands but nothing complex. She was admitted to the MICU where she was started on low dose levophed for systolics in the 80s. In the ICU her family stated that she was more alert than she had been for several days. She was started on Vanc/Zosyn/Fluc and got D5W for hypernatremia. While in the unit, her BP's normalized and she was weaned off pressors. Given her stable condition, she was transferred to the floor. . Upon transfer, vital signs were T- 98.1, HR- 70, BP- 159/71, RR- 25, SaO2- 96% on 2L NC. Patient appears comfortable. Past Medical History: 1. Celiac disease. 2. Hyperlipidemia. 3. Hypothyroidism. 4. History of coronary artery disease status post coronary angioplasty. 5. Status post C-section and incidental appendectomy Social History: [Doctor Last Name ] in [Hospital1 3494] with husband, several children are close by. With regard to ADLs, husband helps with bathing, dressing. Pt and son wish for [Hospital3 ], but husband is resistant Family History: NC Physical Exam: T- 98.1, HR- 70, BP- 159/71, RR- 25, SaO2- 96% on 2L NC Gen: WD/WN, comfortable, NAD. HEENT: Rigid neck Heart: RRR, No MRG Lungs: CTAB Back: Quarter sized opening to sacral decubitus wound with significant undermining and necrosis. Pupils: R 3-2mm, L 4-2mm EOMs: intact Mental status: Awake, not following commands, able to state her name. Motor: Withdraws from pain in both LEs Pertinent Results: ADMISSION LABS: [2154-1-17] WBC 12.1 / Hct 30 / Plt 283 INR 1 / PTT 24.7 Na 145 / K 4.8 / Cl 105 / CO2 25 / BUN 62 / Cr 1.4 / BG 124 ALT 31 / AST 48 / Alk Phos 91 / LDH 178 / TB .3 [2154-1-18] CSF Tube 1 WBC 2110 / RBCs 40 / N 82 / L 3 / M 3 / Macrophages 12 CSF Tube 4 WBF 3430 / RBCs 20 / N 81 / L 1 / M 4 / Macrophages 14 Total Protein 338 / Glucose 46 DISCHARGE LABS: [2154-1-23] WBC 8 / Hct 23.5 / Plt 158 MICROBIOLOGY: [2154-1-17] Blood Cx negative [2154-1-17] Urine Cx - Klebsiella [2154-1-18] CSF Culture - 4 + PMNs on gram stain but no growth on culture 12/5,7,[9-23] Blood Cx negative [2154-1-20] Swab Cx negative STUDIES: [2154-1-17] CXR There is suggestion of free air under the diaphragm. Cross-sectional imaging is recommended for further evaluation. Conversely, this may represent a focally gas distended loop of bowel closely opposed to the undersurface of the left hemidiaphragm. Pneumoperitoneum must be excluded given serious condition of patient. [2154-1-17] CT Abd/Pelvis 1. Decubitus ulcer over the sacrum with subcutaneous gas extending to the underlying bone and gas seen in the spinal canal. This latter finding is concerning for epidural spread of infection. 2. Compression deformity of T9 vertebral body, likely chronic though new from [2151] 3. Large fecal load in the rectal vault and otherwise large amount of gas seen throughout the colon. 4. Cholelithiasis, without cholecystitis. 5. Atherosclerotic disease involving infrarenal abdominal aortic ectasia and coronary arterial calcification. 6. Renal hypodensities as well as the hepatic hyperdensity, suboptimally characterized but likely cysts and are overall appearing unchanged. 7. Thickened adrenal glands, possibly reflecting hyperplasia. [2154-1-17] CT Head - No acute intracranial abnormality. Brief Hospital Course: 1. Meningitis/Sacral decubitus ulcer: Patient found to have deep sacral wound leading to CSF infection. CT scan did not show any new lesions or increased ICP. Wound care performed regularly per wound care team recs. She was found to have purulent CSF fluid with mental status changes. Cultures grew gram positive rods (possible anaerobe) and peptostreptococcus. ID was consulted and recommended adding ampicillin and flagyl to current regimen of vanc/cefipime/fluconazole. Despite this aggressive therapy, the patient did not respond. Surgery felt she was not a surgical candidate. Her mental status worsened and patient's prognosis seemed poor. Given this, palliative care, social work and primary team. Family decided it would be best for the patient to be DNR/DNI and for her to go home with hospice care. The family would like the patient to be continued on IV antibiotics on discharge. ID team recommended zosyn 13.5gm IV via constant effusion every 24 hrs. PICC line placed prior to discharge. In addition, patient will be discharged with IV fluids (normal saline) as needed for hydration. [Hospital 13684] Hospice to manage patient. 2. Dementia: Patient was continued on home dose of aricept. 3. Coronary Artery Disease: Patient continued on aspirin 4. Hypothyroidism: Patient was continued on her synthroid. 5. Orthostatic hypotension Patient's florinef/midodrine were held as pt. non-ambulatory. # ACCESS: PICC # CODE: DNR/DNI # CONTACT: [Name (NI) 4906] [Name (NI) ] [Telephone/Fax (1) 24360] # DISPO: Home with hospice Medications on Admission: Zoloft 50mg daily Aricept 5mg qHS Florinef Midodrine Synthroid 0.125mg daily ASA, Fe, Ca, MVI, Fish Oil, Imodium Discharge Medications: 1. Medication- Zosyn Zosyn 13.5gm IV constant infusion every 24 hours Dispense- 30 2. Heparin Flush 10 unit/mL Kit Sig: One (1) ml Intravenous PRN as needed for line flush: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. Disp:30 units Refills:3 3. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: 1000 (1000) ml Intravenous PRN as needed for hydration: please run at 50-75cc/hr. Disp:30 units Refills:3 Discharge Disposition: Home With Service Facility: EvoCare, RI Discharge Diagnosis: Primary: Meningitis, sacral decubitus ulcer Discharge Condition: Comfortable. Vital signs stable. Discharge Instructions: Ms. [Known lastname ] was admitted to the hospital with a infection stemming from an ulcer on her back. While here, it was found that the infection had gotten into her spinal column, causing an infection of the fluid around the brain. She was initially admitted to the ICU but was transferred to the floor. While here, she did not show much improvement despite being on an aggressive antibiotic medication regimen. The palliative care, social work and primary teams met and determined that it would be best for Mrs. [Known lastname ] to go home with hospice care. She is to continue IV antibiotics- Zosyn 13.5gm IV constant infusion every 24hrs She is to continue gentle IV fluid hydration- Normal saline at 50cc/hr Followup Instructions: Hospice nurses will come to your home and also arrange follow up with medical director from hospice Completed by:[2154-1-26]	[ "414.00", "707.24", "V45.81", "707.07", "290.0", "244.9", "707.21", "038.9", "324.1", "V66.7", "730.08", "995.92", "707.03", "785.52", "272.4", "322.9" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.93" ]	icd9pcs	[ [ [] ] ]	6403, 6445	4206, 5773	292, 299	6533, 6569	2345, 2345	7346, 7477	1926, 1930		5936, 6380		6466, 6512		5799, 5913			6593, 7323			2727, 4183						1945, 2215																						231, 254									327, 1473				2361, 2711				2230, 2326										1495, 1678	1694, 1910
76,927	182,715	41253	Discharge summary	report	Admission Date: [2192-1-2] Discharge Date: [2192-1-11] Date of Birth: [2128-9-15] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG x3(LIMA-LAD, SVG-OM, SVG-Diag) History of Present Illness: 63 year old female who has no known significant past medical history and has not seen a physician in over 15 years. She presented to OSH with chest pain. She reports the pain woke her up from sleep, and resolved within 5 minutes. She went to her PCP after completing her workday and was sent to the ED for evaluation.She ruled in for positive inferior myocardial infarction. She underwent cardiac catheterization/successful PCI with 2 bare metal stents placed for 100% RCA occlusion. Significant multivessel coronary artery disease was evident on cath. She was transferred to [Hospital1 18] for evaluation of revascularization. Aspirin desensitization will be required for a true allergy. Past Medical History: Past Medical History: newly diagnosed IMI and diabetes, hyperlipidemia, , appendicitis, DVT, (R)ankle Fx Past Surgical History:coronary thrombectomy/PCI 2 BMS to RCA on [2191-12-30],(R) ankle stabilization, kidney stone removal ?90s Social History: Last Dental Exam:3 months ago Lives with:married Occupation:consultant and corporate teaching Tobacco:denies ETOH:2 glasses of wine nightly Family History: Family History:heart disease on father's side Physical Exam: General:A&Ox3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: (R)LE superficial varicosities, ?venous stasis changes (R)LE None [] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right:2+ Left:2+ Carotid Bruit -none Right:2+ Left:2+ Pertinent Results: [2192-1-7] 03:46AM BLOOD WBC-9.3 RBC-2.78* Hgb-9.2* Hct-25.5* MCV-92 MCH-33.0* MCHC-36.1* RDW-13.2 Plt Ct-147* [2192-1-4] 07:00PM BLOOD PT-14.5* PTT-31.5 INR(PT)-1.3* [2192-1-7] 03:46AM BLOOD Glucose-170* UreaN-10 Creat-0.4 Na-132* K-4.1 Cl-99 HCO3-25 AnGap-12 [2192-1-5] 09:19AM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-0-2 WBC-[1-21] Bacteri-MOD Yeast-NONE Epi-[1-21] CXR: FINDINGS: AP single view of the chest has been obtained with patient in semi-erect position. Comparison is made with the next preceding similar study of [2192-1-4]. During the interval, left-sided chest tube has been removed. No pneumothorax has developed. There is a diffuse haze over the left base most likely representing some remaining postoperative pleural effusion. No new abnormalities are identified. Previously identified right-sided subclavian approach central venous line remains in unchanged position. IMPRESSION: No pneumothorax following chest tube removal. ECHO: Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior wall. The remaining segments contract normally. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Postbypass The patient is AV paced on a phenylephrine infusion. The left ventricle is more underfilled than before. The inferior wall continues to be hypokinetic with an LVEF of ~50%. The right ventricle mildly dilated with borderline normal function. The tricuspid regurgitation is somewhat sensitive to loading conditions, ranging from mild with a CVP of 10 to moderate with a CVP greater than 20. Mild mitral regurgitation persists. The thoracic aorta is intact post aortic decannulation. Brief Hospital Course: Ms. [Known lastname 54184] was admitted prior to surgery for aspirin desensitization in the ICU. She was then brought to the operating room on [1-2] where she underwent a CABG x3(LIMA-LAD, SVG-OM, SVG-Diag). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility and rehab was recommended prior to returning to her previous living situation. Mrs. [Known lastname 54184] developed atrial fibrillation which was treated with amiodarone and lopressor and couamdin was started. By the time of discharge on POD 7 Mrs. [Known lastname 54184] continued to require assistance with ambulation. The sternal wound and leg incisions were healing and pain was controlled with oral analgesics. Mrs. [Known lastname 54184] was discharged to rehab [Location (un) 89851]of [Location 9583]. All appointments and discharge instructions were advised. Medications on Admission: Tylenol 325 prn, Carvedilol 3.125 twice daily, Glyburide 5 QAM,Novolog SS, Lisinopril 2.5 once daily,Prasugrel 10 once daily, Simvastatin 40 once daily, Ambien 5 HS/PRN Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:6 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): please taper 400 mg po bid x 7 days, then 200 mg po bid x 7 days, then 200 mg po qd. Disp:120 Tablet(s) Refills:2 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:30 Suppository(s) Refills:0 7. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 10 days: prn for pain. Disp:40 Tablet(s) Refills:0 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet, ER Particles/Crystals(s) Refills:0 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day: until lower extremity edema resolved. 14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. warfarin 1 mg Tablet Sig: as directed for afib Tablet PO DAILY (Daily): goal INR 2.0-2.5. 16. lantus insulin 20 units SQ daily at breakfast 17. regular insulin regular insulin dose according to fingerstick before meals and at bedtime 18. Outpatient Lab Work daily INR for coumadin dosing for afib. Goal INR 2.0-2.5 Discharge Disposition: Extended Care Facility: [Location (un) 39857] - [Location 9583] Discharge Diagnosis: coronary artery disease newly diagnosed IMI and diabetes, hyperlipidemia, kidney stones, appendicitis, DVT, (R) ankle Fx, coronary thrombectomy/PCI 2 BMS to RCA on [2191-12-30] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assist Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage edema: 1+ lower extermity edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [2192-1-12] Followup Instructions: The following appointments have been made for you: Surgeon: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2192-1-26] 2:00 Cardiologist: [Doctor Last Name 4922], S [2192-2-8] @ 8:30am You have an appointment to have your surgical incision checked, please come to [Hospital Ward Name ] 6 at [2192-1-18] at 10am. [Telephone/Fax (1) 3071] Please call to schedule the following appointment: Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 250] Completed by:[2192-1-12]	[ "997.1", "V07.1", "278.01", "427.31", "272.4", "410.41", "414.01", "250.00", "V12.51", "V85.34", "V45.82", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]	8448, 8522	4702, 6205	285, 323	8747, 8946	2152, 4679	9912, 10464	1496, 1529		6425, 8425		8543, 8726		6231, 6402			8970, 9889								1195, 1307	1544, 2133																						234, 247									351, 1046																		1090, 1173	1323, 1465
7,050	197,006	19488+57057	Discharge summary	report+addendum	Admission Date: [2105-5-20] Discharge Date: Date of Birth: [2057-6-21] Sex: M Service: SURGERY HISTORY OF PRESENT ILLNESS: This patient is a 47 year-old man with end stage liver disease secondary to alcoholism. He is admitted to [Hospital1 69] on [2105-5-10] for changes in mental status and melena. While in house the patient required therapy for MRSA bacteremia and acute renal failure. The patient went on to have a transesophageal echocardiogram on [5-18] reveling normal ejection fraction, no vegetations, no valve disease, no pulmonary hypertension. On the [5-20] there were no signs of infection, no signs of upper respiratory symptoms, sore throat, rhinorrhea, cough, earache, shortness of breath, chest pain, dysuria, hematuria, nor changes in bowel habits. No nausea or vomiting. PAST MEDICAL HISTORY: End stage liver disease secondary to alcoholic cirrhosis. Ascites. Jaundice. Portal gastropathy. Not bleeding rectal varices revealed on scope examination [2105-5-1]. Cholelithiasis. At this point it was determined that the patient would be evaluated and preoped for liver transplant. MEDICATIONS ON ADMISSION: 1. Protonix 40 mg once a day. 2. Lactulose 30 milliliters twice a day. 3. Propanolol 20 mg twice a day. 4. Lasix 20 mg once a day. 5. Spironolactone 50 mg once a day. 6. Potassium chloride. 7. Mycelex. PHYSICAL EXAMINATION: Temperature 99.5 degrees, heart rate 91, blood pressure 98/70, respiratory rate 18, oxygen saturation 95 percent on room air. The patient was alert and oriented times three and in no acute distress, appearing mildly jaundice throughout. Cranial nerves I through XII were shown to be intact. The patient is mildly icteric. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs or gallops. Respirations cleared to auscultation bilaterally. No rales, wheezes or rhonchi. Abdomen was soft, somewhat distended, nontender. Extremities revealed palpable distal pulses bilaterally, 2 plus mild nonpitting edema. HOSPITAL COURSE: The patient was originally admitted on [2105-5-10] with mental status changes and melanotic stool and was treated for MRSA bacteremia and acute renal failure. The patient had transesophageal echocardiogram on [5-18] revealing a normal ejection fraction, no vegetations and no valve disease and no signs of pulmonary hypertension. On the [5-20] there were no signs of infection in this patient and it was determined the patient would be preoped for possible liver transplant and chest x-ray, electrocardiogram and laboratories were drawn. The patient was given Unasyn, CellCept, ___________, Solu-Medrol, heparin, Fluconazole on call to the Operating Room and the patient was placed at nil per os. Consent was obtained. The patient was typed and crossed and laboratories were drawn at this time revealing a white blood cell count of 13.3, hematocrit 35.0. platelet count of 72, sodium 130, potassium 42, chloride 104, CO2 15, BUN 50 and a creatinine of 2.4, glucose 106. The patient's PT at this time was 10.1, PTT 26 and INR of 5.0, albumin 2.9. The patient was consented and proceeded to the Operating Room on [2105-5-20] and received an orthotopic liver transplant at this time performed by Dr. [Last Name (STitle) ]. The patient was then brought to the Surgical Intensive Care Unit after the procedure and was followed by their staff while continued to be followed by the transplant staff. The patient was noted to receive multiple transfusions in the Operating Room of packed red blood cells and upon admission to the CICU it was noted the patient was doing well postoperatively. The patient was intubated at this time and arterial blood gases were to be followed. The patient at this time was on intravenous fluids at 125 cc per hour, strict Is and Os were monitored in the Surgical Intensive Care Unit. The patient was nil per os at this time and was on an nasogastric tube and his immunosuppressions was arranged by the transplant team. On postoperative day one [2105-5-21] the patient continued to progress well and a duplex angiogram was performed of the liver revealing good arterial and venous flows and the patient was continued on immunosuppression regimen of 1000 of CellCept b.i.d., 90 of Solu-Medrol b.i.d. and 3 mg of Tacrolimus intravenously and 100 mg of Cyclosporin b.i.d. On postoperative day two the patient continued to improve in the Surgical Intensive Care Unit. She received a chest x-ray revealing mild right pleural effusions. The patient was on Vancomycin at this time and received a Vancomycin level of 24.2. On postoperative day three [2105-5-23] the patient was noted to continue to have a low grade fever of 100.4 degrees and blood cultures were sent that subsequently revealed to be negative and another chest x-ray was performed revealing pulmonary edema that was slightly increased from postoperative day two's prior chest x-ray with some right pleural effusion. On postoperative day four [5-24] the patient's temperature maximum was 100.2 degrees and the patient began to be weaned off the ventilator. The patient continued to be followed by the Surgical Intensive Care Unit and was placed on Haldol prn for agitation. He continued to be diuresed using Lasix. ID's recommendations were for Vancomycin, Ganciclovir, Bactrim and Fluconazole to continue at this time. On postoperative day five [2105-5-25] a thoracentesis was performed revealing 900 cc of serosanguinous fluid and sedation was then held. At this point the plan was to continue to wean the patient off the ventilator and to eventually perform extubation. From a cardiovascular point of view the patient was considered stable at this time and the patient was NPO with an negative tube in place. The patient was receiving total parenteral nutrition at this time. Foley catheter was in and the patient was placed on an insulin drip regimen and was receiving heparin subcutaneously every eight hours. The patient received dry dressings to the wound. The patient continued to be followed by infectious disease who suggested checking Vancomycin levels and continue surveillance of cultures and to continue Ganciclovir adjusting for renal function and to continue Fluconazole and Bactrim. On [2105-5-26] the Surgical Intensive Care Unit day six, postoperative day six the patient had his right IJ swan changed to a central venous line and was extubated at this time. It was determined the patient would likely advanced to clear liquids at this time and the nasogastric tube could be discharged. The patient was receiving morphine sulfate as needed for pain at this time and his creatinine was noted to be improving trending downwards from 3.6 to 3.6 on the 20th and [5-25] postoperative days four and five and 3.2 on [5-26] to 2.6 on [5-27]. Infectious disease recommendations on [5-25] were to continue to follow the Vancomycin levels and the patient was on day five of 10 of Vancomycin, because of the preop MRSA bacteremia and to continue Vancomycin resistant enterococcal precautions and to continue prophylaxis with Bactrim, Fluconazole and Ganciclovir. The patient was being followed by nutrition at this time and it was recommended that total parenteral nutrition continue until po reached significant levels and the patient could advance diet as tolerated at this time. On [2105-5-26] postoperative day six the patient pulled the biliary tube and an extension tube needed to be attached and was noted to be still draining bile effectively. The patient was hemodynamically stable at this time and the patient was continued on immunosuppression medications and a cholangiogram was scheduled. On postoperative day seven [2105-5-27] the patient continued to progress well. Vancomycin was continued and the patient's diet was advanced as tolerated. The patient continued in the Surgical Intensive Care Unit it was noted the patient started sips at this time and the cholangiogram showed the tube not to be in the bile duct. The patient was treated on this day with Lopressor for an elevated heart rate reached the 120s to 140s. The patient began to be followed by physical therapy on the [5-27] postoperative day seven it was suggested the patient have inpatient rehab and to be evaluated for progress to see whether the patient would be safe for discharge to home eventually. On postoperative day eight the patient continued to improve in the Surgical Intensive Care Unit. KUB was performed for the broken biliary drain revealing no fragments. The patient was also noted on this day to have somewhat decreased oral intake and a Dobhoff tube was placed. The patient was continued on his immunosuppression regimen of Prednisone, CellCept and ____________ at this time. On postoperative day nine [2105-5-29] the patient complained of mild nausea overnight. The patient had one episode of emesis in the early morning and the patient was at this point now upon the floor on Far 10 and had been discharged from the Surgical Intensive Care Unit on the night of [2105-5-28]. On [2105-5-30] postoperative day ten the patient noted improvement without complaint of pain, nausea and vomiting and was passing gas at this time and having bowel movements. The patient's liver function tests were noted to be decreasing at this time. The patient's sodium was in the 150s. The patient's tube feeds were supplemented with free water and the patient was continued on ______________, Prednisone and CellCept. The patient was then started on evaluation by occupational therapy on the [5-29] postoperative day nine and noted the patient to be functional, but with somewhat decreased mobility and decreased sense of safety and suggested the patient likely be needing rehab placement upon discharge. On [6-1] postoperative day 12 infectious disease was consulted to assist in evaluation due to new fevers to 102.5 degrees at this time with an uncertain source. Blood cultures were sent off, urine cultures and tip cultures from the patient's central line, wound cultures were performed and tissue culture from the wound was performed. All cultures came back negative at this time. C-difficile cultures were also sent and came back all negative. On the [6-2] the patient had been afebrile for 24 hours. On postoperative day 13 and a CAT scan of the chest was performed revealing a right large lower lobe effusion and suggestion from infectious disease was to consider a tap of this under CT guidance. On the [6-3] cultures came back from the wound revealing sparse enterococcus and infectious disease suggested changing Vancomycin to Linezolid 600 mg every 12 hours and on the [6-3] the patient continued to progress and began feeling significantly better. He began to get out of bed and ambulate, passing gas at this time, having bowel movements and felt the pain was very well controlled and had not had any nausea or vomiting. The patient's appetite also began to progress and Vancomycin was stopped at this time. On [6-4] the patient continued to progress well and the patient's Foley was discharged and he was able to ambulate and the patient began to be screened for rehab placement. The patient continued to be followed by infectious disease at this time and they continued to suggest the use of Linezolid. On [6-5], postoperative day 16 the patient complained of several episodes of emesis overnight and PICC line was placed on [6-5], postoperative day 16 and infectious disease continued to suggest the patient to be treated with Linezolid and Zosyn at this time. The patient was stable at this time and the patient's antibiotics regimen was able to be switched to oral with Levofloxacin 500 mg po once a day and Linezolid 600 mg po twice a day with the suggestion to continue therapy for 14 days. On [2105-6-7] postoperative day 18 the patient was continued on tube feeds delivered at 45 cc an hour and rehab screening continued for possible discharge on Tuesday [2105-6-9] and on [6-8] the patient continued without complaints. It was noted that there was mild serous drainage from his operative incision on the left side and the patient was given one running 4-0 suture, which turned out to seal the wound and the patient's bandages for the rest of that day were noted to be dry and clean and the patient continued to be screened for rehab and tube feeds continued. At this time the patient continued to have somewhat limited oral intake and on [2105-6-9] the day of discharge the patient's without complaint at this time with examination revealing vital signs of temperature maximum 99.5, 104 beats per minute, blood pressure 124/86, respiratory rate 20, 99 percent on room air. The patient was in no acute distress. Lungs were clear to auscultation bilaterally. Heart examination was regular rate and rhythm with no murmurs, rubs or gallops. The patient's abdomen was soft, nontender, normoactive bowel sounds with incision with staples in place with no drainage at this time. The patient was doing well and was continued to advise to advance his diet as tolerated, tube feeds continued and rehabilitation placement to occur today at [Hospital1 ]. DISCHARGE DIAGNOSES: Status post orthotopic liver transplant for alcoholic hepatitis [2105-5-20]. End stage liver disease. Portal gastropathy. Multiple varices. DISCHARGE CONDITION: Stable. The patient was instructed to call if fevers, chills, nausea, vomiting or increased drainage or redness from the wound site. The patient was instructed to follow up with liver transplant staff and to have twice weekly laboratories drawn Monday and Thursday for CBC, chem 10, AST, ALT, alkaline phosphatase, albumin, total bilirubin and immunosuppression levels. The patient's appointments were to be scheduled by a liver transplant coordinator. DISCHARGE MEDICATIONS: 1. Bactrim 400 mg one tablet po q.d. 2. Fluconazole 200 mg one tablet po q.d. 3. Propanolol 20 mg one tablet po b.i.d. 4. Pantoprazole sodium 40 mg po q.d. 5. Prednisone 20 mg one tablet po q.d. 6. _______________ one tablet po q.d. 7. Azathioprine 50 mg one tablet po q.d. 8. Valganciclovir 450 mg one tablet po q.d. 9. Furosemide 10 mg po b.i.d. 10. Neoral per level Again, laboratories are to be drawn on a twice weekly basis at this time. DISPOSITION: To [Hospital ] Rehab. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD, PHD[Numeric Identifier ] Dictated By:[Last Name (NamePattern1) 52916] MEDQUIST36 D: [2105-6-9] 12:14:11 T: [2105-6-9] 14:16:57 Job#: [Job Number ] ADDENDUM: Discharge on [6-9] postponed because of wound infection Name: [Known lastname 9841],[Known firstname 140] Unit No: [Numeric Identifier 9842] Admission Date: [2105-5-10] Discharge Date: [2105-6-19] Date of Birth: [2057-6-21] Sex: M Service: [Doctor First Name 1379] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 48] Chief Complaint: end stage liver disease Major Surgical or Invasive Procedure: orthotopic liver transplant History of Present Illness: RE: prior dictation from [2105-6-9] Brief Hospital Course: Patient on [6-9] was planned to be discharged to rehab but upon further exploration of wound it was determined that the pateint would benefit from further wound care and nutritional supplementation via tube feeds at [Hospital1 8]. Patient also began to have episodes of vomiting at this time and dischrge plans were held. An EGD was performed by Dr. [Last Name (STitle) 833] at this time that revealed a normal esophagus and stomach and a nasojejunal tube was placed to supplement nutrition with tube feeds. The following day, [6-10] POD 21, staples were removed from the medial aspect of the wound and packing was put in place and blood cultures and wound cultures were sent as the patient was febrile at this time. Zosyn and linezolid were started at this time. From this point on patient continued to progress and tube feeds of probalance were advanced to goal of 77cc/hr and dressing changes were performed three times a day. By now patient was afebrile. On [6-15] POD 26 patient's Dobhoff tube was no longer in place and patient had to have tube replaced by GI. Patient tolerated the procedure well and tube feeds were continued and physical and occupational therpy began to evaluate the patient again for services and safety after discharge. On [6-18] POD 29 patient was fully screened for rehab and a bed was found for the patient at [Hospital ] Rehabilitation . On the day of discharge [6-19] patient was stable and prepared to be discharged to [Hospital1 ] on three times daily dressing changes, antibiotics, and an immunosuppressant regimen. All vital signs were stable on the day of discharge. Medications on Admission: Ambien Ursodiol Reglan Protonix Vancomycin Octreotide Midodrine Lactulose Discharge Medications: Trimethoprim-Sulfamethoxazole 400-80 mg Tablet Sig: One (1) Tablet PO QD (once a day). Fluconazole 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Prednisone 15 mg Tablet Sig: One (1) Tablet PO QD (once a day). Azathioprine 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QD (once a day). Furosemide 10 mg/mL Solution Sig: Two (2) Injection [Hospital1 ] (2 times a day). Neoral 150 mg PO QD Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: status post orthotopic liver transplant for alcoholic hepatitis [2105-5-20], end stage liver disease, portal gastropathy, varices. Discharge Condition: Stable. Discharge Instructions: Patient to be discharged to rehabilitation facility and to be evaluated for eventual return to home. Patient instructed to notify MD if having increasing pain, drainage from wound, fevers>101. Patient to have three times daily dressing changes at rehab facility, to receive tube feeds of Probalance at 75cc/hr. Followup Instructions: Patient to follow up with liver transplant staff and to have twice weekly labs drawn, Mondays and Thursdays for CBC, Chem 7,10, AST, ALT, alk phos, albumin, T Bili, and immunosuppressant levels. Patients appointments with transplant staff to be scheduled by liver transplant coordinator. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 51] MD, [MD Number(3) 52] Completed by:[2105-6-19]	[ "511.9", "038.11", "998.59", "572.4", "584.9", "995.92", "571.2", "303.90", "789.5" ]	icd9cm	[ [ [] ] ]	[ "96.04", "43.11", "34.91", "88.72", "50.59", "96.6", "38.93", "96.08", "50.69", "43.19", "96.71" ]	icd9pcs	[ [ [] ] ]	17870, 17913	15399, 17051	15278, 15307	18092, 18101		18462, 18907		13326, 13474	17175, 17847		17934, 18071		17077, 17152	2068, 13304		18125, 18439																					1413, 2050										15215, 15240									15335, 15376																		864, 1160
30,667	163,744	17340	Discharge summary	report	Admission Date: [2144-2-10] Discharge Date: [2144-2-18] Date of Birth: [2082-9-7] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 330] Chief Complaint: s/p humerus fracture, R shoulder pain Major Surgical or Invasive Procedure: L sided PICC per IR R femoral HD line placement Diagnostic Paracentesis L-A line Intubation History of Present Illness: 61yo M w hx of chronic hep C and etoh cirrhosis c/b ascites, SBP, variceal bleeding, hepatic encephalopathy presented s/p mechanical fall now with humerus fracture. He was recently inpt at [Hospital1 1774] from [Date range (1) 19792] for weakness, urinary retention, UTI. WBC 13 on admission. Urine cx pos (see below), no diag para performed. Rx with ertapenem for 14d course. Was at rehab for FTT. Approx 1wk prior to this admission (cannot confirm date), had mechanical fall. He hit side of head and right shoulder. Has been rx with tylenol w some relief. Had repeat film (per patient) which showed persistent fracture. Sent in for evaluation. Note, labs prior to d/c from NH include WBC 12.2, INR 2.1, Cr up from baseline. . ED COURSE: afeb, HR 88, BP stable. He was given levaquin 750 PO x1 for unclear reasons. Morphine 2mg IV for shoulder pain. Ortho called: requested CT shoulder which confirmed right shoulder impacted. Ortho rec: no ROM, no weight bearing. CXR showed ? retrocardiac opacity. PCP was notified and requested LFTs. These were markedly worse than baseline. Liver team notified and pt admitted for liver eval. Also, WBC 17 w no bands, Cr 3.1 (up from baseline 1.4), INR 2.6, lactate 2.7, anion gap 10 (albumin 2) . FLOOR COURSE: Pt with bacteremia, coag neg staph PICC line on vanco [2-12], enterbact from PICC line on meropenem [2-11], started flagyl [2-15] for enceph, ECHO neg for vegetations. Worsening renal failure, Cr increasing despite daily albumin, midodrine/octreotide. Pt with significant pain, not improved with lidocaine patch/tylenol prn. Team avoiding narcotics due to encephalopathy, no NSAIDs due to GIB s/p Variceal banding. LLE larger than RLE, LENI negative for DVT. Received 2U PRBC and 2UFFP on [2-11] for Hct drop from 30.0 to 24. HCT appropriately responded, no further melena or hematochezia. Tm 99.4 on [2-11] remained afebrile since then, intial O2 sat 95%RA, O2 Requirement on [2-12] 92%3L NC--> [2-13] 95%5L NC--> On [2-15] desat to 89% 5L NC-->98%[Hospital 48526] transferred to MICU for respiratory distress, hypoxia. Past Medical History: ESLD from hep C, etoh, turned down for tx at [Hospital1 ]. Eval underway here currently - c/b ascites, SBP in [11-1] w strep viridans - variceal bleeding per report: [2143-9-26] EGD noting esophageal varices with banding - per report: Abdominal ultrasound was done on [2143-7-11] noting ascites and no new focal mass or dilated ducts. Main portal and main hepatic artery, right left hepatic veins had normal wave forms - per report: Colonoscopy [2141-6-30] noted 3 adenomatous polyps - admission [Date range (1) 41025] for portasystemic enceph . s/p mech fall last week, shoulder pain, found to have humeral head fracture Bipolar disorder s/p chole UTI: [Date range (1) 41025] rx with multiresistant E Coli and enterobacter rx with ertapenem 1gm daily (stopped [2-1]). f/u [2-4] urine cx neg Social History: Lives at [Hospital3 2558] NH [Telephone/Fax (1) 48527]; has no children, quit smoking 6 years ago, smoked 1 pack for 20 years, drank a quart of vodka a day, last drink was 10 years ago. He was in the military from [2101] - [2103]. He is from [Male First Name (un) 1056]. Family History: Mother is deceased, age 60, heart disease Father is deceased, age 83, heart disease Two brothers, both living, drug and alcohol One sister, living, CAD, diabetes and PVD Physical Exam: VS: 97.5 HR 88 BP 168/80 RR 12 96%NRB I/O -100cc yellow para fluid in bag GEN: in acute distress, writhing in pain HEENT: Dry MM, icteric sclera RESP: coarse BS b/l with expiratory wheezing throughout lung fields, diminshed bs at bases with inspiratory crackles CV: Reg Nml S1, S2, no M/R/G ABD: Soft Distended, tender at LLQ, clear yellow fluid draining in ostomy bag, +BS, +Fluid wave EXT: dry cracked/scaly skin, 2+edema throughout legs, LLE>RLE, warm 1+DP pulses b/l, RUE in splint unable to move due to pain, no inflammation/erythema/warmth at R shoulder NEURO: A&Ox2 (self/place) uncooperative due to pain, does follow simple commands . Pertinent Results: Recent labs at [Hospital1 1774] [2144-1-28]: WBC 13.6 HCT 26.5 PLT 125 Na 133 HCO3 18 INR 2.2 Blood cx from [1-25] neg as of [1-28] Urine cx [1-25] mixed flora diag para unsuccessful . IMAGING: [2144-2-10] CT upper ex: impacted, comminuted fracture of the surgical neck of the right humerus with significant overriding of the fracture fragments . [2144-2-10] Humerus xray: Impacted, comminuted fracture of the surgical neck of the right humerus with significant overriding of the fracture fragments. . [2144-2-11] EGD: 4 cords of grade II varices were seen in the middle third of the esophagus and lower third of the esophagus. There were stigmata of recent bleeding. 3 bands were successfully placed. . [2144-2-13] Pelvic CT: CT PELVIS WITHOUT CONTRAST: There is a large amount of intra-abdominal fluid, consistent with ascites. There is generalized moderate anasarca. There is no localized fluid collection in the thigh areas or in other areas to suggest hematoma. . [2144-2-17] CXR: FRONTAL CHEST RADIOGRAPH: The endotracheal tube, nasogastric tube, and right- sided PICC line are in unchanged positions. The cardiomediastinal silhouette is stable in size. Increased perihilar haziness has markedly decreased indicating resolving pulmonary edema. Left retrocardiac opacity has also mildly improved. Small left-sided effusion has decreased. The right- sided effusion is stable. Partially visualized is the known right humeral neck fracture. IMPRESSION: 1. Resolving pulmonary edema. 2. Decreasing small left-sided pleural effusion and left retrocardiac opacity. . PERTINENT LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2144-2-17] 12:08PM 21.1 [2144-2-17] 04:21AM 11.0 2.09* 7.0* 21.0* 100* 33.3* 33.2 23.4* 59* [2143-12-13] 12:20PM 10.6 2.86* 9.8* 31.5* 110* 34.4* 31.2 17.7* 171 . Glucose UreaN Creat Na K Cl HCO3 AnGap [2144-2-17] 04:21AM 165* 92* 3.4* 140 4.0 109* 20* 15 [2144-2-16] 04:21AM 168* 113* 4.2* 139 4.5 107 16* 21* [2144-2-10] 08:30PM 186* 681 3.1# 135 4.8 109* 142 17 . proBNP [2144-2-15] 04:41PM [Numeric Identifier ] . COAGS: PT PTT Plt Smr Plt Ct INR(PT) [2144-2-17] 04:21AM 27.7 46.3* 2.8* [2144-2-16] 04:21AM 32.3* 49.5* 3.4 [2144-2-10] 08:30PM 26.6* 41.5* 2.6* . HEPARIN DEPENDENT ANTIBODIES TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES POSITIVE COMMENT: Positive for Heparin PF4 Antibody by [Doctor First Name ]. Reported to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 48528], CC7D at 3:30pm. . LFTs: ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2144-2-17] 04:21AM 22 65* 277* 130* 18.6* [2144-2-10] 08:30PM 96* 292* 391* 9.9 . MICRO: [2144-2-11] 9:18 am BLOOD CULTURE Source: Line-picc. FINAL REPORT [2144-2-17] Blood Culture, Routine (Final [2144-2-17]): ENTEROBACTER CLOACAE. FINAL SENSITIVITIES. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 32 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [2144-2-11] 1:40 am BLOOD CULTURE Source: Line-picc. FINAL REPORT [2144-2-16] Blood Culture, Routine (Final [2144-2-16]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES REQUESTED BY DR. [Last Name (STitle) ] (PAGER [Numeric Identifier 48529]) ON [2144-2-14]. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- =>32 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S . [2144-2-11] 1:30 am URINE Source: Catheter. FINAL REPORT [2144-2-12] URINE CULTURE (Final [2144-2-12]): YEAST. >100,000 ORGANISMS/ML.. . [2144-2-17] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-17] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-15] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2144-2-15] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-13] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-13] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2144-2-12] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2144-2-12] BLOOD CULTURE Blood Culture, Routine-FINAL Brief Hospital Course: A/P:61yo M w hx of chronic hep C and etoh cirrhosis c/b ascites, SBP, variceal bleeding, hepatic enceph here s/p fall with right humerus fracture, worsened liver failure, UGIB s/p esophageal variceal banding, coag neg staph and ESBL enterobacter bacteremia, worsening renal failure/HRS now with respiratory distress. . #. Respiratory Failure: Multifactorial, worsenening in setting of fluid overload, diminished UOP despite fluid challenge with albumin, octreotide/midodrine for HRS. Pt also with distended abdomen, in significant pain, ? PNA-L retrocardiac opacity. Intubated on [2-16] as pt failed diuresis with up to 200mg IV lasix. Fluid removal per HD started on [2-16] with some mild improvement im pulmonary edema, however his worsenign mental status precluded spontaneous breathing and weaning from the vent. Post intubation there was blood noted in the ETT and the OGT. GI/Liver was called and plan was deferred to do an EGD due to declining clinical function with hypothermia, bleeding and inability to wean from vent. No paracentesis done while in MICU, pt's ascites not thought to change clinical outcome. He was continued on Abx to cover ? retrocardiac opacity. Per family discussion as noted below pt was made CMO and withdrawal of care including extubation on [2-17] 8pm. . #. Bacteremia: Blood cultures from admission with 2/2 bottles GPC on one set and 2/2 bottles GNR on a separate set, from PICC line. Also recently with ESBL E.coli and Klebsiella UTI and was on ertapenam prior to admission. He had diagnostic tap [2-11] which did not show evidence of SBP although already on antibiotics. He was continued on [Last Name (un) ]/Vanc to cover gpc and gnr, and coag neg staph. Right PICC d/c'd, had left side PICC placed for access and blood draws. Daily surveillance cultures were drawn without new Positive culture data. An echocardiogram showed no evidence of endocarditis. His urine culture with no growth however was on abx prior, >100,000 colonies yeast, he had CBI on the floor which was discontinued in the MICU. Foley was changed. On [2-17] pt became hypothermic, blood cultures redrawn, however pt made CMO that evening. . # acute renal failure: baseline creatinine 1.4, creatinine worsened on maximal doses of HRS treatment, despite increasing and persistent albumin. Urine Na <10 which is consistent with hepatorenal syndrome. No evidence of hydronephrosis on ultrasound. Concern for ATN given hypertension. R sided HD femoral line placed [2-16], HD started on [2-16]. He underwent 1 cycle of HD with removal of 3L. He did not undergo a 2nd cycle as he clinically deteriorated very rapidly. Pt also received a dose of DDAVP for uremic platelets and bleeding from Fem HD line. . #Upper GI bleed: Due to variceal bleed, as EGD on [2-11] showed esophageal varices with stigmata of recent bleeding, treated with banding. Transfused total of 4 untis since admission. Post intubation notable for blood from ETT/OGT. HCT trending down, in setting of coagulopathy with INR 3.3. He received 2 UFFP, vitamin K. He also completed 3 days of octreotide gtt, now on sq octreotide, continued sucralfate, continued IV PPI [Hospital1 ]; reversed coagulopathy on [2-17] due to persistent oozing at fem HD line and bleeding from ETT and OGT. . #. Thrombocytopenia: Pt's PLTS started to trend down, had been on vanco/meropenem, no H2 blocker, HIT Ab sent. At time of death, HIT Ab returned +. . #. humeral fracture: seen by ortho in ED, no surgical intervention, recommended sling and non weight bearing. In significant pain, tylenol and lidocaine patch not controlling pain, no NSAIDs due to GIB w/HCT trending down, had not received narcotics due to encephalopathy and declining AMS and respiratory status. Pain service was consulted which recommended low dose narcotics. On [2-17] pt intubated and was well sedated with fentanyl at low doses given encephalopathy. . #Left lower extremity edema - concerning for possibility of fracture given recent falls and humerus fracture vs DVT. LENI and CT scan with no evidence of fracture, hematoma or DVT. Cause of left leg swelling/pain unclear. [Name2 (NI) ] did not develop any signs of cellulitis. Followed clinically. . #. Coagulopathy - nutritional deficiency, long term abx therapy and decompensated liver function. Vitamin K and FFP provided as noted above. . #ETOH/HCV Cirrhosis: complicated by acute variceal bleeding, encephalopathy, h/o SBP. He continued to have encephalopathy. Liver team followed him closely. He had been taken off the transplant list from [Hospital1 1774] due to + tox screen for benzo/opiates. Liver team was re-considering transplant if he survived this hospitalization. Per family/team meetings pt clinically deteriorated and passed away on [2-18]. Prior to his decline he was continued on lactulose, rifaxamin, midodrine, octreotide as above. . # Bipolar disorder- not on meds, psych consult pre-transplant when not encephalopathic. . #. Code-initially full, per family Meeting on [2-17] pt made DNR/DNI-->CMO with withdrawal of care. Pt was extubated at 8pm on [2-18]. He passed away at 3:40pm on [2-18]. Pt was comfortable maintained on a morphine gtt. Medications on Admission: per NH records 2000cc fluid restriction microdantin 50 proph for UTIs - stopped today tylenol prn pain lactobillus [Hospital1 ] lidoderm patch right arm lactulose 30mg QID prilosec 20 daily amox 250 daily since [2-2] ertapenem IV - finished [2-1] Rifaximin 400mg daily naltrexone 50-100 mg prn pruritus Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA Completed by:[2144-2-18]	[ "456.20", "790.7", "E888.9", "999.31", "041.85", "812.01", "584.9", "070.44", "789.59", "572.4", "571.2", "287.4", "041.19", "518.81", "296.80" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "39.95", "38.95", "38.93", "38.91", "54.91", "42.33" ]	icd9pcs	[ [ [] ] ]	16400, 16409	10787, 16008	311, 404	16461, 16471	4579, 6189	16522, 16555	3730, 3901		16373, 16377		16430, 16440		16034, 16350			16495, 16499									3916, 4560																						234, 273									432, 2549											6227, 10764							2571, 3406	3422, 3714
49,067	114,038	54649	Discharge summary	report	Admission Date: [2112-8-16] Discharge Date: [2112-8-20] Date of Birth: [2045-7-23] Sex: F Service: MEDICINE Allergies: flu shot Attending:[First Name3 (LF) 13685] Chief Complaint: right carotid artery stenosis Major Surgical or Invasive Procedure: [2112-8-16] - right carotid endovascular stent [2112-8-18] - [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] Distal RCA History of Present Illness: 67-year-old woman w/ history significant for HTN, HL, b/l carotid artery stenosis c/b TIA in [2110-6-26]. She was noted to have 70% R-sided CAS, and complete L-sided common carotid artery occlusion with reversal of flow in the external carotid artery and reconstitution of the ICA on the left side. She was watched conservatively, but underwent right-sided carotid endarterectomy with bovine pericardial patch on [2111-7-15] when stenosis progressed from 70% to 95%. On the most recent duplex performed in [2112-7-28], the right-sided carotid stenosis had progressed to being estimated at 70-99%, and thus patient underwent placement of a R carotid artery endovascular stent on [2112-8-16]; tolerated the procedure well, but required neo in the PACU for low blood pressure. On [2112-8-17], as she was lying in bed she had sudden onset 10/10 chest pain in the substernal area which disappeared after 5 minutes without any intervnetion. Did not have any shortness of breath, nausea, voming, diaphoresis. EKG showed non-specific ST changes otherwirse unchanged from prior EKG. She had two more similar episodes of chest pain yesterday each lasting about 5 minutes. She had troponin leak to 0.13 but her CK-MB reamined normal. . Due to concern for unstable angina, she was taken to the cath lab today and found to have 1v CAD with diffuse 40% lesion in mid RCA and 95% lesion in distal RCA. She then had successful PTCA/Stent of distal RCA using DES. Procedure was uncomplicated procedure, LRA with TR band. In the cath lab her A-Line was registering 30-40 points lower than central pressure likely from peripheral vascualr disease. . On arrival to the floor, patient denies any chest pain, shortness of breath, nausea, vomiting, diaohoresis. ankle edema, palpitations, orthopnea or PND. . REVIEW OF SYSTEMs: + Fever which started yesterday as high as 102. Chronic cough. Denies dysuria Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - TIA [2109] presented with dizziness and right facial numbness - s/p bilateral salpingo-oophorectomy done in [2063] - s/p right carotid endarterectomy on [2111-7-15], and bovine pericardial patch by Dr. [Last Name (STitle) 83920] - s/p bilateral cataract surgeries Social History: 100-pack-year history of smoking; however, she did quit successfully two years ago. She has been drinking four or five beers a week. She uses no recreational drugs. She is a retired CNA, retired one year ago. She lives at home with her husband. She lives independently. Family History: Her father had coronary artery disease and myocardial infarction at age 70s. There is no history of stroke. Physical Exam: GENERAL: Appears well in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple, no JVD, +carotid bruits CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Warm and well perfused no edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT with doppler Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT with doppler Pertinent Results: Relevant Labs: [2112-8-16] 11:10PM BLOOD WBC-8.1 RBC-2.93# Hgb-8.5# Hct-24.4# MCV-83 MCH-29.1 MCHC-34.8 RDW-13.2 Plt Ct-244 [2112-8-19] 04:19AM BLOOD WBC-8.1 RBC-3.18 Hgb-9.5* Hct-27.8* MCV-87 MCH-29.8 MCHC-34.1 RDW-13.8 Plt Ct-238 [2112-8-18] 12:00AM BLOOD Neuts-77.6* Lymphs-12.9* Monos-4.0 Eos-5.1* Baso-0.5 [2112-8-17] 06:15AM BLOOD PT-10.8 PTT-28.1 INR(PT)-1.0 [2112-8-19] 04:19AM BLOOD Glucose-92 UreaN-6 Creat-0.9 Na-143 K-4.0 Cl-109* HCO3-27 AnGap-11 [2112-8-17] 11:48AM BLOOD CK-MB-7 cTropnT-0.05* [2112-8-17] 04:15PM BLOOD CK-MB-8 cTropnT-0.07* [2112-8-18] 12:00AM BLOOD CK-MB-9 cTropnT-0.14* [2112-8-18] 02:00AM BLOOD CK-MB-7 cTropnT-0.14* [2112-8-18] 05:05AM BLOOD CK-MB-7 cTropnT-0.13* [2112-8-19] 04:19AM BLOOD CK-MB-6 cTropnT-0.29* [2112-8-19] 04:19AM BLOOD Calcium-7.8* Phos-2.9 Mg-3.4* . Cardiac Cath: [2112-8-18] 1) Selective coronary angiography of this right dominant system revealed one angiographically apparent flow limiting stenosis. The LMCA was normal. The LAD had minimal irregularity. lcx was a very small vessel without significant disease. We did left and right cusp shots to look for an anomalous LCX but none was found. The RCA had diffuse 40% mid and focal 90% distal lesion. 2) Limited resting hemodynamics showed central aortic pressure of 141/53 3) Successful PCI of the distal RCA with 3.0x16mm [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated to 3.5mm (see PTCA comments). . FINAL DIAGNOSIS: 1. One vessel coronary disease 2. Successful PCI of the distal RCA with drug-eluting stent. 3. Continue aspirin indefinitely; plavix 75 mg daily for 12 months minimum. 4. Compared to central aortic pressure, the right radial arterial line was unreliable; recommend weaning vasopressors and removing arterial line once anticoagulation has worn off. . TTE: [2112-8-18] The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Normal regional and global biventricular systolic function. No pathologic valvular abnormalities. . CXR: [2112-8-18] FINDINGS: As compared to the previous radiograph, there are mild bilateral areas of parenchymal opacities, partly obscuring the left and right hemidiaphragmatic contour. These areas of parenchymal opacities could represent pneumonia in the appropriate clinical context. No relevant other change. No evidence of pleural effusions or pulmonary edema. Unchanged size of the cardiac silhouette. At the time of observation at 10:08, the referring physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] was paged for notification, [2112-8-18] (at 10:09). Brief Hospital Course: 67-year-old woman w/ history significant for HTN, HL, b/l carotid artery stenosis c/b TIA in [2110-6-26] s/p stent to right carotids during this elective admission complained of severe chest pain concerning for unstable angina. . # Unstable Angina: Patient was admitted electively and underwent right carotid stent placement due to worsening restenosis of her carotids. She tolerated the procedure well, was extubated, and sent to PACU. On post-operative day 1, she had an episode of [10-5] chest pain that resolved after lying down. There were no associated EKG changes, but cardiac enzymes were sent which showed elevation in troponins therefore cardiology was consulted. She had two similar episodes of chest pain each lasting about 5 minutes and self resolving. Her Ck-MD remained stable however her troponins continued to rise. Due to concern for unstable angina she was taken to the cath lab where she was found to have 95% stenosis of her distal RCA. She had [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] placed with no further chest pains. She was continued on aspirin and plavix and switched to atorvastatin. She was also started on low dose beta blocker. Prior to discharge patient was evaluated by PT who deemed her safe to go home. She was discharged with follow up appointment with PCP's office who will schedule her for a cardiology appointment. . # Hypotension: Patient with BP in the 70s with non-invasive and with A-Line and was started on Neo in the VICU. However central pressures measure in the cath lab were 30-40mmhg higher than non-invasive and A-Line blood pressures most likely in the setting of severe peripheral vascular disease. Therefore she was weaned of neo in the CCU. Her non-invasive and A-Line pressures continue to be in the 70s without any chest pains or SOB and mentation fine. Her home blood pressure was medication Triamterene-Hydrochlorothiazide. . # Fevers: Two days prior to discharge patient was febrile to 102. WBC 11.2. Complained of chronic cough with no sputum production. CXR with possible pneumonia. Therefore she was started on 5 day course of levofloxacin. Her urine and blood culture were negative to date on the day of discharge. . # HLD: Switch simvastatin to atorvastatin in the setting of unstable angina. . Transitions of care: - Blood culture pending at the time of discharge. - Patient will follow up with PCP who will schedule patient for a cardiology follow up for her coronary artery disease. - Patient will also follow up with vascular surgery for monitoring of her carotid stenosis. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Fish Oil (Omega 3) 1000 mg PO BID 2. Simvastatin 40 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 6. Aspirin 325 mg PO DAILY 7. Vitamin D 1000 UNIT PO BID Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Fish Oil (Omega 3) 1000 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Vitamin D 1000 UNIT PO BID 6. Acetaminophen 325-650 mg PO Q4H:PRN headache RX acetaminophen 650 mg 1 tablet(s) by mouth Every 6 hours as needed for pain Disp #30 Tablet Refills:0 7. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 8. Metoprolol Succinate XL 12.5 mg PO DAILY hold for HR <60 RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth Daily Disp #30 Tablet Refills:0 9. Levofloxacin 750 mg PO DAILY RX levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Daily Disp #4 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Right carotid artery stenosis s/p right carotid stent 2. Unstable angina s/p distal RCA stent Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname ], It was a pleasure taking care of you during your hospitalization at [Hospital1 18]. You were admitted to the vascular surgery service for elective placement of right carotid stent due to worsening stenosis of your carotid artery. You tolerated the procedure very well. During your hospital stay you also developed new severe chest pains and you had cardiac cathetherization which showed narrowing of your coronary arteries and a heart stent was placed and new medications started for your heart. During your cardiac procedure it was noted that your blood pressure with a non-invasive blood pressure cuff was 30-40 point lower than your real blood pressure measured directly therefore you may continue to have falsely low blood pressure outside of the hospital. You were admitted to the cardiac intensive unit for further monitoring. You also had fevers and cough during this hospital stay and you have been started on five days of levoflocain antibiotic. While you were in the CCU, you did not have any further chest pain and shortness or shortness of breath. Please follow up for your appointments below. Please take your medications as directed in your discharge medication sheet. Activities Per Vascular Service: - 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 on that area - 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 - You should NOT have an MRI scan within the first 4 weeks after carotid stenting CALL THE VASCULAR OFFICE FOR: [Telephone/Fax (1) 3464] - 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, use or 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 - Bleeding from groin puncture site Followup Instructions: Name: Dr [First Name8 (NamePattern2) 5464] [Last Name (NamePattern1) ] Location: [Hospital 90961] MEDICAL GROUP Address: [Location (un) 111778], [Location (un) ],[Numeric Identifier 66405] Phone: [Telephone/Fax (1) 111779] Appt: [8-24] at 11:30 NOTE: This appointment is with a member of Dr [Last Name (STitle) 111780]??????s team as part of your transition from the hospital back to your primary care provider. **It is recommended you follow up with a cardiologist within 1-2 weeks from your discharge. Please work with Dr [Last Name (STitle) ] to obtain an appt with one in that time frame. . Department: VASCULAR SURGERY When: WEDNESDAY [2112-10-12] at 2:00 PM With: VASCULAR LMOB (NHB) [Telephone/Fax (1) 1237] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: VASCULAR SURGERY When: WEDNESDAY [2112-10-12] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD [Telephone/Fax (1) 2625] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2112-8-20**]	[ "401.9", "486", "443.9", "411.1", "433.30", "433.10", "272.4", "458.9", "V70.7", "V15.82", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.56", "36.07", "00.40", "37.21", "00.63", "00.61", "00.45", "00.66", "00.46" ]	icd9pcs	[ [ [] ] ]	10977, 10983	7278, 9578	300, 440	11124, 11124	4091, 5577	13697, 14972	3182, 3292		10252, 10954		11004, 11103		9888, 10229		5594, 7255	11275, 13673									3307, 4072		2485, 2561																2296, 2377				231, 262									468, 2277								11139, 11251		9599, 9862		2592, 2875						2399, 2465	2891, 3166
11,712	118,093	23794	Discharge summary	report	Admission Date: [2122-4-1] Discharge Date: [2122-4-7] Date of Birth: [2054-1-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: shortness of breath, respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 68 yo male, h/o CAD s/p CABG, multiple PTCA's showing diffuse 3vd, with known systolic and diastolic dysfunction (EF 7/02=15%), presenting now with shortness of breath and pulmonary edema. As per his wife, he had some ?dietary indiscretions (salty foods) the night prior to admission. He woke up this morning with acute shortness of breath requiring tripod positioning. EMS wa called, and he was intubate en route to the ED for hypercarbic respiratory failure. On arrival, he was hypertensive, requiring a nitro gtt that bottomed out his pressures. He was then started on a dopamine gtt, and right SC central line placement was complicated by arterial stick. He became tachycardic to the 130's on dopamine, and he was changed to levophed for pressure support. Bedside TTE showed 2+ MR, EF=20% (on dopa). Multiple attempts to place an arterial line resulted in hematoma (line was finally placed), and blood was aspirated via his NGT. He was transferred to the CCU for further managment where he was maintained on levophed, started on a lasix drip. His pacemaker was also interrogated by EP (?fired for SVT 130's, causing V-tach, then fired resulting in reversion to NSR in 50's). Past Medical History: 1. CAD, s/p CABG with 3vd; has grafts SVG to OM, SVG to D1, LIMA to LAD. Recent cath showing patent grafts with severe native disease 2. CHF, EF 15-30% 3. AICD placed [2114] for recurrent Vtach, [Hospital1 ]-ventricular, [Company ] 4. HTN 5. Hypercholesterolemia 6. Colonoscopy [2-7] showing diverticulosis, polyps 7. EGD [2-7] wnl 8. PVD, s/p iliac stent 9. Hypothyroidism Social History: Retired surgeon, married, non smoker, occasional EtOH Family History: NC Physical Exam: VS: on levophed: HR=131, BP 82/45 100%, intubated Gen:NAD, intubated, elderly gentleman HEENT: PERRL, OP clear Neck: no JVD Lungs: bibasilar rhonchi Heart: RRR, tachy s1/s2, no m/r/g appreciated Abd: soft, nt/nd, nabs, no masses Extr: no c/c/e, PT 1+ bilat Neuro: awake, alert, can respond yes/no; moving all 4 extremities Pertinent Results: [2122-4-1] 04:34PM TYPE-ART TEMP-37.8 RATES-[12-14] TIDAL VOL-450 PEEP-5 O2-40 PO2-124* PCO2-47* PH-7.36 TOTAL CO2-28 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [2122-4-1] 01:51PM LACTATE-2.1* [2122-4-1] 12:28PM GLUCOSE-194* UREA N-40* CREAT-1.6* SODIUM-134 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15 [2122-4-1] 12:28PM CK(CPK)-88 [2122-4-1] 12:28PM CK-MB-NotDone cTropnT-0.05* [2122-4-1] 12:28PM WBC-14.2* RBC-3.44* HGB-11.4* HCT-34.7* MCV-101* MCH-33.0* MCHC-32.7 RDW-13.2 [2122-4-1] 12:28PM PLT COUNT-286 [2122-4-1] 08:10AM DIGOXIN-<0.2* Brief Hospital Course: 1. CAD: He has a history of severe 3vd, s/p CABG with recent catheterization showing patent grafts with totally occluded native vessels. He is not a candidate for any further intervention at this time. It is possible that his salty dietary indiscretions caused an increase in SBP leading to a ?new ischemic event leading to flash pulmonary edema. His enzymes were elevated on admission and remained stable. The decision was made not to anticoagulate given his bleeding. He was continued on his outpatient regimen of Coreg, Lisinopril, and Imdur (Imdur at decreased dose of 60 mg daily secondary to low systolic blood pressures). He never had any symptoms of chest pain or anginal equivalents. He will follow up with Dr. [Last Name (STitle) 60741] at [Hospital3 2005], where he is enrolled in a VEGF trial. 2. CHF: He has a known ischemic cardiomyopathy with systolic and diastolic dysfunction. Bedside TTE on admission showed EF=20% with 2+ MR. [Name13 (STitle) ] likely had flash pulmonary edema in the setting of hypertension. He was initially started on a lasix drip. He declined Swan evaluation to determine CO/CI and pulmonary pressures (recent SWAN at [Hospital3 ] showing PCWP =30, PA 50/36 with mean of 42, RV 50/25 with RA 25). He was intubated for hypercarbic respiratory failure given his pulmonary edema. He was able to be extubated 1 day after admission. Diuresis was continued with IV lasix with good effect. He also received 1 day of lasix with zaroxalyn to maximize diuresis. He was symptomatically improved at time of discharge, and chest X-ray showed improvement in his failure. He was discharged on his outpatient dose of 80 mg PO lasix. He was instructed to weigh himself daily and to adhere to a low salt diet on discharge. 3. Rhythm: He was tachycardic on admission after dopamine (SVT), and he then had episodes of ?ventricular tachycardia. His AICD (biventricular, atrial sensing with ventricular pacing) was interrogated by electrophysiology who believed that the device interpreted the SVT as possible v-tach, fired which caused actual ventricular tachycardia. His pacer was reprogrammed to fire in response to a higher rate (136). When he reverted to sinus rhythm in the 50's, his blood pressure improved. He remained in paced rhythm, 50-60's throughout the rest of his hospital course. He was continued on his amiodarone and had no further events on telemetry. He will follow up in device clinic at [Hospital3 2005]. 4. Hypotension: He was likely in cardiogenic shock on admission and was started on dopamine, changed to levophed (tachycardia in response to dopamine). Pt declined Swan, and his blood pressure improved when his tachycardia resolved. Levophed was discontinued on hospital day 2 (overall hemodynamic status improved with reversion to sinus/paced rhythm). 5. Respiratory: He was intubated in the field for hypercarbic respiratory failure, likely secondary to decreased gas exchange from pulmonary edema. He was extubated on Hospital day 2 and remained stable on nasal cannula O2. He was discharged, saturating stably on room air. 6. ARF/CRF: Creatinine was between 1.4-1.8 during hospitalization. This was likely his baseline. He was instructed to have his creatinine and potassium checked within 3-4 days of discharge. 7. Leukocytosis: likely was a reaction to ischemia, but cultures were checked to rule out infectious etiologies. All cultures were negative (urine, blood, sputum), and chest X-ray was without signs of infiltrate or focal process. He spiked a fever >101.5 during admission, but no source was ever identified and antibiotics were not started. He was afebrile with a normal white count at time of discharge. 8. Anemia: He had a small hematocrit drop in the setting of some IVF, hematoma [2-4] a line, and guaiac positive stools (blood initially aspirated from NGT). Serial CXR's were checked to rule out hemothorax given arterial stick when subclavian line was attempted. He had some blood on top of stools attributed to his hemorrhoids. He had EGD/colonoscopy in [Month (only) 956] that were basically within normal limits (reports were obtained; colonoscopy showing polyps and diverticulosis). He required 1 U PRBC while in-house for a hct of 26.9. Hemolysis labs were checked and were negative. Upon discharge, he was instructed to follow up with his PCP/gastroenterologist to ensure that hematocrit remained stable. 9. Disposition: He was discharged in good condition and will follow up with his cardiologists at [Hospital3 2005]. Medications on Admission: ASA 81 mg Plavix 75 mg Lipitor 80 mg Lasix 80 mg Amiodarone 200 mg [Hospital1 ] Imdur 90 mg Coreg 6.25 mg [Hospital1 ] Levothyroxine 75 mcg Ativan 2 mg Monopril 30 mg NKDA Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. 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 6. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Disp:90 Tablet(s) Refills:3 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Fosinopril Sodium 10 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Congestive Heart Failure 2. Hypercarbic Respiratory failure 3. Coronary Artery Disease Secondary Diagnoses: 1. Biventricular Pacemaker 2. Hypothyroidism 3. Anemia Discharge Condition: Good Discharge Instructions: 1. Please take all your medications as prescribed and described in this discharge paperwork. We made the following changes to your medication regimen: - We changed your Imdur from 90 mg daily to 60 mg daily. This can be titrated up as tolerated as an outpatient 2. Please follow up with your Cardiologists at [Hospital3 ] as described below. 3. Please weigh yourself daily. If you notice weight gain more than 3 lb, please call your doctor. Please adhere to a low salt diet (less than 2 gm each day). 4. Please call your Cardiologist if you are experiencing chest pain, shortness of breath, fever, chills, abdominal pain, or with any other concerns Followup Instructions: 1. Please follow up with Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] at [Hospital 7302]. Please call Dr.[Name (NI) 29750] office to schedule an appointment for thursday or friday of this week ([Telephone/Fax (1) 60742]). At this time, you should have your creatinine and potassium checked, and the need for potassium supplementation can be assessed. 2. You should have GI follow up as an outpatient. You were anemic during this hospitalization and had hemorrhoids. Your hematocrit should be followed to ensure that your blood counts are stable.	[ "414.01", "996.74", "585", "V45.82", "996.04", "280.0", "785.51", "244.9", "518.81", "584.9", "455.2", "285.9", "414.8", "424.0", "428.0", "E879.8", "428.40" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.71", "89.49", "38.91", "99.04", "88.72", "93.90", "96.04" ]	icd9pcs	[ [ [] ] ]	8933, 8939	3100, 7680	354, 379	9173, 9179	2474, 3077	9893, 10471	2111, 2115		7910, 8910		8960, 9072		7706, 7887			9203, 9870									2130, 2455	9093, 9152																					274, 316									407, 1597																		1619, 2024	2040, 2095
17,294	196,476	50431	Discharge summary	report	Admission Date: [2135-2-25] Discharge Date: [2135-3-4] Service: MEDICINE Allergies: Penicillins / Benzodiazepines / Seroquel Attending:[First Name3 (LF) 5827] Chief Complaint: fever. Major Surgical or Invasive Procedure: pericardiocentesis cardiac catheterization History of Present Illness: [Age over 90 ] yo f with PMH CAD, diastolic CHF, HTN, severe alzheimer's dementia presents with fever. Pt was evaluated at NH by visiting for a reported fever of 101,wheezing, SOB, CP. Visiting RN noted pt to have low grade temp 99.4. She was noted to have O2 89-91% at rest and 88% on ambulation, with respir rate 40. Tachycardic to 110. Pt was noted to be confused, not at baseline. Pt has not had flu vaccine (family refused). CXR on [2-23] - negative. . Here, pt is aggitated and unable to provide accurate history. However, she denies recent fever,chills, cough, CP, SOB, n/v/abd pain, diarrhea, urinary sx . In [Name (NI) ], pt was given ceftriaxone and azithro, ativan. Past Medical History: Severe Alzheimer's dementia B meniscal knee tear CAD HTN CHF with diastolic dysfunction Social History: Does not smoke or drink. Never married. HCP is [Name (NI) ] [Name (NI) 105085] (neice) at [Telephone/Fax (1) 105086]. Lives at [Hospital3 ] with personal care attendant Family History: NC Physical Exam: VS: Tm 99.2 Tc 98.3 BP 151/78 HR 87 RR 29 O2 sat 95% 3L NC Gen: disoriented, NAD,breathing comfortably HEENT: PERRL, MMM Neck: JVP not elevated CVS: RRR, nl s1s2, [1-17] holosystolic murmur at LUSB Lungs: bibasilar crackles posteriorly, crackles on R side anteriorly Abd: soft, NT, ND, +BS Ext: 1+ BL LE edema Pertinent Results: REPORTS: . [2135-3-2] TTE: Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal with grossly preserved systolic function. Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion which is somewhat echo dense consistent with organization. The pericardium is probably thickened. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2135-3-1], there is no significant change. . [2135-3-1] Righ heart cath: COMMENTS: 1. Hemodynamic assessment revealed equalization of pericardial, right atrial and wedge pressures at 17 mm Hg. X and Y descents were blunted. Cardiac index was preserved at 3.5. Pulsus was 23 mm Hg. 2. Pericardial space was cannulated and 700 cc of bloody fluid was drained with pericardial pressure dropping from 17 to 3 mm Hg. FINAL DIAGNOSIS: 1. Moderate pericardial tamponade. . [2135-3-1] TTE: Conclusions: There is mild symmetric left ventricular hypertrophy. 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [2135-2-28], the pericardial effusion is much smaller. . [2135-2-28] TTE: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a moderate to large circumferential pericardial effusion with evidence for right atrial diastolic collapse. No right ventricular diastolic collapse is seen. IMPRESSION: Moderate-to-large circumferential pericardial effusion with evidence of increased pericardial pressure. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . CHEST (PA & LAT) [2135-2-27] 10:07 AM IMPRESSION: Massive cardiomegaly, suggestive of pericardial effusion. . CHEST (PA & LAT) [2135-2-25] 6:25 PM IMPRESSION: 1. Marked cardiomegaly. 2. No overt evidence of congestive heart failure. . LABS: . [2135-2-28] 06:40AM BLOOD WBC-8.0 RBC-2.95* Hgb-8.4* Hct-25.8* MCV-88 MCH-28.5 MCHC-32.6 RDW-13.3 Plt Ct-452* [2135-2-27] 07:10AM BLOOD WBC-13.6# RBC-3.25 Hgb-9.4* Hct-28.4* MCV-88 MCH-29.0 MCHC-33.1 RDW-13.3 Plt Ct-557# [2135-2-26] 01:10PM BLOOD Hct-26.5 [2135-2-26] 06:58AM BLOOD WBC-7.2 RBC-3.04* Hgb-8.8* Hct-26.6* MCV-88 MCH-29.1 MCHC-33.2 RDW-13.1 Plt Ct-364 [2135-2-25] 05:49PM BLOOD WBC-7.5# RBC-3.32* Hgb-9.6* Hct-28.4* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.2 Plt Ct-437 [2135-2-28] 06:40AM BLOOD Neuts-83.1* Lymphs-9.0* Monos-5.9 Eos-1.7 Baso-0.4 [2135-2-27] 07:10AM BLOOD Neuts-89.1* Bands-0 Lymphs-6.4* Monos-4.1 Eos-0.3 Baso-0.2 [2135-2-25] 05:49PM BLOOD Neuts-83.2* Lymphs-9.9* Monos-5.2 Eos-1.5 Baso-0.2 [2135-2-28] 06:40AM BLOOD Plt Ct-452* [2135-2-27] 07:10AM BLOOD Plt Smr-VERY HIGH Plt Ct-557# [2135-2-26] 06:58AM BLOOD Plt Ct-364 [2135-2-25] 05:49PM BLOOD Plt Ct-437 [2135-2-28] 06:40AM BLOOD Glucose-114 UreaN-21* Creat-0.9 Na-146* K-4.1 Cl-106 HCO3-29 AnGap-15 [2135-2-27] 07:10AM BLOOD Glucose-134* UreaN-19 Creat-0.9 Na-145 K-4.6 Cl-104 HCO3-26 AnGap-20 [2135-2-26] 06:58AM BLOOD Glucose-103 UreaN-17 Creat-0.8 Na-143 K-4.1 Cl-106 HCO3-28 AnGap-13 [2135-2-25] 05:49PM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-143 K-4.1 Cl-104 HCO3-29 AnGap-14 [2135-2-26] 06:58AM BLOOD CK(CPK)-61 [2135-2-25] 05:49PM BLOOD CK(CPK)-77 [2135-2-26] 06:58AM BLOOD cTropnT-0.01 [2135-2-26] 06:58AM BLOOD CK-MB-NotDone [2135-2-25] 05:49PM BLOOD cTropnT-<0.01 [2135-2-25] 05:49PM BLOOD CK-MB-NotDone [2135-2-28] 06:40AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.3 [2135-2-27] 07:10AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.5 [2135-2-26] 06:58AM BLOOD Calcium-8.7 Phos-4.6* [2135-2-25] 05:49PM BLOOD Iron-21* [2135-2-26] 06:58AM BLOOD VitB12-511 Folate->20 [2135-2-25] 05:49PM BLOOD calTIBC-216* Ferritn-248* TRF-166* [2135-2-25] 05:50PM BLOOD Lactate-1.0 [2135-2-25] 07:49PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2135-2-25] 07:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG . OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro [2135-3-1] 02:00PM 556* [Numeric Identifier 105087]* 12* 83* 3* 2* PERICARDIAL FLUID OTHER BODY FLUID CHEMISTRY TotProt Glucose LD(LDH) Albumin [2135-3-1] 02:00PM 4.9 86 [Numeric Identifier ] 2.8 PERICARDIAL FLUID . MICRO: . [2135-2-26] 8:37 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal aspirate. Rapid Respiratory Viral Antigen Test (Final [2135-2-26]): Respiratory viral antigens not detected. CULTURE CONFIRMATION PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for direct detection of parainfluenza virus in specimens; interpret parainfluenza results with caution. VIRAL CULTURE (Pending): . [2135-2-25] 11:00 pm BLOOD CULTURE Site: ARM AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . [2135-2-25] 7:49 pm URINE Site: CLEAN CATCH FINAL REPORT [2135-2-27] URINE CULTURE (Final [2135-2-27]): NO GROWTH. . [2135-2-25] 5:45 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . [2135-3-2] 10:11 am FLUID,OTHER R/O CMV AND INLFUENZA. EBV CULTURE NOT AVAILABLE. GRAM STAIN (Final [2135-3-2]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending): FUNGAL CULTURE (Pending): ACID FAST SMEAR (Pending): ACID FAST CULTURE (Pending): VIRAL CULTURE (Pending): Brief Hospital Course: [Age over 90 ] yo f with PMH CAD, diastolic CHF, HTN, severe alzheimer's dementia presented with fever. Pt was evaluated at NH by visiting nurse for a reported fever of 101,wheezing, SOB, CP. Visiting RN noted pt to have low grade temp 99.4. She was noted to have O2 89-91% at rest and 88% on ambulation, with respir rate 40. Tachycardic to 110. Pt was noted to be confused, not at baseline. Pt had not had flu vaccine (family refused). On admission, she was ruled out for the flu and started empirically on ceftriaxone and azithromycin for a pneumonia based on a left linear lower lobe opacity that was concerning for pneumonia vs. atelectasis. A repeat PA and LAT CXR on [2-27] was concerning for pericardial effusion. A TTE showed moderate to large circumferential pericardial effusion with evidence for right atrial diastolic collapse, but no right ventricular diastolic collapse. She was subsequently taken to the cath lab and found to have pulsus paradoxus of 23 mm Hg, equalization of pericardial, right atrial and wedge pressures at 17 mm Hg. X and Y descents were blunted. Cardiac index was preserved at 3.5. A pericardiocentesis resulted in the removal of 700 cc of bloody fluid and dropping of pericardial pressure to 3 mm Hg and decrease in the RA pressure. Pericardial drain then resulted in additional 800cc of drainage. A post-cath TTE showed LVEF > 75%, RV chamber size and free wall motion normal, a small pericardial effusion and no right atrial or right ventricular diastolic collapse. . [Age over 90 ] yo f with PMH CAD, diastolic CHF, HTN, severe alzheimer's dementia who presented with fever, hypoxia, and CP. Found to have large pericardial effusion, now stable s/p pericardiocentesis (total of 1500cc bloody fluid removed by procedure and subsequent drain.) . #) Pericardial effusion: Cardiomegaly appeared to have worsened by CXR since [2132]. Echo showed large circumferential pericardial effusion with RA diastolic collapse, but preserved biventricular function. Pt had pericardiocentesis, with 700cc bloody fluid removed. Pericardial fluid analysis - TP > 3, TPeff/TPserum > 0.5, LDHeff/LDHserum > 0.6 --> exudate. - s/p pericardiocentesis with 700 cc bloody fluid removed initially, then 800 cc via pericardial drain. - placed PPD [2135-3-1] on L forearm: negative - may need malignancy and rheumatic workup as outpatient. Pericardial fluid cytology, cx's pending. - pt will need repeat echo in [12-13] weeks for f/u . #) Fever/Hypoxia: Was concerning for viral infection, however pt's viral screen was negative. Pt currently afebrile. Initial CXR without evidence of PNA or CHF. However, WBC increased to 13.6 (then down to 8.0). Echo showed large pericardial effusion, likely reponsible for pt's episode of hypoxia. - blood cx's pending - pericardial fluid cx pending - urine cx negative - pt completed course of azithro/ceftriaxone for CAP. Abx now d/c'd. - pt ruled out for flu - pt now off oxygen, but has occasional episodes of desaturation with ambulation (asymptomatic) - pt also has brief episodes of chest pain without EKG changes. She then forgets she had the chest pain shortly after, and is asymptomatic. . #) Hypernatremia - Na was up to 149, had free H20 deficit of 1.8 L. JVP not seen, no evidence of HF on CXR. appeared to be in hypovolemic or euvolemic hypernatremia (then improved to 145). - corrected with D51/2NS at 100 cc/hr . #) CAD: Per nursing hx, pt was complaining of CP. No EKG changes here. Cardiac enzymes negative x 2 on admission (12 hrs apart). - did not tolerate metoprolol (bradycardia), so metoprolol was d/c'd - continued ASA 81 mg QD - restarted norvasc at 2.5 mg QD . #) Diastolic CHF: Appeared hypovolemic to euvolemic. No signs of CHF on CXR. - held lasix during admission and on d/c . #) HTN: Well controlled. - norvasc held initially, then restarted 2.5mg QD . #) Severe Alzheimer's dementia: Pt has episodes of agitation overnight, treated with olanzapine. -continued 1:1 sitter -continued zyprexa - trazadone qhs added to better control sleep/wake cycles . #) Anemia: Hct was 26 on admission, slightly below baseline (about 28). - hct stable - iron studies consistent with ACD and iron deficiency anemia . #) PPX: eating, pneumoboots (held hep sc given bloody effusion), tylenol, bowel regimen . #) FEN: cardiac diet. . #) Code: Full code . #) Contact: dtr (HCP): [Name (NI) ] [Last Name (un) 105088] ([Telephone/Fax (1) 105086]) Medications on Admission: Aspirin 81mg qd Combivent 2 puff qid Colace 100mg tid Lasix 30mgqd MVI qd Norvasc 10mg qd Zyprexa 2.5mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-13] Puffs Inhalation Q6H (every 6 hours). 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO at bedtime. 7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Last Name (un) 35689] House Discharge Diagnosis: Primary diagnoses: Pericardial Effusion CAP ROMI Secondary diagnoses: CAD diastolic CHF HTN Dementia Discharge Condition: Hemodynamically stable. No complaints. Discharge Instructions: Please seek medical attention immediatley if you experience chest pain, shortness of breath, fevers, chills, nausea, vomiting, or dizziness. You will need a repeat echocardiogram in the next 1-2 weeks. Please call your PCP [Last Name (NamePattern4) ] [Telephone/Fax (1) 608] to schedule this echo. Please take all medications as prescribed. Please attend all follow-up appointments. Followup Instructions: Please follow-up with your PCP in the next week. The phone number is [Telephone/Fax (1) 608]. You will need a repeat echocadriogram in the next 1-2 weeks. Please call your PCP to schedule this test. Provider: [Name10 (NameIs) ],[Name11 (NameIs) 8754] DERMATOLOGY GEN-[Doctor First Name 8754] (NHB) Date/Time:[2135-4-20] 11:30 Completed by:[2135-3-4]	[ "272.0", "496", "331.0", "401.9", "294.10", "486", "428.32", "423.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "37.0", "88.55", "37.21" ]	icd9pcs	[ [ [] ] ]	13599, 13658	8399, 12842	254, 298	13804, 13845	1703, 2608	14288, 14668	1349, 1353		13000, 13576		13679, 13729		12868, 12977		2625, 7612	13869, 14265									1368, 1684	13750, 13783																			8349, 8376		208, 216					7926, 7926		7955, 8316		326, 1017																		1039, 1129	1145, 1333
57,920	181,578	8092	Discharge summary	report	Admission Date: [2181-8-25] Discharge Date: [2181-9-4] Date of Birth: [2100-8-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1185] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [Known lastname ] is an 81 year old man with h/o CV (L hemiplegia), [Hospital 2754] nursing home bound admitted on [2181-8-24] with tonic-clonic seizures at 10:30pm on [2181-8-24] at [Hospital1 ] Health nursing facility and admitted to [Hospital3 ]. In the ED, he was noted to have tongue biting with blood in the oral cavity, and 5 second apneas with respiratory rates of 28 (?Cheynes-[Doctor Last Name 6056]). On the medical [Hospital1 ] the following morning, he had further seizure this AM ([2181-8-25]) and subsequently was transferred to the MICU. In the MICU, he was unresponsive, gargling, RR in the 30s. His son and daughter were at bedside and reversed his DNR/DNI status to full code as they felt they wanted all supportive care done for him now, including intubation. If it becomes futile, they want to withdraw support. Of note, he also had a fever to 101.6 the morning of [2181-8-25], thought to be [3-21] possible aspiration. He was then Keppra loaded with 1000mg ONCE, and also received Ativan 2mg x 3. He was also treated emperically for aspiration pneumonia with vancomycin 1gm IV ONCE, and zosyn 2.25gm IV ONCE. Of note, he had a tmax of 101, WBC 26K. His last ABG priror to intubation was pH 7.37/50/92 (100% NRB). Past Medical History: 1) CVA with subsequent left hemiplegia 2) HTN 3) Diabetes mellitus (insulin dependent) c/b neuropathy 4) Depression/anxiety 5) Dementia 6) Schizophrenia 7) Atrial fibrillation 8) Coronary artery disease s/p myocardial infarction 9) Peptic ulcer disease 10) Prostate CA [81]) Splenic abscess 12) Chronic kidney disease 13) S/p G-tube placement 14) Urinary tract infection with ESBL 15) GI bleed thought to be [3-21] ulcer leading to anemia 16) VRE and MRSA carrier 17) C difficile colitis 18) Seizure disorder Social History: Currently not working, nonsmoker. Family History: Family history is significant for diabetes and heart disease. Physical Exam: On Admission: GEN: Intubated, sedated, minimally responsive only to pain in bilateral lower extremities HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l with good air movement throughout ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Minimally responsive to pain On Transfer to floor on [2181-9-1]: VS HR 90 BP 90/51 RR 7 SaO2 78% on RA General - lying in bed comfortably, eyes closed. Does not respond to voice. Heart - distant heart sounds, normal s1 and s2 Lungs - slow RR with labored breaths and coarse inpiratory rhonchi in anterior lung fields Abdomen - +BS Ext - weak radial pulses bilaterally. cold hands with 3+ non-pitting edema bilaterally. On discharge: Patient [Date Range ]. Pertinent Results: ADMISSION LABS: WBC 22.5 HGB 12.2 HCT 36.9 PLT 348 PT 14.5 PTT 31.3 INR 1.3 Na 140 K 4.5 Cl 104 HCO3 25 BUN 50 Cr 1.7 CSF WBC 2 RBC 0 Poly 0 Lymph 72 Monos 28 Tot Prot 56 Glucose 81 Gram Stain - Culture No Growth Viral Culture Negative (PRELIM) HSV Pending MICRO: Blood cx [2181-8-26]: pending Urine Cx [2181-8-26]: pending [2181-8-26] 9:42 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2181-8-26]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2181-8-29]): SPARSE GROWTH Commensal Respiratory Flora. IDENTIFICATION AND SENSITIVITY REQUESTED PER DR.[Last Name (STitle) 28883] #[Numeric Identifier 28884] ON [2181-8-28]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. MORGANELLA MORGANII. RARE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| MORGANELLA MORGANII \| \| CEFEPIME-------------- 2 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ 2 S <=1 S MEROPENEM------------- 1 S <=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. STUDIES: CXR [2181-8-26]: There is a moderately large right and small to moderate left effusion. There is upper zone re-distribution and mild diffuse vascular blurring, consistent with CHF. There is more hazy opacity throughout the right lung, which could reflect a layering effusion on this supine film. Bibasilar collapse and/or consolidation is present to a small degree. MRI HEAD W/O [2181-8-26]: IMPRESSION: Focal area of restricted diffusion identified on the right frontal lobe, adjacent to the precentral sulcus and areas of moderate restricted effusion on the left temporal lobe with low signal in the corresponding ADC maps. Large sequela of prior chronic infarction on the right middle cerebral artery as described in detail above, and underlying chronic microvascular ischemic disease, prominent ventricles and sulci indicating cortical volume loss. EEG [2181-8-26], [8-27], [8-28], [8-29]: READ PENDING MRI HEAD W/O [2181-8-28]: Chronic infarcts in the right MCA territory with secondary atrophic changes in the brainstem. As compared to the previous MRI, there is resolution of slow diffusion seen in the left temporal lobe. Another focus of slow diffusion seen in the left thalamus previously, but persists, but appears smaller. The anatomical distribution of these changes is unusual for an ischemic etiology, since it does not conform to the posterior cerebral artery territory. Reversible diffusion slowing may be seen in the postictal phase. Followup MRI is recommended. Brief Hospital Course: Pt is an 81 year old man with h/o CV (L hemiplegia), [Hospital 2754] nursing home bound admitted on [2181-8-24] with tonic-clonic seizures leading to respiratory failure, intubation, and now with high fevers concerning for aspiration pneuonia. He was intubated, and cultures sent for workup of infection. Neurology was consulted, and EEG was done which showed seizure activity for which he was loaded with Keppra. He was covered for possible meningitis as well initially. He was extubated after a family meeting, and made CMO. Subsequently antibiotics were discontinued and he was transferred to the medical floors for CMO care. He [Date Range ] on [2181-9-4]. . #. Respiratory failure: Most likely secondary to post-ictal mental status changes leading to somnolence and hypoxemia, with concern for inability to protect the airway. He was continued on the ventilator while seizing (see below). As below, pt likely also had aspiration PNA in the setting of seizures and was treated with abx initially. However, a family meeting was held and he was extubated, and subsequently made CMO. . #. Seizures: Altered mental status initially thought to be secondary to post-ictal encephalopathy versus ongoing seizure. Acute bleed unlikely given negative OSH head CT. Neurologic exam nonfocal other than nonresponsiveness. Consider infectious meningitis/encephalitis given fever, white count, seizure. Neurology was consulted. He was started on Keppra on admission. He was also started on abx for possible meningitis including Ampicillin/Acyclovir/Vanc/Cefepime. LP was initially attempted, but unable to obtain. EEG showed seizure activity in the left posterior quadrant. Given this, he was given add'l Keppra and dosing increased. MRI head w/o showed restricted defect in right front lobe & left temporal lobe. Pt had clinically apparent seizures during his MICU course, and was given Ativan for treatment. EEG continued to be monitored. Repeat LP was done with cultures sent which were negative. Ampicillin was discontinued. Acyclovir was continued until HSV was negative. After family meeting, and code status was changed, antibiotics were discontinued. On the medical floor, we continued levetiracetam 1500mg IV Q12H for comfort. . #. Fever/leukocytosis: Most concerning for aspiration pneumonia given bibasilar infiltrates, fever, leukocytosis to 26. Blood and urine cultures showed no growth. CXR here demonstrated possible consolidation vs. atelectasis. Sputum cultures grew pseudomonas and Morganella, sensitive to cefepime. He was continued on Cefepime/Vanc. As above, considered meningitis, and started on above Abx. WBC was trended and decreased. As above, antibiotics were discontinued. We did not trend labs on the floor. . #. CAD: Plavix and statin were continued in MICU, but were discontinued prior to transfer to the mecial floor. . #. A fib: Likely not on coumadin [3-21] falls risk/dementia. Beta blockade admission given borderline low BP. Metoprolol was restarted at lower dose and uptitrated in the MICU. Beta-blockade was discontinued prior to transfer to the medical floor. . #. HTN: Held home antihypertensives as above initially. As above, BB was restarted. He continued to be hypertensive, but was allowed permissive hypertension given possible CVA. Anti-hypertensives were discontinued prior to transfer to the medical floor. . #. Diabetes: c/b neuropathy. Placed on ISS. Held gabapentin given mental status on admission, and restarted in MICU. This was discontinued before transfer to the medical floor. . #. Comfort Measures: Patient was continued on levetiracetam as above, morphine gtt, and tylenol for comfort on the medical floor. We also continued hyoscyamine and started a scopolamine patch (changed every 3 days) for secretions. The social work team on the medical floor also met with the patient's family. Over night on [9-3] into [9-4], the patient's RR increased to 26. Ativan IV 2mg was given as well as a 4mg IV morphine bolus. His morphine gtt was increased to 5/hr and he still had a high RR, but appeared more comfortable. Mr [Known lastname ] [Last Name (Titles) ] at 9:21am on [2181-9-4]. Medications on Admission: Home Medications: 1) Citalopram 20mg PO daily 2) Clonidine 0.1mg PO BID 3) Docusate 200mg PO daily 4) Glyburide 2.5mg PO daily 5) Vicodin 1 tab PO Q12H 6) Isosorbide dinitrate 10mg 7) Levetiracetam 500 PO Daily 8) Furosemide 40mg PO daily 9) Magnesium oxide 400mg PO daily 10) Metoprolol 150mg PO BID 11) Multivitamin 1 tab PO daily 12) Gabapentin 200mg PO TID 13) Clopidogrel 75mg PO daily 14) Potassium 10 meQ PO daily 15) Simvastatin 20mg PO QHS 16) Trazadone 50mg PO HS 17) Ranitidine 150mg PO BID 18) Bisacodyl 10mg PO Daily PRN 19) Duoneb INH Q6H PRN 20) Vicodin 1mg tab Q6H PRN pain 21) Magnesium hydroxide 10mL PO daily PRN 22) Acetaminophen 650mg PO Q4H PRN pain . Medications on Transfer: Morphine Sulfate 1-5 mg/hr IV DRIP INFUSION Allow bolus: Yes Bolus: 2 mg MR X2 Q1H PRN Hyoscyamine 0.125 mg SL QID PRN excessive secretions LeVETiracetam 1500 mg IV Q12H Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain/fever Discharge Medications: [Date Range ] Discharge Disposition: [Date Range ] Discharge Diagnosis: seizure, aspiration pneumonia Discharge Condition: patient [Date Range ] Discharge Instructions: N/A - Patient [Date Range ]. Followup Instructions: N/A - Patient [Date Range ]. [Name6 (MD) ] [Known lastname ] MD [Doctor Last Name 1189]	[ "V49.86", "V44.1", "348.31", "438.89", "294.8", "585.9", "790.7", "403.90", "300.4", "250.60", "041.19", "345.3", "295.62", "412", "414.01", "584.9", "427.31", "V58.67", "357.2", "578.1", "438.20", "507.0", "518.81", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.97", "96.6", "03.31" ]	icd9pcs	[ [ [] ] ]	11804, 11823	6618, 10793	314, 327	11897, 11924	3281, 3281	12005, 12141	2248, 2312		11762, 11781		11844, 11876		10819, 10819			11948, 11982									2327, 2327			10837, 11493											3234, 3262								263, 276									355, 1639				3297, 6595			2341, 3220										11518, 11739	1661, 2180	2196, 2232
1,658	144,052	22926	Discharge summary	report	Admission Date: [2165-12-22] Discharge Date: [2165-12-30] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Chest Pain and back pain with hypotension Major Surgical or Invasive Procedure: Cardiac Catherization History of Present Illness: Patient 83 year old female with PMHx significant for hypercholesteremia who presented to OSH on [12-21] when she developed chest pain that radiated to her back. She describes the pain as a dull pain (not sharp or tearing pain). Patient denies any SOB, n/v, diaphoresis. Patient states that associated with her chest pain was confusion and trouble speaking(trouble finding words to speak). Patient then became weak and had a fall (did not hit her head). Patient denies LOC. At OSH patient found to be hypotensive (59/37), got CT which r/o aortic dissection. Patient intially started on levophed and later requiring dobutamine. No explaination of decreased BP found per report of Dr. [Last Name (STitle) 11493] and ICU RN at OSH. Pt tachycardic on dobutamine so weaned off and switched to dopamine. Patient had EKG done at outside hospital which showed sinus bradycardia with ST depression II,III,AVF, V5-V6 and J pt elevation in leads V2-V4. Cardiac enzymes done at OSH showed CK 363, CK-MB 33, TropI 6.78. Echo done at OSH reported as consistent with "apical MI" but preserved EF. Given EKG changes, increased cardiac enzymes and, and echo findings patient transferred to [Hospital1 18] for cath. Cath Findings: Right dominant with clean coronaries. RA 15; PAP 48/16; PCWP 30. CO 3.67/CI 2.55 EF 37% Past Medical History: Osteoporosis, hypercholesteremia Social History: no etoh, tobacco, drug use Family History: non-contributory Physical Exam: VS: afebrile, HR 100 BP 98/60 (on dopamine) RR 20 O2Sat 92% on 4L NC Gen: NAD, pain free Heent: MMM, no JVP appreciated, PERRLA, EOMI Cardiac: RRR S1/S2 garade II/VI holosystolic murmur at apex Lungs: Bibasilar crackles about 1/3 up the back Abd: soft NTND NABS no hepatosplenomegaly Ext: no edema, distal pulses +2, R femoral arterial and venous cath with oozing of blood from cath site. no hematoma or bruits. Neuro: AAOx3, CN II-XII intact, MS [5-1] in UE and LE, sensory grossly intact Pertinent Results: [2165-12-22] 04:02PM GLUCOSE-125* UREA N-20 CREAT-0.7 SODIUM-138 POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-22 ANION GAP-10 [2165-12-22] 04:02PM CK(CPK)-552* [2165-12-22] 04:02PM CK-MB-32* MB INDX-5.8 [2165-12-22] 04:02PM CALCIUM-8.4 PHOSPHATE-1.8* MAGNESIUM-1.6 IRON-94 [2165-12-22] 04:02PM calTIBC-256* FERRITIN-75 TRF-197* [2165-12-22] 04:02PM TSH-0.83 [2165-12-22] 04:02PM WBC-10.8 RBC-3.35* HGB-11.0* HCT-31.9* MCV-95 MCH-32.9* MCHC-34.5 RDW-13.3 [2165-12-22] 04:02PM PLT COUNT-148* CHEST (PORTABLE AP): No priors for comparison. There is an intrafemoral Swan-Ganz catheter with its tip in satisfactory position, in the proximal portion of the right interlobar pulmonary artery. There is prominent, ill- defined pulmonary vasculature, with bilateral CP blunting, likely consistent with moderately sized bilateral pleural effusions. These findings are consistent with congestive heart failure. There is no obvious underlying consolidation, however, a basilar process cannot be excluded. No pneumothorax. Visualized soft tissue and osseous structures are unremarkable. Cardiac Cath: 1. Coronary angiography of this right dominant system revealed no significant angiographically apparent coronary disease. The left main coronary artery, LAD, LCx, and RCA demonstrated minimal luminal irregularities. 2. Resting hemodynamics were performed. Right sided filling pressures were moderately elevated (RA mean pressure was 16 mm Hg and RVEDP was 19 mm Hg). Pulmonary artery pressures were moderately elevated (PA pressure was 53/22 mm Hg). Left sided filling pressures were moderately to severely elevated (mean PCW pressure was 28 mm Hg and LVEDP was 30 mm Hg). Prominent V waves were noted in the PCW tracing consistent with mitral regurgitation. Cardiac index was low normal (at 2.4 L/min/m2). There was no significant gradient across the aortic valve upon pullback of the catheter from the left ventricle to the ascending aorta. 3. Left ventriculography revealed a contrast calculated left ventricular ejection fraction of 39%. Severe anteroapical, apical, and inferoapical akinesis to dyskinesis was noted. 2+ mitral regurgitation was noted. Echo ([12-23]): LVEF 25-30% 1. The left atrium is normal in size. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with the apical half of the LV being akinetic. Overall left ventricular systolic function is severely depressed. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is borderline pulmonary artery systolic hypertension. 7.There is a trivial pericardial effusion. Echo: ([12-25]): LVEF 35%-40% The left atrium is normal in size. Left ventricular chamber size is normal. Resting regional wall motion abnormalities include mid to distal anteroseptal and apical hypokinesis/akinesis Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with mild mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is trivial pericardial effusion. Comapred to the prior study of [2165-12-23] (tape reviewed), left ventricular systolic function appears slightly improved. CAROTID SERIES COMPLETE: Less than 40% right ICA stenosis. No stenosis of the left ICA. EKG [12-22]: sinus at 98 TWI in V3-V6 flat Twaves and low voltage in limb leads. Brief Hospital Course: ## Cardiomyopathy - Unclear etiology. Differential include takotsubo, coronary vasospasm, myocarditis. Patient from cath revealed no significant angiographically apparent coronary disease. The left main coronary artery, LAD, LCx, and RCA demonstrated minimal luminal irregularities. Based on history and cath film most likely takotsubo. On admission patient initial echo revealed an LVEF of 25-30% with LV apical akinesis. Based on akinesis patient was put on heparin for anticoagulation. However her platelet count dropped from 140 to 75 after two days in hospital so heparin stopped and HITT antibody sent. Patient was started on argatroban to anticoagulate until HITT Ab results came back. HITT Ab came back negative so patient started back on heparin and coumadin. Her platelets remained stable after being restarted on heparin and coumadin. Patient had TSH and iron studies sent which came back normal. Patient also had edenovirus and [Location (un) ] virus antigens sent which were pending upon discharge. While in hospital patient started on beta-blocker and ACEI. On exam patient appeared wet and CXR consitent with CHF so patient given prn doses of lasix which she responded very well to. During hospital course patient had second episode of chest pain (without EKG changes) but with enzyme leak. Her chest pain seemed to last a few hours and resolved with SL nitro. Felt that chest pain maybe secondary to vasospasm so patient started on long acting nitrate Imdur. She remained chest pain free while on Imdur. ## Hypotension - After cath patient was still hypotensive and was initially kept on dopamine. Cause of hypotension was felt to be most likely due to cardiomyopathy event (Takotsubo). However patient also spiked a fever on HD #2 and blood, urine cultures sent which showed no growth. Patient never looked septic while in hospital and had normal WBC. Patient was eventually taken off dopamine and BP continued to improve. ## ?TIA - From history of slurred speech and weakness with CP symptoms question whether patient had a TIA. She remianed symptoms free while in hospital at [Hospital1 18] so felt that symptoms were intially due to hypotension. Patient had carotid U/S done which came back less than 40% right ICA stenosis. No stenosis of the left ICA. Patient was intially on aspirin, but aspirin was stopped since she was already being anticoagulated with coumadin and given no significant CAD or PVD no need for aspirin and coumadin together. ## History of hyperlipidemia - Gave patient Lipitor while in hosptial. Lipid panel showed HDL 59 and LDL 55. Continued statin ## Thrombocytopenia and anemia - Patient had Hct drop on HD#2 from 30 to 26 but also had a lot of bleeding from groin cath site. Patient got 2 units of blood while in hospital and Hct stabalized at 30. Patient dropped plt from 140 to 75 while in hospital. Heparin stopped and HITT Ab sent however given time course of drop HITT seemed unlikely. Also with fever and anemia question if patient having TTP. Only rare shistocytes seen on smear and patients fibrinogen, LDH, haptoglobin stable. HITT Ab came back negative and her platelet count returned to [Location 213]. ## FEN - Patient with very low Phos during hospitalization. Also patient had low Ca so felt patient had VitD defeciency and given Vit D supplements. As outpatient patient may benefit from being tested for celiac disease given low Ca and Phos. Medications on Admission: Fosomax Oscal Mevacor Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 7. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Primary: Takotsubo Cardiomyopathy vs Focal Myocarditis Seconday: Hypocalcemia/Hypophophatemia: ?Vitamin D Deficiency Osteoporosis Hypercholesterolemia h/o Thyroid Cyst s/p Hysterectomy Thrombocytopenia, resolved (HIT -) Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the emergency department if you develop shortness of breath, dizziness, leg swelling or chest pain. Continue your medications as prescribed and your bloodwork will be checked at your visit to Dr. [Last Name (STitle) 11493] on [1-2]. Please weigh yourself everyday; please contact Dr. [Last Name (STitle) 11493] or Dr. [Last Name (STitle) 28583] if you experience any weight gain. Followup Instructions: An appointment has been made for you to see Dr. [Last Name (STitle) 11493] the cardiologist at the Medical Office Building of [Hospital3 59238], [Apartment Address(1) ], on [1-2] at 1:30pm. It is very important that you go there to get your coumdain levels checked.	[ "428.0", "414.01", "425.4", "435.9", "429.0", "416.8", "285.9", "276.9", "287.5", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "89.64", "37.23", "88.53", "99.04", "88.56", "00.17" ]	icd9pcs	[ [ [] ] ]	10672, 10740	6156, 9611	305, 328	11005, 11013	2334, 6133	11495, 11781	1787, 1805		9683, 10649		10761, 10984		9637, 9660			11037, 11472									1820, 2315																						224, 267									356, 1671																		1693, 1727	1743, 1771
60,326	132,917	37117	Discharge summary	report	Admission Date: [2142-6-5] Discharge Date: [2142-6-7] Date of Birth: [2102-2-28] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: Suboccipital headaches, UE paresthesias Major Surgical or Invasive Procedure: Suboccipical Craniectom for chiari decompression, C1 Laminectomy History of Present Illness: Ms. [Known lastname 13551] is a 40 year old female who was diagnosed in [2136] with a Chiari malformation. At that time she had a fall and that was an incidental finding. She later devloped occipital headaches and parestheias of her UE laterally and dital tot he elbow, particularly when she is extending her neck. MR imaging revealed a Chiari Malformation and a Cervicothoracic synrinx. Past Medical History: C5-6 HNP, C/T syrinx, tmj, lap chole, C-section Social History: Denies ETOH, Tobacco and drug use. Family History: NA Physical Exam: On Discharge: MAE [5-16] with no motor deficit. L strabismus at baseline. Incision C/D/I with staples. Tolerating POs, pain managed, voiding, ambulating Brief Hospital Course: Ms. [Known lastname 13551] was taken tot he OR with Dr. [Last Name (STitle) 739] on [2142-6-5] for a Suboccipital craniectomy and C1 laminectomy. She was extubated post-op and transfered to the SICU for Q1hr neuro checks. A soft collar was recommended for comfort only. On POD1 she was neurologically stable. She had no nausea or emesis. She had neck pain and occipital headache as expected and this was managed with Valium and Dilaudid. She was transfered to the floor and trasnitioned OOB. PT was ordered. Her foley was DC'ed. On [2142-6-7] she was discharged home. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no bm 48hrs. 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for neck pain. Disp:30 Tablet(s) Refills:0 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chiari Malformation Synringomyelia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR NEUROSURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. =With the surgery you had, you are at risk for a chemical meningitis. Neck pain, stiffness, worsening headache, and fever can all [Doctor First Name ] sign of a chemical meningitis. If you develop these symptoms call the office or come to the ER immediately. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [10-23] days for removal of your staples. You may have this done with your PCP if you do not wish to travel to [Location (un) 86]. Please call Paresa at [Telephone/Fax (1) 1272] to make this appointment. ??????Please call ([Telephone/Fax (1) 4676] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2142-6-7*]	[ "336.0", "348.4" ]	icd9cm	[ [ [] ] ]	[ "01.24", "03.09", "02.12" ]	icd9pcs	[ [ [] ] ]	2360, 2366	1189, 1776	357, 423	2445, 2445		4202, 4814	989, 993		1799, 2337		2387, 2424					2596, 4179									1008, 1008														1022, 1166								278, 319									451, 850								2460, 2572										872, 921	937, 973
53,220	172,530	13968	Discharge summary	report	Admission Date: [2138-12-12] Discharge Date: [2138-12-17] Date of Birth: [2079-9-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: asymptomatic, with positive stress test Major Surgical or Invasive Procedure: [2138-12-12] 1. Redo sternotomy. 2. Redo coronary artery bypass graft x3, saphenous vein graft to obtuse marginal-1 and 2 and posterior descending artery. 3. Endoscopic harvesting of the long saphenous vein. History of Present Illness: Mr. [Known lastname ] is a 59 year old male with history of coronary artery bypass in [2124] who was recently noted to have a decrease in his left ventricular function to 30%, now referred for outpatient cardiac catheterization to further evaluate. Past Medical History: Hyperlipidemia Coronary artery bypass [2124] (LIMA to LAD, SVG to OM1, SVG to OM2, SVG to PDA) Hernia repair Social History: Mr. [Known lastname ] lives with his wife. Family History: He reports that he had brothers with coronary artery disease. Physical Exam: Pulse:50 Resp:16 O2 sat:99/RA B/P Right:122/82 Left:145/85 Height:6' Weight:225 lbs General:NAD, alert, cooperative Skin: Dry [xintact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] no Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [] Edema Varicosities: None []well healed scar RLE Neuro: Grossly intact Pulses: Femoral Right: +1 Left:+1 DP Right:+1 Left:+1 PT [Name (NI) 167]: +1 Left:+1 Radial Right: +2 Left:+1 Carotid Bruit Right:none Left:none Pertinent Results: [2138-12-17] 04:30AM BLOOD WBC-6.0 RBC-3.27* Hgb-9.8* Hct-28.6* MCV-87 MCH-30.0 MCHC-34.3 RDW-14.6 Plt Ct-172 [2138-12-17] 04:30AM BLOOD Plt Ct-172 [2138-12-16] 04:30AM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-136 K-3.7 Cl-100 HCO3-29 AnGap-11 Brief Hospital Course: On [2138-12-12] Mr. [Known lastname ] was taken to the operating room and underwent 1. Redo sternotomy. 2. Redo coronary artery bypass graft x3, saphenous vein graft to obtuse marginal-1 and 2 and posterior descending artery. 3. Endoscopic harvesting of the long saphenous vein. with Dr. [Last Name (STitle) ]. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was weaned from pressors. He required diuresis but was extubated by post-operative day two. His wires and chest tubes were removed. By post-operative day four he was ready for transfer to the floor. With further diuresis and nebs his respiratory status improved. By post-operative day five he was ready for discharge to home with services. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth daily PRASUGREL [EFFIENT] - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 21 days. Disp:21 Tablet(s) Refills:2 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. prasugrel 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with ultram Incisions: Sternal - healing well, no erythema or drainage Leg (Left) - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] at [2139-1-12] at 1:15 Cardiologist: Dr. [Last Name (STitle) 11493] [2138-12-29] at 3:30 Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ] in [4-14] 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 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2138-12-17]	[ "414.01", "285.1", "412", "305.1", "414.02", "787.20", "427.89", "287.5", "458.29", "272.4", "327.23", "401.9", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "36.13", "39.61" ]	icd9pcs	[ [ [] ] ]	4494, 4562	2126, 2971	362, 584	4630, 4844	1846, 2103	5768, 6353	1088, 1151		3421, 4471		4583, 4609		2997, 3398			4868, 5745									1166, 1827																						283, 324									612, 871																		893, 1008	1024, 1072
42,196	121,758	43397	Discharge summary	report	Admission Date: [2170-4-4] Discharge Date: [2170-4-18] Date of Birth: [2098-2-28] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Zestril Attending:[First Name3 (LF) 922] Chief Complaint: sepsis Major Surgical or Invasive Procedure: [2170-4-5] Subtotal colectomy and ileostomy History of Present Illness: Patient is a 72 year old female who recently underwent an aortic valve replacement on [2170-3-19]. Her postoperative course was uneventful and she was discharged to rehab on [2170-3-26]. She presented to [Hospital3 417] Hospital yesterday with several days of worsening abdominal pain. In the ED she was febrile to 102, hypotensive, and hypoxic w/ rigors. Of note, at the rehab facility she was started on vancomycin IV, gentamicin IV, and flagyl IV for the abdominal pain. Upon arrival to the OSH she was noted to have a WBC count of 20 with 39% bands with multiple electrolyte abnormalities. A CDiff culture was reportedly positive as well. She was intubated, started on levophed and admitted to the ICU. A CT scan of the abdomen was obtained which per report showed significant ascites, dilated small and large bowel, and possible wall thickening of the colon, without evidence of perforation. She was transferred to [Hospital1 18] for further care. Past Medical History: Toxic colitis with full-thickness colonic ischemia on the sigmoid colon s/p exploratory laparotomy with subtotal colectomy and ileostomy [2170-4-5] PMH: - Aortic valve stenosis - Hypertension - Dyslipidemia - Diabetes Mellitus Type II - History of renal cell carcinoma status post nephrectomy resulting in ESRD, requires peritoneal dialysis since [2164] - History of peritonitis over five years ago - History of herpes Zoster several years ago - History of C. difficile colitis - Anemia - Arthritis, History of Gout - Hyperparathyroidism Social History: Lives: Alone Tobacco: Quit over 40 years ago ETOH: Denies Family History: non contributory Physical Exam: Pulse: 106 Resp:22 O2 sat: 98% B/P Right:118/61 Left: Ax Aline 101/41 Height:4'9" Weight: General:Intubated, sedated Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Decreased at bases Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [] non-distended [] non-tender [] bowel sounds + [] Firm, distended, absent bowel sounds Extremities: Warm [], well-perfused [] Edema Varicosities: None [] 2+ LE edema Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: Left: Pertinent Results: [2170-4-17] 02:37AM BLOOD WBC-8.9 RBC-3.43* Hgb-10.4* Hct-30.2* MCV-88 MCH-30.3 MCHC-34.4 RDW-15.8* Plt Ct-127* [2170-4-16] 01:54PM BLOOD Hct-29.6* [2170-4-16] 02:55AM BLOOD WBC-10.5 RBC-3.77# Hgb-11.6# Hct-33.1* MCV-88 MCH-30.7 MCHC-34.9 RDW-16.4* Plt Ct-116* [2170-4-17] 02:37AM BLOOD Plt Ct-127* [2170-4-17] 02:37AM BLOOD PT-15.9* PTT-65.9* INR(PT)-1.4* [2170-4-16] 02:55AM BLOOD PT-14.7* PTT-58.8* INR(PT)-1.3* [2170-4-15] 02:15AM BLOOD PT-15.6* PTT-87.5* INR(PT)-1.4* [2170-4-14] 12:22PM BLOOD PT-14.7* PTT-68.2* INR(PT)-1.3* [2170-4-14] 04:10AM BLOOD PT-14.9* PTT-72.0* INR(PT)-1.3* [2170-4-17] 02:37AM BLOOD Glucose-123* UreaN-33* Creat-2.4* Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 [2170-4-16] 02:55AM BLOOD Glucose-97 UreaN-51* Creat-3.1# Na-136 K-4.4 Cl-99 HCO3-27 AnGap-14 [2170-4-15] 02:15AM BLOOD Glucose-162 UreaN-35* Creat-2.0* Na-136 K-4.0 Cl-100 HCO3-34* AnGap-6* [2170-4-14] 12:22PM BLOOD Na-139 K-4.7 Cl-100 [2170-4-17] 02:37AM BLOOD ALT-2 AST-13 LD(LDH)-290* AlkPhos-93 Amylase-123* TotBili-0.4 [2170-4-16] 02:55AM BLOOD ALT-5 AST-20 LD(LDH)-309* AlkPhos-113* Amylase-187* TotBili-0.4 [2170-4-15] 02:15AM BLOOD ALT-9 AST-31 AlkPhos-129* Amylase-201* TotBili-0.4 [2170-4-17] 02:37AM BLOOD Lipase-89* [2170-4-15] 02:15AM BLOOD Lipase-158* [2170-4-13] 02:36AM BLOOD Lipase-294* [2170-4-12] 04:11AM BLOOD Lipase-287* [2170-4-17] 02:37AM BLOOD Calcium-9.7 Phos-3.8# Mg-2.3 [2170-4-16] 02:55AM BLOOD Albumin-2.4* Calcium-9.6 Phos-5.4* Mg-2.3 [2170-4-15] 02:15AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.2 [2170-4-14] 12:22PM BLOOD Mg-2.3 [2170-4-16] CXR Final Report AP CHEST, 4:11 P.M., [4-16] HISTORY: Repositioned PICC line. COMPARISON: AP chest compared to [4-16] at 2:57 p.m.: Right PIC line has been repositioned, ending in the low SVC, just proximal to the left internal jugular line that ends at the level of the superior cavoatrial junction and the dual-channel dialysis catheter that ends at and just below the superior cavoatrial junction. Low lung volumes make it difficult to exclude mild interstitial edema. A small left pleural effusion is present. No pneumothorax. Feeding tube passes into the stomach and out of view. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: MON [2170-4-16] 8:37 PM Imaging Lab Brief Hospital Course: The patient was admitted for further management of C. Diff Colitis and septic shock. Transplant surgery was consulted, and the patient was taken to the operating room for an exploratory laparotomy. OR findings included toxic colitis with full-thickness colonic ischemia on the sigmoid colon. She underwent subtotal colectomy and ileostomy with Dr. [First Name (STitle) ]. Post-operatively she was transferred back to the CVICU for invasive monitoring and recovery. Renal was consulted to aid in transition to CRRT from peritoneal dialysis. ID was consulted and made appropriate recommendations for antimicrobial regimen. Vancomycin was initiated for CDiff along with metronidazole. Additionally, Daptomycin and Meropenem were started for gram negative and anaerobic coverage. Amiodarone and anti-coagulation were resumed for paroxysmal atrial fibrillation. Thrombocytopenia developed and HIT would return negative. Platelet count improved. The patient was extubated on POD 6. She received a tunneled HD catheter in IR on [2170-4-13], and was transitioned to HD on [2170-4-13]. TPN and tube feeds were initiated. Amylase and Lipase rose. TPN was held, and enzymes would trend down. TPN was discontinued when the patient tolerated tube feeds at goal. She did receive a PICC on [2170-4-16] for ongoing access and antibiotic administration. The patient will be discharged on 2 weeks of Flagyl. She is discharged to [Hospital ] [Hospital ] Rehab at the [Doctor Last Name 1263], in [Location (un) 686]. Renal will follow up with the facility for HD recommendations. The patient has been advised of all necessary follow-up. Medications on Admission: Amiodarone IV drip Norepinephrine IV drip Fentanyl IV drip Versed IV drip Tigecycline 50 mg IV q12 hours Flagyl 500mg IV q6hours Gentamicin IV Vancomycin 250mg PO QID Hydrocortisone 50 mg IV q6hours Protonix 40mg IV daily Allopurinol 150mg PO daily Midodrine 5mg PO TID Heparin 5000 units SQ q8hours Insulin Sliding Scale Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for temp >38.4 . 2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-10 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing . 5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily x 1 week, then 200mg daily until further instructed. 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [6-29] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing/dyspnea. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 9. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1) Mucous membrane every four (4) hours as needed for sore throat. 10. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for mouth sores. 11. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 11 days: through [2170-4-28]. 14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 15. Ondansetron 2 mg IV Q8H:PRN nausea 16. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): 700 units/hr for goal PTT 50-70, dx: afib. d/c when INR therapeutic on coumadin. 17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: MD to dose daily for goal INR 2-2.5, dx: afib. 18. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per insulin sliding scale. 19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 20. Outpatient Lab Work Labs: PT/INR Coumadin for A-fib Goal INR 2-2.5 First draw [2170-4-18] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Toxic colitis with full-thickness colonic ischemia on the sigmoid colon s/p exploratory laparotomy with subtotal colectomy and ileostomy [2170-4-5] PMH: - Aortic valve stenosis - Hypertension - Dyslipidemia - Diabetes Mellitus Type II - History of renal cell carcinoma status post nephrectomy resulting in ESRD, requires peritoneal dialysis since [2164] - History of peritonitis over five years ago - History of herpes Zoster several years ago - History of C. difficile colitis - Anemia - Arthritis, History of Gout - Hyperparathyroidism Discharge Condition: Alert and Oriented x [2-22], intermittently confused Deconditioned Sternal wound c/d/i without erythema or drainage Abdominal wound clean, packed wet to dry Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] #:[Telephone/Fax (1) 170] Date/Time:[2170-5-1] 1:15 Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 93402]: appointment on [2170-4-24] at 2pm Please call to schedule appointments with your General Surgery, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks, [Telephone/Fax (1) 673] Primary Care Dr. [Last Name (STitle) 3314] in [4-24] weeks. Please call [Telephone/Fax (1) 3183] to schedule your appointment. Nephrology- Please call Dr.[Name (NI) 4857] office [Telephone/Fax (1) 721] on discharge from rehab to arrange for follow-up 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:[2170-4-18]	[ "585.6", "995.92", "272.4", "V10.52", "427.31", "V45.11", "785.52", "008.45", "558.2", "403.91", "038.9", "250.00", "V42.2", "557.9", "287.5" ]	icd9cm	[ [ [] ] ]	[ "38.95", "46.21", "38.93", "99.15", "39.95", "45.79", "96.6" ]	icd9pcs	[ [ [] ] ]	9524, 9567	5198, 6862	293, 343	10158, 10321	2760, 5175	11295, 12217	2011, 2030		7235, 9501		9588, 10137		6888, 7212			10345, 11272									2045, 2741																						247, 255									371, 1348																		1370, 1919	1935, 1995
12,125	107,357	44080	Discharge summary	report	Admission Date: [2183-1-17] Discharge Date: [2183-1-24] Date of Birth: [2114-4-26] Sex: M Service: SURGERY Allergies: Lidocaine / Wheat Starch / Lipitor / Zetia / Percocet / Nexium Attending:[First Name3 (LF) 1234] Chief Complaint: He has had 6 weeks of lower back/hip pain. Major Surgical or Invasive Procedure: Open AAA repair History of Present Illness: 64M with admitted with reports of a AAA. He has had 6 weeks of lower back/hip pain. He had an MRI of his lumbar spine to evaluate for spinal canal stenosis. A 8.8 cm AAA was discovered. (mild R foraminal encroachment at L5/S1). The pain he relates is more laterally then midline. No substernal chest pain. Other recent medical hisotry is a L vitrectomy and retinal repair in [4-23]. Then on [1-8] he had a headache and complete loss of vision in that left eye. He was seen by his opthalmologist who saw nothing wrong with his eye and diagnosed amaurosis fugax. His vision resolved within a few hours although it is still mildy blurry. Unclear what diagnostic tests he underwent for this but he was started on coumadin w/ lovenox bridge. Past Medical History: 1. Hypercholesterolemia 2. HTN 3. CAD as in HPI 4. GERD Social History: etoh: social tob: quit [2164] drugs: none Family History: no family history of aneurysmal disease Physical Exam: Vitals: T 98 HR 89 RR 18 BP 130/107 O2 sat 97% RA Gen: middle-aged man, pleasant Skin: warm and dry skin, no rash HEENT: nc/at, mmm CV: RRR Lungs: CTAB Abd: soft, nt, nd, no HSM Ext: no lower extremity edema, no clubbing, cyanosis or erythema Neuro: nonfocal exam, sensation intact Fem [Doctor Last Name ] DP PT R P P P tri L P P P tri Pertinent Results: [2183-1-17] 01:25PM BLOOD WBC-5.5 RBC-4.41* Hgb-14.9 Hct-39.7* MCV-90 MCH-33.8* MCHC-37.6* RDW-13.1 Plt Ct-189 [2183-1-21] 05:07PM BLOOD Hct-26.1* [2183-1-22] 04:51AM BLOOD WBC-5.1 RBC-3.04* Hgb-10.2* Hct-27.5* MCV-90 MCH-33.4* MCHC-37.0* RDW-13.1 Plt Ct-215 [2183-1-24] 05:19AM BLOOD WBC-6.3 RBC-3.35* Hgb-11.4* Hct-30.0* MCV-89 MCH-33.9* MCHC-37.9* RDW-12.8 Plt Ct-318 [2183-1-17] 01:25PM BLOOD PT-44.6* PTT-52.0* INR(PT)-5.0* [2183-1-24] 05:19AM BLOOD PT-13.5* PTT-28.9 INR(PT)-1.2* Brief Hospital Course: Mr. [Name13 (STitle) ] was admitted from a med-flight transfer on [2183-1-17] with reports of a large AAA as reported on the HPI. He had a CTA of this aneurysm which confirmed its size and enabled pre-op planning. A carotid duplex was obtained to look for a cause of his amaurosis. This did not show any stenosis. The CTA of his torso also did not reveal any obvious source of emboli. The AAA was deemed not a good architecture for EVAR repair. Because of his elevated Inr he was given 1mg of vit k and was transfused with 5 packs of ffp on the way to the OR. He underwent midline, open AAA repair on [1-18]. He was transferred to the CVICU post-op. He remained intubated overnight and was extubated in the morning. He required 1 PRBC transfusion. He did well. He made adequate urine and his pain was controlled with a pca. POD #2 because of continued abd distension a ngt was placed. He had no complications of afib or hypotension. He was transferred to the VICU POD #3. He was diuresed. His swann was removed and his cordis changed to a TL. A popliteal u/s was obtained which was negative for aneurysms. NGT output remained high for the next several days. He was able to get oob and his physical activity was advanced day by day. He did not require a pt consult as he was able to walk with nursing help only. POD 4 his ngt was taken out and he was kept on limited sips. POD 5 he was advanced to clears. POD 6 regular and CVC taken out. Home meds were resumed with the exception of coumadin and lovenox. He should be continued on plavix and asa, more for his coronary arteries than for his AAA repair. Medications on Admission: slow release nitro, asa 81', lisinopril 2.5', nitroquick prn, protonix 40', niacin 1500', cymbalta 100', plavix 75', cymbalta 60', ativan 1', cataflan 50''', ultram 50'''', folic acid 400', metoprolol 25'', coumadin 5', lovenox 80'. 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Folic Acid 1 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 once a day. Discharge Disposition: Home Discharge Diagnosis: AAA post op illeus AAA history Hyperlipidemia HTN CAD w/mult stents. Last in [9-19] when RCA dissected and IABP placed for 2days. history of GERD amaurosis fugax history of L vitrectomy s/p retinal repair Discharge Condition: good Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [6-23] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [2-18] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2183-1-31] 10:30 Completed by:[2183-1-24]	[ "560.1", "272.0", "441.4", "530.81", "401.9", "V45.82", "997.4", "V58.61", "368.8" ]	icd9cm	[ [ [] ] ]	[ "38.44", "38.93" ]	icd9pcs	[ [ [] ] ]	5048, 5054	2309, 3946	365, 383	5308, 5315	1764, 2286	8055, 8239	1322, 1363		4229, 5025		5075, 5287		3972, 4206			5339, 7602	7628, 8032								1378, 1745																						283, 327									411, 1163																		1185, 1242	1258, 1306
16,832	149,054	5146	Discharge summary	report	Admission Date: [2113-8-1] Discharge Date: [2113-8-6] Date of Birth: [2066-9-20] Sex: M Service: MEDICINE Allergies: Labetalol Attending:[First Name3 (LF) 1493] Chief Complaint: Headache, High blood pressure Major Surgical or Invasive Procedure: renal ultrasound History of Present Illness: 46 yom with hx of chronic hepatitis C, cirrhosis, HCC, s/p cadaveric liver transplant 6/[2110]. Liver biopsy performed in [2112-8-12] showed signs of reactivation of Hepatitis C and patient was restarted on ribavarin and interferon in [Month (only) 404] [2112]. Pt was found to be hypertensive at Hepatology appt today with BP of 198/133 despite metoprolol, labetalol and SL nitrate and was then sent to the ER. Pt also reports constant headache which began 5 days ago. HA is frontal pounding type headache. Pain ranges [2116-1-20] and is relieved partially with Tylenol. No photophobia, no visual changes, no diplopia. Pt reports weakness and fatigue x 2 weeks which began after initiation of cyclosporine treatment. Denies CP, SOB, palpitations, fevers/chills, diaphoresis, diarrhea. + urinary frequency, no dysuria. . In ER, Pt with BP 159/125, HR 72, RR 18, T 97.1, O2sat 100%. Pt continued with elevated BP to 230/130's, responded minimally to sublingual nitro and minimal resonse to labetalol but did have adverse reaction to labetolol with flushing and rash. Pt placed on nitro drip. . Past Medical History: Hep C Hepatocellular CA Hypertriglyceridemia HTN . PSH: Liver transplant Sinus surgery Social History: SH: + tobacco 3 pack years, quit 24 years ago negative EtOH, no IVDA Pt is part owner of computer technology business . Family History: FH: Mother with HTN, brain aneurysm Father with [Name2 (NI) ] CA Brother with CABG x 4 . Physical Exam: V/S: T 97.3 BP 168/111 HR 83 RR 12 Gen: NAD HEENT: EOMI, PERRLA, oropharynx clear CVS: +S1, +S2, no M/R/G, RRR LUNGS: CTAB ABD: +BS, NT/ND, +RUQ scar EXT: no peripheral edema, +2 pulses distally NEURO: CN II-XII intact, 5/5 strength all extremities, sensation intact, no babinski Pertinent Results: [2113-8-1] 03:50PM PT-14.1* PTT-30.6 INR(PT)-1.3* [2113-8-1] 03:50PM PLT SMR-VERY LOW PLT COUNT-60* [2113-8-1] 03:50PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [2113-8-1] 03:50PM NEUTS-76* BANDS-0 LYMPHS-12* MONOS-11 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2113-8-1] 03:50PM WBC-3.0* RBC-3.49* HGB-10.6* HCT-32.7* MCV-94 MCH-30.5 MCHC-32.4 RDW-17.9* [2113-8-1] 03:50PM CK-MB-NotDone cTropnT-<0.01 [2113-8-1] 03:50PM LIPASE-32 [2113-8-1] 03:50PM ALT(SGPT)-16 AST(SGOT)-31 CK(CPK)-57 ALK PHOS-53 AMYLASE-99 TOT BILI-1.4 [2113-8-1] 03:50PM estGFR-Using this [2113-8-1] 03:50PM GLUCOSE-79 UREA N-37* CREAT-2.4# SODIUM-138 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 [2113-8-1] 08:00PM URINE HYALINE-0-2 [2113-8-1] 08:00PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [2113-8-1] 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2113-8-1] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [8-1] CT-head w/o contrast: IMPRESSION: No evidence of acute intracranial hemorrhage or mass effect. [8-1] CXR: IMPRESSION: No acute cardiopulmonary process [8-1] Renal U/S: IMPRESSION: Blunted arterial upstrokes with somewhat decreased resistive indices in both kidneys. This pattern can be seen in renal artery stenosis. Further evaluation with an MRA or CTA could be performed on a nonemergent basis. [8-1] EKG: Sinus rhythm Prominent Q wave in aVF - is nonspecific and may be normal variant. Modest nonspecific low amplitude lateral T waves Clinical correlation is suggested. Since previous tracing of [2111-5-25], ST-T wave abnormalities decreased Brief Hospital Course: 46 yom with hx of Hep C, HCC, s/p liver transplant now with reactivation Hep C who presents to ER with Hypertensive emergency. . 1) Hypertensive emergency: Pt presented to liver clinic on [8-1] with BP in 190's/130's which did not respond to metoprolol, labetalol and SL nitrate. Pt sent to the ER for BP control. In the ER patient found to have elevated Cr 2.4, which is above baseline of 1.0-1.3. Pt also with headaches x 5 days which was attributed to elevated blood pressures. There are no focal neurologic deficits. CT scan of the head was negative for hemorrhage or mass effect. Renal u/s ordered to evaluate for RAS, which did show blunted arterial upstrokes which can be seen in RAS. PT then transferred to MICU for BP control. Cause of Hypertensive Emergency likely due to meds vs. renal artery stenosis. Pt began cyclosporine 2 weeks ago and now presents with HTN and ARF, which are both adverse side effects of this medication. Renal U/S today suggestive of RAS. PAtient on nitro drip on ICU, which was weaned prior to transfer to medical floor. Patients cyclosporine was discontinued, patient BP stable on metoprolol 150 [Hospital1 ], cardura 4mg [Hospital1 ]. PAtient will have MRA of kidney as outpatientto further evaluate renal artery stenosis once creatinine back at baseline. . 2) ARF: Pt with Cr of 2.4 on admission, baseline is 1.0-1.3. Etiology is likely HTN emergency [1-13] RAS vs. cyclosporine. Pt also on many medications, so urine sediment and eosinophils sent which ewre negative. cyclosporine discontinued, lisinprol held. . 3) Liver transplant: Pt with transplant in [2111-5-13] [1-13] Hep C cirrhosis and HCC. Pt now with reactivation Hep C on ribavirin and interferon. Cylcosporine discontiued, and Rapamycin started at 2mg. Patient rapamycin level subtherapeutic day of discharge, so given 4mg. He will follow up at liver clinic day after discharge for repeat rapamycin level. Cellcept continued. Medications on Admission: . MEDS: -Protonix 40mg qdaily -Caltrate 600mg [Hospital1 ] -Metoprolol 150mg [Hospital1 ] -Cellcept 500mg [Hospital1 ] -Lisinopril 40mg qdaily -Ambien 12.5 mg qHS Temazepam 30mg qHS PRN Peg interferon alpha 2 A, 135 mcg once per week Ribavarin 400mg [Hospital1 ] Cardura 2mg qdaily -Tricor 48mg qdaily Procrit 60,000 units daily Neoral 150mg PO BID Bactrim daily . Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s)* Refills:2 5. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed. 11. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Acute renal failure . Secondary Chronic hep C hyperlipidemia hepatacellular CA (h/o) Discharge Condition: stable Discharge Instructions: You came to the hospital with very high blood pressure that was difficult to control. We changed your antihypertensives and will give you prescriptions for your new medications. This is likely due do the medication you were on for your liver transplant. we have changed those medications. . You also had kidney abnormalities, including a stenosis of one of the renal arteries, which may have contributed to the hypertension. We sugguest that you f/u for a CT angiogram once your kidney function has normalized. . please f/u with your Hepatologist early this week. Followup Instructions: Please f/u in the liver clinic tomorrow, where they wil draw a fasting Sirolimus level. . Please f/u with your PCP about getting further imaging of your kidney. Completed by:[2113-8-14]	[ "401.0", "E930.6", "070.54", "996.82", "E878.0", "V10.07", "440.1", "272.4", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7465, 7471	3997, 5970	298, 317	7630, 7639	2149, 3974	8251, 8443	1734, 1828		6402, 7442		7492, 7609		5996, 6379			7663, 8228									1843, 2130																						229, 260									345, 1470																		1492, 1580	1596, 1718
3,512	157,024	17592	Discharge summary	report	Admission Date: [2168-5-11] Discharge Date: [2168-5-15] Service: . CHIEF COMPLAINT: Syncope. HISTORY OF PRESENT ILLNESS: The patient is a 79 year old woman with a past medical history of mitral valve prolapse, supraventricular tachycardia on Atenolol, and syncope, who presented to [Hospital3 3583] on [5-9] status post syncopal episode that was proceeded by nausea. The morning of admission, the patient stated that she had had brief loss of consciousness. She denies seizure activity, change in bladder or bowel habit. She had a history of similar episodes in [2158], [2163] and in [1-/2168], with gastrointestinal vagal symptoms. Her initial electrocardiogram showed sinus bradycardia with first degree AV block. In [Hospital3 3583] she developed PSVT at 200 beats per minute which resolved with Valsalva. In the Electrophysiology Laboratory here at [Hospital1 346], the patient had a AVNRT that was ablated and they were unable to re-induce the AVNRT status post ablation. She reported chest pain during the ablation. There were no EKG changes when her sheath was pulled, but pressure decreased to the 40s. She had an echocardiogram that showed a small 5 to 10 cc. effusion that was stable over 90 minutes; no tap was performed. She received intravenous fluids, Atropine and Dopamine transiently and her heart rate increased to the 160s and then decreased to the 130s and then approximately 95. She was 100% on four liters with a blood pressure of 120/60. She was transferred to the Coronary Care Unit for observation. After transfer her vital signs were pulse 80 to 90; blood pressure 125/63; and she reported an occasional five out of ten chest pain that was dull and achy and worse with deep inspiration. ALLERGIES: She has no known drug allergies. PAST MEDICAL HISTORY: 1. Mitral valve prolapse. 2. Billroth II gastrectomy complicated by B12 deficiency. 3. Peripheral vascular disease. 4. Diverticular disease. 5. Peptic ulcer disease. 6. Anxiety. 7. Paroxysmal supraventricular tachycardia. OUTPATIENT MEDICATIONS: 1. Ativan 0.5 mg three times a day. 2. Zantac 150 mg twice a day. 3. Nexium 40 mg q. day. 4. Atenolol 25 mg q. day. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She does not use tobacco or alcohol. She is a social worker. She is divorced and lives with her sons who are very supportive in her care. LABORATORY: Electrocardiogram number one, [2168-5-11], at 05:30 a.m. was 120 beats per minute, tachycardia, first degree arteriovenous block with PR prolongation. Normal axis, poor R wave progression, QRS 0.96. Qs in V3 through V6 and evidence of left ventricular hypertrophy. On [2168-5-11], at 3 p.m., the patient had paroxysmal supraventricular tachycardia at 172 beats per minute with left ventricular hypertrophy in Qs and V3 through V6. PHYSICAL EXAMINATION: Vital signs at the Coronary Care Unit on presentation: Blood pressure was 125/63; pulse is 87; she was afebrile; 100% on three liters nasal cannula; 16 breaths per minute. She was not in no acute distress, lying flat in bed. Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Anicteric. Jugular venous distention was approximately 10 centimeters but again the patient was lying flat. Neck was supple. Lungs were clear to auscultation; no wheezes, rales or rhonchi anteriorly this examination was done. Cardiovascular: The patient was regularly irregular and seemed to have ventricular premature contractions, distant heart sounds. Pulsus was 8 millimeters of Mercury. S1, S2, no murmurs, rubs or gallops were appreciated. Groin with no bruit. Clear, dry and intact, no hematoma. Two out of two dorsalis pedis pulses on the left; on the right one out of two. No cyanosis, clubbing or edema. Present varicose veins. Cranial nerves II through XII were intact. She was alert and oriented times three; she was pleasant. Later electrocardiograms done on the 2nd, were normal sinus rhythm, 81 beats per minute with occasional atrial premature beats, prolonged PR, Qs 1 to 3 centimeters V3 through V6, slight PR depression V2 through V6. Slight PR elevation in AVR, normal voltage, evidence of left ventricular hypertrophy. LABORATORY: Creatinine of approximately 0.7, hematocrit of approximately 33.0. On presentation, her hematocrit was 35.7. with a white blood cell count of 10.8, hemoglobin 12.8, MCV of 90 and platelets 339. ASSESSMENT: The patient is a 79 year old woman with a past medical history of peptic ulcer disease status post Billroth II, diverticular disease, syncope and paroxysmal supraventricular tachycardia who presents from the Electrophysiology Laboratory status post ablation of AVR and AT, complicated by pericardial effusion, decreased blood pressure transiently requiring dopamine. Echocardiogram showing small stable pericardial effusion. Blood pressure stable and the pulsus is approximately 8 centimeters. HOSPITAL COURSE: 1. RHYTHM: Sinus bradycardia with VPCs, VPB, status post ablation for AVRNAT. Permanent pacemaker placement will be done as an outpatient. Beta blocker was initially held given her hypotension. When her pressure was stable and she was eventually restarted on beta blocker, which was titrated up to 25 mg three times a day and Metoprolol. 2. HEMODYNAMICS: The patient remained hemodynamically stable for the rest of her hospitalization, not requiring any more pressors. She had a repeat echocardiogram on the third of [2168-5-10]. Her left atrium was mildly dilated, right atrium was normal in size. Her left ventricular wall thickness, cavity size and systolic function were normal. Her ejection fraction was estimated to be 60%. Her right ventricular cavity was dilated. Right ventricular systolic function was normal. Aortic root was normal in diameter. No aortic regurgitation; trivial mitral regurgitation; two plus tricuspid regurgitation. Mild pulmonary artery systolic hypertension. There was a small pericardial effusion that was circumferential and compared to the prior study on [2168-5-11], the pericardial effusion appeared slightly smaller than the prior study, and there was no atrial indentation. 3. CONGESTIVE HEART FAILURE: There was no evidence of congestive heart failure throughout the remainder of her stay. We monitored for obstructive physiology by following pulsus which was approximately 8 and jugular venous pressure which was approximately 9. The echocardiogram was repeated as stated above, earlier. For coronary artery disease, the patient has a known coronary artery disease history. 4. VALVULAR: The echocardiogram revealed two plus tricuspid regurgitation. 5. HEMATOLOGIC: Hematocrit, coagulation studies and platelets were followed. Hematocrit had been 33 at the outside hospital and was 35 initially on presentation here, then 31 initially presenting to the Coronary Care Unit. On the [5-12], the hematocrit was 25.9. The patient received two units of packed red blood cells with a bump to 31.6. By the date of discharge, it was 36.6 without any further transfusions. It should be noted that the patient had received intravenous fluids during her episodes of hypotension and the low hematocrit may have represented fluid shifts. 6. PULMONARY: The patient has no history of pulmonary disease, however, given the pulmonary hypertension, this issue should be followed up as an outpatient. 7. GASTROINTESTINAL: Proton pump inhibitor for gastrointestinal prophylaxis. 8. RENAL: The patient's renal function remained stable throughout her hospital course. 9. PSYCHIATRIC: The patient received Ativan p.r.n. for anxiety. 10. PAIN: Chest pain likely secondary to procedure. The patient received Tylenol and percocet as well as occasional doses of intravenous morphine for her chest pain. NSAIDs were avoided. 11. PROPHYLAXIS: For gastrointestinal, Protonix, deep vein thrombosis Pneumoboots. The patient was transferred from the Coronary Care Unit to the floor. She was seen by Physical Therapy and was ambulating without assistance. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. AVRT status post ablation. 2. Status post syncopal episode. 3. Transient hypotension. 4. Pericardial effusion. 5. ............. resulting in anemia status post two units of packed red blood cells. 6. Anxiety. 7. Peptic ulcer disease. PROCEDURES: 1. Status post ablation AVNRT. DISCHARGE INSTRUCTIONS: 1. The patient had [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Monitor placed at discharge. The results will be sent to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 284]. 2. The patient is to follow-up at [Hospital ] Clinic. The patient is to call for this appointment in approximately one month following this admission for a possible permanent pacemaker placement. 3. The patient is to follow-up with primary care physician in approximately two weeks. The patient is to call to make this appointment. DISCHARGE MEDICATIONS: 1. Lopressor/Metoprolol tartrate 10 mg three times a day p.o. 2. Nexium. 3. Lorazepam 0.5 mg three times a day. 4. CORONARY ARTERY DISEASE: The patient has known coronary artery disease history. [Doctor First Name 900] [Name8 (MD) 901], M.D. [MD Number(1) 2144] Dictated By:[Last Name (NamePattern1) 1659] MEDQUIST36 D: [2168-7-25] 11:54 T: [2168-7-30] 18:19 JOB#: [Job Number 49036]	[ "998.2", "428.0", "276.5", "997.3", "424.0", "426.89", "E870.6", "518.0", "427.31" ]	icd9cm	[ [ [] ] ]	[ "37.27", "37.34", "37.26", "99.62" ]	icd9pcs	[ [ [] ] ]								8203, 8493	9106, 9562					5022, 8149		8517, 9083																		2099, 2267			2906, 5005										104, 114									144, 1823																		1845, 2075	2285, 2882	8175, 8182
71,883	182,623	38476	Discharge summary	report	Admission Date: [2120-7-1] Discharge Date: [2120-7-13] Date of Birth: [2050-6-1] Sex: F Service: MEDICINE Allergies: Celebrex / Gammagard S/D Attending:[First Name3 (LF) 3233] Chief Complaint: Weakness, Poor appetite Major Surgical or Invasive Procedure: Bone marrow biopsy ([2120-7-2]) History of Present Illness: Ms. [Known lastname ] is a 70 yo woman with chronic cough, GERD, and CLL diagnosed in [2114-1-11] s/p cycle 4 of rituxan/fludarabine/neulasta in [2120-4-11] who presents with increasing weakness, poor PO intake, weight loss, and paroxysmal coughing. She was recently admitted in [Month (only) 547] for bone pain [2-13] neulasta. She did well at first but over the past month has felt that her "body is deteriorating," especially over the last week. She states that she has had very poor appetite as food has no taste, and also she is bothered by a metallic taste in her mouth. She has become increasingly weak and inactive and has lost weight. She forces herself to eat apple sauce, bananas, scrambled eggs, but certain foods that are too dry (like an English muffin) make her choke and trigger coughing spells. Her throat is always very dry and easily irritated. . The coughing spells have been chronic for several years and seemed to worsened last summer. They are productive of clear phlegm that has not changed recently. They are triggered by smells, foods, and moving around. She sometimes coughs so hard that she vomits. Recently, she has started having midline chest pain due to the coughing that radiates to her upper back. She has also been having fevers, chills, and sweats at home, though fevers have always been < 100 degrees. . She was treated approximately 2 weeks ago for a UTI by her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 17918] ([Telephone/Fax (1) 17919]), with cipro 500 mg [Hospital1 ] and pyridium. She was seen last week by her outpatient oncologist, Dr. [Last Name (STitle) 11636] ([Telephone/Fax (1) 62315]), who was concerned about her anemia, left shift, and rising LDH. A bone marrow biopsy was planned for this coming Friday. . She states that there was no acute change that induced her to present to [Hospital1 18] ED last night; her daughter had called her pulmonologist who advised her to come into the ED. . This morning, she continues to have paroxysms of coughing and poor appetite. She denies nausea, dyspnea, chest pain, or back pain currently. . ROS: (+) As above. Also, positive for light-colored stools, intermittent diarrhea, occasional nausea, dyspnea only with the coughing spells. (-) No sick contacts, recent travel, dysphagia, odynophagia, dysuria, hematuria, hematochezia. Past Medical History: CLL HLD Depression Osteoporosis Psoriasis Asthma with chronic cough GERD Hiatal hernia HTN Social History: Smoked <1ppd x 18 years, quit in [2093]. Drinks 3 glasses wine/wk. Used to walk 3 miles/day but is now relatively inactive. Divorced, has 3 children. Used to work as a calendar publisher. Family History: Aunt died of ovarian cancer. Father had emphysema. Physical Exam: Admission Physical Exam: Vitals: 101.6 98.6 108/62 103 20 99% RA General: Elderly lady sitting in chair in NAD HEENT: NCAT. Anicteric, PERRL. MM slightly dry, white lesions on sides of tongue, OP clear. Cluster of ulcerated lesions on left side of upper lip and less on lower lip with some edema. Neck: Supple, no LAD, no thyromegaly. Axilla: ?Subtle LAD in R axilla. Lungs: Deep breath triggers coughing fit, but CTAB. CV: RRR, nl S1 S2, no m/r/g. Abdomen: +BS, soft, non-tender, non-distended. No HSM or masses. No rebound or guarding. Ext: WWP, no edema. No clubbing or cyanosis. Skin: Erythematous scaly plaque on LLE. Neuro: MS: No asterixis. CN: II-XII intact. Motor: No pronator drift. Strength 4/5 in biceps bilaterally. Strength 5/5 in deltoids and triceps bilaterally. Strength 5/5 in ankle flexion/dorsiflexion bilaterally. Sensory: Grossly intact throughout. Touch localization intact, does not extinguish to DSS. . Discharge Physical Exam: VS: 98.9 98.4 124/58 89 20 100%RA GEN: NAD, comfortable, pleasant lady SKIN: psoriatic patches on legs b/l, no rashes HEENT: oropharynx clear, no erythema, no thrush, no LAD CVS: RRR, nl S1 S2, no murmurs rubs or gallops RESP: no increased work of breathing, CTAB, no wheezes or crackles ABD: +BS, NTND EXT: no [Location (un) ] NEURO: A&Ox3, CN II-XII grossly intact Pertinent Results: Admission Labs: [2120-7-1] 07:05PM WBC-1.6# RBC-3.27 HGB-8.9* HCT-26.8* MCV-82# MCH-27.2 MCHC-33.2 RDW-16.9* [2120-7-1] 07:05PM NEUTS-5* BANDS-9* LYMPHS-35 MONOS-35* EOS-10* BASOS-0 ATYPS-4* METAS-1* MYELOS-1* NUC RBCS-1* OTHER-0 [2120-7-1] 07:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL OVALOCYT-1+ PENCIL-NORMAL [2120-7-1] 07:05PM PLT SMR-VERY LOW PLT COUNT-54# [2120-7-1] 07:05PM cTropnT-LESS THAN [2120-7-1] 07:05PM GLUCOSE-101 UREA N-27* CREAT-0.7 SODIUM-133 POTASSIUM-3.1* CHLORIDE-93* TOTAL CO2-22 ANION GAP-21* [2120-7-1] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2120-7-1] 08:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007\ . Discharge Labs: [2120-7-13] Na134 K 3.8 Cl 101 CO2 27 BUN 12 Cr 0.4 Gluc 115 AG 10 Ca 8.7 Mg 2.3 Phos 3.0 UA 1.1 ALT 41 AST 21 AP 132 LDH 497 Tbili 0.8 WBC 1.5 Hct 27.0 Plt 68 ANC 1223 . Pathology: BMB [6-28]: DIAGNOSIS: ATYPICAL LYMPHOID INFILTRATE CONSISTENT WITH LARGE CELL TRANSFORMATION OF CLL/SLL LEFT SHIFTED MYELOID PRECURSORS AND CIRCULATING BLASTS SEEN . Note: An atypical lymphoid infiltrate, which by flow cytometry was comprised of B-cells coexpressing CD10 is seen. This is consistent with large cell transformation ([Doctor Last Name ] type). CD20, CD30, CD15, CD3 are negative within the large cells. CD3 and CD5 highlights T cells. Dim CD5 expression is seen in the large cells. . While CD34, nTdT and CD117 are negative within the large cells, a population of CD34 expressing events are noted by flow cytometry. In addition, myeloids appear left shifted (including rare circulating blasts) and dysplasia is noted. Given the history of chemotherapy, this could be consistent with therapy related dysplastic changes. Definitive diagnostic features of acute myeloid leukemia is not seen in the current marrow evaluation, which is limited by a sub-optimal aspirate. Close follow and clinical correlation along with a repeat biopsy/ aspirate study is recommended at an interval. Findings discussed at the BMT conference on [2120-7-9]. . MICROSCOPIC DESCRIPTION . Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes are decreased in number, normocytic and hypochromic. They exhibit mild anisopoikilocytosis including burr cells, stomatocytes, red cell fragments - occasional tear drop cell. Several nucleated red cells are seen. The white blood cell count appears decreased. Rare pelgeroid forms and neutrophils with toxic granules and vacuoles can be seen. Occasional large atypical lymphoid cells with high N:C ratio, dark blue cytoplasm and prominent nucleoli are present. Platelet count appears markedly decreased. Large forms are seen. A rare giant form is present. Differential count shows 13% neutrophils, 5% bands, 11% monocytes, 65% lymphocytes, 1% eosinophils, 2% basophils, 3% large atypical lymphoid cells. Rare atypical cells suspicious for blasts are seen. . Aspirate Smear: The aspirate material is suboptimal for evaluation due to absence of spicules; however, a 100 cell count was performed and reveals the following: 0% blasts, 0% promyelocytes, 4% myelocytes, 3% metamyelocytes, 7% neutrophils, 0% plasma cells, 66% lymphocytes, 5% erythroid, 15% large, atypical lymphoid cells. The M:E ratio cannot be reliably assessed. Several dysplastic granulocytes are present. . Biopsy Slides: The biopsy material is adequate for evaluation and consists of a 5 mm section of cortical and trabecular bone and periosteum. Cellularity is estimated between 50-60%. Focally, there are areas of fibrosis. There are large, atypical cells with vesicular chromatin and prominent nucleolus present. Marrow clot section is similar to the biopsy. . Reports: . CXR [7-1]: IMPRESSION: No acute cardiopulmonary abnormality. . CT torso [7-2]: IMPRESSION: 1. Marked retroperitoneal lymphadenopathy, which are increased in size and number from [2120-4-30], with additional bulky lymphadenopathy along the iliac chains and pelvic side walls bilaterally. 2. Splenomegaly, which is also increased in size from prior study. 3. Multiple small hypodensities in the liver, which are incompletely characterized. 4. New areas of rarefaction and lucencies in T8, T9, and L5 vertebral bodies. Attention on follow-up studies. . TTE [7-4]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. No clinically-significant valvular disease seen. . CXR [7-5]: IMPRESSION: No pneumonia. Brief Hospital Course: # CLL with transformation to Large B cell lymphoma: [Doctor Last Name 6261] transformation was felt to be very likely due to aggressiveness of neutropenia, as well as worsening LAD and splenomegaly on CT. Other possibilities included viral infection or drug-induced bone marrow suppression. We contact[Name (NI) ] her outpatient oncologist, who encouraged inpatient bone marrow biopsy. Our heme-onc team performed a BM biopsy on [7-2], which showed atypical lymphoid infiltrate consistent with large cell transformation of CLL/SLL. . Pt started on [Hospital1 ] [2120-7-7], which she tolerated well with no nausea. She had tid tumor lysis labs for the first 2 days, then [Hospital1 ], then qday. She was started on Acyclovir ppx [2120-7-11]. She was started on Bactrim ppx on [7-5]. . Pt received her first dose of Neupogen on day of discharge, [2120-7-13]. She was trained on Neupogen injections. Pt will follow-up with Dr. [Last Name (STitle) ] on [2120-7-25]. Pt to return for counts on [2120-7-16] at 8:30am. . # Fever: She had fevers to 102.5 on [7-1] and [7-2]. There was no obvious source of infection. CXR negative, UA negative. We treated empirically with cefepime on [7-1] and acyclovir given the presence of herpetic lesions on her left upper lip. Blood cultures were sent, which returned no growth. Urine cultures were sent, which showed no growth. Viral and fungal assays were sent, which showed negative EBV and CMV . A nasal swab for viral cultlures was contaminated but negative for AFB's. A legionella urine antigen was negative. Cefepime was discontinued on [7-12], and she was switched to Levofloxacin. She did well overnight and had no increased cough or fevers. She was discharged on Levofloxacin 750mg po daily for 10 more days. . # Chronic Cough: Pt came in with cough that she described as worse over the past few weeks. However, after further investigation it was found that she had a chronic cough with previous extensive evaluation, not responsive to inhalers, prilosec, cough suppressants. We treated with albuterol neb PRN and home prilosec. While she was inpatient, Pulmonary was consulted. They recommended to continue nebs and cefepime, in the setting of neutropenia. At this time they suggested continuing treatment for her lymphoma as of primary concern and to try saline nasal spray, which she was started on. While here, her cough improved on med nebs, prilosec and saline nasal spray. . # Transfusion reaction: On [7-4], pt was treated with an IVIG infusion in an attempt to help the cough in the setting of neutropenia. During the transfusion she began coughing, became hypertensive, developed fevers and her O2 sats dropped to 60% on RA. She was placed on a non-rebreather and sent down to the ICU. She was treated with solumedrol, Benadryl and IVF. On [7-5] she was stable and breathing 96% on RA and was transferred back to BMT. . # Herpes on lip: Pt was started on Acyclovir on [7-2], and was continued with treatment until [7-11]. At that time her lip ulceration was improved. . # Hyperlipidemia: continued on Simvastatin. . # Depression: continued on Citalopram. . # Osteoporosis: held Fosamax since pt has been admitted. Continue to hold Fosamax for now on discharge. Will readdress this issue with Dr. [Last Name (STitle) ] on follow-up appointment. Medications on Admission: 1. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 4. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 6. Prilosec 20mg po BID 7. Detrol 2 mg Tablet Sig: Two (2) Tablet PO once a day. 8. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 12. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for nausea. (Not taking Claritin) Took ciprofloxacin 500 mg [Hospital1 ] two weeks ago for UTI Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:10 Tablet(s) Refills:2 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-13] Sprays Nasal TID (3 times a day) as needed for nasal congestion, postnasal drip. Disp:90 2 Refills:2 12. Neupogen 300 mcg/mL Solution Sig: One (1) Injection once a day. Disp:30 Refills:2 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:2 14. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 15. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 16. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 10 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Chronic lymphocytic leukemia with transformation to High-grade lymphoma 2. Chronic cough 3. Herpetic lip lesion . Secondary diagnoses: 1. Hyperlipidemia 2. Depression 3. Osteoporosis 4. GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with increasing weakness, fatigue, and poor appetite. You were found to have low white blood counts. You had fevers for the first couple of days and were started on an antibiotic, and the fevers resolved. You were given IVIg to help with the fever and had a transfusion reaction and you had to go to the ICU. After one night in the ICU you did better and came back to the Bone Marrow Transplant service. You had a bone marrow biopsy that showed your CLL had changed to a high-grade lymphoma. You were started on chemotherapy ([Hospital1 ]), which you tolerated very well with just some minimal nausea. Your blood counts were low and you were given blood. You were also started on Neupogen shots on the day of discharge to help your blood counts increase. . You also had a cough while you were here and were started on an antibiotic. The cough improved and you were continued on an antibiotic for 10 more days from the day of discharge. . You had a herpes sore on your lip that improved on an antiviral medication. . Please follow-up with: Provider: [Name Initial (NameIs) 455] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2120-7-16] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3238], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2120-7-25] 12:00 Provider: [First Name8 (NamePattern2) 3239] [Last Name (NamePattern1) 3240], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2120-7-25] 12:00 . The following medications have been added: START Acyclovir 400mg by mouth every 8 hours to prevent viral infections START Allopurinol 300mg by mouth every day START TMP/SMX 1 tablet by mouth on Monday, Wednesday and Fridays to prevent infections START Omeprazole 20mg by mouth twice per day to prevent acid reflux START Benzonatate 100mg by mouth three times per day to suppress cough START Neupogen 300mcg subcutaneously by injection once per day to increase cell counts START Levofloxacin 250mg 3 tablets every day for 10 more days to prevent infection STOP Aspirin 81mg daily STOP Fosamax 70mg by mouth every week (should readdress use in follow-up with Dr. [Last Name (STitle) ] DO NOT take any aspirin or ibuprofen products Followup Instructions: Provider: [Name Initial (NameIs) 455] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2120-7-16] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3238], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2120-7-25] 12:00 Provider: [First Name8 (NamePattern2) 3239] [Last Name (NamePattern1) 3240], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2120-7-25] 12:00 Completed by:[2120-7-13]	[ "311", "288.00", "272.4", "786.2", "263.1", "054.9", "E879.8", "202.80", "707.03", "279.01", "786.09", "733.00", "696.1", "999.89", "785.0", "493.90", "284.1", "780.61", "112.0", "707.21", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.04", "99.14", "41.31", "99.25" ]	icd9pcs	[ [ [] ] ]	15748, 15754	9776, 13158	307, 345	16011, 16011	4509, 4509	18429, 18875	3097, 3149		14105, 15725		15775, 15911		13184, 14082			16194, 18406			5375, 9753						3189, 4092	15932, 15990																					244, 269									373, 2758				4525, 5359				16026, 16170										2780, 2872	2888, 3081		4117, 4490
54,613	147,449	50926	Discharge summary	report	Admission Date: [2140-8-24] Discharge Date: [2140-8-31] Date of Birth: [2064-11-4] Sex: M Service: MEDICINE Allergies: Lovenox Attending:[First Name3 (LF) 1253] Chief Complaint: hypotension at dialysis Major Surgical or Invasive Procedure: foley placement Blood transfusion x 4 units PRBC History of Present Illness: 75 y/o M with HTN, DM, ESRD on HD, anoxic brain injury, recent lower GI bleed presented to the ED on [8-24] with hypotension at dialysis. Initial VS were 97.6 65 124/67 16 100% 4LNC. Patient had BRB on rectal exam and gross hematuria in foley bag. Labs were significant for a hct of 20 and lactate of 2.5. Patient remained hemodynamically stable in ED however given low hematocrit patient was admitted MICU for further evaluation. GI was consulted however did not want to perform any urgent interventions given recent colonscopy. Prior to transfer patient started 1 unit of pRBCs. . Of note patient was recently admitted from [Date range (1) ] for lower GI bleed thought to be [3-2] tiny mucosal breaks immediately proximal to the dentate line treated with cauterization. A sessile polyp was also found. Patient received 1 unit of pRBCs during this hospitalization. Prior to discharge heparin (which was ordered for DVT prophylaxis after hip fracture) was discontinued however patient was continued on ASA. . In MICU, the pt was administered an additional unit of pRBCs and DDAVP for concern for coagulopathy. CT Ab showed "Thicken bladder wall with high density internal contents, likely hemorrhage or clot" and urology was consulted given concern that hct drop might be due to GU source. Urology replaced the pt's catheter with a 24F Rouche catheter. He was hand irrigated with >1L sterile water and a large amount of clots were removed. He was placed on CBI and urine cytology was requested. Urology noted that once stabilized (without frank hematuria) outpatient cystoscopy would be needed to complete his hematuria workup. The pt continued on dialysis, and during his MICU stay had episodes of delirium/agitation requiring haldol, ativan and zyprexa. The pt was transfered to the [Hospital Ward Name ] on [8-27] for planned cystoscopy on [8-30]. On transfer the pt noted left knee pain, but otherwise did not have any complaints. . Review of systems: Left knee pain. Denies shortness of breath, chest pain, vision changes, nausea, vomiting, diaphoresis, abdominal pain, headache, numbness or change in sensation. Past Medical History: * CKD stage V, on HD MWF * HTN * DM II * Anoxic brain injury * Severe peripheral neuropathy * Glaucoma * Depression Social History: Lives at [Hospital3 537] in JP. niece/HCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Telephone/Fax (3) 105203] 043 Family History: Non-contributory Physical Exam: Vitals: T 98.6, 164/69, 80, 18, 94%RA General: NAD, responsive to verbal command able to answer simple questions 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, 2/6 systolic ejection murmur with radiation to left carotid, rubs, gallops Abdomen: soft, no TTP, no rebound or guarding, +BS, + suprapubic tenderness GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, LUE fistula with bruit 2 PIVs in R UE NEURO: A+Ox1, not oriented to place ("church") or date ("[2111]"). 5/5 strength in upper and lower extremities, sensation grossly intact Pertinent Results: CT AB PELVIS ([2140-8-25]) IMPRESSION: 1. Large fecal load throughout the colon. 2. Colonic wall thickening at the hepatic flexure, likely secondary to prominent haustral fold or peristalsis, correlation with colonoscopy could be considered. 3. Thicken bladder wall with high density internal contents, likely hemorrhage or clot. 4. Pancreatic atrophy with duct dilation, could be better evaluated with MRCP, if clinically indicated. 5. Stable left adrenal enlargement. . . ECG [2140-8-25] Sinus rhythm. Occasional ventricular premature beats. Cytology Report URINE Procedure Date of [2140-8-26] DIAGNOSIS: Urine: NEGATIVE FOR MALIGNANT CELLS. Urothelial cells present singly and in rare clusters, consistent with instrumentation effect. Neutrophils and red blood cells. [2140-8-24] 11:50AM BLOOD WBC-7.7 RBC-2.63* Hgb-6.5* Hct-20.9* MCV-79* MCH-24.8* MCHC-31.2 RDW-15.6* Plt Ct-232 [2140-8-28] 07:00PM BLOOD WBC-8.6 RBC-3.18* Hgb-8.7* Hct-27.1* MCV-85 MCH-27.5 MCHC-32.2 RDW-15.5 Plt Ct-215 [2140-8-29] 06:45AM BLOOD WBC-9.0 RBC-3.38* Hgb-9.3* Hct-28.4* MCV-84 MCH-27.4 MCHC-32.6 RDW-15.8* Plt Ct-222 [2140-8-30] 09:15AM BLOOD WBC-8.8 RBC-3.68* Hgb-10.1* Hct-31.3* MCV-85 MCH-27.6 MCHC-32.5 RDW-15.0 Plt Ct-309 [2140-8-31] 09:11AM BLOOD WBC-9.0 RBC-3.32* Hgb-8.9* Hct-27.7* MCV-84 MCH-26.8* MCHC-32.1 RDW-15.3 Plt Ct-261 [2140-8-29] 06:45AM BLOOD Glucose-86 UreaN-30* Creat-6.9# Na-137 K-5.0 Cl-94 HCO3-28 AnGap-20 [2140-8-30] 09:15AM BLOOD Glucose-126* UreaN-21* Creat-4.5# Na-137 K-5.0 Cl-95 HCO3-31 AnGap-16 [2140-8-31] 09:11AM BLOOD Glucose-146* UreaN-36* Creat-5.7# Na-131 K-5.2* Cl-92* HCO3-31 AnGap-13 [2140-8-26] 04:05AM BLOOD ALT-12 AST-14 AlkPhos-88 TotBili-0.2 [2140-8-24] 11:50AM BLOOD Lipase-23 [2140-8-31] 09:11AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.2 [2140-8-25] 2:42 pm URINE FINAL REPORT [2140-8-26] URINE CULTURE (Final [2140-8-26]): NO GROWTH. [2140-8-24] 6:25 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2140-8-27] MRSA SCREEN (Final [2140-8-27]): No MRSA isolated. Brief Hospital Course: 75 y/o M with HTN, DM, ESRD on HD, anoxic brain injury, recent GI bleed who initially presented to ED for hypotension during dialysis found to have gross hematuria on exam. Patient was admitted to the MICU after noting that hematocrit was down from 26 to 20. Patient transfused one unit of packed RBC on transfer to MICU. Initially, it was thought that patient's bleed was [3-2] GI bleed given recent GI bleed however upon review of presentation, GU bleed appeared more likely. A CT abdomen was completed which showed bladder distension and concern for hemorrhage into bladder. Urology was consulted who recommended continuous bladder irrigation and serial hematocrits. Patient was monitored over course of several days which stable hematocrit. He received a total of 4 units of pRBCs during his time in MICU. Pt was transferred to medical floor, and HCT was followed closely. He did not require further blood transfusion. His urine gradually cleared on CBI with resolution of hematuria. His foley was discontinued and he was able to void. He was scheduled to follow up with Urology as an outpatient for cystoscopy. One other active issue during his MICU stay was agitation, which appeared be [3-2] pain and disorientation. A combination of morphine for pain control (from bladder distention) and zyprexa was used and appeared to control patient's agitation. His acute delirium gradually cleared, and he no longer required zyprexa. # Hypertension, benign At [Name (NI) 1501], pt was previously on amlodipine 10 mg, lisinopril 20 mg, and isosorbide dinitrate 10 mg tid. These were held initially due to hypotension and concern for acute bleeding. After stabilization with blood transfusions, his blood pressure stabilized, and his blood pressure medications were gradually resumed. His lisinopril will be increased at time of discharge from 10 mg po q day back to his home dose of 20 mg po q day. He has been tolerating his other blood pressure medications at home dose, and remains hypertensive. . # DM2: Continued diabetic diet and insulin sliding scale. . # ESRD on HD M/W/F Nephrology followed throughout the hospitalization. He continued hemodialysis on his M/W/F schedule. Last HD [2140-8-31]. - Continued sevelamer, nephrocaps . # Hyperphosphatemia, due to ESRD Pt was noted to have hyperphosphatemia during the admission, which resolved with sevelamer. . # Pain, chronic peripheral neuropathy Pt noted to have pains, likely due to peripheral neuropathy. He was continued on neurontin, which was renally dosing. Started standing tylenol 1g tid. He was continued on lidocaine patch. Medications on Admission: Per last d/c summary 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 4. citalopram 10 mg/5 mL Solution Sig: Fifteen (15) mg PO DAILY (Daily). 5. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 7. PhosLo 667 mg Capsule Sig: One (1) Capsule PO four times a day. 8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO BEFORE DIALYSIS (): 1 hour prior to HD. 9. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) application Topical 1 hour before HD. 10. levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. Neurontin 400 mg Capsule Sig: One (1) Capsule PO at bedtime. 13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 15. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergies. 16. brimonidine 0.2 % Drops Sig: One (1) Ophthalmic every twelve (12) hours: both eyes. 17. Procrit Injection 18. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 19. senna 8.6 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours as needed for constipation. 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 21. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day as needed for constipation. 22. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: [1-31] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 23. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Ten (10) u Subcutaneous qAM: Novolin R sliding scale: <200, no coverage 201-250: 2u 251-300: 4u. 24. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO once a day as needed for agitation: hold for sedation. MEDICATIONS ON TRANSFER: Morphine Sulfate 1-2 mg IV Q4H:PRN pain Nephrocaps 1 CAP PO DAILY Citalopram 20 mg PO/NG DAILY Olanzapine (Disintegrating Tablet) 5 mg PO BID agitation Pantoprazole 40 mg IV Q24H Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Insulin SC (per Insulin Flowsheet) Sliding Scale Order Lidocaine 5% Patch 1 PTCH TD DAILY apply to left knee sevelamer CARBONATE 1600 mg PO TID W/MEALS Allergies: Lovenox Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 6. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. brimonidine 0.2 % Drops Sig: One (1) gtt Ophthalmic [Hospital1 ] (2 times a day): OU. 8. levobunolol 0.25 % Drops Sig: One (1) gtt Ophthalmic twice a day. 9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to left knee . 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation : (has not required for several days). 14. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous QACHS. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: # Acute blood loss anemia # Gross hematuria # Acute Delirium # Hypertension # ESRD on HD M/W/F # DM2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were initially admitted to the ICU due to low blood pressure during hemodialysis. You were found to have significant blood in your bladder. You required blood transfusion and bladder irrigation. The bleeding stopped, and you will need to follow up with Urology as an outpatient. Followup Instructions: Name: [Doctor Last Name ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 37163]: INTERNAL MEDICINE Location: [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] Address: 545A CENTRE ST, [Location (un) ],[Numeric Identifier 6809] Phone: [Telephone/Fax (1) 608] Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge Name: [Last Name (LF) 3748], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 18] - DEPT OF UROLOGY Address: [Last Name (LF) ], [First Name3 (LF) ] 4440, [Location (un) ],[Numeric Identifier 6425] Phone: [Telephone/Fax (1) 3752] When: Thursday [9-15] at 2PM	[ "275.3", "458.21", "365.9", "356.8", "V58.67", "585.6", "V45.11", "250.00", "338.29", "285.1", "293.0", "276.3", "348.1", "403.11", "599.71", "V54.89" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	12361, 12432	5760, 8381	292, 343	12577, 12577	3621, 5737	13063, 13896	2836, 2854		11062, 12338		12453, 12556		8407, 10611			12753, 13040									2870, 3602																		2351, 2515				229, 254									371, 2332								12592, 12729									10636, 11039	2537, 2654	2670, 2820
28,958	190,721	34077	Discharge summary	report	Admission Date: [2103-6-22] Discharge Date: [2103-6-28] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 4071] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: This 88 yo male with a history of CAD presented after a syncopal episode. He was sitting outside on his porch when he felt warm and came inside to sit in his lounge chair. The next thing he remembers is being awakened by his wife shaking him. She had called 911 and they brought him here for evaluation. He was not feeling lightheaded before this episode although he does note that he has been a little lightheaded in the mornings on and off. He had no evidence of seizure and awoke without any lethargy after the episode. He has never had an episode like this in the past. He has generally been feeling well prior to this with no fevers or chills. He is followed closely by his PCP [Last Name (NamePattern4) ]. [First Name (STitle) 1395] who he last saw 4-5 months ago, he last saw his cardiologist Dr. [Last Name (STitle) ] 6 months ago. He says his heart rate is generally 51-59. . In the ED his vitals were; Temp 93.2, Pulse 60s, BP 158/88, RR 20, 100% on 6L. In the ED pacer pads were placed and 4mg Zofran was given. . He generally feels well with no chest pain, shortness of breath, palpitations. His one complaint is hot flashes since his testicular operation. . Past Medical History: 1. Glaucoma - completely blind 2. CAD s/p 4 heart catheterizations, no stents or heart surgery 3. Prostate cancer for which he has never had a positive biopsy but was treated with orchiectomy 4 years ago. No prostate surgery or radiation. 4. Hemorrhoids 5. "Immune deficiency" diagnosed at [Hospital 13128]. . Social History: He used to smoke one pack per day, he quit 45 years ago. He lives with his wife, he used to work as a manager for a manufacturing plant. He rarely has wine . Family History: His mother died of an MI at 81, his brother died of an MI at 41, his father died at 51 of a pneumonia. Physical Exam: VS - Temp 92.8, Pulse 46, BP 157/58, RR 16, 100% on 3L Gen: alert middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 5 cm. CV: PMI located in 5th intercostal space, midclavicular line. Bradycardic, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pertinent Results: EKG demonstrated left bundle branch block, sinus bradycardia at 60, 1st degree AV block, no old to compare. . Labs: [2103-6-22] 04:30PM BLOOD WBC-6.3 RBC-4.14* Hgb-14.1 Hct-41.9 MCV-101* MCH-34.0* MCHC-33.5 RDW-13.5 Plt Ct-208 [2103-6-22] 04:30PM BLOOD Neuts-67.9 Lymphs-22.3 Monos-4.4 Eos-4.9* Baso-0.5 [2103-6-22] 04:30PM BLOOD Plt Ct-208 [2103-6-22] 04:30PM BLOOD PT-11.6 PTT-29.5 INR(PT)-1.0 [2103-6-22] 04:30PM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-107 HCO3-23 AnGap-15 [2103-6-22] 04:30PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0 [2103-6-23] 09:20AM BLOOD TSH-3.0 [2103-6-22] 04:30PM BLOOD CK(CPK)-36* [2103-6-23] 12:30AM BLOOD CK(CPK)-38 [2103-6-23] 09:20AM BLOOD CK(CPK)-48 [2103-6-22] 04:30PM BLOOD cTropnT-<0.01 [2103-6-23] 12:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2103-6-23] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 . CHEST (PORTABLE AP) [2103-6-22]: Single bedside AP examination labeled "semi-erect at 1715 PM" with excessive lordotic positioning and no comparisons on record. Allowing for the factors above, as well as low lung volumes with elevation of the right hemidiaphragm, the lungs are grossly clear. There is prominence of the right paratracheal soft tissues which may represent ectatic brachiocephalic vessels, as the aorta appears tortuous; the cardiomediastinal silhouette is otherwise unremarkable with no evidence of CHF. . TTE [2103-6-26]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal quality. Mildly depressed global left ventricular systolic function. Mild aortic regurgitation. Moderate mitral regurgitation. . CT HEAD W/O CONTRAST [2103-6-27]: There is no hemorrhage, edema, mass effect, or shift of normally midline structures. Detection of a mass is limited given the lack of IV contrast administration and slight patient motion. There is periventricular hypoattenuation consistent with chronic small vessel ischemic disease. The ventricles and sulci are prominent, related to age-expected parenchymal atrophy. Incidental note is made of a left scleral band. The visualized paranasal sinuses are clear. IMPRESSION: 1. No hemorrhage, edema, or mass effect. 2. Chronic small vessel ischemic disease and age-related parenchymal atrophy. . CHEST (PA & LAT) [2103-6-27]: The pacemaker leads terminate in right atrium and right ventricle. The cardiomediastinal silhouette is stable. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: Standard position of the pacemaker leads. No evidence of complications. . Brief Hospital Course: Patient is a 88 year old gentleman who was admitted with syncopal episode and bradycardia. . #. Syncope/Rhythm: His syncopal episode is likely related to his bradycardia/complete heart block. He was admitted with sinus bradycardia, first degree AV block and left bundle branch block. No evidence of seizure activity. He was ruled out for myocardial Infarction with negative cardiac enzymes. His metoprolol was discontinued. His TSH was 3. Patient went into complete heart block with escape rhythm to high teens on [2103-6-25]. He received a total of atropine 2.5 mg IV. His systolic blood pressure decreased from 100s to 70s. He was started on dopamine drip with heart rate increased to 90s. Temporary pacing wire was placed through right femoral approach but patient did not require pacing. Patient was transfered to CCU. He received a pacemaker on [6-26]. His metoprolol was restarted at low dose 25 mg twice a day given questionable history of tachycardia. Patient had small pocket hematoma which was stable at discharge. He received 3 doses of IV vancomycin periprocedure. His antibiotic was switched to clindamycin for 5 days on discharge given penicllin allergy. Patient was recommended rehabilition facility by physical therapy but he refused. Physical therapy worked with him for two session while in hospital. He will go home with VNA and home physical therapy services. . #. Pump: He did not have signs/symptoms of heart failure. Transthoracic echocardiogram showed mild systolic dysfunction (LVEF 45-50%), diastolic dysfunction and moderate mitral regurgitation. Patient was started on low dose lisinopril 5 mg daily and tolerated this well. Metoprolol as above. . #. Increased bowel movements: Patient experienced increased bowel movements after getting milk of magnesia for acid reflux symptoms on day after admission. This resolved with discontinuing milk of magnesia. . #. GI Bleed: Patient had 1 episode of hematemesis on [2103-6-25]. He was otherwise asymptomatic during event and denies any abdominal pain or discomfort. He was started on IV pantoprazole twice a day. He has had occasional guaic positive stools in his stay here. His hematocrit was stable during this stay. He was recommended discussing colonscopy as out patient with his primary care provider. [Name10 (NameIs) ] will be discharged on pantoprazole 40 mg daily. . #. Blindness: He was continued on home eye drops. Pilocarpine drops were transiently held prior to pacemaker palcement. . # Patient received subcutaneous heparin for DVT prophylaxis. . #. Contact: Pt prefers that his daughter [Name (NI) ] [Name (NI) 78620], who lives in RI, be the contact person. [Name2 (NI) ] cell [Telephone/Fax (1) 78621]; work [Telephone/Fax (1) 78622]. Alternative contact is his wife, [Name (NI) 78623], who has Parkinsons [Telephone/Fax (1) 78624]. . Medications on Admission: Cosopt 2%-0/5% Eye Drops Restasis 0.05% Eye Drops Pilocarpine eye drops Acyclovir Ointment Lopressor 125mg PO daily Aspirin 81 mg Flomax 0.4mg oral . Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [Hospital1 ] (2 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Pilocarpine HCl 0.5 % Drops Sig: One (1) Ophthalmic once a day. 8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three times a day for 5 days. Disp:15 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary: Sinus bradycardia Episode of complete heart block with escape rhythm status post pacemaker placement Moderate Mitral Regurgitation Occasional guaic positive stool . Secondary: Coronary artery disease Glaucoma Discharge Condition: Asymptomatic and hemodynamically stable. Discharge Instructions: You were admitted to [Hospital1 69] after passing out. Your symptoms are most likely due to abnormal electrical conduction in your heart called complete heart block. You had a pacemaker placed. . Please take all of the medicaitons as written. Your metoprolol was reduced to 25 mg twice a day. You were started on lisinopril 5 mg daily. You were started on antibiotic called clindamycin three times a day for 5 days to prevent infection around your pacemaker site. You were started on pantoprazole 40 mg daily. . Please keep all of the follow up appointments. . If you develop chest pain, shortness of breath or any other concerning symptoms, please call your primary care doctor or come to the Emergency Department. . It was recommended that you go to a rehabilitation facility to improve your function. You refused to go there and wanted to go home. It was also recommended that you stay in hospital to get 2 to 3 more physical therapy session. You also refused to stay and wanted to go home. You understood the risks and benefits of going home against this advise. Followup Instructions: Cardiology follow up: Dr.[Last Name (STitle) ] was notified regarding your stay here. He asked you to call him next Monday [7-2] to schedule a follow up appointment. His telephone number is [Telephone/Fax (1) 78625]. . Device Clinic follow up (electrophysiology): Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2103-7-5] 10:30 . Primary Care follow up: Dr. [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) ] office will call you on Monday [7-2] to let you know the date and time of your follow up appointment. If you do not hear from them, please call [Telephone/Fax (1) 78626] to find the date and time. Please discuss getting an outpatient colonscopy with your primary care doctor. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4074] Completed by:[2103-6-29]	[ "365.9", "426.0", "998.12", "426.3", "414.01", "427.89", "578.9", "369.00", "E878.1", "424.0" ]	icd9cm	[ [ [] ] ]	[ "37.83", "37.72", "37.78" ]	icd9pcs	[ [ [] ] ]	10141, 10227	6133, 9024	231, 253	10489, 10532	2830, 6110	11661, 11672	1997, 2101		9225, 10118		10248, 10468		9050, 9202			10556, 11638									2116, 2811						12073, 12554																180, 193									281, 1466																		1488, 1805	1821, 1981
10,679	197,143	51192+51193+59322	Discharge summary	report+report+addendum	Admission Date: [2148-5-7] Discharge Date: [2148-5-13] Date of Birth: [2097-9-27] Sex: M Service: TRANS [Doctor First Name 147] HISTORY OF PRESENT ILLNESS: The patient is a 50 year old male status post orthotopic liver transplantation on [2148-3-5], for end stage liver disease secondary to hepatitis C cirrhosis. The patient's post transplantation course was complicated by reactivation of hepatitis C and persistently elevated liver function tests and bilirubin for which the patient was recently hospitalized in the month of [2148-4-1]. The patient underwent an endoscopic retrograde cholangiopancreatography on [2148-4-4], at which time he had a spincterotomy done and a stent placed. The patient underwent a second endoscopic retrograde cholangiopancreatography on [2148-4-19], at which time he had his stent removed. The patient also had left upper extremity deep vein thrombosis for which he was placed on Coumadin and was being followed as an outpatient. The patient was being tested routinely for his laboratory studies including INR and was discovered to have an elevated INR to 5.1 and increased alkaline phosphatase. The patient was contact[Name (NI) ] by the Transplant Office and was advised to be hospitalized for a normalization of the INR and for further work-up of elevated alkaline phosphatase. The patient denied having any nausea, vomiting or diarrhea, nor any fevers or chills. The patient denied having any hematemesis nor bright red blood per rectum nor melena. He was tolerating a p.o. diet and was passing flatus. PAST MEDICAL HISTORY: 1. End stage liver disease secondary to hepatitis C. 2. Cirrhosis status post orthotopic liver transplant on [2148-3-5] complicated by reactivation of hepatitis C and biliary stricture status post endoscopic retrograde cholangiopancreatography with sphincterotomy and stent; status post endoscopic retrograde cholangiopancreatography and removal of biliary stent. 3. Prior to his transplant, the patient has had a history of portal hypertension, gastric varices. 4. Congestive heart failure. 5. Chronic renal insufficiency. 6. Left upper extremity deep vein thrombosis for which he was placed on Coumadin. MEDICATIONS AT HOME: 1. Bactrim Single Strength one tablet p.o. q. day. 2. Regular insulin sliding scale. 3. Valcyte 450 mg p.o. q.o.d. 4. Protonix 40 mg p.o. q. day. 5. Lopressor 25 mg p.o. twice a day. 6. Isordil 30 mg p.o. q. day. 7. CellCept [Pager number ] mg p.o. four times a day. 8. Neoral 75 mg p.o. twice a day. 9. Reglan 5 mg three times a day. 10. Actigall 300 mg p.o. three times a day. 11. Fluconazole 200 mg p.o. q. day. 12. Hydralazine 30 mg p.o. q. day. 13. Prednisone 50 mg p.o. q. day. 14. Humalog 75/25 mixed, 15 units subcutaneously q. a.m. and 4 units subcutaneously q. p.m. 15. Peg-intron 180 micrograms subcutaneously q. weekly. 16. Ribavirin 200 mg p.o. twice a day. 17. Coumadin 2 mg p.o. q. day. ALLERGIES: The patient denies any allergic reactions to medications. PHYSICAL EXAMINATION: On admission, afebrile with temperature 98.8 F.; heart rate of 84; blood pressure 141/92; respiratory rate of 20; 99% on room air. The patient was alert and oriented times three, in no apparent distress; jaundiced with mildly icteric sclerae. Pupils are equal, round and reactive to light and accommodation. Neck was supple and nontender. Cardiovascular examination is regular rate and rhythm, S1, S2, no murmurs were appreciated. Lungs were clear to auscultation bilaterally. Abdomen was soft, mildly tender at epigastric lesion. No rebound, no guarding. Nondistended. Extremities were without any edema, bilateral dorsalis pedis were two plus bilaterally. LABORATORY: Studies on admission with white blood cell count of 3.3, hematocrit of 23.5, platelets of 61. Sodium of 132, potassium of 5.6, chloride 101. Carbon dioxide of 18, BUN 29, creatinine 2.6 and glucose of 240. Calcium 8.2, magnesium 1.4, phosphate 3.9. AST of 133, ALT 38, alkaline phosphatase 987. Total bilirubin 6.5, PT 22.9, PTT 49.0 and INR of 3.5. HOSPITAL COURSE: The patient was admitted for observation because of his elevated INR and obviously decreased hematocrit. The patient received two units of fresh frozen plasma with reduction in INR from 3.5 to 1.7 in the morning of hospital day two. The patient was hydrated and the hematocrit dropped down to 20.8 with stable vital signs. The patient received two additional units of fresh frozen plasma and one unit of platelets giving a platelet count of 54. The patient did not have any melena or bright red blood per rectum and did not drop his blood pressure. The patient's INR was appropriately corrected and hematocrit returned to [Location 213]. The patient underwent ultrasound guided biopsy of the liver to rule out acute cellular rejection and there was no evidence of acute cellular rejection. The patient continued on his immunosuppressive therapy starting on hospital day one, taking Neoral 75 mg p.o. twice a day and CellCept [Pager number ] mg p.o. four times a day and Prednisone 15 mg. The Neoral dose was adjusted as per his morning C2 level, however, these levels tended to fluctuate despite the patient receiving the medication on time. The patient was followed on his liver function test values. The patient peaked to an alkaline phosphatase of 1,041 on hospital day three and the patient received his regularly scheduled Peg-Intron of 150 micrograms subcutaneously in the evening of [5-9], hospital day three. The patient's liver function tests did not significant improve with alkaline phosphatase staying at 1035 and after discussion with Transplant Hepatology, the patient was given a single dose of a short acting Interferon Alpha 2B, three million units subcutaneously times one. Given the patient's history of low platelet count, the patient was observed over the next few days to make sure that his thrombocytopenia did not suffer too greatly and he no longer had further episodes of bleeding. The patient did well otherwise and alkaline phosphatase gradually came down to 846 on the day of discharge, hospital day seven. Given the fact that the patient had recently undergone endoscopic retrograde cholangiopancreatography two times in the month prior to this admission, a repeat endoscopic retrograde cholangiopancreatography was not warranted. The patient did relatively well throughout, tolerating a p.o. diet and he continued on his regular home doses of medication. He is discharged on hospital day seven with close follow-up arranged for the patient. DISCHARGE STATUS: Discharged to home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. End stage liver disease. 2. Hepatitis C cirrhosis status post orthotopic liver transplant. 3. History of deep vein thrombosis on Coumadin with elevated INR and liver function tests. No evidence of acute cellular rejection. No evidence of cholangitis. DISCHARGE MEDICATIONS: 1. Neoral 125 mg p.o. twice a day. 2. CellCept [Pager number ] mg p.o. four times a day. 3. Prednisone 50 mg p.o. q. day. 4. Bactrim Single Strength one tablet p.o. q. day. 5. Valcyte 450 mg p.o. q.o.d. 6. Protonix 40 mg p.o. q. day. 7. Lopressor 25 mg p.o. twice a day. 8. Reglan 5 mg p.o. three times a day. 9. Actigall 300 mg p.o. three times a day. 10. Fluconazole 200 mg p.o. q. day. 11. Hydralazine 30 mg p.o. q. six hours. 12. Isosorbide 30 mg p.o. q. day. 13. Humalog 75/25, 15 units subcutaneously q. a.m. and 4 units subcutaneously q. p.m. 14. Humalog per sliding scale. DISCHARGE INSTRUCTIONS: 1. The patient is to see Dr. [First Name (STitle) ] at the Liver [Hospital 1326] Clinic within one week. 2. The patient is to have his bloods drawn two times a week and every Monday and Thursday by a visiting nurse and the results to be faxed to Transplant Center. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Last Name (NamePattern1) 10201] MEDQUIST36 D: [2148-5-13] 19:06 T: [2148-5-13] 19:08 JOB#: [Job Number 106236] Admission Date: [2148-5-15] Discharge Date: [2148-7-1] Date of Birth: [2097-9-27] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Nausea, vomiting and malaise. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old male status post orthoptic liver transplantation on [2148-3-5] for end-stage liver disease secondary to Hepatitis C cirrhosis. The patient's transplantation course was complicated by reactivation of Hepatitis C and persistently elevated liver function test and bilirubin for which the patient was recently hospitalized in the month of [Month (only) 958] and during that hospitalization had series of endoscopic retrograde cholangiopancreatography wherein he had sphincterotomies and stents placed. He was recently discharged from [Hospital1 69] after being admitted for increased INR and increased liver function tests and the patient's coagulopathy was corrected and the patient was discharged home with slight increase in liver function tests and increased Hepatitis C viral load felt to be responsible for increased liver function tests. The patient was doing very well until the morning of admission on [2148-5-15] where he returned with nausea, vomiting, malaise, no new pain. He still was with baseline discomfort at suture site and had a normal bowel movement at the day of admission. PAST MEDICAL HISTORY: Significant for Hepatitis C, cirrhosis, reactivation of Hepatitis C, enteritis, colitis, gastroenteritis, infections, portal hypertension, hemorrhoids, gastric varices, congestive heart failure, chronic renal insufficiency, deep venous thrombosis, bowel strictures with endoscopic retrograde cholangiopancreatography stents. The patient had a left upper extremity deep venous thrombosis for which he was placed on Coumadin during the last admission. ALLERGIES: The patient denies any allergic reactions to medications. FAMILY HISTORY: The patient's brother had myocardial infarction at age 15, also insulin dependent diabetes mellitus. SOCIAL HISTORY: The patient lives alone at home, has a 15 pack year tobacco history, quit [Holiday ] of [2147]. Does not have any alcohol history. Has a history of remote intravenous drug use years ago. The patient contracted Hepatitis C most likely through sexual contact according to the patient. The patient used to work for the [Company 2318] service. The [Hospital 228] health care proxy is his daughter [Name (NI) 11923], phone number is [Telephone/Fax (1) 106231]. MEDICATIONS: 1. Bactrim single strength q day. 2. Regular insulin sliding scale. 3. Valsite 450 mg q day. 4. Protonix 40 mg q day. 5. Lopressor 25 mg twice a day. 6. Ascorbic Dinitrate 7. CellCept [Pager number ] mg four times a day. 8. Neoral 125 mg q twice a day. 9. Metoclopramide 5 mg three times a day. 10. Estival 300 mg three times a day. 11. Fluconazole 200 mg q day. 12. Hydralazine 30 mg q 6. 13. Prednisone 15 mg q day. 14. Humalog 15 and 4. 15. Interferon 180 mg q week. 16. The patient's Coumadin was on hold. PHYSICAL EXAMINATION: On admission the patient was afebrile at 99.5 with a heart rate of 96 and blood pressure 150/110 with respiratory rate of 30 to 40 and sating 97% on room air. Fingerstick of 158. He was in no acute distress with slight icteric sclera. Alert and oriented times three. Shivering. The patient's heart is regular rate and rhythm. Slight tachycardia with lungs clear to auscultation bilaterally. His abdomen was soft and tender diffusely at baseline. LABORATORY FINDINGS: On admission white count 3.9, crit of 33.7 and platelets 35 with chemistries 133, 5.7, 102, 17, 43, 26 and glucose 185 with a prothrombin time of 13.8, PTT of 39.5 and INR 1.3. AST 29, ALT 119, alkaline phosphatase 803. T-bili of 13. The patient was admitted to the Transplant Service, restarted on his home meds and on hospital day one, Hepatology was consulted and saw the patient and the patient was found to have CVRNA of greater than 700,000 with an echocardiogram of EF 35 to 40% Preoperatively he was greater than 60% The patient had ultrasound to mark biopsy site. The patient had biopsy on hospital day one, which showed focal bile duct proliferation with associated neutral, cannot exclude biliary obstruction, lobular hepatocytes suggestive of early recurrent Hepatitis C, minimal clostasis, no features of acute cellular rejection. At that time on [2148-5-16] the patient continued to have recurrent epistaxis and a chest x- ray that was concerning for volume overload. The patient's node was packed and the patient was started on Lasix at that time. Cardiology was consulted for shortness of breath, fever, or congestive heart failure and electrocardiogram changes in Leads 1, 2, AVL, V4 to V6 with biphasic V3 and they suggested aggressive diuresis, increasing Imdur and Hydralazine with addition of Lopressor. Infectious Disease was also consulted on patient for reactivation of Hepatitis C and inability to tolerate p.o's and increased checking CMV levels, rapid viral nasal washings, Legionella, fractioned bili, and cover with Levofloxacin which was done. The patient was admitted to SICU on [2148-5-16] for respiratory distress, the patient was shortness of breath with labored breathing and right chest tube was placed for significant effusion at that time. The patient was covered with Fluconazole, Bactrim and Levaquin while in the unit. Lasix dose was decreased on hospital day 3, SICU day 2. Pulmonary was consulted. Beta-blockade was restarted, Nitroglycerin drip was stopped. ID continued to see patient and because of low filling pressures Lasix was held at that time. The patient had Pulmonary consult, bronchoscopy done showing normal airways with sanguinous return from BAL and Lingula and right middle lobe. The patient was started on trophic tube feeds on [2148-5-19]. The patient was noted to be in acute renal failure by hospital day four, SICU day three. Lasix was held. The patient remained intubated throughout [5-21], hospital day six, SICU day five and was attempted to wean to extubate by SICU day five. A Swan-Ganz was changed and pulled a catheter by [2148-5-21]. The patient had liver biopsy on SICU day six, hospital day seven. The patient was extubated by [2148-5-22] and transferred to the floor on [2148-5-22] with improved respiratory status by clinical examination and chest x-ray. Hematology was consulted for low platelet count which showed no evidence of microangiopathy, hip was negative, platelets continued to be stable. OT/PT continued to see the patient throughout hospital course. The patient was confused with some fevers. Had a head CT that was negative on hospital day 11. The patient was started on Linezolid p.o. twice a day for bacteremia [2148-5-30]. Nutrition was still an issue by [2148-5-31] as the patient only took in 260 calories with 8 grams of protein. The patient on [2148-6-1] again having altered mental status and shaking chills with fevers and rigors had a temperature T-max of 102.6, right IJ line was placed and the patient was transferred to the Unit where chest x-ray showed possible hospital acquired pneumonia. The patient was in unit for three days and was started back on Zosyn along with Vancomycin, was transferred back to the floor on [2148-6-2], hospital day 19. The patient was continued on Vancomycin and Zosyn. Urine cultures were negative. Sputum was contaminant. The patient was continued on antibiotics. Hepatology continued to see patient and recommended thoracentesis which ws done and was also negative. C. Diff was negative as well. The patient had persistent right pleural effusion. Blood cultures were no growth from [2148-6-5]. The patient continued on tube feeds of ProMod 45 cc's an hour. ENT was consulted for the recurrent epistaxis and recommended humidified air with Afrin. On hospital day 28, vancomycin day 12, Zosyn day 8, the patient started to improve but continued to have low grade fevers at 100 and spiked to 101.4 on Vancomycin day 14, Zosyn day 20. Antibiotics were stopped at this time with the thinking that it was antibiotic related fever and central line was discontinued hospital day 30. The patient continued to have low grade fevers however, the patient's fevers resolved however, the patient spiked again on hospital day 31 to 102. Pleural fluids again thoracenteses and was negative. The patient had CT scan of the abdomen on hospital day 33, showed two new fluid collections in abdominal wall. These were incision and drainage and a wound was open and debrided packed with wet-to-dry dressings. Liver biopsy was again performed on [2148-6-17] which showed marked bile duct proliferation with associated neutrophils, mild portal, mononuclear inflammation with scattered hepatocytes consistent with Hepatitis C. No acute scleral rejection. Mild increase in portal fibrosis, mild iron deficiency and predominantly [Last Name (un) 95709] cells. The patient was CMV negative on [2148-6-18]. C diff continued to be negative. Started to have rehabilitation screening, was afebrile, the patient's confusion decreased when the patient's Reglan was stopped. The wound was continued to be packed with wet-to-dry. Chest tube site was also debrided and packed wet-to-dry. The patient received physical therapy throughout hospital course and Thoracic surgery was consulted on [2148-6-24] for persistent right pleural effusion, since it was loculated the patient would have to undergo open procedure such as a VATs to wash out this effusion and it was also aseptic. Thoracic Surgery recommended no surgery at that time and it was unlikely the right sided effusion was the cause of fevers. CellCept was held for four days for low white counts on hospital day 48. On hospital day 49 the patient had liver biopsy and was discharged to [Hospital ] Rehabilitation Center in good condition without complications and was instructed to have wet-to-dry dressings three times daily on right sided chest tube site and also wound packing wet-to-dry twice a day at [Hospital ] Rehabilitation. Have labs drawn at least twice weekly. Rhabdomycin level, CBC, LFTs, Chem 7 and follow-up within one week to Transplant Center. The patient was also discharged on medications of: 1. Accupril 300 mg three times a day. 2. Zofran 2 to 4 mg intravenous q 6. 3. Bactrim one tab p.o. q day. 4. Prednisone 2.5 mg p.o. q day. 5. Lopressor 25 mg p.o. twice a day. 6. Lasix 40 mg p.o. twice a day. 7. Hydralazine 50 mg p.o. q 6. 8. Imdur 10 mg p.o. three times a day. 9. Epoetin 10,000 units subcutaneously three times a week, Monday, Wednesday and Friday. 10. Sodium chloride nasal spray. 11. Morphine sulfate 2 mg intravenous q 4. 12. Pepcid 20 mg p.o. q day. 13. Levothyroxine 50 mcg p.o. q day for a TSH That was checked on hospital day 46 that showed TSH of 12. 14. Regular insulin sliding scale and 6 units of NPH. 15. Rhodomycin 1 mg 16. CellCept [Pager number ] mg twice a day. The patient's culture data from admission is as follows. [5-16] - urine negative. [5-16] - blood culture negative. [5-16] - CMV, no CMV detected. Urine viral culture - no virus isolated on [2148-5-17]. [2148-5-17] - Legionella urinary antigen negative. [5-17] - aspirate negative for insulins and negative for respiratory virus, negative for influenza viral antigen. Bronchial washings showed gram stain 1+ PMNs, no microorganisms. Respiratory culture - sparse growth oropharyngeal flora. Legionella culture was no Legionella. KOH negative for fungal elements. Immunofluorescent test. Fungal culture no fungus. No acid fast bacilli, no microbacterium, negative for influenza, negative RSV, negative for influenza viral antigen. Swab for VRE showed enterococcus moderate growth, sensitive to chloramphenicol Vancomycin resistant. MRSA screen on [5-20] showed no staph aureus isolated. HCV viral load showed greater than 70 million units on [2148-5-23]. On [2148-5-24] blood cultures showed coag negative staph and sensitive to Clindamycin, Erythromycin, Gentamicin and Oxacillin. [2148-5-24] urine culture was negative. [5-24] - blood culture serology, Group B Cryptococcus antigen was not detected. Catheter tip showed coag negative staph, sensitive to Clindamycin, Erythromycin, Gentamicin and Oxacillin. Coag negative staph from aerobic bottle and no growth from anaerobic bottle [2148-5-25]. The [2148-5-25] fungal culture was negative with coag negative staph. Blood cultures from [5-26] and [5-27] were negative. C. Diff from [5-30] was negative. Urine culture from [6-1] was negative. Blood culture from [6-1] was negative. Blood fungal culture from [6-1] pending still. Blood culture from [6-1] negative. Urine culture from [6-1] negative. Sputum from [6-1] contaminant. Stool from [6-2] C. Diff was negative. [6-3] blood cultures negative swab, viral swab negative. Pleural fluid from [6-3] showed no growth. No PMN's, no mycobacterium. HCV viral load from [6-6] showed greater than 70 million. Catheter tip from [6-11] negative. Urine culture and blood cultures from [6-11] to [6-13] - negative. CMV from [2148-6-14] was negative. Blood cultures from [6-13] to [6-14], urine cultures from [6-13] to [6-16] negative. Pleural fluid from [6-15] negative. Wound abscess [6-19] was no growth as well as [2148-6-25]. Rare growth of coagulase staph, no anaerobes. The patient is instructed to follow-up with Transplant Center at next available visit and call for any questions. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 4841] Dictated By:[Doctor Last Name 9174] MEDQUIST36 D: [2148-7-1] 21:13:54 T: [2148-7-2] 09:59:02 Job#: [Job Number 106237] Name: [Known lastname 17298], [Known firstname ] Unit No: [Numeric Identifier 17299] Admission Date: [2148-5-15] Discharge Date: [2148-7-3] Date of Birth: [2097-9-27] Sex: M Service: [Last Name (un) ] HOSPITAL COURSE: Since the time of dictation, the [Hospital 1325] hospital course is only remarkable for replacement of Dobbhoff feeding tube. Upon discharge, the patient was afebrile with stable vital signs and a physical exam remarkable for a soft, yet distended abdomen with an open abdominal wound packed with wet gauze. DISCHARGE MEDICATIONS: 1. Ursodiol 300 p.o. t.i.d. 2. Bactrim one tablet p.o. q.d. 3. Prednisone 2.5 mg p.o. q.d. 4. Lopressor 25 mg p.o. b.i.d. 5. Lasix 40 mg p.o. b.i.d. 6. Hydralazine 15 mg p.o. q.6. 7. Imdur 10 mg p.o. t.i.d. 8. Epoietin alpha 10,000 units/mL one injection Monday, Wednesday, Friday. 9. Pepcid 20 mg p.o. q.d. 10. Synthroid 50 mcg p.o. q.d. 11. CellCept [Pager number ] mg p.o. b.i.d. 12. Sirolimus 1 mg p.o. q.d. 13. Regular insulin-sliding scale as per flow sheet sliding scale. DISCHARGE DIAGNOSES: Hepatitis C cirrhosis. End-stage liver disease status post orthotopic liver transplant. FOLLOW-UP PLANS: The patient is to followup at Liver [Hospital 2247] Clinic next Wednesday. Patient is to get tube feeds delivered full strength with ProMod at 45 cc/hour and regular diet is to be encouraged. Patient is to have wet-to- dry dressing changes b.i.d. in the abdominal wound and chest tube site. The patient is to have twice weekly laboratories drawn and medications dosed appropriately. DISCHARGE DISPOSITION: To [Hospital6 908]. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 16979] Dictated By:[Last Name (NamePattern1) 17309] MEDQUIST36 D: [2148-7-3] 17:31:00 T: [2148-7-4] 05:23:11 Job#: [Job Number 16904]	[ "584.5", "789.5", "571.5", "070.54", "996.82", "486", "428.0", "511.9", "287.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.04", "96.04", "99.07", "99.05", "50.11", "34.91", "54.91", "33.24", "89.64", "96.6" ]	icd9pcs	[ [ [] ] ]	23895, 24155						10120, 10222	23372, 23462	22839, 23350					22502, 22816		7633, 8337					2268, 3056																11312, 22484				23480, 23871						8355, 8386									8415, 9557																		9580, 10103	10239, 11289	6703, 6710
15,877	166,617	44303+58702+58703+58704+58705	Discharge summary	report+addendum+addendum+addendum+addendum	Admission Date: [2186-2-6] Discharge Date: [2186-2-24] Date of Birth: Sex: Service: SURGICAL HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old male with a remote history of ulcerative colitis which has not been active for about three years when he was on medication. The patient was followed by Dr. [Last Name (STitle) 94995]. The patient developed dull abdominal pain about seven days, mostly over the lower abdomen. The pain had been progressively increasing in intensity, nonradiating. He denied fever but had chills yesterday. No nausea, vomiting, diarrhea, bright red blood per rectum, or dysuria. Normal bowel movements. The pain increased on the night of admission, and he came for evaluation. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. History of depression. Coronary artery disease. Status post catheterization in [2182] which showed mild left anterior descending disease, diffusely, ejection fraction of 45%. History of ulcerative colitis. ALLERGIES: PENICILLIN. MEDICATIONS ON ADMISSION: Atenolol 50 mg q.d., ................. 10 mg q.d., Imdur 30 mg q.d., Lipitor 20 mg q.d., Lisinopril 40 mg q.d. SOCIAL HISTORY: The patient is married, and he lives with his wife and two children. No tobacco or alcohol use. PHYSICAL EXAMINATION: Vital signs: Temperature 99.9??????, pulse 85, blood pressure 173/100, respirations 16, oxygen saturation 94%. General: The patient was in no acute distress. HEENT: Normocephalic, atraumatic. Sclera anicteric. Neck: Supple. No lymphadenopathy. Cardiovascular: Regular, rate and rhythm. No murmurs. Normal S1 and S2. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, distended, tender diffusely to palpation, but mostly over the lower abdomen, right greater than left. Positive guarding and rebound. Rectal: Normal tone. Guaiac negative. Extremities: Exam showed 2+ dorsalis pedis and posterior tibial pulses bilaterally. Neurological: Grossly intact. LABORATORY DATA: White count 10.6, otherwise CBC and electrolytes, and LFTs were normal, as well as amylase and lipase. Abdominal CT was performed showing an inflamed appendix and an incidental 5.6 x 6.6 cm abdominal aortic aneurysm. No free air was noted. HOSPITAL COURSE: The patient was admitted to Dr.[Name (NI) 20848] surgical service. The patient was left NPO and on intravenous fluids and started on intravenous antibiotics. He was taken on [2186-2-6], to the Operating Room where a laparoscopic appendectomy was performed. Postoperatively the patient did not arouse well and was therefore sent to the PACU intubated. The patient was placed on TP while on the PACU but became stridoress and had a decreased oxygen saturation and was therefore revented for respiratory control. The patient did have an increase in oxygen saturation and more comfort in breathing. His was resedated on Propofol to prevent him from biting on the endotracheal tube. Cardiac enzymes were sent to rule out myocardial infarction. They did turn out to be negative. The patient was on Levaquin and Flagyl immediately postoperatively. On postoperative day #1, the patient was weaned and extubated in the Intensive Care Unit. The patient completed his myocardial infarction rule-out protocol. Over the next couple of days, the patient began to become agitated and have respiratory difficulty. He was given Lasix in the hopes that it was caused by fluid overload. However, on the afternoon of the 21st, his mental status was so bad that the patient was moved back to the Intensive Care Unit for close monitoring and possible intubation, as well as treatment for delirium tremens. Multiple agents were used to control the patient's agitation, including Ativan, Haldol, and Clonidine patch. The patient also experienced extreme high blood pressure and a number of agents were used to control this, including Lopressor and Nitroglycerin. The patient was reintubated on the 24th as his agitation peaked, and his respiratory distress had peaked with inability to oxygenate him. Over the course of the next several days, the patient was repeatedly tried to be weaned from his ventilator but was unsuccessful. He also continued to spike temperatures daily. Multiple cultures were sent, and he did have gram-positive cocci in his blood cultures, as well as yeast in his sputum. He remained on a number of agents including Vancomycin, Levaquin, Flagyl, and Fluconazole. A CT was performed to evaluate for possible intra-abdominal causes of the persistent fever. A right subdiaphragmatic collection was found and was eventually drained. However, the patient continued to spike fevers and persistently failed extubation attempts. He was finally started on TPN, as the patient had not been getting any nutrition. This was performed on [2-17]. On that same day, an extensive rash appeared on his body, believed to be consistent with a drug rash. All of his antibiotics were therefore discontinued. Further sputum samples revealed persistent positive gram-positive cocci. The patient was started on Linezolid. Over the course of the next few days, the patient did not make much progress, and it was decided that the patient would eventually need tracheostomy and PEG tube placement. This was discussed with the family, and at that time, it was decided in conjunction with the family, that the patient would be transferred over to the Medical Intensive Care Unit under the direction and care of the Medical Intensive Care Unit attending. Transfer occurred on [2186-2-25]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Last Name (NamePattern4) 12487] MEDQUIST36 D: [2186-2-27] 12:53 T: [2186-2-27] 13:03 JOB#: [Job Number 94996] Name: [Known lastname 7308], [Known firstname 140] Unit No: [Numeric Identifier 15031] Admission Date: [2186-2-25] Discharge Date: [2186-2-28] Date of Birth: Sex: Service: ADDENDUM: This is an Addendum to the previous Discharge Summary. It will include the dates from [2186-2-25] through [2186-2-28]. Briefly, this is a 76-year-old male admitted on [2186-2-6] with acute gangrenous appendicitis with subsequent intraoperative perforation. The patient failed extubation postoperatively and was started on vancomycin, levofloxacin, and Flagyl. The patient was extubated on [2186-2-8] with subsequent reintubation on [2186-2-10] for desaturation. His postoperative course was complicated by fevers. He was continued on vancomycin and levofloxacin with a resultant rash, and the antibiotics were eventually changed to linezolid. On [2186-2-22] the patient was still failing to wean from the ventilator. A Pulmonary consultation was obtained, and a chest x-ray demonstrated persistent bilateral pleural effusions. Due to inability to wean the patient off the ventilator, the patient was scheduled for a tracheostomy and percutaneous endoscopic gastrostomy tube. On [2186-2-25] the care was transferred to the Medical Intensive Care Unit Service. Upon presentation to our service, the patient was on ventilator settings of continuous positive airway pressure plus pressure support 700 X 15 with a positive end-expiratory pressure of 8, a FIO2 of 0.5, with 4 of pressure support. He was saturating at 96% on a propofol drip of 40 per hour with an arterial blood gas of 7.41, PCO2 of 50, and a PO2 of 113. The patient appeared clinically over sedated and under diuresed. We increased the Lasix to 40 mg intravenously twice per day, started Diamox for metabolic alkalosis, and weaned the propofol sedation to off. Subsequently, the patient was able to be successfully extubated after a rapid shallow breathing index score of 28 on [2186-2-27]. The extubation was successful with the patient being able to tolerate a shovel mask to maintain adequate oxygenation. The patient's fluid status was markedly improved, and he was felt to be at euvolemic status on [2186-2-28]. From an Infectious Disease point of view, he completed a 7-day course of linezolid for methicillin-resistant Staphylococcus aureus positive sputum. The arterial line was discontinued on [2186-2-28]. From a cardiac standpoint, the patient was restarted on aspirin and statin. An ACE inhibitor was considered but not initiated at this time. From a nutrition standpoint, the percutaneous endoscopic gastrostomy tube was not needed as the patient was able to tolerate fluid by mouth with no signs of aspiration. Of note, however, the tube feeds which had been at goal of 50 per hour were weaned to off as the nasogastric tube was removed. Of note, the patient's neurologic status was suboptimal compared with his baseline (per discussions with his wife). It was the opinion of the Medical Intensive Care Unit team that this represented a global decline in cognition, status post a 20-day complicated hospital course with intubation, as the patient's mental status was rapidly improving off of the propofol. It is also likely that due to the patient's underlying hepatic insufficiency, the clearance of the propofol would be markedly diminished. There were no focal findings on neurologic examination, and the patient did have a normal computerized axial tomography of the head on [2186-2-10]. On [2186-2-28] the care of the patient was transferred to the medical floor team. DR.[First Name (STitle) ],[First Name3 (LF) 126] 12-675 Dictated By:[Last Name (NamePattern1) 3139] MEDQUIST36 D: [2186-2-28] 14:11 T: [2186-2-28] 14:54 JOB#: [Job Number 15032] Name: [Known lastname 7308], [Known firstname 140] Unit No: [Numeric Identifier 15031] Admission Date: [2186-2-25] Discharge Date: [2186-2-28] Date of Birth: Sex: Service: ADDENDUM: This is an Addendum to the previous Discharge Summary. It will include the dates from [2186-2-25] through [2186-2-28]. Briefly, this is a 76-year-old male admitted on [2186-2-6] with acute gangrenous appendicitis with subsequent intraoperative perforation. The patient failed extubation postoperatively and was started on vancomycin, levofloxacin, and Flagyl. The patient was extubated on [2186-2-8] with subsequent reintubation on [2186-2-10] for desaturation. His postoperative course was complicated by fevers. He was continued on vancomycin and levofloxacin with a resultant rash, and the antibiotics were eventually changed to linezolid. On [2186-2-22] the patient was still failing to wean from the ventilator. A Pulmonary consultation was obtained, and a chest x-ray demonstrated persistent bilateral pleural effusions. Due to inability to wean the patient off the ventilator, the patient was scheduled for a tracheostomy and percutaneous endoscopic gastrostomy tube. On [2186-2-25] the care was transferred to the Medical Intensive Care Unit Service. Upon presentation to our service, the patient was on ventilator settings of continuous positive airway pressure plus pressure support 700 X 15 with a positive end-expiratory pressure of 8, a FIO2 of 0.5, with 4 of pressure support. He was saturating at 96% on a propofol drip of 40 per hour with an arterial blood gas of 7.41, PCO2 of 50, and a PO2 of 113. The patient appeared clinically over sedated and under diuresed. We increased the Lasix to 40 mg intravenously twice per day, started Diamox for metabolic alkalosis, and weaned the propofol sedation to off. Subsequently, the patient was able to be successfully extubated after a rapid shallow breathing index score of 28 on [2186-2-27]. The extubation was successful with the patient being able to tolerate a shovel mask to maintain adequate oxygenation. The patient's fluid status was markedly improved, and he was felt to be at euvolemic status on [2186-2-28]. From an Infectious Disease point of view, he completed a 7-day course of linezolid for methicillin-resistant Staphylococcus aureus positive sputum. The arterial line was discontinued on [2186-2-28]. From a cardiac standpoint, the patient was restarted on aspirin and statin. An ACE inhibitor was considered but not initiated at this time. From a nutrition standpoint, the percutaneous endoscopic gastrostomy tube was not needed as the patient was able to tolerate fluid by mouth with no signs of aspiration. Of note, however, the tube feeds which had been at goal of 50 per hour were weaned to off as the nasogastric tube was removed. Of note, the patient's neurologic status was suboptimal compared with his baseline (per discussions with his wife). It was the opinion of the Medical Intensive Care Unit team that this represented a global decline in cognition, status post a 20-day complicated hospital course with intubation, as the patient's mental status was rapidly improving off of the propofol. It is also likely that due to the patient's underlying hepatic insufficiency, the clearance of the propofol would be markedly diminished. There were no focal findings on neurologic examination, and the patient did have a normal computerized axial tomography of the head on [2186-2-10]. On [2186-2-28] the care of the patient was transferred to the medical floor team. DR.[First Name (STitle) ],[First Name3 (LF) 126] 12-675 Dictated By:[Last Name (NamePattern1) 3139] MEDQUIST36 D: [2186-2-28] 14:11 T: [2186-2-28] 14:54 JOB#: [Job Number 15032] Name: [Known lastname 7308], [Known firstname 140] Unit No: [Numeric Identifier 15031] Admission Date: [2186-2-6] Discharge Date: [2186-3-11] Date of Birth: [2109-6-8] Sex: M Service: HOSPITAL COURSE SINCE PREVIOUS DICTATION: 1. Altered mental status: The patient was transferred to the general Medical floor from the Medical Intensive Care Unit on [2186-2-28], with notable confusion since extubation. On admission to the floor he was noted to have poor short term memory with difficulty with higher functional thinking. The etiology of the patient's confusion was considered to be likely secondary to Intensive Care Unit psychosis and an effect of sedation for three weeks while intubated. This was also suggested by no focal findings on neurological examination. A vitamin B12, folate, TSH and RPR were drawn while the patient was in the unit and these were all negative. The patient's mental status was followed throughout his time on the Medical floor. He was noted to improve somewhat but then began to plateau. When the patient was transferred to the Medicine Service he appeared agitated and was kicking nurses and co-workers. [Name (NI) ] the recommendation of the Medicine attending and given the patient's history of alcoholism, it was decided to place the patient on a standing dose of Serax with Ativan p.r.n. Over the next several hospital days the patient continued to be agitated and confused as well as disinhibited and, at times, in appropriate. A Psychiatry consult was called. They thought that the patient's clinical presentation was most consistent with a delirium likely from his sedation but also contributed to by his benzodiazepines. Therefore, the patient's Serax and Ativan were discontinued and he was placed on a small standing dose of Haldol 1 mg p.o. b.i.d. with Haldol p.r.n. for excessive agitation. The patient improved dramatically on this regimen and was noted to be alert and oriented, answering questions appropriately, following commands. The patient required very little p.r.n. Haldol and his mental status improved significantly over his hospital course. An electroencephalogram was obtained that was significant for global encephalopathy and consistent with delirium. Again, the etiology of the patient's confusion was considered likely secondary to Intensive Care Unit psychosis and a full recovery is anticipated with time. A head CT was obtained on the floor and this was noted to be negative. The patient did not have any focal neurologic findings throughout his hospitalization. 2. Pulmonary: The patient was admitted to the Medicine floor status post extubation on [2186-2-27], after a reportedly difficult wean in the Surgical Intensive Care Unit. The patient had adequate oxygen saturations on four liters and was titrated down to room air but continued good oxygen saturations. The patient was noted to have occasional wheezing on examination consistent with his prior history of reactive airway disease and he was continued on a Combivent inhaler p.r.n. as well as aspiration precautions. 3. Infectious Disease: The patient was transferred from the Medical Intensive Care Unit having been afebrile for the last three days. While in the MICU he was on a seven day course of linezolid which was discontinued per the recommendation of the Infectious Disease consult team. During his stay on the general Medical floor, the patient was noted to have low grade fevers several days after his transfer. Blood cultures and urine cultures were negative throughout his stay on the floor. A chest x-ray showed no consolidation and lung examination was clear. The patient did not have any localizing signs or symptoms and antibiotics were held. Given continuing daily transient low grade fevers on the floor, the patient had an abdominal CT given that he was status post an urgent complicated appendectomy. This abdominal CT was negative for any abscesses or bowel pathology but was significant for a right pleural effusion. A repeat PA and lateral chest x-ray with decubitus films was consistent with a moderate right pleural effusion. An Infectious Disease consult was obtained on [2186-3-8]. The Infectious Disease team agreed with withholding antibiotics given his dramatic improvement and the clinical picture but recommended a possible thoracentesis of this pleural effusion. However, given the patient's clinical improvement over the last several days and weighing the risks of the invasive procedure versus the potential benefits, the Medicine team decided to hold off on the thoracentesis at the present time. Over the remaining several days the patient was noted to be afebrile and he did not require any further treatment with antibiotics. 4. Cardiovascular: Patient was completely hemodynamically stable and normotensive while on the Medicine floor up until [2186-3-8], when he was noted overnight to be hypertensive to 160/95 and tachycardic to 140. An EKG obtained at that time was consistent with sinus tachycardia. Over the following two days the patient had transient episodes of hypertension and tachycardia, usually in the evening and typically associated with flushing and diaphoresis. The etiology of these episodes is unclear at this time. His episodes of paroxysmal hypertension were thought possibly related to carcinoid syndrome of pheochromocytoma; however, it would be unusual to have carcinoid without findings on abdominal CT. Furthermore, there was no evidence of carcinoid on the Pathology report from the appendectomy. A 24 hour urine collection was started for catecholamines and 5-HIAA but was complicated by the patient's condom catheter following off repeatedly. Once the patient received a Foley catheter, a 24 hour urine collection was initiated; however, the results of this are pending at this time. The patient was started on a low dose for lisinopril for blood pressure control and over the final two days of his hospitalization was noted to be normotensive and without episodes of hypertension, tachycardia and low grade fever. 5. Genitourinary: The patient was also noted to have several episodes of urinary retention requiring Foley catheter placement. A review of the patient's medications revealed no medications such as anticholinergics that are typically associated with urinary retention. The rectal examination was notable only for a mildly enlarged non-tender prostate. The patient's urine output was monitored over the following days and was noted to increase; however, several days later the patient reported pain on urination and was holding his urine. A Foley catheter was therefore placed again with a return of 750 cc of urine. The Urology consult service was contact[Name (NI) ] by telephone and they recommended outpatient follow up. The etiology of the patient's urinary retention was considered likely secondary to trauma from multiple catheterizations and given that the patient passed several blood clots once his Foley catheter was placed. It was therefore decided on his last hospital day to keep the Foley catheter in so that his urethral lining would heal before attempting a voiding trial. It is anticipated that the patient will follow up with Urology as an outpatient if his urinary retention continues. He was started on Flomax on the day prior to discharge and was noted to have a brisk and normal urine output through the Foley catheter. 6. Rehabilitation: The patient was evaluated by the Physical Therapy and Occupational Therapy services throughout this admission. They noted dramatic improvement in his functional status and feel that he is an excellent candidate for physical therapy and rehabilitation. The patient demonstrated an ability to sit in a chair and to take several steps with a walker prior to discharge. He will require intensive rehabilitation after being intubated and sedated for three weeks in the Intensive Care Unit. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: Patient is discharged to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Status post appendectomy for acute gangrenous appendicitis. 2. Intensive Care Unit psychosis. 3. Hypertension. 4. Hypercholesterolemia. 5. Deconditioning. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Haldol 1 mg p.o. b.i.d. 3. Lisinopril 5 mg p.o. q. day. 4. __________________ 0.4 mg sustained release p.o. q. hs. 5. Combivent inhaler one to two puffs inhaled q. 6h. p.r.n. wheezing. FOLLOW UP: Patient will be followed by the physicians at the extended care facility. He is instructed to call Dr. [First Name (STitle) 4255], his primary care physician, [Name10 (NameIs) ] schedule a follow-up appointment within one to two weeks after discharge. It is anticipated that Dr. [First Name (STitle) 4255] will arrange a follow up with the urologist as needed if the patient's symptoms of urinary retention continue. [First Name11 (Name Pattern1) 126] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 15033] Dictated By:[Last Name (NamePattern1) 831] MEDQUIST36 D: [2186-3-10] 16:44 T: [2186-3-10] 17:22 JOB#: [Job Number 15034] Name: [Known lastname 7308], [Known firstname 140] Unit No: [Numeric Identifier 15031] Admission Date: [2186-2-6] Discharge Date: [2186-3-15] Date of Birth: [2109-6-8] Sex: M Service: [Location (un) ] HOSPITAL COURSE SINCE PREVIOUS DICTATION: 1. Altered mental status: Patient's mental status continued to improve throughout the remainder of his admission since his transfer from the ICU and once his benzodiazepines were discontinued. He had several episodes of anxiety with hypertension and tachycardia as well as flushing that were considered secondary to panic attacks. The patient was therefore placed on a low dose Zyprexa at night, which resulted in cessation of the panic attacks and resolution of his insomnia. The patient was also started on Prozac, which he had been taking previously as an outpatient. 2. Infectious disease: The patient was noted to have occasional low-grade fevers, but eventually defervesced over the remainder of his hospitalization. Several days prior to admission, a urine sample was positive for over 100,000 gram-negative rods,medial and the patient was placed on levofloxacin for UTI. The patient should receive levofloxacin for a two-week course for what is considered a complicated UTI as the patient had a Foley catheter. 3. Cardiovascular: Patient was hemodynamically stable throughout the remainder of his hospitalization. As noted on the previous discharge summary, he was started on a low dose ACE inhibitor. A beta blocker was subsequently added given some elevation in his heart rate. 4. GU: A Foley catheter was continued for the patient's previously mentioned history of urinary retention. He will need a voiding trial after discharge once his urethra has healed, and his Foley can be discontinued. It would be helpful to have Urology consulted once the patient is discharged in order to comment on his urinary retention and incase he needs a Foley placed again. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Patient is discharged to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Status post urgent appendectomy for acute gangrenous appendicitis. 2. Intensive Care Unit psychosis. 3. Hypertension. 4. Hypercholesterolemia. 5. Deconditioning. 6. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Lisinopril 5 mg p.o. q.d. 3. Tamsulosin 0.4 mg p.o. q.h.s. 4. Combivent 1-2 puffs inhaled q.6h. prn wheezing. 5. Olanzapine 2.5 mg p.o. q.h.s. 6. Simethicone 40-80 mg p.o. q.i.d. prn gas. 7. Fluoxetine 10 mg p.o. q.d. 8. Metoprolol 12.5 mg p.o. b.i.d. 9. Levofloxacin 500 mg p.o. q.d. x11 days. FOLLOWUP: The patient will be followed by the physicians at the rehabilitation facility. He should call his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 4255] to schedule a follow-up appointment within 1-2 weeks after discharge. [First Name11 (Name Pattern1) 126] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 15033] Dictated By:[Last Name (NamePattern1) 831] MEDQUIST36 D: [2186-3-15] 11:26 T: [2186-3-15] 11:35 JOB#: [Job Number 15035]	[ "402.91", "599.0", "518.5", "428.0", "291.0", "303.90", "540.1", "038.8", "788.20" ]	icd9cm	[ [ [] ] ]	[ "00.14", "99.15", "54.91", "96.6", "96.04", "47.01", "96.72", "38.93" ]	icd9pcs	[ [ [] ] ]								25126, 25320	25343, 26246				1085, 1197	2295, 14006																	22263, 23327						1335, 2277	21739, 21818																		161, 760								23343, 25001										783, 1058	1214, 1312	25026, 25105
49,925	108,652	40881	Discharge summary	report	Admission Date: [2152-6-14] Discharge Date: [2152-8-23] Date of Birth: [2101-2-27] Sex: M Service: SURGERY Allergies: Nafcillin / Zosyn / Sulfa (Sulfonamide Antibiotics) / meropenem / tacrolimus Attending:[First Name3 (LF) 695] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2152-6-21] ex lap, LOA [6-28]//12 transjugular liver biopsy [2152-6-30] IR drain placement of right and left fluid collection [2152-7-5] left abdominal drain removed [2152-7-6] Left abdominal drain placed [2152-7-12] LUQ drain placed History of Present Illness: 51M s/p 51M s/p ABOI liver transplant on [2152-1-15] c/b postop abdominal abscesses and hepatic artery stenosis on coumadin presents with 1 day history of worsening abdominal pain and decreased ostomy output. The patient reports he was feeling fine until this morning when he began to have chills at 2:30 am. He subsequently had 3 episodes of non-bilious emesis. He also reports that his abdomen has become progressively more distended from yesterday. He endorses recurrent hicups since this AM. He reports that he has not had any ostomy output since yesterday evening. He has been recording his drain output which have consistently been 30cc per day. His drain output has changed in appearence from dark tea color to dark yellow in the past few days. ROS: (+) per HPI (-) Denies fevers, night sweats, unexplained weight loss, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: HCV/EtOH Cirrhosis c/b Jaundice, Ascites 3 cords of grade I varices were seen starting at 30 cm ([2151-6-3]) ABO incompatible OLT on [2152-1-15] postop abdominal abscesses, Ecoli Heterozygous for H63D MUTATION Hyponatremia MSSA osteomyelitis of the L foot s/p debridement [5-/2151] GERD HTN Gout CAD - pt does not recall h/o MI or stents Cervical laminectomy Social History: Lives w/ wife, walks w/ a cane and is independent w/ ADLs. He quit ETOH in [2151-5-14]. Family History: No h/o liver disease Physical Exam: On admission: Vitals: 98.8 92 140/97 16 100% 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, tender to palpation bilateral upper quadrants, incision clean, dry and intact, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused On discharge: Patient expired Pertinent Results: On Admission: [2152-6-14] WBC-11.8* RBC-4.26* Hgb-11.0* Hct-37.2* MCV-87 MCH-25.7* MCHC-29.5* RDW-20.5* Plt Ct-363 PT-19.6* PTT-56.8* INR(PT)-1.9* Glucose-116* UreaN-27* Creat-1.4* Na-135 K-4.4 Cl-107 HCO3-17* AnGap-15 ALT-14 AST-48* AlkPhos-134* TotBili-1.9* Albumin-3.6 Calcium-9.3 Phos-3.9 Mg-1.5* Cyclspr-88* Lactate-0.9 Brief Hospital Course: 51 y/o male with liver transplant and post op course complicated by fluid collections, mental status changes requiring medication adjustments and prolonged hospitalizations who now presents a few days after clinic visit with increasing abdominal pain. One drain remains in place to drain a known fluid collection. On admission, an NGT was placed, and on KUB to assess placement there was noted to be paucity of bowel gas, with some gaseous distention of right lower quadrant small bowel loops: cannot exclude obstruction. An abdominal CT was obtained showing multiple loops of dilated bowel with transition point within the right lower quadrant approximately 10-15 cm upstream from the end-ileostomy. Decrease in size of multiloculated intra-abdominal fluid collections with interval removal of catheter in the anterior pelvic fluid collection and appropriate position of catheter in the perihepatic fluid collection. Findings were concerning for early or partial small bowel obstruction. The NG tube was kept in place, and medications were converted to IV admisnistration and he received IV fluids. Upon admission there was minimal stool output or gas in the ostomy bag, however over the course of the next 24 hours, stool output increased significantly, and NGT drainage dropped off. NG tube was removed in am of [6-16]. He was allowed sips of clears, but developed significant abdominal pain. NG was replaced with immediate drainage of 900 cc of bilious fluid. He was kept NPO with the NG tube in place for 3 more days. NG was then removed, but he had increased abdominal pain with more bloating. Ostomy output decreased to 200 cc for the day, and the NG tube was replaced. On [6-21], he was taken to the OR by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for ex lap and lysis of adhesions. There was concern for spillage of bowel contents as enterotomies were performed. EBL was approximately 1L. In PACU, he was tachycardic (130s), hypotensive (SBP 70s), and oliguric. PRBC,FFP, albumiun, and 8L crystalloid were administered. He was transferred to the SICU for management. ID was consulted. Tigecycline continued and and Micafungin was started per ID's recommendations. TTE was done to evaluate fluid status (decreased urine output) as he did not have central access. EF was >75 and LV was hyperdynamic. He received IV fluid with improved urine output. Hct remained stable after blood products. A red rubber catheter was placed into the ostomy for stenting. Dark fluid was noted in the ostomy pouch. VS and labs were stable. He transferred out of the SICU. NG was removed after 2 days and sips were started. Dilaudid was initially given for pain. This was switched to Morphine. However, he was still confused and paranoid. Pain meds were minimized. UA was nl, urine culture was pending. Blood cultures were sent. LFTs were notable for increase of t.bili up to 7.3 from 4. The bilirubin continued to rise and peaked at 9.6 on [7-1]. In response to the worsening LFTs, on [6-28] a transjugular liver biopsy was performed. He tolerated the procedure without incident, liver biopsy results showed Bile ductular proliferation with associated neutrophils and mild to moderate intrahepatocytic and canalicular cholestasis, there was no evidence of acute rejection. Early Hepatitis C recurrence cannot be ruled out. An HCV Viral load was sent showing a result of 743,239 IU/mL. (The viral load in [2152-2-13] was 1,170,000 IU/mL). On [6-30], as follow-up to CT done a day earlier, the patient underwent placement of two new drains, which were in response to new areas of fluid concerning for abscess. He underwent placement of an 8 French [Last Name (un) 2823] pigtail catheter to the right multilobulated fluid collection, which yielded malodorous altered blood in keeping with an infected hematoma and which Micro isolated E coli and Vanco resistant enterococcus. He also had an 8 French [Last Name (un) 2823] pigtail catheter into the left flank fluid which appeared dark and serous, but was not overtly infected and was negative on culture. Daptomycin was added. Give high MIC, Daptomycin was changed to Linezolid. The left sided drain was removed on [7-5] for very low output. Patients energy level and mood were depressed. Blood cultures and repeat CT scan [7-5] was done. Blood culture were negative. CT demonstrated smaller right sided abdominal fluid collections. There was a new fluid collection in the left abdomen which communicated superiorly and inferiorly with additional fluid collections which measured 9.7 x 6.2 x >11.3 cm.The LUQ drain was removed. On 5/34, a 10 French drainage catheter was placed into the left intra-abdominal fluid collection with drainage of 200mL dark, brown fluid. This fluid collection appeared to communicate with the more inferiorly located collection extending into the pelvis and a more superiorly located collection inferior and anterior to the pancreatic tail. Gram stain and culture isolated 1 colony of Enterococcus. Anticoagulation was resumed for h/o splenic vein thrombus. TPN was started for poor po/kcal intake. On [7-11], CT demonstrated a new LUQ collection. On [7-12], a drain was placed in this collection and fluid from this collection culture was negative. Tigecycline was stopped on [7-14] and Linezolid on [7-16]. On [7-17], he was made NPO as LUQ drain (#3)amylase and bilirubin were 6174 and 8.4 which was consistent with a bowel leak. TPN continued. He was allowed sips with restriction of no more than 400ml po fluid per day. Pigtail drain outputs averaged 25-85ml/day. Daily forward flushes were done. Transferred into SICU on [2152-8-9] for respiratory distress, tachypneic to the 30s. By [2152-8-10] he was intubated had thoracentesis for pleural effusion getting 1300cc out. He was started on pressors at this point. Over the next few days he was noted to desturate on the vent and required high PEEP as well as suctioning. He was placed on CRRT on [2152-8-13], was still on pressors, and continued on broad spectrum antibiotics. On [2152-8-14] he had his four abdominal drians inspected by IR and two fo them were upsized. Fluid was taken off by CRRT and he was placed on CPAP by the vent. He did have mucous plug episode that he was bronched for. By this point he was on and off levofed to maintain MAP above 60. On [2152-8-18], after being on CPAP all day at 40/5/5 on [8-17], he was extubated and CRRT was stopped. By [2152-8-19] he was re-intubated and placed back on pressors. On [2152-8-20] his repsiratory requirements on the vent were increasing and he was on 100% FiO2 with 14 PEEP. He developed an increased pressor requirement that same day and was found to have cardiac tamponade and had a pericardial drain placed. Despite getting the fluid out of his pericardial sac he continued to have increased pressor requirement and poor function on the vent. On [2152-8-22] a family meeting was held. By [2152-8-23] he was made CMO and once pressors were removed he expired shortly thereafter on [2152-8-23]. Medications on Admission: mycophenolate mofetil 500'', levothyroxine 50', aspirin 81', omeprazole 20', thiamine HCl 100', cyanocobalamin (vitamin B-12) 100', folic acid 1', ferrous sulfate 300'', metoprolol tartrate 25''', enoxaparin 100 mg/mL DAILY (Daily) for 2 weeks, warfarin 12', cyclosporine 100'', pentamidine 300 mg once a month, Kayexalate prn Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Small bowel obstruction Abdominal fluid collections/abscesses vre bacteremia Intestinal leak UTI Depression Malnutrition Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: None-patient expired [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2152-8-25]	[ "401.9", "287.5", "530.81", "599.0", "998.59", "423.9", "567.22", "560.81", "511.9", "263.9", "274.9", "038.9", "244.9", "E878.8", "518.51", "572.3", "V12.51", "414.01", "423.3", "112.2", "V58.61", "785.52", "584.9", "995.92", "V42.7", "041.49" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.04", "96.72", "37.0", "99.15", "54.91", "50.11", "54.59", "34.91", "93.90" ]	icd9pcs	[ [ [] ] ]	10675, 10684	3136, 10264	350, 611	10849, 10858	2782, 2782	10914, 11092	2309, 2331		10643, 10652		10705, 10828		10290, 10620			10882, 10891									2346, 2346														2746, 2763								296, 312									639, 1786							2796, 3113											1808, 2183	2199, 2293
16,320	164,119	49538	Discharge summary	report	Admission Date: [2137-6-29] Discharge Date: [2137-6-30] Date of Birth: [2084-9-5] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Seroquel overdose Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: 52 y/o M with hx of Hep C, depression, panic disorder and past suicide attempts presents to the ED after his roommate found him with lethargic and with an empty bottle of seroquel. He was last seen normal at midnight, and he had called his mother at 7:30 am this morning to tell her he had overdosed. Per report, he was sounding confused and slurring his words at this time. . EMS found him obtunded. In the ED, initial vitals were T 97.3, P 122, BP 122/70, R 24, Pox 95% on RA, FS 167. His GCS was [6-6]. He would occassionally answer his name, but would not open his eyes or answer other questions. While awake, he was given Narcan without any effects. He was then intubated for airway protection. An OG tube was placed, but no apparent pills were suctioned. He received 1L banana bag, 1 amp bicarb, and succ/etomidate and fentyl/versed when intubated. He had worsening aggitation and his sedation was switched to propofol. . He had a head CT in the ED that showed a small frontal subdural hemorrhage. Neurosurgery was consulted. He has no bruising or signs of trauma on his head. . On arrival to the floor, he is aggitated and trying to sit up in bed, does not follow commands and responded to a bolus of propofol. He vomitted once while being moved. Past Medical History: Past psychiatric history: [Month/Day (3) ] disorder NOS (question of bipolar disorder given hypomania on antidepressants) ?Panic disorder with agoraphobia? Narcissism - multiple suicide attempts by OD first at age 18 or so - multiple psychiatric hospitalizations including [Doctor First Name 1191], [Location (un) ], [Hospital1 ], most recently d/c'd from Deac4 [2133-2-27] [Month/Day/Year ] side effects: - Geodon at 120mg [Hospital1 ] : increased akathesia - Paxil at 40mg: pressured speech, increased energy and restlessness Previously treated by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 103614], M.D.; after last hospitalization was referred to a therapist and psychiatrist at the [Location (un) ] Center Social History: (Per prior discharge summary). Patient lives at home with his mother, father and brother. Reports that he has suffered from anxiety since childhood and needed to drop out of college. He was in special classes in school for LD. He reports having gone to several boarding preparatory schools before college without issue, even being "floor leader" in one of the dorms. He is unemployed, on disability, and waiting for a subsidized apartment after living with parents the past 6-7 years. No current relationship. Family History: (per prior discharge summary). A cousin sees a psychiatrist, unknown dx. No suicide attempts. Physical Exam: Vitals: T:97.1, BP: 124/74, P: 97, R: 12, O2: 98% on PS 5/5, 40%. General: intubated and sedated, initially aggitated and trying to get up in bed HEENT: Sclera anicteric, pupils 3mm to 2mm and equal, face is red and dry, dry mucous membranes, supple neck, no LAD, ET tube in place and taped to mouth, OG tube placed, no bruising, abraisions Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, tachycardic in 100s, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm hands, cool feet, palp pulses in all 4 extremities, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated Pertinent Results: Urine tox positive for Benzos (prescribed), cocaine and methoadone (not prescribed). . Serum tox poxitve for TCAs. . [2137-6-29]. CXR. SINGLE AP VIEW OF THE CHEST: An endotracheal tube tip lies 6 cm above the carina. An NG tube appears to extend at least to the stomach, though the tip is not definitively visualized. The heart is normal in size. The mediastinal and hilar contours are normal. The lung volumes are low, with medial basal opacities in the lung likely reflecting atelectasis. No consolidation or edema is identified. There is no pleural effusion or pneumothorax. IMPRESSION: Endotracheal tube tip 6 cm from the carina . CT Head. [2137-6-29]. IMPRESSION: No evidence of acute intracranial hemorrhage, with the previously noted possible subdural hematoma no longer apparent, and may have been artifactual or related to adjacent vessel. Brief Hospital Course: Mr. [Known lastname 103621] [Last Name (Titles) ] a 52 year old male with a long psychiatric history and multiple suicide attempts in past who presents with seroquel, cocaine, and methadone overdose as a suicide attempt. . Suicide attempt/ Overdose. Patient was found to have an empty bottle of seroquel by bedside but his urine was also positive for benzos, cocaine and methadone upon arrival. He reported that he took 90 seroquel in setting of smoking crack cocaine. He was seen by toxicology in the ED. He was treated with an bicarbonate drip and a dose of activated charcoal. He was also intubated in the ED for airway protection, but was extubated a few hours later. His QRS and QTC intervals remained normal. He did not experience hypoglycemia. He showed no evidence of serotonin sydrome. He was monitored with a 1:1 sitter and his psych meds were held until he became more clear at which point all home psychiatric medications except for seroquel were resumed. . History of hepatitis C. His LFTs were checked and were within normal limits. Medications on Admission: Meds (confirmed w/[Company 25282]: [University/College ] St): Seroquel 100 mg AM, 150-200 mg HS Paxil 30 mg AM Klonopin 2 mg TID Geodon 80 mg [Hospital1 ] Propranolol 20 mg TID Neurontin 800 mg TID Protonix 40 mg daily Lovastatin 40 mg HS Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 In-patient Psych facility Discharge Diagnosis: Seroquel overdose Discharge Condition: Fair. Patient is hemodynamically stable. Discharge Instructions: You were admitted to the medical intensive care unit for monitoring after you overdosed on seroquel. In addition, your blood tested positive for methadone (which you are not prescribed), cocaine, and TCAs. You were intubated for airway protection, but were rapidly extubated. You are being transferred to an inpatient psych facility for psychiatric treatment of your suicide attempt. . Please continue taking all medications as you were previously taking with the exception of seroquel which is being held due to your overdose. Your pychiatrists will decide when it is safe for you to resume this [Hospital1 4085]. . Please call your psychiatrist if you have any suicidal thoughts. Followup Instructions: Please follow up with your primary care physician and psychiatrist as needed.	[ "304.01", "070.70", "E950.4", "300.21", "970.8", "969.3", "530.81", "E950.0", "401.9", "311", "E849.0", "965.02", "E950.3", "304.21" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	7279, 7350	4811, 5880	334, 374	7412, 7456	3928, 4788	8193, 8274	3010, 3106		6182, 7256		7371, 7391		5906, 6159			7480, 8170									3121, 3909																						277, 296									403, 1676																		1698, 2464	2480, 2994
5,255	153,484	22150	Discharge summary	report	Admission Date: [2154-10-14] Discharge Date: [2154-10-28] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: Bleeding from rectum Major Surgical or Invasive Procedure: Low anterior resection History of Present Illness: The patient is an 89-year-old male who presented on [2154-6-8] with blood per rectum, which prompted a colonoscopy. A circumferential tumor was found 10 cm from the anal verge and a biopsy showed invasive adenocarcinoma, which was moderately differentiated. The plan was for resection, but it was postponed as the patient was anemic and had an episode of CHF. The patient underwent transfusion with 3 units of PRBC's and diuresis for his CHF, and was discharged 3 days later. The patient underwent radiation therapy as well as neoadjuvant chemotherapy and now presents for definitive treatment for his rectal cancer. Past Medical History: The patient has a history of childhood polio Hypertension BPH Anemia Basal cell skin cancer Difficulty hearing Cataracts Rectal cancer Social History: The patient denies alcohol or tobacco use Family History: Significant for brothers who are deceased from rectal cancer Physical Exam: At presentation, the patient is a pleasant elderly gentleman. There is no cervical, axillary or groin lymphadenopathy. His pupils are anicteric. His heart rate is regular, normal rhythm. No murmurs, rubs or gallops. His lung exam reveals scattered rhonchi diffusely. His abdominal exam, his abdomen is soft, nondistended, and nontender. He has got some weakness of his right leg and some atrophy associated with his childhood polio. Pertinent Results: [2154-10-24] 04:35AM BLOOD WBC-4.3 RBC-3.85* Hgb-11.3* Hct-33.0* MCV-86 MCH-29.4 MCHC-34.3 RDW-14.5 Plt Ct-116* [2154-10-27] 11:19AM BLOOD Glucose-140* UreaN-38* Creat-1.0 Na-139 K-4.0 Cl-105 HCO3-30* AnGap-8 Brief Hospital Course: The patient was admitted to the hospital on [2154-10-14] and was evaluated by cardiology prior to procedure. He was prepared the night before with a bowel prep and hibiclens scrub to his abdomen, as well as IV flagyl and cefazolin for prophylaxis. The patient was taken to the operating room that day, where he underwent a low anterior resection. The patient required 1 unit of PRBC's intraoperatively. During the case, metastases to the liver were noted. [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain as well as a feeding J-tube were place. The post-operative course was complicated by acute episodes of confusion and by episodes of rapid atrial fibrillation and hypertension. On POD#1, tube feedings were started via the patient's J-tube. On post-operative day #2, the patient experienced bouts of rapid atrial fibrillation, which required IV metoprolol to control. On post-operative day #3, the patient received IV lasix for diuresis, which he responded to well. He also began working with the physical therapists and was able to sit up to chair. On post-operative day #4, the patient was started on zestril for hypertension. On the night of post-operative day #4, the patient became acutely confused and removed his [Location (un) 1661]-[Location (un) 1662] drain. Later that night, the patient's telemetry alarm went off secondary to tachycardia to 160 BPM. The patient was found breathing rapidly and was unresponsive to stimuli. He was found to have an oxygen saturation of 60% on 2LNC, which improved to greater than 90% on a non-rebreathing face mask. The patient became more responsive, and was immediately transferred to the ICU for a CHF exacerbation. Chest x-ray at the time demonstrated bilateral pleural effusions, and lasix was given. A right internal jugular central venous line was placed and a right thoracentesis was performed, at which time 1.5 liters of pleral fluid were drained. The patient was agressively diuresed in the ICU, where his cardiac status was closely monitored. On POD#8, the patient had an unwitnessed fall from his bed. Though he was uninjured, he was monitored closely and a sitter was placed at bedside. The patient was medically stable the following day, and was sent to the floor. He was evaluated by the hepatic surgery team as well as the medical oncology team, though no consensus was reached during his hospital stay as far as what treatment, if any, will be necessary for his metastatic disease to his liver. Following transfer to the floor, attention was turned to agressivley rehabilitating and feeding the patient. The patient worked with the physical therapists, ate regular meals and tolerated tube feeds at night without any incidents or episodes of confusion. On post-operative day #12, the patient is now stable for discharge to an extended care facility. Medications on Admission: 1. Lasix 40 mg p.o. q.d. 2. K-Dur 8 mg p.o. q.d. 3. Atenolol 25 mg p.o. q.d. 4. Procrit 40,000 units 1 tablet q.d. 5. Iron sulfate. Discharge Medications: 1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Pantoprazole Sodium 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 Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57850] Healthcare Center - [Location (un) ] Discharge Diagnosis: Rectal cancer w/ liver metastasis Discharge Condition: Stable Discharge Instructions: Please return to hospital or call Dr.[Name (NI) 6275] office if you experience chills or fever greater than 101.5 degrees F. Please return if your wound becomes excessively red, tender or swollen, or if it begins to ooze pus. Please continue to take Boost and Boost pudding for dietary supplementation. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 957] in two weeks. Please call his office at ([Telephone/Fax (1) 57851] for an appointment.	[ "154.1", "518.5", "997.1", "427.31", "293.0", "428.0", "197.7", "401.9", "196.2", "V16.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "48.63", "46.39", "34.91", "45.94", "38.93", "96.6", "50.12" ]	icd9pcs	[ [ [] ] ]	6034, 6172	1964, 4842	284, 309	6250, 6258	1723, 1941	6613, 6762	1193, 1255		5024, 6011		6193, 6229		4868, 5001			6282, 6590									1270, 1704																						224, 246									337, 959																		981, 1118	1134, 1177
31,797	105,809	43729	Discharge summary	report	Admission Date: [2133-10-28] Discharge Date: [2133-11-9] Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[Last Name (NamePattern1) 1167] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Coronary catheterization History of Present Illness: 89 yo F with no prior h/o known CAD who presents with inferior STEMI. . Per home aid pt was sitting at home with friend when the friend noted a change in her demeaner, when home aid came to se her she was unresponsive and her eyes were rolling back and so pt's son was called. After hanging up she noted pt to be diaphoretic and nauseous. Since she seemed to improve somewhat after a few minutes without an intervention the family decided to wait initially but then shortly thereafter pt was holding her chest and said "call an ambulance". . Per EMS, when they arrived, EKG tracings were significant for an inferior STEMI and a code STEMI was activated. She was reportedly hypotensive with SBPs in the 60s while in route to the ED. Initial vitals in the ED were BP 129/80, HR 88, and O2 sat 100% NRB. An EKG confirmed an inferoposterior STEMI. She was given ASA 325 mg po X 1, metoprolol 2.5 mg IV X 1, plavix 600 mg po X 1, and started on heparin and integrillin gtts. A total of 1.5 L of IVFs were given prior to arrival to the cath lab. In the cath lab, the pt was started on a dopamine gtt at 5 mcg/kg/min for hypotension. A cardiac cath was significant for 3 vessel disease with total occlusion and thrombus in the prox RCA, total occlusion of the mid LCx, 80% prox and diffuse mid 70% of the LAD, and 40% prox occlusion of the LMCA. A CI was depressed at 1.77 with mixed venous oxygen saturation of 51%. A IABP was unable to be placed [1-16] tight R iliac lesion. She was then transferred to the CCU for further care with a Swan-Ganz catheter in place and off integrillin and heparin gtts. . When seen in the CCU, she denied any chest pain, or shortness of breath. Her only complaint was that she was cold. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: # Arthritis, knees # s/p kidney removal as child # Anxiety/Depression # s/p cataract surgery - R eye 2 weeks ago, L eye several years ago # Dementia # GERD Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: (on admission) VS: T 95.0 , BP 117/72, HR 97, RR 19, O2 93% on 11L NRB Gen: Elderly female in NAD, appearing anxious. Oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP 7 CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: Resp were unlabored, no accessory muscle use. Mild crackles at bases L>R. No wheezes, rhonchi. Abd: soft, NTND, No HSM or tenderness. Ext: No c/c/e. Skin: feet cold Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: CARDIAC CATH performed on [10-28] demonstrated: 1. Selective coronary angiography of this right dominant system revealed severe three vessel coronary artery disease. The LMCA had diffuse disease with a 40% proximal lesion. The LAD was also diffusely diseased with an 80% proximal lesion and a diffuse 70% lesion. The LCX was totally occluded at the mid vessel. The RCA was totally occluded proximally with an acute thrombus. 2. Resting hemodynamics revealed elevated left and right sided filling pressures with RVEDP of 19 mm Hg and PCWP mean of 25 mm Hg. Cardiac index was depressed at 1.8 l/min/m2. 3. Distal aortagram revealed diffuse aortoiliac disease. . TTE ([10-29]): The left atrium is mildly dilated (4.5x5.6) moderate regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 30-35%). focal hypokinesis of the apical two thirds of the right ventricular free wall mild AR and AS Moderate (2+) mitral regurgitation is seen. . Renal U/S and duplex ([11-4]): The patient is status post left nephrectomy. The right kidney measures 9.2 cm. The renal cortex is markedly echogenic consistent with medical renal disease. A 1.3 cm simple cyst is seen within the mid pole of the right kidney. There are no stones or hydronephrosis. The renal artery and vein are patent, although detailed assessment is limited. There are small bilateral pleural effusions. IMPRESSION: 1. Echogenic renal parenchyma consistent with medical renal disease. Simple right renal cyst. . CXR (AP, [10-28]):There is moderate cardiomegaly. The aorta is elongated. Swan-Ganz catheter tip is in the right main pulmonary artery. There is moderate interstitial pulmonary edema with no pneumothorax or sizable pleural effusions. . CXR ([11-3]): Substantial enlargement of the cardiac silhouette with bilateral pleural effusions and some indistinctness of pulmonary vessels consistent with elevated pulmonary venous pressure. No evidence of acute pneumonia. Some prominence in the azygos region raises the possibility of right-heart failure . ------------- LABS ------------------- [2133-10-28] 08:46PM TYPE-MIX RATES-/28 PO2-30* PCO2-40 PH-7.30* TOTAL CO2-20* BASE XS--6 INTUBATED-NOT INTUBA [2133-10-28] 08:46PM LACTATE-1.5 [2133-10-28] 06:39PM TYPE-ART PO2-123* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 [2133-10-28] 06:39PM O2 SAT-97 [2133-10-28] 06:20PM GLUCOSE-190* UREA N-29* CREAT-1.5* SODIUM-134 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-16* ANION GAP-17 [2133-10-28] 06:20PM CK(CPK)-284* [2133-10-28] 06:20PM CK-MB-50* MB INDX-17.6* cTropnT-0.90* [2133-10-28] 03:15PM CK-MB-NotDone cTropnT-0.41* [2133-10-28] 03:05PM CK(CPK)-82 [2133-10-28] 03:05PM CK-MB-NotDone [2133-10-28] 03:05PM cTropnT-0.43* [2133-10-28] 06:20PM CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-2.2 [2133-10-28] 06:20PM WBC-16.2# RBC-3.69 HGB-11.5* HCT-35.0* MCV-95 MCH-31.1 MCHC-32.8 RDW-14.2 [2133-10-28] 06:20PM PT-14.5* PTT-76.7* INR(PT)-1.3* [2133-10-28] 03:15PM GLUCOSE-138* UREA N-30* CREAT-1.5* SODIUM-140 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-16* ANION GAP-20 [2133-10-28] 03:15PM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-71 ALK PHOS-92 AMYLASE-90 TOT BILI-0.3 [2133-10-28] 03:15PM ALBUMIN-3.6 CHOLEST-225* [2133-10-28] 03:15PM %HbA1c-5.7 [2133-10-28] 03:15PM TRIGLYCER-101 HDL CHOL-85 CHOL/HDL-2.6 LDL(CALC)-120 [2133-10-28] 03:15PM WBC-9.2 RBC-3.67* HGB-11.3* HCT-34.5* MCV-94 MCH-30.8 MCHC-32.7 RDW-14.0 [2133-10-28] 03:15PM NEUTS-80.7* LYMPHS-15.7* MONOS-2.7 EOS-0.9 BASOS-0 [2133-10-28] 03:15PM PLT COUNT-243 [2133-10-28] 03:15PM PT-14.8* INR(PT)-1.3* [2133-10-28] 03:05PM UREA N-30* CREAT-1.6* Brief Hospital Course: As mentioned above, when the pt was seen in the ED at [Hospital1 18] EKG confirmed an inferoposterior STEMI. She was given ASA 325 mg po X 1, metoprolol 2.5 mg IV X 1, plavix 600 mg po X 1, and started on heparin and integrillin gtts. A total of 1.5 L of IVFs were given prior to arrival to the cath lab. In the cath lab, the pt was started on a dopamine gtt at 5 mcg/kg/min for hypotension. A cardiac cath was significant for 3 vessel disease with total occlusion and thrombus in the prox RCA, total occlusion of the mid LCx, 80% prox and diffuse mid 70% of the LAD, and 40% prox occlusion of the LMCA. A CI was depressed at 1.77 with mixed venous oxygen saturation of 51%. A IABP was unable to be placed [1-16] tight R iliac lesion. She was then transferred to the CCU for further care with a Swan-Ganz catheter in place and off integrillin and heparin gtts. When seen in the CCU, she denied any chest pain, or shortness of breath. Her only complaint was that she was cold. In the CCU and later on the floor the following problems were [Name2 (NI) 13744] ad follows; Cardiac Ischemia: - Cath was significant for severe 3 vessel disease with BMS X 3 to RCA for IMI - On arrival to CCU, heparin and integrillin gtts were off - CK peaked 1698, MB 123, MBI 11.5 - ASA, plavix, atorvastatin (80mg) were starteda and continued - On HOD#2 the pt was weaned off dopamine - On HOD#3 the Swan-Ganz was discontinued since CI>2 after starting low dose BB - An attempt to start on ACE-I was done on HOD#3 but d/c'd on HOD#5 due to SBPs in 70s and due to increasing creatinine - HgA1c was tested and returned at 5.7% - Chol panel: total 225, LDL 120, HDL 85, trig 101 . Pump: - Initially with cardiogenic shock s/p STEMI. CI 1.7 with mixed venous O2 sat 51%. - Required pressors for hypotension during cath. - On presentation to CCU, dopamine gtt running at 5 mcg/kg/min. - RN weaned off dopamine gtt entirely in less than 24hrs with SBPs holding in 120s, HR 70-80s. - On HOD#3 the Swan-Ganz was discontinued since CI>2 after starting low dose BB - TTE [10-29] with LVEF 30-35%, akinesis of inferior and inferolateral walls, hypokinesis of apical [1-17] of RV free wall, mild AS, 2+ MR, mild PA systolic HTN, trivial pericardial effusion. - Although LVEF = 30-35%, it was thought that pt likely will recover some of this function --> should get an echo 4-6 weeks out to establish new EF - continued to have significant pulmonary effusions with continued oxygen requirment despite low dose lasix in the setting of a rising creatinine; therefore renal was consulted to thought ATN from dye load and hypotension at cath; their recommnedation was IV lasix with goal of 1L per day -Patient was diuresed with lasix IV and switched to a stable regimen of Lasix 100mg po daily on which she was sating well and Creatinine was improving. . Rhythm: Pt in and out of a-fib during hospital course. Reportedly had palpitations at home for past few weeks. Decision made to not anticoagulate with coumadin given other co-morbidities and fall risk (family and PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] all agreed). Metoprolol was titrated up during the hospital stay and despite this pt kep entering afb with RVR into 130-140s. On HOD#10, the decision was ade to start amiodarone for rhythm control- she should continue amiodarone loading at 400mg po bid for a total of 2 weeks (begun [11-6]) and then decreased to 200mg po bid. In the future she should have LFTs and TFTs checked for amiodarone toxicity. . # Renal Insufficiency: - Pt with only 1 kidney s/p surgery as child for unknown reasons (R kidney remaining). Cr here 1.6 on admission prior to cath which is what the pt's baseline was. - Received HCO3 drip post cath for total of 1L - pt had rising creatinine with a peak at 2.9; therefore renal was consulted to thought ATN from dye load and hypotension at cath (and the ACEI was stopped). Discharge Cr 2.7. . # Pulm - O2 requirement likely [1-16] pulm edema from acute systolic heart failure after MI and 2+MR; diuresed as above - intermittent hyperventilation with resp alkalosis likely [1-16] anxiety since pt not hyperventilating when asleep -100% on room air the morning of discharge. . # Neuro/Psych - dementia and depression/anxiety at baseline; worsening in hosp likely related to new environment and disrupted sleep/wake cycle and UTI found on day#3 - cont. strattera, and melatonin qhs, and lower dose benzo - finished 10 day treatment of UTI with levofloxacin - pt with increased delerium on terazosin (so was only tired once) . # MSK/Arthritis - cont tylenol. no nsaids # GI/GERD - cont PPI # s/p cataract surgery - cont home eye drop meds # FEN/GI - cardiac healthy diet, replete lytes prn. # Ppx - bowel regimen, heparin sq # Dispo - d/c to nursing home Medications on Admission: Strattera 20mg qam Namenda 10mg qam Lorazepam 0.5mg-1mg qhs Prilosec 20mg qday Rozerem (melatonin) 8mg qpm Tylenol 325-625mg q6hrs prn Advil 200mg with meals Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Vigamox Ophthalmic 5. Strattera 10 mg Capsule Sig: Two (2) Capsule PO qam (). 6. Rozerem 8 mg Tablet Sig: One (1) Tablet PO q HS (). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO qam (). 8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 9. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): Please take 2 tablets twice a day for 12 days, then one tablet twice a day for 14 days then once daily after that until directed by a physician to stop taking. Disp:60 Tablet(s) Refills:2 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Lasix 40 mg Tablet Sig: 2.5 Tablets PO once a day. 13. Nevanac 0.1 % Drops, Suspension Sig: One (1) Ophthalmic [Hospital1 ] (): OU. 14. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: ST elevation myocardial infarction Cardiogenic shock [1-16] MI Acute congestive heart failure Acute on chronic renal failure s/p kidney removal as child Paroxysmal atrial fibrillation Anxiety/Depression Urinary tract infection Dementia s/p cataract surgery . Secondary diagnosis: Arthritis, knees GERD Discharge Condition: stable Discharge Instructions: You were admitted to [Hospital1 18] with an ST elevation myocardial infarction. Please take your previous medications as prescribed including the following medications: - please start taking aspirin 325mg daily for secondary cardiovascular prevention (to prevent another heart attack) - Please start taking atorvastatin 80mg daily for your heart and for your cholesterol - Please start taking Toprol XL 100mg daily for your heart and blood pressure - Please start taking clopidogrel (Plavix) 75 mg daily to keep stents open - Please start taking amiodarone as directed to prevent your heart from going into an abnormal rhythm - Please start taking lasix as directed to prevent fluid from accumulating in your lungs. If you develop chest pain, jaw pain, or chest pressure with pain radiating into arm, or if you for any reason become concerned about your medical condition please call 911 or present to nearest ED. - We also gave you Nitroglycerin tablets to take if you experience chest pain, please call 911 or your doctor if chest pain recurs even if it dissapears with nitroglycerine DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO We strongly recommend you stop smoking as discussed Followup Instructions: You should follow up with your primary care physician [Name Initial (PRE) 176] [1-18] weeks of your discharge from the hospital. You should have your primary care physician set you up with a cardiologist who you should try to see within 2 weeks of your discharge. Also have your primary care physician set you up with a kidney doctor (nephrologist) to see within 4-6 weeks of your discharge from the hospital.	[ "311", "294.8", "785.51", "599.0", "285.9", "E947.8", "584.5", "530.81", "428.21", "414.2", "414.01", "410.31", "428.0", "585.9", "715.96", "427.31" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.53", "00.47", "37.22", "00.40", "00.66", "99.20", "36.06" ]	icd9pcs	[ [ [] ] ]	13891, 13957	7465, 12273	242, 269	14326, 14335	3628, 7442	15658, 16081	2845, 2927		12481, 13868		13978, 13978		12299, 12458			14359, 15635									2942, 3609																						197, 204									297, 2525			14281, 14305		13997, 14260													2547, 2704	2720, 2829
83,389	101,581	41146	Discharge summary	report	Admission Date: [2193-1-18] Discharge Date: [2193-1-28] Date of Birth: [2151-6-16] Sex: M Service: MEDICINE Allergies: clindamycin / Penicillins / Levaquin / cefazolin / Bactrim / Sulfamethoxazole / Vancomycin Attending:[First Name3 (LF) 1257] Chief Complaint: Fever Major Surgical or Invasive Procedure: Amputation/disarticulation of 4th finger on left hand at PIP joint. History of Present Illness: 41 y/o with DM, h/o frostbite with chronic finger wound transfered from [Hospital3 ] on [1-18]. He originally presented to his PCP 6 days PTA with worsening pain, swelling, and ? pus production in the left ring finger. Per the pt he chronically has an open wound at this site. He was seen by his PCP and treated with Bactrim near the onset of his symptoms, however did not have significant improvement with this therapy. Upon arrival at the OSH he recieved 1 gm IV vanco prior to transfer to [Hospital1 18]. He denies F/C/S, rash, abd pain prior to admission. . On the evening of arrival to [Hospital1 18] he underwent I+D with production of frank pus and he was started on IV vancomycin. Unfortunately cultures from this I+D appear to be lost. A finger X-ray was concerning for osteo in the left 4th digit. ID was consulted to help with abx management. Late on [1-18] he was sent to the OR for a washout. The procedure was un-complicated and a swab was sent for culture. A bone bx was not done at that time. Per the Hand surgery team the wound has been appearing well without drainage since the time of surgery. . Following the OR ([1-18], 2100) PACU notes mention the onset of diffuse erythema across the face and chest. This was feared to be a rxn to vancomycin and his coverage was switched to vancomycin. ID agreed with switching to Linezolid. . He became persistently febrile starting [1-19] at 9am with Tm of 103.2. Pt has also been progressively tachycardic to 130s, which appears as sinus tachycardia on telemetry. He transiently had a BP of 80/50 which resolved within 15 minutes. He was given a total of 4250cc of IVF [3-19] with 1375 of UO. On the evening of transfer surgery placed a right IJ at the bedside without complications. 3 passes of the right subclavian were first attempted without success. Past Medical History: Diet controlled diabetes mellitus Hyperlipidemia Polio Frostbite leading to amputation of digits Social History: 1ppd x 28 years. Quit smoking several months ago. No alcohol or drug use. Lives at home with cat and cockatoo. Family History: Noncontributory Physical Exam: Admission physical exam: GEN: pleasant, tired but comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM but no OP or nasal lesions.,no jvd, RESP: CTA b/l with good air movement throughout CV: tachy, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly + right CVA tenderness EXT: BL nonpitting edema. multiple finger amputations and BL great toe amputations. left ring finger with 2 palmar and 2 side incisions with wicks. No erythema extending directly from wound. SKIN: no jaundice/no splinters. diffuse erythematous and warm macular rash, blanching, prominant over upper chest, UE. Over BL temporal area, upper chest, and flanks NEURO: AAOx3. Cn II-XII intact. grossly moving all ext (poor cooperation with exam). No sensory deficits to light touch appreciated. Pertinent Results: Admission labs: [2193-1-18] 02:10AM WBC-10.5 RBC-4.98 HGB-14.3 HCT-41.0 MCV-82 MCH-28.7 MCHC-34.9 RDW-13.5 [2193-1-18] 02:10AM GLUCOSE-111* UREA N-14 CREAT-1.1 SODIUM-137 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14 [2193-1-18] 02:10AM PT-14.3* PTT-32.4 INR(PT)-1.2* [2193-1-18] 02:10AM NEUTS-79.5* LYMPHS-13.7* MONOS-4.1 EOS-2.4 BASOS-0.3 . MRI hand [1-21] IMPRESSION: 1. Findings concerning for osteomyelitis at the distal tip of the fourth/ring finger amputation stump. Fluid communicates from skin to amputation stump. Diffuse soft tissue swelling of the ring finger. Remainder of osseous signal is normal. Base of middle phalanx demonstrates normal signal. PIP joint is normal. 2. Abnormal fluid tracking about the extensor tendons and the flexor tendons, contiguous with dorsal fluid in subcutaneous tissues. Could represent tenosynovitis or other fluid. 3. Thenar muscle edema. Lumbrical muscle edema. . [1-21] Echo The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . [1-20] Abdomen/pelvis CT 1. No acute intra-abdominal process; specifically no fluid collections, hydronephrosis, or perinephric stranding; gas-distended colon, but no obstruction or pneumatosis. 2. Prominent inguinal lymph nodes of uncertain clinical significance. 3. Well-corticated bony irregularities of the bilateral iliac bones may represent post traumatic change, enthesopathy, osteochondromas, or heterotopic bone. . Brief Hospital Course: OSTEOMYELITIS OF THE 4TH DIGIT ON LEFT HAND: This was confirmed with MRI. The patient had pus draining from an open wound on this finger. He was brought to the OR on [2193-1-18] for a washout and following this became septic. His septic picture was confounded by severe drug reactions to antibiotics (Bactrim and Vancomycin). He was brought to the ICU and was fluid resuscitated. He subsequently went to the OR again on [1-22] for a rising white count at which time he underwent a finger amputation. He was treated with an additional days of linezolid following the amputation (until [2193-2-5]. He remained in the hospital for several days beyoned his due discharge day to get approval for Zyvox from mass health. Dermatology was consulted after patient developed diffuse erythematous rash with pustules on face and upper body. Dermatology felt the patient likely had AGEP (acute generalized exantematous pustolosis) secondary to Bactrim that had been prescribed while outpatient. Biopsy samples taken that were consistent with AGEP. Per Dermatology recommendations, patient started on triamcinolone cream, which provided some improvement. Patient should only use steroidal topical for 14 days. We also believe that he devloped reaction similar to red man syndrome from Vancomycin. In regards to his diabetes, normally it is diet controlled. During hospitalization, it was controlled with insulin sliding scale. He was discharged home with VNA and PT. He could not remember his home medications, he was asked to resume them and follow up with PCP, [Last Name (NamePattern4) ] ([2193-2-5]), and hand surgery (was asked to call the number for suture removal). He will continue Zyvox until he sees ID on that day. Total discharge time > 30 minutes Medications on Admission: ? simvastatin daily ? metoprolol daily Discharge Medications: 1. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 11 days: last day [2193-2-5]. Disp:22 Tablet(s) Refills:0 2. metoprolol tartrate Oral 3. simvastatin Oral 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. Disp:20 Tablet(s) Refills:0 5. Benadryl 25 mg Capsule Sig: One (1) Capsule PO four times a day as needed for itching. 6. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl Topical QD () for 7 days: do not use on face or genitals. Disp:60 gram tube Refills:1 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Finger osteomyelitis 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 severe infection of your finger which required amputation of your finger and will require you to stay on antibiotics for several days since your amputation (last day [2193-2-5]). You also had a severe rash, likely from Bactrim (an antibiotic) please avoid this medication in the future. Please take your medications as prescribed and make your follow up appointments. Resume old medications as you were unable to provide us with dose. Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [2193-2-5] at 3:30 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Please call the hand clinic at [Telephone/Fax (1) 1228] for a follow up appointment within 10 days of your discharge ([2193-2-5] is a good day for a follow up) from the hospital. (you saw Dr. [Last Name (STitle) ] in the hospital, she performed your surgery) You need to change dressing twice a day but clean your hand dry and clean at all times. You can shower and use water and soap.	[ "730.24", "V46.3", "337.1", "693.0", "E931.0", "038.9", "909.4", "731.8", "E878.5", "997.62", "138", "E849.8", "E929.5", "729.89", "785.0", "790.92", "995.91", "250.80", "E849.7", "727.09" ]	icd9cm	[ [ [] ] ]	[ "38.93", "86.04", "84.01", "86.73", "00.14", "86.11" ]	icd9pcs	[ [ [] ] ]	8019, 8094	5589, 7358	357, 426	8177, 8177	3416, 3416	8833, 9522	2568, 2585		7447, 7996		8115, 8115		7384, 7424			8327, 8810									2625, 3397																						312, 319									454, 2304				3432, 5566	8134, 8156			8192, 8303										2326, 2424	2440, 2552
31,951	194,925	28319+28320	Discharge summary	report+report	Admission Date: [2107-10-4] Discharge Date: [2107-10-10] Date of Birth: [2051-2-13] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 56-year-old male with metastatic renal cell carcinoma admitted to begin cycle II week two high-dose IL-2 therapy. His oncologic history began in [2106-8-27] when he developed bilateral pulmonary emboli with workup revealing right kidney mass and associated tumor thrombus into the IVC. Chest CT revealed multiple small pulmonary nodules. He underwent right radical nephrectomy on [2106-12-14] with clear cell histology noted. Follow-up CTs revealed slow growth of lung nodules. He began cycle 1 week one high-dose IL-2 therapy in [2107-5-27], receiving 14 of 14 doses week one and seven of 14 doses week two complicated by shock and hypotension. Follow-up CTs revealed disease regression. He began cycle II week one high- dose IL-2 on [2107-9-19] receiving 14 of 14 doses. He has fully recovered from week one of therapy and now is ready to begin his next week of therapy. PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, depression, anxiety, history of pulmonary emboli, history of migraine headaches history of eczema. ALLERGIES: Codeine causes dizziness, penicillin causes a rash. MEDICATIONS: Paxil 20 mg p.o. daily, Protonix 40 mg p.o. daily, Relpax 40 mg daily p.r.n. migraine headache, Pravachol 80 mg daily, aspirin and Coumadin currently on hold. PHYSICAL EXAMINATION: GENERAL: Well-appearing male in no acute distress. __________ VITAL SIGNS: 97.4, 110, 118, 132/84, O2 sat 100% on room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. NECK: Supple. LYMPH NODES: No cervical, supraclavicular, bilateral axillary or bilateral inguinal lymphadenopathy. HEART: Regular rate and rhythm, S1, S2. CHEST: Clear to percussion and auscultation bilaterally. ABDOMEN: Rounded, positive bowel sounds, soft, nontender, no HSM or masses. EXTREMITIES: No lower extremity edema. SKIN: Dry desquamation. NEUROLOGIC: Alert, oriented x3. Speech clear and fluent. LABORATORY DATA: Admission labs WBC 12.6, hemoglobin 12.6, hematocrit 35.8, platelet count 366,000, INR 1.1, BUN 28, creatinine 1.8, sodium 135, potassium 5.3, chloride 105, CO2 21, glucose 87, ALT 38, AST 24, CK 21, alk phos 135, total bili 1, albumin 4, calcium 9.1, phosphorus 3.1, magnesium 2.2. HOSPITAL COURSE: Mr. [Known lastname ] was admitted and underwent central line placement to begin therapy. His admission weight was 79.1 kg and he received interleukin-2 600,000 international units per kilogram equaling 47.5 million units IV q.8h. x14 potential doses. During this week he received nine of 14 doses with 5 doses held related to shock requiring vasopressor blood pressure support and toxic encephalopathy. On treatment day #3 he developed hypotension unresponsive to fluid boluses and was placed on dopamine for blood pressure support. He also developed severe arthralgias requiring intravenous morphine for pain control. He had one episode of hypoxia on treatment day #5 thought related to somnolence from narcotics. He was placed on oxygen with O2 sats in the mid 90s on 2 liters. Once weaned off dopamine on treatment day #4 he did not require recurrent vasopressor blood pressure support. He then developed evidence of toxic encephalopathy manifested by confusion and agitation treatment day 4 into 5, prompting IL-2 to be held. His mental status improved and he was given one dose of IL-2 at 3 o'clock on treatment day #5. Mental status improved at the time of discharge. Other side effects during this week included nausea and vomiting improved with Ativan; diarrhea improved with Lomotil; and development of an erythematous skin rash. During this week he developed acute renal failure with a peak creatinine of 6.8. He was oliguric but not anuric during his stay. He developed metabolic acidosis with a minimum bicarb of 18 improved with bicarb repletion. He was anemic without need for packed red blood cell transfusion. He had no thrombocytopenia, coagulopathy or myocarditis noted. He developed hyperbilirubinemia with a peak bilirubin of 2.6 improved to 1.1 at the time of discharge. He had no transaminitis noted. He required intermittent electrolyte repletions. By [2107-10-10] he had recovered from side effects to allow for discharge to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma status post cycle II week two high-dose IL-2 therapy complicated by shock, acute renal failure and arthralgias. DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily x5 days or until you reach baseline weight, Protonix 40 mg p.o. daily, Paxil 20 mg p.o. daily, Relpax 40 mg daily p.r.n. migraine headache, Ativan 1 mg q.6h. p.r.n. nausea/vomiting, Benadryl 25-50 mg q.6h. p.r.n. pruritus, Compazine 10 mg q.6h. p.r.n. nausea/vomiting, ciprofloxacin 250 mg p.o. q.12h. x5 days, Lomotil 150 tablets q.i.d. p.r.n. diarrhea, Coumadin 2 mg p.o. daily with PCP to adjust Coumadin dosing. FOLLOW-UP PLANS: Mr. [Known lastname ] will return to clinic in 4 weeks after CT scans to assess disease response. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. Dictated By:[Last Name (NamePattern1) 18853] MEDQUIST36 D: [2107-10-14] 16:35:50 T: [2107-10-17] 08:33:51 Job#: [Job Number 68751] cc:[Last Name (NamePattern4) 68750] Admission Date: [2107-10-12] Discharge Date: [2107-11-8] Date of Birth: [2051-2-13] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 20640] Chief Complaint: Pain Major Surgical or Invasive Procedure: PICC [2107-10-19] L IJ TLC [2107-10-20] L shoulder arthrocentesis [2107-10-18] L shoulder washout [2107-10-20] R shoulder washout [2107-10-23] History of Present Illness: Mr. [Known lastname ] is a 56-year-old male with a metastatic renal-cell carcinoma who recently has had acute renal failure in the setting of IL-2 therapy. He was readmitted today after discharge on the [10-10], after he called his doctor's office complaining of neck and back pain, in the context of a recent positive culture from a line tip for MRSA. . Today he relates that his pain is "all over," in "every joint" and is especially bothersome when he moves. He cites his right index finger, and legs as the most painful currently. He states that he has felt fatigued since his IL-2 treatment. He denies any fever, chills, sweating, diarrhea, nausea, vomiting, dysuria/frequency, skin rashes, chest pain, abdominal pain. Past Medical History: As noted in prior notes, reviewed in OMR. 1. Hypertension. 2. Hyperlipidemia. 3. Depression. 4. Anxiety. 5. History of pulmonary embolus. 6. History of migraine headaches. 7. History of eczema. . Oncologic history: (as previously noted, confirmed) In [2106-8-27], evaluation for SOB/CP revealed bilateral PE, multiple lung nodules; 3.5 cm renal mass in R kidney, revealed to be extending into R renal vein in hepatic portion of IVC. Bone scan showed osseous met to L 7th rib; head CT negative for brain mets during this initial workup. . Had R radical nephrectomy w/tumor thrombus extraction at [Hospital1 112], with pathology reportedly showing clear cell carcinoma. . [5-2] CT scan: no new evidence of recurrence/metastasis. [6-2]: High dose IL-2 for 1 full week (14/14 planned doses), held in second week ([7-9] doses) for hypotension. Also had a number of additional side effects including acute renal failure as well as hyperbilirubinemia, n/v/d, rash, arthralgias, fatigue. [8-2]: Restaging CT scan shows no evidence of disease progression. [9-2]: Recent hospital admission: planned admit for IL-2, as above. Social History: Works as graphic designer. No tobacco or ilicit drug use. Drinks [12-28] glasses of wine with dinner. Family History: Remarkable for CAD and DM. Physical Exam: Vitals: BP 141/73, HR 119, RR 21, 94% on 2L, Pain [4-5] GEN: Slightly pale, fatigued appearing male, sleepy but fully arousable, pleasant HEENT/NECK: NC/AT. Clear oropharynx, slightly dry MM, no scleral icterus or conjunctival pallor, PERRL, EMOI, no cervical or throacic spine spinal tenderness or masses appreciated, neck supple, full ROM CV: tachycardic, regular rhythm, S1, S2, no m/g/r appreciated RESP: lungs CTAB no w/r/r ABD: slightly distended, NT, +BS, no HSM appreciated, no tymphany to percussion EXT: 2+ edema bilat. warm, well perfused, DP 2+ bilaterally NEURO: +tremor UE bilat. A&Ox3, CNs symmetric, intact, upper extremities: grip [4-30] left, 4+/5 right [1-28] pain, remainder of upper extrs [4-30] bilaterally, lower limited by pain. SKIN: no rash, dry flaking skin PSYCH: pleasant Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2107-11-8] 12:00AM 9.2 3.39* 9.4* 27.9* 83 27.7 33.6 15.7* 267 [2107-11-7] 12:00AM 10.2 3.47* 9.6* 28.4* 82 27.6 33.6 15.7* 265 [2107-11-6] 12:00AM 9.3 3.37* 9.3* 27.5* 82 27.7 34.0 15.7* 276 [2107-10-15] 07:55AM 16.7* 3.26* 8.7* 25.5* 78* 26.5* 33.9 14.9 110* [2107-10-14] 08:00AM 19.1* 3.50* 9.2* 27.2* 78* 26.2* 33.7 15.3 109* [2107-10-13] 07:50AM 17.3* 3.70* 10.1* 29.1* 79* 27.4 34.8 16.6* 145* [2107-10-12] 05:30AM 16.7# 3.84 10.5* 30.6* 80* 27.2 34.1 16.5* 182 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [2107-11-8] 12:00AM 86 12 1.6* 132* 3.8 100 23 [2107-11-7] 12:00AM 92 11 1.6* 134 4.1 100 26 [2107-11-6] 12:00AM 98 11 1.6* 134 3.8 99 26 [2107-10-16] 09:17AM 137* 44* 1.7* 138 3.7 105 22 [2107-10-15] 07:55AM 127* 53* 2.1* 137 3.4 101 23 [2107-10-12] 05:30AM 128* 104* 6.0* 139 4.3 104 19* . [2107-10-12] MR thoracic & cervical spine w/o 1.Increased signal in the prevertebral soft tissues from C2-C4 on STIR sequence, which could represent edema, inflammation, or superimposition of adjacent tissues. Accurate assessment is limited due to lack of IV contrast, to exclude abscess or active inflammation in this location. 2. No evidence of epidural abscess, cord abnormality on the present study. 3. Multilevel degenerative changes in the cervical spine, with mild neural foraminal narrowing, as described above. . [2107-10-12] CXR New bilateral, left much greater than right, and predominantly lower lobe interstitial and nodular opacity; given history of elevated white blood cell count and immunosuppresion raises the concern for an opportunistic pneumonia. The other consideration given cardiomegaly, fissural fluid and right pleural effusion is "asymmetric" pulmonary edema. . [2107-10-14] CT chest 1. Multiple new lung consolidations and pulmonary nodules are more consistent with infection representing either disseminated pulmonary infection either pyogenic or fungal. Given the sudden appearance of the abnormality ( less than two weeks, since [2107-10-4], metastasis is unlikely). 2. Resolution of nodular opacities in left lower lobes since [Month (only) 116] [2106], since some representing inspissated bronchi. 3. New small bilateral pleural effusion and pericardial effusion, most likely reactive. 4. Given the history of pulmonary embolism, the subpleural areas of consolidation may represent pulmonary infarct. Reevaluation with contrast- enhanced study might be warranted if clinically justified. 5. Severe spleno`megaly may be consistent with ongoing infectious process. . [2107-10-14] Transthoracic Echo The patient is tachycardic; LVEF >55%. Moderate pulmonary artery systolic hypertension with right ventricular pressure overload. Small circumferential pericardial effusion without signs of tamponade. The mitral and aortic valves are well seen with no significant regurgitation implying that endocarditis of these valves is unlikely. . [2107-10-17] MRI L shoulder w/o 1. Diffuse edema is present throughout the shoulder muscles with relative sparing of the subcutaneous soft tissues. The finds represent a non-specific myositis. The differential diagnosis remains broad, but would include infection. 2. Moderate glenohumeral joint effusion. 3. Nonspecific 1.5-cm soft tissue mass superficial to the supraspinatus muscle. It is unclear if this arrises from the acromioclavicular joint or represents a discrete soft tissue mass in this patient with a history of metastatic renal cell cancer. . [2107-10-17] Right Upper ext ultrasound Limited study but no evidence of right upper extremity deep vein thrombosis. . [2107-10-17] Liver ultrasound 1. No focal or textural hepatic abnormality. 2. Splenomegaly. 3. Tiny gallbladder polyp. . [2107-10-20] Transesophageal Echo No echocardiographic evidence of endocarditis. . [2107-10-21] MRI R shoulder w/o Large right shoulder joint effusion with extensive fluid collection to the deltoid muscle, extending inferiorly, anterior to the humerus and also superficial to the deltoid muscle. Given the history of systemic bacteremia, the fluid may be of infective etiology, although the appearance is nonspecific. . [2107-10-21] MRV chest w/o 1. Limited evaluation of the central vessels without the administration of gadolinium due to the patient's low eGFR. Non-visualization of the right subclavian and right axillary veins, suggesting possible occlusion. Recent ultrasound, however, demonstrates patency of the right axillary vein. The right internal jugular, right brachiocephalic, and superior vena cava are otherwise widely patent without evidence of thrombus. 2. Left upper lobe lung consolidation concerning for pneumonia. 3. Small bilateral pleural effusions . [2107-10-23] CT head w/o No evidence of infarction or hemorrhage. . Brief Hospital Course: ASSESSEMENT/PLAN: 56 yo M with metastatic RCC s/p IL-2 therapy admitted with MRSA bacteremia cultured from catheter tip who presented with neck, upper back pain and leukocytosis. . # MRSA bacteremia: cultured from catheter tip s/p IL-2 therapy. Evidence on blood cultures from admission until [2107-10-17]. No evidence of vegetation on TTE or TEE but bilateral septic shoulder joints s/p arthroscopy with washout. ID consulted, followed closely with recommendations on vancomycin(start [10-12]) & gentamycin([Date range (1) 68752]) for synergy, levels were closely monitored. Given worsening lungs on imaging and sputum positive for MRSA, Linezolid was initated for a weeks duration. Pt to complete vancomycin regimen 12/10/2207 and follow up with ID service. . # Pulm infiltrates: CT chest concerning for septic emboli versus primary pulmonary infection. Pt without subjective shortness of breath or chest pain, however O2 requirements. During intubation for respiratory distress & mental status changes in [Hospital Unit Name 153], ET tube with yellow sputum, thus also new possibility of aspiration pneumonia. PT was started on levofloxacin and metronidazole for total 7 day course. . # Respiratory distress: with acute mental status changes. Pt with respiratory alkalosis secondary to tachypnea pt was transferred to the MICU and intubated. Head MRI did not show any acute CNS process, LENI's were negative and echo without evidence of RV strain making PE unlikely. Although with MRSA bacteremia undergoing treatment with antibiotics, pt was not septic. Improved ABG's and resolved tachypnea with resolution of mental status changes over the course of [Hospital Unit Name 153]. On return to the floor, pt remained stable. . # Mental Status Changes: s/p general anesthesia for shoulder surgeries; appeared to be possibly toxic in relation to anesthesia also in the setting of with MRSA bacteremia and IV hydromorphone for pain. Further acute worsening of mental status with delirium and hyperventilation, required transfer to the [Hospital Unit Name 153]. Concern for meningitis/encephalitis or new brain lesions but CT head without evidence of lesion. Mental status improved without evidence of fever or leukocytosis, was extubated and did not require lumbar puncture. . # Body/joint pain: Initially admitted with neck & upper back pain, however without focal findings on neurologic examination or point tenderness over spine. Gradually developed generalized body/joint pains, L then R shoulder pain. ?s/e IL-2 therapy. MRI C & T w/o showed increased signal in the prevertebral soft tissues from C2-C4 on STIR sequence which could represent possible edema, inflammation or abscess but limited as no further imaging with constrast due to limited GFR. Imaging of bilateral joints revealed effusions, arthrocentesis revealed infection thus pt underwent bilateral shoulder washout. Provided with IV dilaudid for pain control, however pt with delirium, continued on vicodin which controlled his pain. . # Acute renal failure: Poor GFR with Cr 6.0 on admission [1-28] IL-2 capillary leak syndrome. Renal consulted and followed pt until resolved. Remained stable during the rest of hospital stay at ~1.6. . # Anemia: Most likely r/t anemia of chronic disease. Received blood transfusions during admission. Remained stable. . # RCC: s/p IL-2 treatment, No treatment during admission. Further therapies per Dr.[Last Name (STitle) ] & Dr.[Last Name (STitle) ]. . # Elevated coagulation studies: INR initially concerning for development of DIC/consumptive process, however were relatively stable in the setting of longterm IV antibiotics & some element of liver dysfunction. Recieved a dose of oral vit.K, remained stable during the rest of hospital stay. . # Elevated LFTs: Liver ultrasound showed no focal abnormalities and resolved over time. . Pt reached maximal hospital benefit and was discharged home with services and close followup. Medications on Admission: 1. Lasix 20 mg p.o. till baseline weight 2. Protonix 40 mg p.o. daily. 3. Lorazepam 1 mg q.6h. p.r.n. nausea/vomiting. 4. Benadryl 25 mg to 50 mg q.6h. p.r.n. pruritus. 5. Compazine 10 mg p.o. q.6h. p.r.n. nausea/vomiting. 6. Ciprofloxacin 250 mg p.o. b.i.d. for 5 days. 7. Lomotil 1-2 tabs q.i.d. p.r.n. diarrhea. 8. Paxil 20 mg p.o. daily. 9. Relpax 40 mg p.o. daily p.r.n. migraine headaches. 10.Sarna lotion topically. 11.Eucerin lotion topically. 12.Pravastatin 80 mg qday Discharge Medications: 1. Outpatient Lab Work Please draw CBC, chem 7, liver function tests and vancomycin trough level(prior to dose of vancomycin) every week until [2107-12-5]. Please fax results to ATTN: Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 1419]; office #[Telephone/Fax (1) 457] 2. PICC CARE Please perform PICC care per NEHT protocol 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: Apply to each shoulder, keep on for 12hrs and off for 12hrs. Disp:60 Adhesive Patch, Medicated(s) Refills:0 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:200 Tablet(s) Refills:0 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:20 Tablet(s) Refills:0 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 26 doses: Stop date of antibiotic IV [2107-12-5]. Disp:26 gram Refills:0 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 11. Pravachol 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: MRSA bacteremia Bilateral septic shoulder joints Metastatic renal cell CA Discharge Condition: Stable. Discharge Instructions: You were found to have bacteria in your blood which spread to both shoulder joints. You underwent surgery to washout your shoulders and also received antibiotic therapy which you'll need to continue for a total of 6 weeks. . We have made some changes to your home regimen. We have increased your dose of metoprolol to 75mg [Hospital1 ]. Please discuss these changes with your PCP. . You were noted to have some hearing difficulty, which you report has been followed in the past by specialist. We recommend that you have your hearing re-evaluated. . Please call your PCP or come to the emergency room if you develop chestpain, fevers or any other worrisome signs. Followup Instructions: Follow up with Dr.[Last Name (STitle) ] on [2107-11-21] at 330pm. Office #([Telephone/Fax (1) 58452] . PCP: [Name10 (NameIs) ] up with Dr.[Last Name (STitle) 14522] [2107-11-30] at 1pm.[Telephone/Fax (1) 14525] . Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2107-11-28] 2:30 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 22367], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2107-12-5] 10:00 [Hospital ] clinic at [Hospital 2577] Medical office bldg basement; [Doctor First Name ], [Location (un) 86] MA . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2107-12-5] 3:00	[ "726.12", "403.90", "287.5", "584.9", "415.12", "197.0", "038.11", "711.01", "V10.52", "V09.0", "999.31", "585.9" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.04", "83.13", "96.71", "38.93", "81.91", "80.21", "80.81" ]	icd9pcs	[ [ [] ] ]	20076, 20127	13914, 17886	5813, 5978	20244, 20254	8927, 13891	20969, 21752	8046, 8074	4504, 4649	18415, 20053		20148, 20223		17912, 18392	2452, 4419		20278, 20946									8089, 8908												1502, 2434				5131, 5752						5769, 5775									6006, 6740																		6762, 7907	7923, 8030	4444, 4482
80,778	178,404	39094	Discharge summary	report	Admission Date: [2140-5-11] Discharge Date: [2140-6-2] Date of Birth: [2080-6-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17865] Chief Complaint: Respiratory failure s/p aspiration Major Surgical or Invasive Procedure: Intubation at outside facility Right PICC, s/p removal Left IJ temporary dialysis line, s/p removal s/p percutaneous tracheostomy Right sided chest tube for PTX s/p removal History of Present Illness: 59M with h/o anemia and H. pylori gastritis, remote pancreatitis s/p partial pancreatectomy, admitted to OSH with aspiration after EGD under propofol sedation s/p intubation x 2 with continued respiratory acidosis and difficulty ventilating sent here directly to MICU for continued management. . The patient went to outside facility today for elective EGD for f/u biopsies for H. pylori gastritis diagnosed during admission [2-/2140] for UGIB. Last PO intake was at 10pm the night prior. He was sedated wtih propofol for the procedure and at the end of procedure had episode of desaturation to 80%, vomiting of bilious gastric contents and aspiration. Was intubated, and had bronch which was showing thick white secretions and food particles in right main stem s/p suctioning. Sent to ICU where patient was quickly extubated, but found later to be sweaty, with stridor, and unresponsive on BIPAP so was given solumedrol, and reintubated with #7 ETT. Had difficulty ventilating patient, with PIPs 67, plateau pressure of 38, so vent settings adjusted to pressure control settings and s/p paralysis with vecuronium and rebronch. CXR found to have bilateral patchy infiltrate. ABG was 7.0/106/119 with O2 sat of 82-86%. Initially hypertensive, then hypotensive. Patient initially on vasopressin, being given bicarb gtt, on versed gtt at 6mg/hr. Bedside TTE was normal EF. Also given levofloxacin, flagyl, and IV solumedrol. For access, patient with RIJ and aline. Most recent ABG was 7.06/87/67. Last dose of vecuronium was at 6:30pm. . On arrival to the MICU, patient was intubated, sedated, off any pressors or bicarb gtt. Initial vent settings PEEP 16, FiO2 100. TV around 350, MV 8. ABG showed 6.91/127/187. Lactate 2.6, Hct 44.9, Cr 1.7, WBC 1.5 with 37 bands. Past Medical History: - Gastritis h/o recent H. pylori. Patient with admission in [2-/2140] with acute UGIB, found to have chronic active H. pylori s/p tx with Prevpac. Plan for PPI x 3 months and repeat EGD in [Month (only) 547] to assess for H. pylori (normal colonoscopy [2138]) - severe iron deficiency anemia - remote pancreatitis s/p partial pancreatectomy (in 20s, unclear etiology) - Hypothyroidism - Hyperlipidemia - Lyme disease treated in [2138] - Anxiety Social History: Retired accountant, married. Moderate alcohol use, 4 drinks daily, no tobacco or IVDU. Very functional prior to admission Family History: NC Physical Exam: Vitals: T:96.7 BP:106/76 P:117 R:20 18 O2:95% Initial vent settings PEEP 16, FiO2 100. TV around 350, MV 8 General: Intubated, sedated HEENT: PERRL Neck: supple, RIJ in place Lungs: Fair air movement bilaterally and at apices, with expiratory wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: old midline scar, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, nonedematous, good DP pulses, L a-line in place Pertinent Results: CXR [2140-6-2]: FINDINGS: In comparison with study of [6-1], there is little interval change. Monitoring and support devices remain in place. Continued bilateral pulmonary opacification, most coalescent at the left base, consistent with pneumonia superimposed and vascular congestion. . CXR [2140-5-29]: A tracheostomy tube is present. A right subclavian central line is present, tip overlying proximal SVC. An enteric tube is present, tip extending beneath diaphragm off film. The lungs are hyperinflated. The heart is slightly enlarged. There are extensive irregular patchy opacities in both lungs, most pronounced at left greater than right bases. The appearance is similar to [2140-7-25], although probably slightly worse at the left base. The appearance is compatible with an acute process superimposed on chronic changes and includes ARDS. The possibility of a small component of superimposed CHF cannot be excluded. . EKG: Sinus tachycardia without ST/T wave changes . [2140-5-19] CT Chest/Abd/Pelv: IMPRESSION: 1. Diffuse bilateral pulmonary consolidation, likely reflective of ARDS in combination with infection/aspiration, slightly worsened from the prior study. 2. Moderate right pleural effusion, increased in size. 3. Right internal jugular vein thrombus. 4. Anasarca, with perihepatic and pelvic free fluid. . [2140-6-2] 04:12AM BLOOD WBC-7.0 RBC-2.64* Hgb-8.1* Hct-23.1* MCV-88 MCH-30.9 MCHC-35.3* RDW-16.3* Plt Ct-320 . [2140-5-26] EKG: Sinus rhythm. Consider right atrial abnormality. Non-diagnostic Q waves in leads I and aVL. Since the previous tracing of [2140-5-15] P wave amplitudes are more prominent. . [2140-5-17]: FINDINGS: Note is made that this is a limited examination performed at the patient's bedside. Limited views of the liver demonstrate no focal abnormality. There is no biliary dilatation and the common duct measures 0.4 cm. The portal vein is patent with hepatopetal flow. No gallstones are identified. No ascites is seen in the right upper quadrant. IMPRESSION: No biliary dilatation identified. . [2140-5-13] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). There may be focal inferior hypokinesis but cannot adequately assess regional wall motion. The right ventricular cavity is dilated and free wall motion may be impaired but not well visualized. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are not well seen. No mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: 59M with h/o anemia, recent H.pylori gastritis transferred for severe hypercapneic respiratory failure on ventilator at OSH after aspiration episode during elective EGD procedure found to be in septic shock, DIC, and difficulty with mechanical ventilation. . # Hypercarbic and hypoxic respiratory failure: Severe respiratory acidosis with difficulty ventilating at OSH with evidence of aspiration during EGD. Admit CXR showing bilateral patchy infiltrates and breathing most likely [2-23] aspiration pneumonitis with severe bronchospasm. Bronchospasm and obstruction made him very difficult to ventilate and pCO2 on arrival was >120. Upon arrival to our hospital, he had very elevated pulmonary pressures and was found to have a right pneumothorax, which required chest tube placement. Multiple ventilator modes were attempted, heliox, high-dose steroids and frequent nebs without significant improvement. Bronchoscopy showed very friable mucosa, no bleeding or mucus. BAL was positive for pan sensitive Kleb Pneumo and Ecoli for which he was treated with Meropenem for 8 day course. He was ultimately paralyzed for 4 days to help with ventilation and oxygenation. CVVH was started to help manage the acidosis and pt was slowly weaned from high ventilator support. Unfortunately, given prolongued intubation he has a steroid/ICU myopathy and required perc. tracheostomy placed in the OR by interventional pulmonology. He has remained intermittently febrile and CXR on [5-29] showed a new LLL infiltrate in setting of the setting of resolving bilateral infiltrates. Sputum was positive for K.pneumo that is pan sensitive. He has been treated with 4 days of Levofloxacin for [Month/Day (4) 16630] and will need another 10 days to complete the course. He has been able to tolerate up to 2-3hrs of trach collar at a time but will likely need trach downsize in the near future. Otherwise, he has been rested on AC or pressure support overnight. VBG from [6-2] on pressure support showed 7.32/43/93. . # Sepsis: Patient with leukopenia with 35 bands, hypotension requiring pressors, tachycardia, elevated lactate (peak 4.6). He required massive resuscitation with IVF and was empirically treated with Vanc/Cefepime. Infectious work up was negative, except for E coli/Kpneumo in BAL ([2140-5-12]). Additional infectious work up included blood cultures, urine culture, mycolytics, galactomanan, beta-glucan, CT of chest, abdomen and pelvis that showed sludge in the gallblader without signs of cholangitis. Pt developed elevated bilirubin up to 5.6 with alk phos of 213 that improved on its own. Given that we were sitll having difficulty ventilating him we broaded him to Vanc/Meropenem. There was concern for DIC given anemia and thrombocytopenia. Heme-onc was consulted and thought it was marrow suppression was secondary to infection and vancomycin may be contributing to thrombocytopenia. Infectious disease were consulted and agreed with a 2-week course of Vanc Meropenem which he completed. Patient initially was neutropenic and later developped a WBC count up to 34. Subsequent repeat extensive work up was negative until sputum turned positive for K Pneumo and CXR showed new LLL infiltrate consistent with [Year (4 digits) 16630]. Patient. WBC has trended down with the above interventions and has been within normal range during the last few days. . # H. pylori gastritis s/p repeat EGD: Per records, EGD at OSH on day of admission for repeat biopsies for H. pylori which was diagnosed in [2-/2140] during admission for UGIB and treated with Prevpak and PPI. Patient has been on PPI throughout the whole admission. He has had guaiac positive stools intermitently. We started treatment for H. Pylori with levofloxacin/clarithromycin/pantoprazole (D1 = [6-1]) for 14 days. He will need to continue pantoprazole indefinitely. . # Acute renal failure: Pt was initially started on CVVH for the respiratory acidosis and volume overload. Furthermore, he was hypotensive and received IV contrast. After resolution of his sepsis, he received UF for aggressive volume removal. He was then transitioned to intermittent HD, which he tolerated well. However, in the setting of persistent fevers and his UOP increasing we decided to pull the line. He has been off HD since [5-28] and his UOP has continued to increase. (over 1500ccs in last 24hrs) He has been negative in the last 2 days and furthemore his electrolytes have been within normal range. There is no indication for HD at this time. The renal team feel that given his improving UOP, stable lytes and improving creatinine (7.8 today) that he will not need hemodialysis. In the meantime he can receive lasix as needed for SOB. . # Anemia: Pt was admitted with an HCT of 44 that slowly had been drifting down. He has had two episodes of oropharyngeal bleeding, from mucositis, which was thought secondarily to prolongued intubation. He has been guaiac positive, no BRBPR. He alwasy has bumped adequately to transfusions. It was thought bleeding from gastritis as well as anemia of chronic diseases. Our goal for transfusion has been >21. His las HCT was 23. He has not received any blood transfusion in 2 days. EGD is not an option given that it precipitated all these events. . # Hypothyroidism: TSH at OSH was 4.66. We continued his levothyroxine at current dose. . #. RIJ clot - Pt was found to have a RIJ clot on a CT scan looking for infection. Therefore, he was started on heparin and kept on it until it was decided if he was going to need HD/CVVH (for line placement). We started coumadin 2 mg on day of discharge and pt will need PT/INR followed closely until INR >2, then heparin gtt may be stopped. . #. Oropharyngeal bleeding - Pt had bleeding from palate, which was thought secondarely to prolongued intubation. Pt was examined by ENT, who did not see any visible lesion suspecting of malignancy or infection. . #. Thrombocytopenia - Pt developped thrombocytopenia that coincided with sepsis and later with administration of Vancomycin. His PLT count improved after stopping vancomycin and currently his PLTs are 320. . #. Gastric outlet obstruction - Pt initially underwent an EGD that caused him to aspirate given that his stomach was full of food. It is possible that he has a component of gastric outlet obstruction or dysmotility dysorder. We had a lot of difficulty advancing his tube feeds given high residuals. We tried metoclopramide without any improvement and ultimately had the feeding tube advanced to jejunum. . #. [Name (NI) 16630] - Pt has been in the ventilator for 22 days in this hospital. Pt was started on [2140-5-29] for a 14-day of antibiotic therapy given that in one of the multiple infectious work up for persistent fever pt was found to have a LLL infiltrate. We initially started with cefepime and once we had the results of the sputum culture for pan-sensitive kleibsiella with narrowed to levofloxacin (last day [6-13]) . #. Persistent fever - Pt had been febrile almost daily while in the hospital. Fever spikes have been decreasing with time. He was spiking up to 101 on CVVH, then 102 w/o CVVH and lower every day. Now pt has been afebrile for 48 hours. We have done an exhaustive infectious work up and removed all indwelling lines, exchanged foley. We found the LLL infiltrate and positive sputum, currently we are treating the [Month/Year (2) 16630] for 14 day course of Levofloxacin. Medications on Admission: Celexa 20mg daily MVI daily Iron supplementation Levothyroxine 50mcg daily Medications on Transfer (Ground [Location (un) 7622]): - Versed gtt at 6mg - Given 1L NS - Fentanyl IV 200mg - Vecuronium 7mg IV (last 6:30pm) - Albuterol neb x 2 - Tylenol 650mg PR Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [Location (un) ]: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 2. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: 1-12 units Subcutaneous ASDIR (AS DIRECTED): please adjust per sliding scale. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: 6-8 Puffs Inhalation Q1H (every hour) as needed for wheezing. 4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [Hospital1 ]: One (1) Appl Ophthalmic TID (3 times a day). 5. Levothyroxine 50 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-23] Drops Ophthalmic PRN (as needed) as needed for dry eyes; pt not blinking. 8. Acetaminophen 650 mg/20.3 mL Solution [Month/Day (2) ]: One (1) PO Q8H (every 8 hours) as needed for pain, fever. 9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [Month/Day (2) ]: One (1) PO BID (2 times a day). 10. Calcium Acetate 667 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [Month/Day (2) ]: One (1) Inhalation [Hospital1 ] (2 times a day). 12. Sodium Chloride 0.65 % Aerosol, Spray [Hospital1 ]: [1-23] Sprays Nasal TID (3 times a day) as needed for nasal dryness. 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Month/Day (2) ]: One (1) Cap PO DAILY (Daily). 14. Clarithromycin 250 mg/5 mL Suspension for Reconstitution [Month/Day (2) ]: One (1) PO BID (2 times a day) for 14 days: Last day day [6-15]. 15. Citalopram 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 16. Warfarin 2 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Once Daily at 4 PM: adjust [Name6 (MD) ] rehab MD. 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 18. Levofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q48H (every 48 hours) for 10 days: last day [6-13]. 19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [Month/Year (2) ]: Seven [Age over 90 10973]y (730) units/hr Intravenous continuously until INR>2. 20. Outpatient Lab Work Please draw PT/INR on [6-3] & [6-5], forward results to rehab MD for recommendations regarding adjustment of coumadin. Stop Heparin gtt when INR>2 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 1. Hypercarbic Respiratory Failure 2. Aspiration PNA 3. Septic Shock 4. Acute renal failure requiring temporary CVVH 5. RIJ associated DVT 6. Steroid/ICU myopathy 7. [Hospital6 16630] with pan sensitive Kleb Pneumo 8. Oropharyngeal bleeding 9. Thrombocytopenia 10. Gastric Outlet obstruction 11. Pneumothorax s/p right sided chest tube Discharge Condition: Mental Status: s/p tracheostomy, unable to speak but mouthing words and answering questions appropriately Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted after an aspiration event with severe hypercarbic respiratory failure. You have been managed in the ICU for for last 3 weeks and you are improving signficantly with regards to breathing, kidney function and mental status. You will need ongoing physical rehabilitation and support for weaning from the ventilator. . You will need follow up with pulmonary, renal and gastroenterology after you are discharged from the rehab facility. Please see below for contact numbers to the outpatient clinics. Followup Instructions: You will be followed closely by the rehab physicians for your respiratory and physical therapy needs. . You will need follow up with gastroenterology for your gastritis and the mild gastric outlet obstruction. Please call the gastroenterology unit at ([Telephone/Fax (1) 2233] to schedule a follow up appointment. . When you are being prepared for discharge from rehab, please call the pulmonary clinic to schedule a follow up appointment at ([Telephone/Fax (1) 3554]. . Please call the renal clinic at ([Telephone/Fax (1) 10135] to schedule a follow up appointment.	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30,414	132,405	46690	Discharge summary	report	Admission Date: [2194-1-27] Discharge Date: [2194-3-27] Date of Birth: [2126-12-12] Sex: F Service: CARDIOTHORACIC Allergies: Dopamine / Ivp Dye, Iodine Containing Attending:[First Name3 (LF) 165] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2194-2-2] Surgical Extraction of Teeth [2194-2-12] Redo Sternotomy, Two Vessel Coronary Artery Bypass Grafting(saphenous vein grafts to left anterior descending artery and diagonal), Mitral Valve Repair(26mm Annuloplasty Ring), Tricuspid Valve Repair(34mm Annuloplasty Band). [2194-3-16] Placement of Left Internal Jugular PermCath [2194-3-20] Double-lumen PICC Line Placement via the Left Basilic Venous Approach History of Present Illness: Mrs. [Known lastname 73770] is a 67yoF with extensive cardiac hx, ischemic cardiomyopathy with EF 35%, called in for inpatient diuresis. Patient reports 20lb wt-gain over one month. Patient reports chest pain 2-weeks prior to admission which relieved with nitro. Has had increasing SOB since with orthopnea and increased edema. Reports compliance with medications. Patient can only walk short distances without getting SOB. She cannot go up a flight of stairs without SOB. Sleeps in a recliner. Pt noted increasing lower extremity edema for the past two weeks. In ED, satting 100% ra, +rales, +jvd, vital signs stable. 40mg iv lasix, cxr - slight failure, BNP 5000, anticoagulated for afib, trop 0.2. Pt took aspirin at home, EKG showed no new ischemic changes. Admitted for inpatient diuresis. Past Medical History: 1. Ischemic CM with recent EF 35%, systolic CHF 2. CAD status post three-vessel CABG, cath [2193-7-21]: severe native three vessel CAD, RCA 100%, Prox Mid Cx 90%, SVG-diagonal and SVG-RCA 100% occluded, SVG #3 and LIMA normal (was pretreated for iodine allergy) 3. DM: Insulin dependent, complicated by: nephropathy, retinopathy, neuropathy 4. Chronic Renal Insufficiency(baseline Cr 1.2-1.6) 5. s/p L nephrectomy [2177] due to suspected Renal cell cancer 6. Moderate MR 7. Pulmonary Hypertension 8. Depression 9. Memory difficulties 10. GERD 11. Gout 12. s/p Hysterectomy 13. [2187] Pyelonephritis -> hospitalized for +blood cultures 14. [2189] Breast Abscess -> treated in ED 15. s/p R carotid endarterectomy for 70% R internal carotid stenosis 16. Anemia 17. Hyperlipidemia 18. History of GIB [10/2193] - gastritis found on EGD Social History: Recently left [State 108], was living with daughter/grandson. She lives currently with her son in [Name (NI) 86]. She has a history of smoking, quit in [2174]. No alcohol abuse. Has twice-a-week VNA at home. Family History: Multiple family members with DM. Father died of MI, unknown age. Mother died of lung CA. Physical Exam: Admission VS: T 98.4, 109/40, 87, 16, 99%ra GENERAL: comfortable, tolerating PO HEENT: L eye with cataract, EOMI, anicteric, MMM Neck: JVP elevated up to ear lobes LUNGS: CTA b/l with good air movement anteriorly HEART: RR, S1 and S2 wnl, no m/r/g ABDOMEN: Mild epigastric tenderness to palpation. +BS. No rebound or guarding. EXTR: 2+ chronic LE edema bilat. venous stasis changes bilat LE. NEURO: AAOx3. Cn II-XII intact Pertinent Results: [2194-3-27] 05:01AM BLOOD WBC-15.5* RBC-3.98* Hgb-10.9* Hct-33.6* MCV-84 MCH-27.4 MCHC-32.5 RDW-16.7* Plt Ct-331 [2194-3-25] 08:00AM BLOOD WBC-14.8* RBC-3.95* Hgb-10.9* Hct-32.9* MCV-83 MCH-27.6 MCHC-33.2 RDW-17.1* Plt Ct-310 [2194-3-24] 03:00AM BLOOD WBC-14.7* RBC-3.78* Hgb-10.4* Hct-32.2* MCV-85 MCH-27.4 MCHC-32.2 RDW-16.8* Plt Ct-263 [2194-3-22] 08:15AM BLOOD WBC-15.7* RBC-3.93* Hgb-10.8* Hct-33.7* MCV-86 MCH-27.4 MCHC-31.9 RDW-16.8* Plt Ct-268 [2194-3-21] 04:38AM BLOOD WBC-17.0* RBC-3.90* Hgb-10.9* Hct-32.7* MCV-84 MCH-28.0 MCHC-33.4 RDW-17.3* Plt Ct-316 [2194-1-27] 09:15PM BLOOD WBC-6.8 RBC-3.36* Hgb-8.8* Hct-27.7* MCV-82 MCH-26.2* MCHC-31.8 RDW-15.3 Plt Ct-295 [2194-3-27] 05:01AM BLOOD PT-25.3* INR(PT)-2.5* [2194-3-26] 05:26AM BLOOD PT-26.3* INR(PT)-2.6* [2194-3-25] 04:23AM BLOOD PT-25.9* INR(PT)-2.6* [2194-3-24] 03:00AM BLOOD PT-29.1* PTT-34.3 INR(PT)-3.0* [2194-3-23] 05:57AM BLOOD PT-23.8* INR(PT)-2.3* [2194-3-22] 08:15AM BLOOD PT-19.0* PTT-29.5 INR(PT)-1.8* [2194-3-27] 05:01AM BLOOD Glucose-87 UreaN-35* Creat-4.8* Na-134 K-5.7* Cl-94* HCO3-25 AnGap-21* [2194-3-25] 08:00AM BLOOD Glucose-177* UreaN-39* Creat-4.7* Na-136 K-4.7 Cl-95* [2194-1-27] 09:15PM BLOOD Glucose-88 UreaN-32* Creat-1.1 Na-141 K-4.2 Cl-103 HCO3-31 AnGap-11 CHEST (PORTABLE AP) [2194-3-26] 4:52 PM CHEST (PORTABLE AP) Reason: eval for pleural effusions [Hospital 93] MEDICAL CONDITION: 67 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions REASON FOR EXAMINATION: Followup of a patient after CABG. Portable AP chest radiograph compared to [2194-3-21]. The double-lumen left jugular catheter tip is in distal SVC. The left PICC line tip cannot be visualized, but most likely is in the superior or mid SVC. The cardiomegaly is moderate , stable. The replaced valve is in unchanged position. The post-CABG sternotomy wires and sutures are unremarkable. The NG tube has been removed in the meantime. The bilateral basal atelectasis is grossly unchanged with small left more than right amount of pleural fluid. The patient continues to be in mild failure, although there is no frank pulmonary edema. No substantial pneumothorax is demonstrated. PICC LINE PLACEMENT INDICATION: 67-year-old woman with CABG and mitral valve repair. Please insert a PICC line for TPN. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Drs. [Last Name (STitle) 1832] and [Name5 (PTitle) 4686] performed the procedure. Dr. [Last Name (STitle) 4686], the Attending Radiologist, was present and supervised the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, the left basilic vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a double-lumen PICC line measuring 42 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the left basilic venous approach. Final internal length is 42 cm, with the tip positioned in SVC. The line is ready to use. VIDEO OROPHARYNGEAL SWALLOW [2194-3-17] 2:30 PM VIDEO OROPHARYNGEAL SWALLOW Reason: assess swallow [Hospital 93] MEDICAL CONDITION: 67 year old woman s/p cabg REASON FOR THIS EXAMINATION: assess swallow INDICATION: 67-year-old woman status post CABG. Assess swallow. VIDEO FLUOROSCOPIC SWALLOW: A video fluoroscopic oropharyngeal swallow evaluation was done in conjunction with the speech and swallow pathology division. Bolus formation, control, and tongue movement were severely impaired with consistent premature spillage noted. Once the pharyngeal swallow was initiated palate elevation, laryngeal elevation and epiglottic deflection were within functional limits. No episodes of penetration or aspiration were observed throughout today's evaluation though evaluation was very limited by patient positioning. Solid residue was noted remaining in the mid- to- distal esophagus after the evaluation. IMPRESSION: Severely prolonged oral phase with no definite evidence of aspiration, though evaluation was limited. Retained residue within the esophagus. For further details, please consult the speech and swallow pathology evaluation available on CareWeb. Brief Hospital Course: Initially the patient was diuresed aggressively with a Lasix drip and IV diuril with very good effect, becoming 3-4L negative per day. She lost approximately 15-18lbs of fluid weight this way. However, her creatinine began to rise and it was felt that we had reached the limit of active diuresis. At that time, it was noted that she had 3+ MR on a previous echocardiogram which was likely making her heart failure much worse than it appeared to be. After diuresis, the 3+ MR persisted, suggesting that the MR was not worsened by fluid overload. In discussion with her cardiologist, Dr. [First Name (STitle) 437], and the patient, it was felt that she would benefit from mitral valve, tricuspid valve, and redo CABG. After active diuresis, she was changed to a maintenance dose of oral Torsemide and HCTZ which maintained her volume status. However, her diuretic regimen will likely need to be altered after her surgery. In preparation for surgery she underwent evaluation of her carotids which showed a patent right carotid and a 60-69% stenosis in the left. She was also seen by dental who recommended the extraction of teeth #21, 22, 28, and 29 which was done by Dr. [Last Name (STitle) 2866]. Cardiac surgery also recommended an evaluation by GI given her history of GI bleeding and the increased intraoperative risk given the large heparin dose she would get. She received an EGD with small bowel enteroscopy which showed some small AVMs in the stomach which were cauterized and no further AVMs in the visualized portion of the small bowel. She also received a colonoscopy which only showed a benign appearing polyp that was biopsied but not removed given the plans for surgery. The gastroenterologists felt that she had a moderate risk of bleeding during perioperative time period. She was continued on her PPI twice daily for further prophylaxis. In discussion with the patient and the cardiac surgeons, it was felt appropriate to continue with the surgery. On [2-12] the patient was brought to the operating room where she underwent redo sternotomy/CABGx2(SVG-LAD,SVG-Diag)MVRepair(26 [Doctor Last Name ] ring)TVRepair(34 [Doctor Last Name ] band). Please see OR report for details, see tolerated the operation and was transferred to the cardiac surgery ICU on Milrinone, Levophed and Epinephrine infusions. She received Vancomycin perioperatively as she was an inpatient preoperatively. For several days postoperatively the patient remained intubated and sedated on inotropes and pressors. She had episodes of rapid atrial fibrillation and was startedon amiodarone, as well as heparin and coumadin. She was started on flagyl for ? of cdiff with WBC of 34. She was extubated on POD #3. On POD #4, she required re-intubation for apnea. Seen by ID for continued leukocytosis of unknown etiology and started on empiric vanco and zosyn. Her creatinine rose to 2, and she required higher blood pressures, as well as torsemide and albumin to maintain urine output. She was extubated again on POD #6. Milrinone and vasopressin weans continued. She was started on digoxin for rate control. She converted to sinus rhythm. She was again reintubated on POD #17 for near badycardic near arrest. She was seen by electrophysiology who recommended waiting for clinical improvement prior to pacer placement. She was started on natrecor for diuresis. She was started on tube feeds. Left sided chest tube was placed for pleural effusion. She was seen by orthopedic surgery for decreased ROM in her left shoulder. There were no acute issues found. Yeast grew from her sputum and urine and she was started on fluconazole. She had no further episodes of bradycardia and did not require a pacemaker. She was extubated again on [3-5]. Diuresis and volume status continued to be an issue. She was seen by heart failure and started on sildenafil. On [3-7] she underwent bilateral thoracentesis. Dialysis catheter was placed on [3-9]. CVVH was started for fluid removal. She had rapid atrial fibrillation, and was given iv amiodarone and again became bradycardic. IV Amio was discontinued. Speech and swallow evaluation recommended starting nectar thick and pureed consistencies, with tube feeds as primary source of nutrition. She was changed to HD. Tunnelled dialysis catheter was placed on [3-16]. She was transferred to the floor on [3-18]. She received tube feeds overnight for supplementation. Her dobhoff was then discontinued her appetite improved. Repeat swallowing evaluation on [3-24] receommended continued nectar thick lequids and pureed foods, as well as small sips of thin liquids and modified barium swallow prior to advancing diet. She was ready for discharge to rehab and awaited placement. She was dialysized on [3-27]. She continues on coumadin for atrial fibrillation, and has received 0.5 mg for 4 days. Medications on Admission: ASPIRIN 81 mg--1 tablet(s) by mouth daily CARVEDILOL 3.125 mg--1 tablet(s) by mouth twice a day COLACE 100 mg--1 (one) capsule(s) by mouth twice a day as needed for constipation COUMADIN 2.5 mg--1or 2 tablet(s) by mouth qpm or as directed by [Hospital ] clinic FLUOXETINE 40 mg--1 capsule(s) by mouth daily GABAPENTIN 300 mg--1 tablet(s) by mouth twice daily Humalog Pen 100 unit/mL--3ml four times daily as directed LANTUS 100 unit/mL--30 units at bedtime LISINOPRIL 2.5 mg--1 tablet(s) by mouth twice a day NITROQUICK 0.4 mg--1 tablet(s) sublingually as needed for chest pain do not exceed 3 tabs NYSTATIN 100,000 unit/gram--apply to affected area twice daily as needed for as needed for yeast PLAVIX 75 mg--1 tablet(s) by mouth daily PROTONIX 40 mg--1 tablet(s) by mouth twice a day SIMVASTATIN 20 mg--1 tablet(s) by mouth daily SUCRALFATE 1 gram--1 tablet(s) by mouth four times a day Senna Plus 8.6 mg-50 mg--[1-22] tablet(s) by mouth twice daily as needed for constipation TEMAZEPAM 15 mg--1 capsule(s) by mouth at bedtime as needed for sleep TORSEMIDE 100 mg--1 tablet(s) by mouth twice a day TRAMADOL 50 mg--1 tablet(s) by mouth every 4-6 hours as needed for pain TYLENOL EXTRA STRENGTH 500 mg--2 (two) tablet(s) by mouth three times a day as needed for arthritis pain gel cushion --for power wheelchair icd9 707.05 diagnosis pressure sores Discharge Medications: 1. Simvastatin 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO HS (at bedtime). 2. Fluoxetine 20 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO DAILY (Daily). 3. Ferrous Gluconate 300 mg (35 mg Iron) Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable [Month/Day (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. Amiodarone 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Fluticasone 110 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: 1-2 Puffs Inhalation Q4H (every 4 hours). 9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Sildenafil 25 mg Tablet [Hospital1 ]: Three (3) Tablet PO TID (3 times a day). 12. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Thirty Five (35) units Subcutaneous at bedtime. 13. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: per sliding scale Subcutaneous four times a day. 14. Warfarin 1 mg Tablet [Hospital1 ]: 0.5 Tablet PO ONCE (Once). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 38] Discharge Diagnosis: Diastolic Congestive Heart Failure, Coronary Artery Disease, Mitral and Tricuspid Regurgitation - s/p Redo CABG, MV and TV Repair End Stage Renal Disease Atrial Fibrillation Postop Acute Respiratory Failure Urinary Tract Infection Postop Pleural Effusion Pulmonary Hypertension Diabetes Mellitus Type II Hyertension Elevated Cholesterol Anemia GERD Discharge Condition: Stable. Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr [Last Name (STitle) 7772] in [4-26] weeks, call for appt [Telephone/Fax (1) 170] Dr. [First Name (STitle) 437] in [2-23] weeks, call for appt [Telephone/Fax (1) 4451] Dr. [Last Name (STitle) ] in [2-23] weeks, call for appt [Telephone/Fax (1) 250] Dr. [Last Name (STitle) ] on [2194-6-17] @ 11AM, [Telephone/Fax (1) 1237] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2194-3-27]	[ "424.0", "414.01", "424.2", "280.0", "521.81", "V10.52", "458.29", "486", "272.4", "428.43", "599.0", "250.40", "427.89", "427.31", "584.9", "414.02", "357.2", "V45.73", "511.9", "999.9", "787.21", "585.6", "403.91", "998.0", "250.60", "211.3", "008.45", "537.82", "518.5", "440.0", "428.0", "416.0" ]	icd9cm	[ [ [] ] ]	[ "36.12", "99.04", "88.72", "43.41", "00.13", "89.60", "34.04", "38.93", "23.19", "96.71", "34.91", "39.95", "39.61", "99.15", "35.33", "45.25", "96.6", "38.95", "45.13", "96.04" ]	icd9pcs	[ [ [] ] ]	15855, 15936	8126, 12992	324, 756	16329, 16339	3266, 4682	16675, 17170	2716, 2806		14405, 15832	7070, 7097	15957, 16308		13018, 14382			16363, 16652									2821, 3247																						265, 286	7126, 8099								784, 1585																		1607, 2461	2477, 2700
40,198	101,188	15620	Discharge summary	report	Admission Date: [2196-12-23] Discharge Date: [2196-12-28] Date of Birth: [2137-10-11] Sex: M Service: MEDICINE Allergies: Tylenol / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2387] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with Drug eluting stents to the Left anterior descending artery and left Circumflex artery History of Present Illness: 59 y/o M with h/o CAD s/p PCI (DES in [First Name3 (LF) ], OM1, and LAD in [2191]), DM, and a heavy tobacco history transfered to [Hospital1 18] from [Hospital3 934] Hospital for NSTEMI. He reports that 3 days ago he started feeling generally unwell with a fever. His FS were elevated, so he ate less. By 2 days before transfer he felt sick enough that he called 911. In the ambulance to the ED he developed substernal chest pain. He denies SOB, nausea, or palpitations. Of note, he has had a month of worsening DOE and CP with exertion. He was take no [Hospital3 934] Hospital where he was admitted for ACS. His pain improved with NTG but recurred. An ECG there showed ST depressions in V4-6 with an intial set of negative CEs, but follow up CEs were positive with a TnI of 1.34 from 0.12 8 hours prior. At that time his WBC was notable for 3.5 and he had a low grade fever. Given his ECG changes and elevated TnI he was transfered to [Hospital1 18] for catheterization. . On arrival at [Hospital1 18] he was in [7-30] CP, diaphoretic, and febrile to 100.7. He underwent cath which showed 80% proximal LAD lesion, 90% [Date Range ] in stent restenosis, and a fully occluded RCA with collaterals present. He was started on eptifibatide and a NTG drip for ongoing chest pain and transfered to the CCU. . In the CCU his pain was a [1-31] and the best he had felt in several days. He denies SOB at rest, orthopnea, or LE edema. He feels feverish. . On review of systems, s/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. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for presense of chest pain for the past several days for for the past month with exertion as well as dyspnea on exertion. He denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: multiple PCIs with DES in LAD, [Month/Year (2) ], and OM1 most recent in [2191] -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Cerebral aneurysm - Colostomy with reversal - Ruptured diverticulum s/p Colostomy [6-23] - Cerebral aneurysm [2182] s/p VP shunt (subsequently removed) - Hernia repair - Hip Surgery [2156] - Arthritis - Diabetes, now off hypoglycemics and insulin - HTN - HLD . Social History: - Tobacco: 2PPD age 14 to age 53, 80 or so PYs - etOH: Social only - Illicits: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GEN: NAD, diaphoretic VS: 100.0 82 125/59 21 100% on RA HEENT: JVD to the angle of the jaw, no LAD, neck is supple CV: RR, distant, NL S1S2 no S3S4 +II/VI systolic murmur at the LUSB PULM: Prolonged expiratory phase relative to inspiration, crackles at the bases L>R ABD: BS+, soft, NTND, no HSM LIMBS: No LE edema, mild clubbing SKIN: No hair of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) 22595], no skin breakdown NEURO: Reflexes are 2+ diffusely PULSES: Radial, femoral, TP, and DP pulses are 2+ bilaterally POST CATH CHECK groin without murmur, masses, bruit, or hematoma . ECG: Sinus, 82/min, leftward axis, RBBB, ST-T in I, II, aVL, V4-5, TWI in I, II, III, aVF, V1-6, and possible ST-E in aVR and V1. . At discharge: same as above except HEENT: Decreased JVP Pertinent Results: [2196-12-23] 11:46PM PT-14.3* PTT-26.8 INR(PT)-1.2* [2196-12-23] 11:46PM PLT COUNT-198 [2196-12-23] 11:46PM NEUTS-70.5* LYMPHS-20.4 MONOS-7.9 EOS-0.6 BASOS-0.6 [2196-12-23] 11:46PM WBC-2.6# RBC-4.47 HGB-13.4* HCT-37.3* MCV-84 MCH-29.9 MCHC-35.8* RDW-14.9 [2196-12-23] 11:46PM %HbA1c-7.2* eAG-160* [2196-12-23] 11:46PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.9 [2196-12-23] 11:46PM CK-MB-3 cTropnT-0.07* [2196-12-23] 11:46PM ALT(SGPT)-28 AST(SGOT)-29 LD(LDH)-217 CK(CPK)-179 ALK PHOS-96 TOT BILI-0.8 [2196-12-23] 11:46PM estGFR-Using this [2196-12-23] 11:46PM estGFR-Using this [2196-12-28] 06:40AM BLOOD WBC-4.0 RBC-4.37* Hgb-13.3* Hct-37.0* MCV-85 MCH-30.3 MCHC-35.8* RDW-15.3 Plt Ct-229 [2196-12-26] 07:10AM BLOOD Neuts-61.6 Lymphs-26.8 Monos-9.0 Eos-2.0 Baso-0.7 [2196-12-26] 07:10AM BLOOD ESR-8 [2196-12-25] 05:55AM BLOOD Gran Ct-1600* [2196-12-28] 06:40AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-138 K-4.6 Cl-101 HCO3-25 AnGap-17 [2196-12-28] 06:40AM BLOOD CK(CPK)-107 [2196-12-28] 06:40AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.2 [2196-12-23] 11:46PM BLOOD %HbA1c-7.2* eAG-160* CARDIAC CATH REPORT [12-23]:COMMENTS:Coronary angiography in this right dominant system demonstrate three vessel disease. The LMCA had no angiographic evidence of disease. The LAD had a proximal 80% stenosis. The [Month/Year (2) ] had a 90% instent restenosis with an occluded OM. The RCA was occluded but filled from left to right collaterals. Resting hemodynamic reveal transient systemic hypotension that resolved after fluid resuscitation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. CABG vs PCI of LAD and [Last Name (LF) ], [First Name3 (LF) ] be discussed with primary cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and CT surgery. CXR [12-24]: The heart is normal in size and lungs are clear without vascular congestion or pleural effusion. ECHO [12-26]:The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis (inferior wall worst affected) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Left Ventricle - Ejection Fraction: 50% to 55%. IMPRESSION: Regional LV systolic dysfunction consistent with CAD (inferior ischemia/infarction). Mild mitral regurgitation. Trace aortic regurgitation. EF 50-55%. [12-27] Cath Report: Cath: 80% LAD=> DES x1, [Month/Year (2) 8714]=> DES x1, 175cc contrast, integrellin x 18 hours. Brief Hospital Course: 59 y/o M with h/o CAD s/p PCI (DES in [Month/Year (2) ], OM1, and LAD), DM, and a heavy tobacco histroy who was transfered from an OSH for NSTEMI and was found to have 80% proximal LAD lesion, 90% [Month/Year (2) ] in stent restenosis, and a fully occluded RCA with collaterals as well as a fever and a possible LLL PNA. . # CAD: NSTEMI with Trop peaking of 2.17 at OSH now s/p cath showing 80% proximal LAD lesion, 90% [Month/Year (2) ] in stent restenosis, and a fully occluded RCA with collaterals. Patient was initially a candidate for CABG. He was started on a heparin drip with goal PTT 60-100 3 hours after pulling arterial sheath. We stopped simvastatin and start atorvastatin 80 mg PO HS. He was briefly on a NTG drip for pain and to decrease cardiac work. While in hospital, we changed home metoprolol succinate 50 mg PO daily to metoprolol tartrate 25 mg PO daily to decrease cardiac work and cycled his cardiac enzymes. . # PUMP: Initially presenting with some crackles on exam, JVD elevated and mildly hypoxic, but he may have TR on exam and has a heavy smoking history. His CXR was not particularly congested. We continued lisinopril 2.5 mg PO daily to prevent remodelling. . # Diabetes: Per patient, now off hypoglycemics. a1c 7.2%. . # Fever: Febrile on admission and at OSH. CXR here concerning for LLL PNA. He was given an empiric levofloxacin 750 mg PO daily x 7 days for presumed CAP. BCx no growth. He also had a low WBC count, but his workup for possible neutropenia was negative and his WBC count rebounded prior to discharge: (WBC 2.6 on [12-23], and up to 4 on [12-28]). Medications on Admission: - Aspirin 325 mg PO daily - Simvastatin 20 mg PO HS - Clopidogrel 75 mg PO daily - Metoprolol succinate 50 mg PO daily - Lisinopril 2.5 mg PO daily - Lumigan 1 drop OU [Hospital1 ] - Timolol 1 drop OU [Hospital1 ] 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). Disp:30 Tablet(s) Refills:11 3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 7. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Non ST Elevation Myocardial Infarction Leukopenia Hyponatremia Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and a cardiac catheterization showed some blockages in your heart arteries. Initially we were planning to do surgery but Dr. [Last Name (STitle) ] decided to place 2 stents in blocked arteries instead. This went well and you will need to be on Aspirin and Plavix every day for at least one year and likely longer. Do not stop taking Plavix and aspirin or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you it is OK. Your left groin site had some pain last night but there is no evidence of bleeding under the skin this morning. You should watch the site for any new bruising, bleeding or increasing pain. Call Dr. [Last Name (STitle) ] if you notice this. No lifting more than 10 pounds for one week. No baths or pools for one week. You can shower today. . Medication changes: 1. Increase your simvastatin to 80 mg daily Please keep the rest of your medicines as before Followup Instructions: Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 45127],MD Location: [Hospital ] MEDICAL ASSOCIATES Address: [Location (un) ], [Street Address(1) 4323],[Numeric Identifier 4325] Phone: [Telephone/Fax (1) 5457] When: Monday, [1-9] at 10am Name: [Name6 (MD) ] [Name8 (MD) ],MD Location: [Hospital ] MEDICAL ASSOCIATES Address: [Location (un) ], [Street Address(1) 4323],[Numeric Identifier 4325] Phone: [Telephone/Fax (1) 7960] When:Monday, [1-9]. Please go upstairs to Dr [Last Name (STitle) ] office after your visit with Dr [Last Name (STitle) 5456].	[ "414.2", "410.71", "401.9", "780.60", "996.72", "272.4", "E879.0", "276.1", "414.01", "288.50", "250.00" ]	icd9cm	[ [ [] ] ]	[ "00.46", "88.56", "00.41", "00.66", "99.20", "36.07", "37.22" ]	icd9pcs	[ [ [] ] ]	9874, 9923	7352, 8970	316, 433	10048, 10048	4131, 5771	11185, 11828	3194, 3309		9242, 9851		9944, 10027		8996, 9219		5788, 7329	10199, 11048									3324, 4055		2628, 2767											4069, 4112						11068, 11162			266, 278									461, 2521								10063, 10175				2798, 3075						2543, 2608	3091, 3178
29,316	196,348	34167	Discharge summary	report	Admission Date: [2139-4-27] Discharge Date: [2139-5-26] Date of Birth: [2085-2-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Respiratory Failure. Major Surgical or Invasive Procedure: 1. Flexible and rigid bronchoscopy with stent placement on [2139-5-7] 2. Plasmapheresis [Date range (1) 78742] 3. Mechanical Ventilation [Date range (1) 58652], [Date range (1) 45340], [Date range (1) 78743] when trached History of Present Illness: This 54 yo woman with a history of obesity, asthma, anxiety, kidney stones is transferred from [Hospital3 ] after diagnosis of MG (+ MUSK Ab) with decreasing VC despite treatment with steroids (perdnisone) for consideration of plasmapheresis. She was hospitalized most recently at [Hospital3 ] [4-13] (3rd hosp in 2 months), with respiratory failure/recurrent bronchitis/? ARDS. She was given steroids for treatment of the ? ARDS, recurrent dyspnea. This hospitalization was third decompensation, with spirometry had restrictive physiology. This readmit was reporting horizontal diploplia worse at the end of the day, difficulty holding head up. Acetylcholine receptor ab neg, MuSK +. Dynamic CT concerning for tracheomalacia. EMG neg (upper and lower proximal muscles). Mestinon, IVIG started [4-25], prednisone (60 daily), was improving over weekend, now declining again. VC 1L [4-25], down to 350cc [4-27] so intubated. Became hypotensive to 80's with intubation but improved with ivf (1L->102 SBP) thought secondary to propofol. Of note, she had sinus tach at [Hospital3 ] early in her hospital course, ruled out for MI, TTE [2-28] EF 60%, no valvular [Last Name (LF) ], [First Name3 (LF) ] started on metoprolol. She had a right heart cath with PAP 39/11 (mean 25), with wedge 8. CTA neg for PE. She was treated with BiPAP intermittently, with elevated PCO2: 50-70, which was new. A neurology consult was placed and recommended w/u for MG. Brain MRI reportedly negative, cervical spine MRI with multi-level spinal stenosis. On arrival she was intubated, AC 500/14/0.4/5. Able to nod no pain, no thyroid disease, diet controlled type II DM, never had anything like this before. She does nod yes to the tube/ventilator helping her breathing. Past Medical History: asthma bronchitis GERD obesity panic d/o anxiety s/p ccy kidney stones recent PNA with possible ards that improved on steroids DMII, diet controlled Social History: No smoking, etoh, illicit drug use. Lives with son. Family History: Unknown Physical Exam: VS: T 97.2 HR 65 BP 114/61 RR 14 Sat 100% on AC 500/14/.[3-28] GEN: NAD, intubated but responds appropriately HEENT: AT, NC, PERRLA, EOMI (able to open eyes), no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits NEURO: intubated but arouses easily, CN II-XII grossly intact, 2+ DTR's biceps, triceps, bracioradialis, patellar bilaterally with negative babinski. PSYCH: drowsy but arouses and responds to questions, able to follow commands Pertinent Results: ECG [2139-4-27]: NSR (67), nl axis, intervals, TW flattening in III. Right heart cath [2139-4-20]: Mild pulm htn (39/11, PCWP 8). TTE [2139-2-27]: LVEF 60%, no valvular dysfunction, no effusion, no shunt. PFT's: [2139-3-20]: FVC 1.70(53%), FEV1 1.38(55%), FEV1/FVC (81), TLC 2.42 (53%), DLCo 74%. [2139-4-20]: FVC 0.83(22%), FEV1 0.66(22%), FEV1/FVC (78), TLC 1.68(31%), DLCo 57%. Brief Hospital Course: A/P: 54 yo woman with asthma, recent pna, GERD, anxiety, and respiratory failure with neruomuscular weakness with respiratory failure and apparent tracheomalacia on dynamic CT. 1)Myasthenia [Last Name (un) ]: Patient transferred from OSH with low VC suggestive of NM weakness, AChR-Ab - but + MuSK and recent history of difficulty holding up head, keeping eyes open. EMG at [Hospital3 ] apparently normal. Treated there with ivig, solumedrol, mestinon with no improvement. Patient was admitted to the MICU on [2139-4-27]. She had been intubated at the OSH for respiratory failure. She was seen by neurology and had a plasmapheresis catheter placed. Plasmapheresis was started without complication. The patient was also continued on Mestinon and Prednisone. She looked very comfortable and was doing very well on the vent, with excellent RSBI, NIF, and VC so the patient was extubated on [5-1]. She initially did well but refused BiPAP because of severe anxiety and claustrophobia. She was unable to tolerate BiPAP despite significant doses of valium and she became increasingly fatigued until she was using her accessory muscles of respiration and retaining CO2 on her ABG. For this reason it was decided to re-intubate her before she was in even more severe distress. The intubation was extremely difficult. She required very large doses of Fentanyl/Versed and Propofol, and she was fiberscopically intubated. There was evidence of TBM as elucidated below. She was comfortable on the vent, alert and interactive although she remained quite anxious and was put onto a fentanyl and versed gtt. Her doses of mestinon and prednisone were increased and she completed sessions of plasmaphersis, with the last one on [5-6]. She was extubated on [5-8] to supplemental oxygen by face mask went out briefly to the neuro stepdown unit, but returned after 24 hours for tachypnea. She was stable until [5-17], despite decreasing NIF and VC, when she neuromuscularly decompensated, desatting to 55%. She was ambu-bagged and reintubated, this time, not difficult. She did very well after this intubation, attributed to myasthenic crisis once again, but the decision was made, given the prolonged course of this episode, to undergo trach/peg, which occurred on [5-22] without complication. She also had an additional 5 days of IVIG. She is now weaned to trach mask. VC and nif should continue to be monitored for signs that the patient is tiring. Speech and swallow eval on [5-24] cleared the patient for regular diet. Balloon is down and patient talking with Passy-Muir valve in place. #) MG- refer to crisis as above. Neurology following, patient on cellcept, mestinon and prednisone. Has follow up appt on [2139-6-2] at 9:30am with Dr. [Last Name (STitle) 557]/Zarvin. 2)Asthma: There was some concern that this might have been a misdiagnosis in the setting of undiagnosed TBM and Myasthenia [Last Name (un) ]. Patient's PFT's are unknown, but she did have evidence of bronchospasm during her fiberoptic intubation. Her Singulair and Advair were discontinued, and patient was maintained on albuterol and ipratropium nebs. On [5-8] her albuterol was changed to Xopinex. She initially received QVAR from [Date range (1) 43604], but this was discontinued. 3)Tracheomalacia: Patient had evidence of TBM on her chest VT performed at the OSH. During her fiberoptic re-intubation on [5-1] she was noted to have moderate-severe TBM. A repeat chest CT was performed which showed only moderate TBM so the patient had another fiberoptic bronchoscopy on [5-7] which showed moderate to severe TBM. She was taken to the OR on [5-7] and had a rigid bronchoscopy with silicon stent placement. She was started on Mucinex, lidocaine nebulizers, and codeine IV. She was extubated on [5-8]. Patient should follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in IP. 4)Urinary tract infection: Patient grew Citrobacter in urine. Pansensitive except for Bactrim. Likely foley related. Started on Ceftriaxone on [5-8] for 7 day course. Limited by antibiotic regimen (like Cipro) since it can exacerbate her underlying neurological disorder. 5)Sinus tachycardia: During this admission patient has been in and out of sinus tachycardia with elevations to 160. Per patient, this is has been an ongoing issue. Likely autonomic instability secondary to Myasthenia [Last Name (un) ]. TSH was within normal limits.She transiently had an SVT to 190's during the second intubation, and received amiodarone 150mg IV x 1. Once reintubated for second time, her heart rate came down to 60's. Now that she is on trach mask, she remains with HR in the 60's. No beta blockade given MG. 6)Anxiety/panic d/o: patient is very anxious quite frequently and gets tachycardic in response with worsened respiratory status. Psychiatry was consulted and per their recommendations patient's prozac was increased to 40 mg daily and valium PRN was used to control her acute anxiety. Social work was also consulted for patient support and coping. Valium was stopped at time of discharge since it also can exacerbate her Myasthenia [Last Name (un) ]. Doing well now that she is trached. 7)Diabetes: Diet controlled: SSI while on steroids, with q6 BG checks. Medications on Admission: prednisone 60mg daily, last [4-26] mestinon 120mg tid ivig: [Date range (1) 18023] docusate 100mg [Hospital1 ] prn senna 1 tab prn lispro ssi ketorolac 15mg iv prn metoprolol 50mg po bid cepacol prn erixtra->fondaparinaux 2.5mg sc daily maalox prn bactrim DS three times/week nasal saline fluoxetine 20mg m/w/f, 40mg else duoneb q6 klonopin 0.25mg tid lasix 20mg po daily omeprazole 20 po daily SLNG prn advair 500/50 [Hospital1 ] singulair 10 daily tylenol prn Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: 1. Myasthenia [Last Name (un) ] 2. Acute Respiratory Failure Secondary Diagnosis: 1. Asthma 2. GERD 3. Anxiety 4. Renal Stones 5. Myasthenia [Last Name (un) ] 6. DM, diet controlled Discharge Condition: Fair Discharge Instructions: You were admitted for acute respiratory distress due to newly diagnosed myasthenia [Last Name (un) 2902]. During your admission, you required mechanical ventilation x 3 and intensive care and ultimately tracheostomy and peg tube. Followup Instructions: 1. Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2139-5-27] 1:00	[ "278.00", "996.64", "530.81", "300.00", "519.19", "493.90", "V58.65", "518.81", "358.01", "599.0", "E879.6", "427.89", "250.00" ]	icd9cm	[ [ [] ] ]	[ "99.71", "96.04", "99.14", "43.11", "31.1", "33.22", "38.93", "96.6", "96.05", "96.72" ]	icd9pcs	[ [ [] ] ]	9634, 9713	3775, 9105	335, 578	9967, 9974	3346, 3752	10257, 10420	2649, 2658				9734, 9734		9131, 9611			9998, 10234									2673, 3327																						275, 297									606, 2392			9840, 9946		9753, 9819													2414, 2564	2580, 2633
69,237	138,300	16259+56746	Discharge summary	report+addendum	Admission Date: [2150-12-19] Discharge Date: [2150-12-23] Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 290] Chief Complaint: cyanosis, hypoxemia Major Surgical or Invasive Procedure: PICC placement [2150-12-20] History of Present Illness: [Age over 90 ]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter admitted with hypoxemia and hypercapnia after being found to be cyanotic, confused, and hypoxic at his nursing home. Discharged yesterday after a 2 week admission for aspiration pneumonia, treated with levo/flagyl, with delirium and also atrial fibrillation with RVR. At [Hospital1 1501], he was hypoxic to 70s on 4L O2 by NC, looked cyanotic, was increasingly confused and lethargic. Sats improved to mid 80s on 5L. In the ED, initial vs 100 100 144/74 26 91%RA. ABG 7.47/53/63/40. CXR showed bilateral basalar opacities relatively unchanged from prior. EKG showed Afib rate Given vanco, levo, solumedrol, nebs. V/S prior to transfer 110 130/50 25 85% 6L VM. On the floor, he appeared fatigued/sleepy but conversed normally, oriented x2. Mild shortness of breath with cough occasionally productive of sputum. No chest pain, no abdominal pain. Stated he was having loose stools recently. No nausea or vomitting. No fever, but felt occasional chills. No lightheadedness. No dysuria. No myalgias. Past Medical History: - COPD - [2143] FVC 74% of predicted, FEV1 67% of predicted, FEV1/FVC 90% of predicted, TLC 111% of predicted, RV 145% of predicted. Intermitent home supplemental O2 use. - AFib - CAD - DVT ([2148]) s/p IVC filter - HTN - BPH - GERD - H. pylori gastritis - Gout - Inguinal hernia Social History: Prior to recent admission, lived home alone and was independent with ADLs, lived on a one floor home no stairs, walked around with oxygen intermittently (reportedly 50% of the time). Resident of [First Name8 (NamePattern2) 3075] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ] since recent admission. Quit tobacco quit 40+ years ago. No ETOH. Family History: NC Physical Exam: Admission Physical Exam: General: Alert, oriented to name, knows he is in the hospital in [Location (un) ], MA, NOT oriented to time, no acute distress, using muscles of respirations HEENT: Sclera anicteric, mucus membranes dry, oropharynx clear Neck: supple, JVP not elevated (but difficult to assess), no LAD Lungs: Crackles [2-8] way up at left base, decreased breath sounds at right base, no wheezes, occasional anterior rhonchi CV: afib, 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, 2+ pitting edema LE b/l, 2+ pitting edema with ecchymosis left hand Pertinent Results: [2150-12-21] 1:58 pm URINE Source: CVS. FINAL REPORT [2150-12-22] Legionella Urinary Antigen (Final [2150-12-22]): 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. . [2150-12-21] 5:38 pm STOOL CONSISTENCY: SOFT FINAL REPORT [2150-12-22] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2150-12-22]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [2150-12-21] 12:55 pm SPUTUM GRAM STAIN (Final [2150-12-21]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): YEAST(S). RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. YEAST. MODERATE GROWTH. . [2150-12-19] Portable AP CXR Fleeting opacities, now worsened in left perihilar region, but slightly better on the right. Worsening opacity in the right apical region as well. Edema is favored, although foci of aspiration or pneumonia cannot be entirely excluded. Bilateral pleural effusions again noted, right greater than left. . [2150-12-20] Portable AP CXR Right PICC terminates in the superior vena cava. Heart is enlarged. Mediastinum is within normal limits. There is increased consolidation of the right lower lobe with a moderate right-sided pleural effusion. There is a moderate left pleural effusion with left lower lobe consolidation. There is patchy airspace opacification of the right upper lobe. There is prominent interstitial marking. There is mild congestive failure. IMPRESSION: Interval worsening of the appearance of the chest. Right PICC terminates in the superior vena cava. . Brief Hospital Course: [Age over 90 ]M with COPD on home O2, AFib on lovenox, DVT s/p IVC filter admitted with hypoxemia and hypercapnia after being found to be cyanotic, confused, and hypoxic. #Hospital-acquired pneumonia- Started on an 8 day course of vancomycin and cefepime ([Date range (1) 46367]). PICC line placed [12-20]/ Cultures remained negative. #Acute on chronic diastolic CHF - Treated with bolus diuresis (furosemide 20 mg IV) with decrease in admission weight. Unable to accurately measure urine output as the patient refused a foley catheter. Patient will need to have electrolytes followed closely on Friday, [2150-12-25]. Will continue to diurese and to replete electrolytes as needed. #Atrial fibrillation - Rate controlled with diltiazem and digoxin. Treated with aspirin instead of systemic anticoagulation given his history of falls. #COPD- Continued with albuterol and ipratropium nebulizer. He was started advair. #Nutrition- After discussion with patient and his sister, patient wishes to continue with diet knowing about his aspiration risk. He did have an episode of witnessed aspiration. Patient should adhere to the recommendations of speech/swallow therapy from [12-14] (1. PO diet of nectar thick liquids and pureed solids, 2. Full supervision with all PO intake, 3. Encourage single sips of liquid and slow rate of intake, 4. Meds crushed with purees). #Goals of care- Confirmed DNR/DNI status with the patient and his sister and healthcare proxy, [Name (NI) 1743] [Name (NI) 17839]. If patient cannot adhere to the recommended diet above, please consider "do not rehospitalize" order if it is still consistent with his goals of care. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 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 50 mg/5 mL Liquid Sig: Ten (10) ML PO BID (2 times a day). 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 650 mg Suppository Sig: [2-7] Suppositorys Rectal Q6H (every 6 hours) as needed for pain. 7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous QD (): afib, h/o DVT. 8. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for SOB. 10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO once a day as needed for constipation. 12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for Constipation. 13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: with lasix. 16. Outpatient Lab Work Please check chem 7, magnesium within the next 3 days 17. medication adjustment adjust lasix, KCL supplement based on peripheral edema and potassium level 18. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Discharge Medications: 1. Outpatient Lab Work Please check CBC, Electrolytes (sodium, potassium, chloride, bicarb) as well as BUN and Creatining on Friday [2150-12-25]. Please fax the results to the on-call physician at the rehab. 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. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation: can hold for loose stools. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: can hold for loose stools. 6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: [2-7] Disk with Devices Inhalation [Hospital1 ] (2 times a day). 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): can hold for loose stools. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [2-7] Inhalation Q4H (every 4 hours) as needed for wheeze. 10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 11. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain/fever. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 4 days. 15. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 4 days. 16. magnesium sulfate 4 % Solution Sig: One (1) Injection PRN (as needed). 17. furosemide 10 mg/mL Syringe Sig: Two (2) Injection once a day. 18. potassium chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary diagnoses - Hospital Acquired Pneumonia - Acute on Chronic Diastolic Congestive Heart Failure Secondary diagnoses: - Atrial Fibrillation - Chronic Obstructive Pulmonary Disease - Aspiration - Gastroesophageal Reflux Disease 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 are being discharged from the ICU at [Hospital1 827]. You were admitted for low oxygen levels because you had fluid in your lungs and when you were eating, food would be going down the wrong tube. We also suspect you have apneumonia that you acquired at your last hospitalization. We gave you medications to help you get rid of the fluid and we also watched you very closely when eating, but you had episodes when your oxygen decreased because you swallowed food down the wrong tube. We discussed placing a PEG tube so food would not go into your lungs, but you did not want this. We spoke with you and your sister who is your health care proxy and it was decided that it is more important to make you comfortable and have you eat what you want. You will be discharged to [Location (un) 1456] and they will continue to manage your medical problems. You were started on the following medications: Vancomycin 1gm IV every 24hours (need 4 more days of therapy) Cefepime 2gms IV every 24 hours (need 4 more days of therapy) Lasix 20mg IV daily Potassium Chloride adjust as needed seocndary to lasix dosing The following medication was changed: Diltiazem 90mg by mouth four times a day --> diltiazem 60mg by mouth four times a day. The following medication was stoppped enoxaparin Please continue your other medications as prescribed. Followup Instructions: Make an appoinment after you are discharged from LTAC. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Name: [Known lastname 8527],[Known firstname ] Unit No: [Numeric Identifier 8528] Admission Date: [2150-12-19] Discharge Date: [2150-12-23] Date of Birth: [2055-5-5] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 3776] Addendum: There was an additional discussion prior to the discharge of the patient to [Location (un) 4534]. After speaking with the patient and his sister who is his health care proxy, it was decided to officially make the patient DO NOT REHOSPITALIZE. Discharge Disposition: Extended Care Facility: [Hospital3 2215] - [Location (un) 95] - [Location (un) 4534] [Initials (NamePattern4) ] [Last Name (NamePattern4) 593] [Name8 (MD) 304] MD [MD Number(1) 594] Completed by:[2150-12-23]	[ "496", "274.9", "V12.51", "V46.2", "564.00", "530.81", "790.01", "V58.61", "276.8", "414.01", "427.31", "600.00", "518.83", "416.8", "276.3", "428.0", "401.9", "486", "428.33" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13135, 13406	4985, 6672	248, 281	10768, 10768	2889, 3864	12318, 13112	2098, 2102		8424, 10368		10512, 10615		6698, 8401			10944, 12295									2142, 2870	10636, 10747						3905, 4962															189, 210									309, 1390								10783, 10920										1412, 1702	1718, 2082
14,702	134,242	15934	Discharge summary	report	Admission Date: [2183-10-10] Discharge Date: [2183-10-22] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 496] is an 85-year-old female who has a history of hypertension, coronary artery disease, hypercholesterolemia, and is status post a myocardial infarction in [10-7]. She underwent stenting of her mid left anterior descending coronary artery which was complicated by a retroperitoneal bleed. She was discontinued from [Hospital1 69] on [2182-10-16]. The patient presented on the day of admission as preoperative for an aortic valve replacement after being transfer from [Hospital3 6454] Hospital where she underwent cardiac catheterization showing critical aortic stenosis with a valve area of 0.8 cm sq and an ejection fraction of 25%. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Coronary artery disease. 4. Aortic stenosis. 5. Status post myocardial infarction. 6. Status post cardiac catheterization and balloon angioplasty in [2-7]. 7. Peripheral vascular disease. SOCIAL HISTORY: She lives alone. She is not a smoker nor does she drink alcohol. ALLERGIES: Codeine causes vomiting. Vasotec causes a cough. REVIEW OF SYSTEMS: No fever or cough, no chest pain, no shortness of breath, no palpitations, no nausea or vomiting, and no diarrhea. She also has no history of transient ischemic attack or cerebrovascular accident. PHYSICAL EXAMINATION: Her examination showed an elderly looking female in no apparent distress. Her vital signs showed a temperature of 97.7, heart rate 69, blood pressure 169/97 in the right arm, 193/94 in the left arm, respiratory rate 22, oxygen saturation 94% on room air. HEENT: PERRL, EOMI, trachea midline. Neck: Supple with bilateral carotid bruits. Lungs: Clear to auscultation bilaterally. Heart: 3/6 systolic ejection murmur, regular rate and rhythm. Abdomen: Positive bowel sounds; soft, nontender, nondistended. Extremities: No cyanosis, clubbing or edema. The right shoulder had decreased range of motion. Her dorsalis pedis pulses were weak but positive by Doppler both on the right and the left. Her posterior tibial pulses were equal bilaterally by Doppler. Her femoral pulses were palpable. LABORATORY DATA: Her laboratory studies on admission included a white count of 7.6, hematocrit 44.2%, platelet count 221,000, PT 13.2, INR 1.1, PTT 24.1. Her urinalysis was nitrite positive and a large amount of leukocytes with moderate bacteria and no yeast and 21-50 white blood cells. Her sodium was 135, potassium 4.1, chloride 96, CO2 26, BUN 37, creatinine 1.1, blood glucose of 130. Her preoperative chest x-ray showed no evidence of effusion. Her lungs were clear with no sign of infiltrate. Her echocardiogram at [Hospital3 1280] showed an ejection fraction of 25% with severe aortic stenosis with a peak gradient of 50 mmHg with an aortic valve area of 0.8 cm sq. She also underwent carotid duplex studies which showed less than 45% stenoses bilaterally. HOSPITAL COURSE: The patient did receive a dental consultation for which she was cleared preoperatively. She did begin a course of ciprofloxacin for positive urinary tract infection and otherwise remained in the hospital while awaiting surgery without any further complications. On [2183-10-13] she underwent aortic valve replacement with a #19 CE valve and a mitral valve repair with a #26 annuloplasty ring. The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 132 minutes and cross-clamp time of 115 minutes. She tolerated the procedure well and was transferred to the intensive care unit in normal sinus rhythm on Neo-Synephrine and propofol drips. She had two atrial and two ventricular pacing wires, mediastinal and left pleural chest tubes. On the postoperative night she was extubated without complication. She maintained a cardiac index greater than 2.5 and an insulin drip was started secondary to elevated blood sugars. On her first postoperative day her blood pressure was very labile and she was on and off Neo-Synephrine and nitroglycerin drips trying to keep her blood pressure between 100 and 140. She was started on p.o. Lopressor and IV Lasix and her Swan was discontinued. On the second postoperative day she was noted to be in atrial fibrillation and was started on amiodarone and converted to normal sinus rhythm. By the third postoperative day she remained in normal sinus rhythm and was noted to have wheezing with exertion and anxiety. These were easily treated with albuterol nebulizer treatments. She was also transfused one unit of packed red blood cells on this day for a low hematocrit and her Lopressor at this point had been increased to 100 mg p.o. b.i.d. By postoperative day number four she was taken off her amiodarone drip and started on p.o. amiodarone. Her post-transfusion hematocrit was 28.7 after having been 26.8 prior to transfusion. She was able to ambulate with assistance, having initiated physical therapy and continued to have intermittent wheezing with exertion. Also on postoperative day number four she was noted to have another burst of atrial fibrillation for which she was given amiodarone bolus and 5 mg of IV Lopressor and eventually converted back to normal sinus rhythm. By postoperative day number five she was starting to take on some of her own responsibilities. She did still remain in the intensive care unit for aggressive pulmonary toilet. She also had another burst of atrial fibrillation and was given her Lopressor early. At this point she remained in atrial fibrillation but was kept on her Lopressor and amiodarone. She also at this point was started on a heparin drip for anticoagulation. On postoperative day number seven she was again noted to be in and out of atrial fibrillation and continued on her heparin drip. Her heparin drip was held for several hours so that her pacing wires could be discontinued and they were without incident. She was noted to have frequent loose stools and her Colace was discontinued. On postoperative day number eight she was thought to be slightly improved in her pulmonary status. She was on a stable dose of heparin and her atrial fibrillation on the morning of postoperative day number eight had converted to first degree AV block. It was felt at this point that she could be transferred to the surgical floor, where she spent the night without incident. By postoperative day number nine it was felt that she was ready for transfer to a rehabilitation facility. She will be transferred to [Hospital3 1280] Hospital transitional care unit, where she will continue her heparin drip at 800 units an hour, while she is awaiting her INR to reach a goal of [3-10] on Coumadin. Her discharge examination shows her lungs to have bibasilar crackles with the left greater than the right. She does have audible expiratory wheezing mostly at her throat. Her heart is irregularly irregular with a normal S1 and S2. Her abdomen has positive bowel sounds. She is soft, nontender, nondistended. Her extremities show no pitting edema. Her incisions are clean, dry and intact and her sternum is stable. Her laboratory studies on discharge include a white count of 9.7, hematocrit 28.8, platelet count 237,000. Her PT is 13.8, INR 1.3, PTT 56.3. Sodium 137, potassium 4.9, chloride 98, CO2 29, BUN 29, creatinine 1.4, blood glucose 148. Her discharge chest x-ray shows small bilateral effusions with the left greater than the right. DISCHARGE DIAGNOSES: 1. Aortic valve replacement with a #19 CE valve and mitral valve repair with a #26 annuloplasty ring. 2. Postoperative atrial fibrillation. 3. Peripheral vascular disease. 4. Hypertension. 5. Coronary artery disease. 6. Aortic stenosis. 7. Status post catheterization and balloon angioplasty in [2183-2-5]. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. b.i.d. 2. Lasix 40 mg p.o. b.i.d. for one week. 3. Potassium chloride 20 mEq p.o. b.i.d. for one week. 4. Plavix 75 mg p.o. q. day. 5. Tylenol 650 mg p.o. q. 4 hours p.r.n. 6. Aspirin 81 mg p.o. q.d. 7. Prevacid 30 mg p.o. q.d. 8. Amiodarone 400 mg p.o. q.d. 9. Albuterol metered dose inhaler 1-2 puffs q. 6 hours and p.r.n. 10. Cozaar 25 mg p.o. q.d. 11. Miconazole cream applied vaginally q.h.s. x 6 days. 12. Miconazole powder applied to affected areas t.i.d. 13. Heparin drip 25,000 units in 250 cc at 800 units an hour. 14. Coumadin - on the day of discharge she should receive 2 mg of Coumadin and thereafter should be dosed on a daily basis to a goal INR of [3-10]. In regards to her Coumadin, it was begun on [2183-10-21] when her INR was 1.2. She received 2 mg, and on [2183-10-22] her INR was 1.3 and she will again receive 2 mg. FO[Last Name (STitle) ]P PLANS: She should follow up with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 27267] in one to two weeks; with her cardiologist, Dr. [Last Name (STitle) 1295] in one to two weeks for evaluation of amiodarone and possible Holter monitor; and with Dr. [Last Name (Prefixes) ] in four weeks. She should have her INR and PTT closely monitored while at rehabilitation with daily laboratory studies until her goal INR of [3-10] is reached, then the heparin can be stopped safely. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 45684] MEDQUIST36 D: [2183-10-22] 12:25 T: [2183-10-22] 12:45 JOB#: [Job Number 45685]	[ "041.3", "427.31", "719.41", "398.91", "E878.1", "997.1", "599.0", "401.9", "396.2" ]	icd9cm	[ [ [] ] ]	[ "35.12", "35.21", "39.64", "39.61" ]	icd9pcs	[ [ [] ] ]								7598, 7910	7933, 9638					3070, 7577																							1475, 3052						1253, 1452													139, 819																		842, 1086	1103, 1233
23,842	129,922	16807	Discharge summary	report	Admission Date: [2138-12-25] Discharge Date: [2139-1-2] Date of Birth: [2097-4-25] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 41-year-old gentleman transferred from an outside hospital after falling 12 feet off a roof,hitting the ground on his left side. Denied loss of consciousness. Reported pain in the left neck and shoulder. PHYSICAL EXAMINATION: His blood pressure is 144/80, pulse 84, respiratory rate 18, sats 100% on room air. He is in no acute distress in a hard collar. Neck was immobilized and pain by reports. Neurologically mental status he was awake and alert times three, following commands. Naming intact. Speech fluent. EOMs full. Face symmetric. Hearing intact. His strength is [5-25] in upper extremities. He had [5-25] grip strength. He had decreased pinprick sensation bilateral upper extremities, left more than right as well as in the hand, forearm and shoulder on the left side and subjective numbness in the left hand. His deep tendon reflexes were 1+/4 in the bilateral triceps, otherwise 2+/4. Toes were downgoing. Coordination was within normal limits. Gait within normal limits. CT of the spine with reconstruction showed C6-7 enterolysthesis with slight cord compression and fracture of C7 with 20% canal compromise. The patient was initially admitted to the Trauma Intensive Care Unit and closely monitored. The patient started on Solu Medrol protocol which he completed. Negative head CT on admission. Patient was seen by Dr. [Last Name (STitle) 1327] on [2138-12-26] who discussed cervical surgery with the patient. He will require a C6 corpectomy to decompress the spinal canal and restore axial loading bearing capacity and dorsal fixation and fusion for tension band fixation. The patient proceeded with surgery. On [2138-12-27] the patient was transferred to the regular floor and placed in [Location (un) 976] [Doctor Last Name 3012] Tongs for cervical traction. He remained in until [2138-12-29] when he felt the need to vomit and turned his head violently when the traction came off. The patient was placed in a hard collar and remained in hard collar until surgery. The patient was taken to Surgery on [2138-12-29] and underwent C7 vertebrectomy, C5-T1 cervical fusion and anterior cervical discectomy at C6-7. The patient tolerated the procedure well without complications. Postop vital signs were stable. He was afebrile. His motor strength and slight tricep weakness that was present preop began to improve slightly postop. His sensation continued to be decreased as preop but with improvement. Neurologically he was stable and discharged to home on [2139-1-2] with follow-up for staple removal in one week after surgery in a hard collar. His drains were removed on postop day one and postop day three without problem and he was sent home with a prescription for Percocet for pain. Condition was stable at the time of discharge. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2139-1-5] 15:53 T: [2139-1-5] 16:18 JOB#: [Job Number 35951]	[ "806.05", "E884.9" ]	icd9cm	[ [ [] ] ]	[ "84.51", "81.02", "77.99", "77.79", "80.51" ]	icd9pcs	[ [ [] ] ]																																					414, 3274																			173, 392
40,997	111,040	39171	Discharge summary	report	Admission Date: [2172-1-30] Discharge Date: [2172-2-1] Date of Birth: [2116-10-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Percutaneous Coronary Intervention with 2 drug-eluting stents to Right Coronary Artery History of Present Illness: 55 year old male with history of Hypertension who presented to ED with 2hrs of sudden onset crushing 10/10 chest pain radiating to left arm while vacuuming at work, also with diaphoresis. Initial EKG in the ED showed ST changes in leads II, III, aVF, and he was given morphine, aspirin. Second EKG showed ST elevations in leads II, III, avF with reciprocal T wave inversions, and STEMI pager was activated. Patient was started on heparin drip and integrilin and was sent for emergent Cardiac Catheterization. Patient continued to have 10/10 chest pain until end of catheterization procedure. Two drug eluting stents placed in mid RCA, where 100% occlusion was found. Had percutaneous closure right groin. . Upon arrival to the CCU, the patient was chest pain free with no other symptoms. . Patient notes that he has been having similar chest pain, though significantly more mild, while in bed resting about 2 nights per week for the past two years. He describes the pain as very mild and often radiating to his right arm, slowly increasing in frequency and intensity. . On review of systems, he denies any prior history of stroke, pulmonary embolism. He has had history of GI bleeding [Month (only) ] [2169]. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. OTHER PAST MEDICAL HISTORY: GI Bleed ([2170-10-20], no transfusions) Gastric Ulcer Diverticulosis Depression Left Inguinal Hernia (needing repair) Social History: Speaks Portuguese but can understand some English and Spanish. Works in custodial services and at a junkyard lifting heavy objects. Married. Has a daughter. -Tobacco history: None Family History: Father and many other family members with HTN, HLD. Uncle with Acute MI in early 60s. No family hx of Diabetes. Physical Exam: VS: T=98.3 BP= 139/93 HR=62 RR=14 O2sat=98% 2LNC GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, dry mucus membranes NECK: Supple with JVP up to jaw when lying supine w mild reverse trendelenberg. CARDIAC: Regular Rhythm with occ irreg beats, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, Nontender, Nondistended. No HSM or tenderness. EXTREMITIES: No c/c/e. Left groin inguinal hernia, Right groin w clean bandage, nontender, no hematoma PULSES: Bilateral DP 1+ Pertinent Results: [2172-1-30] 04:45PM BLOOD WBC-14.0* RBC-4.82 Hgb-13.7* Hct-40.7 MCV-85 MCH-28.4 MCHC-33.6 RDW-13.1 Plt Ct-216 [2172-2-1] 08:45AM BLOOD WBC-8.1 RBC-4.48* Hgb-12.7* Hct-38.3* MCV-85 MCH-28.4 MCHC-33.2 RDW-13.3 Plt Ct-196 [2172-1-30] 04:45PM BLOOD Neuts-74.9* Lymphs-19.9 Monos-3.2 Eos-1.7 Baso-0.3 [2172-1-31] 03:06AM BLOOD PT-12.1 PTT-28.5 INR(PT)-1.0 [2172-1-30] 04:45PM BLOOD Glucose-191* UreaN-28* Creat-1.1 Na-140 K-3.9 Cl-104 HCO3-26 AnGap-14 [2172-2-1] 08:45AM BLOOD Glucose-101* UreaN-21* Creat-1.0 Na-141 K-4.0 Cl-106 HCO3-24 AnGap-15 [2172-1-30] 04:45PM BLOOD CK(CPK)-392* [2172-1-31] 03:06AM BLOOD CK(CPK)-916* [2172-1-31] 11:28AM BLOOD CK(CPK)-920* [2172-2-1] 08:45AM BLOOD CK(CPK)-426* [2172-1-30] 04:45PM BLOOD cTropnT-<0.01 [2172-1-31] 03:06AM BLOOD CK-MB-113* MB Indx-12.3* [2172-1-31] 11:28AM BLOOD CK-MB-96* MB Indx-10.4* cTropnT-2.49* [2172-2-1] 08:45AM BLOOD CK-MB-23* MB Indx-5.4 cTropnT-1.24* [2172-1-31] 03:06AM BLOOD %HbA1c-6.0* [2172-1-31] 03:06AM BLOOD Triglyc-73 HDL-34 CHOL/HD-5.1 LDLcalc-124 [2172-1-30] 05:45PM BLOOD Type-ART pO2-295* pCO2-33* pH-7.44 calTCO2-23 Base XS-0 Intubat-NOT INTUBA Comment-O2 DELIVER Cardiology Report Cardiac Cath Study Date of [2172-1-30] 1. Coronary angiography in this right dominant system demonstrated one vessel disease. The LMCA had no angiographically apparent disease. The LAD had mild diffuse disease but no angiographically significant stenoses. The LCx had no angiographically apparent disease but had a small aneurysmal segment in mid-vessel. The RCA was occluded in its mid-portion. 2. Limited resting hemodynamics demonstrated moderate systemic arterial hypertension with SBP 162 mmHg and DBP 106 mmHg. 3. Successful PCI of the RCA with overlapping 3.5x28mm and 3.5x15mm Promus DES, post-dilated to 3.75mm in the proximal and mid-segments. 4. Successful closure of the right femoral arteriotomy site with a Perclose device. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Acute inferior myocardial infarction. 3. Successful PCI of the RCA with DES. Radiology Report CHEST (PORTABLE AP) Study Date of [2172-1-30] 5:02 PM FINDINGS: The lungs are clear without consolidation or edema. The mediastinum demonstrates mild tortuosity of the thoracic aorta. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. There is mild gaseous distention of the stomach incidentally noted. Mild degenerative disease is seen throughout the thoracic spine. No displaced fractures are evident. IMPRESSION: No acute pulmonary process. [Known lastname 86758], [Known firstname 86759] [Hospital1 18] [Numeric Identifier 86760]Portable TTE (Complete) Done [2172-1-31] at 9:24:06 AM FINAL The left atrium is mildly dilated. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior wall. The remaining segments contract normally (LVEF = 55 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([12-21]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Very mild regional left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation with normal valve morphology suggestive of underlying papillary muscle dysfunction. Mild thoracic aorta dilation. [2172-1-31] Transthoracic echo: The left atrium is mildly dilated. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior wall. The remaining segments contract normally (LVEF = 55 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([12-21]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Very mild regional left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation with normal valve morphology suggestive of underlying papillary muscle dysfunction. Mild thoracic aorta dilation. Brief Hospital Course: 55 year old male with hx of HTN, HLD who presented to ED with 2 hours of substernal crushing 10/10 chest pain and evolving ST elevations. . # s/p STEMI: Patient had 2 hours of chest pain by time of arrival in ED, continued chest pain through Catheterization until end of procedure, found to have 100% occlusion mid RCA. Two drug-eluting stents placed in mid RCA. ST elevations in inferior leads resolved after PCI. Patient appears to have had unstable angina for the past two years at night while at rest in bed. He continued to have some intermittent chest pain immediately post catherization. The patient was chest pain free in the 24 hours prior to discharge and had no arrythmias on telemetry in hours 24-48 post-cardiac catherization. He did have some runs of VT and transient bradycardia to 40s that were thought secondary to reperfusion. CKMB peaked at 113 and troponin T at 2.49. The patient was started on integrellin for 18 hours, aspirin, plavix, atorvastatin and metoprolol. Echo showed nearly preserved ejection fraction with some mild posterior hypokinesis. He was set up with a follow up with Dr. [Last Name (STitle) 171], with plan for cardiac rehabilitation. # Hypertension: Patient reported blood pressure baseline to be about 170/110. He takes lisinopril 40mg [Hospital1 ] at home, used to take HCTZ but stopped taking it 2-3 months ago because of nocturia and because his Rx ran out. The patient was continued on lisinopril and started on metoprolol. . # Hyperlipidemia: Patient was told to attempt to control lipids with diet and exercise first but has not been able to make many changes. He was started on atorvastatin 80mg daily . # Gastritis: History of GI bleed, no transfusions, in [2170-10-20], either from gastric ulcer or from diverticulosis. Was explained that he should no longer take omeprazole while on plavix. This was changed to ranitidine. . # Depression: He was continued on fluoxetine 20mg. Medications on Admission: Lisinopril 40mg [Hospital1 ] Aspirin 81mg Omeprazole 20mg Fluoxetine 20mg HCTZ 25mg (stopped taking 3mo ago b/c nocturia x5 and Rx ran out) Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ST Elevation Myocardial Infarction Secondary Diagnoses: Hypertension Discharge Condition: Stable. Alert and Oriented x3. Ambulatory. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital after a having a heart attack. You were taken immediately for a Cardiac Catheterization procedure to place 2 stents into your right coronary artery, where you were found to have complete blockage, which had caused your heart attack. It would benefit you to participate in a Cardiac Rehabilitation program, during which you can work on improving diet and exercise habits. You should discuss this with Dr. [Last Name (STitle) 171] when you see him. The following changes have been made to your medications: - you have been started on plavix (clopidogrel) 75mg a day. Do NOT stop this medication unless instructed by your cardiologist. - Your aspirin dose has been increased from 81mg to 325mg a day. - You have been started on metoprolol, a drug that controls your heart rate, at 25mg a day. - You have been started on atorvastatin (lipitor) 80mg a day to control your cholesterol. - You have been started on ranitidine, a drug that helps stop stomach acid. This is to replace your omeprazole. - Please STOP taking omeprazole, as it may interfere with plavix Please be sure to keep all of your followup appointments. Please seek medical attention if you experience any symptoms concerning to you. Followup Instructions: Please be sure to keep all of your followup appointments. You have been made the following appointment with Dr. [Last Name (STitle) 171], the cardiologist that took care of you while you were in the hospital. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2172-2-24] 1:00 [Hospital Ward Name 23] Clinical Center, [Location (un) 436]. Completed by:[2172-2-1]	[ "429.9", "311", "427.1", "414.2", "562.10", "535.50", "272.4", "414.01", "410.21", "424.0", "401.9", "427.89" ]	icd9cm	[ [ [] ] ]	[ "00.66", "88.52", "37.22", "36.07", "88.55", "00.40", "00.46", "99.20" ]	icd9pcs	[ [ [] ] ]	10692, 10698	7731, 9682	324, 412	10831, 10876	2933, 4907	12196, 12655	2109, 2223		9876, 10669		10719, 10719		9708, 9853		4924, 7708	10900, 12173									2238, 2914	10795, 10810																					274, 286									440, 1665					10738, 10774													1770, 1894	1910, 2093
2,611	153,219	7825	Discharge summary	report	Admission Date: [2192-2-9] Discharge Date: [2192-2-12] Date of Birth: [2128-5-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Increased dizziness, presyncope, exertional angina Major Surgical or Invasive Procedure: Aortic valve replacement with 21 mm [Company 1543] Mosaic valve History of Present Illness: 63 y/o male with known aortic stenosis and single-vessel RCA disease which was stented in [9-9]. Recent increase in symptoms. Underwent cardiac cath which revealed bicupsod AV with severe AS. Referred for surgical eval. Past Medical History: Aortic stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p PCI Hypertension Benign Prostatic Hypertrophy Osteoarthritis Hemorrhoids Remote Bilat. ankle fx s/p Tonsillectomy s/p R. Femoral Pseudoaneurysm repair Social History: Quit smoking [2168] after 20 pk/yrs. Drinks 1 beer/day Family History: Noncontributory Physical Exam: VS: General: NAD, fit male HEENT: EOMI, PERRL, Non-icteric Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR 4/6 SEM which radiates to neck Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema, well healed r. fem scar, -varicosities Neuro: MAE, [6-9] strengths, Non-focal Pertinent Results: [2192-2-9] Echo: PRE-BYPASS: Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis)area <0.8cm2). The mitral valve leaflets are mildly thickened. Mild (1+)mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: preserved biventricular function. Bioprosthesis is aortic position. Well seated and mechamicqally stable. Trace AI. No other change [2192-2-12] CXR: Median sternotomy wires are seen. There is atelectasis at the lung bases, new since the previous study. There are no signs of focal consolidation or overt pulmonary edema. Cardiac silhouette is upper limits of normal. [2192-2-9] 11:30AM BLOOD WBC-15.4# RBC-3.67 Hgb-11.7* Hct-33.4* MCV-91 MC-31.9 MCHC-35.1* RDW-13.7 Plt Ct-147* [2192-2-12] 05:25AM BLOOD WBC-8.2 RBC-3.00* Hgb-9.7* Hct-27.1* MCV-90 MCH-32.2* MCHC-35.7* RDW-13.7 Plt Ct-105* [2192-2-9] 11:42AM BLOOD PT-13.6* PTT-33.5 INR(PT)-1.2* [2192-2-9] 11:42AM BLOOD UreaN-12 Creat-0.7 Cl-112* HCO3-24 [2192-2-12] 05:25AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-136 K-4.3 Cl-100 HCO3-27 AnGap-13 Brief Hospital Course: Mr. [Known lastname 1968] was a same day admit and was brought directly to the OR where he underwent an Aortic Valve Replacement. Please see surgical report for details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one he was doing well and was started on beta blockers and diuretics. He was diuresed towards his pre-op weight. Also on this day his chest tubes were removed and he was transferred to the telemetry floor. Epicardial pacing wires were removed on post-op day two. Physical therapy worked with patient for strength and stability. He improved rather fast with no post-op complications and on post-op day three he was discharged home with VNA services. Medications on Admission: Terazosin 10mg qd, Aspirin 325mg qd, Lopid 300mg [Hospital1 ], MVI, Albuterol PRN, Tylenol 1300mg [Hospital1 ], Amox prn pre dental Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). For 7 days 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 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 Potassium Chloride 20 meq po BID for 7days Gemfibrozil 600mg take half tablet twice daily Terazosin 10mg qhs Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Aortic stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p PCI Hypertension Benign Prostatic Hypertrophy Osteoarthritis Hemorrhoids Remote Bilat. ankle fx s/p Tonsillectomy s/p R. Femoral Pseudoaneurysm repair Discharge Condition: Good Discharge Instructions: No baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving No lifting more than 5 pounds Please call with any questions or concerns Followup Instructions: Dr. [Last Name (STitle) ] in 2 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) ] in 1 week call for appt Dr [Last Name (STitle) ] in 2 weeks call for appt Completed by:[2192-3-2]	[ "424.1", "272.0", "271.3", "428.0", "600.00", "715.95", "414.01", "V45.82", "401.9", "530.81" ]	icd9cm	[ [ [] ] ]	[ "35.21", "88.72", "39.61" ]	icd9pcs	[ [ [] ] ]	4437, 4471	2665, 3505	371, 440	4738, 4744	1371, 2642	5137, 5372	1032, 1049		3695, 4414		4492, 4717		3531, 3672			4768, 5114									1064, 1352																						281, 333									468, 693																		715, 940	956, 1016
48,398	173,152	11280	Discharge summary	report	Admission Date: [2161-6-30] Discharge Date: [2161-7-6] Date of Birth: [2109-6-14] Sex: M Service: MEDICINE Allergies: Morphine / Prilosec / Bactrim Attending:[First Name3 (LF) 11754] Chief Complaint: SOB and BRBPR Major Surgical or Invasive Procedure: Intubation [2161-6-30] Femoral venous line [2161-6-30] History of Present Illness: 52 yo M with diffuse large B cell lymphoma s/p allo stem cell transplant [6-/2160], h/o diverticulosis, hemorrhoids, admitted for fever, cough, and BRBPR, now being transferred from BMT to ICU for hypoxic respiratory distress. . Based on the admission note, patient has been having fatigue and productive cough with white sputum x 4 days as well as fever up to 100.8. There has been wheeze and dyspnea on exertion, which are not relieved by Flovent or Proair. There is also myalgia for 1 day with R> L sinus tenderness. Per report, no sore throat, post-nasal drip, pleuritis, orthopnea, or PND. . Of note, on day of admission, patient had BRBPR on toilet paper and then frank blood in the toilet bowl. This is associated with mild, crampy abdominal pain. Had history of BRBPR but none recently. Stool had been yellowish-brown. Had been having diarrhea since starting antibiotics (7 days) for his left hand cellulitis. He was seen in clinic on day of admission with tachycardia HR 116, T 98.3, BP 129/71 and Hct 29.2 (down from 33.8 on [6-17]) WBC 11.7 with 67% PMN, Creatinine 1.4 (baseline 1.4-1.5). Blood cultures, stool cultures were obtained and patient was given 2L IVNS. Repeat HCT was 27.6. . On arrival to the floor, vitals were t:98.9 bp:150/97 p:113 rr:22 SaO295% RA. He complained of ongoing cough and wheezing and moderate dyspnea on exertion though breathing was comfortable at rest. He was started on antibiotics- azithromycin and ceftriaxone. . At around 11PM, patient was triggerred for increased SOB requiring more oxygen supplement, O2 Sat 84% on RA improved to low 90% on 4L which then improved to mid 90% on NRB. He received lasix 40 mg IV, nebs, and Solumedrol 40 IV x1. At around midnight, patient got up to the bathroom. He was noted to have borderline temp at 100.3, BP 148/94, HR 120, RR 20. As he was returning from the bathroom, he felt more SOB with O2Sat down to 70% on RA which improved to 96% on NRB. Then 50 % on NRB. Code blue was called. Patient was intubated given his respiratory distress and underwent femoral vein catheterization. Subsequently, he underwent CTA to rule out for PE. A couple messages were left for patient's wife for her to call back for updates. . Review of sytems: (+) Per HPI (per admission note) Unable to get ROS given patient is intubated Past Medical History: ONCOLOGIC HISTORY: # Hodgkin's disease over 20 years ago, chemotherapy regimen MOPP/ABVD and mantle radiotherapy # Large B-cell lymphoma: - diagnosed in [3-/2153], status post 4 cycles of R-[Hospital1 ] followed by high-dose cyclophosphamide and autologous stem cell transplant in [8-/2154] - remained in remission until early [2160-1-11] when developed lower abdominal tenderness with CT scanning showing abnormalities within the distal ileum and adenopathy. Endoscopy and colonoscopy were non-diagnostic. Laparoscopic assisted ileocecectomy on [2160-3-19] showed non-Hodgkin's lymphoma with aggressive features. - treated with 2 cycles of ICE plus rituximab in [Month (only) 958] and [Month (only) 547] of [2160] with excellent response to treatment - [2160-6-2] matched unrelated allogeneic transplant on the ATG/TLI/clofarabine study, cohort 4. Day 0 on [2160-6-13]. - [2160-7-14] CMV positive started on Valcyte - [2160-11-26] changed valcyte to acyclovir due to concern for affects on blood counts - [12/2160] month restaging PET scan showed no evidence for lymphoma. - [2161-6-10] left hand cellulitis at the site of thorn stick on #4 digit, treated with 7 days of linezolid . PAST MEDICAL HISTORY: 1. History of lymphoma and Hodgkin's lymphoma as outlined. 2. Pancreatitis status post ERCP in 6/[2154]. 3. Diabetes mellitus type 2, 4. Coronary artery disease with history of MI in [2152], status post POBA 5. Status post splenectomy with diagnosis of Hodgkin's lymphoma. 6. History of GERD with Barrett's esophagus noted on endoscopy. 7. Basal cell carcinoma of the face status post Mohs' excision followed by dermatology. Social History: Married; lives in [Hospital1 10478] MA with his wife. Returned to work at [Company 22957] recently as networking tech. Recently quit smoking, 25 pack year history, occasional marijuana smoking, drinks 2-3 alcoholic drinks daily, denies withdrawl, seizures, denies drinking first thing in the AM. Family History: Father with a history of esophageal cancer Paternal grandfather with a history of lung cancer Grandmother died of MI Physical Exam: Physical Exam on Arrival to the [Hospital Unit Name 153] Vitals: T: 99.8 BP:78/47 P:54 R:25 O2:100% General: sedated, intubated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: right anterior lung field + bronchial sound, clear on the left, no wheeze or rhonchi. CV: RRR, difficult to appreciate m/r/g Abd: soft, NT, ND, BS present, no rebound or guarding, no organomegaly GU: foley, clear yellow urine, ~ 1L since transfer to the [Hospital Unit Name 153] Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Physical Exam on Discharge from BMT service Vitals: T:97.3 BP:148/88 HR:94 R:18 O2:97% RA General: awake, in no acute distress HEENT: no scleral icterus, mucous membranes moist, no oral ulcers Neck: supple Lungs: clear to auscultation bilaterally CV: RRR, no m/r/g Abd: soft, NT, ND, BS present, no rebound/guarding Extremities: warm, well perfused,no cyanosis or edema, 2+ pulses b/l Neuro: alert and oriented x3, moving all 4 extremities Pertinent Results: Labs on Admission [2161-6-30] 09:00AM BLOOD WBC-11.7* RBC-2.72* Hgb-10.0* Hct-29.2* MCV-108* MCH-36.7* MCHC-34.1 RDW-15.4 Plt Ct-399 [2161-6-30] 09:00AM BLOOD Neuts-67.4 Lymphs-27.3 Monos-3.6 Eos-1.4 Baso-0.2 [2161-6-30] 09:00AM BLOOD UreaN-22* Creat-1.4* Na-141 K-4.8 Cl-104 HCO3-25 AnGap-17 [2161-6-30] 09:00AM BLOOD ALT-48* AST-45* LD(LDH)-197 AlkPhos-143* TotBili-0.4 [2161-6-30] 09:00AM BLOOD Albumin-4.5 Calcium-9.1 Phos-3.6 Mg-1.4* [2161-7-1] 12:00AM BLOOD IgG-871 [2161-7-1] 12:00AM BLOOD CK-MB-3 cTropnT-<0.01 [2161-7-1] 04:35AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-4183* [2161-6-30] 09:15PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.012 [2161-6-30] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CTA [2161-7-1]: 1. New widespread confluent consolidations, findings highly concerning for severe multifocal pneumonia. 2. New small-to-moderate bilateral pleural effusions, right greater than left. 3. Standard position of the endotracheal tube and patent tracheobronchial tree. 4. No pulmonary embolism. Labs on Discharge [2161-7-6] 12:20AM BLOOD WBC-13.7* RBC-2.63* Hgb-9.5* Hct-29.1* MCV-111* MCH-36.2* MCHC-32.7 RDW-15.5 Plt Ct-396 [2161-7-4] 12:05AM BLOOD PT-13.4 PTT-27.9 INR(PT)-1.1 [2161-7-6] 12:20AM BLOOD Glucose-292* UreaN-26* Creat-1.1 Na-138 K-4.3 Cl-99 HCO3-29 AnGap-14 [2161-7-6] 12:20AM BLOOD ALT-62* AST-46* LD(LDH)-235 AlkPhos-180* TotBili-0.3 [2161-7-6] 12:20AM BLOOD Calcium-9.1 Phos-2.7 Mg-1.8 [2161-6-30] 09:00AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- Brief Hospital Course: When Mr.[Known lastname 36212] was admitted to the floor, vitals were t:98.9 bp:150/97 p:113 rr:22 SaO295% RA. He complained of ongoing cough and wheezing and moderate dyspnea on exertion though breathing was comfortable at rest. He was started on antibiotics- azithromycin and ceftriaxone. . At around 11PM, patient was triggerred for increased SOB requiring more oxygen supplement, O2 Sat 84% on RA improved to low 90% on 4L which then improved to mid 90% on NRB. He received lasix 40 mg IV, nebs, and Solumedrol 40 IV x1. At around midnight, patient got up to the bathroom. He was noted to have borderline temp at 100.3, BP 148/94, HR 120, RR 20. As he was returning from the bathroom, he felt more SOB with O2Sat down to 70% on RA which improved to 96% on NRB. Then 50 % on NRB. Code blue was called. Patient was intubated given his respiratory distress on [6-30] and underwent femoral vein catheterization. Subsequently, he underwent CTA to rule out for PE. PE was ruled out, but patient was found to have pulmonary edema and multifocal pneumonia. He was started on Vancomycin 1000mg IV q12 and Cefepime 2g IV q8. Of note, a TTE was done which revealed EF 40%, approximately his baseline. Patient was extubated on [7-2] and was saturating well on 3L in the mid 90s. He continued to wheeze and was started on Advair and Ipratropium and Albuterol nebulizers. His infectious work up was unrevealing, and came back negative for EBV, aspergillus, influenza, parainfluenza, RSV, adenovirus, legionella, H. flu and C.diff. He was started on Azithromycin 500mg PO on [7-3]. He was transferred to the floor on [7-3] where he was oxygenating well on room air to the high 90s. However, he was still wheezing a lot, so he was started on Solumedrol 30mg IV daily. On steroids, the wheezing improved significantly. On [7-5], Vancomycin and Cefepime were discontinued and Levofloxacin 750mg PO qd was started. The Solumedrol was discontinued and Prednisone 30mg PO qd was started. Mr.[Known lastname 36212] remained afebrile throughout his admission on the floor. He was no longer wheezing and breathing comfortably without any oxygen requirements. In regards to his bright red blood per rectum, he did not have another such episode. The lower GI bleed was thought to be secondary to hemorrrhoids. Medications on Admission: Per Admission Note from BMT: Acyclovir 400 mg po q 8 hours Atovaquone 1500 mg po q 24 hours Coreg 25 mg po BID Citalopram 30 mg po daily Folic acid 1 mg po daily Furosemide 20mg daily Glyburide 2.5 mg po daily Lansoprazole 30 mg po daily Metoformin 1000 mg po BID Zocor 80 mg po daily Trazodone 75mg PO QHSPRN insomnia prn Vardenafil 20 mg daily PRN Tylenol 325 mg Q6H PRN ASA81 mg Vitamin D3 2,000 unit Tablet Vitamin B12 1,000 mcg Tablet MAGNESIUM OXIDE-MG AA CHELATE [MG-PLUS-PROTEIN] - (OTC) - 133 mg Tablet - 1 (One) Tablet(s) by mouth three times a day NICOTINE (POLACRILEX) - (discharge med) - 2 mg Lozenge - 1 Lozenge(s) every four (4) hours as needed for nicotine withdrawal symptoms Proair as needed dose unknown flovent as needed dose unknown Discharge Medications: 1. acyclovir 400 mg Tablet [Known lastname ]: One (1) Tablet PO Q8H (every 8 hours). 2. atovaquone 750 mg/5 mL Suspension [Known lastname ]: Two (2) PO DAILY (Daily). 3. citalopram 20 mg Tablet [Known lastname ]: 1.5 Tablets PO DAILY (Daily). 4. folic acid 1 mg Tablet [Known lastname ]: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet [Known lastname ]: One (1) Tablet PO DAILY (Daily). 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. azithromycin 250 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q24H (every 24 hours). Disp:1 Tablet(s) Refills:0 8. prednisone 10 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO Q24H (every 24 hours): Take on [7-7] and [7-8]. Disp:6 Tablet(s) Refills:0 9. levofloxacin 750 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q24H (every 24 hours). Disp:8 Tablet(s) Refills:0 10. cyanocobalamin (vitamin B-12) 500 mcg Tablet [Month/Year (2) ]: Two (2) Tablet PO DAILY (Daily). 11. nicotine (polacrilex) 2 mg Lozenge [Month/Year (2) ]: One (1) Gum Buccal every 4 hours as needed as needed for pt request. 12. carvedilol 12.5 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO BID (2 times a day). 13. metformin 1,000 mg Tablet [Month/Year (2) ]: One (1) Tablet PO twice a day. 14. glyburide 2.5 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 15. trazodone 50 mg Tablet [Month/Year (2) ]: One (1) Tablet PO at bedtime as needed for insomnia. 16. ProAir HFA Inhalation 17. Flovent HFA Inhalation 18. Aspirin Low-Strength 81 mg Tablet, Chewable [Month/Year (2) ]: One (1) Tablet, Chewable PO once a day. 19. vardenafil 20 mg Tablet [Month/Year (2) ]: One (1) Tablet PO once a day. 20. Tylenol 325 mg Tablet [Month/Year (2) ]: One (1) Tablet PO every six (6) hours as needed for pain. 21. Vitamin D-3 2,000 unit Capsule [Month/Year (2) ]: One (1) Capsule PO once a day. 22. magnesium oxide-Mg AA chelate 133 mg Tablet [Month/Year (2) ]: One (1) Tablet PO three times a day. 23. prednisone 10 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO once a day for 2 days: Take on [7-9] and [7-10]. Disp:4 Tablet(s) Refills:0 24. lisinopril 5 mg Tablet [Month/Day (4) ]: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Multi-focal pneumonia Pulmonary edema Hemorrhoidal bleed Discharge Condition: Stable Alert and oriented x3 Ambulatory Discharge Instructions: Dear Mr. [Known lastname 36212], You were admitted to the hospital with bleeding from your rectum. At that time, your blood counts were within normal limits and you were in stable condition. When you were on the floor, you had respiratory distress and stopped breathing on your own. At that time, you were transferred to the intensive care unit and had a tube in your throat to help you breathe for 3 days. During that time, you had a CAT scan of your chest which showed pulmonary edema (fluid in your lungs) and a widespread pneumonia in your lungs. You were started on antibiotics intravenously (Vancomycin and Cefepime) for the pneumonia and Lasix (a fluid pill) to remove the water from your lungs. An echocardiogram was taken of your heart which showed that your heart function was stable. Your responded very well to the treatment and you the tube was removed from your throat on [7-2]. You were wheezing a lot and were started on Albuterol, Ipratropium, and and Advair nebulizer treatments to help with your breathing. Your were also started on Azithromycin, another antibiotic. On [7-4], you were transfered from the intensive care unit to to the floor. You were still wheezing a lot, so we started you on intravenous steroids which reduced the wheezing. Since on the floor, you have remained afebrile. On [7-5], we discontinued your intravenous antibiotics and started you instead on an oral antibiotic, Levofloxacin. We also switched you from intravenous steroids to oral steroids (Prednisone.) In regards to the bleeding from your rectum, it was most likely from a hemorrhoid and did not recur during your admission. You did not require a blood transfusion while you were in the hospital. On discharge, there are several medications that you need to take: 1.Azithromycin: 1 dose of 500mg orally to complete the 5 day course 2.Levofloxacin: 750mg daily for 8 days to complete a 10 day course 3.Prednisone: please take 30mg on [7-7] and [7-8] and 20mg on [7-9] and [7-10] As an outpatient, you will need to have a follow up CAT scan of your chest to assess the pneumonia. Dr. [First Name (STitle) ] will decide when you should have this imaging. Also, your blood pressure was a bit high during the hospitalization so we added a new medication, Lisinopril 5mg daily. When you follow up with your primary care physician, [Name10 (NameIs) ] let them know about this new medication. Your liver enzymes were slightly elevated today so please do not take your Simvastatin and come back at 8:00am on [7-7] to have your blood draw so that we can re-check your liver enzymes. Followup Instructions: Department: HEMATOLOGY/BMT When: FRIDAY [2161-7-10] at 9:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], RNC [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "486", "414.01", "202.83", "518.4", "585.9", "799.1", "455.8", "V42.82", "250.00", "518.81", "562.10", "403.90" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71", "33.24" ]	icd9pcs	[ [ [] ] ]	13161, 13167	7589, 9927	304, 368	13268, 13310	5931, 7566	16001, 16321	4781, 4900		10733, 13138		13188, 13247		9953, 10710			13334, 15978									4915, 5912																						251, 266				2643, 2722					396, 2625																		4006, 4443	4459, 4765
32,573	130,824	31418	Discharge summary	report	Admission Date: [2117-7-11] Discharge Date: [2117-7-19] Date of Birth: [2039-5-19] Sex: F Service: NEUROSURGERY Allergies: Shellfish Attending:[First Name3 (LF) 1854] Chief Complaint: Intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 78 y/o F s/p CVA with Right sided weakness 2 wks ago who was convalescing in rehab with significant improvement per family. She was found down last night and sent to the ER and found to have a Right frontal and Left pariental SAH/IPH. Following her notes her mental status seems to have deteriorated. Imaging here confirms the hemorrhages. Also pt has had an issue with seizure d/o since the CVA's for which she is transitioning from dilantin to keppra. She has also been on some risperdal for some delerium symptoms. The patient was also recently treated with intubation and steroids for stridor possibly secondary to aspiration pneumonia. It is however unclear if the patient was adequately treated for a pneumonia from the notes. The patient and family are poor historians but she denies any pain. The patient has been on aggrenox for the CVA. Past Medical History: CVA, HTN, Seizure d/o, Anxiety Social History: patient comes from rehab Family History: unknown Physical Exam: Exam upon admission: T: 98.0 BP: 146/33 HR: 102 R 16 O2Sats 97 RA Gen: Quite somnolent, comfortable, NAD. HEENT: PERRL, EOMI, Laceration on R eyelid Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+, guaiac pos Extrem: Warm and well-perfused. Neuro: Mental status: Quite somnolent and unable to follow commands well Orientation: Oriented to person, place yesterday, and date yesterday. Recall: None. Language: Only one word answers, not always appropriate. Naming intact. Couldn't assess. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Tough to assess. V, VII: Tough to assess. VIII: Hearing intact to voice. IX, X: Wouldn't open mouth. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Wouldn't stick out tongue. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-22] on left [4-22] on Right. Sensation: Grossly intact. Reflexes: B T Br Pa Ac Right 2 2 2 2 - Left 2 2 2 2 - Toes downgoing bilaterally Coordination: Not cooperative for testing Pertinent Results: Pathology Report DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR ANTIBODIES: Ms. [Known lastname 23081] has a new diagnosis of Anti-D antibody. D-antigen is a member of the Rhesus blood group systems. Anti-D antibody is clinically significant and capable of causing hemolytic transfusion reactions. In the future, Ms. [Known lastname 23081] should receive D-antigen negative products for all red cell transfusions. Approximatley 15% of ABO compatible blood will be D-antigen negative. A wallet card and a letter stating the above will be sent to the patient. CT head [7-11]: Hemorrhage along the left aspect of the falx extending towards the vertex is likely subarachnoid extending intraparenchymally with a mild amount of surrounding hypodensity, which may represent edema. This colleciton measures up to 16 x 11mm in axial dimensions. Indistinct hyperdensity at the right frontal lobe may also represent blood within the subarachnoid space, although this is less clear. There is no shift of normally midline structures or evidence of intraventricular blood. Surrounding osseous structures demonstrate no fracture. The mastoid air cells are well aerated. A small mucous retention cyst is seen within the right sphenoid air cell. CT head [7-12]: Once again there is a focus of intraparenchymal hemorrhage along the left aspect of the superior falx cerebri which on today's examination measures 18 x 10 mm and is largely unchanged in size when compared to the examination from one day prior. There are small components of subarachnoid hemorrhage as well. In addition, there is surrounding hypodensity and effacement of the sulci consistent with edema. A small, hyperdense focus along the right frontal lobe looks slightly more pronounced on today's examination. No new areas of hemorrhage are identified. There is no shift of normally midline structures or significant mass effect from the above described hemorrhage. The visualized portions of the soft tissues, osseous structures, paranasal sinuses, and mastoid air cells are unremarkable Brief Hospital Course: 78 year old female admitted with right frontal and left parietal IPH. The patient did have some increased confusion on [7-12] but her CT was stable. She also received 1 unit of PRBCs that day. She had some agitation and required a 1:1 sitter on [7-13]. She seemed to improve with Risperdal and the following day no longer required a sitter. Her neurological exam improved after that. The patient did have a UTI while in the hospital. She had enterococcus in her urine and she was treated with Levaquin. We had the lab check sensitivities and Levaquin was sensitive for enterococcus. She received her last dose on [2117-7-19] prior to discharge. The patient's aggrenox was restarted on [2117-7-18]. She was evaluated by PT and OT who recommended that the patient go to rehab and that she was safe for discharge. She was neurologically stable prior to discharge. Medications on Admission: Aggrenox 200-250'', Dilantin 100''', Keppra 750'', Iron 324', MVI, Prinivil 5', Risperrdal 0.25''', Risperdal 0.25 at 8 pm, Tylenol Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO Q8PM (). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: R frontal and L parietal intraparechymal hemorrhage Discharge Condition: neurologically stable Discharge Instructions: ??????Take your pain medicine as prescribed ??????Exercise should be limited to walking; no lifting, straining, excessive bending ??????Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ??????If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ??????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 Followup Instructions: YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST on the [Hospital Ward Name 517] at [Hospital1 18] on [8-24] at 11:30 am. You have an APPOINTMENT WITH DR.[Last Name (STitle) ] on [2117-8-24] at 1:00pm. Completed by:[2117-7-19]	[ "300.00", "345.90", "401.9", "431", "599.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6587, 6657	4646, 5524	299, 306	6753, 6777	2560, 4623	7725, 7984	1311, 1320		5707, 6564		6678, 6732		5550, 5684			6801, 7702									1335, 1342																						235, 261									334, 1198	1887, 2541						1357, 1631	1646, 1871										1220, 1253	1269, 1295
10,152	164,536	30144	Discharge summary	report	Admission Date: [2189-5-29] Discharge Date: [2189-6-18] Date of Birth: [2115-8-21] Sex: M Service: MEDICINE Allergies: Percocet / Antipsychotic Drug Attending:[First Name3 (LF) 2160] Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: 1. Left Hip Washout and Debridement. 2. Right Hip ORIF. 3. IVC Filter Placement History of Present Illness: This is a 73 yo male with a PMH of atrial fibrillation, dementia, CAD, CHB s/p PM, and HTN who presents as a transfer from OSH with R hip fracture. The patient initially was diagnosed with a left hip fracture in [2189-3-12] at which time he was transferred from the Bahamas to [Hospital1 18]. During that admission he was noted to have a NSTEMI in the preoperative time period, subsequently underwent L hip ORIF, and then had a complicated post-op course notable for hypotension, shock, sepsis, MRSA pneumonia, and torsades requiring defibrillation due to QT prolongation from haldol. He was discharged to rehab on [4-18] where he had a mechanical fall while walking back to his bed from the bathroom under his own power (he was supposed to be helped with all OOB activity), when he tripped and sustained a R hip fracture (impacted, slightly displaced, subcapital hip fracture per OSH x-ray). At the OSH, the patient was noted to have a supratherapeutic INR >10 but stable hematocrit. He was given 2 units FFP and 5mg sc vitamin K with decrease of INR to 4.4. Lasix was held due to acute renal failure (Cre 1.8, baseline 1.2-1.3). Three sets of TnI were checked and were negative (<0.04). Labs were notable for WBC 8.2 and Hct 35.9. The family requested that the patient be transferred to [Hospital1 18] for repair of his hip fracture. . On medicine floor, pt. taken for R hip repair but noted to have abscess over L hip repair site. Abscess drained on [5-31] with gram stain + for GPC. Tx c vancomycin and VAC dressing. On am of [6-1], pt. noted to be hypotensive to 80/50 but afebrile c VAC dressing draining blood, morning hct decreased from 32 to 22 from previous day. Pt was given boluses of normal saline, with temporal response, and then prbc transfusion was begun. Transfered to MICU where pt received 2 units PRBC and hct/BP stabilized. He went for washout of his L hip with vac drain change today. Past Medical History: CAD s/p MI x 2 paroxysmal atrial fibrillation, on coumadin Pacer placed post-MI for complete heart block, replaced x2 (most recently [2-/2188]) HTN h/o multi-infarct dementia depression anxiety h/o Hodgkin's lymphoma L hip fx in [3-18] CRI (baseline Cre 1.2-1.3) ?h/o TIA Social History: Lives with wife in [Name (NI) 3844]. Rare alcohol use; history of tobacco use, but quit a number of years ago. Family History: Non-contributory. Physical Exam: T 97.2 BP 102/60 P 92 R 17 Sat 98%2lNC General: NAD, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, 3/6 systolic murmur, no JVD Pulmonary: CTAB anteriorally Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 2+ DP/PT/femoral pulses, no edema, pain on palpation or movement of right lower extremity Skin: warm, L hip with dressing c/d/i and drain in place draining serosanguinous fluid Neuro: Alert, oriented to person and place, speech clear, follows commands Pertinent Results: Admission labs: [2189-5-29] 11:50PM BLOOD WBC-6.4 RBC-3.61* Hgb-11.3* Hct-32.9* MCV-91 MCH-31.2 MCHC-34.3 RDW-14.1 Plt Ct-241 [2189-5-30] 05:50AM BLOOD Neuts-72.8* Lymphs-20.6 Monos-4.9 Eos-1.6 Baso-0 [2189-5-29] 11:50PM BLOOD PT-24.7* PTT-35.4* INR(PT)-2.5* [2189-6-5] 06:40AM BLOOD ESR-95* [2189-5-29] 11:50PM BLOOD Glucose-99 UreaN-27* Creat-1.5* Na-135 K-4.5 Cl-101 HCO3-26 AnGap-13 [2189-5-30] 05:50AM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.7 Mg-2.1 [2189-6-3] 05:25AM BLOOD PTH-15 [2189-6-5] 06:40AM BLOOD CRP-155.9* . . TISSUE (Final [2189-6-3]): STAPH AUREUS COAG +. HEAVY 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. Trimethoprim/Sulfa sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. VANCOMYCIN SENSITIVITY TESTING CONFIRMED BY ETEST AS (1.5 MCG/ML). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ 2 S . Imaging: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) [2189-5-29] 10:15 PM IMPRESSION: 1. New right femoral neck fracture. 2. Status post ORIF of a recent ([2189-3-12]) intra/subtrochanteric left femur fracture with development of surrounding heterotopic ossification around the left hip. . CHEST (PRE-OP AP ONLY) [2189-5-29] 10:15 PM IMPRESSION: Slight prominence of interstitium, without evidence of failure. . [Numeric Identifier 71837] PERC PLCMT IVC FILTER [2189-6-3] 11:32 AM IMPRESSION: Successful placement of a retrievable IVC filter via the right common femoral vein. Filter may be retrieved within 14 days of placement or left in place as a permanent filter. . CHEST (PORTABLE AP) [2189-6-10] 3:05 PM IMPRESSION: 1. Mild CHF/volume overload. 2. Stable small bilateral pleural effusions. 3. Emphysema. . CT ABDOMEN W/O CONTRAST [2189-6-13] 11:18 AM IMPRESSION: 1. No evidence of new retroperitoneal or thigh hematoma. Improving moderate sized left thigh hematoma. 2. 1.2 cm left renal high-density lesion seen on prior study should be further evaluated with follow up ultrasound or MR. 3. Multiple right simple-appearing renal cysts. 4. There are larger small-to-moderate sized bilateral pleural effusions, right greater than left. 5. Stable small suprarenal abdominal aortic aneurysm measuring 3.1 x 3.3 cm at the celiac axis. . UNILAT LOWER EXT VEINS RIGHT [2189-6-13] 10:20 AM IMPRESSION: No evidence of DVT. . CHEST (PORTABLE AP) [2189-6-15] 8:46 AM IMPRESSION: 1. Slightly worsened interstitial pulmonary edema, with small bilateral pleural effusions. 2. Underlying emphysema. 3. New left basilar opacity, likely atelectasis, but aspiration and early infectious pneumonia are also possible. . CHEST (PORTABLE AP) [2189-6-16] 1:42 PM IMPRESSION: Marked improvement of pulmonary congestive pattern seen on person with advanced COPD on preceding chest examination 1 day earlier. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2189-6-17] 5:45 PM IMPRESSION: 1. No pulmonary embolism. 2. Bilateral pleural effusions, right greater than left in conjunction with left ventricular concentric hypertrophy and mild septal thickening likely represent mild congestive heart failure. Overall, the lungs are improved compared to [2189-4-4]. . FILTER REMOVAL [2189-6-18] 7:41 AM IMPRESSION: IVC venogram demonstrating no thrombus within Optease IVC filter. Unapproachable retrieval of Optease filter, with post-retrieval venogram demonstrating no evidence of thrombus or IVC injury. Brief Hospital Course: 73M h/o CAD, PAF, CHF, CHB s/p PM, CRI, dementia and recent complicated hospital course surrounding left hip fracture repair transferred from OSH with right hip fracture after mechanical fall at rehab and resolving septic L hip s/p washout. . # Left hip MRSA abscess: Found to have pus coming from old surgical site in soft tissue, growing MRSA. Underwent I&D on [5-31] with placement of vac sponge drain, then s/p repeat washout [6-3] and JP drain placement (now removed). Initial washout on [5-31] was complicated by hemorrhagic shock from the surgical site requiring 3 untis pRBC transfusion and transfer to the ICU until his hematocrit stabilized. He was given vitamin K and all anticoagulants were discontinued. An IVC filter was placed on [6-4] given his high risk of DVT/PE and inability to anticoagulate in setting of hip fracture. Remained afebrile. Blood cultures were negative. ESR and CRP elevated. ID team consulted and recommended at least 6 weeks vancomycin treatment. Patient was on IV vancomycin while in house and will remain on this medication for a total of 6 weeks. Patient is to have labs faxed to ID physician as in discharge instructions. patient is also to follow-up with ID as an outpatient. . # Right hip fracture: s/p mechanical fall. Orthopedics was consulted. Patient was at high risk of perioperative cardiac event, as assessed by Cardiology at prior admission. EP consulted after admission and pacemaker interrogated and reset to optimize peri-surgical settings. He underwent ORIF on [2189-6-10] without complications and his post-operative with also uncomplicated. His cardiac enzymes were checked after surgery and they were negative His multiple fractures are likely due to osteoporosis. PTH was normal at 15 and corrected serum Ca2+ normal. He may be some element of vitamin D deficiency and was started on supplementation. IVC filter placed on [6-4] given high risk of DVT/PE, and removed on day of discharge. Patient to follow-up with Ortho as an outpatient and have PT at rehab. Patient also to have 30 days of Lovenox, twice daily, for DVT prophylaxis. Please have his renal function checked, and if his creatinine clearance drops below 30 ml/min, then please discontinue lovenox and treat the patient with SC Heparin. . # DVT risk: Pt is at high risk for DVT given his immobility and mulitple surgical procedures. He could not recieve coumadin because of his large left hip bleed during this hospital course so a temporary IVC filter was placed on [6-4] and removed on discharge. He was discharged on Lovenox twice daily to continue for 30 days from ORIF, and will need to remain on SC heparin there after until the patient is fully ambulatory. . # CAD: s/p NSTEMI in [3-18]. ROMI at OSH. Discharged from last admission on aspirin and plavix but per transfer note not on ASA or plavix, and unclear when or why these were stopped. Initially started on ASA but then held due to post-op bleeding. Statin and beta-blocker were continued. Patient discharged on Lovenox and ASA. Patient will need to address reinitiation of Plavix with outside PCP. # PUMP: EF 35%. Patient continued on BB and was euvolemic upon discharge. . # RHYTHM: h/o torsades/VF arrest. s/p PM for CHB. PAF. ICD not placed during last admission as patient deemed too ill and cause of arrest thought to be reversible ([3-13] QT prolongation from haldol). Continued amiodarone. EP was consulted and evaluated pacemaker. Monitored on telemetry with no significant events. Coumadin will need to be reinitiated on [2189-6-28] as per discharge instructions. . # CRI: Patient with baseline of 1.2-1.5. Patient at baseline upon discharge. Given that patient had CT with contrast 24 hours prior to discharge, his renal function will need to be followed during the week following discharge. Is his Cr climbs and his Cr clearence drops from 42, then his medications will need to be renally dosed and his lovenox will need to be changed to SC heparin for DVT prophylaxis. . # Dementia: Continued namenda, aricept. . # Depression/anxiety: Continued remeron. . # Pressure sore: Wound care nusring was consulted and provided recommendations. . # Renal masses: Seen on CT scan during last admission. ?cyst vs. malignancy. Needs outpatient followup imaging. . . After discussion with the patient and the medical staff, all were in agreement that [Known firstname ] [Known lastname 71838] was a suitable candidate for discharge. Medications on Admission: ASA 325 qd Percocet PRN Dilaudid PCA Simvastatin 40 qd Memantine 10 [Hospital1 ] Donepezil 5 hs Colace/Senna/Dulcolax Mirtazapine 15 hs Amiodarone 200 qd Vitamin D [Numeric Identifier 961] daily Toprol 75 daily Vancomycin 1 g IV q12 Lovenox 40 qd Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO twice daily (). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 16. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID PRN () as needed for hiccups. 17. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Continue until [2189-6-30]. Disp:30 30 Refills:0 18. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day: Continue until [2189-7-12]. 19. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): Continue until [2189-6-29]. 20. Outpatient Lab Work Please draw weekly CBC w/diff, BUN, Cr, LFTs and faxed to Dr. [Last Name (STitle) 67369] [Name (STitle) 3394] @ [Telephone/Fax (1) 432] 21. Outpatient Lab Work On [2189-7-1], please draw INR and have results faxed to Dr. [First Name4 (NamePattern1) 13740] [Last Name (NamePattern1) ] @ [Telephone/Fax (1) ]. 22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: PLEASE START ON [2189-6-28]. 23. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 25. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 26. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 27. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Location (un) ] crestwood Discharge Diagnosis: Primary: 1. Traumatic Right Hip Fracture. 2. Post-op Left Hip ORIF MRSA Wound Infection - Gluteal Abscess. 3. Blood Loss Anemia. 4. Acute Renal Failure. Secondary: 1. CHB s/p pacemaker. 2. 2-Vessel CAD s/p NSTEMI x 3. 3. Systolic Heart Failure - EF 35%. 4. Cardiac Arrest - VT/VF secondary to Haldol associated Long QT. 5. Paroxysmal atrial fibrillation. 6. Hypertension 7. Early Alzheimer's dementia 8. Depression/anxiety 9. Left femoral fracture s/p gamma nail fixation. Discharge Condition: Hemodynamically stable, afebrile, tolerating POs, ambulating with assistance Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml per day Please take all medication as prescribed. Keep all appointments listed below. . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. . You will be on daily Vancomycin until [2189-7-12] You will be on daily Zosyn until [2189-6-29]. You will be on twice daily Lovenox until [2189-6-30]. You will need to restart Warfarin 5 mg daily on [2189-6-28] and have your INR checked every third day and results faxed to Dr. [First Name4 (NamePattern1) 13740] [Last Name (NamePattern1) ] @ [Telephone/Fax (1) ] for dosing modifications. . You will need to have weekly labs drawn (CBC w/diff, BUN, Cr, LFTs) and faxed to Dr. [Last Name (STitle) 67369] [Name (STitle) 3394] (fax:[Telephone/Fax (1) 432]) Followup Instructions: You are scheduled for the following appointments. Please contact the [Name2 (NI) 11686] provider with any questions or if you need to reschedule. . You have an appointment with your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 16827] [2189-7-2] @ 11:45 am Provider: [First Name8 (NamePattern2) 7618] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2189-7-7] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1984], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2189-7-16] 12:40 Provider: [Name10 (NameIs) ] Clinic: [Telephone/Fax (1) 59] Date: [2189-7-21] @ 1:00pm, [Location (un) 8661] Building [Location (un) 436]. Completed by:[2189-6-19]	[ "437.0", "998.0", "733.00", "599.0", "486", "820.8", "998.11", "285.1", "412", "427.31", "414.01", "998.59", "707.07", "593.9", "294.10", "E888.9", "426.0", "V45.01", "331.0", "V09.0", "401.9", "428.0", "584.9", "428.20" ]	icd9cm	[ [ [] ] ]	[ "81.52", "83.45", "99.07", "38.93", "38.7", "93.59", "99.04" ]	icd9pcs	[ [ [] ] ]	15060, 15117	7647, 12127	303, 385	15636, 15715	3464, 3464	16786, 17592	2802, 2821		12432, 15037		15138, 15615		12153, 12409			15739, 16763									2836, 3445																						251, 265									413, 2351				3480, 7624														2373, 2654	2670, 2786
2,029	126,385	44673+58747+58749	Discharge summary	report+addendum+addendum	Admission Date: [2160-4-4] Discharge Date: [2160-4-8] Service: MEDICINE Allergies: Digoxin Attending:[First Name3 (LF) 338] Chief Complaint: Shortness of breath, tachycardia, fever Major Surgical or Invasive Procedure: Continued ventilation History of Present Illness: Pt is an 82 yo female with atrial fibrillation, HTN, amiodarone induced hyperthyroidism, s/p trach/peg and chronically vented, who presents from [Hospital ] Rehabilitation with shortness of breath, tachycardia, and fever to 103. Pt was admitted to [Hospital1 ] from [Date range (3) 95595] with pneumonia from likely rhinovirus with bacterial superinfection. She was treated with appropriate antibiotics and steroid course. She was intubated initially and had difficulty weaning from the vent and thus underwent tracheostomy and PEG placement. The above was further complicated by likely ventilator associated pneumonia. Additionally, the patient, who has tachy-brady syndrome, had many episodes of afib/flutter and RVR with aberrancy (and rate related LBBB). This was controlled with beta blockade. Her amiodarone was discontinued as it caused hyperthyroidism. Additionally, digoxin at that time led to bradycardia. Endocrinology followed Ms. [Known lastname 95596] for her amiodarone-induced hyperthyroidism and a slow prednisone taper was planned. Per review of records from [Name (NI) ], pt was on trach mask for three days but was desaturating to 68% on 100 % trach mask. She was connected back to the vent. Also, per report secretions for 4-5 days but noticed to have frank bleeding since yesterday afternoon. Cultures from [2160-4-3] show >100,000 Vancomycin resistant enterococcus faecolis (sensitive to Linezolid) and >100,000 Methicillin Resistant Staphylococcus (MRSA) (sensitive to linezolid). Also with sputum from [2160-4-3] growing pseudomonas aeruginosa (sensitive to zosyn MIC 64, and gentamicin MIC 4). At 8:30 pm last night, HR to 140s-150s (SVT). She received IV metoprolol 5 mg x 4 without effect. She also received 6 mg of adenosine x1 and then 12 mg of adenosine, and broke into sinus tachycardia briefly. In the ED, VS on arrival were: T: 103, HR: 127. BP: 90/43; RR: 37; O2: 100 on 400/12/100/8. She was given 650 mg acetaminophen pr, 1 gram of vancomycin IV, 1 gram of ceftazidime IV, and 10 mg of dexamethasone. She also received 40 meq of potassium chloride and 500 mg IV metronidazole. Also given 3 L NS with improvement of BP. EKG showed afib with LBBB, shown to cardiology. Past Medical History: 1. CV: -Atrial fibrillation, status post two ablations last in '[52] on amiodarone chronically as well as coumadin. -Pump: Echo from [2-/2160]- Normal wall motion and EF; 1+AR, 2+ TR -CAD: Stress ECG in [June 2157] with borderline EKG evidence of myocardial ischemia in the absence of anginal symptoms with 6min on [Doctor First Name ]. 2. Hypertension 3. Hypercholesterolemia 4. Status post total abdominal hysterectomy 5. Chronic cough followed by Dr. [Last Name (STitle) 575] 6. Anxiety 7. Back pain - DJD of L4-L5 and L5-S1 and spondylolisthesis followed by Dr. [First Name (STitle) 4223] of Ortho. 8. s/p trach and peg as above 9. Amiodarone induced hyperthyroidism Social History: Prior to last hospitalization, lived alone in same building as her son. Since above, has been at [Hospital ] Rehabilitation. No history of smoking. No EtOH. Family History: S: died of lung cancer; M: breast cancer Physical Exam: VS: T: 98.6; BP: 116/75; Hr: 105; AC 400/12/100/8 RR: 18, Tv 420 Gen: intubated, responds appropriately to questions. HEENT: PERRL. Falls asleep when trying to do EOM. Neck: Trach in place CV: RRR S1S2. No M/R/G Lungs: Anteriorly: diffusely scattered crackles/rales. Good air movement Abd: Soft, NT, ND. PEG tube in place Back: Unable to assess Ext: Trace edema. DP 1+ Neuro: Can moves all four extremities. Biceps/brachio/patellar reflexes [11-19]. Answers questions appropriately. Cannot do more formal assessment as pt falls asleep. Pertinent Results: Labs on admission: [2160-4-3] 11:55PM BLOOD WBC-39.0# RBC-3.33 Hgb-9.1* Hct-28.3* MCV-85 MCH-27.2 MCHC-32.1 RDW-17.8* Plt Ct-582* [2160-4-3] 11:55PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 [2160-4-3] 11:55PM BLOOD PT-42.7* PTT-42.0* INR(PT)-4.9* [2160-4-3] 11:55PM BLOOD Glucose-165* UreaN-26* Creat-0.4 Na-135 K-2.8* Cl-93* HCO3-32 AnGap-13 [2160-4-3] 11:55PM BLOOD ALT-79* AST-61* CK(CPK)-21* AlkPhos-264* Amylase-45 TotBili-0.3 [2160-4-3] 11:55PM BLOOD CK-MB-NotDone cTropnT-0.06* [2160-4-3] 11:55PM BLOOD Albumin-2.6* Calcium-7.2* Phos-3.3 Mg-1.6 [2160-4-3] 11:55PM BLOOD TSH-2.3 [2160-4-4] 10:00AM BLOOD Type-ART pO2-108* pCO2-53* pH-7.39 calTCO2-33* Base XS-5 Microbiology: [2160-4-7] c-diff- pending [2160-4-6] c diff- negative [2160-4-5]-Source: Endotracheal. GRAM STAIN (Final [2160-4-5]): [9-11] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Preliminary): ? OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. BEING ISOLATED FOR FURTHER IDENTIFICATION AND SENSITIVITIES. [2160-4-5]- blood culture x 2- pending [2160-4-4]- c diff negative Brief Hospital Course: Pt is an 82 yo female with atrial fibrillation, HTN, amiodarone induced hyperthyroidism, s/p trach/peg and chronically vented, who presents from [Hospital ] Rehabilitation with SOB, fever, and tachycardia. Sputum from [Hospital1 ] grew out pseudomonas. 1. Respiratory [Name (NI) 37370] Pt was on a trach mask for three days prior to decompensation. The current respiratory failure is likely secondary to a ventilatory associated pneumonia. Sputum from [Hospital1 ] grew out pseudomonas, sensitive to gentamycin (MIC 4) and Zosyn (MIC 64) only. We started patient on gentamycin and zosyn for a planned 14 day course (to end on [4-17]). Pt was able to be changed to pressure support on HD1 and tolerated that for a few hours. HD 2, pt had tachypnea after a few minutes on pressure support. On hospital day 3 changed to pressure support and then tolerated trach mask with out need for vent. Would consider adding inhaled tobramycin once IV antibiotics are complete for ten more days until she is decannulated. 2. Fever/leukocytosis- Pt has urine growing MRSA and VRE from [Hospital1 ]. Additionally sputum growing pseudomonas as above. Will treat pseudomonal infection as above and UTI with linezolid x 14 days (last dose 5/31). Panculture data is as above. Additionally, pt has bilateral pleural effusions. Given the multiple likely etiologies for fever, and the fact that the pleural effusions are bilateral, they were not tapped. Her fever resolved with antibiotics and her leukocytosis slowly trended down. She should have a repeat urine culture after her course is complete to ensure resolution of infection. 3. Tachycardia/ atrial fibrillation- Patient has known tachy-brady syndrome with history of SVT with aberrancy. We continued her metoprolol q6 hours with holding parameters and monitored her on telemetry. Initial component of tachycardia was secondary to hypovolemia which was corrected with IVF on admission. In terms of anticoagulation, INR was 4.4 on admission which drifted down. Given guaiac positive stools and anemia, pt's outpatient cardiologist was emailed who is conteplating the necessity of anticoagulation for the paf. Coumadin was restarted at time of discharge. Needs outpatient GI work up. 4. Amiodarone induced hyperthyroidism-on prednisone 5 mg po qday as outpatient. The steroids were increased to hydrocortisone 50 mg q6 hours initially and changed back to rehab dose steroids on HD 3. TSh and T4 were rechecked and were normal. 5. Anxiety- alprazolam prn and Quetiapine qhs were continued. 6. LLE swelling- mildlower extremity swelling L>R. LENIs were negative for clot. Neurology saw patient for LLE pain/weakness and thought that her exam was most likely consistent with a mypoathy, likely from both steroids and deconditioning. They recommended aggressive physical therapy, further work-up if fails to improve. This can be continued to be followed by a neurologist while at [Hospital1 ]. 7. F/E/N- continued Nutren 1.5 at 40 cc/hour through PEG tube. Electrolyte check and repletion. Please continue fish oil, calcium carbonate, and probiotics. 8. She has a PICC in plce for long term antibiotics. She was maintained on a PPI for GI prophylaxis, and her coumadin was restarted for DVT prophylaxis. She is full code. Medications on Admission: Calcium Carbonate 1250 mg [Hospital1 ] Fishoil 1000 mg qday Colace 100 mg [Hospital1 ] Fentanyl 25 mcg q72 hours Regular insulin sliding scale Lansoprazole 30 mg po qday Metoprolol 25 mg po q6 hours Prednisone 5 mg po qday Quetiapine 25 mg po qhs Senna 2 qhs Trazodone 25 mg qhs Warfarin- on hold for INR>4 Discharge Medications: 1. Calcium Carbonate 500 mg (1,250 mg) Tablet [Hospital1 ]: 2.5 Tablets PO BID (2 times a day). 2. Omega-3 Fatty Acids 550 mg Capsule [Hospital1 ]: Two (2) Capsule PO DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Insulin Regular Human 100 unit/mL Solution [Hospital1 ]: as directed per scale Injection ASDIR (AS DIRECTED). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Quetiapine 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Alprazolam 0.25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed. 9. Linezolid 600 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q12H (every 12 hours) for 9 days. 10. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One Hundred (100) mg PO BID (2 times a day). 11. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed. 12. Ipratropium Bromide 17 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q6H (every 6 hours). 13. Albuterol 90 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q6H (every 6 hours). 14. Prednisone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6 HR (). 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Last Name (STitle) ]: One (1) ML Intravenous DAILY (Daily) as needed. 17. Piperacillin-Tazobactam 4.5 g Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 9 days. 18. Gentamicin in Normal Saline 80 mg/50 mL Piggyback [Last Name (STitle) ]: Eighty (80) mg Intravenous Q24H (every 24 hours) for 9 days. 19. Coumadin 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime. 20. Warfarin 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime): Monitor INR to keep therapeutic level of [12-22]. . 21. probiotics [Date Range ]: 0.5 tsp twice a day: Please give via PEG. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Ventilator associated pneumonia Urinary Tract infection Atrial fibrilation GI bleed Discharge Condition: Good Discharge Instructions: You were diagnosed with a ventilator associated pneumonia. You were treated with IV ABX and need to finish a 14d course. Your rehab facility should have you re-evaluated if your respiratory status worsens, you have increased secretions, or fevers. . You were also evaluated by a neurologist for left leg weakness. It is recommended that you be followed by a neurologist while at rehab. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1980] [Last Name (NamePattern4) 1981], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2160-4-29] 10:50 . Please follow up with your Endocrinologist after discharge from rehab. . Please follow up with Dr. [Last Name (STitle) ] for your atrial fibrilation and Tachy Brady syndrome. . You were found to have occult blood in your stool. This is probably secondary to gastrits from your prednisone. You are on medication, lansoprazole, for this. You should have an outpatient GI work up to evaluate this. . Your rehab should start inhaled tobramycin after you complete your IV antibiotics. Name: [Known lastname 15156],[Known firstname 11834] Unit No: [Numeric Identifier 15157] Admission Date: [2160-4-4] Discharge Date: [2160-4-8] Date of Birth: [2077-5-8] Sex: F Service: MEDICINE Allergies: Digoxin Attending:[First Name3 (LF) 10790] Addendum: In terms of her anticoagulation, the patient's cardiologist was NOT notified by email prior to discharge about the risk and benefits of continuing anticoagulation. Rather, the ICU team decided that given the stability of her hematocrit and no further evidence of active bleeding, it was reasonable to resume her coumadin. However, the risk/benefit should be readdressed if she were to again demonstrate signs of GI bleeding. Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] [Doctor First Name 3354] [First Name8 (NamePattern2) ] [Name8 (MD) 3353] MD [MD Number(2) 10791] Completed by:[2160-4-9] Name: [Known lastname 15156],[Known firstname 11834] Unit No: [Numeric Identifier 15157] Admission Date: [2160-4-4] Discharge Date: [2160-4-8] Date of Birth: [2077-5-8] Sex: F Service: MEDICINE Allergies: Digoxin Attending:[First Name3 (LF) 1015] Addendum: After discussion and review of her case again, it is recommended that Ms. [Known lastname ] stop her anticoagulation with coumadin until she her stools are guaiac negative, or until she is able to undergo a GI workup with colonoscopy and endoscopy. Given that she will be on long term antibiotics, steroids, and tube feeds, her risk for GI bleed, despite being on GI prophylaxis, likely outweighs the benefit of anticoagulation at this time. If her stools [Last Name (un) 15167] guaiac negative and a GI workup does not reveal any evidence of bleeding, then it may be reasonable to resume her coumadin. We will notify her cardiologist of this recommendation as well. A copy of this addendum will be faxed to [Hospital ] rehab. In addition, these recommendations were discussed verbally with the [Hospital1 ] physicians at the time of the patient's transfer. Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1016] MD [MD Number(2) 1017] Completed by:[2160-4-10]	[ "285.29", "272.0", "414.01", "427.89", "E942.0", "401.9", "E878.8", "511.9", "244.9", "486", "427.31", "242.80", "518.81", "599.0", "999.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	15077, 15315	5473, 8771	252, 275	11702, 11709	4074, 4079	12143, 13559	3455, 3497		9136, 11472		11595, 11681		8797, 9113			11733, 12120									3512, 4055							5193, 5450															173, 214									303, 2541							4093, 5152											2563, 3261	3277, 3439
44,677	169,883	38653	Discharge summary	report	Admission Date: [2160-2-16] Discharge Date: [2160-2-19] Date of Birth: [2138-2-13] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: jaw pain Major Surgical or Invasive Procedure: [2160-2-18] 1. S/P ORIF mandibular symphysis 2. Closed reduction with intermaxillary fixation of bilat. condyle fractures 3. Removal of dental fragments History of Present Illness: 22M transferred from [Hospital ] hospital after a fall straight onto his face from standing. Per reports, there was no syncope reported at the scene. The patient has limited recollection of the event but denies any syncope. As a result of the fall, he suffered bilateral mandibular fractures. He was found to have marijuana and a pink powder but only tested positive for EtOH. Past Medical History: 1. ADHD Social History: Student at [Last Name (un) 26428] Collage ETOH + Tobacco +MJ Family History: non contributory Physical Exam: Vitals: T: 99.9 degrees Fahrenheit, BP: 137/81 mmHg supine, HR 65 bpm, RR 16 bpm, O2: 96 % on RA. I/O: +83 since midnight. Gen: Somnolent but arousable, uncomfortable but no acute distress Eyes: No conjunctival pallor. No icterus. ENT: MMM. OP clear. CV: JVP normal. PMI in 5th intercostal space, mid clavicular line. RRR. nl S1, S2. No murmurs, rubs, clicks, or gallops. Full distal pulses bilaterally. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. No HSM. Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy. SKIN: Laceration on chin, sutures clear/dry/intact. NEURO: A&Ox3. CN 2-12 grossly intact. PSYCH: Mood and affect were appropriate. Pertinent Results: [2160-2-16] 06:45AM WBC-15.3* RBC-4.60 HGB-15.0 HCT-42.3 MCV-92 MCH-32.6* MCHC-35.4* RDW-12.3 [2160-2-16] 06:45AM PLT COUNT-348 [2160-2-16] 06:45AM ASA-NEG ETHANOL-160* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2160-2-16] 06:52AM GLUCOSE-121* LACTATE-3.2* NA+-148 K+-4.0 CL--105 TCO2-19* [2160-2-16] 06:45AM UREA N-11 CREAT-0.8 [2160-2-16] CT C spine : 1. No evidence of C-spine fracture. 2. Bilateral mandibular condylar fractures and fracture of the body of the mandible as described above. \ [2160-2-17] CT Mandible : Bilateral mandibular condyle fractures as well as a symphyseal fracture. There is medial displacement of the condylar processes bilaterally with dislocation of the TMJ. Brief Hospital Course: Mr. [Known lastname 85875] was transferred to [Hospital1 18] Emergency Room for further evaluation of his mandibular fracture. He was evaluated by the Trauma service and admitted to the Trauma floor, maintained NPO and hydrated with IV fluids. Following assessment by the Oral surgeons plans were for surgical repair on 2//[8-19]. In the interim he was evaluated by the Cardiology service as he had a dropped QRS noted on telemetry. His heart rate was very labile from 50 to 110. His EKG was normal and they felt that his slower heart rates and dropped qrs were in the setting of vagotonia. He was totally asymptomatic and required no further treatment. He was taken to the Operating Room on [2160-2-18] for ORIF of his mandible. he tolerated the procedure well and returned to the PACU in stable condition. Following transfer to the Trauma floor he continued to make good progress. He was able to swallow soft foods and his pain was controlled with Roxicet elixir. He had a panorex film done on [2160-2-19] which showed good alignment and after an uneventful recovery was discharged to home with his parents on [2160-2-19]. Due to the fact that he lives in N.J. he will follow up with an Oral surgeon there on [2160-12-31] for suture removal and he will come back to see Dr. [First Name (STitle) ] 0n [2160-2-29]. Medications on Admission: none Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). Disp:900 ML(s) Refills:2 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. Disp:250 ML(s) Refills:0 3. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig: Ten (10) mls PO three times a day: Thru [2160-2-25]. Disp:250 mls Refills:1 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis S/P Fall 1. Bilateral mandibular condyle fractures 2. Symphyseal mandibular fracture Secondary diagnosis 1. ADHD Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: * You recently underwent surgery to fix your jaw fracture. * You [Month (only) ] have wires in your mouth to stabilize your jaw. Keep wire cutters with you at all times. If you develop any nausea or vomiting, cut the wires on each side of our mouth so as not to aspirate. If you cut the wires you need to return to the Emergency Room right away. * Your mouth will be swollen for a few days, maybe more. Sleep with your head elevated on 2 pillows to help reduce the sewlling. Ice packs to your face for the first 24-36 hours may help. Expect some numbness in your lips or gums for a few weeks. Your lips will be dry. Use Vaseline or Chap Stick as needed. * Your dressing may be removed on [2160-2-22]. * Oral hygiene is important for healing. Rinse your mouth after every meal with Peridex or Listerine mouthwash for [7-19] days. After that use a half and half solution of salt water or mouthwash and continue to be vigilant in oral care. Brush your teeth gently for the first week. Avoid disrupting the incisions in your gums. The stitches in your mouth will fall out on their own but it takes time. If you spit them out, don't be concerned. This is normal. * No heavy lifting greater than 10 pounds for 2 weeks. No bending over for 2 weeks. No contact sports for 8 weeks. * No restrictions with showering or bathing. * Your diet should consist of very soft foods or liquids, nothing that requires chewing. * Call your surgeon if you have any of the following; Persistent fevers greater than 101 A sudden shift of your bite or bones New bleeding Any new symptom that concerns you * Call [Telephone/Fax (1) 55393] for a follow up appointment on [2160-2-29] with Dr. [First Name (STitle) ]. Followup Instructions: Call Dr. [First Name (STitle) ] at [Telephone/Fax (1) 55393] for a follow up appointment [2160-2-29]. Call your family dentist for a referral to a local Oral surgeon for follow up [2160-2-22] for suture removal. Completed by:[2160-2-27]	[ "305.00", "802.39", "873.63", "314.01", "802.26", "E888.1" ]	icd9cm	[ [ [] ] ]	[ "76.76", "23.19", "96.71" ]	icd9pcs	[ [ [] ] ]	4385, 4391	2515, 3876	323, 482	4566, 4566	1746, 2492	6525, 6785	1023, 1041		3931, 4362		4412, 4545		3902, 3908			4711, 6502									1056, 1727																						275, 285									510, 894								4580, 4687										916, 925	941, 1007
46,586	160,823	49043	Discharge summary	report	Admission Date: [2134-4-3] Discharge Date: [2134-4-8] Date of Birth: [2079-10-6] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath and hypotension Major Surgical or Invasive Procedure: [2134-4-3] - Emergent Re-Exploration for bleeding, Evacuation of clot and hemostasis. History of Present Illness: This 54 year old male was seen at [Location (un) ] Hospitla earlier today with complaints of back pain and chest pain. His blood pressure at that time was in the 200s systolic. A CT scan done there showed a type A dissection. He was transferred here on a Nipride dripand emergently taken to the Operating Room. On [2134-3-21] he underwent emergency repair of complex type A aortic dissection with total arch replacement with size 28 Gelweave graft. Recently discharged on [3-30]. Woke this morning at around 430 am with back pain, diaphoresis, lightheadedness. Seen at [Location (un) ] and was hypotensive. Resuscitated with total of [2124] cc crystalloid and started on dopamine drip. Med flight here. CT showed no evidence of extension of dissection or rupture. Emergency echocardiogram showed large pericardial effusion with evidence of tamponade. Admitted and will undergo emergency drainage of pericardial effusion Past Medical History: ascending aortic dissection hypertension h/o prostate cancer s/p knee surgery Social History: 35 pack year smoking history. Drinks 1 gallon of vodka per week (1-2 drinks per night - very large drinks) Family History: Non contributory Physical Exam: General: NAD, alert and cooperative HEENT: EOMI, PERRLA Neck: FROM, supple Cardio: no murmur Neuro/Psych: awake, alert, follows instructions Gastrointestinal: No masses. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: +2. DP: +1. PT: +1. LLE Femoral: +2. DP: +1. PT: +1. Pertinent Results: [2134-4-3] ECHO The left atrium is moderately dilated. The left atrium is elongated. 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. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The appearance of the ascending aorta is consistent with a normal tube graft. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. A mobile density is seen in the distal aortic arch consistent with an intimal flap/aortic dissection. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. 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. Physiologic mitral regurgitation is seen (within normal limits). There is a large pericardial effusion. The effusion appears to have the consistency of blood. There are no echocardiographic signs of tamponade. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. Brief Hospital Course: Mr. [Known lastname 3311] was admitted to the [Hospital1 18] on [2134-4-3] for emergency surgery for tamponade. He was taken to the operating room where evacuation of clot and hemostasis was achieved. Postoperatively he was taken to the intensive care unit for monitoring. He remained intubated and sedated overnight with tight blood pressure control. On postoperative day one, he was allowed to wake and was extubated. The endocrinology service was consulted for elevated catecholamines in his urine. Pheochromocytoma was very unlikely given no adrenal lesions on ultrasound. His blood pressure will be watched as an outpatient and further worked-up will be performed if his blood pressure becomes unmanageable. Later on postoperative day two, he was transferred to the step down unit for further recovery. He worked with physical therapy daily. He continued to make steady progress and was discharged to his home on [2134-3-11]. He will follow-up with Dr. [First Name (STitle) ] and his primary care physician as an outpatient. As he currently does not have a cardiologist, an appointment has been made for him to follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] as an outpatient. Medications on Admission: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). [Hospital1 ]:6 Disk with Device(s) Refills:2 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every [Hospital1 2974]). [Hospital1 ]:4 Patch Weekly(s) Refills:2 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 weeks: take 2 tablet twice daily for two weeks, then one tablet twice daily for two weeks, then stop medicine. [Hospital1 ]:112 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for PAIN for 4 weeks. [Hospital1 ]:60 Tablet(s) Refills:0 7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed for SORE THROAT. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for TEMP/PAIN. 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. [Hospital1 ]:30 Tablet(s) Refills:0 10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. [Hospital1 ]:30 Tablet(s) Refills:2 11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). [Hospital1 ]:135 Tablet(s) Refills:2 12. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a day. [Hospital1 ]:120 Tablet(s) Refills:2 13. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 1 weeks. [Hospital1 ]:28 Capsule(s) Refills:0 Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]: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). [Hospital1 ]:90 Tablet, Delayed Release (E.C.)(s) Refills:4 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. [Hospital1 ]:60 Capsule(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. [Hospital1 ]:50 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Hospital1 ]:60 Tablet(s) Refills:2 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1 Inhalation Disk with Device Inhalation [Hospital1 ] (2 times a day) for 1 months. [Hospital1 ]:1 Disk with Device(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 months: Take for 1 month and then per primary care physician. [Name Initial (NameIs) ]:30 Tablet(s) Refills:0 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every [Name Initial (NameIs) 2974]). [Name Initial (NameIs) ]:4 Patch Weekly(s) Refills:2 10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. [Name Initial (NameIs) ]:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 932] VNA Discharge Diagnosis: Tamponade s/p repair of Type A Aortic Dissection [2134-3-21] ascending aortic dissection hypertension h/o prostate cancer s/p knee surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Monitor your blood pressure at home daily, If systolic blood pressure (Top number) is greater then 140mmHg, please call you primary care physician. [Name10 (NameIs) 357] call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon Dr. [First Name (STitle) ] Phone:[Telephone/Fax (1) 170] Date/Time: [2134-5-10] 1:00PM Primary Care Dr.[Last Name (STitle) ] in [1-16] weeks Please follow-up with Cardiologist Dr. [Last Name (STitle) ] [Name (STitle) 2974] [5-7] 9:20 AM. [Telephone/Fax (1) 62] 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:[2134-4-8]	[ "E878.2", "401.9", "785.50", "998.11", "427.32", "305.01", "427.31", "V10.46", "423.3", "496" ]	icd9cm	[ [ [] ] ]	[ "39.41", "34.03" ]	icd9pcs	[ [ [] ] ]	8027, 8085	3454, 4683	311, 403	8272, 8368	1967, 3431	9075, 9654	1624, 1642		6504, 8004		8106, 8251		4709, 6481			8392, 9052									1657, 1948																						236, 273									431, 1381																		1403, 1483	1499, 1608
27,282	155,062	21862	Discharge summary	report	Admission Date: [2113-12-8] Discharge Date: [2113-12-17] Date of Birth: [2066-7-30] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: abdomenal pain Major Surgical or Invasive Procedure: open appendectomy History of Present Illness: Mr. [Known lastname 57356] is a 47-hour-old gentleman with severe diabetes mellitus, coronary artery disease, congestive heart failure and chronic renal insufficiency who presented to the emergency room with a 24-hour history of worsening abdominal pain which initially began in the lower abdomen, progressing subsequently to the right lower quadrant, followed by becoming more diffuse in nature. Although he has not been febrile, he had been experiencing some chills. On exam initially, he was noted to have significant abdominal tenderness maximally in the right lower quadrant and suprapubic region. His white blood cell count was 18,000. A plain radiograph evidenced no free air consistent with a viscus perforation and we subsequently obtained a CT scan which demonstrated minimal fat stranding around a 12 mm fluid filled appendix. Based on these findings the patient was taken urgently to the operating room for planned laparoscopic appendectomy. He notably was on Coumadin for atrial fibrillation. This was managed with vitamin K as well as fresh frozen plasma in a perioperative period. Past Medical History: 1. Renal insufficiency, originally diagnosed [10/2110] (Baseline creatinine, 3.4, last checked [2113-3-21] and [2113-4-26] 2. PVD (US study [5-2]: R ABI 1.6/ L ABI 0.8) 3. Diabetes type II since age 18 4. DM Retinopathy 5. HTN 6. CAD s/p 2V CABG(SVG-OM) 7. CHF 8. Hypertension 9. Diabetes since age 18 10. Mitral commisuroplasty ([2110]) 11. Biatrial maze 12. Epicardial LV lead placement ([2110]) 13. Atrial fibrillation/flutter s/p DCCV 14. Prior occipital CVA ([2098]) 15. Hypercholesterolemia 16. Anemia: baseline Hct 24-25 from [3-1] and [4-29], receives 40K U Procrit weekly 17. Depression Social History: Denies alcohol or tobacco. Lives at home with his wife. [Name (NI) 1403] at digital copy store. Family History: NC. Mother died of cancer in her 80s. Physical Exam: Afebrile, VSS gen: NAD CV: + s1s2 Pulm: decreased bibasilar BS ABd: obese, mildly distended, incision c/d/i EXt: no c/c/e Pertinent Results: [2113-12-16] 05:30AM BLOOD WBC-10.1 RBC-2.72* Hgb-7.9* Hct-25.1* MCV-92 MCH-28.9 MCHC-31.4 RDW-19.2* Plt Ct-455* [2113-12-8] 07:47AM BLOOD WBC-17.4# RBC-3.52 Hgb-10.3* Hct-33.3* MCV-95# MCH-29.2 MCHC-30.9* RDW-19.0* Plt Ct-454* [2113-12-16] 05:30AM BLOOD PT-17.1* PTT-38.0* INR(PT)-1.5* [2113-12-16] 05:30AM BLOOD Glucose-82 UreaN-51* Creat-6.2# Na-142 K-4.1 Cl-105 HCO3-24 AnGap-17 [2113-12-13] 09:15AM BLOOD Glucose-85 UreaN-101 Creat-9.0* Na-138 K-4.8 Cl-103 HCO3-15* AnGap-25* [2113-12-8] 07:47AM BLOOD Glucose-125* UreaN-63* Creat-4.8# Na-140 K-4.9 Cl-110 HCO3-14* AnGap-21* [2113-12-13] 09:00PM BLOOD CK(CPK)-65 [2113-12-13] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.13* [2113-12-16] 05:30AM BLOOD Calcium-8.0* Phos-4.8* Mg-1.9 [2113-12-13] 02:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2113-12-13] 02:45PM BLOOD calTIBC-230* Ferritn-213 TRF-177* [2113-12-10] 02:12PM BLOOD PTH-242* [2113-12-13] 02:45PM BLOOD PSA-0.9 [2113-12-13] 09:15AM BLOOD Digoxin-1.5 [2113-12-13] 02:45PM BLOOD HCV Ab-NEGATIVE [12-8]: 1. Thickened inflamed appendix with appendicolith at the tip. No findings to suggest complication, and the cecum is normal in appearance. 2. Reticular and ground-glass opacities in both lung bases, which may be sequela of chronic fluid overload. Brief Hospital Course: THe patient was taken to the operating room for an open appendectomy; for details please see operative note. THe patient required vit K, FFP, bicarbonateand ICU monitoring initially; he remained intubated in the ICU immediately postoperatively. The patient's fluid status was closely monitored, as well as his electrolytes and hematcrit. The patient was evaluated by the nephrology in addition, who made daily recommendations for medication and general management. The patient was restarted on home medications when appropriate. During his stay, his renal function worsened, and the patient required dialysis. A tunnelled line was placed, and the patient was evaluated for fistula placement. On discharge, the patient was sent for out patient rehab, and was instructed to follow up with nephrology. From a cardiovascular standpoint, the patient was put on a beta blocker as well as digoxin. When appropriate, the patient was restarted on coumadin, and dosed accordingly. He later received aspirin, zocor, hydralazine PRN. Hematocrits were monitored serially as well. The patient's respiratory status was satisfactory following extubation, but received PRN nebs. The patient was put on Zosyn during his stay, and monitored for signs of hemodynamic instability, sepsis and abscess. The patient initially had an NGT, which was removed without any further issues. His diet was advanced once the patient's bowel function began returning, and the patient tolerated it well. He was put on an H2 blocker, sliding scale and heparin SC for prophylaxis. The patient was also evaluated and treated by PT and OT, and evaluated for possible rehab, for which he was not a candidate. The patient was discharged home in stable condition, tolerating diet, ambulating without assistance, voiding, passing gas and having bowel movements, with pain well controlled. Medications on Admission: dig 0.125, toprol XL 100, lisinopril 10, atenolol, vytorin [10/2086], lasix 20, asa 81, allopurinol 100, procrit, keflex, Fe 325, coumadin 5mg, colchicine 0.06, Lantus 40 Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) for 3 days. Disp:3 Tablet(s) Refills:1 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 10. Outpatient [Name (NI) ] Work PT/PTT/INR Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: perforated appendecitis acute renal failure Discharge Condition: stable Discharge Instructions: Incision Care: Keep clean and dry. -You may wash surgical incisions, but no showering (sponge baths). -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. * Continue to ambulate several times per day. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in [1-24] weeks (next Thursday); call ([Telephone/Fax (1) 2537] to make an appointment. Please follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 6457] at [Telephone/Fax (1) 7318] regarding your INR and coumadin dosing on Monday (they open at 8am on Monday, and we have left a message with their answering service); you must have your PT/PTT/INR drawn at that time. Please follow up with nephrology at [Telephone/Fax (1) 60]. You have an appointment with Dr. [First Name (STitle) 2105] [Name (STitle) 2106], MD on [2114-1-1] at 3:30; call [Telephone/Fax (1) 673] for further information or changes.	[ "285.21", "V45.81", "540.0", "414.00", "427.31", "276.3", "780.09", "585.5", "403.91", "276.2", "V64.41", "584.9" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.07", "38.95", "47.09" ]	icd9pcs	[ [ [] ] ]	6823, 6881	3831, 5694	330, 350	6969, 6978	2465, 3808	8341, 9061	2269, 2308		5920, 6800		6902, 6948		5720, 5897			7002, 7002							7018, 8318		2323, 2446																						276, 292									378, 1480																		1502, 2135	2151, 2253
57,288	133,596	3735	Discharge summary	report	Admission Date: [2167-9-10] Discharge Date: [2167-9-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4588] Chief Complaint: congestive heart failure exacerbation Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [Age over 90 ]M with a medical history of systolic heart failure (EF 30%), complete heart block s/sp PPM, chronic renal insufficiency (basline cr 1.5-1.8) presents with worsening lower extremity edema and confusion. Recently discharged on [2167-8-14] for acute on chronic systolic heart failure. Was back to baseline mental status at home (oriented at baseline although occasionally forgets location) on PO lasix regimen maintaining weight of 159. Then over the past week started to gain weight, become progressively more short of breath at rest, not sleeping much [3-10] to shortness of breath and becoming progressively more confused. Lasix has been uptitrated from 60/40AM/PM to 120BID. Had been on beta blocker but that has been held likely due to asymptomatic bradycardia. ROS notable for orthopnea. [Doctor First Name ] chest pressure, fever. . He was recently admitted in early [Month (only) 205] with progressive SOB, malaise, confusion and worsening LE edema. At that time he was initially on a lasix gtt on the floor but required ICU transfer for worsening mental status thought [3-10] hypercarbia, requiring BIPAP for <12 hours. . In the ED, initial vs were: 97.3 35 129/67 33 92. She initially triggered for bradycardia (30s) but EKG showed paced rhythm, rate of 60. Labs notable for creatinine of 2.5, troponin of 0.13, BNP of [Numeric Identifier 16837] (last admission [Numeric Identifier 2686]). ABG: 7.38/64/77/39. UA and culture drawn. He was given lasix 80mg IV. Started on CPAP with possible improvement in mental status. 1 18G for access. Vitals on transfer: 58 127/60 30 100% CPAP. . On the MICU, patient taken off CPAP and placed on 2L NC. No complaints. Put out 500cc in 2hrs to 80IV lasix given in ED. . He was transferred to the floor after 1 night. While he looked ill in the MICU that morning, he improved greatly throughout the day, receiving another 80mg IV lasix with good UO, and per the MICU team lookedlike a whole new person. Cr improved to 2.2 from 2.5 with diuresis. Past Medical History: Past Medical History: - DM - HL - CRI - Complete heart block s/p [Company 1543] Kappa dual chamber pacer placed in [2154] - CHF, EF ~ 15%, ECHO 2 mo ago; improved to 25% after diuresis Social History: Lives with wife in CT. Active, independent in ADLs up until 1mo ago. - Tobacco: distant - Alcohol: denies - Illicits: denies Family History: Non-contributory Physical Exam: Vitals: 119/49 75 26 98%2LNC General: Caucasian male, 1 sentence dyspnea [Year (4 digits) 4459]: Sclera anicteric, MMM, oropharynx clear Neck: JVP to jawline at 30 degrees, no LAD Lungs: tachypnia, decreased breath sounds at bases CV: S1, S2 regular rhythm, normal rate, III/VI SM apex Abdomen: soft, non-tender, non-distended Ext: warm, 3+ edema to knees b/l. NEURO: oriented to self, birthdate, DOW M-Th, MAE antigravity Pertinent Results: Labs on Admission [2167-9-10] 06:25PM BLOOD WBC-8.3 RBC-3.80* Hgb-11.2* Hct-35.7* MCV-94 MCH-29.5 MCHC-31.4 RDW-15.0 Plt Ct-162 [2167-9-10] 06:25PM BLOOD Neuts-78.8* Lymphs-13.7* Monos-6.0 Eos-0.9 Baso-0.6 [2167-9-10] 06:25PM BLOOD PT-14.4* PTT-28.7 INR(PT)-1.3* [2167-9-10] 06:25PM BLOOD Glucose-248* UreaN-86* Creat-2.5* Na-138 K-4.8 Cl-93* HCO3-33* AnGap-17 [2167-9-10] 06:25PM BLOOD CK(CPK)-69 [2167-9-10] 06:25PM BLOOD CK-MB-6 cTropnT-0.13* proBNP-[Numeric Identifier 16837]* [2167-9-10] 11:24PM BLOOD Calcium-9.2 Phos-5.0# Mg-2.7 [2167-9-12] 06:41AM BLOOD VitB12-1858* [2167-9-10] 06:25PM BLOOD Type-ART pO2-77* pCO2-64* pH-7.38 calTCO2-39* Base XS-9 Intubat-NOT INTUBA [2167-9-10] 06:31PM BLOOD Glucose-227* Lactate-2.2* Na-139 K-5.4* Cl-89* [2167-9-13] 10:53AM URINE RBC-21-50* WBC->50 Bacteri-FEW Yeast-NONE Epi-0-2 Other Key Labs [2167-9-15] 06:40AM BLOOD Glucose-139* UreaN-72* Creat-2.1* Na-145 K-4.0 Cl-94* HCO3-43* AnGap-12 [2167-9-14] 06:00AM BLOOD Glucose-95 UreaN-72* Creat-2.1* Na-144 K-4.4 Cl-93* HCO3-44* AnGap-11 [2167-9-13] 08:53AM BLOOD Glucose-171* UreaN-68* Creat-2.0* Na-146* K-3.3 Cl-94* HCO3-45* AnGap-10 [2167-9-14] 06:00AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 [2167-9-13] 08:53AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1 [2167-9-13] 07:12AM BLOOD pO2-63* pCO2-66* pH-7.45 calTCO2-47* Base XS-17 [2167-9-13] 05:07AM BLOOD Type-ART pO2-100 pCO2-71* pH-7.44 calTCO2-50* Base XS-19 [2167-9-13] 04:06AM BLOOD Type-ART pO2-49* pCO2-65* pH-7.47* calTCO2-49* Base XS-19 [2167-9-13] 07:12AM BLOOD Glucose-187* Lactate-1.7 Na-141 K-4.1 Cl-89* [2167-9-15] 06:40AM BLOOD WBC-12.3* RBC-3.47* Hgb-9.9* Hct-32.7* MCV-94 MCH-28.6 MCHC-30.4* RDW-15.0 Plt Ct-189 [2167-9-14] 06:00AM BLOOD WBC-22.7* RBC-3.39* Hgb-10.1* Hct-31.5* MCV-93 MCH-29.7 MCHC-31.9 RDW-14.8 Plt Ct-163 [2167-9-13] 08:53AM BLOOD WBC-34.6# RBC-3.41 Hgb-10.2* Hct-32.3* MCV-95 MCH-30.0 MCHC-31.7 RDW-15.0 Plt Ct-183 Microbiology: Blood cultures from [9-12] and [9-13]: still pending at time of discharge Ucx from [9-10]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. ucx from [9-13]: <10,000 organisms/ml Imaging: CXR [9-10]: Lung volumes are low. Cardiomegaly is stable. Mediastinal contours are also stable. There are bilateral pleural effusions as well as pulmonary edema and bibasilar opacities, which are nonspecific, though likely atelectatic. CXR [9-13]: no interval change Echo [9-11]:The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with mid to distal left ventricular near akinesis. There is an apical left ventricular aneurysm. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is moderately dilated with mild global hypokinesis. 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 to moderate ([2-7]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Brief Hospital Course: [Age over 90 ]M with a medical history of systolic heart failure (EF 30%), complete heart block s/sp PPM, chronic renal insufficiency (basline cr 1.5-1.8) presents with acute on chronic systolic heart failure and acute on chronic renal failure. # ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: The patient was admitted to the MICU (given need for BiPAP in ED) with clinical, lab (elevated BNP compared to prior), and radiographic evidence of volume overload consistent with decompensated heart failure. He diuresed well with IV lasix boluses and was transferred to the floor given improved respiratory and mental status. His lasix was increased to 120mg PO BID. Of note he can be given IV lasix if he refuses his PO lasix while his acute CHF is continuing to resolve. Please note that we would recommend starting a low dose of carvedilol (suggest 6.25mg daily) once his current episode of acute CHF resolves. # ALTERED MENTAL STATUS: waxing and [Doctor Last Name 688] mental status with reduced orientation and inattention consistent with delirium. Brief episodes of mild agitation including concerns that hospital staff were not acting in his best interests and holding him against his will. Given small doses of prn haldol and olanzapine. Possible etiologies include renal failure, decomensated CHF, or hypercarbia (although blood gas not significantly different from prior). Impaired sleep wake cycle may have contributed as the patient had not been sleeping well the past several nights due to respiratory distress. Possible contribution from potential UTI although cultures. # LEUKOCYTOSIS: Elevated WBC without fevers spiking to WBC ~34 in the three days after pt ripped out his foley. Unclear if inflammatory response vs transient infection but patient remained afebrile with stable hemodynamics and no diarrhea. Started on vanc/cefepime which were stopped prior to discharge. Leukocytosis resolved by time of discharge and patient remained afebrile. # ACUTE ON CHRONIC RENAL FAILURE: Patient with baseline creatinine of 1.5 to 1.8 with creatinine of 2.5 on admission. Urine with hyaline casts suggesting pre-renal failure likely secondary to decompensated CHF. He was diuresed with lasix and his renal function improved. # DIABETES: Held oral hypoglycemic was held on admission and his sugars were well controlled on an ISS. His oral hypoglycemic was restarted on discharge. # Hypernatremia: Briefly hypernatremic to 149 likely [3-10] free water deficit. Resolved. #Code: Please note that this patient was made DNR/DNI while in house. Medications on Admission: - aspirin 81mg daily - glimepiride 2mg daily - furosemide 60mg QAM and 40mg QHS - metoprolol succinate 25mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO twice a day. 3. Ramipril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 6. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection twice a day for 2 days: Please only give IV Lasix if patient is refusing his PO lasix. Only give through [2167-9-17]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: PRIMARY: CHF, systolic, acute on chronic Acute on chronic renal failure Leukocytosis SECONDARY: DM Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [Known lastname 16832], You were admitted to the hospital because of increasing shortness of breath, leg swelling, and confusion. While in the hospital, you initially managed in the ICU with diuretics. You did well there, and were subsequently sent to the general medical floor. Your breathing continued to improve. We had a urinary catheter in your bladder to measure your urine output, but you pulled this out one of the nights. This caused some trauma to your urethra and some blood loss. It was subsequently removed and you did not have any urinary issues after. Finally, you had a bit of agitation which we managed with agitation medications. You seemed to improve from this as well. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Geriatrics at rehab Restarting Beta blockers once CHF stable	[ "785.51", "V45.01", "780.09", "272.4", "995.91", "403.90", "585.9", "038.9", "780.97", "276.0", "428.23", "518.81", "584.9", "428.0", "250.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10302, 10368	6998, 7917	300, 306	10512, 10512	3249, 6975	11518, 11581	2765, 2783		9720, 10279		10389, 10491		9582, 9697			10697, 11495									2798, 3230																						223, 262									334, 2389								10527, 10673										2433, 2606	2622, 2749
50,104	114,065	22284	Discharge summary	report	Admission Date: [2150-2-18] Discharge Date: [2150-2-23] Date of Birth: [2078-3-20] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 165] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [2150-2-18] Emergency coronary artery bypass graft x4: Left internal mammary artery to left anterior ascending artery, and saphenous vein grafts to posterior descending artery and a sequential saphenous vein graft to obtuse marginal and diagonal arteries. Endoscopic harvesting of the long saphenous vein. History of Present Illness: Ms. [Known lastname 58066] is a 71 year old woman who was admitted to [Hospital ] Hospital with chest pain radiating down her left arm for 30-45 days occurring with exertion. A subsequent cardiac catheterization revealed coronary artery disease with 95% left main stenosis. She therefore was transferred to [Hospital1 771] for emergent surgery. Past Medical History: Hypertension Elevated Cholesterol Peripheral vascular disease s/p Bilateral Carotid endarectomy with restenosis Diabetes Mellitus type 2 Cataracts bilateral Pneumonia Social History: [Hospital 8735] home health aide Tobacco denies ETOH denies Lives with spouse Family History: Father deceased at 60 from myocardial infarction uncles and aunts with heart disease unsure of details Physical Exam: General No acute distress, pleasant, well nourished Skin Right groin with rash no raised - yeast HEENT PERRLA, EOMI Neck supple full ROM no lymphadenopathy Chest Clear to auscultation bilateral Heart regular no murmur/rub/gallop Abdomen soft, nontender, obese, + bowel sounds no palpable masses Extremities warm well perfused no edema Varcosites superficial bilateral Neuro grossly intact, uses cane for ambulation due to arthritis Pulses palpable Carotids + bruit bilateral Pertinent Results: [2150-2-22] 04:08AM BLOOD WBC-10.8 RBC-3.50* Hgb-9.8* Hct-27.9* MCV-80* MCH-28.0 MCHC-35.1* RDW-15.6* Plt Ct-211 [2150-2-18] 11:25AM BLOOD WBC-7.7 RBC-3.84* Hgb-10.2* Hct-29.3* MCV-76* MCH-26.5* MCHC-34.7 RDW-15.0 Plt Ct-279 [2150-2-22] 04:08AM BLOOD Plt Ct-211 [2150-2-20] 01:36AM BLOOD PT-15.2* PTT-27.6 INR(PT)-1.3* [2150-2-18] 11:25AM BLOOD Plt Ct-279 [2150-2-18] 11:25AM BLOOD PT-14.5* PTT-23.7 INR(PT)-1.3* [2150-2-18] 06:15PM BLOOD Fibrino-263 [2150-2-23] 04:50AM BLOOD UreaN-46* Creat-1.6* K-4.2 [2150-2-20] 01:36AM BLOOD Glucose-169* UreaN-47* Creat-2.4* Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 [2150-2-18] 11:25AM BLOOD Glucose-159* UreaN-59* Creat-2.0# Na-138 K-4.3 Cl-103 HCO3-28 AnGap-11 [2150-2-18] 11:25AM BLOOD ALT-17 AST-21 LD(LDH)-254 CK(CPK)-203* AlkPhos-117 Amylase-34 TotBili-0.3 [2150-2-18] 11:25AM BLOOD Lipase-17 [2150-2-18] 11:25AM BLOOD CK-MB-5 cTropnT-0.01 [2150-2-23] 04:50AM BLOOD Mg-2.7* [2150-2-18] 11:25AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.9# Mg-2.3 [2150-2-18] 11:21AM BLOOD %HbA1c-7.8* [2150-2-18] 11:25AM BLOOD TSH-2.6 [Known lastname ],[Known firstname ] L [Medical Record Number 58067] F 71 [2078-3-20] Radiology Report CHEST (PA & LAT) Study Date of [2150-2-22] 9:22 AM [Last Name (LF) ],[First Name3 (LF) ] CSURG FA6A [2150-2-22] 9:22 AM CHEST (PA & LAT) Clip # [Clip Number (Radiology) 58068] Reason: r/o inf, eff [Hospital 93] MEDICAL CONDITION: 71 year old woman with cabg REASON FOR THIS EXAMINATION: r/o inf, eff Final Report CHEST RADIOGRAPH INDICATION: Status post CABG. COMPARISON: [2150-2-20]. FINDINGS: As compared to the previous radiograph, there is no relevant change. Sternal wires after CABG. Moderate cardiomegaly with signs of mild overhydration. Subtle increase in interstitial markings, best seen in the lateral aspects on the frontal projection. A retrocardiac atelectasis causes mild consolidations on the lateral radiograph and air bronchograms and an opacity on the frontal radiograph cleared. There is no evidence of newly occurred focal parenchymal opacities. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: SUN [2150-2-22] 1:25 PM [Known lastname ],[Known firstname ] L [Medical Record Number 58067] F 71 [2078-3-20] Cardiology Report ECG Study Date of [2150-2-18] 9:16:10 PM Normal sinus rhythm. Q waves in leads III and aVF. Decreased R wave in leads V1-V4 with ST-T wave changes in leads V1-V6. Compared to the previous tracing of [2150-2-18] inferior infarction of undetermined age persists. The ST-T wave changes in the precordial leads are similar to those seen previously. Clinical correlation is suggested. Read by: [Last Name (LF) ],[First Name3 (LF) 125] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 [Telephone/Fax (3) 58069]/427 52 -5 15 Brief Hospital Course: Admitted to intensive care unit for preoperative workup which revealed creatinine 2.0, and was taken to the operating room. She underwent coronary artery bypass graft surgery, see operative report for further details. She received vancomycin for perioperative antibiotics. She was transfered to the intensive care unit for hemodynamic monitoring. She was somulent, which delayed extubation until post operative day two, however there was no neurological deficits. She continued to progress and was ready to transfer to the floor later on post operative day two. Physical therapy worked with her on strength and mobility. She was diuresised however her creatinine was monitored closely which peaked on [2-20] to 2.4 from baseline 2.0 prior to surgery. It has since decreased and remains at 1.6. She was ready for discharge to rehab on post operative day five. Sternal incision with steri strips no erythema no drainage mammary support on Left endovascular harvest sites no drainage no erythema Edema +2 bilateral lower extremities preop weight 104 kg discharge weight 112 kg Medications on Admission: levothyroxine 75 mcgm daily lasix 40mg [Hospital1 ] zocor 40mg daily amlodipine/benazepril 5/20mg daily gabapentin 300mg [Hospital1 ] ASA 325 mg daily protonix 40mg daily coreg 25mg daily lantus 68 units HS Humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Combivent 18-103 mcg/Actuation Aerosol Sig: 2-4 puffs Inhalation four times a day. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: alternate with ultram. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: alternate with percocet . 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: . 12. Insulin Glargine 100 unit/mL Solution Sig: Sixty Eight (68) units units Subcutaneous at bedtime. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. sliding scale insulin Bedtime Glargine 68 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-65 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 66-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-130 mg/dL 2 Units 2 Units 2 Units 0 Units 131-150 mg/dL 4 Units 4 Units 4 Units 0 Units 151-180 mg/dL 6 Units 6 Units 6 Units 2 Units 181-210 mg/dL 8 Units 8 Units 8 Units 4 Units 211-240 mg/dL 10 Units 10 Units 10 Units 6 Units 241-280 mg/dL 12 Units 12 Units 12 Units 8 Units Discharge Disposition: Extended Care Facility: [Location (un) 29789] Country Manor - [Location (un) 29789] Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Elevated cholesterol Peripheral vascular disease Diabetes Mellitus type 2 Carotid stenosis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Dr [Last Name (STitle) ] (you will see dr [Last Name (STitle) ] instead of Dr [First Name (STitle) ] in [1-27] weeks at the [Hospital1 ] Heart Center ([Telephone/Fax (2) 6256]) Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37063] after discharge from rehab ([Telephone/Fax (1) 37064]) Dr [First Name8 (NamePattern2) 3924] [Last Name (NamePattern1) 20222] after discharge from rehab ([Telephone/Fax (1) 6256]) [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2150-2-23]	[ "403.90", "250.00", "585.9", "440.20", "433.10", "278.00", "414.01", "366.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "39.61", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]	8326, 8420	4903, 5991	311, 623	8601, 8608	1931, 3403	9119, 9748	1316, 1420		6278, 8303	3443, 3471	8441, 8580		6017, 6255			8632, 9096									1435, 1912																						261, 273	3503, 4880								651, 1011																		1033, 1201	1217, 1300
10,729	132,679	19539+57062	Discharge summary	report+addendum	Admission Date: [2201-5-24] Discharge Date: [2201-6-1] Date of Birth: [2128-7-8] Sex: F Service: CSU ADMISSION DIAGNOSES: 1. Aortic stenosis. 2. Mitral stenosis. 3. Diabetes mellitus. 4. Congestive heart failure. 5. Coronary artery disease - status post angioplasty and stenting of RCA. 6. Gastroesophageal reflux disease. 7. Gout. 8. Rheumatic fever. 9. Psoriasis. 10. Status post hysterectomy. 11. Status post C-section x2. 12. History of GI bleed (secondary to Plavix). DISCHARGE DIAGNOSES: 1. Aortic stenosis - status post aortic valve replacement with 21 mm Magna CE pericardial valve. 2. Mitral stenosis - status post mitral valve replacement with 25 mm Mosaic porcine valve. 3. Pleural effusion. 4. Diabetes mellitus. 5. Congestive heart failure. 6. Coronary artery disease - status post angioplasty and stenting of RCA. 7. Gastroesophageal reflux disease. 8. Gout. 9. Rheumatic fever. 10. Psoriasis. 11. Status post hysterectomy. 12. Status post C-section x2. 13. History of GI bleed (secondary to Plavix). ADMISSION HISTORY AND PHYSICAL: Ms. [Known lastname ] is a 72 year old woman with history of aortic stenosis and mitral stenosis secondary to history of rheumatic fever who was admitted electively preop for a valve replacement. Preoperatively, her aortic valve area was 1.07 and her mitral valve area was 0.88. She had been hospitalized 3 weeks prior to admission with an episode of congestive heart failure which had required her to be intubated, but had recovered from this episode. When she presented preoperatively, she was afebrile with a pulse in the 70s, blood pressure 140s and her O2 saturation was 98% on room air. She was not in any distress. She had a few psoriatic plaques over her joints, but otherwise she had no ecchymosis. She was not jaundiced. Her lungs were clear bilaterally. Her heart was regular. She had a 3/6 systolic ejection murmur. Her abdomen was otherwise soft and obese, but nontender. She had 2+ bilateral lower extremity edema and slight erythema of the lower extremities, but she was certain it was not secondary to any cellulitis as she said it had been longstanding and unchanged. Her preoperative labs included a white blood cell count of 8.6 with a hematocrit of 33. Her preoperative BUN and creatinine were 39 and 1.0. HOSPITAL COURSE: As noted, the patient was admitted on [2201-5-24] and subsequently taken to the operating room on [2201-5-25] where she underwent an aortic valve replacement with a 21 mm Magna Supraannular CE pericardial valve and a mitral valve replacement with a 25 mm Mosaic porcine valve. Cardiopulmonary bypass time was 147 minutes and cross clamp time was 122 minutes. The patient tolerated the procedure well and was taken immediately postoperatively to the Cardiac Surgery intensive care unit. She was extubated on postoperative day 0 and did quite well on the remainder of her hospitalization. We began aggressive diuresis on postoperative day 1 and we were able to remove the chest tubes by postoperative day 3. Physical therapy saw her throughout the course of her hospitalization for active rehabilitation. Interestingly, intraoperatively, it was noted that there was what appeared to be possibly purulent material around the aortic valve when it was excised and fluid from this was sent for gram stain. The gram stain evidenced no microorganisms, but nonetheless, we consulted the Infectious Disease service for a question of perivalvular abscess. Blood cultures were drawn and the patient was started empirically on broad-spectrum antibiotics. She never became febrile and her white count remained normal. After her cultures had come negative, it was felt that this was not secondary to any sort of infectious process and therefore antibiotics were stopped. By postoperative day 5, the patient was doing quite well with physical therapy. She was afebrile and otherwise hemodynamically normal and her remaining hospitalization focused on diuresis. By postoperative day 7, the patient was afebrile with a pulse that ranged between the 70s to 90s with a blood pressure in the 150s. She was saturating 99% on 2 liters nasal cannula. Her lungs had decreased breath sounds at the bases bilaterally with a few crackles, but she was otherwise regular. Her incision was clean and her sternum was stable. Her extremities had 2+ edema. It was felt that as she was doing well that she could be discharged to rehabilitation in stable condition. Prior to her discharge, her white blood cell count was 14 with a hematocrit of 33. The platelet count was 424. Her BUN and creatinine were 15 and 0.7. Chest x-ray showed the presence of bilateral effusions for which she was being diuresed with Lasix. DISCHARGE MEDICATIONS: Colace p.r.n., aspirin 81 mg p.o. once daily, Tylenol p.r.n., Percocet as needed for pain, Milk of Magnesia p.r.n., Lipitor 40 mg once daily, glyburide 2.5 mg p.o. once daily, colchicine 0.5 mg p.o. once daily, Lopressor 50 mg p.o. b.i.d., Protonix 40 mg p.o. once daily, captopril 6.25 mg p.o. t.i.d., Lasix 80 mg p.o. b.i.d. and potassium chloride 20 mEq p.o. b.i.d. [Last Name (STitle) 53004]harge weight was 101.8 kg. Her preoperative weight was 97.8 kg. She is to follow up with Dr. [Last Name (Prefixes) ] in his office in 4 weeks and to follow up with primary care physician within the week. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Doctor Last Name 3763] MEDQUIST36 D: [2201-6-1] 12:48:08 T: [2201-6-1] 13:48:46 Job#: [Job Number 53005] Name: [Known lastname ], [Known firstname 9854] Unit No: [Numeric Identifier 9855] Admission Date: [2201-5-24] Discharge Date: [2201-6-4] Date of Birth: [2128-7-8] Sex: F Service: CSU Patient was originally planned to go to a rehabilitation facility on [2201-6-1]. On that morning, she experienced an episode of atrial fibrillation with rapid ventricular response and hypotension. Initially, attempts were made to manage her medically with beta-blockade and amiodarone. This was unsuccessful, and she continued to remain hypotensive. She was therefore taken to the electrophysiology lab, and underwent d-c cardioversion with 200 joules x1. She converted back into sinus rhythm and remained hospitalized for 2 days subsequently to the cardioversion, for monitoring, and diuresis. She had 1-short run of atrial fibrillation on the day after cardioversion, but returned spontaneously to sinus rhythm. She was started on amiodarone 400 mg t.i.d. and with subsequent taper as listed in her discharge medications. Her beta-blockade was switched to atenolol 75 mg once a day, and she had a short course of aggressive diuresis with IV Lasix. She was ready for discharge to rehab in stable condition on [2201-6-4] with the following changes in her medication: Lopressor was discontinued. She was started on atenolol 75 mg once a day, amiodarone 400 mg p.o. t.i.d. for 7 days, followed by 400 mg p.o. b.i.d. for 7 days, followed by 400 mg once a day for 7 days, and then 200 mg once a day ongoing. She was to continue Lasix 80 mg IV b.i.d. for 3 days, followed by Lasix 80 mg p.o. b.i.d. standing. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 3125] Dictated By:[Doctor Last Name 3498] MEDQUIST36 D: [2201-6-4] 09:44:00 T: [2201-6-4] 09:58:48 Job#: [Job Number 9856]	[ "997.1", "274.9", "398.91", "V45.82", "530.81", "401.9", "427.31", "E878.1", "396.0", "696.1", "250.00", "414.01" ]	icd9cm	[ [ [] ] ]	[ "99.04", "34.04", "39.61", "39.64", "99.61", "35.21", "89.68", "35.23" ]	icd9pcs	[ [ [] ] ]								547, 2363	4795, 7553					2381, 4771																					155, 526
22,366	112,996	25626	Discharge summary	report	Admission Date: [2182-7-4] Discharge Date: [2182-7-9] Date of Birth: [2144-1-6] Sex: M Service: CARDIOTHORACIC Allergies: Wellbutrin Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->PDA) [2182-7-5] History of Present Illness: 38 y/o male w/ significant cardiac risk factors and history who presented to OSH w/ 3 weeks of chest pain. Pt. was ruled in w/ enzymes and had Cath on [2182-7-2] which revealed severe 3 vessel disease. Medically managed and then transferred to [Hospital1 18] on [7-4]. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction 8 yrs ago w/ PCI/Stenting to LAD Hypertension Hypercholesterolemia Social History: Married w/ 4 children +Tobacco x 17 yrs- 1/2ppd Occ. ETOH, -IVDA Family History: Father alive, MI at age 36, Uncles x 4 w/ MI's (all deceased at age 50-60's) Physical Exam: VS: 98.4 51 121/72 20 99%RA General: NAD, awake, alert, comfortable HEENT: NC/AT, PERRLA, EOMI, O/P clear Neck: Supple, -LAD, -thyromegaly, -carotid bruits Lungs: CTAB, -w/r/r Heart: RRR, poss. diastolic blowing murmur w/ SEM @ LUSB Abd: Soft, NT/ND +BS Ext: Trace Edema -c/c, DP [12-9]+ Neuro: 5/5 Strength, sensation intact throughout Pertinent Results: [2182-7-4] 07:52PM BLOOD WBC-9.0 RBC-5.38 Hgb-15.6 Hct-44.4 MCV-82 MCH-29.1 MCHC-35.3* RDW-13.2 Plt Ct-171 [2182-7-7] 06:22AM BLOOD WBC-10.8 RBC-4.10* Hgb-12.0* Hct-34.0* MCV-83 MCH-29.3 MCHC-35.2* RDW-13.1 Plt Ct-124* [2182-7-9] 06:25AM BLOOD Hct-32.2* [2182-7-4] 07:52PM BLOOD PT-13.6* PTT-26.9 INR(PT)-1.2 [2182-7-6] 04:11AM BLOOD PT-14.3* PTT-28.4 INR(PT)-1.4 [2182-7-4] 07:52PM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-139 K-4.5 Cl-101 HCO3-31 AnGap-12 [2182-7-7] 06:22AM BLOOD Glucose-131* UreaN-14 Creat-0.7 Na-135 K-4.4 Cl-99 HCO3-28 AnGap-12 [2182-7-9] 06:25AM BLOOD K-3.8 [2182-7-4] 07:50PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2182-7-4] 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, pt was admitted on [7-4], and consented to surgery. On HD #2 pt was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see op note for surgical details. Pt. tolerated the procedure well with no complications and was transferred to the csru in stable condition only on a Propofol gtt. Later on op day pt was weaned from mechanical ventilation and Propofol and was extubated. He was awake, alert, MAE and following commands. On POD #1 was only on a Insulin gtt, his Swan-Ganz catheter was removed and he was doing well and transferred to telemetry floor. Diuretics and B-blockers were initiated per protocol. On POD #2 both his chest tubes and Foley catheter were removed. On POD #3 his epicardial pacing wire were removed. Pt. appeared to be recovering well with no complications and physical exam was unremarkable. Pt was ambulating well with PT and at level 5 by POD #4. His labs were stable and he was discharged home with the appropriated f/u appointments. Medications on Admission: 1. Crestor 10mg qd 2. Toprol XL 50mg qd 3. ASA 81mg qd 4. Lisinopril 10mg qd 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:50 Tablet(s) Refills:0 4. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA Care [Location (un) 511] Discharge Diagnosis: Coronary artery disease (w/ h/o Myocardial Infarcation 97 & PCI to LAD) s/p Coronray Artery Bypass Graft x 3 Hypertension Hypercholesterolemia Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powder on wounds. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 56487] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Completed by:[2182-7-24]	[ "428.0", "410.71", "401.9", "V45.82", "412", "424.0", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.12", "88.72" ]	icd9pcs	[ [ [] ] ]	4431, 4494	2180, 3211	285, 329	4681, 4687	1331, 2157	5029, 5202	877, 955		3338, 4408		4515, 4660		3237, 3315			4711, 5006									970, 1312																						235, 247									357, 639																		661, 779	795, 861
3,415	121,904	2206	Discharge summary	report	Admission Date: [2168-8-26] Discharge Date: [2168-9-1] Date of Birth: [2094-3-5] Sex: M Service: CARDIOTHORACIC ADMITTING DIAGNOSIS: Coronary artery revascularization HISTORY OF PRESENT ILLNESS: Briefly, this is a 74-year-old man who has had a history of a stent to his proximal RCA back in [2161] after noting new chest pain and a positive exercise stress test. Since then, he has been feeling fairly well until several months prior to admission when he began to notice significant dyspnea on exertion. He noticed these symptoms after walking up small hills or after several flights of stairs. Along with his shortness of breath, he occasionally noted mild chest pressure, although it was significantly less than the pain he had felt prior to his RCA stent. He also reports feeling extremely fatigued and has not been able to be nearly as active as her normally was. A nuclear stress test was done [2168-6-1]. The patient did develop chest discomfort and the ECG was notable for [Street Address(2) 11741] depressions anterolaterally. For this, he was referred to outpatient cardiac catheterization and on [2168-5-14], the patient underwent a coronary angiography that demonstrated a right dominant system with two vessel disease. Th[Last Name (STitle) 11742] was normal. The proximal LAD was normal. There was a 50% mild LAD lesion. D3 had a 90% stenosis at its origin. The medium sized septal vessel had no flow limiting disease. There was a 50% ostial left circumflex lesion and diffuse mild disease in the proximal vessel up to 30% before OM1. There was 50% ostial lesion of the RCA. The proximal RCA had diffuse mild disease up to 40% with 50% lesion. There was an 80% stenosis of the origin of the PDA. The ejection fraction was estimated at 68% and no mitral regurgitation or stenosis was noted. The patient was noted to have mild aortic stenosis. Given these findings of two vessel coronary artery disease, mild aortic stenosis with a normal ejection fraction and a non hemodynamically significant circumflex disease, the patient underwent rotational atherectomy and percutaneous transluminal coronary angioplasty of the D3 lesion and successful direct stenting of the mid LAD. He was subsequently referred to Dr. [Last Name (Prefixes) ] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Status post RCA stent 3. Mild aortic stenosis 4. Prostate cancer treated with surgery 5. Peripheral vascular disease 6. Remote thyroid surgery 7. Abdominal aortic aneurysm repair in [2166] 8. Disc surgery 9. Prostatectomy in [2164] ALLERGIES: He had no known drug allergies. ADMISSION MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Norvasc 2.5 mg p.o. q.d. 3. Imdur 60 mg p.o. q.d. 4. Mevacor 20 mg p.o. q.d. 5. Prinivil 40 mg p.o. q.d. SOCIAL HISTORY: Noncontributory PHYSICAL EXAMINATION: He was clear to auscultation with a regular rate and rhythm. Systolic ejection murmur 2 to [2-9] radiating to the neck. ABDOMEN: Soft EXTREMITIES: Well perfused with no edema. HO[Last Name (STitle) ] COURSE: The patient was admitted to the [Hospital6 1760] on [2168-8-26] where he underwent a coronary artery bypass graft x5 performed by Dr. [Last Name (Prefixes) ], assisted by Dr. [Last Name (STitle) 11743] as follows: Left internal mammary artery to LAD, saphenous vein graft to PDA with a jump graft to the RCA, saphenous vein graft to OM, saphenous vein graft to diagonal as well as a #23 pericardial aortic valve replacement. Postoperatively, the patient required Nipride and nitroglycerin in the cardiac surgery recovery unit to control his blood pressure. He also required platelets and some FFP to reverse his postoperative coagulopathy and platelets dysfunction secondary to the pump. He did well and was transferred to the floor on postoperative day #3. However, he was noted to have developed atrial fibrillation subsequent to the surgery and was begun on amiodarone. While on the amiodarone and Lopressor which was added postoperatively as well, the patient converted into a sinus bradycardia. The Lopressor was first stopped and then the amiodarone was stopped. However, the patient had a persistent sinus bradycardia in the 50s to 60s range and was asymptomatic. He was ambulating well with physical therapy and tolerating a regular diet. Given the fact that he was in a sinus rhythm without any symptoms, it was not felt that he needed further medical treatment. The patient was discharged on a regular diet. On postoperative day #6, he was afebrile with a pulse rate in the 50s and a blood pressure in the 160s/70s saturating 96%. He was clear to auscultation with a regular rate and rhythm. His sternum was stable and dry. His abdomen was soft and he had moderate lower extremity edema. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. 2. Potassium chloride 20 milliequivalents p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Protonix 40 mg p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Sliding scale insulin 7. Motrin 400 mg p.o. q6h prn 8. Captopril 25 mg p.o. t.i.d. 9. Percocet 1 to 2 p.o. q 4 to 6 hours prn 10. Serax 15 mg p.o. q hs prn DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass grafting 2. Status post coronary artery stenting and atherectomy 3. Status post abdominal aortic aneurysm repair 4. Prostate cancer, status post prostatectomy 5. Thyroid nodule removal 6. Hypertension 7. Hypercholesterolemia 8. Aortic stenosis, status post aortic valve replacement 9. Status post laminectomy [Last Name (STitle) ] DR.[Last Name (Prefixes) 413],[First Name3 (LF) 412] 02-351 Dictated By:[Name8 (MD) 4720] MEDQUIST36 D: [2168-8-30] 17:44 T: [2168-9-1] 10:36 JOB#: [Job Number 11744]	[ "997.1", "250.00", "427.89", "414.01", "401.9", "427.31", "411.1", "V45.82", "424.1" ]	icd9cm	[ [ [] ] ]	[ "36.14", "35.21", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]								5256, 5886	4901, 5235									2731, 2873																			2930, 4878																			231, 2361									167, 202									2383, 2708	2890, 2907
17,065	104,633	14897	Discharge summary	report	Admission Date: [2165-6-23] Discharge Date: [2165-6-28] Date of Birth: [2085-6-17] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1267] Chief Complaint: fear of eating / syncopal episodes Major Surgical or Invasive Procedure: none History of Present Illness: 80 yo male with known Type B dissection ([1-13]) has had a fear of food for about one month. Now presents with 2 syncopal episodes and admitted to [Hospital 1474] Hospital. CT revealed ? 7 cm thoracic aneurysm. Transferred to [Hospital1 18] for evaluation by Dr. [Last Name (STitle) ]. Had a 30# weight loss, but no abdominal pain or chest pain. He has had dysphagia with both liquids and solids. Past Medical History: Type B aortic dissection MI/CAD/2 LAD stents Afib SVT / s/p AV ablation HTN prostate Ca/XRT/ bone mets GERD elev. lipids s/p appendectomy Social History: no tobacco or ETOH Family History: lives with wife Physical Exam: 97.5 right 112/50 left 118/56 ( on esmolol) HR 82 RR 13 100% sat on 4L NC 65 kg alert and oriented x 3 NAD, PERRL no JVD, no carotid bruits CTAB RRR abd soft, NT, ND, no pulsatile mass bilat. carotids/brachials/radials/fems/pops/ 2+ bilat. DP/PT 1+ Pertinent Results: [2165-6-28] 08:30AM BLOOD WBC-6.1 RBC-3.31* Hgb-9.8* Hct-29.7* MCV-90 MCH-29.5 MCHC-32.9 RDW-23.8* Plt Ct-135* [2165-6-28] 08:30AM BLOOD Plt Ct-135* [2165-6-27] 12:27AM BLOOD PT-15.2* PTT-24.1 INR(PT)-1.4* [2165-6-27] 12:27AM BLOOD Glucose-138* UreaN-31* Creat-1.0 Na-141 K-4.1 Cl-113* HCO3-18* AnGap-14 [2165-6-27] 12:27AM BLOOD Calcium-7.0* Mg-2.4 [2165-6-23] 06:06PM BLOOD calTIBC-199* TRF-153* [Known lastname ],[Known firstname ]:[Hospital1 18] Radiology Detail - CCC Record #[Numeric Identifier 43669] FINAL REPORT INDICATIONS: 80-year-old man with known type B aortic dissection, who presented to an outside hospital with dysphasia. Concern is that the aorta has enlarged. COMPARISONS: [2164-1-21]. That was an MR of the torso. More recent studies are not available. TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis were obtained in the arterial phase of intravenous contrast administration. CT OF THE CHEST WITH IV CONTRAST: There is no axillary, hilar, or mediastinal lymphadenopathy. Coronary artery calcifications are noted. There is a type B dissection, as noted previously with the false lumen beginning shortly after the takeoff of the left subclavian artery, about 2 cm more distally. The aorta is ectatic. At the level of the passage into the abdomen at the diaphragmatic hiatus the aorta is overall slightly larger, measuring 6.4 x 4.4 cm in axial dimensions, compared to 3.6 x 4.9 cm previously. There is some narrowing of the true lumen at the diaphragmatic inlet, as low as 2.3 x 0.6 cm in axial dimensions. At all levels, there are few calcifications along the outer wall of the aorta. The celiac, and superior and inferior mesenteric arteries are supplied by the true lumen which is well opacified. The left common iliac is supplied by the true lumen entirely. As noted on the prior MR, the dissection extends into the proximal right external iliac artery, where it appears that the distal arterial distribution for the right leg is supplied by the true lumen. The false lumen ends in the proximal right common iliac artery. The internal iliac artery on the right is also supplied by the true lumen. At the site of the gastroesophageal junction, the axial dimensions of the aorta are somewhat larger than before, mostly because of expansion of the false lumen since the prior study. At this level, it measures 4.3 x 5.4 cm in axial dimensions (series 8, image 86) compared to 3.7 x 3.2 cm previously. There is bibasilar atelectasis and tiny right effusion, but otherwise the lungs are clear. CT OF THE ABDOMEN WITH IV CONTRAST: There is contrast in the gallbladder, probably from a recent CT. The liver appears normal. Although there is motion artifact limiting evaluation of the upper abdomen, the pancreas, spleen, and adrenal glands appear normal. There are several hypoattenuating foci bilaterally in the kidneys, the larger ones over a cm, which can be characterized as cysts and are unchanged since the prior MR study. A few subcentimeter bilateral hypoattenuating foci, however, are too small to characterize. There is no mesenteric or retroperitoneal lymphadenopathy or free air or fluid. Stomach, small and large bowel are within normal limits. CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder, and a large right diverticulum, which could be due to prior obstruction. The prostate and seminal vesicles are unremarkable. The sigmoid and rectum are within normal limits. There is a trace free fluid only, but no pelvic or mesenteric lymphadenopathy. BONE WINDOWS: There is very extensive involvement of sclerotic metastatic disease, attributed to the history of prostate cancer throughout the visualized skeleton. IMPRESSION: 1. Type B aortic dissection extending from the ascending aorta and terminating in the right external iliac artery. Its overall structure is similar to [2164-1-21], but particularly near the diaphragmatic hiatus, the overall size of the aorta is somewhat larger, particularly because of increased size of the false lumen. 2. Some compression of the true lumen at the same level. 3. Large bladder diverticulum. 4. Very extensive sclerotic metastases. The findings were discussed with [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] shortly after the study. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1507] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7832] Approved: MON [2165-6-24] 8:33 PM Procedure Date:[2165-6-24] INDICATION: 80-year-old man with dysphasia and thoracic aortic aneurysm. No comparison studies. BARIUM ESOPHAGRAM: Exam was limited to prone and supine evaluation of the distal esophagus given limited patient mobility and blood pressure lability. Within the upper esophagus, there is limited filling seen at the level of the aortic arch and lower trachea, corresponding with site of adjacent thoracic aortic aneurysm with dissection. Distal to this region, there is no evidence of stricture or abnormal dilatation. Mucosal abnormalities were difficult to assess given limitations of the study and lack of double contrast. Barium does pass freely through the esophagus; however, multiple tertiary esophageal contractions are noted. No evidence of hiatal hernia. Barium passes through the stomach promptly. IMPRESSION: limited filling of the upper esophagus at level of the aortic arch, likely secondary to mass effect caused by thoracic aortic aneurysm. These findings could explain patient's dysphagia. Tertiary contractions consistent with presbyesophagus. No evidence of hiatal hernia. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10270] DR. [First Name (STitle) 3934] [Name (STitle) 3935] Approved: WED [2165-6-26] 10:21 PM Procedure Date:[2165-6-26] Brief Hospital Course: Admitted on [6-23] and esmolol drip used for tight BP control. Evaluated for possible surgery or stent grafting. CT scanning repeated as well as esophageal evaluation done. Determined not to be a surgical candidate by Dr. [Last Name (STitle) ]. UTI and oral [Female First Name (un) ] diagnosed and treated with abx. Also diagnosed with mass effect of aneurysm on esophagus as well as aging motility. IV BP meds titrated to oral meds with goal SBP 120's.To follow up with Dr. [Last Name (STitle) ] (GI)to monitor dysphagia. Cleared for discharge to rehab on [6-28]. Medications on Admission: casodex 50 mg daily ? zocor 20 mg daily flomax 0.4 mg daily toprol XL 50 mg daily prednisone 10 mg [Hospital1 ] prozac 10 mg daily megace fentanyl patch 50 q week morphine q 3-4 hours Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: Type B aortic dissection MI CAD/ 2 LAD stents Afib/ SVT prostate CA /XRT/ with bone metastases HTN GERD elev. lipids UTI oral [Female First Name (un) ] presbyesophagus s/p AV ablation s/p appendectomy Discharge Condition: stable Discharge Instructions: tight BP control (SBP 120's) Completed by:[2165-6-28]	[ "112.0", "414.01", "599.0", "441.01", "185", "596.3", "V45.82", "198.5", "787.2", "272.0", "530.81", "530.89", "427.31", "412", "401.9", "427.89" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8182, 8241	7358, 7944	313, 320	8490, 8499	1286, 7335		975, 992				8262, 8469		7970, 8159			8523, 8582									1007, 1267																						239, 275									348, 762																		784, 923	939, 959
22,350	196,083	12582	Discharge summary	report	Admission Date: [2159-4-26] Discharge Date: [2159-5-8] Date of Birth: [2096-12-22] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 62-year-old female with a history of ovarian mass diagnosed [2159-4-11] secondary to abdominal swelling, flu-like symptoms and bloating. The patient reported a 17 lb weight loss since [2158-10-22]. The patient reported diarrhea alternating with constipation, early satiety and anorexia. PAST MEDICAL HISTORY: Significant for hypertension, diabetes, increased cholesterol, shortness of breath secondary to increased fluids, mild ascites, transient viral encephalitis, ankle and hand swelling, previous surgeries, history of ovarian cystectomy in [2130], D&C in [2127], appendectomy, history of lipoma excision of the neck. ALLERGIES: Codeine and Morphine. MEDICATIONS: On admission, HRT which was stopped [2159-4-12], Aspirin stopped [2159-4-12], Vitamin E stopped, Multivitamin, Colace, Lasix as needed and Zocor. PHYSICAL EXAMINATION: Vital signs on admission, blood pressure 143/94, pulse 77. Generally patient appeared in no apparent distress. Head and neck exam, anicteric, no lymphadenopathy. Neck supple. Pupils equal, round and reactive to light and accommodation. Chest clear to auscultation bilaterally. Cardiac exam, normal S1 and S2, regular rate and rhythm. Abdomen distended, brown, soft, diffusely tender, especially in the right upper quadrant. Extremities, no edema, no paresthesias. HOSPITAL COURSE: The patient underwent exam under anesthesia, TAH BSO, omentectomy, debulking, resection of tumor with optimal debulking on [2159-4-26] for ovarian cancer. The patient tolerated the procedure well. EBL was 700 cc. The findings were bulky adherent right side of uterus and pelvic wall. Posterior cul-de-sac nodularity. Omental adhesions to anterior abdominal ligaments, unable to palpate liver and diaphragm secondary to adhesions and moderate ascites. Right ovary was 10 cm by 8 cm by 10 cm and mobile, normal uterus with studding, sigmoid adherent to left ovary. No complications during the procedure. The patient tolerated the procedure well and was admitted to the Gyn/Onc service. On postoperative day 0 the patient dropped hematocrit down to 21 from intraoperative hematocrit of 36. The patient was transfused two units of packed red blood cells, 2 units FFP, ABG was 7.29, 40, 88. Repeat ABG was 7.28, 52 and 88. Post transfusion hematocrit was stable at 33 to 34. The patient dropped blood pressures to 80. The patient was bolused with normal saline times two. The patient denied shortness of breath and chest pain. The patient was admitted to the medical ICU for decreased blood pressure secondary to hypotension and increased temperature of 101.4 on the floor. 1. Cardiovascular: Hypotension secondary to intraoperative losses, fluid shift secondary to removal of ascites, status post transfusion of two units packed red blood cells and aggressive intraoperative volume repletion. The patient's hematocrit became stable and patient began to be normotensive. Pulmonary, there was evidence of respiratory acidosis status post surgery secondary to possible decrease in central respiratory drive. 2. ID: Patient spiked a fever and was started on Levo, Flagyl on postoperative day 0. On postoperative day #1 the patient's temperature decreased down to 99.0 from overnight temperature of 101.4. The patient's blood pressures ranged from 71/42 to 116/58 with normalization of blood pressure secondary to aggressive hydration. The patient's hematocrit was stable at 33. The patient had a white count of 17.9. All other lab work was within normal limits. Patient had an NG tube placed which was discontinued on postoperative day #2. The patient remained npo until postoperative day #3. The patient had been started on Levophed in the ICU for hypotension which was weaned. The patient was transferred to the general Gyn/Onc floor on postoperative day #2 where pain management was addressed by APS secondary to difficulty managing pain. The patient remained npo with NG tube in place. Patient's blood pressure remained stable. Postoperative day #3 the patient's hematocrit decreased to 27. The patient underwent transfusion of one unit of packed red blood cells with increase in hematocrit to 33.5. On postoperative day #4 with stable blood pressures and remained on Levo, Flagyl. 3. Nutrition-wise the patient was started on TPN. Epidural was in place for pain management which was weaned per APS service and patient was started on Dilaudid PCA. The patient remained npo with NG tube in place until postoperative day #5. NG tube was pulled on postoperative day #5. The patient has increased discomfort secondary to gas pain with slow return of bowel function. The patient remained on TPN. On postoperative day #7 the patient was started on sips which were tolerated. On postoperative day #8 the patient continued to have excellent pain control and was advanced to soft solids and po pain meds along with Percocet with ongoing TPN. On postoperative day #9 the patient had a small amount of nausea and vomiting but continued to advance diet slowly with soft solids without much discomfort. Her lab work remained stable with sodium of 135, potassium 4.3. TPN was continued. On postoperative day #10 patient's TPN was changed to ?????? prior volume and she was changed to a low residue diet which she tolerated well and continued to have good pain control with po pain meds on Percocet. She remained afebrile, antibiotics were discontinued and patient was discharged to home on postoperative day #11 with TPN discontinued and adequate toleration of low residual diet and normal chemistry and laboratory evaluation. The patient was evaluated by Dr. [Last Name (STitle) ] from Heme/Onc with follow-up plan for chemotherapy. The patient was discharged to home on [2159-5-8], postoperative day #11 with adequate pain control, ambulating, voiding and follow-up plan to see Dr. [Last Name (STitle) ]. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Percocet 1-2 tabs po q 3-4 hours prn, Zantac, Effexor. FOLLOW-UP: Patient to follow-up on Monday, [2159-5-14] with Dr. [Last Name (STitle) ] for discussion of chemotherapy. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 26060] Dictated By:[Last Name (NamePattern4) 9014] MEDQUIST36 D: [2159-5-11] 16:06 T: [2159-5-11] 19:54 JOB#: [Job Number 38933]	[ "789.5", "997.4", "276.2", "E878.2", "997.3", "183.0", "458.2", "518.0", "560.1" ]	icd9cm	[ [ [] ] ]	[ "45.62", "54.4", "65.61", "99.15", "68.4" ]	icd9pcs	[ [ [] ] ]				6102, 6111					6135, 6593					1529, 6080																							1040, 1511																			160, 468																		491, 1017
53,192	123,631	36598	Discharge summary	report	Admission Date: [2195-9-8] Discharge Date: [2195-9-13] Date of Birth: [2116-10-20] Sex: F Service: SURGERY Allergies: Iodine / Iodipamide Meglumine Attending:[First Name3 (LF) 3223] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 78yo F fall from toilet onto bathtub hit head, GCS of 3 at scene. OSH attempt to intubate then cric pt and failed, went into PEA arrest, brought back and transferred to [Hospital1 18]. Past Medical History: Metastatic Lung CA, DMII, HTN, COPD, Asthma, ?arrythmia per pt husband Social History: unknown Family History: unknown Physical Exam: Pt expired. Pertinent Results: CT Head IMPRESSION: 1. Extensive subcutaneous emphysema involving the visualized facial and scalp soft tissues. Small bifrontal soft tissue hematoma. No fracture. 2. No evidence of acute intracranial abnormalities. 3. Extensive chronic small vessel ischemic disease. CT Torso 1. Extensive soft tissue emphysema. 2. Pneumomediastinum, pneumoperitoneum, left pneumothorax. No visceral organ injury or hemoperitonuem. 3. Extensive diverticulosis without diverticulitis. 4. Multiple left renal low-attenuation lesions and a non specific right renal enhancing focus. Further characterization with ultrasound on an emergent basis should be considered. 5. Right upper lobe collapse with a right hilar mass and a LUL mass consistent with known malignancy. 6. Multiple hepatic hypoattenuating lesions, the largest is a simple cyst, the others are too small to characterize. MRI Head/C-Spine . Type [3-10] dens fracture. No epidural hematoma or spinal canal narrowing. No evidence of anterior or posterior longitudinal ligament disruption. Extensive prevertebral soft tissue edema. 2. Fluid in the joints between the C1-C2 lateral masses, and between the C1 lateral masses and the occipital condyles, without evidence of widening. 3. Marrow edema along the superior endplates of T1 and T3 without loss of height with apparent fracture lines. Brief Hospital Course: 78yo F fall from toilet onto bathtub hit head, GCS of 3 at scene. OSH attempt to intubate then cric pt and failed, went into PEA arrest, brought back and transferred to [Hospital1 18]. Pt was unresponsive on arrival and taken to the trauma bay. Upon arrival she was determined to have a Type 3 Dens Fracture, b/l pneumothorax and was reported to be s/p PEA 10 minutes. She was taken to the Trauma ICU intubated. A long conversation was held with the patient's family and after several days in the ICU the surgical staff and the family felt that the patient's situation was not going to improve. She was made CMO and terminally extubated on [9-13], she quickly passed away following removal of the tube. Medications on Admission: Pt deceased Discharge Medications: Pt deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: n/a [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226]	[ "493.20", "V66.7", "V12.54", "512.1", "276.4", "E870.8", "806.00", "401.9", "518.5", "250.00", "427.5", "807.09", "998.81", "780.01", "162.9", "568.89", "E884.6", "V58.67", "E947.8" ]	icd9cm	[ [ [] ] ]	[ "34.09", "96.72", "38.93", "33.24", "96.6", "38.91" ]	icd9pcs	[ [ [] ] ]	2886, 2895	2075, 2788	294, 300	2947, 2957	709, 2052	3014, 3148	653, 662		2850, 2863		2916, 2926		2814, 2827			2981, 2991									677, 690																						250, 256									328, 518																		540, 612	628, 637
66,389	150,989	39155	Discharge summary	report	Admission Date: [2174-4-4] Discharge Date: [2174-4-11] Date of Birth: [2101-11-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: Right upper quadrant pain status post laparoscopic cholecystectomy Major Surgical or Invasive Procedure: [2174-4-4]: Exploratory laparotomy, abdominal hemorrhage washout and clot removal and suture ligation and argon beam coagulation of the gallbladder fossa bleeding with the cystic duct stump bleeding. History of Present Illness: 72 year old male had a laparoscopic cholecystectomy and intraoperative cholangiogram on [2174-3-23] at [Hospital 189] Hospital. Pathology was chronic cholecystitis. The patient was having low grade temperatures while he was on the surgical floor during his recovery and his blood cultures were positive for pan sensitive E.coli. He also developed new onset atrial fibrillation. He was on Coumadin previously for stroke that lost his left upper vision but that had been held. After he had atrial fibrillation he was started on digoxin, verapamil and restarted on Coumadin. He was discharged on [3-29] on Augmentin. He returned to the hospital with right upper quadrant ultrasound on [3-31] and CT scan showed "ascites" so he was discharged home. He returns to the Emergency Department because his right upper quadrant pain increased significantly today. He denies nausea or vomiting. He has not had a bowel movement in 2 days. His bowel movements have all been small since surgery. He has not passed gas until arrival to the emergency department. He denies fever, chills or night sweats. Past Medical History: PMHx: type II DM, HTN, Stroke 18 years ago with TIA in [12/2173], atrial fibrillation since surgery on [3-23], hyperlipidemia, h/o herpes infection, obesity. . PSHx: laparoscopic cholecystectomy [2174-3-23], Right knee surgery, s/p T&A. Social History: Patient drinks rarely. Quit smoking over 40 yrs ago. Family History: Non-contributory. Physical Exam: On Admission: Vital Signs: T 95.1 HR 97 BP 121/78 RR 18 O2 Sat 99% 2 L NC General: No acute Distress Lungs: Clear to Auscultation bilaterally Cardiac: Regular rate and rhythm, S1/S2 Abdomen: Soft, tender in the right upper quadrant, distended, no rebound, no guarding Rectal: Normal tone, no gross blood, guaiac negative . At Discharge: AVSS/afebrile HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B) COR: RRR ABD: Midline incision with ........ c/d/i. BSx4. Appropriately tender to palpation along incision, otherwise soft/NT/ND. EXTREM: WWP; no c/c/e. NEURO: A+Ox3. Non-focal/grossly intact. Pertinent Results: On Admission: [2174-4-4] 09:24PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2174-4-4] 09:24PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2174-4-4] 09:24PM URINE RBC-62* WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [2174-4-4] 09:24PM URINE HYALINE-3* [2174-4-4] 09:24PM URINE MUCOUS-RARE [2174-4-4] 07:51PM TYPE-ART PO2-129* PCO2-49* PH-7.35 TOTAL CO2-28 BASE XS-0 [2174-4-4] 07:51PM GLUCOSE-199* LACTATE-2.1* [2174-4-4] 07:51PM freeCa-1.21 [2174-4-4] 07:37PM GLUCOSE-142* UREA N-38* CREAT-2.7* SODIUM-142 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 [2174-4-4] 07:37PM CALCIUM-8.4 PHOSPHATE-4.6* MAGNESIUM-1.8 [2174-4-4] 07:37PM WBC-15.5* RBC-2.84* HGB-8.3* HCT-23.6* MCV-83 MCH-29.2 MCHC-35.2* RDW-14.5 [2174-4-4] 07:37PM PLT COUNT-249# [2174-4-4] 07:37PM PT-15.2* PTT-30.9 INR(PT)-1.3* [2174-4-4] 06:32PM GLUCOSE-181* LACTATE-3.7* NA+-138 K+-4.8 CL--105 TCO2-24 [2174-4-4] 06:32PM HGB-7.8* calcHCT-23 [2174-4-4] 06:32PM freeCa-1.08* [2174-4-3] 11:00PM GLUCOSE-235* UREA N-30* CREAT-2.3* SODIUM-141 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-20 [2174-4-3] 11:00PM ALT(SGPT)-109* AST(SGOT)-28 CK(CPK)-38* ALK PHOS-200* TOT BILI-0.3 [2174-4-3] 11:00PM LIPASE-29 [2174-4-3] 11:00PM cTropnT-0.02* [2174-4-3] 11:00PM CK-MB-NotDone [2174-4-3] 11:00PM WBC-31.0* RBC-3.68* HGB-10.5* HCT-32.6* MCV-89 MCH-28.6 MCHC-32.2 RDW-13.8 [2174-4-3] 11:00PM NEUTS-95.0* LYMPHS-3.0* MONOS-1.7* EOS-0.2 BASOS-0.2 [2174-4-3] 11:00PM PLT COUNT-776* [2174-4-3] 11:00PM PT-22.0* PTT-29.0 INR(PT)-2.1* . IMAGING: [2174-4-3] AP CXR: Low lung volumes. No subdiaphragmatic free air. . [2174-4-3] ABD X-Ray: Gaseous distention of the stomach. Non-obstructive bowel gas pattern. Please refer to CT abdomen/pelvis report for further details. . [2174-4-3] ABD/PELVIC CT W/CONTRAST: 1. Moderate amount of high density ascites which could reflect intraperitoneal blood. Please correlate with hematocrit for signs of active bleeding. 2. Incompletely characterized hepatic lesions that can be further characterized with MRI. If concern for bile leak persists, the MRI should be performed with Eovist. 3. Small pericardial effusion. 4. Diverticulosis, no evidence of diverticulitis. 5. Bilateral renal cysts. . [2174-4-3] ECHO: Left ventricular wall thickness, cavity size and regional/global systolic function are normal but hyperdynamic (LVEF >75%). The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . [2174-4-4] Gallbladder Scan: No evidence of bile leak during the time of the study. . [2174-4-4] CT PARACENTESIS: Successful CT-guided aspiration of fluid in the right abdomen, which yielded frank blood, confirming hemoperitoneum. Samples were sent for Gram stain and culture, as well as hematocrit. . [2174-4-4] CXR: In comparison with the earlier study of this date, there is increasing retrocardiac opacification. This could represent lower lobe collapse with small effusion. In the appropriate clinical setting, however, the possibility of pneumonia would have to be considered. There has been interval placement of an endotracheal tube with its tip approximately 6.5 cm above the carina. Right IJ central catheter remains in place. Nasogastric tube is in the upper stomach, with the tip now pointing towards the antrum. . [2174-4-6] UNILAT UP EXT VEINS US LEFT PORT: No evidence of left upper extremity DVT. Nonvisualization of the left cephalic vein. . MICROBIOLOGY: SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL: GRAM STAIN (Final [2174-4-6]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2174-4-9]): THIS IS A CORRECTED REPORT ([2174-4-9]). REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 86741], [2174-4-9], 3:04PM. Commensal Respiratory Flora Absent. BACILLUS SPECIES. 1 COLONY ON 1 PLATE. PREVIOUSLY REPORTED AS RARE GROWTH GRAM NEGATIVE ROD [2174-4-8]. . [2174-4-4] URINE CULTURE-FINAL: NO GROWTH. [2174-4-4] ABSCESS GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC CULTURE-FINAL: GRAM STAIN (Final [2174-4-4]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2174-4-7]): NO GROWTH. ANAEROBIC CULTURE (Final [2174-4-10]): NO GROWTH. . [2174-4-4] BLOOD CULTURE-FINAL: NO GROWTH. [2174-4-4] MRSA SCREEN-FINAL: NEGATIVE. [2174-4-4] BLOOD CULTURE - FINAL: NO GROWTH. Brief Hospital Course: The patient was transferred and admitted to the General Surgical Service on [2174-4-3] for evaluation of right upper quadrant pain status post laparoscopic cholecystectomy on [2174-3-23], which was performed at [First Name5 (NamePattern1) 189] [Last Name (NamePattern1) ]. Admission abdominal/pelvic CT revealed a moderate amount of high density ascites which could reflect intraperitoneal blood. The study incompletely characterized hepatic lesions. The patient was admitted to the [Hospital Unit Name 153], made NPO, started on IV fluid rescusitation, and started on IV Vancomycin and Meropenem for E. coli sepsis (Blood cultures from OSH grew E. coli). A gallbladder study performed on [2174-4-4] did not reveal a bile leak. A subsequent CT-guided aspiration of fluid from the right abdomen yielded frank blood, confirming hemoperitoneum. Coumadin had been discontinued, and the INR reversed with a dose of Vitamin K IV as well as 3 units of FFP. He also received 3 units of PRBCs for a falling hematocrit down to 18.5 pre-operatively. . Later on [2174-4-4], the patient underwent exploratory laparotomy, abdominal hemorrhage washout and clot removal and suture ligation and argon beam coagulation of the gallbladder fossa bleeding with the cystic duct stump bleeding, which went well without complication (reader referred to the Operative Note for details). The patient received an additional 2 units of PRBCs and FFPs intra-operatively. After a brief, uneventful stay in the PACU, the patient was sent to the SICU intubated, NPO with an NG tube, on IV fluids and continued on antibiotics, with a foley catheter and JP drain in place, briefly on IV Neoepinephrine for pressure control, a Propofol drip, and Dilaudid IV PRN for pain control. The patient was hemodynamically stable. . On POD#2, the patient was sucessfully extubated. The NG tube was discontinued, and the patient started on sips. Empiric IV Meropenem was discontinued. On POD#3, the patient was transferred to the floor. . Post-operative pain was initially well controlled with the Dilaudid IV PRN, which was converted to oral pain medication when tolerating clear liquids. The patient was advanced to clears on POD#3. Diet was progressively advanced as tolerated to a diabetic regular diet by POD#5. The foley catheter was discontinued at midnight of POD#5. The patient subsequently voided without problem. JP was discontinued on POD#6. Lovenox and Coumadin were started on POD#6 given the patient's history of atrial fibrillation and TIA. Once the patient's INR is therapeutic, the Lovenox will be discontinued. At discharge, his INR was 1.5. INR goal 2.5; therapeutic range 2-3. His primary care provider (PCP) has kindly agreed to manage this transition. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a diabetic regular diet, ambulating, voiding without assistance, and pain was well controlled. He will continue on the Lovenox-Coumadin bridge. He was discharged home with VNA services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Verapamil SR 240mg 1 tab PO daily. 7. Vitamin D Oral 8. Vitamin C Oral 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Over-the-counter. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Vitamin D Oral 10. Vitamin C Oral 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [4-26] hours as needed for pain. Disp:40 Tablet(s) Refills:0 15. Metformin 500 mg Tablet Sig: 0.5 Tablet PO once a day. 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO daily in the evening. Disp:30 Tablet(s) Refills:0 17. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 0.8mL (80mg) Subcutaneous every twelve (12) hours. Disp:14 Pre-filled syringe Refills:1 Discharge Disposition: Home With Service Facility: Visiting Nurse of Greater [Hospital1 189] Discharge Diagnosis: Primary: 1. Intra-abdominal hemorrhage. 2. E.coli sepsis 3. Acute renal failure . Secondary: 1. New onset atrial fibrillation 2. H/O CVA and TIA 3. Type II DM 4. HTN Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-30] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: 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. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . Coumadin (Warfarin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [Name Initial (PRE) ]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin??????/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [Name5 (PTitle) ] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [Location (un) 2831] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin??????/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Please call ([Telephone/Fax (1) 39389] to arrange a follow-up appointment with Dr. [Last Name (STitle) 32668] (PCP) in [1-22] weeks. . [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 10132], NP (Surgery Service) will contact you in the next few days to arrange a time to return for staple removal. You may call ([Telephone/Fax (1) 86742] to speak to Mr. [Name13 (STitle) 10132] with questions. . Please call ([Telephone/Fax (1) 8105] to schedule a follow-up appointment with Dr. [First Name (STitle) 2819] (Surgery) in 2 weeks. Completed by:[2174-4-11*]	[ "518.5", "E878.8", "V15.82", "995.91", "038.42", "401.9", "V12.54", "285.1", "789.59", "276.52", "278.00", "998.11", "584.9", "272.4", "427.31", "250.00", "V58.61", "288.60" ]	icd9cm	[ [ [] ] ]	[ "54.19", "96.71", "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]	13405, 13481	7667, 11343	382, 588	13691, 13691	2747, 2747	18275, 18881	2084, 2103		12035, 13382		13502, 13670		11369, 12012			13839, 14422							14438, 18252		2118, 2118													2455, 2728									275, 344									616, 1724							2762, 7644	13706, 13815										1746, 1997	2013, 2068
20,421	161,478	54011	Discharge summary	report	Admission Date: [2171-10-31] Discharge Date: [2171-11-6] Date of Birth: [2091-3-9] Sex: M Service: MEDICINE Allergies: Univasc / Celexa / Heparin Agents Attending:[First Name3 (LF) 348] Chief Complaint: hypoxia and diarrhea Major Surgical or Invasive Procedure: intubation, arterial line insertion History of Present Illness: Per MICU Admission Note 80 yo male with PMH of brain tumor, recently admitted after intracranial hemorrhage. Was at rehab today when found unresponsive with O2 sat of 50%. Recently has been on trach collar during day and vent at night. Initial workup at OSH ED. He was briefly placed back on vent and transferred to [Hospital1 18].He was normotensive here and not hypoxic on 100% but with altered mental status. Narcan did not help and no new focal findings. Head CT was unchanged. CTA torso - no PE, belly ok. WBC of 33. Transiently hypotensive. 2L NS ok. Got a-line and semi clean groin line. Vanc, cefepime, flagyl. A little more awake upon admission. VS: 99.8 R, 63 122/73, 550 x 16 on 5 peep 100% fio2 - satting 100%. Past Medical History: Brain tumor: MR c/w low grade glioma; has been followed since [8-/2169] Hemorrhagic stroke [8-/2171] at site of biopsy CAD s/p CABG x 4 (LIMA->LAD, SVG->OM1, OM2, PDA) [2168]. HTN AFib no longer on coumadin (has been on amiodarone) Dyslipidemia Myelodysplastic Syndrome: BM Bx [8-1] MDS vs CML, followed by [Month/Year (2) 2539] Prostate Cancer s/p radictal prostatectomy and simultaneous penile implant [2155] Hyperparathyroidism h/o DVT, no CTA done b/c of CKD--treated w/ IVC filter and lovenox, filter has since been removed. Was on warfarin until hemorrhagic stroke. Gout Subclinical Hypothyroidism Allergic Rhinitis Reflux Pharyngitis Colonic Polyps ? Essential Tremor Anhedonia, attempted celexa but became lightheaded Low back pain, ? spinal stenosis Peripheral neuropathy h/o Fen/Phen use Social History: Soc Hx: Married. Has been in nursing home. No tobacco, ETOH, drug use Family History: NC Physical Exam: Initial MICU PE GEN: NAD, interactive, though non-verbal. HEENT: AT, scar present over right pariatal area, trancheostomy in place with very mild skin breakdown. CV: RRR, nl S1 and S2, no MRG - sounds are distant. PULM: Course mechanical BS throughout. No true rhonchi or crackles. ABD: PEG in place and site is c/d/i, NT/ND, obese, with present BS. EXT: No pitting edema, pale nail beds, no wounds, no cyanosis. NEURO: Moderate left sided hemiparesis (at baseline), non-verbal but able to answer with simple questions. PE on transfer to floor PE: T 96.9 102-120/52-62 HR 69 RR22 95% 50% FM GEN: NAD, interactive, though non-verbal. HEENT: AT, scar present over right parietal area, trancheostomy in place with very minimal skin breakdown and erythema. CV: RRR, nl S1 and S2, no MRG - sounds are distant and difficult to auscultate over coarse BS. PULM: Course BS throughout and transmitted upper airway sounds. No crackles. ABD: PEG in place and site is c/d/i, NT/ND, obese, with present BS. EXT: No pitting edema, pale nail beds, no wounds, no cyanosis. Left foot with nonpitting edema NEURO: Moderate left sided hemiparesis (at baseline), non-verbal but able to answer with simple questions, nods head. Pertinent Results: [2171-10-31] 04:22PM BLOOD WBC-33.5# RBC-3.11 Hgb-9.2* Hct-29.3* MCV-94 MCH-29.4 MCHC-31.2 RDW-14.0 Plt Ct-67* [2171-11-2] 04:27AM BLOOD WBC-18.0* RBC-2.76* Hgb-8.2* Hct-25.0* MCV-90 MCH-29.6 MCHC-32.8 RDW-14.9 Plt Ct-60* [2171-11-6] 07:49AM BLOOD WBC-19.0* RBC-2.81* Hgb-8.3* Hct-25.2* MCV-90 MCH-29.5 MCHC-32.9 RDW-15.1 Plt Ct-67* [2171-10-31] 04:22PM BLOOD Neuts-18* Bands-2 Lymphs-10* Monos-61* Eos-3 Baso-0 Atyps-0 Metas-2* Myelos-4* [2171-11-4] 03:54AM BLOOD Neuts-22* Bands-1 Lymphs-8* Monos-60* Eos-5* Baso-1 Atyps-1* Metas-1* Myelos-1* [2171-10-31] 04:22PM BLOOD Glucose-169* UreaN-86* Creat-1.1 Na-149* K-4.6 Cl-111* HCO3-32 AnGap-11 [2171-11-2] 03:38PM BLOOD Glucose-130* UreaN-56* Creat-0.7 Na-148* K-3.9 Cl-118* HCO3-26 AnGap-8 [2171-11-6] 07:49AM BLOOD Glucose-113* UreaN-45* Creat-0.8 Na-142 K-4.3 Cl-107 HCO3-30 AnGap-9 [2171-10-31] 04:22PM BLOOD ALT-13 AST-18 CK(CPK)-7* AlkPhos-101 TotBili-0.2 [2171-11-1] 04:10AM BLOOD LD(LDH)-119 CK(CPK)-3* [2171-11-1] 03:18PM BLOOD CK(CPK)-7* [2171-10-31] 04:22PM BLOOD cTropnT-0.07* [2171-11-1] 04:10AM BLOOD CK-MB-NotDone cTropnT-0.05* [2171-11-1] 03:18PM BLOOD CK-MB-NotDone cTropnT-0.06* [2171-11-1] 04:10AM BLOOD Calcium-11.2* Phos-3.3 Mg-1.8 [2171-11-4] 03:54AM BLOOD Albumin-2.9* Calcium-10.9* Phos-2.5* Mg-1.8 [2171-10-31] 04:43PM BLOOD Lactate-1.3 CXR [11-3]: IMPRESSION: Bibasilar opacities, suspicious for pneumonia. Interval improvement on the left. Evidence for small left effusion unchanged CXR [11-5] REASON FOR EXAM: 80-year-old man with hypoxia and respiratory distress and elevated white blood count, please evaluate for pneumonia. Since [2171-11-3], sternotomy wires are still intact. A tracheostomy is in unchanged position. Right PICC tip is not seen. Bibasilar opacity increased could be atelectasis, pneumonia or aspiration. Standard PA and lateral views or better inspiration AP could further characterize this. Minimal blunting of the left costophrenic angle is unchanged, altough it was partly excluded on this study. . CT HEAD [10-31]: IMPRESSION: Unchanged right frontal lobe heterogeneous mass with resolution of post-biopsy hemorrhage and pneumocephalus. No acute intracranial hemorrhage. CT Torso [10-31]: IMPRESSION: 1. Limited study for assessment of pulmonary embolism secondary to technical factors. No central PE. 2. Enlarged pulmonary artery reflective of pulmonary hypertension. 3. Moderate cardiomegaly. 4. Peritracheostomy secretions and debris. 5. Cholelithiasis. No evidence of acute cholecystitis. 6. Innumerable cysts of the kidneys bilaterally, stable compared to [2168]. MICRO: Blood cx NGTD Urine cx NG Sputum RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. C diff negative x 2 [2171-11-1] 11:35AM BLOOD Lactate-0.6 Brief Hospital Course: For details regarding previous prolonged hospital course at [Hospital 792]Hospital and [Hospital1 18], please see prior discharge summary [2171-10-25]. MICU Course: Mr. [Known lastname ] was admitted to the MICU for a hypoxic episode at rehab. Flexible bronchoscopy was performed on arrival and showed focal tracheomalacia with airway occlusion. Tracheostomy tube change performed. He was not hypoxic upon arrival and was quickly weaned to trach mask which he tolerated for 48 hours prior to transfer to the floor. He was treated with broad-spectrum antibiotics including Zosyn, Vancomycin and Flagyl for possible HCAP/VAP and C. Diff. Antibiotics were weaned quickly as pt was not hypoxic, not febrile, and had a negative chest x-ray. The flagyl was stopped after 3 C. Diff stool studies came back negative. The patient was briefly on pressors overnight the night of admission but these were discontinued in the morning and he remained hemodynamically stable. He was kept in the MICU for thick secretions requiring frequent suctioning but was transferred to the floor as he was off the vent for over 48 hours and secretions thinning. For his brain tumor, Keppra was continued for seizure prophylaxis and his neuro-oncologist was contact[Name (NI) ]. The family was also requesting a new rehab placement and this process was started with case management. Floor Course On the floor, he remained hemodynamically stable and afebrile. Vancomycin was restarted [11-5] since pt was having increased sputum production, sputum cultures grew MRSA, he had an elevated WBC of 20, and ? bibasilar infiltrates on CXR [2171-11-5]. He should continue for total 10 day course of vancomycin. He was not continued on Zosyn since MRSA was felt to cause of pneumonia given sputum culture results. If he develops fever, increase in WBC, or increased sputum production, would consider broadening coverage but it was not felt to be neccessary at the time of discharge. He continued to have diarrhea with rectal tube in place but had 3 negative C. difficile toxins, most recently [11-5]. His AFib was well controlled on metoprolol 12.5 mg PO BID. This dose may need to be titrated based on BP and HR. Insulin was stopped since he was not requiring any in house and does not carry diagnosis of diabetes. He was continued on all of his outpatient medications for his chronic medical problems. ASA 81mg daily was added given his history of MI and he is now approx. 2 months out from his hemorrhage. We continued to hold Coumadin given recent hemorrhagic CVA [9-2]. Medications on Admission: 1. Senna 8.6 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO BID 2. Docusate Sodium 50 mg/5 mL Liquid 3. Metoprolol Tartrate 25 mg PO BID 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY. 5. Allopurinol 100 mg Tablet 2 Tablet PO DAILY 6. Simvastatin 40 mg Tablet PO DAILY 7. Acetaminophen 325 mg PO Q6H PRN for pain. 8. Nystatin 100,000 unit/g Cream [Last Name (STitle) ]: Apply to affected areas. 9. Levetiracetam 500 mg PO BID 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation QID (4 times a day). 11. Oxycodone-Acetaminophen 5-325 5-10 MLs PO Q6H PRN for pain. 12. Ascorbic Acid 90 mg/mL Drops PO DAILY 13. Zinc Sulfate 220 mg 14. Insulin Regular Human 100 unit/mL SS Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 days. 2. Senna 8.6 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO BID (2 times a day) as needed. 3. Colace 50 mg/5 mL Liquid [Last Name (STitle) ]: Five (5) ml PO twice a day as needed for constipation. 4. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. 6. Allopurinol 100 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Levetiracetam 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [Last Name (STitle) ]: Two (2) Puff Inhalation QID (4 times a day). 11. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 12. Acetylcysteine 20 % (200 mg/mL) Solution [Last Name (STitle) ]: One (1) neb Miscellaneous Q8H (every 8 hours) as needed for thick secretions. 13. Zinc Sulfate 220 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 14. Ascorbic Acid 90 mg/mL Drops [Last Name (STitle) ]: One (1) ml PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis 1. Hypoxemic Respiratory Failure 2. Health Care Associated Pneumonia Secondary Diagnosis Brain tumor, likely low grade glioma AFib Stage 2 sacral decubitus ulcer CAD HTN MDS HIT Discharge Condition: Hemodynamically stable, satting high 90s on 50% trach mask, afebrile Discharge Instructions: You were admitted to the hospital because you had low oxygen saturations at your rehab facility. You had your trachesostomy tube changed on admission [2171-10-31]. We started antibiotics to treat you for pneumonia and you should complete a 10 day course. We made the following changes to your medications 1. We added Vancomycin which you should continue for 6 more days 2. We added ASA 81 mg 3. We decreased the dose of your Metoprolol in half since your BP was on the lower side 4. We stopped your insulin since you were not requiring this medication and did not have high blood sugars Please return to the ER or call your primary care physician if you develop shortness of breath, cough, fever, chills, chest pain, numbness or weakness or any other concerning symptoms. Followup Instructions: Provider: [Name10 (NameIs) 5005] [Last Name (NamePattern4) 5342], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2171-11-11] 1:00 Provider: [Name10 (NameIs) 706] [Name10 (NameIs) 4338] Phone:[Telephone/Fax (1) 327] Date/Time:[2171-11-11] 11:55 Please also call your primary care doctor at 617 [Telephone/Fax (1) 110725] to make an appointment in the next 1-2 weeks.	[ "274.9", "486", "272.4", "V55.0", "438.20", "252.00", "707.22", "427.31", "519.19", "518.81", "238.75", "191.1", "414.00", "401.9", "289.84", "707.03", "V45.81", "V10.46", "787.91" ]	icd9cm	[ [ [] ] ]	[ "96.71", "97.23", "33.21" ]	icd9pcs	[ [ [] ] ]	11196, 11268	6248, 8833	315, 352	11508, 11579	3321, 6030	12406, 12808	2073, 2077		9640, 11173		11289, 11487		8859, 9617			11603, 12383									2092, 3302							6065, 6225															254, 277									380, 1123																		1145, 1969	1985, 2057
11,071	185,728	26590	Discharge summary	report	Admission Date: [2161-2-12] Discharge Date: [2161-2-27] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Toprol Xl Attending:[First Name3 (LF) 2181] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: 82M with PMH sig for afib s/p PCM placement 10 wks ago and recent UTI/PNA tx with Vantin (started [2-8]) presented to [Hospital3 7569] with pleuritic CP, EKG without ST changes. Pt given 40 mg IV lasix for ?CHF and a total of 6 mg IV morphine for pain and BP dropped to 85/40, was bolused with IVF and pressure improved to 114/52 and pt transferred to [Hospital1 18] ED for further evaluation of possible tamponade. CTA at [Location (un) ]: no PE, no dissection, no pleural effusion, small dense pericardial effusion c/w blood. Also at OSH, BNP 357. . In [Hospital1 18] ED, bedside echo revealed 1-2 cm circumferential pericardial effusion, no tamponade or RV collapse. WBC elevated at 16 and OSH blood cultures taken 3 days ago returned [3-19] positive for MRSA. Received Vancomycin, DA gtt, Zosyn, decadron 4 mg IV. R SCL central line placed and pt started on sepsis protocol given hypotension. (Lactate only 1.3 and pt afebrile). . On presentation, the pt denied chest pain, shortness of breath, fevers, chills. He endorsed pain in his lower back and shooting pains down his right leg to his ankle. Denied orthopnea, PND, new leg swelling. Past Medical History: recent hospitalization at [Hospital ] Hosp [2081-2-2] with anemia (Hct checked at PCP office and noted to be 22, pt feeling weak. C-scope and EGD done during admission neg for source). PNA/UTI last wk, dx at [Hospital ] Hosp sacral decub CHF OSA on CPAP afib s/p PCM placement 10 wks ago LBP Depression MRSA + (bcx returned today) T2DM GERD hx osteomyelitis L 2nd toe THR R hip (hardware in place) hx spinal stenosis, s/p several surgeries on lumbar spine hx GIB Anemia pMIBI at [Location (un) ] this year negative Social History: pt lives with his wife, who is a nurse. [First Name (Titles) 65618] [Last Name (Titles) ] of smoking (quit in '[20]) and denies EtOH . Family History: nc Physical Exam: 98.3, 119/56, 70, 17, 95% Gen: Obese W male lying in bed in NAD HEENT: EOMI, PERRL, dry mucous membranes, erythema of posterior soft palate and posterior hard palate Chest: Bibasilar crackles L>R CV: RRR, S1/S2 intact, -MRG appreciated Abd: obese, soft, NT, ND +BS Buttock: 2 stage 2 ulcers on the R buttock Ext: 7cm area erythema at L lateral maleolus, R 2nd toe hammer toe with mild erythema, pain on range of motion of R hip Neuro: CN 2-12 intact. AAO x3. moves all 4 limbs spontaneously Pertinent Results: [2161-2-12] 04:22AM PT-13.0 PTT-21.0* INR(PT)-1.1 [2161-2-12] 04:22AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MICROCYT-3+ [2161-2-12] 04:22AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MICROCYT-3+ [2161-2-12] 04:22AM NEUTS-88.7* LYMPHS-6.4* MONOS-3.8 EOS-0.9 BASOS-0.3 [2161-2-12] 04:22AM WBC-15.9* RBC-4.04* HGB-10.4* HCT-31.3* MCV-77* MCH-25.7* MCHC-33.2 RDW-21.5* [2161-2-12] 04:22AM TSH-20* [2161-2-12] 04:22AM calTIBC-235* FERRITIN-205 TRF-181* [2161-2-12] 04:22AM ALT(SGPT)-45* AST(SGOT)-47* LD(LDH)-431* ALK PHOS-95 AMYLASE-15 TOT BILI-0.3 [2161-2-12] 04:22AM CK(CPK)-63 [2161-2-12] 04:22AM CK-MB-2 cTropnT-0.01 [2161-2-12] 04:22AM GLUCOSE-120* UREA N-23* CREAT-1.3* SODIUM-138 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-20 . TTE [2161-2-12]: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. 5. There is a small to moderate sized pericardial effusion with fibrin deposits on the surface of the heart. 6. Compared with the findings of the prior study (images reviewed) of [2161-2-12], there has been no significant change. . Ankle/foot/hip xr 1. Status post right hip arthroplasty with a bipolar hip prosthesis. No evidence of hardware loosening. 2. Old fracture of the distal fifth right metatarsal. No evidence of osteomyelitis in the right foot or ankle, but bone scan may be considered if clinical suspicion is high. . CXR: 1. There is enlargement of the cardiac silhouette, which may reflect an element of cardiomegaly and associated pericardial effusion. 2. There is haziness at the left costophrenic angle, consistent with atelectasis and probable very small effusion. . TEE [2161-2-18] 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. Two discrete, 5-10mml [Last Name (un) ], filamentous, and highly mobile echodensities are noted on the right atrial lead in the body of the right atrium c/w vegetations or thrombi. A tiny secundum atrial septal defect (ASD) is present. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but without discrete vegetation. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild [1+] mitral regurgitation is seen. There is a trivial pericardial effusion. IMPRESSION: Filamentous, mobile, echodensities on the RA pacing lead c/w thrombus or vegetation. . Bone Scan: Findings consistent with osteomyelitis of the lateral aspect of the right ankle. . LE US b/l: Findings indicating old thrombus involving the right superficial femoral and popliteal veins, no acute venous thrombosis involving either lower extremity. . CTA chest [2163-2-20] 1. No evidence of pulmonary embolism. 2. Moderate-to-large pericardial effusion. 3. Calcified splenic artery. 4. Likely atelectasis of the left lung base. . CTA abdomen [2163-2-21] 1. No evidence for septic emboli or abscess. 2. Left adrenal lesion, incompletely characterized. Further evaluation is recommended with MRI examination. 3. No significant change in the large pericardial effusion and left basilar effusion. Brief Hospital Course: 1. Hypotension: Most likely cause was sepsis. Ddx included tamponade but bedside echo in the ED revealed 1-2 cm circumferential pericardial effusion, without evidence of tamponade or RV collapse. WBC elevated at 16 and OSH blood cultures taken 6 days prior to presentation to [Location (un) ] returned [3-19] positive for MRSA. Received Vancomycin, Dopamin gtt, Zosyn, decadron 4 mg IV. R SCL central line placed and pt started on sepsis protocol given hypotension, although Lactate only 1.3 and pt afebrile. In the MICU, the patient was volume repleted and his pressors weaned. Levaquin was added to the vancomycin that was started in the ED but this was stopped shortly thereafter as the pt improved only on vanco. He was started on synthroid supplementation as TSH was high and FT4 low. He received another ECHO demonstrating no change since his ER ECHO. As he was doing better following fluid repletion and was maintaining his pressure w/out support, he was called out to the floor for further management of his condition. On the floor the pt continued to be normotensive and Aldactone and Lasix were restarted. Pulsus paradoxus remained within normal limits. A repeat TTE was done and showed moderate to large pericardial effusion with marked interval increase. Further workup as below. . 2. MRSA bacteremia: Suspected source of MRSA bacteremia included recent complicated pacemaker placement at OSH (?causing chronic pericardial effusion) vs. sacral decubitus ulcer vs. vs. LE cellulitis vs. hx osteomyelitis R 2nd toe vs. infected hardware in R hip. Ankle/foot/hip x-rays w/out evidence of osteo. TTE was negative for vegetations. A TEE was positive for filamentous, mobile, echodensities on the RA pacing lead c/w thrombus or vegetation. An ID consult was obtained and it was recommended to add on Rifampin 300mg [Hospital1 ]. It was suggested to remove the device but this was not pursued as the risk of the procedure were thought to outweigh the benefits. Also, it was considered uncertain whether the vegetations on the pacemaker wires truely represented an infection. A course of Vancomycin and Rifampin for 6 weeks was suggested, until the [2161-3-27]. Then a ESR should be repeated and the Abx course should be prolonged by two weeks if the ESR is still positive. Afterwards the pt will have to stay on lifelong suppression therapy assuming the pacemaker is colonized. Doxycycline could be choosen as the MRSA is susceptible to this antibiotic. The pt should have weekly CBC/diff, BUN, Crea, ALT, AST, Alk Phos, Tbili and Vanco trough. Results should be faxed to [Telephone/Fax (1) 17715], for the ID fellow, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2505], to review. He remained afebrile on the antibiotic, WBC normalized and the pt clinically improved. A PICC line was placed to allow for outpatient antibiotic treatment. . 3. Pericardial effusion: DDx includes infectious (bacterial, fungal, viral) vs. malignant vs. mechanical related to recent PCM placement. According to the pt's cardiologists oral report the pericardial effusion hd been noted even before the PCM was placed. Echo on admission was most consistent with blood, inflammation or other cellular elements. TTE did not show any signs of tamponade or vegetations. Pulsus paradoxus remained within normal limits on the floor and the pt remained normotensive. A TEE showed a trivial pericardial effusion. A repeat TTE was done and showed moderate to large pericardial effusion with marked interval increase. On the [2161-2-25] a pericardiocentesis was performed and 450cc of serosanguinous fluid were removed. A drain was placed which subsequently yielded 180cc over the next 24 hours. The pt remained normotensive, afebrile and with negative pulsus paradoxus. The drain was removed on the subsequent day and the pt was called out to the floor for further management. Prelimninary analysis showed a negative Gram stain, negative AFB smear , no fungus isolated, Cx NTD. Cytology was pending. The pt remained normotensive with a normal pulsus paradoxus. Follow up will be with Dr. [Last Name (STitle) 1911]. Pt will have a repeat ECHO on the [2-6] at 2pm. Dr. [Last Name (STitle) 1911] will contact him with the results after that and will make an appointment with him. . 4. Hypoxia (92-95% on RA). Concerning for PE. LENIs indicated old thrombus involving the right superficial femoral and popliteal veins, no acute venous thrombosis involving either lower extremity. No evidence for PE on CTA. Most likely related to pt's chronic lung changes and OSA. Pt on oxygen 2l as needed on ambulation at home as well as on BIPAP at home. Home BIPAP settings were continued in the hospital. PFTs are recommended as on outpatient. . 5. RLE cellulitis with osteomyelitis: Cellulitis continued to improve and was resolved on day four of admission. Bone scan was suggestive for osteomyelitis in the R ankle. Vancomycin treatment as above. . 6. Sacral decub ulcer: no sign of infection. Wound care consult obtained: suggested wound gel (Duoderm gel) then Duoderm layer on top. Protect with dry foam adhesive over entire area. The pt was placed in a Kinair bed to allow for better healing. Ft was adviced on frequent turning. . 7. CHF: EF 55% on ECHO. BNP > 300 at outside hospital. Aldactone and Lasix were restarted on day three of admission. As the BP normalized, diureses was enforced until pt reached a euvolemic state. The pt was weaned of oxygen and was kept I/o even during the rest of the hospital stay. . 8. Afib s/p PCM placement: rate well controlled. Pacemaker was interrogated and was functioning as expected. Pt continued on amiodarone. Anti-coagulation was held as it was thought to possibly aggravate pericardial effusion and pt also had recent hx of GIB. Aspirin 325 was started. . 9. Hypothyroidism: Pt was found to be hypothyroid with a TSH of 20. Synthroid supplementation was initiated. Further workup should be pursued as an outpatient . 10. Anemia: concerning for GIB as pt with recent GIB (EGD and colonoscopy negative at OSH), but guaiac negative during admission. Hemolysis labs negative. No suggestions for bleeding from other sources. Received 1U of blood [2161-2-14]. IRon studies c/w anemia of chronic disease. Vit B12 and Folate normal. Started on iron supplements. . 11. Adrenal mass: Left adrenal lesion, 2.8x2.1cm, incompletely characterized. Further evaluation is recommended with MRI examination. Medications on Admission: Oscal Vit D Lasix 40 Lipitor 10 Flomax 0.4 Lexapro 20 Provigil Advair amiodarone 300 ditropan 5 aldactone 25 colace 100 [Hospital1 ] KCl prn FeSO4 Protonix 40 Vantin 100 mg PO BID X 10 days (started [2-8]) Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours): To be continued through [2161-3-27]. If ESR elevated at that time, continue for another 2 weeks. 2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 3. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 4. Diclofenac Sodium 0.1 % Drops Sig: One (1) drop Ophthalmic QID (4 times a day). 5. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): To be continued through [2161-3-27]. If ESR elevated at that time, continue for another 2 weeks. 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 8. Ferrous Sulfate 325 (65) 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. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane TID (3 times a day) as needed. 16. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO QD (). 17. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 20. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED). 21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 22. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection Q8H (every 8 hours). 24. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 25. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Lifecare of [Location (un) ] Discharge Diagnosis: Methicillin resistant staph aureus bacteremia Pericardial effusion Infected pacemaker wires Chronic lower extremity deep venous thrombosis Sacral decubitus ulcer Right lower extremity cellulitis with osteomyelitis Hypothyroidism Anemia of chronic disease Atrial fibrillation Secondary: Obstructive sleep apnea Congestive heart failure Depression Type 2 Diabetes Mellitus Gastroesophageal reflux disease Spinal stenosis Discharge Condition: Transfers with help. Moving bowels and bladder. Intermittent O2 requirement, occasionally uses home O2. Discharge Instructions: You will be on antibiotics for the next few weeks, until [2160-3-27] at which time you will have a lab draw that will help to determine how much longer you will need them. Once you are finished with the antibiotics through your IV line, you will go on oral antibiotics that you will be on indefinitely to keep the infection under control. You should tell the doctors/nurses at rehab if you have any symptoms that are concerning to you, such as fevers/chills, chest pain, shortness of breath, rapid heart beat, etc. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4340], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2161-3-24] 11:00 . You should follow up with your primary care doctor within the next couple of week. Please call to make an appointment: [Last Name (LF) 11375],[First Name3 (LF) ] R. [Telephone/Fax (1) 31592]. . You have a repeat ECHO on the [2-6] at 2pm. Dr. [Last Name (STitle) 1911] will contact you with the results after that and will make an appointment with you.	[ "428.0", "530.81", "682.6", "285.9", "427.31", "423.9", "285.29", "780.57", "250.00", "996.61", "995.91", "730.26", "038.11", "707.03", "244.9", "496", "V43.64", "V09.0" ]	icd9cm	[ [ [] ] ]	[ "37.0", "99.04", "38.93", "37.21", "00.13", "88.55" ]	icd9pcs	[ [ [] ] ]	15446, 15505	6255, 12718	252, 285	15969, 16077	2749, 6232	16646, 17176	2218, 2222		12983, 15423		15526, 15948		12744, 12960			16101, 16623									2237, 2730																						201, 214									313, 1484																		1506, 2038	2054, 2202
6,287	102,507	805	Discharge summary	report	Admission Date: [2106-10-31] Discharge Date: [2106-11-15] Date of Birth: [2028-12-1] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Ciprofloxacin / Penicillins Attending:[First Name3 (LF) 2297] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 77 year-old female with osteoporosis and multiple vertebral compression fractures status post vertebroplasty and kyphoplasty last [10-8] by Dr. [Last Name (STitle) 5730] at [Hospital1 2025] (T10), also with COPD and bronchiectasis on home oxygen 2L/min for 1 month, and chronic hyponatremia secondary to SIADH, who presents from home with increasing back pain. * She reports that she has baseline back discomfort from her multiple previous interventions, but has noted significant worsening in the past 2 days, bilateral with midline sparing, wrapping around to axilla bilaterally, worse at the level of her most recent surgery but also diffuse. She denies paresthesia or new extremity weakness, no difficulty urinating or defecating. She denies fever or chills. On a different note, she reports chronic severe shortness of breath, stable over the past month, for which she uses 2L home oxygen. She denies phlegm production, no chest pain, and endorses mild chronic LE edema which has been attributed to her Norvasc. She sleeps with multiple pillows due to her kyphosis and SOB, no change recently. * In ED, T 98.2, HR 76, BP 182/75, RR 24, Sat 100% on 2L/min. T and L-spine X-rays did not reveal new fractures, CXR with findings consistent with bronchiectasis, CT chest without PE but with interval increase in bronchiectatic and peribronchial inflammatory changes. She was evaluated by neurosurgery, deemed to be intact neurologically. She is being admitted for ongoing pain control. Past Medical History: # chronic back pain, compression fractures # COPD with bronchiectasis dx [2080]. [2103] with MYCOBACTERIUM KANSASII and pseudomonas. # hemorrhoids # hemorroidal prolapse with GIB # SIADH # perirectal abscess s/p I/D in [3-7] # Pulmonary nodules # Lower extremity edema # osteoporosis # mitral valve prolapse # spinal stenosis # 1+ MR, [1-4]+ TR, 1+ AR echo [2103] # multi-nodular thyroid Social History: The patient has a 7.5 pack year history, but quit >40 years ago, occasional alcohol use, and no other drug use. The patient lives with adult daughter in [Name (NI) 4288]. Family History: non contributory Physical Exam: T 97.6, HR 96 (73-96), BP 142/78 (138-142/76-78), RR 22, 100%2L/min. GEN: Cachectic, kyphotic elderly female, in NAD. HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM, no oral ulcerations, no LAD, no decreased ROM NECK: No carotid bruit. JVP less than 5cm ASA. RESP: Early inspiratory crackles, R>L, worse in upper thorax, heard both anteriorly and posteriorly, without bronchial breathing. CVS: RRR, S1/S2, Faint systolic murmur heard at RUSB, without radiation. GI: Soft, non-tender. EXT: Trace bilateral ankle edema. NEURO: CN II-XII intact, 4/5 strength in all extremities MSK: There is no midline spine tenderness. She has tenderness to palpation in paraspinal areas bilaterally. no CVAT Pertinent Results: labs: [2106-10-30] 04:50PM BLOOD WBC-11.8* RBC-3.95* Hgb-12.1 Hct-33.8* MCV-86 MCH-30.7 MCHC-35.8* RDW-13.0 Plt Ct-445* [2106-11-2] 06:57AM BLOOD WBC-10.7 RBC-4.03* Hgb-11.5* Hct-36.2 MCV-90 MCH-28.6 MCHC-31.9 RDW-13.0 Plt Ct-562* [2106-10-30] 05:50PM BLOOD D-Dimer-1229* [2106-10-30] 04:50PM BLOOD Glucose-87 UreaN-20 Creat-0.4 Na-129* K-4.1 Cl-86* HCO3-33* AnGap-14 [2106-11-1] 06:35AM BLOOD Glucose-91 UreaN-17 Creat-0.4 Na-129* K-4.4 Cl-87* HCO3-36* AnGap-10 [2106-11-3] 06:35AM BLOOD Glucose-104 UreaN-18 Creat-0.4 Na-126* K-4.3 Cl-84* HCO3-37* AnGap-9 [2106-11-1] 06:35AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 [2106-11-1] 06:35AM BLOOD TSH-0.37 . Imaging: CTA CHEST W&W/O C &RECONS [2106-10-30] 8:31 PM IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Extensive bronchiectasis and peribronchial inflammation is again seen, with nodular opacities adjacent to these areas suggesting mucoid impaction or inflammation. These findings have increased in comparison to prior study. 3. Extensive compression deformities within the thoracic spine, with changes related to vertebroplasty. 4. Hypodensity within the left thyroid gland and an exophytic thyroid nodule extending inferiorly. . CT T-SPINE W/O CONTRAST [2106-10-30] 8:31 PM IMPRESSION: Again seen are multiple compression deformities within the thoracic and lumbar spine, with mild narrowing of the spinal canal, greatest at T11/12 level. There is very limited evaluation on CT of intrathecal contents, representing a concern for cord abnormality, and further evaluation with an MRI should be obtained. NOTE ADDED IN ATTENDING REVIEW: Agree overall with above. There is severe, diffuse osteopenia with thoracic kyphoscoliosis, but no evidence of acute alignment abnormality. The severe T7 and less marked T6 (and L4) compression deformities are of indeterminate age, and an acute component cannot be excluded; in this regard, comparison with prior (outside) cross-sectional studies would be helpful. The moderate ventral spinal canal narrowing at the T12 level reflects retropulsion of that dorsal vertebral cortex. No definite vertebroplasty material is identified within the epidural space. . L-SPINE (AP & LAT) [2106-10-30] 5:50 PM IMPRESSION: Interval increase in the number of vertebral bodies, status post kyphoplasty. Probable upper thoracic spine compression fractures, however, this is inadequately evaluated on this examination secondary to motion. . T-SPINE [2106-10-30] 5:50 PM IMPRESSION: Interval increase in the number of vertebral bodies, status post kyphoplasty. Probable upper thoracic spine compression fractures, however, this is inadequately evaluated on this examination secondary to motion . CHEST (PA & LAT) [2106-10-30] 5:50 PM IMPRESSION: 1. Stable appearance of the chest with upper lobe interstitial densities and bronchiectasis, stable. 2. COPD. . ECHO Study Date of [2106-11-1] Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no left ventricular outflow obstruction at rest or with Valsalva. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([1-4]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2103-9-10], estimated pulmonary artery systolic pressure is similar. Right ventricle cavity size may now be larger. . MR THORACIC SPINE W/O CONTRAST [2106-11-2] 9:36 AM IMPRESSION: 1. 1.3-cm well defined round lesion in the posterior part of the T5 vertebral body, which is indeterminate. Malignancy cannot be excluded based on this appearance. 2. Edema in the posterior parts of the T9 and T10 vertebral bodies, which could be related to post-vertebroplasty edema. 3. Retropulsed fragments of the collapsed vertebral bodies at various levels, contacting the cord with narrowing of the ventral canal at T7 and T12 levels; nerve root impingement at T12 level cannot be excluded, but not definitive. . Blood cultures: [6-8] GPCs (2 bottles speciated as MRSA) Brief Hospital Course: Mrs. [Known lastname ] is a 77 year-old female with osteoporosis and multiple compression deformities s/p several kyphoplasties, also with bronchiectasis and COPD, admitted with intractable bilateral back pain. Her pain proved difficult to control throughout her stay, as she was especially sensitive to narcotic medications, twice becoming nearly unresponsive after receiving them. On the second episode, when the patient was unresponsive after receiving her dose of dilaudid as well as Phenergan she was sent to the ICU when she was found to be in hypercarbic respiratory distress. She received Narcan x 2 with good effect, however the following day the patient continued to retain carbon dioxide at an amount that seemed greater than her baseline. She was started on intermittent bipap with little effect. At this time the patient's culture results returned with 6/6 bottles of GPCs, two of which were speciated as MRSA. The patient had been started on vancomycin and her white count was improving but her respiratory status continued to decline. CXR was consistent with pneumonia. After 3 days of relatively stable vital signs (expecte for respiratory) in the ICU, while on vancomycin for her bacteremia, the patient suddenly went into afib at 170s. Her BP dropped to as low as 53 systolic. These values were only minimally responsive to a total of 3L of IVF, and 7.5 metoprolol IV. Several prolonged discussions were had with the patient and her daughter [Name (NI) 5731], as well as her friend [Name (NI) ], addressing code status, beginning on her day of transfer to the MICU and continuing throughout her stay. The patient was uncertain what exactly she would want done and had difficulty with this conversation, but did express several times that she did not want to be intubated. At the time of her hypotension, the patient was not able to communicate her wishes. Per discussion with the overnight ICU attending, the patient's daughter, and the resident on-call who was quite familiar with the patient and her daughter, the patient was made DNR/DNI and the decision was made not to insert a central line but to give support IVF only. The patient's BP remained low, staying in the 60s for several hours with minimal UOP. She remained on bipap and became less responsive over the several hours. Her bipap was eventually removed at her daughter's request. The patient became apneic and was pronounced at 3:15am on [2106-11-15]. Medications on Admission: Celexa 15 mg daily Lopressor 12.5 mg PO TID Norvasc 2.5 mg daily Atrovent nebs [Hospital1 ]-TID prn Actonel 35 mg PO Qweek (Sun) Lorazepam 0.5 mg PO BID-TID prn Neurontin 300 mg PO BID Darvocet 100 mg PO TID Pepcid 20 mg daily Colace 200 mg daily Tums [Hospital1 ] Vitamin D 400 units daily NaCl 1gm daily Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Back Pain & Pneumonia, MRSA sepsis . Secondary Diagnosis: 1. Depression 2. COPD/BRONCHIECTASIS 3. SIADH 4. RECTAL FISSURE 5. OSTEOPOROSIS 6. H/O HYPOTHYROIDISM Discharge Condition: deceased, DNR/DNI Discharge Instructions: deceased Followup Instructions: deceased Completed by:[2106-11-15]	[ "507.0", "253.6", "396.3", "397.0", "V09.0", "995.92", "427.31", "733.00", "451.84", "E937.8", "518.81", "999.2", "038.11", "785.52", "E935.2", "724.2", "494.0", "338.29" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10772, 10787	7912, 10378	333, 340	11010, 11029	3307, 7889	11086, 11126	2541, 2559		10743, 10749		10808, 10808		10404, 10720			11053, 11063									2574, 3288																						284, 295									368, 1899			10885, 10989		10827, 10864													1921, 2331	2347, 2525
8,467	166,733	18392	Discharge summary	report	Admission Date: [2138-3-26] Discharge Date: [2138-4-7] Date of Birth: [2064-4-16] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2186] Chief Complaint: Transfer from [Hospital 1474] hospital for epidural abscess Major Surgical or Invasive Procedure: 1. Partial vertebrectomy of L3 and L4. 2. Fusion at L3-L4. 3. Vertebral Spacer at L3-L4. 4. Anterior instrumentation L3-L4. 5. Autograft, bone morphogenic protein, and allograft. 6. Debridement 7. Incision and drainage 8. Echocardiogram History of Present Illness: 73yo M transferred from [Hospital 1474] hospital for epidural abscess. Pt has h/o colon can to liver, s/p resxn with serosal implants in [9-22]. Pt states he has been receiving chemotherapy up until 1 week ago. States he first developed back pain 5 weeks ago but was still able to ambulate with his cane. Last week it was worse and he was seen in clinic. An MRI was done and this showed a signal abno in L3 L4 ?disciitis vs osteo without a definitive epidural abscess. Initially on Vanc and Cipro on Friday but then seen by ID who reccommended no abx but a bone biopsy, blood cx. He was also seen by spine who repeated the MRI and this showed L3-4 osteomyelitis and discitis and an epidural abscess, 5cm. He was subsequently restared on Vancomycin for Corynebacterium in blood cx from Fri; Followup cx has been NGTD. CXR also showed small pleural effusion and attempt was made to tap it, but pt did not tolerate the procedure and asked that it be deferred. He did undergo a CT-guided aspiration/biopsy at the L3-4 disc space on [2138-3-26] and the pt was transferred to [Hospital1 18] immediately following this. No results from this were sent. . Currently pt denies sensory deficits or weakness. States he is not able to walk because of severe pain. States pain is worst when he sits up or twists his back. No bowel or bladder incontinence. Past Medical History: -epidural abscess -colon cancer with mets to liver s/p resection [9-22]. Oncologist is Dr. [Last Name (STitle) 1132]. -CAD s/p CABG x4 in '[34]. -hypercholesterolemia -DM with neuropathy. -persistent R foot ulcer Social History: Lives alone in apartment in [Location (un) 1475]. Is married but "separated" from his wife, although they still help each other - he states he gives her one of his pensions and she helps him with medicines etc. Quit tobacco in [2121] after smoking 1 ppd for "a very long time". Drank ETOH heavily until 8 years ago when he quit. Denies IVDU. Has children but they are not nearby. Family History: NC Physical Exam: 98.6, 104/50, 96, 20, 96% RA Gen: in NAD, but winces in pain with movements of his back. HEENT: Clear OP, MM very dry. NECK: Supple, No LAD, No JVD CHEST: Port a cath in R chest, no erythema or tenderness. CV: RR, NL rate. NL S1, S2. II/VI SEM at LSB with radiation to apex. LUNGS: + crackles at L base>R base. ABD: Pt very tense in abdomen (states belly is fine, but he is weary of his back). Well healed midline scar from chest down to pubis. No HSM. EXT: No edema. Dressing c/d/i over R LE ulcer. 1+ DP pulses BL NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout, though weary of moving back. Back: + ttp of lumbar spine and paraspinal muscles, R>L. No erythema or swelling noted. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Na: 135, K 4.5, Cl 96, CO2 27, BUN 12, Cr 0.7, Glu 167, Ca 8.4, Vanco trough 13, WBC 5.3, Hct 32.0, plt 330, INR 1.0. . No culture data was sent. . STUDIES: MRI lumbar spine ([Hospital1 1474] [2138-3-25]): L3-4 osteomyelitis, discitis , and epidural abscess. Degenerative changes including multilevel central spinal stenosis. Impression on teh anterior aspect of the lower spinal cord at T11-12 by disc bulge. Addendum: Findings are c/w paraspinous extension of infection anteriorly and laterally into the medial aspects of the psoas muscles bilaterally at the L3 and L4 levels. . CXR ([Hospital1 1474] [2138-3-24]): Persistent unchanged L mid and lower lung field airspace disease with moderate L pleural effusion. Brief Hospital Course: 73 yo M transferred from [Hospital1 1474] with h/o colon cancer with known liver mets now with epidural abscess and corynebacterium bacteremia: . # Epidural abscess: The patient was evaluated by orthopedic spine consult service and ID. He was continued on IV vancomycin throughout his course and had therapeutic troughs. The patient was taken to the OR twice with orthopaedics. Please see the operation notes for details about the surgeries. The patient was briefly admitted to the ICU for low hematocrit and hyponatremia immediately following the surgery but was then transferred back to the floor in stable condition. The patient had a PICC line placed and will continue a 8 week course of antibiotics. The patient will also wear a back brace at all times while out of bed. . # Candidemia: The patient was noted to have a positive blood culture from [3-27]. The patient was started on Diflucan. Ophthalmology was consulted and ruled out ocular spread. The patient's portocath was removed. The tip was culture negative. The patient will get a total of a two week course of Diflucan. . # Corynebacterium bacteremia: presumably Corynebacterium in epidural abscess as well. The patient had no blood cultures to grow corynebacterium while hospitalized. . # Pleural effusion:The patient was noted have an effusion on CXR. IP was consulted and did a thoracentesis. The tap was negative for malignant cells. A repeat CT was done showing nodular thickening along the right major and minor fissure, concerning for intrapleural tumor implants. IP reviewed the films and recommended continue oncologic care according to outpatient course and pleurodesis if the pt becomes symptomatic [2-21] fluid accumulation. The patient will follow up with his oncologist. . # Foot ulcer: diabetic ulcer s/p surgery but never healed. Wound care was consulted and made recommendations for ulcer care. His dressings were changed by the nursing staff accordingly. #Anemia: His HCT remained stable post-surgery. The patient was continued on his iron supplements. Medications on Admission: -Iron Sulfate 300mg po tid -Procrit 40,000 units SC qFriday -Lovenox 40mg SC q24 for DVT ppx -Albuterol/Atrovent nebs q4 -Morphine 2-4mg IV q3-4 prn -Mylanta 30cc po q6 prn -Pepcid 20mg po daily -insulin sliding scale -glipizide 5mg po bid -metformin 500mg po bid -metoprolol 50mg po daily -Vancomycin 1.5gm q12 hours Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 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. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 14 days. 12. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 7 days. 13. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): To finish on [2138-5-27]. 17. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 19. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous at dinner time. 20. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1) Subcutaneous four times a day: As directed by sliding scale-please see attached scale. Discharge Disposition: Extended Care Facility: [Hospital ] rehab & skilled care center Discharge Diagnosis: Primary diagnosis: Epidural abscess Secondary diagnosis: -colon cancer with mets to liver s/p resection [9-22]. -CAD s/p CABG x4 in '[34]. -hypercholesterolemia -DM with neuropathy. -persistent R foot ulcer Discharge Condition: Stable, afebrile Discharge Instructions: You were diagnosed with an epidural abscess. Continue to take the antibiotics as directed. Take the pain medication as directed and do not drive while taking this medication. Call the doctor or return to the ED for: -fever>102 -chest pain or shortness of breath -worsening pain or weakness in your legs, loss of bowel or bladder function or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6400], MD Phone:[Telephone/Fax (1) 457] on [2138-5-15] at 11:00am. Please follow up with Dr [Telephone/Fax (1) 50646]-[2138-04-18] at 10:00am. Please follow up with Dr. [Last Name (STitle) 1132], your oncologist, in [2-22] weeks	[ "V45.81", "707.13", "996.62", "197.7", "357.2", "V02.4", "730.08", "197.2", "276.1", "250.60", "722.93", "272.0", "567.31", "V58.67", "V58.65", "790.7", "V10.00", "197.0", "112.5", "324.1", "250.80" ]	icd9cm	[ [ [] ] ]	[ "84.51", "34.91", "81.06", "38.93", "84.52", "03.09", "81.62", "83.39", "99.04", "86.05", "80.51" ]	icd9pcs	[ [ [] ] ]	8734, 8804	4241, 6304	335, 581	9063, 9082	3484, 4218	9503, 9853	2639, 2643		6672, 8711		8825, 8825		6330, 6649			9106, 9480									2658, 3465																						232, 297									609, 1970			8882, 9042		8844, 8861													1992, 2218	2234, 2623
28,808	178,431	13021	Discharge summary	report	Admission Date: [2138-12-28] Discharge Date: [2139-1-4] Date of Birth: [2077-10-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization and IABP insertion [12-29] Coronary artery bypass grafting with left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior diagonal artery. [12-30] History of Present Illness: Mr. [Known lastname 39868] is a 61 year old gentleman with a PMH signficant for CAD s/p [Known lastname 7792] in [2-21] with cardiac catheterization x2 and PTCA in [2123], HTN, [Hospital 39871] transferred from OSH for chest pain with ECG changes. The patient states that he developed chest pain yesterday morning described as [8-24] chest pressure radiating to both arms associated with dyspnea. He denies any other associated symptoms including diaphoresis, nausea, or vomiting. These symptoms lasted for approximately 30 minutes until EMS arrived and symptoms were relieved with sublingual nitroglycerin. He was taken to OSH where he was found to have ST depressions in the lateral leads. Overnight, he continued to have chest pain that was requiring additional doses of SL nitroglycerin, so he was started on a nitroglycerin gtt and transferred to OSH CCU. This morning, he continues to have lateral ST depressions although biomarker negative and was transferred to [Hospital1 18] for PCI. Of note, EMS reports that during transfer from OSH to [Hospital1 18], his nitro gtt was stopped mom[Name (NI) 11711] and the patient developed chest pain. Prior to transfer, the patient was also plavix loaded, treated with lovenox, and started on an integrillin gtt. Of note, the patient was hospitalized at [Hospital1 18] in [2138-2-16] for hematemesis secondary to [Doctor First Name ]-[Doctor Last Name ] tear with a hct of 13 complicated by a [Doctor Last Name 7792] that was medically managed. Currently, the patient is chest pain free without anginal equivalent. He also denies any shortness of breath, diaphorersis, n/v, or pain radiation to his arms or jaw. * Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PMH:Hypertension, hyperlipidemia, coronary artery disease s/p [Doctor Last Name 7792]/PTCA, Anemia, Hematemesis [2-15] [Doctor First Name ]-[Doctor Last Name ] tear/esophogeal varices-banding, ETOH abuse, Anxiety, h/o hepatic encephalopathy Social History: Alcohol Quit 2/[2138]. In past drank 1 pint/day Tobacco: Quit [2123], prior 3 ppd x 25 years. Occupation: retired Lives with wife, [Name (NI) ], in [Name (NI) 39869]. One daughter. Denies any IV, illicit, or herbal drug use. Family History: Mother died at 80yo of MI Physical Exam: Admission VS 97.9 119/79 77 18 97%2L nc Gen: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate or erythema. Neck supple without cervical LAD. CV: Nl S1+S2. ?S4. PMI at 5th intercostal space at midclavicular line. No precordial heave. JVP flat. Lungs: CTAB Abd: S/NT/ND +bs Ext: No c/c/e. Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Discharge VS 98.2 106/67 62 18 95%RA General: pleasant to speak with Chest: Lungs clear. Sternum stable, dry and intact. Slight erythema at distal pole COR: Regular Abdomen: soft and nontender with normoactive bowel sounds Extremities: trace edema Pertinent Results: [2138-12-28] 09:02PM CK(CPK)-47 [2138-12-28*] 09:02PM CK-MB-NotDone cTropnT-0.02 [2138-12-28] 03:52PM GLUCOSE-80 UREA N-15 CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [2138-12-28] 03:52PM WBC-6.7 RBC-3.64# HGB-11.7# HCT-32.0* MCV-88# MCH-32.0 MCHC-36.4* RDW-14.2 [2138-12-28] 03:52PM PLT COUNT-180 [2138-12-28] 03:52PM PT-14.7* PTT-145.4* INR(PT)-1.3* [Known lastname ],[Known firstname ] [Medical Record Number 39872] M 61 [2077-10-31] Cardiology Report C.CATH Study Date of [2138-12-29] BRIEF HISTORY: This is a 61 year old male witwh hypertension, hyperlipidemia, coronary artery disease with 2 prior NSTEMIs who developed rest angina. He was evaluated at an outside facility and found to have ST depressions laterally on ECG, without cardiac enzyme elevation. He was referred for cardiac catheterization for persisting chest pain. INDICATIONS FOR CATHETERIZATION: CAD. Rest angina. PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French left [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 5 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 30cc wire guided catheter, inserted via the right femoral artery. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 100 ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 90 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 80 8) DISTAL LAD DISCRETE 80 9) DIAGONAL-1 DIFFUSELY DISEASED 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 15) OBTUSE MARGINAL-2 DISCRETE 100 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 01 hour36 minutes. Arterial time = 01 hour36 minutes. Fluoro time = 3 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 100 ml, Indications - Renal Premedications: Versed 0.5mg iv Fentanyl 50mcg iv Integrilin 10.8 ml/hr iv Nitroglycerine 100mcg/min iv Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Other medication: Nitroglycerine 60mcg/min iv Atropine 0.5mg iv Nitroglycerine 0.4mg sl Cardiac Cath Supplies Used: 8.0MM ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC - ALLEGIANCE, CUSTOM STERILE PACK - [Company ], LEFT HEART KIT 5.0MM [Company ], MULTIPACK COMMENTS: 1. Selective coronary angiography of this right dominant system revealed severe 3 vessel coronary artery disease. The LMCA was not obstructed. The LAD had serial stenoses: 90% proximal, 80% mid and distal. D1 had diffuse disease. The LCX did not have obstructive disease, but OM1 had severe diffuse disease, and OM2 was occluded in the mid portion. The RCA was occluded proximally, with left to right collaterals to the PDA. 2. Limited resting hemodynamics revealed normal systemic arterial pressures with a central aortic pressure of 104/62 mm Hg. 3. A 8F 40cc intraaortic baloon pump was placed and positioned at the level of the carina, with good diastolic augmentation. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful placement of an intraaortic balloon pump. ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. CARDIOLOGY FELLOW: [Last Name (LF) ],[First Name3 (LF) ] H. ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] M. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 39873]Portable TTE (Complete) Done [2138-12-29] at 3:43:38 PM FINAL Inpatient DOB: [2077-10-31] Age (years): 61 M Hgt (in): 70 BP (mm Hg): 95/53 Wgt (lb): 145 HR (bpm): 80 BSA (m2): 1.82 m2 Indication: Abnormal ECG. Chest pain. Coronary artery disease. ICD-9 Codes: 786.51, 414.8, 424.0 Test Information Date/Time: [2138-12-29] at 15:43 Interpret MD: [Name6 (MD) ] [Name8 (MD) 4082], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ], RDCS Doppler: Full Doppler and color Doppler Test Location: West CCU Contrast: None Tech Quality: Adequate Tape #: 2008W058-1:06 Machine: Vivid [7-22] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.7 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.4 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 256 ms 140-250 ms Findings Images obtained on IABP 1:1. LEFT ATRIUM: Normal LA and RA cavity sizes. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal aortic diameter at the sinus level. Focal calcifications in aortic root. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. CLINICAL IMPLICATIONS: Based on [2137] 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. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2138-12-29] 16:34 Brief Hospital Course: Patient with known coronary artery disease, seen at outside hospital. He had persistent lateral ST depressions at OSH, although he has been cardiac biomarker negative, given ECG and persistent chest pain when off nitroglycerin gtt, concerning for ACS. He was plavix loaded and started on ASA, statin, beta blocker, integrillin gtt, lovenox, and nitro gtt and transferred to [Hospital1 18] for cardiac catheterization. The patient was taken to cardiac cath on [2138-12-29] which showed 3 vessel disease and serial LAD lesions. An intra-aortic balloon pump was placed and the patient was transferred to the CCU to await cardiothoracic surgery. He was initially chest pain free after the cath. He was taken to CT surgery the morning of [2138-12-30] where he had coronary artery bypass grafting x3 with left internal mammary to left anterior deceding artery, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior diagonal artery. Please see OR report for details. He tolerated the operation well and was transferred to the intensive care unit in stable condition. He remained hemodynamically stable in the immediate post-op period was neurologically intact and extubated within hours of arrival to ICU. He continued to progress and his Intra aortic ballon pump was removed on POD1. On POD2 he was transferred to the stepdown floor for continued care and monitoring. He experienced some paroxysmal atrial fibrillation and was started on Coumadin. His medications were titrated, activity progressed and on POD 5 he was discharged home with visiting nurses. Medications on Admission: Aspirin 325 mg daily Metoprolol 50 mg po bid Ursodiol 0.5 mg [Hospital1 ] simvastatin 20 mg daily lisinopril 5 mg daily Omeprazole 20 mg daily 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 8. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: Take 7.5 mg [1-4] and [1-5]. Dr[Name (NI) 9654] office will call with dose to take after those days. Disp:75 Tablet(s) Refills:0 9. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: please take 7.5 mg [1-4] and [1-5]. Dr[Name (NI) 9654] office will call with dose to take after. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: s/p CABGx3(LIMA-LAD, SVG-OM, SVG-PDA)[12-30] s/p cardiac catheterization and IABP insertion [12-29] PMH:Hypertension, hyperlipidemia, coronary artery disease s/p [Month/Year (2) 7792]/PTCA, Anemia, Hematemesis [2-15] [Doctor First Name ]-[Doctor Last Name ] tear/esophogeal varices-banding, ETOH abuse, Anxiety, h/o hepatic encephalopathy Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. No powder creams or lotions on incision site. Take all medications as prescribed. Call for any fever, redness or drainage from wound sites. Followup Instructions: [Hospital 409] clinic in 2 weeks Dr [Last Name (STitle) ] in 4 weeks Dr [Last Name (STitle) 7047] 1-2 weeks for cardiology follow up. He will also follow your INR. VNA will draw labs with results to his office, and they will call with dose. Dr [Last Name (STitle) 12832] in [2-16] weeks Completed by:[2139-1-4]	[ "412", "414.2", "414.01", "401.9", "530.89", "427.31", "411.1", "997.1", "272.4", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "36.15", "37.61", "97.44", "88.56", "37.22", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]	14954, 15009	11823, 13414	333, 600	15416, 15462	3785, 4714	15716, 16053	3078, 3105		13612, 14931		15030, 15395		13440, 13589		7428, 11358	15486, 15693									3120, 3766					11381, 11800						5936, 7411										4747, 5917	283, 295									628, 2522																		2544, 2803	2819, 3062
54,444	111,972	35354	Discharge summary	report	Admission Date: [2135-2-4] Discharge Date: [2135-2-23] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Subdural hematoma of the posterior fossa with mass effect and hydrocephalus Major Surgical or Invasive Procedure: Suboccipital craniectomy and evacuation of subdural hematoma [2135-2-5] PEG placement [2135-2-22] Posterior fossa wound revision [2135-2-22] History of Present Illness: 84 yo M with 2 days of headache and weakness presented to OSH with a subdural hematoma. Pt was anticoagulated on coumadin for mechanical heart valve. Pt was given 2 units of FFP and 10 mg IV vitamin K. On admission to, pt was confused, but moving all extremities with intact facial expression. Pt's mental status decreased s/p ED transfer, and pt was intubated for GCS 5. Past Medical History: Mitral valve regurgitation with prosthetic heart valve ([Hospital 10014]) Pacemaker Gastric ulcer CHF HTN Aortic valve insufficiency Hyperlipidemia Social History: Widowed Power of attorney Nephew Physical Exam: On admission: O: T:98.0 BP: 143/67 HR: 83 R 19 O2Sats 100%RA Gen: Intubated, sedated HEENT: Pupils: 2 mm, fixed Extrem: Pale Neuro: Mental status: Intubated, sedated. Orientation: unable to assess Cranial Nerves: I: Not tested II: 2mm fixed. Motor: Moving all 4 extremities Toes upgoing bilaterally Brief Hospital Course: 84 yo M with 2 days of headache and weakness presented to OSH and was found to have subdural hematoma. Pt is anticoagulated on Coumadin for mechanical heart valve. Pt was given 2 units of FFP and 10 mg IV vitamin K. Pt was confused on admission to [Hospital1 18], but moving all extremities with intact facial expression. Pt's mental status decreased s/p ED admission, and pt was intubated for GCS 5. Patient was taken to the OR emergently for a sub occipital craniotomy for evacuation of the SDH. He went to the ICU where he was found to have a LLL PNA and antibiotic therapy with vancomycin and Zosyn was started. Heparin drip was started on [2-10] to start anticoagulation given the patients mechanical heart valve and incidentally on [2-11] a left upper extremity DVT was diagnosed. On [2-15] patient was noted to be increasingly lethargic and continuously tachypneic, a pulmonary consult was obtained, they perceived his tachypneic to be central in nature. On this day, pt. was also noted to have CSF leaking from his incision, an additional staple was placed at the site of the leak and the drainage stopped, but the wound eventually opened and he had to be taken back to the OR for a wound revision which happened on [2135-2-21]. On this hospital stay, the patient failed multiple swallow evaluations by speech therapy and received a surgical PEG by GI on [2135-2-21]. On the day of discharge, [2135-2-23] pt. was evaluated for the development of hydrocephalus via CT scan which was negative. Anticoagulation was initiated with IV heparin for both his upper extremity DVT and his pre-existing mechanical heart valve. He will go to rehab with on going therapy and he is to be monitored closely there. Medications on Admission: ASA 81 mg q day Atenolol 25 mg Docusate 100 mg [Hospital1 ] Lovenox 80 mg [Hospital1 ] Ferrous sulfate 325 mg Lasix 160 QAM, 80 mg QPM Claritin 10 mg Nitroglycerin SL PRN PPI KCL tab 40 mEq q day Prazosin 1 mg cap [Hospital1 ] Psyllium Simvastatin 20 mg q day Travoprost Warfarin 2 mg Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [12-31] Drops Ophthalmic PRN (as needed). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [Month/Day (2) ]: One (1) Appl Ophthalmic PRN (as needed). 3. Docusate Sodium 50 mg/5 mL Liquid [Month/Day (2) ]: One (1) PO BID (2 times a day). 4. Simvastatin 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 5. Prazosin 1 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: One (1) Tablet, Delayed Release (E.C.) PO at bedtime as needed. 8. Hydralazine 10 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Acetaminophen 160 mg/5 mL Solution [Month/Day (2) ]: [12-31] PO Q6H (every 6 hours) as needed for fevers/pain. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Hold for SBP <110 and HR <60. 13. Clonidine 0.2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Hydromorphone 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 17. Lasix 20 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO twice a day. 18. Heparin (Porcine) in NS 10 unit/mL Kit [Last Name (STitle) ]: One (1) Intravenous On going: IV heparin for anticoaculation, use weight base protocol to achieve theraputic PTT 40-60. . Discharge Disposition: Extended Care Facility: [Hospital 24759] [Hospital ] Rehab Hospital Discharge Diagnosis: posterior fossa subdural hematoma LUE DVT Wound dehisence Malnutrition Dysphagia Altered mentation Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Pt. is leaving to rehab on a heparin drip, he need to be anticoagulated for an upper extremity DVT and for a mechanical valve. please check his ptt at 4:00pm and six hours there after, and adjust the drip as needed to achieve a theraputic PTT ( goal 40-60) then start coumadin therapy. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in __20 _days ( from [2135-2-22]) removal of your staples or sutures. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in ___4____weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[2135-2-23]	[ "424.1", "453.8", "V43.3", "486", "E849.7", "263.9", "998.31", "997.09", "428.0", "E878.8", "432.1" ]	icd9cm	[ [ [] ] ]	[ "86.22", "01.31", "02.12", "43.11", "38.93" ]	icd9pcs	[ [ [] ] ]	5625, 5703	1478, 3223	339, 493	5846, 5854		7724, 8100			3571, 5602		5724, 5825		3249, 3548			5878, 7701									1138, 1138																						224, 301									521, 897	1365, 1455						1152, 1283	1298, 1349										919, 1073	1089, 1123
16,367	196,887	5024	Discharge summary	report	Admission Date: [2163-1-18] Discharge Date: [2163-2-7] Date of Birth: [2109-1-9] Sex: F Service: MEDICINE Allergies: Haldol / Compazine / Phenergan / Tigan / Flagyl Attending:[First Name3 (LF) 1377] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Removal of tunneled cath (previously used for tPN) History of Present Illness: 54yo F with Crohn's s/p ileostomy and subsequent short gut syndrome with port-a-cath placement for TPN who presents with progressive right sided chest pain that comes in waves. The pt reports sharp 10/10 chest pain under the right breast which is getting progressively worse. The pain is worsened with deep inspiration or movement. It initially started one day previously but has gotten significantly worse over last 12 hours. It is associated with SOB as well as fevers, chills. The pt denies abd pain, n/v or increased ostomy output. . Given her fever, sx of chest pain and SOB as well as an elevated WBC count, she was initially thought to have a PNA. She was therefore given ceftriaxone 1g IV x1 and azithromycin 500mg PO x1 in the ED. As the CXR was without any evidence of PNA, or PTX, the pt subsequently received a CTA to evaluate for PE which revealed multifocal bilateral PNA but no PE. At this time, she was given Vancomycin 1g IV x1. She was also given morphine 2mg x3, 4mg IV x2, dolasetron 12.5mg x2 and ativan 1mg IV x1. Past Medical History: 1. Crohn's disease, dx [2131] s/p three bowel resections and eventual ileostomy, resulting in short gut syndrome 2. Restless leg syndrome 3. ? Parkinsons vs. EPS side effects from risperdal 4. Chronic idiopathic pancreatitis, as demonstrated on CT in [9-26] 5. Arthritis s/p "pin placement" in left foot [5-26] 6. Degenerative disc disease s/p two back surgeries in 80's 7. Benzo and opiod addiction 8. Paranoia/Depression, h/o auditory hallucinations, ?mania 9. Port-a-Cath placement for IV hydration in setting of short gut syndrome, complicated by clotting x 4, requiring replacement . Abd CT performed [9-26] showed multiple calcifications in the body and tail of the pancreas with a larger cystic lesion in the tail of the pancreas. A second 9 mm cystic lesion is seen in the head of the pancreas. These findings are consistent with chronic pancreatitis with pseudocyst formation Social History: lives w/ her husband in [Name (NI) 86] area; smokes [5-29] cig/d (30 pack year history); no alcohol or recreational drug use, has had addiction to benzodiazepines and opioids in the past Family History: Mother-[Name (NI) 4522]; Daugher-IBS, colitis; Mother--breast CA,; Father-[Name (NI) ] tumor, no DM, no CAD Physical Exam: V: 101.4, 102, 167/54 -> 159/77, 24 -> 16, 98% RA -> 96% RA Gen: middle aged obese female lying in bed on her left side asleep, speaking slowly. appears younger than stated age HEENT: PERRL, OP clear, MMM CV: RRR, s1, s2 distant Chest: crackles at right base with [Month (only) ]. air movement. tender over right chest Abd: obese, multiple surgical scars. Ileostomy bag present with gas and stool. absomen soft, tender to palpation over RUQ, but no guarding or rebound Ext: tr edema, 2+ DP bilaterally Pertinent Results: [2163-1-18] 01:30AM GLUCOSE-208* UREA N-21* CREAT-1.3* SODIUM-138 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15 [2163-1-18] 01:30AM CK(CPK)-31 [2163-1-18] 01:30AM cTropnT-<0.01 [2163-1-18] 01:30AM WBC-14.4# RBC-3.82 HGB-11.5* HCT-33.5* MCV-88 MCH-30.2 MCHC-34.5 RDW-14.7 [2163-1-18] 01:30AM NEUTS-78.0* LYMPHS-17.0* MONOS-4.6 EOS-0.3 BASOS-0.1 [2163-1-18] 01:30AM PLT COUNT-128* [2163-1-18] 01:30AM PT-12.3 PTT-26.1 INR(PT)-1.0 . CTA [2163-1-18] - IMPRESSION: 1. No definite pulmonary embolism is identified. 2. Peripheral patchy opacities are seen bilaterally, most consistent with multifocal pneumonia. . CXR [2163-1-18] - There are faint ill-defined opacities within the right lower lung zone and left upper lung zone could represent a multifocal pneumonic process. . CXR [2163-1-27] - IMPRESSION: Multilobar pneumonia with interval worsening in the left lung but slight improvement in the right lower lobe. . Head CT [2163-2-3] - Ordered to evaluate for changes to explain delta MS CONCLUSION: Left parietal subcortical hypodensity, likely ischemic. No definite changes since the MR of in [2160-6-8]. . CXR [2163-2-3] IMPRESSION: Marked improvement. Brief Hospital Course: 54yo F with Crohn's disease s/p ileostomy with subsequent short gut syndrome with port-o-cath for TPN presents with acute onset pleuritic chest pain with fever, chills, and sob. . 1. Chest pain/Fever/Chills: The acute onset of chest pain was initially very concerning for a PE, however the Chest CT demonstrated multifocal consolidation consistent with a bacterial PNA. This is consistent with the remainder of the pt's history including fever, chills, sob and an elevated WBC count. The pt was given ceftriaxone/azithromycin/vancomycin in ED. Blood, urine and sputum culutres were sent. Pt's blood cultures came back positive for Staph Aureus and Enterococcus, both were pansensitive. Sputum culture also returned with Staph. Aureus. Ceftriaxone and azithro were discontinued, and Vacomycin was continued. Pt initially was hypoxic requiring NRB for O2 sat of 94%, with any attempt to wean she would desat. Pt was intubated prior to tunneled catheter removal, see below. (The tunneled catheter later came back for negative for culture.)Earlier that day pt had a chest x ray which showed diffuse infiltrative process concerning for ARDS. Post procedure pt remained intubated on ARDSnet protocol. She self extubated the first day and was reintubated without any complications. Her O2 requirement improved on the vent over the next few days and she was weaned off the vent on [2162-1-26]. After extubation her o2 requirement was down to 1L NC with sats in mid 90s. She was transferred to the floor for further managment. . The patient remained afebrile when she transferred to the medicine service. She was weaned off the oxygen and for the remainder of her course her O2sats were stable on room air. The patient had completed her antibiotic course while in house. 2. Hx of multiple port-o-cath clots: Although the pt is on warfarin chronically, her INR was subtherapeutic. Goal INR [2-25]. Initially coumadin was increased, however given concern for infected line, general surgery was consulted who removed the line in the ICU. . 3. ARF: Pt initially with mild [Doctor First Name 48], this was thought to be due to dehydration, after initial volume repletion her renal function improved to her baseline. . 4. Psych: The pt has a history of paranoia/depression. ON admission she was taking Quetiapine 300 mg QHS and Clonazepam 1mg QAM, 1mg Q3PM, 2 mg PO QHS. Quetiapine was continued however clonipin was initially held when she was intubated on fentynyl/versed. This was restarted post extubation. Intially after being transferred from the ICU to the medicine service the patient was mentating appropriately. Her course later became complicated by visual and auditory hallucinations. She made disturbing comments to the hospital personnel. She was unable to sleep at night, often pacing the halls. She required a 1:1 sitter. Psychiatry was consulted. They felt that her presentation was secondary to delirium and was multifactorial. They attributed it to polypharmacy, recent infection (pneumonia) and insomnia. A head CT was done which ruled out any acute processes. The patient refused an LP. They made recommendations for adjustments to her anti-psychotic medications. At discharge the patient was on clonazepam 1mg tid, seroquel 300 [Hospital1 ] and neurontin 600 QAM, 1200 QPM and 1200 QHS. The [Hospital 228] hospital course was prolonged because of her delirium. Once her mental status improved she was discharged. . 5. ?Parkinson's Disease/ Akithesia: The patient was maintained Sinemet. 6. Pain: In addition to her usual neuropathy pain, the pt initially appeared to have significant pain from the multi-focal PNA as well. (Home regimen, Gabapentin 800 mg PO QAM, 1600 mg PO Q3PM, 1600mg PO QHS. This was held in the ICU and she was given diluadid prn for pain control. The patient's narcotic and psych regimen was evaluated by psychiatry during her delirium. Please see above for their recommendations. . 7. FEN: Given her hx of ileostomy secondary to crohn's disease and resultant short gut syndrome, the pt requires nutritional support via TPN. After removal of tunneled line pt was given tube feeds while she was intubated. The patient was transitioned to a low fat, low residue diet. 8. PPX: PPI and heparin SC 9. Dispo: The patient was discharged home and instructed to follow up with her PCP. [Name10 (NameIs) ] follow up scheduled with psychiatry. Medications on Admission: 1. Quetiapine 300 mg QHS 2. Clonazepam 1mg QAM, 1mg Q3PM, 2 mg PO QHS 3. Ferrous Sulfate 325 PO Daily 4. Carbidopa-Levodopa 25-250 mg PO 5 TIMES PER DAY. 5. Gabapentin 800 mg PO QAM, 1600 mg PO Q3PM, 1600mg PO QHS 6. Heparin Lock Flush 10 unit/mL Daily as needed. 7. Saline Flush 8. Prevacid 30 mg PO twice a day. 9. Vistaril 50 mg once a day as needed for nausea. 10. Zofran 4 mg PO once a day as needed for nausea. 11. Vitamin B-12 1,000 mcg/mL One Injection every other week. 12. Vicodin 5-500 mg 1-2 Tablets PO every six (6) hours PRN 13. Warfarin 1 mg PO HS. 14. TPN Discharge Medications: 1. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: Four (4) Cap PO W/ MEALS AND SNACKS (). Disp:120 Cap(s) Refills:2 2. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO 5 TIMES A DAY (). Disp:150 Tablet(s) Refills:2 3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Disp:5 bottles Refills:2 6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:3 tubes Refills:2 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 8. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 9. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Neurontin 300 mg Capsule Sig: Three (3) Capsule PO three times a day: take 2 tabs in the morining, 4 tabs in the afternoon, and 4 tabs in the evening. Disp:100 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital6 486] Discharge Diagnosis: Pneumonia Discharge Condition: Good Discharge Instructions: You are to return to the hospital immediately if you should experience any chest pain, shortness of breath, fevers or any other worrisome symptom. . Please continue taking your medications as prescribed. Followup Instructions: Provider: [Name10 (NameIs) 19240],[Name11 (NameIs) 19241] PSYCHIATRY OPD Phone:[Telephone/Fax (1) 1387] Date/Time:[2163-2-15] 3:30 . Please followup with your primary care physician [Name Initial (PRE) 176] [1-24] weeks of discharge. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2163-6-12]	[ "V44.2", "585.9", "579.3", "996.62", "518.81", "486", "038.11", "995.92", "584.9" ]	icd9cm	[ [ [] ] ]	[ "96.72", "99.04", "38.93", "99.15", "33.24", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	10855, 10905	4504, 8928	317, 369	10958, 10964	3250, 4481	11216, 11627	2591, 2709		9551, 10832		10926, 10937		8954, 9528			10988, 11193									2724, 3231																						267, 279									397, 1435																		1457, 2362	2378, 2575
8,380	144,698	51664	Discharge summary	report	Admission Date: [2103-9-11] Discharge Date: [2103-10-1] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Hip [Hospital ] Transfer from OSH for cath Major Surgical or Invasive Procedure: LHORIF PICC placement History of Present Illness: 87 yo man with CAD s/p CABG/PTCA, ischemic CMP EF 30%, A.fib admitted to [Hospital ] Hosp on [2103-9-10] s/p fall w/ L hip fx. No h/o syncope. Patient with h/o A.fib apparently rate controlled at OSH, no ischemic EKG changes, TnI negative and CK negative, BNP 459. Echo performed showed inferolateral hypokinesis c/w ischemia and EF of 30%. Mild MR, Trace TR, mild LVH. Normal RV size and function. Patient transferred to [Hospital1 18] for cath. Upon arrival, pt was taken to cath lab, which was subsequently cancelled due to lack of evidence supporting intervention. Vitals signs unremarkable. Upon initial eval, pt denied any complaints (no sob, cp, abd pain, some shoulder pain, no leg pain). Past Medical History: 1. Ischemic CMP EF 30% 2. Paroxysmal A.fib 3. Aortic sclerosis 4. CAD s/p CABG x4 in [2078], PTCA [2089], s/p MI (remote). 5. HTN 6. PVD, carotids 50-70% on right; 80-90% on left 7. Normal pressure hydrocephalus with a right ventricular shunt [12-8] 8. GERD 9. HOH 10. Dementia 11. L hip fracture, falls x 10 [Month/Year (2) 1686] 12. h/o UTIs 13. hyperlipidemia 14. h/o depression 15. TURP x 4 --last 2 [Month/Year (2) 1686] ago, bladder scapping to ?malignant cells Social History: Worked in Wool trade. Assissted Living (Inn at [Doctor Last Name ] [Doctor Last Name ]). Widowed, wife died 1 [1-8] [Name2 (NI) 1686] ago, married 54 [Name2 (NI) 1686]. Five sons, one daughter. Denies tobacco use, alcohol socially in past. Family History: Mother died of an MI suddenly in late 60s. No CA in family. Physical Exam: VS: 98 78 150/74 20 95% RA Ht 5'7" Wt 175 lbs Gen: frail elderly M, NAD, lying flat in bed, HOH Heent: OP clear, MM dry, anicteric, PERRL Chest: Expiratory wheeze throughout. Bibasilar crackles, R>L. CVS: nl S1 S2, RRR, [2-12] <> @ RUSB, [2-12] HSM at apex Abd: soft NT/ND, BS+, no HSM appreciated Ext: warm, L leg in brace, moves toes, 2+ dp pulses b/l Neuro: HOH, responds appropriately, grossly intact Pertinent Results: At OSH: WBC 12.8 Hct 34.8 Plts 194 Cl 101 HCO3 27 Glu 125 Bun 16 Cr 1.0 Ca 9.8 TP 6.4 Alb 4.2 T.bili 0.7 AP 94 AST 15 ALT 13 Na 139 K 3.3 Cl CK 61 TnI <0.1 BNP 459 On Admission: WBC 12.9 Hct 31.3 Plts 169 Na 142 K 3.6 Cl 103 HCO3 30 Glu 117 Bun 22 Cr 1.2 Ca 8.9 Phos 4.0 Mg 2.1 Cardiac Enzymes CK CKMB TropT Hct [9-24] 9:10A 40 ND 0.68 33.9 [9-24] 6:20A 42 ND 0.63 33.8 (1U tx) [9-18] 0[Telephone/Fax (2) 107048].2 [9-18] 0110 95 0.82 [9-17] 1538 119 14 0.86 (2U tx) [9-17] 0615 147 12 0.78 23.9 [9-16] 2215 149 11 0.63 23.8 [9-16] 0416 106 15 0.51 21.7 [9-15] 0530 99 7 0.18 22.9 [9-14] [2028] 110 2 0.05 25.2 . Studies: EKG [2103-9-13]: SR at 75 bpm, RBBB, VPB, prolonged PR , old Q-waves in 2,3,aVF; these were unchanged compared to previous EKG . Echo [2103-9-11] Aortic sclerosis with adequate opening, septal knuckle, mild MR, trace TR, RV wnl, LVH, Reverse E/A ratio c/w non compliant LV, mitral annular calcification, EF of 30% with inferolateral hypkinesis c/w infarction. Per Daughter [4-11] [Month/Day (1) 1686] ago had echo with EF 40-45%. . [2103-9-15] EF 35%. 3+/4+ MR. . Carotid Duplex ([2103-9-12]): b/l 60-69% stenosis . EEG ([2103-9-14]): This is an abnormal EEG in the waking and drowsy states due to the slow background rhythm and bursts of generalized delta slowing. These abnormalities suggest a moderate encephalopathy, which may be seen with infections, medication effect, toxic metabolic abnormalities, or ischemia. . MRI/MRA head ([2103-9-14]): No acute stroke. No hemorrhage.Moderate ventriculomegaly. Diffuse thickening of the meninges most likely secondary to right parietal shunt. Old left cerebellarinfarct. Normal circle of [Location (un) 431] with no areas of abnormality. . CT Head w/out contrast ([2103-9-14]): Allowing for differences in technique from MR,no significant change. Please note that this examination is very limited by motion artifact. . CXR Pa/lat ([2103-9-18]): Interval development of bilateral basal hazy opacities which may represent multifocal pneumonia . CT Head w/o contrast ([2103-9-20]): 1) Severely motion limited study. 2) Allowing for this, no evidence of hemorrhage. 3) Ventricles are just slightly more prominent than the CT of [2103-9-14]; without a baseline study for reference, it is difficult to assess for shunt malfunction. . Neck soft tissues ([2103-9-21]): Suboptimal exam. Normal airway. . CT Head w/o contrast ([2103-9-23]): 1. No significant change in size of enlarged ventricles with shunt present in the right lateral ventricle. 2. No evidence of hemorrhage. . CXR [9-24] r/o CHF (final): 1. Small bilateral pleural effusions persist. 2. Slight interval improvement in pulmonary vascular congestion. . CTA Chest ([2103-9-24]) (final): 1. No evidence of PE. 2. Bilateral pleural effusions and atelectases. 3. Small scattered subcentimeter lymph nodes. 4. Scattered peripheral nonspecific opacities in the right upper lobe. . [2103-9-26] CATH [Last Name (LF) 60559],[First Name3 (LF) ]/C Successful placement of a 4 French single lumen 42 cm PICC by way of the right brachial vein with the tip at the cavoatrial junction. The line is ready for use. . [9-27] EEG Abnormal EEG due to the disorganized and mildly slow background and due to the bursts of generalized slowing. These slowings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There was occasional additional focal slowing in the right anterior quadrant. No epileptiform features were evident. . [9-28] CXR Mild pulmonary edema has improved substantially since [9-27] and small bilateral pleural effusions have decreased. The heart is normal size. Left lower lobe atelectasis is stable. No pneumothorax. Tip of the right PICC line projects over the right atrium. . [9-28] CXR Left base airspace disease and probable small pleural effusion, without appreciable interval change allowing for differences in positioning . [9-28] CT Left Lower Ext 1. Hematoma with layering fluid-fluid level expanding the vastus intermedius, lateralis, and rectus femoris. 2. No evidence for hardware complication. 3. Dense atherosclerotic disease of the visualized arteries. . [9-30] CXR Bibasilar atelectasis with mild hydrostatic edema. Brief Hospital Course: Pt had several issues addressed during this admission: . 1. Hip Fracture: The patient fractured his L hip in a mechanical fall. The L hip was repaired with an ORIF on [2103-9-13]. DVT prophylaxis with Lovenox 30 [Hospital1 ]. Physical therapy worked with him to improve weight bearing on his L leg. . 2. Neuro: The patient had a GTC seizure soon after hip surgery. The patient was evaluated by both neurology and neurosurgery. Neurology was concerned that his presentation of L sided weakness on the floor could represent either a new stroke or a [Doctor Last Name 555] paralysis after seizure activity. MRI/MRA of the brain was negative for an acute lesion although it did reveal an old L sided infarct. Mild ventriculomegaly was noted but, in consultation with neurosurgery, this was felt to not represent malfunctioning of his VP shunt and the decision was made to defer tapping the shunt. An EEG showed no specific seizure focus but rather demonstrated a diffuse encephalopathy c/w a toxic-metabolic derangement. He was loaded with phenytoin and tolerated the load well. His mental status improved in the ICU until he was near his baseline per his daughter, sleeping much of the day, occasionally disoriented/confused but able to answer questions and interact. He remained disoriented on the floor and phenytoin 300 daily was continued for 10 days for his seizures. Keppra was started and titrated up to 1000 [Hospital1 ], with no subsequent seizures. His mental status continued a waxing/[Doctor Last Name 688] course consistent with delerium. Geriatrics was consulted and thought his delerium was multifactorial, likely a combination of reversed day/night cycles, unfamiliar location, pneumonia and multiple medications. Soft restraints and a sitter were required for his delerium. Zyprexa was started at bedtime to help with agitation and have him sleep at night. Trazadone was started for insomnia. In the hours prior to his passing, pt was comfortable in no acute distress. . 3. CV: The patient was initially transferred for cardiac catheterization but this was deferred prior to surgery. In the ICU, an ECHO was checked and demonstrated new (since [2094]) 4+MR along with significant hypokinesis and akinesis of the LV. His cardiac medications were discontinued after his seizure and were restarted back on the floor. There were several cardiovascular sub-issues addressed during his course: a. Ischemia: Patient dropped hematocrit to 21 during his ICU stay. He had increase in CE, max troponin T of 0.86. After transfusion to 33, his CE trended downward. However, he complained of chest pain on several occasions, demanding sublingual nitrates. Patient had baseline ST depressions in V2-V5 which were stable during these events. Pt was started on isosorbide dinitrate, and thereafter pt was chest-pain free. b. CHF: Echo from [2094] showed EF of 35%. Echo on [9-15] w/ EF of 25-30%. Patient had bilateral crackles on exam consistently and evidence of pulmonary edema on multiple CXRs throughout his course. Afterload reduction with AceI and isosorbide dinitrate were started. Lasix 40 [Hospital1 ] was started on HD 14, with improvement in respiratory symptoms. Lasix was dosed both orally and IV depending on the gravity of need. Ultimately, pt's pulmonary edema became significant one day before his demise following a blood transfusion; he received Lasix and improved. However, due to continued need for transfusion, pt's family was consulted, and it was agreed that pt should be made CMO on [2103-9-30]. All measures were discontinued beyond pain management, and his respiratory status began to decline, likely in absence of diuresis. Pt ultimately died peacefully from cardiopulmonary failure, likely secondary to decompensated CHF w/ pulmonary edema. c. Rhythm: History of Afib, but Afib was not appreciated on telemetry. Metoprolol was continued until pt was made CMO. d. LV thrombus: 3 cm LV thrombus seen on ECHO. Anticoagulation with coumadin was started, goal INR [2-9]. INR to 9.1 on [9-24], recovery with vitamin K. Coumadin restarted on [9-25]. Once pt developed a left thigh hematoma, however, anticoagulation was ceased and reversal was initiated with vitamin K. e. HTN: Controlled using BB, AceI, isordil, and lasix; goal SBP > 120 (due to carotid stenosis) but < 140 (due to CHF); pt's BP was well-controlled on the floor using this regimen. . 4. Respiratory: Once transferred to floor, patient became tachypneic w/ RR 25-40 and appeared to be in moderate distress. Distress resolved with ipratropium neb. CXR revealed bilateral infiltrates suggestive of pneumonia. Zosyn was added to patient's regimen for 6 days and Levofloxacin/flagyl for 3 days. Repeat CXR showed resolution of infiltrates but respiratory distress remained. Neck soft tissue film showed no evidence of oropharyngeal or tracheal abnormality. After restarting home Lasix, respiratory status improved; oxygen, prn Lasix, and Atrovent nebs were the mainstays of pt's respiratory support. . 5. Fever: The patient developed low grade temps in the ICU that were first attributed to post-surgical atelectasis. However, on the day prior to call-out his BCX grew GPC and he was started on vancomycin. No speciation was available at the time of call out to tailor therapy. However, based on the cultures being positive in [2-14] bottles this may represent a skin contamination. Patient was on vancomycin for 7 days. Subsequent blood cultures were negative. Pt remained afebrile for the remainder of his course. . 6. Hypernatremia: Due to poor po water intake, patient had serum sodium up to 147, with a free water deficit of 2.1L. He was initially encouraged to drink thickened water, with no benefit. 1L of free water was given by IV. Once CMO was instituted, pt's sodium continued to rise. . 7. Left Thigh Hematoma: on [9-29] pt developed a swollen, tender, firm left thigh, but retained distal dorsalis pedis pulses; sensation was difficult to ascertain given pt's ALOC. CT of the LLE revealed a hematoma expanding the vastus intermedius, lateralis, and rectus femoris muscle bellies. Given the proximity of this hematoma to pt's ORIF on [2103-9-13], orthopedic attending E.K. [Doctor Last Name 1005] was consulted and evaluated pt. Dr. [Last Name (STitle) 1005] did not advise draining the hematoma given the high likelihood of reexpansion; rather, he opted for reliance on tamponade effect slowing blood collection, INR reversal with vitamin K, and stopping anticoagulation as a means of therapy. The medicine team agreed with this approach, and serial HCTs were followed. Pt's HCT remained unstable (although vitals were unchanged), so he was transfused several units (each followed by lasix for developing pulmonary edema) until pt's family agreed to CMO on [2103-9-30]. . Pt's last living examination was performed at 08:30 AM on [10-1], when he was breathing but failed to respond to verbal or touch; his lung sounds were congested bilaterally, but were not significantly changed from his inpatient baseline. He was comfortable and in no acute distress. At 09:00, pt was found breathless; examination revealed the following: unresponsive to noxious stimuli, no breath sounds, no heart sounds, no carotid pulse, pupils fixed and dilated at 5 mm w/o reaction to light, and no corneal reflex. Pt was pronounced dead at 09:00 on [2103-10-1]. Upon his passing, pt's daughter was [Name (NI) 653]; autopsy was offered, but the family deferred. Pt's PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 13013] of [Hospital ] Medical Associates, was notified of his passing. Medications on Admission: Outpatient Medications - ASA EC 325 mg daily - Coreg 12.5 mg [Hospital1 ] - Lexapro 5 mg daily - Norvasc 10 mg daily - Fibercom 625 mg [Hospital1 ] - Nexium 40 mg daily - Imdur 20 mg daily - Proscar 5 mg daily - Nitro TP 0.2 mg/hr daily, removed at bedtime - Lasix 40 mg [Hospital1 ] - Lisinopril 20 mg daily - Lipitor 10 mg daily Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1. Left Hip Fracture s/p ORIF w/ subsequent hematoma. 2. NSTEMI. 3. Systolic Heart Failure EF ~ 25% 4. Atrial Fibrillation. 5. LV Apical Thrombus. 6. Generalized Tonic-Clonic Seizure - Left Sided [Doctor Last Name 555] Paralysis. 7. Aspiration Pneumonia. 8. Delirium. 9. Malnutrition - Moderate Degree. Secondary: 1. Dementia. 2. Normal Pressure Hydrocephalus s/p VP Shunt. 3. Coronary Artery Disease s/p CABG 4. Ischemic Cardiomyopathy 4+ Mitral Regurgitation. Discharge Condition: Deceased. Discharge Instructions: None. Followup Instructions: None. Completed by:[2103-10-2]	[ "428.41", "507.0", "V45.82", "349.82", "331.3", "518.81", "V45.2", "401.9", "E885.9", "780.39", "820.21", "584.9", "276.0", "780.6", "410.71", "344.89", "427.31", "294.10", "412", "V45.81", "433.10", "263.9", "293.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "99.07", "38.93", "79.15", "99.04" ]	icd9pcs	[ [ [] ] ]	15168, 15183	7040, 14745	307, 330	15713, 15724	2385, 2550	15778, 15814	1875, 1936		15139, 15145		15204, 15204		14771, 15116			15748, 15755									1951, 2366																						221, 269									358, 1071					15223, 15692		2564, 7017											1093, 1582	1598, 1859
47,874	165,554	35530	Discharge summary	report	Admission Date: [2177-8-6] Discharge Date: [2177-8-18] Date of Birth: [2121-4-11] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Dilaudid / Codeine Attending:[First Name3 (LF) 5790] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: Flexible bronchoscopy with bronchoalveolar lavage and aspiration; right thoracotomy with tracheoplasty with mesh, right main-stem bronchus and bronchus intermedius bronchoplasty with mesh, and left main-stem bronchus bronchoplasty with mesh History of Present Illness: 56-year-old woman who has COPD and also severe diffuse tracheobronchomalacia. She underwent a Y-stent trial and had a remarkable improvement in her dyspnea with the stent in place. Ms. [Known lastname 80906] does have significant COPD, and prior to the operation, a long discussion was held with her in regard tothe fact that we would only be fixing the central airways with a stabilization via tracheobronchoplasty, but we would certainly not be improving her lung function. In addition, given her quite impaired lung function, we were concerned that she might have some more difficulty getting through an operation of this magnitude. Nonetheless, she wished to proceed, and given the fact that her stent trial was as remarkably positive as it was, we elected to proceed. Past Medical History: COPD, high cholesterol, ?OSA, HH/reflux, hypothyroid, distant seizure history, DM2 Social History: She is married and lives with her husband. She has taken voluntary retirement due to her respiratory problems. She denied any consumption of alcohol. She is an ex-smoker who quit 8 years ago having accumulated at least 30-pack years smoking. Family History: Father died of silicosis. Mother died of ischemic heart disease. Pertinent Results: [2177-8-6] 09:00AM BLOOD WBC-5.3 RBC-4.88 Hgb-13.2 Hct-41.5 MCV-85 MCH-27.0 MCHC-31.7 RDW-14.0 Plt Ct-379 [2177-8-9] 02:55AM BLOOD WBC-3.1* RBC-3.00* Hgb-8.2* Hct-25.6* MCV-85 MCH-27.3 MCHC-32.0 RDW-15.0 Plt Ct-220 [2177-8-12] 02:46AM BLOOD WBC-2.4* RBC-3.23* Hgb-8.6* Hct-27.7* MCV-86 MCH-26.6* MCHC-31.0 RDW-14.4 Plt Ct-295 [2177-8-15] 04:20AM BLOOD WBC-7.1# RBC-3.29* Hgb-8.7* Hct-28.2* MCV-86 MCH-26.5* MCHC-30.8* RDW-14.6 Plt Ct-352 [2177-8-6] 09:00AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-141 K-4.3 Cl-100 HCO3-31 AnGap-14 [2177-8-6] 09:00AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-141 K-4.3 Cl-100 HCO3-31 AnGap-14 [2177-8-8] 12:56PM BLOOD Glucose-150* UreaN-18 Creat-1.0 Na-134 K-4.7 Cl-101 HCO3-28 AnGap-10 [2177-8-11] 02:36AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-26 AnGap-15 [2177-8-15] 04:20AM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-144 K-3.6 Cl-102 HCO3-33* AnGap-13 [2177-8-6] 06:05PM BLOOD CK(CPK)-1055* [2177-8-7] 03:33AM BLOOD CK(CPK)-2673* [2177-8-7] 10:00AM BLOOD CK(CPK)-3515* [2177-8-7] 05:24PM BLOOD CK(CPK)-2700* [2177-8-8] 03:11AM BLOOD CK(CPK)-1710* [2177-8-7] 10:00AM BLOOD CK-MB-31* MB Indx-0.9 [2177-8-6] 06:05PM BLOOD CK-MB-37* MB Indx-3.5 [2177-8-15] 04:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 [2177-8-15] 08:37AM BLOOD Vanco-19.5 [2177-8-14] 03:28AM BLOOD Vanco-22.0* [2177-8-13] 01:54AM BLOOD Vanco-31.6* [2177-8-12] 10:03AM BLOOD Type-ART pO2-60* pCO2-51* pH-7.34* calTCO2-29 Base XS-0 Brief Hospital Course: Ms. [Known lastname 80906] is a 56-year-old woman who has COPD and also severe diffuse tracheobronchomalacia. She underwent a Y-stent trial and had a remarkable improvement in her dyspnea with the stent in place. Ms. [Known lastname 80906] does have significant COPD, and prior to the operation, a long discussion was held with her in regard to the fact that we would only be fixing the central airways with a stabilization via tracheobronchoplasty, but we would certainly not be improving her lung function. In addition, given her quite impaired lung function, we were concerned that she might have some more difficulty getting through an operation of this magnitude. Nonetheless, she wished to proceed, and given the fact that her stent trial was as remarkably positive as it was, we elected to proceed. On [2177-8-6] taken to the operating room for tracheobronchoplasty admitted to lthe ICU post-op intubated, required IVF for low UOP and edpidural for pain control. albumin and hespan for low mean arterial pressures. Extubated on POD # 3 and placed on bipap-requiring reintubated for stidor. Treated with nebs patient improved and again extubated with-out difficulty. Again continued with bipap. POD 5 duresed with lasix. Advanced diet and patient tolerated well. POD #6 transfer to the floor chest tube out. Continues with her CPAP at night Cellulitis at incision site treated with vancomycin x1 dose. Cellulitis improved. On [2177-8-13] transfered back to the ICU due to Oliguria/anuria, hypovolemia w/o shock. Treated with IVF with improvement. [2177-8-14] transfered back to floor. [2177-8-15] OOB ambulating in room with O2-CPAP at night-continuing with nebs. Tolerating DM-diet well. Plan for discharge to rehab-awaiting placement. Medications on Admission: albuterol, formotorol, levothyroxine, metformin, lisinopril, montelukast, omeprazole, simvastatin, loratidine Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. Budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) ML Inhalation [Hospital1 ] (2 times a day). 14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-3] Puffs Inhalation Q6H (every 6 hours) as needed for COPD. 15. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation [Hospital1 ] (2 times a day). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing and SOB. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 18. Insulin sliding scale q 6 hours Q6H Regular Glucose Insulin Dose 0-80 mg/dL [1-3] amp D50 81-120 mg/dL 0 Units 121-160 mg/dL 2 Units 161-200 mg/dL 4 Units 201-240 mg/dL 6 Units 241-280 mg/dL 8 Units 281-320 mg/dL 10 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Tracheal Bronchial Malasia Discharge Condition: stable Discharge Instructions: Please call Dr. [Last Name (STitle) ] with any questions or concerns [Telephone/Fax (1) 2348]. Call with fever greater than 101.5 call with increased cough, shortness of breath or increased secretions. Followup Instructions: You have a follow up appointment with Dr. [Last Name (STitle) ] on the [Hospital Ward Name ] [Location (un) 448] of the [Hospital Ward Name 121] Building in the CHEST DISEASE CLINIC on [2177-9-2] at 10 am. You need to arrive 45 minutes early and go to the clinical center [Location (un) 470] radiology for Chest X/Ray.	[ "272.0", "519.19", "682.2", "530.81", "244.9", "250.00", "584.9", "998.59", "276.2", "E878.8", "496", "276.52" ]	icd9cm	[ [ [] ] ]	[ "96.04", "33.48", "38.91", "96.71", "31.79", "33.24" ]	icd9pcs	[ [ [] ] ]	7396, 7471	3397, 5182	320, 562	7542, 7551	1844, 3374	7809, 8156	1757, 1825		5343, 7373		7492, 7521		5208, 5320			7575, 7786																															259, 282									590, 1372																		1394, 1478	1494, 1741
3,460	124,134	17062	Discharge summary	report	Admission Date: [2119-6-20] Discharge Date: [2119-6-30] Date of Birth: [2054-7-14] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Cirrhosis secondary to EtOH and hepatocellular carcinoma status post chemo embolization. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male with cirrhosis, hepatitis B and C, hepatocellular carcinoma status post chemo embolization, now presenting for orthotopic liver transplant. Has been admitted twice previously for potential liver transplants on [2119-4-10] and [2119-5-11]. Both were cancelled due to inappropriate organs. Feeling well. No recent infections. No fever, chills, nausea, vomiting, shortness of breath, chest pain, headache, dysuria, other associated symptoms. Retired, lives in [Location ], Mass. PAST MEDICAL HISTORY: Hypertension, type 2 diabetes, alcoholic cirrhosis, hepatocellular carcinoma status post chemo embolization in [2117]. MEDICATIONS AT HOME: Nadolol 60 mg p.o. daily, Lantus insulin 22 units every p.m., Humalog insulin p.r.n. sliding scale, and some vitamins. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a retired high school teacher. Quit tobacco years ago, 20 years of smoking x1-2 packs per day. Long time alcohol, stopped a couple of years ago. Not married, no children. No IV drug use. PHYSICAL EXAMINATION: On physical exam, temperature is 97.9, heart rate 65, BP 130/86, respiratory rate 18, ninety-three percent on room air. No acute distress. Normal carotids. Pupils equal, round, reactive to light. EOMs intact. Ocular fundus clear. No cervical lymphadenopathy or masses. Lungs: Clear to auscultation. No wheezes, rhonchi, rales. Positive gynecomastia. Heart: Regular rate and rhythm. No murmurs. Abdomen: Nondistended. Normal active bowel sounds. Abdomen soft and nontender, no scars, no hernias. Extremities: No CCE, 2+ dorsalis pedis pulses bilaterally. Mood: Normal affect. HOSPITAL COURSE: Labs were drawn. Preop work up was done. He was taken to the OR on [2119-6-21], by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816]. He underwent a piggyback liver transplant with Roux-en-Y biliary anastomosis. Please see operative report for details. The patient tolerated the procedure well. There were no complications. He was recovered in the surgical intensive care unit. His LFTs increased on postop day #1, baseline was AST of 36, ALT of 34, alkaline phosphorus 75, total bilirubin 0.8. These increased to an AST of 1701. ALT 1046, alkaline phosphorus 84, total bilirubin 3.3. A liver duplex was done. This demonstrated a 12 cm complex mass consistent with hematoma along the under surface of the liver. Normal venous and arterial hepatic waveforms with appropriate direction of flow. No evidence of intra or extrahepatic biliary ductal dilatation, ascites, or hepatic parenchymal mass. His liver function tests improved. He was gradually weaned from the vent and extubated on postop day 1. He was transferred to the medical surgical floor on postop day 1. He had a medial and lateral JP that were draining large amounts of serosanguineous fluid, a Roux tube draining bilious drainage. His diet was gradually advanced. His vital signs were stable. His LFTs continued to trend down. His creatinine increased on postop day #1 from the baseline of 0.7 up to 3.0. His medications were renally dosed including fluconazole and Valcyte. He was started on Prograf 2 mg b.i.d. Prograf levels were monitored. He continued on a steroid taper as well as CellCept twice a day. His creatinine increased to 5.1. He experienced a drop in his hematocrit to 23.2. There was concern for hemolytic uremic syndrome. A haptoglobin was normal. LDH was high. His fibrinogen was normal. A smear for schistocytes was normal. A reticulocyte count was normal. He was given 10 units of cryoglobulin and DDAVP x2. He was placed on telemetry. He underwent an endoscopy to assess for upper GI bleeding when he experienced some lower GI bleeding. He passed 2 large melanotic stools. Findings for the upper endoscopy demonstrated a normal duodenum. There was some erythema in the lower third of the esophagus, as well as erosion and erythema in the cardia, stomach body, and antrum compatible with nasogastric tube trauma, otherwise an EGD was normal to the second part of the duodenum. On postop day 5, his hematocrit decreased to 20.1 with the GI bleeding. He was given 2 units of packed red blood cells and his hematocrit increased to 26.7. The creatinine improved slightly today. It decreased down to 3.7 on postop day 9. BUN was 81. On postop day 7, he did experience sudden nausea and vomiting after taking 2 Percocets, but given the history of diabetes, an EKG was done. This demonstrated a T-wave inversion in V4 and T-wave flattening in V5 and V6. CKs and troponins were done. These were negative. He was on telemetry. He had no further incidents. He denied chest pain and shortness of breath at that time and his vital signs were stable. Of note, the patient did have a Roux tube cholangiogram on [6-26], which was postop day 5, this demonstrated patent anastomosis without leak. There was filling of the common bile duct, the distal portion of the main left and right intrahepatic ducts, and prompt emptying into the duodenum. There was some mild edema at the anastomotic site, however, there was no evidence of leakage of contrast. He tolerated the procedure well. His Roux tube was capped on that same day. Physical therapy followed the patient and cleared him for a safe discharge home without PT. A bedside swallow evaluation was done for evaluation of swallowing after the patient complained of a piece of the [Location (un) 6002] getting stuck in his esophagus after swallowing. Also complains of a hoarse voice that has gotten progressively worse during hospital course. Findings included that the patient was coughing during swallowing with thin liquids and with puree. This was felt coughing was secondary to secretions. There was concern for the vocal cord impairment given his report of progressive worsening of his voice over the admission. Recommendations included continuing advancement of diet and an evaluation by ENT for vocal cord quality. He was seen by otolaryngology on [2119-6-27]. There were no notable exam findings. No indication for any surgical intervention. Recommendations included shovel mask with cool mist for humidification, nasal saline rinses b.i.d., reflux precautions with the head of the bed up 45 degrees, and PPI b.i.d., as well as follow up with Dr. [Last Name (STitle) ] about 1-2 weeks after discharge. The patient continued to progress with his diet and did well. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consult was obtained for hyperglycemia. He was restarted on his bedtime glargine insulin and sliding scale Humalog. His blood sugars improved. His [Location (un) 1661]-[Location (un) 1662] drains were removed. He had large dark ecchymotic areas over bilateral lower back sites. He required dressing changes for serosanguineous drainage from the Roux tube site. Of note, on postop day 9, hepatology had planned to do a liver biopsy for a total bilirubin of 6.6. Biopsy was deferred for a decrease in total bilirubin to 5.1. Plan was to discharge the patient home with visiting nurse [First Name (Titles) ] [Last Name (Titles) ] of incision and Roux tube, as well as glucose control, and medication teaching. CONDITION ON DISCHARGE: Stable, ambulatory, tolerating a regular diet, with stable vital signs. PLAN: Plan is to follow up in the outpatient clinic with twice weekly labs monitoring CBC, Chem-10, LFTs, and Prograf level. Will also have follow up [Doctor Last Name ] in [12-12] weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(2) 3762] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2119-6-30] 14:43:07 T: [2119-7-3] 09:32:53 Job#: [Job Number 47967]	[ "571.2", "070.30", "155.0", "250.00", "401.9", "070.70" ]	icd9cm	[ [ [] ] ]	[ "87.54", "50.59", "38.93", "50.22", "00.93", "45.13" ]	icd9pcs	[ [ [] ] ]														1969, 7497							983, 1141																1375, 1951										171, 261									290, 814																		837, 961	1158, 1352	7522, 8049
15,575	134,763	17903	Discharge summary	report	Admission Date: [2107-5-9] Discharge Date: [2107-6-5] Date of Birth: [2043-12-24] Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: Briefly, this is a 63 year old male who has a history of metastatic rectal carcinoma who had been seen by Dr. [Last Name (STitle) ] in [Location (un) 4121] where he had a resection of his primary tumor as well as a liver resection. He returns now to [Hospital1 69] on [2107-5-9], for an elective caudate lobe resection for recurrence as well as radiofrequency ablation of the lateral segmental mass as well as insertion of an infusion pump into his hepatic artery. The patient has a past medical history significant for his rectal cancer, hypertension, hernia repair. rheumatic fever as a child and high cholesterol. He has had cerebrovascular accidents in the past with multiple infarctions in his lacunar area. The patient was taken to the Operating Room on [2107-5-9], where a caudate lobe resection, radiofrequency ablation of lateral segment mass and infusion pump procedure was performed. The patient tolerated the procedure. Please see Operating Report for further details of that operation. The patient was transferred to the floor postoperatively. The Acute Pain Service was consulted for management of his epidural. He tolerated the procedure well and was continued on antibiotics, Unasyn, for prophylaxis. He slowly began having difficulty with oxygenation on [2107-5-11], where he dropped his O2 saturation to 86% and his respiratory rate rise to 40. It was decided that the patient would be transferred to the Intensive Care Unit on [2107-5-11], and he was transferred there. MEDICATIONS UPON ADMISSION: 1. Lopressor 100 mg p.o. twice a day. 2. Cardizem 120 p.o. q. day. 3. Pravachol 40 mg p.o. q. day. 4. Zestril 15 mg p.o. q. day. The patient also has a colostomy from his primary rectal cancer resection. HOSPITAL COURSE: During his hospital course, as noted before, he had pulmonary respiratory desaturations on [2107-5-11], and was transferred to the Intensive Care Unit. At that time, his white blood cell count rose to 15.5. His physical examination was unremarkable. He was awake, alert and oriented. His lungs were clear. His heart was regular. His abdomen was soft and nontender. He had multiple blood cultures drawn at that time for the respiratory difficulty which ended up being negative throughout. The patient was having agitation at that time and continued to be monitored for this agitation. He had a CT scan which ultimately showed no new infarctions or lesions. It was felt that the confusion was secondary to the radiofrequency ablation and chemotherapy agents that were given, and he was continued to be monitored for this. Neurology was consulted for this confusion. Neurology felt that limiting his medications would be one step in helping to clear his confusion. It was felt that while it could represent an infectious encephalopathy, it was more likely due to the toxic effects of his radiofrequency ablation. He began having fevers on [2107-5-14], and there was a question of whether his wound was infected. CT scan two days earlier was negative. His white blood cell count continued to be elevated during this time, reaching a high of 37.5. He was continued on his Unasyn for this elevated white count as well as his temperatures. His confusion remained throughout his hospital course and on [2107-5-15], AmBisome was started for a question of Candidal infection. Ultimately, this Candidal infection was determined to be [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563] and it was decided that upon further work-up that he would require a 28 day course of AmBisome. It was decided at that time that he would ultimately need removal of his infusion port, however, because of his status, it was felt that it could be postponed until later. On [2107-5-18], it was decided that he would be taken back to the Operating Room for a re-exploration and for removal of his infusion pump. It was found that on [2107-5-18], during exploration, he had a large abscess that ultimately grew out [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563]. He was washed out and continued on his AmBisome for this reason; please see Operating Report for further details. He was continued on his Unasyn and AmBisome for that time, however, postoperatively, in order to broaden coverage, his Unasyn was changed to Zosyn. The patient was continued on total parenteral nutrition throughout his hospital course and originally a central line was placed, however, as his infection cleared a PICC line was placed. His white count rose as stated previously, to a high of 37.6 on postoperative day ten and one, and after the washout it continued to be elevated, however, slowly trended down . At the time of discharge, his white blood count was 14.0 and he had multiple blood cultures, port cultures and PICC line cultures, which were all negative for anything. He also had an echocardiogram which revealed no vegetations on his valves and an Ophthalmology examination which was also negative for embolic events. The patient stayed in the Intensive Care Unit after the second operation. The patient was transferred out of the Intensive Care Unit on [5-23]/3004, on postoperative day number 14 and 5, after being afebrile for over five days. His white count had decreased down to 18 at this time and he was started on a clear liquid diet as well as continuing on his total parenteral nutrition. His [Location (un) 1661]-[Location (un) 1662] drains, which were placed at the time of the second operation, had slow output throughout his hospital course and were removed, the first one removed on postoperative day, [5-31], postoperative days number 22 and 13; and the second one being removed on postoperative day number 25 and 11 on [6-3]. The patient continues to improve. His mental status slowly began to clear, however, he was not back to his baseline levels even upon time of discharge. The patient was kept on sitters until [2107-5-29], for agitation and for monitoring. After that, he was able to be maintained without any sitters and was much more appropriate at that time. Blood cultures, urine cultures, port cultures, were all negative after the original blood and Operating Room culture were positive for [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563]. On [2107-5-26], after multiple cultures were negative and no bacteria were discovered, the Zosyn was stopped and he was continued only on his [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 563]. He was kept on morphine intermittently for pain control, Haldol for confusion, Lopressor, Protonix, and Regular insulin for his total parenteral nutrition. The patient was also transfused two units of blood on [2107-5-28], postoperative days 19 and 10, for a low hematocrit of 25.6. His wound, which was left open after the second operation, was packed with normal saline wet-to-dry dressing. Granulation slowly improved the wound site, therefore a VAC drain was placed. The VAC drain put out low amounts and continued wound healing and was removed just prior to discharge to the rehabilitation facility. Instructions were given for assessment of the wound upon arrival to the rehabilitation facility with the decision of whether wet-to-dry dressing or VAC dressing could be used. The patient slowly improved mentally and Physical Therapy was consulted for ambulation on [2107-5-31]. The patient began ambulating with Physical Therapy and he did well. Nutrition was also following and calorie counts were started on [2107-5-31]. Over the next three days, it was found that the patient was taking more and more of his nutritional requirements by mouth. Two days prior to discharge, he was able to take 75 percent of his caloric needs and 75 percent of his protein needs p.o., tolerating a regular diet with Boost supplementation and his total parenteral nutrition was continued in order to help him with wound care and to boost his immune status. He was also started on Marinol 5 mg p.o. twice a day to enhance his appetite. The patient was discharged on [2107-6-5], while tolerating a regular diet. His wound was clean, dry and intact. He continued to have an elevated respiratory rate up into the 20s and 30s, even at time of discharge, and a heart rate that was tachycardic to the low 100s; however, his O2 saturations were normal at 98% and the patient was able to ambulate and tolerate exercise. The patient's pulmonary status was good, however,there was a small right pleural effusion noted on chest x-ray which was decreasing in size. His port was in good position. He had a PICC line placed in his left arm which was used for total parenteral nutrition and antibiotics. His Foley catheter was removed. He did have some hematuria after the Foley insertion which he had noted before as in the past history, It fully resolved, however, the patient was incontinent of urine. Urine cultures were negative and the patient was watched carefully for this. His abdominal drains were removed and sites were dressed. There was some slight fibrinous serous drainage from those [Location (un) 1661]-[Location (un) 1662] sites upon discharge, however, the output had decreased. The wound itself was clean, dry and intact and granulating well when the VAC drain was removed. Mentally, his confusion had improved, however, he was still not oriented to place but was able to be interactive and cooperative both with the staff and with family who were present throughout his hospital course. His total parenteral nutrition had been stabilized for approximately two weeks prior to discharge with only minor modifications of electrolytes. His white blood cell count as noted before, was returning to normal with the last one being 14.7. His hematocrit after his transfusions stabilized at approximately 30.0 and his platelet count was normal at 230. His electrolytes were all within normal limits. His creatinine was watched carefully for the long duration of his AmBisome treatment. His discharging creatinine was 1.2, up ever so slightly from his baseline of 1.0. His liver function tests were all within normal limits. His alkaline phosphatase was 218 and his ALT and AST were normal. His total bilirubin was also normal at 0.3. Infectious Disease was consulted and it was planned that the patient would have a 28 day course AmBisome. Upon time of discharge, he would have completed 22 days, therefore, six more days were needed and he would complete his course of AmBisome on [2107-6-11]. He was going to be continued on Protonix 40 mg p.o. q. day. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg p.o. twice a day. 2. Cardizem 120 p.o. q. day. 3. Pravachol 40 p.o. q. day. 4. Zoloft 15 mg p.o. q. day p.r.n. 5. Protonix 40 mg p.o. q. day. 6. Regular insulin sliding scale. His morphine and Haldol were held due to somnolence and he was only treated intermittently with pain medications, specifically with dressing changes. He also had Marinol added to his regimen, 5 mg p.o. four times a day as well as Boost supplementation for his diet. The patient was discharged to a rehabilitation facility on [2107-6-5], [Hospital 10680] Rehabilitation Facility in [Location (un) 4121], [State 4260]. FOLLOW-UP INSTRUCTIONS: He was instructed to follow-up with Dr. [Last Name (STitle) 49614], Dr. [Last Name (STitle) 49615], and Dr. [Last Name (STitle) 49616], all at the [Location (un) ] Hospital and at [Hospital 10680] Rehabilitation facility for further care. DISCHARGE DIAGNOSES: 1. Rectal cancer, status post resection and colostomy. 2. Status post right hepatectomy for metastases. 3. Now status post caudate lobe resection, radiofrequency ablation and infusion pump insertion. 4. Status post exploratory laparotomy washout and removal of infusion port. 5. Depression. 6. Hypertension. 7. High cholesterol. 8. Cerebrovascular accidents in the past. DISPOSITION: The patient is discharged to the rehabilitation facility as planned and he will have an ambulance ride. DISCHARGE INSTRUCTIONS: 1. He will be continued on his total parenteral nutrition throughout the ambulance ride as well as continue at the rehabilitation facility. 2. To continue his Physical Therapy. 3. Continue with wound care at that time. CONDITION ON DISCHARGE: Stable. NOTE: A copy of the patient's chart as well as copy of all radiologic reports and culture data will be included in his discharge packet. If there are any questions, the receiving facility is instructed to contact myself or Dr. [Last Name (STitle) ] for further information. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[First Name (STitle) ] MEDQUIST36 D: [2107-6-4] 17:53 T: [2107-6-4] 18:13 JOB#: [Job Number 49617] cc:[Last Name (un) 49618]	[ "112.89", "560.81", "998.59", "V10.05", "511.9", "997.3", "438.9", "197.7", "401.9" ]	icd9cm	[ [ [] ] ]	[ "54.59", "86.06", "50.29", "38.93", "99.15", "54.12", "54.92", "50.3" ]	icd9pcs	[ [ [] ] ]								11835, 12335	10889, 11528					1969, 10866		12359, 12582																																								183, 1726							1740, 1950								11554, 11814					12608, 13182
74,935	197,685	38029	Discharge summary	report	Admission Date: [2161-6-17] Discharge Date: [2161-6-22] Date of Birth: [2111-7-6] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5790] Chief Complaint: Metastatic synovial sarcoma with left upper lobe pulmonary nodule concerning for metastatic disease Major Surgical or Invasive Procedure: [2161-6-17]: Video-assisted thoracoscopy left upper lobectomy, bronchoscopy with bronchoalveolar lavage, and left cephalic vein cutdown, double-lumen port placement. [2161-6-17]: Wide resection left thigh mass. History of Present Illness: Mrs. [Known firstname 2152] [Known lastname 61723] is a 49 year old female with left thigh synovial sarcoma diagnosed through biopsy on [2159-11-27]. She underwent radiation followed with wide resection of the left thigh. She was followed with imaging and on recent CT chest she was found to have a 27 x 34 x 31 mm lingular mass and a 4-mm noncalcified solid pulmonary nodule in the apical segment of the right upper lobe which could be metastatic. Tissue is requested. She also has what appears to be local recurrence in the left thigh. She denies fevers, chills, but has nightsweats and fatigue. She has been followed by psychiatry for depression. She denies dyspnea or cough. Past Medical History: DM HTN Asthma anemia arthritis Depression PAST SURGICAL HISTORY: 1. Posterior spinal fusion at L4-L5 in [2159-2-1] at [Hospital6 11241]. 2. Hysterectomy and unilateral oopherectomy at the age of 32 for fibroids. After the resection, she was told that she had a small focus of cancer, but that it was all resected and she required no follow-up treatment. 3. Bladder suspension [2154] 4. Tubal ligation. 5. Wide resection left thigh synovial sarcoma [2160-2-20] Social History: She is from [Male First Name (un) 1056]. She is not currently working. She has never used any tobacco. She does not drink any alcohol. Family History: Mother- HTN, alive [Name (NI) 12238] died age 69 with DM, HTN, CHF, strokes Physical Exam: Discharge vital signs: T 96.7, BP 130/68, HR 84-102SR, RR 18, O2 sats 93%RA Discharge Physical Exam: Gen: pleasant in NAD Lungs: wheezes b/l CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [2161-6-20] 06:45AM BLOOD WBC-9.5 RBC-3.54* Hgb-10.4* Hct-32.0* MCV-90 MCH-29.4 MCHC-32.5 RDW-15.4 Plt Ct-252 [2161-6-20] 06:45AM BLOOD Glucose-236* UreaN-10 Creat-0.6 Na-136 K-4.6 Cl-99 HCO3-27 AnGap-15 [2161-6-20] 06:45AM BLOOD Calcium-9.6 Phos-2.8 Mg-2.1 [2161-6-20] CXR: REASON FOR EXAMINATION: Evaluation of the patient after removal of chest tube. PA and lateral upright chest radiographs were reviewed in comparison to [2161-6-20] study obtained at 09:34 a.m. Current study demonstrates interval development of minimal apical pneumothorax. The left lung opacity is unchanged as well as right basal atelectasis. Port-A-Cath catheter tip is at the level of cavoatrial junction. Small pleural effusion cannot be excluded, in particular on the left. CXR [2161-6-22]: Improved left effusion, no appreciable PTX Echo [2161-6-19]: Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Ms. [Known lastname 61723] was taken to the operating room on [2161-6-18] by Dr. [Last Name (STitle) ] for VATS left upper lobectomy and left port-a-cath placement and by Dr. [First Name (STitle) 4223] for resection of left thigh mass. She recovered in PACU and transfered to SICU overnight for respiratory monitoring and Bipap. On POD 1 she transferred to [Hospital Ward Name 121] 9. Below is a systems review of her hospital course: Pulmonary: Aggressive pulmonary toilet with nebulizers and chest PT were initiated early on. A left Chest tube was discontinued POD 2, with stable postpull film, with improved left effusion. The patient saturated on room air 94% ambulating on day of discharge. CV: The patient initially was hypertensive and tachycardic- eventually controlled with addition of metoprolol- which was added to her discharge regime. She remained in SR 70-80's on discharge. Her home antihypertensives were continued. She was diuresed with lasix POD 1. Echo was done revealing normal heart function. Nutrition/GI: Her diet was advanced and tolerated. GU: Her foley was discontinued POD 1, and she voided. Electrolytes were watched and repleted. Endo: She had blood glucose monitoring throughout with blood sugars which remained 150-350, despite augmenting her regime. She will followup with [Last Name (un) ] as an outpatient next week. Neurologic: The patient was given dilaudid IV postop then successfully transitioned to po oxycodone and torodol for pain, which was effective by date of discharge. She was slow to wake up, but progressed over the first 24 hours in her stay. She was seen by social work for depression and expressed SI, with a plan but stated that she was not currently suicidal and if she progressed in such thinking (per social work) she would talk with her husband, psych and call 911. PT: The patient was ambulating independently when PT came to evaluate her, therefore they signed of. Dispo: She was deemed stable and safe for home dc with husband on [2161-6-22]. She will followup with Dr. [First Name (STitle) 4223], Dr. [Last Name (STitle) 30343] and [Last Name (un) ] early [Month (only) ]. She will followup with oncology for chemotherapy once surgically cleared. She will followup with her PCP [Name Initial (PRE) 16337]. VNA will follow her. Medications on Admission: AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth three times a day FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - Dosage uncertain GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth in am and at 4pm, and 3 capsules at bedtime HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - one Tablet(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a day and one Prn METHYLPHENIDATE - 5 mg Tablet - 1 Tablet(s) by mouth two in the AM one at noon NAPROXEN - (Prescribed by Other Provider) - 250 mg Tablet - 1 (One) Tablet(s) by mouth twice a day with food OLANZAPINE [ZYPREXA] - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime OMEPRAZOLE - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 84939] - 40 mg Capsule, Delayed Release(E.C.) - Capsule(s) by mouth VENTOLIN - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice daily CIMETIDINE [TAGAMET HB] - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth as needed DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS SULFATE [SLOW FE] - (Prescribed by Other Provider) - 142 mg (45 mg iron) Tablet Extended Release - one Tablet(s) by mouth daily INSULIN NPH & REGULAR HUMAN [HUMULIN 70-30] - (Prescribed by Other Provider) - 55 units in am, 32 units in the pm SENNOSIDES - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for constipation Discharge Medications: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day: one tab in am, and one tab at 4pm. 4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 5. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): noon. 6. methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 7. Calcarb 600 With Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 8. Slow Fe 142 mg (45 mg iron) Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:60 neb Refills:1 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:60 neb Refills:1 11. Home nebulizer Home nebulizer machine and supplies for pt who needs nebulizers with hx of asthma and s/p left upper lobectomy MH#[Telephone/Fax (5) 84940] 12. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as needed for pain. Disp:100 Tablet(s) Refills:0 17. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 18. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:21 Tablet(s) Refills:0 19. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:0 20. lorazepam 1 mg Tablet Sig: half Tablet PO every eight (8) hours as needed for anxiety. 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 22. Insulin Glucose level Novolog 70/30 Novolog Novolog 70/30 Novolog < 150 0 55 0 0 32 0 151 190 2 55 0 2 32 0 191 230 4 55 0 4 32 0 [Telephone/Fax (2) 84941] 6 32 2 271 310 8 55 4 8 32 4 [Telephone/Fax (2) 84942] 6 10 32 6 [Telephone/Fax (2) 84943] 8 12 32 8 391 430 14 55 10 14 32 10 > 431 15 55 12 15 32 12 (Take as you were directed by [Last Name (un) ]- followup with [Last Name (un) ] on [2161-7-8] at 10am) 23. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 24356] VNA Discharge Diagnosis: Metastatic synovial sarcoma DM HTN Asthma anemia arthritis Depression left upper lobe nodule left thigh recurrent sarcoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers greater than 101.5 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage Chest tube site: remove dressing and cover site with bandaid until healed Left thigh: Keep steri- strips covering incision. No bandage needed. Call if this becomes swollen, red or drains. Pain: -Take tylenol 1000mg by mouth every eight hours. -Ibuprofen- take 600mg by mouth every 8 hours x 1 week. -Oxycodone- take 5-15mg by mouth every 4-6 hours as needed for breakthrough pain. Try to decrease amount and stop over next [3-5] weeks. Activity: -Weight bearing on left leg as tolerated. -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until cleared by providers -No driving while taking narcotics -No lifting greater than 10 pounds -Use incentive spirometer 10x each, five times a day. -Use nebulizer as directed for wheezing and shortness of breath. Medications: Please note you are on a new medication for your heart rate called metoprolol 25mg tab by mouth twice a day. Please check your blood pressure and heart rate twice a day for a few days and if your blood pressure less than 100 systolic (top number) or Heart rate less than 60 Beats per minute hold the metoprolol. You should see your primary care physician to fine tune your blood pressure medications in the next 2 weeks. Diabetes: Check your blood sugars before meals and at bedtime- take insulin as you were and followup with your PCP for further management. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [0-0-] [2161-7-7] 1:30pm on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) ] Chest X-Ray [Location (un) 861] Radiology 30 minutes before your appointment [Name8 (MD) 4223], MD, [Doctor First Name ] E. Office Phone: ([Telephone/Fax (1) 5238] Office Location: [Hospital Ward Name 23] 2 Department: Orthopaedic Surgery Organization: [Hospital1 18] Followup on [2161-7-6] at 2:45pm Followup with Dr. [Last Name (STitle) ] with oncology- we are working on this appointment for you. Followup with your primary care physician [Last Name (NamePattern4) ] [2161-6-25] at 3:30pm Name: [Last Name (LF) 9468],[First Name3 (LF) ] S.F. Location: [Street Address(1) 4323] HEALTH ASSOCIATES Address: [Street Address(2) 9469], [Location (un) ],[Numeric Identifier 4325] Phone: [Telephone/Fax (1) 9470] Fax: [Telephone/Fax (1) 84944] Follow up with [Last Name (un) ] Diabetes Center [2161-7-8] at 10am [Telephone/Fax (1) 2384] Completed by:[2161-6-22]	[ "197.0", "250.00", "786.01", "785.0", "285.9", "171.3", "401.9", "536.3", "311", "493.90", "716.90" ]	icd9cm	[ [ [] ] ]	[ "83.39", "86.07", "32.41", "33.24" ]	icd9pcs	[ [ [] ] ]	10875, 10935	3982, 4420	409, 631	11101, 11101	2363, 3959	12870, 14001	2031, 2113		8139, 10852		10956, 11080		6353, 8116	4438, 6327		11252, 12847								1441, 1855	2128, 2205																						270, 371									659, 1353								11116, 11228										1375, 1418	1871, 2015		2230, 2344
64,965	129,633	55014	Discharge summary	report	Admission Date: [2131-5-23] Discharge Date: [2131-6-26] Date of Birth: [2105-5-2] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3565] Chief Complaint: cocaine overdose Major Surgical or Invasive Procedure: Placement of central line Placement and removal of chest tube Placement and removal of temporary hemodialysis line Placement of tunneled dialysis line Intubation x2 Abdominal fasciotomy with revision PICC line placement History of Present Illness: 26 year old male with a history of cocaine abuse transferred to [Hospital1 18] ED from OSH with cocaine overdose. He was apparently seen by a bystander on the street earlier in the day injecting a needle into his arm. When approached, he was unresponsive. He was taken by EMS to OSH, where he was found to have a rectal temp of 108, HR in the 170s with peaked T waves on ECG. K was 5.9, he was given calcium/insulin/D50. CK was 696, CK-MB 14.6, troponin 2.0. At one point, he was noted to have arm twitching, thought to be [Last Name (LF) 112320], [First Name3 (LF) ] he was given ativan. He then became agitated and was subequently intubated, given fentanyl for sedation. He also received rectal tylenol, ice/cooling blankets. He became hypotensive to the 70s-80s, started on peripheral Levophed, and transferred to [Hospital1 18] via [Location (un) 7622]. On arrival to the ED, patient's BPs were in the low 100s on peripheral levophed. Toxicology was consulted, brought up the possibility of bath salts given hyperthermia; however, appparently patient's mother states that he only injects cocaine. Utox returned positive for cocaine. Tox suggested sedation with propofol; hwoever, due to hypotension, he was kept on fentanyl and midazolam. Initial labs were notable for WBC count 14.1, Hct 54, ALT 46, AST 190, CK [2022], MB 38 Trop .85, Cr 2.5. He was seen by cardiology in the ED, thought unlikely to be secondary to ACS, more likely to be myonecrosis. CT head/spine showed no acute process. He was seen by neuro, felt [Year (4 digits) 112320] prohylaxis not indicated and that the arm shaking could have been a focal [Year (4 digits) 112320] from hyperthermia. A subclavian was attempted, got access after 3 sticks, complicated by a PTX. Patient started to drop pressures, concern for tension PTX, chest tube placed in ED, lung re-expanded on repeat film. Per report from [Last Name (LF) ], [First Name3 (LF) ] have knicked artery as well, pressure held for 15 minutes. He was also given 3 L NS down in ED. On transfer, he was CMV 100% 450 12 PEEP 5 Levophed at .06 with HR 105 BP 104/61, fentanyl 75 mcg/hr. Past Medical History: Cocaine abuse Social History: Unable to obtain Family History: Unable to obtain Physical Exam: ADMISSION EXAM: General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi; chest tube in place Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Unable to assess due to sedation Pertinent Results: ADMISSION LABS: [2131-5-23] 07:00PM BLOOD WBC-14.1* RBC-6.20 Hgb-18.2* Hct-54.9* MCV-89 MCH-29.4 MCHC-33.2 RDW-13.3 Plt Ct-158 [2131-5-23] 07:00PM BLOOD Neuts-83* Bands-2 Lymphs-6* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-1* [2131-5-23] 07:00PM BLOOD PT-12.9* PTT-36.2 INR(PT)-1.2* [2131-5-23] 07:00PM BLOOD Glucose-60* UreaN-33* Creat-2.5* Na-144 K-4.3 Cl-108 HCO3-20* AnGap-20 [2131-5-23] 07:00PM BLOOD ALT-46* AST-190* CK(CPK)-[2022]* AlkPhos-93 TotBili-0.2 [2131-5-23] 07:00PM BLOOD Lipase-442* [2131-5-23] 07:00PM BLOOD CK-MB-38* MB Indx-2.0 [2131-5-23] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2131-5-23] 08:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG . MICRO: [2131-6-4] 12:57 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [2131-6-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2131-6-8]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. . Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- 16 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 I CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R . [2131-6-4] 3:48 pm SWAB PERITONEAL FLUID. FINAL REPORT [2131-6-17] GRAM STAIN (Final [2131-6-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2131-6-7]): A swab is not the optimal specimen collection to evaluate body fluids. [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH. . [2131-6-16] 5:47 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. FINAL REPORT [2131-6-19] Fluid Culture in Bottles (Final [2131-6-19]): ENTEROCOCCUS SP.. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 1 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R . IMAGING: [6-20] CT A/P: Severe wall thickening and edema throughout the small and large bowel, with moderate intra-abdominal and intrapelvic ascites. The findings are compatible with ischemia from vascular or infectious causes. Other processes such as angioedema and advanced vascultitis can have similar findings in the appropriate clinical setting. There is no venous gas or pneumatosis. [6-20] Abd U/S: 1. No portal vein thrombus identified; however, reverse flow is seen in the splenic vein in the midline consistent with portal hypertension. 2. No hepatic artery thrombus is identified. 3. Small stable hyperechoic lesion centrally in the right lobe likely represents a small hemangioma. No additional liver lesion is identified and no biliary dilatation is seen. 4. Ascites. TTE: Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. NCHCT: No CT evidence to suggest cerebral edema or other anoxic brain injury allowing for motion. Brief Hospital Course: 26 year old man who presented with cocaine overdose complicated by acute liver failure, respiratory failure, rhabdomyolysis, dense ATN requiring HD and abdominal compartment syndrome s/p abdominal fasciotomy complicated by septic shock with DIC, intra-abdominal bleeding which could not be stopped surgically and thus transitioned to comfort measures and subsequent death. # Cocaine overdose: Patient with history of cocaine abuse as well as other illicits per the family, was found down by a bystander. Tox screen positive for cocaine, unclear whether he took anything else, endorsed using benzos once awake and responsive. # Altered Mental Status: Intubated and sedated at admission, initially non-responsive off sedation. Lactulose started and mental status improved, also placed on rifaximin. Lactulose continued prn once stool output increased, and patient oriented x3. # Shock: Likely a combination of severe dehydration (was found down in the hot sun) and direct cocaine toxicity. Patient was fluid rescusitated and was inititally on pressors which were later weaned and then had to be restarted, weaned off again [6-20]. # Respiratory failure: Patient was initially intubated for agitation and altered mental status. He was extubated on hospital day #2, however was reintubated the same day for hypoxemic respiratory distress. He was found to have E. coli on BAL and completed an 8 day course for VAP. He was subsequently extubated successfully and maintained normal SpO2 on room air. . # Pneumothorax: Patient developed a right-sided pneumothorax as a complication of a subclavian line placement in the ED. A chest tube was placed with re-expansion of the lung and eventually removed. . # Liver failure: Patient developed liver failure, complicated by coagulopathy and hypoglycemia. He was supported with blood products (plateletes, FFP). The etiology is felt to be secondary to direct cocaine toxicity and shock. Hepatitis serologies were consistent with prior Hep B vaccine and prior Hep A exposure. Hep C, EBV, CMV were all negative. A liver biopsy was obtained which showed necrosis with fungal elements. His bilirubin remained markedly elevated throughout. # Fungemia: Patient with yeast on urine and sputum cultures and later found to have yeast on peritoneal fluid and liver biopsy. He was started on micafungin with plan for course defined by whether or not there was a drainable fluid collection in the liver. . # Renal failure: Patient developed anuric renal failure. A temporary HD line was placed and CVVH was started. A tunneled HD line was later placed and CVVH/HD were continued and eventually transitioned to HD once hemodynamics improved, though still required additional volume with HD initially. . # DIC: Patient developed DIC in the setting of shock and multiorgan failure. This was confirmed by schistocytes on his blood smear. He was supported with platelets, FFP, and cryo as needed and recovered counts. . # Abdominal compartment syndrome: Patient developed worsening abdominal distention and bladder pressures in the low 20s. Surgery was consulted and the patient was taken for an abdominal fasciotomy and left open for >72h. He was eventually taken back to the OR for closure and later developed wound dehiscence requiring wound vac. He developed worsening abdominal pain and markedly reduced stool output later in course, c/f SBO. KUB showed no dilated loops or air fluid levels, he was kept NPO and improved within 24h. . # Diarrhea: Pt. developed profuse diarrhea after starting tube feeds. GI was consulted and this was felt to be a malabsorptive process. Bile salt excess also possible, consider cholestyramine. # Diffuse Intraabdominal bleeding in setting of DIC from GNR bacteremia. After a short period of relative stabilization from above events, on [6-25], pt developed altered mental status, rising lactate, and was found to have new GNR bacteremia and ultimately severe intraabdominal bleeding with recurrent abdominal wound dehiscence. He went to the OR for an attempt at closure, at which time the severity of the abdominal bleeding was noted and he went into shock. He was in hypovolemic and septic shock. He was volume resuscitated > 40 units of blood products with > 15 units of PRBC, > 10 units of FFP, 10 units of cryo, DDAVP and 4 units of Plt. He continued to have ongoing coagulopathy with intrabdominal bleeding which was likely from his portal hypertension varices which are not amenable to surgically management. A family meeting was held to explain the grave prognosis and explain that since we could not stop his intrabdominal bleeding with surgical or medical means. He was maintained on three pressors until family decided to transition to comfort measures. Family was at bedside at his terminal event on [6-26]. Medications on Admission: None Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A	[ "518.81", "570", "038.9", "512.1", "998.81", "998.30", "970.81", "729.73", "995.92", "304.21", "728.88", "785.52", "785.50", "286.6", "572.3", "997.31", "E878.8", "584.5", "E854.3", "789.59", "287.5", "041.49" ]	icd9cm	[ [ [] ] ]	[ "54.19", "54.12", "39.95", "33.24", "54.62", "38.97", "96.72", "50.11", "50.12", "54.61", "38.95" ]	icd9pcs	[ [ [] ] ]	12639, 12648	7754, 8391	320, 541	12697, 12702	3390, 3390	12754, 12760	2832, 2850		12611, 12616		12669, 12676		12582, 12588			12726, 12731									2865, 3371																						264, 282									569, 2745				3406, 7731				8406, 12556										2767, 2782	2798, 2816
60,039	100,012	21833	Discharge summary	report	Admission Date: [2177-3-12] Discharge Date: [2177-3-22] Date of Birth: [2109-6-26] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[First Name3 (LF) 1505] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: [2177-3-14] Coronary ARTERY BYPASS GRAFTING x3 with: Left Internal Mammary Artery to Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse Marginal Artery, Saphenous Vein Graft to Posterior Descending Artery History of Present Illness: 67 year old man with known coronary artery disease-s/p stents x 6(2004x5 and [11-21]) who developed exertional angina while walking [3-9]. Angina resolved w/ rest after few minutes. Angina recurred [3-11], patient was brought to [Hospital ] Med Ctr where enzymes were negative. He had cardiac catheterization which showed: tapering distal LM,70% osteal LAD,90% mid RCA. LVEF 60% by LVgram. He was then transferred to [Hospital1 18] for surgical management of his coronary artery disease. At the time of transfer he was pain free. Past Medical History: Coronary artery disease(PCI/stents x6), Hypertension, HYPERCHOLESTEROLEMIA, CA- Left vocal cord(RT/chemo)[3-20] PSH:Left knee arthroscopy, Left chest Portacath Social History: Works as administrator at [University/College 33918]. Married, 2 children. Tob: Former smoker, quit 30 yrs ago. ETOH: Drinks a few beers or cocktails per night. No drugs Family History: Brother: MI at 60, uncle: MI at 50 Mother: htn Physical Exam: Pulse: Resp: O2 sat: B/P Right:130/72 Left: 128/72 Height: 70" Weight:175# General:WDWN, NAD Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x]glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur n Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: Admission Labs: [2177-3-12] 04:05PM PT-11.7 PTT-23.8 INR(PT)-1.0 [2177-3-12] 04:05PM PLT COUNT-199 [2177-3-12] 04:05PM NEUTS-78.7* LYMPHS-9.6* MONOS-5.6 EOS-5.6* BASOS-0.5 [2177-3-12] 04:05PM WBC-6.9 RBC-3.93* HGB-14.0 HCT-38.2* MCV-97# MCH-35.6* MCHC-36.6* RDW-13.5 [2177-3-12] 04:05PM %HbA1c-5.2 eAG-103 [2177-3-12] 04:05PM ALBUMIN-4.1 MAGNESIUM-1.7 [2177-3-12] 04:05PM ALT(SGPT)-36 AST(SGOT)-24 LD(LDH)-148 ALK PHOS-100 TOT BILI-2.0* [2177-3-12] 04:05PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [2177-3-12] 04:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2177-3-12] 04:33PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 Discharge Labs: Radiology Report CHEST (PORTABLE AP) Study Date of [2177-3-17] 7:29 AM Final Report: Comparison with study of [3-15], all of the monitoring and support devices have been removed except for the left subclavian catheter and the right IJ sheath. With the chest tube removed, there is no evidence of pneumothorax. Residual opacification at the left base is consistent with atelectasis and effusion. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Borderline normal RV systolic function. AORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: No MS. Mild (1+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Small 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. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Focused Intraoperative TEE during chest exploration for post-operative bleeding. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Borderline normal RV free wall function. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results. Brief Hospital Course: Mr [Known lastname 732] was transferred fro [Hospital ] Med Ctr for surgical management of his coronary artery disease. After the usual pre-operative workup he was brought to the operating room for coronary artery bypass grafting on [2177-3-14]. Please see the operative report for details. In summmary he had: Coronary Artery Bypass Grafting x3 with Lwft Internal Mammary Artery to Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse Marginal Artery, and Saphenous Vein Graft to Posterior Descending Artery. His cardiopulmonary bypass time was 51 minutes with a crossclamp time of 39 minutes. He tolerated the operation well and post-operatively was transferred to the cardiac surgery ICU in stable conditio. He remained hemodynamically stable in the immediate post-op period. He woke from anesthesia neurologically intact and was extubated on the operative day. On POD1 he continued to have significant drainage from his chest tubes and was brought back to the operating room for mediastinal exploration-no source of bleeding was found. He tolerated this procedure well and was again returned to the cardiac surgery ICU in stable condition. He recovered from anesthesia and was extubated shortly after the surgery was completed. He remained hemodynamically stable throughout this period. All tubes lines and drains were removed per cardiac surgery protocol. On POD 3 he was transferred from the ICU to the stepdown floor for continued post-op care and recovery. Physical therapy worked with the patient to advance his activities of daily living and to improve strength and endurance. POD # 4, Pt develope some drainage from his sternal incision. He was started on IV Vancomycin. Betadine was cleanse TID was started. from POD # [4-19], pts wound improved. He is to be discharged on PO keflex x 10 days. His wound on DC is without drainage. On POD 10 was discharged home with visiting nurses. He is to follow up with Dr [Last Name (STitle) ] in 3 weeks, He has a sternal check [3-26] on [Hospital Ward Name ] 6. He is to follow up with his cardiologist, appt made, He was also instructed to follow up with his PCP. Medications on Admission: Lisinopril 20mg daily, Lipitor 80mg daily, Plavix 75 mg [Last Name (LF) ], [First Name3 (LF) ] 325mg daily, Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 4. [Last Name (un) 1724] Lisinopril 20mg daily,EcASA 325mg daily,Lopressor 25mg [Hospital1 ],Plavix 75mg daily,NTG prn,Lipitor 80mg daily 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 8. potassium chloride 8 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day for 7 days. Disp:14 Tablet Extended Release(s) Refills:0 9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:40 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Bypass Grafting x3 PCI/stents(6) PMH: Hypertension, HYPERCHOLESTEROLEMIA, CA- left vocal cord(RT/chemo)[3-20] PSH:lt knee arthroscopy, LT chest Portacath Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [First Name (STitle) ] [Name (STitle) ] on [2177-4-10] at 9AM at [Hospital1 ] Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5874] on [2177-4-16] at 3PM Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ],[First Name3 (LF) 488] J. [Telephone/Fax (1) 8036] in [4-15] weeks You have a wound check scheduled for [5-26] at 1000 hrs, please come to [Hospital Ward Name ] 6 at this scheduled time. Thw midlevelers will look at your wound to see if this is stable. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication Goal INR First draw Results to phone fax Completed by:[2177-3-22]	[ "998.11", "413.9", "V15.3", "V45.82", "272.0", "401.9", "V15.82", "V87.41", "E878.2", "V10.21", "414.01" ]	icd9cm	[ [ [] ] ]	[ "34.03", "36.12", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	8668, 8727	5186, 7348	294, 519	8966, 9176	2190, 2190	10017, 10925	1495, 1543		7515, 8645		8748, 8945		7374, 7492			9200, 9994			3033, 5163						1558, 2171																						237, 256									547, 1099				2206, 3015														1121, 1287	1303, 1479
66,384	171,738	6674	Discharge summary	report	Admission Date: [2128-3-27] Discharge Date: [2128-4-4] Date of Birth: [2078-11-16] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 11552] Chief Complaint: Chest pain, SOB, cough Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 25457] is a 49 year old female with history of coronary artery disease s/p NSTEMI [2120] with DES to the RCA and PDA, DES to RCA x2 in [7-11], moderate to severe mitral regurgitation, T1DM s/p kidney transplant x 2 and pancreas transplant, peripheral vascular disease, currently undergoing an evaluation for kidney retransplantation and possible mitral valve repair, transferred from OSH with chest pain. . Pt states that 3 weeks ago she had a high fever, with myalgias, and improved after a few days. Then starting 5 days ago on Monday, she developed fever, and again myalgias. She has been having chest pain for several months now, but it got worse this week. Her chest pain is normally in the epigastrium and center of her chest, lasting for 10mins at a time, "coming and going," sometimes associated with activity. This week it became worse up to [11-15] pain, worse with lying down and relieved by leaning forward. The pain is different from her NSTEMI in [2120], which back then was radiating to her left arm. The pain is also worse with coughing and laughing. She has also been having to use additional pillows to sleep this past week: she normally sleeps on 2 pillows and has now been using 2 additional pillows. She has also had fever to 101 earlier this week, with dry cough, non-productive. She had one episode of emesis earlier this week, bringing up food, no blood or bile. She spoke with her PCP, [Name10 (NameIs) 1023] gave her two doses of Levaquin and referred her to the ED after CXR demonstrated bilateral lower lobe infiltrates. . She was sent to the ED at [Hospital 10315] Hospital where she received 1 dose of 100mg of Doxycycline, ASA 162 mg, Nitro SL, morphine, heparin gtt, and lopressor 5mg IV x3. ECG demonstrated new ST depressions in I, aVL, V4-V6, and TWI in III and aVF. Given concern for NSTEMI, she was transferred to [Hospital1 18]. . On arrival to the CCU, her VS were afebrile, HR 94, BP 163/89, RR 18, 90% on 4L NC. When she arrived, she was having continued chest pain and SOB. She was started on nitro gtt for chest pain control and BP management, which brought her CP down to zero. She continues to feel very SOB and is having chills. . Pt recently discharged for elective right and left heart catheterization in [Month (only) 404]. However, at that time, decision was made to not proceed given renal failure and concern for needing to initiate dialysis if proceded with cath. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: Coronary artery disease: NSTEMI in [6-8] treated with PDA stenting ([6-8]). She had another catheterization in [7-11] for unstable angina which was treated with two drug eluting RCA stents. Her last catheterization was in [4-/2124] which revealed patent PDA and RCA stents, with 40% proximal LAD and proximal RCA stenoses that were hemodynamically insignificant by pressure wire -PERCUTANEOUS CORONARY INTERVENTIONS: [7-11] DES x2 to RCA, c/b NSTEMI and left femoral pseudoaneurysm (treated conservatively) cath [4-12] with patent PDA and RCA stents. 40% proximal LAD and proximal RCA stenoses. 3. OTHER PAST MEDICAL HISTORY: Type I diabetes, s/p simultaneous pancreas-kidney transplant in the mid [2107] followed by a repeat pancreas transplant and then subsequently kidney retransplant in [2117] ESRD [3-10] FSGS, s/p pancreas/kidney transplant x 2 ([2112], [2-/2117]) Peripheral vascular disease (R fem-tib bypass ([1-6]) c/b right AV fistula aneurysm s/p repair ([11-9]). Overall poor access candidate) Charcot joint, right foot s/p retinal detachment and enucleation of left eye s/p D & C ([3-10]) s/p Hysterectomy ([4-9]) s/p TMJ surgery Social History: Lives in [Location 14078], [State 2748] with mother. [Name (NI) ] support system is mother, aunt who lives nearby and close friends. [Name (NI) 1403] as a teacher of special education students. She is currently on leave given her medical problems. [Name (NI) 1139] history: Smoked 5 pack years in her 20s, quit after; no current use. ETOH: very occasional use. Illicit drugs: none. Family History: Noncontributory for premature coronary artery disease or sudden cardiac death. No family history of diabetes. Physical Exam: ADMISSION PHYSICAL: VS: T=97 BP 163/89, HR 94, RR 18, 90% on 4L NC GENERAL: Pleasant female, appears mildly uncomfortable, leaning forward sitting on bed. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Dry MM. NECK: Supple with JVP elevated to mandible CARDIAC: Tachycardic, +S1, S2. III/VI systolic murmur at apex. No thrills, lifts. No S3 or S4. LUNGS: Leaning forward, using accessory mm to breath, decreased breath sounds at bases bilaterally, rales up to [4-9] of lungs b/l, no wheezes ABDOMEN: +BS, Soft, NTND. No HSM or tenderness. EXTREMITIES: warm, dry, 1+ edema at ankle bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ unable to palpate DP or PT pulses Left: Carotid 2+ unable to palpate DP or PT pulses . DISCHARGE PHYSICAL: VS: 98.9 148/80 92 16 98% RA GENERAL: pleasant, comfortable appearing, NAD HEENT: sclera anicteric, MMM CARDIAC: RRR, normal S1 S2, 2/6 systolic murmur heard throughout precordium LUNGS: diminished breath sounds at bases, no wheezes or rales ABDOMEN: normoactive bowel sounds, soft, NT, ND EXTREMITIES: warm, DPs 2+ bilaterally, RLE with 2+ edema to mid-shin, LLE with trace edema to just above level of ankle Pertinent Results: ADMISSION LABS: FeUrea 40s% [2128-3-27] 03:31PM CREAT-3.8* SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 [2128-3-27] 03:31PM AMYLASE-68 [2128-3-27] 03:31PM LIPASE-43 [2128-3-27] 03:31PM MAGNESIUM-1.8 [2128-3-27] 03:56AM CK-MB-3 cTropnT-0.08* proBNP-[Numeric Identifier ]* [2128-3-27] 03:56AM LD(LDH)-295* CK(CPK)-35 [2128-3-27] 03:56AM VIT B12-1508* FOLATE-GREATER TH [2128-3-27] 03:56AM WBC-5.9# RBC-3.26* HGB-9.7* HCT-29.5* MCV-91 MCH-29.9 MCHC-33.1 RDW-15.9* [2128-3-27] 03:56AM NEUTS-78* BANDS-0 LYMPHS-17* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2128-3-27] 03:56AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-1+ BURR-1+ TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL [2128-3-27] 03:56AM PLT SMR-LOW PLT COUNT-130* [2128-3-27] 03:56AM PT-13.9* PTT-50.6* INR(PT)-1.2* . OTHER PERTINENT LABS: [2128-4-3] 01:25PM BLOOD rapmycn-16.5* [2128-3-30] 05:37AM BLOOD WBC-3.7* RBC-2.54* Hgb-7.4* Hct-22.4* MCV-88 MCH-29.2 MCHC-33.2 RDW-15.4 Plt Ct-97* [2128-3-28] 07:29AM BLOOD Ret Aut-3.3* [2128-3-30] 05:37AM BLOOD ALT-14 AST-24 LD(LDH)-307* AlkPhos-55 TotBili-0.3 [2128-3-27] 03:56AM BLOOD CK-MB-3 cTropnT-0.08* proBNP-[Numeric Identifier ]* [2128-3-31] 03:40PM BLOOD CK-MB-4 cTropnT-0.26* [2128-4-1] 05:15AM BLOOD CK-MB-3 cTropnT-0.25* [2128-3-31] 06:00AM BLOOD CK(CPK)-38 [2128-3-31] 03:40PM BLOOD CK(CPK)-43 [2128-4-1] 05:15AM BLOOD CK(CPK)-40 Amylase-59 [2128-3-27] 03:56AM BLOOD VitB12-1508* Folate-GREATER TH [2128-3-28] 05:38AM BLOOD Hapto-198 [2128-3-29] 06:16AM BLOOD Cortsol-19.5 [2128-4-3] 07:30AM BLOOD HBsAg-PND HBsAb-PND HAV Ab-PND IgM HBc-PND [2128-4-3] 07:30AM BLOOD HCV Ab-PND [2128-4-1] PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-IgG positive, IgM negatvie [2128-3-29] HEPARIN DEPENDENT ANTIBODIES- Negative for Heparin PF4 Antibody Test by [Doctor First Name ] [2128-3-29] 04:45PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN: negative [2128-3-29] 04:45PM BLOOD B-GLUCAN: negative DISCHARGE LABS: [2128-4-4] 09:50AM BLOOD WBC-4.4 RBC-3.29* Hgb-9.6* Hct-29.4* MCV-89 MCH-29.2 MCHC-32.8 RDW-15.7* Plt Ct-126* [2128-4-4] 09:50AM BLOOD Glucose-139* UreaN-102* Creat-3.4* Na-143 K-3.6 Cl-106 HCO3-26 AnGap-15 [2128-4-4] 09:50AM BLOOD Amylase-91 [2128-4-4] 09:50AM BLOOD Lipase-109* [2128-4-4] 09:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 [2128-4-4] 09:50AM BLOOD tacroFK-5.3 . MICRO; [2128-4-3] CMV Viral Load: pending [2128-4-1] CMV IgG ANTIBODY: positive; CMV IgM ANTIBODY: negative [2128-3-30] Blood Culture: pending [2128-3-30] CRYPTOCOCCAL ANTIGEN: not detected [2128-3-30] Blood Culture: pending [2128-3-30] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-pending; BLOOD/AFB CULTURE-pending [2128-3-29] Legionella Urinary Antigen: negative [2128-3-27] Blood Culture: negative [2128-3-27] URINE CULTURE: GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. [2128-3-27] URINE CULTURE: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [2128-3-27] BLOOD CULTURE: negative [2128-3-27] MRSA SCREEN: negative . STUDIES: CXR [2128-3-27]: Large area of dense consolidation in the left lower lung is either pneumonia or severe pulmonary hemorrhage. Milder interstitial edema is seen elsewhere, accompanied by small right pleural effusion. Heart is top normal size, increased since prior examination. No pneumothorax. . CXR [2128-3-28]: Lung volumes are even lower today. Severe consolidation in the left perihilar lung extending to the base is stable, more widely distributed consolidation in the right lung is more severe today. Findings could in large part be due to asymmetric pulmonary edema, but I suspect extensive pneumonia as well. Mild-to-moderate cardiomegaly is stable. Small-to-moderate bilateral pleural effusions are presumed. No pneumothorax. LENIS [2128-3-28]: No DVT of the bilateral lower extremity. . CXR [2128-3-29]: In comparison with the study of [3-28], there is mildly improved inspiration. The diffuse bilateral pulmonary opacifications are consistent with severe pulmonary edema. However, a more coalescent area of opacification with air bronchograms in the left perihilar region is suggestive of superimposed pneumonia. . CXR [2128-3-30]: Compared to most recent prior, there has been improvement in bilateral perihilar and upper lobe opacities. There is persistent, but improved pulmonary edema with near resolution of bilateral pleural effusions. Please refer to concomitantly performed chest CT for more detail. IMPRESSION: Improving multifocal consolidations and pulmonary edema. . CT chest ([2128-3-30]): The visualized portions of the thyroid gland are normal. Atherosclerotic vascular calcification is extensive throughout the visualized vascular tree. Calcification of the ascending aorta is dense. Similarly calcification of the coronary arteries is global and extensive. Calcification of the mitral valve annulus may extend into the papillary muscle. Calcification at the left ventricular apex is thin and arc-like, likely reflecting myocardial scarring. The interventricular septum is well seen, suggesting anemia. The left brachocephalic vein is stenotic and calcified. Enlargement of the left atrium is moderate. The caliber of the pulmonary arteries is within normal limits. Edema of the mediastinal fat is diffuse. No axillary or mediastinal lymph nodes are enlarged. No pericardial effusions. Bilateral pleural effusions are symmetric and simple. The airways are patent to the subsegmental levels. Diffuse bilateral ground-glass opacities are predominantly central with subpleural sparing likely cardiogenic pulmonary edema. No cavitating lesions seen. This study is not tailored for evaluation of subdiaphragmatic structures. Visualized portions of the liver and spleen are unremarkable. Calcification of the renal arteries is extensive. Atrophy of the native kidneys bilaterally is severe. BONY STRUCTURES: No destructive lytic or sclerotic bony lesions suspicious for malignancy are seen. IMPRESSION: Given the sequence of radiographic findings from [3-27] to [3-30], despite the initial appearance of lingular consolidation, the findings are most consistent with resolving cardiogenic pulmonary edema. . ECHO ([2128-3-29]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis. Intrinsic systolic function likely worse given the severity of mitral regurgitation. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2128-2-4], the function of the inferior and inferolateral walls appears moderately depressed on the current study. Function of these segments may have been borderline depressed on the priror studies, although not reported as such. The right ventricle appears dilated and hypokinetic on the current study. Degree of mitral regurgitation is probably worsened by tethering of the chordae by the hypokinetic inferior/inferolateral walls. The right ventricle appears dilated and hypokinetic on the current study. Estimated pulmonary artery systolic pressure is similar. Brief Hospital Course: 49 year old female with history of coronary artery disease s/p NSTEMI [2120] with DES to the PDA, DES to RCA x2 in [7-11] complicated by post-procedure MI and left femoral arterial pseudoaneurysm, moderate to severe mitral regurgitation, T1DM s/p kidney transplant x 2 and pancreas transplant, peripheral vascular disease, currently undergoing an evaluation for kidney retransplantation and possible mitral valve repair, transferred from OSH with chest pain, SOB, and cough. ACTIVE ISSUES: #. Chest pain: Differential included NSTEMI vs. demand ischemia in setting of HTN and worsening HF, vs. pericarditis or myocarditis. Her presentation was initially felt to be most consistent with a myopericarditis given recent URI symptoms and mild troponin leak. Unlikely NSTEMI given symptoms dissimilar to chest pain from previous MI. Demand ischemia possible in setting of worsening heart failure given orthopnea, increasing DOE, and elevated JVP on examination. Serial ECG's demonstrated ST depressions in inferolateral leads. Trop at OSH 0.16, with previous flat trops last in 1/[2128]. Cardiac enzyme was 0.08 X1 on arrival, in the setting of renal failure. She was treated with ASA 325mg, Atorvastatin 80mg (which she refused, and was eventually transitioned back to her home Crestor). She was on heparin gtt overnight, which was discontinued the morning after arrival given higher suspicion of perimyocarditis, pleuritic chest pain from possible pneumonia, hypertension vs. acute coronary syndrome. ACE-inhibitor was held initially given acute kidney injury. She was initially placed on IV labetalol for improved BP control, in addition to nitroglycerin gtt, and was eventually transitioned back to her home Coreg, with addition of Imdur for better blood pressure control. The patient has a history of recent antihypertensive titrations, including trials of hydralazine, clonidine and amlodipine to which she developed side effects (such as headache, LE edema, fatigue). She had several additional episodes of chest pain after transfer from the MICU to the floor, without EKG changes or rise in cardiac enzymes. Patient will likely benefit from cardiac cath, though this has been on hold given concern that additional dye load will precipitate need for HD. Patient will follow-up with cardiologist Dr. [First Name (STitle) 437] following discharge on [2128-4-14]. She remained CP free for several days prior to discharge, and it was felt that her chest pain may have been secondary to demand ischemia in setting of sCHF exacerbation. . #. sCHF: Patient's dyspnea likely due in part to sCHF exacerbation. Chest imaging confirmed pulmonary edema, and TTE [3-29] demonstrated LVEF of 30-35%. Patient was diuresed, with subsequent improvement in dyspnea and decreased oxygen requirement. Patient was back to baseline weight of ~115 pounds prior to discharge. She was discharged on lasix 40mg PO BID, and will continue on this regimen through her follow-up visit with Dr. [First Name (STitle) 437] on [2128-4-14]. . # Mitral regurgitation: Per TTE from [1-15], pt had preserved EF with moderate to severe MR, though may have been underestimated. Pt now with likely decompensated worsening MR in setting of illness and possible demand vs. myocarditis as above. As above, ACEI was initially held. Beta blocker was used in addition to Nitroglycerin gtt for initial blood pressure control. Patient later transitioned to oral anti-hypertensive regimen of carvedilol 25mg [Hospital1 ] and Imdur 30mg daily. Repeat TTE [3-29] demonstrated worsened MR. [Name13 (STitle) ] will follow-up with cardiologist Dr. [First Name (STitle) 437] [2128-4-14]. . # ? Pneumonia: Bilateral infiltrates seen on CXR at OSH. Repeat CXR here showed bilateral consolidation. Pt's exam notable for rales bilaterally and poor air exchange. She was initiated on broad spectrum abx with Vanc, Cefepime and Azithromycin. Blood cultures did not show any growth, urine legionella was negative. Patient refused both nasopharyngeal swab and aspirate on >3 occasions for rapid respiratory viral illness screens, although the risks and benefits of this test was discussed. Ultimately Infectious Disease was consulted. Cryptococcal antigen negative, beta D glucan and galactomannan also negative. CT chest was more consistent with resolving cardiopulmonary edema than overt infectious process. Given decreased suspicion for PNA, antibiotics were discontinued. Patient completed 5/5 days of azithro, as well as 5 days of vanc/cefepime. Rapamune pneumonitis was considered but in discussions with Renal Transplant and Infectious Disease, her infiltrative process on CXR and CT chest was not suggestive of this. Sputum cultures showed did not show significant growth. Patient remained afebrile, and without leukocytosis. She was satting well on RA prior to discharge. . # Acute on chronic kidney disease s/p kidney transplant: Cr baseline unclear, was 3.4 on last discharge in [2-/2128] but had also had some spikes into Cr3s during Summer [2127]. Urine lytes demonstrated FeUrea in the 40s twice, suggestive of an intrinsic process. The renal transplant team was consulted and felt she continues with chronic rejection of her renal graft. She may have had a prerenal, poor forward flow --> ATN component and was gently diuresed. She was continued on her home regimen of Tacrolimus, Sirolimus, Prednisone; with levels checked daily. She was continued on Bactrim for PCP prophylaxis until her WBC, RBC, platelets all declined with concern for myelosuppression. Bactrim was held, with subsequent improvement in cell counts. Patient's Cr peaked at 5.1 on [2128-4-1], and there was concern patient may need HD during this admission. However, Cr trended back down to near baseline at 3.4 on day of discharge. Patient did not meet criteria for urgent dialysis during this admission, though it is possible she will require HD in near future. She has difficult access, and will likely require tunneled HD line in R IJ when dialysis is initiated. The patient was instructed to follow-up with her nephrologist as soon as possible, and will continue to have outpatient monitoring. . # HTN: Presented with BP elevated to systolic 160s. She was placed on a nitro gtt initially. On hospital day 1, IV labetalol was used. Her BP improved, and she was transitioned to oral Coreg 25mg twice daily. Imdur was added with subsequent improvement in BP. Patient was discharged on previous home regimen of carvedilol 80mg daily, with Imdur 30mg daily added to regimen. She will follow-up with her cardiologist Dr. [First Name (STitle) 437] on [2128-4-14]. . # Diabetes mellitus type 1: Patient is status post pancreas and kidney transplant, and has not been on any therapy. QID fingersticks were checked, and she was placed on an insulin sliding scale as needed. . # Hyperlipidemia: On Crestor 10mg qhs at home. Started on Atorvastatin 80mg daily, given initial concern for acute coronary syndrome, which the patient declined. She was resumed on her home Crestor. . # Anemia, normocytic: Chronic, most likely [3-10] CKD. Recent iron studies one month PTA demonstrated normal iron levels, low transferrin and low TIBC. Vitamin B12 and folate were high. HCT decreased to 22.4 during this admission, and given patient's worsening fatigue and general malaise, she was transfused 2 units pRBCs with subsequent appropriate rise in HCT. HCT remained stable, and was at approximate baseline at time of discharge. Patient should continue to receive weekly Aranesp injections; was converted to 3x/week epo while inpatient as Aranesp non-formulary. . # Pancytopenia: Likely in part due to immunosuppressant medications +/- Bactrim, and cell counts improved after Bactrim was held. Patient tested for G6PD and was not deficient; could be on dapsone in future if need for PCP [Name Initial (PRE) ]. HIT antibody was negative. . LABS/STUDIES PENDING AT TIME OF DISCHARGE: -CMV viral load -Hepatitis serologies -Blood cultures [2128-3-30] TRANSITIONAL ISSUES: -Patient was a full code during this admission. -Patient will follow-up with cardiology regarding sCHF, worsening MR, HTN, CP, and CAD. She was discharged on carvedilol 80mg daily, Imdur 30mg daily, and lasix 40mg [Hospital1 ]. [Month (only) 116] need medication adjustment as outpatient. -Patient will follow-up with nephrologist. [Month (only) 116] need HD soon. Should continue with routine lab monitoring, and drug levels should also be monitored. Will need PPD prior to HD. Medications on Admission: MEDICATIONS: - ASA 81mg daily - prednisone 5 mg Tablet qday - ranitidine HCl 150 mg Tablet [Hospital1 ] - rosuvastatin 10 mg Tablet qhs - sirolimus 1 mg Tablet 2 tabs qday - tacrolimus 0.5 mg Capsule, q12hrs - sulfamethoxazole-trimethoprim 400-80 mg Tablet 1 MWF - multivitamin qday - senna 8.6 mg Tablet 1 tabs [Hospital1 ] - Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) dose Injection once a week. - ergocalciferol (vitamin D2) 50,000 unit cap qmonth - calcium-vitamin D3-vitamin K 500-100-40 mg-unit-mcg Tablet, [Hospital1 ] - nitroglycerin 0.4 mg Tablet, Sublingual prn - carvedilol CR 80mg daily - Viactiv - Zemplar, dose unknown *Pt recently stopped taking her hydralazine [3-10] headache, adn stopped amlodopine [3-10] leg swelling. She had been on Clonidine a couple of weeks ago, but discontinued it one week ago, and states her BP was in fact lower than previous. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 9. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) dose Injection once a week. 10. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 11. calcium-vitamin D3-vitamin K 500-100-40 mg-unit-mcg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain, may take up to three times as needed for chest pain. 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s)* Refills:2 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 16. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 17. carvedilol phosphate 80 mg Cap, ER Multiphase 24 hr Sig: One (1) Cap, ER Multiphase 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: systolic congestive heart failure exacerbation, acute on chronic renal failure, anemia, pancytopenia Secondary Diagnoses: hypertension, coronary artery disease, Type 1 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 25457], You were admitted to the hospital with chest pain and shortness of breath, and you were initially admitted to the ICU. We were concerned you may have a pneumonia, and started you on antibiotics. A CT scan of your chest later showed that your trouble breathing was most likely due to extra fluid in the lungs, caused by an exacerbation of your heart failure, and not due to an infection. You received lasix to help remove the fluid, and your symptoms improved. We stopped your antibiotics. An echocardiogram of your heart showed that the heart is not pumping as well as it previously was, and that your mitral regurgitation (leaky valve) has also worsened. It is very important that you follow up with Dr. [First Name (STitle) 437] as scheduled. While you were here, you kidney function appeared to be worsening. We monitored your BUN and creatinine closely, and the levels were decreasing at the time of your discharge. Your creatinine was 3.4 on the day of discharge. It is still likely that you may need dialysis soon, and you should follow-up with Dr. [Last Name (STitle) 25458] as soon as possible. We noticed that your blood cell counts were low while you were here, which may have been a side effect of the bactrim. We stopped the bactrim, and your cell counts improved. You were very anemic, and we gave you 2 units of blood. Your hematocrit improved and remained stable after the transfusion. We made the following changes to your medications: 1. INCREASED aspirin to 325mg daily 2. DECREASED ranitidine to 150mg daily 3. STOPPED bactrim 4. STOPPED Zemplar 5. STARTED isosorbide mononitrate 30mg daily (for high blood pressure) 6. STARTED lasix (furosemide) 40mg twice daily (please discuss the medication with Dr. [First Name (STitle) 437] at your appointment on [2128-4-14]) 7. STARTED sevelamer carbonate 800mg three times per day with meals We did not make any other changes to your medications. Please continue to take them as you have been doing. Please discuss your medication list with Dr. [Last Name (STitle) 25458] and with Dr. [First Name (STitle) 437], as they may need to continue adjusting what medications you are taking. As part of your work-up for starting on dialysis, you will need to have a PPD placed by your outpatient providers Please continue to have your routine lab work done to monitor your kidney function. You should go for lab work this week. Followup Instructions: Please call Dr.[Name (NI) 25459] office tomorrow morning to schedule a follow-up appointment as soon as possible. We will fax a summary of your hospital course to him for review. The clinic number is [Telephone/Fax (1) 25460]. Department: CARDIAC SERVICES When: WEDNESDAY [2128-4-14] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "284.89", "V45.82", "E849.7", "582.9", "276.2", "E931.0", "414.01", "403.91", "713.5", "V42.83", "996.81", "428.0", "584.9", "E878.0", "585.5", "250.61", "272.0", "285.21", "E933.1", "424.0", "428.23", "E849.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	25585, 25591	14421, 14905	307, 313	25841, 25841	6487, 6487	28491, 29057	5023, 5135		23969, 25562		25612, 25733		23036, 23946			25992, 27475			8604, 14398						5150, 6468	25754, 25820	3381, 4000													22515, 23010		27504, 28468					245, 269		14921, 22494							341, 3271				6503, 7391		7413, 8588		25856, 25968				4031, 4586						3293, 3361	4602, 5007
29,556	187,997	8107	Discharge summary	report	Admission Date: [2157-6-12] Discharge Date: [2157-6-18] Date of Birth: [2074-11-7] Sex: M Service: MEDICINE Allergies: Penicillins / Lidoderm / fentanyl Attending:[First Name3 (LF) 5141] Chief Complaint: dyspnea, weakness, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 82 year old with paroxysmal afib, h/o superior mesenteric vein thrombosis on coumadin since [2143], chronic renal insufficiency (baseline Cr 1.2-1.3) and MM diagnosed in [2144], on Revlimid therapy (last dose 1 week ago) recently diagnosed UTI on Cipro, awoke this morning with new weakness, SOB and malaise. Revlimid has been held since [6-7]. On Tues. [6-7] pt. experienced dysuria, dribbling stream and difficulty urinating. Was seen at [Hospital1 18] [Location (un) 1439], UA was done and per pt. was dx with UTI and given Cipro. He states his symptoms are slightly improved since last week but that he has continued to have difficulty urinating. His wife states that over the course of the week he was intermittently confused, at one point getting lost on his way from the bathroom, though patient denies this. On the day prior to admission the patient developed a productive cough and shortness of breath. He does not produce frank sputum and denies hemoptysis. States that his appetite has been decreased over the past week or so. Denies any fevers or chills, nausea, vomiting, changes in ostomy output or sick contacts. [Name (NI) ] does endorse increased weakness. He ambulates with a walker at baseline but on the day of admission was unable to ambulate without assistance so he presented to the ED. In the ED, febrile to 101.6. BP 110/82 P 88 RR 22 91%RA. Started on levaquin and vanco and also received duonebs for wheeze. CXR concerning for multifocal pneumonia. Patient could not provide urine sample. Blood cultures were sent and patient was started on levofloxacin and vancomycin for PNA vs. UTI. Patient was originally requested for medicine floor bed, but he dropped his pressures into 80/40's with increased sluggishness and O2 desaturation to 88%. He was responsive to 2L NS and supplemental O2. On arrival to the MICU, patient's VS: T 96.2 P 83 BP 82/55, RR 21 91% 2LNC Past Medical History: MULTIPLE MYELOMA TREATMENT HISTORY: # Multiple Myeloma: on treatment with Revlimid Initially presented with T12 compression fracture, ARF, hypercalcemia and SMV thrombosis in [2143]. During this evaluation he was diagnosed with MM. Treated with 6 cycles of VAD then on Thalidomide in [12-12]. He received monthly Pamidronate from the time of diagnosis to [8-/2147] when he was switched to Zometa. He continued thalidomide until [10/2148] when it was stopped due to debilitating symptoms of ataxia and peripheral neuropathy. He continued monthly Zometa until [12/2150], when he was switched to every other month. In [4-/2151], the Zometa was stopped for concern of right lower jaw osteonecrosis. Mr. [Known lastname 4460] was off all therapy for his myeloma since that time. Bone marrow biopsy done on [2152-10-30] showed a marrow cellularity of 28-30%, interstitial infiltrate of plasma cells occurring singly and in clusters. By CD138 immunohistochemical staining, plasma cells were 5-10% of marrow cellularity. Kappa restricted. He started a Decadron burst on [2152-11-15]. After this first cycle of Decadron he developed an infection in his mouth and lower extremity weakness so he did not start his second cycle until [12-19]. He started cycle 1 Velcade on [2153-1-30]. He had radiation to the T11-L3 spine given 300 x 8 fractions for a total of 2400 cGy from [2-14] to [2153-2-23]. He started cycle 2 Velcade on [2153-3-6] - he received 2 doses but the rest was held due to shortness of breath and weakness. He started cycle 3 on [2153-4-17]. This course was complicated by a hospitalization for EColi sepsis with unclear source. EMG showed diffuse complicated neuropathy. The Bence [Doctor Last Name ] Proteins in his urine were negligible since he received his last cycle of Velcade until [7-21] when they again begain to rise. His FLR also began to rise at that time. As his UPEP began to double and FLR rose, the decision was made to start him on Revlimid. He started Revlimid 5 mg weekly x 1 wk, 10 mg weekly x 1 wk, 15 mg weekly x 1wk for 21/28 days in [11-20]. . OTHER PAST MEDICAL HISTORY: # T12-L2 vertebral compression fractures # Hyperlipidemia # Chronic kidney disease stage 3, recent baseline Cr 1.7 # Peripheral neuropathy # Paroxysmal atrial fibrillation # Osteonecrosis of the jaw # Melanoma of left thigh s/p resection and LN dissection at age 28 # H/o superior mesenteric vein thrombosis and possible [Known lastname ] vessel arterial disease, s/p colostomy [2143] # NSTEMI # GI bleed Social History: Married, non-smoker, no alcohol, retired. Previously worked as a printer and a chicken farmer. Family History: Brother died of a metastatic poorly differentiated neuroendocrine tumor of unknown primary in his 60s. Mother died of an MI at age 62. Father died of unknown causes at age [Age over 90 ]. Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, audibly wheezing, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, [Age over 90 2994] Neck: supple, no elevated JVP appreciated, no LAD CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated Lungs: Diffuse polyphonic wheezing with prolonged expiratory phase. No stridor. No rales or rhonchi on auscultation. ABD: BS+, soft, NTND, colostomy present in RLQ, area is clean, dry and intact without evidence of skin breakdown GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, no focal deficits. Gait deferred. ADMISSION PHYSICAL EXAM: General: oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, [Age over 90 2994] CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated Lungs: Scattered rare wheeze and rhonchi ABD: BS+, soft, NTND, colostomy present in RLQ, area is clean, dry and intact without evidence of skin breakdown GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, no focal deficits. Gait deferred. Pertinent Results: ADMISSION LABS [2157-6-12] 06:40PM LACTATE-2.4* [2157-6-12] 06:30PM GLUCOSE-117* UREA N-20 CREAT-1.2 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18 [2157-6-12] 06:30PM estGFR-Using this [2157-6-12] 06:30PM WBC-5.2 RBC-4.84 HGB-15.0 HCT-46.3 MCV-96 MCH-31.1 MCHC-32.5 RDW-14.7 [2157-6-12] 06:30PM NEUTS-78.4* LYMPHS-12.9* MONOS-8.3 EOS-0.2 BASOS-0.2 [2157-6-12] 06:30PM PLT COUNT-151 MICRO Respiratory Virus Identification (Final [2157-6-13]): POSITIVE FOR PARAINFLUENZA TYPE 3. BCx no growth ([6-12], [6-13], [6-14]) Urine legionella negative UCx no growth [6-13] IMAGING CXR [6-12]: Subtle opacities in the lower lungs compatible with multifocal pneumonia. CXR [6-15]: There is unchanged borderline cardiomegaly. There is some improvement of the airspace opacities within the right base which may represent prior improved atelectasis or early infiltrate. There remains a left retrocardiac opacity and likely [Known lastname ] bilateral pleural effusions. There are no signs for overt pulmonary edema. No pneumothoraces are identified. DISCHARGE LABS: [2157-6-18] 08:40AM BLOOD WBC-5.5 RBC-4.87 Hgb-14.4 Hct-46.6 MCV-96 MCH-29.5 MCHC-30.9* RDW-15.0 Plt Ct-278 [2157-6-18] 08:40AM BLOOD PT-24.0* PTT-42.2* INR(PT)-2.3* [2157-6-18] 08:40AM BLOOD Glucose-112* UreaN-17 Creat-0.9 Na-142 K-4.3 Cl-108 HCO3-25 AnGap-13 [2157-6-18] 08:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0 URINE: [2157-6-13] 12:36AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2157-6-13] 12:36AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2157-6-13] 12:36AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [2157-6-13] 12:36AM URINE Hours-RANDOM Creat-95 Na-34 K-60 Cl-43 Brief Hospital Course: BRIEF HOSPITAL COURSE: 82 year old with paroxysmal afib, h/o superior mesenteric vein thrombosis on coumadin since [2143], chronic renal insufficiency (baseline Cr 1.2-1.3) and MM diagnosed in [2144], on Revlimid therapy (last dose 6/25 or [6-7]) recently diagnosed UTI on Cipro, awoke on the day of admission with new weakness, SOB and malaise. Found to have multifocal PNA, likely parainfluenza in origin. The patient had a brief stay in the ICU, and recovered significantly over the course of the hospital stay after stabilization in the ICU. ACUTE ISSUES: # PNA/Bronchitis: Pt presented with acute onset SOB and cough and had CXR findings c/w multifocal PNA. He was started on vancomycin and Levaquin in the ED. Due to low suspicion for HCAP, his antibiotics were subsequently changed to aztreonam and Levaquin based on the patient's history of anaphylaxis with penicillins. Rapid viral testing was sent which came back positive for parainfluenza virus. As a result, the patient was placed on contact precautions. [Name2 (NI) ] was febrile on presentation. Multiple blood cultures and urine cultures were drawn, all of which returned no growth. He spiked a new fever on [6-13]. He was wheezing on presentation which improved with nebulizers. The patient was discharged from the ICU on 6L nasal cannula. He quickly improved over the course of days, and was ultimately discharged to home on room air, saturating in the mid-90% range and comfortable. The patient completed 8 total days of antibiotics. # Pulmonary Edema/CHF: On [6-12], patient was given IVF due to low urine output of prerenal etiology (FENa 0.28%). He developed acute SOB with wheezing and rales on exam and dropped his O2 sat to 88% during the episode thought to be due to diastolic CHF. The patient's most recent echo in [12/2156] showed preserved EF but moderate AS with LVH. His respiratory status and SOB improved with Lasix and doses of IV morphine. The patient had no other issues of pulmonary edema after this episode. # Mouth pain: Patient with significant mouth pain during hospitalization, attributable to his known osteonecrosis of the jaw. He used his home chlorhexadine mouthwash, cephasol and also lidocaine-containing mouthwash for symptomatic relief. The patient was evaluated by the oral and maxillofacial surgery team during the admission, who deferred surgical or aggressive management until outpatient, but did advise on symptomatic control. # SIRS/Hypotension: Pt was hypotensive in the ED but responsive to fluid boluses and did not require pressors. He remained responsive to fluid boluses throughout his stay. Pressures were stable at the time of transfer to the floor on [2157-6-14]. He required no more fluid boluses after arriving on the OMED [Hospital1 ]. # Decreased UOP: The patient initially presented to the ICU with dysuria, dribbling stream and difficulty urinating. He was seen by his PCP [Last Name (NamePattern4) ] [6-7] where he reportedly had a positive UA and was started in Cipro. He was unable to provide a urine sample on arrival to the ED on [6-12], but began to have good UOP once he arrived in the [Hospital Unit Name 153]. Pt's residual volumes were 182-183 on bladder scan and it was determined that he Most likely required more fluids in the setting of insensible losses [1-13] fever and general decreased PO intake over the past few days. He was given 500cc of crystalloid and developed pulmonary edema as described above. The patient's foley catheter was removed on [2157-6-16], and he passed his voiding trial, with normal urine output. # UTI: Pt. on Cipro for a UTI diagnosed at an outside facility. Cultures here were negative but he is covered for urinary pathogens with Levaquin (which he received for a total of 7 days during this hospitalization). A Foley was placed to monitor urine output during diuresis after pulmonary edema developed, which was succesfully discontinued prior to his discharge. STABLE ISSUES: # Anticoagulation: Pt on Coumadin for superior mesenteric vein thrombosis in [2143]. His INR was monitored while in the [Hospital Unit Name 153] and his Coumadin was dosed appropriately, keeping in mind that antibiotics can affect the metabolism of warfarin. His INR was stable on discharge. # Multiple Myeloma: Pt. on Revlimid therapy which was held in the setting of infection. Dr. [Last Name (STitle) ] came to see the patient and is concerned about his clinical course especially within the setting of this new infection. Followup will be needed with outpatient oncologist as patient was in the middle of a cycle and we stopped his treatment upon diagnosis of UTI. TRANSITIONAL ISSUES: 1. Need to follow up with outpatient oncologist Dr. [Last Name (STitle) ] re: re-starting Revlimid treatment. 2. Patient to follow-up with primary community oral surgeon regarding symptomatic treatment of his jaw osteonecrosis. 3. Home PT Medications on Admission: MVI, Ciprofloxacin 500 mg PO BID since [2157-6-7], Revalimid 15 mg PO for 21 days, held since [6-7], levothyroxine 25 mcg daily, omeprazole 10 mg qhs, oxycodone 5mg qhs, warfarin 5 mg tab, 2.5 mg while on Cipro for a goal INR [1-14]. Discharge Medications: 1. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for pain: Do not drive or drink alcohol while taking this medication. . 5. saliva substitution combo no.2 Solution Sig: Thirty (30) ML Mucous membrane TID (3 times a day) as needed for mouth pain. Disp:qs ML(s) Refills:0 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 7. Peridex 0.12 % Mouthwash Sig: Thirty (30) ml Mucous membrane twice a day. Disp:1 bottle Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 932] VNA Discharge Diagnosis: Primary Diagnosis: bilateral influenza, parainfluenza Secondary Diagnosis: multiple myeloma osteonecrosis of the jaw Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 4460], It was a pleasure taking care of you. You were admitted to the [Hospital1 69] for low blood pressure and evidence of pneumonia. It appears that you had a viral pneumonia that was severe. You had a brief period of time in the intensive care unit. Your respiratory status recovered well. You should continue to take all of your medications you had previous to your hospitalization, EXCEPT: - ADD caphasol (Saliva solution) mouthwash - ADD tylenol for pain control - ADD Peridex mouth wash twice daily You were on a higher dose of Warfarin a couple weeks prior to the hospitalization. You will need to continue to recheck bloods to monitor INR to see if the Warfarin dose needs to be adjusted. Followup Instructions: You met the oral surgeon doctors here for treatment of your osteonecrosis of the jaw. Call their office to make an appointment for follow-up in [1-14] weeks. This apopintment can be on Wednesday AM/PM or Friday AM clinics. Please call to make an appointment [Telephone/Fax (1) 28910]. The location is [Location (un) ], [Location (un) ], [Hospital Ward Name 23] bld, [Hospital6 ]. Department: HEMATOLOGY/BMT When: TUESDAY [2157-6-28] at 12:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 23455], NP [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2157-6-28] at 12:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], 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: DERMATOLOGY AND LASER When: FRIDAY [2157-7-8] at 10:45 AM [Telephone/Fax (1) 3965] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site	[ "038.9", "995.91", "599.0", "518.82", "427.31", "412", "356.9", "272.4", "V12.51", "V44.3", "428.31", "733.49", "487.0", "203.00", "V58.61", "428.0", "V10.82", "585.3", "480.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14390, 14448	8341, 13018	325, 332	14610, 14610	6456, 7585	15558, 16863	5030, 5225		13580, 14367		14469, 14469		13309, 13557			14793, 15535			7601, 8295						5939, 6437															13039, 13283							255, 287									360, 2283			14545, 14589		14488, 14524			14625, 14769										4486, 4900	4916, 5014
31,120	171,455	33318	Discharge summary	report	Admission Date: [2129-3-6] Discharge Date: [2129-3-14] Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 5547] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: s/p exploratory laparoscopy, open cholecystectomy with JP drain placement History of Present Illness: Ms. [Known lastname 77331] is an 88-year-old Indian female with a long history of hypertension and chronic renal insufficiency who presented to the [Hospital1 ] [Hospital3 628] with at least 3 days of worsening right upper quadrant abdominal pain. She underwent a CT scan of the abdomen there that demonstrated a distended gallbladder with wall thickening. A right upper quadrant ultrasound was then obtained that confirmed acute cholecystitis with a large gallstone in the fundus and another large gallstone impacted in the neck of the gallbladder. Her liver function tests were within normal limits. Given her significant medical comorbidities, I advised transfer into [Location (un) 86] where she arrived late last night and early this morning she was given intravenous antibiotics and was hydrated overnight. Given relative hypotension and low urine output likely secondary to the systemic inflammatory response from this septic gallbladder, I advised urgent cholecystectomy Past Medical History: small bowel lymphoma chronic renal insufficiency (cr 2.0) hypertension Physical Exam: afebrile, vital signs within normal range NAD, talking small amounts of english neck supple chest clear heart regular, no mrg abdomen soft, non distended, appropriately tender around the RUQ incision, which is opened at the lateral aspect and packed with saline gauze. no drains or hernia. no erythema. NABS. LE warm, well-perfused with minimal edema Pertinent Results: [2129-3-7] 05:10AM BLOOD WBC-14.4* RBC-3.72* Hgb-11.1* Hct-33.6* MCV-90 MCH-29.8 MCHC-33.1 RDW-13.3 Plt Ct-152 [2129-3-7] 12:56PM BLOOD WBC-8.9 RBC-3.21* Hgb-9.5* Hct-28.6* MCV-89 MCH-29.5 MCHC-33.1 RDW-13.4 Plt Ct-128* [2129-3-8] 02:55AM BLOOD WBC-9.6 RBC-3.12* Hgb-9.3* Hct-28.1* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 Plt Ct-152 [2129-3-9] 02:00AM BLOOD WBC-12.3* RBC-3.23* Hgb-9.6* Hct-29.4* MCV-91 MCH-29.8 MCHC-32.7 RDW-13.6 Plt Ct-173 [2129-3-10] 12:15AM BLOOD WBC-10.2 RBC-3.12* Hgb-9.5* Hct-28.1* MCV-90 MCH-30.3 MCHC-33.7 RDW-13.6 Plt Ct-150 [2129-3-11] 02:21AM BLOOD WBC-9.0 RBC-3.20* Hgb-9.6* Hct-30.0* MCV-94 MCH-30.0 MCHC-31.9 RDW-13.6 Plt Ct-166 [2129-3-12] 06:25AM BLOOD WBC-8.2 RBC-3.07* Hgb-9.2* Hct-28.6* MCV-93 MCH-30.1 MCHC-32.3 RDW-13.7 Plt Ct-206 [2129-3-12] 10:50AM ASCITES TotBili-3.1 ------------ [2129-3-7] 11:15 am SWAB BILE. A swab is not the optimal specimen collection to evaluate body fluids. FINAL REPORT [2129-3-11] GRAM STAIN (Final [2129-3-7]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [2129-3-11]): 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). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. ANAEROBIC CULTURE (Final [2129-3-11]): NO ANAEROBES ISOLATED. ------------ [2129-3-7] 11:10 am SWAB Site: PERITONEAL A swab is not the optimal specimen collection to evaluate body fluids. Fluid should not be sent in swab transport media. Submit fluids in a capped syringe (no needle), red top tube, or sterile cup. FINAL REPORT [2129-3-13] GRAM STAIN (Final [2129-3-7]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2129-3-10]): NO GROWTH. ANAEROBIC CULTURE (Final [2129-3-13]): NO GROWTH. ---------- [2129-3-13] 12:18 pm SWAB Site: ABDOMEN Source: ruq incision. GRAM STAIN (Final [2129-3-13]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): RESULTS PENDING. ANAEROBIC CULTURE (Pending): [Hospital ] [Hospital 93] MEDICAL CONDITION: 88 year old woman with cholecystitis REASON FOR THIS EXAMINATION: pre-op chest XRAY HISTORY: Pre-operative chest. FINDINGS: No previous images. Poor inspiration may account for some of the prominence of the transverse diameter of the heart. However, some enlargement of the cardiac silhouette is seen with elevation of pulmonary venous pressure. No evidence of acute pneumonia. ------------ The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Electronically signed by [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2129-3-9] 15:15 --------------- DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Approved: MON [2129-3-7] 12:56 PM ------ Sinus rhythm with atrial premature beats. Intraventricular conduction delay with left axis deviation. Left atrial abnormality. Probable left ventricular hypertrophy. Compared to the previous tracing of [2129-3-7] no diagnostic change. Brief Hospital Course: ID: Admitted and taken to the OR on hospital day 1, with diagnosis of cholecystitis from OSH - [Hospital1 18] [Location (un) 620]. Intraoperatively, a decision was made to perform an open procedure, based on the laparoscopic findings of purulent fluid intraperitoneally. Postoperatively, the pt was taken to the ICU intubated for monitoring of her fluid status given the diagnosis of necrotic gallbladder and sepsis. She was placed on cipro and flagyl emperically. On POD1, cultures returned with GPC on gram stain so ampicillin was started then changed to vancomycin as well. The pt remained afebrile throughout her hospital course, and on POD4, the vanc and flagyl were held. She will be discharged on PO ciprofloxacin for a total of 14 days of antibiotics. CV: Troponin leak postoperatively. Cardiology was consulted and interpreted this as being a troponin leak secondary to demand ischemia. EKG as noted above. She was started on aspirin and a statin postoperatively and will continue these upon discharge along with her beta blocker. Pulm: Extubated on POD1 and given lasix for pulmonary edema, she did not have any additional respiratory events throughout her course. Renal: Postoperatively, pt was oliguric, making 315cc the day of operation and only 77cc postoperatively over 12 hours. She was resuscitated agressively on POD1 and was over 6L positive; her urine responded the following day with 900cc. Creatinine bumped from 2.0 to 3.0 on POD2, but subsequently trended down off her home HCTZ. Nephrology was consulted and recommended continued hydration for prerenal azotemia and ATN. Upon discharge her Cr was 1.9 and urine output adequate. She will have follow up with nephrology upon discharge. GI: Her diet was advanced upon return of bowel function and upon discharge she was tolerating a regular diet with tid supplements without nausea. PT: ambulated with PT once she was on the floor. Recommendations included continued physical therapy work to improve strength and conditioning. Wound: opened slightly postoperatively on the lateral aspect (about 15% of its length) and packed with wet-to-dry dressings twice daily. should continue upon discharge. Medications on Admission: cardura 1.5 [Hospital1 ] lopressor 50 [Hospital1 ] HCTZ 25 qd prilosec 20 qd piroxican neurontin 100 [Hospital1 ] xanax 0.5 qhs Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: acute cholecystitis acute renal failure demand cardiac ischemia 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 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. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Call to arrange an appointment to see your primary care physician [Last Name (NamePattern4) ] [1-12] weeks to adjust your diuretics and cardiac medications. Call to arrange an appointment to see Dr. [Last Name (STitle) 1924] in [2-14] weeks. ([Telephone/Fax (1) 55864]. Call to arrange to see Nephrology at [Hospital1 18] in the next [2-14] weeks.	[ "V64.41", "571.5", "584.5", "574.00", "403.90", "997.1", "202.80", "038.9", "785.52", "410.91", "585.9", "995.92" ]	icd9cm	[ [ [] ] ]	[ "51.22", "38.93", "50.12" ]	icd9pcs	[ [ [] ] ]	9738, 9815	6337, 8534	232, 308	9923, 9930	1814, 4412	11379, 11759			8724, 9715	4548, 4585	9836, 9902		8560, 8701			9954, 11018							11033, 11356		1441, 1795																						178, 194	4614, 6314		4444, 4511						336, 1332																		1354, 1426
66,326	192,701	53699	Discharge summary	report	Admission Date: [2180-12-23] Discharge Date: [2181-1-2] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3991] Chief Complaint: Chest pain, dysphagia Major Surgical or Invasive Procedure: [2180-12-23] endotracheal intubation History of Present Illness: 87F Russian-speaking p/w approximately 2-1/2 hours of substernal chest "squeezing" that occurred thursday evening, resolved spontaneously. She denies any fevers, cough, shortness of breath, diaphoresis, nausea, abdominal pain. She reports that shortly after her chest tightness occurred, she developed odynophagia and dysphagia dominantly on the left side. She saw her PCP today, who was concerned about possible EKG changes, and was sent to the ED for further evaluation. . In the ED initial VS were T 100 HR 88 BP 139/75 RR 16 SpO2 99%/RA. Looked well. Exam significant for tender cervical lymphadenopathy, tonsillar swelling. EKG similar to prior. Given ASA, Troponins negative x 2, plan for am stress test. Overnight she developed change in speech, and wasn't managing her secretions well. On exam, worsening tonsillar edema. CT neck showed Large retropharyngeal phlegmon from C2 to T2. Given solumedrol and unasyn and felt much better. Taken to OR and intubated under direct visualization. ENT present, did not think there was a need for drainage. Transferred to CCU intubated and sedated. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Hyperparathyroidism and thyroid nodule with resultant hypercalcemia. 2. Essential tremor including involvement of the voice. 3. Anxiety, depression. 4. Hyperlipidemia. 5. Arthritis. Social History: She continues to live independently. She has visiting nurses and a supportive family as well. No toxic habits. Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 96.7 BP: 125/60 P: 78 R: 21 O2:96 General: intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Pertinent Results: ADMISSION LABS: [2180-12-22] 03:59PM BLOOD WBC-11.5* RBC-4.77 Hgb-13.2 Hct-40.2 MCV-84 MCH-27.7 MCHC-33.0 RDW-13.3 Plt Ct-319 [2180-12-22] 03:59PM BLOOD Neuts-76.4* Lymphs-17.2* Monos-4.9 Eos-1.1 Baso-0.5 [2180-12-22] 03:59PM BLOOD PT-11.5 PTT-28.3 INR(PT)-1.1 [2180-12-22] 03:59PM BLOOD Glucose-143* UreaN-20 Creat-1.0 Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 [2180-12-22] 03:59PM BLOOD cTropnT-<0.01 [2180-12-22] 10:00PM BLOOD cTropnT-<0.01 [2180-12-25] 11:44PM BLOOD CK-MB-2 cTropnT-<0.01 [2180-12-24] 04:14AM BLOOD Calcium-9.5 Phos-2.2* Mg-2.1 [2180-12-25] 11:44PM BLOOD TSH-0.099* [2180-12-23] 12:53PM BLOOD Lactate-1.1 [2180-12-23] 12:53PM BLOOD freeCa-1.30 [2180-12-23] 12:53PM BLOOD Type-ART Temp-35.9 Rates-16/2 Tidal V-450 PEEP-5 FiO2-100 pO2-108* pCO2-35 pH-7.46* calTCO2-26 Base XS-1 AADO2-574 REQ O2-94 -ASSIST/CON Intubat-INTUBATED [2180-12-22] 06:52PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2180-12-22] 06:52PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2180-12-22] 06:52PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 . MICRO: [12-23] BLOOD CULTURE NO GROWTH TO DATE [12-23] SPUTUM CULTURE NEGATIVE . IMAGING: CT NECK [12-23]: FINDINGS: There is phlegmonous change throughout the retropharyngeal space extending from the C2 vertebral body level to the level of the T2 vertebral body at the level of the great vessel origins off the aortic arch. This is slightly more prominent on the left compared with the right. An area of central hypodensity at the C4-C5 vertebral body level might represent a developing abscess within this phlegmonous collection (2;47). The oropharynx is narrowed by retropharyngeal soft tissue, but remains patent. The trachea is displaced anteriorly but is not narrowed. The carotid arteries are closely associated with this collection, but remain patent and normal appearing. The vertebral arteries are patent bilaterally in a left dominant system. The internal jugular veins are patent bilaterally. There is a 1.6 x 1.0 cm lymph node at the superior margin of the left parotid. The thyroid gland is diffusely enlarged with multiple nodules, a hypodense nodule in the region of the isthmus measures 12 mm. The visualized portions of the paranasal sinuses are clear. The mastoid air cells and middle ear cavities are clear. Intracranially, there is a 4.3 x 5.1 cm meningioma within the left posterior fossa, which is not significantly changed when compared with MR examination of [2177-8-1]. The visualized lung apices are clear. IMPRESSION: 1. Retropharyngeal soft-tissue changes extending from the C2 vertebral body level to the T2 vertebral body level at the level of the aortic arch. While this narrows the oropharyngeal airway and displaces the trachea anteriorly, the airways remain patent. No distinct focal fluid collection. 2. Left posterior fossa meningioma, stable in appearance when compared with [2177-8-1]. . [12-24] MRI NECK: FINDINGS: Again seen is extensive retropharyngeal swelling with evidence of edema extending into the parapharyngeal spaces and the carotid spaces bilaterally. This causes slight anterior displacement of the pharynx. Note, however, that the severity of the swelling appears to have improved substantially since the neck CT of [12-23]. On the neck CT, there was a suggestion of hypodensity within the retropharyngeal swelling that raised a possibility of a fluid collection. The MR shows no evidence of such a collection. There is an apparent enlarged lymph node posterior to the left lobe of the thyroid, extending into the superior mediastinum. Although the location adjacent to the thyroid gland would be compatible with a parathyroid mass, the extensive descent into the mediastinum makes this more likely collection of pathologically enlarged lymph nodes. The indurated tissue continues to causes anterior displacement of the airway, but again improved since the CT of the 17th. There is an endotracheal tube in place. There is a left pleural effusion, incompletely evaluated on this examination. There is a suggestion of a small right pleural effusion. If this is of clinical concern, correlation with a chest CT may be helpful. Again noted are multiple inhomogeneous nodules in the thyroid gland, with the right lobe larger than the left. There is an apparent cyst in the isthmus. The sagittal images demonstrate disc protrusions at T1-T2 and at T4-5. Again demonstrated is a left posterior fossa enhancing mass apparently arising from the tentorium. This is most likely a meningioma. The lesion measures approximately 4.5 cm in diameter. CONCLUSION: Continued extensive retropharyngeal induration with anterior displacement of the airway. However, this appearance has improved substantially since the neck CT of [2180-12-23]. Left pleural effusion and possible right pleural effusion, incompletely evaluated. No drainable fluid collection detected. Incidentally noted are thyroid nodules and upper thoracic spine disc protrusions. Probable lymphadenopathy adjacent to the left lobe of the thyroid gland, vs parathyroid mass. CT neck [12-29] FINDINGS: There has been marked reduction in retropharyngeal soft tissue edema which was previously causing marked airway narrowing. The thickness of the retropharyngeal soft tissues in the anteroposterior plane now measures 7.5 mm in thickness compared to 20.2 mm previously (301B:91). There is a 1.5 x 1.0 x 4.0 cm craniocaudally oriented oblong structure behind the trachea, and directly abutting the esophagus, causing some rightward displacement of the esophagus (2:66, 301B:106). This structure is deep to the left lobe of the thyroid gland, but is distinct from it. It shows intermediate contrast enhancement. This lesion was far more edematous, and did not show contrast enhancement on the prior CT from [2180-12-23]. There is another indeterminate ovoid nodule, showing strong contrast enhancement, in the retropharyngeal space, superior to the lesion mentioned previously (2:54, 301B:100). The remainder of the study is not markedly changed from the prior scan. The neck vessels enhance bilaterally without significant stenosis. Again noted is a large calcified meningioma in the posterior fossa. IMPRESSION: 1. Marked reduction of retropharyngeal soft tissue edema. 2. Indeterminate enhancing structure adjacent to the esophagus and deep to the thyroid gland, which, given its anatomic location and access into the retropharyngeal tissue planes, may represent the source of the acute inflammatory reaction previously seen. This structure may represent a Zenker's diverticulum of the esophagus which underwent microperforation causing retropharyngeal hemorrhage and inflammation. The other possibility is a spontaneously ruptured parathyroid adenoma causing retropharyngeal hemorrhage and inflammatory response, which has been described in the literature in a few cases. We recommend further evaluation with a barium esophagram (upper GI series), and repeat of the parathyroid scan. The study and the report were reviewed by the staff radiologist. DR. [Last Name (STitle) 71587] [Name (STitle) ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2180-12-30] 9:19 AM CT head [12-30] FINDINGS: No acute intracranial hemorrhage, large vascular territory infarct or shift of midline structures is present. A right frontal convexity meningioma measures 12 x 16 mm (previously measuring 17 mm). A left posterior fossa meningioma measures 36 x 41 mm (previously measuring 38 x 50 mm). No new mass lesions are noted. The ventricles and sulci are normal in size and configuration except for the fourth ventricle which is mildly effaced by the meningioma, unchanged. The visible paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Essentially unchanged left posterior fossa and right frontal convexity meningioma. The study and the report were reviewed by the staff radiologist. Esophogram [12-29] FINDINGS: Lateral and AP serial radiographs were obtained while patient ingested Optiray and then thin barium. There is no evidence for a diverticulum. Within the laryngopharynx, there is a filling defect which narrows the esophageal lumen. It is difficult to determine whether this is intra- or extra-luminal, but correlation with previous studies suggests that this is secondary to retropharyngeal swelling. Tertiary contractions of the distal esophagus are noted. No other esophageal mucosal abnormalities were seen. Please note, the study was limited by the restrictions in patient positioning. IMPRESSION: Filling defect at the level of the larynx which could represent retropharyngeal swelling. No definite diverticulum seen. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 24374] DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6888] Approved: FRI [2180-12-29] 8:52 PM CXR [12-31] Final Report INDICATION: New PICC line. COMPARISON: [2180-12-28]. FINDINGS: As compared to the previous radiograph, the patient has received a new right-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the cavoatrial junction. There is no evidence of complication, notably no pneumothorax. As compared to the previous image, the lung volumes have increased, likely reflecting improved ventilation. The pre-existing signs of overhydration has decreased. Also decreased is the extent of a pre-existing retrocardiac atelectasis and a likely left pleural effusion. The study and the report were reviewed by the staff radiologist. Discharge labs: [2181-1-2] 07:14AM BLOOD WBC-9.7 RBC-4.33 Hgb-11.9* Hct-37.3 MCV-86 MCH-27.4 MCHC-31.8 RDW-14.3 Plt Ct-209 [2181-1-2] 07:14AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-140 K-3.5 Cl-105 HCO3-29 AnGap-10 [2181-1-2] 07:14AM BLOOD Calcium-9.2 Mg-2.0 Brief Hospital Course: 87 yo F p/w chest pressure, dysphagia ruled out for MI in the ED but found to have retropharyngeal deep space infection, now intubated. # Retropharyngeal Phlegmon: Unclear etiology, but based on imaging, looks more consistent with infectious etiolgy than malignancy. The patient was intubated for airway protection and started on a course of Unasyn and steroids. ENT was following the patient while in the unit. Fiberoptic scoping initial airway edema that improved with antibiotics and steroids. A follow up MRI and then CT scan showed improvement in airway swelling compared to prior CT. The patient was extubated the day prior to being called out from the ICU. After extubation, the patient was oxygenating well on nasal cannula which was weaned to room air. On repeat imaging, the phlegmon was thought to possibly be related to an esophageal diveritculum with micro-performation (which was ruled out with barium esophogram) versus a parathyroid adenoma rupture due to a lesion seen on previous parathyroid uptake scan. Patient had parathyroid ultrasound which showed on preliminary read to have an enlarged right parathyroid nodule up to 2.5cm, thyroid nodules and a new left parathyroid nodule. The ultrasound was unable to visualized the site of increased parathyroid uptake posterior to the trachea seen in [2179]. Radiology suggested repeat parathyroid uptake scan as an outpatient in approximately two weeks, after further decrease in edema, at which point they felt that it could still be determined if the etiology of this phlegmon was rupture of the parathyroid adenoma posterior to the trachea. They also suggested parathyroid nodule and thryoid nodule biopsy which can be considered as an outpatient. She was changed to Ertapenem at time of discharge to more easily complete a total [2-10] week course of IV anitbiotics to be completed on [1-9], though the ID team was confident that a termination of [1-5] would also be adequate. Prednisone was weaned to 20mg at time of discharge on [1-2]. PICC line was placed on [12-31]. # Respiratory Failure: The patient was intubuated for laryngeal edema and airway protection. She was started on steroids and antibiotics, and imaging and fiberoptic scoping showed improvement in airway swelling over the course of her MICU stay. The patient was not intubated for underlying airway disease and she was doing very well on pressure support, and was easily extubated. # afib: The patient went into afib while in the unit; unclear if this is new onset as the patient describes feeling heart palpitations in the past. Possibly related to underlying infection/inflammation versus new onset ischemia. Found to have new RBBB on EKG; however older EKGs with evidence of interventricular conduction delay. Possible that increased vagal tone [2-9] phlegmon could have triggered afib. She was rate controlled with metoprolol 12.5 mg q8h and was started on anticoagulation with coumadin 3 mg daily. On call out to the floor, the patient had converted back to sinus rhythm. Her coumadin was stopped given ecchymosis on neck anteriorly and in posterior pharynx. She was monitored on tele with no recurrence of atrial fibrillation. As an outpatient she should have AF express monitor to track for recurrence of atrial fibrillation over a 2 week period. Son declined this monitor at time of discharge, however she had been on telemetry for several days without episodes of atrial fibrillation. Non-active issues: # Hyperlipidemia - The patient was continued on her home Simvastatin. Transitional Issues: - Steroid taper as per primary care doctor. - Pt has a enlarged thyroid and parathyroid adenomas which should be followed as an outpatient. - Pt should have AF express monitor as an outpatient. If she has recurrent episodes of atrial fibrillation, she may require anticoagulation. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 (One) Tablet(s) by mouth every week AMMONIUM LACTATE - 12 % Lotion - apply twice a day CHLORHEXIDINE GLUCONATE - (Prescribed by Other Provider) - 0.12 % Mouthwash - Use as directed daily as needed FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily MOM[Name (NI) ] [ELOCON] - 0.1 % Cream - apply to rash twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually every 5-10 minutes x 3 as needed for chest pain PROPRANOLOL - 20 mg Tablet - 1 Tablet(s) by mouth daily SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth every evening Medications - OTC ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth twice a day as needed for as needed for pain No more than 12 tablets per day ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CETIRIZINE - 10 mg Tablet, Chewable - 1 Tablet(s) by mouth daily as needed for allergy/scratching in throat CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - 1 Tablet(s) by mouth daily LEG BRACE - Misc - Use as directed daily Dx 715.90 Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. [Name (NI) ]:30 Tablet Extended Release 24 hr(s) Refills:0 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take a total of 20mg daily until told to decrease your dose by a doctor. [Last Name (Titles) ]:30 Tablet(s) Refills:0 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 6 days: continue through Monday [1-9]. [Month/Day (2) ]:6 grams Refills:0 10. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection before and after antibiotic dose for 6 days. [Month/Day (2) ]:12 doses Refills:0 11. Heparin Flush 10 unit/mL Kit Sig: One (1) kit Intravenous once a day as needed for if line not in use. [Month/Day (2) ]:2 days Refills:0 12. PICC line dressing changes Q7 days and prn for soilage 13. potassium chloride 20 mEq Packet Sig: One (1) packet PO once a day. [Month/Day (2) ]:30 packets Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Infusion Discharge Diagnosis: PRIMARY: retropharyngeal edema . SECONDARY: hypercalcemia atrial fibrillation (now resolved) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 11300], It was a pleasure taking care of you at [Hospital1 827]. You were admitted for swelling of your throat. You were in the ICU and required intubation (breathing tube). You were treated with antibiotics and steriods and the swelling went down. It is unclear what the cause of the swelling is, but it could have been an infection or from your parathyroid gland. Therefore, it is necessary to stay on antibiotics through [1-9]. PICC line should be pulled by VNA on [1-9] or [1-10] after your last dose of antibiotics is given on [1-9]. If there are any questions about your antibiotics, they should be directed to Dr. [Last Name (STitle) 23] or the infectious disease team at: [Telephone/Fax (1) 457] We have made the following changes to your medications: START Prednisone at 20mg daily with plan to decrease to 15mg daily after evaluated at [Hospital3 ] with Dr. [Last Name (STitle) ]. START metoprolol for an irregular heart rate START potassium 20meq daily or eat a bannana daily STOP lasix STOP propanolol You should have a repeat CT scan of your neck this week through Dr. [Last Name (STitle) ]. You should also have your labs (potassium) checked at that visit. Dr. [Last Name (STitle) ] will discuss when you should have a parathyroid scan done as an outpatient. Followup Instructions: Dr.[Name (NI) 30824] office will call you with an appointment for between 1230-3pm on Thursday. If you do not hear from your office by Wednesday please call her at [Telephone/Fax (1) 1300]. Department: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [2181-1-17] at 12:00 PM With: [Hospital ] CLINIC [Telephone/Fax (1) 41] Building: LM [Hospital Unit Name ] [Location (un) 895] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE Department: [Hospital3 249] When: TUESDAY [2181-2-27] at 10:40 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990], [First Name3 (LF) ] [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990] DO 12-BJM	[ "518.81", "300.4", "716.90", "225.2", "333.1", "401.9", "427.31", "272.4", "784.49", "V58.61", "226", "252.00", "786.59", "478.6", "478.24", "227.1", "787.22", "733.00" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "96.71", "31.42" ]	icd9pcs	[ [ [] ] ]	19687, 19752	13115, 16600	274, 316	19889, 19889	2970, 2970	21416, 22396	2276, 2285		18165, 19664		19773, 19868		17015, 18142			20040, 20832			12836, 13092						2325, 2951															16707, 16989		20861, 21393	1467, 1915				212, 236		16615, 16686							344, 1448				2986, 12819				19904, 20016										1937, 2129	2145, 2260
71,414	173,143	35475	Discharge summary	report	Admission Date: [2195-1-15] Discharge Date: [2195-1-19] Date of Birth: [2123-7-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: STEMI Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stents to right coronary artery History of Present Illness: This is a 71 year-old male with a history of hyperlipidemia who is transferred from [Hospital3 ] for cath after presenting with chest pain. Chest pain was described as L-sided chest tightness, [6-29], occuring 1 hour prior to presentation to OSH while pt was breaking up ice with sledge hammer in front of house. Pain was associated with L hand and wrist weakness, diaphoresis, and improved with lying down. Pt subsequently called for taxi cab, which brought him to [Hospital1 ]. No nausea or shortness of breath. Same symptoms persisted at rest. There is no history of exertional dyspnea, PND, orthopnea, presyncope, very active, normally jogging 1 mile 4 days a week during the summer. He went jogging 4 hours prior to the onset of chest pain. . In the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], initial vitals were T:98.6 HR:57 BP:174/86 RR:16 O2Sat:99% RA. Patient had taken ASA 650mg PO at home. He received a heparin bolus and was started on heparin gtt. He also received Atorvastatin 80mg PO x 1, Plavix 600mg PO x 1, Nitro SL x 2 with improvement of CP to [12-30]. CXR showed no acute findings. Pt was transferred to [Hospital1 18] for cath and further management. . In the cath lab, RCA mid-segment occlusion was stented x Xience DES x3. Pt had questionable episode of complete heart block vs. ?vagal response during procedure, and required RV temporary transvenous pacing, now removed with block resolved. Past Medical History: Hyperlipidemia CAD, type 2 DM as above ?Lung decortication s/p shrapnel injury in [2152] Social History: Retired, used to work for military and as administrator in Department of Health and Human Services. Never smoked, rare ETOH history. Never married, lives in [Hospital1 ] with his nephew. Family History: Mother passed away from liver cancer, had "touch og" diabetes. Father passed away with Alzheimers disease. Physical Exam: VS - T 98.9 HR 87 BP 116/79 RR 18 O2sat 99% RA Ht. 70 inches, Wt. 198 pounds Gen: overweight middle aged man with central adiposity in NAD. Oriented x3. HEENT: EOMI without lid lag stare. OP clear with MMM Neck: small thyroid, no nodules, no [Doctor First Name ] CV: slightly distant heart soundsRRR, nl s1s2, no MRGs Chest: CTAB, no wheezes, rales Abd: Soft, NDNT. No organomegaly Ext: No edema, 2+ DPs, no tremor, distal pulses 2+, nl sensation to monofilament. no ulcers, scars, nails well trimmed Skin: normal temperature and texture Pertinent Results: Admission Labs [2195-1-15] WBC-15.4* RBC-5.02 Hgb-15.5 Hct-43.8 MCV-87 MCH-30.9 MCHC-35.5* RDW-13.5 Plt Ct-231 PT-15.6* PTT-109.1* INR(PT)-1.4* Glucose-387* UreaN-15 Creat-1.1 Na-137 K-4.2 Cl-102 HCO3-20* AnGap-19 ALT-24 AST-23 AlkPhos-96 Amylase-42 TotBili-0.4 CK-MB-95* MB Indx-8.6* cTropnT-4.43* Calcium-8.6 Phos-1.9* Mg-1.8 VitB12-395 %HbA1c-11.2* Other Labs [2195-1-16] Triglyc-179* HDL-44 CHOL/HD-5.0 LDLcalc-141* [2195-1-19] Calcium-8.4 Phos-3.2 Mg-2.2 [2195-1-15] CK-MB-95* MB Indx-8.6* cTropnT-4.43* [2195-1-15] CK-MB-85* MB Indx-6.0 cTropnT-5.82* [2195-1-16] CK-MB-56* MB Indx-4.6 [2195-1-17] CK-MB-11* MB Indx-2.7 cTropnT-1.58* [2195-1-15] CK(CPK)-1409* [2195-1-16] CK(CPK)-1221* [2195-1-17] CK(CPK)-403* [2195-1-15] Glucose-303* UreaN-13 Creat-1.1 Na-137 K-4.0 Cl-99 HCO3-27 AnGap-15 [2195-1-17] Glucose-209* UreaN-18 Creat-1.0 Na-135 K-4.1 Cl-100 HCO3-26 AnGap-13 [2195-1-19] Glucose-163* UreaN-28* Creat-1.2 Na-139 K-4.3 Cl-104 HCO3-27 AnGap-12 [2195-1-15] PT-15.6* PTT-109.1* INR(PT)-1.4* [2195-1-19] PT-12.7 PTT-25.3 INR(PT)-1.0 [2195-1-16] WBC-12.5* RBC-4.95 Hgb-15.0 Hct-43.6 MCV-88 MCH-30.4 MCHC-34.4 RDW-13.1 Plt Ct-214 [2195-1-18] WBC-9.8 RBC-4.72 Hgb-14.4 Hct-41.9 MCV-89 MCH-30.5 MCHC-34.3 RDW-13.0 Plt Ct-197 [2195-1-19] WBC-11.6* RBC-4.68 Hgb-14.6 Hct-41.9 MCV-89 MCH-31.2 MCHC-34.9 RDW-12.9 Plt Ct-204 Radiology Sinus bradycardia. Inferior myocardial infarction of indeterminate age. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 55 154 78 426/417 -2 -41 173 COMMENTS: 1. Selective coronary angiography in this right dominant patietn revealed two vessel CAD. The LMCA was normal and the LAD had mild luminal irregularities. The LCX had two serial 70-80% lesions with some haziness. The RCA had mid vessel acute occlusion with thrombus. 2. Resting hemodynamics with BP 144/61 with HR 46 in sinus with episodes of heart block treated with pacemaker. Patient had transient AIVR after dottering the RCA for about 5 seconds. Right heart cath with RA 18mmHG, RV 39/13, PA 39/23, PCWP 22. The PA sat was 64% and cardiac index was 1.7. These findings are consistent with elevated filling pressures in left and right as well as RV infarct physiology. 3. Stenting of the RCA with 3 Xience stents from proximal to distal 3.5x18 overlapped with 3.5x23 then a few mm gap followed by a 3x23. 4. Plan for post MI care over weekend and then stenting of LCX prior to discharge. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute inferior STEMI with RV infarct 3. Stenting of RCA with 3 DES after thrombectomy [2195-1-16] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis. The remaining segments contract normally (LVEF = 40-45%). 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Brief Hospital Course: Patient is a 71 y/o M with history of hyperlipidemia, no prior cardiac history, who presents with chest pain after exertion and is found to have STEMI on EKG. Now s/p cath with stents x 3 to RCA. #. CAD: Pt was admitted with inferior STEMI and had cardiac catheterization [2195-1-15] with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 3 to RCA (culprit lesion). His biomarkers trended down with CKs peak at 1409 on [1-15] and TnT peaked at 5.82 on [1-15]. He did well post-procedure with chest pain fully resolved. He was started on ASA 325 and Plavix 75 daily as well as metoprolol 25mg PO BID, atorvastatin 80 daily and lisinopril 10mg daily. He should have follow up stress test in 1 month to evaluate LCx disease. He was also started on diabetes management as discussed below. #. Pump: Pt denies any previous ECHOs. No clinical signs/sx of heart failure on exam. However, cath showed elevated PCWP (mean 22), and RAP approximating PCWP, indicating RV failure. Clinically otherwise euvolemic. He had echo on [1-16] which showed mild regional left ventricular systolic dysfunction c/w CAD and LVEF 40-45%. Will continue on lisinopril. #. Hyperlipidemia: Pt is on Lipitor 10mg daily at home. Has not seen his PCP for the past 15 years. Lipid profile with significant HLD so atorvastatin was increased to 80mg daily for hyperlipidemia as well as management of STEMI. He was seen by nutrition for dietary counseling. # Hyperglycemia: Pt has not seen his PCP [Name Initial (PRE) ] 15 years. Serum blood sugars on admission were 300s. This is most likley secondary to underlying untreated DM Type 2. HbA1c 11.2. He was started on HISS and lantus which was uptitrated to 17units qhs.FS improved to 100s with this regimen. He was also started on metformin 500mg PO BID. He should uptitrate this dose to 100mg PO BID as tolerated approximately 1 week after discharge. He was seen by [Last Name (un) ] on day of discharge and will follow up with them as an outpatient. He was also started on lisinopril as above. #. Access: PIV #. Code: FULL Medications on Admission: Lipitor 10mg PO daily Glucosamine 1 tab PO daily Aspirin PRN pain (pt took 650mg PO prior to arrival to ED) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop taking unless Dr. [Last Name (STitle) ] tells you to. Disp:30 Tablet(s) Refills:11 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): increase to 1000mg [Hospital1 ] in 1 week as tolerated. Disp:60 Tablet(s) Refills:2 7. Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:1 box Refills:2 8. One Touch Ultra Test Strip Sig: One (1) strip In [Last Name (un) 5153] four times a day. Disp:1 box Refills:2 9. BD Insulin Pen Needle UF Orig 29 x [11-21] Needle Sig: One (1) shot Miscellaneous at bedtime: use with lantus solostar 1 dose qhs. Disp:90 needles Refills:0 10. Lantus Solostar 300 unit/3 mL Insulin Pen Sig: Seventeen (17) units Subcutaneous at bedtime: take 17 units qhs or as directed. Disp:2 pens Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: ST elevation Myocardial Infarction Diabetes Mellitus Type 2 Chronic Systolic dysfunction: EF 40% Hyperlipidemia Discharge Condition: [1-18]: Cholest Triglyc HDL CHOL/HD LDLcalc 221* 1791 44 5.0 141 Hemodynamically stable, afebrile Discharge Instructions: You had a heart attack in the inferior portion of your heart. You had a cardiac catheterization with 3 drug eluting stents to your right coronary artery. You are now on Plavix (clopodigrel) that is used to prevent your stents from clotting off. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking Plavix unless Dr. [Last Name (STitle) ] tells you to. You were found to be diabetic with elevated blood sugars. You were started on a long acting insulin and an oral medicine. Your goal blood sugars are 80-120. New medicines: 1. Lantus Insulin: a long acting insulin that keeps your blood sugar low all day. 2. Aspirin: to prevent blood clots 3. Clopodigrel: a platelet inhibitor that prevents the stents from developing clots. 4. Metoprolol: a beta blocker that slows your heart rate and helps your heart recover from the heart attack 5. Lisinopril: a blood pressure medicine that helps your heart recover from the heart attack. 6. Atorvastatin (Lipitor): your dose has been increased to 80 mg daily to lower your cholesterol levels. . Please take all medicines as directed. Talk to Dr. [Last Name (STitle) ] if you have any trouble with taking any of the medicines. You have a followup appt at [Hospital ] clinic to learn more about diabetes and insulin. . Please call Dr. [Last Name (STitle) ] if you have any chest pain, trouble breathing, nausea or a new cough. . Because of the heart attack, the pumping function of your heart is weakened. You need to monitor yourself for fluid retention that could cause trouble breathing or swelling in your legs. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Followup Instructions: Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone: [Telephone/Fax (1) 62] Date/Time: [2-8] at 3:40pm. . [Hospital ] Clinic: Follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] on Monday [2-16] at 3pm in [Hospital ] clinic. The clinic will call the pt at home with an earlier appt. . Primary Care: Dr. [Known firstname ] [Last Name (NamePattern1) 22552] Phone: [Telephone/Fax (1) 4475] Date/Time: Tomorrow [1-20] at 1:30pm.	[ "997.1", "427.89", "414.01", "426.0", "429.9", "E879.0", "272.4", "410.41", "250.00" ]	icd9cm	[ [ [] ] ]	[ "00.40", "37.21", "39.64", "88.56", "99.20", "00.66", "36.07", "00.47" ]	icd9pcs	[ [ [] ] ]	10006, 10063	6442, 8522	320, 396	10219, 10325	2913, 5436	12111, 12633	2227, 2335		8681, 9983		10084, 10198		8548, 8658		5453, 6419	10349, 12088									2350, 2894																						275, 282									424, 1886																		1908, 2003	2019, 2211
13,841	116,944	49209	Discharge summary	report	Admission Date: [2146-2-14] Discharge Date: [2146-2-18] Date of Birth: [2082-7-27] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 63-year-old gentleman who is relatively asymptomatic from his coronary artery disease had a murmur detected on a physical exam this past [Month (only) 359] prior to admission. The workup revealed a dilated ascending aorta of 5.2 cm and 3-vessel disease. Cardiac catheterization performed at [Hospital6 3872] on [2145-12-29] showed a LAD 80% lesion, a circumflex 80% lesion, a PDA 80% lesion, mild aortic insufficiency, and an ejection fraction of 76%. An echocardiogram performed on [2145-9-30] showed an EF of 60%, an aortic root of 4.2 cm, mild AI, and mild MR. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Raynaud disease. 3. Hypertension. 4. Hyperlipidemia. 5. Osteoma of the left leg, status post removal in [2135]. 6. Status post deviated septal repair in [2115]. 7. Wisdom teeth removal in [2110]. 8. He also has a history of herniated disc with occasional lower leg paresthesia. MEDICATIONS PRIOR TO ADMISSION: Procardia XL 30 mg p.o. daily, atenolol 25 mg p.o. daily, aspirin 325 mg p.o. daily, and Zocor 20 mg p.o. daily. ALLERGIES: He had no known allergies. CARDIOLOGIST: His cardiologist is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 32255]. PRIMARY CARE PHYSICIAN: [Name10 (NameIs) ] primary care is Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 5263]. FAMILY HISTORY: He has a positive family history. His father had a stroke and a CVA. SOCIAL HISTORY: Mr. [Known lastname 91245] is a retired engineer. He lives with his wife who has early dementia, and he is the primary caregiver to his wife. [Name (NI) ] has no tobacco history whatsoever and rarely uses alcohol. REVIEW OF SYSTEMS: He denied any CVA symptoms, TIA, or syncope, as well as claudication; but he did have a positive history with Raynaud's which improved with the treatment with Procardia. PHYSICAL EXAMINATION: He was 5 feet 11 inches, 152 pounds, his pulse was regular at 60, blood pressure on the right was 120/80, on the left 118/78. He was in no apparent distress and was well appearing. His skin was warm and dry. He had no lesions or rashes. His pupils were equally round and reactive to light and accommodation. His EOMs were intact. His neck was supple with no JVD. His lungs were clear bilaterally. His heart was regular in rate and rhythm with a loud S2 and a grade [11-25] to 2/6 systolic ejection murmur. His abdomen was soft, nontender, and nondistended with bowel sounds present. He had no peripheral edema. He had a mild paresthesia on the lateral aspect of his left thigh and lower leg. He had some venous dilation of his left lower extremity, but the left leg vein appeared suitable for a possible conduit with no varicosities present. He was alert and oriented x 3 with 5/5 strength and a steady gait. He had 2+ bilateral femoral, DP, PT, and radial pulses. No carotid bruits were appreciated. PREOPERATIVE LABORATORY DATA: White count of 5.8, hematocrit of 44.2, and platelet count of 245,000. PT of 13.4, PTT of 33.1, and INR of 1.1. Sodium of 140, K of 4.1, chloride of 99, bicarbonate of 33, BUN of 21, creatinine of 1.0, with a blood sugar of 74. His urinalysis was negative. ALT of 25, AST of 25, alkaline phosphatase of 66, amylase of 77, total bilirubin of 0.7, total protein of 7.0, albumin of 4.5, globulin of 2.5, and HBA1C of 5.2%. RADIOLOGIC STUDIES: Preoperative EKG revealed a sinus bradycardia at 51 with an intraventricular conduction delay, and left axis deviation, and a question of an old anteroseptal myocardial infarction. Preoperative chest x-ray revealed evidence of emphysema with no pneumonia or congestive heart failure. HOSPITAL COURSE: The patient was referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for coronary artery bypass grafting with possible ascending aortic replacement for his dilated ascending aorta. He was admitted on the [10-17] and underwent a coronary artery bypass grafting x 2 with a LIMA to the diagonal, and a vein graft to the OM1, and an ascending aortic replacement with a 28-mm Gelweave 2 graft as well as resuspension of his aortic valve. He was transferred to the cardiothoracic ICU in stable condition on a Levophed drip at 0.05 mcg/kg/min and a propofol drip at 30 mcg/kg/min. In the cardiothoracic ICU that evening he was quickly weaned off his Levophed as his SBPs were rising into the 130s, and nitroglycerin and Nipride were added in and titrated up to keep his systolic blood pressure below 110. He received a blood transfusion with PA diastolic pressures in the teens with a CVP of 13. He also received 4 units of FFP and 2 packs of platelets from anesthesia due to an INR of 2.5, and when he came out of the OR he received an additional 2 units of fresh frozen plasma and 2 units of packed cells for a hematocrit of 23.8. He also received repletion of his low potassium. Over the course of the evening, he was weaned from his propofol slowly in preparation for extubation and was sedated overnight. He did have a postoperative rash and was administered some Benadryl. The following morning he was on a nitroglycerin drip at 4. He was in a sinus rhythm at 72 with a blood pressure of 119/73. Postoperative laboratories showed a BUN of 17, a creatinine of 1.0, a K of 4.6, a hematocrit of 29 (after 2 units of packed red blood cells). His PA line was removed. He began Lopressor beta blockade as well as Lasix diuresis and remained in the cardiothoracic ICU. He was also seen by the case manager. On postoperative day 2, his Lopressor was increased. His heart rate was 77. He was hemodynamically stable. His creatinine rose only slightly to 1.2. His pacing wires were discontinued. His mediastinal tubes were discontinued. His pleural tube remained in place, and he was transferred out to the floor where he was seen and evaluated with physical therapy to begin his ambulation. He immediately made excellent progress with ambulating and progressing his activity level on the floor. On postoperative day 3, he was alert and oriented. His hematocrit remained stable at 28.9. He was restarted on his oral medications including aspirin and continued to finish his perioperatively vancomycin. His sternum was stable. His incision was clean, dry, and intact. His left endoscopic vein harvest incision was clean and dry with no erythema, and his pleural tube was removed. Case management arranged for VNA services for the patient. DISCHARGE STATUS: On postoperative day 4, he did do a level V ambulation. He was doing extremely well postoperatively, and he was ready for home to home with VNA. On the day of discharge his blood pressure was 116/64, in sinus rhythm at 77, saturating 94 percent on room air. His incisions were clean, dry, and intact. DI[Last Name (STitle) 408]E FOLLOWUP: He was instructed to follow up in our postoperative wound clinic at 2 weeks post discharge and to see Dr. [Last Name (Prefixes) ] in the office at 4 weeks post discharge. Also, the patient was instructed to follow up with his primary care physician [Name Initial (PRE) ] [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3613] [Last Name (NamePattern1) 5263] - in approximately 3 weeks post discharge. DISCHARGE DISPOSITION: He was discharged to home with VNA services on [2146-2-18]. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 2 with resuspension of aortic valve and replacement of ascending aorta. 2. Coronary artery disease. 3. Raynaud disease. 4. Hypertension. 5. Hyperlipidemia. 6. Status post osteoma of left leg. 7. Status post deviated septal repair. 8. Wisdom teeth removal. 9. Herniated disc. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. once a day (for 10 days). 2. Potassium chloride 20 mEq p.o. once a day (for 10 days). 3. Colace 100 mg p.o. twice a day. 4. Enteric coated aspirin 81 mg p.o. once a day. 5. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. as needed (for pain). 6. Zocor 20 mg p.o. once a day. 7. Metoprolol 50 mg p.o. twice a day. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2146-3-22] 08:51:56 T: [2146-3-22] 10:49:03 Job#: [Job Number 103185]	[ "441.2", "401.9", "396.3", "414.01", "443.0", "272.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "38.45", "99.07", "35.39", "99.05", "99.04", "36.11", "39.61" ]	icd9pcs	[ [ [] ] ]	7424, 7489						1547, 1617	7510, 7842				7868, 8454		3854, 7400																			1132, 1530				2071, 3836						1877, 2048													165, 751																		773, 1099	1634, 1857
26,555	137,636	14684+14685	Discharge summary	report+report	Admission Date: [2161-5-29] Discharge Date: [2161-6-16] Date of Birth: [2103-4-8] Sex: M Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: The patient is a 58 year old homeless man with a history of bipolar disease who attempted suicide on [2161-5-25], after ingesting thirty to fifty 500 mg Depakote tablets. The patient was taken to [Hospital 1474] Hospital where he was treated with charcoal. His Valproic Acid level was 247, peaking at 269. He was treated initially with charcoal but, because he became more obtunded during the course of the day, the patient was transferred to the Medical Intensive Care Unit on [2161-5-26]. The patient's urine toxicology screen was also positive for Cocaine and he was also found to have pancreatitis with an elevated lipase of 1083 and an amylase of 588 with normal liver function tests. Hemodialysis was planned for the patient and a femoral Quinton catheter was placed but hemodialysis was delayed secondary to hypotension which developed. On [2161-5-27], the patient was noted to have an ammonia level of 276. CT scan of the head was performed which was negative for any acute changes. The patient continued to receive activated charcoal with Sorbitol every four hours via nasogastric tube from [2161-5-26], onward with a decrease in Valproic Acid levels down to 225 on [2161-5-27], 83 on [2161-5-28], and 30 on [2161-5-29]. His ammonia level on 06/w8/02, was 36. On [2161-5-28], the patient intubated for hypoxia, a large a/A gradient and for aspiration pneumonia. He had been receiving Tequin intravenously from [2161-5-28], to [2161-5-29], but then was changed to Ceftriaxone and Clindamycin. His chest x-ray at that time reported showed increasing bibasilar infiltrates. Additionally on the night of [2161-5-27], the patient was noted to have a seizure with a twitching and shaking of his left arm, jaw and left side of face. A repeat CT scan of the brain was performed without contrast which revealed no changes. On [2161-5-29], the patient was transferred to the [Hospital1 41532] Medical Intensive Care Unit, for further management of his hypoxia, hypotension and seizures. PAST MEDICAL HISTORY: 1. Chronic pancreatitis. 2. Bipolar disorder. He is being treated with Zyprexa 15 mg once daily and Depakote 250 mg p.o. twice a day. 3. Hypertension for which he received Hydrochlorothiazide 25 mg once daily. 4. History of Cocaine use. 5. Transurethral resection of prostate in [2154]. 6. Acute renal failure in [2154], secondary to urinary retention. 7. History of seizures ?. The patient received Tegretol as an outpatient medication. 8. Status post hernia repair. MEDICATIONS ON TRANSFER: 1. Famotidine 20 mg intravenously q12hours. 2. Propofol intravenously. 3. Versed 12 mg q.h. 4. Artificial Tears to both eyes. 5. DW5 at 75 cc/hour. 6. Multivitamins 10 ml/once daily. 7. Folic Acid 1 mg intravenously once daily. 8. Thiamine 100 mg intravenously once daily. 9. Charcoal with Sorbitol q4hours PGT. 10. Ceftriaxone two grams intravenously q8hours. 11. Clindamycin 600 mg intravenously. 12. Carnitine 1250 mg intravenously q8hours. At the time of transfer, the patient was intubated and mechanically ventilated on FIMV, respiratory rate 12, tidal volume 650 cc and PEEP at 7.5 and FIO2 at 60%. SOCIAL HISTORY: The patient smokes one pack per day of cigarettes. He reportedly denies alcohol use. He lives in a homeless shelter and has a history of polysubstance abuse. His health care proxy is a lawyer, [Name (NI) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 43221], who is also his friend, telephone [Telephone/Fax (1) 43222]. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: General - unresponsive. Vital signs revealed temperature maximum of 104, heart rate 60s, blood pressure 104/80, respiratory rate 16. Neck - no jugular venous distention, carotid uptakes were shallow. Chest - scattered rhonchi. Cardiovascular - heart sounds distant. Gastrointestinal - The abdomen is soft, bowel sounds hypoactive, no masses. Extremities - no cyanosis, clubbing or edema. Pedal pulses were 1+ bilaterally. Neurologically unresponsive. The pupils are constricted, minimally responsive to light. LABORATORY DATA: On ventilatory settings of a tidal volume of 750 cc and PEEP of 8 and FIO2 of 60%, respiratory rate 22, arterial blood gases revealed pH 7.39, pCO2 29, pO2 77, bicarbonate 18. White blood cell count was 9.6, hematocrit 31.7, platelets 58,000. Glucose 62, blood urea nitrogen 15, creatinine 1.0. Sodium 140, potassium 4.0, chloride 112, CO2 18, ammonia 36. Sputum gram stain showed 1+ gram positive cocci, 1+ gram negative rods, 1+ gram positive rods. Electrocardiogram revealed sinus tachycardia, right bundle branch block, left atrial deviation, left anterior fascicular block at [Hospital 1474] Hospital. Arterial blood gases dated [2161-5-30], at 10:15 a.m. at vent settings of assist control tidal volume 700 cc and rate of 20, PEEP of 8 and FIO2 60%, showed a pH of 7.42, pCO2 30 and pO2 of 72. Chest x-ray showed vague haziness at both bases. No congestive heart failure. Heart size normal. HOSPITAL COURSE: 1. Pulmonary - The patient was treated for multilobar aspiration pneumonia. A chest CT done [2161-6-1], showed atelectasis, bibasilar collapse, ground glass opacities in the right middle lobe and lingula. The patient has remained agitated and occasionally desynchronous with a vent requiring increasing sedation as needed and was intermittently paralyzed. The patient also had increasing secretions which limited his weaning from the vent and required aggressive pulmonary toilet with intermittent desaturations. The patient was trached on [2161-6-11]. At present, the patient is being weaned from his Ativan and Fentanyl drips and is being transitioned over to a Fentanyl patch and Haldol p.o. medication. He has been switched over to pressure support of 5 and a PEEP of 5 with a FIO2 of 40%. His oxygen saturation is 96% on these settings with a respiratory rate of 20 to 30s and a tidal volume at 700. 2. Infectious disease - The patient has had low grade fevers with intermittent spikes into 101. The patient has been pancultured numerous times and lines have been changed. The cause of the fever is suspected to be pneumonia. The patient has been receiving an aggressive antibiotic regimen including Ceftazidime for which he is completing a fourteen day course, Vancomycin for which he is also completing a fourteen day course, and Flagyl for which he received eighteen days. The only culture positive result thus far has been sputum culture which has been positive for coagulase positive Staphylococcus aureus which is resistant to Methicillin. CT scan of the sinuses was done looking for sinusitis which showed thick frontal, ethmoid, left maxillary, sphenoid sinus mucosa consistent with sinusitis. Otherwise, no obvious other source of infection has been determined. 3. Neurologic - The patient's baseline mental status is unclear. [Name2 (NI) 6] electroencephalogram was done to evaluate for possibility of neurological recovery on [2161-6-1], which showed encephalopathy, likely secondary to medication, however, no evidence of focal neurological deficit was found. A repeat head CT scan was done which was negative. A lumbar puncture was also negative. The patient's mental status has improved over the hospital course from unresponsiveness to now being able to open his eyes. However, the patient is minimally responsive to vocal commands. 4. Cardiovascular - The patient has been hypotensive intermittently throughout his hospital course, occasionally requiring Dopamine for pressure support. The hypotension is likely secondary to sepsis. Currently, the patient now has become hypertensive to blood pressure in the 190 to 200 over 90 to 100 range. The patient has been started on Diltiazem 60 mg p.o. four times a day with good response in his blood pressure which is now in the 140 to 150s over 70 to 90s. 5. Hematology - An abdominal CT which was done to look for evidence of pancreatitis showed incidentally the presence of a right common iliac deep vein thrombosis. The patient has been on therapeutic doses of Heparin. We will be transitioning him to Coumadin as soon as all his procedures/lines have been completed. 6. Gastrointestinal - The patient's pancreatitis has resolved with amylase and lipase levels within normal range. Abdominal CT scan performed on [2161-6-1], showed no evidence of pancreatitis, shotty retroperitoneal lymphadenopathy, bilateral renal stones, thickened terminal ileum ?, and a right common iliac deep vein thrombosis. A percutaneous endoscopic gastrostomy tube was placed on [2161-6-13], for nutrition and tube feeds were started with Peptamen with a goal rate of 70 cc/hour. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation for ventilatory weaning. DISCHARGE DIAGNOSES: 1. Depakote overdose. 2. Status post pancreatitis. 3. Pneumonia, aspiration and Methicillin resistant Staphylococcus aureus. 4. Difficulty weaning from ventilator. 5. Hypertension. 6. Substance abuse. 7. Seizure history. MEDICATIONS ON DISCHARGE: 1. Diltiazem 60 mg p.o. three times a day. 2. Peptamen VHP tube feeds at 70 ml/hour. 3. Heparin drip. 4. Beclomethasone Dipro one spray per nostril twice a day. 5. Acetaminophen 325 to 650 mg p.o. q4-6hours p.r.n. 6. Lansoprazole oral solution 30 mg nasogastric once daily. 7. Vancomycin one gram intravenously q8hours. 8. Miconazole Powder 2% one application TP three times a day p.r.n. 9. Albuterol Sulfate Ipratropium four puffs inhaled q4-6hours. 10. Haldol 2 mg p.o. q8hours. 11. Fentanyl 75 mcg q72hours. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[Last Name (NamePattern1) 1336] MEDQUIST36 D: [2161-6-15] 16:21 T: [2161-6-15] 18:37 JOB#: [Job Number ] Admission Date: [2161-5-29] Discharge Date: [2161-7-6] Date of Birth: [2103-4-8] Sex: M Service: Medicine Intensive Care Unit EXAM AT ADMISSION: GENERAL APPEARANCE: The patient is unresponsive. VITAL SIGNS: Blood pressure 104/60, heart rate 60, respiratory rate 16, temperature 104?????? NECK: No jugular venous distention. Carotid uptakes are shallow. CHEST: Clear to auscultation bilaterally with scant rhonchi. HEART: Heart sounds are distant. ABDOMEN: Soft, bowel sounds are hypoactive. There are no masses to palpation. EXTREMITIES: No cyanosis, clubbing or edema. Dorsalis pedis palpable 1+ bilateral. NEUROLOGIC: Unresponsive. Pupils are constricted and minimally responsive to light. ADMISSION LABS: Arterial blood gases: pH 7.39, PCO2 29, PO2 77. White blood count 9.6, hematocrit 31.7, platelets 58. Chem-7: Sodium 140, potassium 4.0, chloride 112, bicarbonate 18, BUN 15, creatinine 1.0, glucose 62, ammonia level 36. Sputum shows gram stain, 1+ gram positive cocci and 1+ gram positive rods and 1+ gram negative rods. IMAGING: Electrocardiogram: Sinus tachycardia with right bundle block. Chest x-ray showed vague heaviness at the bases bilaterally, no evidence of congestive heart failure and normal heart size. BRIEF HOSPITAL COURSE: Mr. [Known lastname 43223] is a 58-year-old gentleman with a history of bipolar disease who attempted suicide on [2161-5-25] after ingesting 30 to 50 500 mg Depakote tables. His mental status has fluctuated from completely unresponsive to responsive to commands. He has had a long hospital course. Briefly, his hospitalizations started at [Hospital 1474] Hospital where he was taken after his overdose. There, he was treated with charcoal. The valproic acid level was 247, peaking at 269. The patient's urine toxicology screen was also positive for cocaine and he was also found to have pancreatitis with an elevated lipase of 1083 and an amylase of 588 with normal liver function tests. He became more obtunded during the course of the day and was transferred to the Medical Intensive Care Unit on [2161-5-26]. On [2161-5-27], a CT scan of the head was performed which was negative for any acute changes and on the night of [2161-5-27], the patient was noted to have a seizure with twitching and shaking of his left arm, jaw and left side of the face. A repeat CT scan of the brain was performed without contrast which revealed no changes. On [2161-5-29], the patient was transferred to [Hospital6 256] Medical Intensive Care Unit for further management of his hypoxia, hypotension and seizures. An electroencephalogram was done here to evaluate for possibility of neurological recovery on [2161-6-1] which showed encephalopathy likely secondary to medication. However, no evidence of focal neurological deficit was found. A lumbar puncture was also negative. The long hospital course has been complicated by prolonged intubation, now status post tracheostomy, hypertension, pancreatitis, aspiration pneumonia, deep venous thrombosis, bowel hypermotility, gram negative rod bacteremia, as well as persistent low grade fevers and new onset rigidity. 1. FEVERS: Mr. [Known lastname 43223] has had recurrent low grade fevers with occasional spikes. Several urine, sputum and blood cultures have been repeated which have shown Methicillin resistant Staphylococcus aureus and gram negative rods in the sputum which are not Pseudomonas and number of yeast in the urine and gram negative rod bacteremia in the blood. He has had an extensive course of antibiotics, total of 24 days for levofloxacin and vancomycin which have not resolved his low grade fevers and occasional spikes. Completed his 24 day course. A sputum culture showed, once again, gram negative rods for which he has been started on Zosyn for a couple of days ............ to switch to ceftriaxone once culture and sensitivity proved it was sensitive to ceftriaxone. 2. RESPIRATORY FAILURE: Mr. [Known lastname 43223] had respiratory failure and aspiration pneumonia which required intubation and then tracheostomy. Weaning attempts were often limited by episodes of tachypnea, agitation and copious secretion which required sedation with Ativan and fentanyl drip. However, the patient was finally was successfully weaned off the vent and able to tolerate blow by oxygen through the tracheostomy. 3. DEEP VENOUS THROMBOSIS: A deep venous thrombosis in the iliac vein was accidentally discovered on CT of the abdomen. Before Mr. [Known lastname 43223] was started on anticoagulation with heparin and Coumadin with the heparin to be continued until therapeutic level would be achieved on Coumadin. While anticoagulated, however, Mr. [Known lastname 43223] developed a hemorrhage into his right psoas muscle. Anticoagulation was immediately stopped. Mr. [Known lastname 43223] was transfused and because of the need to stop the anticoagulation and the concept of known deep venous thrombosis in a patient who is mobile ............., an IVC filter was placed. The procedure was performed without any complication. The hematocrit at discharge was 32.2. 4. ABDOMINAL PAIN: Mr. [Known lastname 43223] has been having constant abdominal pain throughout his hospitalization. He has had an ileus which had resolved and since his resolution has been able to tolerate tube feeds well and is now receiving both feedings and medications through the PEG. 5. HYPERTENSION: Mr. [Known lastname 43223] was found to be hypertensive. He was treated with Lopressor which was titrated to 50 mg tid with good blood pressure control. 6. RIGIDITY: Mr. [Known lastname 43223] developed new onset rigidity after being started on Haldol for management of his agitation. The rigidity was associated with tremors. The neurology service was consulted for management of this new symptom. The etiology of the rigidity at this time is still unclear. The rigidity could have been caused by the Haldol masking an already present Parkinson or otherwise could be idiopathic. Mr. [Known lastname 43223] was, however, started on Sinemet for treatment of the rigidity assuming that it could be secondary to longstanding Parkinson's disease now unmasked by the Haldol. The rigidity has slowly yet steadily improved since Mr. [Known lastname 43223] has been started on Sinemet. DISCHARGE CONDITION: Fair DISCHARGE STATUS: [Hospital3 672] Hospital DISCHARGE CODE: DNR which has been discussed both with Mr. [Known lastname 43224] health care proxy who is Mr. [Name13 (STitle) 43221] and with Mr. [Known lastname 43223] himself. DISCHARGE DIAGNOSES: 1. Valproic acid overdose 2. Pancreatitis 3. Hypertension 4. Respiratory failure 5. Iliac deep venous thrombosis 6. Ileus 7. Psoas muscle hemorrhage 8. New onset rigidity and tremor 9. Aspiration pneumonia 10. Gram negative rod bacteremia DISCHARGE MEDICATIONS: Dictation ends abruptly. [Name6 (MD) ] [Last Name (NamePattern4) 5837], M.D. [MD Number(1) 8285] Dictated By:[Last Name (NamePattern1) 43225] MEDQUIST36 D: [2161-7-6] 13:31 T: [2161-7-6] 14:14 JOB#: [Job Number 43226]	[ "966.3", "780.39", "E950.4", "518.81", "507.0", "790.7", "453.8", "577.0", "560.1" ]	icd9cm	[ [ [] ] ]	[ "31.1", "38.91", "43.11", "96.04", "03.31", "96.6", "38.93", "96.72", "38.7" ]	icd9pcs	[ [ [] ] ]		11403, 16523		16545, 16794			3754, 3772	16815, 17064	17088, 17374			9322, 10837		5264, 8949																							3795, 5247																			168, 2225				10854, 11379													2757, 3374	2247, 2732	3391, 3737	8974, 9046
46,446	168,689	44144	Discharge summary	report	Admission Date: [2102-4-2] Discharge Date: [2102-4-4] Date of Birth: [2045-6-20] Sex: F Service: MEDICINE Allergies: Penicillins / Shellfish Derived Attending:[First Name3 (LF) 10593] Chief Complaint: Seizure/Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 94740] is a 56F with a history of celiac disease, hypothyroidism, anxiety and depression who presented to [Hospital1 18] [Location (un) 620] with complaints of feeling lightheaded and concern for dehydration. Per OSH documentation, she spent the day yesterday doing exertional yardwork and burning brush in her yard (possibly some smoke inhalation, though denies burning in the lungs or coughing in response to smoke). Around 1:00 PM, she began to feel nauseated, dizzy, and pre-syncopal. She also reported perioral and hand numbness/tingling. She felt that she may have overheated and become dehydrated, and called EMS where she was BIBA to [Location (un) 620]. On arrival to [Location (un) 620], vitals were T 97.7, HR 84, BP 152/110, RR 16, O2 sat 97% on RA. Labs were notable for serum sodium of 124 and negative tox screen. She was given 1L of NS bolus for presumed dehydration. During her evaluation at [Location (un) 620], she was found to be more confused. She developed a headache and a head CT was ordered. Radiology found lack of sulci concerning for possible cerebral edema. She then had a witnessed ? generalized tonic-clonic seizure in the ED (5-minute duration, + incontinence, received IV lorazepam which terminated seizure as well as 2g IV Mg). Fingerstick was normal and tox screen was negative. She was then transferred to [Hospital1 18] for further management. . In the ED, initial VS were T 97.8, HR 94, BP 100/50, RR 16, O2 sat 98% on 2L NC. On arrival, she was noted to be awake and oriented x 3, and able to provide her own history (was described as post-ictal leaving [Location (un) 620]). She was evaluated by the neurology service who felt that her presentation was most consistent with proviked seizure secondary to hyponatremia. They recommended MRI brain and slow correction of hyponatremia to avoid CPM. She was initially continued on IVF with NS for a total of 3L between here and OSH, and made "large volume" urine. Given borderline low BPs while in ED (to SBP in 90s), patient received ceftrizxone, vancomycin and acyclovir to cover for possible meningitis. She has not had fever or meningeal signs. Vitals on transfer to MICU were T 98.0, HR 88, BP 94/52, RR 12, 100% on 2L NC. . Of note, she had a similar presentation to [Hospital1 ] [Location (un) 620] in [Month (only) ] [2099] when she was found to be hyponatremic to 127 after strenuous yard work. She was symptomatic at that time with palpitations and generalized weakness. During that hospitalization, her sodium improved to 141 with volume resuscitation. TSH was slightly elevated, but her levothyroxine dose was not adjusted. On arrival to the MICU, patient's VS were HR 89, BP 89/40, 100% on 2L NC. She is unable to remember many of the events overnight, including the seizure itself. She understands that she is in the ICU, but states she is confused about why she is here, and cannot remember if anyone told her about her low sodium and seizure. She endorses mild right temporal headache, but otherwise no pain. Feels sleepy and as though her thinking is not as clear as usual. 1400 cc's of pale yellow urine were emptied from catheter bag on arrival to ICU. Review of systems: (+) Per HPI (-) Denies fever, chills, recent weight loss or gain. She does have night sweats which is not unusual for her. She does reoprt skipping meals and unhealthy dietary habits. Endorses sinus tenderness, rhinorrhea and congestion related to seasonal allergies. No photo/phonophobia, no neck stiffness. Also reports sore throat which she says may be due to burning her throat on hot coffee yesterday. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies current nausea, any vomiting, diarrhea, dark or bloody stools. She does have some constipation which she attributes to her Celiac disease and some associated abdominal discomfort. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Depression - Anxiety - Celiac disease - Hypothyroidism - ADHD - Hypercholesterolemia - s/p tonsillectomy - s/p appendectomy Social History: She works as a psychologist in the [Location (un) ] schools. She is married but her husband lives in [Name (NI) 6607], and therefore she is mostly by herself at home. She denies smoking (never-smoker), alcohol or illicit drug abuse. Family History: There is a family history of seizures in her grandmother and cousin. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T: 98.6 ??????F, HR: 88 bpm, BP: 81/55 mmHg, RR: 14 insp/min, SpO2: 98%RA General: Sleepy (closes eyes frequently during history, has to be prompted to answer some questions), but oriented x 3. She is confused about overnight events but able to provide history consistent with prior documentation of events leading up to admission. Appears euvolemic at this time. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple (no meningeal signs), JVP not elevated, no LAD or thyromegaly appreciated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, mild tenderness to palpation over lower abdomen which pt feels is from some constipation, no rebound or guarding GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Excoriations on upper extremities from scrapes with brush doing yardwork Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Patient appears overall somewhat tremulous (most noticeable in hands, tongue) though no fasciculations . DISCHARGE PHYSICAL EXAM: Vitals normal A and O x 3, ambulatory without assist No focal neurologic deficit on exam Pertinent Results: ADMISSION LABS: =============== [2102-4-2] 03:36AM BLOOD WBC-6.2 RBC-4.12* Hgb-12.3 Hct-37.0 MCV-90 MCH-29.9 MCHC-33.2 RDW-12.3 Plt Ct-225 [2102-4-2] 03:36AM BLOOD Neuts-77.0* Lymphs-18.3 Monos-4.1 Eos-0.3 Baso-0.4 [2102-4-2] 03:36AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-120* K-4.2 Cl-92* HCO3-21* AnGap-11 [2102-4-2] 03:36AM BLOOD ALT-20 AST-30 AlkPhos-56 TotBili-0.5 [2102-4-2] 03:36AM BLOOD Lipase-19 [2102-4-2] 03:36AM BLOOD cTropnT-<0.01 [2102-4-2] 03:36AM BLOOD Albumin-3.5 Calcium-7.4* Phos-2.9 Mg-2.2 [2102-4-2] 03:36AM BLOOD Osmolal-251* [2102-4-2] 03:36AM BLOOD TSH-1.1 [2102-4-2] 09:29AM BLOOD Cortsol-5.5 [2102-4-2] 09:50AM BLOOD Lactate-1.0 [2102-4-2] 03:41AM BLOOD Lactate-2.2* [2102-4-2] 09:50AM BLOOD freeCa-1.17 [2102-4-2] 04:30AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2102-4-2] 04:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2102-4-2] 04:54AM URINE Hours-RANDOM Creat-23 Na-61 K-29 Cl-51 [2102-4-2] 04:54AM URINE Osmolal-261 PERTINENT LABS: =============== [2102-4-2] 03:36AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-120* K-4.2 Cl-92* HCO3-21* AnGap-11 [2102-4-2] 09:29AM BLOOD Glucose-94 UreaN-8 Creat-0.5 Na-132* K-3.8 Cl-103 HCO3-23 AnGap-10 [2102-4-2] 03:51PM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-3.6 Cl-110* HCO3-23 AnGap-11 [2102-4-2] 03:36AM BLOOD Osmolal-251* [2102-4-2] 03:36AM BLOOD TSH-1.1 [2102-4-2] 09:29AM BLOOD Cortsol-5.5 [2102-4-2] 04:54AM URINE Osmolal-261 [2102-4-2] 10:22AM URINE Osmolal-70 [2102-4-3] 02:00PM URINE Osmolal-139 DISCHARGE LABS: =============== MICRO/PATH: =========== [2102-4-2] MRSA SCREEN MRSA SCREEN: PENDING [2102-4-2] BLOOD CULTURE Blood Culture: NGTD [2102-4-2] BLOOD CULTURE Blood Culture: NGTD [2102-4-2] BLOOD CULTURE Blood Culture: NGTD IMAGING/STUDIES: ================ MRI Brain Non-Con [2102-4-2]: IMPRESSION: Study is substantially motion-limited; however, there is no evidence of acute intracranial abnormality, with no finding to suggest cerebral edema, and no pathologic focus of enhancement. Sodium at discharge: 142 Brief Hospital Course: 56F with Celiac disease, hypothyroidism, depression, and [Hospital 94741] transferred from BIDN for hyponatremic seizure following rigorous yardwork and brush burning and free water intake. ACTIVE DIAGNOSES: # Seizure, Likely from Acute-Onset Hyponatremia: Patient had single episode of seizure (first lifetime episode) following strenuous yard work and new-onset hyponatremia to as low as 120 on arrival in our ED. She had head CT at [Location (un) 620] c/w cerebral edema, MRI performed here without evidence of abnormality or cerebral edema. Cortisol and TSH normal. Serum osms were low on arrival here 251 with initial urine osm > 100 at 261 and urine Na > 40 at 61 suggestive more of a picture consistent with SIADH. Following administration of 3L NS (most at BIDN, some here) she produced copious volumes of dilute urine with correction of her serum sodium to wnl's without neurological sequelae (presumably due to the acute nature of her hyponatremia). Her home effexor and trazodone were held for concern of contributing to her hyponatremia as was her adderral given concern for lowering her seizure threshold. She was evaluated and cleared by neurology and seen by nephrology who recommended no further neurologic evaluation, and was offered nephrology follow up in clinic. She had a TSH and cortisol level checked which were normal. She was counseled extensively on the need to avoid excessive free-water intake, especially when exerting herself, and advised to rehydrate with solute-containing fluids. She will follow up with her PCP in the coming days to ensure that sodium is stable. All of her home medications were started upon discharge. Na level was stable from 139-143 on several checks in the last 2 days of this hospitalization. CHRONIC DIAGNOSES: # Hypothyroidism: Stable. TSH wnl's, maintained on her home levothyroxine dose. # Depression/Anxiety: Stable. Initially held Effexor and trazodone, restarted prior to discharge # ADHD: Stable. Initially held amphetamine but then restarted upon discharge. Note was sent to PCP regarding [Name9 (PRE) 48258] of need for Adderall. TRANSITIONAL ISSUES: - repeat sodium within the next week to ensure stability - Follow-up with Nephrology in clinic within the next one month. - She had a CT scan at BIDN with the following findings with suggestion to repeat this study at six weeks. CONCLUSION: BIBASILAR ATELECTASIS. PATCHY TREE-IN-[Male First Name (un) ] NODULAR TYPE DENSITY SEEN IN THE UPPER LOBES PERIPHERALLY. DIFFERENTIAL DIAGNOSIS INCLUDES INFECTIOUS OR INFLAMMATORY ETIOLOGY. SIX-WEEK FOLLOW-UP IS RECOMMENDED TO ENSURE RESOLUTION. NO ADENOPATHY. NO PLEURAL EFFUSION. STUDY IS SOMEWHAT LIMITED BY THE LACK OF IV CONTRAST. Medications on Admission: - Fexofenadine 60 mg by mouth twice a day - Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-200 unit by mouth twice a day (per patient, not taking recently) - Effexor XR 75 mg 24 hr by mouth daily (in pharmacy, [Hospital1 ]) - Levothyroxine 75 mcg by mouth daily - Trazodone 100 mg PO at bedtime (takes one tablet, not half) - Adderall 10 mg PO BID - Lipitor 10 mg PO daily - Flonase nasal spray PRN Discharge Medications: 1. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 2. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 3. Effexor XR 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 4. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO once a day. 5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Adderall 10 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Flonase 50 mcg/actuation Spray, Suspension Sig: One (1) Nasal once a day as needed for allergy symptoms. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hyponatremia Seizure Secondary Diagnosis: depression/anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after having a seizure. The seizure occurred in the setting of a low sodium level. You likely had a low sodium level due to the water and soda that you drank on a hot day. You had an MRI of your brain that did not show any changes, and was normal. Your sodium level returned to [Location 213] quickly, and you did not have any additional symptoms. Repeat sodium levels were stable, and you were able to go home on [2102-4-4]. No changes were made to your medications. Please see below for your follow up appointments. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] C. Location: [Hospital1 ] HEALTHCARE-[Location (un) 8596] Address: [Location (un) 8597], [Location (un) ],[Numeric Identifier 3862] Phone: [Telephone/Fax (1) 8598] Appt: [4-12] at 1:15pm -> it is important that you keep this appointment to recheck your sodium level. You will also be contact[Name (NI) ] by Dr. [Last Name (STitle) 94742] [Name (STitle) 17159] of nephrology for a follow up appointment.	[ "314.01", "579.0", "244.9", "300.4", "272.0", "780.39", "276.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12393, 12399	8555, 8750	322, 328	12524, 12524	6308, 6308	13265, 13765	4835, 4906		11737, 12370		12420, 12420		11309, 11714			12675, 13242			7997, 8511						4946, 6174													8526, 8532		10697, 11283			3607, 4410				252, 284									356, 3588			12482, 12503	6324, 7414	12439, 12461			12539, 12651			7430, 7981					8769, 10675		4432, 4560	4576, 4819		6199, 6289
76,037	104,600	6129	Discharge summary	report	Admission Date: [2124-10-2] Discharge Date: [2124-10-3] Date of Birth: [2068-5-18] Sex: F Service: MEDICINE Allergies: Ampicillin Attending:[Last Name (NamePattern4) 290] Chief Complaint: Vomiting coffe ground like stuff Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [Known firstname 553] [Known lastname 23957] is a 56 year old woman with a history of ITP s/p splenectomy and recently diagnosed DM2 who presents from her PCP office with new onset coffee ground emesis. . Ms. [Known lastname 23957] describes waking up this morning and feeling unwell while running errands. On return back to the house she felt extremely fatigued and lightheaded after walking up the four stairs from her driveway to the front door and had to sit down. She described the sensation of sudden fevers and chills. She reports having sudden sharp substernal chest pain while seated that lasted a few minutes. She was concerned that this chest pain might be a heart attack so she went inside to take aspirin. On the way to the kitchen she vomited dark brown coffee grounds. She took two baby aspirin and called her spouse. She did not want to go to the Emergency Department so her spouse called her PCP who instructed her to come in. On her walk into the office she had another episode of coffee ground emesis. In clinic she was found to be tachycardic and was instructed to go immediately to the Emergency Department for concern for a GI bleed. . In the ED, initial vs were: T 96.4 P 111 BP 115/73 R 18 O2 sat 100% RA. NG lavage was positive for coffee grounds. Her rectal exam revealed melanotic guaiac positive stools. EKG showed sinus tachycardia with [Street Address(2) 4793] depression I and aVL. CXR was negative for an acute process. Her initial hct returned at 36 down from recent 43 on [2124-9-13]. Repeat hct, however, fell to 26. GI services was consulted. During her evaluation she had one transient episode of hypotension to 79/54 which quickly responded to IV fluids. Patient received protonix bolus and continuous drip, 2 u pRBC, and 3 L IV NS prior to transfer to the ICU. . On the floor, patient reports feeling much better since receiving her blood transfusions in the Emergency Department. She is no longer light headed and fatigued. She reports only having two episodes of coffee ground emesis which both occured prior to arrival to the ED. On further questioning she admits to one day of dark tarry stools but has not had any further bowel movements since her arrival. She denies any history of GI bleeding or ulcers. She denies use of alcohol or anticoagulation. She denies recent GI illness or repeated emesis or heaving. When asked about NSAID use she does report a significant increase in her NSAID use after a recent dental procedure. She describes taking 3 Advil tablets at time up to every four hours. She states she probably averages 12 pills per day over the last two weeks. She also reports starting a prescription strength NSAID that she took in addition to the Advil after her dental procedure. She was also given a prescription for Percocet and often alternated her Advil doses with 2 extra strength Tylenol. Patient reports taking up to 8 extra strength Tylenol each day (4 grams). Past Medical History: 1) Hypertension: Toprol XL 50mg. 2) High cholesterol/triglycerides: Zocor 3) Irritable Bowel Syndrome: with constipation alternating with diarrhea and lower abdominal pain. 4) Migraine headaches: several times monthly 5) ITP s/p laparoscopic splenectomy ([12/2112]): initially relapsed following splenectomy but has had stable, normal platelet levels for last 10 years. 6) Diabetes Mellitus Type 2: last hemoglobin A1C of 8.3 [2124-9-13]. started metformin. 7) Serologies: neg hepatitis w/u '[11], neg [Doctor First Name ], RF '[13] Social History: Social History: Patient lives with her spouse. She is unemployed. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies . Family History: Family History: Mother - cerebral aneurysm Physical Exam: Physical Exam: Vitals: T: 98.5 BP: 141/85 P: 109 R: 16 O2: 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no hepatomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes . Pertinent Results: [2124-10-2] 02:47PM BLOOD WBC-9.6 RBC-3.74* Hgb-11.4* Hct-36.1 MCV-97 MCH-30.6 MCHC-31.7 RDW-12.8 Plt Ct-338 [2124-10-2] 05:55PM BLOOD WBC-8.1 RBC-2.74# Hgb-8.7 Hct-25.8# MCV-94 MCH-31.7 MCHC-33.6 RDW-12.7 Plt Ct-245 [2124-10-3] 04:42AM BLOOD WBC-10.6 RBC-3.74# Hgb-11.2# Hct-34.1 MCV-91 MCH-29.9 MCHC-32.8 RDW-14.9 Plt Ct-207 [2124-10-2] 02:47PM BLOOD Neuts-64.4 Lymphs-30.5 Monos-3.6 Eos-0.6 Baso-0.9 [2124-10-3] 04:42AM BLOOD PT-12.4 PTT-22.2 INR(PT)-1.0 [2124-10-2] 02:47PM BLOOD Glucose-178* UreaN-38* Creat-0.6 Na-137 K-4.6 Cl-103 HCO3-24 AnGap-15 [2124-10-3] 04:42AM BLOOD Glucose-84 UreaN-15 Creat-0.5 Na-142 K-3.4 Cl-113* HCO3-21* AnGap-11 [2124-10-3] 04:42AM BLOOD ALT-47* AST-35 CK(CPK)-91 AlkPhos-50 TotBili-0.9 [2124-10-3] 04:42AM BLOOD CK-MB-2 cTropnT-<0.01 [2124-10-3] 02:04PM BLOOD CK-MB-2 cTropnT-<0.01 [2124-10-3] 04:42AM BLOOD Phos-2.4* Mg-1.9 [2124-10-2] 02:52PM BLOOD Glucose-179* Lactate-2.9* K-4.4 Brief Hospital Course: #GI Bleed: Patient with hematocrit drop 17 pts (43-->26) since PCP [Name Initial (PRE) ] [2124-9-13]. She had two witnessed episodes of coffee ground emesis on the day of admission as well as one of day of dark tarry bowel movements. In the ED she was noted to have no known history of GI bleeding or PUD. She denies history of recent GI illness, upper endoscopy, or liver disease. She has a history of ITP which has been in remission for 10 years and presents today with normal platelet count. Patient does admit to significant increase in NSAID use due to recent dental procedures. She is not able to quantify the exact amount of NSAIDs but reports taking 3 Advil tablets at one time multiple times each day over the last two weeks. She also states she was started on a prescription strength NSAID that she took in addition to the Advil over the last two weeks. She was without hemodynamic compromise. Since her transfusion in the ED, her lightheadedness, shortness of breath, or sharp chest pain resolved. Pt Hct was stable overnight and EGD did not show any areas of active bleeding. She was on a pantoprazole drip, and was switched to PO BID. She remained asymptomatic throughout the day and her diet was advanced from NPO to regular. Pt tolerated her diet and was ready for discharge to home. She was instructed to avoid NSAIDs for at least the next 6-8 weeks as well as to not get an MRI for one month. She was given tramadol for 1 month and her outpatient physician said he would manage her pain thereafter. . # Chest pain: Clinical history is unlikely to represent ACS with unstable plaque. Given her active bleed this may represent demand ischemia. The sharp sudden nature of the pain is more consistent with GI or musculoskeletal pain. Her chest discomfort may be related to gastritis or ulcer. No evidence of mediatinal widening to suggest esophageal perforation. Repeat EKG showed no concerning findings. Her cardiac enzymes were negative x2. Her aspirin was held in the setting of GI bleed. The patient was advised to follow up with a cardiologist for an exercise stress test. . #Transaminitis: AST/ALT mildly elevated. Unclear etiology. Negative hepatitis work-up in the past. Slightly more elevated than expected for NASH. She does admit to taking acetaminophen 1 gram q4 hours in addition to Perocet over the last two weeks. LFTs were trended and they were trending back to normal at the time of discharge. . #Diabetes Mellitus Type 2: Hold metformin while inpatient. Pt was put on an insulin sliding scale during her admission and was discharged to home on her oral hypoglycemics. # Hypertension: Blood pressure currently well controlled. Hold home antihypertensives. . Pt was discharged to home with instructions to follow up with her PCP [Last Name (NamePattern4) ] 6 weeks or [Name (NI) 23958] if she had any change in clinical status or any medical concerns that needed to be addressed. Medications on Admission: Metformin Toprol XL 50mg, Zocor 40mg, Vitamin D Levsin (Hyoscyamine) prn Maxalt (Rizatriptan) prn Hydrocortisone 2.5 % Ibuprofen 200 mg three daily Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:2 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. ketoconazole 2 % Cream Sig: One (1) Topical PRN as needed for Rash. 6. hydrocortisone valerate 0.2 % Ointment Sig: One (1) Topical once a day. 7. hydrocortisone 2 % Lotion Sig: One (1) Topical once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper Gastrointestinal Bleed Secondary Diagnosis: Hypertension High cholesterol/triglycerides Irritable Bowel Syndrome. Migraine headaches: several times monthly ITP s/p laparoscopic splenectomy Diabetes Mellitus Type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from [Hospital1 18]. You were admitted to the hospital because you woke up feeling unwell. You were lightheaded, weak, had fevers/chills, tachycardia and vomited coffe ground color vomit two times before seeing your Primary Care Physician. [Name10 (NameIs) ] sent you straight to the hospital as you physician was concerned about bleeding from your stomach or in that area. You presented to the emergency department and you had a drop in your red blood cells compared to previously. You were transfused 2 units of packed red blood cells and given fluids. Your blood levels stabilized after those two transfusions and further transfusions were not required. It is believed that the bleeding occurred because of the NSAID's that you were taking. It seems that you were taking a lot of advil and ot her anti-inflammatories that aggrevate the stomach lining and can cause it to bleed. It is important that you do not take NSAIDs in the next 6-8 weeks and try to avoid them in the future. You should follow up with Dr. [First Name (STitle) 679] regarding pain management. Do not have an MRI done for 1 month after being discharged from the hospital. The following medication was added: Omeprazole 40mg by mouth daily. Tramadol every 6 hours as needed for pain. The following medications were stopped: Ibuprofen 200 mg three daily Other NSAID's Followup Instructions: Please call Dr. [First Name (STitle) ] at [Telephone/Fax (1) 682]. You should follow up with Dr. [First Name (STitle) 679] 6 weeks after leaving the hospital. NO MRI FOR ONE MONTH. DISCUSS WITH DR. [First Name (STitle) ] ABOUT FOLLOWING UP FOR A CARDIAC STRESS TEST. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "250.00", "E935.9", "280.0", "272.4", "346.90", "401.9", "786.59", "578.9", "564.1" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	9604, 9610	5687, 8634	311, 317	9894, 9894	4688, 5664	11458, 11883	4071, 4099		8832, 9581		9631, 9631		8660, 8809			10045, 11435									4129, 4669																						239, 273									345, 3318			9701, 9873		9650, 9680			9909, 10021										3340, 3896	3929, 4038
46,943	108,688	44423	Discharge summary	report	Admission Date: [2175-8-19] Discharge Date: [2175-8-23] Date of Birth: [2122-1-31] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a 53 year-old male with past suicide attempts who presents with antidepressant overdose in an apparent suicide attempt. He was transported to [Hospital1 18] by EMS ambulance after being observed stumbling in the street. He reported that he wanted to kill himself and had taken a whole bottle of his diabetes medication and an entire bottle of his antidepressants, but was unable to identify what he had ingested. On arrival, he was hypotensive to the 80's, diaphoretic with altered mental status. In the ED, he received 2X Narcan with no effect; 2L NS with good effect; and was intubated for airway protection given worsening mental status, with BP rising transiently to the 160's. Toxicology recommended checking the QRS, which was 102, with a "normal" QTc and deferral of activated charcoal given inability to identify the overdosed medications. Otherwise, Cr was elevated to 2.8, lactate to 5.4, ut mag, potassium remained wnl. Psychiatry was consulted. . On transfer to the [Hospital Unit Name 153], his SBP was in the 130's. He was sedated on propofol and placed on A/C 400x 14 FiO2 1.0, peep 5. No ABG was drawn in the ED on these settings. His access is an EJ 18g on the right, 22 in hand. . . ROS: unable to be obtained given that patient is intubated and sedated. Past Medical History: Depression with history of suicide attempts x 2 Schizoaffective/Bipolar disorder Non-insulin-dependent diabetes mellitus. History of Grave's disease/Hypothyroidism Status post right leg surgery secondary to trauma. MIBI in [2169] showed global hypokinesis EF 40% Physical Exam: Physical Exam: Vitals: T: 95.7ax BP: 97/56 HR: 50 RR: 18 O2Sat: 100% on A/C 400x18 fio2 0.40 peep 5. GEN: sedated on vent, no obvious trauma HEENT: EOMI, pupils small but equal. sclerae anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, edentulous NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: very faint heart sounds, but RRR, no M/G/R, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Obese, soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Plantar reflex downgoing bilaterally. No rigidity, neck stiffness, hyperreflexia or clonus. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses Pertinent Results: [2175-8-19] 07:49PM ALT(SGPT)-20 AST(SGOT)-14 LD(LDH)-143 ALK PHOS-53 TOT BILI-0.2 [2175-8-19] 07:49PM ALBUMIN-3.5 CALCIUM-7.3* PHOSPHATE-3.5 MAGNESIUM-1.9 [2175-8-19] 07:49PM TSH-4.2 [2175-8-19] 07:49PM VALPROATE-<3 [2175-8-19] 03:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2175-8-19] 03:27PM LACTATE-5.4* K+-4.5 [2175-8-19] 03:10PM GLUCOSE-242* UREA N-11 CREAT-1.3* SODIUM-140 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [2175-8-19] 03:10PM estGFR-Using this [2175-8-19] 03:10PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1 [2175-8-19] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2175-8-19] 03:10PM WBC-8.8 RBC-4.16* HGB-12.8* HCT-37.8* MCV-91 MCH-30.8 MCHC-33.9 RDW-14.4 [2175-8-19] 03:10PM NEUTS-70.6* LYMPHS-21.8 MONOS-4.9 EOS-2.2 BASOS-0.5 [2175-8-19] 03:10PM PLT COUNT-326 ECG: Sinus rhythm at 61 bpm, normal axis, normal PR and QRS intervals, slightly prolonged QTc interval, good R-wave progression, no ST or T-wave changes. No significant changes from [2169], but compared to serial EKG's from earlier this evening, the patient is more bradycardic. . Imaging: CXR: lower lung volumes, ETT in good position. Compared to CXR in [2169], increase vascular markings, but no other obvious change. No infiltrates. . Ct head: Provisional Findings Impression: No intracranial hemorrhage Brief Hospital Course: Assessment: This is a 53 year-old male with an extensive psychiatric history with past suicide attempts who presents with antidepressant overdose in an apparent suicide attempt. SUICIDAL IDEATION / OVERDOSE -patient was initially admitted to the ICU after intubation in the Emergency Department for airway protection. His exact ingestion was unknown, toxicology was consulted. He experienced no hemodynamic instability or other signs or symptoms to suggest a specific toxidrome. He required no specific treatment other than supportive care and observation. He was quickly extubated and transferred to a general medical floor where he was continued on 1:1 sitter as he continued to be actively suicidal. He was seen by psychiatry and continued inpatient care was recommended. He was behaviorly stable and appropriate. Specific psychiatric medicines were held and deferred to the inpatient psych setting. 2.DM II uncontrolled with complications -Pt may have ingested metformin in his gesture, as evidenced by an initial lactic acidosis on admission. His blood sugars remained stable and on transfer to the floor his metformin was restarted. He should continue his metformin since he will be in a monitored environment with finger blood sugar checks with sliding scale coverage at least twice a day. Further care of his diabetes will be deferred to his outpatient providers. 3. SCHIZOAFFECTIVE/BIPOLAR/DEPRESSION -carries these diagnoses prior to admit. last med list obtained included: Effexor, Lamictal, Risperdal, and Trileptal. No specific recommendations regarding these medications were made by the psychiatry consult service and was deferred to his inpatient care team. He was receiving only prn Haldol which he would request. 4. HYPOTHYROID -continued on last known replacement Synthroid dose. TSH was within therapeutic levels. 5. HTN, BENIGN -lisinopril continued. Medications on Admission: unknown Discharge Medications: 1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Tablet PO three times a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. INSULIN SLIDING SCALE Discharge Disposition: Extended Care Facility: [Hospital3 8063] - [Location (un) ] Discharge Diagnosis: suicidal ideation / ingestion schizoaffective disorder bipolar disorder depression DM II uncontrolled with complications hypothyroid Discharge Condition: improved, afebrile, no complaints, no shortness of breath, no physical pain Discharge Instructions: per inpatient psych facility you should have your blood sugar checked at least 2 times a day for the next week as your metformin has been restarted and your blood sugars may be higher in the first few days as your medicine is restarted. Followup Instructions: per psych facility follow up with your primary provider as scheduled and/or as needed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673] Completed by:[2175-8-23]	[ "969.0", "496", "584.9", "V62.84", "296.80", "276.2", "250.02", "E950.4", "295.70", "E950.3", "458.9", "244.9", "962.3" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	6671, 6741	4226, 6107	331, 337	6918, 6996	2739, 4133	7281, 7528			6165, 6648		6762, 6897		6133, 6142			7020, 7258									1983, 2720																						276, 293									365, 1662		4142, 4203																1684, 1953
12,355	198,712	24048	Discharge summary	report	Admission Date: [2142-3-23] Discharge Date: [2142-4-8] Date of Birth: [2104-8-23] Sex: F Service: MEDICINE Allergies: Tegretol / Sulfa (Sulfonamides) / Doxycycline Attending:[First Name3 (LF) 5644] Chief Complaint: transfer from MICU with rhabdomyolysis, ARF Major Surgical or Invasive Procedure: Right internal jugular tunnelled line placement History of Present Illness: 37yoW with h/o ivdu, bipolar disorder, asthma who presented to [Hospital1 ] s/p fall with ?syncope after heroin abuse. Patient fell in the bathroom and was unconscious for an unspecified amount of time but thought to be between 9-12hours. On presentation to [Hospital1 ] she complained of right hip and back pain, and bilateral LE numbness, and was found to be in rhabdomyolysis. She was transferred to [Hospital1 18] ED where CK >200,000 and creatinine 3.0 with UA +blood, no RBCs, +muddy brown casts. She received 6L D5W and 3amps bicarb and was admitted to the MICU. . In the MICU, nephrology, psychiatry, and neurology services were consulted. Initial CT showed a right flank hematoma, edematous soft tissue in the neck, and cerebral edema. She was anuric. A foley catheter was inserted, and she continued to receive aggressive IVFs. She was oliguric, and by day 3 was 1600cc positive. IVFs were discontinued and she was treated with lasix 120mg iv x1. Patient exhibited bilateral lower extremity weakness. MR showed no evidence of cord compression. Neurology consult found bilateral weakness not consistent with a focal CNS lesion. She was initially in a C-collar after her fall. She was cleared by clinical exam, CT, and MR. . On presentation today she complains of sharp and aching pain all over including her head, chest, abdomen, back, and all four extremities. She denies shortness of breath, nausea, vomiting, diarrhea, constipation, dysuria. patient has a h/o ivdu, but had been off heroin for 7years. This was her first time using since then. She expressed regret saying "this was stupid stupid." Mood is "ok." She denies any SI. Past Medical History: IVDU Bipolar disorder asthma s/p right knee surgery Social History: lives alone in [Location (un) 47]; works part time in Pizza shop +tob: 5cig/day x5yrs denies etoh ivdu per hpi Family History: Mother with HTN denies any FH/o substance abuse, psychiatric disorders, heart disease, asthma, diabetes, cancers Physical Exam: T 97.8 Tm 99.1 HR 71 RR 18 BP 126/73 95%RA Gen: sitting up, uncomfortable, drifting to sleep occasionally, moaning slightly in pain HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, no LAD, no JVP CV: RRR, no mrg Resp: trace right base crackles, o/w CTA Abd: +BS, soft, ttp RUQ, LUQ, midepigastric, no guarding, no rebounding Ext: [12-16]+ B pitting edema Skin: tattoos on RUE, chest Neuro: A&Ox3, CN II-XII intact, sensation intact grossly, strength 5/5 RUE, 4+LUE, 4+/5 BLE with hip flexion, knee extension and flexion. coordination intact to FTN. gait deferred Pertinent Results: Head CT [2142-3-23]: No intracranial hemorrhage is identified. Cannot exclude mild diffuse cerebral edema, MRI might be helpful for further evaluation, if clinically indicated. CT spine [2142-3-23]: 1) No evidence of fracture or subluxation within the cervical spine. 2) Extensive asymmetric inflammation/edema within the posterior musculature of the right neck. This finding could represent an infectious process or the sequelae of trauma. CT Abd/Pelvis [2142-3-23]: 1) Large hematoma and soft tissue injury in the muscles of the right flank. 2) No intraabdominal or pelvic acute injuries. Spine MR [2142-3-23]: - C-spine: Mild degenerative changes. No evidence of intraspinal fluid collection. No evidence of extrinsic spinal cord compression or intrinsic spinal cord signal abnormalities. Diffuse increased signal within the muscles and soft tissues of the neck and upper back. This could be secondary to diffuse muscular inflammation and clinical correlation recommended. - T-spine: No evidence of spinal cord compression or intraspinal fluid collection in the thoracic region. No evidence of compression fracture or spinal stenosis. - L-spine: Mild degenerative changes at L5-S1 level. Otherwise, unremarkable study of the lumbar spine. [2142-3-23] 07:00AM URINE AMORPH-MOD [2142-3-23] 07:00AM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2 [2142-3-23] 07:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2142-3-23] 07:00AM URINE COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.011 [2142-3-23] 07:00AM PT-13.4 PTT-23.3 INR(PT)-1.1 [2142-3-23] 07:00AM PLT COUNT-256 [2142-3-23] 07:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2142-3-23] 07:00AM NEUTS-94.1* BANDS-0 LYMPHS-3.4* MONOS-2.4 EOS-0 BASOS-0.1 [2142-3-23] 07:00AM WBC-24.1* RBC-4.91 HGB-14.6 HCT-42.1 MCV-86 MCH-29.6 MCHC-34.5 RDW-12.5 [2142-3-23] 07:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2142-3-23] 07:00AM CALCIUM-6.9* PHOSPHATE-8.7* MAGNESIUM-2.1 [2142-3-23] 07:00AM CK-MB-GREATER TH [2142-3-23] 07:00AM cTropnT-0.23* [2142-3-23] 07:00AM CK(CPK)-[Numeric Identifier 61167]* [2142-3-23] 07:00AM GLUCOSE-178* UREA N-45* CREAT-3.0* SODIUM-138 POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-17* ANION GAP-25* [2142-3-23] 07:22AM K+-5.5* [2142-3-23] 08:03AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2142-3-23] 08:03AM URINE HOURS-RANDOM [2142-3-23] 11:30AM PLT COUNT-224 [2142-3-23] 11:30AM NEUTS-92.5* BANDS-0 LYMPHS-4.5* MONOS-2.7 EOS-0.1 BASOS-0.1 [2142-3-23] 11:30AM WBC-20.6* RBC-4.20 HGB-12.6 HCT-35.6* MCV-85 MCH-29.9 MCHC-35.2* RDW-12.4 [2142-3-23] 11:30AM CALCIUM-6.2* PHOSPHATE-5.1* MAGNESIUM-1.8 URIC ACID-11.3* [2142-3-23] 11:30AM CK-MB-GREATER TH cTropnT-0.21* [2142-3-23] 11:30AM LIPASE-286* [2142-3-23] 11:30AM ALT(SGPT)-535* AST(SGOT)-1325* CK(CPK)-[Numeric Identifier 61168]* ALK PHOS-81 AMYLASE-1109* TOT BILI-0.4 [2142-3-23] 11:30AM GLUCOSE-149* UREA N-45* CREAT-3.2* SODIUM-137 POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-19* ANION GAP-19 [2142-3-23] 06:43PM PT-13.9* PTT-24.7 INR(PT)-1.2 [2142-3-23] 06:43PM PLT COUNT-221 [2142-3-23] 06:43PM WBC-22.3* RBC-4.27 HGB-12.7 HCT-35.5* MCV-83 MCH-29.7 MCHC-35.6* RDW-12.6 [2142-3-23] 06:43PM ALBUMIN-2.9* CALCIUM-6.2* PHOSPHATE-4.4 MAGNESIUM-1.8 [2142-3-23] 11:35PM GLUCOSE-136* UREA N-52* CREAT-4.5* SODIUM-138 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-18* ANION GAP-18 Brief Hospital Course: 37yoW with h/o if drug use, asthma, and bipolar disorder who was transferred from an outside hospital with rhabdomyolysis and acute renal failure. During her hospitalization the following problems were addressed: 1. Rhabdomyolysis: The patient was at first treated with aggressive iv fluids, NS and D5W with bicarb to alkalanize the urine. Initial CK was 200,000. This value trended down throughout her hospitalization. Secondary to her renal failure, she stopped making urine. She consequently became fluid overloaded. She was treated with one dose of iv lasix prior to transfer to the floor, but did not put out urine to this. She was not given any subsequent iv fluids, and CK's continue to decline. Pain was controlled with morphine. Her needs were calculated, and she given standing MS Contin as she has a risk of heroin abuse. Pain was also somewhat relieved after dialysis was started and fluid taken off. She was discharged on Percocet for pain control. 2. Acute renal failure: Renal service was consulted. Findings were consistent with ATN. She became oliguric, making only about 40-60cc/urine per day. On [2142-3-27] she had a tunnelled right subclavian line placed by IR and was started on hemodialysis. Her urine output began to increase to around 300 cc per day at discharge. She will continue on hemodialysis as an outpatient until her renal function returns. 3. Weakness/numbness: Neurology service was consulted to assess the patient's diffuse weakness, numbness and paresthesias. She had no localizing signs to suggest a central nervous system lesion. It was felt her weakness likely resulted from muscle breakdown, complicated by fluid overload causing nerve compression, and distal neuropathy secondary to alcohol and drug use. Physical therapy was consulted and recommended continued therapy. Pain was treated as stated above. 4. Anemia: the patient had a left pelvic hematoma noted on CT. Hct was also low and at first gradually declined, concerning for acute bleed. Iron studies and hemolysis studies were nondiagnostic. Hct stabilized. Anema was thought to be due to initial blood loss in her hematoma and complicated by acute inflammatory state. Additionally, she did have some bright red blood per rectum after transfer to the floor. Hemolysis lab was positive with low haptoglobin and high LDH and high reticulocyte count. Hematology was consulted. Peripheral smears showed only mild hemolysis. Since her LDH was trending down and her haptoglobin was obtained after transfusion and her Coombs was negative, this was thought not to be hemolysis. She remained hemodynamically stable and was transfused to keep Hct>21. Patient has been repeatedly guaic negative and her bimanual vaginal exam was negative. Patient refused EGD although she has been told that there could be a potential source of bleeding. Patient understands the consequence of not having that done. She was transfused with appropriate Hct bump. Her hematocrit was stable above 27 for 48 hours before discharge without transfusion. 5. Psych: the patient has a history of bipolar disorder. The psychiatry team was consulted and spoke at lenght with her outpatient psychiatrist. They did not find her presentation consistent with bipolar I, and more consistent with bipolar II, which was confirmed by her outpatient psychiatrist. She was continued on her Zoloft at half dose given the acute renal failure. Topomax was discontinued in the setting of acute renal failure. Additionally the psych team did not feel this would be a beneficial medicine used as a single [Doctor Last Name 360]. They felt she was safe to continue on Zoloft alone. Additionally she will follow-up with an outpatient therapist. The psych team was also able to gather information that the patient had been off heroin for 6months before this relapse. Social work was additionally consulted. 6. Rash She was found to have an erythemaous total body rash which appeared to be a drug rash. THe only medication that could have caused that was morphine, which was taken off. She refused to have narcotics taken off. She was on benadryl for the rash which helped her symptomatically, but this was changed to [Doctor First Name 130] as she developed urinary retention. 7. Urinary retention - Though she began to make ~300 cc urine daily, she had difficulty with excretion. This was thought to potentially be due to the anticholinergic effects of benadryl. She was discharged with a foley catheter and can have a repeat voiding trial on [4-10]. 8. Hypothyroidism. The patient was found to have a TSH of 22 and free T4 of 0.8, which suggests hypothyroidism. She reports a family history of thyroid problems and constipation. This may have predisposed her to rhabdomyolysis in the first place. She was put on 50 mcg synthroid daily and we recommend rechecking thyroid function tests in the outpatient setting in [5-23] weeks to monitor improvement. 9. Dispo: she was evaluated by OT and PT who recommended rehab placement. She was discharged to [Hospital1 ] with plans in place for outpatient hemodialysis. She will follow up with her primary care physician and psychiatrist. She is a full code. 10. Vaginal bleeding - The patient had an episode of vaginal bleeding and no pap smear in > 5 yeard. This should be done in outpatient follow-up. Discharge Medications: 1. Cetylpyridinium Chloride Lozenge Sig: One (1) lozenges Mucous membrane every 4-6 hours as needed for sore throat. 2. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 7. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 10. Calcium Acetate 667 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [3-21] hours: not to exceed 4 g tylenol daily. 15. Fexofenadine HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: rhabdomyolysis induced acute renal failure heroin use bipolar disorder hypothyroidism vaginal bleeding drug rash iron deficiency anemia Discharge Condition: stable, with persistent rash and occasional nausea Discharge Instructions: You are being discharged to [Hospital3 ]. Please return to the hospital or call your doctor if you have increased weakness of your lower extremities, bleeding, uncontrollable pain or if there are any concerns at all Please take all prescribed medication and make sure that you adhere to the dialysis schedule Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] [Hospital3 249], [Location (un) ], central suite Phone:[Telephone/Fax (1) 250] Date/Time:[2142-5-2] 1:30 Please adhere to dialysis schedule as outlined by the renal team Please call ([Telephone/Fax (1) 24780] to scheduled an appointment with psychiatry	[ "244.9", "276.6", "E884.6", "584.5", "723.1", "493.90", "728.88", "296.7", "922.2", "788.20", "305.1", "285.1", "693.0", "304.02", "573.0", "782.0", "623.8", "719.7", "E947.9" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	13751, 13821	6799, 12166	349, 399	14001, 14053	3063, 6776	14416, 14800	2326, 2440		12189, 13728		13842, 13980					14077, 14393									2455, 3044																						266, 311									427, 2102																		2124, 2177	2193, 2310
17,859	102,099	22497	Discharge summary	report	Admission Date: [2141-5-2] Discharge Date: [2141-5-21] Date of Birth: [2098-9-8] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Vancomycin / Propoxyphene / Morphine Sulfate Attending:[Last Name (NamePattern1) 1561] Chief Complaint: increased difficulty breathing, increased secretions Major Surgical or Invasive Procedure: bronchoscopy tracheoplasty tracheostomy History of Present Illness: 42 yo M admitted for diagnostic bronch on [5-2]. Pt has hx of tracheomalacia and is s/p tracheobronchoplasty in [8-17] (Dr.[Last Name (STitle) 952]). Developed increased secretions, cough, and resp.difficulty since [12-17], bronch shows a-way collapse and secretions s/p tracheoplasty redo [5-10]. [5-17]--portex exchanged 6->8. Past Medical History: PMHx: Mounier-[Doctor Last Name 6530] Syndrome, tracheomalacia,Parkinson's Dz, Retinitis Pigmentosa (legally blind), esophageal stricture (s/p dilatation '[39]), MRSA in sputum, multiple ortho surgeries (digits and back), s/p Nissen fundoplication, rhabdomyelosis left shoulder [4-18] Parkinson's disease. Gastroesophageal reflux disease. Legally blind with macular degeneration and retinitis pigmentosa. Chronic bronchitis. Tracheobronchitis. Tracheobronchomalacia. Social History: lives in [State 4565], has fiance and mother who reside there as well Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2141-5-17] 06:19AM 7.8 3.47* 9.6* 28.1* 81* 27.6 34.1 13.5 272 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2141-5-17] 06:19AM 272 [2141-5-17] 06:19AM 12.81 26.9 1.1 HEPARIN DOSE 0 1 NOTE NEW NORMAL RANGE AS OF 12 AM [2141-5-13] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2141-5-17] 06:19AM 86 16 0.8 144 3.9 106 29 13 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2141-5-17] 06:19AM 1484* OTHER ENZYMES & BILIRUBINS Lipase [2141-5-6] 04:00AM 20 CPK ISOENZYMES CK-MB MB Indx cTropnT [2141-5-15] 04:23AM 3 ADD ON CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron Cholest [2141-5-17] 06:19AM 8.5 4.8* 2.0 LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc [2141-5-6] 04:00AM 1571 42 4.4 113 1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE HEPATITIS C SEROLOGY HCV Ab [2141-5-10] 11:45PM NEGATIVE RADIOLOGY Final Report CT TRACHEA W/O C W/RECONS [2141-5-3] 1:58 PM [Hospital 93] MEDICAL CONDITION: 42 year old man with trachemomalacia REASON FOR THIS EXAMINATION: Need dynamic CT of airways to evaluate for tracheomalacia CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 42-year-old man with tracheomalacia. TECHNIQUE: Contiguous 2-mm axial CT images of the chest were obtained without the administration of IV contrast [Doctor Last Name 360]. Additional images at dynamic expiration, at end-expiration, and during cough were obtained. Multiplanar reformations are reconstructed. COMPARISON: CT trachea dated [2140-8-7]. FINDINGS: Again note is made of tracheomegaly, transverse diameter measuring 2.6 cm. Note is made of thickening of tracheal wall with calcification, which somewhat obscures posterior membrane. At end-expiration and dynamic breathing, note is made of excessive collapsibility of trachea and bilateral main stem bronchus, representing severe tracheobronchomalacia. Note is made of multiple areas of air trapping at end-expiration. There is no mediastinal or hilar lymphadenopathy. Note is made of coronary artery calcification. The limited evaluation of upper portion of the lungs demonstrates non- calcified pulmonary nodules measuring 3 mm in diameter in the superior segment of right lower lobe, unchanged since [2140-1-14]. Previously-noted multiple patchy opacities appear to be resolved. Again note is made of focal thickening of right major fissure. There is no suspicious lytic or blastic lesion noted in the skeletal structures within the scan area. IMPRESSION: 1. Severe tracheobronchomalacia. 2. Mild tracheomegaly with tracheal wall thickening with calcification. The wall thickening of the trachea may be due to relapsing polychondritis, or due to prior stenting provided in the history. Please correlate clinically with the patient history and also with physical findings. 3 Unchanged appearance of 3-mm non-calcified nodule in the right lower lobe. 4. Coronary artery calcification. 5. Air trapping. Multiplanar reformation images confirmed the above finding. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7210] [Name (STitle) 7211] [Doctor Last Name 7205] DR. [First Name (STitle) 7204] [Name (STitle) 7205] Approved: WED [2141-5-3] 5:10 PM RADIOLOGY Final Report SHOULDER 1 VIEW LEFT PORT [2141-5-11] 10:17 PM [Hospital 93] MEDICAL CONDITION: 42 year old man s/p tracheoplasty - now with pain REASON FOR THIS EXAMINATION: ? fracture HISTORY: Shoulder pain. This exam consists of internal and external rotation frontal radiographs of the left shoulder. Additional views not ordered or obtained. No fracture or bone destruction. On limited views available, I cannot entirely exclude anterior subluxation of the humerus (doubtful). No periarticular soft tissue calcifications and no comparison exams. DR. [First Name (STitle) ] M. [Doctor Last Name ] Approved: FRI [2141-5-12] 12:45 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [2141-5-14] 8:28 AM [Hospital 93] MEDICAL CONDITION: 42 yo male s/p CT removal REASON FOR THIS EXAMINATION: Eval for PTX INDICATION: 42-year-old male patient, status post chest tube removal. COMMENTS: Portable AP radiograph of the chest is reviewed and compared with the previous study of yesterday. The right chest tube has been removed. No pneumothorax is identified. There is continued small loculated right pleural effusion with subcutaneous emphysema in the right chest wall. The tracheostomy tube, right jugular IV catheter, and right-sided PICC line remain in place. The left lung appears clear. There is continued mild cardiomegaly. IMPRESSION: No pneumothorax. DR. [First Name (STitle) 7204] [Name (STitle) 7205] Approved: SUN [2141-5-14] 8:40 PM Brief Hospital Course: 42y/o w/ complex medical and surgical history admitted [2141-5-3] for evaluation of increased difficulty breathing and increased secretions w/ trachealmalacia and s/p tracheoplasty. Bronchoscopy done- severe TBM, right mainstem patent, left mainstem patent, BAL of RLL. Placed on antibiotics for prophylaxis of increased secretions. BAL pending. Pt maintained on antibiotics, receiving aggressive nutritional (TPN), CPT, physical therapy support, and PICC line placement ([5-5]) in preparation for re-do tracheoplasty done [2141-5-11]. Episode of conjuctivitis [2141-5-9] treated w/ 4-7 days of Erythromycin opthal ointment and ciprofloxacin optahlmic solution. [5-11]- s/p re-do tracheoplasty via R thoracotomy (7-8 hour surgery- see operative note), stable post-op, tracheostomy #8 portex in place on ventilator and transferred to SICU. Pain service consulted, controlled to fentanyl/bupivicaine.1% epidural as well as fentanyl gtt Bronchoscopy POD#1> mild edema, repair successful, small amt of secretions-cleared via scope (see report). C/O and observation of significant L shoulder (AC joint) pain, tenderness, swelling after being in Left lateral decub position for duration of surgery via Right thoracotomy. Seen by Ortho- diagnosis of L shoulder rhabdomyelosis, w/ CPK's peaking [5-12] and starting to decrease. POD#2 Continues on ventilator SIMV +PS w/ good ABG. Vent weaned w/o complication to trach mask, chest tube d/c. Pain control continues w/ Fentanyl epidural and fentanyl gtt. POD#3 [5-14]- Foley removed, transitioned off fentanyl drip to meperidine and fentanyl patch, heplocked except for TPN. Epidural catheder removed. CK continued to decline. POD#4 [5-15]- Pt transfered to floor after d/c of fentynal drip. Pain control on floor optimized. Trach changed at beside from 8 Portex w/ cuff to 6 Portex with no cuff POD#5 [5-16]- TPN d/c'ed and diet advanced to clears. Adequate pain control, optimized by APS with decrease on fentynal patch. Opthamology consult obtained for ? erythema and drainage from R (good) eye. Started on erythromycin and ciloxan for putative conjuctivitis. POD#6 [5-17]- Diet advanced slowly, tolerated well. Nutrition consult suggested full liquids. PT evaluation. Progressed well, but continued on IV linezolid. POD#7 [5-18]- Continued to assist with pulm toilet, diet advanced to POs as tolerated and pain controlled on fentynal patch. OT evaluation cleared pt for discharge. POD#8 [5-19]- Bronchoscopy for final evaluation before discharge. Medications on Admission: prilosec 40', cough syrup, sinemet (25/100)", Neurontin 800"' Discharge Medications: 1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 2. Cetylpyridinium Chloride Lozenge Sig: One (1) lozenge Mucous membrane five times a day as needed. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-15] Drops Ophthalmic PRN (as needed). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 6. Meperidine HCl 50 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. 7. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Erythromycin 5 mg/g Ointment Sig: One (1) drops Ophthalmic QHS (once a day (at bedtime)). Disp:1 1* Refills:0 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Mounier-[Doctor Last Name 6530] Syndrome, tracheomalacia, GERD, Parkinson's Dz, Retinitis Pigmentosa (legally blind), esophageal stricture (s/p dilatation '[39]), MRSA in sputum, multiple ortho surgeries (digits and back), s/p Nissen fundoplication, rhabdomyolysis of left shoulder Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office or Dr.[Name (NI) 58422] office for: fever, chest pain, shortness of breath, clogging of tracheostomy. REsume all medications as prior to hospitalization. TAke all medications as directed. Documents to be discharged with: discharge summary, operative note, note for airline. Followup Instructions: Follow w/ [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD pulmonologist as per Dr.[Name (NI) 1816] instructions. Completed by:[0-0-0]	[ "748.61", "728.88", "369.4", "996.59", "494.1", "519.1", "466.0", "332.0", "519.02", "372.00" ]	icd9cm	[ [ [] ] ]	[ "31.79", "99.15", "03.90", "00.14", "31.1", "33.24", "33.21", "38.93", "96.56", "97.23" ]	icd9pcs	[ [ [] ] ]	10133, 10139	6385, 8933	384, 426	10472, 10478	1421, 2557	10840, 11008			9045, 10110	5640, 5666	10160, 10451		8959, 9022			10502, 10817																															292, 346	5695, 6362								454, 808																		830, 1311	1327, 1402
21,773	128,838	24371	Discharge summary	report	Admission Date: [2146-5-18] Discharge Date: [2146-5-25] Date of Birth: [2091-10-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: ESLD Major Surgical or Invasive Procedure: liver transplant [2146-5-18] History of Present Illness: 54 y.o. male with HCV cirrhosis and HCC s/p RFA. Has had sinus infection over last two weeks for which he has been taking augmentin. Does have slight chills and night sweats since the sinus infection. Has had slight chills and night sweats since the sinus infection. Has had urinary retention in the past and has difficulty starting stream. No dysuria. Past Medical History: etoh cirrhosis hypertension GERD lap chole h/o polysubstance abuse in 80s h/o etoh abuse, quit 2 yrs pta Social History: h/o etoh, none x 2 years, no drug use, no tobacco lives with dtr Family History: no h/o CA or liver dz Physical Exam: 98.1 62 137/78 18 94%RA WD/WN, comfortable, NAD Lungs CTA bilat, slight crackles at base Cor S1S2, RRR Abd soft, +BS, slight tenderness to palp in RLQ Ext warm, well perfused Neuro Awake, alert, cooperative with exam, nl affect Pertinent Results: On Admission: [2146-5-18] WBC-5.1 RBC-3.90* Hgb-13.3* Hct-36.9* MCV-95 MCH-34.1* MCHC-36.1* RDW-14.9 Plt Ct-105* PT-14.0* PTT-34.9 INR(PT)-1.2* Fibrinogen-181 Glucose-103 UreaN-21* Creat-0.8 Na-139 K-3.9 Cl-103 HCO3-27 AnGap-13 ALT-54* AST-59* AlkPhos-108 TotBili-0.4 Albumin-4.3 Calcium-9.4 Phos-4.2 Mg-2.0 On Discharge [2146-5-25] WBC-8.2 RBC-3.07* Hgb-10.2* Hct-29.2* MCV-95 MCH-33.3* MCHC-35.0 RDW-16.6* Plt Ct-147* Glucose-94 UreaN-16 Creat-0.7 Na-137 K-4.1 Cl-101 HCO3-29 AnGap-11 ALT-241* AST-63* AlkPhos-297* TotBili-1.1 Albumin-3.0* Calcium-8.3* Phos-4.0 Mg-1.4* HBsAb-POSITIVE, FK506-10.7 Brief Hospital Course: He underwent deceased donor liver transplant, piggyback technique with portal vein to portal vein anastomosis, proper hepatic artery to common hepatic artery anastomosis, common bile duct to common bile duct anastomosis on [2146-5-18]. Surgeon was Dr. [First Name (STitle) ] [Name (STitle) ]. Please see operative report for details. He received induction immunosuppression consisting of solumedrol and cellcept. His donor was Hepatitis B core positive. During the anhepatic phase, he received HBIG 10,000 units then 5000 units IV once a day on pod [12-31]. HbSab levels remained greater than 450. Lamivudine was also given qd. Postop, he did well. U/S of liver on pod 0 showed patent vessels. He was extubated and transferred out of the SICU on pod 2. Prograf started on pod 2. LFTs trended down. Diet was advanced without problems. The lateral JP was removed on pod 5. The medial JP was draining 275cc/day of serosanguinous fluid, this was removed prior to discharge on [5-25]. The incision was well approximated, without redness, clean and dry. [Last Name (un) ] was consulted for hyperglycemia. Insulin sliding scale and long acting insulin were started, to continue insulin therapy at home. PT cleared him for home. Medications on Admission: Triamterene/HCTZ- 25/37.5, Prilosec 20' Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. LaMIVudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Ten (10) ML PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Mycophenolate Mofetil 250 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous once a day. 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) units Subcutaneous at bedtime. Disp:1 bottle Refills:2 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:1 bottle Refills:1 14. syringes insulin syringes 1 box refill:1 15. Other test strips 1 box refill:2 16. lancets 1 box refill:1 17. Kayexalate Powder Sig: Thirty (30) grams PO per instructions from transplant office for elevated potassium. Disp:4 doses Refills:2 18. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Tacrolimus 1 mg Capsule Sig: Six (6) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: HCV/HCC cirrhosis Discharge Condition: good Discharge Instructions: Please call transplant office [Telephone/Fax (1) 673] if fevers, chills, nausea, vomiting, inability to take medications, incision redness/bleeding/drainage, jaundice or any questions [Month (only) 116] shower, pat incision dry Labs every Monday and Thursday. Followup Instructions: [Name6 (MD) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2146-6-2] 3:20 [Name6 (MD) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2146-6-9] 10:20 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2146-6-9] 11:00 CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2146-8-12] 10:30 Completed by:[2146-5-25]	[ "530.81", "155.0", "401.9", "V11.3", "V15.82", "070.54", "571.5", "E932.0", "251.8" ]	icd9cm	[ [ [] ] ]	[ "99.07", "00.93", "99.06", "99.05", "50.59", "99.14" ]	icd9pcs	[ [ [] ] ]	4897, 4903	1883, 3132	318, 353	4965, 4972	1252, 1252	5288, 5757	962, 985		3222, 4874		4924, 4944		3158, 3199			4996, 5265									1000, 1233																						274, 280									381, 735							1266, 1860											757, 863	879, 946
49,955	147,205	40687	Discharge summary	report	Admission Date: [2100-11-25] Discharge Date: [2100-12-4] Date of Birth: [2046-9-8] Sex: M Service: MEDICINE Allergies: metformin / PhosLo / Glyburide Attending:[First Name3 (LF) 2290] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: temporary dialysis line placement tunneled dialysis line placement History of Present Illness: 54M with ESRD HD-dependent, diabetes, MR coming in from dialysis to the ED with chief complaint of low grade temps (99.1) as well as altered mental status. . History was obtained partly from ED signout, partly from Dialysis fellow, and partly from brother [Name (NI) ] as patient is not responding to questions at this moment. . History of chronic exit site infections at his dialysis catheter site and new onset confusion today at hemodialysis. Pt. has a R IJ tunneled HD catheter that was last changed on [2100-10-13], and per report from ED has had blood cultures grow coag-positive and coag negative staph in the past, for which he has been receiving vancomycing in HD. Patient is unable to give history. . [First Name8 (NamePattern2) ] [Name (NI) ] (HCP) - spoke to patient, who was lethargic, but mental state was ok. . In ED, initial vitals were, temp 98.4 HR 102 BP 144/87 RR 16 POx100%. CXR: unremarkable EKG: sinus tach 100 NA/NI no STEMI CT head: Negative IN ED: Given Vanc, Zosyn ,CTX (only given Vanco in ED). Also noted to have hyperkalemia - given insulin, caGluc, started on d5 drip (for high lactate). - UA sent - [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 88988] - Renal Fellow called and asked to admit. - Patient may need an LP - not done in ED. - [Month (only) 116] need redosing of antibiotics. -being admitted to ICU to altered mental status. - Brother - is HCP [Name (NI) ] full code) ([Telephone/Fax (1) 88989] [First Name8 (NamePattern2) ] [Known lastname 24642]. . MEDICATIONS GIVEN IN ED: Insulin 10U regular IV x1, D5W 1LNS, Vancomycin, Zosyn 4.5g IV. On Exam there, was noted to be "Alert but not oriented, unable to answer questions". LP was not done, LP as inpatient -> renal wants to do dialysis emergently and hold on LP until after. . Patient was admitted for altered mental status. . On the floor, patient was obtunded . Review of sytems: unable to obtain, given patient's obtunded mental state at time of admission. Past Medical History: ESRD HD-dependent - 2 years now. Diabetes - Type 2. MR hx of atrial fibrillation when septic Social History: Lives at [Hospital 745] Health Center, per Brother. [Name (NI) ]: none EtOH: None Alcohol: None Family History: unknown Physical Exam: ADMISSION EXAM: 98.4 HR 102 BP 144/87 RR 16 POx100% General: Obtunded. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: tachycardic, could not appreciate murmurs due to body habitus 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: A&Ox1 (name only), responds to voice by opening eyes only, and occasionally answering questions . DISCHARGE EXAM: VS: Tm 98.7 F, BP 124/72 HR 72 RR 18 100% RA General: sleepy, not interested in answering questions. HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD, R tunneled dialysis line in place, mild oozing from site, nontender, non errythematous Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: regular rate and rhythm Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [2100-11-25] 01:20PM BLOOD WBC-7.8 RBC-4.74 Hgb-13.6* Hct-40.3 MCV-85 MCH-28.8 MCHC-33.9 RDW-15.4 Plt Ct-158 [2100-11-25] 01:20PM BLOOD Neuts-81.5* Lymphs-13.2* Monos-4.0 Eos-0.9 Baso-0.4 [2100-11-25] 01:20PM BLOOD PT-10.9 PTT-28.6 INR(PT)-1.0 [2100-11-25] 01:20PM BLOOD Glucose-81 UreaN-55* Creat-10.8* Na-138 K-6.8* Cl-100 HCO3-19* AnGap-26* [2100-11-25] 01:20PM BLOOD ALT-59* AST-52* CK(CPK)-127 AlkPhos-111 TotBili-0.4 [2100-11-25] 11:52PM BLOOD Calcium-9.3 Phos-5.0* Mg-2.2 [2100-11-25] 11:52PM BLOOD Prolact-5.2 TSH-0.58 [2100-11-25] 02:12PM BLOOD Lactate-2.2* K-7.1* [2100-11-25] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . DISCHARGE LABS: [2100-12-4] 06:42AM BLOOD WBC-7.9 RBC-3.32* Hgb-9.3* Hct-28.4* MCV-85 MCH-28.1 MCHC-32.8 RDW-14.8 Plt Ct-231 [2100-12-4] 08:17AM BLOOD PT-11.3 PTT-80.9* INR(PT)-1.0 [2100-12-4] 06:42AM BLOOD Glucose-150* UreaN-54* Creat-10.0# Na-144 K-4.8 Cl-101 HCO3-27 AnGap-21 [2100-12-4] 06:42AM BLOOD ALT-134* AST-90* AlkPhos-87 TotBili-0.2 [2100-12-4] 06:42AM BLOOD Calcium-9.3 Phos-6.9* Mg-2.6 . IMAGING: CXR [2100-11-25]: SEMI-UPRIGHT AP VIEW OF THE CHEST: Right-sided dual-lumen central venous catheter tip terminates in the cavoatrial junction. The heart size is normal. Mediastinal and hilar contours are unremarkable. There is no focal consolidation, pleural effusion or pneumothorax. There is elevation of left hemidiaphragm. No acute osseous abnormality is seen. Low lung volumes are present. IMPRESSION: Elevated left hemidiaphragm. No acute cardiopulmonary abnormality. . Head CT [2100-11-25]: FINDINGS: There is no evidence of hemorrhage, edema, shift of midline structures, or major vascular territorial infarction. The ventricles and sulci are normal in size and configuration. No suspicious osseous lesions are identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial abnormality . RUE U/S [2100-11-27]: FINDINGS: Grayscale and color Doppler son[Name (NI) 493] imaging was performed of the bilateral subclavian, right jugular, right axillary, right basilic, and right cephalic veins. In one of the brachial veins, there is incomplete compressibility and echogenic material within it. There is still some discernable Doppler flow in this vessel, indicative of a nonocclusive thrombus. IMPRESSION: Nonocclusive thrombus of one of the brachial veins. . TTE [2100-11-29]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. IMPRESSION: Very suboptimal image quality. Preserved global left ventricular systolic function. No definite valvular abnormality or pathologic flow identified. If clinically indicated, a TEE would be better able to define any valvular pathology . Venogram [2100-12-3]: IMPRESSION: 1. Bilateral upper extremity venograms demonstrate non-occlusive right brachial thrombus as on the prior ultrasound. Moderate right subclavian stenosis is seen along the midpoint of the vein with extensive collateralization. Mild-to-moderate stenosis of the central most portion of the left subclavian vein is also noted. 2. Successful placement of right internal jugular temporary HD line with VIP port. The line is ready to use. . MICROBIOLOGY: Blood Culture, Routine (Final [2100-12-1]): [Female First Name (un) ] PARAPSILOSIS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVE TO Fluconazole sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. . CATHETER TIP-IV Source: HD line. FINAL REPORT [2100-12-1] WOUND CULTURE (Final [2100-12-1]): [Female First Name (un) ] PARAPSILOSIS. >15 colonies. SENSITIVE TO Fluconazole. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [Hospital1 69] Clinical Microbiology Laboratory.. sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. . CSF;SPINAL FLUID SOURCE: LP // CSF #3. GRAM STAIN (Final [2100-11-26]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2100-11-28]): NO GROWTH. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. HSV negative . Other blood cultures negative at time of discharge. Two blood cultures are pending. Brief Hospital Course: 54M with ESRD HD-dependent, diabetes, MR in from dialysis with chief complaint of low grade temps and AMS. History of chronic exit site infections at his dialysis catheter site and new onset confusion at hemodialysis, now back to baseline. . ACTIVE ISSUES: # fungemia: Pt has history of positive fungal cultures at dialysis for which he was previous treated with Diflucan, last dose given [2100-11-13]. Since then, he has continued to have positive fungal cultures without any apparent treatment. Blood cultures here were positive for [Female First Name (un) 564] Parapsilosis, sensitive to fluconazole. Pt was evaluated by ophtho, with no evidence of any endophalmitis but he does have enlarged cup to disk ratio which should be followed as outpatient. TTE was performed which was a very poor study but no valvular abnormalities noted. Pt is now s/p tunneled dialysis line placement ([12-2]) and blood cultures have remained clear. Infectious disease was consulted. Given sensitivities, he was recommended to continue on fluconazole for a total of 6 weeks (last dose 1/23). His liver function tests and CBC with diff should be monitored every other week and results should be faxed to the infectious disease nurses. . # elevated LFTs: Pt noted to have increased LFT to low 100s, which have remained stable. This is likely related to fluconazole. He has no history of hepatitis that we are aware of. His labs should be checked every other week. If his LFTs continue to rise, he may need to be taken off fluconazole and switched to micafungin. . # RUE DVT: Pt was noted to have swelling in his right arm. An ultrasound revealed a clot in R brachial vein. He was started on a heparin drip with bridging to Coumadin. His goal INR is [1-21]. He remained subtherapeutic at time of discharge so he was sent to rehab for continued bridging. He was started on Coumadin 3mg daily. He previously had been on Coumadin and therapeutic at 5mg, however given concurrent fluconazole, he was started at a lower dose of Coumadin. However, given that INR remained flat, he was increased to Coumadin 4mg on discharge. He should have repeat INR drawn on [12-6]. . #Altered Mental status: Pt was admitted with altered mental status which improved within 24 hours of admission. He had an LP as work-up for is AMS, which was unrevealing. It is likely that his AMS was secondary to his fungemia. . # bacteremia: Pt has had negative bacterial blood cultures while here, though he has been treated for coag negative staph with vanc 1gm and gentamycin 80mg for unknown bacteria at dialysis. His course of antibiotics was not well defined. However, he did complete 5 day course of vancomycin after his tunneled dialysis line was pulled as per ID recommendations. . CHRONIC ISSUES: # ESRD: Pt is on HD x 2 years. He has a history of recurrent infections. During this admission, his tunneled line was pulled and initially had a temporary line placed. This was followed by another tunneled line placed [12-2] once blood cultures remained clear. Pt would likely benefit from more permanent HD access given his recurrent infections with lines. This should be discussed with the patient and his brother. [Name (NI) ] had a venogram completed at this admission. . # atrial fibrillation: Per PCP, [Name10 (NameIs) ] has history of afib when septic, otherwise seems to remain in sinus rhythm. Had previously been anticoagulated, but not in past 2-3 months. He will be discharged on his home dose of Lopressor. He is also being anticoagulated, but for DVT rather than a fib. . # DM: Pt is not on insulin at home, he is on glipizide 5mg. This was held while patient was hospitalized but resumed upon discharge. . #Seizure disorder: Pt was continued on home dose of Keppra, 500 mg [Hospital1 ] with additional 250 mg after HD. . TRANSITIONAL ISSUES: Pt is full code. . [Name (NI) ] brother [Name (NI) ] should be contact[Name (NI) ] for any further questions: ([Telephone/Fax (1) 88989] . He needs labs checked every other week, including CBC with diff and LFTs while on fluconazole. . Goal INR is [1-21]. He should likely be anticoagulated for 3 months in setting of RUE clot. Medications on Admission: glipizide 5 mg daily clonidine 0.1 mg [Hospital1 ], hold on mornings before HD folic acid 1mg daily keppra 250mg with dialysis, 500 mg [Hospital1 ] on other days lopressor 100mg [Hospital1 ] zyprexa 5mg qHS simvastatin 40mg daily aspirin 81 mg daily Discharge Medications: 1. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO AFTER HD (). 10. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day. 11. fluconazole 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): continue until [1-10]. 12. warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 13. heparin drip Diagnosis: DVT Patient Weight: 80 kg Current Infusion Rate: 1150 units/hr Target PTT: 60 - 100 seconds PTT <40: 3200 units Bolus then Increase infusion rate by 300 units/hr PTT 40 - 59: 1600 units Bolus then Increase infusion rate by 150 units/hr PTT 60 - 100: PTT 101 - 120: Reduce infusion rate by 150 units/hr PTT >120: Hold 60 mins then Reduce infusion rate by 300 units/hr 14. Outpatient [Name (NI) ] Work Pt should have INR checked on [12-6]. 15. Outpatient [Month/Year (2) ] Work CBC with differential, LFTs checked on [12-6] and thereafter weekly and faxed to: Infectious disease R.Ns. at ([Telephone/Fax (1) 1353]. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or to on [Name8 (MD) 138] MD in when clinic is closed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: fungal infection renal disease on hemodyalisis Secondary: diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 24642], It was a pleasure taking care of you at [Hospital1 827]. You were admitted because you were confused. We found that you had a fungus infection in your dialysis line. That line was removed and another one was placed. We also found that you had a blood clot in your arm so you were started on a blood thinner. . Your blood pressure was low after dialysis today (85/40s). The dialysis doctors feel they [Name5 (PTitle) ] have taken off more fluid than normal. You got 250cc bolus and your blood pressure came up to 110s so we feel that you are safe to go. If your blood pressure is low again tonight, you should get another fluid bolus. . Please make the following changes to your medications: 1. Start taking coumadin 4mg daily. 2. Continue heparin drip until INR is theraputic at 2-3 on sliding scale attached. 3. Start fluconazole 200mg daily until [1-10]. 4. Please hold all of your blood pressure medications unless your blood pressure is consistently greater than 120. . You should discuss with your brother the possibility of having more permanent dialysis access, as you seem to have problems with continued infections. The more permanent access has less risk of infection. . You will also need to follow up with the infectious disease doctors to monitor your antibiotics and blood counts while you're on the medication. Followup Instructions: Department: INFECTIOUS DISEASE When: FRIDAY [2100-12-24] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 13125] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or to on [Name8 (MD) 138] MD in when clinic is closed. Completed by:[2100-12-6*]	[ "112.5", "427.31", "319", "999.32", "274.9", "276.2", "995.91", "453.82", "585.6", "276.7", "345.80", "348.30", "V45.11", "250.00", "V58.69" ]	icd9cm	[ [ [] ] ]	[ "39.95", "86.05", "03.31", "38.95" ]	icd9pcs	[ [ [] ] ]	15115, 15181	8838, 9080	313, 382	15302, 15302	3868, 3868	16853, 17437	2678, 2687		13348, 15092		15202, 15281		13061, 13325			15453, 16161			4607, 8815						2702, 3295				3311, 3849											12686, 13035		16190, 16830					252, 275		9095, 11013		2344, 2423					410, 1376		1385, 2326		3884, 4591				15317, 15429						11613, 12665				2445, 2540	2556, 2662
32,531	119,826	13560	Discharge summary	report	Admission Date: [2156-6-12] Discharge Date: [2156-6-18] Date of Birth: [2076-3-4] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2534] Chief Complaint: transfer for UGI bleed Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 80 M w/ extensive PMH including prior h/o R colonic AVM bleed requiring admission to [Hospital1 18] [1-/2155] s/p admitted to [Hospital1 ] on [6-7] from nursing home w/ black stools (UGI bleed) and weakness. Pt presented with chest pain and HCT 20. Pt had hypotension and a witnessed seizure after receiving nitroglycerin. He was fluid resuscitated with resolution of symptoms. He had UGI scope on [6-8] that demonstrated "duodenal ulcer x2, gastroparesis, and esophgitis." Pt received a total of 10 units PRBC and was stable pressure-wise. He was transferred to [Hospital1 18] for further management. Past Medical History: 1. Atrial fibrillation, on Coumadin 2. CAD status post ? MI in [1-/2155] in setting of anemia 3. CHF with unknown EF 3. DM type 2 for 20 years 4. Chronic LE ulcers 5. Recurrent UTIs 6. Gout 7. Chronic renal insufficiency, baseline creatinine unknown 8. Hypertension 9. Benign prostatic hyperplasia 10. Prior upper GI bleed in [1-/2155] requiring 3 units of FFP and 8 units of PRBCS at [Hospital1 ]. EGD with ? esophageal bleed. 11. Stenotic valve. 12. Peripheral vascular disease status post toe amputations in 11/[2153]. Social History: He lives with his daughter and her 2 children. He has 2 other sons. Ex-[Name2 (NI) 1818], ex-drinker. Family History: Non-contributory. Physical Exam: T96.0, HR 87 (a-fib), BP 125/54, RR 17 Sat 98% 2L NC GEN: NAD, A/O HEENT:PERRL CV: Irreg, II/VI SEM PULM: CTAB ABD: S/NT/ND MS/Ext: + R chest wall pain to palp on lateral R pectoral B/L LE diabetic ulcers Pertinent Results: [2156-6-12] 05:59PM GLUCOSE-50* UREA N-27* CREAT-0.9 SODIUM-141 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-24 ANION GAP-10 [2156-6-12] 05:59PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-2.0 [2156-6-12] 05:59PM WBC-10.7# RBC-3.00* HGB-9.3* HCT-26.2* MCV-87 MCH-30.8 MCHC-35.4* RDW-16.0* [2156-6-12] 05:59PM PLT COUNT-193 [2156-6-12] 05:59PM PT-14.0* PTT-27.5 INR(PT)-1.2* CHEST (PORTABLE AP) [2156-6-12] 8:31 PM The NG tube tip is off the film, at least in the stomach. There is no pneumothorax. The left subclavian line with tip in the SVC is unchanged. The lungs are clear. UNILAT UP EXT VEINS US RIGHT PORT [2156-6-14] 12:10 PM No deep vein thrombosis in the right upper extremities. Please note that the central line was not visualized secondary to overlying bandages. FOOT AP,LAT & OBL BILAT [2156-6-17] 4:37 PM no osteomyelitis EGD [2156-6-12] Esophagus: Mucosa: A streak of erythema of the mucosa with no bleeding was noted in the gastroesophageal junction. These findings are compatible with mild esophagitis. Stomach: Normal stomach. Duodenum: Excavated Lesions Multiple acute cratered ulcers were found in the duodenal bulb ranging from 5 mm to 2.5 cm. The largest ulcer had a pigmented spot vs. visible vessel that was actively oozing fresh blood. A second smaller ulcer also had a pigmented spot that was activley oozing fresh blood. Both ulcers were first injected with 10-20 cc's of diluted epinephrine prior to cautery. [Hospital1 ]-CAP Electrocautery was then applied for hemostasis successfully. Both ulcers were washed extensively after injection and cautery without evidence of further oozing. Impression: Streak of erythema in the gastroesophageal junction compatible with mild esophagitis Ulcers in the duodenal bulb (thermal therapy) on d/c: [2156-6-18] 06:20AM BLOOD WBC-7.4 RBC-2.92* Hgb-8.7* Hct-26.2* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.4 Plt Ct-278 [2156-6-18] 06:20AM BLOOD Glucose-121* UreaN-11 Creat-1.1 Na-142 K-3.8 Cl-105 HCO3-29 AnGap-12 Brief Hospital Course: Below is a hospital course by systems. The patient went first to the SICU and came out to the general floor for 48 hours prior to d/c. The patient was taken off anticoagulation secondary to the UGI bleed, but remained on GI prophylaxis and boots for DVT prophylaxis throughout. The patients bleeding stopped and fluid status and electrolytes were normalized through the hospital course. Podiatry was consulted secondary to his chronic LE diabetic ulcers. Urology was consulted for a difficult foley placement secondary to penile swelling from the fluid resuscitation. Chronic pain was consulted to maximize his PO pain regimen. NEURO: While in the ICU, the patient experienced delerium, which promply resolved after minimizing sedation/anxiolytics, reformatting his pain regimen to minimize narcotics, as well as moving out to the floor. He is A/O x 4 upon d/c, CV: Pt remained in a-fib with some runs of trigeminy and PVC's, which has been a chronic and unchanged arrhythmia. His anticoaglation was held secondary to the GI bleed and should be restarted 1 month after d/c. He continues on lopressor and amiodarone for rate control. The patients fluid status was normalized as described below. PULM: During ICU care, the pt. had minimal O2 requirements w/ 2 L NC, and is off O2 and sats of 100% on RA. CXR was NEG and no other issues. GI: The patient received endoscopy on the day of admission that found esophagitis, and 2 bleeding duodenal ulcers. Hemostasis was established with epi injection and electrocautery. The patient was transitioned from NPO to a regular heart healthy, diabetic diet throughout the hospital stay. HEME/ID: The pt. received a total of 11 U PRBCs b/w the transferring hospital (10 U) and [Hospital1 18] (1U). He remained stable w/ Hct of 26 after tx. Throughout the stay the pt. was afebrile w/ WBCs highest at 12 and stable at 8 upon d/c. GU/Renal: The patient was edematous and fluid overloaded upon admission secondary to fluid and blood resuscitation. This was subsequently diuressed over the hospital stay to a euvolemic state. electrolytes were repleted appropriately. The pt. experienced some incontinence secondary to bladder spasm, and urology was c/s to place a foley because it was difficult with the penile edema from the fluid resusc. His foley was d/c'd today and a voiding trial is pending. Pt. is dtv b/w [4-5] and will be at [Hospital1 1501], if no void foley must be replaced. Ext: Podiatry has seen the patient for chronic ulcers on LE 2nd DM. He had +Cx pseudomonas, and was started on [Hospital1 ] acetic acid dressing changes. He is not currently prescribed ABx per podiatry, but the organism is resistant to quinalones, and if the wound becomes purulent, another [Doctor Last Name 360] should be chosen to Tx. No surgical intervention was necessary, and no osteomyelitis was seen on XR. He should arrange close f/u with Dr. [First Name (STitle) 1557] in [Location (un) 1110]. he continues on his pain Rx for neuropathic pain. He should receive PT/OT at the [Hospital1 1501]. Medications on Admission: Lovenox 40 SC', plavix 75', neurontin 300''', lopressor 25''??, elavil 50', lasix, hydroxyzine?, flomax 0.4', allopurinol 100'', folic acid 1', ASA 81', Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed. 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 14. Insulin Regular Human 100 unit/mL Solution Sig: Three (3) Injection ASDIR (AS DIRECTED). 15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for anal pruritis. 16. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 18. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML Injection DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 ] Care [Location (un) 5871] Discharge Diagnosis: Upper GI bleed Esophagitis Duodenal Ulcers Discharge Condition: good Discharge Instructions: You have been treated for upper gastrointestinal bleed. You received a total of 11 units of blood cells, as well as an endoscopy which found signs of esophagitis and 2 duodenal ulcers. The bleeding stopped and you have been stable. We are dischargin you to a skilled nursing facitlity for further care. Please continue the medications we prescribe on discharge and then resume your home medications as per your treating physician upon leaving the [Hospital1 1501]. Please let your care provider know if you have fever, chills, bleeding from rectum, coughing or vomiting blood, severe abdominal pain, nausea, dizziness, changes in your mental abilities, or any other symptoms that worry you. Please follow up with your primary care physician, [Name10 (NameIs) 40960] and GI physician as described below. Followup Instructions: 1. Primary care physician: [Name10 (NameIs) ] make an appointment to follow up in 1 month to restart your coumadin therapy. 2. Podiatry: please arrange follow up within 2-4 weeks with Dr. [First Name (STitle) 1557] in [Location (un) 1110]. 3. Gastrointestinal physician: [Name10 (NameIs) ] up as needed by primary care. Completed by:[2156-6-18]	[ "532.00", "428.0", "357.2", "250.60", "530.19", "250.80", "600.00", "V58.61", "414.01", "585.9", "707.14", "403.90", "707.07", "274.9", "707.13", "412", "427.31" ]	icd9cm	[ [ [] ] ]	[ "44.43", "38.93" ]	icd9pcs	[ [ [] ] ]	8893, 8966	3971, 7040	293, 305	9053, 9060	1921, 3948	9922, 10289	1661, 1680		7243, 8870		8987, 9032		7066, 7220			9084, 9899									1695, 1902																						231, 255									333, 960																		982, 1521	1537, 1645
26,324	109,209	5583	Discharge summary	report	Admission Date: [2123-10-15] Discharge Date: [2123-10-17] Date of Birth: [2067-11-14] Sex: F Service: HISTORY OF PRESENT ILLNESS: Patient is a 55-year-old female with a past medical history of diabetes, hypertension, chronic renal insufficiency, who presented with nausea, vomiting, dehydration, and hyperglycemia/DKA, as well as headaches and dizziness x3 weeks. In the ED, the patient was found to be hypertensive to the 220 systolic. PAST MEDICAL HISTORY: 1. Hypertension. 2. Insulin dependent diabetes. 3. Atypical chest pain. 4. Chronic renal insufficiency, baseline 1.2-1.5. 5. Asthma. 6. Depression. 7. B12 deficiency. 8. History of UTIs. 9. History of small bowel obstructions x2. 10. Spinal stenosis with a left foot neuropathy. 11. Status post gastric bypass surgery in [2113]. 12. Status post cholecystectomy. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco and no alcohol. Lives with daughter and granddaughter. FAMILY HISTORY: Mother with hypertension and migraines. Father with hypertension and CAD. OUTPATIENT MEDICATIONS: 1. Lipitor 10 mg a day. 2. Atenolol 50 mg a day. 3. Cozaar 25 mg a day. 4. B12 100 mcg a day. 5. Insulin NPH 25 units q.a.m. and 16 units q bedtime. 6. Regular insulin-sliding scale. PHYSICAL EXAM ON ADMISSION: Temperature 96.8, blood pressure 186/74, heart rate 93, respiratory rate 15, and 97% on room air. General: Pleasant female in no acute distress. Heart was regular, rate, and rhythm S1, S2. Lungs were clear to auscultation bilaterally. Abdomen was obese, soft, nontender, and positive bowel sounds. Extremities: No clubbing, cyanosis, or edema. Neurologic: Awake, alert, and oriented times three. Mentating well. Cranial nerves II through XII are intact. Reflexes are 2+ and symmetric bilaterally. Negative Kernig's and negative Brudzinski's. Strength is [4-5] in all extremities. Sensation is intact. LABORATORY DATA ON ADMISSION: White count 10.5, hematocrit 47.2, platelets 312. Sodium 138, potassium 5.9, chloride 102, bicarb 22, BUN 34, creatinine 2.0, glucose 309. Calcium 9.3, magnesium 18, phosphorus 5.3. Albumin 4.4, total bilirubin 0.4, ALT 18, AST 74, alkaline phosphatase 298, lipase 74, INR 1.1. CK 173 down to 130, MB of 5 and troponin negative x2. ABG: 7.34/41/89, lactate 2.7. CT head: No hemorrhage, no mass effect, and normal head CT. Chest x-ray: No acute process. KUB: Stool throughout colon, no dilated loops of bowel. EKG: Normal axis or intervals, slight ST depression laterally, slight tachycardia at 95. Urinalysis: Moderate blood, 500 protein, 1,000 glucose, negative for ketones, negative leuks, no reds, no whites, occasional bacteria, and no yeast. HOSPITAL COURSE BY PROBLEM: 1. Diabetic ketoacidosis: Patient with an anion gap of 17, but negative ketones in the serum and urine. There was no clear precipitating factor. Urine cultures and blood cultures were negative. Patient was treated with an insulin drip and IV fluids with better control of her sugars and by the following morning had no further nausea, vomiting, and felt much improved. Patient was changed over to regular insulin-sliding scale and will be discharged on her home dose of NPH. 2. Headache: Patient underwent a CT of the head as well as MRI which were both negative for pathology. Originally, there was a concern for possible subarachnoid hemorrhage, therefore a lumbar puncture was attempted, however, it failed. Neurology was consulted, and felt that as patient's symptoms improved after IV fluids and control of her hyperglycemia, there was no need for further workup unless the headache intensity increased again. 3. Cardiovascular: Patient had diffuse ST depressions on admission EKG. Repeat EKG showed that these depressions had resolved. Patient was ruled out for MI. Troponin was negative x3. Patient was continued on aspirin and beta blocker. It was felt that the patient may benefit from an outpatient ETT MIBI in the future. 4. Chronic renal insufficiency: Patient's creatinine was near baseline at the time of discharge. 5. Increased CKs/increased AST: Patient with elevated CKs to the 250s as well as a high AST during this admission. This was felt to be possibly secondary to Lipitor as this was a new medication for the patient, and therefore Lipitor was held. Patient was asked to followup with her primary physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] regarding this issue. 6. Hypertension: Patient was continued on her losartan and her atenolol was increased to 75 mg q.d. 7. Abdominal pain: This was felt to be chronic in nature and thought to be possibly secondary to adhesions. Patient has had a history of multiple abdominal surgeries including two small bowel obstructions. Patient had a CT of the abdomen that was negative for pathology. 8. Status post gastric bypass: CT of the abdomen did show a communication between the excluded and the neostomach. It was felt that contrast had filled the excluded stomach and it had not filled as reflux from the distal limb, therefore, there must be an abnormal communication. Patient will likely need followup regarding this matter as well. At discharge, patient was in good condition with adequately controlled blood sugars and hypertension, and with much improved symptoms. FINAL DIAGNOSIS: Diabetic ketoacidosis. SECONDARY DIAGNOSES: 1. Anemia. 2. Hypertension. RECOMMENDED FOLLOWUP: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] within 1-2 weeks as well as to have an outpatient stress test and for followup regarding her gastric bypass surgery. DISCHARGE MEDICATIONS: 1. Losartan 25 mg once a day. 2. Aspirin 81 mg a day. 3. Atenolol 75 mg a day. 4. Vitamin B12 50 mcg a day. 5. NPH insulin 24 units q.a.m., 16 units q.p.m. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 15868] Dictated By:[Name8 (MD) 13747] MEDQUIST36 D: [2123-10-17] 16:37 T: [2123-10-19] 06:45 JOB#: [Job Number 22443]	[ "250.11", "276.5", "285.9", "593.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]							997, 1072		5675, 6093						5367, 5391											5412, 5652								1096, 1294																			2752, 5349			159, 468		2339, 2724					1960, 2329											490, 895	912, 980
32,435	173,167	51072	Discharge summary	report	Admission Date: [2192-12-25] Discharge Date: [2193-1-18] Date of Birth: [2122-2-1] Sex: F Service: MEDICINE Allergies: Ceclor / Grass Pollen-[State 19827] Blue, Standard / Ragweed Attending:[First Name3 (LF) 1674] Chief Complaint: hypotension/fall weakness Major Surgical or Invasive Procedure: none History of Present Illness: 70 yo F with HTN, hypothyroid presents s/p fall at home. She reported fall occured in the setting of 'weakness'. She apparently hit her head and was transferred to ED. Per ED note patient was febrile at home (unclear how high). In the ED, patient had a CT head that was negative. She also had a CXR that showed a LLL opacity, possibly PNA. Patient was given a dose of levofloxacin and was being prepared for transfer to floor when it was noted that her systolic pressure was in the 70's. She had a lactate drawn that came back at 2.4. Patient was mentating. A central line was placed, she was gicev 2L of IVF and a dose of ceftriaxone. Her SBPs increased only to the 80's, therefore levophed was started. repeat lactate was down to 0.9. Last set of vitals per ED resident BP 83/47, HR 70, O2 sat 96% on 2L/RA (NC comes off). Patient mentating well, has foley in place with good UOP. Admitted to ICU for further management. .. 70 y.o. W with HTN, hypothyroid who initially presented to the ED s/p fall at home in the setting of 'weakness' and fever. In the ED patient had negative head CT, was found to have a PNA, and was admitted to the ICU for hypotension to the 70's and lactate of 2.4. Now improved, on multiple antibiotics for influenza pna with suspected bacterial superinfection. Past Medical History: Hypertension Asthma Hypothyroidism. Bilateral total knee replacements left thumb CMC joint arthritis Social History: Does not smoke, does not drink alcohol. She is able to do all of her housework including cooking. Family History: non contributory vis a vis current issues Physical Exam: VS: 99.4 148/90 96 24 94% on 3 L by face mask GEN: NAD HEENT: AT, NC, no conjuctival injection, anicteric, think brownish coating on tongue, MMM, neck supple CV: RRR, nl s1, s2, no m/r/g PULM: coarse ronchi BL, L > R, fairly good air movement throughout ABD: soft, obese, NT, ND, + BS EXT: warm, dry, +2 distal pulses BL NEURO: alert & oriented, CN II-XII grossly intact PSYCH: appropriate affect Pertinent Results: Admit labs: [2192-12-25] 01:45AM WBC-12.9# RBC-4.26 HGB-13.3 HCT-39.1 MCV-92 MCH-31.2 MCHC-34.0 RDW-14.4 [2192-12-25] 01:45AM NEUTS-87.7 LYMPHS-7.5* MONOS-4.5 EOS-0.2 BASOS-0.1 [2192-12-25] 01:45AM PLT COUNT-185 [2192-12-25] 01:45AM GLUCOSE-119* UREA N-25* CREAT-1.3* SODIUM-138 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16 [2192-12-25] 01:45AM LD(LDH)-267* CHEST (PA & LAT) Reason: r/o PNA [Hospital 93] MEDICAL CONDITION: 70 year old woman with fevers and cough REASON FOR THIS EXAMINATION: r/o PNA INDICATION: 70-year-old female with fevers and cough. Rule out pneumonia. COMPARISON: [2187-8-14]. PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal. Mediastinal and hilar contours are unchanged and unremarkable. Aortic arch calcifications are noted. Within the left lung base in the anterior left lower lobe, there is opacity, which could represent pneumonia. Given its somewhat linear appearance, atelectasis is an alternative etiology. The overlying soft tissue obscures detailed evaluation of this region. There are no pleural effusions and there is no pneumothorax. IMPRESSION: Left lower lobe opacity, probably representing pneumonia. However, given linear configuration, atelectasis is an alternative explanation. CT HEAD W/O CONTRAST Reason: S/P FALL [Hospital 93] MEDICAL CONDITION: 70 year old woman s/p fall. + hit head. no loc REASON FOR THIS EXAMINATION: r/o bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 70-year-old female status post fall. Rule out bleed. No comparison studies. TECHNIQUE: Non-contrast CT of the head. FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. [Doctor Last Name ]-white matter differentiation is preserved. The ventricles are prominent, likely due to central atrophy. There is moderate diffuse white matter hypodensity most likely representing chronic microvascular disease. There is no evidence of acute major vascular territorial infarction. The visualized paranasal sinuses demonstrate moderate ethmoid sinus mucosal thickening and mild bilateral right greater than left maxillary sinus mucosal thickening. There is no evidence of fracture. The surrounding soft tissue structures are unremarkable. Cataract surgical changes of the globes are seen bilaterally. IMPRESSION: No acute intracranial abnormalities. Extensive microangiopathic changes and central atrophy ============================================================ CHEST (PA & LAT) [2193-1-5] 10:16 AM CHEST (PA & LAT) Reason: ? interval change [Hospital 93] MEDICAL CONDITION: 70 year old woman with asthma, pneumonia, flu REASON FOR THIS EXAMINATION: ? interval change FRONTAL AND LATERAL CHEST RADIOGRAPH INDICATION: Asthma, pneumonia, flu. Evaluate interval change. COMPARISON: [2192-12-29]. FINDINGS: There is an air-fluid level at the lower mediastinum compatible with a hiatal hernia. There is no significant pulmonary consolidation. There is some minimal left basilar atelectasis. Note is made of a left shoulder hemiarthroplasty. There is thoracic spinal degenerative discogenic disease. IMPRESSION: Basilar atelectasis. Hiatal hernia. ===================================================== ECG: Sinus rhythm Borderline first degree A-V delay Left atrial abnormality Modest nonspecific ST-T wave changes Since previous tracing of [2192-1-26], probably no significant change Discharge labs: Brief Hospital Course: Patient admitted to ICU on [12-25]. In ICU patient patient requiring 4-5liters oxygen, started on levaquin for pneumonia, given aggressive fluids for hypotension likely from dehydration/infection. Levaquin changed to vancomycin and aztreonam on [12-29] with continued fever spikes and continued significant oxygen requirment. Patient started on prednisone taper, nebulizers. Slowly improved with stabilization of pulm status, hemodynamics, oxygen to 3l requirement and bp's improved from 70's to 100's by transfer to floor on [12-31]. On the floor from [1-1] on. Completed 8day course of vancomycin and aztreonam for possible hospital acquired pneumonia. Maintained on prednisone, nebs, humidified O2, chest PT. Despite aggressive Rx for above issues, patient still appeared very dyspneic and hence CTA chest was done that revealed bilateral PE's. In further w/u, pt was also found to have bilateral DVT's. Started on IV heparin and coumadin to target INR [12-23]. Patient is advised to have age appropriate ca screening. She has never had a colonoscopy and mammogram was 3 years back. Given new VTE, should have testing for hidden / occult malignancy. ECHO showed Diastolic CHF, chronic - stable. On ASA, statin, lisinopril, metoprolol. Incidental finding of pulmonary nodules see on CT chest - needs follow up. (pt informed). CT abd/pelvis as part of malignancy w/u with non specific LAD. Radiology recommends repeat CT torso in approx 6 weeks ([2193-2-19]).Pt to d/w PCP regarding [Name9 (PRE) ] [Name9 (PRE) ] CT's. Hypothyroidism - is on levothyroxine. TSH significantly elevated and FT4 is low. Increased dose of levothyroxine to 125 microgram/day. Recheck in [2-24] weeks recommended. Hypertension - HCTZ, lisinopril, metoprolol continued after hypotension resolved. Hyperlipidemia - on statin Depression - on zoloft. Mood stable. Dispo - eventually home with PT after clinical improvement. Medications on Admission: (per OMR): Levothyroxine [Synthroid] 112 mcg 1 Tablet(s) by mouth once a day Lisinopril-Hydrochlorothiazide 20 mg-12.5 mg Tablet by mouth once a day Metoprolol Succinate [Toprol XL] Sertraline 50 mg Tablet 1 Tablet(s) by mouth QD (once a day) Simvastatin [Zocor] Ascorbic Acid [Vitamin C] Aspirin [Ecotrin] 325 mg Tablet Calcium-Cholecalciferol (D3) [Os-Cal 500 + D] Ferrous Sulfate Multivitamin with Iron-Mineral [Centrum] Omeprazole 20 mg Capsule Vitamin E .. .. Heparin 5000 UNIT SC Q8H Acetaminophen [Telephone/Fax (1) 1999] mg PO Q6H:PRN Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN Albuterol [11-21] PUFF IH Q4H SOB Albuterol 0.083% Neb Soln 1 NEB IH Q6H Ipratropium Bromide Neb 1 NEB IH Q6H Aspirin EC 325 mg PO DAILY Levothyroxine Sodium 112 mcg PO DAILY Aztreonam 1000 mg IV Q8H Multivitamins 1 CAP PO DAILY Benzonatate 100 mg PO TID Pantoprazole 40 mg PO Q24H Bisacodyl 10 mg PO/PR DAILY:PRN constipation PredniSONE 40 mg PO DAILY Duration: 5 Doses Captopril 6.25 mg PO TID Sertraline 50 mg PO DAILY Docusate Sodium 100 mg PO BID Simvastatin 40 mg PO DAILY Guaifenesin [3-30] mL PO Q6H Vancomycin 1000 mg IV Q 12H Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: 1. Acute Respiratory Failure 2. Influenza 3. Bacterial pneumonia 4. Asthma with acute exacerbation 5. Pulmonary embolism and deep vein thrombosis, legs 6. Hypotension 7. Pulmonary nodules Secondary: 1 Hypertension 2. Hypothryoidism 3. Hyperlipidemia 4. Depression. Discharge Condition: Stable, afebrile, satting mid 90's on room air, ambulating, good PO intake. Discharge Instructions: Follow up as below. All medications as prescribed. You will be given enough prednisone to take one pill a day until Monday, when you see Dr. [Last Name (STitle) 12646]. If Dr. [Last Name (STitle) 12646] is concerned about your breathing, he might ask that you continue prednisone, and will need to give you a prescription for that. Use your inhalers as directed. New inhalers have been added. Take vitamin D and calcium. If you have fevers, chills, worsening shortness of breath, chest pain or any other new concerning symptoms, contact your doctor. Since you were diagnosed with clots in your legs and lungs, you will take blood thinners for at least 6 months. It is important to have your blood tests closely monitored during this time. You are advised to discuss with your doctor about the following issues: - you have some spots seen on the lung scan and in the abdomen as we discussed. You will need to have a CT scan of the chest and abdomen repeated in about 3 months. - Discuss with your doctor [First Name (Titles) ] [Last Name (Titles) 51794] a mammogram, pap smear and colonoscopy. Followup Instructions: Appointment to see Dr. [Last Name (STitle) 12646] [1-21] at 3pm, [Location (un) ] Office. INR check - VNA will check INR tomorrow ([1-19]) and then 2 times per week. They will call the Saturday results to Dr. [Last Name (STitle) ] and all other results after that they will fax to Dr. [Name (NI) 106075] office at fax [Telephone/Fax (1) 92693], if problem call [Telephone/Fax (1) 4615]. You also have the following previously scheduled appointments:Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2193-4-22] 11:25 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 17785],MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2193-4-22] 11:45 Please make an appointment to see Dr. [Last Name (STitle) ] within the next 3 weeks. Continue the inhalers until you see him. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2193-1-23]	[ "518.81", "482.9", "276.51", "453.41", "272.4", "584.9", "401.1", "487.0", "415.19", "428.32", "493.92", "518.89", "244.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	9216, 9291	5906, 7855	351, 357	9600, 9678	2408, 2842	10840, 11875	1932, 1975			5047, 5093	9312, 9579		7881, 9193			9702, 10817			5883, 5883						1990, 2389																						286, 313	5122, 5863								385, 1675																		1697, 1800	1816, 1916
18,245	198,864	52773	Discharge summary	report	Admission Date: [2139-3-16] Discharge Date:[2139-3-31] Service: CARDIAC AGE: 78. DATE OF DISCHARGE: Pending. CHIEF COMPLAINT: Severe two vessel coronary artery disease and aortic stenosis. HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old gentleman with a history of rheumatic heart disease in the past and a known history of aortic stenosis, who presented with progressive congestive heart failure. Transthoracic echocardiogram revealed critical aortic stenosis with an ejection fraction of 20%. Cardiac catheterization showed an ejection fraction of 20% with severe three-vessel disease. The patient was admitted for cardiac surgery. PAST MEDICAL HISTORY: History revealed rheumatic fever, aortic stenosis. MEDICATIONS ON ADMISSION: Medications included Aspirin 325 mg q.d. HOSPITAL COURSE: The patient [Year (4 digits) 1834] a coronary artery bypass graft times three on [2139-3-16]. The patient was transferred to the CSR Unit intubated and on vasopressors. The patient remained on the vasopressors over the next few days. The ventilatory support was weaned slowly over the next couple of days. He was extubated on [2139-3-19]. On [2139-3-19] he was found to be hypothermic, at which point fungal and blood cultures were sent. Cardiac rhythm was also noted to be in atrial flutter with PACs and PVCs on [2139-3-19] and EP Cardiology consultation was obtained. They recommended cardioversion. Cardioversion was attempted on [2139-3-20] unsuccessfully and the patient remained in atrial flutter. He was started on Amiodarone for rate control. On [2139-3-22] it was noted that the LFTs were rising. The Amiodarone was held as a possible cause of the jaundice. He was started on heparin drip and Lopressor. Gastrointestinal consultation was obtained on [2139-3-22] for hyperbilirubinemia. The diagnosis of postoperative cholestasis was made, and the patient was started on Actigall. The blood cultures on [2139-3-21] showed gram-positive cocci and gram-negative rods and he was started on Ceftriaxone. On [2139-3-22] he spontaneously converted to normal sinus rhythm. He was also started on Levaquin and subsequently changed to Oxacillin. Abdominal CT scan was performed on [2139-3-22], which showed no abnormalities. The LFTs started improving gradually over the next few days. The patient was transferred to the regular floor on [2139-3-26]. He continued to be stable. A PIC line was placed on [2139-3-30] for IV antibiotics. The patient is currently ready for discharge to a rehabilitation facility. The liver function tests are normalizing gradually. He will continue to have IV antibiotics for a total of a two-week period. MEDICATIONS ON DISCHARGE: 1. Actigall 300 mg b.i.d. 2. Oxacillin 2 grams IV q.4h. up to [4-7]. 3. Ceftriaxone one gram IV q. 24 hours, up to [4-4]. 4. Colace 100 mg b.i.d. 5. Aspirin 325 mg q.d. 6. Lopressor 50 mg b.i.d. 7. Albuterol and Atrovent nebulizers q.4h.p.r.n. FO[Last Name (STitle) ]P CARE: The patient will followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 141] in two weeks from discharge. He will also followup with Dr. [Last Name (Prefixes) ] in four weeks from discharge. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2139-3-31] 09:57 T: [2139-3-31] 10:06 JOB#: [Job Number ]	[ "790.7", "428.0", "997.1", "427.32", "414.01", "E878.2", "576.8", "997.4", "395.0" ]	icd9cm	[ [ [] ] ]	[ "35.21", "37.26", "36.15", "39.61", "42.23", "99.61", "36.12", "88.72" ]	icd9pcs	[ [ [] ] ]												2774, 3570	778, 820	838, 2748																																	150, 676																											699, 751
60,534	140,655	4355	Discharge summary	report	Admission Date: [2101-8-25] Discharge Date: [2101-8-31] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2569] Chief Complaint: aphasia and right sided weakness Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: Eu Critical [Doctor First Name ] (last name is [Known lastname ]) is a [Age over 90 ] yo woman with PMHx of dementia, HTN and CKD who presented as a code stroke for decreased speech and R-sided neglect. Per patient's nursing home ([First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]), she was last seen completely well 3 days ago. For the last 2 days she has been c/o malaise and fatigue but was otherwise herself. It was found that she had elevated BP's into the 190's during that time point and her sx were attributed to her HTN. Then at 9am on [8-25] she was brought her breakfast by an aide. Normally Ms. [Known lastname ] can feed herself, but she was complaining that she "couldn't see" her breakfast. She also answered "yes" and "ok" to some other questions but was overall less talkative than usual. Then at 11am she was checked on again and was noted to be not speaking at all and possibly not looking at anything on the right side. An ambulance was called and she was brought to the ED where a Code Stroke was called. Given her CKD, she was unable to get a CTA, but her NCHCT showed no signs of early stroke and no hemorrhage. Therefore, even though it was somewhat unclear the exact time of onset, she was given tPA as her head CT and her medical conditions showed no contraindication. Her son was called to discuss tPA with prior to admisinstration of the medication. Her neurological improved as she became mroe conversant and her R leg bexame less weak. She also was able to track a small amount past midline. However at around 2:40pm she was seen to become unresponsive by the ED staff and was intubateed. She was loaded with 1 gram of phenytoin and a stat NCHCT was obtained to look for hemorrhage, which was negative, and patient was admitted to the ICU. The patient is unable to complete ROS as she was not responding to commands or most questions. Past Medical History: PMH: - dementia (per NH and her NP's report pt's baseline is that she can carry on a normal superficial conversation, but as soon as you start asking where she is and the year etc she will not know. Also, she uses a wheelchair at baseline, but is able to stand on both feet and pivot into the wheelchair and is able to move herself around in bed. She feeds herself and is able to say when she has to use the restroom, but isn't always able to get there and is therefore incontinent of urine and stool) - depression (possibly ith psychotic features vs [Last Name (un) ] body dementia as per [Hospital ] nursing home, [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]) - insomnia - glaucoma - h/o a positive PPD test - CKD stage 3 - HTN Social History: no smoking as per the nursing home, has a son who is her health care proxy who lives in NJ. Family History: unknown Physical Exam: Physical Exam: Vitals: T:97.2 P:78 R: 16 BP: 195/98 SaO2: 97% on RA General: Awake, somewhat 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: NIH Stroke Scale score was :14 1a. Level of Consciousness: 1 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 1 3. Visual fields: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 1 6b. Motor leg, right: 2 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 1 10. Dysarthria: 0 11. Extinction and Neglect: 2 -Mental Status: Is able to say that she is in a hospital when given choices. Reports her age as "75", then answers "75" repeatedly for many subsequent questions. She can follow some commands when they are mimed to her. She does respon at one point "not too good" when asked how she is. Patient was able to name chair on the NIHSS card, but said "dunno" or stayed silent to the others. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VF show decreased blink to threat in the R eye. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus but patient unable to cross the midline to the R. V: Facial sensation intact to light touch. VII: Mild R facial droop, facial musculature otherwise symmetric. VIII: Hearing intact to snapping bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Patient unable to cooperate with formal strength testing, but on our exam, she was able to list both arms off the bed and keep them there. However, she was only able to lift her left leg off the bed for about 5 seconds, and then slowly dropped to the ground. On the RLE, the patient was unable to lift the leg off the bed except to noxious stim and then the response was minimal also. -Sensory: She can feel noxious throuhgout but is unable to currently cooperate with more formal testing. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was mute bilaterally. -Coordination: patient unable to cooperate -Gait: Deferred =================================== Discharge Exam Vitals not checked as patient is comfort measures only, respiratory rate ~20. Appears comfortable, snoring lightly. No apneic episodes. Somewhat arousable to voice and light touch. No spontaneous movement observed. Noxious stimuli not applied. Pertinent Results: ADMISSION LABS: [2101-8-25] 12:00PM BLOOD WBC-5.8 RBC-3.90* Hgb-10.9* Hct-34.8* MCV-89 MCH-27.9 MCHC-31.3 RDW-13.3 Plt Ct-180 [2101-8-25] 12:00PM BLOOD PT-11.8 PTT-28.4 INR(PT)-1.1 [2101-8-25] 12:15PM BLOOD Creat-2.1* [2101-8-26] 03:31AM BLOOD Glucose-117* UreaN-22* Creat-1.6* Na-136 K-4.3 Cl-105 HCO3-22 AnGap-13 [2101-8-26] 03:31AM BLOOD ALT-8 AST-20 LD(LDH)-206 CK(CPK)-110 AlkPhos-78 TotBili-0.3 [2101-8-26] 03:31AM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.1 Mg-0.9* RELEVANT LABS: [2101-8-26] 03:31AM BLOOD Cholest-255* Triglyc-182* HDL-43 CHOL/HD-5.9 LDLcalc-176* [2101-8-26] 03:31AM BLOOD %HbA1c-5.5 eAG-111 [2101-8-26] 03:31AM BLOOD TSH-0.78 CARDIAC ENZYME: [2101-8-25] 12:00PM BLOOD CK-MB-2 cTropnT-0.05* [2101-8-26] 03:31AM BLOOD CK-MB-3 cTropnT-0.03* PHENYTOIN: [2101-8-26] 03:31AM BLOOD Phenyto-7.2* [2101-8-27] 04:22AM BLOOD Phenyto-12.1 MICROBIOLOGY: MRSA SCREEN NEGATIVE NEUROLOGY - EEG: [2101-8-25]: This is an abnormal continuous ICU monitoring study because of a single electrographic seizure arising from the left central occipital region as described above, lasting about 2 minutes. There is also discontinuous background with subtle attenuation of faster activity over the right hemisphere, suggestive of severe encephalopathy with focal cortical dysfunction over the right hemisphere. There are brief runs of sharply contoured theta rhythm over the left central region. There is no previous study to compare. IMAGING: [2101-8-25] CT HEAD: 1. No intracranial hemorrhage. 2. Extensive age-related involution and small vessel ischemic disease. 3. 1.7 x 1.5 x 1.4 cm pituitary mass with bony sellar expansion which could be further characterized by MRI if not previously known. [2101-8-26] TTE: 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%). A mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is a small somewhat mobile echodensity on the anterior mitral leaflet, likely representing a focal area of calcification. A vegetation, papillary fibroelastoma or other pathology cannot be excluded, but is less likely. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mobile focal mitral calcification as described above. Moderate resting mid-cavitary LV gradient. [2101-8-26] CT HEAD: 1. 5 cm x 5 cm right parietal lobe hemorrhage with extension into the left lateral ventricle occipital [Doctor Last Name 534], with a corresponding 5mm midline shift to the left. 2. Hypodensity around the hemorrhage extending to the overlying cortex which may represent edema or evolving infarction. [2101-8-26] MRI/MRA OF HEAD: IMPRESSION: Large right cerebral hematoma is identified with mass effect on the right lateral ventricle. Multiple areas of chronic microhemorrhages are seen. Small vessel disease noted. Prominence of the left lateral ventricle may indicate early hydrocephalus. Followup CT recommended as clinically appropriate. IMPRESSION: 12 x 10 mm fusiform left cavernous carotid aneurysm. Dolichoectasia of the arteries of anterior and posterior circulation seen. No vascular occlusion. Brief Hospital Course: Ms. [Known lastname ] is a [Age over 90 ] yo woman with poor baseline functional status (wheelchair bound), PMH of dementia, HTN and CKD who initially presented from her nursing home with right sided weakness and neglect. She was given tPA in ED with some improvement. However, patient became unresponsive and intubated, treated for presumed seizure with dilantin and admitted to the ICU. Her repeat head CT in ICU showed a large right parietal IPH with midline shift. After discussion with family members, decision was made to to make patient comfort measures only and she was extubated and transferred to the floor. Unnecessary labs, fingersticks, vitals and medications were discontinued. She was started on prn morphine for pain and dyspnea. She was continued on IV dilantin while in house, but as it cannot be continued on discharge, will transition to scheduled ativan to assist with possible seizures. Patient is being discharged to [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] for further end of life care. Medications on Admission: celexa 30mg QD - HCTZ 25mg QD - lisinopril 10mg QD - MVI QD - vit B12 100mcg QD - vitamin D 800 IU QD - tylenol 1,000mg [Hospital1 ] - omeprazole 20mg [Hospital1 ] - artificial tears [Hospital1 ] - calcium carbonate 500mg TID - trazodone 50mg QHS - travatan 0.001% eye drops, 1 drop to both eyes QHS - tylenol PRN pain/fever - bisacodyl supp. 10mg QD PRN constipation - calcium carbonate 1,000mg PRN GERD - robitussin 20mL TID PRN cough - milk of magnesia 30mL Qd PRN constipation - fleets enema PRN constipation - duoneb PRN wheeze Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] - [Location (un) 538] Discharge Diagnosis: Primary Diagnosis: intraparenchymal hemorrhage, stroke Secondary Diagnosis: dementia, chronic kidney disease, hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic, sometimes arousable. Activity Status: Bedbound. Discharge Instructions: Mrs [Known lastname ] had right sided weakness and was found to have a stroke. She was given blood thinning medication called tPA for the stroke. She became less responsive and was intubated and admitted to the ICU. In the ICU, repeat head CT showed that she had right intraparenchymal hemorrhage. After a family meeting, it was decided to focus on patient's comfort and she was extubated. Followup Instructions: None [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "997.02", "434.91", "342.90", "585.3", "365.9", "294.20", "784.3", "518.81", "311", "780.39", "781.8", "780.52", "V46.3", "781.94", "365.70", "431", "E934.4", "403.90" ]	icd9cm	[ [ [] ] ]	[ "96.71", "89.19", "99.10", "96.04" ]	icd9pcs	[ [ [] ] ]	11504, 11626	9860, 10909	285, 311	11793, 11793	6199, 6199	12354, 12473	3170, 3179				11647, 11647		10935, 11481			11936, 12331						4482, 6180			3209, 4076																						213, 247									339, 2258		9018, 9837	11723, 11772	6215, 7714	11666, 11702			11808, 11912										2280, 3045	3061, 3154
30,428	114,693	32201	Discharge summary	report	Admission Date: [2163-12-24] Discharge Date: [2164-1-5] Date of Birth: [2101-8-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: acute mitral regurg Major Surgical or Invasive Procedure: [2163-12-26] MVR (onx 25mm/33mm) History of Present Illness: 62yo man with hx of asthma and mitral regurg comes in from OSH with acute mitral regurgitation. Three months ago, he had several weeks of a cough, treated with inhalers with improvement. Then two days ago, he experienced CP, PND, and orthopnea. This persisted. Last night, he had severe orthopnea and had increasing fatigue so his wife brought him to OSH around 5am on [12-24]. . At OSH, initial EKG showed sinus tachy, nl axis, nl intervals. Peaked T waves V3-V4. CXR showed pulm edema. Received lasix 20 IV in ED. Then hypotensive so required NS bolus. Developed resp distress so started BiPAP and solumedrol 150 IV. Received another 20 IV lasix but BP dropped so received 1000 NS bolus. To ICU: O2 sat remained low 80s% on 100% NRB. Intubated at 12:15pm w AC 500/16 100% PEEP 5. O2 sats remained 90-93%. Sedated with propofol and fentanyl. No pressors were started. . Echo per report showed MV prolapse with likely acute flail leaflet ? chordae rupture. . Patient transferred here urgently and went directly to cath lab. Initial BP 80s/60. Tachycardic to 120. IABP placed and SBP improved to the 90s, MAP at 65. Coronaries were examined and were clean. Swan placed with wedge of 31 (with steep V waves), RA 9, RV 64/19, PA 70/30 (51). TEE showed posterior mitral leaflet flail and severe MR. Cardiac surgery consulted. The IABP site on right was bleeding so it was resited to left groin. MAPs dropped and cardiac index 1.55 so periph dopa started with good response. . Also received lasix 40mg IV with approx 1L UOP in cath lab. Creatinine increased from 1.4 to 1.8 then stabilized at 1.7. ABGs here were 7.23/56/86 so RR increased. Then 7.31/43/138 then 7.26/48/97 w lactate 1.4 so Vt increased and Peep increased. Past Medical History: Asthma hernia repair Mitral regurg: per wife, pt had systolic murmur noted on pre-job physical years ago and has not had an echo or further workup Social History: married with wife. [Name (NI) ] [Name2 (NI) ] or etoh. works at a bakery. functionally, very high functioning with good exercise tolerance. Family History: No CAD or known structural heart disease Father with parkinson's and stroke Physical Exam: VS: 97.3 HR 102 Cuff pressure 95/65, [Month (only) ] [Last Name (un) 6043] 103, assist systole 90, PAP 51/43 (mean 47) Dopa at 4 AC 600/22 FiO2 80% Peep 12 GEN: sedate but arousable to voice. NEURO: opens eyes on request. Squeezes bilat hands and moves feet on request. HEENT: pupils pinpoint but equally reactive. MMM CARDS: JVP 8-10 but diff to assess. Palpable thrill. Tachy, regular. [5-29] holosystolic murmur at apex with heave. RESP: crackles at based. on respirator ABD: BS+ NT ND, holosystolic murmur heard at epigastrium. soft. no rebound EXT: no edema. 2+ DP and PT both feet (assessed by me and intern). Groin sites: right with small 2x2 hematoma, no bruit. left with art and venous lines. ACCESS: Right IJ CVL (OSH line), left arterial balloon pump groin, left venous swan. PULSES: as above Pertinent Results: [2164-1-5] 06:45AM BLOOD WBC-13.9* RBC-3.93* Hgb-11.6* Hct-34.9* MCV-89 MCH-29.4 MCHC-33.1 RDW-13.8 Plt Ct-887# [2163-12-24] 06:00PM BLOOD WBC-21.4 RBC-4.50* Hgb-14.2 Hct-41.8 MCV-93 MCH-31.5 MCHC-33.9 RDW-13.3 Plt Ct-387 [2164-1-5] 06:45AM BLOOD Plt Ct-887# [2164-1-5] 06:45AM BLOOD PT-29.2 PTT-146.7* INR(PT)-3.1* [2164-1-4] 06:30AM BLOOD PT-21.5* PTT-94.4* INR(PT)-2.0* [2164-1-3] 01:10PM BLOOD PT-17.4* PTT-45.7* INR(PT)-1.6* [2164-1-3] 10:40AM BLOOD PT-17.7* INR(PT)-1.6* [2164-1-2] 09:18PM BLOOD PT-16.2* PTT-31.5 INR(PT)-1.5* [2164-1-5] 06:45AM BLOOD Glucose-108* UreaN-21* Creat-1.2 Na-139 K-4.7 Cl-101 HCO3-26 AnGap-17 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 75295], [Known firstname 251] [Hospital1 18] [Numeric Identifier 75296] (Complete) Done [2163-12-26] at 10:08:04 AM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2101-8-17] Age (years): 62 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Cardiogenic shock for MVR. ICD-9 Codes: 428.0, 786.05, 799.02, 424.1, 424.0 Test Information Date/Time: [2163-12-26] at 10:08 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW-:1 Machine: [Pager number 30532] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe (4+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: No 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 This was a focused study on patient in shock, with IABP, for urgent MVR. Pre-Bypass: No spontaneous echo contrast is seen in the left atrial appendage. There is moderate global right ventricular free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Post Bypass: Patient is on Milrinone. Well-seated and functioning mitral prosthesis. No leak, no MR. [First Name (Titles) ] [Last Name (Titles) ]. Aorta intact. RV systolic fxn is good. LV is globally mildly depressed. Brief Hospital Course: He was taken to the operating room on [2163-12-26] where he underwent an MVR. He was transferred to the ICU in critical but stable condition on milrinone, neo and propofol. He inadvertently pulled out his own balloon pump but remained stable. He was extubate on POD #1. He was given 48 hours of perop vancomycin because he was in the hospital preoperatively. He was transfused for HCT 22. He was started on coumadin for his mechanical valve. He was pancultured for elevated wbc and started on Zosyn for presumed aspiration pneumonia. He initially failed swallow evaluation and was seen by ENT for question of pharyhgeal pouch seen on video swallow. He was transferred to the floor on POD #5. He passed repeat swallow evaluation. He remained on heparin gtt awaiting a therapeutic INR, and was ready for discharge home on POD # 10. He completed a one week course of zosyn. His wife spoke with Dr. [Last Name (STitle) ] office who has agreed to follow his coumadin, doses and discharge info were faxed there. Medications on Admission: Beclomethasone Advair 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 BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Check INR [1-6] with results to Dr. [Last Name (STitle) ]. Disp:60 Tablet(s) Refills:0 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: MR now s/p MVR acute systolic heart failure Asthma Discharge Condition: good. Discharge Instructions: Calll with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week, Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Coumadin to be followed by Dr. [Last Name (STitle) ], have INR checked [1-6]. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (STitle) ] 2 weeks and for coumadin follow up Dr. [Last Name (Prefixes) ] 4 weeks Completed by:[2164-1-5]	[ "493.90", "428.0", "584.9", "785.51", "787.22", "429.5", "507.0", "518.81", "428.21", "276.7", "998.11", "424.0", "285.9" ]	icd9cm	[ [ [] ] ]	[ "35.24", "39.61", "99.04", "37.21", "88.72", "99.05", "37.61", "97.44", "96.71", "89.60", "88.56", "96.6" ]	icd9pcs	[ [ [] ] ]	9240, 9295	7066, 8083	341, 380	9390, 9398	3445, 7043		2508, 2585		8155, 9217		9316, 9369		8109, 8132			9422, 9761				9812, 9947					2600, 3426																						282, 303									408, 2155																		2177, 2325	2341, 2492
69,701	136,064	13323	Discharge summary	report	Admission Date: [2168-10-31] Discharge Date: [2168-11-6] Date of Birth: [2104-11-16] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: exertional dyspnea Major Surgical or Invasive Procedure: aortic valve replacement (25mm tissue) History of Present Illness: 63 year old man with aortic stenosis and underwent cardiac catheterization in [2168-4-4] due to shortness of breath that revealed 80% LAD lesion and underwent successfull PCI/stenting of his LAD. He now presents for cardiac catheterization as preoperative evaluation for aortiv valve surgery. Past Medical History: Aortic Stenosis Coronary Disease, Prior silent inferior MI s/p PCI Hypertension Hyperlipidemia ETOH Abuse has reduced intake last drink [10-30] Cervical radiculopathy Left shoulder tendonitis Paget's disease based upon recent CT of head Prior treatment for depression Past Surgical History: PCI/Stenting of OM([2160]), LAD([2168-4-4]) Tonsillectomy Social History: Race: Caucasian Last Dental Exam: clearance in office Lives with: wife Occupation: Office Manager Tobacco: Quit [2168-4-4]. 50 pack year history ETOH: Patient admits to alcohol abuse/binge drinking. Wife reports that he is an "alcoholic" - verbalizes less intake since [Month (only) ] - unclear as to amount - admits to glass wine [10-30] Family History: Father CAD deceased age 67. Mother developed CAD in her 60's and died in her 80's. Brother with CABG in his mid 60s. Physical Exam: HR 62 RR 16 O2 sat 97% blood pressure rt 153/94 lt 166/88 General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic ejection murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: alert and oriented x3 nonfocal Pulses: Femoral Right: cath site Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit: right murmur left murmur Pertinent Results: ECHO [2168-11-1] Prebypass No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apical and mid portions of the inferior and inferoseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results on [2168-11-1] at 845am Post bypass Patient is A paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. It appears well seated and the leaflets move normally. Trivial central aortic insufficiency present. Aorta is intact post decannulation. CHEST RADIOGRAPH [2168-11-5] INDICATION: Vascular repair. COMPARISON: [2168-11-2]. FINDINGS: The sternal wires and metallic parts of the valve are in unchanged, normal position. Moderate cardiomegaly, unchanged as compared to the previous examination. The pre-existing retrocardiac and left basal atelectasis has improved. Overall, the ventilation of the lung parenchyma is improved. Minimal right basal atelectasis, minimal right pleural fluid that extends into the major fissure. No focal parenchymal opacities suggesting pneumonia. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: SAT [2168-11-5] 1:20 PM Brief Hospital Course: Mr [Known lastname 40558] is a 64-year-old male with worsening symptoms related to critical aortic stenosis, with known coronary artery disease, status post percutaneous interventions with occluded right coronary artery. On [2168-11-1] mr. [Known lastname 40558] was taken tot he operating room where he underwent an aortic valve replacement (25mm Tissue value). post operatively he was transferred to the ICU intubated and sedated. He awoke neurologically intact and was weaned from the ventilator and extubated. His betablocker and statin therapy was resumed and was started on laisx and diuresed toward his pre-operative weight. Lisinopril was added for hypertension. He was transferred from the ICU to the step down unit. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated by physical therapy for strength and conditioning and was cleared for discharge to home. On POD# 5 Mr. [Known lastname 40558] was cleared for discharge to home by Dr. [Last Name (STitle) ] with VNA services an all appointments were advised. Medications on Admission: Toprol XL 25 daily, Crestor 20mg, ASA 325mg Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 13. Effient 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: AVR(25mm tissue) [2168-11-1] Aortic stenosis,CAD,s/p MI, s/p PCI,Hyperetnsion,Hyperlipidemia,ETOH Abuse has reduced intake last drink [10-30],Cervical radiculopathy,Left shoulder tendonitis,Paget's disease based upon recent CT of head,Prior treatment for depression Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Trace pedal Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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: The cardiac surgery office [Telephone/Fax (1) 170] will call you with the date and time of your follow up appointments with your surgeon, Dr. [Last Name (STitle) ] and your cardiologist. Plaese contact Dr. [Last Name (STitle) ] [Telephone/Fax (1) 8725] to schedule a follow up appointments to be seen in 4 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:[2168-11-6]	[ "291.81", "401.9", "518.0", "303.90", "416.8", "412", "496", "424.1", "414.2", "272.4", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56", "35.21", "39.61" ]	icd9pcs	[ [ [] ] ]	6959, 7010	4288, 5364	342, 383	7328, 7506	2319, 4265	8347, 8871	1480, 1599		5458, 6936		7031, 7307		5390, 5435			7530, 8324								1027, 1095	1614, 2300																						284, 304									411, 710																		732, 1004	1111, 1464
61,540	177,109	4606	Discharge summary	report	Admission Date: [2190-7-2] Discharge Date: [2190-7-8] Date of Birth: [2106-10-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: endoscopy, colonoscopy History of Present Illness: 83 y/o Russian-only speaking M with hx of dCHF, COPD, HTN, and BPH who presented to the ED with a headache and lightheadedness. He reports no nausea, vomiting, diarrhea. His last BM was yesterday and had bright red blood in it. He says his stools are always dark given that he takes iron. He also states that over the weekend last week, he was admitted to an OSH for anemia and was given a blood transfusion and sent home. He did not have an endoscopy or colonoscopy. Of note, he also is carrying a prescription for levoquin for an unknown reason. He doesn't know why he is supposed to be taking it. He denies fainting, falling, abdominal pain. He has never had a colonoscopy or endoscopy before. He does not take NSAIDs, drink etoh or have a hx of ulcers of GERD like symptoms. . In the ED, initial vitals were afebrile, P 70, BP 130/90, R 24 and 98% on 2L. He was guiac positive with bright red blood on the rectal exam. He had a NGL that returned bile without blood. His vital signs were stable throughout his ED course. He had one 18g and one 16g PIV placed. GI evaluated him in the emergency room and requested a nuclear red blood tagged scan this evening. He did receive 2 units of blood in the ED for a hct of 22.1. . On arrival to the floor, he is feeling well. He complains of a headache, but otherwise has no complaints. Past Medical History: 1. Diastolic CHF 2. Hypertension 3. BPH 4. COPD/Restrictive PFTs 5. Osteoarthritis 6. Left cataract surgery 7. Renal mass removed in [2186] 8. History of cellulitis in left lower extremity in [2181] 9. Right greater than left venostasis 10. PUD 11. Chronic renal insufficiency Social History: Russian-speaking. Smoked 1ppd x 20 yrs, quit 40 years ago. Denies current tobacco, alcohol, or illicit drug use. Lives alone in senior living facility. Has home health aid 4d per week. Pt has VNA but has had issues with noncompliance in the past. Family History: There is no family history of premature coronary artery disease, unexplained heart failure, or sudden death. Physical Exam: Tc-97.3 BP- 158/70 RR- 22 O2 sat-97% on 3L Gen: NAD, alert, lying in bed CV: RRR Lungs: mild crackles at right lung base Abd: soft, NT, ND, +BS Ext: no pedal edema Neuro: alert and oriented x 3, CN II-XII grossly intact Psych: mood, affect appropriate Pertinent Results: [2190-7-2] 07:21PM HCT-25.2* [2190-7-2] 01:46PM GLUCOSE-140* UREA N-53* CREAT-2.2* SODIUM-141 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-31 ANION GAP-13 [2190-7-2] 01:46PM estGFR-Using this [2190-7-2] 01:46PM ALT(SGPT)-6 AST(SGOT)-10 ALK PHOS-81 TOT BILI-0.4 [2190-7-2] 01:46PM cTropnT-0.02* [2190-7-2] 01:46PM ALBUMIN-3.4* [2190-7-2] 01:46PM WBC-5.4 RBC-2.33* HGB-7.0* HCT-22.1* MCV-95 MCH-30.1 MCHC-31.8 RDW-16.1* [2190-7-2] 01:46PM NEUTS-83.5* LYMPHS-12.9* MONOS-2.8 EOS-0.6 BASOS-0.2 [2190-7-2] 01:46PM PLT COUNT-120* [2190-7-2] 01:46PM PT-16.0* PTT-29.7 INR(PT)-1.4* . CXR [2190-7-2] IMPRESSION: New dense opacification at right lung base concerning for infection, particularly given short term development since [2190-6-9]. Recommend follow-up to resolution. . EKG [7-2] NSR, RBBB, ST depression in II, TW flattening in precordial leads [2190-7-5] 07:20PM BLOOD Hct-30.5* [2190-7-4] 05:50AM BLOOD WBC-4.7 RBC-3.36* Hgb-9.9* Hct-31.0* MCV-92 MCH-29.3 MCHC-31.8 RDW-16.5* Plt Ct-110* [2190-7-3] 12:34AM BLOOD WBC-5.2 RBC-3.17# Hgb-9.3# Hct-28.5* MCV-90 MCH-29.2 MCHC-32.5 RDW-16.8* Plt Ct-108* [2190-7-5] 05:01AM BLOOD Glucose-105* UreaN-41* Creat-1.8* Na-145 K-4.2 Cl-109* HCO3-30 AnGap-10 [2190-7-4] 05:50AM BLOOD Glucose-95 UreaN-41* Creat-1.8* Na-144 K-4.2 Cl-106 HCO3-31 AnGap-11 Brief Hospital Course: # Bright red blood per rectum: The patient presented with a hematocrit of 21, down from a baseline hematocrit of 30, with maroon stools with clots. The patient was actively bleeding and symptomatic despite stable vital signs. The patient received 2 units of packed red blood cells in the emergency room and an additional unit upon arriving in the MICU. The gastro-intestinal team was consulted and planned to scope the patient (colonoscopy and upper endoscopy)on Tuesday [7-6]. The patient was treated with IV pantoprazole and an oral bowel regiment (no stool since admission). The patient's hematocrit was stable overnight without active bleeding and stable vital signs. In total, patient received 5 units of blood with Hct increaed to around 30. The patient was transferred to the floor on the afternoon of [7-3] for further management. On the floor, his hematocrits were stable. He was prepped for endoscopy and underwent the procedure on [7-7]. [Last Name (un) ] and EGD did not reveal any source of bleeding. GI suggests out-pt capsule study and repeat screening [Last Name (un) ] at discretion of PMD as prep was not adequate to screen for colon CA. . # Right Lower Lung Opacity: The patient's CXR had a right lower lobe opacity on chest xray. It was decided to not pursue treatment as the patient was asymptomatic, afebrile, and had a normal white count. Of note - the patient was given a prescription for levaquin one week prior at an OSH for reasons the patient does not recall. . # Diastolic Congestive Heart Failure: The patient has known diastolic congestive heart failure with multiple admissions in the past few months for shortness of breath. The patient was considered to be at risk for developing flash pulmonary edema while receiving transfusions. The patients pressures and respiratory status were stable overnight. On the floor, his home medications (labetalol, lasix, amlodipine) were restarted. . # Hypertension: The patient was normotensive on admission to the MICU. The patient has a history uncontrolled hypertension. The patient's anti-hypertensive medications were held to maintain normo-tensive pressures as the patiet was at risk for flash edema given blood products and diastolic heart failure. His home medications were restarted on the floor. To control his blood pressure, his labetalol was increased to 400 mg tid and captopril was added and up-titrated to 50 mg tid. On discharge, his blood pressures are controlled with SBP in 150s. Will discharge patient on increased dose of HTN medications. Recommend follow-up with PCP for adjustment of meds. . # Chronic Obstructive Pulmonary Disease: The patient is on 2 liters of nasal cannula oxygen supplementation at home. The patient was administered albuterol nebulizer treatment as needed and was continued on his home dose of tiotropium and fluticasone inhalers during his stay. The patient did not have any episodes of respiratory distress in the MICU. On the floor, he was kept on [3-5] L of oxygen and had stable O2 sats. . # CKD: The patient's creatinine was 2.2 on admission to the MICU which is up from baseline of 1. The patient was likely pre-renal on admission secondary to blood loss. The patient's creatinine was 1.7 at the time of discharge form the MICU. On the floor, Cr remained at 1.8. . # BPH: The patient was continued on doxazosin and finasteride daily. . # Glaucoma/Cataracts: The patient was continued on his home eye drop regiment. . # Nutrition: As the patients's hematocrit was stable and there was no active bleeding evident, he was advanced to a soft diet on [7-3]. He was kept NPO for the procedure. He advanced to regular diet prior to discharge. Medications on Admission: Nexium 40 mg daily Finasteride 5 mg daily Spiriva 18 mcg daily Albuterol neb Lorazepam 1 mg qHS Tobramycin-Dexamethaxone 0.3-0.1% gtts [Hospital1 ] MVI daily Ferrous sulfate 300 mg daily Brimonidine 0.15% gtts q8hrs Dorzolamide-Timolol 2-0.5% gtts [Hospital1 ] Latanoprost 0.005% gtts qHS Polyvinyl Alcohol-Povidone 1.4-0.6% Dropperette PRN Doxazosin 4 mg daily ASA 325 mg daily Labetolol 400 mg [Hospital1 ] Amlodipine 5 mg daily Fluticasone 110 mcg 2 puffs [Hospital1 ] Lisinopril 5 mg daily Lasix 60 mg daily Home O2 for COPD Discharge Medications: 1. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:180 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed. 13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 16. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary Diagnosis: GI Bleed Secondary Diagnosis: 1. Diastolic CHF 2. Hypertension 3. BPH 4. COPD/Restrictive PFTs 5. chronic renal insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for blood in your stools. You were transfused blood for anemia. You underwent a procedure called endoscopy and colonoscopy, and no source of bleeding was identified. Please continue your medications. Please CHANGE your labetalol dose to 400 mg three times a day. Please START captopril 50 mg three times a day. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please keep the following appointments. If you cannot make an appointment, please call to reschedule. Name: [Last Name (LF) ],[First Name3 (LF) ] L. Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: [State 4607], [Location (un) ],[Numeric Identifier 588] Phone: [Telephone/Fax (1) 4606] Appointment: [Telephone/Fax (1) 766] [2190-7-19] 11:15am Department: SURGICAL SPECIALTIES When: WEDNESDAY [2190-8-4] at 10:30 AM With: UROLOGY UNIT [Telephone/Fax (1) 164] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910]	[ "403.90", "455.0", "600.00", "574.20", "296.80", "365.9", "428.0", "585.9", "578.1", "535.50", "285.9", "416.8", "366.9", "496", "511.9", "428.32" ]	icd9cm	[ [ [] ] ]	[ "45.13", "45.23" ]	icd9pcs	[ [ [] ] ]	9820, 9906	4123, 7840	330, 355	10096, 10096	2721, 4100	10695, 11455	2321, 2431		8435, 9797		9927, 9927		7866, 8412			10247, 10672									2446, 2702																						274, 292									383, 1733			9977, 10075		9946, 9956			10111, 10223										1755, 2041	2057, 2305
11,861	135,677	22419	Discharge summary	report	Admission Date: [2132-7-28] Discharge Date: [2132-8-3] Date of Birth: [2105-5-5] Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine / Tramadol Attending:[First Name3 (LF) 3853] Chief Complaint: "Abdominal pain, nausea and vomiting." Major Surgical or Invasive Procedure: none History of Present Illness: 27 yo hx of IDDM and recent admission for UGI bleed and gastroparesis presents with back pain, abdominal pain, increasing n/v x1 day. She was in her usual state of health until this AM, when she had an increase in low back pain (LBP is chronic from [2124] MVC). She describes the pain as sharp, [7-9] in lower lumbar region, no radiation. She took her usual meds, including her insulin, but says she was not eating much due to the pain. Started having diffuse abdominal pain and vomiting around 5 pm, emesis was bilious and non-bloody with no coffee grounds. Estimates that she vomited x3 at home. States she was walking down the street and the back pain got so bad she could no walk anymore, so she called EMS. In the ambulance, her fingerstick was found to be >500. . She says she has had been taking her insulin as prescribed, eating the same or less than normal. Sugars have recently been in the 200s at home. Cannot identify any precipitating factors leading up to today's [Month/Year (2) ]. Says she is "always chilled" but otherwise denies any recent fevers, abdominal pain (prior to today), diarrhea, dysuria (though notes increased frequency), cough, shortness of breath, or upper respiratory [Month/Year (2) ]. . Initial vitals in the ED were 98.8 128 148/101 18 100% RA Exam was unremarkable. Vomited multiple times in the ED, looked bilious. Labs were remarkable for Chem panel showing glucose of 686, Cr 1.4, HCO3 19 (anion gap 20), K >10.0 but grossly hemolyzed w repeat 4.5, phos 6.3. CBC remarkable for hct 32.3 (comparable to previous). UA with >1000 glucose, 80 ketones. Urine cx pending. She was given 3L NS, 4 mg IV zofran, 1 mg diluadid x2. Started on an insulin drip @ 7U/hr with no bolus. Vitals on transfer were 98.0 118 138/96 18 100%RA . On arrival to the MICU, the patient is actively vomiting bilious, non-bloody emesis. Complaining of severe low back pain, appears uncomfortable. . Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Diabetes mellitus type I: diagnosed age 16 in [2120] after her first pregnancy. - Severe anxiety/panic attacks - Previous admissions for nausea/vomiting with h/o esophagitis and with concern for diabetic gastroparesis on metoclopramide - Esophagitis / H. Pylori [6-/2128] and again [8-/2130] - Stage I diabetic nephropathy - Grade I esophageal varices seen on scope in [2132-1-1], negative liver ultrasound, normal LFTs, hep panel negative - Anxiety/panic attacks - Depression - Hyperlipidemia - S/P MVA [5-3] - lower back pain since then. - S/P MVA [2130], ex-lap - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [2122], not menstruating secondary to being on Depo-Provera - Genital Herpes - H pylori, s/p 2-week triple therapy on [2132-1-24] Social History: Lives with her 9 yo son. On disability. - Tobacco: quit "years ago" - Alcohol: [12-2] glasses wine or champagne at holidays/special occasions (none recently) - Illicits: none, denies IVDU Family History: Grandmother with diabetes, no other significant family history Physical Exam: On admission: Vitals: T: 97.5 BP: 155/100 P: 125 R: 24 O2 sat: 96% General: Alert, oriented, actively vomiting and in moderate distress secondary to back pain [Month/Day (2) 4459]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: hypoactive BS, soft, mildly tender diffusely, non-distended, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No skin tenting. . On discharge, pertinent exam findings include: Neck: R neck puncture site where IJ line was removed (no bleeding, dressing clean/dry/intact) Resp: CTAB, good air movement bilaterally; R axilla puncture site where pigtail catheter was removed (no bleeding, dressing clean/dry/intact) Abd: soft, NT, ND Pertinent Results: [2132-7-28] URINE: CREAT-25 SODIUM-59 POTASSIUM-16 CHLORIDE-17 UCG-NEGATIVE OSMOLAL-635 COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.023 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG LABS ON ADMISSION: [2132-7-28] BLOOD: GLUCOSE-686* UREA N-39* CREAT-1.4* SODIUM-130* POTASSIUM- GREATER TH CHLORIDE-91* TOTAL CO2-19* ALT(SGPT)-24 AST(SGOT)-83* ALK PHOS-60 TOT BILI-0.5 LIPASE-34 CALCIUM-10.0 PHOSPHATE-6.3# MAGNESIUM-2.3 WBC-10.5# RBC-3.70 HGB-10.6* HCT-32.3* MCV-87 MCH-28.7 MCHC-32.9 RDW-13.0 NEUTS-88* BANDS-0 LYMPHS-10* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY- OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL BURR-OCCASIONAL PLT SMR-NORMAL PLT COUNT-201 [2132-7-30] BLOOD TSH-1.0 MICRO: [8-2] Legionella Urinary Antigen negative [7-30] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST NEGATIVE [7-29] BLOOD HELICOBACTER PYLORI ANTIBODY TEST POSITIVE [7-28] MRSA SCREEN-FINAL NEGATIVE LABS PRIOR TO DISCHARGE: [2132-8-3] BLOOD: WBC-7.6 RBC-2.93* Hgb-8.7* Hct-25.1* MCV-86 MCH-29.6 MCHC-34.4 RDW-13.4 Plt Ct-185 Plt Ct-185 Glucose-250* UreaN-11 Creat-1.1 Na-136 K-3.4 Cl-100 HCO3-30 AnGap-9 Calcium-8.4 Phos-3.0 Mg-1.7 [2132-7-29] CXR: Interval re-positioning of right IJ line with tip in low SVC. [2132-8-2] CXR: There is a new large right pneumothorax surrounding the right lung with some mediastinal shift to the left. The right IJ line is again visualized. There is no infiltrate or effusion. [2043-8-3] CXR: New right-sided pigtail catheter with reexpansion of the right lung. [2043-8-3] CXR: No pneumothorax. Pigtail catheter no longer within the thoracic cavity. Brief Hospital Course: ASSESSMENT AND PLAN: 27 yo hx of IDDM and recent admission for UGI bleed and gastroparesis presents with increased back pain, abdominal pain, n/v x1 day, found to be hyperglycemic with diabetic ketoacidosis. . ACTIVE ISSUES: . # Diabetic ketoacidosis: History and labs consistent with DKA. Glucose >500 in ambulance and 686 in the ED, ketones in urine, chem panel showed anion gap metabolic acidosis. There was no clear precipitating factor. When she arrived to the unit there was a delay in treatment because she lost both peripheral IVs. We could not get new peripheral access and so a Right IJ line had to be placed. Of note, on her last admission, she also needed a central line placed. She was initially treated with an insulin pump that was titrated according to ICU protocol. She was also given normal saline and her anion gap closed appropriately. When she appeared euvolemic, she was switched over to D5,1/2NS, and when her gap closed she was started on sub Q insulin. She was initially started on her home dose lantus of 20 units in the am and then the regiment was transitioned to a pm dose, which is when she takes it at home. Her FSG became stable. [Last Name (un) ] was consulted and followed throughout the hospital admission. Pt was scheduled with f/u at [Last Name (un) ]. . # Pneumothorax: [Hospital ] hospital course was c/b large right-sided pneumothorax. Approximately 1 day after transfer from ICU to floor, patient developed tachycardia to the 140s. Since patient was N/V and not tolerating POs, dehydration was suspected and pt was given IV boluses. Tachycardia did not resolve. A CXR revealed a large right sided pneumothorax. Thoracics was consulted, who placed a pigtail catheter. Subsequent CXRs showed resolution of the pneumothorax. Pt with no known risk factors for pneumothorax; pneumothorax thought to be secondary to R IJ central line placement. However, developed several days after R IJ was placed. . # Abdominal pain: Secondary to DKA vs. hyperglycemic exacerbation of gastroparesis. Abdominal exam was benign, but effort was made to rule out intraabdominal process. We intially held her reglan and then restarted it later on. We also sent off a stool PCR for H. pylori since it was unclear whether she had been treated appropriately in the past as well as C.diff. C. diff studies were neg. Unsurprisingly, the H.pylori antibody was postitive, as pt has had H. pylori in past but the PCR was rejected and not run. As abdominal pain was decreasing, this was deferred for further w/u to the outpatient setting. Patient was scheduled with GI follow-up. . # Nausea and vomiting: Continued her Reglan and zofran. Her last gastric emptying study showed she was on upper limits of normal. She had continued voiting at the time of transfer to the floor despites attempting to optimize her medications. There was some concern that she was forcing emesis when physicians were around because she seemed to tolerate food well and not vomit when no one was paying attention and then start vomiting when people entered the room. . # Depresssion: Psych and SW was consulted during admission, and did not feel patient was a danger to herself. They saw no role for inpatient psych admission, but suggested patient attend a day program at [Hospital 1680] Hospital and an intake interview was scheduled. Psych also recommended close psych f/u and pt start a SSRI. Pt was started on Celexa 20 mg QD, which she tolerated well. . # Acute kidney injury: Cr increased to 1.4 on admission from baseline of 0.8-1.0, likely secondary to dehydration from DKA. She had good urine output and her creatinine improved with fluid rescusitation. . # Hyponatremia: Na 130 on admission, corrects to 136 when accounting for hyperglycemia. As she was fluid rescusitated with normal saline, she became hypernatremic. Her free water deficit was calculated and she was treated appropriately with IVF. Her sodium returned to within normal range. . # Back pain: Exacerbation of chronic back pain [1-2] MVC in [2124], no new trauma. She was treated with dilaudid IV 1mg Q4H:PRN and tylenol 1gm IV Q8H. Her home regiment of gabapentin and amytriptyline was continued. She was transitioned to a PO regiment once she was able to tolerate PO. Her pain had improved at the time of transfer to the floor and plan was to wean off her dilaudid prior to discharge. Psych was consulted during the admssion and recommended d/c pt's amytriptyline. Patient was not discharged on amytriptyline. . #Anemia: Pt was admitted with Hct of 32.2 and d/c with Hct of 25.1. No signs or [Year (4 digits) ] of active bleeding. Pt started on iron supplementation and advised to follow-up as an outpatient for anemia w/u. . # TRANSITIONAL ISSUES: -On discharge, pt's hemoglobin was 8.7 g/dL; please follow up on her anemia as an outpatient. Medications on Admission: amitriptyline 10 mg hs gabapentin 300mg TID lisinopril 10 mg qday (HOLD) lantus 20 units hs (HOLD) humulog sliding scale - 1 unit for every 40 mg/dl over 140 (HOLD) metoclopramide 10 mg with meals (HOLD) zofran 4 mg q8h PRN nausea ativan - unknown dose, prescibed by outpatient psychiatrist Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical PRN (as needed) as needed for Itching. 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for lower back pain: 12 hours on, 12 hours off as needed for lower back pain. 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Lantus 100 unit/mL Solution Sig: 20 U Subcutaneous at bedtime. 7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS. 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Nizhoni Health System Discharge Diagnosis: Primary diagnosis: Diabetic ketoacidosis Secondary diagnoses: Pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], You were admitted to [Hospital1 69] after calling emergency medical services for increased back pain, abdominal pain and nausea and vomiting. You were found to have very high blood glucose levels and diabetic ketoacidosis, and admitted to the intensive care unit for further management to get your blood sugar decreased to a safe level. You saw a diabetes specialist to help manage your diabetes. You were also given medications for your back pain. Your abdominal pain resolved with time. Nausea and vomiting was a recurrent problem for you during this hospital admission, and you received medications to help with these [Hospital1 ]. When you were able to eat again, you were discharged. You have been referred to a gastrointestinal specialist for further work-up of the causes underlying your abdominal pain, nausea and vomiting. You also saw a social worker and psychiatrist, who started you on a new medication for your depression. She also recommended a partial psychiatric program and close psychiatric care for better management of your [Hospital1 ] depression and anxiety. On [2132-8-2], a chest x-ray showed that you had a right-sided pneumothorax, which means that air had collected between your right lung and the chest wall. The thoracic surgery team put a tube (called a pigtail catheter) in your chest to drain the air. Repeat chest x-rays showed that the pneumothorax had resolved. On [2132-8-3], the pigtail catheter was removed. A chest x-ray done after removal of the tube looked stable. MEDICATION CHANGES: START Citalopram 20 mg PO QD-- you were started on this medication to help with the treatment of your depression. STOP Amitriptyline 10 mg once nightly-- you should STOP taking this medication. START ferrous sulfate (iron pill) 325 mg once per day. The iron pills may make your stools appear darker than usual. START ascorbic acid (vitamin C) 100 mg once per day. Take the iron and vitamin C pills at the same time. For pain, you may take over-the-counter tylenol as needed (do not exceed 4 grams per day). You may also take the prescribed vicodin as needed for pain, but try to avoid taking the vicodin if you can. Your follow-up appointments are listed below. It is important to attend all these appointments in order to feel your best. It was a pleasure taking care of you. Please continue taking your other home medications without any changes. Please don't hesistate to contact the hospital or your primary doctor with any concerning [Date Range ]. Followup Instructions: Please make sure you go to the following outpatient appointments that we have scheduled for you: Please call Thoracic Surgery clinic ([Telephone/Fax (1) 3020]) for an appointment in 1 week with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. You will need to have a chest x-ray done prior to this appointment; please ask the thoracic surgery clinic about how/when to get the x-ray when you call for the appointment. Please call your PCP to schedule [Name Initial (PRE) ] follow-up appointment by [Last Name (LF) 2974], [2132-8-8]. You will need to have your blood drawn next Wednesday or Thursday to check your blood counts prior to this appointment. You should go to your PCP's office to have the blood drawn. Intake appointment at [Hospital1 1680] [Location (un) ] Partial Hospital Program on Wednesday [8-6] at 9:15am. Location: [Street Address(2) 4195], [Location (un) ] MA. ([Telephone/Fax (1) 58275]. Department: SPINE CENTER When: THURSDAY [2132-8-7] at 10:00 AM With: [Name6 (MD) 1089] [Name8 (MD) 1090], MD [Telephone/Fax (1) 3736] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: [Hospital3 ] [2132-8-12] at 1:45 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: [Hospital Ward Name ] [2132-8-15] at 10:00 AM With: [Initials (NamePattern4) ] [Last Name (NamePattern4) 11716] [Name8 (MD) 11717], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Name: [Last Name (LF) 20556], [First Name7 (NamePattern1) 553] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Apartment Address(1) 20557], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2490] When: [Telephone/Fax (1) 3816], [8-19], 2PM Completed by:[2132-8-6]	[ "276.0", "536.3", "250.13", "V58.67", "250.43", "530.7", "288.60", "V15.41", "583.81", "285.9", "456.1", "584.9", "276.1", "E879.8", "041.86", "296.22", "724.5", "512.1", "272.4", "250.63", "300.01", "338.29", "789.00" ]	icd9cm	[ [ [] ] ]	[ "38.97", "34.04" ]	icd9pcs	[ [ [] ] ]	13257, 13309	7238, 7448	337, 344	13429, 13429	4837, 5164	16153, 18555	3808, 3873		12438, 13234		13330, 13330		12122, 12415			13580, 15146									3888, 3888	13393, 13408																	2331, 2759	15166, 16130			258, 299		7463, 11978							372, 2312					13349, 13372		5178, 7215	13444, 13556					12001, 12096					2781, 3581	3597, 3792
27,721	122,827	47639	Discharge summary	report	Admission Date: [2135-12-2] Discharge Date: [2135-12-12] Date of Birth: [2100-9-15] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 3127] Chief Complaint: The patient was admitted from an outside hospital on [12-2] with nausea, vomiting and epigastric pain. Major Surgical or Invasive Procedure: None History of Present Illness: The patient presented to an outside hospital with a one day history of nausea, vomiting and epigastric pain. At the outside hospital, a CT abdomen showed a large hepatic mass in the right lobe of the liver with evidence of acute on chronic hemorrhage. She was transfused 2 units of PRBCs and transferred to [Hospital1 18]. Past Medical History: Diabetes type I Hypertension Social History: Engaged to be married, no children Occassional EtOH, no tobacco Oral contraceptive pill Family History: No history of liver disease Physical Exam: Vital signs Temp 100.0 HR 114 BP 116/75 Resp Rate 18 Sat 97% RA Neuro- the patient is in no acute distress, alert and oriented x 3 Cardiology- regular rythmn, tachycardic Pulmonary- clear to ausculation bilaterally Abdomen- soft, tender to palpation RUQ, non distended, bowel sounds present Extremities- no edema Pertinent Results: [2135-12-12] 05:40AM BLOOD WBC-13.2* RBC-3.35* Hgb-10.2* Hct-31.5* MCV-94 MCH-30.3 MCHC-32.3 RDW-14.0 Plt Ct-519* [2135-12-8] 05:05AM BLOOD ALT-391* AST-76* AlkPhos-198* Amylase-39 TotBili-2.0* [2135-12-2] 08:07PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2135-12-2] 08:07PM BLOOD HCV Ab-NEGATIVE CHEST (PA & LAT) [2135-12-8] 8:15 AM FINDINGS: No previous images. The patient has taken a poor inspiration. There is extensive opacification consistent with a large right pleural effusion and underlying atelectasis or possibly even pneumonia. Less marked changes are seen at the left base. The upper lungs are essentially clear. CT ABD W&W/O C [2135-12-5] 9:08 AM COMPARISON: Outside hospital multiphasic CT dated [2135-12-2]. TECHNIQUE: Axial MDCT images were obtained through the abdomen prior to and following the intravenous administration of 150 ml of Optiray, in multiple phases. Coronal and sagittal reformations are provided. CONTRAST: Intravenous nonionic contrast was administered due to the rapid rate of bolus injection required for this examination. Oral contrast is present in the colon from a previous administration. CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: Again seen in the right lobe of the liver is a large intraparenchymal hematoma measuring 10.6 x 14.5 cm in greatest transaxial dimension. This contains heterogeneous internal density, but no evidence of active extravasation of contrast on multiple phases. A large subcapsular hematoma which tracks along with dome and right lateral aspect of the liver is approximately unchanged in size (14.4 x 7.1 x 8.1 cm). Heterogeneous, enhancing parenchyma is seen about the right lateral aspect of the intraparenchymal hematoma, and shows prompt arterial phase enhancement to the degree that is greater than the normal hepatic parenchyma, and persistent delayed phase enhancement similar in degree to the hepatic parenchyma. No other definite hepatic lesions are identified; several hypodense foci tracking in a curvilinear pattern through the right lobe, likely represents intraparenchymal tracking of hemorrhage, although the pattern is unusual and might relate to mass effect from the intraparenchymal hemorrhage. There is an accessory left hepatic artery arising separately from the left gastric artery, and additional right and left hepatic arteries arising in a conventional fashion from the common hepatic artery. Portal veins and hepatic veins are patent. There is no evidence of tumor thrombus in the portal veins. In the left upper quadrant, a 2.1 cm heterogeneously dense structure (3A:33) shows connection to the gastric fundus (image 29), consistent with a gastric diverticulum. The spleen, adrenal glands and kidneys appear unremarkable. There are no pathologically enlarged mesenteric or retroperitoneal lymph nodes. The pancreas appears within normal limits, and there is no dilation of the pancreatic duct. Since the examination of [12-2], the amount of blood tracking throughout the abdomen has increased slightly, although there is no evidence of extravasation of contrast or new clot to suggest a site of active bleeding. Large bilateral low-density pleural effusions have increased since the previous examination, along with corresponding atelectasis of the lower lobes. The imaged portions of the heart and pericardium appear unremarkable. BONE WINDOWS: Bone windows show no evidence of suspicious lytic or sclerotic osseous lesions. MULTIPLANAR REFORMATS: Coronal and sagittal reformations are helpful in delineating the above described findings. IMPRESSION: 1. Intraparenchymal and subcapsular hepatic hematoma arising from a heterogeneously enhancing right lobe mass, without evidence of active extravasation and no significant change in size since [2135-12-2]. 2. Mild increase in intraperitoneal hemorrhage within the abdomen, a finding which could reflect previous bleeding or redistribution of hemorrhage from the previous examination. 3. Heterogeneously enhancing parenchyma about the periphery of the hemorrhage suggests underlying mass. Adenoma is considered most likely given demographics, although if patient has risk factors for liver disease, hepatoma would be considered. 4. Large bilateral pleural effusions and bilateral lower lobe atelectasis. Findings are not suggestive of hemothorax. 5. Gastric diverticulum. Brief Hospital Course: The patient was admitted to the ICU on [2135-12-2] from an outside hospital and her hematocrit was measured every four hours. In the ICU, the patient received fluids and had serial abdominal exams to assess for any acute change. On [2135-12-4] the patient's diet was advanced from clears to as tolerated. [2135-12-5] two units of PRBCs were transfused for a decreasing hematocrit. CT abdomen showed no active extravasation and no significant change in size of hematoma since [12-2]. The patient was closely monitored in the ICU and remained afebrile and stable and was transferred to the floor on [2135-12-8]. Chest x-ray on [12-8] showed a right lower lobe consolidation and was started on a 14 day course of levofloxacin. [12-9] A cardiology consult for tachycardia was obtained and they assumed the tachycardia was due to an acute illness (anemia, fever) with some stress response. The patient continued to do well without need for further blood transfusion. She is to be discharged home [12-12]. Medications on Admission: Insulin pump ASA 81 Lisinopril 20 mg qd Folate 1mg qd OCP - Necon Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:20 Tablet(s) Refills:0 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for 7 days. Disp:20 Tablet(s) Refills:0 6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release 12 hr(s) Refills:0 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 9 days. Disp:9 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hepatoma Discharge Condition: Good Discharge Instructions: Please return to the nearest emergency department if you should have a fever greater than 101.5, excessive nausea, vomiting, diarrhea, increased pain, lightheadedness, dizziness, palpitations, shortness of breath, varying blood sugars or should there be any other worrying symptoms. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in two weeks with a CT scan of the abdomen. Please call [Telephone/Fax (1) 100644] to make an appointment and arrange the CT abdomen Please follow up with your PCP within one week regarding tachycardia.	[ "486", "250.01", "568.81", "511.9", "537.1", "V45.85", "518.0", "285.1", "532.90", "401.9", "V58.66", "V58.69", "573.9" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	7838, 7844	5716, 6756	388, 395	7897, 7904	1304, 5693	8235, 8499	925, 954		6872, 7815		7865, 7876		6782, 6849			7928, 8212									969, 1285																						242, 350									423, 752																		774, 804	820, 909
17,808	186,937	43709+58651	Discharge summary	report+addendum	Admission Date: [2124-7-11] Discharge Date: [2124-7-13] Date of Birth: [2076-4-3] Sex: M Service: [Hospital1 ] CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: This is a 48-year-old Caucasian male with history of hypertension, hypoglycemia, end stage renal disease requiring hemodialysis for the past three years with failed cadaveric renal transplant who was found on [2124-7-11] passed out in his car by police. At that time he was noted to be extremely somnolent and when awakened by the police, he took sugar pills on the scene. Prior to that he had not been to hemodialysis in at least 5 days. The patient was brought to the Emergency Room by [University/College 5130] Police where he was originally in the psych area and was declining blood draws. Blood work revealed a potassium of 7.8, BUN 101 and creatinine of 14.6. He was seen emergently by renal consult and was rapidly prepared for hemodialysis. In the Emergency Room he was given two amps of D50, one amp of calcium, 5-10 units of insulin, 1 mg Ativan and Kayexalate for hyperkalemia. EKG was notable for wide paced beats with two QRS morphologies. There were T wave inversions present in leads 1, 2, AVL, AVF, V4, V5. ST elevations were present in 2, 3, AVF, V3 through V6. Serum tox screen was negative. Arterial blood gases revealed PH of 7.35, and lactate of 1.101. Telemetry in the ER was notable for a wide fast beats which were thought to be originally ventricular tachycardia. He was started empirically on an Amiodarone drip. At that time he was transferred to the MICU for further stabilization. In the MICU he was emergently dialyzed for hyperkalemia and uremia. Post dialysis potassium was noted to be 8.1 and thought secondary to the effects of D50 insulin and bicarb. On [2124-7-12] he was dialyzed once again with potassium of 4.7 the morning of [2124-7-12]. MICU course was notable for hypoglycemia as low as 9. He had known history of hypothyroidism, hypoglycemia and adrenal insufficiency and thought to be in a great amount of stress. At this time he was given stress doses of IV steroids. Hypoglycemia was managed initially with D50, then D10 drip and then D5 with subsequent improvement of hypoglycemia. D50 drip was finally discontinued on [2124-7-12] when he left the MICU. The patient's altered mental status improved during his MICU course. He was seen by neurology who believed that his altered mental status was secondary to metabolic derangement including uremia, hypoglycemia and recent Heroin use. EEG was obtained to rule out non convulsive status. Results from the EEG are still pending. At this time he was transferred to the [Hospital1 ] service for further management. PAST MEDICAL HISTORY: 1) Hypoglycemia. 2) Hypertension, poorly controlled. 3) Status post pacemaker AICD secondary to prolonged QT syndrome. 4) History of Heroin use. 5) Mitral valve endocarditis. 6) End stage renal disease on hemodialysis for the past three years. 7) Patient is status post cadaveric transplant in [2101] which has failed. 8) Hepatitis C. 9) Hypothyroidism. 10) Recurrent C. diff infection. 11) History of pancreatitis. 12) Status post multiple AV fistulograms and balloon angioplasties. Patient has right cubital AV fistula which is still usable. 13) Cholelithiasis. 14) Status post gunshot wound in [2096]. 15) History of small bowel obstruction. ALLERGIES: Ativan, Sulfa, Erythromycin, Neurontin and Tagamet. The patient does not know reactions to these medications. MEDICATIONS: Levoxyl 100 mcg po q d, Minoxidil 2.5 mg po q d, Phos-Lo 2 mg po tid, Labetalol 500 mg po bid, Prednisone 10 mg alternating with 7.5 mg qid, Nephrocaps 1 mg po q d, Norvasc 10 mg po q d. Meds on transfer from the unit include: RenaGel 800 mg po tid, Levoxyl 100 mcg po q d, Nephrocaps one capsule po q d, Kayexalate prn, Clindamycin 300 mg po q 6 hours, Hydrocortisone 50 mg IV q 8 hours and D50 drip. LABORATORY DATA: On transfer, CBC showed white count of 7.9, hematocrit 38.2, platelet count 177,000, Chem 7 showed a sodium of 132, potassium 6.1, chloride 93, CO2 24, BUN 54, creatinine 12.4, blood sugar 205, potassium 6.1, calcium 9.2, phosphorus 8.1, magnesium 1.8. TSH was 1.8. PHYSICAL EXAMINATION: On transfer vital signs, temperature 98.6, pulse 85, blood pressure 120/55, respiratory rate 13. In general, this is a thin African American male lying in bed, in no acute distress. HEENT: Arcus senilis bilaterally, extraocular movements intact, pupils are equal, round, and reactive to light, oropharynx clear, JVD approximately 10 cm. Cardiovascular, regular rate and rhythm, paced, normal S1 and S2, 3/6 systolic murmur in the lower left sternal border, radiating to the right carotid. Lungs, mild right basilar crackles. Abdomen, normoactive bowel sounds, nontender, non distended, old left lower quadrant cadaveric transplant in place. Extremities, clean, dry and intact, no swelling. Neuro, alert and oriented times three. HOSPITAL COURSE: 1. Renal: Repeat potassium the night of transfer was 4.1. Labs the morning of [2124-7-13] showed a potassium of 4.1, BUN 48 and creatinine 10.3. He has undergone two days of hemodialysis and will likely no longer need emergent dialysis. He will need to resume his normal schedule of dialysis when he is discharged. 2. Neurology: Mr. [Known lastname 13469] had altered mental status, likely secondary to uremia, hypoglycemia, recent Heroin use. Patient's mental status seemed to be back to baseline and neurology consult was signed off. 3. Cardiovascular: In the MICU Mr. [Known lastname 13469]' pacemaker and ICD was interrogated by the electrophysiology service. They could not find any indication of prior ventricular tachycardia in the last few days. He was kept on telemetry with no further abnormalities. 4. Endocrine: Mr. [Known lastname 13469] was continued on Levoxyl for his hypothyroidism. He was also restarted on his home dose of steroids 10 mg alternating with 7.5 mg every other day. Fingersticks were continued to be checked q 2 hours for the next four hours after which Mr. [Known lastname 13469] refused further fingersticks. Blood sugar on morning of [2124-7-13] was noted to be 79-91. 5. ID: Mr. [Known lastname 13469] had chest x-ray which showed possible retrocardiac opacity. This suggested possibly aspiration in the setting of altered mental status. He was started on Levaquin and Flagyl for one day and then switched to Clindamycin on [2124-7-12]. Repeat chest x-ray showed no infiltrate or effusions. On [2124-7-13] all antibiotics were discontinued. DISPOSITION: Mr. [Known lastname 13469] will be discharged home. He will follow-up with his primary care physician and renal physician for normal hemodialysis schedule. All home medications will be restarted at this time. DISCHARGE DIAGNOSIS: 1. Uremia secondary to non compliance. 2. Hypoglycemia. 3. Adrenal insufficiency. 4. End stage renal disease on hemodialysis. 5. Heroin use. DISCHARGE MEDICATIONS: Levoxyl 100 mcg po q d, Minoxidil 2.5 mg po q d, Phos-Lo 2 mg po tid, Labetalol 500 mg po bid, Prednisone 10 mg alternating with 7.5 mg q d, Nephrocaps 1 tab po q d, Norvasc 10 mg po q d. DR. [First Name (STitle) ] Dictated By:[Name8 (MD) 8073] MEDQUIST36 D: [2124-7-13] 10:02 T: [2124-7-13] 21:13 JOB#: [Job Number 93942] Name: [Known lastname 14859], [Known firstname ] Unit No: [Numeric Identifier 14860] Admission Date: [2124-7-11] Discharge Date: [2124-7-17] Date of Birth: [2076-4-3] Sex: M Service: [Location (un) ] HISTORY OF THE PRESENT ILLNESS: Mr. [Known lastname ] is a 48-year-old African-American male admitted with altered mental status secondary to opiate use, hypoglycemia, and uremia secondary to noncompliance with hemodialysis. The patient was supposed to be discharged on [2124-7-13]. However, it was discovered that Mr. [Known lastname ] was homeless after his brother kicked him out of the house and he had no place to go. Placement was difficult secondary to the patient loosing his bed secondary to dialysis and returning to shelters late at night. Thus, he was held for possible placement to rehabilitation. The patient has had no other medical issues at this time. PEG on 64/[2124] showed low voltage disorganized and unusually slow background likely secondary to widespread encephalopathy affecting the cortical and subcortical structures. Medications, metabolic disturbances, infection, anoxia, were among the possible causes. There were no prominent focal abnormalities and no focal epileptiform features. Mr. [Known lastname ] will be discharged to rehabilitation or to shelter on [2124-7-17]. Of note: Mr. [Known lastname ] [Last Name (Titles) ] hemodialysis on Friday, [2124-7-14] and again on Monday [2124-7-17]. DR.[First Name (STitle) 904],[First Name3 (LF) 1327] 12-983 Dictated By:[Name8 (MD) 1037] MEDQUIST36 D: [2124-7-17] 11:16 T: [2124-7-17] 11:23 JOB#: [Job Number ]	[ "255.4", "276.7", "305.50", "244.9", "V45.02", "403.91", "780.9" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]									7128, 9278		6957, 7104			5068, 6936																							4315, 5051										162, 186									215, 2772																		2795, 4292
30,298	178,803	47622	Discharge summary	report	Admission Date: [2109-3-5] Discharge Date: [2109-3-15] Date of Birth: [2030-1-22] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Verapamil Attending:[First Name3 (LF) 348] Chief Complaint: C. difficile and ascites Major Surgical or Invasive Procedure: Paracentesis Arterial Line Placement History of Present Illness: Mrs. [Known lastname 100616] is a 79 year old female with a history of hypertension, coronary artery disease, congestive heart failure, COPD and lung cancer who was admitted to [Hospital3 7569] on [2109-2-23] with worsening diarrhea. The patient has been in and out of the hospital for most of the winter with recurrent pneumonia. Her most recent infection was approximately three weeks ago. She was discharged to rehab and ultimately home. Three days after returning home she began to experience diarrhea, up to [3-26] bowel movements per day. She presented to [Hospital3 7569] on [2109-2-23] for her diarrhea. On admission she was found to have a WBC count of 40,000 with a diffusely tender abdomen. She was found to be c. diff positive. She was initially started on IV flagyl for c. diff as well as levofloxacin and prednisone out of concern for a COPD flare. Her antibiotics were switched to PO flagyl and PO vancomycin on [2109-2-25] out of concern that she was not improving. On this regimen she reports that the frequency of her diarrhea did decrease to [11-21] bowel movements per day. Her white blood cell count decreased from 42k on admission to 15.7 on [2109-3-5]. There was concern, however, that she was developing abdominal distention. She underwent an abdominal CT scan on [2109-3-4] which showed significant ascites throughout the abdomen, mucosal enhancement throughout the colon with probable diffuse wall thickening and thickening of the terminal ileum without evidence of obstruction. Given concern for the ascites, the primary team at [Location (un) ] wanted to pursue paracentesis. Her INR has fluctuated throughout her hospitalization at [Location (un) ] and on [2109-3-4] was 7.0. She received vitamin K 10 mg PO x 1. Her family requested that she be transferred to [Initials (NamePattern4) ] [Last Name (NamePattern4) 86] hospital for further care. On review of systems she denies fevers, chills, chest pain, shortness of breath, palpitations, PND, orthopnea. She does endorse lightheadedness and feeling dehydrated. She endorses right sided abdominal pain, [11-21] bowel movements per day. She continues to pass flatus. Her abdomen has become increasingly distended over the past week. She denies dysuria or hematuria. She endorses chronic leg swelling which she reports has not worsened significantly over the past week. Past Medical History: Hypertension Coronary Artery disease s/p MI and CABG x 2 Tachybrady syndrome s/p pacemaker placement Atrial Fibrillation Diastolic CHF (EF 60%) COPD - previously on home oxygen but not currently Squamous Cell Lung Cancer - s/p ressection in [2098] Small Cell Lung Cancer - s/p chemotherapy and radiation in [2101] as well as cranial XRT. Social History: She lives in [Location 11269] in an [Hospital3 ] facility. She has a 50 pack year smoking history but quit many years ago. She is divorced. She occassionally drinks alcohol. Family History: Mother died at age 54 of heart disease. Her father was an alcoholic. She has one sister who died of cancer of the back. Physical Exam: Vitals: 96.3 BP: 82/58 HR: 117 RR: 18 O2: 98% on 2L General: Elderly female, lying in bed, no acute distress HEENT: PERRL, EOMI, sclera anicteric, MM dry, oropharynx with trace thrush Neck: JVP flat at 30 degrees, no LAD CV: irregularly irregular, s1 + s2, soft SEM at LUSB, no rubs or gallops Resp: bronchial breath sounds at bases, no wheezez, rales GI: distended, + fluid wave, mild tenderness to palpation in RLQ, no rebound tenderness or guarding, +BS GU: foley in place draining clear yellow urine Ext: WWP, 1+ pulses, 3+ pitting edema to thighs Neuro: Alert and oriented x 3, no focal deficits Pertinent Results: Hematology: [2109-3-6] 06:00AM BLOOD WBC-10.8 RBC-4.28 Hgb-12.4 Hct-37.3 MCV-87 MCH-29.0 MCHC-33.3 RDW-15.6* Plt Ct-205 [2109-3-13] 06:05AM BLOOD WBC-8.8 RBC-3.94* Hgb-11.7* Hct-34.6* MCV-88 MCH-29.6 MCHC-33.6 RDW-16.9* Plt Ct-212 [2109-3-6] 06:00AM BLOOD Neuts-94.4* Bands-0 Lymphs-2.9* Monos-2.2 Eos-0.4 Baso-0.1 [2109-3-15] 07:10AM BLOOD PT-32.0 INR-3.3 Chemistries: [2109-3-6] 06:00AM BLOOD Glucose-75 UreaN-26* Creat-1.3* Na-132* K-3.5 Cl-101 HCO3-18* AnGap-17 [2109-3-13] 06:05AM BLOOD Glucose-64* UreaN-17 Creat-1.0 Na-136 K-4.0 Cl-107 HCO3-18* AnGap-15 [2109-3-7] 09:35AM BLOOD ALT-15 AST-26 LD(LDH)-212 CK(CPK)-46 AlkPhos-85 TotBili-0.4 [2109-3-6] 06:00AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8 Other: [2109-3-7] 02:57PM BLOOD calTIBC-127* Ferritn-513* TRF-98* [2109-3-7] 09:35AM BLOOD Cortsol-25.9* Hepatology Workup: [2109-3-7] 02:57PM BLOOD CEA-53* CA125-487* [2109-3-8] 08:45PM BLOOD AFP-9.1* [2109-3-8] 08:45PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE [2109-3-7] 09:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2109-3-7] 09:35AM BLOOD HCV Ab-NEGATIVE [2109-3-7] 02:57PM BLOOD ALPHA-1-ANTITRYPSIN-208H [2109-3-7] 02:57PM BLOOD CERULOPLASMIN-22 Urinalysis: [2109-3-6] 08:07PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2109-3-6] 08:07PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2109-3-6] 08:07PM URINE RBC-[4-30]* WBC-[4-30]* Bacteri-OCC Yeast-MOD Epi-0 [2109-3-6] 08:07PM URINE Hours-RANDOM UreaN-209 Creat-35 Na-34 [2109-3-6] 08:07PM URINE Osmolal-296 Paracentesis: [2109-3-8] 03:32PM ASCITES TotPro-1.8 Albumin-1.3 [2109-3-8] 03:32PM ASCITES WBC-100* RBC-9500* Polys-63* Lymphs-2* Monos-28* Mesothe-3* Macroph-4* EKG: Atrial fibrillation Premature ventricular contractions or aberrant ventricular conduction Extensive ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rhythm Low lead voltage Imaging: CHEST (PORTABLE AP) [2109-3-5] 9:05 PM The patient has had median sternotomy and coronary bypass grafting. Transvenous right atrial and right ventricular pacer wires extend continuously from the left axillary pacemaker, terminating alongside remnant leads originating in the right axilla. No pneumothorax present. Pleural effusion, if any, is minimal. Lungs grossly clear. Heart size top normal. PORTABLE ABDOMEN [2109-3-5] 9:05 PM There is apparent centralization of the bowel loops suggesting the presence of ascites. No evidence of free intraperitoneal air is visualized. No concerning bowel gas pattern is noted. The small bowel and large bowel loops are unremarkable. The visualized portion of the lung bases demonstrates small bilateral effusion. Mild degenerative changes of the lumbar spine is noted. Severe degenerative changes of both hip joints are also identified. Echocardiogram [2109-3-6]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal infero-lateral hypokinesis. There is no ventricular septal defect. The right ventricular cavity is dilated The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal 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. ABDOMEN U.S. (COMPLETE STUDY) PORT [2109-3-7] 9:18 AM The liver is markedly heterogeneous in echotexture with nodular contour, likely representing cirrhosis or fibrosis. There is no focal liver lesion or intra- or extra-hepatic ductal dilatation. Gallbladder is normal. Common bile duct measures 3.4 mm. There is large amount of ascites in the right upper and bilateral lower quadrants. Spleen is normal in size. Right kidney measures 8.9 cm. Left kidney measures 8.1 cm. There is a hypoechoic nodule in the right upper pole measuring 1 cm, likely representing complex cyst. There is no other solid lesion or stone or hydronephrosis. On Doppler ultrasound study, patency and appropriate waveforms are seen in bilateral and main portal veins, main and left hepatic arteries, and three hepatic veins. ART EXT (REST ONLY) [2109-3-12] 10:28 AM FINDINGS: The ABI on the right is 0.96 and on the left is 0.81. Doppler tracings demonstrate triphasic waveforms diffusely on the right and through to the popliteal level on the left. Volume recordings are in [Location (un) ] with the Doppler tracings. Upper extremity ABI demonstrates 1.27 at the wrist level on the right and 1.17 on the left. Arterial tracings demonstrate triphasic waveforms through to the radial levels bilaterally, ulnar waveforms are monophasic. Volume recordings are in [Location (un) ] with the Doppler tracings. Microbiology: Blood Cultures [2109-3-7]: negative Peritoneal Fluid Culture [2109-3-8]: Gram stain with 2+ polymorphonuclear cells, no microrganisms. Aerobic culture negative. Anaerobic culture no growth to date. Peritoneal Cytology [2109-2-25]: Negative for malignant cells. Brief Hospital Course: Mrs. [Known lastname 100616] is a 79 year old female with a history of hypertension, coronary artery disease, congestive heart failure, COPD and lung cancer who was admitted to [Hospital3 7569] on [2109-2-23] with worsening diarrhea. Triggered this morning for hypotension. Clostridium Difficile: The patient presented with clostridium difficle colitis which was refractory to initial management with PO flagyl and PO vancomycin. On admission she was also taking levofloxacin for presumed COPD exacerbation. The levofloxacin was discontinued on admission to this hospital and she was placed on PO vancomycin alone. When she was transferred to the ICU she was also started on IV flagyl. On this regimen she showed significant clinical improvement with resolution of her leukocytosis and her diarrhea. Prior to discharge the IV flagyl was discontinued. She will complete a ten day course of antibiotics from the date of discontinuation of levofloxacin. Peripheral Vascular Disease: During this admission the patient was noted to have cool, cyanotic upper and lower extremities. She was seen by the vascular surgery consult service and underwent non-invasive vascular studies which showed mild-to-moderate left-sided tibial disease and small vessel disease in both hands. Given her lack of symptoms, no interventions are planned. She can follow up with vascular surgery if she were to develop pain or claudication. Hypotension: During this admission the patient's blood pressures were consistently in the 80s to 90s systolic. While in the medical intensive care unit she had an arterial line placed which recorded arterial blood pressures which were [9-9] mm Hg higher than cuff pressures recorded. Given her peripheral vascular disease her systolic blood pressures were maintained in the 90s systolic to ensure adequte perfusion. Atrial Fibrillation/Tachy-brady syndrome: The patient is s/p pacemaker placement for tachy-brady syndrome. On admission she was taking digoxin alone with suboptimal rate control. She was started on low dose metoprolol with improvement in her rate control and no change in her systolic blood pressures. She was continued on her coumadin with fluctuating INRs. On discharge she was taking 3 mg daily. She will need to have her INR monitored closely at rehab with her coumadin adjusted to acheive a target INR between [12-23]. Acute on Chronic Diastolic Heart Failure: During this admission she had an echocardiogram which demonstrated a preserved ejection fraction. Clinically she showed evidence of total body volume overload with peripheral edema but also appeared intravascularly dry. On [2109-3-6] she developed acute respiratory distress and hypoxia. This was attributed to her chronic lung disease as well as acute pulmonary edema. She was treated with intravenous lasix with rapid improvement but required a short stay in the medical intensive care unit. Given her ascites her diuretic regimen was changed to include lasix and spironolactone. Given her hypotension her diuretics were kept at low doses. On discharge she continued to have significant lower extremity edema and ascites but her respiratory status was stable. COPD: The patient has a history of COPD and has required low dose home oxygen in the past. Patient is not on home oxygen but has been in the past. On presentation she was being treated for a COPD exacerbation with levofloxacin and prednisone. On admission her CXR and lung exams were clear. Her levofloxacin and prednisone were discontinued. As above, she did have a significant episode of respiratory distress during this hospitalization which required transfer to the ICU. It was thought that her respiratory distress was most likely secondary to pulmonary edema in the setting of borderline respiratory function at baseline. She was continued on her home doses of advair and spiriva. She also received albuterol nebulizers on a PRN basis. Osteoporosis: No active inpatient issues. Her alendronate was held in the setting of her acute illness but was restarted at the time of discharge. Anxiety: No active inpatient issues. She was continued on lorazepam 0.5 mg daily. Restless Legs: No active issues. She was continued on ropinirole. Diet: During this admission there was concern that the patient might be aspirating while eating given her recurrent episodes of pneumonia this year. She was noted in the medical intensive care unit to have significant coughing while eating. Serial CXRs showed no evidence of infiltrates. She was evaluated by our speech and swallow team who recommended ground solids while the patient was unable to wear her dentures and chew appropriately. By discharge they did not think that she exhibited signs of aspiration with thin liquids. Her diet can be advanced from ground solids to regular consistency when she is able to wear her dentures. Vaccinations: The patient recieved pneumovax during this admission. Code: Full Code Communication: Daughter [Telephone/Fax (1) 100617] (h), [Telephone/Fax (1) 100618] (c). [Telephone/Fax (1) 100619] (w) Medications on Admission: Coumadin 4 mg [Hospital1 ] Digoxin 0.125 mg every other day Alendronate 70 mg qweekly Lasix 80 mg daily Klor-con 20 meq daily Lorazepam 0.5 mg daily Pantoprazole 40 mg daily Ropinirole 1 mg PO daily Advair 250/50 daily Tiotropium 1 cap daily Benzonate 100 mg PO daily Multivitamin Discharge Medications: 1. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 7. Multivitamin Capsule Sig: One (1) Capsule PO once 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. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO once a day. 11. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once Daily at 16): Please check patient's INR on Saturday, [3-16]. Please titrate coumadin for target INR between [12-23]. . Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: Clostridium Difficile Atrial Fibrillation Chronic Diastolic Heart Failure COPD Peripheral Vascular Disease Discharge Condition: Stable. Requiring significant assistance with ambulation. Breathing comfortably on room air. Discharge Instructions: You were seen and evaluted for your diarrhea. You were treated for clostridium difficile with antibiotics. You were also evaluate by our liver service for the swelling in your abdomen and our vascular surgery service for your blue toes. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Please take lasix 20 mg daily instead of 40 mg daily 2. Please take spironolactone 50 mg daily 3. Please take Toprol XL 25 mg daily 4. Please take coumadin 2 mg daily instead of 4 mg daily. Her INR should be checked on Saturday, [3-16] and her coumadin adjusted to achieve a target INR between [12-23]. Please keep all your follow up appointments as scheduled. Please seek immediate medical attention if you experience any fevers > 101.5 degrees, chest pain, shortness of breath, worsening abdominal pain or distension, worsening diarrhea or any other concerning symptoms. Please keep all your follow up appointments as schedule. Please seek immediate medical attention if you experience any fevers > 101.5 degrees, chest pain, difficulty breathing, worsening abdominal pain, increased abdominal swelling or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] one week after you are discharged from rehab. The office phone number is [Telephone/Fax (1) 16827]. Provider: [Name10 (NameIs) 1382] [Name11 (NameIs) 1383], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2109-6-24] 9:30	[ "443.9", "V10.11", "428.33", "518.81", "428.0", "496", "427.31", "733.00", "008.45", "789.59", "V45.81", "112.0", "333.94" ]	icd9cm	[ [ [] ] ]	[ "54.91" ]	icd9pcs	[ [ [] ] ]	16520, 16591	9728, 14853	316, 355	16751, 16847	4165, 9705	18100, 18452	3405, 3528		15189, 16497		16612, 16730		14879, 15166			16871, 18077									3543, 4146																						252, 278									383, 2817																		2839, 3187	3203, 3389
9,923	184,192	8251	Discharge summary	report	Admission Date: [2194-12-3] Discharge Date: [2194-12-13] Date of Birth: [2127-12-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: Increased shortness of breath. Major Surgical or Invasive Procedure: Right heart catheterization on [2194-12-4]. History of Present Illness: Patient is a 66 year old woman with a history of CAD (status post MI in [2186] and [2191]), dilated cardiomyopathy, and CHF (EF 20-25% in [2186], 50% in [2191], 35% in setting of moderate to severe MR), who presented for a scheduled ECHO appointment today with two weeks of increasing shortness of breath. Patient had been hospitalized in [2194-10-1] for a CHF exacerbation, but the symptoms, currently, are not nearly as severe. She endorses 8 pillow orthopnea, PND, and decreased ability to sleep over the past several weeks. She denies any chest pain, palpitations, or abdominal pain. She endorses an infrequent cough, productive of green sputum. She denies any recent weight gain or pedal edema. She also denies altering her diet over the holidays, as her daughter prepares her meals and is "careful not to use too much salt." She states that her exercise tolerance has not changed markedly since [Month (only) ]. She can climb one flight of stairs, but only does so once a night. She can go to the supermarket and push a cart through the aisles. Patient is a direct transfer from outpatient clinic and is scheduled to be evaluated for an AICD or mitral valve replacement, after patient diuresed. On review, patient denies any previous sick contacts, hemoptysis, fevers, chills, or rigors. Past Medical History: -- HTN -- CHF, EF 20-25% in [2186], 50% in [2191] -- CAD, s/p MI [2186], [2191] -- CRI, baseline Cr 1.9-2.1 in [2191], 3.0 more recently per PCP's office -- DMII Social History: She has a 30 pack-year history of smoking; she quit in [2186]. She does not consume EtOH. Denies illicit substance use. She lives alone and has five daughters. Family History: No family history of CAD or DM. Physical Exam: T:98.7 BP:148/73 HR:76 RR:22 O2saturation:100% on room air Gen: Pleasant, well appearing. Sitting up in bed. Appears stated age. HEENT: Slight conjunctival pallor. No icterus. Slightly dry mucous membranes. Oropharynx clear. NECK: Supple. JVD appreciated 3cm below ear lobe. No cervical or supraclavicular lymphadenopathy. CV: RRR. Normal S1 and S2. Slight 4/6 systolic murmur in apex and left lower sternal border. No rubs or [Last Name (un) 549] appreciated. LUNGS: Crackles in lower lung fields, bilaterally. Upper lung fields clear to auscultation, bilaterally. No wheezes or rhonci appreciated. ABD: Normal active bowel sounds in all four quadrants. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. EXT: Warm and well perfused. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally. SKIN: No rashes, ulcers, petechiae, or pigmented lesions. No ecchymoses. No xerosis. NEURO: Alert and oriented to person, place, date. Affect appropriate. Pertinent Results: Right cardiac cath ([2194-12-4]): Patient noted to have wedge of 36, RA 15, PA 55, RVED 22, CI 3.25. . EKG([2194-12-3]): Sinus rhythm of 85. Left axis. Left bundle branch noted. Could not appreciate any ST segment elevations. . EF ([2194-12-3]): EF 35%. The left atrium is mildly dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with basal to mid inferior akinesis. Overall left ventricular systolic function is moderately depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue synchronization imaging demonstrates no significant left ventricular dyssynchrony. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe ([1-3]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate left ventricular systolic dysfunction (regional) without significant left ventricular dyssynchrony. Mild aortic stenosis. Moderate mitral regurgitation. . [2194-12-5] Renal U/S: IMPRESSION: 1. No hydronephrosis. 2. Cholelithiasis without evidence of cholecystitis. . [2194-12-9] Vein mapping: IMPRESSION: Patent bilateral subclavian veins and bilateral brachial arteries. Although both cephalic and basilic veins are patent, they are all less than 0.20 cm. . [2194-12-9] ECHO: Conclusions: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal to mid inferior wall. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential (0.6 cm) pericardial effusion. . [2194-12-9] Right heart cath: COMMENTS: 1. Resting hemodynamics revealed mildly elevated mean PCPW of 15mmHg. Cardiac index was normal at 3.8 l/min/m2. . [2194-12-12] Carotid artery u/s: IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. Brief Hospital Course: ASSESSMENT AND PLAN: 66 year old woman with CAD, status post MI in [2186] and [2191], moderate MR, EF 35%, and CHF who was hospitalized in [Month (only) ] [2193] for CHF exacerbation, who presented for a scheduled appointment today and was noted to have increased shortness of breath over the past two weeks. Admitted for fluid management of CHF and potential MVR and/or ICD. . #) CHF: The patient was noted to have an EF of 35% on [2194-12-3], in setting of moderate MR. [Name13 (STitle) ] has had increasing shortness of breath in the past several weeks. She denies any chest pain or palpitations. She denies any noncompliance with her diet as an outpatient and denies any recent weight gain or increased lower extremity swelling. Right heart cath on [2194-12-4] revealted a wedge pressure of 36, RA 15, PA 55, and a CI 3.25. She was aggressively diuresed with lasix despite her acute on chronic renal failure. A repeat right heart cath on [2194-12-9] revealed much improved hemodynamics with a wedge pressure of 15 with a CI of 3.8. She was continued on hydralazine, isosorbide and amlodipine. An ECHO on [2194-12-9] showed 3+MR and mild AS with an LVEF of 30-40%. She was consulted by CT surgery for possible MVR. She had preop labs drawn and carotid U/S which showed bilateral less than 40% stenosis. She will also need a left heart cath prior to surgery. This will be scheduled for next week and she will return the night before for pre-cath hydration. Dr.[Name (NI) 1565] office will contact her when the exact date is established. She may also need a BiV ICD in the future as a preventative measure. . #) CAD: known CAD s/p MI in [2186] and [2191]. She had no active ischemia during this admission. She was continued on aspirin, ezetimibe, plavix, metoprolol and imdur. Her lipid panel showed TG 99, HDL 30, LDL calc 100. . #) rhythm: maintained on telemetry with occassional PVCs. . #) Diabetes TypeII: Continued humalog 50-50 at home doses, but hold glipizide, due to renal insufficiency. Started NPH. . #) Acute on chronic renal failure: Appears that patient's creatinine function 3.0 on last admission and her baseline is about 2-2.5, which is most likely the result of longstanding diabetes and hypertension. Her creatinine peaked at 4.9 but she still continued to make urine. At discharge her Cr was 3.8. A renal consult was obtained and she will likely need dialysis in the near future. A renal u/s was performed which showed no hydronephrosis. Vein mapping was performed and the patient was informed about fistula placement. She preferred to wait and follow this up as an outpatient. SPEP and UPEP were sent and found small monoclonal free lambda spike without a heavy chair; she should follow up in 6 months (likely MGUS, doubtful myeloma kidney). The renal team recommended she be sent out on calcium carbonate at a high dose 650mg TID with meals. . #) Anemia: Appears to be chronically anemic. Hematocrit between 28-31. Most likely due to anemia of chronic disease with iron deficiency and CRI as causes. She was on ferrous sulfate replacement and nephrology started her on epogen as well. She was guiac negative here, but should have an outpatient colonoscopy as she says she has never had one before. . #) Endocrine: She had marked elevated of calcium on admission (11.8). A PTH was sent and was found to be 14. Vitamin D1, 25 was sent and found to be 7. SPEP and UPEP were sent. SPEP found gamma globulin and UPEP showed only albumin. Her calcium quickly returned to [Location 213] limits and it was thought to have been elevated secondary to exogenous replacement she was taking (4 pills a day). . She was continued on her levothyroxine for hypothyroidism. . #) FEN: Will maintain on low salt, cardiac, diabetic diet. . #) Prophylaxis: Will order pneumoboots. Start bowel regimen and PPI. . #)CODE: FULL Medications on Admission: -hydralazine 25 qid -isosorbide SR 30 -toprol 25 [Hospital1 ] -amlodipine 2.5qd -ezetimibe 10 qd -levothyroxine 75mcg qd -clopidogrel 75 qd -ferrous sulfate 325 qd -humalog 50-50 9qam, 10 qhs -glipizide 5 qd -norvasc 5qd -lasix 80 po bid -asa 325 -toprol xl 50 qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 tablet(s) Refills:2 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. HydrALAzine 25 mg Tablet Sig: 1.5 tablets PO every six (6) hours. Disp:180 tabs Refills:2 12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000U Injection QMOWEFR (Monday -Wednesday-Friday). Disp:15 mL(s) Refills:2 13. TUMS Extra Strength Smoothies 750 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO qAC: please take three times a day with meals in the middle of the meal. Disp:90 Tablet, Chewable(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Congestive heart failure- left ventricular systolic dysfunction with EF ~35%, +3-4MR end-stage-renal disease Mitral regurgitation Discharge Condition: good, AFVSS, SaO2 100% on room air Discharge Instructions: Please take all of the medications prescribed for you. We have decreased your lasix dose to 80mg daily and increased your hydralazine dose to 35mg four times per day. You were admitted with congestive heart failure; to treat this you will need to limit your salt intake to 2g daily, limit your fluid intake to 1.5L/day and you should weigh yourself daily. If you gain > 2 lbs or if you have difficulty breathing you should contact your PCP or cardiologist who may want to increase your lasix dose. . You should seek medical attention if you have chest pain, shortness of breath, gain >2lbs, are light-headed or pass out, or for any other concerns. . You were also admitted because of your worsening kidney function. You should follow up in the nephrology clinic as listed below. You should stop taking your glyburide because it is not handled well by the kidneys. You should also adhere to a renal diet which is low in things like potassium and phosphorus which your kidneys are unable to extrete properly. We are also starting you on epogen shots for your anemia which is associated with your kidney disease . You will need to be readmitted to the hospital next week to be prepared for your heart catheterization and your mitral valve repair. Dr. [Last Name (STitle) 2357] will contact you with details about this Followup Instructions: Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2195-1-5] 10:40 . You will be readmitted later next week. if you have questions about this call [Telephone/Fax (1) 29292] Completed by:[2194-12-15]	[ "585.9", "250.40", "244.9", "272.0", "403.91", "268.2", "V58.67", "428.0", "414.01", "583.81", "584.9", "412", "996.64", "790.5", "424.0", "285.29", "425.4" ]	icd9cm	[ [ [] ] ]	[ "00.13", "99.04", "37.21" ]	icd9pcs	[ [ [] ] ]	11954, 11960	6392, 10302	347, 396	12134, 12171	3313, 6369	13546, 13831	2158, 2191		10621, 11931		11981, 12113		10328, 10598			12195, 13523									2206, 3294																						277, 309									424, 1752																		1774, 1959	1975, 2142
2,338	114,726	9337	Discharge summary	report	Admission Date: [2159-10-22] Discharge Date: [2159-10-29] Date of Birth: [2097-9-24] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone Attending:[First Name3 (LF) 2297] Chief Complaint: weakness Major Surgical or Invasive Procedure: intubation CVL placement History of Present Illness: This is a 62 yom with history of CAD s/p CABG x 5 in [2144], UGIB, Chronic Systolic CHF (EF 20%), hx of VT s/p PPM/ICD in [2144], Afib on Coumadin, Hyperlipidemia who presents from home with weakness x 10 days. Patient reports feeling increasing weakness over this time, +dry cough as well. He denies any worsening SOB but does report some worsening orthopnea and PND. He sleeps with two pillows at baseline and this has not increased over this time frame. He denies any worsening DOE or pedal edema. He weighs himself every 2 days and has not noted any increase in weight. Last wednesday he, reports 2 episodes of ICD firing when he was getting out of the bathtub. He denies any syncope, fall, chest pain, N/V or diaphoresis during this event. He denies any recent fevers, chills, SOB, chest pain, N/V, abdominal pain, diarrhea, hematochezia, melena, dysuria or hematuria. Patient reports +anuria over the past week, states he has not urintated in 7 days. He took double his dose of lasix over the weekend given his anuria but did not have any urine output. . Of note, patient has been in the hospital twice over the past two months. He was hospitalized from [8-24] - [8-27] for a CHF exacerbation. He presented to the hospital with SOB and found to have a lactate of 13.7. Sepsis was a concern but not infectious source was found. CXR was done and showed +pulmonary edema, he was diuresed over the course of his hospitalization and his lactate trended down to normal. LFT were also noted to be elevated with peak AST of 2094 and peak ALT 711 with Tbili peak of 5.2 and INR of 4.7. This was thought to be [1-1] congestive hepatopathy. Lorazepam, clonazepam, simvastatin, midodrine, and zolpidem were also discontinued at that time out of concern for causing hepatic damage. He was again hospitalized from [Date range (1) 31933] for ICD firing. On the morning of [9-15] he went into afib with RVR and a CODE BLUE was called, he was intubated and shocked and started on amiodarone. He was extubated successfully and went home on Amiodarone as well as low dose digoxin. . Per the wife, patient visited his podiatrist on friday and a small pocket of fluid was opened which was thought to be non-infectious, however, Cipro 750mg daily was started. Wife also reports decreased UOP over the weekend and +SOB on friday so Lasix was increased from 40mg to 60mg with no increase in UOP noted. . In the ED, initial VS: Temp 96.5, HR 117 afib, BP 86/53, RR 28, 99% 2L NC. He was given Levoflox 750mg IV x 1, Flagyl 500mg IV x 1, Vanco was ordered but not given. He received 1.5L IVF. EP was consulted and interrogated his pacer. He was noted to have afib with RVR on friday, no episodes of Vtach. Past Medical History: Coronary Artery Disease s/p 5 vessel CABG in [2144] Anterior MI [2144] Large UGIB in [2154] thought to be secondary to a combination of gastritis, nsaids, and coumadin (required intubation and tracheostomy secondary to MRSA ventilator associated pneumonia) Chronic systolic heart failure (EF 20% by last echocardiogram) History of VT s/p BiV pacer and ICD placement in [2144] now s/p multiple device changes most recently in [2157]. Left hip arthritis Hyperlipidimia Hypothyroidism Atrial Fibrillation (not on anticoagulation secondary to GI bleeding) Osteomyelolitis on L foot 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: -CABG: Five vessel CABG in [2144] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: [Company 1543] Concerto biventricular ICD placed in [2158-3-30]. He has three leads. The RV lead is a [Company 1543] 6943 implanted [2150-9-18]. The atrial lead is a Guidant 4464 also implanted in [2150-8-30]. His LV lead is a [Company 1543] 4193 implanted in [2153-7-30] and the ICD device was implanted in [2158-3-30]. Social History: Lives at home with his wife, has two sons. Denies any EtOH, tobacco or illicit drug use Family History: father who died of MI at 61 Physical Exam: Vitals - T: BP: HR: RR: 02 sat: GENERAL: NAD, lying in bed comfortably HEENT: NCAT, EOMI, PERRLA CARDIAC: +S1/S2, no M/R/G, irregular rhythm, irregular rate LUNG: mild dry crackles in bilateral bases, no ronchi, no wheezing ABDOMEN: +BS, soft, NT/ND, no hepatosplenomegaly EXT: no C/C/E, +dopplerable bilateral pedal pulses, +venous stasis changes LLL > RLE, +blanching erythma LLE, +2 clean bases ulcers on superior anterior portion of left foot, no exudate/pus noted DERM: no rashes Pertinent Results: [2159-10-22] 07:07AM BLOOD WBC-14.3# RBC-4.33 Hgb-10.4* Hct-37.6* MCV-87# MCH-24.0* MCHC-27.7# RDW-19.3 Plt Ct-320# [2159-10-29] 03:04AM BLOOD WBC-13.1* RBC-4.32* Hgb-10.4* Hct-35.1* MCV-81* MCH-24.1* MCHC-29.6* RDW-20.1* Plt Ct-148* [2159-10-29] 03:04AM BLOOD PT-33.1* PTT-51.3* INR(PT)-3.4* [2159-10-24] 03:30AM BLOOD PT-71.7* PTT-56.1* INR(PT)-8.4* [2159-10-22] 07:07AM BLOOD Glucose-20* UreaN-27* Creat-1.8* Na-131* K-4.7 Cl-92* HCO3-11* AnGap-33* [2159-10-25] 04:03AM BLOOD Glucose-62* UreaN-42* Creat-1.7* Na-128* K-4.6 Cl-93* HCO3-20* AnGap-20 [2159-10-29] 03:04AM BLOOD Glucose-118* UreaN-47* Creat-2.4* Na-128* K-4.8 Cl-97 HCO3-22 AnGap-14 [2159-10-22] 07:07AM BLOOD ALT-170* AST-616* CK(CPK)-103 AlkPhos-177* TotBili-4.8* DirBili-3.3* IndBili-1.5 [2159-10-24] 03:30AM BLOOD ALT-394* AST-1250* LD(LDH)-610* AlkPhos-153* TotBili-4.1* [2159-10-29] 03:04AM BLOOD ALT-349* AST-595* AlkPhos-144* TotBili-15.2* [2159-10-22] 07:07AM BLOOD CK-MB-7 proBNP-5108* [2159-10-22] 07:07AM BLOOD cTropnT-0.08* [2159-10-22] 02:53PM BLOOD CK-MB-NotDone cTropnT-0.04* [2159-10-23] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.06* [2159-10-23] 05:22PM BLOOD CK-MB-NotDone cTropnT-0.06* [2159-10-29] 03:04AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.5 [2159-10-29] 07:39AM BLOOD Vanco-28.0* [2159-10-26] 02:58AM BLOOD Cortsol-29.1* [2159-10-26] 02:58AM BLOOD Digoxin-0.6* [2159-10-29] 03:09AM BLOOD Type-ART pO2-152* pCO2-38 pH-7.38 calTCO2-23 Base XS--1 . Echo: The left atrium is markedly dilated. The right atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF<20%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No valvular vegetations seen (reasonable-quality study). No intracardiac or significant transpulmonary shunting seen. Dilated left ventricle with severe global systolic dysfunction. Dilated right ventricle with moderate global systolic dysfunction. Moderate mitral regurgitation. Severe tricuspid regurgitation. At least moderate pulmonary hypertension. . Liver US: IMPRESSION: 1. Limited study from obscuration of marked gastric distention. Incomplete assessment of the gallbladder. 2. Moderate amount of ascites. 3. Unchanged diffusely echogenic liver, may be from fatty deposition or congestive hepatopathy, however more advanced liver disease such as cirrhosis or fibrosis cannot be excluded. 4. Abnormal periodicity of the hepatopetal portal venous flow, unchanged. Brief Hospital Course: 62 yom with history of CAD s/p CABG x 5 in [2144], UGIB, Chronic Systolic CHF (EF 20%), hx of VT s/p PPM/ICD in [2144], Afib on Coumadin, Hyperlipidemia who presents from home with weakness x 10 days found to have sepsis. See below for discussion of each problem. . # Sepsis: Mr. [Known lastname 31930] presents with lactate of 11.9, Afib with RVR to 140s and leukocytosis of 14.3 all consistent with sepsis. He is also c/o of cough over the past week. Patient has history of MRSA PNA requiring intubation in the past, CXR with ?LLL infiltrate. will treat broadly at this time as there is no clear source. Urinalysis negative. Blood Cx, Urine Cx drawn. Grew GCPs and meropenem was started. He required pressors and was unable to be weaned. Evenutally his family decided on DNR and then to stop escalation of care and he passed away while still requiring pressors. . # Transaminitis: Unclear etiology at this time but may be related to sepsis and mild shock liver as lactate 11.9. CT done and shows no biliary cause. Serum tox negative for acetaminohen, patient denies EtOH use. Patient had similar presentation in [7-/2159] which was thought [1-1] shock liver/hypotension. ?Amiodarone related. Had multiple ultrasounds while admitted without clear cause and was thought to be from shock liver. His bili was 15 prior to his death. . # ARF: Likely related to sepsis, BUN/Cr less than 20, so more likely related to ATN. will treat with IVF and trend. Initially given IVFs given sepsis but then was diuresed. No HD needed as escalation of care was not wanted by the family. . # Afib with RVR: Currently, patient is in Afib with normal rate s/p fluids. Currently not on Coumadin, but INR elevated, likely [1-1] liver dysfunction. We held amiodarone given hepatitis. He had tachycardia and hypotension while febrile. Attempted to control fever with tylenol and cooling blanket but were unable to decrease heart rate in the setting of afib and sepsis. . # ICD firing: per patient, ICD fired x 2. EP consulted in ED and pacer interrogated, no Vtach noted, patient has been in afib with RVR over the weekend. EP followed along and ICD was turned off. . # Chronic CHF: Patient with history of chronic CHF. Had echo showing worsening function during sepsis. He continued to make good urine output through his course until the final day, and was not aggressively diuresed due to his low BPs. We tried to avoid excess IVFs, though. . # Respiratory Failure: was intubated during admission for respiratory failure with possible LLL infiltrate, although LE wound was likely the cause of his sepsis. Unable to be weaned off the ventilator during his admission. . # CAD s/p CABG: No signs of MI at this time, CK flat and Trop 0.[4-6] be related to ARF. Not on BB, ACE-I as outpatient. . # He passed away after his family was informed of his poor prognosis and his worsening liver failure and unchanging hemodynamics despite treatment with pressors and antibiotics. He became tachycardic and more hypotensive while febrile and pressors were not uptritrated and he passed away. Medications on Admission: Midodrine 5mg PO TID Levothyroxine 50mcg PO DAILY Bupropion HCl 50mg PO BID Amiodarone 400 mg PO DAILY Furosemide 40mg PO DAILY Digoxin 125mcg PO EVERY OTHER DAY Simvastatin 40mg PO DAILY Spironolactone 25mg PO BID Citalopram 10 mg PO DAILY Ativan 2mg PO qHS PRN insomnia Ambien 10mg PO qHS PRN insomnia Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: sepsis systolic heart failure Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2160-2-1]	[ "459.81", "276.1", "V45.02", "570", "V58.61", "038.11", "412", "428.0", "286.9", "311", "251.2", "995.92", "244.9", "276.2", "785.51", "414.8", "428.23", "716.95", "427.31", "785.52", "518.81", "272.4", "584.5", "682.7", "287.5", "707.19", "V45.81", "427.1" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	11664, 11673	8179, 11282	296, 322	11746, 11755	4866, 8156	11807, 11840	4317, 4346		11636, 11641		11694, 11725		11308, 11613			11779, 11784									4361, 4847		3744, 4196																				248, 258									350, 3065																		3087, 3724	4212, 4301
18,498	181,661	43315+58608	Discharge summary	report+addendum	Admission Date: [2113-5-7] Discharge Date: [2113-5-26] Service: CT Surgery PRESENT ILLNESS: Mr. [Known lastname 93293] is a 78-year-old male with history of chronic atrial fibrillation, status post MI, who had excellent exercise tolerance despite the long history of mitral valve prolapse with secondary moderate mitral regurgitation on echo [11/2110] in an outside hospital. The patient suddenly developed dyspnea on exertion on [2113-5-7] while walking, coupled with diaphoresis. The patient denied any symptoms of chest pain, fever, nausea, vomiting, abdominal pain or lower extremity edema. When the patient presented to the Emergency Department, it was noted that the patient had atrial fibrillation with rapid ventricular response which required beta blockers to improve the rate control. The patient remained tachycardiac, despite the increased amount of beta blockers administered. At this point, to determine the etiology of DOE, the patient was evaluated with a cardiac echo which showed worsening of mitral regurgitation along with decreased ejection fraction and questionable flail leaflet. Although no fevers were documented, white blood cell count was noted to be 15, after admission, and the patient underwent a transesophageal echo for evaluation for vegetation. Given the current circumstances of a very acute onset of cardiac symptoms, the patient underwent a cardiac catheterization to further define the mitral regurgitation, as well as evaluate for any evidence of coronary artery disease, since surgical intervention would most likely be necessary. Upon obtaining the cardiac catheterization, the patient was defined to have proximal RCA 90% occluded, along with LM 20%, DX2 70% occluded. Mitral regurgitation was severe at 4+ with normal aortic valve. At this time, the patient was transferred to the Coronary Care Unit for initiation of close monitoring in order to improve the hemodynamics for mitral valve replacement and/or CABG by Cardiothoracic Surgery Service. PAST MEDICAL HISTORY: Status post MI [2109], chronic atrial fibrillation with anticoagulation, history of mitral valve prolapse with mild flail seen on echo in the past, and prostate problems (BPH), status post TURP times three, status post CCY. ALLERGIES: Proscar, penicillin. MEDICATIONS: Lisinopril, 10 mg PO q d; metoprolol, 100 mg PO t.i.d.; ranitidine, 150 mg PO b.i.d.; simvastatin, 20 mg PO q d; aspirin, 325 mg PO q d. LABORATORY/DIAGNOSTICS: Patient's labs at the time of discharge, [2113-5-26]: White blood cell 9.5, hematocrit 28.3, platelets 395. Chemistry: Sodium 135, potassium 3.2, chloride 96, bicarbonate 27, BUN 24, creatinine 1.4. PT 16.1, PTT 45.7, INR 1.7. Calcium 8.4, phosphorus 3.8, magnesium 1.7. Patient's potassium was replaced with approximately 80 mEq of potassium prior to discharge. Patient's magnesium was replaced with 4 grams prior to discharge. PHYSICAL EXAMINATION: Vital signs: Temperature 98, blood pressure 136/87, pulse 90 and irregular, history of atrial fibrillation, respirations 16, 95% on room air. HEENT: Sclerae anicteric. Cranial nerves II-XII intact. No evidence of cervical lymphadenopathy. Mucous membranes moist. On the right lateral surface of the tongue, there is an ulceration since the operation, probably caused from prolonged compression by endotracheal tube. Chest: Clear to auscultation bilaterally. Irregular rhythm, rate, no appreciable murmur noted. Sternotomy site was clean. No evidence of erythema, no evidence of drainage, and stability was confirmed with palpation. Abdomen: Positive bowel sounds. No evidence of hepatosplenomegaly. Soft, nondistended, nontender. No inguinal lymphadenopathy noted. Extremities: +1 symmetric edema, packings noted in the left lower graft site, as well as left lower leg. No evidence of erythema noted there, although serosanguinous drainage was obtained. HOSPITAL COURSE: Mr. [Known lastname 93293] is a 78-year-old male with past medical history remarkable for chronic atrial fibrillation and status post MI in [2109], who presents with acute worsening of dyspnea on exertion evaluated by the Medicine Service with transesophageal echo, as well as cardiac catheterization. The patient's cardiac catheterization revealed 90% RCA stenosis with pressure dampening and serial 70% lesions in the second diagonal branch of LAD. Additionally, the patient was noted to have severe mitral regurgitation with systolic function depressed with a calculated ejection fraction of 40% and global hypokinesis. Given these findings, the patient underwent an uncomplicated mitral valve repair with resection of posterior leaflet and [Doctor Last Name 405] 28 mm annuloplasty ring placement. The patient also underwent an uncomplicated CABG times two (SVG to DIAG, SVG to RCA). Postoperatively, the patient was transferred to the CSRU, intubated, on Levophed, vasopressant, propofol for sedation. On postoperative day one, the patient remained A paced - V paced with no evidence of ectopy and continued on SIMV ventilation. The patient's chest tubes remained on wall suction during this time. By postoperative day number two, the patient's pressure continued to improve and the pressors were weaned off. The patient was, also, extubated, oxygenating well, with only minimal supplemental oxygen via nasal cannula. By postoperative day number four, the patient was transferred to the floor in good condition with mild serosanguinous drainage noted in the left lower extremity of the graft sites. The patient was initiated on physical therapy for both rehabilitation screening purpose and for endurance training purpose. With increased drainage noted on the left lower extremity by the following day, the patient was initiated on levofloxacin for presumptive treatment of wound infection secondary to peri-incisional erythema which had worsened over a 24 hour interval. Prior to initiating anticoagulation, patient's pacer wires were discontinued after successfully initiating a dose of metoprolol without any incidence of bradycardia. Since the patient's weight had also substantially increased since admission, the patient's Lasix dosing was also re-titrated higher. By postoperative day number eight, the patient was therapeutic on heparin drip at approximately 800 units per hour with PTT at 45.7 with goal range between 40-60. The patient's INR on the Coumadin regimen had also increased to 1.7 with the expected target to be between 2-2.5. By postoperative day number nine, the patient was cleared by the Physical Therapy Service, as well as the Case Management Service, for a discharge to rehabilitation. The patient's anticoagulation regimen, at this time, was to be changed to Coumadin 3 mg alternating with 4 mg. Because, on the date of discharge, the patient's potassium level was found to be 3.2 after an aggressive diuresis, 80 mEq of potassium was administered orally along with 4 grams of magnesium placement for a magnesium level of 1.7. These electrolyte values are to be rechecked on [2113-5-27] and potassium administration re-titrated to prevent any episode of hypokalemia. Given the dramatic improvement in the patient's clinical status, decision was made to discharge the patient on [2113-5-26] to a rehab facility where patient can get the proper wound care for lower extremity wound dressing, dry packing, to be changed twice daily. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Per rehab facility. DISCHARGE DIAGNOSES: Status post mitral valve repair with resection of posterior leaflet and [Doctor Last Name 405] 28 mm annuloplasty ring, CABG times two (SVG to DIAG, SVG to RCA). Congestive heart failure. Hypokalemia. Re-titration of diuretics for hypovolemia. DISCHARGE MEDICATIONS: Zaroxolyn, 5 mg PO q d; Lasix, 40 mg PO t.i.d.; levofloxacin, 500 mg PO q d times 10 additional days; Coumadin, 4 mg, 3 mg to be alternated. Patient is to be administered 3 mg of Coumadin on [2113-5-26] as the initiating dose of the cycle. Patient should also have a chemistry drawn on [2113-5-26] to check for presence of any hypokalemia or hypomagnesemia secondary to diuresis. Metoprolol, 75 mg PO t.i.d.; aspirin, 325 mg PO q d; Nystatin oral suspension, 5 cc PO q.i.d.; potassium chloride, 40 mEq PO b.i.d. during the administration of Lasix, as well as metolazone (this lowish should be re-titrated for adequate diuresis); simvastatin, 10 mg PO q d; Zantac, 150 mg PO b.i.d.; Colace, 100 mg PO b.i.d.; Tylenol, 650 mg PO q 4 hours p.r.n. pain; dilaudid, 2-4 mg q 4-6 hours p.r.n. pain. FOLLOW-UP PLANS: The patient was instructed to follow up with Dr. [Last Name (STitle) 1537] in four weeks. Patient was also instructed to follow-up with cardiologist, Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], seven to ten days after discharge. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2113-5-26] 09:39 T: [2113-5-26] 10:53 JOB#: [Job Number ] cc:[Last Name (NamePattern4) 15456] Name: [Known lastname 14715], [Known firstname ] Unit No: [Numeric Identifier 14716] Admission Date: [2113-5-7] Discharge Date: [2113-5-26] Date of Birth: [2034-7-21] Sex: M Service: ADDENDUM: Upon careful review of the patient's laboratory values, the patient's creatinine level was determined to be 1.4, elevated from 1.2 the day prior. Because aggressive diuretic regimen had been initiated since the last creatinine check, metolazone was discontinued and Lasix dosage was decreased from 40 mg t.i.d. to 20 mg p.o. b.i.d. Given this finding, the Cardiothoracic Service requested [Hospital3 6278] facility to contact Dr. [First Name (STitle) ], pager number 39-625 on [2113-5-27] with the value of creatinine level on the patient. Additionally, the physician at the [Hospital3 643] facility should retitrate the diuretic accordingly to prevent the patient from developing acute renal insufficiency secondary to diuretics. Please addend the discharge medication and change the Lasix from 40 mg p.o. t.i.d. to 20 mg p.o. b.i.d. and discontinue the metolazone. [First Name11 (Name Pattern1) 63] [Last Name (NamePattern4) 1508], M.D. [MD Number(1) 1509] Dictated By:[First Name (STitle) 14717] MEDQUIST36 D: [2113-5-26] 10:55 T: [2113-5-26] 11:52 JOB#: [Job Number 14718]	[ "396.2", "292.12", "414.01", "998.59", "600.0", "398.91", "412", "427.31", "E878.1" ]	icd9cm	[ [ [] ] ]	[ "88.56", "39.61", "36.12", "37.23", "35.12", "88.53" ]	icd9pcs	[ [ [] ] ]								7541, 7792	7816, 8620					3943, 7447																							2956, 3925				8638, 10615																																	2056, 2933		7472, 7519
2,091	135,391	15932	Discharge summary	report	Admission Date: [2139-2-16] Discharge Date: [2139-2-21] Date of Birth: [2086-7-18] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF THE PRESENT ILLNESS: This is a 52-year-old male transferred with a past medical history of diabetes on insulin since [51]-years-old. The patient presented for an ETT. Denied any recent history of fatigue, chest pain, or shortness of breath. The patient had an ETT for screening purposes which showed an asymptomatic [Street Address(2) 1766] elevation at the aVL and 2.5-3.[Street Address(2) 45681] at the inferolateral leads. PAST MEDICAL HISTORY: 1. Type 1 diabetes. 2. Childhood asthma. PAST SURGICAL HISTORY: None. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Mevacor. 2. Lantus 36 units in the a.m., 10 units in the p.m. 3. Regular insulin 8 units in the a.m., 4 units in the p.m. PHYSICAL EXAMINATION ON ADMISSION: The patient was alert and oriented times three, somewhat anxious. The patient had a regular rate and rhythm. The lungs were clear to auscultation. LABORATORY DATA: White count 9.0, hematocrit 38.7. INR 0.9. Platelets 157,000. The electrolytes were within normal limits. HOSPITAL COURSE: The patient underwent a cardiac catheterization on the night of admission which showed LAD 80% mid, 70% distal, 50% distal diffuse disease with an occluded tiny diagonal, proximal large OM with 70% disease, and RCA with luminal irregularities with focal proximal 60-70% stenosis. The patient underwent a CABG times four with [Known lastname ] to LAD, SVG to the PDA, SVG to the OM, and SVG to the diagonal. The patient tolerated the procedure well. The patient was extubated postoperatively and transferred to the floor on postoperative day number two. The patient continued to do very well. The patient was able to tolerate a regular diet. The patient was ambulating well. The patient was cleared by Physical Therapy as level V on postoperative day number four. The patient was having good p.o. pain control. The patient underwent his postoperative x-ray within 24 hours of discharge which was notable for a pneumothorax, 15% on the right and 5% on the left, confirmed per Radiology. The patient was observed overnight. The patient was completely asymptomatic. A chest x-ray was repeated on postoperative day number five which showed no change in the aforementioned pneumothorax. The patient was felt to be ready for discharge with a follow-up within the next week with his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 10088], and a follow-up in four weeks with Dr. [Last Name (STitle) ], and with his cardiologist in two to three weeks. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg b.i.d. 2. Atorvostatin 20 mg q.d. 3. Colace 100 mg b.i.d. 4. Pantoprazole 30 mg q.d. 5. Percocet one to two tablets q. four hours p.r.n. 6. Tylenol 650 mg q. four hours p.r.n. 7. Enteric coated aspirin 325 mg q.d. 8. Lasix 20 mg b.i.d. times seven days. 9. Potassium chloride 20 mEq b.i.d. times seven days. 10. Insulin sliding scale; Lente 36 units in the a.m., 10 units in the p.m.; regular insulin 8 units in the a.m., 4 units in the p.m. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with VNA. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft times four with left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior descending artery, obtuse marginal, and diagonal. Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2139-2-21] 07:30 T: [2139-2-21] 19:49 JOB#: [Job Number 45682] cc:[Last Name (NamePattern4) 45683]	[ "401.9", "E849.7", "E878.2", "272.0", "250.01", "411.1", "512.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.13", "88.56", "37.22", "88.53", "39.61" ]	icd9pcs	[ [ [] ] ]									2742, 3213		3305, 3687			1243, 2719				783, 933						699, 760																																							948, 1225											631, 675		3238, 3283
51,256	107,101	33487+57850	Discharge summary	report+addendum	Admission Date: [2139-7-6] Discharge Date: [2139-7-15] Date of Birth: [2075-5-2] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8790] Chief Complaint: Hematuria, flank pain Major Surgical or Invasive Procedure: None History of Present Illness: 64yF with history of left renal cell carcinoma presenting with left flank pain and substernal chest pain. She was diagnosed with renal cell carcinoma in [5-/2139] and started on Sutent 5 days ago. After her first dose of Sutent, she noticed hematuria that started after the dose and improved throughout the subsequent day (until her next dose). After 3 doses, she had occasional blood clots and even had difficulty urinating secondary to the clots. She was seen in the ED on [7-3] and was sent home after a negative workup. On the day of admission, she developed abdominal/flank pain that was [11-15] in quality and constant in nature. At the same time, she developed substernal chest pressure, non-radiating, associated with nausea and one episode of vomiting, but no shortness of breath or diaphoresis. As her discharge instructions from the ED indicated that she should come to the ED if she experienced any abnormal symptoms, her family brought her to the ED. . In the ED, she received 1 liter normal saline, 4mg IV morphine x 2, and zofran 4mg x 1, with resolution of her symptoms. She was admitted for pain control and rule out. Past Medical History: PAST ONCOLOGIC HISTORY: - [2138]: Began noticing a "bulge" in her left flank which slowly grew in size and discomfort. - [2139-5-14]: CT abdomen/pelvis showed a very large left renal mass about 16 cm in largest diameter with question of invasion of the left renal vein. The lung bases showed multiple pulmonary nodules, the largest of which was 15 mm in diameter, concerning for pulmonary metastases. - [2139-5-29]: CT chest confirmed multiple pulmonary nodules, the largest of which was 16 x 16 mm in the left lung base. There were also scattered subcentimeter nodules in the remainder of both lungs. . PAST MEDICAL HISTORY: Hypertension [5-14] Successful Aflutter Ablation Atrial Fibrillation Asthma Chronic low back pain Arthritis Hysterectomy Tonsillectomy Anxiety Social History: She is originally from [Country 5881]. She moved here about seven years ago and currently lives with her daughter and son-in-law. She is a former smoker, having quit within the past 2 months. She was previously smoking [4-9] cigarettes per day. She denies any alcohol or illicit drug use. Family History: Her father died of cardiovascular disease. She has five siblings, all of whom are healthy to the best of her knowledge. Her mother is alive at age 64 and essentially healthy. She denies any known malignancies in a first or second-degree relative. Physical Exam: Vitals: T98.9F, BP 182/40, HR 64, RR 20, Sat 94%RA General: Appears older than stated age, no acute distress HEENT: EOMI, PERRL, MMM, OP clear Heart: RRR, normal S1/S2, 1-2/6 systolic murmur at LUSB Lungs: CTA bilaterally Abdomen: Soft, non-distended. Point of maximal tenderness over large palpable mass in LUQ. No rebound/guarding. Ext: Warm, well-perfused, no c/c/e Pertinent Results: [2139-7-6] 02:00PM BLOOD WBC-4.8 RBC-5.54* Hgb-13.8 Hct-42.9 MCV-78* MCH-24.9* MCHC-32.2 RDW-15.7* Plt Ct-156 [2139-7-7] 07:30AM BLOOD WBC-7.1 RBC-5.36 Hgb-13.9 Hct-41.7 MCV-78* MCH-26.0* MCHC-33.4 RDW-15.1 Plt Ct-156 [2139-7-6] 02:00PM BLOOD Neuts-70.5* Lymphs-21.8 Monos-3.9 Eos-3.4 Baso-0.5 [2139-7-7] 07:30AM BLOOD Neuts-73.2* Lymphs-16.7* Monos-6.5 Eos-3.3 Baso-0.2 [2139-7-9] 04:27AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+ [2139-7-6] 02:00PM BLOOD PT-29.2* PTT-31.0 INR(PT)-2.9* [2139-7-7] 07:30AM BLOOD PT-33.7* PTT-31.5 INR(PT)-3.4* [2139-7-6] 02:00PM BLOOD Glucose-100 UreaN-22* Creat-1.0 Na-138 K-4.1 Cl-103 HCO3-23 AnGap-16 [2139-7-7] 07:30AM BLOOD Glucose-98 UreaN-18 Creat-1.2* Na-140 K-3.9 Cl-105 HCO3-27 AnGap-12 [2139-7-6] 02:00PM BLOOD ALT-34 AST-33 LD(LDH)-269* CK(CPK)-70 AlkPhos-68 [2139-7-6] 02:00PM BLOOD Lipase-26 [2139-7-8] 07:50AM BLOOD CK-MB-2 [2139-7-7] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01 [2139-7-6] 02:00PM BLOOD cTropnT-<0.01 [2139-7-7] 07:30AM BLOOD CK(CPK)-51 [2139-7-8] 07:50AM BLOOD CK(CPK)-36 [2139-7-6] 02:00PM BLOOD Calcium-8.7 Phos-4.6* Mg-1.9 [2139-7-10] 05:20AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.3 Mg-2.2 UricAcd-3.8 [2139-7-9] 05:38AM BLOOD Hapto-44 [2139-7-8] 08:12PM BLOOD Lactate-1.0 [2139-7-8] 05:55PM URINE Color-[Location (un) ] Appear-Cloudy Sp [Last Name (un) ]-1.020 [2139-7-8] 05:55PM URINE Blood-LG Nitrite-POS Protein->300 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.5 Leuks-NEG [2139-7-8] 05:55PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [2139-7-6] 03:30PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2139-7-6] 03:30PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2139-7-6] 03:30PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2139-7-8] 5:50 pm URINE Source: Catheter. FINAL REPORT [2139-7-10] URINE CULTURE (Final [2139-7-10]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . BLOOD CULTURES NEGATIVE TO DATE X2 . CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized left lower lobe are two pulmonary metastases, measuring 1.5 cm and 1.9 cm, which are larger compared to [2139-5-29], previously measured 1.1 cm x 1.4 cm respectively. A pulmonary nodule also within the right lower lobe (2:2) measures 1.4 cm, previously measured 1.0 cm. Dependent atelectases are present. There is no pleural effusion. The visualized heart and pericardium are unremarkable, without pericardial effusion. Redemonstrated is a large mass arising from the mid to upper pole of the left kidney, which measures grossly 17 cm x 11 cm x 13 cm, which is not significantly changed from prior study. The mass is heterogeneous in attenuation, with areas of low attenuation, likely reflective of necrosis. Also scattered within the mass are linear and rounded hyperdense foci, which on a chest CT, from [2139-5-29], appears similar, and may reflect areas of calcification. Extensive feeding vessels to the mass are seen. There is invasion and extension into the left renal vein, similar to prior study. Additionally, there is moderate hydronephrosis of the left kidney, which demonstrates delayed excretion of contrast. Within the collecting system are areas of heterogeneous attenuation, which is concerning for tumor invasion. There is gallbladder wall edema, which is minimally distended. There is also mild intrahepatic biliary duct dilatation. The liver, spleen, pancreas, right adrenal gland, and right kidney are unremarkable. The left adrenal gland is not well visualized, and is obscured by the adjacent large mass. The stomach, small and large bowel loops are unremarkable. There is no free air or free fluid. Scattered mesenteric and retroperitoneal lymph nodes are not enlarged by CT size criteria. No retroperitoneal hematoma or hemoperitoneum is seen. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder and rectum are unremarkable. There is no pelvic free fluid or adenopathy. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Large left renal mass, not significantly changed in size compared to prior MRI, with evidence of left renal vein invasion. 2. Moderate left hydronephrosis with likely tumor invasion into the collecting system. 3. Mildly distended gallbladder, with gallbladder wall edema, and mild prominence of the intrahepatic ducts. Correlation with LFTS and right upper quadrant symptoms is suggested. If clinical concern for acute cholecystitis, consider ultrasound for further evaluation. 4. Pulmonary metastasis, slightly increased in size from prior study. . [2139-7-9] ECHO The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. . [2139-7-13] BARIUM SWALLOW IMPRESSION: Moderate esophageal dysmotility, with no evidence of diverticulum, webs or strictures. A barium tablet passes freely through the esophagus without any delay. . [2139-7-14] CXR IMPRESSION: Clear improvement of temporary pulmonary congestion pattern [2139-7-8], consistent with fluid overload and temporary left-sided congestion. Brief Hospital Course: 64yoF with newly diagnosed L renal cell carcinoma, just started on Sutent, who was admitted with hematuria/urinary retention, LUQ abdominal pain, and through admission found to be febrile with AFib and RVR likely due to UTI. . 1. Hematuria: Thought to be either from newly started Sutent (~30% incidence) vs known tumor invasion into collecting system on CT vs worsening of renal cell carcinoma (of note, pt also with tumor invasion into L renal vein). She was having issues with urinary retention at home and on admission, and so had a Foley placed intermittently through admission, which was stopped by discharge as she was seen to urinate without difficulty. . Sutent was held initially but restarted by discharge and she was dischaged on Sutent, and not having any hematuria by discharge. Of note, her Coumadin which was a home med given AFib/Flutter issues, was held through admission and CONTINUES to be held, in the setting of hematuria and potential for bleeding into renal mass. This should be further assessed by PCP. . 2. Admission to MICU for fevers, AFib with RVR, UTI: On day 2, pt was noted to have fevers to 102 with subsequent AFib with RVR. She remained hemodynamically stable and was transferred to MICU for closer monitoring where she was found to have a pansensitive Ecoli UTI and treated broadly at first, then narrowed to IV Zosyn which she completed a full course for. She was called out of MICU in stable condition and had no further unstable events, although she did have occasional RVR which was treated with nodal agents as below. All blood cultures were negative. . 3. AFib with RVR: S/p ablation in the past. Admitted in sinus, however pt noted to have AFib with RVR and short bursts of atrial tachycardia/non sustained supraventricular tachycardias. In the ICU she was continued on her home Verapamil course but was noted to have some pauses which required down titration of her home dosage. After call out from MICU, her nodal [Doctor Last Name 360] required uptitration and by discharge she was sent home on her home dose of 240 mg ER. . IMPORTANTLY though, she was stopped on her home Coumadin dosage due to a supratherapeutic INR which peaked to 5.0 and hematuria. Her CHADS2 score was calculated at 1, but in discussion with her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 11139], he recommended keeping her on Coumadin. The risks/benefits were discussed with the family, and she was kept OFF Coumadin by discharge, given she was still on Sutent. This will need to be followed up. Her INR was normal by discharge, she got PO Vitamin K. . 4. LUQ abd pain: Likely due to very large renal mass, LFT's and lipase were normal. No hemorrhage seen on CT. Pain was controlled with MS Contin, which she was discharged on, with short acting Morphine for breakthrough. . 5. Chest pain: Cardiac enzyme negative x2 and without worrisome EKG changes to suggest cardiac etiology. Also, had clean cath in 10/[2138]. Likely due to LUQ renal mass. . 6. Hypoxia: During her trigger on day 2 for which she went to MICU, she was noted to have hypoxia to the high 80's. She had an echo with a normal EF >55%, mild MR, and mild pulmHTN. She was variably on O2 by NC with good response. She also became slightly volume overloaded by physical exam and CXR showing mild volume overload and small bilateral pleural effusions and so was gently diuresed with good improvement in her O2 sats to 95-96% RA and also clearing of her CXR. By discharge she was satting well on RA at rest and ambulating and appeared more euvolemic. . DISPO: She was discharged in stable condition and her family endorsed that they would make f/u appointments with Dr. [Last Name (STitle) 11139]. A copy of this discharge summary will also be faxed to Dr. [Name (NI) 77650] office. She has f/u with [Hospital1 18] Hematology Oncology on [8-3]. . She was FULL CODE during admission. Medications on Admission: Sutent 50mg daily Ferrous sulfate 325mg daily Warfarin 5mg daily (10mg on Sunday) Singulair 10mg daily Celebrex 200mg daily Verapamil 240mg daily Citalopram 20mg daily Zolpidem 10mg daily Alprazolam 0.5mg Q8H PRN Discharge Medications: 1. Sutent 50 mg Capsule Sig: One (1) Capsule PO daily (). 2. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 3. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:30 Tablet(s) Refills:0 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left renal cell carcinoma Hematuria Urinary retention Afib with RVR Urinary tract infection Chest pain of unlikely cardiac origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to BIDMD with hematuria, urinary retention, and abdominal pain, all likely from your large renal cell carcinoma. You spent some time in the intensive care unit due to your fevers causing a rapid heart rate. You were treated for a urinary tract infection and your fevers and heart rate resolved. Your Sutent was held briefly, but restarted prior to admission. You continue to have some blood in your urine. The following medication changes were made while you were admitted: 1. Please do not take coumadin. You continue to have blood in your urine and this increases your tendency to bleed. 2. We started you on MS Contin for long acting pain control. You may also take immediate release morphine for breakthrough pain. 3. We gave you a supply of zofran to take if you have nausea. Only take this medication if needed. 4. Take regular stool softners as you are likely to get constipated from you pain medications. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5387], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2139-8-3] 5:00 Provider: [First Name4 (NamePattern1) 488] [Last Name (NamePattern1) 6401], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2139-8-3] 5:00 Please contact your primary care doctor Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 11139] at [Telephone/Fax (1) 11144] and arrange for a follow up appointment in 1 to 2 weeks. Completed by:[2139-7-19] Name: [Known lastname 12548],[Known firstname 5185] Unit No: [Numeric Identifier 12549] Admission Date: [2139-7-6] Discharge Date: [2139-7-15] Date of Birth: [2075-5-2] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12550] Addendum: DC summary was faxed to Dr.[Name (NI) 12551] office at [Telephone/Fax (1) 12552] on [2139-7-19] at 1701pm Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 12553] MD [Last Name (un) 12554] Completed by:[2139-7-19]	[ "041.4", "338.29", "599.0", "287.5", "189.0", "197.0", "514", "785.0", "724.2", "786.59", "401.9", "V15.82", "599.71", "788.20", "286.9", "427.31", "799.02", "591", "716.90", "493.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	17608, 17775	9962, 13869	335, 342	15429, 15429	3321, 9939	16538, 17585	2665, 2916		14132, 15226		15276, 15408		13895, 14109			15580, 16515									2931, 3302																						274, 297									370, 1519								15444, 15556										2182, 2331	2347, 2649

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