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7,671	160,689	10046	Discharge summary	report	Admission Date: [2196-6-23] Discharge Date: [2196-7-7] Date of Birth: [2148-4-6] Sex: F Service: HISTORY OF PRESENT ILLNESS: 48-year-old female with extremely severe vasculopathy. Known left subclavian stenosis, previous aorto-bifemoral bypass, complicated cardiac disease with multiple interventions. She was transferred for elective catheterization with known left main bypass grafting. The patient complains of right leg numbness post cardiac catheterization. Cardiac catheterization of [2196-6-23] demonstrates right coronary artery graft and native vessel totally occluded, left main trunk disease of 50%, anterior descending native vessel totally occluded and bypass graft with a proximal and marginal shows an 81% stenosis, second obtuse marginal with a 50% stenosis. Left ventricle shows inferior akinesis. There is a left subclavian total occlusion. Vascular was requested to evaluate the patient for right leg numbness post cardiac catheterization. PAST MEDICAL HISTORY: Coronary artery disease with angioplasty to the circumflex in [2192], stent placement to the right coronary artery secondary to re-stenosis in [2192-10-1], coronary artery bypass grafting with saphenous vein grafts to the right coronary artery and diagonal coronary artery in [2193]. She had a repeat catheterization in [2195-12-2] for unstable angina. Her graft was patent to the diagonal. She had severely diseased right coronary artery graft and required stenting of the right coronary artery graft. A follow up catheterization in [2196-1-1] showed patent diagonal and right coronary artery grafts with a 50% stenosis of the diagonal. She was treated medically. She underwent a repeat cardiac catheterization in [Month (only) 956] of this year which showed distal left main trunk mildly tapered, irregular left anterior descending artery with diagonal saphenous vein graft patent but graft with a 70% stenosis The circumflex was a non-dominant system with 50% stenosis of the first obtuse marginal. The right coronary artery was dominant. The vein graft to the right coronary artery was patent with stents x2. There was a 95% in stent stenosis and a 60-70% stenosis at the anastomosis. Medical history includes hypothyroidism on Synthroid therapy, history of seizure disorder, trauma related to motor vehicle accident in [2181] on medical therapy, history of HIT, bilateral carotid disease. She has a history of heparin induced thrombocytopenia which was complicated by thrombosis. She also has allergies to Codeine, Sulfa and Ceclor, reactions unknown. Previous surgery includes the coronary artery surgery, aorto-bifemoral bypass grafting in [2194], left shoulder surgery for Erb's palsy at the age of 12, appendectomy in [2166], cervical spine surgery in [2175], lumbosacral spine surgery in [2195-12-2], bladder suspension in [2174]. Medications at the time of admission included aspirin 1 q day, Nitro-Patch .4 mg q day, Ultrase 2.5 mg q day, Atenolol 50 mg q day, Plavix 75 mg q day, Lipitor 40 mg q day, Tri-Chlor 20 mg q day, Depakote 500 mg q a.m., 500 mg at noon and 750 mg q p.m., Neurontin 300 mg b.i.d., Synthroid .15 mg q day, Prevacid 15 mg q day, Darvocet p.r.n., Flexeril 10 mg b.i.d., Celebrex 200 mg q day, Microcide 12.5 mg q day, Premphase 1 q day, Zovirax lip ointment on a p.r.n. basis. PHYSICAL EXAMINATION: Vital Signs: Temperature 99.1, heart rate 71 and blood pressure 120/64. Oxygen saturation 100% on 1 liter by nasal cannula. The patient is in no acute distress but complains of right leg numbness and discomfort in the supine position in bed. HEENT exam was unremarkable. There is no jugular venous distention. Chest is clear to auscultation bilaterally. Heart has a regular rate and rhythm with no murmurs, rubs or gallops. Abdomen is benign. Extremities show a mottled, cool right lower extremity distally with Dopplerable dorsalis pedis pulses bilaterally. She has an atrophied right upper extremity related to her palsy. Neurologically, she is intact. LABORATORIES: White count 8.4, hematocrit 30.2. Coagulation studies were normal. BUN 16, creatinine 0.7, potassium 4.0, TSA 0.20, FT4 1.41. HOSPITAL COURSE: Initially after catheterization she could not move her leg at all which was not a vascular problem. However, she had sever underlying vascular disease that appeared to be acutely worse.The patient was begun on a Hirudin drip and she improved back to her perceived baseline and recommendations were for long term anticoagulation. It was determined, from the cardiac standpoint, with cardiology and cardiothoracic surgery, that the patient's coronary artery disease would be treated medically. Further evaluation of her peripheral vascular disease was going to be done with a MRA. However, her right leg symptoms worsened and she started to show signs of muscle damage in her right leg.She underwent a MRA on [2196-6-28] which demonstrated that the ascending aorta was of normal caliber. The innominate artery is normal and gives rise to the right subclavian which is also normal with a low grade, mild stenosis at the junction of the right subclavian and axillary artery. The left common carotid origin is normal. The left subclavian shows a high grade stenosis at its take-off but is normal in the remainder of its course. The descending thoracic aorta is normal. The right common femoral artery has retrograde filling of the external iliac artery and the right hypogastric artery. The right common femoral is normal and gives rise to normal profunda branches. The right superficial femoral artery is widely patent and communicates with a normal caliber popliteal. The left common femoral shows reconstitution via collaterals. There is focal stenosis to a 1.7 cm normal segment above the origin of the superficial femoral and profunda arteries. The left superficial femoral artery is widely patent and there is a normal appearing trifurcation. On [2196-6-29], the patient underwent a right axillo-bifemoral bypass graft. She tolerated the procedure well and was transferred to the SICU for continued care. The Hirudin drip was continued for a goal PTT of 50 to 70. The patient was extubated on postoperative day two. Coumadin was begun and she was transferred from the SICU to the VICU. The patient was evaluated by physical therapy who felt that the patient will need some rehabilitation for gait training and strengthening prior to being discharged to home. Her Swan-Ganz was converted to a CVL on postoperative day number three. She was followed by Cardiology and remained stable cardiac-wise. Kefzol was started for right pretibial erythema. On postoperative day five, she was transferred to the regular nursing floor for continued care. Goal INR was [3-5]. On postoperative day number six, physical therapy was requested to re-evaluate the patient and rehabilitation screening was begun. A brace was applied to the right foot. Aspirin was added to her drug regimen and the Kefzol was converted to Keflex. MEDICATIONS AT DISCHARGE: Neurontin 300 mg b.i.d., Synthroid 1.25 mcg q day, Nitro-Patch 0.4 mg q day, Atenolol 50 mg b.i.d. (hold for systolic blood pressure of less than 110, heart rate of less than 60), Colace 100 mg b.i.d., Depakote 500 mg q a.m., 500 mg q lunch and 750 mg q h.s., Ranitidine 150 mg q12 hours, Coumadin 5 mg q h.s., Lipitor 40 mg q day, Percocet 1-2 tablets q4-6 hours p.r.n. pain, Flexeril 10 mg q8 hours p.r.n., Benadryl 50 mg intravenously q4-6 hours p.r.n. pruritus, Morphine Sulfate 2-4 mg subcutaneously q6 hours p.r.n., Hydrochlorothiazide 12.5 mg q day, Keflex 400 mg q.i.d., aspirin 325 mg q day. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post left heart catheterization. 2. Ischemic right lower extremity, status post right axillo-bifemoral bypass. 3. Hypothyroidism with medication adjustment. 4. Seizure disorder, controlled. The patient should follow up with Dr. [Last Name (STitle) ] as requested. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3409] Dictated By:[Last Name (NamePattern1) 17652] MEDQUIST36 D: [2196-7-6] 09:29 T: [2196-7-6] 09:53 JOB#: [Job Number 3842]	[ "440.31", "411.1", "998.2", "447.1", "682.6", "780.39", "414.01", "V45.81", "244.9" ]	icd9cm	[ [ [] ] ]	[ "39.49", "88.53", "88.55", "37.22" ]	icd9pcs	[ [ [] ] ]								7747, 8333						4248, 7108																					3422, 4230		7123, 7725																		157, 1003														1026, 3399
10,188	181,572	9009+9010	Discharge summary	report+report	Admission Date: [2110-2-20] Discharge Date: [2110-3-26] Date of Birth: [2047-12-12] Sex: M Service: CARDIOTHORACIC Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath, drainage from sternal wound Major Surgical or Invasive Procedure: [2-20] Repair of right ventricle laceration and sternal wound debridement [2-20] Reopen sternotomy for right ventricular compression [2-24] Sternal debridement, Laparotomy with pedicle omental flap procedure, Open jejunostomy tube placement, Bilateral advancement skin and subcutaneous chest flaps. [2110-3-6] Split-thickness skin graft to omental flap and sternal wound. Measurements 12 x 20 cm with a split-thickness skin graft 12,000 of an inch meshed 1:1.5. 2. Preparation of recipient sternal wound by debridement and excision of necrotic skin and subcutaneos tissue and repositioning and securing and preperation of omental flap. [2110-3-21] Tracheostomy Tube (Percutaneous) History of Present Illness: This is a 62 year old gentleman who underwent a recent Aortic to Descending aorta bypass for Coarctation of the Aorta in [Month (only) 956] of [2109]. He had developed HIT in the post-operative period and was started on argatroban which was transitioned over to Coumadin. He had some serosanguinous drainage at the inferior portion of his sternotomy which had cleared prior to discharge. He now presents with increasing shortness of breath and some stenral instability. There has been some serosanguinous drainage from his wound. Past Medical History: Status-post ascending aorta to descending aorta bypass graft with 18mm gelweave [2110-1-29] Coarctation of the distal Arch s/p Surgical Repair of Arch/Desc. Aorta w/ Homograft via Left Thoracotomy at age 13 Bicuspid Aortic Valve Congestive Heart Failure Hypercholesterolemia Psoriatic Arthritis Osteoarthritis Asthma Sciatica Hemorrhoids Meckel's Diverticulum s/p surgery Right Lung Nodule s/p L2-L3, L4-L5 sacral fusion s/p L Subacromial decompression via arthroscopy s/p Appendectomy s/p Open Cholecystectomy s/p R Inguinal Hernia Repair s/p Nasal surgery for deviated septum s/p Lens Implants Social History: No tobacco, no etoh. Married with 2 children. Family History: Maternal Uncles died in 50's from MI Physical Exam: ON admission: V/S: Afebrile, 98% room air, normotensive, 90kg Gen: WD/WN, no acute distress, not in discomfort CV: regular rate and rhythm, no murmur, slight rub Pulm: crackles appreciated in left base, normal inspiratory effort Chest: sternal wound intact, trace serosanguinous drainage, no erythema Abd: Soft, NT/ND + BS, obese Extr: 1+ edema Derm: psoriatic lesions Neuro: conversant, CN 2-12 grossly intact Discharge: VS:T 97 HR 94SR BP 113/56 RR 30 Sat 93% 40% Trach collar Gen: NAD Neuro: responsive, follows commands, MAE Resp: Coarse, diminished in bases CV: RRR, Incision w/skin graft CDI Abdm: soft, NT/NABS. feeding tube intact Ext: warm, no CCE Pertinent Results: [ Truncated results only; please contact Medical [Name2 (NI) ] department of [Hospital1 18] for more detailed results-- [Telephone/Fax (1) 2806]] [2110-2-19] 08:30PM BLOOD WBC-9.8 RBC-3.31* Hgb-10.2* Hct-30.0* MCV-91 MCH-30.7 MCHC-33.9 RDW-15.4 Plt Ct-818* [2110-2-20] 05:56AM BLOOD WBC-8.2 RBC-3.11* Hgb-9.4* Hct-28.2* MCV-91 MCH-30.3 MCHC-33.4 RDW-15.4 Plt Ct-664* [2110-2-20] 11:45AM BLOOD WBC-17.1# RBC-3.91# Hgb-12.2# Hct-34.8 MCV-89 MCH-31.2 MCHC-35.1* RDW-14.3 Plt Ct-213# [2110-2-20] 01:35PM BLOOD WBC-17.1* RBC-4.93# Hgb-15.4# Hct-42.9 MCV-87 MCH-31.1 MCHC-35.8* RDW-14.1 Plt Ct-226 [2110-2-23] 03:56PM BLOOD WBC-9.1 RBC-3.68* Hgb-11.3* Hct-31.3* MCV-85 MCH-30.7 MCHC-36.0* RDW-14.7 Plt Ct-143* [2110-2-27] 10:52AM BLOOD WBC-13.7* RBC-4.04* Hgb-11.9* Hct-34.9* MCV-87 MCH-29.5 MCHC-34.1 RDW-15.0 Plt Ct-372 [2110-3-8] 02:51AM BLOOD WBC-16.8* RBC-3.00* Hgb-8.8* Hct-26.3* MCV-88 MCH-29.2 MCHC-33.3 RDW-15.6* Plt Ct-689* [2110-3-22] 03:13AM BLOOD WBC-8.9 RBC-3.27* Hgb-10.2* Hct-28.9* MCV-88 MCH-31.3 MCHC-35.4* RDW-17.2* Plt Ct-529* [2110-3-23] 03:01AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.5* Hct-28.7* MCV-89 MCH-29.4 MCHC-33.0 RDW-17.2* Plt Ct-517* [2110-3-24] 03:00AM BLOOD WBC-10.3 RBC-3.29* Hgb-9.8* Hct-29.3* MCV-89 MCH-29.8 MCHC-33.5 RDW-16.9* Plt Ct-537* [2110-3-25] 12:00AM BLOOD WBC-11.1* RBC-3.31* Hgb-9.7* Hct-29.5* MCV-89 MCH-29.2 MCHC-32.8 RDW-16.6* Plt Ct-536* [2110-2-19] 08:30PM BLOOD Neuts-68.5 Bands-0 Lymphs-12.5* Monos-5.3 Eos-12.9* Baso-0.7 [2110-2-19] 08:30PM BLOOD PT-32.0* PTT-32.2 INR(PT)-3.4* [2110-3-25] 03:21PM BLOOD PT-16.8* PTT-32.1 INR(PT)-1.5* [2110-3-26] INR: 1.4 [2110-3-8] 02:51AM BLOOD Ret Man-2.3* [2110-2-19] 08:30PM BLOOD Glucose-119* UreaN-13 Creat-1.2 Na-133 K-3.9 Cl-97 HCO3-23 AnGap-17 [2110-2-20] 05:56AM BLOOD Glucose-151* UreaN-12 Creat-1.4* Na-131* K-3.6 Cl-96 HCO3-24 AnGap-15 [2110-2-21] 01:55AM BLOOD Glucose-145* UreaN-14 Creat-1.0 Na-134 K-3.9 Cl-109* HCO3-19* AnGap-10 [2110-2-22] 03:25AM BLOOD Glucose-82 UreaN-13 Creat-0.9 Na-133 K-5.0 Cl-104 HCO3-21* AnGap-13 [2110-3-15] 10:00AM BLOOD K-3.9 [2110-3-16] 12:23AM BLOOD Glucose-151* UreaN-24* Creat-1.1 Na-150* K-3.3 Cl-110* HCO3-26 AnGap-17 [2110-3-17] 04:14AM BLOOD Glucose-143* UreaN-22* Creat-1.1 Na-147* K-3.3 Cl-110* HCO3-27 AnGap-13 [2110-3-24] 03:00AM BLOOD Glucose-164* UreaN-15 Creat-0.8 Na-143 K-3.7 Cl-105 HCO3-22 AnGap-20 [2110-3-25] 12:00AM BLOOD Glucose-210* UreaN-16 Creat-0.8 Na-147* K-4.2 Cl-109* HCO3-26 AnGap-16 [2110-2-19] 08:30PM BLOOD CK(CPK)-60 [2110-2-21] 10:58AM BLOOD ALT-21 AST-52* LD(LDH)-384* AlkPhos-72 Amylase-23 TotBili-1.6* [2110-2-22] 11:33AM BLOOD ALT-25 AST-53* LD(LDH)-417* AlkPhos-88 TotBili-0.8 [2110-2-28] 09:47AM BLOOD ALT-17 AST-35 LD(LDH)-257* AlkPhos-124* Amylase-36 TotBili-0.6 [2110-3-24] 03:00AM BLOOD ALT-23 AST-19 LD(LDH)-300* AlkPhos-121* Amylase-109* TotBili-0.4 [2110-3-25] 12:00AM BLOOD ALT-22 AST-27 LD(LDH)-244 AlkPhos-118* Amylase-102* TotBili-0.4 [2110-2-21] 10:58AM BLOOD Lipase-10 [2110-2-23] 02:20AM BLOOD Lipase-9 [2110-2-28] 09:47AM BLOOD Lipase-25 [2110-3-20] 09:30PM BLOOD Lipase-99* [2110-3-25] 12:00AM BLOOD Lipase-129* [2110-2-21] 10:58AM BLOOD Albumin-2.1* Mg-1.8 [2110-3-20] 09:30PM BLOOD Albumin-1.1* [2110-3-24] 03:00AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.5 Mg-2.3 [2110-3-25] 12:00AM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.3 Mg-2.1 [2110-2-23] 03:56PM BLOOD TSH-6.9* [2110-3-13] 03:26AM BLOOD TSH-6.5* [2110-2-28] 09:47AM BLOOD T4-7.1 T3-97 Free T4-1.2 [2110-3-6] 02:30AM BLOOD T4-6.6 T3-93 Free T4-1.1 [2110-3-13] 03:26AM BLOOD T4-7.4 T3-107 [2110-2-22] 11:33AM BLOOD Cortsol-15.0 [2110-2-28] 06:39PM BLOOD Cortsol-29.4* [2110-2-28] 09:47AM BLOOD antiTPO-17 [2110-2-27] 08:25PM BLOOD Vanco-13.6* [2110-3-1] 09:34AM BLOOD Vanco-16.6* MICROBIOLOGY: [2110-2-24] Aortic wound: MRSE [2110-3-2] Blood Culture: VRE [2110-3-2] Urine Culture: > 100,000 yeast [2110-3-2] Sputum Culture: S. Aureus [2110-3-4] Urine Culture: > 100,000 yeast [2110-3-4] Catheter Tip Culture: MRSE [3-8] Sputum Culture: MRSA [2110-3-6] Subcutaneous Fat Culture: Enterococcus [3-23] Sputum Culture: negative [3-23] urine culture: negative [3-20] blood cullture: negative [3-23] stool culture and c. diff: negative RADIOLOGY: [2110-2-17] CXR: : The enlarged cardiomediastinal silhouette is unchanged from [2110-2-14] and [2110-1-31], presumably postoperative related changes. The left basilar atelectasis/consolidation is unchanged. Small left-sided pleural effusion is unchanged. The pulmonary vascularity is normal in appearance. There is no pneumothorax. There is a left-sided PICC line with its tip in stable position in the mid left subclavian vein. [2110-3-5] Abdominal Ultrasound: Liver is normal in size. No intrahepatic lesions demonstrated. The visualization of the left lobe suboptimal due to the presence of overlying chest wall wound. No intra- or extra- hepatic biliary dilatation. The patient is post- cholecystectomy. No free intraabdominal fluid or upper abdominal collections demonstrated. Spleen is normal in size at 10.2 cm. Both kidneys are normal in size, the right measures 10.4 and the left 10.2 cm, no hydronephrosis or hydroureter. Doppler assessment of the hepatic vasculature shows main portal vein with normal hepatopetal directional flow. The left main and right hepatic veins are patent. [2110-3-22] CXR: There is again demonstrated a tracheostomy tube, left chest tubes, right PICC and a right subclavian central venous catheter in stable position. There is no pneumothorax. There are persistent bibasilar densities, left greater than right, and left retrocardiac opacity. There are unchanged small bilateral pleural effusions, left greater than right. No new opacities are seen. Brief Hospital Course: This is a brief discharge summary for a prolonged hospitalization for this 62 year old gentleman who presented on [2110-2-20] with sternal wound drainage status-post tube grafting of ascending to descending aorta for coarcation in [Month (only) 956] of [2109]. Hospital course is summarized by organ systems: From a Cardiac Surgery standpoint, the patient was noted to have worsening bloody drainage and a fever to 103 on the morning after his evening admission. He was taken emergently to the operating room where sternal wound was opened and a laceration to the right ventricle was appreciated and repaired (please see the operative note of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] for full details). Several hours later that evening he was again returned to the operating room for poor hemodynamics in the ICU with evidence of right ventricular compression; hematoma was evacuated and the sternal wound was left open. He was then actively diuresed for several days and returned to the operating room on [2110-2-24] for omental flap and subcutaneous chest flap closure of his sternal wound (please see the operative note of Dr. [Known lastname 951] [Last Name (NamePattern1) 952] w/ Thoracics Surgery for full details); a J-tube was placed during this operation. A VAC dressing was left in place during this operation and after significant wound closure, split thickness skin grafts were then harvested and grafted to the wound site (please see the operative note of Dr. [Known lastname 951] [Last Name (NamePattern1) 952] from [2110-3-6] for full details). His wound demonstrated appreciable improvement over the next few weeks. JP drains were left in place under his wound, with planned removal by Thoracics surgery once there was trace to no output. From a Cardiovascular standpoint, the patient required intermittant amiodarone for sinus tachycardia and bursts of Afib. During a portion of his hospital course he presented with hypotension (with cause most likely from sepsis, with endocrinologic abnormalities ruled-out) and required pressors, however he was weened off pressors and amiodarone for several weeks prior to discharge. From a pulmonary standpoint, the patient was noted to have bilateral pulmonary effusions and MRSA pneumonia during his hospital course. He also required intermittant nebulizors. Despite antibiotic treatment for his pneumonia, he failed 2 extubation attempts. He therefore underwent percutaneous tracheostomy on [2110-3-21] (please see the operative not of Dr. [Known lastname 951] [Last Name (NamePattern1) 952] for full details). He was eventually weened to trach-mask ventilation via his trach tube. From a neurologic standpoint, the patient required sedation for an extensive period of time due to his intubation. Once extubated, he required intermittant ativan to counter withdrawal symptoms from being on a versed drip. By the time of his discharge he demonstrated marked improvement in alertness with ability to communicate with staff via alphabet cards and ability to fully comprehend staff members. He was seen by endocrinology for elevated TSH levels but was felt to have subclinical hypothyroidism and had normal T4 levels. From a hematologic standpoint the patient was admitted with a known diagnosis of heparin-induced thrombocytopenia, and he had been on coumadin since early [2110-2-5]. While he was in the peri-operative period for his various procedures he was maintained on an argatroban drip but this was eventually discontinued and transitioned to Coumadin, with near-therapeutic levels by [2110-3-25]. His goal is to continue on Coumadin for HIT for approximately 2-3 months. From an infectious standpoint the patient had a fever to 103 on hospital day 2 and was found to have infectious drainage from his mediastinal wound growing MRSE. He also had VRE bacteremia, yeast infections in his urinary tract, and MRSA in his sputum throughout his hospital course. Infectious disease consultation was obtained early in his hospital course with appropriate treatment of these infections; eventually he had pan-negative cultures prior to discharge. He will complete a 28-day course of Linezolid for his VRE bacteremia, MRSA pneumonia, and MRSE woudn infection oon [2110-4-2]. From a GI standpoint, the patient demonstrated poor oral intake given his comorbidities and a J-tube was placed at the time of his wound closure operation of [2110-2-24]. He was on goal tube feeds for several weeks prior to discharge. His albumin levels were normal prior to discharge and prevacid was used for stress ulcer prophylaxis. At time of discharge, the patient was afebrile for over 24 hours, tolerating goal tube feeds, communicating with staff, and stable from a cardiovascular/pulmonary standpoint. A rehab facility with vent-assistance was found and he was discharged with planned follow-up with Cardiac and Thoracic surgery. All questions were answered to the satisfaction of himself and his proxy prior to discharge. Medications on Admission: methorexate 7.5 mg po qwednesday, vistaril 25 mg 5x/day, dovonexzonolon topically Qdaily Dovonex topically Qdaily Clindamycin topically Qdaily Singulair Albuterol Serevent Flovent Elavil 10 mg po qdialy Quinine 325 mg po qhs Flexeril Lipitor 10 mg po qdaily Aspirin Lopressor 25 mg po BID Remicaid 700 mg po Q6 weeks Discharge Medications: 1. Acetaminophen 500 mg Capsule Sig: [12-9] Capsules PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-9] Drops Ophthalmic PRN (as needed). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QOD (). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). [through [2110-4-2], completion of 28 day course] 13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 16. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO PRN (as needed) as needed for K<4.0. 17. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4-6H (every 4 to 6 hours) as needed. 19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: titrate to goal INR 2-2.5. 20. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Calcium Gluconate 2 gm / 100 ml D5W IV PRN Free Cal <1.12 to run over 1 hr. 22. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN mg <2.0 23. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 24. Dextrose 50% 12.5 gm IV PRN glucose < 60 Recheck glucose q 30 minutes until glucose > 100 25. Metoclopramide 10 mg IV Q6H:PRN nausea/vomiting 26. Furosemide 40 mg IV TID 27. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 28. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 29. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic QID (4 times a day): in OU. 30. Clindamycin Phosphate 1 % Solution Sig: One (1) Appl Topical DAILY (Daily). 31. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 32. Doxepin 5 % Cream Sig: One (1) application Topical daily (): for psoriasis. 33. Sliding Scale Insulin (Regular) as needed (check q6H fingersticks) Discharge Disposition: Extended Care Facility: [Hospital3 105] Discharge Diagnosis: Primary: Sternal Wound Dehiscence with laceration of right ventricle Secondary: heparin induced thrombocytopenia, failure to thrive, ventilatory-dependence, VRE bacteremia, MRSE aortic infection, MRSA pneumonia, urinary tract infection, hyperlipidemia, chronic afib, mental status changes, psoriatic arthritis Discharge Condition: Tolerating tube feeds. Ventilating via trach-mask. Communicating via commands. Good pain control. Hemodynamically stable. Discharge Instructions: Take all medications as prescribed. No lifting > 10# for 2 months. No creams, lotions or powders to any incisions. Tube feeding via J-tube. The patient may shower, no bathing for 1 month. Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] upon discharge from rehab ([Telephone/Fax (1) 170]) Follow-up with Dr. [Known lastname 951] [Last Name (NamePattern1) 952] upon discharge from rehab Dr. [Last Name (STitle) 10220] (cardiologist) is no longer seeing outpatients, you can follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5293] or Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5543] at [Hospital1 18] cardiology Completed by:[2110-3-26] Admission Date: [2110-3-26] Discharge Date: [2110-3-27] Date of Birth: [2047-12-12] Sex: M Service: CARDIOTHORACIC Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[First Name3 (LF) 1283] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt admitted to [Hospital1 18] [2-20] for sternal wound debridement. Had debridemnet and flap closure with prolonged hospitalization ultimately requiring tracheostomy and J tube placement. Pt was scheduled for d/c to rehabilitation yesterday but during ambulance transport became dyspnic and was returned to [Hospital1 18] for evaluation. CXR revealed small-mod right pleural effusion that was drained(approximately 500cc serosang fluid). The pt was brought back to the CSRU and placed on pressure support ventilation. His Lasix was changed to Bumex and Zaroxlyn was added to assist diuresis. Past Medical History: Status-post ascending aorta to descending aorta bypass graft with 18mm gelweave [2110-1-29] Coarctation of the distal Arch s/p Surgical Repair of Arch/Desc. Aorta w/ Homograft via Left Thoracotomy at age 13 Bicuspid Aortic Valve Congestive Heart Failure Hypercholesterolemia Psoriatic Arthritis Osteoarthritis Asthma Sciatica Hemorrhoids Meckel's Diverticulum s/p surgery Right Lung Nodule s/p L2-L3, L4-L5 sacral fusion s/p L Subacromial decompression via arthroscopy s/p Appendectomy s/p Open Cholecystectomy s/p R Inguinal Hernia Repair s/p Nasal surgery for deviated septum s/p Lens Implants Social History: No tobacco, no etoh. Married with 2 children. Family History: Maternal Uncles died in 50's from MI Physical Exam: Discharge: Gen: NAD Neuro: Alert-responsive, MAE, follows commands Pulm: Course, diminished in bases CV: RRR, incision w graft CDI Abdm: soft, NT/NABS. J tube intact Ext: warm, no CCE Pertinent Results: [2110-3-26] 04:48PM GLUCOSE-69* UREA N-20 CREAT-0.7 SODIUM-147* POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-30 ANION GAP-14 [2110-3-26] 04:48PM WBC-10.4 RBC-3.15* HGB-9.2* HCT-28.1* MCV-89 MCH-29.3 MCHC-32.8 RDW-16.1* [2110-3-26] 04:48PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.026 [2110-3-26] 04:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG Brief Hospital Course: As above in HPI. See D?C summary from [3-26] Medications on Admission: See discharge medications from [3-26] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours) as needed. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): continue through [4-2] then doxycycline. 11. Lansoprazole Oral 12. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 14. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic QID (4 times a day). 15. Calcipotriene 0.005 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for for psoriasis. 16. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for 1 doses: adjust dose to maintain target INR 2-2.5. 17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-9] Puffs Inhalation Q4H (every 4 hours) as needed. 19. Bumetanide 0.25 mg/mL Solution Sig: Two (2) mg Injection [Hospital1 ] (2 times a day). 20. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: until after f/u with [Hospital ] clinic. Discharge Disposition: Extended Care Facility: [Hospital1 ] Northeast Discharge Diagnosis: See worksheet from [3-26] Discharge Condition: good Discharge Instructions: keep wounds clean nad dry OK to shower, no bathing. Take all medication as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Dr [Last Name (STitle) ] upon d/ from rehab Dr [Last Name (STitle) 952] upon d/c from rehab [Hospital ] clinic [2110-4-21] @ 10:30AM Completed by:[2110-3-27]	[ "482.41", "861.03", "458.8", "112.2", "997.1", "996.61", "747.10", "038.9", "287.4", "459.0", "428.0", "518.5", "746.4", "V09.80", "998.31", "V09.0", "511.9", "995.92", "996.62", "420.90", "427.31" ]	icd9cm	[ [ [] ] ]	[ "86.74", "34.03", "99.15", "86.22", "96.72", "00.17", "31.1", "86.69", "88.72", "39.61", "00.14", "96.04", "77.61", "38.93", "93.56", "46.39", "96.6", "86.72", "37.49", "99.61" ]	icd9pcs	[ [ [] ] ]	23046, 23099	21084, 21134	19013, 19019	23173, 23180	20616, 21061	23367, 23547	20358, 20396		21226, 23023		23120, 23152		21160, 21203			23204, 23344									20411, 20597																				18966, 18975										19047, 19655							2402, 3050							19677, 20278	20294, 20342
24,312	142,355	8543	Discharge summary	report	Admission Date: [2170-9-24] Discharge Date: [2170-10-2] Service: ADMISSION DIAGNOSES: 1. Myelodysplastic syndrome (MDS). 2. Subdural hematoma. DISCHARGE DIAGNOSES: 2. Subdural hematoma. HISTORY OF PRESENT ILLNESS: This is an 81 year-old man who has a known history of myelodysplastic syndrome. He was originally hospitalized at an outside hospital after he presented with expressive aphagia on [2170-9-24] in the setting of profound thrombocytopenia. A head CT he was transferred to the [Hospital1 18] MICU. In the MICU a neurosurgery consult was obtained. The neurosurgery team felt he was not a good surgical candidate secondary to the size of his subdural hematoma as well as his thrombocytopenia. Given the patient's history of known MDS, hematology/oncology consult was obtained to address his thrombocytopenia. The recommendations included to continue transfusing platelets to keep the platelet count greater then 100,000 and to continue his steroids to decrease cerebral edema and to aid the patient's response to the platelet transfusion and also to simply continue to monitor the patient's leukocytosis. The initial feeling in the MICU was the patient may have a source of infection and the patient was continued on Ceftazidime one gram q 8 hours. Throughout the course of the admission, however, no obvious source for infection was obtained (negative chest x-ray, negative urinalysis, negative blood cultures). The patient's antibiotics were discontinued on hospital day number two after it was clear there was no infectious etiology for his leukocytosis. The patient was stable throughout the course of his MICU hospitalization and he was transferred to the regular floor on hospital day number three after his mental status changes (expressive aphasia/global aphasia) improved. While on the floor the patient's neurological status simply continued to improve gradually. The patient's serial neurological examinations were benign. The recommendation by the hematology and general surgery services were to keep the patient's platelet count above 50,000 for the first week after his documented bleed. Neurosurgery recommended to repeat the head CT in two weeks time to assess the possibility of a slowly worsening subdural hematoma (sooner if clinically indicated). The patient's steroids were slowly tapered off and he will not be going home on any steroid therapy. The patient has required multiple platelet transfusions during this hospitalization and on the day of discharge his platelet count is now 65,000. His white blood cell count peaked at 71.6 and on discharge it is 69.6. The patient's mental status has continued to improve. He has been seen by physical therapy throughout the course of his hospitalization on the general medicine floor and the patient will be discharged to St. [Known firstname 11042] Hospital for short term rehabilitation. The patient will follow up with his hematologist/oncologist in one weeks time. In addition the patient will have daily platelet checks at his rehab facility. The recommendations per the neurosurgery team was to keep his platelet count greater then 50,000 for the first seven days after his bleed. The patient has remained afebrile for the last 48 prior to his discharge. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Neutrophos one packet po t.i.d. 2. Protonix 40 mg q.d. 3. Propanolol 40 mg b.i.d. 4. Nifedipine 30 mg po q.d. 5. Colace 100 mg b.i.d. 6. Prednisone 10 mg q.d. times seven days followed by 5 mg q.d. times seven days and then off. The patient will be discharged to St. [Known firstname 11042] Medical Center in [Hospital1 189], [State 350] with follow up in a weeks time with his hematologist/oncologist and also his primary care physician as needed. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 4872] MEDQUIST36 D: [2170-10-2] 09:24 T: [2170-10-2] 09:53 JOB#: [Job Number 30054]	[ "780.6", "272.0", "253.6", "432.1", "401.9", "V10.05", "784.3", "733.13", "205.10" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]								185, 209	3350, 4088																									104, 164																					238, 3292																3317, 3326
77,220	166,608	35767	Discharge summary	report	Admission Date: [2191-1-4] Discharge Date: [2191-1-15] Date of Birth: [2133-6-4] Sex: M Service: SURGERY Allergies: Bactrim Attending:[First Name3 (LF) 2869] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: pancreaticocystojejunostomy, Component separation ,Ventral hernia repair with mesh [2191-1-4] History of Present Illness: Mr. [Known lastname 81329] is a 57 M with complex medical hx including necrotizing pancreatitis and a pancreatic pseudocyst in [2187], s/p open cholecystectomy, necrosectomy and cyst-jejunostomy with roux en y omega loop in [2189-7-22] which was subsequently complicated by distal CBD stricture s/p stenting. His postoperative course was further complicated by chylothorax treated with talc pleurodesis which led to the development of chylous ascites which he has removed Q 2-3 weeks with paracentesis. He presented earlier this year with worsening abdominal pain and emesis, and imaging showed a recurrent pancreatic pseudocyst. He presents now for surgical treatment of the pseudocyst as well as his ventral hernia. Past Medical History: MEDICAL & SURGICAL HISTORY: 1. DM2 diagnosed in [10/2187], on insulin. 2. Necrotizing pancreatitis, pancreatic pseudocyst, and cholangitis that required ex-lap in [7-/2189], with open cholecystectomy, pancreatic pseudocyst jejeunostomy, modified roux-en-y and pancreatic necrosectomy. He had bilateral chylothorax in [10/2189] that required pleurodesis and was recently ([3-/2190]) admitted with chylous ascites that required paracentesis. 3. History of SVT with first episode during admission of necrotizing pancreatitis. He has had 4 episodes since [7-/2189], all of them terminated by ATP or diltiazem. 4. L5 herniated disc. 5. SMV thrombosis. 6. Hx of melanoma, no recurrence. Social History: He works with a software business company. Married twice. He lives at home with his 4 children. He does not smoke or use drugs. He previously drank [3-27] drinks per week, but has not drunk alcohol for the past two years. Family History: No biliary or pancreatic disease Physical Exam: Physical exam on discharge: Tm 98.9, Tc 98.1, HR 79, BP 101/62, RR 20, 97% on RA NAD, AAOx3 Chest clear to auscultation b/l HR regular, M/G/R Abdomen firm but flat, appropriately tender, incision C/D/I without drainage. LUQ [Month/Day (3) 19843] serosanguinous. No clubbing/cyanosis/edema Pertinent Results: [2191-1-4] 08:39PM WBC-23.1# RBC-4.03 HGB-9.3* HCT-30.6* MCV-76* MCH-23.1* MCHC-30.4* RDW-16.6* [2191-1-4] 08:39PM PLT COUNT-893* [2191-1-4] 08:39PM ALBUMIN-3.1* CALCIUM-8.2* PHOSPHATE-5.5* MAGNESIUM-1.6 [2191-1-4] 08:39PM ALT(SGPT)-26 AST(SGOT)-43* ALK PHOS-163* AMYLASE-89 TOT BILI-0.7 [2191-1-4] 08:39PM GLUCOSE-195* UREA N-21* CREAT-1.1 SODIUM-132* POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-21* ANION GAP-14 [2191-1-4] 08:39PM LIPASE-15 [2191-1-12] 03:07AM BLOOD PT-45.4* PTT-66.9* INR(PT)-4.5* [2191-1-13] 06:20AM BLOOD PT-67.6* INR(PT)-6.8* [2191-1-13] 05:50PM BLOOD PT-37.4* PTT-40.4* INR(PT)-3.7* [2191-1-14] 06:25AM BLOOD PT-34.7* PTT-41.4* INR(PT)-3.4* [2191-1-15] 06:55AM BLOOD PT-22.3* PTT-36.4 INR(PT)-2.1* ****[1-14] abdominal ultrasound: INDICATION: 57-year-old man with pancreatitis and complicated medical history, evaluate for ascites. COMPARISON: Doppler ultrasound, [2190-12-14]. FINDINGS: A limited evaluation of the four quadrants of the abdomen was performed. A trace of free fluid is seen in the left upper quadrant. A trace of complex loculated fluid is seen in the left lower quadrant. No ascites is seen in the right abdomen. IMPRESSION: Only trace ascites seen in the abdomen. Brief Hospital Course: Mr. [Known lastname 81329] [Last Name (Titles) 1834] pancreatic pseudocyst-jejunostomy and ventral hernia repair with component separation and overlay mesh on [2191-1-4]. Postoperatively he was admitted briefly to the ICU for hypotension that responded to volume as well as turning down the epidural. He was transferred to the floor on POD 3. His epidural was discontinued and his pain was eventually controlled with PO dilaudid and a two-day course of toradol. His foley was replaced once for urinary retention but then removed successfully. He began passing flatus and was advanced to clears and then advanced to lowfat diet. His [Date Range 19843] output remaind low and non-chylous, and an abdominal ultrasound demonstrated only trace ascites. [Last Name (un) ] was consulted to manage his blood sugars and his fingersticks were adjusted. His subcutaneous JP drains were removed prior to discharge, leaving behind one intraperitoneal [Last Name (un) 19843]. Physical therapy was consulted and he was cleared for discharge home. He was started on a heparin drip and coumadin for his history of SMV thrombosis. However, both were held when he became supratherapeutic to 6.8 on [1-13]. He received 2 units of FFP and 1 mg of PO Vit K as well, and his INR was down to 2.1 on the day of discharge. He will be instructed to resume Coumadin at 1mg daily at home with plans to re-check his INR on [Month/Year (2) 766] [1-17]. Medications on Admission: diltiazem 120', lasix 80', spironolactone 150', Lantus 25 QHS, ISS (humalog), magnesium oxide 400'', lovenox SQ 60'' (held [1-3]), dilaudid [12-25*] Q8H prn, colace 100'', FeSO4 325''', MCT Oil 15'', Senna 8.6'' prn Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s)* Refills:2 6. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:100 Tablet(s) Refills:0 8. insulin glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous at bedtime. 9. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous QACHS: please provide pt with printout of inpatient sliding scale. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Ventral hernia, chyle leak, pancreatic pseudocyst Splenic and smv occlusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [Company 269] CareNetwork has been arranged. They will do your INR lab work Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have any of the following: temperature of 101 or greater, shaking chills, nausea, vomiting, jaundice, increased incision or abdominal pain, abdominal distension, incision redness/bleeding/drainage, or [Telephone/Fax (1) 19843] outputs increase significantly or drainage stops. -empty drains and record output. Bring record of [Telephone/Fax (1) 19843] outputs to next clinic appointment - no driving while taking pain medication -you may shower - do not lift anything heavier than 10 pounds, no straining - Start taking 1mg of Coumadin daily tonight ([2190-1-15]), and continue this dose. You will have lab work drawn on [Month/Day/Year 766] and we will adjust your dose accordingly. - You will be discharged on half of your normal dose of diltiazem (30 mg twice a day) - You should stop taking your lasix for the time being. Followup Instructions: PLEASE CALL Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] on [Telephone/Fax (1) ] to schedule a followup appointment for Thursday [1-20] or [Month/Day (4) 766] [1-24] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2874] Completed by:[2191-1-15]	[ "V58.67", "788.29", "557.1", "V10.82", "790.92", "577.2", "457.8", "250.02", "289.59", "553.21", "285.1" ]	icd9cm	[ [ [] ] ]	[ "53.61", "52.22", "52.96", "40.9", "03.90" ]	icd9pcs	[ [ [] ] ]	6414, 6463	3788, 5259	281, 380	6582, 6582	2489, 3765	7759, 8076	2125, 2160		5532, 6391		6484, 6561		5285, 5509			6732, 7736									2175, 2175											2203, 2470									226, 242										408, 1141									6597, 6708					1163, 1865	1881, 2109
32,453	132,015	32316	Discharge summary	report	Admission Date: [2131-7-15] Discharge Date: [2131-7-21] Date of Birth: [2089-3-19] Sex: M Service: MEDICINE Allergies: Morphine / Codeine Attending:[First Name3 (LF) 10293] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [First Name3 (LF) ] History of Present Illness: This is a 42 year old male with a history of alcoholic cirrhosis and chronic pancreatitis with history of grade II varices s/p banding of varices in [11-27] who presented to the ED with abdominal pain and coffee ground emesis. Pt reports having refrained from ETOH for the last 6 months since last discharge from [Hospital1 18] in [Month (only) 1096]. However yesterday "fell of the waggon" after getting into a heated argument with his ex-wife and drank 2 pints of [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and another 1.5 pints earlier today. Soon after his binge this afternoon at approximately 4 pm, he began to have abdomial pain [2132-5-26] (up from [3-30] baseline) nausea and vomited x1. Described the emesis as being coffee ground material. Also reports having 2 loose, dark brown, foul smelling stools at home prior to admission. His last PO intake was at noon and his last BM was around 2 PM. . EDVS 98.1 127/83 HR 82 RR 16. He had an episode of coffee ground emesis upon placement of NGT. NG lavage with 300 cc coffee ground material, guaiac positive on exam. His hematocrit stable at 39.3, given 2 L IVF. He was seen by liver fellow who felt that this was likely not an active variceal bleed and more likely gastritis in setting of ETOH binge and he is being admitted to the [Hospital Unit Name 153] with plan for [Hospital Unit Name ] in AM. . Upon arrival to [Hospital Unit Name 153], he reports epigastric pain radiating to his back, similar to his pain from pancreatitis. No other complaints. . Review of systems: (+) Per HPI, R knee baseline pain. In [Month (only) ] s/p cholecystectomy at [Hospital1 2025] for gallstones. (-) Fevers, chills, SOB, CP, palpitations, lightheadedness, LOC Past Medical History: - Alcoholic cirrhosis, [Hospital1 ] w/ grade II varices s/p banding following bleed in [11-27], portal gastropathy, esophagitis - Chronic pleural effusions - Chronic pancreatitis - Alcohol dependence: began drinking heavily at age 30 to 35, has been sober for the past 6 mo. Has been in detox, dual-diagnosis units in the past. ? Hx of DTs, no seizures. - Bipolar disorder, on multiple medications PSH: Cholecystectomy [5-29] Social History: Divorced, lives alone. Has daughter in [Name (NI) 614] and son in [Name (NI) 3320]. ETOH as above. Denies tobacco or other illicits. Family History: Family history of alcoholism. Physical Exam: VS: BP 120/77, HR 74 RR 14, Sat 95% RA GEN: NAD, AO x 3 HEENT: AT, NC, PERRLA, EOMI, 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, ND, + BS, TTP in epigastrium, no guarding or rebound. Laparoscopic and open cholecystectomy scars C/D/I. EXT: warm, dry, +2 distal pulses BL NEURO: alert & oriented, CN II-XII grossly intact PSYCH: appropriate affect Pertinent Results: [2131-7-16] 03:31PM BLOOD WBC-2.4# RBC-3.88 Hgb-10.3* Hct-30.2* MCV-78* MCH-26.4* MCHC-34.0 RDW-14.9 Plt Ct-103* [2131-7-16] 09:34AM BLOOD Hct-30.4* [2131-7-16] 01:54AM BLOOD WBC-5.3 RBC-4.41* Hgb-11.4* Hct-33.8* MCV-77* MCH-25.9* MCHC-33.8 RDW-15.1 Plt Ct-136* [2131-7-15] 07:35PM BLOOD WBC-6.6# RBC-5.00 Hgb-13.3* Hct-39.3* MCV-79* MCH-26.5* MCHC-33.8 RDW-14.4 Plt Ct-196 [2131-7-16] 01:54AM BLOOD Neuts-51.6 Lymphs-41.9 Monos-3.4 Eos-2.8 Baso-0.4 [2131-7-15] 07:35PM BLOOD Neuts-57.7 Lymphs-36.3 Monos-2.9 Eos-2.4 Baso-0.6 [2131-7-16] 09:34AM BLOOD PT-17.2* INR(PT)-1.5* [2131-7-15] 07:35PM BLOOD PT-17.3* PTT-30.6 INR(PT)-1.5* [2131-7-16] 01:54AM BLOOD Glucose-71 UreaN-6 Creat-0.6 Na-146* K-3.4 Cl-109* HCO3-26 AnGap-14 [2131-7-15] 07:35PM BLOOD Glucose-145* UreaN-6 Creat-0.7 Na-146* K-3.6 Cl-105 HCO3-25 AnGap-20 [2131-7-15] 07:35PM BLOOD ALT-29 AST-102* CK(CPK)-74 AlkPhos-306* TotBili-1.1 [2131-7-15] 07:35PM BLOOD Lipase-14 [2131-7-15] 07:35PM BLOOD cTropnT-<0.01 [2131-7-16] 01:54AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.5* [2131-7-15] 07:35PM BLOOD Albumin-4.8 [2131-7-15] 07:35PM BLOOD ASA-NEG Ethanol-309* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2131-7-16] 02:05AM BLOOD Type-ART pO2-84* pCO2-43 pH-7.41 calTCO2-28 Base XS-1 [2131-7-16] 02:05AM BLOOD Lactate-1.5. [2131-7-15] 07:47PM BLOOD Hgb-13.9* calcHCT-42 [2131-7-16] 07:07AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2131-7-16] 07:07AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2131-7-16] 07:07AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [2131-7-16] 07:07AM URINE CastHy-1* [2131-7-16] 07:07AM URINE Mucous-RARE . . Final Report INDICATION: Epigastric pain. COMPARISON: [2130-11-18]. PA AND LATERAL VIEWS OF THE CHEST: Nasogastric tube tip terminates within the fundus of the stomach. Cardiomediastinal and hilar contours are normal. The lungs are clear. The pulmonary vascularity is normal. No pleural effusion or pneumothorax is present. The osseous structures are within normal limits. IMPRESSION: No acute cardiopulmonary abnormality. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: SUN [2131-7-15] 10:23 PM . . . Date: Monday, [2131-7-16] Endoscopist(s): [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [First Name8 (NamePattern2) 2530] [Last Name (Titles) ], MD Patient: [Known firstname ] [Known lastname 53917] Ref.Phys.: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Birth Date: [2089-3-19] (42 years) Instrument: ID#: [Numeric Identifier 75522] Indications: Hematemesis Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The patient was administered conscious sedation. A physical exam was performed prior to administering anesthesia. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Mucosa: Esophagitis with no bleeding was seen in the lower third of the esophagus. Protruding Lesions 2 cords of grade I to II varices were seen in the esophagus, with out stigmata of recent bleeding. Stomach: Mucosa: And congestion, erythema and mosaic appearance of the mucosa were noted in the stomach. These findings are compatible with portal hypertensive gastropathy. Protruding Lesions A single 2 cm non-bleeding nodule was seen in the antrum consistent with pancreatic rest as seen in prior [Numeric Identifier ]. Duodenum: Normal duodenum. Impression: Esophageal varices Esophagitis in the lower third of the esophagus And congestion, erythema and mosaic appearance in the stomach compatible with portal hypertensive gastropathy Nodule in the antrum Otherwise normal [Numeric Identifier ] to second part of the duodenum Recommendations: Follow up with his gastroenterologist with in 2 weeks. Additional notes: Source of bleeding is likely esophagitis. Recommend starting po PPI and discontinue octreotide. If bleeding recurs will do [Numeric Identifier ] again. Continue follow up of serial hematocrits. ---- Abdominal U/S with Dopplers ([2131-7-18])- 1. Markedly heterogeneous echotexture to the liver, consistent with the patient's history of cirrhosis. Although no definite mass is identified, evaluation is somewhat limited given the heterogeneity. 2. No abnormal fluid collection identified. 3. Nonvisualization of the pancreas. 4. Findings consistent with portal hypertension, including splenomegaly and trace ascites. ---- Microbiology: [2131-7-18] URINE URINE CULTURE-<10,000 organisms [2131-7-18] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2131-7-18] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2131-7-16] MRSA SCREEN MRSA SCREEN-negative Brief Hospital Course: 42M with history of alcoholism, EtOH cirrhosis grade II varices, chronic pancreatitis associated with UGIB. # GI bleed: Likely upper GIB given his history and presentation. Given what appears to have been transient bleed, etiology of bleed more likely gastritis/ulcer than variceal bleeding. [Doctor First Name ] [Doctor Last Name ] tear also on differential. Pt was hemodynamically stable without active bleeding in [Hospital Unit Name 153]. He was made NPO, started on aggressive IVF, placed on a protonix and octreotide drip, given cipro for prophylaxis of SBP, and taken to [Hospital Unit Name ] in morning by GI, where they found esophageal varices, esophagitis in the lower third of the esophagus, and portal hypertensive gastropathy, and unspecified nodule in the antrum, with otherwise normal [Hospital Unit Name ]. Although no active bleeding was visualized, it is thought that his initial hematemesis was due to esophagitis. At this point he was continued on his PPI but his octreotide and cipro were discontinued and monitored post-procedurally in the [Hospital Unit Name 153] where he remained hemodynamically stable and had a stable HCT of 30. He was subsequently transferred to the floor where he remained hemodynamically stable with a stable hematocrit. He was discharged on [Hospital1 ] PPI and instructed to continue propanolol as long as pulse > 60. # ETOH cirrhosis: With known varices and gastropathy, mild coagulopathy, transaminitis with AST>ALT. Recent ETOH binge in setting of social stressors. He was given folate, thiamine, MVI. Social work was consulted, but the patient was unable to return to the HOPE shelter [1-22] relapse. He was set up with an alternative shelter. He was placed on a CIWA scale for potential withdrawal however did not require any during his hospitalization. The patient's LFTs, INR, and albumin did not change acutely. Ambien was held in light of hepatic dysfunction. # Chronic pancreatitis: History of pancreatitis, with epigastric pain on admission. Suspect epigastric pain more likely related to bleed but also possible that he also had pancreatitis in setting of ETOH binge. The patient's lipase was 14 so we did not suspect a pancreatic process. Nonetheless, he was kept NPO and given IVF in the setting of his GIB. Pain remained a [5-30] in serverity throughout hospitalization (baseline is [2-27]), for which he was given morphine, then dilaudid, then oxycodone (at his home dose). He was supplied with a limited amount of oxycodone until his PCP appointment on [2131-7-24]. He was advised not to drink ETOH with this medication. He also had some anxiety surrounding this pain and his social situation, for which he was given a limited supply of ativan (also advised not to drink ETOH with this medication). He was also given PRN lactulose for constipation from narcotic use. # Anion gap: With metabolic acidosis with anion gap of 16 on admission. Supect this was likely ketoacidosis in setting of ETOH. Lactate was 1.5. Gap has since closed. # QT prolongation: Initially QTc 460, on QT prolonging meds at home. There was concern that starting ciprofloxacin for SBP ppx would also prolong QT. Cipro was d/c'd in the setting of no active variceal bleed, and repeat EKG did not show any further prolongation. Notably, the patient was also on multiple antipsychotics which can cause QT prolongation, which were held in the ICU, but restarted on the floors. The patient was restarted on ciprofloxacin as an outpatient in light of fever while on the floors (see below). # Fever: After transfer to the floor, the patient had a temperature to 101. There was no obvious source of infection. Urine culture was negative and blood cultures have been negative to date. In light of abdominal pain, ? biliary origin was suspected, but bilirubin had trended down from 2.0 to 1.0 and 0.8 on the day of the fever. He had no evidence of biliary collection on abdominal ultrasound. He was started on ceftriaxone 1gram Q24 with the temperature spike and continued on this for three days. He was then given an additional 7 days of ciprofloxacin to be completed on [2131-7-27]. # Coagulopathy: Likely related to poor liver synthetic function. Vit K deficiency also possible in setting of poor nutrition. The patient received Vit K x1. Would recommend rechecking INR at a later date and further outpatient workup. Medications on Admission: Celexa 40 Quetiapine 400 Trazodone 200 Multivitamin Propranolol 10 [Hospital1 ] Prilosec 40 Ambien 10 Pancrease with meals Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Quetiapine 400 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 4. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please measure your pulse. If it is less than 60, do not take this medication. Disp:60 Tablet(s) Refills:2 10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: please continue until [2131-7-27]. Disp:7 Tablet(s) Refills:0 12. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO Q8 PRN as needed for anxiety: DO NOT DRINK ALCOHOL with this medication. It can also make you tired. Disp:10 Tablet(s) Refills:0 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6-8 PRN as needed for pain: Do not drink alcohol with this medication. . Disp:10 Tablet(s) Refills:0 14. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO three times a day: Please use as needed until having regular bowel movements. Disp:500 ml Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Acute upper GI bleed 2. Cirrhosis 3. Esophageal Varices 4. Esophagitis 5. Portal Gastropathy 6. Chronic Pancreatitis 7. Alcohol Dependence Discharge Condition: Stable hematocrit, afebrile x 24 hours, no signs of withdrawal, stable vital signs Discharge Instructions: You were admitted to the hospital on [2131-7-15] because you were vomiting blood. You had an upper endoscopy, which showed that you have varices (dilated blood vessels) in your esophagus, inflammation of your esophagus, and portal gastropathy (dilated blood vessels in your stomach). You should continue to take propanolol to prevent bleeding, but be sure to take your pulse before taking this medicine. Only take it when your pulse is more than 60 beats per minute. Your abdominal pain is secondary to chronic pancreatitis. You are being discharged with a limited supply of oxycodone for your pain. Do not drink alcohol while taking this medication. You should follow up with your PCP for pain management this week. Avoid NSAIDS like aspirin and ibuprofen, as these pain medications can cause GI bleeding. If you choose to use tylenol, be sure not to exceed 2 grams in 24 hours because you have liver disease. You are also being discharged with lorazepam (ativan) 0.5mg, which you can take as needed for anxiety. Never drink alcohol with this medication. Note that this medication can also make you drowsy. You had a fever, which may indicate infection, while you were in the hospital. Continue to take ciprofloxacin until [2131-7-27]. The following changes were made in your medications: START taking thiamine, folate, protonix (2x a day), sucralfate (4x a day), and lactulose (3x a day as needed for constipation). START taking lorazepam and oxycodone as needed. START taking ciprofloxacin until [2131-7-27]. ONLY take your propanolol when your heart rate is greater than 60 beats per minute. STOP taking prilosec. STOP taking ambien (because you have liver disease). You have met with our social worker regarding alcohol abstinence. You were advised of the risks associated with continued alcohol use, including worsening medical condition. Return to the ER if you experience fevers/chills, loss of consciousness, bloody stools, bloody vomit, abdominal pain worsening in severity or quality, chest pain, shortness of breath, or any other symptoms concerning to you. Followup Instructions: 1. Please keep your appointment with Dr. [Last Name (STitle) 75523] on [2131-7-24]. 2. Please schedule an appointment with your psychiatrist in one week. 3. Please schedule an appointment with the hepatology clinic in [12-22] weeks. The phone number is [Telephone/Fax (1) 2422].	[ "571.2", "296.80", "537.89", "276.2", "577.1", "300.00", "303.91", "456.20", "780.60", "284.1", "794.31", "286.9", "530.19" ]	icd9cm	[ [ [] ] ]	[ "96.07", "45.13", "94.62" ]	icd9pcs	[ [ [] ] ]	14970, 14976	8630, 13046	289, 314	15162, 15247	3306, 8607	17395, 17696	2750, 2781		13224, 14947		14997, 15141		13072, 13201			15271, 17372									2796, 3287																1929, 2114				241, 251										342, 1910														2136, 2576	2592, 2734
48,373	161,511	39089	Discharge summary	report	Admission Date: [2182-4-26] Discharge Date: [2182-5-4] Date of Birth: [2117-7-15] 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: Coronary artery bypass grafting x3: Left internal mammary artery graft, left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery. [2182-4-30] History of Present Illness: 64 yo M with past medical history significant for positive family history of premature coronary artery disease who was admitted to OSH [2182-4-24] with exertional chest pain. He ruled out for MI, but had a positive stress test and was transferred to [Hospital1 18] for cardiac catheterization. We are asked to consult for surgical revascularization Past Medical History: coronary artery disease hypercholesterolemia Hypertension GERD colon polyps Social History: Occupation:Electrician Tobacco:quit 3-4 months ago [2-16] ppd x 30 years ETOH:couple of beers/week Family History: Twin Brother died of MI age 53 Physical Exam: Pulse:71 Resp:18 O2 sat:97% RA B/P Right: Left: 157/91 Height:5'9" Weight:97.5kg General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [] 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] Extremities: Warm[x] well-perfused[x] Edema/Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [Name (NI) 167]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post-bypass: The patient is not receiving inotropic support post-CPB. Biventricular systolic function is preserved. All findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were communicated to the surgeon. [2182-5-4] 07:10AM BLOOD WBC-11.9* RBC-4.09* Hgb-11.0* Hct-34.2* MCV-84 MCH-27.0 MCHC-32.2 RDW-14.0 Plt Ct-289 [2182-5-4] 07:10AM BLOOD Glucose-88 UreaN-20 Creat-1.0 Na-140 K-4.2 Cl-101 HCO3-28 AnGap-15 Brief Hospital Course: The patient was admitted to the hospital for cardiac cath and preop testing. He did have a urinary tract infection which was treated with cipro. He was brought to the operating room on [2182-4-30] where the patient underwent coronary artery bypass x 3. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given the length of his preoperative stay. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamics were maintained with neo-synephrine. This was weaned and 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. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: ASA 325mg daily Colace 100mg po daily Lisinopril 10mg po daily Zolpidem 5mg po qHS PRN Simvastatin 40mg po daily Plavix - last dose:300mg [4-26] Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/fever . 4. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks. Disp:28 Tablet(s) Refills:0 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 8. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours) for 1 doses. Disp:3 Tablet(s) Refills:0 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:qs Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: coronary artery disease PMH: hypercholesterolemia Hypertension GERD colon polyps Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr.[Last Name (STitle) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 55984] in [2-16] weeks Cardiologist Dr. [Last Name (STitle) ],[First Name3 (LF) 177] A. [Telephone/Fax (1) 5315] in [2-16] weeks Completed by:[2182-5-4]	[ "041.85", "599.0", "272.0", "997.5", "410.71", "414.01", "530.81", "458.29", "788.5", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.12", "39.61", "37.22", "00.66", "36.15", "00.40", "88.56" ]	icd9pcs	[ [ [] ] ]	5824, 5885	3173, 4461	331, 536	6010, 6106	1844, 3150	6646, 7071	1160, 1193		4661, 5801		5906, 5989		4487, 4638			6130, 6623									1208, 1825																				281, 293										564, 923														945, 1023	1039, 1144
27,695	182,483	656	Discharge summary	report	Admission Date: [2104-10-7] Discharge Date: [2104-10-20] Date of Birth: [2046-8-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Transferred from OSH for management of CAD, PCI vs CABG Major Surgical or Invasive Procedure: [10-15] CABG x 4 History of Present Illness: This is a 58 year old male with a history of hypertension, type II DM, hyperlipidemia, chronic renal insufficiency, and polysubstance abuse who presents from an OSH s/p cardiac cath for further management of his coronary disease. Per report from [Hospital6 5016], Mr. [Known lastname ] was admitted on [2104-9-30] with epigastric discomfort that subsequently developed into chest pain radiating to the jaw and left shoulder. Per the patient, he has been having intermittent abdominal pain associated with nausea and vomitting for approximately 2.5 weeks to 1 month. The abdominal pain is in the epigastrium, not associated with eating or with position and is non-radiating. The abdominal pain has resolved since being in the hospital. . On the evening of [2104-9-30], he reports that his abdominal pain, was accompanied by 8 out of 10 substernal chest pain. The chest pain radiated to his jaw and left shoulder. This pain lasted for approximately 1 hour and resolved in the ED at [Hospital3 ]. He does not recall precipitating factors for this chest pain. But does report that his roommate informed him that he had "passed out" for an unknown period of time on this same evening. The patient does not recall this event. . At [Hospital6 5016], he was found to have a Utox positive for cocaine and benzos. From review of records, his cardiac markers were negative x 1, and it is unknown whether there were any EKG changes. Per report, he was advised to undergo a cardiac cath, but the patient was initially reluctant, until today, the patient finally became agreeable to the procedure. On cardiac cath at [Hospital3 ], he was found to have 95% RCA, 90% LAD, and 90% LCx disease. He was transferred to [Hospital1 18] for further management of his coronary disease, originally for plans for PCI. . On arrival to the [Hospital1 18] cath holding area, he reported having 5/10 chest pain. He was given SL NTG x 2, lopressor IV 5 mg x 1, and NTG gtt. He became hypotensive to SBP 60s and was given IVF NS 400cc which brought up his blood pressure to SBP 130s. He was restarted on NTG gtt for persistent chest pain. No EKG findings noted at the time. Per evaluation by Dr. [Last Name (STitle) ], he was transferred to the CCU with plans for CABG. He currently denies chest pain. He does report that he has [7-8] diffuse HA that started earlier today since being started on the nitro gtt. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Insulin dependent diabetes mellitus Hyperlipidemia Cocain abuse Tobacco abuse Chronic Renal Insufficiency (Cr 1.3 to 1.5 at baseline) GERD "Stomach ulcers" Social History: He currently lives with a friend, is unemployed. He smokes [1-1] PPD to 2 PPD x 40 years, reports active cocaine use (he last used 2 weeks ago), has been drinking ETOH "more than usual" since his wife's death, he reports "blacking out" from ETOH binges, but denies history of seizures or DTs from withdrawl. 0/4 CAGE questionnaire. He denies IVDA. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 96.9 , BP 165/95 , HR 61 , RR 16 , O2 100 % on 2 L NC Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, JVP flat. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Right groin cath site with dressing dry and in tact. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: CAROTID SERIES COMPLETE [2104-10-8] 2:19 PM IMPRESSION: No significant ICA or CCA stenosis bilaterally . CHEST (PRE-OP PA & LAT) [2104-10-8] 10:08 AM The lungs are clear. There is minimal bilateral apical pleural thickening. There is no pneumothorax. The cardiac silhouette and pulmonary vasculature are within normal limits. IMPRESSION: No acute cardiopulmonary process. . TTE [2104-10-8] at 10:16:08 AM The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). There is mild focal hypokinesis of the mid infero-lateral segment. 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) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Torn mitral chordae are present. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . PFTs: WNL CHEST (PA & LAT) [2104-10-19] 8:20 AM Two views. Comparison with [2104-10-17]. A slight interval change in streaky density of the left base consistent with subsegmental atelectasis. No pleural fluid is identified. The right lung remains clear. The patient is status post median sternotomy and CABG as before. There is a homogenous density in the retrosternal space consistent with postsurgical change. The bony thorax is grossly intact. IMPRESSION: Mild subsegmental atelectasis left base. No pleural effusion is identified. Post-surgical change in the mediastinum. [2104-10-20] 10:55AM BLOOD Hct-30.6* [2104-10-18] 07:15PM BLOOD WBC-10.5 RBC-3.17* Hgb-9.9* Hct-28.5* MCV-90 MCH-31.3 MCHC-34.9 RDW-14.1 Plt Ct-285 [2104-10-7] 09:00PM BLOOD WBC-7.2 RBC-4.15* Hgb-12.6* Hct-36.5* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.8 Plt Ct-257 [2104-10-18] 07:15PM BLOOD Plt Ct-285 [2104-10-15] 12:20PM BLOOD PT-13.3* PTT-35.4* INR(PT)-1.2* [2104-10-7] 09:00PM BLOOD PT-12.7 PTT-25.4 INR(PT)-1.1 [2104-10-7] 09:00PM BLOOD Plt Ct-257 [2104-10-20] 10:55AM BLOOD Glucose-172* UreaN-27* Creat-1.4* Na-140 K-4.5 Cl-99 HCO3-31 AnGap-15 [2104-10-18] 07:15PM BLOOD Glucose-277* UreaN-27* Creat-1.6* Na-135 K-4.4 Cl-96 HCO3-28 AnGap-15 [2104-10-17] 02:18AM BLOOD Glucose-109* UreaN-16 Creat-1.2 Na-138 K-4.4 Cl-101 HCO3-27 AnGap-14 [2104-10-7] 02:30PM BLOOD Glucose-152* UreaN-19 Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-26 AnGap-13 [2104-10-7] 02:30PM BLOOD ALT-18 AST-14 CK(CPK)-63 AlkPhos-139* Amylase-54 TotBili-0.3 DirBili-0.1 IndBili-0.2 Brief Hospital Course: He continued to be chest pain free, but was kept on the heparin gtt until surgery. For his history of Abdominal pain/history of "ulcers, he refused stool guaiac, but GI consultation was obtained which showed that the patient had no current need for endoscopy. Tox screen for cocaine was negative, and he was seen by addiction services and social work. He was taken to the operating room on [10-15] where he underwent a CABG x 4. He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was transferred to the floor on POD #2. He did well postoperatively and was ready for discharge home on POD 5. Medications on Admission: ASA 325 Diltiazem 120 Lopid 600 [Hospital1 ] Protonix 40 Lantus 50 qhS Lexapro 10 Ativan prn Ambien 10 qhs Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. 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 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 8. Toprol XL 100 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:0 9. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Lantus 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. Disp:QS 1 month Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Agency Discharge Diagnosis: primary: 3 vessel coronary artery disease Secondary: cocaine dependence hypertension diabetes renal insufficiency GERD Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions,creams or powders to incisions. No heavy lifting or driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) 5017] 2 weeks Dr. [Last Name (STitle) ] 4 weeks Completed by:[2104-10-21]	[ "414.01", "585.9", "403.90", "250.60", "272.4", "304.20", "530.81", "305.1", "357.2" ]	icd9cm	[ [ [] ] ]	[ "99.04", "39.61", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]	9797, 9867	7601, 8252	378, 401	10031, 10039	4937, 7578	10324, 10436	3962, 4044		8414, 9774		9888, 10010		8278, 8391			10063, 10301									4059, 4918																				283, 340										429, 3384														3406, 3577	3593, 3946
12,613	168,201	16564+16595+56779+56780	Discharge summary	report+report+addendum+addendum	Admission Date: [2135-12-27] Discharge Date: [2136-10-17] Date of Birth: [2075-9-3] Sex: M Service: SURGERY Allergies: Remicade Attending:[First Name3 (LF) 4111] Chief Complaint: 60M with fistulizing Crohn's s/p subtotal colectomy and end iliostomy originally presenting on [2135-12-28], with progressively worsening weight loss, poor exercise tolerance and worsening peristomal fistula. Major Surgical or Invasive Procedure: 1. Exploratory laparotomy 2. Lysis of adhesions (four hours) 3. Drainage of peritoneal abscess 4. Ileal resection 5. Recreation of ileostomy 6. Enterotomy and closure 7. Feeding jejunostomy 8. Debridement of abdominal skin and subcutaneous tissue right lower quadrant 9. Reapproximation of fascia 10. Closure of right ileostomy site 11. Therapeutic flexible bronchoscopy at 12. Placement of tracheostomy 13. PICC line placement 14. AICD monitoring/interrogation History of Present Illness: 60M with history of Crohn's (dx in '[08]). Has had muyltiple EC fistulae and repairs, ultimately leading to end ileostomy. Presented with increased weakness/fatigue, 20lb. weight loss, increasing greenish outout from ostomy. Past Medical History: Crohn's Crohn's fistula Cachexia cardiomyopathy '[10] ileostomy and total colectomy ([3-/2114]) Fistula repair x3 (twice in 86, again in 98) AICD placed [8-11] pulmonary fibrosis h/o v. tach Social History: smoked 1.5 PPD for 40 years, moderate ETOH Family History: Non-contributory Physical Exam: 100.3 106 100/68 12 96RA 55Kg A&Ox3, NAD lungs CTA Cardiac RRR, no M/R/G Well healed scar from AICD plcmt Abdomen soft, diffusely tender iliostomy pink, healthy appearing fistula with mod. amt. of greenish output LE warm, well perfused guiac positive Pertinent Results: WBC7.0 HCT 41.5 plt. 155 PT 13.8 PTT 28.6 INR 1.2 Na 131 K 4.6 Cl 27 CO2 26 BUN 19 Cr .9 Glu 83 Ca 8.5 Mg. 1.6 Alb 2.7 Brief Hospital Course: Surgical (chief complaint) [2136-1-11] Fistulogram performed, showing stricture of the distal small bowel adjacent to the ostomy site. Contrast injected into the patient's suspected enterocutaneous fistula demonstrated communication with small bowel. [2137-1-25] Exploratory laparotomy; lysis of adhesions (four hours); drainage of peritoneal abscess; ileal resection; recreation of ileostomy; enterotomy and closure and feeding jejunostomy with general surgery ([Doctor Last Name 957]). Debridement of abdominal skin and subcutaneous tissue right lower quadrant, reapproximation of fascia, closure of right ileostomy site, placement of VAC dressing and delay of tensor fascia lata flap of the right leg with plastics ([Location (un) ]). Post-op, patient was kept intubated and swan left in place. Intermittent hypotension required multiple transfusions and levophed drip. By POD 2, the flap placed by plastics becmae increasingly congested (thought to be due to pressor use), and was ultimately lost. Pressors were eventually d/c'd on POD#4. Abdominal wound re-opened as plastics flap died. This was ultimately allowed to heal by secondary intent with a wound vac. [2136-2-9]- As patient continued to have febrile episodes and leukocytosis, he had an abdominal CT which confirmed no anastomotic leaks or fluid collections. [2136-2-17]-The patient developed a communication between his ostomy and his wound. This was repaired at the bedside by plastics with alloderm. Neuro [2136-2-25] The patient started having episodes of body jerking in setting of elevated pCO2 and BUN. His exam [Last Name (un) ] nonfocal and notable for inability to follow commands. The body jerking was consistent with myoclonic jerks that was though to be due to metabolic abnormalities or seizures. An EEG was abnormal due to the presence of a slow and disorganized background rhythm in the 6 to 7 Hz theta frequency range with generalized bursts of 1 to 2 Hz delta frequency slowing. The findings suggested deep, midline subcortical dysfunction, consistent with an encephalopathy. In addition, occasional delta frequency slowing was seen independently over the frontal temporal regions and this suggests multi focal subcortical dysfunction affecting the anterior quadrants. No epileptiform abnormalities were seen. Ultimately, these mental status changes were deemed to be metabolic, and resolved as TPN & tube feeds were adjusted. Pulmonary [2135-12-27]- PFTs for operative clearance [2136-1-26]- Post-op, there was persistent diffculty weaning the patient from the ventilator, ultimately requiring a trachesotomy. [2136-2-2]- Re-intubated for pulmonary distress. Self-extubated the following day and and aspirated. Bedside therapeutic flexible bronchoscopy performed. Airway cleared of bile. Continued to have right middle lobe and right lower lobe partial collapse. Multiple repeat bronchoscopies. [2136-2-3]-Repeat bronchsocopy for continued poor oxygenation. [2136-2-11]- As the patient's fluid requirments went up, oxygenation became more and more difficult. Likewise, vent wean became impossible. As this fluid was slowly diuresed, oxygenation improved dramatically. [2136-2-16]- percutaneous trachesotomy for slow wean from vent. There was very little progress with vent weant. As diuresis progressed, however, the patient could tolerate longer and longer periods of CPAP, and ultimately trach collr trials. Of note, the patient developed a pattern where he would often "loose his respiratory drive" while lying in bed. While never apnic, pC02 ofte increased and there was increased lethargy. These episodes could never be linked to over sedation, and it was observed that simply moving the patient to a reclining chair would often result in increased alterness and improved respiratory drive. [2136-2-17]-The patient had the first of several v-ach episodes. All subsequently ruled-out for MI Cardiac [2135-12-27]-Cardiac work-up for possible operation. EF 50% [2136-1-27]-First of several V. tach events,vital signs remained stable throughout. AICD interrogated and adjusted. [2136-2-11]-Starting on POD 9, the patient had the first of several hypotensive events. These epidoses usually saw SBPs in the 60-90 range. However, urine output stayed acceptable, and the patient was mentating throughout. Fluid boluses had to be given very sparingly in that oxygenation became more and more of an issue. Nutrition [2135-12-28]-Subclavian attempted for TPN [2136-1-8]-PICC placed for nutrition, TPN started. [2136-1-30]-Trickle tube feeds started through J-tube. [2136-2-2]-CVL re-sited to R. IJ [2136-2-11]-As attempts were made to slowly advance tube feeds, progress was slowed by [Doctor First Name ] residuals. Ultimately an upper GI with small bowel follow-through was done, which confirmed that there were no structural obstrctions. With the addittion of reglan, TF tolerance gradually improved. Patient ultimately tolerated hepatamine very well. [2136-2-28]-Patient "tolerated" placement of passy muir valve in that he did not desat or present with any overt respiratory distress when the cuff was down and the PMV placed, but his vocal quality was very weak and barely audible. [2136-3-6]-Underwent a repeate swallow. Trials of thin and nectar thick liquids were attempted with the cuff deflated. The patient's pharyngeal swallow was stronger and more effective, with less residue remaining, decreasing his risk of aspiration. Since pt's performance was noted to be better with cuff deflated, as he continued to wean from the vent and wa able to tolerate trach collar, it is suggested that PO trials be attempted with cuff deflated as tolerated. Heme By [2136-1-29], patient was having persistent thrombocytopenia. All heparin was stopped and access devices were changed to heaprin-free, although all asssays for HIT anti-bodies ultimately came back negative. ID Pre-op, the patient was found to have pneumonia, multi resistant E. coli, treated with Zosyn. Also, there was yeast in urine pre-op, treated on fluconazole. Thereafter, he developed intermittent septicemia, treated with Zosyn. Post-op, patient was started on vancomycin, levofloxacin, flagyl and fluconazole. As he continued to febrile episodes, he was treated empirically with meropenum and fluconazole. [2136-2-13] Patient was started on linezolid for VRE. [2136-3-17]-All Abx were d/c'd Renal [2136-1-23] Intermittent azotemia and ARF developed as patient was advanced on TPN. Amino acids changed to nephromine. [2136-2-11] POD [10/2081], the patient underwent a very gentle, slow diuresis with lasix. Ultimately 20-30kg of fluid weight was gradually removed. Summary As Mr. [Known lastname 47006] pulmonary, cardiac, nutrition, and surgical issues improved, there were more and more opportunites for physical rehab. In general he responded very well to these sessions. Likewise, oral feeding was well tolerated so long as it was done under close supervision. Discharge Medications: Erythromycin 0.5% Ophth Oint 0.5 in OD QID Gabapentin 300 mg PO HS Bismuth Subsalicylate 60 ml PO TID mixed with 480 cc of tube feedings q 8rs Loperamide HCl 3mg ORAL [Hospital1 ] Ipratropium Bromide Neb 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Morphine Sulfate (Oral Soln.) 1-2 mg PO Q4-6H:PRN Paroxetine HCl 40 mg PO DAILY Metoclopramide 10 mg IV Q6H Insulin SC Sliding Scale Epoetin Alfa 4000 UNIT SC Pantoprazole 40 mg IV Q12H Nystatin Oral Suspension 1 ml PO QID traZODONE HCl 25 mg PO HS:PRN Folic Acid 1 mg PO DAILY Sotalol HCl 40 mg PO BID Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: (see admission diagnosis) Resolving meatbolic encephalopathy Resolving ileus Recurrent sepsis Slow vent wean Pulmonary fibrosis Discharge Condition: stable, regimen on TPN and TFs unchanged for 2 weeks. Discharge Instructions: Physical rehab as prescribed. Will arrange follow-up with Dr. [Last Name (STitle) 957]. Completed by:[2136-4-10] Admission Date: [2135-12-27] Discharge Date: [2136-10-16] Date of Birth: [2075-9-3] Sex: M Service: [Last Name (un) ] ADDENDUM: As previously summarized in earlier discharge summaries, this patient has had a complex hospital course. This dictation will summarize the events essentially from the last discharge summary up until his anticipated discharge on [2136-10-16] or shortly thereafter. The patient largely had an unremarkable hospital course for the latter month of his stay. On [9-20] and 12, it was noted that the patient did have multiple episodes of ventricular bigeminy as well as frequent PVCs that could not be explained by electrolyte abnormalities or otherwise. The cardiology and electrophysiology services were consulted and the electrophysiology service ended up interrogating and readjusting the patient's AICD in place. Subsequent to this, the patient had also some adjustments of his antiarrhythmic and antihypertensive medications into a more stable regimen. Other than this, the patient had only one significant event for the remainder of hospital stay. This occurred on [2136-10-12]. On this date, the patient had what in retrospect turned out to be a hypoglycemic seizure. Further workup including head CT and EEG remained negative. The neurology service was consulted and did agree that the patient had a significant hypoglycemic seizure. They had no significant recommendations following this. From another physiologic standpoint, the patient continued to do well and weaned off of his ventilator dependence slowly but surely. On the date of this dictation, [2136-10-16], the patient could tolerate approximately 6 hours on tracheostomy mask collars with no ventilatory support at that time. He had not as of yet been attempted either overnight or for 24 hour period without ventilator support. He was tolerating his tube feeds, however, and had a euvolemic fluid balance that was auto-maintained. His stoma functioned well and without difficulty. The patient was free of pain and cognizant of all the issues going on around him. He and his sister were ready for transfer to rehab with intermittent ventilator support. MEDICATIONS AT TIME OF DISCHARGE ON [2136-10-16]: 1. Captopril 6.25 mg t.i.d. 2. Sotalol 120 mg b.i.d. 3. Prednisone 5 mg t.i.d. 4. Insulin sliding scale - please see attached handout. 5. Vitamin B12 1000 mcg injection every 2 weeks x 4 more weeks. 6. Ferrous sulfate 500 mg daily. 7. Folate 1 mg daily. 8. Prevacid 30 mg b.i.d. 9. Imodium 2 mg q.4h. 10. Paxil 40 mg daily. 11. Zinc sulfate 220 mg daily. 12. Nystatin suspension 20 ml b.i.d. in tube feed. 13. Tylenol p.r.n. 14. Combivent inhaler 1-2 puffs q.4h. 15. Potassium iodide 0.5 ml t.i.d. 16. Kaopectate 30 ml t.i.d. 17. Pyridoxine 50 mg daily. 18. Epogen 4000 units subcutaneously Monday, Wednesday and Friday. 19. Meropenem 1 g IV q.8h. DIET: The patient has tolerated 2/3 strength Impact with fiber at a rate of 110 cc/hr through his jejunostomy tube. DISPOSITION: The patient should go to rehab. INSTRUCTIONS: 1. The patient should follow up with Dr. [Last Name (STitle) 957] in 4 weeks' time. 2. He should continue to increase the length of his tracheostomy mask trials with aggressive pulmonary toilet with the goal of independence from mechanical ventilation. 3. The patient should have careful attention paid to his stage 1 decubitus ulcer on his coccyx. 4. The patient should work with physical therapy and occupational therapy to regain strength and with a goal of being ambulatory. Should the patient experience significant symptoms of abdominal pain, nausea or vomiting or other worrisome symptoms such as fever, he should return to see Dr. [Last Name (STitle) 957] in the office. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 26005] Dictated By:[Last Name (NamePattern1) 23688] MEDQUIST36 D: [2136-10-16] 09:06:04 T: [2136-10-16] 09:37:46 Job#: [Job Number 47050] Name: [Known lastname 8675],[Known firstname ] Unit No: [Numeric Identifier 8676] Admission Date: [2135-12-27] Discharge Date: [2136-10-17] Date of Birth: [2075-9-3] Sex: M Service: SURGERY Allergies: Remicade / Heparin Sodium Attending:[First Name3 (LF) 484] Addendum: In brief, the patient is a 60-year-old gentleman who has had a long complicated hospital course, which has been fully detailed in a prior discharge summary. He has a long history of Crohn's disease. He has been at [Hospital1 8677] for complications resulting from an enterocutaneous fistula. At the start of this segment of his hospital course, had an episode of sepsis and was re-admitted to the surgical intensive care unit with alter mental status changes, on a ventilator, and tube feeds. The following details his hospital course that spans [Date range (3) 8678]: He was immediately treated with antibiotics. Due to subsquent bacterial/fungal growths in his sputum, urine, and blood a long course of anibiotics and antifungals, including Vancomycin, Cefepine, Gentamycin and Ambisone, were administered and his condition slowly improved over this period. However, he continues to have intermittent respiratory distress with oxygen desaturations and hypercapnea, tachycardia, and hypertension. In the early course of this duration he had episoes of myoclonic jerks. An EEG was done on [2136-4-27] showed no seizure activities, but abnormal presence of a slow and disorganized background consistent with a mild to moderate encephalopathy of toxic, metabolic, or anoxic etiology. This condition eventually resolved when metabolic causes of mutipharmacy was reduced. An echocardiography was done on [2136-5-24] showing the left ventricular systolic function less vigorous when compared to the same study done on [2136-1-27], A bronchoscopy was done on [2136-5-25] showing no abnormal airways and no TBM. He has been followed very closely by physcial therapy to work on improving his deconditioned state. Pertinent Results: RESPIRATORY CULTURE (Final [2136-5-2]): PSEUDOMONAS AERUGINOSA. MOD GROWTH RESPIRATORY CULTURE (Final [2136-5-12]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES. PROTEUS MIRABILIS. UNKNOWN AMOUNT. RESPIRATORY CULTURE (Final [2136-5-11]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES. PROTEUS MIRABILIS. SPARSE GROWTH. RESPIRATORY CULTURE (Final [2136-5-18]): PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. PROTEUS MIRABILIS. MODERATE GROWTH. AEROBIC BOTTLE (Final [2136-5-25]): CITROBACTER FREUNDII COMPLEX. RESPIRATORY CULTURE (Final [2136-6-6]): PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH. URINE CULTURE (Final [2136-6-27]): YEAST. 10,000-100,000 ORGANISMS/ML RESPIRATORY CULTURE (Final [2136-6-29]): PSEUDOMONAS AERUGINOSAS 10,000-100,000 ORGANISMS/ML. RESPIRATORY CULTURE (Final [2136-7-8]): PSEUDOMONAS AERUGINOSA. MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. YEAST. MODERATE GROWTH. URINE CULTURE (Final [2136-7-10]): YEAST. >100,000 ORGANISMS/ML.. AEROBIC BOTTLE (Final [2136-7-16]): ENTEROCOCCUS FAECALIS. WOUND CULTURE (Final [2136-7-16]): ENTEROCOCCUS SP. >15 colonies. URINE CULTURE (Final [2136-7-17]): YEAST. 10,000-100,000 ORGANISMS/ML. 2ND ISOLATE. <10,000 organisms/ml. RESPIRATORY CULTURE (Final [2136-7-26]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML OF TWO COLONIAL MORPHOLOGIES RESPIRATORY CULTURE (Final [2136-7-27]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML OF TWO COLONIAL MORPHOLOGIES. [2136-5-2] 05:03AM BLOOD WBC-12.5# RBC-4.16 Hgb-11.7* Hct-38.7* MCV-93 MCH-28.2 MCHC-30.4* RDW-14.8 Plt Ct-170 [2136-5-12] 03:52AM BLOOD WBC-3.9* RBC-3.36* Hgb-9.8* Hct-31.6* MCV-94 MCH-29.1 MCHC-31.0 RDW-16.0* Plt Ct-112* [2136-5-21] 03:49AM BLOOD WBC-3.9# RBC-3.02 Hgb-8.9* Hct-27.8* MCV-92 MCH-29.6 MCHC-32.2 RDW-15.8* Plt Ct-90* [2136-5-23] 11:48AM BLOOD WBC-19.6# RBC-3.18 Hgb-9.4* Hct-30.0* MCV-94 MCH-29.4 MCHC-31.2 RDW-15.4 Plt Ct-83* [2136-5-24] 02:49PM BLOOD WBC-24.7* RBC-3.05* Hgb-8.7* Hct-28.0* MCV-92 MCH-28.5 MCHC-31.0 RDW-15.5 Plt Ct-77* [2136-5-25] 03:19AM BLOOD WBC-16.7* RBC-2.84* Hgb-8.1* Hct-26.2* MCV-92 MCH-28.5 MCHC-31.0 RDW-15.3 Plt Ct-61* [2136-6-5] 03:35AM BLOOD WBC-2.9* RBC-2.61* Hgb-7.3* Hct-23.4* MCV-90 MCH-28.0 MCHC-31.2 RDW-14.9 Plt Ct-154 [2136-6-26] 01:41PM BLOOD WBC-20.7* RBC-4.81 Hgb-13.6* Hct-42.4 MCV-88 MCH-28.3 MCHC-32.1 RDW-16.8* Plt Ct-166 [2136-7-14] 03:19AM BLOOD WBC-3.6* RBC-2.94* Hgb-8.1* Hct-25.6* MCV-87 MCH-27.4 MCHC-31.4 RDW-16.4* Plt Ct-58* Discharge Disposition: Extended Care Facility: [Hospital6 41] - [Location (un) 42] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 485] MD [MD Number(1) 486] Completed by:[2136-9-16] Name: [Known lastname 8675], [Known firstname ] Unit No: [Numeric Identifier 8676] Admission Date: [2135-12-27] Discharge Date: Date of Birth: [2075-9-3] Sex: M Service: [Last Name (un) ] ADDENDUM: This is going to span the time from [2136-7-22] until [2136-9-14]. In brief, the patient is a 60-year-old gentleman who has had a long complicated hospital course, which has been fully detailed in a prior discharge summary. In brief, he has a history of Crohn's disease originally. He is from [Location (un) 8679], who has been in the hospital being treated for complications resulting from an enterocutaneous fistula. At the start of this segment of his hospital course, the patient has been in Intensive Care Unit on a ventilator undergoing therapy for respiratory infection for fungemia and bacteremia. The following details his hospital course. On [2136-7-23], the patient was taken to the operating room by the thoracic surgical team, where he underwent a video- assisted thoracoscopy and pleurodesis of his right chest. This was performed for a persistent right pleural effusion and persistent pneumonia, which was refractory to therapy. He tolerated this procedure well and postoperatively was in the Intensive Care Unit with 3 chest tubes to 20 cm of water suction. He, otherwise, remained hemodynamically stable. He received both parenteral and antral nutrition and remained on antibiotics, including Vancomycin and meropenum for pseudomonas and enterococcal positive cultures from the sputum and urine, respectively. Postoperatively, he continued to undergo vent weaning, antibiotics therapy, and physical therapy. He remained on antral and parenteral nutrition. The thoracic team subsequently began a chemical pleurodesis at the bedside over the course of 3 days to help reduce pleural fluid drainage. He, otherwise, remained in stable condition. During the next days of his recovery, he was diuresed, after the VAT pleurodesis remained approximately 8 kg above his dry weight, and this was diuresed gently over the next several days and weeks. After receiving a full course of antibiotics on [8-3], his antibiotics were discontinued, continued ventilatory wean, and diuresis. On [8-5], a routine blood culture that had been sent demonstrated gram negatives. Gram-negative bacteremia, though remained hemodynamically stable, meropenem was restarted at this time. He was continued with the diuresis and vent wean. At this point, once we had him to dry weight, we had quite a bit of difficulty with his ventilatory wean. There was a component of it, which appeared to be due to anxiety when he would go on to trach mask trials. We attempted to relieve this with p.r.n. Ativan, which seemed to work well, and he did have periods of time where he would remain on a trach collar for a significant amount of time. On [8-16], he developed an episode where he had a 12-beat run of V-tach. This spontaneously resolved. An echocardiogram was performed, which demonstrated a global hypokinesis and an EF of 25-30%, which had actually decreased from a previous echocardiogram, which was 45%. He was ruled out for myocardial infarction and cardiology was called. They felt at this time, this may be an overall indication of his stress from his severe illness. This also be an indication of why he was having a difficult time weaning from the vent. We did adjust his anti- arrhythmics to optimize him to help prevent future events such as these and give him optimal regimen, too. Also during this time, the chest tubes were removed by the thoracic team. On [2136-8-21], the patient spiked a temperature to 100.9 with accompanied tachycardia and hypotension. He was given some fluids and pan cultured. He also had a thrombocytopenia of 78. He was immediately started on broad-spectrum antibiotics, including fungal coverage. He was documented to have fungemia. After changing his left subclavian line over a wire, the decision was made to transition him completely to tube feeds, discontinue his parenteral nutrition, and re-site his line to the right IJ. He also underwent bronchoscopy, which was okay. A chest x-ray showed an accumulation of right pleural effusion, and this was tapped via percutaneous pigtail catheter in the radiology lab. After this episode of sepsis, his recovery was quite slow, but he did make progress every day. He was treated with a full course of caspofungin, continued on meropenum, and he had empiric Vancomycin, but there was no gram positive cultures, and this was discontinued after several days. The catheter tip also grew yeast, and this was felt to all be due to the parenteral nutrition he had been receiving. There would be no glucose through his IVs from this point on. Since then, he has continued to recover. He required further diuresis, and he is now currently at his dry weight, weaning off the ventilator, albeit slow, but he does make progress every day. He has been receiving physical therapy. He has been out of bed, at the edge of the bed, though he is yet to have weight beared fully, as he is severely deconditioned. He is receiving nutrition completely via the jejunostomy tube. Ileostomy has been functioning normally. At this point, the best course of action would be for him to continue with a ventilatory wean, perhaps at a facility which would better suit his chronic respiratory failure and who would be able to better situate him. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 7851] Dictated By:[Last Name (NamePattern1) 8680] MEDQUIST36 D: [2136-9-14] 17:19:24 T: [2136-9-15] 14:19:24 Job#: [Job Number 8681] cc:[Last Name (NamePattern4) 8682]	[ "799.4", "515", "569.69", "425.4", "401.9", "569.5", "287.5", "038.8", "599.0", "780.39", "V53.32", "584.9", "348.31", "569.81", "518.84", "511.9", "117.9", "482.82", "427.1", "251.2", "482.1", "568.0", "555.9", "995.92", "567.2" ]	icd9cm	[ [ [] ] ]	[ "45.91", "46.23", "31.1", "45.62", "00.14", "38.93", "34.09", "96.6", "54.72", "99.15", "34.91", "46.39", "86.67", "54.59", "96.72", "34.92" ]	icd9pcs	[ [ [] ] ]	19059, 25113	1968, 9062	482, 959	9918, 9973	16347, 19036		1521, 1539		9085, 9654		9768, 9897					9997, 16328									1554, 1806																				230, 444										987, 1218														1240, 1445	1461, 1505
3,463	189,831	23959	Discharge summary	report	Admission Date: [2163-5-8] Discharge Date: [2163-5-11] Service: NEUROLOGY Allergies: Quinidine/Quinine & Derivatives Attending:[First Name3 (LF) 618] Chief Complaint: scheduled intervention of 80% stenosis at touchdown of SVG to OM Major Surgical or Invasive Procedure: PCI Intubation History of Present Illness: 82yo M h/o CAD s/p CABG '[53], AS, CHF (EF 20%), HTN, DM2, hyperlipidemia, Afib on coumadin, stroke [10-4], who underwent cardiac catheterization with a bare metal stent to OM on [5-9] with coumadin held for the procedure and given heparin gtt since by sliding scale and restarted on coumadin 10mg qhs x 1 last night, who c/o headache and became more difficult to arouse today and also vomitted, with head CT finding large left occipital bleed. Code stroke was called at 2:25pm in order to "get anesthesia, respiratory and neurology to the bedside". We were consulted at 2:10pm prior to this and arrived at 2:15pm. The patient has since been given protamine 50mg IV, etomidate 8cc at 2:20 and succinylcholine 5cc at 2:22pm. My exam took place prior to paralytics. Past Medical History: 1) CAD s/p CABG [2153] (LIMA and SVGx2, no other anatomical data available). Patent grafts on [10-4] cath. s/p PTCA to LAD [10-4]. 2) AS: S/p AV valvuloplasty [10-5] 3) CHF: EF 20% 4) Atrial fibrillation since [2153]: h/o quinidine tx, but intolerant [3-4] pancytopenia 5) CVA: [10-4] in Broca's area, no residual effects 6) T2DM: with neuropathy, nephropathy 7) Carotid stenosis: [5-5] carotid U/S demonstrating moderate right-sided plaque with 60-69% carotid stenosis. On the left, there is less than 40% stenosis. 8) Hypertension 9) Hyperlipidemia 10) Gout 11) s/p right inguinal herniorrhaphy 12) h/o retinal hemorrhage 13) actinic keratosis 14) h/o rheumatic heart disease age 10 with pericarditis Social History: Retired physician, [Name10 (NameIs) 61032] in National Institute of Health. Lives in [State ] and [Location (un) ] with wife, no children. No smoking. Occasional glass of wine. Follows low salt diet. Sugars controlled to 120-150 mean. Family History: Father with rheumatic heart disease, one sister. Mother healthy until her death at age [Age over 90 ]. Physical Exam: Blood pressure was 111/70 mm Hg while seated. Pulse was 77 beats/min and regular, respiratory rate was 20 breaths/min with an oxygen saturation of 96% on room air and temperature of 97.0. . Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 3cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, clicks or gallops, but an audible systolic murmur heard loudest at the upper sternal border. The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ On transfer to neuro-ICU, his exam was as follows: NEURO MS [Name13 (STitle) ] response to verbal stimuli. Responds to sternal rub by raising his left arm to resist me. Does not open his eyes spontaneously but resists eye opening CN Pupils 2->1.5mm b/l, no blink to threat from right. Eyes conjugate and roving horizontally with full EOM. + corneal reflex on the left, none on the right. No obvious facial droop. Motor No response to noxious stimuli in the right arm. Withdraws right leg to pain; moves left arm/leg spontaneously. Reflexes toes mute b/l. Two hours later, his left pupil was fixed and dilated, he did not awaken to noxious stimuli. He had no corneal reflexes but had a retained gag. He withdrew the left arm and leg to pain, but the right arm had extensor posturing. Pertinent Results: [2163-5-8] 07:50PM DIGOXIN-0.4* [2163-5-8] 07:50PM GLUCOSE-176* UREA N-31* CREAT-1.5* SODIUM-136 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [2163-5-8] 07:50PM WBC-6.9 RBC-3.68* HGB-11.1* HCT-33.4* MCV-91 MCH-30.2 MCHC-33.3 RDW-16.3* Brief Hospital Course: 82 yo male with PMH of CAD, 3 vessel CABG, recent aortic valvuloplasty, DM, HTN, dyslipidemia s/p hospitalization [Date range (3) 61033] with worsening dyspnea related to aortic stenosis presenting for cath intervention for 80% stenosis at touchdown of SVG to OM on [2163-5-9]. On [2163-5-10], he complained of headache and became difficult to arouse, after vomiting several times. Stat head CT showed a large left occipital ICH and the patient was transferred immediately to the neuro-ICU after intubation. His anticoagulation was rapidly reversed with protamine, FFP and platelets, and aspirin, plavix, coumadin and heparin were discontinued; however, two hours later, despite these measures he was in deep coma, with the left pupil fixed and dilated and no longer moving the left side, except to pain, with extensor posturing on the right. Repeat head CT showed expansion of the ICH into the ventricles, with significant midline shift and compression of the brainstem (ie, herniation). Neurosurgery declined intervention after speaking with the family about his dismal prognosis. The patient continued to decline, developing bilateral extensor posturing and among brainstem reflexes he preserved only a weak gag. After extensive discussions with the family and the [Hospital 228] health care proxy, given that he had clearly stated his wishes not to be in a dependent, debilitated state, the decision was made to initiate comfort measures only and the patient expired. Medications on Admission: Pravastatin 20 mg q daily Aspirin 81 mg Tabletq daily Ramipril 1.25 mg [Hospital1 ] Carvedilol 6.25 mg [Hospital1 ] Allopurinol 200 mg q daily Digoxin 125 mcg QOD Coumadin 7.5 mg qHS Finasteride 5 mg q daily Furosemide 10 [Hospital1 ] Tamsulosin 0.4 mg q daily Discharge Medications: Expired Discharge Disposition: Home Discharge Diagnosis: Intracerebral hemorrhage with subfalcine, uncal and transtentorial herniation Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2163-5-12]	[ "431", "433.30", "585.9", "274.9", "424.1", "272.4", "V58.61", "600.00", "250.40", "427.31", "V45.81", "357.2", "250.60", "997.02", "403.90", "414.01", "428.0", "583.81" ]	icd9cm	[ [ [] ] ]	[ "00.45", "37.22", "88.52", "99.07", "88.55", "00.66", "36.06", "00.40", "99.05" ]	icd9pcs	[ [ [] ] ]	6894, 6900	5047, 6539	305, 322	7021, 7030	4762, 5024	7086, 7216	2169, 2278		6862, 6871		6921, 7000		6565, 6839			7054, 7063									2293, 4743																				199, 267										350, 1129														1151, 1888	1904, 2153
4,907	167,900	23737	Discharge summary	report	Admission Date: [2154-3-23] Discharge Date: [2154-4-8] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6195] Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: Open reduction/internal fixation [3-24] History of Present Illness: Mrs. [Known lastname ] is a [Age over 90 ] year old female with COPD on 2L O2 at baseline, who presented s/p fall on [3-22] onto her R side when going from chair to walker. She denies any LOC or head injury at the time, and fall was purely mechanical. She was seen by cardiology for pre-op evaluation; she has no known history of CAD, but does have very low functional capacity. Given the necesity of doing the surgery earlier rather than later, defered cath and proceeded to surgery on [3-24], ORIF. Past Medical History: COPD, on home O2, 2L at baseline. Anxiety Anemia (33.6 on admission here, unclear etiology, no outside records). Social History: Denies smoking, alcohol, or drug use. She lives at home with her daughter. Family History: Unable to obtain. Physical Exam: VS: 98.6, 120/60, 87, 16, 98% on 2L Gen: Slim, frail appearing elderly caucasian female, resting comfortably in bed. MS: Alert and oriented to person but not time. Neck: No JVD. CVS: RR, normal rate, 3/6 systolic murmur heard best at apex, with rad to axilla. Lungs: Rales at L base. Abd: NABS, soft, NT/ND. Extr: R thigh with dressing c/d/i. DP palpable on L but not R, however feet warm b/l with good capillary refill. No c/c/e. Venodynes in place. Pertinent Results: CT OF THE PELVIS WITHOUT IV CONTRAST: There is a complex intertrochanteric fracture through the right femur. The distal fracture fragment is medially angulated and externally rotated. The lesser trochanter has been fractured. The neck of the femur and the head appear to be intact. There is soft tissue edema in the region surrounding the fracture. Note is made of a 2.2 x 2.4 cm radiopaque gallstone in the gallbladder. There are extensive calcifications of the aorta and iliac arteries. The imaged loops of bowel are unremarkable, given the limited nature of the study. The left hip appears to be within normal limits. A Foley catheter is seen in the bladder. THREE VIEWS OF THE RIGHT KNEE WITH ONE ADDITIONAL VIEW OF THE RIGHT LEG: There is no evidence of acute fracture. The joint spaces are preserved. No definite knee effusion identified. Vascular calcifications are noted. EKG [3-23]: Sinus rhythm First degree A-V block Probable septal infarct - age undetermined Possible left atrial enlargement No previous tracing CXR [3-23]: AP VIEW OF THE CHEST: IMPRESSION: 1. Biapical scarring. 2. Abnormal contour at the left paraspinal region near the diaphragm that cannot be entirely separated from the aorta. This may represent an atypically laterally positioned hiatal hernia, but saccular aortic aneurysm is not excluded. Dedicated PA and Lateral views of the chest are recommended when the patient is clinically capable for further characterization. Alternatively, CT could be obtained. 3. No radiographic evidence of pneumonia or overt CHF. EKG [3-24]: Sinus tachycardia. First degree atrio-ventricular conduction delay. P-R interval 0.24. Cannot exclude prior anterior myocardial infarction. Possible inferior myocardial infarction. Compared to the previous tracing of [2154-3-23] multiple abnormalities as previously noted persist without major change. CXR [3-25]: IMPRESSION: Rounded opacity in the retrocardiac region which appears contiguous with the heart and probably represents a left ventricular aneurysm. This does not clearly appear to be associated with the descending thoracic aorta. A CT scan is recommended for further evaluation. HIP PA and LAT [3-26]: IMPRESSION: Status post ORIF right intertrochanteric fracture in overall anatomic alignment. Evidence for impaction at the fracture line, with backing out of the screw, as described. No hardware loosening. CT HEAD [3-26]: IMPRESSION: No evidence of intracranial hemorrhage or infarct on this limited study. MRI with diffusion-weighted imaging is more sensitive to evaluate for an acute infarct. CT CHEST [3-26]: IMPRESSION: 1. Distension and filling of the esophagus with debris is present. This is associated with a probable hiatal hernia. Clinical correlation is required for further interpretation. Given the history of aspiration, evaluation by upper GI series may be useful after evacuation of the debris within the esophagus for further characterization of the anatomic course of the esophagus and stomach. 2. Multiple pulmonary opacities primarily peripherally. Images are most consistent with the provided history of aspiration. Follow-up examination after appropriate treatment is recommended. 3. Coronary artery and aortic calcifications. Transthoracic echo [3-26]: Conclusions: 1. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. 2. The aortic valve leaflets are moderately thickened. 3. The mitral valve leaflets are mildly thickened. There is moderate MAC and thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. [2154-3-23] 01:30PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.018 [2154-3-23] 01:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-8.0 LEUK-SM [2154-3-23] 01:30PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [2154-3-23] 12:50PM GLUCOSE-107* UREA N-17 CREAT-0.5 SODIUM-133 POTASSIUM-3.1* CHLORIDE-91* TOTAL CO2-32* ANION GAP-13 [2154-3-23] 12:50PM CK(CPK)-145* [2154-3-23] 12:50PM CK-MB-3 cTropnT-<0.01 [2154-3-23] 12:50PM WBC-7.3 RBC-3.93* HGB-11.4* HCT-33.6* MCV-86 MCH-29.1 MCHC-34.0 RDW-13.2 [2154-3-23] 12:50PM NEUTS-79.0* LYMPHS-14.0* MONOS-6.4 EOS-0.4 BASOS-0.3 [2154-3-23] 12:50PM PLT COUNT-238 [2154-3-23] 12:50PM PT-13.8* PTT-28.0 INR(PT)-1.2 Brief Hospital Course: Hospital Course from [Date range (1) 46466] Mrs. [Known lastname ] is a [Age over 90 ] year old female on 2L home O2 for COPD, with low functional capacity, who presented with R intertrochanteric femoral fracture, had an ORIF on [3-24], post-op course complicated by transient tachycardia and hypoxia necessitating transfer to medicine service, as well as aspiration pneumonia and dysphagia, and a UTI. 1) Hip fracture: The patient had an ORIF on [3-24], with estimated blood loss of 200 cc. She received 800 cc IVF, and her post-op hct was found to be 28.7 (down from 33) therefore she was transfused 1 UPRBC and her hematocrit subsequently remained stable. Post operatively, however, she was noted to have a sinus tachycardia of 110-120, with stable blood pressure. Her oxygen requirement was also slightly above baseline at 3L. She was therefore transfered to the medicine service (from orthopedics). 2) Tachycardia: Her post-operative tachycardia was sinus, and transient, resolving within a day. However, while on ortho service, cardiology was called and a rule out MI was performed, with negative cardiac enzymes. She was monitored on tele without events. She was started on metoprolol 5 mg IV Q 6 hours (couldn't take PO meds - see below), and her heart rate remained in the 70s and 80s for the remainder of the hospitalization. Her brief post-operative tachycardia was likely related to her anemia, anxiety, and post-operative state with pain. 3) Hypoxia: She was never far from her baseline of 98% on 2L. It is felt that her brief hypoxia was likely related to mild fluid overload from IVF received in surgery and PRBCs, as well as an underlying aspiration pneumonia (see below). She was started on levaquin and gently diuresed, with improvement back to baseline of 2 L within a day. She was given atrovent NEBs intermittently as well for her COPD. 4) UTI: As above, post-operatively she was found to have a UTI. Levaquin started [3-25] for a planned 5 day course, however the course was lengthened to treat for her aspiration pneumonia as well. 5) Aspiration: The patient was noted to have a mass just above the esophagus on CXR on admission, thought to possibly represent a left ventricular aneurysm. However, an echo did not demonstrate an aneurysm. A CT scan was done to better evaluate the mass, which demonstrated a dilated esophagus filled with food, as well as a likely hiatal hernia to explain the mass. As swallow study was done which demonstrated the patient to be aspirating food of all consistency. It is unclear whether her oropharyngeal dysphagia is related to the high level of food in her esophagus or simply related to the anesthesia used during the operation. On further history the patient has had esophageal strictures in the past, and GI was therefore called to perform an EGD to further evaluate the possible hiatal hernia and dilate any strictures, however they could not advance the scope or remove any of the food particules during the EGD secondary to impacted food and reddened esophageal mucosa. They recommended thoracics involvement, however the thoracic surgeons advised waiting 2 weeks to see if the food clears on its own rather than doing esophageal disimpaction secondary to the high risk of the procedure and necessity for general anesthesia. The family agreed to placing a PICC for TPN for the next 2 weeks, after which time the patient will have a repeat CT scan to see if the food has slowly moved on its own enabling GI to do another scope to further evaluate the obstruction. She will also have a repeat swallow study at that time to see if the oropharyngeal component of her dysphagia has resolved. She will be maintained on strict NPO until then, with aspiration precautions. 6) Aspiration pneumonia: Multiple areas of consolidation were seen on her CT scan, consistent with aspiration pneumonia. She was started on levaquin and flagyl on [3-25], to complete a 14 day course. Hospital Course [Date range (1) 60627] Patient was going to be transferred to rehab. However she began to have increasing respiratory effort and hypoxia. She was was transferred to the mICU on [4-2] for respiratory distress. Her code status was reversed and she was intubated. Her hypoxia was thought likely [1-2] aspiration/food bolus in esophagus. EGD on [4-4] revealed that the esophageal blockage had resolved. She was extubated without difficulty, and transferred to the floor. However she then became hypoxic again likely having pulm edema secondary to rapid afib. She initially improved on bblockers and diuresis. Then the patient again became tachypnic and hypoxic. CXR c/w worsening pulm edema. Poor prognosis was discussed with the family and she was made CMO. The patient died 4:59am on [2154-4-8]. Medications on Admission: Detrol Colace HCTZ 25 mg daily SQ heparin Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6198] MD, [MD Number(3) 6199]	[ "820.21", "530.89", "997.3", "427.31", "799.4", "285.9", "E888.9", "599.0", "496", "507.0", "276.1" ]	icd9cm	[ [ [] ] ]	[ "99.04", "96.71", "45.13", "79.35", "99.15", "96.04", "38.93" ]	icd9pcs	[ [ [] ] ]	11137, 11152	6183, 11016	274, 319	11204, 11214	1623, 6160	11267, 11403	1113, 1132		11108, 11114		11173, 11183		11042, 11085			11238, 11244									1147, 1604																				222, 236										347, 868														890, 1004	1020, 1097
19,928	170,291	17489+17504	Discharge summary	report+report	Admission Date: [2178-5-9] Discharge Date: [2178-5-14] Date of Birth: [2159-5-21] Sex: F Service: ADDENDUM: This Addendum goes to Job #[Numeric Identifier 48840]. HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 1. MOBILITY ISSUES: The patient was significantly deconditioned after transfer from the Medical Intensive Care Unit to the floor. A Physical Therapy consultation was obtained, and Physical Therapy worked with the patient for two days. On the first day, she was very weak and required assistance with walking. On the second day of physical therapy, she was doing very well. She was able to walk up and down two flights of stairs and ambulate without assistance. Physical Therapy felt that she was safe for discharge, as she was ambulating and walking without assistance and doing well. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-AFC Dictated By:[Last Name (NamePattern1) 14484] MEDQUIST36 D: [2178-5-14] 15:25 T: [2178-5-14] 18:00 JOB#: [Job Number 48841] Admission Date: [2178-5-9] Discharge Date: [2178-5-14] Date of Birth: [2159-5-21] Sex: F Service: [Location (un) 2655] HISTORY OF PRESENT ILLNESS: Ms [Known lastname ] is an 18 year old female transferred from [Hospital6 33] for further management here at [Hospital6 256]. She had previously been a very healthy 18 year old who is very active in her school and sports. Approximately four days prior to admission she began feeling nauseated, vomiting and had diarrhea (greenish) for several episodes. She was feeling so poorly that she stayed home from school one day, and felt that she was very lethargic. During that time period, she was also having her menses. When she was on day #4 of her menses, she was feeling so poorly, that she stayed in bed, and did not change her tampon for approximately 16 to 24 hours. However, on menses day #1 through 3, she had been changing her tampons regularly. During the 24 hours prior to admission, she noted an acute onset of lethargy, headaches, and fevers. She was brought to [Hospital6 33] approximately 3 AM by her parents. About that time, she had diffuse erythroderma noted over her face, and chest. She complained of a sore throat and headache for greater than 24 hours, but did not have a stiff neck. She was found to have severe oropharynx injection with exudate and tonsillar inflammation. A rapid Streptococcus was negative. She has a history of multiple prior episodes of Streptococcus pharyngitis. Blood cultures times two were sent. Urine culture was sent. Vaginal examination revealed a tampon in place, and that was sent to Microbiology. Her temperature at [Hospital6 33] was 102.8, heartrate was in the 170s and her initial systolic blood pressure was approximately 100. However, within a short amount of time, her systolic blood pressure dropped to the 70s, and she was only minimally responsive to intravenous fluids. She was given 8 liters of fluid and her systolic blood pressure increased only to the 80s. At that point in time, Dopamine was started. In addition, an lumbar puncture was done to rule out meningitis, and it revealed two white blood cells, 13 red blood cells, normal glucose and normal protein. Initial chest x-ray was reportedly unremarkable, but the patient had a significant oxygen requirement (she was on a nonrebreather and face mask). Arterial blood gases done was 7.34/26/80. Other notable laboratory data included a white blood cell count of 19,000 (32% bands), creatinine 1.5, normal liver function tests and her coags were increased to an INR of 2.6, PTT 60 with positive fibrin split products (FSP). At [Hospital6 3426], she received 2 gm of Ceftriaxone, 2 gm of Oxacillin, 500 mg of Azithromycin, 600 mg of Clindamycin. She was then transferred to [Hospital6 2018] for further management. PAST MEDICAL HISTORY: 1. Psoriasis, 2. History of Streptococcus pharyngitis. PAST SURGICAL HISTORY: None. MEDICATIONS AS AN OUTPATIENT: 1. Orthotricyclin; 2. Antibiotics prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is an 18 year old student, senior in high school. She lives at home with her family, and has not had any recent travels. She has had no sick contacts. She is an avid basketball player and is the captain of her basketball team. She was last sexually active several months ago, and reports consistent condom use. She has a remote naval ring and tongue piercing. She has a tattoo on her lower back as well. Positive tanning bed use. PHYSICAL EXAMINATION: Vital signs on transfer to [Hospital6 1760], temperature maximum was 102.8, temperature currently 97.2, blood pressure 78/40s, heartrate 130s, respiratory rate in the 20s, oxygen saturation 96% on 100% nonrebreather. On physical examination this is in general a young woman in acute distress. Head, eyes, ears, nose and throat: Conjunctival hyperemia, extraocular movements intact, pupils equal, round and reactive to light, anicteric. Chest: Rales at the right one-third base, left lung was clear. Cardiovascular: Regular rhythm, tachycardiac with a rate in the 130s. Abdomen, soft, nontender, nondistended, positive bowel sounds. Skin: Diffuse erythema on the face, chest and arms. LABORATORY DATA: On admission (from the outside hospital) white blood cell count 18.7, hematocrit 40.4, platelets 205, 61% neutrophils, 32% bands, sodium 134, potassium 3.6, chloride 99, bicarbonate 18, BUN 30, creatinine 1.5, glucose 115, calcium 8.9, AST 39, ALT 22, total protein 6.7, albumin 3.7, alkaline phosphatase 53, total bilirubin 1.2, amylase 51, mono screen negative. Cerebrospinal fluid, white blood cells 2, red blood cells 3, cell count 3, glucose 72, total protein 18. Arterial blood gases, 7.34/26/80 on 2 liters of nasal cannula, 95% oxygen saturation. IMPRESSION: An 18 year old female, previously healthy, who had some sort of a viral gastroenteritis on her menstruation days 1 through 3. On the fourth day of her menstruation she was feeling so ill from her gastroenteritis that she did not change her tampon for approximately 16 to 24 hours. She now presents with an apparent toxic shock syndrome, with hypotension, tachycardia, and erythroderma, febrile to 102 degrees. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit (MICU) and infectious disease consult was obtained. The patient was started on antibiotics with Clindamycin and Oxacillin as well as vaginal Oxacillin. She was given intravenous immunoglobulin for her toxic shock syndrome antibodies. Blood cultures were drawn, and vaginal vault cultures were drawn as well. Otorhinolaryngology evaluated her and their evaluation ruled out any peritonsillar abscess or neck abscess. On hospital day #2, the patient continued to be very tachypneic with respiratory rate in the 40s and blood gas revealed a pH of 7.1. At this point in time she was intubated. She was kept on the ventilator for one day, with resolution of her acidemia, and her pH returned to 7.38, and a carbon dioxide of 30. She was extubated without event, and was observed in the Medical Intensive Care Unit and then was transferred to the floor. She was given voluminous amounts of fluids to support her hypertension. At a certain point in the Medical Intensive Care Unit she was on three pressors, (Dopamine, Neo-Synephrine, Vasopressin), to support her blood pressure in addition to the fluids. After transfer to the floor, she auto-diuresed and her urine output was very brisk. While she was in the Medical Intensive Care Unit her chest x-ray showed interstitial increase in her edema, likely secondary to fluid overload, however, after being on the floor, repeat chest x-ray was obtained and showed significant resolution of interstitial edema, this is likely secondary to the fact that the patient is auto-diuresing and urine output was good, and her pulmonary status was good. She was breathing 96 to 97% on room air and was very comfortable. 1. Infectious disease - Vaginal vault swab was obtained and a pelvic examination was done. Speculum examination revealed cervix with a closed os. Mucopurulent appearing drainage in the vaginal vault. No foreign bodies noted. Bimanual examination revealed no cervical motion tenderness, no adnexal tenderness, and no foreign body was felt. The vaginal vault as well was sent off for micro studies and they subsequently revealed positive Staphylococcus aureus, positive Escherichia coli. Staphylococcus aureus was sensitive to Clindamycin, sensitive to Methicillin and resistant to Ampicillin. Escherichia coli was pansensitive. Infectious disease consultation was obtained, and they recommended intravenous antibiotics of Oxacillin 2 gm intravenously q. 4 hours, Clindamycin 900 mg intravenously q. 8 hours, Ceftriaxone 2 gm intravenously q. day. The patient was given his antibiotics and was also given intravenous immunoglobulin for the treatment of Staphylococcal and Streptococcal toxic shock syndrome. In addition, [Hospital 48862] Hospital sent to [Hospital6 256] the patient's culture from the tampon. These cultures have been forwarded to the CDC to check for toxic production by the Staphylococcus. These are still pending at the time of discharge. On the day of discharge the patient was on day #6 of her antibiotics. She is to start Dicloxacillin 500 mg p.o. q.i.d. times eight days to complete a 14 day course of antibiotics. She is to follow up with Infectious Disease, (Dr. [Last Name (STitle) 48863] on [4-23], at 10 AM. She has been instructed to not use tampons until further advised. At the time of her follow up appointment with Infectious Disease in one month, she will have repeat serologies (convalescent) for antibodies drawn. We have discussed the risk of relapse with [Known firstname 11709] and it is 30% in all patient's and the risk of relapse is decreased if she is treated with Betalactam antibiotic as she was. Ultimately, whether or not she can use tampons will depend on whether or not she forms antibodies to the toxic shock syndrome toxin. Until these convalescent titers are drawn she has been instructed to not use tampons. 2. Hypotension - Hypotension is likely secondary to toxic shock syndrome toxin. The patient was placed on pressors, Neo-Synephrine, Vasopressin, as well as Dopamine during her Medical Intensive Care Unit. She was given voluminous amounts of fluids to support her blood pressure as well. After the intravenous immunoglobulin and antibiotics were given she appeared to be less hypotensive and pressors were weaned off. After weaning off of pressors, she has been able to maintain her blood pressure quite well with systolic 100 to 120s without events. 3. Cardiovascular - Electrocardiogram showed some rate-related ST depressions. At that point in time her rate was between the 140s to 150s. Her creatinine kinases were cycled and it was noted that she did have a troponin leak with troponins in the range of 1 to 8 and her creatinine kinases were in the range of 100 to 600, and MB fraction was in the range of 2 to 20. An echocardiogram was done and it revealed decreased ejection fraction of 35%. Her right ventricle had a moderate global hypokinesis, her right ventricle size and free wall motion were normal. The impression was there was moderate global left ventricular global hypokinesis with a normal right ventricle. There was no pericardial effusion and no vegetations were seen. This was likely secondary to the toxic shock syndrome antibody and toxic metabolic state, toxic metabolic assault to her myocardium. It is recommended that she have a repeat echocardiogram done in three weeks after discharge. This has been discussed with her primary care physician, [Name10 (NameIs) ] her primary care physician will schedule [Name Initial (PRE) ] follow up echocardiogram in three to four weeks. 4. Diarrhea - The patient had diarrhea prior to admission, likely secondary to gastroenteritis. In addition she also had diarrhea during her hospital admission. There is question whether this was antibiotic-induced or not. Clostridium difficile was sent off on [2178-5-10] and this was negative, however, the patient continued to have diarrhea and another Clostridium difficile was sent off on [2178-5-14], on the day of discharge. The patient has been instructed if she continues to have diarrhea to tell her primary care physician and another Clostridium difficile will be sent. We will follow up on the Clostridium difficile results here, and if it is positive, we will notify the patient as well as her primary care physician. [Name10 (NameIs) ] negative, no one will be notified. 5. ? Pregnancy - The urine ACG as well as urine HCG were negative. 6. Culture data - Sputum culture showed contamination with oropharyngeal secretions. Respiratory culture showed no predominance of any respiratory pathogens (no Streptococcus pneumonia, no Hemophilus influenza, no M-Catarrhalis evidence). Catheter tip (this was done after her right internal jugular central line was taken out) showed preliminarily no significant growth at the time of discharge. Blood cultures, at the time of discharge, blood cultures showed no growth, this was still a preliminary result. Urine cultures, no growth. Stool test, negative for Clostridium difficile on [2178-5-10]. Vaginal cultures, negative for Group B Beta Streptococcus. Throat swab, negative for Neisseria, Gonorrhea. Throat swab, negative for Beta Streptococcus Group A, with moderate growth of oropharyngeal Flora. Cultures from the vaginal swab from [Hospital6 3426] showed Staphylococcus aureus: sensitive to Clindamycin, sensitive to Methicillin, resistant to Ampicillin. It also grew out Escherichia coli pansensitive to everything. 7. Liver - As regards the toxic shock syndrome, the patient also suffered an assault to her liver. At various points during her hospital admission, her liver enzymes were elevated, with a high bilirubin up to 2.2, AST to 108, ALT 143, and LDH up to 503. It was advised that the patient have repeat liver function tests done in one week, to evaluate the resolution. She does not complain of any right upper quadrant pain, and it is not tender to palpation in this area. 8. Pulmonary - The patient was intubated on the evening of [2178-5-9] (on the evening of hospital day #1) and was subsequently extubated on [2178-5-10]. Serial chest x-rays were done on the patient which initially showed diffuse infiltrates, consistent with fluid overload or pneumonic infiltrates or adult respiratory distress syndrome. They also showed diffuse alveolar infiltrates as well. After she was extubated and breathing well on her own, a repeat chest x-ray showed a significant interval improvement in her pulmonary edema with just minimal interstitial edema persistent. There was still some patchy bibasilar infiltrates, and a very small pleural effusion, but these were both significantly improved. At the day of discharge, the patient was breathing quite well, sating 96 to 98% on room air and was not dyspneic on exertion. With the patient auto-diuresed with her urine output being so brisk, she was diuresing much of the fluid off and she should have full resolution of the minimal pulmonary edema and pleural effusions. I suggest repeat chest x-ray in one to two weeks with her primary care physician to evaluate the resolution. 9. Hematology - It is a question of whether the patient had heparin-induced thrombocytopenia. The patient's initial platelet counts were in the 200 range on the day of admission, and subsequently decreased to 94,000 on [2178-5-12]. Heparin-induced thrombocytopenia (HIT) antibodies were sent, which were positive. At this point in time, the patient was not given any more heparin. The heparin dependent antibodies were negative, PM4 antibody by [Doctor First Name ]. This was a low positive result and it may represent interference due to recent intravenous immunoglobulin administration. It is recommended to repeat the evaluation by serotonin release assay. This will be deferred to the primary care physician, [Last Name (NamePattern4) ] ? recheck heparin dependent antibodies. 10. Viral antibody panels - Ebstein-[Doctor Last Name ] virus IgG positive, Ebstein-[Doctor Last Name ] virus IgM negative. These results are interpreted as indicative of a past Ebstein-[Doctor Last Name ] virus infection. Monospot test was negative as well. At the time of discharge, the toxic shock antibody panel is pending. When the patient follows up with Infectious Disease, the toxic shock antibody panel results will be reviewed. In addition, at this point in time, the results from the CDC (whether the Staphylococcus aureus culture produces toxins) will also be reviewed. The correlation between the antibody production as well as toxin production, will be reviewed by infectious disease to advise the patient on future management options. 11. Dermatology - The patient had diffuse erythroderma on her chest, arms and face. This slowly resolved throughout the course of her admission. On the day of discharge, she was doing well with no evidence for erythroderma. She was cautioned that her hands and feet may declamate in the next one to two weeks. This should be expected and is not abnormal. DISPOSITION: On the day of discharge, the patient is afebrile, breathing very well, oxygen saturation 96 to 97% on room air, hemodynamically stable. Repeat chest x-ray significantly improved. She is ambulating and eating and she is discharged in good condition. MEDICATIONS ON DISCHARGE: 1. Dicloxacillin 500 mg p.o. q.i.d. for eight days (from [2178-5-15] through [2178-5-22]) 2. Dextromethorphan 5 to 10 cc q. 12 hours prn as needed for cough DISCHARGE DIAGNOSIS: 1. Toxic shock syndrome 2. Sepsis secondary to Staphylococcus aureus toxin 3. Liver shock 4. Cardiac dysfunction (globally depressed left ventricular function), ejection fraction 35% 5. Pulmonary edema secondary to capillary leak, secondary to sepsis 6. ? Heparin-induced thrombocytopenia. FOLLOW UP APPOINTMENTS: 1. The patient should follow up with her primary care physician (Dr. [First Name (STitle) ] in one week. At her follow up appointment she should have liver function tests (ALT, AST, total bilirubin, alkaline phosphatase, her LDH) as well as PT, PTT, and INR drawn to check for resolution/down trend. If the patient's diarrhea/loose stools persist she is to tell her primary care physician and have her Clostridium difficile checked. In addition, the patient needs a repeat echocardiogram in three weeks, to evaluate her left ventricular function. 2. Follow up with Infectious Disease, (Kassuto) on [2178-6-23] at 10 AM. At this point in time she will have convalescent titers for antibodies drawn. DISCHARGE INSTRUCTIONS: The patient had fevers, chills, lightheadedness and she is to return to the Emergency Department. The patient has been instructed to not use tampons again until further instructions. She will have her laboratory data drawn in one month, and at that time, Infectious Disease will be following her and will instruct her whether or not she may use tampons again. She is to take her medications as prescribed. If she continues to have loose stools or diarrhea, she is to notify her primary care physician and to have her stools tested for Clostridium difficile. In addition the skin on her hands and feet may begin to peel off in one to two weeks, this is to be expected and is not abnormal. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 48864] Dictated By:[Name8 (MD) 48865] MEDQUIST36 D: [2178-5-14] 15:32 T: [2178-5-14] 18:02 JOB#: [Job Number 48840]	[ "939.2", "276.6", "040.82", "287.4", "570", "038.11", "041.11", "514", "518.82" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "38.93" ]	icd9pcs	[ [ [] ] ]											17994, 18291	17805, 17973		6372, 17779		19052, 20005							4048, 4165												4655, 6354																		18315, 19027		1259, 3943														3966, 4024	4182, 4632
30,630	154,416	33716	Discharge summary	report	Admission Date: [2156-2-2] Discharge Date: [2156-2-5] Date of Birth: [2091-8-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: [Hospital 78010] Hospital to hospital transfer for Atrial flutter Major Surgical or Invasive Procedure: radiofrequency ablation of right atrial flutter History of Present Illness: Patient is 64 yo male with distant history atrial fibrillation not on anticoagulation who was transferred to [Hospital1 18] ED for management of atrial flutter/atrial fibrillation. Patient noted palpitations 1 day prior to presentation to [Hospital3 ]. He checked his BP and which he noted was SBPs in 100s and HRs in the 130s. He thought this may be his PAF and therefore did not present to the ED. The morning of admission he felt very fatigued and lightheaded, so he called EMS and was taken to [Hospital3 ]. There he was given diltiazem and went into sinus rhythm, but was hypotensive with SBPs in the 70s. He went back into aflutter and cardioversion with 50 joules was attempted, but was unsuccessful and SBPs dropped to the 50s and he was started on neosynephrine and transferred to [Hospital1 18] for further management. . Of note, in [2154-4-15] he had afib after bowel prep for colonscopy and was admitted and started on coumadin, metoprolol and digoxin. The in [10-21] he underwent surgery to remove a small bowel tumor and his coumadin was stopped at this time. Per his report, he was in NSR and therefore was not continnued on coumadin. Again in [12-23] he felt lightheaded and presented to the [First Name4 (NamePattern1) 46] [Last Name (NamePattern1) ] and was found to be in a fib. He underwent a thallium stress which revealed possible inferior wall ischemia and had cardiac cath on [2156-1-20] with clean coronaries and preserved EF. He was started on propafenone 150 mg po Q8h. He had been feeling well until he devloped the palpitations and fatigue 2 days ago. . In the ED, HR were in the 140s and narrow complex. He was given adenosine and showed a flutter with variable conduction, but in further looking at this, at times it seemed irreuglar and more consistent with atrial fibrillation. He was given 2 L IVF, was weaned off neo drip and give diltiazem 10mg IV without a change and then 20 mg IV with HR 90s-100s but dropped SBP 70s-80s. Given that cardioversion was already attempted once at OSH, the ED did not feel comfortable cardioverting, and he was tranferred to the CCU for further management. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains. He has had URI sx over the past few days. Denies black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. Past Medical History: Hypertension PAF years ago, was on coumadin, but stopped given in NSR Colon Cancer [2138] s/p resection and chemo/radiation Small bowel cancer s/p resection in [2153] No CAD history Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: He does not know his family history because he is adopted. Physical Exam: VS: T 98.4 , BP 92/51 , HR 120s , RR 16 , O2 100 % on 2 L Gen: Middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: no JVD CV: Tachycardic with irregularly irregualr rate, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. well healed midline abdominal scar Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: ================ ADMISSION LABS ================ 7.3 \______/ 258 / 38.5 \ Neuts-69.6 Lymphs-22.7 Monos-5.4 Eos-2.0 Baso-0.3 PT-12.2 PTT-23.9 INR(PT)-1.0 Glucose-96 UreaN-12 Creat-1.0 Na-141 K-3.8 Cl-111* HCO3-24 AnGap-10 cTropnT-<0.01 Calcium-8.3* Phos-2.1* Mg-2.0 TSH-3.7 =================== DISCHARGE LABS =================== 3.9 \______/ 261 / 35.0 \ Neuts-60.7 Lymphs-30.1 Monos-5.5 Eos-3.3 Baso-0.3 PT-13.6* PTT-57.9* INR(PT)-1.2* UreaN-12 Creat-1.0 K-4.1 Mg-2.2 ============== IMAGING ============== [2156-2-3] TRANS-THORACIC 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 normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. =========== ECG =========== [2156-2-2] Atrial flutter with rapid ventricular response. No previous tracing available Brief Hospital Course: 64 year old gentleman with history of paroxysmal atrial fibrillation / atrial flutter, admitted with hypotension, s/p radiofrequency ablation, in improved condition. # Atrial fibrillation/atrial flutter: Per review of oust ide records, patient had recently undergone outpatient evaluation for initiation on anti-arrhythmic therapy with Propafenone. On transfer, patient arrived with neo synephrine for blood pressure support for SBP in 70's with HR in 140's. After IVF boluses, pressor support was weaned off and esmolol drip was started to provide rate control. This intervention however was limited by hypotension and was discontinued. Patient tolerated rates of 110's to 140's with systolic pressure above 120. Propafenone dose was increased to 225 mg PO TID and low dose beta blocker was started. TEE demonstrated preserved EF and no structural abnormalities. After 24 hours, patient was taken to EP lab and underwent radiofrequency ablation of an atypical flutter circuit. A second atrial arrhytmia (atrial tachycardia) was found to arise from left atrium, but this was not intervened on during this hospitalization. Patient tolerated procedure very well and remained in sinus rhythm thereafter. Patient has been instructed to continue anti-arrhythmic therapy with propafenone and Toprol XL, for details please see medications section. Anticoagulation adressed below. Patient will require outpatient stress testing as he will be treated with class IC antiarrhythmic. He will be followed in outpatient [Hospital ] clinic by Dr [Last Name (STitle) ] and cardiology clinic by Dr [First Name (STitle) 4640] # Anticoagulation : Patient is at risk for embolic event both because of paroxysmal atrial fibrillation / atrial flutter and from recent RFA. Anticoagulation was achieved with heparin drip during hospitalization and transitioned to Lovenox as he is bridged over to Coumadin. Patient will require close monitoring of INR which will be managed by primary care physician. # FEN: Patient tolerated a cardiac diet # Prophylaxis: heparin drip # Code: Patient remained full code during this admission. # Communication: Patient and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 78011] (friend and HCP) Medications on Admission: Metoprolol 25 mg po Qday ASA 325 mg po qday Propafenone 150 mg po Q8h Discharge Medications: 1. Propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 3. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime for 3 days. Disp:0 Tablet(s) Refills:0 4. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous [Hospital1 ] (2 times a day) for 5 doses. Disp:300 mg Refills:0 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: To be started in 3 days after 3 doses of 5 mg. This dose may be adjusted by Dr. [Last Name (STitle) 33667] according to your bloodwork. . Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. typical atrial flutter 2. atypical atrial flutter Secondary: 1. hypertension 2. paroxysmal atrial fibrillation Discharge Condition: Stable blood pressure in normal sinus rhythm. O2 saturations stable on room air. Ambulating without difficulty. Discharge Instructions: You were admitted to the hospital for atrial flutter. You had a radiofrequency ablation performed and your propafenone dose has been increased. You have also been started on the blood thinner coumadin due to your atrial flutter. You will take 5 mg every night for 3 days and then decrease to 2.5 mg from then on. This dose may be adjusted by Dr. [Last Name (STitle) 33667] according to your bloodwork. You will need to take lovenox injections for 2 days while your coumadin becomes therapeutic. Please note that your aspirin dose has been decreased to 81 mg while you are also on coumadin. You will need to have blood work performed on Monday [2156-2-9] to have your INR checked which measures the effectiveness of your coumadin medication. Please go to Dr.[Name (NI) 78012] office to have this test performed. You will need to wear [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor after discharge from the hospital as you were instructed prior to discharge. You have been scheduled for an exercise stress test as below to assess your tolerance of the increased propafenone dose. Please follow up with your your PCP as below as well as with Dr. [Last Name (STitle) ] who will be your new Electrophysiologist. Please call your doctor or return to the hospital if you experience any chest pain, shortness of breath, palpitations, numbness, tingling, weakness, or any other concerns. Followup Instructions: Please go to Dr.[Name (NI) 78012] office on Monday [2156-2-9] at 10 am to have your INR checked. Phone: [Telephone/Fax (1) 78013] Please call Dr.[Name (NI) 78012] office to schedule a follow up appointment as needed. Phone: [Telephone/Fax (1) 78013] Please come to [Hospital1 18] exercise stress lab in [Hospital Ward Name 23] [Location (un) 436], cardiac services to have your exercise stress test performed on [2156-2-18] at 10:45 am. Phone: [Telephone/Fax (1) 16588]. No food or caffeine 1 hour prior. Comfortable clothing and flat sneakers recommended. Please follow up with Dr. [Last Name (STitle) ] on [Hospital Ward Name 23] 7 at [Hospital1 18] on [2156-2-20] at 11am. Phone [Telephone/Fax (1) 9832]	[ "V10.05", "V15.3", "427.31", "401.9", "427.32" ]	icd9cm	[ [ [] ] ]	[ "37.34", "37.26" ]	icd9pcs	[ [ [] ] ]	8963, 8969	5729, 7996	382, 432	9137, 9253	4441, 5706	10740, 11515	3529, 3589		8117, 8940		8990, 9116		8022, 8094			9277, 10717									3604, 4422																				273, 344										460, 3174														3196, 3388	3404, 3513
59,977	127,266	340	Discharge summary	report	Admission Date: [2143-11-17] Discharge Date: [2143-11-23] Date of Birth: [2096-10-21] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: 47M admitted for liver transplantation. Most recent hospitalization for R VATS biopsy of a lung nodule concerning for metastatic HCC. ROS: denies fevers, chills, nausea, vomiting, diarrhea, dysuria, hematuria, URI symptoms, cough, shortness of breath, or any other pain or discomfort Major Surgical or Invasive Procedure: Orthotopic liver transplantation done on [2143-11-19] Past Medical History: HBV Heptocellular Carcinoma s/p RFA Hamartoma. Hypertension. Social History: Cantonese and has a high school education. He is married and has two children, ages 15 and 17. He is a restaurant cook. He has no history of alcohol use. He smoked one pack of cigarettes per day in the past but quit 10 years ago. He has no history of IV drug use, marijuana use, blood transfusions, tattoos, or piercing. Family History: His family medical history is significant for his mother who is alive and healthy. His father died of unknown causes. Physical Exam: 98.4 111 135/98 18 97% RA Gen: NAD HEENT: EOMI, not jaundiced, mucous membranes moist, no cervical lymphadenopathy, no supraclavicular lymphadenopathy, no JVD Chest: CTAB, RRR, no M/R/G Abdomen: soft, non-tender, non-distended Extremities: no edema, 2+ radial pulses bilaterally, fully ambulatory without difficulty Neuro: A&Ox3, MAE Pertinent Results: At admission [2143-11-18] 12:32AM BLOOD WBC-5.8 RBC-4.70 Hgb-14.6 Hct-42.2 MCV-90 MCH-31.2 MCHC-34.7 RDW-14.2 Plt Ct-202 [2143-11-18] 12:32AM BLOOD PT-12.3 PTT-28.2 INR(PT)-1.0 [2143-11-18] 12:32AM BLOOD Glucose-105 UreaN-15 Creat-0.6 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-13 [2143-11-18] 04:48PM BLOOD ALT-1635* AST-1851* AlkPhos-47 Amylase-53 TotBili-1.9* DirBili-0.9* IndBili-1.0 [2143-11-18] 12:32AM BLOOD Albumin-4.4 Calcium-9.2 Phos-2.6* Mg-2.3 At discharge: [2143-11-23] 05:45AM BLOOD WBC-8.8 RBC-3.42# Hgb-10.8# Hct-30.5# MCV-89 MCH-31.6 MCHC-35.4 RDW-15.0 Plt Ct-141* [2143-11-23] 05:45AM BLOOD Glucose-109* UreaN-20 Creat-0.6 Na-139 K-3.6 Cl-103 HCO3-27 AnGap-13 [2143-11-23] 05:45AM BLOOD ALT-482* AST-157* AlkPhos-90 TotBili-1.1 [2143-11-23] 05:45AM BLOOD Albumin-3.6 [2143-11-22] 05:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE T [2143-11-23] 05:45AM BLOOD tacroFK-5.6 [2143-11-22] 05:00AM BLOOD tacroFK-7.0 [2143-11-20] 05:00AM BLOOD tacroFK-2.2* US Abdomen:IMPRESSION: 1. Patent and appropriate hepatic vasculature. 2. Small subhepatic hematoma. Brief Hospital Course: Orthotopic liver transplant done on [2143-11-18] Was in the ICU for 24 hours. He was extubated the same day of surgery First day post op he had an ultrasound: IMPRESSION: 1. Patent and appropriate hepatic vasculature. 2. Small subhepatic hematoma. His post operative period was uneventful. He was started on his immunosuppressive meds per protocol: Steroid taper; MMF 1000", Tacro dosed per levels [Last Name (un) ] was consulted for management of his sugars. He was sent home on insulin after he was taught to self inject insulin according to scale. He was also sent home on Glyburide He was also advised to take the hepatitis B immunoglobulin( receivedd Day [2-11] in hospital) 7th 14th 21st and 28th post op day and then monthly He was given some lasix for diuresis He received 2 units PRBC for a hct which was drifting down just before discharge. He was discharged on postop day5 Medications on Admission: Active Medication list as of [2143-11-17]: Medications - Prescription CLOTRIMAZOLE [MYCELEX] - 10 mg Troche - 5 daily x5 daily NIFEDIPINE [NIFEDICAL XL] - (Prescribed by Other Provider) - 60 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth once a day TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC CALCIUM CARBONATE [CALTRATE 600] - (OTC) - 600 mg (1,500 mg) Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO ONCE (Once) for 1 doses. 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Tacrolimus 1 mg Capsule Sig: asdir Capsule PO Q12H (every 12 hours): Dosage to be adjusted according to levels. 11. Insulin Lispro 100 unit/mL Solution Sig: One (1) 100 units Subcutaneous ASDIR (AS DIRECTED). Disp:2 1 Refills:2 12. HepaGam B >312 unit/mL (5 mL) Solution Sig: One (1) 5000 units Intramuscular once: Dose to be given on Day 7, Day 14. 13. Nicardipine 60 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 14. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Tablet, Chewable(s) 15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every 4-6 hours as needed for pain. Disp:30 Tablet Sustained Release(s) Refills:0 16. Glyburide 5 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: Hepatitis B Virus Heptocellular Carcinoma status post Orthotopic liver transplantation Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications, yellowing of skin or eyes, increased abdominal pain or any other concerning symptoms. Labwork at the [Hospital ] Medical Building Lab every Monday and Thursday No heavy lifting No driving if taking narcotic pain medication You may shower, allow water to run over incision and pat area dry. [Month (only) 116] be left open to air Drink enough fluids to keep urine light yellow in color Monitor Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2143-11-27] 1:30 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2143-11-28] 10:00 Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2143-12-5] 9:30 Completed by:[2143-11-26]	[ "790.29", "571.5", "458.29", "456.21", "070.32", "E932.0", "572.8", "155.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "00.93", "50.59" ]	icd9pcs	[ [ [] ] ]	5702, 5751	2734, 3635	602, 662	5882, 5889	1597, 2065	6525, 6969	1106, 1227		4155, 5679		5772, 5861		3661, 4132			5913, 6502									1242, 1578												2079, 2711								278, 564																								684, 747	763, 1090
78,797	127,662	52281	Discharge summary	report	Admission Date: [2177-10-16] Discharge Date: [2177-10-30] Date of Birth: [2114-8-14] Sex: F Service: MEDICINE Allergies: Ampicillin / Compazine / Tegaderm / Tincture Of Benzoin Attending:[Doctor Last Name 10493] Chief Complaint: Shortness of breath, hypoglycemia Major Surgical or Invasive Procedure: broncoscopy, esophagastroduodenoscopy, intubation, removal of lap band History of Present Illness: The patient is a 63 year old female with a past medical history of type II diabetes on an insulin pump complicated by gastroparesis, OSA, HTN, s/p gastric banding and several food and drug allergies that presented to clinic with hypoglycemia and shortness of breath. Dr. [Last Name (STitle) 17143] brought the patient to the ED, where she was given salumedrol, epinephrine, benadryl, and pepcid for suspected allergic reaction. The patient was in respiratory distress and began having altered mental status. Her respiratory effort increased and she was noted to have an O2 sat of 79%. She was placed on 100% NRB and sats improved to 95%. She continued to have increased work of breathing and worsening respiratory distress. She was placed on NIV and shortly after she began vomiting with suspicion for aspiration. Anesthesia was called and the patient was intubated for protection of her airway. . Review of systems were not obtained due to the patient's sedation. Past Medical History: 1. Obesity (BMI 43) S/P Gastric Banding ([6-/2172]) tightening ([5-16]) - Dr. [Last Name (STitle) ] 2. Hypertension 3. Congestive Heart Failure 4. Type I Diabetes (Uses Insulin Pump) 5. DM Neuropathy 6. Dyslipidemia 7. DJD 8. OSA on BiPAP 9. H/O LE Osteomyelitis S/P Toe Amps 10. Breast DCIS S/P Excision 11. H/O Bowel Obstruction (Tx: NG Decompression) 12. h/o left plantar ulcer s/p ABX and debridement Social History: Lives with cat, never smoked, no etoh. Born and raised in [State 5887]. She has a college degree. She has never married, but raised 2 adopted children. She lives alone and has a cat. She works out of her home as an organizational consultant. Family History: Her father has cardiac disease and her sister has ovarian cancer. Mother died at the age of 67 of complications of a long history with hypertension and diabetes mellitus; she was also obese. Her father died at the age of 74 of coronary artery disease, and had had a CABG at the age of 50. She had one younger sister who died of ovarian cancer. Ms. [Known lastname 10653] has had genetic testing, and did not have the gene for familial ovarian and breast cancer. She is not aware of any other disorders that run in her family. Physical Exam: Exam on Admission: . GENERAL: Obese female sedated on propofol, not responding to stimuli or commands HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Poor dentition. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP= difficult to assess due to body habitus LUNGS: diffusely rhonchorus, poor air movement biaterally. ABDOMEN: NABS. Obese Soft, NT, ND. Midline, epigastric scar. No HSM EXTREMITIES: Cool extremities distally, with 2+ palpable radial and DP pulses No edema or calf pain. SKIN: No rashes/lesions, ecchymoses. NEURO: Intubated and sedated, not responding to commands. . On discharge, [Name (NI) 4650], pt was alert and oriented, faint 1/6 SEM, lungs with faint bibasilar crackles. Pertinent Results: On admission: . [2177-10-16] 06:15PM BLOOD WBC-14.8# RBC-5.00 Hgb-13.0 Hct-40.9 MCV-82 MCH-26.1 MCHC-31.8 RDW-14.2 Plt Ct-188 [2177-10-16] 06:15PM BLOOD PT-13.8* PTT-24.1 INR(PT)-1.2* [2177-10-16] 06:15PM BLOOD Glucose-152* UreaN-16 Creat-1.2* Na-140 K-4.0 Cl-100 HCO3-35* AnGap-9 [2177-10-16] 06:15PM BLOOD cTropnT-<0.01 [2177-10-16] 06:15PM BLOOD Calcium-8.8 Phos-4.8# Mg-1.9 [2177-10-16] 10:16PM BLOOD Type-ART PEEP-5 pO2-221 pCO2-63* pH-7.25* calTCO2-29 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2177-10-16] 06:38PM BLOOD Lactate-1.2 [2177-10-17] 08:06PM BLOOD Hgb-12.1 calcHCT-36 [2177-10-17] 08:06PM BLOOD freeCa-1.16 . On discharge: . [2177-10-29] 10:35AM BLOOD WBC-10.6 RBC-5.05 Hgb-13.0 Hct-40.0 MCV-79* MCH-25.7* MCHC-32.5 RDW-15.0 Plt Ct-507* [2177-10-29] 06:55AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-138 K-3.7 Cl-101 [2177-10-27] 07:35AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 [2177-10-25] 11:28AM BLOOD Type-ART pO2-89 pCO2-33* pH-7.51* calTCO2-27 Base XS-3 Intubat-NOT INTUBA [2177-10-25] 11:28AM BLOOD Lactate-1.0 . CXR on admission: Bibasilar opacities most prominent in the left retrocardiac area. Considerations include atelectasis or infectious consolidation. These might be distinguished with a repeat study with better inspiration. . CT chest [10-16] 1. Large distention of the esophagus with a coiled nasogastric tube. This tube should be removed. 2. Extensive bilateral pulmonary consolidations with aspirated material visualized in the left mainstem bronchus and in distal segmental airways as above. 3. Dense atherosclerotic calcification involving the mitral annulus and coronary arteries. 4. Scattered pulmonary nodules. These should be followed up with a dedicated CT of the chest in six months after acute presentation resolves. . Abd film: Moderate amount of stool in the sigmoid and descending colon consistent with constipation. There is no evidence of large or small-bowel obstruction. . Doppler UE: No upper extremity deep venous thrombosis. . CT ABD: 1. Interval development of ground-glass opacity in the lungs bilaterally. This likely represents edema. Interval decrease in more focal solid consolidations in the left lung when compared to prior exam. Small bilateral pleural effusions. 2. Extensive hilar lymphadenopathy as described above, possibly reactive. 3. Left thyroid gland nodule. Further non-urgent thyroid ultrasound is recommended. 4. Pulmonary nodules. Followup chest CT within six months is recommended. 5. Indeterminate left renal lesion in the lower pole, incompletely characterized. further evaluation with ultrasaound is recommended. 6. Fibroid uterus. 7. Multilevel degenerative changes with moderate-to-severe canal stenosis particularly within the lumbar spine. 8. No evidence of bowel obstruction. . CTA Chest: 1. Interval development of ground-glass opacity in the lungs bilaterally. This likely represents edema. Interval decrease in more focal solid consolidations in the left lung when compared to prior exam. Small bilateral pleural effusions. 2. Extensive hilar lymphadenopathy as described above, possibly reactive. 3. Left thyroid gland nodule. Further non-urgent thyroid ultrasound is recommended. 4. Pulmonary nodules. Followup chest CT within six months is recommended. 5. Indeterminate left renal lesion in the lower pole, incompletely characterized. further evaluation with ultrasaound is recommended. 6. Fibroid uterus. 7. Multilevel degenerative changes with moderate-to-severe canal stenosis particularly within the lumbar spine. . LE Doppler There is no ultrasound evidence of deep venous thrombosis of the left lower extremity. . Barium swallow: Severe esophageal dysmotility which appears unchanged with the comparison study. The appearance is not typical of achalasia. . CXR [10-25]: The tip and side port of the nasogastric tube are beyond the gastroesophageal junction within the fundus of the stomach. Cardiac silhouette is within normal limits. The right IJ central venous catheter has been removed. There remained some mild prominence of the pulmonary interstitial markings without focal consolidation. Brief Hospital Course: 63 yo female with a past medical history [Month/Year (2) 65] for DM II, HTN, OSA, and multiple allergies transfered to the [Hospital Unit Name 153] for respiratory failure, aspiration and pneumonia in the context of lap band migration. . Hypoxemic respiratory failure - The patient was noted to be in respiratory distess with altered mental status in ED. There was a concern for allergic reaction, and the patient received Epinephrine, Solumedrol, Benadryl and H2 blocker. She was also found to be profoundly hypoxemic and was placed on NRB with transient imporvement in O2 sats, and eventually on NIV due to increased work of breathing. Shortly after, she began vomiting and had to be intubated for protection of her airway. ABG was consistent with a mixed acid base disorder with primary respiratory acidosis and a metabolic alkalosis, the latter likely secondary to her outpatient furosemide. Underlying etilogies include aspiration PNA, pneumonitis, infectious processes such as bacterial and viral pneumonia. On presentation to [Hospital Unit Name 153], the patient was maintained on mechanical ventilation for protection of her airway. Her oxygenation status was monitored with serial ABGs. She received right IJ CVL for access. On day 2, she was noted to have complete opacification of a left hemithorax on CXR, likely secondary to mucus plug, which improved significantly with suctioning. The patient remained hemodynamically stable throughout and did not require pressors. She received flexible bronchoscopy, which revelealed mucus with inspissated food particles in LLL segments. Some of the food particles were successfully removed at that time. She was transferred to the [Hospital Ward Name ] ICU for rigid bronchoscopy to remove remaining aspirated material. At the time of transfer, the patient is hemodynamically stable and is satting well on AC 400/26. On MICU7, pt received rigid bronchoscopy with good effect--collapsed segments expanded. Pt was extubated on [10-23]. Ceftriaxone was discontinued as it was felt to be redundant with levaquin for covg of CAP. At the time of tx to the floor, she had completed 9 days of vancomycin, levaquin, flagyl. On the floor, patient remained clinically stable with no further episodes of hypoxia and minimal oxygen requirements. . Pneumonia - On admission, most likely diagnosis was aspiration PNA given migration of lap band and esophageal obstruction. Aspiration pneumonitis was a possibility as well. CAP, flu, and other viral etiologies were considered as well. The patient was noted to have dense consolidation in LLL on imaging, c/w aspiration or CAP. The patient was also noted to have leukocytosis due to either an infectious process or steroid therapy that she received while in the ED. The patient was started treatment with Levofloxacin and Flagyl for coverage of suspected pathogens based on etiologies described above. Vancomycin and Ceftriaxone were added to cover for Staph given h/o Diabetes as well as to double cover GNR. She completed a 10 day course of antibiotics and remained stable on the floor with no fever or respiratory distress. WBC remained slightly elevated, however with no localizing symptoms and clinical improvement, abx were not restarted. On discharge, pt was satting well with nl WBC and no fever. . Megaesophagus -- On admission, the patient was noted to have markedly dilated esophagus. She was evaluated by surgery and underwent removal of her gastric band due to extremely high risk of aspiration. She tolerated the procedure well. Her Hct remained stable. She was transiently hypotenisve, but responded well to IVF bolus and did not require pressors. Following surgery, the patient was maintained NPO and NGT was placed to suction. After extubation, barium swallow revealed extensive esophageal dysmotility and she was placed on a bariatric diet after several days of PPN. She had no additional aspiration events after initiation of a bariatric diet and was discharged to rehab on stage 3 of the diet. . Hypoglycemia/DM II - On admission the patient was hypoglycemic due to underlying infectious process vs pump malfunction. Pump was stopped and the patient was started on SSI for glucose control. Finger sticks were monitored q4 hours. The patient became significantly hyperglycemic and had to be started on insulin gtt with hourly finger sticks. On MICU7, pt transitioned to lantus and humalog sub Q. She was maintained on 60 units of glargine (decreased to 30 units given decreased PO intake) and aggressive ISS. On discharge, sugars were running between 100 and 150s. She was discharged on glargine 30 units and a humalog sliding scale. . Hypertension - On admission, the patient's BP meds were held with the plan to give IV labetalol or hydralazine if the patient become hypertensive. After extubation, BP trended up even on home dose of diovan, hydralazine was uptitirated to 30mg qid. On transfer to the floor, pressures somewhate elevated with home diovan and hydralazine. Hydralazine was discontinued and she was started on amlodipine and HCTZ, as well as home dose of spironolactone which may need to be uptitrated as an outpatient for optimal BP control. . Persistent Fevers: No organisms isolated from sputum or blood UA not striking for infxn. It is conceivable that persistent fevers were the consequence of inflammation secondary to pneumonitis PNA, or line infection given that IJ line was removed out of concern for pus draining from insertion site. Given UE edema, SVC thrombus and UE DVTs were also excluded with CTA and dopplers repectively. Fevers improved after abx. . Lung Nodules: [Month (only) 116] be due to aspiration event but would recommend out-pt follow up with repeat imaging in 6 month. . CHF: stable. She was continued on her home dose of metoprolol. . Thyroid Nodule: left thyroid gland nodule. Further non-urgent thyroid ultrasound is recommended. . Depression: cymbalta was held in the MICU and then not restarted given that it is unable to be crushed. Pt states that she did not feel that she needed it and was warned of possible adverse effect. Would use caution in restarting anti-depressants as [1-16] wk washout period is recommended to prevent seratonergic side effects. . # Rash: new errythematous intertriginous rash on neck suspicious for fungal infection was treated with miconazole powder. Medications on Admission: -celebrex 200 mg q day -[Doctor First Name 130] 60 mg [Hospital1 ] -Ca with vit d q day -furosemide 20 mg [Hospital1 ]-spironolactone 50 mg a day -vitamin E 400 U q day -Diovan 80 mg [Hospital1 ] -Prilosec OTC 20 mg q dat -Trilipix 135 mg q day -Vitamin B-12 q day -Niaspan 1000 mg q day -Aspirin 81 mg q day -vitamin C 100 mg q day -cymbalta 60 mg q dday -vesicare 10 mg q day -fiver capsule q day -clonazepam 0.5 mg [Hospital1 ] -alpha lipoic acid 100 mg q day -metoprolol tartrate 50 mg -MV -omega 3 -glucosamine with MSM [Hospital1 ] -trazadone 50 mq q HS -zantac 300 mg q day -simvastatin 10 mg qHS -insulin pump Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for fevers, pain. 2. Valsartan 40 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder [Hospital1 ]: One (1) Appl Topical TID (3 times a day). 4. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 6. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 7. Hydrochlorothiazide 12.5 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 8. Amlodipine 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. [Doctor First Name ] 60 mg Tablet [Doctor First Name ]: One (1) Tablet PO twice a day as needed for allergy symptoms. 10. Aspirin 81 mg Tablet [Doctor First Name ]: One (1) Tablet PO once a day. 11. Calcium 500 mg Tablet [Doctor First Name ]: One (1) Tablet PO twice a day. Tablet(s) 12. Celebrex 200 mg Capsule [Doctor First Name ]: One (1) Capsule PO once a day. 13. Clonazepam 0.5 mg Tablet [Doctor First Name ]: One (1) Tablet PO twice a day. 14. Furosemide 20 mg Tablet [Doctor First Name ]: One (1) Tablet PO twice a day. 15. Metamucil Oral 16. Multivitamin Tablet [Doctor First Name ]: One (1) Tablet PO once a day. 17. Niacin 250 mg Tablet [Doctor First Name ]: One (1) Tablet PO twice a day. 18. Omega-3 Fatty Acids Capsule [Doctor First Name ]: One (1) Capsule PO once a day. 19. Simvastatin 10 mg Tablet [Doctor First Name ]: One (1) Tablet PO at bedtime. 20. Trazodone 50 mg Tablet [Doctor First Name ]: One (1) Tablet PO at bedtime. 21. Vitamin B-12 Oral 22. Vitamin C Oral 23. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. 24. Zantac 15 mg/mL Syrup [Last Name (STitle) ]: Twenty (20) ml PO at bedtime. 25. Vitamin E 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 26. Vesicare 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 27. Glucosamine Msm Oral 28. Vitamin D Oral 29. Alpha Lipoic Acid Oral 30. Insulin Glargine 100 unit/mL Solution [Last Name (STitle) ]: Thirty (30) units Subcutaneous at bedtime. 31. Humalog 100 unit/mL Solution [Last Name (STitle) ]: One (1) unit Subcutaneous four times a day: Please give per insulin sliding scale. 32. Spironolactone 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 745] Health Care Center Discharge Diagnosis: esophageal dysmotility, aspiration pneumonia Discharge Condition: stable, tolerating stage 3 of bariatric diet, afebrile. Discharge Instructions: You were admitted for aspiration in the context of migration of your lap band, which lead to pneumonia and required an ICU admission. You improved with supportive care and antibiotics. Your lab band was removed however you were found to have continued esophageal dysmotility, therefore your diet was advanced cautiously. You were tolerating stage 3 of the bariatric diet on discharge. . Please take your medications as prescribed and follow up with your doctors [First Name (Titles) 3] [Last Name (Titles) 4030] below. Your trilipix and cymbalta were held given that they cannot be administered as crushed pills, however you may restart them once you resume a regular diet and you should contact your physician if you are feeling depressed. Additionally, you were started on hydrochlorothiazide and amlodipine for your blood pressure and you were switched to insulin glargine and humalog for diabetes. You will need to see surgery in 2 weeks and should continue taking stage 3 of the bariatric diet until that time. . Please return to the hospital or call your doctor if you should experience increased difficulty swallowing, aspiration, new cough or fever, or any other symptoms that are concerning to you. Followup Instructions: Please follow up with surgery as [Last Name (Titles) 4030] below: . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 305] Date/Time:[2177-11-12] 9:15 . Additionally, please schedule an appointment with Dr. [Last Name (STitle) 16258] after you leave the rehab facility and keep the following previously scheduled appointments: . Provider: [Name10 (NameIs) ] INTAKE,ONE [Name10 (NameIs) ] ROOMS/BAYS Date/Time:[2177-12-2] 12:00 Provider: [Name10 (NameIs) 17853] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[Telephone/Fax (1) 3020] Date/Time:[2177-12-2] 9:30 Provider: [Name10 (NameIs) ] SACKS, LICSW Phone:[Telephone/Fax (1) 1387] Date/Time:[2177-11-27] 1:30 . Finally, you were found to have a lung nodule as well as a thyroid nodule. You will need to follow up with your primary care physician for further [Name9 (PRE) 8019] of these lesions. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495]	[ "934.8", "V14.0", "519.19", "327.23", "V58.67", "530.0", "464.11", "518.0", "518.82", "V45.86", "536.3", "V17.3", "996.59", "V18.0", "530.5", "996.69", "788.5", "311", "507.0", "V17.49", "V49.71", "357.2", "780.97", "401.9", "V45.85", "110.8", "V16.41", "272.4", "278.01", "530.89", "721.3", "250.60", "564.3" ]	icd9cm	[ [ [] ] ]	[ "33.22", "33.23", "98.15", "96.72", "99.17", "93.90", "89.32", "86.05", "96.04", "44.97" ]	icd9pcs	[ [ [] ] ]	17487, 17551	7742, 14145	353, 426	17640, 17698	3560, 3560	18966, 20060	2147, 2679		14838, 17464		17572, 17619		14171, 14815			17722, 18943									2694, 2699													4243, 4655							280, 315										454, 1425							4669, 7719							1447, 1866	1882, 2131
26,705	120,975	43441+58624	Discharge summary	report+addendum	Admission Date: [2170-7-8] Discharge Date: [2170-7-25] Date of Birth: [2133-6-10] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 297] Chief Complaint: status asthmaticus Major Surgical or Invasive Procedure: R and L subclavian lines Numerous bronchoscopies History of Present Illness: This is a 34 year old African American male with a history of severe asthma, who presents with progressive shortness of breath and wheezing for three to four days. The patient has a long history of asthma consisting of more than 90 admissions as well as Intensive Care Unit stays and intubations. The patient was last admitted to the [Hospital1 69] in [2168-3-28] and discharged on a Prednisone taper. Pt reports progressively worsening wheezing, shortness of breath and cough. The cough has been nonproductive and the patient denies any fevers, chills, chest pain or sputum production. Normal peak flows for the patient is in the range of 400 to 600. Past Medical History: 1. Asthma. 2. Gastroesophageal reflux disease. Social History: Approximately 15 pack years tobacco history. Quit 2 months ago. Occasional alcohol. Employed as an auto mechanic, married and has two children. Family History: Asthma Physical Exam: Gen: NAD, A& O X 3, confined to bed because of weakness Heent: R eye diplopia, PERRL, MMM Neck: No JVD Heart: RRR, no mrg Lungs: Few wheezing and rhonchi, much improved from admission Abd: soft, nt/nd, + BS Ext: R knee pain, L achilles tendon pain (after rupture) Neuro: Able to move all extremities but only 2/5 strength B UE, and 3/5 strength B LE. Normal reflexes. Pertinent Results: [2170-7-24] 04:30AM BLOOD WBC-10.6 RBC-3.33* Hgb-10.4* Hct-30.2* MCV-91 MCH-31.2 MCHC-34.4 RDW-16.1* Plt Ct-152 [2170-7-8] 10:46PM BLOOD WBC-16.9# RBC-4.50 Hgb-13.6* Hct-41.0 MCV-91 MCH-30.2 MCHC-33.1 RDW-12.4 Plt Ct-247 [2170-7-19] 12:03PM BLOOD WBC-42.3* RBC-3.59* Hgb-11.2* Hct-33.2* MCV-93 MCH-31.2 MCHC-33.7 RDW-15.0 Plt Ct-259 [2170-7-21] 03:58AM BLOOD Neuts-69 Bands-12* Lymphs-8* Monos-8 Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-0 [2170-7-21] 03:58AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ [2170-7-24] 04:30AM BLOOD Plt Ct-152 [2170-7-21] 03:58AM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [2170-7-24] 04:30AM BLOOD Glucose-71 UreaN-22* Creat-0.6 Na-140 K-3.8 Cl-107 HCO3-23 AnGap-14 [2170-7-19] 04:00AM BLOOD ALT-51* AST-65* LD(LDH)-593* CK(CPK)-1091* AlkPhos-57 TotBili-0.4 [2170-7-14] 11:24AM BLOOD CK(CPK)-1066* [2170-7-15] 04:06AM BLOOD ALT-50* AST-68* LD(LDH)-378* AlkPhos-67 TotBili-0.3 [2170-7-14] 11:32PM BLOOD CK-MB-3 cTropnT-<0.01 [2170-7-14] 05:18PM BLOOD CK-MB-4 cTropnT-<0.01 [2170-7-14] 11:24AM BLOOD CK-MB-3 cTropnT-<0.01 [2170-7-24] 04:30AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2 [2170-7-16] 11:54AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2170-7-21] 11:28AM BLOOD Type-ART Temp-37.2 Tidal V-1000 PEEP-0 O2-40 pO2-117* pCO2-35 pH-7.49* calHCO3-27 Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU [2170-7-20] 07:28AM BLOOD Type-ART Temp-37.1 Tidal V-880 PEEP-8 O2-60 pO2-55* pCO2-35 pH-7.41 calHCO3-23 Base XS--1 Intubat-INTUBATED [2170-7-15] 02:41PM BLOOD Type-ART Temp-37.2 Rates-/17 Tidal V-550 PEEP-12 O2-80 pO2-96 pCO2-80* pH-7.33* calHCO3-44* Base XS-11 AADO2-406 REQ O2-70 Intubat-INTUBATED Vent-CONTROLLED [2170-7-14] 10:49AM BLOOD Type-ART Temp-37.8 pO2-90 pCO2-93* pH-7.29* calHCO3-47* Base XS-13 [2170-7-12] 05:31PM BLOOD Type-ART Temp-37.0 Rates-12/ Tidal V-920 PEEP-5 O2-40 pO2-65* pCO2-54* pH-7.47* calHCO3-40* Base XS-13 Intubat-INTUBATED [2170-7-15] 06:52AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-6.5 Leuks-NEG [2170-7-13] 12:05 pm BRONCHOALVEOLAR LAVAGE r/o Influenza A & B, RSV. GRAM STAIN (Final [2170-7-13]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2170-7-16]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. HEAVY GROWTH. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Brief Hospital Course: 1. Status Asthmaticus / Respiratory failure: Pt was transferred intubated (on steroids and paralytics), started on 125 mg IV solumedrol, emperic antibiotics (levofloxacin and vancomycin), mdi's (q2-4 hours) and aggressive suctioning. His paralytics were discontinued. The pt remained bronchospastic and quite difficult to ventilate and oxygenate during this hospitalization. His secretions were thick and difficult to suction, requiring 4 bronchoscopies. He also had a negative CTA for acute PE. Subsequent to these therapeutic bronchoscopies, his oxygenation temporarily improved, for, on average, 24 hours. He is now on PO prednisone and will continue nebs, and linezolid for a total of 14 days. 2. MRSA: The pt also had florid 3+ MRSA growing from sputum cultures and BAL's. He was treated with vancomycin, then linezolid for this. His WBC count elevated to a max of 42 with a significant bandemia and left shift, including myelocytes and promeylocytes. Hematology was consulted and evaluated his peripheral smear, which showed no evidence of myeloproliferative disorder. This leukomoid reaction was attributed to a combination of steroids and MRSA tracheobronchitis. He had an extensive workup including numerous chest CT's, abdominal CT, head CT, sinus CT, CTA. The pt's leukocytosis and low grade fevers were not resolving on vancomycin and ID recomended linezolid for better pulmonary penetrence. He was also treated emperically for C.diff colitis with PO flagyl, but this was eventually stopped after numerous negative C.diff stool assays (however, he still has a C.diff toxin pending that was a send out lab). On linezolid, the pt defervesced after 4 days, and his leukocytosis resolved (of note, this is also when the pt's IV solumedrol was rapidly tapered and eventually switched to PO prednisone). Currently pt is without signs/symptoms of active infection, although he does still have some watery secretions. ID also recommended imipenim to cover emperically for gram negative bacteria, for a 7 day course. 3. Steroid Myopathy: Once the pt was extubated, he was found to be extremely weak, not able to lift his hands, arms, legs, feet or head from the bed. This was attributed to steroid myopathy, with CK's >1000. He was not treated emperically for rhabdomyolesis because his CK's were not at the level one would expect in rhabdo (i.e. > [Numeric Identifier 961]) and he had no associated electrolyte abnormalities. He will need extensive PT/OT to help get back to his independant status. His myopathy appears to be dose-dependant to steroids and is now improving daily. The pt did have a previous episode of similar weakness after being intubated for a prolonged period also. 4. Hyperglycemia: Pt developed steroid induced hyperglycemia while in the MICU. He was covered effectively with insulin drip and then SC insulin SS when the dosage decreased. 5. Access: Pt had an A-line, Right and Left subclavian lines placed during his MICU stay. Now, he still has a R-SC line for antibiotics (imipenim). Will contact ID and discuss the possibility of stopping imipenim today (day [5-4]) so this line can come out (it was placed 5 days ago). 6. Anemia: Hct down to 30. Pt developed occultly heme positive stools after he was extubated. This was thought to be due to stress-gastritis, uncompletely covered with PPI. He will be D/C'd with PO protonix 40 mg po QD. No transfusion requirements. No longer heme positive. 7. Tachycardia: Pt developed a tachycardia during his MICU stay. This was thought to be due to beta-agonists and anticholinergics (nebs), infection, and hyperadrenergic response [1-29] intubation. This resolved once the pt was extubated. He had no troponin leak or dynamic EKG changes during his tachycardic episodes. Full CODE Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours). Disp:qs Refills:2 2. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation Q3H (every 3 hours). Disp:qs Refills:2 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD (once a day) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q1-2H () as needed for asthma. Disp:qs Refills:0 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2-4H (every 2 to 4 hours) as needed for asthma. Disp:qs Refills:0 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:qs ML(s) Refills:0 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). Disp:60 ML(s) Refills:2 8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs Refills:2 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a day). Disp:10 Tablet(s) Refills:0 10. 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 11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 54351] - [Location (un) 5503] Discharge Diagnosis: Status Asthmaticus secondary to MRSA pneumonia Discharge Condition: Good Discharge Instructions: Frequent suctioning Aggressive PT/OT Continued nebs, antibiotics as below. Continue chest physiotherapy Followup Instructions: Dr.[Last Name (STitle) 21714] Completed by:[2170-7-25] Name: [Known lastname ],[Known firstname 77] C Unit No: [Numeric Identifier 14754] Admission Date: [2170-7-8] Discharge Date: [2170-7-25] Date of Birth: [2133-6-10] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 1225] Chief Complaint: Status Asthmaticus Major Surgical or Invasive Procedure: right and left SC lines 4 bronchoscopies History of Present Illness: as above Past Medical History: 1. Asthma. 2. Gastroesophageal reflux disease. Social History: Approximately 15 pack years tobacco history.Quit 2 months ago. Occasional alcohol. Employed as anauto mechanic, married and has two children. Family History: Asthma Physical Exam: as above Pertinent Results: as above Brief Hospital Course: as above Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation Q6H (every 6 hours). Disp:qs Refills:2 2. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation Q3H (every 3 hours). Disp:qs Refills:2 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD (once a day) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q1-2H () as needed for asthma. Disp:qs Refills:0 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2-4H (every 2 to 4 hours) as needed for asthma. Disp:qs Refills:0 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:qs ML(s) Refills:0 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). Disp:60 ML(s) Refills:2 8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs Refills:2 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO QD (once a day). Disp:20Tablet(s) Refills:0. Take this for 5 days. Then 2 tablets by mouth once a day. 10. 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 11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 6219] - [Location (un) 2653] Discharge Diagnosis: Status Asthmaticus secondary to MRSA pneumonia Discharge Condition: Good Discharge Instructions: Frequent suctioning Aggressive PT/OT Continued nebs, antibiotics as below. Continue chest physiotherapy Pt to taper steroids as follows: 5 days at 40 mg po qD then stay at 20 mg po qD until pt meets with Dr.[Last Name (STitle) 14757] After pt finishes rehab, he should make an appointment with orthopedics, in their clinic at [Hospital1 8], for further evaluation of L achilles heal rupture. Followup Instructions: Dr.[Last Name (STitle) 14757] [Known firstname 77] [Last Name (NamePattern4) 1226] MD [Last Name (un) 1227] Completed by:[2170-7-25]	[ "493.91", "482.41", "359.4", "518.81", "535.41", "285.9", "790.6", "530.81", "V58.65" ]	icd9cm	[ [ [] ] ]	[ "33.22", "96.72", "96.56", "00.14", "96.04" ]	icd9pcs	[ [ [] ] ]	12723, 12797	11165, 11175	10753, 10796	12888, 12894	11132, 11142	13345, 13529	11080, 11088		11198, 12700		12818, 12867					12918, 13322									11103, 11113																				10694, 10715										10824, 10834														10856, 10905	10921, 11064
13,171	165,021	44133	Discharge summary	report	Admission Date: [2107-6-27] Discharge Date: [2107-7-8] Date of Birth: [2030-4-23] Sex: M Discharging Service: CARDIOTHORACIC SURGERY ADMITTING DIAGNOSES: 1. Type A aortic dissection. 2. End-stage renal disease on hemodialysis. 3. Hypertension. 4. Hyperlipidemia. 5. History of gallstone pancreatitis. 6. Gout. 7. History of nephrolithiasis. DISCHARGE DIAGNOSES: 1. Type A aortic dissection, status post repair. 2. End-stage renal disease on hemodialysis. 3. Hypertension. 4. Hyperlipidemia. 5. History of gallstone pancreatitis. 6. Gout. 7. History of nephrolithiasis. ADMITTING HISTORY AND PHYSICAL: The patient was admitted at 2:00 am on [2107-6-27], when he initially presented with some weakness, fatigue, and chest pain with a productive cough. He was initially worked-up in the ER for rule out MI. The patient's initial cardiac work-up did not show any evidence of ischemia, but serial cardiac enzymes were drawn and there was concern for pulmonary embolism. Therefore, the patient underwent a CAT scan which demonstrated a type A aortic dissection. When the patient initially came in, he was afebrile at 96.4??????, pulse rate 79, blood pressure 148/89, with a respiratory rate of 18, and he was sating 93% on room air. His initial exam, as per records, indicated that he was in no acute distress without any jugulovenous distention. He had decreased breath sounds in the left lower lobe; otherwise, he was clear. The heart was regular without murmur, rub or gallop. The abdomen was soft. There was no peripheral edema noted and no focal neurologic deficits. At the time cardiothoracic surgery was called, the patient already had a room on the floor and notably had a systolic blood pressure in the 230s. His admitting white count was 8.9 with a crit of 44.2, and platelets of 256. His potassium was 5.6, with a BUN and creatinine of 46 and 13.4, respectively. HOSPITAL COURSE: Given the acute nature of the patient's diagnosis, he was taken emergently to the operating room for repair of his aortic dissection. Preoperatively, he was immediately started on blood pressure control with labetalol. He underwent surgical repair of his dissection with resuspension of his aortic valve and replacement of the ascending aorta with Gelweave graft. His EF preop was noted to be about 30%, and postop was about 40-45%. He was on cardiopulmonary bypass for 94 minutes, with a crossclamp time of 71 minutes. Intraoperatively, he received 3 units of fresh frozen plasma, 1 pack of platelets, and 2 units of packed red blood cells. He was taken immediately to the Cardiac Surgery Recovery Unit postoperatively where he was slow to extubate due to lethargy. He continued his hemodialysis while in the Intensive Care Unit. On postoperative days #1 and #2, he remained sedated on dobutamine. Late on postoperative day #2, he was weaned off dobutamine and Nitro drip was used for control of blood pressure. He began to experience episodes of restlessness in the evening, and agitation on the evening of postoperative day #2 which continued several days into his hospital course. On postoperative day #3, the patient was transferred to the floor, medically stable, but his mental status changes and agitation continued. A CT scan was done which did not show any acute evidence of a CVA. His electrolytes were checked, and any mental status altering medications, such as narcotics, were discontinued. He continued to experience these episodes; therefore, neurology was consulted, and per their opinion this was most likely sun-downing which could be controlled with low doses of Haldol prn. The patient continued his Tuesday, Thursday, Saturday hemodialysis course throughout his hospitalization without any difficulty, and hemodialysis was also an aid in controlling the patient's blood pressure and removing volume. The patient's blood pressures remained elevated and fluctuated quite a bit with highs in the 200s, but consistently running in the 160s-180s. A goal was set for him at slightly above 140 systolic which was achieved at the time of discharge. The patient's postoperative course on the floor was unremarkable except for mental status changes, as mentioned previously. The patient's blood pressure was maintained around the 140s-150s systolic near time of discharge. His pulses remained excellent in all four extremities. He had been off having sitters for 24 hours prior to discharge, and he had been ambulating with assistance without notable difficulty. His discharge white count was 8.0 with a hematocrit of 34.3, and a platelet count of 371. The potassium was 4.4, and BUN and creatinine were 59 and 10.6, respectively. He was discharged to rehab in good condition with excellent mental state where he was alert and oriented x 3, and had returned to what his family described as his baseline. DISCHARGE MEDICATIONS: 1) aspirin 325 mg qd, 2) Lopressor 50 mg [Hospital1 ], 3) pantoprazole 40 mg qd, 4) Norvasc 5 mg qd, 5) captopril 75 mg tid, 6) sevelamer 800 mg 1 tablet tid, 7) calcium 667 mg 2 tablets tid with meals. DISCHARGE INSTRUCTIONS: He was encouraged to engage in light activity, but avoid heavy exertion for one month. Continue on a renal diet. Continue all recommendations as per his nephrologist. He is to follow-up with Dr. [Last Name (STitle) ] in 4 weeks. Follow-up with his nephrologist and primary care physician [Name Initial (PRE) 176] 1 week. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 94717] MEDQUIST36 D: [2107-7-8] 10:26 T: [2107-7-8] 09:26 JOB#: [Job Number 94718]	[ "274.9", "V13.01", "998.11", "441.01", "423.0", "293.0", "403.91", "441.1" ]	icd9cm	[ [ [] ] ]	[ "39.95", "35.11", "39.61", "38.45" ]	icd9pcs	[ [ [] ] ]								396, 1920	4901, 5109					1938, 4877		5134, 5745
292	179,726	14272	Discharge summary	report	Admission Date: [2103-9-27] Discharge Date: [2103-9-28] Date of Birth: [2046-9-17] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 57-year-old female with history of primary sclerosing cholangitis, inferior myocardial infarction, and sepsis who fell eight feet onto a concrete floor on [2103-9-18] and broke her right sacrum, right proximal femur, inferior superior rami, left humeral neck and nondisplaced right orbital fracture. She presented to the [Hospital6 16029] where CT Scan of the C spine was negative and where patient received open reduction internal fixation of the right femur. On [2103-9-18], CT Scan of the head revealed right intraparenchymal frontal bleeding subarachnoid bleed. The patient was transfused with two packed red blood cells, eight units of platelets while in the ICU there. On [2103-9-21], the patient was transferred to the floor at [Hospital1 11485]. On [2103-9-25], the patient had an episode of hematemesis and was transferred to the [Hospital1 11485] ICU where she received two units of platelets. On [2103-9-26], the patient had another episode of hematemesis and was then brought for EGD where they sclerosed a 3.5 rent in the lower esophagus. The patient also received one unit FFP and Octreotide. On [2103-9-27], the patient was then transferred to [Hospital1 69] with the following medications. ADMISSION MEDICATIONS: 1. Oxycodone. 2. Propanolol. 3. Percocet. 4. Colace. 5. Spironolactone. 6. Actigall. 7. Lactulose. 8. Octreotide. 9. Levophed. On the air transfer to the [Hospital1 188], patient's Levophed had to be increased from 14 to 20 mcg per hour. She also received 750 cc of IV fluids, 2 mg Ativan and 2 units of packed red blood cells during the air transfer. ALLERGIES: None. MEDICATIONS AT HOME: 1. Actigall 300 mg p.o. q.i.d. 2. Zestoretic 10/12.5 one tablet p.o. q.d. 3. Aldactone 50 mg p.o. b.i.d. 4. Levoxyl 100 mcg p.o. q.d. 5. Propanolol 20 mg p.o. b.i.d. 6. Prilosec 20 mg p.o. q.d. PAST MEDICAL HISTORY: 1. Two cesarean sections. 2. [2098] inferior myocardial infarction with arrest and cardioversion. 3. Hypothyroidism. 4. Hernia. 5. Cholecystectomy. 6. Pneumonia with sepsis in [2099]. 7. In [2097] primary sclerosing cholangitis by ERCP biopsy. 8. In [2102], ascites with Klebsiella bacteremia treated with Gentamycin and Ciprofloxacin. 9. [2103-7-12], ascites with liver transplant work up by [Hospital1 69]. PHYSICAL EXAMINATION: On admission with a temperature of 97.2 F, pulse 88, blood pressure 104/63 on a ventilator SIMV 700 times 15 with a PEEP of 5 and FIO2 of 100%. Generally this patient is intubated and not arousable to painful stimuli. Head, eyes, ears, nose and throat: She had right orbital ecchymosis. Pupils are 8 mm, fixed and dilated bilaterally with sluggish reaction to light. Tympanic membranes are normal. Icteric eyes and bloody oropharynx. Neck is supple. Cardiovascular: Regular rate and rhythm. Normal S1, S2. No murmurs or thrills noted. Chest: Coarse rhonchi heard bilaterally. Abdomen is distended with positive fluid wave. Extremity: +3 pedal edema bilaterally in the upper and lower extremities. Lower extremities are cool to touch. Skin: Jaundice noted, but no spider angiomas noted. There is no caput medusas seen. LABORATORY: Upon admission labs were a white count of 38.1 with the following differential of 54% neutrophils, 34% bands, 5% lymphocytes and 4% monocytes. Hematocrit was 22.4, platelets 198,000. Sodium 135, potassium 5.5, chloride 104, bicarbonate 13, BUN 40, creatinine 1.0, anion gap 18, glucose 84, calcium 8.1, phosphorus 4.4, magnesium 1.6. PT 20.5, PTT 35.1, INR 2.9. Total bilirubin is 11, ALT 75, AST 163, amylase 385. Albumin 2.0, LDH 651, alkaline phosphatase 164, lipase 56, fibrinogen 145, Fibrogen degradation products is 80 to 160. D-dimer is greater than 2,000. ABG is 7.42 with pCO2 of 21 and pO2 of 250 on tidal volume is 700 with respiratory rate of 15, PEEP of 5 and FIO2 of 100. Urinalysis is hazy with large blood and positive nitrates, 30 protein and 100 glucose is noted. Urine micro shows six to 10 red blood cells with greater than 50 white blood cells and many bacteria. Urine blood and acidic cultures are pending. Serum osmolality pending. Ascites chemistry with a protein of 1.5, glucose 108, creatinine 0.8, LDH 100, amylase 12, total bilirubin 2, albumin 0.6, lactate 13.8. HOSPITAL COURSE: 1. GI: Hepatology Team was consulted and they decided not to perform an EGD at this time due to the patient being hemodynamically unstable. Instead, an oral gastric tube was placed and we lavaged 1.6 liters of dark blood. A paracentesis was performed and 3.5 liters of acidic fluid was removed. The patient was continued on Octreotide and given Protonix 40 mg IV b.i.d. for prophylaxis. The patient was typed and crossed, but we were unable to get any blood for transfusion due to difficult type and cross. 2. CARDIOVASCULAR: Hypotension, the Levophed was increased to 30 mcg per kilogram per minute, however patient remained hypotensive so Vasopressin 0.04 units per minute was added. The patient was also bolused with one liter of normal saline every hour. Since no packed red blood cells were available, the patient was infused with 25 grams of Albumin. Finally, Dopamine was added at 10 mcg per kilogram per minute to control the low blood pressure. The patient's blood pressure on these triple pressures and fluid boluses was still settling around a systolic blood pressure of 80. 3. RESPIRATORY: The patient was initially put on SIMV at 700 cc times a respiratory rate of 15 with PEEP of 5 and FIO2 of 100%. Since the ABG shows quite a low CO2 and high PO2, the patient was switched over to assist-control at 550 cc times 15 with a PEEP of 5 and FIO2 of 60%. Her ABG at this time showed a pH of 7.34, CO2 21 and pO2 of 144. However, patient was overbreathing the respiratory with additional respiratory rate of 30 rather than the set 15. So she was switched over to assist-control 550 cc with a respiratory rate of 30, PEEP of 5 and FIO2 of 60%. It is believed that the patient is overbreathing to compensate for her metabolic acidosis. 4. RENAL: The patient did have a high BUN and a normal creatinine. These values reflect that the patient was having an upper GI bleed. She also had a metabolic acidosis with anion gap. It is believed that this is due to the lactate production due to the ischemia both to her organs. We attempted to maintain a blood pressure above systolics of 80s to profuse her organs, however her metabolic acidosis continued to worsen with a anion gap of 20 and bicarbonate of 11. She was also overbreathing with less CO2 compensation. Her gasses were showing a pH of 7.18 with a pCO2 of only 27. 5. INFECTIOUS DISEASE: Patient was initially given Levofloxacin 500 mg times one for prophylaxis for possible EGD. Since her white count was shown to be 38 with a large bandemia, we started Ceftazidine 2 grams IV t.i.d. for treatment of primary spontaneous bacterial peritonitis. We also attempted to pan culture her which showed no results at this time. 6. NEUROLOGICALLY: At 2 AM, the patient began to have seizures. She was given 200 mg of Fosphenytoin, 40 mg of Ativan and 20 mg of Valium. From 2 AM to 10 AM, the patient was only able to stop seizing for a couple of minutes for about three to four times throughout the whole period. We were finally able to obtain a CT Scan of the head which revealed diffuse cerebral edema and effacement of the sulci. No extraocular hemorrhage was found. There were punctate areas of high attenuation in the right frontal cortex that likely represented a contusion. Also, it seems that her cerebral tapholes were heading toward herniation. Neurosurgery was consulted, but no treatment could be given at this time. Neurology was consulted and en EGD was obtained showing electrical activity representing myoclonic actions. This myoclonic activity is likely due to hypoxic injury to brain. Neurology informed the Team who then informed the family of the poor neurologic prognostic factors. Patient continued to receive Phenobarbitol and then was put on a Propofol drip for her presumed seizure activity at the time. She was also given 25 gram of Mannitol to lessen the cerebral edema. DISPOSITION: Around 12:45 PM on [2103-9-28], the patient's family did visit her. After the visit, the family decided that the patient should be comfort measures only. Her pressor medications were stopped. Then the patient was extubated. At 1:08 PM on [2103-9-28], Mrs. [Known firstname 501] [Known lastname 42396] passed away due to hypovolemic and septic shock. DISCHARGE DIAGNOSES: 1. Hypovolemic and septic shock. 2. Upper GI bleed secondary to esophageal tear. 3. Ascites secondary to portal hypotension which is secondary to the primary sclerosing cholangitis. 4. Cerebral edema secondary to hepatic failure. 5. Ischemic hepatitis. 6. Sepsis. 7. Lactic metabolic acidosis. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ], M.D. Dictated By:[Last Name (NamePattern1) 4270] MEDQUIST36 D: [2103-9-30] 13:26 T: [2103-10-3] 11:13 JOB#: [Job Number ]	[ "572.3", "576.1", "038.9", "780.39", "276.5", "456.20", "276.2", "789.5", "785.59" ]	icd9cm	[ [ [] ] ]	[ "96.04", "54.91", "96.71" ]	icd9pcs	[ [ [] ] ]								8822, 9383						4518, 8801			1450, 1837				1858, 2059														2547, 4501																				162, 1427														2081, 2524
16,465	192,433	19628	Discharge summary	report	Admission Date: [2172-12-5] Discharge Date: [2172-12-16] Date of Birth: [2125-10-24] Sex: F Service: MED Allergies: Lopressor / Penicillins / Keflex / Percocet / Erythromycin Base Attending:[First Name3 (LF) 2181] Chief Complaint: 1. Nausea 2. Vomiting 3. Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 47-year-old woman with a history of coronary artery disease, status post myocardial infarction, type I diabetes mellitus intermittently on dialysis, peptic ulcer disease, and gastroparesis who presents with a two-day history of nausea and vomiting. These symptoms lead to four hospitalizations in the last 4 weeks. Two hospitalizations were at [Hospital6 5016] ([Location (un) 7661], MA), one was at [Hospital6 3105], and the last was here when she was discharged on [2172-11-29]. She states that for the last two days she has had intractable nausea and vomiting. It was particularly bad after hemodialysis on [12-5]. The patient experienced epigastric pain but is passing gas. She does not report any bloody vomitus or melanotic stools, fever, chills, chest pain, shortness of breath, or cough. These episodes are normally well treated with Zofran and Reglan as the patient feels well goes home for a short period of time before they start up again. Upon her [11-29] discharge from here, the patient was to go for gastric emptying study. Past Medical History: 1. Diabetes Mellitus Type 1 - nephropathy - retinopathy - neuropathy 2. Gastroparesis 3. Myocardial infarction ([2169]) - status post CABG x 4 vessels 4. Hypertension 5. Renal Disease - dialysis x 5 weeks 6. Peptic ulcer disease - status post GI bleed 7. Status post c-sections x2 Social History: Lives with husband and two children in [Name (NI) 7661]. Worked as a probation officer up 3 years PTA. No history of smoking, no EtOH or other drugs. Gets physical therapy 3x/week at home. Family History: No history of diabetes, heart disease, or cancer. Physical Exam: T 97.6 BP 165/85 P 88 RR 24 General: Pt appears slightly lethargic, slow to answer questions, NAD. HEENT: sclera anicteric, PEERL, EOMI Chest: CTA bilateraly, no wheezes, crackles, rhonchi CV: RRR S1 S2 III/VI systolic @ RSB Abdom: Soft, mild epigastric tenderness, ND + BS moderate distension. Extremities: no c/c/e Neuro: A&O x 3 Pertinent Results: [2172-12-5] 06:20PM BLOOD WBC-5.4 RBC-6.04* Hgb-16.9* Hct-52.4* MCV-87 MCH-27.9 MCHC-32.2 RDW-15.8* Plt Ct-204 [2172-12-7] 06:00AM BLOOD WBC-6.7 RBC-5.11 Hgb-14.1 Hct-45.0 MCV-88 MCH-27.6 MCHC-31.3 RDW-16.1* Plt Ct-192 [2172-12-11] 06:44AM BLOOD WBC-6.6 RBC-4.57 Hgb-12.8 Hct-39.2 MCV-86 MCH-28.1 MCHC-32.8 RDW-15.6* Plt Ct-167 [2172-12-6] 07:15AM BLOOD Neuts-87.0* Lymphs-7.8* Monos-3.7 Eos-1.0 Baso-0.5 [2172-12-11] 06:44AM BLOOD Neuts-52 Bands-1 Lymphs-12* Monos-15* Eos-19* Baso-1 Atyps-0 Metas-0 Myelos-0 [2172-12-8] 06:10AM BLOOD PT-13.2 PTT-50.2* INR(PT)-1.1 [2172-12-8] 03:20PM BLOOD PT-16.6* PTT-50.2* INR(PT)-1.7 [2172-12-11] 06:44AM BLOOD PT-13.0 PTT-32.0 INR(PT)-1.1 [2172-12-5] 06:20PM BLOOD Glucose-159* UreaN-26* Creat-2.1# Na-138 K-4.3 Cl-100 HCO3-26 AnGap-16 [2172-12-7] 05:00PM BLOOD Glucose-280 UreaN-42* Creat-3.1* Na-136 K-4.9 Cl-104 HCO3-14* AnGap-23* [2172-12-9] 09:20AM BLOOD Glucose-158* UreaN-27* Creat-2.4* Na-137 K-4.0 Cl-107 HCO3-22 AnGap-12 [2172-12-11] 06:44AM BLOOD Glucose-150* UreaN-30* Creat-3.0* Na-138 K-4.1 Cl-104 HCO3-25 AnGap-13 [2172-12-6] 07:15AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.8 Staphylococcus coagulase negative in blood cultures Brief Hospital Course: The patient was admitted to medicine for intractable nausea and vomiting. Her symptoms triggered an episode of diabetic ketoacidosis. These were treated with zofran, reglan, ativan and an insulin sliding scale. She required a one-day ICU stay for close monitoring and aggressive management. Upon transfer to the floor, the patient's symptoms resolved and she could maintain good oral intake. Although she remained asymptomatic and afebrile throughout, she was found to have a gram positive coagulase negative bacteremia at the site of her dialysis line on [12-9]. The line was removed on [12-12] and a temporary femoral line was inserted. She received renal doses of vancomycin. A second tunneled line was placed on [12-15] after her blood cultures were cleared for more than two days. The procedure was successful and the patient was discharged on [12-16] on her usual medications and with an appointment to visit Dr. [Last Name (STitle) ] of transplant surgery to schedule an arteriovenous fistula placement. She will continue to take vancomycin for one week post-discharge. Medications on Admission: 1. Valsartan 40 mg PO once a day 2. Metoclopramide HCl 10 mg PO 4 times a day before meals and at bedtime 3. Aspirin 81 mg PO once a day 4. Atorvastatin Calcium 10 mg PO every other day 5. Carvedilol 6.25 mg PO 2 times a day 6. Calcitriol 0.25 mcg PO every other day 7. Sertraline HCl 50 mg PO once a day 8. B Complex-Vitamin C-Folic Acid 1 mg PO once a day 9. Sevelamer HCl 400 mg PO 3 times a day with meals 10. Docusate Sodium 100 mg PO twice daily as needed for constipation 11. Pantoprazole Sodium 40 mg PO once daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Metoclopramide HCl 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous at dialysis for 7 days. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain for 4 days. Disp:12 Tablet(s) Refills:0 14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every [7-21] hours. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Primary: 1. Gastroparesis 2. Diabetic ketoacidosis 3. Nausea and vomiting 4. Gram positive coagulase negative bacteremia Secondary: 5. Coronary heart disease 6. Hypertension 7. Peptic ulcer disease Discharge Condition: Good Discharge Instructions: You were hospitalized for an episode of nausea, vomiting and abdominal pain. This caused your diabetes to be out of control and required a short stay in the ICU. Your problems were aggressively treated with intravenous medications and an insulin sliding scale. Blood drawn from your dialysis line revealed some microbes which required antibiotics and the removal of your line. A dialysis line was replaced today prior to your discharge. You must continue your vancomycin for another 10 days. This will be given to you during the dialysis sessions. It is important that you follow up with your primary care provider within one week of discharge. Please call your doctor or go to the emergency department if you develop: * uncontrolled nausea, vomiting * fever / chills * shortness of breath * any worrisome symptoms Followup Instructions: 1. Follow up with primary care provider within one week of discharge 2. Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2173-1-4] 3:00 Completed by:[2172-12-16]	[ "276.5", "250.11", "357.2", "412", "790.7", "362.01", "536.3", "276.2", "428.0", "250.61", "250.51", "996.62", "403.91", "V45.81", "250.41" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95", "38.93" ]	icd9pcs	[ [ [] ] ]	6645, 6728	3674, 4772	361, 367	6969, 6975	2419, 3651	7838, 8130	1997, 2048		5345, 6622		6749, 6948		4798, 5322			6999, 7815									2063, 2400																				282, 323										395, 1463														1485, 1771	1787, 1981
609	126,909	12392	Discharge summary	report	Admission Date: [2110-3-3] Discharge Date: [2110-3-7] Date of Birth: [2037-11-16] Sex: F Service: CARDIAC SURGERY CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old female who was recently discharged from [Hospital6 649] from the vascular surgery service on [2110-2-27] during which she was being worked up for left calf claudication and a non healing ulcer. The angiography had revealed left superficial femoral artery stenosis at the adductor canal and during the work up for surgical treatment, the stress test was found to be positive. The cardiac catheterization was performed on [2110-2-26] which revealed severe two vessel disease. The LAD had moderate diffuse disease with 80% stenosis in the proximal portion. The RCA had an 80% mid lesion and a 90% distal followed by serial severe lesions distally and it was noted that she had severe left ventricular diastolic dysfunction. She was evaluated by the cardiothoracic surgery service and it was deemed that she would coronary artery bypass graft prior to having her SFA bypass by the vascular surgery service. She was discharged home and was to return to [Hospital6 2018] on the day of admission to have coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Diabetes mellitus type II 2. Hypertension 3. Hypercholesterolemia 4. Glaucoma PAST SURGICAL HISTORY: 1. Right mastectomy in [2096] ADMISSION MEDICATIONS: 1. Glucophage 850 mg po tid 2. Avandia 4 mg po bid 3. Glucotrol XL 10 mg po bid 4. Zestril 10 mg po qd 5. Lipitor 40 mg po qd 6. Xalatan eyedrops 7. Resqula eyedrops 8. Patanol eyedrops 9. Cosopt eyedrops 10. [Doctor First Name ] 60 mg po bid 11. Sucralfate 1 gm q day ALLERGIES: CODEINE PHYSICAL EXAM: GENERAL: The patient is an obese white female in no acute distress. VITAL SIGNS: Her pulse is 98, blood pressure 181/64, temperature 99.6??????. HEAD, EARS, EYES, NOSE AND THROAT: She is alert and oriented x3. She has no jugular venous distention, no carotid bruits. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm with no murmurs. ABDOMEN: Obese, soft and nontender. EXTREMITIES: She has a left lower leg ulcer with Doppler signals in the distal pulses. IMAGING: Electrocardiogram shows normal sinus rhythm with a rate of 69, no evidence of ischemia and a left shift. ADMISSION LABS: White count of 6.6, hematocrit of 33.1, platelets 250. PT 12.2, PTT 26.6, INR 1.1. Her sodium is 143, potassium is 3.7, chloride of 106, bicarbonate of 29, BUN of 10, creatinine of 0.6, glucose of 111. Calcium was 8.9, magnesium 1.5, phosphorous 3.1. HOSPITAL COURSE: The patient on the day of admission went to the Operating Room where she underwent a coronary artery bypass graft x2. The grafts were left internal mammary artery to the diagonal, saphenous vein graft to the right PDA. She tolerated this procedure well. She was transferred to the Cardiac Intensive Care Unit on a drip of propofol at 20 mcg per kg per minute and Neo at 0.3 mcg per kg per minute. In the first postoperative day, the patient was weaned to be extubated. Her drips were weaned. She remained hemodynamically stable through the first postoperative night. On postoperative day #1, she was transferred to the floor in stable condition. On the floor, she remained hemodynamically stable. She was started on her Lopressor which was appropriately adjusted for a heart rate around 80. Her chest tubes were discontinued on postoperative day #2. Her pacer wires were discontinued on postoperative day #3. Physical therapy evaluated the patient and deemed her appropriate for a short stay in rehabilitation. She is tolerating a regular diet. She is placed on her preoperative hypoglycemic agents. Her blood sugars have remained in good control. She is stable and ready to be discharged. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post coronary artery bypass graft x2 2. Diabetes mellitus 3. Hypertension 4. Hypercholesterolemia 5. Glaucoma DISCHARGE MEDICATIONS: 1. Lasix 20 mg po bid x7 days 2. Potassium chloride 20 milliequivalents po bid x7 days 3. Colace 100 mg po bid 4. Zantac 150 mg po bid 5. ASAC 325 mg po qd 6. MVI po qd 7. Zinc 240 po qd 8. Vitamin C 500 mg po bid 9. Santyl ointment on the left leg [Hospital1 ] per application 10. Glucophage 850 mg po tid 11. Lipitor 40 mg po qd 12. Glucotrol XL 10 mg po bid 13. Avandia 4 mg po bid 14. Patanol eyedrops [Hospital1 ] 15. Cosopt eyedrops [Hospital1 ] 16. Resqula eyedrops [Hospital1 ] 17. Lopressor 50 mg po bid 18. Xalatan eyedrops q hs 19. Dilaudid 2 to 4 mg po q4h prn 20. Insulin sliding scale DISCHARGE CONDITION: Stable FOLLOW UP: She will follow up with Dr. [Last Name (STitle) 1537] in four weeks. She will follow up with Dr. [First Name (STitle) ] in two to three weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 3835] MEDQUIST36 D: [2110-3-7] 08:38 T: [2110-3-7] 08:57 JOB#: [Job Number 38570]	[ "278.00", "250.00", "364.9", "429.9", "272.0", "440.23", "414.01", "401.9", "411.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.11" ]	icd9pcs	[ [ [] ] ]				4736, 4744				3915, 4066	4089, 4714					2689, 3894			1475, 1779						1416, 1452		1794, 2399						4756, 5188														165, 177										206, 1285					2416, 2671									1307, 1393
7,180	166,739	28922	Discharge summary	report	Admission Date: [2132-1-9] Discharge Date: [2132-1-24] Date of Birth: [2063-2-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: asymtomatic Major Surgical or Invasive Procedure: [1-11] redo sternotomy/replacement of ascending ao/total arch/graft to innominate/graft to LCCA/AVR (19mmCE magna) History of Present Illness: 58 yo M s/p ascending aorta and hemiarch and AV resuspecsion for type A dissection in [7-9]. Post op course was c/b right leg ischemia requiring fem-fem bypass and fasciotomy, and CVA with no residual deficit. In 08.07 he had cerebellar hemorrhage likely related to new coumadin with supratherapeutic INR. Most recent chest CT shower increase in size of pseudoaneurysm. Admitted for surgery. Social History: Pt is a retired machinist. Lives with his wife. Former [Name2 (NI) 1818], quit. 3 drinks/day for years. Family History: No history of stroke. Father with CHF Physical Exam: HR 68 BP 136/78 Lungs CTAB Heart RRR 2/6 Murmur Abdomen benign Extrem warm, no edema, RLE healed incision Bilateral healed groin incisions Brief Hospital Course: Cardiac catheterization on [1-9] on showed no significant CAD and confirmed aortic arch and extensive thoracoabdominal dissection. He was taken to the operating room on [1-11] where he underwent a redo-sternotomy, replacement of aortic arch, and AVR. He was transferred to the ICU in stable condition. He was given 48 hours of vanocmycin as he was in the hospital preoperatively. He was volume overloaded post-op and remained intubated until POD #4. He continued to be hypoxic after extubation and required aggrewssive diuresis and intermittent BiPAP for several days. His respiratory status improved with nebs and diuresis. He failed his initial swallow evaluation and a dobhoff tube was placed. Repeat evaluation the following day recommended thin liquids and ground solids. He was transferred to the floor on POD #11. On the floors he continued to work with nursing and physical therapy to improve his strength and endurance. He was noted to have some sternal drainage from the lower portion of his incision, which was opened to allow drainage and then packed with DSD. On POD 13 it was decided he was ready for discharge to rehabilitation with continued wound packing to the mediastinal incision. Medications on Admission: altace 5', ASA 325', lopressor 50"', norvasc 10', simvastatin 40' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: s/p redo sternotomy/replacement of ascending ao/total arch/graft to innominate/graft to LCCA/AVR (19mmCE magna)[1-11] PMH CVA, HTN, ^chol, fem fem bypass, fasciotomy, cochlear implant, pseudoaneurysm of Aortic arch w/dissection from arch to abdm ao Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving x6 weeks Followup Instructions: Dr. [Last Name (STitle) 32683] 2 weeks Dr. [Last Name (STitle) 8573] 2 weeks Dr. [First Name (STitle) ] 4 weeks - pt to call for all appointments [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2132-1-24]	[ "441.03", "285.9", "511.9", "997.3", "996.74", "424.1", "747.21" ]	icd9cm	[ [ [] ] ]	[ "39.61", "88.56", "88.72", "37.22", "88.42", "38.45", "39.59", "35.21", "96.6", "34.91" ]	icd9pcs	[ [ [] ] ]	3804, 3853	1239, 2450	331, 452	4151, 4161		4439, 4719	1020, 1061		2566, 3781		3874, 4130		2476, 2543			4185, 4416									1076, 1216																				280, 293										480, 877															893, 1004
13,628	154,538	51862	Discharge summary	report	Admission Date: [2123-10-8] Discharge Date: [2123-11-10] Date of Birth: [2049-2-1] Sex: M Service: SURGERY Allergies: Ambien Attending:[First Name3 (LF) 371] Chief Complaint: chest pain, "heartburn" Major Surgical or Invasive Procedure: [2123-10-13] Cardiac catheterizaation (without intervention) [2123-10-15] Colonoscopy (with polypectomy) [2123-10-18] Flexible sigmoidoscopy [2123-10-20] Right anterior septum cautery for epistaxis [2123-10-21] Flexible sigmoidoscopy [2123-10-25] Diverting colostomy, Hartmann's pouch and placement of presacral drain and drainage of a submucosal hematoma from the rectum Import Major Surgical or Invasive Procedure History of Present Illness: Mr. [Known lastname ] is a 74 yo M w/ h/o MVR/AVR [1-12] rheumtic heart disease, A fib, CHF, s/p BiV pacer, HTN, hyperlipidemia, COPD, CKD baseline Cr 1.6, obesity who presents with chest pain which started [10-7]. It was described as epigastric and associated with nausea, vomitting, diaphoresis and "sour feeling". It improved with maalox in ED. He had 2 sets of cardiac enzymes which were negative. His nuclear stress did show a "moderate fixed defect of inferior wall, moderated reversible defect of inferolateral wall, new partially reversible defect of anterior wall. A cardiac catherization was done on [10-11]. On arrival to the floor, pt has no compliants. He does state he has had increasing DOE for the last 10 days or so which his inhalers initially helped. Pt also c/o mild ankle edema just during the day today. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: # Mechanical MVR/AVR ([2098]) [1-12] rheumatic fever # Atrial fibrillation s/p AV node ablation, biventricular pacer ([2115]) on anticoagulation # Biventricular pacer . 3. OTHER PAST MEDICAL HISTORY: # COPD # Asthma # GERD # Osteoarthritis # Bilateral total knee replacements [1-12] OA # Gout # Hypothyroidism [1-12] amiodarone # Chronic Kidney Disease Stage II, baseline cr 1.6 # anemia # Melanoma # obesity # ETOH use # insomnia # hemorrhoids # h/o cellulitis # h/o MRSA PNA # osteopenia # # s/p Cholecystectomy # s/p Appendectomy Social History: # Personal: Lives with wife and 2 step sons aged 45 and 34. Pt states he could walk 3mi at a time recently but hasn't been able to do this in several mo. Can walk up 3 flts at a time. # Professional: Retired construction worker. # Tobacco: 1ppd x 15y, quit [2083]. # Alcohol: Former binge alcohol abuse x30y (hard liquor), quit mid [2102]. last drank 3 mo ago- 3 drinks at that time # Recreational drugs: Experimental mescaline in youth. Family History: # Mother d 85: Asthma # Father d 99 [10-22]: PAD, HTN # Siblings (5B, 2S): HTN, unknown, rheumatic fever Physical Exam: VS: T=99.2 BP= 104/68 HR= 64 RR=18 O2 sat= 97% on RA GENERAL: Obese M in NAD. Oriented x3. Mood, affect appropriate. [Month/Year (2) 4459]: NCAT. Sclera anicteric. NECK: Supple with JVP of 8 cm. CARDIAC: RRR, 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.obese EXTREMITIES: trace pedal edema bilat, WWP, trace TP bilat. SKIN: + hyperpigementation on calves c/w venous stasis Physical examination upon discharge: Vital signs: bp=108/54, hr=61. resp. rate 18, t=97.5, oxygen saturation 98% RA General: NAD, sitting in chair, alert and oriented CV: Ns1, s2, -s3, -s4, no murmurs LUNGS: Clear Abdomen: Soft, non-tender,ostomy with light brown watery stool, wet to dry dressing to lower aspect of wound, wound margins erythematous, no exudate Extremities: +1 edema lower ext., mild erythema lower aspect of legs bil., + dp bil Pertinent Results: ADMISSION LABS: [2123-10-8] 03:45AM BLOOD WBC-11.1* RBC-4.23* Hgb-12.5* Hct-36.5* MCV-86 MCH-29.4 MCHC-34.1 RDW-17.2* Plt Ct-162 [2123-10-8] 03:45AM BLOOD Neuts-70 Bands-2 Lymphs-17* Monos-7 Eos-3 Baso-1 Atyps-0 Metas-0 Myelos-0 [2123-10-8] 03:45AM BLOOD PT-31.1* PTT-32.7 INR(PT)-3.1* [2123-10-8] 03:45AM BLOOD Glucose-112* UreaN-58* Creat-1.7* Na-135 K-4.5 Cl-101 HCO3-25 AnGap-14 [2123-10-10] 05:40AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.6 [2123-10-8] 03:45AM BLOOD ALT-27 AST-38 AlkPhos-86 TotBili-0.6 [2123-10-8] 03:45AM BLOOD cTropnT-<0.01 [2123-10-8] 09:43AM BLOOD cTropnT-LESS THAN LABS UPON TRANSFER TO MICU: [2123-10-25] 06:30AM BLOOD WBC-28.0* RBC-3.08* Hgb-9.3* Hct-27.7* MCV-90 MCH-30.2 MCHC-33.6 RDW-17.2* Plt Ct-231 [2123-10-24] 09:05AM BLOOD Neuts-87.1* Lymphs-7.1* Monos-4.6 Eos-1.1 Baso-0.2 [2123-10-25] 06:30AM BLOOD PT-18.6* PTT-86.5* INR(PT)-1.7* [2123-10-25] 06:30AM BLOOD Glucose-123* UreaN-49* Creat-2.4# Na-132 K-5.1 Cl-96 HCO3-28 AnGap-13 [2123-10-25] 06:30AM BLOOD Calcium-8.4 Phos-3.9 Mg-3.0* EKG [2123-10-8] Ventricular paced rhythm. The underlying rhythm is probably atrial fibrillation [2123-11-8]: KUB IMPRESSION: Essentially unchanged air filled loops of large and small bowel, representing unchanged ileus CXR [2123-10-8] IMPRESSION: No acute intrathoracic process. Stress test/perfusion scan: [2123-10-8]: IMPRESSION: Uninterpretable ECG for ischemia. No anginal type symptoms reported. Appropriate hemodynamic response to Persantine. Nuclear report filed separately IMPRESSION: Abnormal study. There is a moderate fixed defect of the inferior wall with associated hypokinesis, a moderate reversible defect of the inferolateral wall, and a new partially reversible defect of the anterior wall. New, moderate left ventricular enlargement. Left ventricular ejection fraction 37% (previously 47%). CARDIAC CATH [2123-10-13] COMMENTS: 1. Selective coronary angiography of this co-dominant system demonstrated no angiographically apparent, flow-limiting coronary artery disease. The LMCA was normal in apperence. The LAD had mild lumenal irregularities with small caliber branch vessels. The LCx was a co-dominant vessel with minor irregularities. The RCA had mild disease. FINAL DIAGNOSIS: 1. Non-obstructice coronary artery disease. EGD [2123-10-15] Impression: Granularity in the antrum compatible with gastritis (biopsy) Otherwise normal EGD to third part of the duodenum COLONOSCOPY [2123-10-15] Impression: Polyp at 15cm in the Rectosigmoid junction (15cm) (polypectomy, endoclip) Otherwise normal colonoscopy to cecum PATHOLOGY FROM [2123-10-15] POLYPECTOMY 1. Stomach, antrum, biopsy (A): Focal superficial iron deposition in the lamina propria, consistent with iron pill gastropathy (confirmed on iron stain). 2. Polyp, rectosigmoid, polypectomy (B-C): Adenoma. FLEXIBLE SIGMOIDOSCOPY [2123-10-18] Impression: Blood in the up to 30cm from the anal verge. There was no blood proximal to this. (endoclip) Otherwise normal sigmoidoscopy to 30cm from anal verge FLEXIBLE SIGMOIDOSCOPY [2123-10-21] Impression: Post-Polypectomy site with friable mucosa but no stigmata of recent bleeding. (injection, endoclip) Prior endoclipped site (clipped on [2123-10-18]) appeared clean without any friable mucosa, stigmata or recent bleeding, or active bleeding. Otherwise normal sigmoidoscopy to 20cm from the anal verge CT ABDOMEN/PELVIS W/O CONTRAST [2123-10-24] IMPRESSION: 1. High-density material within the rectum may represent stool, although blood cannot be excluded. Clinical correlation with stool sample or physical exam recommended. 2. Two fat containing midline abdominal wall hernias appear grossly uncomplicated by CT although minimal stranding may represent an element of strangulation. Clinical correlation with point tenderness recommended. 3. Distended bladder. ABDOMEN (SUPINE & ERECT) [2123-10-24] NG tube coiling in esophagus. Multiple distended loops of bowel concerning for bowel obstruction or ileus ECHO: [2123-10-25]: Suboptimal image quality.The left atrium is markedly dilated. The right 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. Tricuspid regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2122-4-29], no definite change. If indicated, a TEE would better assess for endocarditis [2123-11-10]: Current lab work: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2123-11-10] 05:30 8.4 2.56* 7.4* 22.7* 89 29.0 32.8 16.2* 404 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos NRBC [2123-11-2] 05:40 80* 2 11* 6 0 0 0 1* 0 1* RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Tear Dr [MD Number(4) ] [Name (STitle) ] [2123-11-2] 05:40 1+ NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2123-11-10] 05:30 404 [2123-11-10] 05:30 33.0* 33.9 3.3* LAB USE ONLY [2123-11-10] 05:30 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2123-11-10] 05:30 91 28* 1.4* 131* 4.2 95* 27 13 Using this patient's age, gender, and serum creatinine value of 1.0, Estimated GFR = 73 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure [2123-11-8]: IMPRESSION: Essentially unchanged air filled loops of large and small bowel, representing unchanged ileus. Brief Hospital Course: Mr. [Known lastname ] is a 74y/o gentleman with h/o mitral and aortic valve replacements [1-12] rheumatic heart disease, A fib s/p ablation and BiV pacer, systolic CHF (EF 40%), HTN, HLD, COPD, CKD baseline Cr 1.6, obesity who presented with epigastric/chest pain and abnormal stress test. His cardiac cath showed no disease requiring intervention. Due to his mechanic valves, he needs to be anticoagulated (INR 2.5-3.5), so while he was admitted and on a Heparin drip for his cardiac cath, the decision was made to perform EGD/colonoscopy to investigate a S.bovis blood culture from 1 year prior. Colonoscopy showed 3cm polyp at rectosigmoid junction, which was removed (path negative for malignancy). He had a subsequent GI bleed requiring blood transfusions, 2 flexible sigmoidoscopies to place clips to the polypectomy site. His course was further complicated by leukocytosis/fever, hypotension, as well as ileus vs obstruction. CXR for NG tube placement suggested free air under the right diaphragm. Surgery consult was called and he was transferred to the ICU. He was taken to the Operating Room on [10-25] for repair of his perforated simoid colon. His operative course was stable. He did receive blood during the procedure, but was extubated in the operating room and maintained stable hemodynamics. His post-operative pain was managed with dilaudid. He began sips and advanced to a clear diet. On [10-29] he was transferred to the surgical floor. Upon admission to the surgical floor, his vital signs have been stable. His Coumadin was resumed at his preop dose and his INR is in the 2-2.5 range. He is tolerating a regular diet and his pain is well controlled. His stoma is slightly necrotic superficially and has some circumferial separation with a yellow wound bed and friable tissue. He has had a small amount of formed soft stool. The Ostomy nurse has been following him on a regular basis and attempting to teach his wife ostomy care as Mr. [Known lastname ] is unable to do it due to his large pannus. His abdominal wound became cellulitic on post op day 7 without any drainage and Vancomycin was started without any improvement. After 2 days the lower pole of the incision was opened up and packed with minimal drainage. A VAC dressing was eventually applied [2123-11-5] and his cellulitis resolved after the wound was opened. Vancomycin was stopped on [2123-11-5]. He developed urinary retention on [2123-11-3] and had his Foley catheter replaced. He will need another voiding trial as he becomes more ambulatory. Mr. [Known lastname ] continues to expel some bloody drainage from his rectal hematoma and his hematocrit has been in the 23-25 range since [2123-10-28]. After a long complicated admission he will be discharged to a short term rehab so that he can increase his mobility, improve his endurance and gradually be proficient in his ostomy care. His abdominal vac dressing has been removed and replaced with a wet-dry dressing. He will need to have re-application of the VAC dressing. Of note, NO RECTAL TEMPERATURES OR RECTAL PROCEDURES . Medications on Admission: ALLOPURINOL - 300 mg daily CICLOPIROX - 0.77 % Gel - apply to abdomen folds twice a day COLCHICINE - 0.6 mg daily PRN gout (last taken 2 days ago) ENALAPRIL MALEATE - 20 mg [Hospital1 ] FLUTICASONE - 50 mcg- [12-12] sprays each nostril once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250-50 mcg- 1 puff [Hospital1 ] FUROSEMIDE - 80 mg daily IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL [Male First Name (un) ]- 1 neb QID prn SOB IPRATROPIUM-ALBUTEROL 103 mcg (90 mcg)-18 mcg- 1-2 puffs QID PRN LEVOTHYROXINE - 88 mcg daiyl METOPROLOL SUCCINATE - 50 mg daily ORPHENADRINE CITRATE - 100 mg [Hospital1 ] prn BACK PAIN PANTOPRAZOLE [PROTONIX] - 40 mg [Hospital1 ] SILDENAFIL [VIAGRA] - 50mg PRN TRAZODONE - 50 mg Tablet - [12-12] to 1 tab QHS PRN WARFARIN 5 MG Mon and Fri, 7.5 MG all other days FERROUS SULFATE - 325 mg daily LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: 1 tab on [Month/Day (2) 766] and Friday, 1.5 tabs on all other days. 2. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 4. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for gout. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. ciclopirox 0.77 % Gel Sig: One (1) application to abdomen folds Topical twice a day. 10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [12-12] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 13. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. orphenadrine citrate 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for back pain. 16. sildenafil 50 mg Tablet Sig: One (1) Tablet PO once as needed for sexual activity. 17. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 18. trazodone 50 mg Tablet Sig: [12-12] to 1 Tablet PO at bedtime as needed for insomnia. 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 20. sodium chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal TID (3 times a day). 21. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 22. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: hold for diarrhea. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Chest pain/abnormal stress test Diagnostic colonoscopy secondary to strep bovis bacteremia Perforated sigmoid colon, submucosal hematoma. Right anterior epistaxis Wound infection Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - needs assistance Discharge Instructions: You came to the ER because of abdominal/chest discomfort and you were admitted to the Cardiology floor because of an abnormal stress test. You underwent cardiac catheterization and were found to have no heart vessel blockages that needed to be opened. You have been pain free since admission. Your pain may have been related to acid reflux. . In addition, you have a history of Strep bovis (a bacteria) and as a result you required a colonoscopy. Since you were on a Heparin drip anyway, you had this done while you were here. After the procedure, you had problems with severe lower abdominal pain, bleeding from your rectum and fever. You went to the operating room on [10-25] where you were found to have a perforated sigmoid colon. You underwent a colostomy and drainage of a rectal hematoma. You are now preparing for discharge with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You may see blood or dark/black material from your rectum over the next few weeks. That is from the rectal hematoma which is liquifying and draining. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-19] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 2 weeks. Call the [Hospital ] Clinic at [Telephone/Fax (1) 107400] for a follow up appointment in [2-11] weeks. Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2123-11-17] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2123-12-16] 9:40 Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2124-1-26] 9:00 Completed by:[2123-11-10*]	[ "E870.4", "E942.0", "285.1", "E878.8", "274.9", "715.90", "276.1", "427.31", "403.10", "788.20", "553.20", "211.4", "585.2", "584.9", "998.2", "278.01", "569.61", "530.81", "560.1", "428.22", "998.11", "535.50", "V43.3", "E849.7", "V85.41", "682.2", "998.12", "784.7", "244.3", "428.0" ]	icd9cm	[ [ [] ] ]	[ "48.0", "21.03", "48.36", "37.22", "53.59", "45.16", "46.10", "45.43", "88.56" ]	icd9pcs	[ [ [] ] ]	17247, 17317	10899, 14047	289, 738	17564, 17564	4219, 4219	20150, 20817	3068, 3178		15012, 17224		17338, 17543		14073, 14989		6527, 10874	17719, 20127									3193, 3768		2033, 2215																		226, 251									3785, 4200	766, 1939					4235, 6510				17579, 17695		2246, 2588			1961, 2013	2604, 3052
30,780	118,787	52644	Discharge summary	report	Admission Date: [2190-9-18] Discharge Date: [2190-10-1] Date of Birth: [2116-7-31] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 4963] Chief Complaint: syncope, subdural hematoma, subarachnoid hemorrhage, fever Major Surgical or Invasive Procedure: None History of Present Illness: 74 yoM w/ a PMHx significant for CAD s/p CABG, HTN, DM, alzheimer's dementia, ischemic systolic CHF (EF 40%) presented s/p syncopal events presenting after a recent syncopal event on [9-18] in which he suffered head trauma and subdural and subarachnoid hemorrhages, with no subsequent neurosurgical intervention and resolving hemorrhages by CT. He has an altered mental status from his baseline per his family (worse confusion) however per staff has been improving over the past 3 days in his ability to interact. Syncopal event is thought to be due to sinus pauses up to 5 seconds (noted in trauma ICU) for which a pacemaker has been planned. Has recently developed fevers thought to be due to pneumonia/aspiration pneumonia vs pneumonitis seen on CXR. Given his current infection his pacemaker plcmnt has been postponed and he has been transferred to the medicine service. Past Medical History: Hypertension CAD- s/p CABG about 20yrs ago. abnormal stress and cath in [1-3] at [Hospital1 18] ischemic cardiomyopathy with EF of 40% DM II Alzheimer's dementia history of recurrent syncope Social History: No tobacco use; occasional ETOH, no illicits. Retired from purchasing. Family History: unaware Physical Exam: VS: 99.3 150/80 52 16 98% RA GEN: NAD, AOX1, pleasantly confused. HEENT: MMM, OP clear CARD: RRR, no m/r/g PULM: bibasilar ronchi, L > R, no rales or wheezes Abd: soft, NT, ND, no masses, BS +, no hepatosplenomegaly EXT: WWP, no c/c/e Pertinent Results: admission cbc: wbc 15.6 hct 39.2 plt 247 discharge cbc: wbc 8.1 hct 34.5 plt 462 admission chemistry: glucose 158, sodium 138, potassium 4.2, cl 101, bicarb 25, bun 19, cr 1.0 discharge chemistry: glucose 158, sodium 135, potassium 4.2, cl 99, bicarb 27, BUN 17, Cr 0.9 LFTs [9-29]: ALT 91, AST 65, LDH 275, T bili 0.4, alk phos 94 [2190-9-28]: dilantin level 11.7, albumin 3.5 C diff toxin A: negative x 2 CXR PA / Lat: [2190-9-22]: Bibasilar consolidation, right greater than left, which may be due to aspiration or evolving aspiration pneumonia. Head CT [2190-9-23]: Stable subdural heterogeneous hemorrhages bilaterally. Slight decrease in the largest of the intraparenchymal hemorrhages as described above with surrounding edema. Evolution of the bilateral subarachnoid blood. Head CT [2190-10-1]: Continued evolution of bilateral subdural, subarachnoid and intraparenchymal hemorrhages. No new hemorrhage is visualized. EKG [2190-9-18]: sinus bradycardia, rate 52, nl axis, 1st degree AV block, LAE VIDEO OROPHARYNGEAL SWALLOW: This exam was performed in conjunction with the speech pathologist. Various consistencies of barium were administered. The oral and pharyngeal phases were normal with good epiglottic deflection and laryngeal valve closure. There was no residue in the valleculae or piriform sinuses. There was no penetration or aspiration with any consistency. IMPRESSION: Normal swallow study. Brief Hospital Course: Sudural hematoma- due to syncope likely related to sinus pauses of up to 5 seconds found on telemetry. Patient has had multiple falls in the past, unfortunately the most recent fall led to SDH and SAH. These have been stable over time on repeat CT scans and per neurosurgery he is okay to start anti-platelet agents and subcutaneous heparin for DVT prophylaxis. His mental status is stable and he is AOx0, occasionally he is able to state his first name if provided with his last name. He is interactive and does follow commands but is unable to hold a appropriate or intelligent conversation. His SDH / SAH must be followed by neurosurgery at the appointment that has been made for him. At this time he will also have a repeat head CT scan. He is on dilantin for seizure prophylaxis and must have his levels checked once per week, his discharge dilantin level was 11.7 ([9-28]), and an albumin of 3.5. Goal dilantin level is [10-16]. He has been restarted on plavix for his drug eluting stents and aspirin has currently been held. This can be restarted per neurosurgery upon discharge however we held it as we hoped to introduce the anti-platelet agents singly rather than together. Sinus Pauses- Patient had sinus pauses 3-5 seconds while monitored on telemetry in the trauma ICU. He was evaluated by EP cardiology as an inpatient and they thought given his sinus pauses of up to 5 seconds he would need to have a pacemaker for the indication of symptomatic sick sinus syndrome. The initial plan was to have this pacer placed inpatient however the patient became febrile likely due to aspiration pneumonia. He was on IV antibiotics for this and pacer placement was deferred until outpatient. He should have this pacer placed before returning home and should be considered a fall risk at least until placement of pacer. Of note, while on the medicine service, the patient did not have prolonged pauses on telemetry. The rehab should coordinate his pacer placement to be timed appropriately- Prior to discharging the patient to his home or long term living facility. He has a follow up appointment with his outpatient cardiologist to help coordinate this. Aspiration Pneumonia- febrile with signs of aspiration pneumonia. Treated with Unasyn, last dose on of [2190-9-30] for a total 8 day course. Seen by ID inpatient for antibiotic choice. Afebrile for at least 96 hours pre discharge and blood cultures were negative. video swallow study revealed normal swallowing so patient was discharged on a normal consistency diet. DM- relatively well controlled as inpatient, see discharge regimen and adjust accordingly. Medications on Admission: Gemfibrozil 600mg po bid Metformin 500mg po bid Isosorbide 30mg po daily plavix 75mg daily ASA Toprol 100mg daily Lisinopril 40mg po daily Lipitor 20mg daily HCTZ 12.5mg daily Aricept 10mg daily Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Tablet(s) 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Insulin Glargine 100 unit/mL Solution Sig: as directed as directed Subcutaneous at bedtime: please inject 6 units of glargine insulin subcutaneously qhs. 5. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous qac and qhs: humalog sliding scale, starting with 2 units of insulin for a Blood glucose of 120, increase by 2 units of insulin for every 40 increase in blood glucose. FS qac and qhs, for qhs scale start with 2 units of insulin for blood glucose over 200. . 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): 5000 u sc tid. 10. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 11. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Subdural hematoma Subarachnoid hemorrhage Aspiration pneumonia Symptomatic sick sinus syndrome Secondary Diagnosis: Diabetes Mellitus Anemia Coronary Artery Disease Discharge Condition: stable, AOx 0 to 1, pleasant and able to interact and follow commands. Discharge Instructions: You were admitted to the hospital after a fall and suffered a bleed in your head. You were initially on the neurosurgery service but no surgery was indicated in your case. You were transferred to the medicine service because of pneumonia. You have been treated for this. You will need follow up with Cardiology EP (electrophysiology) for a pacemaker placement. You will also need follow up with neurosurgery. Followup Instructions: You have an appointment with your neurosurgeron Dr. [Last Name (STitle) ] on Tuesday [10-19] at 2:45 p.m. (this appt is in the [Hospital Unit Name 3269] on the [Location (un) 470] 3B on the [Hospital Ward Name 517] of [Hospital1 18]) You will need to have a CT scan of your head prior to this appointment. This will be at 2:00 p.m. on the same day in the Clinical Center on the [Hospital Ward Name 517] of [Hospital1 18] on the [Location (un) 448], nothing to eat 3 hours before this. You have an appointment with your Cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73] on Wednesday [10-13] at 9:40 a.m. in [Hospital Ward Name 23] 7 on the [Hospital Ward Name ] of the [Hospital1 18]. Phone [Telephone/Fax (1) 62]. Please have the patient follow up with his PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1576],[First Name3 (LF) 1575] [Telephone/Fax (1) 1579] within 2-4 weeks of his discharge. You have an appointment with Behavioral Neurology. Dr. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 860] [Doctor Last Name ], [Location (un) ] [Apartment Address(1) ], [12-2] Thursday at 2:30 p.m. ([Telephone/Fax (1) 1703]	[ "428.20", "507.0", "780.97", "V64.1", "V58.67", "294.10", "427.81", "E888.8", "414.00", "401.9", "428.0", "V45.81", "250.00", "414.8", "331.0", "851.86", "285.9", "E849.9" ]	icd9cm	[ [ [] ] ]	[ "99.07" ]	icd9pcs	[ [ [] ] ]	7639, 7709	3352, 6000	345, 352	7938, 8011	1875, 3329	8473, 9784	1591, 1600		6246, 7616		7730, 7730		6026, 6223			8035, 8450									1615, 1856																				247, 307										380, 1264			7866, 7917			7749, 7845								1286, 1486	1502, 1575
65,824	194,922	47348	Discharge summary	report	Admission Date: [2133-2-22] Discharge Date: [2133-2-27] Date of Birth: [2049-11-29] Sex: M Service: MEDICINE Allergies: Vicodin / Percocet / Darvocet A500 / Oxycodone / Vancomycin / Adhesive Tape Attending:[First Name3 (LF) 2641] Chief Complaint: Epistaxis and dark stools Major Surgical or Invasive Procedure: Hemodialysis Esophagogastroduodenoscopy History of Present Illness: Mr. [Known firstname 1692] [Known lastname 656] is an 83 y/o man with PMH of CAD s/p 3V CABG in [2122], NSTEMI in [2-2] with DES in left main, ESRD on HD, PVD, AAA s/p repair, bullous pemphigoid, h/o UGIB 2 months ago, ischemic colitis [3-6], who presents with black stool and bleeding through his nose. . He was in his prior state of health until [2132-12-15], when he presented to the [Hospital1 18] with blood in his stool. He required a total of 7 RBC units and 2 FFPs (with normal INR) with an HCT nadir of 24.7. He was initially intubated to protect the airway. He underwent EGD on [12-16], which showed blood in the esophagus, stomach and duodenum with a clot in the alter that could not be removed. Subsequent EGD 2 days latar showed only mild inflammation of mucosae. Findings were atributed to steroids he was taking for his pemphigus. No biopsies reports available. Patient was discharged to rehab on pantoprazole [Hospital1 ] with an HCT of 37. . On day of admission at the nursing home, he had multiple bowel movements with black, smelly stools that were concerning for melena. Of note, patient reported nose bleed for 1 hour yesterday that dripped through the back of his nose and stopped spotaneously. He denies any abdominal pain, fever, chills, rigors, vomiting blood, cough, shortness of breath, diziness, lightheadedness, chest pain, palpitations. He has been taking his medications as prescribed including omeprazole 20 mg Daily (he was on pantoprazole 40 [Hospital1 ] at discharge). There was concern about GIB and he was transfered to our hospital for evaluation. . In the ER his initial vital signs were: Pain 0/10, R 97.3 F, HR 70 BPM, BP 116/40 mmHg, RR 16 X', SpO2 98% on RA. He looked comfortable, without abdominal pain and had marroon stools in his rectal vault taht were frankly guaiac positive. His ECG showed NSR without any signs of ischemia. His HCT was 29 down from 37 2 months ago. Patient had an NGL, whcich showed [Initials (NamePattern4) ] [Last Name (NamePattern4) 17993] fluid that cleared. There were no clots or coffee grounds. He received IV protonix x1 and was T&C 2 RBC units. GI was made aware as well as renal (per report) and patient was admitted to the [Hospital Unit Name 153] with 2 18G for hemodynamic monitoring. . His [Hospital Unit Name 153] course was notable for transfusion of 1 unit PRBC for HCT drop to 25 from 29. HCT remained stable. Epistaxis stopped and no evidence of GI bleed since admission. The patient was transferred to the [Hospital Ward Name ] for hemodialysis. Also, the patient has a history of a recent diagnosis of squamous cell CA of the tongue base, this was visualized by the ICU team and felt not to be the source of bleeding. ENT deferred scope to evaluate epistaxis. Also evaluated by GI who did not see urgent need for scoping. . On arrival to the medical floor, the patient is resting comfortably with no complaints. Has not moved bowels since [2133-2-22]. No further epistaxis. Past Medical History: 1)CAD -s/p 3-vessel CABG in [2122] (LIMA-LAD, SVG-RCA-occluded, SVG-OM1/OM3 occluded) -s/p NSTEMI in [2-2] (DES in L main) 2)ESRD -LUE AVF, HD MWF -Per patient, has congenital left kidney hypoplasia 3)AAA -s/p repair ([2123]) 4)PVD -s/p aortobililiac graft in [2123] -s/p left CEA in [2123] ([2132-5-22] US showed right ICA 70-79% stenosis, left ICA 1-39% stenosis) 5)Ischemic colitis -Admitted [2132-3-9] for bloody diarrhea, uneventful hospital course 6)Spinal stenosis -s/p discectomy and arthrodesis at C5-C6 and C6-C7 [2130-12-4] -Baseline impairment in walking (uses motoroized wheelchair or walker) 7)Right renal tumor, suspicious for RCC, undergoing watchful waiting, followed by Dr. [Last Name (STitle) 3748] 8)Prostate cancer -s/p brachytherapy in [2122] 9)Abdominal wall abscess in [5-5], s/p I&D, cultures grew Actinomyces 10)Cholangitis -s/p CCK in [2130-3-21] 11)Bullous pemphigoid (diagnosed in [7-/2132]) -Dermatologist is Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] 12)s/p Cataract surgery on left eye 13) Diverticulosis 14) S/p UGIB with a possible ulcer on EGD that required 7 RBC units and 2 FFPs Social History: Lives alone at [Location (un) 33866] [Hospital3 400] Residency. He previously worked as a district manager for Metropolitan Life. 60 pack-year smoking history, quit 10 years ago. Occasional social alcohol use. Family History: One daughter (53) and son (57), both in good health. One sister with diverticulitis. Physical Exam: VITAL SIGNS - T 98.6 HR 67-80 BP 128-136/49-60 RR 18 O2 95% RA GEN: NAD, pleasant HEENT: anicteric sclera, MMM, OP clear NECK: supple, no JVD LUNGS: CTAB with no w/r/r. CV: RRR with 3/6 LUSM heard across precordium; median sternotomy scar noted. ABD: soft, NT, ND, +BS in 4 quadrants. No g/r/r. EXTREMITIES: no pedal edema, 1+ DP bilat SKIN: scattered red raised rash across extremities and torso NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout Pertinent Results: Complete Blood Count: [2133-2-22] 02:30PM BLOOD WBC-12.6* RBC-3.11* Hgb-8.8* Hct-29.2* MCV-94 MCH-28.4 MCHC-30.3* RDW-16.7* Plt Ct-227 [2133-2-22] 08:07PM BLOOD Hct-25.2* [2133-2-23] 03:52AM BLOOD WBC-11.2* RBC-3.36* Hgb-9.9* Hct-30.8* MCV-92 MCH-29.5 MCHC-32.2 RDW-16.8* Plt Ct-217 [2133-2-23] 06:26PM BLOOD Hct-27.0* [2133-2-24] 08:10AM BLOOD WBC-10.5 RBC-2.94* Hgb-8.6* Hct-26.9* MCV-92 MCH-29.2 MCHC-31.9 RDW-17.5* Plt Ct-222 [2133-2-24] 04:44PM BLOOD Hct-27.3* [2133-2-25] 07:30AM BLOOD WBC-8.6 RBC-3.12* Hgb-9.1* Hct-28.4* MCV-91 MCH-29.3 MCHC-32.2 RDW-17.1* Plt Ct-232 [2133-2-26] 07:44AM BLOOD WBC-10.8 RBC-3.39* Hgb-9.9* Hct-30.8* MCV-91 MCH-29.2 MCHC-32.1 RDW-17.9* Plt Ct-233 [2133-2-27] 10:30AM BLOOD Hct-31.6* [2133-2-22] 02:30PM BLOOD Neuts-77.2* Lymphs-11.9* Monos-7.4 Eos-3.1 Baso-0.4 . Basic Metabolic Profile: [2133-2-22] 02:30PM BLOOD Glucose-128* UreaN-107* Creat-6.7# Na-137 K-4.4 Cl-98 HCO3-22 AnGap-21 [2133-2-23] 03:52AM BLOOD Glucose-87 UreaN-117* Creat-7.5* Na-140 K-5.4* Cl-99 HCO3-21* AnGap-25* [2133-2-24] 08:10AM BLOOD Glucose-72 UreaN-51* Creat-4.3# Na-137 K-3.5 Cl-96 HCO3-29 AnGap-16 [2133-2-26] 07:44AM BLOOD Glucose-78 Na-140 K-3.4 Cl-98 HCO3-32 AnGap- [2133-2-23] 03:52AM BLOOD Albumin-3.1 Calcium-9.1 Phos-5.3# Mg-2.5 [2133-2-24] 08:10AM BLOOD Albumin-2.9 Calcium-8.2* Phos-3.6# Mg-1.8 [2133-2-25] 07:30AM BLOOD Calcium-8.7 Phos-5.1* Mg-1.9 [2133-2-26] 07:44AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8 . Liver Function Tests: [2133-2-23] 03:52AM BLOOD ALT-15 AST-32 LD(LDH)-289* AlkPhos-105 TotBili-0.7 [2133-2-24] 08:10AM BLOOD ALT-9 AST-18 AlkPhos-95 TotBili-0.3 . ECG ([2133-2-22]): Sinus rhythm. There are Q waves in the inferior leads consistent with prior myocardial infarction. There is a late transition that is probably normal. Non-specific ST-T wave changes. Left atrial abnormality. Compared to the previous tracing there is no significant change. . EGD [2133-2-26]: Normal mucosa in the esophagus Patchy gastritis in antrum and fundus Patchy duodenitis in duodenal bulb Otherwise normal EGD to third part of the duodenum Recommendations: Our findings do not account for a bleeding source from esophagus to second part of duodenum Continue high dose PPI Brief Hospital Course: This is an 83 y/o man with PMH of CAD s/p 3V CABG in [2122], NSTEMI in [2-2] with DES in left main, ESRD on HD, PVD, AAA s/p repair, bullous pemphigoid, h/o UGIB 2 months ago, ischemic colitis [3-6], was originally admitted to the [Hospital Unit Name 153] on [2133-2-22] with black stool and epistaxis. #. Melena/Epistaxis - Given patient's history, initial concern for UGIB due to melanotic stools and history of PUD. However, patient had history of severe epistaxis lasting for several hours that corresponded with the onset of melena. Initial Hct drop since prior discharge led to 1 unit PRBC transfusion in the [Hospital Unit Name 153], though patient remained hemodynamically stable. After discussion with GI team, emergent EGD was deferred. ENT team did not recommend a scope to evaluate epistaxis but will need outpatient follow up. Patient remained hemodynamically stable during his ICU course with no further bleeding requiring aggressive resuscitation. Upon transfer to the medicine floor, hematocrit remained stable in the high 20s, and patient was transfused one more unit during hemodialysis prior to discharge. Did not have any further episodes of melena of epistaxis. GI team was re-consulted to discuss utility of scoping procedure given indeterminate source of bleeding in setting of high bleeding risk (chronic aspirin, long-term prednisone for bullous pemphigoid, platelet dysfunction with ESRD) and prior significant UGIB. Patient underwent EGD, which did not show any source of bleed to cause melena. Patient discharged with PO PPi, and close ENT follow up. #. Anemia - Upon admission, hematocrit found to be 29, which is significantly lower from 37 approximately 2 months prior. Anemia in this patient likely multifactorial. Patient with ESRD on HD, diverticulosis, recent epistaxis, history of PUD, with ferritin of 510, TIBC 192, Iron 23, Trans 148, Folate 15.2, B12 865 on [11-5]. Received 2 units PRBCs during hospitalization as above and hematocrit was trended closely. Remained hemodynamically stable at the time of discharge with stable hematocrit. #. CAD - Pt with known CAD s/p CABG in [2122] and NSTEMI s/p DES in [2130]. Pt chest pain free and with normal ECG. Aspirin was initially held in the setting of melena and hematocrit drop but will be restarted as an outpatient at dose of 81mg daily on [2133-3-12], 2 weeks after normal EGD. Patient continued on home metoprolol and statin. # Squamous Cell CA of tongue - Patient is currently deferring treatment with radiation or chemotherapy. Will need follow up with ENT as an outpatient. #. PVD/AAA - Stable. Pt was evaulated with CT during last hospitalization for possible fistula, but work up was negative. He has a graft and has been asymptomatc. #. ESRD - Renal service followed patient in house. Was on M/W/F hemodialysis schedule. Started nephrocaps daily per renal recs and discontinued vitamin B complex given initiation of nephrocaps. Received one unit prbcs during HD as above and epo with HD. #. Bullous pemphigoid - Continued on low dose 5mg PO daily prednisone initially. Contact[Name (NI) ] outpatient dermatologist, who reported that if no active bullae were present, it would be reasonable to taper down prednisone. His dose was reduced to 4mg daily and will be tapered by 1mg per week until discontinued. He will follow-up with his dermatologist as an outpatient. Clobetasol ointment could be used for solitary lesions. #. Diverticulosis - Stable. Medications on Admission: Home Medications. * Metoprolol 25 mg PO BID * Simvastatin 40 mg PO daily * Aspirin 81 mg PO Daily * Ezetimibe 10 mg PO Daily * Omeprazole 20 mg PO Daily * Midodrine 5 mg PO QTUTHSA PRIOR to hemodialysis. * Citalopram 20 mg PO Daily * Prednisone 5mg daily * Acetaminophen 325 mg Q6 hrs PRN pain/fever * Simethicone 80 mg PO QID * Calcium carbonate 500 mg PO TID * Calcium Acetate 667 mg PO TID * Sevelamer Carbonate 1600 mg PO TID * Senna 8.6 mg PO BID PRN constipation * Colace 100 mg PO BID * B Complex-Vitamin C-Folic Acid 1 mg PO Daily * Oxazepam 10 mg Capsule PO QHS * Natural tears * Guaifenesiin 40 mg ab TID * Tramadol 50 mg PO Q6hrs PRN pain * Compazine 10 mg PO BID PRN n/v Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 5. Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA): Please give prior to HD. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Take 4mg daily until switch to 3mg daily on [3-5]. On [3-12], decrease to 2mg daily. On [3-19], decrease to 1mg daily. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Fever / pain. 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for epigastric pain. 10. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 17. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 18. Natural Tears (PF) Ophthalmic 19. Calcium Carbonate 500 mg (1,250 mg) Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Extended Care Facility: [Hospital 27838] Rehab and [Hospital ] Care Center Discharge Diagnosis: Primary: Melena Epistaxis End stage renal disease Secondary: Coronary artery disease Bullous pemphigoid Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Discharge Instructions: You were admitted to the hospital for black stools after a nose bleed. You were monitored in the intensive care unit and received 2 units of blood to improve your blood count. Imaging of your upper GI tract did not show any signs of bleeding to cause dark stools, and you likely swallowed blood from your nose bleed. Your aspirin was held, and you should slowly decrease the amount of prednisone you take to decrease your chances of another bleed. Please follow-up with your dermatologist and ENT as below. The following changes were made to your medications: 1. Held your aspirin. You should begin taking 81mg of aspirin a day on [2133-3-12]. 2. Decreased your prednisone to 4mg daily. On [3-5], reduce to 3mg daily. On [3-12], reduce to 2mg daily. On [3-19], reduce to 1mg daily. You should see your dermatologist as below to discuss this further. 3. Increased your omeprazole to 40mg twice daily. You can discuss how long to need to stay on this increased dose at your follow-up appointment with Dr. [Last Name (STitle) ] in [3-31]. Started nephrocaps vitamin daily in place of your vitamin B complex. 5. Increased your sevelamer to 2400mg three times a day. Followup Instructions: Dermatology provider [Last Name (NamePattern4) ]. [First Name (STitle) ] on [2133-3-17] at 11:45. This appointment is at her [Location (un) 55] office on [Street Address(2) 74298]. If you need to reschedule, please call [Telephone/Fax (1) 3965]. ENT provider [Last Name (NamePattern4) ]. [Last Name (STitle) ] on [2133-3-24] at 1:40. Their office is located at [Last Name (NamePattern1) ]. If you need to reschedule, please call [Telephone/Fax (1) 41]. Previously scheduled appointments: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 463] Date/Time:[2133-4-2] 2:15 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2133-4-16] 2:40	[ "578.1", "530.81", "285.21", "784.7", "285.1", "535.50", "141.9", "694.5", "236.91", "414.00", "441.4", "V45.81", "V10.46", "535.60", "V45.11", "562.10", "585.6", "443.9" ]	icd9cm	[ [ [] ] ]	[ "45.13", "96.34", "39.95" ]	icd9pcs	[ [ [] ] ]	13897, 13982	7876, 11397	363, 405	14131, 14131	5562, 7853	15458, 16302	4935, 5021		12130, 13874		14003, 14110		11423, 12107			14237, 15435									5036, 5543																				298, 325										433, 3462									14146, 14213					3484, 4684	4700, 4919
14,571	157,813	11018	Discharge summary	report	Admission Date: [2136-4-23] Discharge Date: [2136-5-2] Date of Birth: [2058-5-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: [2136-4-24] - Cardiac catherization [2136-4-27] - Aortic Valve replacement (23 mm pericardial) Coronary Artery Bypass Graft x1 [2136-4-27] History of Present Illness: Mr. [Name14 (STitle) 35682] is a 77 year-old male with a history of CAD and aortic stenosis who presents with dyspnea. Had been in his usual state of health until approximately two weeks ago when he began feeling dyspnea on exertion. Previously, he was able to walk >100 feet and multiple flights of stairs without any SOB. He began feeling quite dyspneic with 2 flights of stairs. Also noted a cough, "gurgling" and SOB with lying flat. No PND noted. He has no prior history of syncope. Regarding chest pain/discomfort, he is vague. Did not take his medications last night (he takes all his meds at night and will forget to take every 2 weeks or so). He awoke at 1am on the morning of admission to urinate. After lying back down he felt extremely short of [Name14 (STitle) 1440] with the gurgling sound in his throat. He had an extremely hard time catching his [Last Name (LF) 1440], [First Name3 (LF) ] he called a cab to bring him to the ED. In the ED, vitals showed HR 120, BP 205/117, RR 19, 85% on 2 liters. He was unable to speak in complete sentences given dyspnea. Started NRB. SL nitro was given; 40mg IV lasix given; additional nitro given; aspirin 325mg given. CPAP was started. IV nitro was started but pressures dorpped to 50/palp and the nitro was quickly shut off. Pressures remained over 100 systolic thereafter with rates in the 90s. He was weaned to 5 liters NC with sats in the 93-95% range and a RR of 18. 950cc of total UO put out. ROS: No fevers/chills/weight change. No palpatations, nausea/vomiting, diarrhea/constipation. No weakness/numbness. Past Medical History: 1. Aortic stenosis: Values as of [8-9] ECHO: - Peak Gradient: 75 mm Hg - Mean Gradient: 50 mm Hg - Valve Area: 0.7 cm2 (nl >= 3.0 cm2) - EF >55% 2. Coronary artery disease - EF of 59%. - Right-dominant system - LMCA: 40% lesion - LAD stent patent; proximal 30% stenosis proximal to the stent - Ramus Intermedius: 50% ostial stenosis. - LCX: free of flow-limiting disease. - RCA: calcified 30% lesion proximally. 3. Hyperlipidemia: - [8-9]: TC 195, TG 45, HDL 104, LDL 82 4. Chronic obstructive pulmonary disease - FVC 69% predicted; FEV1 71%; MMF 39%; FEV1/FVC 103% 5. PUD: Gastritis on EGD of [1-10] 6. OA 7. Alcohol use 8. Asbestosis Social History: Drinks ~six pack per day plus wine. No history of withdrawal. Non-smoker. Lives with wife. Family History: NC. Physical Exam: vitals - AF, BP 118/66, HR 94, RR 20, O2 96% on 5 liters gen - lying in bed with NC on, in no distress heent - JVP is 2-3 cm above the clavicle at 30 degrees; +HJ reflux; full carotid pulses without apparent delay cv - tachycardic with harsh systolic murmur pulm - crackles about 1/3 up on right; at base on left abd - soft and non-tender; liver palpable but non-tender ext - warm; 1+ edema bilaterally; DPs easily palpable Pertinent Results: 129 92 8 ------------ 165 3.7 25 0.6 WBC 10.5 N:85.3 L:9.4 M:2.9 E:1.6 Bas:0.8 PLT 292 HCT 43.9 PT: 12.5 PTT: 26.5 INR: 1.1 UA: 1.007/6.5; otherwise negative Lactate:2.1 Trop-T: <0.01 CK: 102 MB: 7 proBNP: 4603 EKG ([2136-4-23]): Sinus tachycardia with a rate of ~120bpm. Normal axis. IVCD and LAA. LVH. ST-depressions in V5-V6. CXR ([2136-4-23]): Findings most consistent with pulmonary edema with superimposed pneumonia difficult to exclude. [2136-4-24] Cardiac Cath COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated only minimal coronary artery disease. The left main was calcified in the distal portion of the vessel with a 30-40% stenosis. The left anterior descending artery demonstrated a widely patent stent in the proximal portion of the vessel with no other significant disease. A large ramus intermedius demonstrated a 50% ostial lesion. The left circumflex demonstrated a 30-40% lesion at the origin of the vessel. The right coronary artery was a large diameter vessel with only minimal disease. 2. Lv ventriculography was deferred. 3. The aortic valve was not crossed after discussion with surgeon. Previous cardiac catheterizations and Echocardiograms demonstrated critical aortic stenosis with a valve area of approximately 0.7-0.8 cm2. 4. Limited resting hemodynamics demonstrated low right (RVEDP = 6 mm Hg) and left (mean PCWP 10 mm Hg) heart filling pressures. The cardiac index was preserved at 2.9 L/min/m2). [2136-4-25] Carotid Duplex Ultrasound No significant ICA stenosis bilaterally [2136-4-24] ECHO The left atrium is mildly dilated. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) are severely thickened/deformed. There is severe aortic valve stenosis (area 0.7cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2135-9-2], the LV systolic function is now less vigorous, mitral regurgitation is slightly more prominent and pulmonary arterial systolic pressure is higher. The severity of aortic stenosis is similar. Brief Hospital Course: Mr. [Known lastname 35683] was admitted to the [Hospital1 18] on [2136-4-24] for further management of pulmonary edema. He was diuresed and admitted to the cardiac care unit. He underwent a cardiac catheterization which revealed a patent LAD stent and a 50% ramus stenosis. An echocardiogram was performed which showed severe aortic stenosis as previously known with an aortic valve area of 0.7cm2. Given the severity of his disease, the cardiac surgical service was consulted. As a right middle lobe nodule was noted on chest x-ray, the thoracic surgical service was consulted. It was recommended that a CT scan be obtained and that he follow-up with Dr. [Last Name (STitle) 35684] as an outpatient. On [2136-4-27] Mr. [Known lastname 35683] was taken to the operating room where he underwent coronary artery bypass grafting to one vessel and an aortic valve replacement using a 23mm pericardial valve. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. By postoperative day one, Mr. [Known lastname 35683] had awoke neurologically intact and had been extubated. He was then transferred to the step down unit for further recovery. Mr. [Known lastname 35683] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [Known lastname 35683] continued to make steady progress and was discharged home on postoperative day five. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin Toprol Lipitor HCTZ Multivitamin Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks: please take 40mg twice a day for 7 days then decrease to 40mg once a day for 1 week . Disp:21 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day for 2 weeks: please take 20 meq twice a day for 1 week then decrease to 20meq once a day for 1 week - discontinue when lasix complete . Disp:56 Tablet Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Aortic stenosis s/p AVR Coronary artery disease Congestive heart failure, diastolic Chronic obtructive pulmonary disease Peptic ulcer Hyperlipidemia Osteoarthritis Asbestosis Secondary: 1. Chronic obstructive pulmonary disease 2. Hyperlipidemia 3. Prior PUD Discharge Condition: Good Discharge Instructions: Please shower daily, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2136-6-28] 8:00 Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2136-7-4] 9:40 Provider: [Name10 (NameIs) 1570],[Name11 (NameIs) 2162] [Name12 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2136-7-4] 10:00 Dr [Last Name (STitle) ] in 4 weeks please call to schedule appt [Telephone/Fax (1) 170] [Hospital Ward Name 121] 2 wound check [5-11] at 11 am [Telephone/Fax (1) 3633] Dr [Last Name (STitle) ] in [12-6] weeks please call to schedule appt [Telephone/Fax (1) 1579] Dr [Last Name (STitle) ] in [1-7] weeks please call to schedule appt Follow-up with Dr. [Last Name (STitle) ] as instructed. [Telephone/Fax (1) 170] Completed by:[2136-5-2]	[ "496", "501", "414.01", "715.98", "272.0", "428.30", "533.90", "428.0", "424.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21", "37.23", "88.56", "36.11" ]	icd9pcs	[ [ [] ] ]	8955, 9030	5966, 7611	329, 482	9333, 9340	3363, 5943	9823, 10679	2898, 2903		7702, 8932		9051, 9312		7637, 7679			9364, 9800									2918, 3344																				281, 291										510, 2100														2122, 2774	2790, 2882
28,646	168,829	14229	Discharge summary	report	Admission Date: [2184-10-4] Discharge Date: [2184-10-11] Date of Birth: [2112-7-5] Sex: M Service: MEDICINE Allergies: Penicillins / Lisinopril / Levofloxacin Attending:[Last Name (NamePattern4) 290] Chief Complaint: dyspnea and hypoxia Major Surgical or Invasive Procedure: none . History of Present Illness: This 72M pediatrician was diagnosed with T-cell lymphoma 4 weeks ago and is followed up by Dr [Last Name (STitle) 3315] at [Hospital3 328]. He subsequently developed fever and petechial rash prior to receiving his chemotherapy without infectious cause identified. He was given (19 days ago) CHOP and reportedly did well with this. He recieved G-CSF on day 2 of CHOP. He subsequently did well in the intervening weeks after chemotherapy and went through neutropenic phase without complication. His WBC subsequently recovered to 3.5K as of last week. . He states that he has had a subacute shortness of breath on exertion and a dry non-productive cough since approximately 2 weeks ago. However on friday [10-1] pt developed a fever to 101.6 along with maculopapular rash over his trunk and legs as well as a mild cough. He was given levofloxacin empirically for possible pneumonia and his fever came down on [10-2]. He subsequently developed nausea and mucositis associated with chemo and was treated with zantac. Sunday [10-3], pt developed progressive malaise and fatigue and was seen at [Hospital3 ] Hospital for temp of 100.8. Initial labs notable for leukocytosis of 22K with left shift, query G-CSF effect vs infection; acute renal failure with creatinine at 2.2 (baseline 1.1); and abnormal LFT's: SGOT 94, SGPT 201, alk phos 329, TB 1.6, direct bili 1.0, lipase 13. LDH 476. RUQ U/S demonstrated thickened, edematous gallbladder wall but no peri-cholecystic fluid (could be due to contracted state), but nl pancreas, liver and cbd. There was medium amount of ascites and small pleural effusions. CXR revealed atelectasis of RLL with interval improvement, and small bilateral effusions. He was therefore given a dose of ertapenem in the ER for potential biliary infection. He received 1mg of PO vitamin K. He was transferred for further care. . On arrival to BMT floor pt complained of feeling fatigued, has dry mouth and feeling short of breath which is affecting his ability to speak. On arrival to the BMT unit he was feeling progressivly short of breath and requiring supplimental O2 (O2sat 94% on 4L). His vital signs on arrival T [Age over 90 ]F HR 132 RR 26 BP 94/70. He was given 500cc bolus of NS and transferred to the ICU. He also received a dose of acetaminophen. Past Medical History: - SCC of left chest wall - BCC of nose and ear - Hypertension - Asthma since childhood - DVT (4 weeks ago) - s/p appendectomy as a child - sigmoid diverticuli Social History: Retired pediatrician; Ex-smoker of cigars; Alcohol occasionally; daughter was internal medicine housestaff at [Hospital1 18], brother is cardiologist at [Name (NI) 498] Family History: CAD on mother's side; sister CVA Physical Exam: Admission: temp 97 112 100/59 20 96%4L Gen: fatigued, moist skin. speaking in full sentences neck supple, no jvd rrr, nl s1+s2, no m/r/g bilateral end inspiratory crackles, no wheeze or rhonchi [Last Name (un) 103] mild tenderness RUQ, no rebound/guarding/regidity, no shifting dullness, nl bs no o/c/c diffuse papular rash on erythematous base all blanching. no vesicles. no lesions on palms/soles/oral mucosa. a&o x 3, cns [1-12] grossly intact Pertinent Results: [2184-10-4] 08:23PM WBC-22.1* RBC-4.33* HGB-13.4* HCT-39.7* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.1 [2184-10-4] 08:23PM NEUTS-85* BANDS-7* LYMPHS-1* MONOS-4 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-2* [2184-10-4] 08:23PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [2184-10-4] 08:23PM PLT SMR-LOW PLT COUNT-80* [2184-10-4] 08:23PM PT-46.8* PTT-40.2* INR(PT)-5.4* [2184-10-4] 08:23PM FIBRINOGE-680* [2184-10-4] 08:23PM GLUCOSE-151* UREA N-36* CREAT-1.7* SODIUM-135 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-18* ANION GAP-13 [2184-10-4] 08:23PM ALBUMIN-2.3* CALCIUM-6.8* PHOSPHATE-1.3* MAGNESIUM-2.1 URIC ACID-5.6 [2184-10-4] 08:23PM ALT(SGPT)-66* AST(SGOT)-24 LD(LDH)-445* ALK PHOS-453* AMYLASE-6 TOT BILI-0.7 [2184-10-4] 08:23PM LIPASE-7 GGT-214* . . . CHEST CT WITHOUT INTRAVENOUS CONTRAST: Please note, evaluation is limited secondary to lack of intravenous contrast administration. The heart and great vessels are grossly unremarkable. Note is made of striking axillary lymphadenopathy, left greater than right. The largest lymph node located in the superior aspect of the left axilla measures 4.1 x 2.4 cm (2:15). A right hilar lymph node is pathologically enlarged and measures 1.9 x 1.1 cm (2:31). There are several prevascular and mediastinal/precarinal lymph nodes, none of which meet dcriteria for pathology by CT. Lung windows demonstrate a possible, ill-defined opacity in the anterior aspect of the left upper lobe (2:19). There is bilateral basilar bronchovascular thickening. Small bilateral pleural effusions with associated compressive atelectasis are also present. No pulmonary nodules are identified. CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Please note, lack of intravenous contrast administration limits detailed evaluation of the intra- abdominal organs. The liver is grossly unremarkable. Once again, the gallbladder wall is noted to be markedly thickened measuring 1.6 cm in maximal dimension (2:72). Note is made of periportal pathologic lymphadenopathy with lymph nodes measuring 1.6 cm, and 1.5 cm in short-axis dimensions respectively (2:66, 2:70). The pancreas, adrenal glands, and kidneys appear grossly unremarkable. A small amount of perinephric fluid is noted bilaterally. The spleen is prominent measuring 14 cm in coronal dimension. There are multiple, non-pathologic retroperitoneal and mesenteric lymph nodes. A small amount of fluid is noted tracking in the paracolic gutters bilaterally. There is no free air within the abdomen. The abdominal portions of the large and small bowel appear grossly unremarkable. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Please note, lack of intravenous contrast administration limits detailed evaluation of the pelvic organs. A moderate amount of fluid is noted to track along the paracolic gutters entering within the pelvis. Note is made of a few sigmoid diverticula. There is no evidence of diverticulitis. The prostate is mildly enlarged measuring 5.2 x 4.8 cm (5.2 cm, transverse dimension). The bladder and intrapelvic loops of small bowel are grossly unremarkable. There is prominent pathologic inguinal lymphadenopathy with the largest lymph node located in the right groin measuring 2.6 x 2.0 cm (2:126). OSSEOUS STRUCTURES: A few curvilinear/scalloped deformities of the endplates of S1, L5, and L3 are noted with associated sclerosis. These are slightly atypical in appearance but most likely represent Schmorl's nodes. No suspicious lytic or blastic lesions are identified. IMPRESSION: 1. Extensive axillary, hilar, mediastinal, portal, and inguinal lymphadenopathy likely consistent with patient's underlying history of T-cell lymphoma. No previous examinations are available at this time for comparison. 2. Please note, detailed evaluation of the intrathoracic, abdominal, and pelvic organs is limited secondary to lack of intravenous contrast administration. Thickening of the basilar bronchovascular walls could indicate an infectious or inflammatory process. Small bilateral pleural effusions with associated atelectasis, a focal opacity in the right lower lobe and another focus in the left upper lobe could represent focal atelectasis/inflammation versus infection/aspiration, particularly at the bases. Clinical correlation is recommended. 3. Highly irregular, thickened gallbladder wall without distension is better evaluated on concurrent ultrasound examination from the same date. No additional findings on this limited non-contrast CT evaluation. 4. Mild-to-moderate abdominal and pelvic ascites of unclear etiology. Mild bilateral perinephric fluid also noted also of unclear etiology. 5. Enlarged prostate. Vanco trough 13.4 Beta-glucan pending, Galactomannan pending, Mycoplasma DNA pending Blood Cx pending Nasopharyngeal Aspirate for Fungal Cx pending Rapid Respiratory Viral Antigen Screen negative, Cx pending IMAGING: ECG ([10-5]) - Atrial flutter with rapid ventricular response. ECG ([10-6]) - Sinus rhythm; Consider left atrial abnormality; Low limb lead QRS voltages - is nonspecific . Portable CXR ([10-4]) - Cardiac silhouette is within normal limits. There is elevation of the right hemidiaphragm of uncertain cause. Although no definite pneumonia is appreciated, the area behind the heart and the elevated hemidiaphragm cannot be properly evaluated in the absence of a lateral view. Specifically, no hilar or mediastinal adenopathy is appreciated. . Abdominal US ([10-5]) - 1. No evidence of biliary dilatation. 2. Abnormal but nondistended gallbladder, with a 1.4 cm wall. The imaging findings are nonspecific, and may represent edematous or infiltrative change of the wall. Emphysematous cholecystitis is considered unlikely given the lack of shadowing/air seen within the wall as well as the lack of distention of the gallbladder. 3. Small hepatic hilar lymph nodes, mild splenomegaly. . CT Torso without Contrast ([10-4]) - 1. Extensive axillary, hilar, mediastinal, portal, and inguinal lymphadenopathy likely consistent with patient's underlying history of T-cell lymphoma. 2. Thickening of the basilar bronchovascular walls could indicate an infectious or inflammatory process. Small bilateral pleural effusions with associated atelectasis, a focal opacity in the right lower lobe and another focus in the left upper lobe could represent focal atelectasis/inflammation versus infection/aspiration, particularly at the bases. 3. Highly irregular, thickened gallbladder wall without distension. 4. Mild-to-moderate abdominal and pelvic ascites of unclear etiology. Mild bilateral perinephric fluid also noted also of unclear etiology. 5. Enlarged prostate. Brief Hospital Course: The patient is a 72-yo retired pediatrician with a recently diagnosed T-cell lymphoma s/p one cycle of CHOP (D+26), who presented with fever, rash, persistent dry cough, elevated LFTs, acute renal failure, and worsening oxygen requirement, transferred out of the ICU for continued care. He was also noted to have one episode of BRBPR and multiple episodes of atrial fibrillation with rapid ventricular response on exertion, which were symptomatic with palpitations and dizziness, and resolved with rest. . #. Fevers - The pt presented with fever, leukocytosis with left shift and bandemia, persistent non-productive cough, and worsening oxygen requirement, raising concern for a pneumonia. CXR on admission was unremarkable, and non-contrast chest CT was also non-specific. Culture data has all shown NGTD, with Urine Legionella antigen negative, Mycoplasma pneumonia DNA not detected, and beta-glucan and galactomannan currently pending. He was started on broad spectrum antibiotics, including Vancomycin, Aztreonam, Azithromycin, and Flagyl. The Infectious Disease team was involved with his care. His hypoxia greatly improved since his admission, with resolution of his dyspnea and tachypnea, and weaned off oxygen to room air. He defervesced and remained afebrile >72hrs, so his antibiotic regimen was changed to Meropenem and Azithromycin. A repeat portable CXR was non-diagnostic, and the patient completed his full course Azithromycin as an inpatient. He was discharged on daily Ertapenem to be taken as an outpatient for 7 more days. . #. Hypoxia - The pt presented with a significant oxygen requirement, dyspnea, and tachypnea. His CXR was unremarkable as above, and non-contrast chest CT was non-specific. He was treated as above for a probable pneumonia, although all micro data was negative. He significantly improved with this treatment, with resolution of his tachypnea, dyspnea, and hypoxia. His SOB also improved with an ipratropium inhaler that had been started for mild wheezing. A repeat portable CXR was again non-diagnostic. His antibiotic regimen was completed as above. . #. h/o DVT - The patient had a history of DVT approx 4 weeks prior to this hospitalization, being treated with coumadin at home for anticoagulation. His INR was supratherapeutic to >7 on admission, and reportedly up to 9 at OSH. He received Vitamin K, and his INR trended down to below 2.0 prior to restarting his coumadin. He was discharged to home with a plan to restart his coumadin at 5mg daily for now, with daily INR checks and adjustments to be made to his coumadin dose. He would be bridged to a therapeutic level with Lovenox as an outpatient. . #. Atrial tachycardia - The patient had an episode of A-fib with RVR in the MICU, in the setting of increased sympathetic tone with infection, fever, and dehydration. This was treated with IV Lopressor, and the pt had a good response to this. The cardiology team was involved, and recommended continuing on a low-dose beta-blocker such as Metoprolol 25mg. The patient was started on Metoprolol 12.5 for ectopy noted on his telemetry, but he developed wheezing after this, so the medication was discontinued with relief of wheezing. He then had a TTE that was unrevealing. He was noted to have more episodes of symptomatic A-fib with RVR while on the floor, so he was started on a low-dose CCB with good control and no further events on telemetry. This low-dose CCB was changed to a long-acting formulation prior to discharge. . #. BRBPR - The patient described 1 episode of BRBPR when trying to move his bowels. He noted that this was more bleeding than he has had in the past (h/o hemorrhoidal bleeding). He also has known sigmoid diverticula, seen on a screening colonoscopy here 5 years ago. His vital signs were stable, but his hematocrit slowly trended downward to 30 from 37.5 before stabilizing. His bleeding was felt to most likely be hemorrhoidal bleeding in the setting of his low platelets, but given the recent supratherapeutic INR, the GI team was consulted as other causes of bleeding such as diverticula were also being considered. The GI team also felt that this was likely hemorrhoidal bleeding and not a more serious source given his small amount of bleeding. The did however recommend further work-up of the gallbladder, including labwork and an MRCP. The patients hematocrits stabilized prior to discharge and he had no further evidence of bleeding. He was continued on Protonix. . #. Thrombocytopenia - The patient presented with thrombocytopenia and continued decrease in platelet count throughout the admission. He was not on any medications suspected to cause thrombocytopenia, although he had recently been on Levofloxacin which may have contributed. HITT was also considered given the diagnosis of a DVT 1 month prior that likely would have been treated with heparin. Heparin-dependent antibodies were negative for HITT, with anti-platelet antibody pending, but the patient's platelet count was recovering prior to discharge, up to 178 from a nadir of 50. . #. Abdominal discomfort - The patient initially presented to OSH with elevated LFTs and RUQ US findings of gallbladder wall thickening, which was confirmed on RUQ US here. The GGT on admission was not helpful as it was indicative of both bony and hepatic sources of elevated Alk Phos. There was concern for lymphomatous involvement rather than infection. The patient's LFTs continue to trend downward without intervention, and he had only very mild discomfort on deep palpation of RUQ, without any associated symptoms. His Flagyl was discontinued given the low likelihood of cholecystitis, and he was seen by GI and General Surgery, who recommended further work-up including a HIDA scan / MRCP. His HIDA scan was negative for cholecystitis, with hepatitis serologies, CMV viral load, [Doctor First Name ], anti-smooth muscle antibody, and total IgG pending on discharge. MRCP was not done given his improvement and the negative HIDA scan. . #. Rash - The patient initially presented with a diffuse erythematous blanching maculopapular rash. Initial DDx included drug rash to Levaquin, infectious, or lymphomatous involvement. Evaluation by Dermatology advised that the rash is most likely a drug reaction to Levaquin, and it was recommended that he use topical Clobetasol for treatment. The rash continued to improve in color and extent during the hospitalization, and was resolved prior to his discharge. . #. Acute renal failure - The patient initially presented to OSH with Cr 2.2, up from baseline 1.1. Urine lytes reportedly consistent with pre-renal picture, and Renal U/S essentially normal. His creatinine improved to baseline with IVF hydration. . #. T-cell lymphoma - The patient was diagnosed with T-cell lymphoma approx 4 weeks prior to his admission, and is now s/p first cycle of CHOP (D+26). Further chemotherapy is to be determined by the pt's primary oncologist, Dr. [Last Name (STitle) 3315], at [Hospital1 4601]. Continue communication with him regarding likelihood of receiving next cycle of CHOP. . Medications on Admission: [Doctor First Name 130] 60mg [Hospital1 ] levaquin 250mg daily protonix 40mg daily tylenol prn coumadin 7.5mg/5mg alternating Discharge Medications: 1. DILT-CD 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 2. Valacyclovir 1 g Tablet Sig: One (1) Tablet PO every twelve (12) hours for 10 days. Disp:20 Tablet(s) Refills:0 3. Lovenox 120 mg/0.8 mL Syringe Sig: One [Age over 90 ]y (120) mg Subcutaneous once a day: Until therapeutic INR achieved on coumadin. 4. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Dose to be adjusted based on INR daily. Disp:60 Tablet(s) Refills:2 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 7 days. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Sepsis with Multi-Organ failure 2. Pneumonia 3. Gallbladder wall thickening 4. Thrombocytopenia 5. Acute Liver Failure 6. Acute Renal Failure 7. Atrial Fibrillation with Rapid Ventricular Response 8. Hemorrhoidal Bleeding 9. Drug Rash 10. history of DVT Secondary Diagnosis: - T-cell lymphoma Discharge Condition: Afebrile, vital signs stable, off supplemental oxygen, pain-free, with resolving rash, normalizing laboratory values including platelet count, white blood cell count, LFTs, renal function tests, and INR . Discharge Instructions: You were admitted to [Hospital1 69] on Monday, [2184-10-4], for fever, and you presented with a cough, shortness of breath, rash, acute renal failure, elevated liver function tests, a supratherapeutic INR, and low platelets. You also developed hypotension likely from dehydration and/or sepsis, so you were treated in the ICU for a day, with great improvement in your clinical status. Imaging tests including chest X-rays and CT-scans of the torso showed a possible pneumonia. A liver/gallbladder ultrasound showed a thickened gallbladder wall but no evidence of acute cholecystitis. You were rehydrated with IV fluids and started on broad-spectrum antibiotics including Vancomycin, Aztreonam, Azithromycin, and Flagyl, and you continued to do well. You were seen by Infectious Disease, who helped us adjust your antibiotics: you received a full 7-day course of Azithromycin, and you were kept on Meropenem until discharge, at which point you were changed to Ertapenem, which you will need to continue for 7 more days. You were seen by Dermatology for your rash, which was felt to be due to the Levaquin that you had started prior to your admission. You developed multiple episodes of atrial fibrillation with rapid ventricular rate, so you were evaluated by Cardiology and started on low-dose Cardizem (you developed wheezing on low-dose metoprolol, which was treated with an ipratropium inhaler). You also had one episode of bloody stools, so you were evaluated by Gastroenterology, who felt that the bloody stools were likely hemorrhoidal and did not warrant further work-up at this time. You were also seen by General Surgery for your gallbladder findings, and a HIDA scan was done which was negative. Liver work-up for your gallbladder findings was also done, all of which was normal or is still pending. As you continued to do well, your platelet count trended back up to normal, your LFTs trended down to normal, your acute renal failure resolved with hydration, your rash resolved, your INR trended back down to a therapeutic level, and your fevers resolved and you did not require any further supplemental oxygen. You had no further episodes of bleeding or atrial tachyarrhythmias. You recovered nicely and were up walking around the floor well, and you were evaluated by Physical Therapy, who determined you had no acute needs at this point. A PICC line was placed so that you may continue to take your IV Ertapenem once daily. You should come to the outpatient clinic on 7 [Hospital Ward Name 1826] at [Hospital Ward Name 42299] daily to receive your Ertapenem and Lovenox, and to get INR checks. You will be receiving the Lovenox here to bridge you until your INR reaches a therapeutic level. You should resume your coumadin tonight and continue to take 5mg daily until otherwise advised based on your INR levels this week. . You should continue to take your medications as prescribed below. You should resume your coumadin tonight, at 5mg daily, until otherwise advised based on your daily INR checks this week. You should follow-up with Dr. [Last Name (STitle) ] in Cardiology and Dr. [Last Name (STitle) 3315] at [Hospital3 328] as below. Followup Instructions: Dr. [Last Name (STitle) ] - Friday [2184-10-22] at 2:40pm - phone ([Telephone/Fax (1) 22784]. Dr. [Last Name (STitle) 3315] - you should call Dr.[Name (NI) 42300] office at [Hospital 10596] and schedule an appointment to meet with him in the next week. . [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "575.8", "427.32", "287.5", "511.9", "054.9", "275.41", "427.31", "584.9", "789.59", "038.9", "570", "486", "995.92", "202.88", "518.0", "455.8", "427.89", "782.1", "276.51" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	18429, 18435	10352, 17420	327, 336	18794, 19001	3600, 10329	22231, 22649	3073, 3107		17604, 18406		18456, 18456		17446, 17581			19025, 22208									3122, 3581																				268, 289										364, 2680			18753, 18773			18475, 18732								2702, 2863	2879, 3057
60,864	126,364	480	Discharge summary	report	Admission Date: [2197-5-16] Discharge Date: [2197-5-19] Date of Birth: [2148-5-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 613] Chief Complaint: Hypothermia, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 49M with HBV, HCV and ESRD [1-11] HIV on dialysis for 25 years presents with purulent drainage from around the peritoneal dialysis catheter with an exposed cuff. He dialyzes himself at home and follows up at [Hospital 4029] Clinic sporadically. He presented to [Hospital 4029] Clinic today and was sent to [Hospital1 18] ED for the exposed catheter cuff and exit site infection. The peritoneal dialysis catheter is working and he reports clear output. The patient denies fevers, chills, nausea, vomitting, abdominal pain, diarrhea. He does not recall last bowel movement. He reports decreased appetite and weight loss but unsure how much. He was dialyzed last night. The patient is a very poor historian. There is a note in his paperwork from [Last Name (un) 4029] that he was admitted to [Hospital1 336] from [2197-5-4] to [2197-5-9] but it does not state why. The patient reports that it was for infection of his peritoneal dialysis catheter and he was treated with antiobiotics. On initial evaluation in the ED, the patient was reportedly very somnolent and unresponsive to sternal rub but then aroused without intervention and was able to answer questions. CD4 count was 273 2 years ago and the patient is reportedly non-compliant with his medications. Past Medical History: * HIV - diagnosed HIV+ in [2178] while he was in Guantanamo Bay. He received political asylum. He feels his HIV infection was the result of receipt of blood transfusions as a result of injuries sustained while being interrogated in a jail in [Country 2045]. He sustained several gunshot wounds and lacerations, as well as blunt trauma. He reported having CMV retinitis of the R eye that was diagnosed in [2186]. It was treated with a ganciclovir implant, but was further complicated by chronic pain that resulted in enucleation. He also had a work up for a pulmonary nodule in [2178], that ultimately was felt to be consistent with latent TB infection, and he was treated with 6 months of INH therapy in one report, up to a year in another. He also had pneumococcal sepsis in [2185]." * Hepatitis B * Venous thromboembolism * Depressive disorder & anxiety * CMV infection * History of tuberculosis * chronic kidney disease stage V due to HIV, on peritoneal dialysis, followed at [Last Name (un) 4029] in [Location (un) ] on [State ] St. * Chronic constipation * h/o XRT at MEEI for SCC in his left ear * Hypertension * Syphilis [Month (only) ] l993 c/b neurosyphilis, treated with IV penicillin x10days * Hepatitis C antibody positive * s/p PD catheter placement [2190], numerous HD catheters and AV fistulas; all failed Social History: Tobacco [12-11] PPDx 20 years, no ETOH, unemployed and lives alone in an apartment and he has CMA nursing help at home. No crack use or other drug use. Family History: Noncontributory to HIV/MS changes Physical Exam: On admission: Vitals: 96.7 (92.8 on repeat) 66 156/98 22 100% 3L GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: bilateral crackles at lung bases R>L, decreased breath sounds ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, some purulence produced with milking of skin around catheter, no surrounding cellulitis, no palpable masses DRE: patient refused Ext: RUE/LUE AVF sites thrombosed per patient, LLE/RLE (?removed) AVG sites Pertinent Results: ADMISSION LABS -------------- [2197-5-16] 03:30PM BLOOD WBC-3.5* RBC-2.66* Hgb-7.6* Hct-24.0* MCV-90 MCH-28.6 MCHC-31.6 RDW-22.4* Plt Ct-57* [2197-5-16] 03:30PM BLOOD Neuts-88* Bands-0 Lymphs-10* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [2197-5-16] 06:47PM BLOOD PT-11.9 PTT-29.5 INR(PT)-1.0 [2197-5-17] 04:00AM BLOOD WBC-3.1* Lymph-12* Abs [Last Name (un) ]-372 CD3%-75 Abs CD3-278* CD4%-14 Abs CD4-52* CD8%-58 Abs CD8-214 CD4/CD8-0.2* [2197-5-16] 03:30PM BLOOD Glucose-101* UreaN-30* Creat-8.9* Na-137 K-4.9 Cl-98 HCO3-30 AnGap-14 [2197-5-16] 03:30PM BLOOD ALT-78* AST-90* LD(LDH)-516* AlkPhos-251* Amylase-104* TotBili-0.2 [2197-5-17] 04:00AM BLOOD Calcium-7.5* Phos-5.3* Mg-1.9 [2197-5-16] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . MICROBIOLOGY ------------ [2197-5-16] 02:00PM ASCITES WBC-3* RBC-0 POLYS-0 LYMPHS-68* MONOS-0 MESOTHELI-16* MACROPHAG-16* OTHER-0 [2197-5-16] 03:30PM WBC-3.5* RBC-2.66* HGB-7.6* HCT-24.0* MCV-90 MCH-28.6 MCHC-31.6 RDW-22.4* . [2197-5-16] 2:00 pm PERITONEAL FLUID GRAM STAIN (Final [2197-5-16]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . Blood cultures [2197-5-16] x 2: pending, no growth to date . [2197-5-17] 12:55 am SPUTUM Site: INDUCED GRAM STAIN (Final [2197-5-17]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2197-5-17]): TEST CANCELLED, PATIENT CREDITED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2197-5-17]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS. Specimen is only screened for Cryptococcus species. New specimen is recommended. ACID FAST SMEAR (Final [2197-5-17]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): . [2197-5-17] 4:00 am IMMUNOLOGY Source: Venipuncture. FINAL REPORT [2197-5-18] HIV-1 Viral Load/Ultrasensitive (Final [2197-5-18]): 88 copies/ml. . [2197-5-16] 2:00 pm SWAB EXIT SITE DRAINAGE. WOUND CULTURE (Preliminary): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). HEAVY GROWTH. . IMAGING ------- Chest X-ray on admission: IMPRESSION: Right perihilar hazy opacity which may reflect asymmetric pulmonary edema, but infection also is in the differential. Small bilateral pleural effusions. Limited evaluation of the right lung apex. . CT head on admission: 1. No acute intracranial process. 2. Near-complete opacification of the bilateral mastoid air cells, unchanged on the left, but new on the right. 3. Increased size and number of lucencies within the calvaria should be correlated clinically with any history of malignancy, and a bone scan can be obtained for further evaluation. This finding was communicated to Dr. [Last Name (STitle) ] [Last Name (STitle) ] Dr. [Last Name (STitle) 4033] at 12:20 a.m. via telephone on [2197-5-17]. 4. Extensive paranasal sinus disease, as described above. 5. Extensive chronic small vessel ischemic disease, not significantly changed compared to [2195-3-11]. . CXR [2197-5-18]: As compared to the previous radiograph, there is increased parenchymal opacity in the right perihilar lung areas. Although unilateral pulmonary edema would be more likely than pneumonia, pneumonia cannot be excluded on grounds of the radiologic appearance. Unchanged size of the cardiac silhouette. Unchanged vascular stent. Brief Hospital Course: 49 year old Haitian male with poorly controlled HIV (last CD4 count 273 in [2194], in-house level 52), HBV coinfection and a history of longstanding peritoneal dialysis who presented [5-16] with mental status change, hypotension, and hypothermia. . ACTIVE ISSUES ------------- # Pneumonia: community acquired pneumonia vs. PCP pneumonia, patient is on prophylactic Bactrim at home. He presented with hypothermia and altered mental status. CD4 count was noted to be 52. Patient was initially on vancomycin/zosyn for empiric coverage, then switched to PO moxifloxacin for planned five day course after blood cultures remained negative. Chest X-ray showed perihilar opacity. Patient will continue bactrim prophylaxis upon discharge. Sputum cultures were obtained but were contaminated. Infectious disease was consulted and recommended the above antibiotic therapy, as well as continuing prophylactic Bactrim. . # HIV: CD4 count measured at 52 during admission, viral load 88 copies. Patient was continued on his home HAART regimen, as well as prophylactic Bactrim. Patient will likely require re-evaluation of his HAART regimen upon discharge. . # Pancytopenia: patient was noted to be pancytopenic during his hospital stay, and it is unclear if this is chronic. This may be related to his HIV, or other etiology, however this was not worked up further due to patient's insistence to be transferred to [Hospital ] Hospital. . # Bradycardia: on [2197-5-17] patient had a pause on telemetry (8 seconds) with transient hypotension to the 80s and hypoxia to the 80s which recovered within seconds. Later in the evening he had two episodes of bradycardia to the high 20s which was self-limited within seconds and asymptomatic. Electrolytes, cardiac enzymes and EKG were within normal limits; a cardiology consult was obtained and no further evaluation or intervention was recommended. . # Head imaging abnormality: patient was noted to have lucencies in the calvarium on head CT. This was not worked up further due to patient's insistence to be transferred to [Hospital ] Hospital. . # End-stage renal disease on peritoneal dialysis: patient presented with concern for peritoneal dialysis port site infection, with purulent fluid coming from the site. Cultures were obtained via diagnostic paracentesis and were preliminarily negative upon discharge. Patient is on Calcitriol 0.5 and sinacalcet 150 mg daily. Renal was consulted for performance of peritoneal dialysis while patient was hospitalized. CBC should be trended for further signs of infection. . # Anemia: likely combination of bone marrow suppression as well as chronic kidney disease. The patient recieved one unit RBCs for Hct 22.9 with an appropriate bump to 26.9. Epoeitin was held given concern for possible malignancy on head CT. . INACTIVE ISSUES --------------- # Hypertension: patient is on lisinopril and amolodipine at home. His home blood pressure medications were resumed after they were initially held due to his presenting sepsis-like picture. . TRANSITION OF CARE ------------------ # Follow-up: patient will be discharged to [Hospital ] Hospital per his request. Patient will require antibiotics to finish course of antibiotics for community acquired pneumonia. Blood cultures and peritoneal cultures are currently pending and will need to be followed up. There was also concern for malignancy of CT head that will need to be followed up. This was not addressed during the [Hospital 228] hospital stay given his refusal for further work-up. He should receive CBC and Chem10 every day for monitoring. Epoietin is being held at the current time due to the concern for malignancy on CT head. This should be re-evaluated in the near future. . # Code status: presumed full . # CONTACT: patient, [Name (NI) ] (HCP) [Telephone/Fax (1) 4034] . Medications on Admission: Calcium Carbonate 600'' Lamivudine 50' Epoetin Alfa [Numeric Identifier 389] monthly SQ Gentamicin cream apply daily to the exit site Lisinopril 10' Norvasc 10' (hold for hypotension) PhosLo 3 tabs with meals 667''' Potassium Salts 10' Prilosec 20' Rocaltrol 0.5 mcg' Sensipar 150' Viread 300 PO Qweek Zerit 15' Zyprexa 5' Discharge Medications: 1. lamivudine 10 mg/mL Solution Sig: Fifty (50) milligrams PO DAILY (Daily). 2. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: Please give with meals. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. cinacalcet 30 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 9. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (MO). 10. stavudine 15 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 11. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO daily () for 5 days. Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Community-acquired pneumonia Bradycardia Secondary diagnosis: delirium/ metabolic encephalopathy HIV/AIDS chronic kidney disease stage V, on peritoneal dialysis Anemia of chronic disease Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 122], It was a pleasure caring for you at the [Hospital1 827]. You came for further evaluation of altered mental status and hypothermia. Further testing showed that you had a pneumonia, for which you are being treated with antibiotics. There was also concern for infection of your peritoneal dialysis insertion site. Cultures were obtained from this area, and revealed no evidence of infection. You are now being discharged to [Hospital ] Hospital for further treatment. Dr. [First Name (STitle) 4035] at [Hospital ] Hospital was contact[Name (NI) ] and accepted the patient for transfer. The following changes have been made to your medications: We STARTED Bactrim We STARTED moxifloxacin, which should be taken for five days total We STOPPED Epoeitin for the time being, which should be further re-evaluated in the future Followup Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office at [Telephone/Fax (1) 673] to schedule a follow-up appointment in ~2 weeks after discharge. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "780.65", "E849.8", "285.21", "V12.09", "403.91", "564.00", "996.81", "348.39", "294.11", "E878.0", "585.6", "042", "486", "V64.3", "V15.81", "252.00", "V43.0", "070.30", "427.89", "284.1" ]	icd9cm	[ [ [] ] ]	[ "54.98" ]	icd9pcs	[ [ [] ] ]	13310, 13325	8015, 11887	338, 344	13589, 13589	3826, 5187	14647, 14955	3250, 3286		12264, 13287		13346, 13346		11913, 12241			13742, 14624									3301, 3301				6342, 6609	5999, 6309															264, 300				6644, 6731						372, 1671			13428, 13568			13365, 13407	6977, 7992	5270, 5963	13604, 13718					1693, 3060	3076, 3234		5219, 5234
66,084	114,446	10424	Discharge summary	report	Admission Date: [2115-6-18] Discharge Date: [2115-6-26] Date of Birth: [2060-7-26] Sex: F Service: CARDIOTHORACIC Allergies: Demerol / Oxycontin / Morphine Sulfate / Darvocet-N 100 Attending:[First Name3 (LF) 5790] Chief Complaint: Recurrent right pleural effusion Major Surgical or Invasive Procedure: [2115-6-20] Right pleural effusion drainage with pigtail placement and talc pleurodesis History of Present Illness: [Known lastname 34440] is a 54 year-old woman whp is s/p R VATS decortication, mechanical pleurodesis, and doxycycline chemical pleurodesis for recurrent effusion/trapped lung on [2115-6-7]. The pathology was benign. I suspect the etiology of the effusion was cardiac (valvular) + previous chest radiation. Unfortunately she developed recurrent dry cough, chest pain, SOB 3 days ago. She has some wheezing. She denies fevers, chills, or sweats. Past Medical History: ALLERGIES: demorol, morphine, oxycontin (all cause dizziness, nausea, vomiting) Cardiac Risk Factors: +Diabetes, +Dyslipidemia, Hypertension Other Past History: - CHF diastolic : baseline BNP in 300s - Aortic stenosis - Mitral regurgitation - Pulmonary hypertension - DM2: on insulin since [2112] - Recurrent pleural effusions: Since [2113], s/p multiple thoracenteses. Pleurex cath inserted in [3-/2115] for drainage at home; averages 550cc every other day. Exudative but negative for infection and malignancy with negative bx from [4-14] thorascopy. - H/o Hodgkin's lymphoma: Dx [2078]. S/p thymectomy, splenectomy. S/p mantle, abdominal, and pelvis XRT. - H/o breast cancer: T1cNo ER+/PR+ invasive ductal carcinoma in left breast, s/p left mastectomy and chemo. On anastrozole. - H/o Hurtle cell thyroid nodule: s/p total thyroidectomy at [Hospital1 2177] followed by radioactive iodine. - Pericarditis and pleuritis: In [2094], s/p pleurocentesis and pericardiocentesis, rx'ed with abx - LUE tremor - S/p mutiple surgeries for basal cell carcinoma - Chronic leukocytosis/Thrombocytocis for past 2 years: JAK2 and MPLW 515 mutations drawn by her hematologist still pending - S/p TAHBSO for fibroids Social History: Pt lives with her husband and works as community developer for city of [Hospital1 1474] and a youth organizer in her church. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Drinks only occasionally. Family History: There is no family history of premature coronary artery disease or sudden death. Father died in 80s, had COPD and AFib. Mother living in 80s, has DM2. 10 siblings including an older brother s/p prosthetic valve replacement. Has 2 children including 35yo son with diverticulitis and 33yo daughter with Tetralogy of Fallot s/p 3 surgeries at CHB and s/p ICD placement. Physical Exam: 96.5 73 136/70 22 94RA WNWD NAD AAx3 Decreased BS R to halfway up chest RRR soft NT ND no LE edema Pertinent Results: Labs on Admission: [2115-6-18] 12:46PM BLOOD WBC-8.3 RBC-5.82* Hgb-9.8* Hct-34.8* MCV-60* MCH-16.9* MCHC-28.3* RDW-18.4* Plt Ct-728* [2115-6-18] 12:46PM BLOOD PT-27.3* PTT-29.6 INR(PT)-2.7* [2115-6-18] 12:46PM BLOOD Glucose-104 UreaN-14 Creat-0.6 Na-137 K-4.6 Cl-102 HCO3-26 AnGap-14 [2115-6-18] 12:46PM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 Labs prior to expiration: [2115-6-25] 09:09PM BLOOD WBC-21.6# RBC-5.65 Hgb-9.6* Hct-34.9* MCV-62* MCH-16.9* MCHC-27.4* RDW-19.9* Plt Ct-475* [2115-6-25] 01:17AM BLOOD PT-18.3* PTT-29.1 INR(PT)-1.7* [2115-6-24] 02:35PM BLOOD Fibrino-778* [2115-6-25] 09:09PM BLOOD Glucose-108* UreaN-40* Creat-2.2* Na-136 K-6.2* Cl-93* HCO3-13* AnGap-36* [2115-6-25] 02:30PM BLOOD ALT-29 AST-66* CK(CPK)-10* AlkPhos-77 TotBili-0.7 [2115-6-25] 09:09PM BLOOD CK-MB-NotDone cTropnT-0.05* [2115-6-25] 02:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2115-6-23] 02:10PM BLOOD CK-MB-NotDone cTropnT-0.04* [2115-6-22] 07:59PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2115-6-25] 09:09PM BLOOD Calcium-9.1 Phos-8.8# Mg-2.5 [2115-6-26] 01:58AM BLOOD Type-ART pO2-244 pCO2-36 pH-7.48* calTCO2-28 Base XS-4 [2115-6-26] 12:43AM BLOOD Type-ART pO2-88 pCO2-40 pH-7.18* calTCO2-16* Base XS--12 [2115-6-25] 11:12PM BLOOD Type-ART pO2-101 pCO2-43 pH-7.17* calTCO2-17* Base XS--12 [2115-6-25] 09:25PM BLOOD Type-ART pO2-175* pCO2-41 pH-7.09* calTCO2-13* Base XS--17 [2115-6-26] 12:43AM BLOOD Lactate-14.8* K-5.1 [2115-6-25] 11:12PM BLOOD Lactate-17.4* K-5.0 [2115-6-25] 09:25PM BLOOD Lactate-14.8* Imaging: CHEST (PORTABLE AP) Study Date of [2115-6-25] 8:26 PM: Small multiloculated right pleural effusion has increased over the course of the day, not as large as it was on [6-23]. Tiny volume of pleural air at the base of the right lung is stable. Basal and apical pleural tube are unchanged in their respective positions. There is appreciably greater congestion and possibly mild edema in the right lung now than earlier in the day. Moderate-to-severe cardiomegaly is stable. Minimal left perihilar edema has also developed. Tip of the new Swan-Ganz catheter projects over the bifurcation of the pulmonary arteries. ET tube in standard placement, transvenous right atrial and right ventricular pacer leads unchanged in standard placements as well. RUQ U/S: Normal son[Name (NI) 493] appearance of the kidneys bilaterally. Prominent fluid-containing structure with internal debris in the left upper quadrant may represent gastric contents versus pleural effusion with heterogeneous internal debris, incompletely evaluated. Further imaging can be performed if indicated. TTE [2115-6-25]: The left atrium is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with borderline normal free wall function. There is abnormal septal motion/position. The aortic valve is abnormal. The aortic valve is not well seen. Moderate (2+) aortic regurgitation is seen. Mild to moderate ([2-8]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. CT CHEST W/CONTRAST Study Date of [2115-6-21] 4:18 PM 1. Persistent large multiloculated right pleural effusion. New loculated hydropneumothoraces are likely related to pleural catheter placement. 2. New high attenuation along diaphragmatic pleural region, probably representing talc deposition given history of interval talc treatment. 3. Improving left lower lobe opacity which may be due to resolving area of infection or inflammation. 4. Septal thickening, probably reflecting hydrostatic edema, but attention to this area on followup CT may be helpful to exclude lymphangitic carcinomatosis Brief Hospital Course: Mrs. [Known lastname 34440] was a very pleasant 54 year-old female who unfortunately was readmitted for recurrent right pleural effusion following a right VATS decortication, mechanical/doxycycline pleurodesis . Her chest CT showed an increase of the right-sided pleural effusion, partially divided/organized in two major compartments. Her coumadin was held on admission. . On [6-20]/009 she underwent placement of a pigtail catheter and talc pleurodesis by IR. She received 2u FFP periprocedure. Pigtail was inserted without complications, 1350cc of straw colored fluid was drained. Post-procedure CXRs showed continued right pleural effusion. Her WBC was elevated, which we attributed to the talc pleurodesis, as she was otherwise w/o signs or symptoms of infection. It quickly became evident that the pigtail placed was too small in diameter for adequate drainage of this multiloculated effusion and that she would need a repeat R VATS decortication with placement of a pleurx catheter. . On [2115-6-22] patient developed tachycardia with rates to the 150s and a drop in SBPs to 90-80s. The rhythm initially appeared to be sustained Vtach. However, on closer inspection of her rhythm strip and in consultation with cardiology, it was determined that she actually had afib RVR with aberrancy. She was immediately transferred to the unit and given IV lopressor. She later spontaneously converted to sinus rhythm without any further intervention. It also became quickly apparent to us that she was particularly preload dependent given her severe AS, which manifested as a prominent drop in SBPs with HRs >120s. Her urine output remained adequate before and after these episodes of afib. She was afebrile. Her electrolytes were closely monitored and repleted PRN. She remained in the unit until [2115-6-24] when she underwent a repeat R VATS decortication with placement of a pleurx catheter. Please see Dr. [Name (NI) 5794] operative note for details. She tolerated the procedure well and was transferred back to the SICU extubated. . In the early am of [2115-6-25] she again was in and out of afib with RVR. Her SBP was 70-80s requiring neosynephrine. She was given an amiodarone loading dose and then drip. She was also given 2 500 NS boluses for soft pressures. She never lost consciousness and had a strong peripheral pulse during these episodes. She also was found to have hyperkalemia, for which she received insulin, bicarb, and kayexylate. Repeat K 2 hours following treatment was 4.9. Her Cr was stable. Her urine output for most of the morning was adequate at ~25cc per hour. However, she suddenly became oliguric with outputs ~5cc/hr by 5:00am that morning. There was some debate at that point whether she was vol depleted or overloaded. Urine electrolytes were sent which showed a FENA of 3%, not c/w a prerenal state. Her creatinine bumped to 1.7. Ultimately it was decided that we should attempt diuresis, and she was given 10mg lasix. She did not respond, and became anuric. She again was intermittently in afib with RVR on an amio drip. Serial ABGs were obtained which showed a severe metabolic acidosis most likely caused by renal failure with a pH of 7.21, CO2 42 and HCO3 18. Subsequent ABGs showed worsening acidosis. Lactate was 13.8 and later trended upward to a max of 17. At this point, it became obvious that she was deteriorating fast and the etiology of this decline was unclear. Of note, her clinical exam was stable. She did not have abdominal pain or surgical abdomen and her chest tubes were adequately draining sersang fluid. . Renal and cardiology consults were immediately obtained. Renal thought she might have urosepsis given the presence of WBC casts. Again, she remained afebrile. She did have leukocytosis, although this temporally was consistent with her recent talc/doxy pleurodesis. A urinalysis taken on [6-22] showed 6-10 WBCs with mod bacteria, but was believed to be contaminated given the presence of [7-17] epi cells. Urine culture from that time eventually was negative. Urinalysis from [2115-6-23] was also negative for infection. Thus, there was few sxns and signs of urosepsis and was generally felt to be an unlikely cause of her sudden deterioration. Regardless, we immediately empirically started her on vanc/zosyn at that time. . Cardiology recommended stating a dilt drip and another amio load followed by drip for her continued intermittent afib with AVR. They were unsure if her metabolic acidosis and rising lactate was consistent with cardiogenic shock or sepsis physiology. We needed a swanz catheter. A TTE showed elevated PCWP with a preserved EF>55%. The aortic valve was not well visualized. There was moderate TR and mild MR. . On the evening of [6-25] patient was emergently intubated for worsening ABGs. A swanz catheter was inserted. Post swan CXR showed appropriate line placement without new PTX. The following plan for the evening was placed - obtain hemodynamic data, start CVVH to correct the metabolic acidosis, and cont vanc/zosyn. Her abdominal exam was stable. Serial ABGs were closely monitored. Bicarb was given for severe metabolic acidosis, which began to improve after CVVH was started. Hemodynamics were remarkable for a SVO2 60s, SVR >1300 (while on 3 of neo), PA pressures 60s/30s, wedge 28, mixed venous O2 50s, CO 2.4, fick CI 1.5. Cardiology believed the thermodilution was inaccurate given her severe valvular pathology and calculated the CI to be 2.3 (corrected for hemoglobin). They ultimately did not feel she was in cardiogenic shock and instead attributed the decline to peripheral vasodilation despite the high SVR and low SVO2. Thus, we still did not have an adequate explanation for the rising lactate and ARF. We contemplated the idea that she had thromboembolic acute mesenteric ischemia in the setting of intermittent afib, but ultimately felt this was extremely unlikely given the fact that she did not have abdominal pain or tenderness on exam. Again, urosepsis seemed an unlikely cause. Ultimately, we did not understand the exact cause of acute decline, but were actively managing here metabolic acidosis and renal failure by CVVH and bicarb drip. CVVH was started at 0000 [2115-6-26]. She was relatively rate controlled for most of the evening with HR in the 110s, and SBP by aline in the 100-110s (neo of 3). Her Hct was stable in the low 30s. . At approximately 1:45am, patient suddenly went into PEA arrest. She was without a pulse and unresponsive. ACLS protocol was immediately instituted. She was given CPR with approximately 6 rounds of epi/atropine. Multiple rds of CaCl and bicarb were given. At approximately 10 minutes into the code, she regained a pulse with a SBP to the 50s. However, this was temporary and then became asystolic. Bedside ultrasound was negative for a pericardial effusion. She did intermittently regain a rhythm, at times vfib, and was shocked as appropriate. But she never regained a sustainable rhythm and ultimately the code was called at 2:19am. Medical examiner declined the case and the death certificate was signed. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): until INR 2.0 . 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed to maintain INR 2.0-3.0 for L DVT. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Regular Insulin Sliding Scale Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expried Discharge Instructions: NA Followup Instructions: NA Completed by:[2115-7-1]	[ "997.1", "276.2", "V10.72", "250.00", "428.30", "427.1", "424.1", "416.0", "428.0", "V45.01", "427.31", "427.5", "V10.3", "511.9", "584.9" ]	icd9cm	[ [ [] ] ]	[ "34.04", "99.60", "34.52", "39.95", "96.04", "34.06", "34.92", "96.71" ]	icd9pcs	[ [ [] ] ]	15351, 15360	7056, 14232	355, 449	15411, 15420	2989, 2994	15471, 15503	2487, 2855		15324, 15328		15381, 15390		14258, 15301			15444, 15448									2870, 2970																				283, 317										477, 935							3008, 7033							957, 2190	2206, 2471
20,884	102,114	48713	Discharge summary	report	Admission Date: [2151-5-13] Discharge Date: [2151-5-18] Date of Birth: [2086-6-28] Sex: M Service: CCU MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old male with a history of coronary artery disease, status post LAD stent in [2145] complicated by in-stent thrombosis after one week status post thrombectomy. The patient had a coronary artery bypass graft in [2145] with LIMA to LAD, SVG to OM1, SVG to PDA, to PLV for a nonintervenable lesion of the PDA. The patient also has a history of hypertension, elevated cholesterol. He had a Persantine MIBI in [9-7] for unstable angina which showed only a small fixed inferior defect which was thought to be artifact and an ejection fraction of 63%, now presenting with worsening exertional chest pain and shortness of breath for the last month. The patient was found to have new T wave inversions in leads II, aVF, V2 through V4 on the EKG. He was admitted for catheterization initially to the CMI Service. The patient reports chest pain with minimal exertion such as walking one to two blocks or climbing two to three flights of stairs associated with shortness of breath. Denied any chest pain at rest. Denied paroxysmal nocturnal dyspnea, lower extremity edema, orthopnea. At catheterization, he was noted to have two 80% serial lesions between the RPDA and RPL anastomoses. When the wire crossed these lesions, the patient became bradycardiac and had an asystolic arrest. He had CPR for two minutes and was started on dopamine transiently for low blood pressure and regained normal sinus rhythm. He was given epinephrine and Atropine and an intra-aortic balloon pump was placed temporarily and transvenous pacing wires were used temporarily and removed after catheterization. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.6, heart rate 67, blood pressure 119/69, respirations 15, saturating 99% on room air. General: He was in no acute distress, alert and oriented times three. HEENT: Mucous membranes moist. No jugular venous distention. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Slight parasternal tenderness to palpation. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: Without edema, slight oozing of the left groin A line site. There was 1+ dorsalis pedis pulses bilaterally, 2+ posterior tibial pulses bilaterally. LABORATORY/RADIOLOGIC DATA: White count 10.6, hematocrit 36.9, platelets 152,000. Chemistries revealed a sodium of 145, potassium 4.3, chloride 105, bicarbonate 28, BUN 21, creatinine 1.2, glucose 100, INR 1.0. The EKG was normal sinus rhythm, rate of 70, normal axis and intervals, Q waves present in leads III and aVF, ST elevations of 3 mm in II, III, and aVF and biphasic T present in V6. Persantine MIBI in [9-7] showed mild fixed inferior defect, ejection fraction of 63%. His cardiac catheterization this admission showed a right atrial pressure of 5, pulmonary artery pressure of 16, right ventricular pressures of 23/6, pulmonary capillary wedge mean pressure of 9. Cardiac output of 3.26, cardiac index of 1.71. Left ventriculogram showed normal ejection fraction with no mitral regurgitation. Left main was normal. LAD showed mild in-stent occlusion, distal filling via LIMA. No significant disease. Left circumflex showed distal subtotal occlusion with small distal vessel, RCA showed an occluded PDA and mid PL branch, both filling via saphenous vein graft. Mild disease SVG to RPDA to RPL. Serial 80% lesions between anastomoses to RPDA and RPL. LIMA to LAD is normal, SVG to OM is occluded. HOSPITAL COURSE: The patient underwent stenting of serial 80% lesions between the RPDA and RPL anastomoses. An intra-aortic balloon pump was placed for 24 hours. During the catheterization, after the wire was passed over the 80% lesions in the RCA, the patient underwent asystolic arrest, had CPR initiated for two minutes, regained normal sinus rhythm after being given epinephrine and Atropine. The patient had transvenous pacing wires placed which were removed after his catheterization. After his interventions, the patient was noted to have ST elevations in inferior leads and complained of chest pain. 1. ACUTE INFERIOR MYOCARDIAL INFARCTION SECONDARY TO DISTAL EMBOLIZATION DURING PCI: EKG after catheterization showed residual ST elevation in II, III, and aVF. Peak CKs were in the 2,000 range with no evidence of RV infarction by right heart catheterization. His pain was controlled with a nitroglycerin drip and Dilaudid p.r.n. initially. After about eight hours post catheterization, his pain subsided. He was continued on a beta blocker which was titrated up, aspirin, Plavix, Lipitor, Integrilin for 18 hours post catheterization, and heparin until his sheath was pulled. 2. HYPOTENSION: The patient was transiently hypotensive during catheterization and was placed on dopamine temporarily which was discontinued after the patient left the catheterization laboratory. He had an intra-aortic balloon pump placed for 24 hours after catheterization to improve his coronary perfusion. He was easily taken off the balloon pump the next day. 3. HEMATURIA: The patient was with gross hematuria after catheterization, likely secondary to combination of Bivalirudin, Integrilin, Plavix, and aspirin during his catheterization. Possible Foley trauma. He was started on continuous bladder irrigation for 24 hours. The patient had several episodes of large clots obstructing which were flushed and suctioned out of his continuous bladder irrigation. After his Integrilin was discontinued, his hematuria resolved over the next day and his catheter was pulled after his urine drained clear. 4. HYPERTENSION: The patient's blood pressure was well controlled. His Lopressor was titrated up and he will be discharged on 150 mg of Toprol XL a day. He was not initiated on an ACE inhibitor but may benefit from treatment with Ramipril per his outpatient cardiologist. 5. SUPERFICIAL THROMBOPHLEBITIS: On the patient's third hospital day, he was noted to have swelling and tenderness over his left dorsum of his hand associated with a peripheral IV site. The peripheral IV was pulled. There was erythematous tracking noted up to the antecubital fossa. The patient was also noted to spike a low-grade fever to 100.9. Blood cultures were drawn. He was started on vancomycin for 24 hours which was then switched to oxacillin 2 grams IV q. eight hours for two days and he was discharged home on dicloxacillin for one week. On the day of discharge, his fever had improved and his white count came down. 6. HYPERCHOLESTEROLEMIA: He was started on Lipitor 80 mg p.o. q.d. for an acute myocardial infarction. 7. GLUCOSE INTOLERANCE: Per the patient's wife, he has a history of elevated glucose which has previously been diet-controlled. He was maintained on a sliding scale insulin in the hospital and the patient's fingersticks were noted to be consistently in the 120-200 range and he will likely need additional treatment initiated as an outpatient. 8. GROIN RASH: On the patient's fourth hospital day, he was noted to have an itchy erythematous groin rash in his intertriginous areas. It was consistent with [Female First Name (un) 564] with satelite lesions present. He was started on Clotrimazole b.i.d. and he was discharged on a two week course of Clotrimazole. DISCHARGE STATUS: The patient is ambulatory, chest pain-free, saturating well in room air. DISCHARGE DISPOSITION: The patient will be discharged home with home services for medication teaching. FOLLOW-UP PLANS: The patient is to follow-up with his primary care provider in two weeks after discharge. He is also to follow-up with his cardiologist, Dr. [Last Name (STitle) ], in two weeks. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Multivitamin one p.o. q.d. 4. Fish oil one capsule p.o. b.i.d. 5. Lipitor 80 mg p.o. q.d. 6. Clotrimazole 1% cream one application b.i.d. to groin. 7. Dicloxacillin 250 mg p.o. q. six hours times one week. 8. Toprol XL 150 mg p.o. q.d. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 5819] MEDQUIST36 D: [2151-5-18] 12:34 T: [2151-5-19] 18:45 JOB#: [Job Number 102412]	[ "V17.3", "250.00", "112.5", "780.6", "999.2", "410.41", "414.02", "997.1", "401.9" ]	icd9cm	[ [ [] ] ]	[ "37.22", "36.01", "36.07", "99.20", "36.06", "37.61", "97.44", "88.53", "37.78", "88.56" ]	icd9pcs	[ [ [] ] ]	7632, 7713								7937, 8532					3725, 7608																										7731, 7914																						1836, 3707
69,851	150,632	54206	Discharge summary	report	Admission Date: [2119-7-10] Discharge Date: [2119-7-20] Date of Birth: [2050-6-9] Sex: F Service: MEDICINE Allergies: Codeine / Iodine; Iodine Containing / Levaquin Attending:[Last Name (NamePattern1) 4377] Chief Complaint: Left sided clumsiness and weakness. Major Surgical or Invasive Procedure: None. History of Present Illness: Time Code Stroke called: 12:43pm (24h clock) Time Neurology at bedside for evaluation: 12:49 pm (24h clock) Time (and date) the patient was last known well: 12:30 pm NIH Stroke Scale Score: 8 t-[MD Number(3) 6360]: NO, chronic thrombocytopenia given lymphoma with platelets of 60 today Reason for Consult: Called by Emergency Department to evaluate CODE STROKE Please see stroke fellow note for full details. HPI: In brief, this is a 69 year old female with recurrent B cell lymphoma (on [Hospital1 ] chemotherapy since [2119-5-22]), atrial fibrillation (on rate control), history of c diff, hx of DVT, HTN who presented to the ED with sudden onset of confusion associated with left facial droop and left arm weakness. Per husband they were driving to an oncology appointment and suddenly she didn't look right and she couldn't tell where a cup was in space to take a drink. She couldn't stand up out of the car to get her into the ED. In the ED, attending noted left face and arm weakness and called a code stroke within 15 minutes of symptom onset. NIHSS 8 as below for left arm weakness, limb ataxia, and facial droop. In the ED, VS 122/82-144/73. Initially taken to head CT that did not show early evidence of stroke. Patient repeatedly asking for Dr.[Name (NI) 14047] opinion, in addition to motor symptoms she had decreased sensation over her right arm and was noted to develop right gaze preference on repeated exams. She had urgent MRI/MRA head and neck because of a contrast allergy. Labs revealed platelets of 60 and tPA contraindicated. Case was discussed in the ED with [Name (NI) ]. [First Name (STitle) ], [Name5 (PTitle) ], and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and intervention deferred. Following the MRI which showed right thalamic stroke, heparin started and placed in IVF with goal BP ~160. She was admitted to the ICU for further management. NIH Stroke Scale score was 8 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 2 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 1 8. Sensory: 2 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 2 On ROS, completed a course of chemotherapy last week. + right atrial thrombus on echo. Took neupogen shot today. Past Medical History: ONCOLOGIC HISTORY: 1. Diagnosed in [12/2116] and received six cycles of R-[Hospital1 ] with her last cycle on [2117-4-19]. . 2. MVA in [7-/2117] with extensive injuries including C2 fracture. Following recovery, she received one cycle of maintenance rituximab in 12/[2116]. . 3. Follow up PET scan in [12/2117] showed worsening adenopathy with biopsy consistent with her known lymphoma. She received two cycles of ICE chemotherapy on [2118-2-22] and [2118-3-23] with resolution of her FDG-avid adenopathy. . 4. Received high-dose Cytoxan for stem cell mobilization and collections on [2118-4-22] followed by an autologous stem cell transplant on the BEAM regimen starting on [2118-5-19]. D 0 was on [2118-5-26]. . 5. Her chemotherapy and posttransplant course were complicated byproctitis and rectal pain which resolved with recovery of her counts. She also was noted for lymphocytosis of unclear etiology felt possibly related to an autoimmune process. She also developed a drop in her DLCO with concern for pneumonitis. She was initiated on a prednisone taper with improvement in her pneumonitis. At the end of [2118-7-19], she was noted for hemolysis with a slight drop in her hematocrit and hemoglobin. This was fully evaluated and felt related to increasing lipids with increasing triglycerides seen in the setting of a higher glucose with her steroid use. . 6. Restaging CT scan on [2118-11-1] showed a new single 21.7 mm focus of prevascular adenopathy. She underwent CT guided LN biopsy on [2118-11-23] which unfortunately showed recurrence of her B-cell lymphoma with aggressive features. There was also a small component of a possible T cell lymphoma noted on one of the cores. Follow up PET/CT scan on [2118-12-7] showed further progression of her disease with new markedly FDG avid anterior mediastinal nodal mass compared to previous PET-CT. New mediastinal (including anterior, precarinal and subcarinal), right hilar, retrocrural, retroperitoneal and right iliac FDG avid lymphadenopathy. . 7. Elected to proceed forward on Protocol #08-064 with treatment with Pralatrexate and Gemzar. She required periodic admissions during the course of her treatment. Following 2 cycles of therapy, repeat PET scan on [2119-1-30] showed a 44.6% decrease in lymph nodes which is considered stable disease. She received 3 and [11-19] cycles of therapy with noted disease progression on CT scan and PET scan. . 8. [2119-4-5]--Admitted for 1st cycle of ESHAP. . 9. Admitted on [2119-4-16] for fever/neutropenia with cough and probable pneumonia. Treated with Cefpodoxime. Readmitted on [2119-4-24] with cough, weakness, electrolyte abnormalities and noted C. diff infection, now on oral vancomycin. . 10. Follow up CT scan showed a mixed response, with interval decrease of mediastinal lymphadenopathy but increased of retroperitoneal lymphadenopathy. It was not clear whether this was related to her recent infections or progression of lymphoma particularly as her LDH had increased again. Decision was made to proceed with treatment with Gemzar/Oxaliplatin which was initiated on [2119-5-2]. . 11. Mrs. [Known lastname 103705] underwent a repeat CT torso on [2119-5-17], which demonstrated further progression of her disease, with enlarged retroperitoneal lymph nodes. Her counts remained low and she underwent bone marrow aspirate and biopsy on [2119-5-18] which showed no evidence for lymphoma. The decision was made to proceed with a course of [Hospital1 ] which was initiated on [2119-5-22]. . . PAST MEDICAL HISTORY: 1. Recurrent NHL. 2. Atrial fibrillation, on Diltiazem, Metoprolol with rate control. Was on Coumadin which has been on hold with recent treatment. Digoxin discontinued since early [1-/2119] due to increased dig level and bradycardia. 3. CHF, most recent EF >55% on [2119-1-26]. 4. History of DVT in left leg [8-/2116], treated with Lovenox 5. Hypertension 6. Vasculitis, treated with Imuran for one year. 7. Asthma 8. Palindromic Rheumatism 9. Pancreatitis [12-20] Imuran 10. GERD 11. MVA, [7-/2117] with bilateral C2 vertebral foramen fracture/C2 body fracture, manubrium fracture, right rib fractures of ribs six through eight, left distal radial/ulnar styloid fracture. 12. Prior torn rotator cuff (left) tendon tear (right) arm. 13. Recurrent proctitis 14. Corynebacterium in joint fluid in [2-/2118] tx'd w/ Vancomycin. 15. Increased triglycerides/hypercholesterolemia, now on Tricor 16. C. difficile infection Social History: Mrs. [Known lastname 103705] is married with two children. Her husband continues to be a tremendous support. She is retired. She used to work as a teacher, librarian, and account manager. Quit smoking 41 years ago with 10 pack year history. Denies alcohol use and illicit drugs. Family History: Mother - no cancer. Maternal aunt - BR CA in 40's. Father - cerebellar hemorrhage; leg amputation due to "poor circulation." Physical Exam: Vital sign: BP: 134/76 RR: 16 HR: 72 100% on 2 Liters GENERAL: Pleasant, fatigued appearing HEENT: Sclera anicteric, oropharynx dry without lesions or thrush. JVP wnl LN: No cervical, SC LAD LUNGS: decreased BS at bases b/l HEART: Irregularly irregular rhythm without murmurs, rubs, or gallops ABDOMEN: Soft, nondistended, normal bowel sounds, diffuse TTP throughout. No rebound/guarding. EXTREMITIES: no edema Neuro exam: Mental status: Awake and alert, oriented to time, place and person. no aphasia, no dysarthria. mild sign of agnosia, denies she is having stroke. CN: II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. visugal field cut with right hemianopsia. no gaze prference initially but later she has slight gaze preference to right side with visual neglect as well. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: facial sensation normal, mild facial drooping to left side. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength 5/5 except [2-20] with left upper extremity. Sensation: total loss of sensation with left side, unaware of touch at all. DTR: B T Br Pa Ac Right 1 1 1 1 1 Left 1 1 1 1 1 coordiantion: limb ataxia with left arm gait: deferred. NIHSS: 1 for facial drooping, 1 for visual field, 1 for left arm weakness, 1 limb ataxia, 2 for sensory loss, 2 for extinction.total score=8 . ON DISCHARGE: Exam unchanged except the neuro-exam: Alert and oriented to person, place, time. CN 2 -12 intact. Right visual field cut. Face symmetric, no tongue deviation. Strength 4/5 in UE and LE, bilaterally. Ambulate with assistance. Sensation intact. Pertinent Results: 1. Labs on admission: - WBC-17.8# RBC-3.25 Hgb-10.0* Hct-30.2* MCV-93 MCH-30.7 MCHC-33.0 RDW-20.4* Plt Ct-60* - Neuts-95.7* Lymphs-3.4* Monos-0.4* Eos-0.5 Baso-0.1 - PT-12.8 PTT-41.1* INR(PT)-1.1 - Fibrino-201# - ESR-9 - Gran Ct-[Numeric Identifier 111073]* - Glucose-216* UreaN-21* Creat-0.6 Na-141 K-3.6 Cl-103 HCO3-30 AnGap-12 - CK-MB-2 cTropnT-<0.01 - Calcium-8.9 Phos-3.0 Mg-1.5* - VitB12-GREATER TH - HbA1c-6.8* eAG-148* - Triglyc-199* HDL-65 CHOL/HD-2.5 LDLcalc-59 LDLmeas-77 - BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . 2. Discharge Labs: - WBC-5.3 RBC-3.02* Hgb-10.0* Hct-29.0* MCV-96 MCH-33.2* MCHC-34.5 RDW-20.2* Plt Ct-65* - Neuts-53 Bands-2 Lymphs-19 Monos-16* Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-7* NRBC-1* - PT-13.4 INR(PT)-1.1 - Gran Ct-3020 - Glucose-140* UreaN-9 Creat-0.8 Na-142 K-4.1 Cl-104 HCO3-30 AnGap-12 - ALT-12 AST-11 LD(LDH)-242 AlkPhos-99 TotBili-0.3 - Albumin-3.7 Calcium-9.2 Phos-4.4 Mg-1.6 . Initial CT head in ED [7-10]: IMPRESSION: No acute intracranial process; please note MRI is more sensitive for the detection of acute stroke. . Initial MRI [7-10]: 1. Acute infarct in the right thalamus. This finding was discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22924] at 2:42 p.m. [2119-7-10]. 2. Irregularity within the anterior circulation and right distal vertebral artery which may be related to artifact or atherosclerotic disease. 3. Lack of flow in the right posterior cerebral artery just beyond its origin, which may represent occlusion or high-grade stenosis. . Subsequent NCHCT [7-11]: IMPRESSION: 1. New 1.7-cm right thalamic hematoma within the pulvinar in the location of recent ischemic infarct is consistent with hemorrhagic conversion. Mild peripheral zone of edema exerts no significant mass effect. There is no notable midline shift or evidence of transtentorial or tonsillar herniation. 2. New right occipital hypoattenuation extending to cortical surface and involving the visual cortex is concordant with symptoms and concerning for extension of ischemic infarction. . Subsequent HCHCT [7-13]: FINDINGS: There is an evolving appearance of right PCA infarction and subsequent edema in the right occipital lobe. There is stable appearance of right thalamic hemorrhage. The edema is exerting mass effect on adjacent structures with no appreciable shift of normally midline structures. There is no change from prior exam two days ago. The osseous structures are unremarkable. Sinuses are well aerated. There are mild vascular calcifications in the cavernous carotid arteries. Unchanged appearance of left frontal osteoma and hyperostosis frontalis. IMPRESSION: Evolving right PCA stroke. Stable appearance of right thalamic hemorrhage. Brief Hospital Course: ICU Course . Initial exam significant for Foix's triad of left homonymous hemianopia, left hemianesthesia (all modalities) and left hemiplegia. She also demonstrated left hemi-neglect. These findings changed during the first two days. On admission and that evening, some left arm movement and left grasp were notable with extinction on left face. On the morning of [7-11] anisocoria was more evident (for unclear reasons left pupil was larger) and sensory loss was denser with loss of light touch and no response to painful stimulation (either reflexive or cortical). Repeat NCHCT revealed some hemorrhagic conversion consistent with leakage rather than frank hemorrhage given low Houndsfield units. Heparin was stopped and blood pressure parameters changed from maintain hypertension to maintain high normal pressure and sitting the patient up. She gradually improved with examination on the morning of [7-12] revealing increased, although ataxic movement of the left arm and return of diconnected pain sensibility (aversive component retained without accurate localization). Her mental state remained quite clear throughout, with some somnolence on [7-11] in the morning and evening. She was oriented in all respects throughout. Given hemorrhage and worsened AF with reduction of beta-blocker at admission, home medications were restarted at typical doses with improvement of AF. On [7-13], neurologic exam was further improved with purposive use of left hand and more attentiveness to her left side. . [Month/Year (2) 3242] Course . Patient was transferred to the [Month/Year (2) 3242] service for further management, specifically, to monitor while counts nadired given recent [Hospital1 ]. On admission to the floor, her neuro exam was as above. Upon discharge, her neuro exam was much improved, only remarkable for right visual field cut. Strength and balance improved. Speech coherent. Alert and oriented. She had been on Neupogen QOD and was changed to daily upon transfer. Anticoagulation was held. Platelets were transfused to keep greater than 50. She had one episode of BRBPR that was attributed to hemorrhoids in the setting of thrombocytopenia without significant Hct drop. Counts nadired on [7-15] at 986 and neupogen was discontinued on [7-16]. Her other home meds were continued and she remained rate controlled with irregular rhythm throughout. She was discharged to rehab. On discharge, was started on Aspirin 81 mg every other day for stroke prophylaxis. Medications on Admission: ACYCLOVIR - 200 mg Capsule - 2 (Two) Capsule(s) by mouth three times a day ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) inhaled every 4 hours as needed CLONIDINE - 0.1 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day DILTIAZEM HCL - (Dose adjustment - no new Rx) - 240 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth DAILY (Daily) FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1 Tablet(s) by mouth once a day FENTANYL - 50 mcg/hour Patch 72 hr - 1 Patch(s) every seventy-two (72) hours FLUCONAZOLE [DIFLUCAN] - 200 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE - 220 mcg Aerosol - 1 puff inhaled twice daily rinse mouth after use FOLIC ACID - 1 mg Tablet - 2 Tablet(s) by mouth once a day PLEASE DISPENSE 3 MONTH SUPPLY HYDROCORTISONE - (Prescribed by Other Provider) - 2.5 % Cream - appl rectal twice a day as needed for as needed for rectal pain HYDROCORTISONE-PRAMOXINE - 1 %-1 % Cream - Apply to affected areas twice to three times per day as needed for rectal pain HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet - 2 Tablet(s) by mouth every four (4) hours as needed for breakthrough pain LIDOCAINE HCL - (Prescribed by Other Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) - 5 % Ointment - Aplly to affected areas twice to three times per day as needed LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - One application 1 hour prior to each port-a-cath access LIPASE-PROTEASE-AMYLASE [CREON 20] - 497 mg (66,400 unit-[Unit Number ],000 unit-[Unit Number ],000 unit) Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth three times a day LORAZEPAM - 0.5 mg Tablet - [11-21] Tablet(s) by mouth every six (6) hours total of 2mg every six hours as needed METOPROLOL TARTRATE - (Prescribed by Other Provider: [Name10 (NameIs) ] [Last Name (STitle) ] and [Name5 (PTitle) ]) - 50 mg Tablet - 2 Tablet(s) by mouth every morning and night. 100mg [Hospital1 ] NIFEDIPINE 2% OINTMENT - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120]) - - Apply 3 times daily to rectum until resolution of pain decrease to 2 times daily for one week then 1 time daily for one week and then stop OMEPRAZOLE-SODIUM BICARBONATE [ZEGERID] - 40 mg-1.1 gram Capsule - 1 (One) Capsule(s) by mouth once a day ONDANSETRON HCL - 4 mg Tablet - 2 (Two) Tablet(s) by mouth every eight (8) hours as needed for nausea PENTAMIDINE [NEBUPENT] - (Prescribed by Other Provider; GIVEN [2119-6-6]) - 300 mg Recon Soln - 300 mg(s) inhaled every month for 6 months Diluted in 6 ml sterile water administered via aerosol. Please administer 2 puffs of albuterol prior to treatment as needed. PREDNISONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day, once taper completed SULFAMETHOXAZOLE-TRIMETHOPRIM - (On Hold from [2119-6-11] to unknown for thrombocytopenia) - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day VANCOMYCIN [VANCOCIN] - (Prescribed by Other Provider) - 250 mg Capsule - 1 Capsule(s) by mouth twice a day Medications - OTC CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet - 1 (One) Tablet(s) by mouth once a day DIPHENHYDRAMINE-ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg-25 mg Tablet - 2 Tablet(s) by mouth at bedtime as needed for insomnia ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth Daily along with a 200 mg tablet for total of 1,200 IU daily LORATADINE - (OTC) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day MAGNESIUM - (Prescribed by Other Provider; 1 twice per day) - Dosage uncertain OMEGA-3 FATTY ACIDS - (OTC; taking 900 mg tablets) - 1,000 mg Capsule - 1 Capsule(s) by mouth four times a day Using GNC triple Strength 900 mg EPA + DHA /pill SENNOSIDES-DOCUSATE SODIUM [SENNA PLUS] - (OTC) - 8.6 mg-50 mg Tablet - 2 (Two) Tablet(s) by mouth once a day as needed for constipation Discharge Medications: 1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Two (2) puffs Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 3. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Please hold for sBP <100, HR <55. 4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (): Pt will bring with her to rehab. 5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Creon 20 497 mg (20,000- 75K-66.4K unit) Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): Please hold for sBP <100, HR <55. 11. Zegerid 40-1.1 mg-gram Capsule Sig: One (1) Capsule PO once a day. 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 15. Cyanocobalamin (Vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Omega-3 Fatty Acids 500 mg Capsule Sig: Two (2) Capsule PO four times a day. 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a day. 22. Hydrocortisone-Pramoxine [11-18] % Cream Sig: One (1) dose Rectal three times a day as needed for pain: Hemorrhoid cream, to be applied prn for hemorrhoid pain. 23. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed. 24. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) application Topical twice a day as needed for pain: TO be used prn for hemorrhoid pain. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: 1. Right thalamic stroke 2. B cell lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with left sided clumsiness and you were found to have a stroke on MRI. You were started on anticoagulation but a repeat CT scan of your brain showed bleeding around the site of the stroke so anticoagulation was stopped. You were stabilized in the intensive care unit and your neurologic exam improved. You worked with physical therapy. You were transferred to the bone marrow transplant unit to watch your counts nadir and we transfused you platelets and red blood cells. . Some of your medications were changed during this admission: STOPPED: 1. CLONIDINE - 0.1 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day 2. NIFEDIPINE 2% OINTMENT - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120]) - - Apply 3 times daily to rectum until resolution of pain decrease to 2 times daily for one week then 1 time daily for one week and then stop 3. SULFAMETHOXAZOLE-TRIMETHOPRIM - (On Hold from [2119-6-11] unknown for thrombocytopenia) - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day Followup Instructions: 1) MRI & MRA of the brain with Gad [2119-8-17] @ 12:00 pm, [Hospital Ward Name 23] [Location (un) ] 2) Neurology Follow up with Dr. [Last Name (STitle) 7741] [2119-8-23] @ 2:30 pm, [Hospital Ward Name 23] [Location (un) ] 3) [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3919], [Last Name (NamePattern1) 280] Phone:[Telephone/Fax (1) 3241] Date/Time:[2119-7-31] 2:30 4) [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4380], MD Phone:[Telephone/Fax (1) 3237] Date/Time:[2119-7-31] 2:30 5) [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern1) 13280], MD Phone:[Telephone/Fax (1) 3965] Date/Time:[2119-8-7] 9:00 Completed by:[2119-7-20]	[ "V12.51", "429.89", "401.9", "368.46", "202.88", "287.5", "493.90", "342.92", "428.0", "272.4", "434.11", "455.8", "V42.82", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	21410, 21482	12522, 15034	350, 357	21570, 21570	9717, 9725	22886, 23636	7683, 7810		19094, 21387		21503, 21549		15060, 19071			21753, 22863		10303, 12499							7825, 8251													9453, 9698							275, 312										385, 2773							9739, 10287		21585, 21729					6423, 7366	7382, 7667
30,300	195,592	34211	Discharge summary	report	Admission Date: [2197-5-27] Discharge Date: [2197-6-23] Date of Birth: [2129-5-19] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 148] Chief Complaint: Bile leak s/p Laparoscopic cholecystectomy Major Surgical or Invasive Procedure: incisional hernia repair ERCP/stent, perc biloma drain, lap CCY (OSH) History of Present Illness: 68 year old woman with hx of CAD s/p CABG, COPD, CKD, DM2 who is referred to [Hospital1 18] after developing septic shock with multi-organ failure following elective cholecystectomy. She presented for elective lap chole on [2197-5-24]. She tolerated the initial procedure well and was admitted to the surgical floor on [2197-5-24] ~4pm. At approximately 4pm on [2197-5-25] she developed nausea and was found to be hypotensive to sbp ~58 with recheck of sbp ~90s. She was transfered to the ICU. She responded to fluid boluses. She had a HIDA scan that showed biliary leak. She had a subhepatic pigtail catheter placed. On [2197-5-26] ~7pm she was found to be tachycardic with moderate respiratory distress. She was intubated with 7.5 cm ETT. CXR confirmed adequate placement. She then developed an SVT and treated with adenosine then amiodarone. She was started on levophed and vasopression for hypotension. Access with left femoral line and left femoral art line placed. Amiodarone was discontinued and dobutamine added. A PA catheter was placed. Troponin was elevated. Lactate was 8.1. Her urine output continued to decreased and she was dialyzed for severe acidosis. She received 2 units of pRBCs and 2 units of FFP. Digoxin was added for additional rate control. Decision was made to transfer her to [Hospital1 18] for ERCP. Past Medical History: CAD s/p CABG diastolic CHF COPD (PFT [2190] - FEV1 42%, TLC 119%, DLCO 54%) peripheral vascular disease - s/p CEA hypertension chronic kidney disease (baseline Cr ~1.7-2 Diabetes mellitus Physical Exam: 103.8, 121, 112/61, 24, vent 100% Gen: well nourished, obese HEENT: PERRL, Poor dentition CV: PMI normal, S1,S2 Chest: breath sounds clear Abd: soft, bowel sounds prestn, distended, bowels sluggish, sub-hepatic drain in RUQ Ext: trace edema Pertinent Results: [2197-5-28] 12:50AM BLOOD WBC-13.6# RBC-3.33 Hgb-10.2* Hct-30.1* MCV-90 MCH-30.4 MCHC-33.7 RDW-17.2* Plt Ct-118* [2197-6-3] 01:54AM BLOOD WBC-31.9# RBC-3.14 Hgb-9.2* Hct-28.8* MCV-92 MCH-29.4 MCHC-32.1 RDW-16.9* Plt Ct-113# [2197-6-23] 09:25AM BLOOD WBC-13.0 RBC-2.74* Hgb-8.0* Hct-25.0* MCV-91 MCH-29.2 MCHC-32.0 RDW-17.7* Plt Ct-293 [2197-5-27] 05:53PM BLOOD Glucose-87 UreaN-50* Creat-2.8* Na-138 K-4.9 Cl-102 HCO3-19* AnGap-22 [2197-5-30] 09:38AM BLOOD Glucose-152* UreaN-92* Creat-4.3* Na-131* K-5.1 Cl-98 HCO3-20* AnGap-18 [2197-6-17] 02:29AM BLOOD Glucose-81 UreaN-62* Creat-2.1* Na-147* K-4.1 Cl-109* HCO3-27 AnGap-15 [2197-6-21] 06:38AM BLOOD Glucose-71 UreaN-33* Creat-1.5* Na-143 K-4.3 Cl-104 HCO3-33* AnGap-10 [2197-5-27] 10:28AM BLOOD ALT-2604* AST-3673* LD(LDH)-4380* CK(CPK)-1520* AlkPhos-83 Amylase-452* TotBili-1.7* [2197-5-30] 01:43AM BLOOD ALT-2800* AST-1786* LD(LDH)-1472* AlkPhos-195* Amylase-155* TotBili-1.2 [2197-6-16] 02:08AM BLOOD ALT-80* AST-48* AlkPhos-203* Amylase-29 TotBili-0.5 [2197-5-27] 10:28AM BLOOD Lipase-8 [2197-5-31] 12:32PM BLOOD Lipase-33 [2197-6-16] 02:08AM BLOOD Lipase-11 [2197-5-27] 10:28AM BLOOD CK-MB-42* MB Indx-2.8 cTropnT-1.39* [2197-5-28] 12:50AM BLOOD CK-MB-24* MB Indx-0.8 cTropnT-1.34* [2197-6-21] 06:38AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8 [2197-6-19] 06:00AM BLOOD calTIBC-190* Ferritn-163* TRF-146* [2197-6-19] 06:00AM BLOOD Triglyc-120 [2197-5-28] 10:15AM BLOOD TSH-1.9 [2197-5-28] 10:15AM BLOOD T4-3.2* T3-54* [2197-6-18] 09:45AM BLOOD Digoxin-0.6* . ERCP BILIARY ONLY PORTABLY BY TECH [2197-5-27] 1:51 PM FINDINGS: Seven fluoroscopic images were obtained without a radiologist present and submitted for review. These demonstrate clips in the right upper quadrant. Contrast injection demonstrates filling of the cystic duct stump with free contrast extravasation identified. IMPRESSION: Biliary leak identified from the cystic duct remnant. . CT ABDOMEN W/O CONTRAST [2197-5-29] 2:47 PM IMPRESSION: 1. Large amount of pneumoperitoneum and surgical defect in the anterior abdominal wall. Dilated proximal small bowel. Contrast has not yet progressed to the distal small bowel. The distal small bowel loops appear somewhat decompressed. While no free contrast is seen in the abdomen, a distal small bowel perforation is not entirely excluded. The dilated proximal small bowel may represent postoperative ileus. If clinically indicated, followup delayed imaging may be obtained to assess the progress of contrast through the remaining small bowel loops. 2. Status post cholecystectomy and biliary tube in place, percutaneous drain in the right lower quadrant. No focal collection of free fluid in the abdomen is seen. 3. Non-specific lesion in the right hepatic lobe, which may represent a cyst. Further assessment may be obtained as clinically indicated with ultrasound. 4. Bilateral adrenal enlargements, likely representing adrenal hyperplasia. Clinical correlation is needed. 5. Two left-sided low-density renal masses likely representing cysts. . ECHO Conclusions The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion . MRI ABDOMEN W/O CONTRAST [2197-5-31] 1:44 PM IMPRESSION: 1. Limited study due to lack of contrast, and non-breathhold technique due to the fact that the patient was intubated. 2. No discrete fluid collections are seen in the right upper quadrant. No evidence of intrahepatic or extrahepatic biliary dilatation. 3. Suggestion of anomalous insertion of the posterior right hepatic duct into the proximal left hepatic duct. If clinically indicated, a repeat study may be obtained when patient's conditions improves (utilizing breathhold imaging) to provide more detail for assessment of the intrahepatic biliary anatomy. 4. Anasarca and small amount of free intraperitoneal fluid. Small bilateral pleural effusions. . CHEST (PORTABLE AP) [2197-6-9] 6:02 AM SINGLE FRONTAL VIEW OF THE CHEST: The cardiomediastinal silhouette is stable and unremarkable. A right subclavian catheter tip terminates in the low SVC. A nasogastric tube terminates below the field of view with side port well below the GE junction. A left internal jugular catheter tip terminates over the lower left brachiocephalic vein. There is mild stable vascular congestion with no overt failure. Lung volumes are low and stable with stable mild linear atelectasis bilaterally. There are bilateral pleural effusions with components of fissural loculation which are overall unchanged. . PORTABLE ABDOMEN [2197-6-15] 11:37 AM IMPRESSION: Dilated loops of small bowel centrally, likely representing an ileus. . CHEST (PORTABLE AP) [2197-6-17] 5:33 AM IMPRESSION: AP chest compared to [6-15] and 9: Mild pulmonary vascular congestion suggests continued left ventricular decompensation, but there is minimal if any pulmonary edema. Small bilateral pleural effusions, right greater than left, have increased. Heart size is top normal. Opacification at the right lung base is probably atelectasis. Tip of the left PIC catheter projects over the junction of the brachiocephalic veins and a right subclavian dual-channel central venous line ends in the upper SVC. No pneumothorax. . VIDEO OROPHARYNGEAL SWALLOW [2197-6-22] 9:19 AM IMPRESSION: Slight penetration and aspiration with thin liquids, but not with nectar thick or straight solids. Brief Hospital Course: This is a 68 year old female who was found to have biliary leak (HIDA) and had perc drain placed in biloma with copious amounts of bile. Intubated at [Hospital1 392]. Required levophed/vasopressin, received dobutamine. Dialyzed for acidosis. FFPx2, PRBCx2. Transferred to [Hospital1 18] for ERCP. [5-27]: Admitted to [Hospital Unit Name 153], underwent ERCP with stent placed in CBD after cystic duct stump leak discovered. Transferred to TICU. Septic shock: likely from biliary source with bile leak and peritonitis. Was volume repleted (PCWP elevated). additionally complicated by myocardial depression due to sepsis. notable poor end-organ perfusion as gauged by [Last Name (un) ], lactic acidosis. Levophed for now but if persistently tachycardic would use neosynephrine. Dobutamine as adjunct to levophed. Steroids were changed to hydrocortisone 50 IV q6 for now. Abx: vanc (dosed by level)/cefepime/flagyl . Respiratory Failure: likely ARDS +/- aspiration in setting of sepsis and altered mental status. also with hx of COPD likely would benefit from longer expiratory times. Elevated cardiac enzymes: likely related to demand ischemia and myocardia depression in setting of sepsis. no EKG changes to suggest unstable plaque. Diabetes mellitus: controlled blood sugars. She was stable on NPH [Hospital1 ] and a sliding scale. . Acute Renal failure: Has oliguric ARF prob ATN, has L IJ dialysis cath placed here, on CVVHDF. HD for hyperkalemia yesterday. Was also on a bicarb gtt Likely sepsis related ATN complicated by severe metabolic acidosis (lactic acid +/- uremia). Meds were dosed for GFR <10 - amphogel x3 days for phos binding Taken off CVVH on Mon. AM, so no opportunity for more fluid off. Follwing for now--try HD Tues AM. Did well on HD Tues; but may actually be recovering from her ARF. She continued to recover and she was no longer requiring HD and her catheter was removed. She was restarted on her home Bumetanide and Spironolactone and were gently diureses her. Hypernatremia: She received free water boluses for hypernatremia. [5-28]: MRCP w/o evidence collection or intra/extrhepatic ductal dilatation. [6-3]: Fluconazole for yeast in sputum/urine [6-6]: Weaning pressors, failed speech & swallow eval [6-7]: Tolerating fluid neg on CVVH. Bowel reg advanced. [6-8]: Intermittent CVVH, NGT placed, Tube feeds held, increased NPH [6-9]: Transfused 1 unit pRBCs [6-12]: CVVH stopped. ENT consulted for vocal cord dysfunction. Failed speech & swallow eval. ENT reported left supraglottic edema not causing airway compromise, but definitely interfering with normal vocal cord function. Start PPI at double dose [Hospital1 ] to be given 1/2 hour prior to meals on an empty stomach to promote laryngeal recovery. Humidified air / O2 via shovel mask to soothe airway. Decadron 10mg IV q8h x 3 doses. [6-14]: Right HD catheter placed, HD started, dobhoff placed [6-15]: She has been all-in-all improving, she was straining, she felt an acute pain and a rip in the upper part of her abdomen. What ensued was an incarcerated hernia that could not be reduced. I diagnosed this prior to the operation and indicated to her that she needed an emergency operation to take care of this. She had a Primary repair of incarcerated ventral incisional hernia with mesh overlay consisting of Alloderm biomesh. Noted incarcerated omentum that was necrotic. She recovered from this surgery as expected. Her diet was slowly advanced and she was tolerating a regular (pureed diet) at time of discharge. Her pain was well controlled. Her abdomen was soft and nontender. She has one drain in place. Her incision was C/D/I with . Speech and Swallow evaluated her and recommended pureed solids and nectar thich fluids. Medications on Admission: Klonipin .5 ''', Allopurinal 100", Lipitor 20', Lopressor 50", Prilosec 20', Spironolactone 50", Bumetanide 2", Flexeril PRN, ASA 81', flovent, combivent. Discharge Disposition: Extended Care Facility: [Doctor First Name 37] House Rehab & Nursing Center - [Location (un) 38] Discharge Diagnosis: Cystic stump bile leak Hernia Acute Renal Failure Sepsis Vocal cord dysfunction Respiratory Failure 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 skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[11-22] lbs) for 6 weeks. * Monitor your incision for signs of infection * You may shower and wash. No tub baths or swimming. Keep your incision clean and dry. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 3 weeks. Call [Telephone/Fax (1) 1231] for an appointment.	[ "585.6", "427.1", "511.9", "428.0", "V45.81", "785.52", "584.9", "E878.8", "414.00", "552.21", "038.43", "424.1", "255.8", "568.89", "427.31", "518.81", "707.05", "995.92", "428.30", "576.1", "496", "287.5", "276.7", "570", "997.4", "E849.8" ]	icd9cm	[ [ [] ] ]	[ "99.15", "38.93", "51.85", "96.72", "51.87", "99.04", "96.07", "39.95", "38.95", "53.61" ]	icd9pcs	[ [ [] ] ]	12373, 12480	8377, 9490	322, 394	12624, 12631	2268, 8354	14222, 14343					12501, 12603		12194, 12350			12655, 14199									2006, 2249																	9507, 12168			240, 284										422, 1775														1797, 1991
48,038	196,872	8835	Discharge summary	report	Admission Date: [2145-8-7] Discharge Date: [2145-8-12] Date of Birth: [2112-9-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3991] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 174] is a 32yo F with history of non-Hodgkin's lymphoma as a child, and recent detection of meningioma s/p resection c/b CVA in [2145-6-6] who presents from rehab with lethargy. Per report, she has been more lethargic than usual for the past 3 days, with decreased responsiveness compared to her baseline. . In the ED, her initial vitals were 98.9 105 138/80 16 97% 6L via trach. She had a CXR which showed questionable aspiration and a positive UA. She was given vancomycin and unasyn, and admitted to the ICU as she requires a ventilator during the night as per rehab. Her vitals on transfer were 99, 105, 117/75, 20, 96% on RA. On arrival to the ICU, she was nonverbal but following commands. . The patient had an infectious work-up which showed Coag negative staph in her urine and blood. The patient was initially covered broadly, but was narrowed to vancomycin. The patient's family notes that her mental status has improved and the patient remained afebrile, with a normal WBC. The patient was thens table for trasnfer to the floor. Past Medical History: Non-Hodgkins lymphoma diagnosed at birth, ? treated with radiation to posterior skull Stomach tumor diagnosed at age 2.5years s/p chemo and XRT Basal cell carcinoma s/p excision [2144] and [4-16] Genital herpes Reverse cataracts Meningioma s/p resection c/b CVA, in [2145-6-6] Social History: Patient has been in rehab since d/c in early [Month (only) ]. She was previously a PCT in newborn nursery at [Hospital1 18]. No tobacco use but previously drank alcohol socially. Family History: Diabetes Physical Exam: Admission to MICU: Vitals: T: 99.6 BP: 116/92 P: 121 R: 24 O2: 91% on 35% TM General: Somnolent but arouses to voice and follows commands HEENT: Sclera anicteric, MMM, clear oropharynx Neck: supple, trach in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. G-tube in place. GU: Foley Back: Macular, confluent erythematous [Hospital1 ] across upper back Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Left 3rd nerve palsy left pupil 6mm fixed, right pupil [5-9], L facial droop, wiggles toes on R, weak hand squeeze on R, strength intact on L side Physical Exam on Discharge: VS: T=97.3, BP=112/80, HR=86, RR=18, 97% on 35% trach mask Gen: Alert, follows commands, interactive HEENT: Left eye remains closed Neck: Trach in place CDI Lungs: Some coarse rhonchi in upper lung fields improved with suctioning, no crackles or wheezes CV: RRR, no MRG Abd: soft, ND, NT, +BS, no rebound or guarding, GTube in place CDI GU: Foley draining yellow urine Back: [Month/Day (4) ] improved Ext: warm no edema, good pulses Neuro: Left 3rd nerve palsy left pupil 6mm fixed, right pupil [5-9], L facial droop, wiggles toes on R, weak hand squeeze on R, strength intact on L side Pertinent Results: Admission: [2145-8-7] 04:10PM BLOOD WBC-11.5* RBC-4.77# Hgb-13.2# Hct-39.9# MCV-84 MCH-27.7 MCHC-33.1 RDW-15.6* Plt Ct-334 [2145-8-9] 03:05AM BLOOD WBC-8.8 RBC-4.19* Hgb-11.2* Hct-34.6* MCV-83 MCH-26.8* MCHC-32.4 RDW-15.3 Plt Ct-277 [2145-8-7] 04:10PM BLOOD Glucose-91 UreaN-17 Creat-0.3* Na-146* K-3.4 Cl-108 HCO3-26 AnGap-15 [2145-8-9] 03:05AM BLOOD Glucose-149* UreaN-13 Creat-0.3* Na-145 K-3.7 Cl-109* HCO3-26 AnGap-14 [2145-8-8] 04:00AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.9 [2145-8-9] 03:05AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3 [2145-8-8] 06:09AM BLOOD Type-ART Temp-37.4 pO2-49* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 Intubat-INTUBATED Vent-SPONTANEOU [2145-8-7] 04:40PM BLOOD Lactate-1.7 Images: [8-7] Chest PA/Lat: IMPRESSION: No pneumonia URINE CULTURE (Final [2145-8-11]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- 32 S OXACILLIN------------- =>4 R TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S Blood Culture, Routine (Final [2145-8-10]): Reported to and read back by [Doctor First Name 3688] [Doctor Last Name ],7/03/11,3:10PM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [2145-8-8]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [2145-8-8]): GRAM POSITIVE COCCI IN CLUSTERS. RESPIRATORY CULTURE (Final [2145-8-10]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. MODERATE 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. 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 RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Brief Hospital Course: This is a 32 year old female with PMH of non-Hodgkin's lymphoma and meningioma s/p resection c/b CVA in [Month (only) 116] who presented from rehab with lethargy and was found to have a UTI and bacteremia with coagulase negative staphylococcus. . # Urosepsis with Coag negative staph: Her altered mental status was caused by a UTI and bacteremia speciated out as coagulase negative staph aureus. Her urine grew coag-negative staph; one blood Cx showed coag-negative staph; her sputum Cx grew methacillin resistant coag-positive staph, which was a colonizer of her chronic tracheostomy and did not cause her clinical symptoms. She was initially treated on vanc and cefepime, until the sensitivities came back, after which the cefepime was discontinued. Her mental status had improved during her stay and she is now back at baseline according to her family. A vanco trough was checked after 4 doses of the antibiotics, which came back subtherapeutic. The vanco was redosed to 1250 mg [Hospital1 ] and her trough was 17. The patient will continue to receive the vancomycin for a 10 day course ending on [2145-8-17]. . # Chronic respiratory failure: There were no signs of infection or respiratory compromise on CXR in the ED or in the MICU. We kept her on her trach mask during the day with vent support PRN at night. Her trach aspirate did grow out MRSA, but this was a chronic colonizer. She was transitioned from ventilator support to vent use prn and did not require the vent during hospitalization. . # Back [Date Range ]: She has had a [Date Range ] composed of erythematous macules coalescing into patches on her back for the past month. Per her mother, the [Name2 (NI) ] appears the same as usual. She has been treated with triamcinolone which was continued and the [Name2 (NI) ] looked improved upon discharge. . # h/o meningioma s/p CVA: Her neuro exam remained at baseline. Her neuro exam is significant for a Left 3rd nerve palsy left pupil 6mm fixed, right pupil [5-9], L facial droop, wiggles toes on R, weak hand squeeze on R, strength intact on L side We continued her home keppra and decadron, and notified the neurosurgery team of her admission. . The patient was discharged to [Hospital 38] Rehab in stable condition. She did not need a PICC, because the rehab facility could do IV antibiotics through a PIV. The patient's blood cultures have subsequently remained negative, but any positive results will be reported to the patient. Medications on Admission: Acetaminophen 650 mg/20.3 mL Solution Sig: [2-7] PO Q6H PRN Docusate sodium 50 mg/5 mL Liquid [Hospital1 ] Senna 8.8 mg/5 mL DAILY (Daily). Dalteparin 5000 units daily Aspirin 81 mg daily Ranitidine 150mg [Hospital1 ] Levetiracetam 500 mg [Hospital1 ] Dexamethasone 2 mg PO BID Lactulose 20gm daily Triamcinolone daily to back Bisacodyl 10mg PR PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 6. senna 8.8 mg/5 mL Syrup Sig: Five (5) mL PO once a day. 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 8. triamcinolone acetonide 0.1 % Cream Sig: One (1) Appl Topical DAILY (Daily): Apply to back for [Age over 90 ]. 9. acetaminophen 325 mg/10.15 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO every six (6) hours as needed for pain. 10. vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous twice a day for 6 days: Please give 1250 mg [Hospital1 ]. Last dose on [8-17]. 11. dalteparin (porcine) 5,000 unit/0.2 mL Syringe Sig: One (1) Subcutaneous once a day. 12. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital ] Rehab in [Location (un) 38] Discharge Diagnosis: Urinary tract infection Bloodstream infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for lethargy and for treatment of a urinary tract infection. The infection had spread into your bloodstream. Your infection was treated with antibiotics. You can be discharged to rehab today. The following changes were made to your medications: You will continue IV vancomycin 1250 mg twice a day until [2145-8-17]. Otherwise, all of your medications will remain the same. Followup Instructions: Please follow-up with your Primary care doctor, Dr. [Last Name (STitle) ], after discharge from rehab. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990] DO 12-BJM	[ "V44.0", "599.0", "790.7", "041.19", "V10.79", "378.51", "518.83", "348.30" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.97" ]	icd9pcs	[ [ [] ] ]	10537, 10611	6488, 8976	324, 330	10701, 10701	3431, 6465	11318, 11569	1966, 1976		9393, 10514		10632, 10680		9002, 9370			10881, 11295									1991, 2787											2815, 3412									263, 286										358, 1431									10716, 10857					1453, 1744	1760, 1950
3,879	166,346	50000	Discharge summary	report	Admission Date: [2156-1-21] Discharge Date: [2156-2-13] Service: MEDICINE Allergies: Quinine Attending:[First Name3 (LF) 10842] Chief Complaint: Transferred from [Hospital3 ] for acute on chronic renal failure (Cr 3.7 {baseline 2.5-3.0), K 5.5). Major Surgical or Invasive Procedure: thoracentesis Swan Ganz Catheter placement History of Present Illness: Mr. [Known lastname ] is an 82 yo man with a h/o CAD s/p CABG [2147], s/p AVR [2147], atrial fibrillation, DM2, CHF (EF 55%), CRI (cr 2.5-3.0), who has been at [Hospital3 ] since a pacemaker placement following a pacemaker placement at [Hospital1 18] in early [1-4] who was transferred back here for acute on chronic renal failure. He reports that he has generally felt well since his discharge from [Hospital1 18]. He does complain of exertional dyspnea which he has had for several months and may be slightly worse now. He becomes dyspneic after walking for 10-15 minutes or walking up a flight of stairs. He denies any dyspnea at rest, orthopnea, or PND. He also denies any CP or palpitations. He denies any dysuria or hematuria. He endorses a fair appetite but feels like he may have been drinking less the past few days at rehab. He is unsure if he has a history of a large prostate. He also denies any recent fevers, chills, sweats, headache, abdominal or back pain, or blood in his stools. In the ED he was given one dose of kayexalate, a Foley catheter was placed and he was admitted to medicine. Past Medical History: 1. cad s/p cabg '[47] (LIMA -> LAD) 2. AVR [2147] with bioprosthetic valve. 3. Atrial fibrillation. 4. DM2. 5. HTN. 6. CHF - EF 55% in [12-5]. 7. s/p pacer placement [1-4] c/b post pacer placement hematoma. 8. CRI (baseline creatinine 2.5-3.0). 9. Hyperlipidemia. 10. Thyroid nodule. 11. GERD. Social History: Prior to rehab had lived with wife, spent [2-2] year in [State 108], [2-2] in [Location (un) 86]. Has been in rehab since most recent d/c. Non-smoker, non-drinker. Previously did "office-work." Family History: Not contributory. Physical Exam: T 95.5 P 60 BP 110/62 RR 16 O2 sat 96% RA. General: Lying in bed, pleasant, NAD. HEENT: Anicteric, MMM, OP clear. Neck: Supple, JVP flat, no LAD. Heart: RRR, nl S1, S2, no extra sounds. Lungs: CTAB. Abd: Soft, NT, ND, normal bowel sounds. Rectal: large, smooth prostate. Ext: [2-2]+ pitting edema in BLE. Neuro: A&O x 3, CN 2-12 intact, [5-5] in BUE, BLE. Pertinent Results: Labs: labs on admission: wbc 9.3, hct 27.2, plt 203 Na 138, K 5.5, Cl 107, HCO3 16, BUN 105, Cr 3.9, glucose 66, Ca 8.2, Ph 6.2, Mg 3.2 Hematocrit trend: 27.2 -> 26.9 -> 28.9 (after transfusion of 1 unit) -> Creatinine trend: 3.9 -> 3.9 -> 3.6 -> INR trend: 3.2 -> 3.8 -> 4.6 -> Urine: [1-20] U/A: Trace leuks, negative nitrites, 0-2 WBCs, occ bacteria. No eosinophils. UNa <10, FeNa <0.05%. Microbiology: [1-20] Urine culture: no growth. [1-21] C. difficile: negative. Imaging: [1-20] CXR: IMPRESSION: No definite CHF. Bilateral pleural effusions, increased since [2156-1-2]. Continued left base atelectasis, an underlying consolidative process cannot be fully excluded. [1-20] Renal U/S: No hydronephrosis or obstructing renal calculi identified. Ascites is present. Right Heart Cath [2155-2-6] FINAL DIAGNOSIS: 1. Severe biventricular volume overload. 2. Severe pulmonary arterial hypertension. 3. Cardiac index of 2.2 L/min/m2. Echo [2156-2-9] Conclusions: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload.The aortic root is mildly dilated. The ascending aorta is moderately dilated.A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification with mild associated inflow gradient. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. Compared with the prior study (tape reviewed) of [2155-12-16], mitral inflow gradient is now slightly lower. Brief Hospital Course: Mr. [Known lastname ] is an 82 year old male with h/o CAD s/p CABG [2147], s/p AVR [2147], atrial fibrillation, DM2, CHF (EF 55%), CRI (cr 2.5-3.0), who has been at [Hospital3 ] since a pacer placement earlier this month who now presents with acute on chronic renal failure transfer to CCU for tailoring therapy of CHF with Swan Ganz catheter and made Confort Measures only on [2156-2-12]. #Status: After discussing clinical situation with Mr [Known lastname 34454] wife and PCP Dr [Name (NI) 12167], patient was made CMO on [2156-2-12]. Goal of care was directed to confort. Patient passed away on [2156-2-13]. He was pronounced dead at 3:30pm. # Pulmonary: Patient had an episode of worsening respiratory distress, with increase pleural efussion and worsening pulmonary infiltrates, intubated on [2156-2-9]. Patient extubated [2156-2-11]. Chest x ray on [2156-2-12] showed left pulmonary collapse. Given code status of patient, no further interventions were attempted. # Pleural effusion: Thoracentesis performed [2155-2-9], TP ratio 0.29, LDH ratio 0.59, LDH pleural 152 (UNL 250). Compatible with transudade. likely secondary to CHF. Serum efussion albumine gradient >1.2 also suggesting transudate. Gram stain negative for bacterias, -- CX aerobic final negative, . #. Acute on chronic renal failure: This was thought to be likely multifactorial. His BUN/Cr ratio and urine electrolytes supported a pre-renal etiology as did his decreased po intake in the days preceding admission. His history of an enlarged prostate also supported an obstructive component and he was noted to have a post-void residual of 300 at rehab. In addition a urinalysis was somewhat suggestive of an infectious process. A renal ultrasound was negative for hydronephrosis or an obstructing stone. He was initially treated with gentle IV hydration and a blood transfusion given his history of CHF. He was also started on ciprofloxacin for a presumed urinary tract infection. His creatinine slowly trended down but stabilized at 3.1 initially. Patient was transfer to the CCU for tailored therapy. A couple of days after admission to CCU creatinine started to increase, and urine output started to decline. His mental status started to decline. Given thios situation a possibility of dialysis or CVVH was discussed with renal team and also patient's wife. Ms [Known lastname ] felt that going into dialysis would not have been what his husband would have wanted. This possibility was declined. #. Cardiac: He was initially continued on all of his cardiac medications - metoprolol, hydralazine, isosorbide, aspirin, and atorvastatin. His systolic blood pressure was in the 90s-100s over his first several hospital days and his blood pressure medications were titrated down. He was on only metoprolol 50 [Hospital1 ]-->37.5. CCB was held. On [2156-2-2] transferred to [Hospital Ward Name 121] 3 for initiation of Nesiritide therapy. Multiple episodes of AFIB with RVR throughout hospitalization. Initially remained hemodynamically stable throughout. He had a swan ganz catheter placed for tailored therapy. Patient was transfer to CCU. Attempts were made to optimize cardiac output but despite therapy pulmonary edema and bilateral pleural effusions worsened associated with worsening kidney fuction. Therapy was discontinued after patient's wife decided to direct goal of care towards confort measures only. #. BPH: He was continued on terazosin and finasteride until he was made CMO. . # Leukocytosis: Patient developed leukocitosis whil in the CCU, initially treated with TMP-SMX for UTI. Patietn spiked on [2155-2-11] and broad antibiotics were started Zosyn - Vancomycin [2155-2-12] A/B d/c given change in goals of care to confort measures. . ## DM: RISS. Was taking glyburide 5 mg at rehab but stopped due to persistent hypoglycemia here. Patient was control with regular insulin sliding scale. . ## Sacral decub: On duoderm. -- [2156-2-9] [4-3]+ edema over sacrum extending to neck . ## R Toe ulcer: - foot x-rays on [2-5] with patchy demineralization but no evidence of osteo. Medications on Admission: metoprolol 100 [Hospital1 ] atorvastatin 80 qd pantoprazole 40 d insulin sliding scale asa 81 hydral 10 tid glyburide 5 qd tylenol prn iron 325 qd terazosin 1 qd finasteride 5 qd isosorbide mononitrate 30 qd ntg prn flagyl 500 tid coumadin (has been getting 3 mg the past few days at rehab). Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: 1. Acute on chronic renal failure. 2.Cardiac Heart Failure Discharge Condition: Patient passed away Discharge Instructions: n/a Followup Instructions: N/A Completed by:[2156-2-16]	[ "280.0", "518.84", "585.4", "V45.01", "V43.3", "599.0", "584.9", "707.14", "707.03", "428.33", "403.91", "273.8", "V58.61", "427.31", "792.1", "600.01" ]	icd9cm	[ [ [] ] ]	[ "37.21", "00.13", "99.07", "38.93", "99.04", "96.04", "34.91", "89.64", "96.71" ]	icd9pcs	[ [ [] ] ]	9400, 9415	4854, 9026	321, 365	9536, 9557	2533, 2544	9609, 9643	2114, 2133		9372, 9377		9436, 9436		9052, 9349		3386, 4831	9581, 9586									2148, 2514																				177, 283										393, 1535						9455, 9515	2558, 3369							1557, 1868	1884, 2098
26,864	138,818	49898	Discharge summary	report	Admission Date: [2113-5-3] Discharge Date: [2113-5-7] Date of Birth: [2056-10-3] Sex: M Service: MEDICINE Allergies: Anti-Inflam/Antiarth Agents Misc. Classf Attending:[First Name3 (LF) 783] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 56 year old male with a history of DM, hep C, idiopathic cardiomyopathy w/ EF 50%, and chronic pain presents with 1 week of presyncope and found to be hypotensive at his cardiologist's office today. The patient states that he was started on diovan 40mg daily 1 month ago and for the past 1 week has been symptomatically orthostatic. No fatigue, no CP, no SOB, no orthopnea, no pedal edema or weight changes. No PND. No fevers, chills or night sweats. No pain anywhere beyond his baseline. No increase in baseline hip pain, no change in baseline spinal stenosis pain. No diarrhea, good PO intake, nausea x 3 days, good appetite. Rest of ROS is negative. He was recently started on diovan 40mg daily and had been on lisinopril 40mg daily. He also is on coreg 12.5mg po bid which had not been changed recently. In addition he was prescribed HCTZ 12.5mg daily but had not been taking this. Initial VS were: T 98.3 HR 84 BP 81/54 RR 20 O2 sat 100% RA The patient was noted to be in acute renal failure and was symptomatically orthostatic. Access was obtained with 2 PIV 18g and he was given 4L IVF (bedside ultrasound suggested that his IVC was collapsable). His SBP nadir was 76 and following IVF improved to 90. He was noted to have a K of 5.9 with slight QRS widening. Toxicology was called and suggested calcium gluconate 2g given that the patient is on a beta blocker, as well as an amp of bicarb to see if his QRS narrows (as the patient is on a TCA). In addition the patient has had recurrent prosthetic hip infections, currently w/o pain, fever or leukocytosis- a CRP and ESR was sent to follow the course of this. Given that the patient had a low sodium and elevated K a dose of decadron was given for possibility of adrenal insufficiency. Prior to transfer to the floor his VS were: BP 90/63, HR 72, sat 100% on 3L NC Past Medical History: DM2, proteinuria PE x2 on lifelong coumadin Congenital hip dysplasia s/p reconstruction at age 10, multiple hip replacement over the years; most recently [1-/2111] (R hip revision) Hypertension Hepatitis C (fibrosis on biopsy; followed by Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2643]) Chronic Pain syndrome Cardiomyopathy (normal cath [2-/2111]): EF 50-60% s/p Laminectomy Social History: Pt currently unemployed, lives alone and uses a cane. Denies current tobacco use, quit years ago. No recent EtoH use, quit ~10yrs ago. Denies IVDU. Family History: There is a family history of diabetes. His mother and maternal grandmother both had heart disease. Physical Exam: VITAL SIGNS: T 98.0 HR 70 BP 120/81 RR 10 O2 100% on 3L GEN: NAD, AOX3 HEENT: JVP 7cm, OP clear, MM slightly dry CHEST: CTAB CV: RRR, no m/r/g, soft heart sounds ABD: moderate distension, BS+, NT, no masses or organogealy. moderate distension. No fluid wave or shifting dullness. EXT: wwp, no c/c/e, DP and PT 2+ bilaterally Pertinent Results: Admission: [2113-5-3] 01:45PM WBC-8.1 RBC-4.52* HGB-13.8* HCT-39.8* MCV-88 MCH-30.5 MCHC-34.6 RDW-13.6 [2113-5-3] 01:45PM NEUTS-71.4* LYMPHS-23.2 MONOS-3.8 EOS-1.2 BASOS-0.4 [2113-5-3] 01:45PM PLT COUNT-332 [2113-5-3] 01:45PM PT-48.4* PTT-43.9* INR(PT)-5.3* [2113-5-3] 01:45PM SED RATE-50* [2113-5-3] 01:45PM ALT(SGPT)-21 AST(SGOT)-33 CK(CPK)-412* ALK PHOS-113 TOT BILI-0.3 [2113-5-3] 01:45PM cTropnT-0.02* [2113-5-3] 01:45PM CK-MB-5 proBNP-50 [2113-5-3] 01:45PM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-5.5# MAGNESIUM-2.2 [2113-5-3] 01:45PM GLUCOSE-212 UREA N-57* CREAT-4.4# SODIUM-128 POTASSIUM-5.9* CHLORIDE-93* TOTAL CO2-26 ANION GAP-15 Abd Ultrasound: Limited study with right kidney not visualized. Left kidney grossly within normal limits with no hydro and good main renal artery arterial waveform. Trace ascites. pCXR :Increased linear opacity in the left lung base, for which atelectasis is favored; however PA and lateral chest radiographs are recommended to exclude pneumonia. Echo [4-25]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [2112-11-4], the findings are similar with low normal left ventricular systolic function. Brief Hospital Course: 1. Hypotension: most likely medication effect with component of dehydration. All medications held at admission and BP normalized. Received 4 L of fluid initially and tolerated well. Echocardiogram repeated and results were similar to prior. Cortisol and TSH WNL. Thought to be due to aggressive anti-hypertensive regimen. BP returned to hypertensive range with withholding of all medications and the meds were restarted one-by-one with careful monitoring of BPs. Pt's PCP and cardiologist were consulted by email. Metoprolol was not restarted due to concern of masking hypoglycemic symptoms. Also there was a question of whether pt is compliant in taking meds at home, leading to continued up-titration of medications. Pt was discharged home on Lisinopril, Diovan (to improve proteinuria per renal), and amlodipine. 2. ARF: presented with creatinine of 4.4 from 1.2 in the setting of ACE/[Last Name (un) ] combination and dehydration. Received 4L NS with improvement to 2.7. FENa was >1%, in the setting of hydration. Held ace and [Last Name (un) ]. No evidence of RAS on doppler on left kidney, right kidney not visualized. ACEI and [Last Name (un) ] were restarted. Pt was followed by renal service. 3. Hyponatremia: Improved with hydration. 4. Hyperkalemia: in setting of ARF, ACE and [Last Name (un) ] use, and hyperglycemia. Treated initially with insulin, bicarb and improved. Was given Kayexelate. Should be monitored as outpatient, since pt on two K-sparing agents. 5. Wide QRS: with LBBB, QRS 130. Per tox recs in the ED, given 1 amp of bicarb without change in QRS, so bicarb gtt not started. Unlikely tricyclic (on nortriptyline at home) toxicity since it didn't improve with bicarb. Remained stable. 6. Slightly elevated troponin: in the setting of ARF. Resolved. 7. h/O PE: INR was supratherapeutic for most of hospital stay - warfarin was held. 8. DM/Hyperglycemia: initially received lower dose of insulin in the setting of renal failure and was hyperglycemic. Restarted home dose of insulin with Humalog SS. AM and PM doses of his home 70/30 were increased prior to discharge as pt's AM finger sticks remained high. 9. Chronic pain: held nortriptyline 75mg daily briefly while in renal failure with wide QRS. FULL CODE Medications on Admission: MS contin 30mg po bid Oxycodone 5mg po bid prn Amlactin cream Coreg 12.5mg po bid Neurontin 400mg po tid Folate 2mg po daily HCTZ 12.5mg po daily (not taking) Humalog sliding scale Insulin 70/30 22 units in a.m., 15 units prior to dinner Lisinopril 40mg daily Nortriptyline 75mg po daily polyethylene glycol daily prn Viagra 50mg po prn (last used 1 month ago) Simvastatin 80mg daily Bactrim DS 2 tabs [Hospital1 ] for prosthetic joint infection prophylaxis Coumadin 5mg daily Diovan 40mg daily ASA 81mg daily Colace and senna prn Discharge Medications: 1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 3. AmLactin Cream Sig: One (1) application Topical once a day. 4. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: as directed. 12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 13. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen Sig: as directed Subcutaneous twice a day: 24 units in the morning, 18 units in the evening. . 15. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed Subcutaneous twice a day: use the sliding scale provided by primary care doctor. 16. Outpatient Lab Work INR and Chem 7 panel on [Last Name (LF) 766], [2113-5-8] 17. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 19. Diovan 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Hypotension Acute renal failure Electrolyte abnormalities Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital because you were found to be hypotensive during your visit with your cardiologist. You were given intravenous fluids which brought your blood pressure back to normal. All of your blood pressure medications were withheld initially; and Lisinopril and Valsartan were restarted and a new medication called Amlodipine was added. Lab tests showed that your kidneys were not functioning well when you were admitted. It has since improved back to the previous level of function. It's not clear why your blood pressure has been fluctuating recently. It's important that you take all of your medications as directed. Changes were made to your medication regimen: 1) Stopped Carvedilol (also called Coreg) 2) Stopped Hydrochlorothiazide 3) Increased Aspirin to 325 mg once a day 4) Started Amlodipine 5mg daily for blood pressure control 5) Changed insulin regimen to 24 units in the morning, 18 units in the evening Your INR (Coumadin level) was initially high during your hospital stay so coumadin was withheld for 3 days. Please have your INR measured on [Last Name (LF) 766], [5-8]. Your doctor will give you further instructions on how much Coumadin to take based on that INR result. If you experience more lightheadedness, dizziness, loss of consciousness, chest pain, palpitations, or any other symptoms concerning to you, please call Dr.[Name (NI) 11945] office at [Telephone/Fax (1) 250] or return to the emergency room. Followup Instructions: Appointment #1 MD: Dr. [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ] Specialty: internal medicine/ pcp Date and time: Thursday, [5-16] 9:20am Location: [Location (un) ], [Location (un) 86] [Hospital Ward Name 23] Bldg, [Location (un) ] Phone number: [Telephone/Fax (1) 250] Appointment #2 MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP Specialty: cardiology Date and time: Tuesday, [5-9] 2:30pm Location: [Location (un) ], [Location (un) 86] [Hospital Ward Name 23] Bldg, [Location (un) 436] Phone number: [Telephone/Fax (1) 62] [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2113-5-10]	[ "425.4", "724.00", "250.00", "338.4", "V58.61", "584.9", "426.3", "458.0", "V62.0", "276.51", "070.70" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9631, 9689	5122, 7388	310, 316	9800, 9811	3286, 5099	11334, 12127	2820, 2921		7973, 9608		9710, 9779		7414, 7950			9835, 11311									2936, 3267																				259, 272										344, 2206														2228, 2638	2654, 2804
1,517	105,812	22038	Discharge summary	report	Admission Date: [2142-1-12] Discharge Date: [2142-1-24] Date of Birth: [2082-8-31] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Atorvastatin Attending:[First Name3 (LF) 165] Chief Complaint: Sternal wound drainage and pain with associated fever to 102 Major Surgical or Invasive Procedure: sternal debridement([1-17]) with plate/pec flap closure([1-19]) PICC line placement, 4F single lumen [1-23] History of Present Illness: Pt s/p CABG/MVR/ASD closure on [2141-12-25] discharged home [2142-1-1]. Returned on [1-12] with sternal drainage. She was admitted for further management. Past Medical History: MI [2138] PCI to LAD and LCX [2138] HTN lipids obesity MVA [2140] s/p bilat knee arthroscopy s/p deviated septum repair Social History: Denies tobacco, ETOH, drug use Family History: Mother with DM. Denies CAD. Physical Exam: Admission: VS T 98.3 HR 82 BP 120/76 RR 20 O2sat 96%RA Gen NAD Neuro A&Ox3, nonfocal exam CV RRR no murmur. Sternal wound w/purulent drainage and surrouding erythema Pulm CTA bilat Abdm obese, NT/ND/NABS Ext trace edema, palpable pulses bilat Discharge VS T 99.1 HR 86SR BP 117/52 RR 20 O2sat 93%RA Neuro A&Ox3, nonfocal exam Pulm CTA-bilat CV RRR no MRG. Sternal incision CDI. JP drains x3 w/serosang drainage Abdm soft, NT/NABS Ext warm, well perfused 1+ pedal edema bilat Pertinent Results: [2142-1-12] 07:15PM GLUCOSE-114* UREA N-12 CREAT-0.9 SODIUM-142 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [2142-1-12] 07:15PM WBC-7.1 RBC-2.81* HGB-8.6* HCT-25.6* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.5 [2142-1-12] 07:15PM PLT COUNT-359 [2142-1-12] 07:15PM PT-13.2* PTT-31.6 INR(PT)-1.1 [2142-1-23] 05:30PM BLOOD WBC-10.9 RBC-3.26* Hgb-9.5* Hct-28.6* MCV-88 MCH-29.0 MCHC-33.1 RDW-14.5 Plt Ct-402 [2142-1-23] 05:30PM BLOOD Plt Ct-402 [2142-1-21] 03:31AM BLOOD PT-14.9* PTT-32.1 INR(PT)-1.3* [2142-1-23] 05:30PM BLOOD Glucose-125* UreaN-17 Creat-0.7 Na-135 K-4.2 Cl-98 HCO3-30 AnGap-11 [2142-1-23] 05:30PM BLOOD ALT-215* AST-203* LD(LDH)-318* AlkPhos-150* TotBili-0.5 RADIOLOGY Final Report CHEST (PA & LAT) [2142-1-23] 3:29 PM CHEST (PA & LAT) Reason: pleural effusion [Hospital 93] MEDICAL CONDITION: 59 year old man s/p sternal debridement flap closure REASON FOR THIS EXAMINATION: pleural effusion INDICATION: Assess for pleural effusion. COMPARISON: Comparison is made to study performed one hour earlier. FRONTAL AND LATERAL CHEST RADIOGRAPHS. Multiple plates and screws again seen overlying the mediastinum. Right-sided PICC seen at least to the level of the distal SVC, tip not well evaluated on this study. Other linear densities overlying the chest possibly represent pacing wires. Cardiac and mediastinal contours appear stable. Right sided atelectasis again seen. No new focal consolidations seen within the lungs. No evidence of pleural effusion. IMPRESSION: No evidence of pleural effusion. Otherwise, little change from prior. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] RADIOLOGY Final Report CT CHEST W/CONTRAST [2142-1-15] 6:21 PM CT CHEST W/CONTRAST Reason: evaluate for fluid collection [Hospital 93] MEDICAL CONDITION: 59 year old man with s/p CABG mv repair with sternal wound infection REASON FOR THIS EXAMINATION: evaluate for fluid collection CONTRAINDICATIONS for IV CONTRAST: None. CT CHEST REASON FOR EXAM: Evaluate for fluid collection. Patient post CABG with sternal wound infection. TECHNIQUE: Multidetector CT through the chest following administration of IV contrast. 5, 1.25-mm collimation images and coronal reformations were reviewed. FINDINGS: Retrosternal fluid collection located in the anterior mediastinum at the level of the superior sternum body / aortic arc, measures 53 x 39 mm with high density (37 Hounsfield units). It is probably partially hemorrhagic. It continues inferiorly with a small precardial collection. There is no pericardial effusion. Cardiac size is slightly enlarged, patient is post CABG. Wide dehiscense of the soft tissues anterior to the sternum extends several cm, 3.5 cm below the xiphoid process. It is not associated with fluid, though a small fistulous connection to the prevascular space could be present but not visible. The sternum is apposed with no bone destruction to suggest osteomyelitis. The airways are patent to segmental level. There are few subcentimeter paratracheal lymph nodes. The lungs are clear. Left pleural effusion is small. The upper abdomen showed no abnormalities. IMPRESSION: Upper retrosternal fluid collection probably partially hemorrhagic, free of definite connection to the wide soft tissue dehiscence anterior to the sternotomy inferiorly, though a small sinus tract is not excluded. No evidence of osteopmyelitis. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 3901] [Name (STitle) 3902] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Brief Hospital Course: Patient was admitted with sternal wound drainage on [1-12]. His wound was opened and packed with normal saline wet to dry dressing. Plastic surgery and infectious disease consults were obtained. A CT of chest showed substernal fluid collection and on [1-17] he was taken to the OR for sternal debridement and wire removal. The chest was left open and Mr. [Known lastname ] was chemically paralyzed and sedated for 48 hours. He was then returned to OR on [1-19] for sternal plating and pectoral flap closure by the plastic surgery serrvice. Please see OR reports for details. After closure pt returned to cardiac surgery ICU. His sedation was weaned and he was extubated on POD1. He continued to progress and was transferred to the step down floors on POD2. Mr. [Known lastname ] continued to do well and on [2142-1-24] it was decided the patient was stable and ready for discharge home with visiting nurses and home infusion service. He will follow-up with the plastic surgery service, Dr. [First Name (STitle) ] and his cardiologist as an outpatient. Medications on Admission: Lisinopril 5' Toprol XL 100' Plavix 75' Pravachol 80' ASA325' Darvocet-prn Percocet-prn Ibuprofen-prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks: 20mEq [Hospital1 ] for 1 week then 20mEq QD x 2 weeks. Disp:56 Capsule, Sustained Release(s) Refills:0 6. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 2 weeks. 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm Intravenous Q 8H (Every 8 Hours) for 6 weeks. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 40mg [Hospital1 ] x1 week then 40mg QD x2 weeks. Disp:60 Tablet(s) Refills:2 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: start on [1-26]. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: s/p sternal debridement([1-17]) s/p plate/pec flap closure([1-19]) PMH: s/p CABG/MVR [12-10], ^chol, HTN, obesity, OA, bilat knee arthroscopy, Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: Plastic Surgery - Dr [First Name (STitle) ] ([Telephone/Fax (1) 57665] please call for follow up appointment Dr [First Name (STitle) ] in [2-4] weeks ([Telephone/Fax (1) 11763] please call for appointment Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5866], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2142-2-16] 10:30 Labs: weekly Vancomycin trough, CBC with diff, ESR, CRP, Cr, LFT with results to Dr [Last Name (STitle) ] ([Hospital ] clinic) [Telephone/Fax (1) 432] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2142-1-24]	[ "401.9", "E878.1", "278.01", "998.32", "272.4", "414.01", "998.59", "V45.81", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "86.22", "34.03", "34.79", "38.93" ]	icd9pcs	[ [ [] ] ]	8339, 8391	5316, 6397	353, 474	8590, 8599	1437, 2263	9111, 9774	890, 919		6550, 8316	3474, 3543	8412, 8569		6423, 6527			8623, 9088									934, 1418																				253, 315	3572, 5293									502, 670														692, 825	841, 874
12,103	112,106	19021	Discharge summary	report	Admission Date: [2107-7-19] Discharge Date: [2107-7-31] Date of Birth: [2051-5-31] Sex: M Service: COLORECTAL SURGERY/GREEN SURGERY HISTORY OF PRESENT ILLNESS: This is a 56-year-old man with a history of ulcerative colitis since [2098]. The patient was hospitalized almost annually for flareups. His current flare began three weeks ago at which time he was admitted to [Hospital3 9683] for the past three weeks. He was recently started on IV hydrocortisone and sent home several days prior this admission. The patient complained of increasing symptoms over the weekend with severe lower abdominal pain with po intake, low grade fevers, nausea, vomiting, and [6-26] bloody bowel movements per day. PAST MEDICAL HISTORY: Ulcerative colitis. PAST SURGICAL HISTORY: None. MEDICATIONS: 1. Hydrocortisone 100 mg tid. 2. Two Ativan prn. 3. Iron. 4. Folic acid. 5. Prevacid. ALLERGIES: 6-mercaptopurine, reaction jaundice. SOCIAL HISTORY: No tobacco and occasional alcohol. FAMILY HISTORY: Mother with [Name (NI) 4522] disease. REVIEW OF SYSTEMS: No chest pain, shortness of breath, palpitations, no dysuria, hematuria, or hematemesis. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature at 99.4, heart rate 100, blood pressure 117/86, respirations 16, and pulse oxygenation 98% on room air. He was alert and oriented times three in no acute distress. His sclerae were anicteric. His mucous membranes were moist. His heart rate was regular, rate, and rhythm with no murmurs, rubs, or gallops. His lungs were clear to auscultation bilaterally. His abdomen was soft, tender in the lower quadrants to palpation, with no guarding and positive bowel sounds. Rectal examination was grossly heme positive, with positive external hemorrhoid visualized. His extremities were warm and well perfused with no edema. A CT scan of the abdomen on admission showed no evidence of free air obstruction or abscess with diffuse colonic thickening and loss of haustral folds and multiple nodular filling defects in the transverse colon. Please see full report for details. LABORATORIES ON ADMISSION: A complete blood count is as follows: White blood cell count 8.0, hematocrit 33.1, platelet count 201. White blood cell count differential 90% neutrophils, no band neutrophils, 6.4 lymphocytes, 3.2% monocytes. Electrolytes as follows: Sodium 136, potassium 3.9, chloride 100, HCO3 29, BUN 15, creatinine 0.8, glucose of 187. The patient was admitted to the Colorectal Service under Dr. [Last Name (STitle) 1888], and he was written for a diet of nothing by mouth, IV fluids, medicated with IV steroids, antibiotics, and was given a routine preoperative assessment with electrocardiogram and chest x-ray. On postoperative day two, the patient received a peripherally inserted central catheter line for administration of total parenteral nutrition. He was started on a morphine sulfate PCA for pain control. He was visited by the enterostomal nurse therapist for education and discussion of ileostomy care. On hospital day four, the patient was taken to the operating room for a restorative proctocolectomy, diverting ileostomy. Please see full operative report for details of the procedure. Following the procedure, the patient was hypotensive with elevated heart rate and decreased urine output. He was infused with both his Lactated Ringers as well as Hespan for volume resuscitation. His urine output responded marginally to these boluses. The patient's postoperative hematocrit and electrolytes were all within normal limits except for a magnesium of 1.3 for which he was given 2 grams of magnesium intravenously. After several hours of time postoperatively, the patient was noted to have dysnomia and difficulty speaking a Neurology consult was obtained at the time. Please see full Neurology consult note for details. A CT scan of the head was obtained with no abnormalities noted. The patient was transferred to the Surgical Intensive Care Unit team care for monitoring and volume resuscitation on a Neo-Synephrine drip. On postoperative day one, the patient's blood pressure stabilized, and the patient was taken to MRI for further evaluation of his speech difficulties. The MRI was suggestive of an acute left temporal infarct with no mass effect or midline shift and no acute occlusion. Please see full MRI report for details. The patient was further worked up for cause of the left temporal infarct and on an transesophageal echocardiogram was noted to have a small atrioseptal defect with right to left flow. Clinically, the patient's aphasia was improving. His colostomy was viable and putting out small amounts of liquid brown stool. The patient remained on total parenteral nutrition with consultation from a nutritionist on staff, and the patient was seen by Dr. [Last Name (STitle) ] for evaluation of closure of the atrioseptal defect. On hospital day 11, postoperative day six, the patient was deemed stable enough to return to the surgical floor and was transferred from the Intensive Care Unit. He was able to tolerate regular diet. His pain was well controlled. He was able to ambulate and had no further neurological changes or complaints. On postoperative day eight, he was deemed in stable enough condition to transfer to home with visiting nurse services. Addendum: Patient underwent a colonoscopy on hospital day two, which showed severe ulcerations of the colon. Please see full colonoscopy report for details of procedure. DISCHARGE DIAGNOSIS: 1. Ulcerative colitis primary status post restorative proctocolectomy with diverting ileostomy. 2. Left temporal lobe cerebral infarct. 3. Atrioseptal defect. 4. Secondary hypotension, hypovolemia. CONDITION ON DISCHARGE: Good and stable. DISCHARGE STATUS: To home with visiting nurses. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg tablet one tablet po q day. 2. Clopidogrel 75 mg tablet one tablet po q day. 3. Tylenol #3 30/300 1-2 tablets po q4h as needed for pain. 4. Loperamide 2 mg one capsule po qid. 5. Prednisone 5 mg tablets three tablets po q day x1 week, then two tablets 10 mg po until followup with Dr. [Last Name (STitle) 1888]. 6. Pravastatin 20 mg tablet one tablet po q day. FOLLOW-UP PLANS: 1. Patient is to followup with Dr. [Last Name (STitle) 1888] in Colorectal Surgery in [1-20] weeks, and has been the office number to call for an appointment. 2. Dr. [Last Name (STitle) ], Interventional Cardiology for repair of atrioseptal defect. The patient has been given office number to call for an appointment. In addition, the patient is referred to Visiting Nurses Association Services for dressing changes, dry gauze twice a day as well as ostomy care routine twice a day. He is instructed to take a regular diet and regular activity as tolerated. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) ], M.D. Dictated By:[Last Name (NamePattern1) 5657] MEDQUIST36 D: [2107-8-8] 11:17 T: [2107-8-16] 08:12 JOB#: [Job Number 51943]	[ "745.5", "518.0", "556.4", "556.6", "557.0", "998.2", "280.0", "997.02", "458.2" ]	icd9cm	[ [ [] ] ]	[ "48.69", "99.77", "88.72", "47.19", "63.81", "45.25", "46.01", "38.93", "45.8", "99.15" ]	icd9pcs	[ [ [] ] ]							1039, 1082		5884, 6268		5569, 5768												812, 969																	6285, 7111	1102, 1213														190, 744							2156, 5548							767, 788	986, 1022	5793, 5861
25,225	147,080	3973	Discharge summary	report	Admission Date: [2179-3-16] Discharge Date: [2179-3-21] Date of Birth: [2147-8-13] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin / Heparin Agents Attending:[First Name3 (LF) 552] Chief Complaint: Dizziness, nausea, hypotension Major Surgical or Invasive Procedure: Video EEG History of Present Illness: 31F with SLE and h/o endocarditis, and Right elbow graft infection presenting with weakness, hypotension, dizziness and nausea. Pt was hypotensive upon arrival to dialysis today. She was dialyzed and given back 1.6L of fluid with improvement in her BP and other sx. Pt received vancomycin at dialysis and blood cultures were drawn. Pt was then transferred from dialysis to the [Hospital1 ] for further evaluation of her constitutional symptoms. Enroute she was complaining of chest pain that was sharp and pleuritic - resolved with dilaudid. Patient endorsed dizzyness/lightheadedness and nausea during episode of hypotension. Also pleuritic chest pain as above. No fevers, SOB, no diaphoresis, no vomiting, diarrhea or constipation. Review of systems is otherwise negative. In the emergency department her vitals were 98.3, 98/66, 100, 18, 100% NRB. Improved upon arrival did get zofran in ED, Blood cx and vanco were drawn/given at dialysis. She remains afebrile, pressure did dip to the 70s/50s in ED resolved without fluid, EKG, CXR normal Past Medical History: -SLE diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - h/o MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [2166]. In [2173], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [8-/2175] complicated by rejection and capsule rupture 11/[2174]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [2177-6-24]. Complicated by wound./Hardware infection requiring BKA [2177-11-21] - [2178-4-2] RUE AVG excision - s/p CVA -[2179-2-4] RUE AVG I&D ALLERGIES: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin / Heparin Agents Social History: Lives at home with husband and son. [Name (NI) ] smoking, occasional alcohol, no drug use. Originally from [Country ]. Used to work at [Hospital1 18]. Family History: Noncontributory Physical Exam: VITAL SIGNS: T=98.4 BP= 110/70 HR= 108 RR= 18 O2= 96% RA PHYSICAL EXAM GENERAL: Pleasant, Cushingoid fetures, in NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple CARDIAC: Regular rhythm, normal rate. distant heart sounds, but no murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: Prominent surgical scars NABS. Soft, NT, ND. No HSM EXTREMITIES: S/p L BKA. No edema or calf pain on L, 2+ dorsalis pedis/ posterior tibial pulses. Large ulcer on R elbow s/p graft removal Pertinent Results: [2179-3-16] 12:15PM WBC-8.3 RBC-4.21# HGB-12.6# HCT-38.1# MCV-90 MCH-29.8 MCHC-33.0 RDW-20.6* [2179-3-16] 12:15PM NEUTS-65.2 LYMPHS-30.2 MONOS-3.1 EOS-0.7 BASOS-0.7 [2179-3-16] 12:15PM PLT COUNT-113* . [2179-3-16] 12:15PM PT-14.0* PTT-32.5 INR(PT)-1.2* . [2179-3-16] 12:15PM GLUCOSE-86 UREA N-17 CREAT-4.9# SODIUM-135 POTASSIUM-6.6 CHLORIDE-94* TOTAL CO2-27 ANION GAP-21* . [2179-3-17] 12:15PM BLOOD CK-MB-NotDone cTropnT-0.22* [2179-3-18] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.18* . [2179-3-17] 12:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [2179-3-17] 09:12AM BLOOD Type-ART pO2-80* pCO2-45 pH-7.48* calTCO2-34* Base XS-8 . ECG: sinus at 83 with freq PVCs, RAD, normal intervals, ?TWI laterally vs. artifact, poor baseline . CXR: IMPRESSION: Central vascular congestion with marked improvement in volume balance from prior study. Pulmonary arterial hypertension. Indwelling dialysis catheter stable. . [2179-3-17] CT HEAD: IMPRESSION: No acute intracranial process with residual encephalomalacia with dystrophic mineralization, presumably sequelae of old parenchymal hemorrhage with superimposed renal insufficiency. . [2179-3-18] CT HEAD: IMPRESSION: No acute intracranial process; however, this is a significantly limited study due to streak artifact from EEG leads. Please consider repeating after removal of EEG leads. . [2179-3-19] Video EEG: IMPRESSION: This telemetry captured no pushbutton activations andno ongoing seizure activity. The background activity was intermixed with slow waves suggestive of widespread encephalopathy. In addition, there was intermittent focal slowing in the left parasagittal area with occasional sharp waves in the same region. These last two abnormalities suggest a cortical and subcortical dysfunction in the left parasagittal area. Brief Hospital Course: MICU COURSE: transfer to the MICU from medicine floor with episodes of unresponsiveness. Patient was at her baseline during morning rounds. Shortly after, her nurse found her blood pressure to be 84/D with report of lethargy, which was confirmed by her intern. While her intern was in the room, she went from being lethargic to fully unresponsive, which resolved after less than one minute. After transfer to the MICU patient had at least 5 witnessed unresponsive episodes that were independent of hemodynamics. Neuro was consulted due to possibility of seizure. STAT head CT revealed changes consistent with known pathology, but no new lesions identified. Neurology concerned about seizures, thus video EEG monitoring initiated on morning of [2179-3-18] prior to transfer to the floor. No infectious etiologies were identified while patient in the MICU. She received dialysis on morning of transfer to the floor and tolerated it well. Of note, patient well known to have baseline blood pressures in the range of systolics 80-100s. . 31F with SLE and h/o endocarditis presenting with weakness, hypotension, dizziness and nausea. . #. Hypotension: Still unclear at this point. Initial cause was most likely hypovolemia. Endocrine was curbsided about adrenal insufficiency but state it would not be a primary cause - if she were stressed, it could account for the hypotension, but not in and of itself. Patient has been afebrile and most often assymptomatic so sepsis is much less likely. Last ECHO was [2179-1-29] with EF of 70% and unchanged from prior. Patient initially responded well to fluids and is currently at her baseline. She also received Vanc at HD and blood cultures were drawn. We also discussed with transplant surgery an ID who feel antibiotic are not indicated at this point. - Prednisone 10 was given initially, but reduced to 5 mg as adrenal insufficiency is unlikely primary cause per endocrine curbside. - Patient had SBP above 100 for 24 hrs prior to discharge . # Chronic pain: Patient is usually on 100 fent patch and PO dilaudid, all of which were held in the setting of hypotension and unresponsive episode. Chronic pain saw her and feel narcotics likely aren't contributing to these 2 etiologies and her oral dilaudid was started with good effect. - Continue PO diluadid . #. ESRD on HD: completed dialysis today. On Tu/[Last Name (un) ]/Sat schedule - On HD schedule per renal - continue nephrocaps, sevelimir, calcitriol, and cinacalcet . # Unwitnessed fall on [2179-3-18]: Patient states she was so uncomfortable that she had to get up. No head trauma, no LOC. CT head without big bleed, but unable to fully assess due to EEG leads. She is at baseline without neuro deficits. . #. Unresponsiveness: Unclear cause. Head CT without acute process after episodes. Neuro was consulted and Video EEG was without seizures. No change in antiepileptics. . #. Seizures DO: Neurology following and Video EEG without seizure. - Continue home dose of antiepileptics. . #. Right elbow wound: no purulence drainage. Wound is followed by Transplant. Per pt, she was to begin the use of a wound vac home via established VNA. Transplant does not think it's infected and recommended d/c'ing vancomycin - wet to dry dressing changes . Medications on Admission: Fentanyl 100 mcg/hr Patch 72 hr --> taken off in the ED yesterday Amitriptyline 100 mg HS Tizanidine 2 mg TID Topiramate 50 mg HS Levetiracetam 500 mg [Hospital1 ] Calcium Acetate 1334 mg TID W/MEALS Nephrocaps 1 DAILY Calcitriol 0.25 mcg DAILY Lactulose 10 gram/15 mL (30) ML PO DAILY Pantoprazole 40 mg Q24H Prednisone 10 mg DAILY Aspirin 81 DAILY Cinacalcet 30 mg DAILY Acetaminophen 325 mg Q6H as needed. Dilaudid 8 mg Tablet PO q3h as needed Epoetin Alfa 10,000 U with HD Senna PRN Docusate 100mg [Hospital1 ] PRN Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 14. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 15. Epogen 10,000 unit/mL Solution Sig: [Numeric Identifier 961] ([Numeric Identifier 961]) units Injection with hemodialysis. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Hypovolemic hypotension . Secondary: Seizure disorder End-stage renal disease on hemodialysis Adrenal insufficiency Discharge Condition: Fair, at baseline, on room air, Blood pressures 88-117/palp-70s which is at baseline for her. Assymptomatic. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 L . You came to the hospital for hypotension with dizzyness/nausea. A head CT showed no new changes. You were given a dose of vancomycin, but blood cultures were negative and this was stopped. While in the hospital you also had an episode of unresponsiveness requiring a MICU transfer even though your blood pressure was stable. A video EEG showed no evidence of seizures. The Endocrinology team felt your hypotension was not due to adrenal insufficiency. Your transplant and ID doctors [Name5 (PTitle) ] not feel you have an infection and so stopped antibiotics. . Medication changes: - Do not take tizanidine until you see your PCP [Name Initial (PRE) ] [Name10 (NameIs) ] not take amitriptyline until you see your PCP [Name Initial (PRE) ] [Name10 (NameIs) ] have stopped your fentanyl patch based on the Chronic pain service recommendations. Please do not use this until you see your PCP. [Name Initial (NameIs) ] Please take your other medications as prescribed. . Call your doctor or return to the ED if you feel dizzy/lightheaded, have headaches, chest pain, shortness of breath, fevers, abdominal pain, nausea, vomiting, diarrhea, or other concerns. Followup Instructions: Please call Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ] for an appointment in 4 weeks in the Neurology division ([Telephone/Fax (1) 7394]. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2179-3-26] 3:00 Provider: [Name10 (NameIs) 306] [Name Initial (MD) 307] [Name8 (MD) 308], M.D. Date/Time:[2179-4-2] 11:20 Completed by:[2179-3-21]	[ "276.52", "780.09", "E878.2", "569.89", "282.5", "276.3", "996.62", "530.81", "287.31", "338.29", "285.29", "582.81", "V42.0", "V12.54", "V49.75", "585.6", "276.7", "710.0", "255.41", "403.91", "345.90", "789.59" ]	icd9cm	[ [ [] ] ]	[ "89.19", "39.95" ]	icd9pcs	[ [ [] ] ]	10339, 10397	5171, 8435	402, 414	10566, 10678	3273, 4279	12036, 12502	2685, 2702		9012, 10316		10418, 10545		8461, 8989			10702, 11400									2717, 3254																		11420, 12013		332, 364										442, 1493		4509, 5148												1515, 2488	2504, 2669
74,252	159,132	55064	Discharge summary	report	Admission Date: [2154-8-17] Discharge Date: [2154-8-27] Date of Birth: [2076-11-10] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2154-8-18] exlap, LOA, colostomy takedown, new colostomy History of Present Illness: Patient is 77 patient s/p Hartmann's for perf'ed diverticulitis ([2154-5-3] at [Hospital1 3278]) now presenting with sudden onset of excruciating abdominal pain, midepigastric region. Patient was visiting her husband at the [Hospital1 18] when the pain started, thus came to the ED. She had one episode of emesis, non-bilious and non-bloody. She has been having normal colostomy output, flatus at baseline as well. She denies any fever, or chills, night sweats prior. Currently feels cold. She denies hematemesis, hematochezia or melena. Past Medical History: PMH: - HTN - hypercholesterolemia - hypothyroidism - perforated diverticulitis PSH: [2154-5-3] Hartmann's [2096] - presacral neurectomy Social History: SH: non-smoker, social etoh - few times a week, no illicit drugs Family History: FH: non-contributory Physical Exam: PE on admission: VS: 99.1 87 143/61 19 97 2L NC General: NAD CV: RRR Pulm: CTA b/l Abd: abdomen obese, mildly distended, tender to percussion and palpation, rebound tenderness, involuntary guarding especially mid abdomen and left LLQ and midabdomen Extrem: no LE edema On discharge: GEN: NAD CV: RRR Pulm: CTA b/l Abd: obese, LLQ tenderness improved EXtreme: no LE edema Pertinent Results: [2154-8-22] 05:30AM BLOOD WBC-13.3* RBC-4.29 Hgb-12.2 Hct-37.1 MCV-87 MCH-28.4 MCHC-32.8 RDW-15.1 Plt Ct-431 [2154-8-21] 08:01AM BLOOD WBC-14.5* RBC-3.94* Hgb-11.4* Hct-34.7* MCV-88 MCH-28.9 MCHC-32.8 RDW-14.9 Plt Ct-364 [2154-8-20] 09:10AM BLOOD WBC-13.3* RBC-3.71* Hgb-10.6* Hct-32.9* MCV-89 MCH-28.6 MCHC-32.2 RDW-15.0 Plt Ct-292 [2154-8-19] 01:45AM BLOOD WBC-10.2# RBC-3.75* Hgb-10.7* Hct-32.9* MCV-88 MCH-28.4 MCHC-32.4 RDW-15.1 Plt Ct-260 [2154-8-18] 04:33AM BLOOD WBC-5.7# RBC-4.27 Hgb-12.3 Hct-37.5 MCV-88 MCH-28.7 MCHC-32.7 RDW-15.3 Plt Ct-277 [2154-8-17] 03:50PM BLOOD WBC-13.9* RBC-4.83 Hgb-13.8 Hct-42.2 MCV-88 MCH-28.6 MCHC-32.7 RDW-15.2 Plt Ct-313 [2154-8-23] 05:25AM BLOOD Glucose-108* UreaN-6 Creat-0.5 Na-136 K-3.7 Cl-97 HCO3-29 AnGap-14 [2154-8-22] 05:30AM BLOOD Glucose-149* UreaN-8 Creat-0.4 Na-136 K-3.5 Cl-99 HCO3-29 AnGap-12 [2154-8-21] 08:01AM BLOOD Glucose-109* UreaN-7 Creat-0.5 Na-133 K-3.6 Cl-98 HCO3-23 AnGap-16 [2154-8-20] 09:10AM BLOOD Glucose-84 UreaN-10 Creat-0.5 Na-136 K-4.3 Cl-102 HCO3-24 AnGap-14 [2154-8-19] 01:45AM BLOOD Glucose-121* UreaN-10 Creat-0.6 Na-137 K-4.5 Cl-103 HCO3-27 AnGap-12 [2154-8-18] 01:59PM BLOOD Na-137 K-4.3 Cl-104 [2154-8-18] 04:33AM BLOOD Glucose-189* UreaN-10 Creat-0.6 Na-140 K-3.5 Cl-105 HCO3-23 AnGap-16 [2154-8-17] 03:50PM BLOOD Glucose-120* UreaN-14 Creat-0.7 Na-139 K-4.0 Cl-98 HCO3-27 AnGap-18 [2154-8-17] 03:50PM BLOOD ALT-13 AST-18 AlkPhos-93 TotBili-0.5 Imaging: [8-17] ECG Sinus rhythm with first degree A-V conduction delay and baseline artifact. Possible left anterior fascicular block. Cannot exclude an inferior wall myocardial infarction of indeterminate age. Poor R wave progression. Cannot exclude an anterior wall myocardial infarction of indeterminate age. No previous tracing available for comparison. [8-17] CT of abdomen and pelvis with contrast: Free air and fluid within the abdomen and within the parastomal hernia, consistent with bowel perforation. The possible origin is the thickened proximal jejunum which has a significant amount of surrounding fluid, in which case ischemic bowel becomes a concern. Another diagnostic consideration is diverticulitis within the parastomal hernia pouch, given the more extensive free air at this location. [8-20] ECG Sinus rhythm with prolonged P-R interval. Left axis deviation consistent with left anterior fascicular block. In addition, possible underlying inferior wall myocardial infarction is not excluded. Very slow R wave progression across the precordium raises question of lead placement as well as underlying anterior wall myocardial infarction, chronic obstructive pulmonary disease, etc. Possible left atrial abnormality. QTc at the upper limits of normal with non-specific ST-T wave change. Compared to the previous tracing of [2154-8-17] lateral R wave progression is slower with reduced lateral precordial voltage, although lead placement might not be strictly comparable. Clinical correlation is suggested. [8-23] CT of abdomen and pelvis with contrast 1. No retained sponge within the abdominal cavity or pelvis. 2. Focal subcutaneous fat stranding overlying the left flank, extending to the dermis, may reflect cellulitis. No fluid collection is detected. 3. Post-left lower quadrant colostomy revision. Wound dressings fill midline and left paramedial soft tissue defects. 4. Trace left abdominal free fluid. Brief Hospital Course: Ms. [Known lastname 72855] was taken to the OR the night of admission for exploratory laparotomy. See operative report for details. She was transferred to the ICU post-op for close monitoring. N: She was intubated and sedated. When sedation was weaned, she was alert and responsive. Her pain was controlled with a dilaudid PCA. CV: She had low urine output overnight and was bolused with normal saline. Pulm: She was extubated successfully in the morning and her O2 sat was stable on NC. GI: She was kept NPO, awaiting return of bowel function. She had an NGT overnight and that was removed in the morning. Heme: Her hematocrit remained stable ID: no issues On [8-19] (hospital day 3), Mrs. [Known lastname 72855] was transferred to the surgical floor under the ACS service. Her antibiotics of Cipro and Flagyl were continued. The patient had frequent episodes of nausea which zofran was administered. At the same time, she was kept NPO and IV fluids were initiated. Her pain was managed via a dilaudid PCA. A portable abdominal radiograph was conducted which ruled out an ileus. Her antibiotics were discontinued on hospital day 8 as she had no fevers or leukocytosis. Her mid-line abdominal wound and left lateral prior colostomy wound were packed with wet-to-dry dressings twice daily. Overall the wounds improved during her stay. Because Mrs. [Known lastname 72855] was experiencing increased left lower quadrant pain with some noted induration to the area, a CT of her abdomen and pelvis was obtained. It was negative for any acute processes, but showed some fat stranding within the left flank. Once her nausea subsided, Mrs. [Known lastname 72855] was slowly started on a clear diet and advanced thereafter. Prior home medications, which were verified with her PCP, [Name10 (NameIs) ] resumed. Oral pain medications were initiated. Her pain regimen was titrated upwards due to reported increased pain on hospital days 7 and 8. In addition to oxycodone, around the clock tylenol was also administered. Toradol was given intermitently as well. Physical therapy was consulted early on during Mrs.[Last Name (un) 112381] course. After multiple occasions of therapy,it is their recommendation that Mrs. [Known lastname 72855] be transferred to an acute care rehabilitation due to her deconditioned state. Ostomy teaching was also conducted during this admission by the wound/ostomy nurse. Further assistance with be provided during her rehabilitation stay. At this time, the patient is tolerating a regular diet well. She has had no episodes of nausea or vomiting. Her left-sided colostomy is putting out semi-formed stool. Per patient report, she is still experiencing [8-30] pain at times, mostly in her LLQ. She has had no leukocytosis or fevers. Medications on Admission: ASA 81', levoxyl 25', cardura 2'', centrum MV, lasix 40', simvastatin 40' Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Levothyroxine Sodium 25 mcg PO DAILY 3. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain 4. Doxazosin 2 mg PO BID 5. Acetaminophen 650 mg PO Q6H pain 6. Furosemide 40 mg PO DAILY 7. Simvastatin 40 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Perforated sigmoid colon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came into the hospital with abdominal pain from a perforation in your bowel. You needed a surgery to remove a piece of your colon and create a new colostomy. You were admitted to the acute care service for your hospital stay. Monitoring Ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-30] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD When: THURSDAY [2154-9-12] at 2:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: THARWAT [Initials (NamePattern4) ] [Doctor Last Name 72900], MD Specialty: Primary Care When: Monday [9-16] at 1pm Address: [Street Address(2) 72901], [Location (un) ],[Numeric Identifier 72902] Phone: [Telephone/Fax (1) 63184] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	[ "567.9", "562.11", "568.0", "401.9", "272.0", "569.69", "244.9", "458.29" ]	icd9cm	[ [ [] ] ]	[ "46.43", "54.59", "54.4", "45.75" ]	icd9pcs	[ [ [] ] ]	8349, 8420	5135, 7955	318, 381	8489, 8489	1662, 5112	11092, 11842	1228, 1251		8080, 8326		8441, 8468		7981, 8057			8672, 10562						10577, 11069			1266, 1269													1554, 1643							264, 280										409, 960							1283, 1540		8504, 8648					982, 1129	1145, 1212
16,582	176,466	14338	Discharge summary	report	Admission Date: [2110-7-7] Discharge Date: [2110-7-14] Date of Birth: [2039-5-5] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 71-year-old with a history of severe chronic obstructive pulmonary disease and multiple compression fractures who received her care at [Hospital3 ] who presents for elective vertebroplasty. She has had significant pain and decreased ability to do activities underwent vertebroplasty of the T6 and T9 levels on [2110-5-29] here at [Hospital1 69]. She then presented on the 8th for elective vertebroplasty at levels T10, T11, T12 and L1. The procedure went well without difficulty. However, post procedure she had decreased oxygen saturation to the 70's and so was admitted to the Medicine Service initially for observation. Her sats are typically 91 to 92% on two liters of home O2 secondary to her severe chronic obstructive pulmonary disease and she has poor respiratory reserve. After the procedure when her sats dropped into the 80's she received nebulizers and 6 liters nasal cannula and her sats came up to 90 to 91% However, she remained oxygen dependent. PAST MEDICAL HISTORY: 1. Severe chronic obstructive pulmonary disease on chronic home O2. Baseline pCO2 in the high 40's with baseline peak flows 250 to 300. 2. Osteoporosis complicated by multiple thoracic and lumbar compression fractures. 3. Hypothyroidism. 4. Coronary artery disease status post myocardial infarction in [2085] with normal left ventricular function on echo in [2109-10-31]. 5. Breast cancer status post cyst removal. 6. Status post appendectomy. 7. Status post cholecystectomy. 8. Colonoscopy was normal in [2105]. 9. Gastroesophageal reflux disease/hiatal hernia/peptic ulcer disease on Carafate 10 mg question of gastric antral polyps on CT. 10. Obstructive sleep apnea on BYPAP at night. MEDICATIONS: 1. Synthroid 150 mg q day. 2. Celexa 60 mg q day. 3. Accolade 20 mg q day. 4. Wellbutrin SR 150 mg q day. 5. Diltiazem CD 240 mg q day. 6. Ativan 1 mg q h.s. 7. Prevacid 30 mg q day. 8. Albuterol/Atrovent nebulizer q 6 hours around the clock at home. 9. Multivitamin. 10. Calcium carbonate 500 mg three times a day. 11. Carafate 1 gram b.i.d. ALLERGIES: Penicillin, Tetanus and Clorox bleach. SOCIAL HISTORY: She quit smoking after a 100 to 150 pack year history. She quit approximately ten years ago. No alcohol use. PHYSICAL EXAMINATION: This is an obese elderly woman in mild respiratory distress who has a temperature of 97.8, blood pressure of 124/78, pulse 86, respiratory rate of 22, sating 91 to 92% on room air. Head, eyes, ears, nose and throat exam is unremarkable. Her heart is regular with no murmurs, rubs or gallops. Her lungs are diffusely wheezy. Her abdomen is obese and benign. Extremities are without edema. HOSPITAL COURSE: [First Name8 (NamePattern2) ] [Known lastname ] was admitted to the medical floor. She continues to have a high oxygen requirement. She was treated for a chronic obstructive pulmonary disease exacerbation with intravenous Solu Medrol that was then changed to oral Prednisone and tapered. She also received frequent nebulizer treatment. Chest x-ray demonstrated [Hospital1 ]-lobar pneumonia of the left upper and left upper lobes. She was started on Levo and Flagyl for a 14 day course. On the day of transfer she was day seven of 14 from her Levofloxacin and Flagyl. Her chest x-rays were showing slight improvement by the time of transfer. Her respiratory status worsened initially secondary to her pneumonia requiring a brief Intensive Care Unit stay for close monitoring and frequent nebulizer treatments. As her pneumonia improved, she returned to the medical floor. Her respiratory status was greatly improved by the time of transfer. She will likely need pulmonary rehabilitation upon discharge. She was transferred to [Hospital3 ] where she gets the majority of her care under Dr. [Last Name (STitle) 12184] for the rest of her hospital needs as well as a transfer to rehabilitation. DISCHARGE DIAGNOSIS: 1. Vertebroplasty at T10, T11, T12 and L1 for compression fractures secondary to osteoporosis. 2. Multi-lobar pneumonia likely secondary to aspiration, peri-intubation. DISCHARGE MEDICATIONS: 1. Synthroid 150 mcg q day. 2. Celexa 60 mg q day. 3. Accolade 20 mg q day. 4. Wellbutrin SR 150 mg q day. 5. Diltiazem CD 240 mg q day. 6. Prevacid 30 mg q day. 7. Albuterol/Atrovent nebulizer q 6 hours around the clock. 8. Multivitamin. 9. Calcium carbonate 500 mg q day. 10. Carafate 1 gram b.i.d. 11. Levofloxacin 500 mg q day times seven days. 12. Flagyl 500 mg three times a day times seven days. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-ADF Dictated By:[Last Name (STitle) 42529] MEDQUIST36 D: [2110-7-14] 16:30 T: [2110-7-14] 19:11 JOB#: [Job Number 42530]	[ "733.00", "733.13", "244.9", "491.21", "997.3", "412", "414.01", "E878.8", "486" ]	icd9cm	[ [ [] ] ]	[ "78.49" ]	icd9pcs	[ [ [] ] ]									4322, 4972		4119, 4299			2876, 4098																					2464, 2858																				157, 1148														1170, 2312	2329, 2441
58,257	193,109	49949	Discharge summary	report	Admission Date: [2142-6-21] Discharge Date: [2142-6-26] Date of Birth: [2092-10-25] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 348] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Placement of central catheter while in ICU. History of Present Illness: Ms. [Known lastname 1191] is a 49 year old woman with HIV infection (CD4 450 on [5-30]), chronic hepatitis C, lumbar stenosis, presented to PCP with worsening altered mental status over the past week. She was sent to the ED by her PCP, [Name10 (NameIs) 1023] noted her to be hypotensive to 92/60 and disoriented to time and place. Her family sent a note with her relaying the increasing confusion over the past week, with poor med compliance and somnilence. She had been spending most of the day in bed, had new urinary and fecal incontinence and was unable to walk or stand on her own. She also was not eating and complaining of sore, swollen legs. She had pain in the feet and legs if anything contact[Name (NI) ] her skin, even the slipper she was wearing. . In the ED, initial vitals were 98.8 69 146/124 16 100. Her blood presure dropped to systolics in 80s. Her SBP did not respond to IVF initially. She was treated with 5L IVF, with some improvement, but not resolution. She had a right IJ placed under sterile conditions and she was started on leveophed 0.09 mcg/kg. She has been stable on this dose for the last x [12-1] hours. She had a negative NH3 level and head CT. A RUQ ultrasound showed a distended gall bladder without stones. A shock ultrasound showed a collapsable IVC and mild right lung base effusion. She was seen by transplant who felt she was not a surgical candidate and felt the gall bladder was unlikely the source, but recommended MRCP for further evaluation. She did not get a lumbar puncture because of her INR of 1.8. She was treated with Vanc and Zosyn, as well as 2 grams of ceftriaxone. She was not given antivirals. Prior to transfer, her vitals were HR 60 BP 95/60 on gtt RR 20 Sat 98/2L. Her CVP was 12. . On the floor, she is in severe lower extremitiy pain. She has a vague sense of where she is but is unable to confirm much of this history. Past Medical History: - HIV, diagnosed in [2121], on atazanavir boosted with ritonavir, lamivudine, and raltegravir (but not taking). Her last CD4 count on [2142-5-30] was 354 with a viral load that was undetectable. Her risk factor for HIV is intravenous drug abuse that she gave up in [2121]. - Hepatitis C (Genotype 3A) dx in [10/2136], worsened with alcohol (one bottle of wine per night ++). She had progressive deterioration in her liver function with her last albumin 2.8, INR 1.5, spleno-megally and thrombocytopenia - Spinal stenosis, and chronic pain in the feet and legs from this and HIV-related peripheral neuropathy; treated with fentanyl patch. She had an MRI scan in [11/2136] that documented multilevel lumbar disc degeneration and spinal stenosis. She refused surgery. - chicken pox, measles, mumps and [Doctor First Name 533] measles as a child. - meningitis at age 2 - lower spine cyst, s/p surgery at age 4 - s/p appy at age 6 - Hypertension, recently improved with cirrhosis - G1P1 (vaginal delivery) - mild cervical dysplasia. - Depression Social History: She has smoked 1 pack per day for almost 30 years. She drinks wine and vodka on a daily basis. She used IV drugs. She was born and raised in [Location (un) 86]. She moved to [State 760] to live with her sister and her husband after her sister was involved in a boating accident that rendered her paralyzed. She is moving back up to [State 350] (in [Location (un) 3320]) now that her sister and brother-in-law are moving back to [State 350]. She was separated from her husband about 12 years ago, and he died about 8 years ago. She lives with her brother-in-law (her sister has passed away) and her son and his wife. She completed 12th grade. She does not work, and is on disability due to the neuropathy. Her husband died of AIDS but was an intravenous drug abuser as well. Family History: Mother died (70) of leukemia; Father died at 63 of lungh cancer. 8 brothers in good health, and 1 brother died of AIDS due to IV drug abuse. 1 sister paralyzed due to an accident. Irish and Italian descent. Physical Exam: Vitals: T: 97.7 BP:114/67 (79) P:59 R: 18 O2: 100/4L NC General: Alert, waxing and [Doctor Last Name 688] sensorium with 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 at LUSB, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds quiet, no rebound tenderness or guarding, no organomegaly Back: Focal L5 tenderness Ext: Warm, well perfused, dopplerable pulses, no clubbing, cyanosis or edema Rectal: decreased rectal tone, G(-) Neuro: CN 2-12 intact; [4-3] upper strength; left hyperreflexia; pedal hyperasthesia; diffuse LE tenderness L>R; (+) babinski. on left (-) on right; No asterixis Pertinent Results: WBC on admission 9.3, trended upward and by discharge was 13.4, but was medically stablilized and afebrile. N91.5 L4.5 M3.8 . H/H on admit 11.1/32.7 and dropped down to 10.0/32.1 by discharge likely due to fluid resuscitation. . Plts 130 --> 113 . Fibrinogen 198 --> 181 Parasite smear negative . Chems on admission significant for BUN/Cr 40/2.3 --> discharge 18/0.9 Also Na was 129 --> discharge 136 Phos was low by d/c 3.1 --> 2.1, Mg 1.3 admit --> 1.7 d/c . LFTs ALT/AST admit 43/92 --> 30/50 discharge LDH 287 --> 279 CK 90 AlkP 143 --> 103 by d/c amylase 50, lipase 43 Tbili 7.2 admit --> 4.5 d/c with Dbili 2.7 trending down to 2.0 Alb 2.2, 2.0 . Trop <0.01 . Haptoglobin <20 x3 Ammonia 61 Cortisol 9.1 --> 30 mins after stim 18.2 --> 60 mins after stim 21.9 Serum tox negative all substances . UA with 3-5 WBC's, neg nitrites, trace leuks, mod bact. x2 2nd UA with 21-50 RBC's Urine tox negative UreaN 343, Creat 39, Na 108 . UCx negative, BCx negative x2 . Other Studies: [2142-6-20] Liver/Gallbladder U/S: 1. Markedly distended gallbladder and dilated CBD. No choledocholithiasis. Evaluation of son[Name (NI) 493] [Name2 (NI) 515] sign could not be performed due to altered mental status (hepatic encephalopathy). A HIDA scan or MRCP is recommended to further evaluate. 2. Cirrhosis with small amount of perihepatic ascites. [2142-6-20] AP CXR: No acute intrathoracic process. [2142-6-20] CT head w/o: 1. No acute intracranial hemorrhage. MR is more sensitive in detection of acute stroke and small masses. 2. Right maxillary, ethmoidal and sphenoidal sinus mucosal disease [2142-6-21] EKG: Sinus bradycardia. The Q-T interval is prolonged. Low voltage in the precordial leads. No previous tracing available for comparison. [2142-6-22] MRI head w/o: Limited study with only T1-weighted images obtained. Demonstrate no mass effect or hydrocephalus. [2142-6-22] MRI spine w/o: Degenerative changes from L1-2 to L5-S1 level with spinal stenosis as described above. No intraspinal fluid collection seen. Mild spinal stenosis is seen at L2-3 and moderate spinal stenosis at L3-4 and L4-5. Foraminal changes as described above, predominantly on the right side at L3-4 and L4-5 levels. Bilateral moderate foraminal narrowing is seen at L5-S1 level. Brief Hospital Course: Assessment and Plan: This is a 49 year old woman with HIV, HCV, lumbar stenosis presenting with hypotension, altered mental status, leg pain. The pt was admitted to ICU. . # HYPOTENSION: Collapsable IVC and no evidence of fluid overload suggestive of hypovolemic or septic shock. The patient had a history of poor fluid intake. The patient improved after agressive IVF. We obtained a cortisol stim test that was normal. Initially she was covered with broad spectrum antibiotics, including vancomycin, flagyl, cefepime, and acyclovir. However, we did not feel that her hypotension was due to sepsis and we discontinued her antibiotics prior to floor transfer. By discharge, 2 blood cultures and 1 urine culture were still negative. ID followed the patient throughout her MICU stay. On the floor, the pt did not have any episodes of hypotension and remained hemodynamically stable until discharge. . # ALTERED MENTAL STATUS: This was most likely related to encephalopthy [1-1] liver failure. The patient's mental status improved once she was restarted on lactulose. Head CT and tox screen negative. When her mental status improved, the pt stated that she had been non-compliant with her lactulose at home. . # BACK and LEG PAIN: Patient with longstanding spinal stensois with neropathy. Neurosurgery consulted in ICU, however, once spinal/brain MRI were normal, they signed off. Pain was well controlled once transferred to the floor. . # HIV: Continued antiretrovirals. ID recommended changing Lamivudine from 100mg PO qday to 150mg PO bid. Pt currently on Lamivudine, Atazanavir, Ritonavir, and Raltegravir. . # HCV and ALCOHOLIC CIRRHOSIS: Was started on Lactulose, Rifamixan, B12, folate, and thiamine. On follow up, would reassess need for B12, folate, thiamine. . # ANEMIA: Hct 32.7 from baseline 35-40. No known bleeding but likely has varices. Negative guaic. Patient' haptoglobin was down and LDH elevated suggesting hemolysis. Again, her HCT was stable and no acute intervention was necessary. By discharge, her Hct was stable. . # ACUTE RENAL FAILURE: Cr 2.3 from baseline 1.1. Casts in urine c/w pre-renal, either from hypotension or hepatorenal. Patient's creatinine improved with IVF. . # FLUID OVERLOAD: The pt was felt to be fluid overloaded and so Lasix 20mg IV and Spironolactone 100mg PO qday were started with appropriate UOP response. At follow up would monitor volume status and reassess need for continued meds. Also, have recommended close followup of electrolytes at rehab and also with MD follow up. Medications on Admission: Home Medications: Atazanavir 300 mg by mouth once daily (with ritonavir) Ritonavir 100 mg by mouth once daily (with atazanavir) Raltegravir 400 mg by mouth [Hospital1 ] Lamivudine 150 mg by mouth [Hospital1 ] Furosemide 20 mg by mouth daily Potassium Chloride 10 mEq by mouth [Hospital1 ] Nadolol 20 mg by mouth daily for hypertension Spironolactone 25 mg by mouth once daily Lactulose 20 gram/30 mL twice per day Bupropion HCl 200 mg SR by mouth once daily Fentanyl 100 mcg/hour x 2 patches every 48 hours Support stockings for varicose veins Soft cervical collar for cervical disk disease Senna 8.6 mg by mouth [Hospital1 ] Discharge Medications: 1. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)): Take with Ritonavir (Norvir). 2. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a day: Take two tablespoons (30cc's) by mouth twice per day. . 5. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day: Take with Atazanavir (Reyetaz). 9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Primary Diagnosis: 1. Presumed hepatic encephalopathy due to home noncompliance with Lactulose Secondary Diagnoses: - HIV, diagnosed in [2121], on atazanavir boosted with ritonavir, lamivudine, and raltegravir (but not taking). Her last CD4 count on [2142-5-30] was 354 with a viral load that was undetectable. Her risk factor for HIV is intravenous drug abuse that she gave up in [2121]. - Hepatitis C (Genotype 3A) dx in [10/2136], worsened with alcohol (one bottle of wine per night ++). She had progressive deterioration in her liver function with her last albumin 2.8, INR 1.5, spleno-megally and thrombocytopenia - Spinal stenosis, and chronic pain in the feet and legs from this and HIV-related peripheral neuropathy; treated with fentanyl patch. She had an MRI scan in [11/2136] that documented multilevel lumbar disc degeneration and spinal stenosis. She refused surgery. - chicken pox, measles, mumps and [Doctor First Name 533] measles as a child. - meningitis at age 2 - lower spine cyst, s/p surgery at age 4 - s/p appy at age 6 - Hypertension, recently improved with cirrhosis - G1P1 (vaginal delivery) - mild cervical dysplasia. - Depression Discharge Condition: Good Discharge Instructions: You were admitted to [Hospital1 18] for altered mental status and hypotension presumably because you had not been taking your home Lactulose, and were having leg pain. You were in the ICU, where you were given IV fluids and and started on IV antibiotics. However, no infectious source was found and antibiotics were discontinued. You also received an MRI of your spine which did not show any cause for your mental status or your leg pain. Your legs were also thought to be quite swollen and you were started on two diuretics with appropriate response. . You home medication regimen has been changed slightly. Because you were started on Spironolactone, please do not take Potassium this. Also, you were started on some vitamins while in hospital--Folate, B12, and Thiamine. Please also reassess the electrolytes checked soon due to restarting Lasix and Spironolactone. . Please return to the hospital for: fevers, chills or night sweats, pain uncontrolled with over the counter medicines, uncontrollable nausea, vomiting, or diarrhea, confusion or altered mental status. Followup Instructions: Pt was started Spironolactone and Lasix while in hospital--please monitor electrolytes. Please follow up with Dr. [Last Name (STitle) ] on: [Last Name (LF) 766], [7-2]@ 2:30pm Location: [Last Name (NamePattern1) 11102] Phone number: [Telephone/Fax (1) 457] To have your WBC and electrolytes checked. Completed by:[2142-7-5]	[ "304.93", "401.9", "042", "785.59", "721.3", "V15.81", "287.5", "348.30", "338.29", "V15.82", "584.9", "356.8", "790.92", "780.97", "285.29", "303.91", "276.1", "571.2", "070.71" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11803, 11854	7544, 8453	290, 336	13080, 13087	5236, 7521	14210, 14561	4211, 4421		10775, 11780		11875, 11875		10108, 10108			13111, 14187									4436, 5217	11992, 13059		10126, 10752																	229, 252										364, 2288						11894, 11971			8468, 10082					2310, 3381	3397, 4195
17,083	169,225	5636	Discharge summary	report	Admission Date: [2101-6-27] Discharge Date: [2101-7-13] Date of Birth: [2029-12-9] Sex: M Service: Medicine - [Doctor Last Name ] CHIEF COMPLAINT: Shortness of breath and lower extremity edema. HISTORY OF PRESENT ILLNESS: The patient is a 71 year old male with a history of diabetes Type 2, congestive heart failure, atrial fibrillation who presented with a two week history of increasing progressive shortness of breath. He was in his usual state of health prior to two weeks ago and he could perform all of his activities of daily living without dyspnea on exertion. Shortness of breath with walking several steps or stairs has developed over the last two weeks. Furthermore there was increase in lower extremity swelling after two days. Review of systems was also positive for paroxysmal nocturnal dyspnea as well as orthopnea. The patient states he has never had these symptoms before. He denies chest pain. There is also an increase in scrotal swelling as well as abdominal girth associated with his decrease in his appetite. He is not complaining of fever, chills, cough, bright red blood per rectum, melena, dysuria, frequency, nausea, vomiting, diarrhea or constipation. PAST MEDICAL HISTORY: 1. Diabetes Type 2; 2. Congestive heart failure, there is an old discharge summary with reference to a past ejection fraction noted at 35%; 3. Atrial fibrillation on Coumadin for 17 years; 4. Gout; 5. Hypertension; 6. Status post left hip replacement; 7. Prior silent myocardial infarction (anterior septal); 8. Past admission on [4-7] for shortness of breath and rule out myocardial infarction. MEDICATIONS ON ADMISSION: 1. Coumadin 2.5 mg q. day 2. Digoxin 250 mcg q. day 3. Allopurinol 300 mg q. day 4. Colchicine 0.6 mg q. day 5. Glipizide 5 mg q. day 6. Lasix 80 mg q. day 7. Zaroxolyn 2.5 mg q. day 8. Captopril 25 mg b.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone but in the same building as his daughter. [Name (NI) ] is retired. He denies current alcohol use, however, he was a "drinker" in the past when his children were teenagers. He has been a cigar smoker for the last 50 years. FAMILY HISTORY: Family history was non-contributory. PHYSICAL EXAMINATION: Temperature was 99.5, heartrate 69, blood pressure 132/62, respirations 22, oxygen saturation 96% on room air. General, the patient is lying comfortably in no acute distress. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light. Extraocular motions were intact. Oropharynx clear. Neck, obese. Prominent irregular jugular pulse. jugulovenous pressure is not easily discernible, however, it is elevated. Cardiovascular, irregularly irregular heartrate with a II/VI holosystolic murmur at the left upper sternal border. Respiratory, decreased air movement and inspiratory and expiratory wheezes at lower half of chest bilaterally. Bibasilar crackles, right greater than left. Abdomen, obese, distended. Positive bowel sounds, soft, nontender. Genitourinary, pleural edema, per Emergency Department examination. Extremities, 2+ lower extremity edema to the calf bilaterally. Neurological, alert and appropriate. Cranial nerves II through XII intact with no gross motor defects. LABORATORY DATA: White blood cell count 6.5, hematocrit 34.6, platelets 158, MCV 90, differential 65 neutrophils, 21% lymphocytes. PT 17.3, INR 2.1, sodium 141, potassium 2.2, chloride 101, bicarbonate 27, BUN 53, creatinine 1.4, glucose 104. CPK 126, troponin 1.1 to 1.5, Digoxin 1.1. Chest x-ray, there was no evidence of congestive heart failure or infiltrate on the examination. Electrocardiogram, atrial fibrillation at 77 beats/minute, poor R wave progression. Left anterior vesicular block with left axis deviation, mild ST increased in V1 to V2, however, the electrocardiogram is unchanged from [6-6]. ASSESSMENT: This is a 71 year old male with a history of congestive heart failure (low ejection fraction by report), atrial fibrillation, diabetes Type 2 who presented with progressive shortness of breath over a two week period along with dramatic lower extremity swelling and scrotal edema consistent with congestive heart failure exacerbation. The clear chest x-ray is not surprising as this is a compensated congestive heart failure. Also with a troponin leak up to 1.5 which is likely secondary to strain from a heart failure. HOSPITAL COURSE: 1. Cardiac - The patient was admitted to rule out myocardial infarction and to work up and treat the congestive heart failure exacerbation. Diuresis was begun with intravenous Lasix with good response. A transthoracic echocardiogram showed markedly decreased left ventricular systolic function with an ejection fraction of 20 to 25% as well as decrease in right ventricular systolic function. His clinical examination, however, was most consistent with right heart failure with increased neck veins and lower extremity edema. His Captopril was titrated up. Cardiology was consulted to work up potential ischemic cause of congestive heart failure exacerbation and he underwent the right and left heart catheterization (after adequate diuresis and holding the Coumadin and Lovenox) on [2101-7-4]. While the Coumadin was held, the Lovenox was started, however, it was held one day prior to the procedure and begun one day after the procedure. Catheterization showed no significant coronary artery disease but severely elevated right and left filling pressures without evidence of constriction or restriction, left ventricular end diastolic pressure of 32 mm/hg, ejection fraction of 20%, mild mitral regurgitation, severe global hypokinesis, moderate pulmonary hypertension. Causes for nonischemic cardiomyopathy including hemachromatosis, amyloid and thyroid disease were ruled out and with his history of prior alcohol use it is likely this is secondary to ethyl alcohol. Coumadin was restarted on [7-6]. Then, on [7-7], the patient developed a rapidly growing hematoma at the right groin site where his femoral artery and vein were accessed for catheterization. Ultrasound showed a pseudoaneurysm of the right femoral artery. Vascular Surgery was immediately contact[Name (NI) ] and he emergently went to the Operating Room for repair of this common femoral artery pseudoaneurysm (Dr. [Last Name (STitle) ]. The patient was admitted to the Cardiac Intensive Care Unit status post surgery to be monitored over night where he recovered without incident and was extubated and returned to the floor on [7-9]. By [7-13], his fluid status was much improved. His Captopril was changed to Lisinopril and he was tolerating Lisinopril 10 q. day (20 q. day caused blood pressure to drop), Digoxin was decreased as his chronic renal insufficiency was worse and he was on a rather high dose as an outpatient. Coumadin was restarted on [7-11]. Of note, his admission weight was 197 lbs and had decreased to 186.5 lbs on discharge. Of note he also had many episodes of nonsustained ventricular tachycardia and ventricular tachycardia which were asymptomatic. He may need to be considered for an electrophysiology study in the future. 2. Heme - The patient was on Coumadin for many years for atrial fibrillation. This was held prior to the catheterization and his INR was 1.2 the day of the procedure. He was briefly on Lovenox which was complicated by a right groin hematoma, three to four days status post catheterization. He resumed his Coumadin greater than 48 hours status post repair of the artery and his INR was 1.25 at discharge. His Coumadin will need to be titrated to a goal of INR 2 to 3 in rehabilitation. 3. Gout - His medications were held during the initial diuresis and he experienced a flare in his right knee and then in his left knee with lowgrade temperatures twice during his stay. This resolved with the addition of Colchicine prn. 4. Endocrine - The patient has a history of diabetes mellitus Type 2, his blood sugars, however, were very well controlled during his hospital stay on Glipizide. 5. Renal - His baseline creatinine seems to be between 1.1 and 1.5. It did increase to 1.8 status post dye load during the catheterization but returned to baseline of about 1.4 by discharge. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility. He is set up to see Dr. [Last Name (STitle) ] in Vascular Surgery on [2101-7-26] at 1:15 PM for suture removal. He is also set up to see his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 5361] on [7-29], at 3 PM. The patient was given the number for the congestive heart failure clinic and we are going to schedule an appointment today, the nurse practitioner was not available in order to schedule an appointment in the next couple of weeks. The patient has agreed to do this. DISCHARGE MEDICATIONS: 1. Coumadin 5 mg q. day-titrate to an INR of 2 to 3 2. Digoxin 0.125 mg q. day 3. Allopurinol 300 mg q. day 4. Colchicine 0.6 mg q. day 5. Glipizide 5 mg q. day 6. Lasix 40 mg b.i.d. 7. Lisinopril 10 mg q. day 8. Metolazone 2.5 mg q. day 9. Regular insulin sliding scale 10. Tylenol prn 11. Ambien prn [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) 210] MEDQUIST36 D: [2101-7-13] 14:54 T: [2101-7-13] 15:10 JOB#: [Job Number 22573]	[ "416.0", "428.0", "427.1", "V11.3", "427.31", "998.12", "E879.0", "425.5", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23", "88.53", "39.31", "83.09" ]	icd9pcs	[ [ [] ] ]							2228, 2266		9004, 9581				1684, 1940	4480, 8338																					2289, 4462										185, 233										262, 1228														1251, 1658	1957, 2211	8363, 8981
21,429	117,995	15850	Discharge summary	report	Admission Date: [2163-9-4] Discharge Date: [2163-9-9] Date of Birth: [2097-3-31] Sex: M Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: This is a 66-year-old male, status post motor vehicle crash, prolonged extrication, less than 5 minutes loss of consciousness, restrained driver, hemodynamically stable in transit. No complaints on arrival. PAST MEDICAL HISTORY: Past medical history of hypertension. MEDICATIONS ON ADMISSION: The patient's home medications included Lasix 40 mg p.o. q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 97.6, pulse was 87, respiratory rate was 18, blood pressure was 151/74, oxygen saturation was 100%. In general, alert and oriented times three. Moved all extremities. Pupils were equal, round, and reactive to light and accommodation; 3 mm. Right parietal laceration of approximately 6 cm. Trachea was midline. Cardiovascular revealed a regular rate and rhythm. Lungs were clear to auscultation. No crepitus. Abdomen revealed bowel sounds were present. Protuberant and nontender. Rectal was negative. Pelvis was stable. Extremities revealed no deformities. Neck had no stepoff, no deformities. PERTINENT LABORATORY DATA ON PRESENTATION: Initial laboratories with complete blood count which revealed white blood cell count was 11, hematocrit was 38.2, platelets were 201. Coagulations revealed PTT was 13.5, PTT was 26.2, INR was 1.3. Fibrinogen was 226. Amylase was 41. Chemistry-7 revealed sodium was 139, potassium was 4.6, chloride was 105, bicarbonate was 27, blood urea nitrogen was 18, creatinine was 0.9, and blood glucose was 127. Arterial blood gas revealed 7.43/41/159. Lactate was 3.1. Toxicology screen was negative. Urinalysis revealed 3 to 5 red blood cells. RADIOLOGY/IMAGING: The patient had a CT of the head on [9-4] which showed a large bilateral subarachnoid hemorrhage with a right frontal lobe contusion. Chest x-ray was negative. Pelvic x-ray was negative. CT of the cervical spine was negative. CT of the abdomen and pelvis were negative for trauma. A well circumscribed rounded approximately 19-cm X 25-cm mass in the parenchyma of the right adrenal gland. Multiple bilateral simple renal cysts. One of the cysts in the right kidney had possibly ruptured. A CT of the pelvis was negative except for the findings noted above. Thoracic and lumbar spine x-rays were negative. HOSPITAL COURSE: Neurosurgery was consulted. They recommended loading the patient with Dilantin 100 mg intravenously t.i.d., keep blood pressure below 150, hold aspirin and Coumadin; if the patient is on these medications, and correct coagulations as needed. A repeat head CT in the morning. The patient had a repeat head CT on [9-5] which showed a slight increase in the right frontal contusion and the subarachnoid hemorrhage; no shift. The patient had a follow-up head CT on [9-6] to check the size of the hemorrhage which was stable; no changed from [9-5]. The patient's large head laceration was closed using a running locked stitch for hemostasis. In the Trauma Intensive Care Unit, the patient persistently removed collar, trying to get out of bed. He was given Haldol with good effect. A right subclavian line was placed in the Unit. The patient was alert and oriented times two; disoriented to place, moved all extremities. Sensation was grossly intact. The patient stepped down to the floor. The Foley was decided. The patient was able to urinate. However, the patient had gross hematuria; per family. Urinalysis was sent which had greater than 50 red blood cells in the urine. Urology was consulted for the possibly ruptured renal cyst to determine if further imaging was necessary. They determined to just monitor urinalysis and outpatient followup with Urology for the right adrenal mass and renal cyst. No urgent workup was necessary. The patient's neck was cleared with negative flexion extension. No pain on palpation and with range of motion. The patient worked with Occupational Therapy and Physical Therapy. Physical Therapy noted that the patient's gait was unsteady and was at increased risk for fall and would benefit from short term inpatient rehabilitation stay for balance mobility. Neurology/Rehabilitation evaluated the patient and determined that no acute long-term benefit from rehabilitation stay; however, the family wound recommend the need rehabilitation based on the family's ability to provide one-to-one supervision over the coming week after discharge. Recommended changing Dilantin to 300 mg p.o. q.d. and to check a level after three days and to discontinue if no seizures after three months. DISCHARGE DIAGNOSES: 1. Subarachnoid hemorrhage. 2. Right frontal contusion. 3. Adrenal mass of uncertain etiology. 4. Bilateral renal cysts. 5. Hematuria. 6. Previous diagnosis of hypertension. DISCHARGE PLAN: 1. For the subarachnoid hemorrhage and the right frontal contusion; stable per Neurosurgery. Stable examination and on CT. Follow up with Neurology/Rehabilitation as necessary in one month with Dr. [First Name (STitle) ]. 2. Follow up with Neurosurgery in one month (telephone number [Telephone/Fax (1) 274]). 3. Follow up in the Trauma Clinic (telephone number [Telephone/Fax (1) 274]) in two weeks. MEDICATIONS ON DISCHARGE: 1. Dilantin 300 mg p.o. q.d.; check level in five days. 2. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed (for pain). 3. Lasix 40 mg p.o. q.d. (as previous medication). 4. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). 5. Zantac 150 mg p.o. b.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Dulcolax 10 mg p.r. q.d. as needed (for constipation). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern1) 21669] MEDQUIST36 D: [2163-9-8] 21:15 T: [2163-9-8] 21:27 JOB#: [Job Number 45560]	[ "599.7", "401.9", "E812.0", "593.2", "255.9", "873.0", "920", "853.02", "780.99" ]	icd9cm	[ [ [] ] ]	[ "86.59", "38.93" ]	icd9pcs	[ [ [] ] ]								4767, 4948				5409, 6045	468, 2478	2497, 4746																																									170, 379												4964, 5383		402, 441
29,347	146,160	42920	Discharge summary	report	Admission Date: [2198-6-30] Discharge Date: [2198-7-7] Service: MEDICINE Allergies: Zantac / Penicillins / Vancomycin / Levaquin / Lisinopril Attending:[First Name3 (LF) 134] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: - Cardiac catherization with placement of cardiac stent. - Transfusion of packed red blood cells. History of Present Illness: Patient is an 84 year old female with history of atrial fibrillation, status-post pacemaker for tachy-brady syndrome, anemia, and hypertension who presented to the emergency room with chest pain. Patient states she was doing laundry at home, sat down, and started to experience severe squeezing chest pain, about [9-26] at rest, around 12:15 PM. Her pain radiated to her back and jaw. She denies any associated nausea, diaphoresis, or shortness of breath. She took two sub-lingal nitroglycerin, however noted no improvement, so she called 911. . In the ER, her blood pressure was 112/80, heart rate was 60, and her oxygen saturation was 100% on room air at presentation. An EKG was completed which demonstrated ST elevations in V2-V6 and code STEMI was activated. She was given Heparin, Integrillin bolus 180, Plavix 600 mg, and ASA 325 mg. She was taken to catherization laboratory where she had a LAD with 100% stenosis at origin. She had a bare metal stent placed to LAD. She complained of severe chest pain with ballon inflation. ECG after the procedure noted to have STE >5mm V2-V5. Her pain improved gradully down to [2200-1-18]. . On review of symptoms, she states has been having shortness of breath for several weeks thought to be secondary to anemia, which improved after blood transfusion. She does report dark stools, with colonoscopy within the last year reported to be "negative." . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. +Chest pain and Shortness of breath. Past Medical History: A. fib Tachy-Brady syndrome s/p [Company 1543] dual chamber pacemaker [2196-5-17] HTN CKD (baseline 1.5-1.6) Mastocytosis s/p Chemo Osteoporosis GERD Cataracts back pain s/p epidural PUD s/p gastrectomy ([2186]) s/p cholecystectomy s/p hemorrhoidectomy s/p TAH/BSO S/p L hip replacement ECHO [1-20]- normal EF ETT and stress echo [1-20]- no inducible/reversible ischemic changes Social History: Patient lives alone. There is no history of ETOH/tobacco. She previously worked in sales (toys). She is widowed. Her daughter lives nearby and is involved in care. Family History: Non-contributory Physical Exam: At admission to the intensive care unit: VS: 97.5 BP 130/57 HR 76 RR 16 O2 99%2L. . Gen: Elderly female lying in bed in NAD, Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple - JVP not assessed as pt lying flat. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Right groin site dressing c/d/i. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: LABORATORY DATA at time of admission: Trop-T: <0.01 . 142 \| 108 \| 41 AGap=11 -------------<118 4.4 \| 23 \| 1.6 (baseline 1.5-1.6) estGFR: 31/37 (click for details) CK: 99 Ca: 9.4 Mg: 2.4 P: 2.0 proBNP: 2419 . MCV 92 8.8 >---< 194 .....32.7 .N:83.1 L:12.1 M:3.2 E:1.4 Bas:0.2 . PT: 28.1 PTT: 27.3 INR: 2.8 . . CARDIAC ENZYMES [2198-6-30] 01:43PM BLOOD CK(CPK)-99 [2198-6-30] 08:24PM BLOOD ALT-177* AST-612* LD(LDH)-1703* CK(CPK)-4759* AlkPhos-114 TotBili-0.5 [2198-7-1] 03:21AM BLOOD ALT-150* AST-426* LD(LDH)-1523* CK(CPK)-2819* AlkPhos-103 TotBili-0.5 [2198-6-30] 01:43PM BLOOD CK-MB-NotDone proBNP-2419* [2198-6-30] 01:43PM BLOOD cTropnT-<0.01 [2198-6-30] 08:24PM BLOOD CK-MB-238* MB Indx-5.0 cTropnT->25 [2198-7-1] 03:21AM BLOOD CK-MB-147* MB Indx-5.2 cTropnT-22.95* . Laboratories upon discharge: [2198-7-7] 06:41AM BLOOD Na-143 K-4.2 Cl-109 HCO3-23 UreaN-56 Creat-2.0Glucose-117 06/21/08BLOOD WBC-7.3 Hgb-11.1 Hct-32.6 MCV-93 MCH-31.5 MCHC-34.1 RDW-18.2 Plt Ct-163 [2198-7-7] 06:41AM BLOOD PT-21.7 PTT-26.8 INR(PT)-2.1 . [2198-6-30]: Cardiac Catherization 1. Coronary angiography of this left dominant system revealed significant 2 vessel coronary artery disease. The LMCA had no angiographically significant coronary disease. The LAD had a 100% total occlusion proximally with a 50% mid stenosis. The LCX was a large, dominant vessel without significant coronary disease. There was a ramus with a 40% stenosis. The RCA was a small, non-dominant vessel without significant coronary disease. 2. Resting hemodynamics revealed a mildly elevated SBP at 148 mm Hg. A right heart catheterization was not performed. 3. Left ventriculography was deferred. 4. Successful PCI/stent to proximal LAD with a 2.5x15mm Vision stent and postdilated with a 2.75mm NC balloon. Excellent result with normal flow down vessel and no residual stenosis. Patient left cath lab in stable condition. Right heart cath was not peformed because patient on coumadin. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute anterior myocardial infarction, managed by acute PCI. 3. Successful PTCA/stent to proximal LAD with bare metal stent. . EKG [2198-6-30]: Baseline artifact. Sinus rhythm. ST segment elevations in leads I, aVL, V1-V5. Acute anteroseptal myocardial injury. Compared to the previous tracing ST segment elevations are new. TRACING #1 . Chest X-ray [2198-6-30]: IMPRESSION: No acute intrathoracic pathology including no pneumonia or heart failure. . [2198-7-2]: Transthoracic Echo: Conclusions The left atrium and right atrium are normal in cavity size. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with near akinesis of the distal half of the anterior septum and anterior walls, distal inferior wall and apex. The remaining segments contract normally (LVEF = 25-30 %). Tissue Doppler indicates an increased E/e' suggesting an increased LVEDP (>18mmHg). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (LAD distribution). Increased LVEDP. Compared with the prior study (images reviewed) of [2196-4-12], regional left ventricular systolic function is new. Brief Hospital Course: Patient is an 84 year old female with history of hypertension, atrial fibrillation, tachy-brady syndrome status post pace-maker placement, who presented with chest pain and EKG findings concerning for a ST elevation myocardial infarction. # Coronary artery disease/Ischemia: Patient has a history of hypertension, but no other significant coronary artery disease risk factors, and presented with chest pain. Her initial EKGs were concerning for an anterior ST elevation myocardial infarction. A code STEMI was activated and patient was taken to the catherization laboratory. She had a bare metal stent placed in her proximal LAD which was found to have 100% occlusion. It was noted that she had worsening of her ST elevations after the procedure despite TIMI 3 flow and improvement in the patient's symptoms. It was suspected that she had some degree of distal embolization given the timing of her worsening ST elevations and improvement in her symptoms. After catherization, she was monitored in the cardiac intensive care unit. She was started on a 325 mg aspirin, Plavix 75 mg, 80 mg atorvastatin, and metoprolol. She will need to continue the aspirin and Plavix unless instructed to stop by her cardiologist. She has a history of an allergy to ACE-Inhibitors that included urticaria, so [First Name8 (NamePattern2) ] [Last Name (un) ] was started instead. A GP IIb/IIIa [Doctor Last Name 360] was not used given her elevated INR of 2.8. . Her cardiac enzymes trended upward after her procedure, with a peak CK of 4759 and peak troponin of greater than 25. . She continued to have mild chest "tightness" and "pressure" on and off for 24-48 hours after her procedure. Her pain was initially treated with a nitroglycerin drip, and then morphine as needed. Her EKG demonstrated persistent ST elevations in some lateral leads, persisted post-catherization; Q waves were noted in the anterior waves as well. On [2198-7-6], she was in atrial fibrillation and noted to have persistent ST elevations in V3 and V4 only; a copy of her last EKG is enclosed in the packet sent with the patient to rehabilitation. . Her dose of metoprolol was titrated upward as tolerated by her blood pressure, which was at times on the lower side with systolics in the 90's. At time of discharge she was on 75 mg of metoprolol tartrate [Hospital1 ]. . # Heart function: A transthoracic echo was completed, which, as suspected given the extent of her infarction, demonstrated a depressed ejection fraction of 25% with apical akinesis. Patient was already on anticoagulation for her atrial fibrillation, which would also serve as protective against a left ventricular thrombosis given the akinesis. She initially appeared somewhat fluid overloaded, and was diuresed with lasix. She then appeared fairly euvolemic, without a significantly elevated JVP, rales on lung exam, or peripheral edema. A daily dose of lasix 20 mg was started, however this was held due to her worsening renal function, poor oral intake, and poor urine output, as she appeared to be dry on exam. Due to her elevated creatinine (acute on chronic renal insufficiency) and her continued euvolemic status, lasix was not started on this hospitalization. The patient may require lasix 20 mg daily for maintanence in the future. Her volume status should be monitored closely at rehabilitation. Her diet should be restricted to 2 grams of sodium daily. * She was instructed to follow her weight daily, and may benefit from standing lasix if she starts to develop edema, dyspnea, or other findings consistent with congestive heart failure. . # Rhythm: Patient has a history of atrial fibrillation and is status-post pacemaker placement for tachy-brady syndrome. Patient converted to atrial fibrillation on the 16th at 1:00 AM post-myocardial infarction. Over the first 24-48 hours, her heart rate was difficult to control-- she was treated used escalating doses of metoprolol (PO and IV), and she was briefly on a trial of an esmolol gtt. However, her blood pressure did not tolerate the esmolol or increased doses of beta-blocker and her heart rate remained in the 100-120 range. It was also been noted that she flipped in and out of atrial fibrillation and sinus tachycardia. Her heart rate improved with some small fluid boluses after it was felt she appeared hypovolemic on exam. . Given the difficulties with bringing her heart rate under better control, patient was started on amiodarone orally. Digoxin was stopped at time of admission given concerns over her worsening renal insufficiency and in the setting of her acute infarct. . She will continue on amiodarone 400 mg TID for a total of 7 days, then titrate down to 400 mg [Hospital1 ] on [7-9] for two weeks, and then 400 mg daily starting [7-23]. Her liver function tests and thyroid function tests were checked at time of starting her amiodarone. She will need pulmonary function tests to be completed on an outpatient basis, and have her liver function tests followed on a regular basis while on amiodarone. . At time of discharge, her rate control had improved with a heart rate mainly in the 80's to 90's range. Further up-titration of her beta-blocker may be completed while in rehabilitation or on an outpatient basis as tolerated by her blood pressure. Toprol XL (the long-acting form of metoprolol--her outpatient medication) was changed to the short-acting form metoprolol 75 mg [Hospital1 ] since she crushes her pills due to baseline pill swallowing difficulties. It is very important not to crush the long-acting form of metoprolol, the toprol XL. Crushing Toprol XL releases all of the time-released medication at once and could cause a dangerous drop in blood pressure. The patient was counseled regarding the above. . Patient's warfarin was initially held given her supratherapeutic INR at admission. Her wafarin was re-started, but a reduced dose given the initiation of amiodarone therapy which was likely to effect the metabolism of her warfarin. * She will need an INR/PT/PTT checked on Tuesday, [7-10], to check her INR (goal [2-18]), and then weekly after that time as followed by her primary care physician's office. She may need further titration of her warfarin dosing as her amiodarone dosing changes. . It was noted that her pacemaker appeared to be inappropriately firing at times on telemetry. EP was consulted and her device was interogated. It was felt that there was atrial undersensing, and her device was adjusted accordingly For pacemaker monitoring she has the following followup: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2198-7-10] 11:30 AM . # Chronic renal insufficiency: Patient has a history of stage 4 chronic renal insufficency with a baseline creatinine of 1.6. She received about 270 cc of contrast dye during the catherization. She also received intravenous fluids with a bicarbonate drip and mucomyst for renal protection. During her stay, her creatinine ranged from 1.4 to 2.1. It was felt that the bump in her creatinine was secondary to contrast nephropathy versus a pre-renal volume depleted state. Her urine electrolyte studies were consistent with this as well. * She will need a basic electrolyte panel including BUN and creatinine checked on Tuesday, [7-10] to monitor her creatinine and BUN to ensure that it is stable to improved. . # Hypertension: This was not an active issue during her stay, as her systolic blood pressure ranged from 90-120 for the most part. She was managed with metoprolol tartrate and losartan. . # Anemia: Patient has a history of anemia and has been followed by hematology as an outpatient, requiring transfusions about once a month. She was also recently started on Procrit on [6-26]. Her anemia has had an extensive work-up as a outpatient and has been managed on that basis. Given her low hematocrit at time of admission to the intensive care unit (25.8), and given her ischemia from her infarction, she was transfused one unit of packed red blood cells. Her stools remained guaiac negative during her stay. Hematology was contact[Name (NI) ] during her stay and recommended to continue her Procrit as needed for a Hb less than 11. * Patient was to receive her next dose of Procrit on [2198-7-10], and will need to touch base with her hematologist, [First Name8 (NamePattern2) 916] [Last Name (NamePattern1) ]/[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 11576] to discuss further Procrit dosing. She has an appointment scheduled with Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10384], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2198-7-10] 11:30 AM at [Hospital1 18] if Procrit may not be dosed at rehabilitation. Please cancel/reschedule this appointment as necessary. . * She will need a complete blood count checked on [2198-7-10] to monitor her hematocrit and hemoglobin. . # Dark stools: Patient reported dark stools at time of admission. She had a colonosocpy on [12-23] that demonstrated diverticulosis. Her stools were guaiac negative during her stay. . # Diarrhea: Patient developed watery diarrhea during her stay, with approximately one episode per day. The patient felt the episodes were related to taking her atorvastatin. Her diarrhea was c. difficile negative. Atorvastatin was changed to simvastatin to see if there was improvement in her symptoms. Her daughter also reported that in the past she has had diarrhea associated with her mastocytosis. Imodium was used as needed for her diarrhea. . # Disposition: Patient was evaluated by physical therapy and a short stay at rehabilitation was recommended. Follow-up was arranged with her cardiologist. She also has an outpatient procrit shot scheduled for [2198-7-10], as well as followup scheduled for a pacemaker interrogation with EP. . # Code: Patient was full code during her stay. Medications on Admission: Coumadin 2 mg, HCTZ 25, Lanoxin 0.0625, metoprolol succinate 200 mg, Norvasc 5, spironolactone 25, Avapro 300, SLTNG 0.3 p.r.n. (rarely used), acetaminophen 650 p.r.n. Folate 1 mg b.i.d. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [Month/Day/Year ]: Four (4) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Tramadol 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed: As needed for pain. 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Last Name (STitle) ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Do not leave on for more than 12 hours in 24 hour period. 6. Nitroglycerin 0.3 mg Tablet, Sublingual [Last Name (STitle) ]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 7. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Guaifenesin 100 mg/5 mL Syrup [Last Name (STitle) ]: 5-10 MLs PO Q6H (every 6 hours) as needed. 9. Losartan 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID PRN as needed. 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [Last Name (STitle) ]: 15-30 MLs PO QID (4 times a day) as needed. 12. Psyllium Packet [Last Name (STitle) ]: One (1) Packet PO TID (3 times a day) as needed: As needed. 13. Amiodarone 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day): Take 400 mg TID for another day, then 400 mg [Hospital1 ] for two weeks, then 400 mg daily. Tablet(s) 14. Warfarin 1 mg Tablet [Hospital1 ]: One (1) Tablet PO Once Daily at 4 PM. 15. Camphor-Menthol 0.5-0.5 % Lotion [Hospital1 ]: One (1) Appl Topical QID (4 times a day) as needed. 16. Simvastatin 40 mg Tablet [Hospital1 ]: 1.5 Tablets PO DAILY (Daily). 17. Loperamide 2 mg Capsule [Hospital1 ]: One (1) Capsule PO QID (4 times a day) as needed. 18. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day) as needed: As needed for constipation. 19. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: Three (3) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary diagnosis: - ST Elevation Myocardial Infarction - Atrial fibrillation Secondary diagnoses: - Coronary artery disease - Anemia Discharge Condition: - Stable. Discharge Instructions: You were admitted after experiencing chest pain. You underwent cardiac catherization and had a stent placed into an occluded artery. You were monitored in the cardiac intensive care unit. Your medications were adjusted to improve your heart rate and blood pressure control. Physical therapy evaluated you and felt a short stay in rehabilitation was best. . Please contact your primary care physician, [Name10 (NameIs) 2085], or go to the emergency room if you experience chest pain not relieved by nitroglycerin, new or worsening chest pain or chest tightness, difficulty breathing, palpitations, bleeding, fevers, inability to keep down food or drink, persistent diarrhea, or other concerning symptoms. . As your heart systolic (pumping) function is diminished, you should make the following lifestyle/diet changes: Please weigh yourself every morning, and call Dr. [Last Name (STitle) 1016] if you note a weight gain of more than 3 lbs. Also, please restrict you sodium intake to 2 grams daily. . The following medication changes were made: - You were started on Plavix to keep your coronary artery open. Do NOT stop or miss doses unless directed by your cardiologist. - You were started on Amiodarone to help control your atrial fibrillation. You will need to take this three times a day until [2198-7-9] when you will start 400 mg twice a day until [2198-7-23] when you will start 400 mg daily. - HCTZ, Lanoxin, Norvasc, Avapro, and Spironolactone were all stopped. - Coumadin (also called Warfarin) was reduced to 1 mg daily. - Avapro was stopped and a medication called Losartan was started in place. - Your dose of Toprol XL (the long-acting form of metoprolol) was changed to the short-acting form metoprolol 75 mg [Hospital1 ] since you crush your pills. It is very important not to crush the long-acting form of metoprolol, the toprol XL. Crushing Toprol XL releases all of the time-released medication at once and could cause a dangerous drop in your blood pressure. Please take the short-acting form of metoprolol as prescribed. - A cholesterol medication called Zocor was also started. - Ultram and a lidoderm patch were added to control your back and hip pain. - A full strength Aspirin (325 mg) was started. Followup Instructions: 1. Please follow up with your cardiologist, Dr. [Last Name (STitle) 1016], at an appointment made for you on Thursday, [7-19], at 10:00 AM. . 2. Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 2204], within 1-2 weeks after discharge. His office has been called and is aware that you will need a follow up appointment. ph: [Telephone/Fax (1) 2205] . 3. You will need your INR (Coumadin level) checked on Tuesday, [7-10], as well as well basic electrolytes including BUN and creatinine. Results should be sent to your primary care physician's office at ([Telephone/Fax (1) 92636]. . 4. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10384], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2198-7-10] 11:30 AM. Patient was started on Procrit 20mEq on [2198-6-26], with a scheduled appointment on [2198-7-10]. According to her hematologist, she should be dosed with procrit on a every other week schedule, with need for Procrit if Hb <11. . 5. For pacemaker monitoring: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2198-7-10] 11:30 AM	[ "584.9", "787.91", "403.90", "428.0", "V45.01", "276.52", "585.4", "283.9", "V43.64", "530.81", "788.20", "427.31", "366.9", "410.11", "428.21", "414.01", "593.9", "733.00" ]	icd9cm	[ [ [] ] ]	[ "00.40", "00.45", "37.22", "00.66", "99.20", "99.04", "88.56", "36.06" ]	icd9pcs	[ [ [] ] ]	19785, 19870	7351, 17316	275, 375	20048, 20060	3539, 4351	22354, 23555	2612, 2630		17554, 19762		19891, 19891		17342, 17531		5539, 7328	20084, 22331									2645, 3520	19990, 20027																			224, 237									4367, 5522	403, 1990						19910, 19969								2012, 2414	2430, 2596
58,452	176,067	40427	Discharge summary	report	Admission Date: [2178-8-6] Discharge Date: [2178-8-15] Date of Birth: [2092-12-28] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Aortic valve replacement with a 19-mm Biocor tissue valve. History of Present Illness: 85 year old female with significant medical history of hypertension and hyperlipidemia. She reports shortness of breath with minimal activity relieved with rest. She also reports moderate lower extermity edema. Her echo results demonstrate severe aortic stenosis with a peak gradient of 78, a mean gradient of 42 and an aortic valve area of 0.8 cm. The LVEF was 55-60%. She was referred for cardiac catheterization and is now referred to cardiac surgery for an aortic valve replacement and coronary artery bypass graft. Past Medical History: Hypertension Hyperlipidemia Neck arthritis Degenerated joint disease Diverticulitis s/p sigmoid resection Social History: Lives with:husband Contact:[Name (NI) 1692] (son) Phone #[Telephone/Fax (1) 88604]. Occupation:retired Cigarettes: Smoked no [] yes [x] last cigarette 2 weeks ago Hx:4 cigarettes/day x 50 years Other Tobacco use:denies ETOH: < 1 drink/week [x] [2-9] drinks/week [s] >8 drinks/week [] Illicit drug use:denies Family History: none Physical Exam: Pulse:58 Resp:16 O2 sat:96/RA B/P Right:128/68 Left: 155/74 Height:5' Weight:197 lbs General: Skin: Dry [X] intact [] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade __III (holosystolic)____ Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [X] _2+ Bilat____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: Palp Left:Palp No hematoma or PSA at insertion site (R) DP Right:Palp Left:Palp PT [Name (NI) 167]:Palp Left:Palp Radial Right:Palp Left:Palp Carotid Bruit Right:None Left:None Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 88605], [Known firstname 4617] [Hospital1 18] [Numeric Identifier 88606]Portable TTE (Focused views) Done [2178-8-8] at 1:58:01 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2092-12-28] Age (years): 85 F Hgt (in): 60 BP (mm Hg): 95/66 Wgt (lb): 210 HR (bpm): 87 BSA (m2): 1.91 m2 Indication: Valvular heart disease. H/O cardiac surgery. ICD-9 Codes: V43.3, 424.1 Test Information Date/Time: [2178-8-8] at 13:58 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Test Type: Portable TTE (Focused views) Son[Name (NI) 930]: Doppler: Limited Doppler and color Doppler Test Location: [Location 13333]/[Hospital Ward Name 121] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2011W000-0:00 Machine: Vivid q-2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% >= 55% Left Ventricle - Stroke Volume: 72 ml/beat Left Ventricle - Cardiac Output: 6.29 L/min Left Ventricle - Cardiac Index: 3.29 >= 2.0 L/min/M2 Aortic Valve - Peak Velocity: 3.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 39 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 21 mm Hg Aortic Valve - LVOT pk vel: 1.10 m/sec Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.00 Findings This study was compared to the prior study of [2178-8-6]. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated descending aorta. AORTIC VALVE: AVR well seated, normal leaflet/disc motion and transvalvular gradients. No AR. MITRAL VALVE: No MS. Trivial MR. PERICARDIUM: No pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. No echocardiographic signs of tamponade. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality as the patient was difficult to position. Suboptimal image quality - body habitus. Suboptimal image quality - patient unable to cooperate. Emergency study performed by the cardiology fellow on call. Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [8-6]/201, no change. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2178-8-9] 11:32 ?????? [2170] CareGroup IS. All rights reserved. [2178-8-15] 05:05AM BLOOD WBC-10.1 RBC-3.38* Hgb-10.8* Hct-32.5* MCV-96 MCH-31.9 MCHC-33.2 RDW-16.4* Plt Ct-267 [2178-8-14] 05:20AM BLOOD WBC-11.0 RBC-3.46* Hgb-10.8* Hct-33.0* MCV-95 MCH-31.3 MCHC-32.8 RDW-16.6* Plt Ct-214 [2178-8-15] 05:05AM BLOOD PT-24.7* INR(PT)-2.3* [2178-8-14] 05:20AM BLOOD PT-24.8* INR(PT)-2.3* [2178-8-13] 07:15AM BLOOD PT-22.1* INR(PT)-2.0* [2178-8-12] 05:00AM BLOOD PT-20.6* INR(PT)-1.9* [2178-8-11] 02:19AM BLOOD PT-15.7* PTT-28.9 INR(PT)-1.4* [2178-8-6] 12:29PM BLOOD PT-14.0* PTT-39.3* INR(PT)-1.2* [2178-8-6] 11:05AM BLOOD PT-14.6* PTT-37.2* INR(PT)-1.3* [2178-8-15] 05:05AM BLOOD Glucose-92 UreaN-39* Creat-1.3* Na-145 K-3.9 Cl-106 HCO3-29 AnGap-14 [2178-8-14] 05:20AM BLOOD Glucose-94 UreaN-41* Creat-1.2* Na-146* K-4.6 Cl-110* HCO3-27 AnGap-14 [2178-8-13] 07:15AM BLOOD Glucose-97 UreaN-41* Creat-1.2* Na-145 K-3.6 Cl-109* HCO3-27 AnGap-13 [2178-8-11] 02:19AM BLOOD Glucose-94 UreaN-52* Creat-1.6* Na-142 K-3.7 Cl-105 HCO3-26 AnGap-15 [2178-8-15] 05:05AM BLOOD Mg-2.1 [2178-8-14] 05:20AM BLOOD Phos-3.4 Mg-2.3 Brief Hospital Course: On [2178-8-6] Ms.[Known lastname ] was taken to the operating room and underwent Aortic valve replacement with a 19-mm Biocor tissue valve. Cross clamp time=47 minutes. Cardiopulmonary Bypass time=76 minutes. Please refer to operative report for further surgical details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. She awoke neurologically intact and was extubated postoperative night without incident. She weaned off pressor support. Beta-blocker/Statin/Aspirin and diuresis was initiated. All lines and drains were discontinued per protocol. POD#1 she was transferred to the step down unit for further monitoring. On POD#2 she went into new postoperative Atrial fibrillation with ventricular response rate 40-50s and associated hypotension and oliguria. Ms.[Known lastname ] was transferred back to CVICU for further intensive care monitoring. A TTE was done and showed the aortic valve prosthesis well seated, with normal leaflet/disc motion and transvalvular gradients/no pericardial effusion/no echocardiographic signs of tamponade. Electrophysiology was consulted for rhythm recommendations. She was placed on Amiodarone once her rate improved and beta blocker resumed. Her rhythm converted back into sinus. However, anticoagulation was already initiated for her paroxysmal atrial fibrillation. She required PRBC transfusion for postoperative anemia likely due to hemodilution. More aggressive diuresis was initiated. Acute kidney injury occurred with a peak rise in creatinine to 2.0 from her baseline of 0.9. She continued to respond well to diuresis and over the remainder of her hospital course her renal function improved with her creatnine trending back down towards her baseline. She did exhibit some confusion and received Haldol. This cleared. Ms.[Known lastname ] slowly progressed and on POD#5 she was transferred to the step down unit. Physical Therapy was consulted for evaluation of strength and mobility. She was started on Cipro for a positive urinalysis. This was discontinued when the culture revealed contamination. On POD#8 she was cleared for discharge to [Hospital 1474] [Hospital ] rehab. All follow up appointments were advised. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - [1-4] Tablet(s) by mouth daily Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - one Tablet(s) by mouth daily IBUPROFEN - (Prescribed by Other Provider) - 200 mg Capsule - three Capsule(s) by mouth as needed for neck pain Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for bronchospasm. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for bronchospasm. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose to change daily for goal INR 2-2.5, dx: afib. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 40mg [Hospital1 ], then please re-evaluate. 15. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 1474] Hospital TCU - [Hospital1 1474] Discharge Diagnosis: Critical symptomatic aortic stenosis. -s/p Aortic valve replacement with a 19-mm Biocor tissue valve. Past Medical History: Hypertension Hyperlipidemia Neck arthritis Degenerated joint disease Diverticulitis s/p sigmoid resection Discharge Condition: Alert and oriented x3 nonfocal Deconditioned, ambulating Incisional pain managed with Tylenol prn Incisions: Sternal - healing well, no erythema or drainage 2+ pitting edema bilateral lower extremities Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on [9-9] at 1:30pm in the [Hospital ] medical office building [Hospital Unit Name ] Cardiologist:Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] on [9-8] at 3:20pm Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 6699] in [1-4] 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 Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [2178-8-16], then Monday, Wednesday, Friday until INR stable. Please arrange coumadin follow up upon discharge from rehab Completed by:[2178-8-15]	[ "427.31", "272.4", "414.01", "458.29", "285.9", "997.1", "424.1", "V43.65", "401.9", "715.90", "584.9", "518.5", "V43.64", "E878.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.97", "35.21" ]	icd9pcs	[ [ [] ] ]	11268, 11350	6971, 9237	332, 393	11626, 11830	2205, 6948	12754, 13641	1430, 1437		9718, 11245		11372, 11475		9263, 9695			11854, 12731									1452, 2186																				271, 293										421, 943														11497, 11605	1089, 1413
48,504	174,090	3034	Discharge summary	report	Admission Date: [2172-9-30] Discharge Date: [2172-10-8] Date of Birth: [2092-7-20] Sex: F Service: MEDICINE Allergies: Aspirin / Shellfish / Mushroom Flavor Attending:[First Name3 (LF) 2641] Chief Complaint: hip pain Major Surgical or Invasive Procedure: none History of Present Illness: 80 y/o w/ DM2, HTN, HLD, and CAD, presents after a mechanical fall at home. 4 days prior to admission, she was getting out of bed and slided on her back/buttocks to the ground. She denied lightheadedness or dizziness preceeding fall, did not lose consciousness, and denied head strike. She was on the floor for 4 hours, and was helped back to chair with the help of EMS. Since the fall she has been having pain in her right hip. Over the past two days she made almost no urine. She also endorses intermittent chest pain for the past 1-2 weeks, which she attributed to indigestion. Pt denied SOB, HA, N/V/D, weakness, presyncope, recent sickness, or [First Name3 (LF) ] contact. There has been no medication changes. Initial ED vitals: 98 68 130/44 16 98%. Labs notable for CK [Numeric Identifier 14452], trop 0.15, Cr 6.6 (baseline 1.2), BUN 73, K 6.1. ECG showed peaked T waves in the anterior leads. She received 10 units of IV insulin, 1 amp D50, 1 amp bicarbonate, and 30g kayexalate. Foley catheter placed with little to no urine output. 2L of NS given, but urine output still minimal. Bilateral hip x-rays were negative for fracture, CXR negative for acute intrathoracic process, and renal ultrasound did not show hydronephrosis or nephrolithiasis. She also received oxycodone/acetaminophen 5/325mg once for pain. ED reports CP is reproducible on exam. Vitals prior to transfer 98.0 F 114/38, 63, 16 100% RA. On arrival to the MICU, Pt's VS were 97.2, 69, 195/71, 21, 98% on RA. Her K improved with kayexelate, insulin, bicarb. She has received total of 6L IVF, but has not picked up UOP. She is only putting out 10 cc per hour. Her CXR remains clear, and she is maintaining O2 sats. She does have LE edema, and she was transferred out to medicine for continued management of her rhabdo and [Last Name (un) ]. On transfer, her vitals were 97.5 142/45 61 13 98%RA. Currently, on the floor, the pt does not c/o pain or SOB. She is comfortable and eager to ambulate. Most recent labs: K 4.7, HCO3 21, Cr 6.5. Past Medical History: 1. Coronary artery disease (history of single vessel coronary artery status post acute coronary syndrome in [7-31], cardiac catheterization showed 100% LAD occlusion at the first diagonal branch, which was treated with a placement of overlapping Cypher stents) 2. Hyperlipidemia 3. Hypertension: Fairly well controlled on medication (at times incompliant per PCP [Name Initial (PRE) 14453]) 4. Diabetes: Type II 5. Osteoarthritis 6. Obesity 7. Cellulitis: L-foot [9-/2160], R-leg [6-/2162] 8. Cataracts: s/p L-eye cataract removal Social History: Pt lives with husband at home. - Tobacco: denies - Alcohol: social - Illicits: denies Family History: [Name (NI) ] - unclear hx 2 brothers CAD [Name (NI) 6419] sides diabetes, type II Denies family history of cancer or anemia. Physical Exam: Physical Exam on admission: Vitals: 97.2, 69, 195/71, 21, 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear 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, no flank tenderness on percussion GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 1+ pitting edema in LE bilaterally, several cutaneous wounds over left shin ([1-29] recent injury), tenderness on deep palpation over right hip Physical Exam on discharge: Vitals: T 98.3, BP 150/42 (150s-180s)/(40s-70s), HR 57, RR 18, O2Sat 100%RA FBG: 160 (3H), 202 (4H), 191 (3H), 145 (15L) I: 0.88 L, O: 2.9 L (net: approximately -2L) General: Alert, oriented, no acute distress Neck: supple, JVP was not 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-tender, non-distended, bowel sounds present, no organomegaly, no flank tenderness on percussion, no CVA tenderness GU: No Foley cathether Ext: warm, well perfused, 2+ pulses, no clubbing, no cyanosis, 2+ pitting edema in hands and lower extremities to the knees b/l, slightly improved from yesterday, several dressed cutaneous wounds over left shin ([1-29] recent injury) Skin: ecchymoses on R forearm Neuro: AAOx3. Cranial nerves II-XII intact. 5/5 strength in deltoids, TAs b/l. 4+/5 strength in IPs b/l. No asterixis. Pertinent Results: Labs on admission: [2172-9-30] 12:15PM BLOOD WBC-8.8# RBC-3.83* Hgb-11.1* Hct-36.3 MCV-95 MCH-29.0 MCHC-30.6* RDW-13.6 Plt Ct-252 [2172-9-30] 12:15PM BLOOD Glucose-100 UreaN-73* Creat-6.6# Na-139 K-6.1 Cl-105 HCO3-24 AnGap-16 [2172-9-30] 12:15PM BLOOD ALT-314* AST-821* LD(LDH)-1287* CK(CPK)-[Numeric Identifier 14452]* AlkPhos-85 Amylase-70 TotBili-0.3 [2172-9-30] 09:48PM BLOOD CK-MB-91* MB Indx-0.2 cTropnT-0.14* [2172-9-30] 06:53PM BLOOD cTropnT-0.15* [2172-9-30] 12:15PM BLOOD CK-MB-90* MB Indx-0.2 cTropnT-0.15* [2172-9-30] 09:48PM BLOOD Calcium-8.2* Phos-5.6* Mg-2.2 [2172-10-1] 04:06AM BLOOD Type-ART Temp-35.9 Rates-/2 pO2-94 pCO2-40 pH-7.35 calTCO2-23 Base XS--3 Intubat-NOT INTUBA [2172-9-30] 10:06PM BLOOD Type-[Last Name (un) ] pH-7.26* Comment-GREEN TOP [2172-10-1] 04:06AM BLOOD Lactate-0.9 [2172-9-30] 10:06PM BLOOD Lactate-1.9 [2172-10-1] 04:06AM BLOOD freeCa-1.07* [2172-9-30] 10:06PM BLOOD freeCa-1.03* [2172-9-30] 05:25PM URINE Color-DKAMBER Appear-Cloudy Sp [Last Name (un) ]-1.017 [2172-9-30] 05:25PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2172-9-30] 05:25PM URINE RBC-23* WBC-3 Bacteri-FEW Yeast-NONE Epi-5 [2172-9-30] 05:25PM URINE CastGr-4* CastHy-4* Urine sediment ([2172-9-30]): + muddy brown casts BILAT HIPS (AP,LAT & AP PELVIS) ([2172-9-30]): IMPRESSION: No evidence of acute fracture or dislocation. CHEST (PA & LAT) ([2172-9-30]): IMPRESSION: No acute intrathoracic process. RENAL U.S. ([2172-9-30]): IMPRESSION: Grossly normal study, specifically with no hydronephrosis or nephrolithiasis. CHEST (PORTABLE AP) ([2172-10-1]): IMPRESSION: Little overall change. Slight mediastinal widening likely due to patient positioning. CHEST (PORTABLE AP) ([2172-10-1]): Lungs are clear. Heart size is top normal. Large hiatus hernia is chronic. No pleural abnormality. Labs on discharge: [2172-10-8] 07:25AM BLOOD WBC-8.8 RBC-3.25* Hgb-10.0* Hct-29.3* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.0 Plt Ct-379 [2172-10-8] 07:25AM BLOOD Glucose-102* UreaN-96* Creat-6.8* Na-140 K-3.7 Cl-99 HCO3-25 AnGap-20 [2172-10-8] 07:25AM BLOOD Calcium-8.4 Phos-6.0* Mg-2.0 Brief Hospital Course: Patient is a 80 y/o woman with h/o DM2, HTN, HLD, and CAD who presented with hyperkalemia and [Last Name (un) ] in the setting of recent mechanical fall and elevated CK, concerning for rhabdomyolitis. Active Issues: # Acute kidney injury: Pt presented with Cr 6.1, with last Cr 1.2 in [2172-3-27]. The cause of her [Last Name (un) ] was likely multifactorial. Her FeUrea of <10% at presentation in the s/o diuretic use is c/w prerenal kidney injury, likely [1-29] decreased PO intake in the days prior. She developed toxic ATN secondary to rhabdomyolysis in s/o fall with elevated CK. Her rhabdomyolysis was possibly worsened by her simva 80mg (she has been stable on simva 80 since [2168]). The continued use of potentially renal toxic medication (i.e., lisinopril) likely exacerbated her kidney injury. Pt was initially oliguric in the ICU averaging around 10 cc/hr after receiving seven liters of NS. However, once she reached the floor she had a rapid resumption of her renal function and was able to avoid the placement of a dialysis catheter. She was likely in post-ATN diuresis on discharge, averaging nearly negative 2 L per day of UOP. In the setting of [Last Name (un) ] ACE-inhibitor, HCTZ and metformin was held. Simvastatin was held out of concern for worsening of muscle breakdown. Pt did recieve one dose of allopurinol for an elevated uric acid of 8.1. # Metabolic acidosis: Pt's bicarb was closely monitored for concern of metabolic acidosis. It trended down to a nadir of 12 on [2172-10-2]. She received multiple ampules of sodium bicarb and was then placed on a sodium bicarb drip with appropriate response. Her bicarb was WNL and stable on discharge. # Hyponatremia: Pt became hyponatremic after the sodium bicarb drip with significantly increased dependent edema. She had no pulmonary edema. In the setting of her [Last Name (un) ], she was most likely unable to reabsorb sodium efficiently with her injuried tubules, precipitating a hypervolemic hyponatremia. After discontinuation of her sodium bicarb gtt, her hyponatremia resolved. # Hyperkalemia: She likely developed hyperkalemia in the setting of rhabdomyositis and [Last Name (un) ]. There were peaking T-waves in ED, but no change compared to 1/[2171]. Pt was given calcium, glucose/insulin, kayxelate and 6L NS in the ICU. Once on the floor, initial potassium was 5.4, for which she reiceved a dose of kayexalate, after which her potassium was WNL and stable. # Anemia: Pt's anemia was most likely dilutional in nature, given her fluid intake greater than urine output. Her hematocrit was trended and monitored on this admission. # Chest pain: Pt has a history of CAD s/p LAD stenting in [2165]. However, her history is atypical for ACS. Chest pain was completely resolved once she arrived on the floor. Per ED signout, pain was reproducible on palpation. Cardiac enzymes mildly elevated, but stable, with troponin 0.15, MB 20, confounded by poor renal clearance. Chest pain was most likely related to indigestion (see Hiatal hernia section below). # HTN: Pt presented with BP 208/66, likely in the setting of [Last Name (un) ] and fluid overload. Lisinopril and hydrochlorothiazide were held given [Last Name (un) ], with continuation of metoprolol tartrate 25 mg qid. She was also discharged on amlodipine 5 mg daily. # DM2: Pt has documented DM2, on metformin 1g/d. Last A1c 7.3 in [2172-3-27]. Metformin was held in light of elevated creatinine and pt was placed on a humalog sliding scale and lantus 15 units at bedtime. # HLD: Pt was stable on simvastatin 80 mg since [2168]. Pt denied possibility of overdose. Simvastatin was held because of concern for muscle breakdown. Pt will be started on atorvastatin 40 mg as outpatient. # Hiatal hernia: Pt has a retrocardiac opacity concerning for hiatal hernia per CXR report. She also complains of heart burn. However, pt is not on treatment for GERD despite close PCP [Name Initial (PRE) 4939]. She may need outpatient follow-up to make sure not secondary to other etiology. Pt was treated empirically with famotidine initially and then omeprazole on this admission. Transitional Issues: -Pt takes care of [Name Initial (PRE) ] husband and [Name2 (NI) ] daughter, and was unable to do so during her illness. She will need support with family coping. -Pt was DNR/DNI on this admission. -Pt will follow up with Nephrology in early Novemeber -Pt will need Chem10 checked every other day for the first week at rehab, then twice a week until discharge. Please call Dr. [Last Name (STitle) ] with any worsening of her renal function. Medications on Admission: DIAZEPAM - 5 MG [Hospital1 ] HYDROCHLOROTHIAZIDE - 25 mg daily INSULIN GLARGINE [LANTUS] - 35 units sc qam LISINOPRIL - 20 mg daily METFORMIN - 500 mg [Hospital1 ] METOPROLOL SUCCINATE [TOPROL XL] - 100 mg daily NITROGLYCERIN [NITROSTAT] - 0.3 mg PRN SIMVASTATIN - 80 mg daily CYANOCOBALAMIN - 1,000 mcg daily FERROUS SULFATE [IRON (FERROUS SULFATE)] - 325 mg daily Discharge Medications: 1. diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: please take 15 units at bedtime. 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. sliding scale Please see attached humalog sliding scale Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Rhabdomyolysis Acute kidney injury Secondary: Diabetes Mellitus Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [Known lastname 4223], It was a pleasure to take care of you during your admission at the [Hospital1 69]. You were admitted for hip pain following your fall at home. We ran a number of blood and imaging tests during your admission. Due to muscle breakdown from when you fell down, your kidneys stopped making urine. We treated you with fluids and medications to adjust the level of electrolytes in your body. We considered starting dialysis when you were not making much urine, but you kidney's responded to our treamtment and you did not require any dialysis. You are now ready for discharge to a rehab facility. Please follow up with Dr. [Last Name (STitle) ] one to two weeks after dicharge from your rehab facility. MEDICATION CHANGES STARTED OMEPRAZOLE 20 MG DAILY STARTED AMLODIPINE 5 MG DAILY STARTED HUMALOG SLIDING SCALE STOPPED SIMVASTATIN 80 MG STOPPED HCTZ 25 MG DAILY STOPPED LISINOPRIL 20 MG DAILY STOPPED METFORMIN 500 MG TWICE A DAY CHANGED LANTUS TO 15 UNITS AT BEDTIME Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4094]: INTERNAL MEDICINE Location: [Hospital3 249] [Hospital1 ]/EAST Address: [Location (un) ], E/CC-6, [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 250] Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2172-10-28] at 1:30 PM With: [Doctor Last Name ] [First Name8 (NamePattern2) 251] [Name8 (MD) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "276.7", "272.4", "250.00", "553.3", "715.90", "414.01", "V49.86", "401.9", "276.1", "285.9", "728.88", "278.00", "276.2", "584.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13126, 13192	7160, 7366	307, 314	13334, 13334	4874, 4879	14561, 15393	3063, 3197		12249, 13103		13213, 13313		11850, 12226			13517, 14538									3212, 3226											3922, 4855			11367, 11824						259, 269		7382, 11345				6863, 7137				342, 2371							4894, 6843		13349, 13493					2393, 2944	2960, 3047
16,001	149,304	50136	Discharge summary	report	Admission Date: [2143-10-30] Discharge Date: [2143-11-11] Date of Birth: [2099-12-31] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 43-year-old man with history of recurrent optic nerve schwannoma on the right side, status post several craniotomies, who presented to [Hospital1 1444] after having generalized tonic clonic seizure on [10-30]. The other day had fever of 101 and upper respiratory symptoms for about 7 days prior to the seizure. The patient received 5 mg of Valium in the Emergency Room, was intubated for lethargy and transferred to neuro ICU. His initial lab data revealed acidosis believed to be secondary to seizure. MRI revealed an area of enhancement posterior to the right orbital prosthesis which was thought to be residual tumor. Also found to have cervical lymphadenopathy and multiple sub cm lymph nodes seen throughout the neck. Head CT showed encephalomalacia in the right frontal and temple region most likely related to previous surgery. Three days after the admission he started to have spiking fever up to 101 on [11-2]. At this time he had been hospitalized in neurology service. Since that time his temperatures were in the range of 99 to T max 104. His work-up for fever was initiated. This included LP which revealed 40 white blood cells with predominance of lymphs, 87 RBC, protein 96 and glucose 92. Cultures were negative. He was treated with Ceftriaxone and Vancomycin from [10-30] which was discontinued on [11-3]. He developed rash which was believed to be secondary to either antibiotics or Dilantin. Antibiotics and Dilantin were discontinued and he was started on Depakote. After this change, rash did improve. His other work-up for fever included blood cultures which were negative, sputum from [11-2] showing gram negative rods, gram negative diplococci, urine culture was negative and Lyme was negative. Chest x-ray was also negative and ultrasound of the abdomen were also unremarkable. During the hospitalization on neurology service he also developed transaminitis for which had abdominal ultrasound and KUB, as well as EBV, RS, [Doctor First Name ] and ESR which were within normal limits. For further work-up of fever he was transferred to medicine service. PAST MEDICAL HISTORY: Hypertension, recurrent Schwannoma of the right optic nerve, status post multiple surgeries. MEDICATIONS: On transfer, Robitussin prn, Depakote 250 mg [Hospital1 ], Lipitor 20 mg po q d, Atenolol 25 mg po q d, Hydrochlorothiazide 25 mg po q d, Protonix 40 mg po q d, Ativan 1 mg po prn. ALLERGIES: Penicillin, Percocet and contrast dye after which he develops rash. SOCIAL HISTORY: Denies smoking or alcohol history. FAMILY HISTORY: Unremarkable for history of Schwannoma. PHYSICAL EXAMINATION: General, temperature 98.4, T max on [11-6] 100.8, heart rate 79, respirations 18, blood pressure 112/64, 95% on room air. HEENT: Revealed right sided eye prosthesis, left pupil reactive to light from 5 to 4 mm, extraocular movement in the left eye full, mucus membranes are moist. Neck without LAD or JVD. Cardiac exam reveals S1 and S2, regular rate and rhythm, no murmur. Lungs, clear to auscultation with decreased breath sounds in the right base. Abdomen soft, nontender, non distended with positive bowel sounds. Extremities without edema. Skin revealed macular rash in the abdomen and extremities. Neurologically has normal mental state, right eye prosthesis, otherwise non focal exam. HOSPITAL COURSE: This is a 43-year-old man with history of recurrent right optic nerve Schwannoma, now admitted for seizure and fever work-up. 1. Fever: The patient was transferred from neurology to medicine service for further work-up of fever. The T max during the hospitalization was 101 and since that time he only had low grade fever to 100. His work-up was unremarkable for infectious sources and it was therefore felt that his elevated temperature is most likely related to drug fever as patient also developed rash after antibiotics and Dilantin. After discontinuation of the above medication, his rash improved and he stayed afebrile for four days. 2. Transaminitis: This was felt to be also secondary to medications and his LFTs were trending down. He had ultrasound of the right upper quadrant which was unremarkable. 3. Neurology: The patient has history of generalized tonic clonic seizures in the setting of fever. He was started on Dilantin after which he developed a rash and for this reason was switched to Depakote and had no additional seizures during the hospitalization. His EEG revealed abnormal findings due to presence of permanent focal right hemisphere subcortical structure abnormality. He was discharged on 750 mg of Depakote with still subtherapeutic level. He should have repeat Depakote level several days after discharge and the dose might be further increased. LABORATORY DATA: White blood count on admission 15.4, on discharge 5.8, hematocrit 37.2, hemoglobin 13.3, platelet count 304,000, INR 1, PTT 20.9, fibrinogen 512, ESR 45. Urinalysis was negative with traces of protein, 4 RBC, 2 WBC, few bacteria. CSF revealed 14 white blood cells, 87 RBC, protein of 96, glucose 92, sodium 142, potassium 3.9, chloride 105, CO2 29, creatinine 0.7, BUN 10, LD 252, ALT initially 197, on discharge 149, AST on admission 257, decreased to 100, CK initially 9,717, decreased to 1,025, calcium, potassium, magnesium within normal limits. The patient's MRI and head CT as described in the hospital course. DISCHARGE DIAGNOSIS: 1. Generalized tonic clonic seizures. 2. Drug fever. 3. Recurrent right optic nerve Schwannoma. DISCHARGE MEDICATIONS: Unchanged as medication on transfer with the exception of Depakote which will be 500 mg po q a.m. and 250 mg po q p.m. Patient was discharged home in stable condition with follow-up with Dr. [Last Name (STitle) ] on [2143-11-13] when the level of Depakote should be checked and the range should be kept between 50-100. [Name6 (MD) 251] [Last Name (NamePattern4) 6366], M.D. [MD Number(1) 6367] Dictated By:[Last Name (NamePattern1) 6063] MEDQUIST36 D: [2143-11-11] 11:32 T: [2143-11-12] 18:32 JOB#: [Job Number 104659]	[ "693.0", "780.6", "V10.85", "401.9", "790.5", "465.9", "599.7", "272.0", "780.39" ]	icd9cm	[ [ [] ] ]	[ "03.31", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]							2761, 2802		5726, 6321		5602, 5702			3548, 5581																					2825, 3530																				159, 2294														2317, 2691	2708, 2744
16,644	183,141	6874	Discharge summary	report	Admission Date: [2183-11-24] Discharge Date: [2183-12-1] Service: CARDIOTHORACIC Allergies: Sulfonamides Attending:[First Name3 (LF) 1283] Chief Complaint: near syncope, known AS, no chest pain Major Surgical or Invasive Procedure: CABG X 3, AVR (#21 tissue) History of Present Illness: 82 y/o female w/near syncope, known AS. Also with significant right internal carotid artery stenosis, S/P carotid stent by Dr. [First Name (STitle) ] in [2183-8-31]. Echo: EF 60%, [Location (un) 109] 0.6, peak grad 70. CAth revealed 3vCAD, EF 70% Past Medical History: DM, Hyperlipidemia, HTN, AS; CHF; appendectomy; hysterectomy; dyspnea after walking 15 min; sleeps with 3 pillows; s/p 2 cath in past 4 years Social History: Lives alone No h/o tobacco, etoh, or drug use Family History: non-contributory Physical Exam: pre-op exam WNL, grade III/VI systolic murmur, K+ 5.2, creat 1.3, other pre-op labs WNL Pertinent Results: [2183-11-29] 06:45AM BLOOD WBC-12.3* RBC-4.70 Hgb-12.8 Hct-37.2 MCV-79* MCH-27.2 MCHC-34.4 RDW-20.1* Plt Ct-179 [2183-11-30] 06:00AM BLOOD Hct-36.6 [2183-11-30] 06:00AM BLOOD Glucose-112* UreaN-23* Creat-1.1 Na-139 K-4.6 Cl-102 HCO3-28 AnGap-14 Brief Hospital Course: Admitted directly to OR on [2183-11-24] Underwent CABG X 3, AVR (21mm tissue), post-op tx. to CSRU on dobutamine, insulin, and propofol gtts, weaned from ventilator, and extubated the day of surgery. POD # 1 Dobutamine weaned off, respiratory acidosis, requiring aggressive pulmonary toilet, with intermittant BIPAP. Improved by later that day, transfused, and diuresed. IV NTG for hypertension POD # 2 transferred to telemetry floor, chest tubes removed POD # 3 creatinine up to 1.7, JP drain removed from left upper leg incision, NPH insulin resumed at half of her pre-op dose, oral antihypertensives increased POD # 4 short non-sustained atrial fibrillation early in am (with controlled rate), creatinine back down to 1.1, lasix increased for worsening edema Left upper leg draining from JP site, large area of old hematoma noted POD # 5 beagn ambulation, but still requiring oxygen and assistance POD # 6 no further AFib, still with dificulty ambulating POD # 7 stable and ready for transfer to rehab Medications on Admission: [Date Range ] 325 daily NPH insulin, 44Units Q am and 10 units of NPH with 5 humalog Q PM [Date Range ] 75 mg daily (lifelong) Cozaar Toprol XL 25mg daily Protonix 40 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous Q AM: Humulin NPH insulin, 30 Units s/c Q am, and 10 units s/c Q PM. 14. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: One (1) vial Subcutaneous three times a day: sliding scale humalog s/c TID/AC: BS 120-150 = 2Units BS 150-200 =4 Units BS 200-250 = 6 units BS > 250 = 8 units. 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous Q AM: Humulin NPH insulin, 30 Units s/c Q am, and 10 units s/c Q PM. 14. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 15. Humalog 100 unit/mL Solution Sig: One (1) vial Subcutaneous three times a day: sliding scale humalog s/c TID/AC: BS 120-150 = 2Units BS 150-200 =4 Units BS 200-250 = 6 units BS > 250 = 8 units. Discharge Disposition: Extended Care Facility: Life Care Center of [Location 15289] Discharge Diagnosis: CAD AS HTN DM Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no lifting > 10 # or driving for 1 month no creams, lotions or ointments to any incisions may apply dry dressings to thigh incision and change as needed for drainage Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet [Last Name (NamePattern4) 2138]p Instructions: with Dr. [Last Name (STitle) 6700] in [3-4] weeks with Dr. [Last Name (STitle) ] [3-4] weks woth Dr. [Last Name (Prefixes) ] in 4 weeks Completed by:[2183-12-1]	[ "426.11", "428.0", "V12.59", "276.2", "285.9", "E878.8", "424.1", "278.00", "997.1", "272.0", "433.10", "414.01", "427.31", "401.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "99.09", "35.21", "36.12", "39.61", "99.05", "99.04", "93.90", "88.72" ]	icd9pcs	[ [ [] ] ]	5517, 5584	1251, 2263	265, 294	5642, 5648	970, 1228		829, 847		2497, 5494		5605, 5621		2289, 2474			5672, 5986			6037, 6225						862, 951																				188, 227										322, 585														607, 750	766, 813
4,587	167,141	7616+7617+55853	Discharge summary	report+report+addendum	Admission Date: [2149-11-30] Discharge Date: [2149-12-29] Date of Birth: [2077-8-1] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 72 year old man with a past medical history of congestive heart failure, diabetes mellitus type 2, hypertension, peripheral vascular disease and chronic renal insufficiency who was initially congestive heart failure and acute renal failure. He had a protracted hospital course and was intubated for bilateral pneumonia and congestive heart failure. He also ruled in for an myocardial infarction. His hospital course was also complicated by hypoglycemia and hypothermia, and new onset atrial fibrillation, mental status changes and acute renal failure. He was placed on Bi-PAP for question of obstructive [2149-11-25]. However, he was only there for eight hours until he developed acute shortness of breath and productive cough. He was hypoxic to 70% on two liters nasal cannula. Arterial blood gas revealed 7.45/50/30 and brought back to [Hospital3 ] for further evaluation. Chest x-ray showed pulmonary edema and he was diuresed with Bumex/Diuril with initial subjective improvement. He was readmitted to the Intensive Care Unit for Bi-PAP. He was on Levaquin initially started on [11-25] for urinary tract infection. He was initially diuresed with Bumex and Hydrochlorothiazide and was eventually started on Lasix gtt with supplemental Diuril twice a day. Once sensitivities returned on urine cultures, Pseudomonas sensitive to Ciprofloxacin, Gent and Ceptaz, he was started on Ceptaz and then Ciprofloxacin was added on [11-26]. Ceptaz was discontinued on [11-27]. He did not succeed with trial of Bi-PAP and was intubated on [11-26] with persistent hypoxemia. He ruled in for an myocardial infarction, peak CPK of 339, MB index of 8.9 and troponin peak of 10.5 He was started on aspirin and Nitropaste. A transesophageal echocardiogram was done which showed a "new AS myocardial infarction" and ejection fraction of 25 to 30%. BUN/creatinine increased from baseline range; creatinine 3.5 to 94/5.6 and urine output fell to 20 to 30 cc per hour, FENA calculated at 3.26%. He was subsequently started on amiodarone gtt and Lasix gtt for management of presumptive cardiogenic shock and congestive heart failure on [11-28]. Urine output initially picked up to 70 cc per hour on this regimen. He also had a hematocrit drop to 24.6 and was transfused with 2 units of packed red blood cells with appropriate increase in his hematocrit. Family requested transfer to [Hospital1 188] on [2149-11-30], for further management and dialysis, ultra-filtration after there with no improvement on current regimen. PAST MEDICAL HISTORY: 1. Congestive heart failure. Last TTE prior to current hospitalization was an ejection fraction of 50%. 2. Type 2 diabetes mellitus times 20 years. 3. Hypertension. 4. Peripheral vascular disease status post right fourth and fifth toe amputations. 5. Chronic renal insufficiency with creatinine rise to 3.0 on previous admissions. 6. Gout. 7. Chronic lower extremity edema. 8. Obstructive sleep apnea on C-PAP. 9. History of negative recent Persantine thallium test. 10. History of guaiac positive stools in the past but no record on this admission. 11. Anemia of chronic renal disease on Epogen. 12. History of atrial fibrillation. 13. Coronary artery disease status post Dobutamine Cardiolyte [2149-11-17]. Large defects anteroseptal fixed, septal partial inferior fixed, moderate defect, inferior apical fixed ejection fraction 43%. MEDICATIONS: As an outpatient: 1. Levaquin 500 mg p.o. q. day from [11-25] until [11-29] for a presumed urinary tract infection. 2. Diuril 250 mg p.o. twice a day. 3. Bumex 60 mg p.o. twice a day. 4. Norvasc 10 mg p.o. q. day. 5. Epogen 10,000 units subcutaneously q. week. 6. Lipitor 40 mg p.o. q. day. 7. Subcutaneous heparin 5,000 units twice a day. 8. Tums two tablets p.o. three times a day. 9. Colace 100 mg p.o. twice a day. 10. Sliding scale of Humalog. 11. Hydrochlorothiazide 25 mg p.o. twice a day. 12. Bi-PAP at night at setting of 20/1013. 13. Nystatin powder to groin three times a day. 14. Tylenol p.r.n. 15. Ambien 5 mg p.o. q. h.s. 16. Milk of Magnesia 30 cc p.o. q. six p.r.n. constipation. 17. Dulcolax suppositories 10 mg p.r. q. day for constipation. 18. Mylanta 15 to 30 cc after a loose bowel movement. 19. Lactulose 30 cc p.o. q. h.s. p.r.n. constipation. MEDICATIONS ON TRANSFER: 1. Nitropaste 1 inch q. six hours. 2. Reglan 10 mg four times a day. 3. Hydrochlorothiazide 25 mg twice a day. 4. Epogen 10,000 subcutaneously q. week. 5. Lipitor 40 mg p.o. q. day. 6. Heparin 5,000 units subcutaneously twice a day. 7. Tums 2 mg p.o. twice a day. 8. Colace 100 mg p.o. twice a day. 9. Nystatin Powder three times a day. 10. Ciprofloxacin 500 mg p.o. q. day. 11. Prevacid 30 mg p.o. q. day. 12. Amiodarone gtt 24 micrograms per kilogram per minute. 13. Lasix gtt 20 mg per hour. 14. Aspirin 162 mg p.o. q. day. 15. Tube feeds, Nevosource. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Quit smoking 20 years ago; positive heavy alcohol use until four to six weeks prior to admission. The patient is married and has several children. The patient is full code. FAMILY HISTORY: Mother and father died from cancer. Brother with myocardial infarction at age 55. PHYSICAL EXAMINATION: On admission, temperature of 99.2 F.; temperature maximum of 101.1 F.; heart rate 84 to 96; blood pressure of 90/58 to 126/46; respiratory rate 26. Initial ventilatory settings, AC-Mode, 750 by 14, 50% FIO2, PEEP of 5, arterial blood gas revealed 7.40/39/76. Generally, alert and oriented, responds to voice and follows commands. HEENT: Pupils equally round and reactive to light. Extraocular muscles are intact. ET tube in place. Neck was supple; no jugular venous distention. Chest: Crackles at bases bilaterally. Rhonchi bilaterally. Heart regular, S1, S2, no murmurs, rubs or gallops. Abdomen was soft, nontender, nondistended. Positive bowel sounds, no bruits. Extremities: Chronic venous changes. Two plus pitting edema. Neurologic was nonfocal. LABORATORY: CBC with white count of 11.9, hemoglobin 9.4, hematocrit 30.4, platelets 187,000. Sodium 133, potassium 3.9, chloride 93, CO2 26, BUN 94, creatinine 5.6, calcium 6.9, phosphorus 6.1, albumin 1.8, total protein 5.8. Infectious Disease: [11-27], blood cultures times two no growth to date; [11-26], ova and parasites pending. C. difficile negative. [11-26] blood cultures times two, no growth to date. [11-26] urine culture, greater than 100,000 Pseudomonas sensitive to Ceptaz, Ciprofloxacin, Tobramycin, Piperacillin, Levaquin, Imipenem. [11-30], C. difficile negative times three. [Hospital1 18] LABORATORY: White count of 13.8, hematocrit 29.8, platelets 193,000. INR 1.5, PT 14.7, PTT 41.7. Sodium 132, potassium 3.9, chloride 89, bicarbonate 26, BUN 95, creatinine 5.7, glucose 147. Albumin 2.5, calcium 7.1, phosphorus 5.8, magnesium 1.7, CK 101, MB 17, troponin 16.8; was 1.3% several hours off Lasix gtt. EKG on [11-30], upon arrival to [Hospital1 18]: Wandering atrial pacemaker at 99, first degree AV block, left axis deviation. T wave flattening in I, T wave inversion in AVL. Persistent 1 to [Street Address(2) 1766] depression in V3 through V6, worsened since [11-29], but improved since [11-26]. These changes are new since early [11-8]. BRIEF SUMMARY OF HOSPITAL COURSE: This is a 72 year old male with a past medical history of type 2 diabetes mellitus, coronary artery disease and congestive heart failure with recent myocardial infarction and Pseudomonal urinary tract infection, question urosepsis, that is complicated by congestive heart failure and worsening oliguric, acute on chronic renal failure, who was transferred to [Hospital1 18] on [11-30] for further management of renal and cardiac issues. 1. Pulmonary: The patient was initially intubated for pneumonia and congestive heart failure at [Hospital3 ]. He was eventually extubated but placed on Bi-PAP. The patient was discharged to Rehabilitation on [11-25] but returned with hypoxemic respiratory distress the same day with arterial blood gas of 7.45/50/30. Chest x-ray was consistent with pulmonary edema and diuresed with improvement. Readmitted to the Intensive Care Unit for Bi-PAP but eventually re-intubated on [11-26] for persistent hypoxemia. He was transferred here at the family's request intubated. His congestive heart failure was treated as below but apparently without significant improvement in chest x-ray. Wean on pressure support was attempted on [12-9], and he was eventually extubated on [12-10], but became hypoxemic to the high 80s and reintubated after a trial of Bi-PAP on [12-12]. Thoracentesis was done on [12-12] for large bilateral pleural effusion, and left drained approximately 1 liter consistent with exudate and negative culture, thought to be consistent with congestive heart failure. On [12-13], given his persistent congestive heart failure with Cardiology consultation planning catheterization, he was transferred to he CCU team. Post catheterization and with continued dialysis, improved pressure support of 15/5, extubated on [12-18]. He became increasing hypercarbic and asked to wear Bi-PAP 15/5 FIO2 of 50% with some improvement. However, the patient was intermittently refusing Bi-PAP. The patient was intermittently weaned off Bi-PAP and remained off Bi-PAP on [12-26] for approximately two days with no acute worsening in arterial blood gas. It was thought, however, that patient would benefit from bi-PAP at night. The patient had an original gas off Bi-PAP 12 noon on [12-24] of 7.26/50/91. The patient continued on Bi-PAP until 5 p.m. when another arterial blood gas was drawn which revealed a gas of 7.33/46/120. At 2 a.m., 40% cool nebulizer arterial blood gas revealed 7.34/44/95. The patient had an a.m. arterial blood gas on [12-26], revealing 7.30/49/85. It was at this time that the patient was thought to likely benefit from Bi-PAP at night. The patient was anticipating discharge to Rehabilitation with this plan in place. The patient, at times, subjectively complains of dyspnea, however, arterial blood gases during these times were essentially unrevealing for worsening respiratory status. 2. Cardiology: Hemodynamically, the patient was diuresed originally with Bumex/Diuril with initial subjective improvement and started on Lasix drip. After myocardial infarction with his peak CK of 339, a transesophageal echocardiogram was done showing new AS myocardial infarction and ejection fraction of 25 to 30%. The patient was originally started on amiodarone as well and urine output picked up initially. The patient was transferred here on Amiodarone and Lasix gtt which were discontinued and he was changed to Levophed. A Swan showed a cardiac index of 1.89 with an SVR of 18. Transesophageal echocardiogram here showed moderate to severe hypokinesis with an ejection fraction of 30%. Both Cardiology and Renal recommended Dopamine instead of Levophed. On Dopamine, his Swan showed pulmonary wedge pressure of 30, cardiac index of 1.5, SVR of 734, read as consistent with congestive heart failure. Zaroxolyn and Dobutamine were added and the patient subsequently went into atrial fibrillation. Eventually, off all pressors on [12-7] and Hydralazine and Isordil were titrated up. The patient was re-Swanned on [12-11], with an initial pulmonary capillary wedge pressure of 16, but then the next day pulmonary capillary wedge pressure was 26 with an index of 2.25. He also had new T wave inversions and eventually taken to catheterization on [12-15]. Since catheterization, he has continued hemodialysis and diuresis with improvement to extubation. 3. Coronary artery disease: The patient ruled in for myocardial infarction at initial presentation at [10/2149], with peak CKs in the 300s. After increasing wedge pressures and anterior T wave inversions, he was eventually taken to the catheterization laboratory on [12-15]. An 80% proximal left anterior descending lesion was stented. Post-cath the patient was placed on Plavix and continued on aspirin. Beta blocker was held because of congestive heart failure and Lipitor was continued. 4. Rhythm: The patient had eight to ten beat run of non-specific ventricular tachycardia on [12-5]. The patient developed atrial fibrillation in [Hospital1 ] in 11/[2148]. The patient back in sinus but went back into atrial fibrillation on Dobutamine. On the CCU Team, he was loaded on amiodarone for atrial fibrillation and Digoxin, but has remained in atrial fibrillation. It was unclear prior to discharge what the exact status or plan for cardioversion in the future will be. This will be addressed in an addendum discharge. 5. Renal: BUN/creatinine increased from baseline of 3.5 to 5.6 and urine output fell in the setting of a myocardial infarction. Thought sepsis/cardiogenic shock ATN. Renal ultrasound was also negative. However, urine output continued to be marginal and fluid status was positive and he was eventually started on Ultra-filtration/hemodialysis on [12-5]. Six kilograms were removed from [12-5] until [12-11], although his urine output continued to decrease. The patient continued on hemodialysis throughout the length of his hospital stay and it was presumed he would continue hemodialysis as an outpatient. 6. Infectious Disease: The patient had urinary tract infection treated with Levaquin on [11-25], later returned as Pseudomonas and he was started on Ciprofloxacin/Gent and Ceptaz. On [12-1], a new right lower extremity cellulitis was noted and he received seven days of Vancomycin. He was treated for a urinary tract infection with Ciprofloxacin on [12-16] for three days although culture later was negative. The patient also developed left upper lobe infiltrate with increased white count and was started on Vancomycin on [12-16], after sputum culture grew out Methicillin resistant Staphylococcus aureus pneumonia. The patient was to continue a 14 day course to finish on [2149-12-30]. 7. Endocrine: The patient ruled out for renal insufficiency and continued on sliding scale insulin for control of diabetes mellitus. 8. Hematology: Initial studies on transfer were consistent with low-grade DIC. Schistocytes negative on peripheral smear and was treated with Vitamin K. Though initially thought to have uremic platelets causing continuous oozing from line sites and given DDAVP. Also transfused five units of packed red blood cells over the course of admission to maintain a hematocrit of approximately 27. The patient was given Epogen at dialysis. The patient was attempted on anti-coagulation for atrial fibrillation but had continued oozing from line/venipuncture with loss of one to two packed red blood cells. The patient was kept off anti-coagulation heparin and Coumadin. The patient was put on aspirin and Plavix post. 9. Psychiatric: The patient was started on Paxil for depression. 10. Code Status: The patient had multiple discussions regarding code status with patient and family. At time of this dictation, the patient is a full code. This appears to be an ongoing discussion with the family and the patient. 11. Lines: The patient had a right subclavian Quinton dialysis catheter placed on [12-12], through which he continued on dialysis. 12. Fluids, Electrolytes and Nutrition: The patient was started on tube feeds for nutrition. The patient tolerated tube feeds without side effects. The patient began tolerating p.o. intake on his own. At time of dictation, the patient was being transitioned from tube feeds to oral feeding. DISCHARGE STATUS: The patient was discharged to Rehabilitation. CONDITION AT DISCHARGE: The patient is in fair condition. The patient, however, is severely deconditioned. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Chronic renal insufficiency. 3. Methicillin resistant Staphylococcus aureus pneumonia. DISCHARGE MEDICATIONS: 1. Reglan 5 mg p.o. four times a day. 2. Prevacid Elixir 30 mg p.o. q. day. 3. Lipitor 40 mg p.o. q. day. 4. Regular insulin sliding scale. 5. Aldactone 25 mg p.o. q. day. 6. Nepro tube feeds at 45 cc per one hour. 7. TUMS 500 mg p.o. three times a day. 8. Vancomycin 1 gram intravenously single dose after dialysis until [12-30]. 9. Aspirin 325 mg p.o. q. day. 10. Plavix 75 mg p.o. q. day which should be stopped on [1-15]. 11. Digoxin 0.125 mg p.o. after dialysis. 12. Captopril 37.5 mg p.o. three times a day. 13. Nephrocaps, one p.o. q. day. 14. Epogen 5000 units intravenously three times a week after dialysis. 15. NPH insulin 10 units subcutaneously q. a.m., and 6 units subcutaneously q. h.s. 16. Ativan 0.5 to 1 mg intravenously q. four p.r.n. 17. Tylenol 650 mg p.o. q. six p.r.n. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 5587] Dictated By:[Last Name (NamePattern1) 1324] MEDQUIST36 D: [2149-12-26] 12:51 T: [2149-12-26] 13:33 JOB#: [Job Number 27792] Admission Date: [2149-11-30] Discharge Date: [2150-1-2] Date of Birth: [2077-8-1] Sex: M Service: [Doctor Last Name ] NOTE: This is a STAT addendum Discharge Summary covering the period from [2149-11-30] to [2150-1-2]. HOSPITAL COURSE: 1. PULMONARY: From a pulmonary standpoint, the patient had no further complications of pulmonary edema after discharge from the Medical Intensive Care Unit to the floor. The patient completed a course of vancomycin for methicillin-resistant Staphylococcus aureus pneumonia. 2. CARDIOVASCULAR: From a cardiovascular standpoint, the patient had no recurrence of pulmonary edema. He did experience episodic Wenckebach heart rhythm with a rate in the 50s with very rare sinus pauses. This was thought to be secondary to the amiodarone that the patient was on. His amiodarone dose was titrated down to 200 mg q.d. Electrophysiology was re-contact[Name (NI) ] regarding this. They did not feel that there was need for pacemaker for bradycardia at this time, but rather suggested that the patient's amiodarone be decreased to 200 mg q.d. as mentioned above. Otherwise, the patient was continued on his cardiac regimen. He had several follow-up electrocardiograms that continued to show sinus rhythm with left axis deviation, intraventricular conduction delay, left ventricular hypertrophy by voltage, and ST depressions in V2 and V3 that were unchanged when compared to previous electrocardiograms. The patient had no symptomatic complaints of shortness of breath or chest pain for the rest of his hospitalization. 3. RENAL: From a renal standpoint, the patient was continued on hemodialysis through a tunnel Perm-A-Cath. Nephrology followed the patient while in the hospital, and the decision was made that the patient would be discharged on hemodialysis through his tunnel catheter and would have both Renal followup and followup in Transplant Surgery Clinic for a possible arteriovenous fistula placement. 4. INFECTIOUS DISEASE: From an infectious disease standpoint, the patient completed a course of vancomycin for methicillin-resistant Staphylococcus aureus pneumonia. The patient had episodes of diarrhea while in the Intensive Care Unit. Clostridium difficile toxin and fecal leukocytes were negative both in the Intensive Care Unit and on the floor. 5. ENDOCRINE: From and endocrine standpoint, the patient had a negative workup for adrenal insufficiency in the Intensive Care Unit. On the floor he was continued on a regular insulin sliding-scale and NPH regimen with very good glycemic control. 6. HEMATOLOGY: From a hematologic standpoint, the patient had received a total of 5 units of packed red blood cells and had been started on Epogen with a very stable hematocrit throughout his hospitalization. 7. PSYCHOSOCIAL: From a psychosocial standpoint, the patient continued to evidence a reluctance to participate in his recovery; refusing to wear BiPAP for his sleep apnea and refusing to work with Occupational Therapy and Physical Therapy. The patient had already been started on Paxil for depression, and it was felt that his attitude was most likely secondary to his medical condition. He was strongly encouraged to participate in activities that would help improve his conditioning. Toward the end of the hospitalization the patient became more participatory in his recovery. 8. FLUIDS/ELECTROLYTES/NUTRITION: From a fluids, electrolytes, and nutrition standpoint the patient was continued on tube feeds and began to take food orally during the last few days of admission. He began to show increasing interest in oral nutrition. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: 1. The patient was to be discharged with a follow-up appointment in the [Hospital 2793] Clinic with Dr. [First Name4 (NamePattern1) 6930] [Last Name (NamePattern1) 3271] on Tuesday, [2150-1-12], at 2:30 p.m. 2. He was also arranged to follow up in the Cardiology Clinic with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on Monday, [1-12], at 1:20 p.m. 3. The patient was arranged to have an evaluation for arteriovenous fistula placement in the Transplant Surgery Clinic with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2150-1-15], at 2:30 p.m. DISCHARGE STATUS: The patient was discharged to [Hospital ] Rehabilitation Facility. MEDICATIONS ON DISCHARGE: 1. Enteric-coated aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. (until [2150-1-15]). 3. Paxil 20 mg p.o. q.h.s. 4. Nepro tube feeds (goal 75 cc per hour). 5. Tums 500 mg p.o. t.i.d. 6. Digoxin 0.125 mg p.o. post dialysis only. 7. Captopril 37.5 mg p.o. t.i.d. 8. Reglan 5 mg p.o. q.i.d. 9. Renese supplement 1 p.o. t.i.d. 10. Lipitor 40 mg p.o. q.d. 11. Regular insulin sliding-scale. 12. NPH insulin 10 units subcutaneous q.a.m. and 6 units subcutaneous q.p.m. 13. Nephrocaps 1 tablet p.o. q.d. 14. Epogen 5000 units intravenous three times per week by dialysis nurse. 15. Miconazole powder applied to affected areas b.i.d. 16. Amiodarone 200 mg p.o. q.d. 17. Colace 100 mg p.o. b.i.d. p.r.n. 18. Ativan 0.5 mg to 1 mg intravenously q.4h. p.r.n. 19. Tylenol 650 mg p.o. q.6h. p.r.n. for pain. 20. Oxycodone 5 mg to 10 mg p.o. q.6h. p.r.n. for pain. 21. Prevacid elixir 30 mg p.o. q.d. DISCHARGE INSTRUCTIONS: 1. The patient was allowed an American Diabetes Association cardiac diet. 2. He should wear BiPAP at night for obstructive sleep apnea. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus pneumonia. 2. Coronary artery disease, status post myocardial infarction. 3. Congestive heart failure. 4. Acute renal failure; on hemodialysis. 5. Atrial fibrillation. 6. Hypertension. 7. Type 2 diabetes. 8. Gout. 9. Obstructive sleep apnea. 10. Anemia of chronic renal disease. 11. History of guaiac-positive stools. [Initials (NamePattern4) ] [Last Name (NamePattern4) 8873] [Name8 (MD) ], M.D. [MD Number(1) 8874] Dictated By:[Last Name (NamePattern1) 5246] MEDQUIST36 D: [2150-1-1] 17:15 T: [2150-1-1] 17:40 JOB#: [Job Number 23327] Name: [Known lastname 4804], [Known firstname 63] P Unit No: [Numeric Identifier 4805] Admission Date: [2149-11-30] Discharge Date: [2149-12-28] Date of Birth: [2077-8-1] Sex: M Service: [Doctor Last Name 633] Medicine HOSPITAL COURSE: From the pulmonary standpoint, the patient was status post intubation and biPAP for congestive heart failure and pneumonia. The patient was successfully weaned from low flow oxygen and successfully transferred to the floor. The patient was gradually able to be weaned further on supplemental oxygen. He carried the diagnosis of obstructive sleep apnea requiring biPAP. The patient continued treatment for Methicillin-resistant Staphylococcus aureus pneumonia with Vancomycin dose after dialysis by a trough less than 15. The patient was scheduled to stop Vancomycin on [12-30]. From the cardiovascular standpoint, the patient was status post myocardial infarction with ejection fraction of approximately 30% and multiple episodes of congestive heart failure as well as atrial fibrillation. The patient was on Amiodarone at 400 mg p.o. q. day and was also be considered for direct current cardioversion once stable. The patient was planned to eventually be continued on Amiodarone at 200 mg p.o. q. day. He was monitored on Telemetry while on the floor. From a renal standpoint, the patient had chronic renal insufficiency, status post acute renal failure, now hemodialysis dependent. The Renal Service was following and the patient needed plans for longterm access. The patient would likely require arteriovenous graft or arteriovenous fistula as well as a tunneled catheter while the arteriovenous graft or arteriovenous fistula matured. The patient continued on hemodialysis while being cared for on the floor. From the infectious disease standpoint, the patient was continued on Vancomycin for Methicillin-resistant Staphylococcus aureus pneumonia. Clostridium difficile toxin and fecal leukocytes were sent from the patient's stool to evaluate episodes of diarrhea the patient had in the Medical Intensive Care Unit. From an endocrine standpoint, the patient was ruled out for adrenal insufficiency. Diabetes Type 2 was managed with standing dose NPH and regular insulin scale as dictated by fingerstick blood sugars. From a hematologic standpoint, the patient had anemia on presentation and after transfusion of five units packed red blood cells was able to maintain his hematocrit at a stable level. He was receiving Epogen at hemodialysis. From a psychiatric standpoint, the patient evidenced symptoms of depression and had been treated with Paxil in the Intensive Care Unit. This was continued while in the hospital. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged with an appointment in [Hospital ] Clinic as well as Cardiology Clinic. DISCHARGE MEDICATIONS: 1. Enteric coated Aspirin 325 mg p.o. q. day 2. Plavix 75 mg p.o. q. day until [2150-1-15] 3. Paxil 20 mg p.o. q.h.s. 4. Nephro tube feeds, goal of 45 cc/hr 5. TUMS 500 mg p.o. q.i.d. 6. Digoxin 0.125 mg p.o. post dialysis only 7. Captopril 37.5 mg p.o. t.i.d. 8. Reglan 5 mg p.o. q.i.d. 9. Prevacid elixir 30 mg p.o. q. day 10. Lipitor 40 mg p.o. q. day 11. Regular insulin sliding scale 12. NPH 10 units subcutaneously q. AM, and 6 units subcutaneously q PM 13. Nephrocaps 1 tablet p.o. q. day 14. Epogen 5000 units intravenously three times per week by the dialysis registered nurse 15. Aldactone 25 mg p.o. q. day 16. Amiodarone 400 mg p.o. q. day 17. Miconazole powder, apply to affected areas b.i.d. 18. Vancomycin dose per trough after dialysis to be discontinued on [2149-12-30] 19. Colace 100 mg p.o. b.i.d. prn 20. Ativan 0.5 mg to 1 mg intravenously q. 4 hours prn 21. Tylenol 650 mg p.o. q. 6 hours prn pain 22. Oxycodone 5-10 mg p.o. q. 6 hours prn pain The patient with a history of obstructive sleep apnea should continue BiPAP at settings of 15/5 at night. DISCHARGE DIAGNOSIS: 1. Methicillin-resistant Staphylococcus aureus pneumonia 2. Coronary artery disease status post myocardial infarction 3. Congestive heart failure with an ejection fraction of approximately 30% 4. Acute renal failure on hemodialysis 5. Atrial fibrillation 6. Hypertension 7. Diabetes mellitus Type 2 8. Gout 9. Obstructive sleep apnea 10. Anemia of chronic renal disease 11. History of guaiac positive stools [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ], M.D. [MD Number(1) 3301] Dictated By:[Last Name (NamePattern1) 2134] MEDQUIST36 D: [2149-12-28] 15:30 T: [2149-12-28] 16:16 JOB#: [Job Number 4806]	[ "511.9", "286.6", "482.41", "518.81", "584.9", "428.0", "410.11", "038.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56", "96.04", "34.91", "36.06", "38.95", "89.64", "36.01", "96.72" ]	icd9pcs	[ [ [] ] ]							5390, 5474	23152, 24112	26761, 27853		27874, 28580	22042, 22967		24130, 26581		22991, 23130																7629, 16145			5497, 7600		21240, 21276													21296, 22015					152, 2743													4577, 5180	2765, 4552	5197, 5373	26606, 26738
31,592	119,552	33471	Discharge summary	report	Admission Date: [2176-10-20] Discharge Date: [2176-10-23] Date of Birth: [2114-9-29] Sex: F Service: MEDICINE Allergies: Darvocet-N 50 / Percocet Attending:[First Name3 (LF) 1145] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Right and left heart catheterization at OSH History of Present Illness: 62F with DM, HTN, dyslipidemia, CAD (IMI '[67]; RCA stent '[70]; LCX stents [10-20] @ [Hospital1 336], [4-20] @ [Hospital1 18], and [7-21] @ [Hospital1 1474] for instent thrombosis) developed acute chest discomfort which is predominantly nausea Saturday am, lasted several hours, remitted for an hour, then recurred and so she presented to the ED at [Hospital3 417] Hosp. Her prior ischemic pains were substernal chest tightness. EKG there c/w inferior STEMI and she was taken to the cath lab. . From OSH notes, access was difficult [3-16] body habitus. Cath showed normal LMCA, 40% ostial, 60% mid, and 80% distal lesions in the LAD; Hazy prox lesion in the LCX at the site of prior stents and 95% stenosis; and a proximally occluded RCA. PTCA to the LCX required several balloon dilations and after recoil there was 50-60% residual stenosis. She was transferred to [Hospital1 18] for consideration of CABG; Reopro gtt started at 1am for planned duration 12 hours. RFA and RFV sheaths in place at time of transfer. Past Medical History: Obesity HTN Hyperlipidemia CAD s/p prior IMI in [2167], NSTEMI in [2170] and in [10-20] s/p RCA stents (2 overlapping Penta stents to RCA in [2170]) and 2 Taxus stents to LCx in [10-20] at [Hospital1 336], with unsuccessful PCI of the RCA) CHF- LV diastolic dysfunction DMII (poorly controlled) C/B neuropathy COPD Respiratory failure requiring tracheostomy 8 months ago, s/p trach reversal s/p CVA w/ residual R sided Weakness s/p C section h/o cocaine use, none for 20 years Social History: Social history is significant for the absence of current tobacco use, remote history of cigarette smoking. H/O ETOH abuse, no ETOH x 10 years. H/O cocaine use, none for many years. Family History: H/O CAD in siblings and mother with renal failure. Physical Exam: VS - T 98.5 HR 101 BP 116/73 RR 18 98% 2L Gen: NAD. Oriented x3. Very anxious appearing HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10 cm. CV: soft heart sounds given body habitus, [3-20] late peaking crescendo decrescendo murmur at the RUSB without radiation to carotids and without pulsus parvus et tardus Chest: lungs are clear, difficult to assess given habitus Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: 1+ pitting pedal edema bilaterally symmetrical Skin: + stasis dermatitis, ankles wrapped in ace bandages [3-16] weeping. No ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ DP dop PT dop Left: Carotid 2+ DP dop PT dop Pertinent Results: EKG: presentation: SR STE in II, III, aVF with Q waves. STE in V3-V4 as well. STD with biphasic Twaves in I, aVL. post-cath: No significant change from above. [Hospital1 18] arrival: still with STE & Q in inferior and ant precordial leads; same STD in high lateral leads. . CARDIAC CATH: report from [Hospital3 417] Hosp: normal LMCA, 40% ostial, 60% mid, and 80% distal lesions in the LAD; Hazy prox lesion in the LCX at the site of prior stents and 95% stenosis; and a proximally occluded RCA. PTCA to the LCX required several balloon dilations and after recoil there was 50-60% residual stenosis . 2D-ECHOCARDIOGRAM performed on [3-/2097] (report from OSH): EF 45-50 %, diastolic dysfunciton and moderate concentric LVH. Moderate AS with a valve area of 1.2cm and peak gradient 27, mean gradient 18. [2176-10-22] CXR Enlarged heart. Prominent hila with pulmonary vascular congestion. No obvious evidence for consolidation or pleural effusion. Brief Hospital Course: 62F with DM2, extensive prior CAD including multiple instent thromboses, now presents with ~18 hrs of nausea found to have inferior wall Q-wave MI . # CAD/Ischemia: IMI due to instent thrombosis of LCx stent with chronically occluded RCA. Attempted PTCA at [Hospital3 417] with sub-optimal angiographic result and no resolution of ST elevations, so referred to [Hospital1 18] for further eval. However, given Q wave infarction and pt's co-morbid conditions--uncontrolled DM2, h/o of lung disease requiring trach in the past, pt. previously denied for CABG and would be denied on same grounds at this time. Pt. was transferred on heparin and abciximab, asa, plavix, high dose atorvastatin with arterial and venous sheaths still in place. Decision was made not to recath as imaging from [Hospital3 ] did not show an intervenable lesion. Pt. had an episode of bleeding from around her sheaths and so they were pulled and she had an episode of bleeding from the venous sheath site. Pressure was held for 30 minutes and the bleeding resolved, Hct remained essentially stable so there was no concern for major bleeding. After leaving the CCU pt. had multiple episodes of sharp chest pain worse w/ palpation of chest associated with shortness of breath and anxiety. These episodes were not associated with EKG changes, her cardiac enzymes continued to trend downward and her symptoms were resolved with reassurance. . # Pump: h/o diastolic CHF with EF 40-45%, echo here showed mild LV systolic function. Hypokinesis of basal half of inferior and inferiolateral segment and distal half of septum. EF of 45%. Pt. did not appear acutely volume overloaded on discharge, she had chronic appearing edema of her legs which did not change over the course of her admission. Her furosemide was held because of concern for hyportension after recieving increased doses of carvedilol. We uptitrated her carvedilol from 6.25 [Hospital1 ] at home to 25mg [Hospital1 ] on d/c. Her lisinopril was decreased to 20mg daily because of carvedilol induced hypotension. . # Rhythm: SR/ST. Monitored on Telemetry, little ectopy (PVC's). Pt. had warfarin listed in her admission medications, but her INR was 1.3 on presentation. . # Valves: Murmur suggests AS consistent with prior report of moderate AS. Will check echo as above. . # HTN: Pt. was actually hypotensive through most of this admission, most likely secondary to her partial right ventricular infarct. . # DM: A1c was 9.1 so poorly controlled. She was maintained on her home dose of insulin as we did not have time to uptitrate her basal insulin. . # Depression: continued escitalopram . # Code: full . # Communication: with patient Medications on Admission: Aspirin 325mg daily Plavix 75mg daily Coreg 12.5mg daily Lipitor 80mg daily lasix 40mg [Hospital1 ] lisinopril 40mg daily imdur 90mg daily insulin levemir 100units daily and humalog 30units + sliding scale prior to meals nexium 40mg daily lexapro 20mg daily neurontin 100mg tid potassium chloride Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain for 3 doses: call 911 if first dose is not effective. Tablet, Sublingual(s) 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Injection 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Detemir 100 unit/mL Solution Subcutaneous 11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital ] Rehab Discharge Diagnosis: Primary Diagnosis: Inferior MI . Secondary Diagnoses: Hypertension Hypercholesterolemia DM2 diastolic CHF COPD Respiratory failure in [2175] required tracheostomy, which has subsequently been reversed h/o CVA with residual R sided weakness s/p c-section Discharge Condition: Good, pain free Discharge Instructions: You were transferred here from your outside hospital because you had had a heart attack. They looked at your coronary vessels to try and help your blood flow to your heart and improved it as much as they could. They thought you still should be evaluted for cardiac bypass and sent you here to accomplish this. Unfortunately, because of your very difficult to control diabetes the surgeons felt the surgery would present more danger than benefit to you. Thus we managed your pain and maximized your medications. . Your medications have been changed. Your plavix (clopidogrel) was doubled to 150mg/daily because of your history of clotting in your stents. Your lasix (furosemide) was held temporarily because of low blood pressure, your doctor may want to restart this once you have adjusted to the carvedilol. Your carvedilol was changed to 25mg twice daily for added protection of your heart, this caused your blood pressure to be low. Your lisinopril was decreased to 20mg daily because your blood pressure was low, your doctor may want to increase this again after you adjust to the carvedilol. Your daily potassium chloride was held while you were not recieving furosemide. . Please keep all scheduled follow up appointments as these are important to manage your health. . Please go to the emergency room or call your doctor if you have fever>101, chest pain, shortness of breath, inability to tolerate food by mouth, or any other distressing changes in your health. Completed by:[2176-10-23]	[ "428.32", "278.00", "428.0", "998.11", "496", "459.81", "V58.67", "V45.82", "414.01", "438.20", "250.00", "E879.0", "272.4", "410.41", "458.9", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8101, 8153	4016, 6703	298, 344	8455, 8473	3027, 3993		2175, 2227		7055, 8078		8174, 8174		6729, 7032			8497, 10001									2242, 3008	8228, 8434																			248, 260										372, 1434						8193, 8207								1456, 1958	1974, 2159
26,161	172,884	12670	Discharge summary	report	Admission Date: [2107-10-9] Discharge Date: [2107-10-13] Date of Birth: [2060-1-14] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 5037] Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: 47F s/p LURT [12-18], admitted for urosepsis. Had recent cardiac cath 2 vessel stent [2107-9-14]. Course c/b pyelo (ESBL kleb PNA UTI) treated with meropenem, sent home on 14 days of imipenem. Was off abx for 1 week, came back w/ dysuria, back pain, T 100 at home. Borderline low bp sbp98, +orthostatic so admitted to ICU. [10-3] repeat Ucx enterococci VRE. On linezolid/meropenem empirically. Started on stress steroids, now tapered to pre-admit dose. Immuran held. CT abd neg for acute process. Txred to floor on [10-10]. Past Medical History: IDDM ESRD s/p living unrelated renal transplant [12-18] Hyperlipidemia Hypothyroidism Retroperitoneal bleed sinusitis IBS h/o hypertension but recently treated for orthostatic hypotension with midodrine CAD S/P stenting in [2107-9-15] Social History: Denies EtOH and tobacco Family History: non-contributory Physical Exam: VS - 97.3 105/62 69 20 99% on RA Gen - awake, alert, sitting in the [Last Name (un) ] next to the bed. NAD HEENT - NCAT, Has tag of skin on the left buccal surface (of note the patient has seen an OMF surgeon regarding biopsy of this lesion) MMM, PERRL, EOMI. Neck - supple, no LAD Cor - RRR nl S1,S2 no M/R/G Chest - CTA B, no W/R/R Abd - s/nt/nd +BS, incisional wound with one fistula draining serous fluid in the midline, no pain with palpation of transplanted kidney. On left flank there is a scar from where the fluid drain was located. There is no pain, erythema, or swelling. Ext - no c/c/e left D/P is difficult to find, but palpable. The right foot is in a cast. Per patient she has fractured toe. Pertinent Results: [2107-10-9] 2:49 pm URINE Site: CLEAN CATCH URINE CULTURE:KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 8 S TETRACYCLINE---------- PND TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [2107-10-9] 02:49PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.008 [2107-10-9] 02:49PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [2107-10-9] 02:49PM URINE RBC-0-2 WBC-[1-2]* Bacteri-MANY Yeast-NONE Epi-[4-17] [2107-10-9] 12:35PM BLOOD WBC-2.7* RBC-4.00* Hgb-11.9* Hct-34.0* MCV-85 MCH- 29.7 MCHC-35.0 RDW-17.6* Plt Ct-233 [2107-10-13] 06:00AM BLOOD WBC-2.0* RBC-3.35* Hgb-9.9* Hct-28.7* MCV-86 MCH-29.7 MCHC-34.6 RDW-17.4* Plt Ct-230 Brief Hospital Course: After transfer from MICU the patient declined fever, chills, nausea, vomiting, dysuria, and hematuria until the time of discharge. Objectively, the patient's vital signs remained stable. On the day prior to discharge the patient complained of diarrhea. C.diff toxin was negative. The patient's phyisical exam revealed a cutaneous fisutla in the midline below the umbilicus at the end of the patient's tranplant surgery scar. Dr. [First Name (STitle) ], from tranplant surgery saw the patient and offered to close the fisutla in [7-21] weeks when the patient's cardiac condition had quieted down - she had coronary artery stents place on [2107-9-15]. ID was consulted regarding the optimal antibiotic regimen. They suggested 3 weeks total of Meropene. They were concerned about the patient white blood cell count and suggested that the primary team consider bone marrow suppression as a possible etiology. To this end the patient was asked to have a CBC drawn the day after discharge and to have the results sent to Dr. [Last Name (STitle) 17253], the patient's tranplant nephrologist. The patient was also given the number of the [Hospital ] clinic and asked to follow up with them at her convenience. Urology was consulted to help identify the reason for the patient's recurrent UTIs. They suggested a Voiding Cystourethrogram (VCUG), which demonstrated reflux. Urology did not feel that an acute intervention was indicated and asked for follow up of the patienet in their clinic. An apointment was arranged. Regarding the patient's diabetes, she was encouraged to follow up at the [Last Name (un) ] Diabetes center. The patient was also notified of her appointment to follow up with her cardiologist Dr. [Last Name (STitle) 171]. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Lorazepam 1 mg PO Q4-6H as needed. 4. Acetaminophen 650 mg PO every [5-19] hours as needed for fever, pain. 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Thirty ML PO QID as needed for indigestion. 6. Tacrolimus 2 mg PO BID 7. Prednisone 5 mg PO DAILY 8. Azathioprine 75 mg PO DAILY 9. Levothyroxine 75 mcg PO DAILY 10. Citalopram 60 mg PO DAILY 11. Sodium Bicarbonate 650 mg PO BID 12. Pantoprazole 40 mg Tablet, Delayed Release PO Q24H 13. Conjugated Estrogens 0.625 mg Tablet PO DAILY 14. Buspirone 5 mg PO TID 15. Phenobarb-Belladonna Alkaloids 16.2 mg/5 mL Five mL PO Q 6 HRS as needed for indigestion. 16. Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY 17. Ezetimibe 10 mg PO DAILY 18. Valganciclovir 900 mg PO DAILY 19. Insulin Glargine Fourteen units Subcutaneous at bedtime. 20. Nystatin 100,000 unit/mL Five ML PO QIDACHS 21. Midodrine 5 mg PO TID Discharge Medications: 1. PICC PICC care per routine protocol 2. Meropenem 500 mg Recon Soln Sig: One (1) gram Intravenous every eight (8) hours for 17 days. Disp:51 grams Refills:0 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QIDACHS (4 times a day (before meals and at bedtime)). 15. Outpatient Lab Work Complete blood count. Please call results to Dr. [First Name (STitle) ] [Name (STitle) ] ([Telephone/Fax (1) 673]) 16. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 19. Phenobarb-Belladonna Alkaloids 16.2 mg/5 mL Elixir Sig: Five (5) ml PO QID (4 times a day) as needed for IBS. Disp:6000 ml Refills:0 20. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 21. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: - Endstage renal disease status post transplant - Urosepsis - Ureteral reflux - Autonomic neuropathy with hypotension - Insulin dependent diabetes - Anemia of inflammation as well as probable bone marrow suppression - Antibiotic associated diarrhea Discharge Condition: Good, afebrile. Followup Instructions: Please follow up with your appointments listed below in Cardiology, Urology and Transplant [Hospital 10701] Clinic. Please follow up at Infectious disease clinic at ([Telephone/Fax (1) 4170] Please follow up with Dr. [First Name (STitle) ] and with the [Last Name (un) ] Diabetes Center as discussed (you had mentioned having the numbers for these clinics). Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989] Date/Time:[2108-1-2] 10:20 Provider: [First Name8 (NamePattern2) 161] [Name11 (NameIs) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2107-11-11] 8:30 Provider: [Name10 (NameIs) 161] [Name8 (MD) 6476], MD Phone:[Telephone/Fax (1) 921] Date/Time:[2107-10-21] 8:30 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2107-10-21] 9:30 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2107-10-25] 1:00 Infectious disease clinic. [Name6 (MD) 2105] [Name8 (MD) 2106] MD [MD Number(2) 5038] Completed by:[2107-10-14]	[ "E878.0", "996.81", "285.8", "599.0", "998.6", "041.3", "585.6", "414.01", "403.91", "337.1", "250.61", "593.70", "564.1", "E849.8", "V45.82", "244.9", "E878.8" ]	icd9cm	[ [ [] ] ]	[ "87.77" ]	icd9pcs	[ [ [] ] ]	8010, 8093	3258, 5035	277, 284	8386, 8404	1942, 3235	8427, 9666	1177, 1195		6041, 7987		8114, 8365		5061, 6018												1210, 1923																				231, 239										312, 853														875, 1119	1135, 1161
11,876	103,445	8774	Discharge summary	report	Admission Date: [2145-6-25] Discharge Date: [2145-7-13] Date of Birth: [2090-12-8] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This patient is a 55-year-old man status post cadaveric renal transplant on [2145-4-21], complicated by wound hematoma and opening of the wound. The patient has been managed on an outpatient basis with a VAC dressing and has been discharged to rehabilitation prior to this admission. The patient presented today to the Clinic where an exposed renal graft was noted in the wound. PHYSICAL EXAMINATION: Temperature 97.9 degrees Fahrenheit, heart rate 83, blood pressure 182/86, respiratory rate 20 and oxygen saturation 100 percent on room air. The patient was awake and alert in no apparent distress. The patient's heart was in regular rate and rhythm with no murmurs, rubs or gallops. His lungs were clear to auscultation bilaterally. His abdomen was noted to have a wound VAC dressing in place; otherwise, it was soft, non-tender, non-distended, normoactive bowel sounds. His extremities were warm. Distal pulses were two plus and he had no peripheral edema in both lower extremities and slight peripheral edema in his left upper extremity at the site of where he had a prior fistula for hemodialysis. HOSPITAL COURSE: At this point the patient was admitted to [Hospital1 69] and was continued on his prior medications from a recent discharge medicine list and his VAC was placed to continuous suction. The patient was also followed by the Renal Transplant Service who also noted his creatinine to reveal excellent graft function. The patient was on vancomycin during this time one gram q. 48h. to protect against potential wound pathogens. The plan at this time was to have Plastic Surgery to see the patient to evaluate a possible wound flap to cover the exposed graft. On [2145-6-29], hospital day five, the patient continued to progress well. Was voiding without complaint and the service was waiting for Plastic Surgery evaluation at this time for potential wound flap coverage. The patient's vital signs were stable during this time. The patient was afebrile throughout his hospital stay up until this point. The patient was given nutritional supplements with meals, Boost three times a day, and on [2145-6-30], the patient was visited by the Plastic Surgery service. On [2145-6-30], the patient was found in his room to be complaining of feeling hot and generally "not well." Vital signs were taken revealing a blood pressure of 204/109 with a heart rate of 144, breathing at 70 percent on room air. The patient received 5 mg of intravenous push Lopressor. Blood pressure at this point was 208/111, heart rate 137. Blood gases were drawn. Electrolytes and blood cultures were sent and Foley catheter was inserted. A second dose of intravenous Lopressor was given and his blood pressure was 206/90 at this point, heart rate of 137 and at this point 10 mg of intravenous Lopressor was hung and 10 mg was pushed. The patient continued to have labored breathing. Was alert and oriented but sleepy and arousable. Chest x-ray revealed what looked like a likely pneumonia. Electrocardiogram showed sinus tachycardia. His blood gases at this point were pO2 of 82, pCO2 of 54 and a pH of 7.19. The patient at this point was transferred to the Surgical Intensive Care Unit. A central venous line was also placed at this point without complications with the patient having insufficient peripheral access for the purpose of ABG drawing, hemodynamic monitoring. The patient at this point was on metoprolol on hydralazine 25 mg q. 6h. The plan was for serial ABG's. The patient was placed on nonrebreathable oxygen mask. On the same day Plastic Surgery saw the patient and recommended that patient would likely benefit from right gracilis flap to protect and cover the open wound with kidney graft exposed. The patient was then consulted to see Cardiology after this bout of respiratory distress and sinus tachycardia who recommended tighter blood pressure control and metoprolol was thus restarted at a dose of 150 mg p.o. b.i.d. and aspirin was continued 325 mg q. day. On SICU day two, the patient was noted to be significantly improved and vital signs were within normal limits. His blood pressure was 161/82 at this point and he was saturating at 95 percent on room air with a heart rate of 83. The patient at this point was on vancomycin, Zosyn and Bactrim. This was the second day of Zosyn. At this point the plan was for Plastic Surgery, after seeing the patient on hospital day eight, [2145-7-2], to bring the patient to the Operating Room on Monday for likely gracilis flap, possible rectus flap and they would pre-op the patient for surgery. The patient then was transferred back to the floor later in the day after noted to be doing very well. His vital signs were stable. The patient was saturating well and his heart rate and blood pressure were within normal limits. Blood pressure at this point was 115/68. He had no complaints of shortness of breath or chest pain at this time. On the 17th day of [Month (only) 30676] hospital day nine, the patient continued to progress well and the patient was scheduled for stress echocardiogram as preoperative evaluation after events that led to the patient being transferred to the Surgical Intensive Care Unit. Echocardiogram revealed moderate inferior wall hypokinesis with an ejection fraction of approximately 27-28 percent and it was determined at this point that the patient would likely benefit from cardiac catheterization. The patient, however, required two negative sets of blood cultures which were drawn on the 16th and [7-3] which eventually came back negative and the patient was brought to cardiac catheterization on [7-9] revealing that the patient had normal coronary arteries. No signs of stenosis. Ejection fraction at this point was noted to be in the mid 30's, approximately 35 percent. The patient continued to progress well during his hospital stay, was afebrile and without complaint and at this point was awaiting possible of Plastic Surgery flap closure for his open wound. The patient was also followed by Physical Therapy and Occupational Therapy who suggested that the patient would likely benefit from a stint in rehabilitation before being discharged to home and, upon learning that the patient would not be able to be scheduled for plastic surgery closure until the following week, likely to occur on [7-20] or 4th of [2144], it was determined that the patient could be discharged to rehabilitation on the wound VAC. The patient was stable on the day of discharge. The patient was afebrile. The rest of his vital signs were within normal limits. DISCHARGE DIAGNOSES: Status post cadaveric renal transplant [2145-4-17] with open wound and exposed kidney. End-stage renal disease. Diabetes mellitus type 2. Hypertension. Hepatitis C virus. CONDITION ON DISCHARGE: Stable. DISPOSITION: The patient was to be discharged to rehabilitation facility where patient would have wound VAC changes every fourth day, to [Name8 (MD) 138] M.D. if patient had any increasing fevers, chills, nausea, vomiting, decreased urine output, excessive blood coming from site of wound VAC or if there were any other questions. DISCHARGE MEDICATIONS: 1. Bactrim one tab q. day. 2. Metoclopramide 10 mg p.o. q.i.d. 3. Protonix 40 mg p.o. q. day. 4. Percocet 5/325 one to two tablets p.o. q. 4-6h. as needed pain. 5. Regular insulin sliding scale as directed per sliding scale. 6. Colace 100 mg p.o. b.i.d. 7. Prednisone 10 mg p.o. q. day. 8. ____________ 450 mg p.o. q. day. 9. Epogen 20,000 units three times per week, Monday, Wednesday and [Name8 (MD) 2974]. 10. Nystatin 5 mL p.o. q.i.d. 11. Metoprolol 150 mg p.o. b.i.d. 12. Heparin 5000 units one injection three times a day. 13. Azathioprine 75 mg p.o. q. day. 14. Furosemide 40 mg p.o. q. day. 15. Clonidine 0.2 mg p.o. t.i.d. 16. Aspirin 325 mg p.o. q. day. 17. Cyclosporin 125 mg p.o. b.i.d. 18. Hydralazine 37.5 mg q.i.d. DISPOSITION: Patient stable and to be discharged to rehabilitation facility. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816], M.D. [MD Number(2) 6727] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2145-7-13] 12:49:02 T: [2145-7-13] 14:01:07 Job#: [Job Number 19457]	[ "038.19", "038.43", "996.81", "410.71", "995.91", "428.0", "998.32", "070.51", "403.91" ]	icd9cm	[ [ [] ] ]	[ "93.59", "38.91", "37.22", "88.56", "38.93" ]	icd9pcs	[ [ [] ] ]								6833, 7013	7407, 8551					1318, 6811																					592, 1300																				183, 569																7038, 7384
25,490	197,289	48298	Discharge summary	report	Admission Date: [2179-4-2] Discharge Date: [2179-4-5] Service: CCU ADMITTING DIAGNOSIS: Myocardial infarction. HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old woman who presented to the Emergency Department after approximately 24 hours of "hot and sizzling" chest pain. The pain was substernal. It began the afternoon prior to admission. The patient denied radiation. She denied palpitations, shortness of breath, diaphoresis, nausea, or vomiting. The patient took Tums without relief. The patient was unable to sleep the night prior to admission secondary to the chest pain. The patient denies palpitations. On the morning of admission, the patient noticed increase in pain. She went to see her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. She was then sent to the Emergency Department. In the Emergency Department, she received nitroglycerin, Lopressor, Morphine, and Heparin. The patient denies at baseline shortness of breath or orthopnea. She denies paroxysmal nocturnal dyspnea. She denies fevers, chills. She has no urinary symptoms. She denies cough. At baseline, the patient is able to walk up a flight of stairs without shortness of breath. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Hypothyroidism. 4. Left lower lobe bronchiectasis. 5. Myoclonal gammopathy. 6. Neuropathy. 7. Degenerative joint disease. MEDICATIONS AT HOME: 1. Lipitor 10 mg po q day. 2. Synthroid 50 mcg po q day. 3. Dyazide 37.5/25 po q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies alcohol or tobacco use. She lives alone. FAMILY HISTORY: Her mother had a stroke at age 57. There is no family history of myocardial infarction, diabetes, or hypertension. PHYSICAL EXAMINATION ON ADMISSION: The heart rate is 69, blood pressure 147/69, respiratory rate 20, oxygen saturation is 99% on 2 liters by nasal cannula. The patient is afebrile. General: The patient is in no apparent distress. HEENT: Pupils are equal, round, and reactive to light bilaterally. Extraocular eye movements were intact. The mucous membranes were moist. Neck: There are no carotid bruits bilaterally. CVS: Has regular, rate, and rhythm. There are no murmurs, rubs, or gallops. Chest was clear to auscultation bilaterally. Abdominal: Bowel sounds are pleasant. Abdomen is soft and nontender. Rectal: Occult blood negative. Extremities: Distal pulses are palpable bilaterally. There is no lower extremity edema. There is a right sheath in the right groin. LABORATORIES: White count is 11.0, hematocrit 42.2, platelets 309. Sodium 137, potassium 3.9, chloride 96, bicarb 26, BUN 24, creatinine 1.3, glucose 125. A CK is 1,387, MB 174, troponin greater than 50. Arterial blood gas shows a pH of 7.42, CO2 of 42, oxygen of 78. ELECTROCARDIOGRAM: Shows sinus rhythm at a rate of 74. There is [Street Address(2) 101748] depression in V1 through V5. There is upright T wave in V1. CARDIAC CATHETERIZATION: There is total occlusion of the proximal left circumflex. This was stented. The mid left anterior descending artery has an 80% lesion before the diagonal. There were faint collaterals to antengel small distal vessels at the end of initially occluded OM-1. There was 70% ramus. The right coronary artery has a 50% stenosis. HOSPITAL COURSE: The patient was admitted to the CCU after her cardiac catheterization, where her left circumflex was stented. There was an 80% lesion of the left anterior descending artery, which was not intervened on. 1. Cardiovascular: The patient had a non-ST elevation myocardial infarction by enzymes. She had her left circumflex stented in the catheterization laboratory. Her 80% left anterior descending artery was not intervened upon. It is recommended the patient have a stress test as an outpatient to determine if the lesion in the left anterior descending artery is significant. The patient was started on aspirin and Plavix postprocedure. She was also started on low-dose beta blocker. The patient was not started on an ACE inhibitor as her blood pressure ran in the low 100s after the addition of the beta blocker. The patient was initially maintained on Integrilin for 18 hours after cardiac catheterization. The patient had a transthoracic echocardiogram during this admission. This showed an ejection fraction of 60-65%. There was mild dilation of the left atrium. Otherwise, the echocardiogram was normal. There were no wall motion abnormalities noted. 2. Hematology: The day after the patient's cardiac catheterization, she was noted to have a 10 point hematocrit drop down to a hematocrit of 31. A CT scan was obtained to rule out retroperitoneal bleed. This revealed a hematoma in the right thigh. The patient was transfused 1 unit of packed red blood cells. Her hematocrit bumped appropriately. Her hematocrit remains stable throughout the rest of her stay in the hospital. 3. Renal: The patient's creatinine was slightly elevated during this admission. Her baseline creatinine is approximately 1.0-1.1. Her hematocrit was 1.3-1.4 during this admission. This was felt secondary to dye received during cardiac catheterization. Her creatinine should be checked as an outpatient. 4. Endocrine: The patient has a history of hypothyroidism. Her thyroid function was checked and was normal during this admission. 5. Pulmonary: The patient has a history of bronchiectasis, though she has no active pulmonary issues during this admission. 6. GI: The patient was kept on a proton-pump inhibitor during her stay in hospital. 7. FEN: The patient was started on a low sodium, cardiac diet during this admission. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post myocardial infarction, status post stenting of left circumflex. 2. Right thigh hematoma. 3. Anemia, requiring transfusions. 4. Hypercholesterolemia. 5. Hypertension. 6. Hypothyroidism. 7. Left lower lobe bronchiectasis. 8. Monoclonal gammopathy. 9. Neuropathy. 10. Degenerative joint disease. MEDICATIONS AT DISCHARGE: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q day for nine months. 3. Lopressor 12.5 mg po q day. 4. Lipitor 10 mg po q hs. 5. Levothyroxine 50 mcg po q day. DISCHARGE FOLLOWUP: The patient will follow up for Cardiology with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9474] on [11-23] at 10 am. The patient will require an outpatient stress test to evaluate whether her left anterior descending artery lesion requires intervention. She should also have an outpatient abdominal/pelvic ultrasound to evaluate a left ovarian cyst which was found incidentally during this admission. The patient will continue to be followed by her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ]. DR.[Last Name (STitle) ],[First Name3 (LF) 900] 12-248 Dictated By:[Last Name (NamePattern1) 222] MEDQUIST36 D: [2179-4-5] 15:01 T: [2179-4-6] 10:21 JOB#: [Job Number 101749]	[ "E878.8", "401.9", "620.2", "414.01", "410.51", "244.9", "998.12", "494.0", "285.1" ]	icd9cm	[ [ [] ] ]	[ "88.53", "99.10", "36.01", "88.55", "37.22", "36.06" ]	icd9pcs	[ [ [] ] ]							1669, 1807	5743, 6089						3381, 5722							1449, 1574																6103, 6265													6286, 7123					160, 1238							1822, 3363			107, 131				1260, 1428	1591, 1652
46,733	142,215	37179	Discharge summary	report	Admission Date: [2102-4-27] Discharge Date: [2102-5-12] Date of Birth: [2052-10-6] Sex: M Service: PLASTIC Allergies: Cefazolin / Sertraline Hcl / Zoloft Attending:[First Name3 (LF) 5883] Chief Complaint: Bronchopleural fistula, left chest, status post empyema drainage. Major Surgical or Invasive Procedure: [2102-5-5]: Flexible bronchoscopy with fibrin glue removal. 1. Rigid bronchoscopy using the Dumon black bronchoscope. 2. Flexible bronchoscopy. 3. Fibrin glue application in left upper lobe stump. [2102-5-4]: Flexible bronchoscopy with fibrin glue injection. [2102-5-3]: Flexible bronchoscopy. [2102-4-27]: 1. Closure of chest wall following open flap drainage for empyema with [Initials (NamePattern4) ] [Last Name (NamePattern4) 72148]-type procedure. 2. Open closure of major bronchopleural fistula. 3. Pedicled pectoralis muscle flap. 4. Anterolateral thigh and vastus lateralis free flap to left chest wall. 5. Local advancement flap closure of left chest wall, greater than 30 cm2. 6. Partial rib resection, second rib. 7. Split-thickness skin graft to left anterior thigh. History of Present Illness: Mr. [Known lastname 3968] is a very pleasant but unfortunate 49-year-old male who has a history of multiple pneumothoraces more so on the left than on the right, and whom has recently been treated for a left-sided aspergillosis. He underwent a left upper lobectomy complicated by bronchopleural fistula and necessitating a [Last Name (un) 72148] window. He has been followed by infectious diseases for his aspergillosis and is currently on Vorizonazole for suppression. He is here for repair of his bronchopleural fistula and left sided chest cavity reconstruction. Past Medical History: Numerous pneumothoraces since age 18 L>R, chest tube (last time 20 years prior to [Hospital ] hospital) L apical posterior segmentectomy in [2077] L pleurodesis LUL wedge resection with LLL bleb resection and LOA and nodal dissection [2101-11-21] multiple pneumonias infected LLL bullae colonic abscesses depression anxiety appendectomy hernia left aspergillus fumigatus empyema [2101-12-30] left modified [Last Name (un) 72148] window and debridement of empyema cavity, closure of bronchopleural fistula, serratus anterior muscle flap, latissimus muscle flap, and bronchoscopy with bronchoalveolar lavage for left aspergillus fumigatus empyema with bronchopleural fistula. [2102-3-24] Irrigation and debridement of left chest through [Last Name (un) 72148] window, remodeling of serratus muscle flap and wet-to-dry dressing change. Closure bronchopleural fistula. Social History: Ex-smoker, 30 pack-years. Quit on [2100]. Remarried almost a year ago. Has two children. Family History: Mother healthy, alive, had mild stroke at 73 Father died at 70 of brain aneurysm Siblings has 5 brothers and 3 sisters all in good health Physical Exam: Pre-Procedure PE from Anesthesia Record [2102-4-27]: Pulse-->92/min B/P-->116/68 O2Sat-->97% RA General: thin, nad Mental/Psych: a/o Airway: as documented in detail in Anesthesia report Dental: Other (good teeth, one left upper front tooth missing) Head/neck Range of motion: Free range of motion Heart: rrr no M or bruits Lungs: Clear to Auscultation (other: left side diminished airflow) Abdomen: firm, nontender, no organomeg or masses Extremities: no cce Other: raspy, soft voice, DSD L chest wound, anicteric, nor thyromeg, no [Doctor First Name ]. Pertinent Results: [2102-4-27] 06:17PM GLUCOSE-137* UREA N-11 CREAT-0.6 SODIUM-136 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [2102-4-27] 06:17PM estGFR-Using this [2102-4-27] 06:17PM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.5* [2102-4-27] 06:17PM WBC-12.2* RBC-3.89* HGB-10.0* HCT-31.2* MCV-80* MCH-25.7* MCHC-32.0 RDW-13.8 [2102-4-27] 06:17PM PLT COUNT-396 [2102-4-27] 06:17PM PT-13.3 PTT-26.7 INR(PT)-1.1 . CHEST XRAY [Hospital 93] MEDICAL CONDITION: 49 year old man with hx of mult pneumothoraces, s/p L upper lobectx for aspergillosis c/b bronchopleural fistula. Had [Last Name (un) 72148] window. Now s/p left pec free flap, left anterior thigh free flap, omental harvest [2102-4-27] with multiple chest tubes. Now with one remaining chest drain in place to 'pneumostat'. REASON FOR THIS EXAMINATION: Please assess status of left lung 24 hours s/p chest drain to pneumostat and prior to d/c to rehab. thanks! Final Report PROCEDURE: Chest PA and lateral. REASON FOR EXAM: History of multiple pneumothoraces, pleural fistula with [Last Name (un) 72148] window. Followup. FINDINGS: Comparison was made to previous chest radiograph of one day prior. The appearance of the left hemithorax is unchanged except to note filling in of a small air pocket ajacent to the tip of the chest drain. The position of the chest tube and air collection in the left apex remains stable with atelectasis in the left lower lung. The right lung is grossly normal with stable apical pleural thickening. IMPRESSION: Extensive postoperative changes in the left hemithorax post [Last Name (un) 72148] procedure, essentially unchanged since the previous study. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: WED [2102-5-10] 4:48 PM Brief Hospital Course: The patient was admitted to the plastic surgery service on [2102-4-27] and had a repair of bronchopleural fistula, closing of the [Last Name (un) 72148] window, a pedicled pectoralis muscle flap that was put into the second interspace and then a free anterolateral thigh flap with a free vastus lateralis flap for coverage and closure of the defect. The patient underwent bronchoscopies with/without fibrin glue applications on [2102-5-3], [2102-5-4] and [2102-5-5]. The patient tolerated all of these procedures well. . Neuro: Post-operatively, the patient received Dilaudid 0.2-0.6 mg IV Q4H:PRN PAIN with poor effect. He was increased to Dilaudid 0.6-1.2 mg IV Q3H:PRN PAIN and Lorazepam 1 mg PO/NG Q8H:PRN was added for anxiety. Unfortunately this was also not adequate pain control so in the morning of [2102-4-28] patient was placed on a dilaudid PCA--> Dilaudid 0.12 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 1.2 mg. Gabapentin 300 mg PO/NG TID was also added to his pain regimen. This combination offered adequate pain control for the patient for a good amount of the day. During the evening of [2102-4-28], patient was transferred to the floor and was experiencing increased levels of pain so his PCA was increased to Dilaudid 0.25 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0 mg(s)/hour 1-hr Max Limit: 2.5 mg with good effect. On [2102-4-29], the Dilaudid PCA was discontinued and patient had the following for pain control; Dilaudid 2-4 mg PO/NG Q4H:PRN pain with Dilaudid 0.25 mg IV Q4H:PRN for breakthrough pain. On [2102-5-2], patient expressed that he was actually unhappy with his current regimen and requested that he be placed back on a pain regimen that had worked well for him the past. The dilaudid was discontinued and the following pain regimen started; Oxycodone SR (OxyconTIN) 10 mg PO Q12H pain with OxycoDONE (Immediate Release) 5-10 mg PO/NG Q3H:PRN for breakthrough pain and Cyclobenzaprine 10 mg PO/NG TID:PRN for muscle spasms. This regimen actually worked very well for the patient until [2102-5-3], s/p his bronchoscopy when he requested an increase in his Oxycontin dosing to accomodate an increase in his pain. His oxycontin was changed to 20mg PO Q12H with good effect. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was relatively stable from a pulmonary standpoint; vital signs and O2 saturation were routinely monitored. The left chest cavity drainage was maintained by two chest tube drains. A leak was noted to both chest tube drains on [2102-5-2] and they were placed back to Pleurevac drainage system. Patient then underwent several bronchoscopies and fibrin glue applications to try and locate/eliminate air leaks. In the end, one of the chest tubes stopped leaking and was able to be removed. One chest tube drain continued leaking and was eventually placed to 'pneumostat' device prior to discharge. . Left chest flap: The flap viability was monitored via flap protocol with flap checks including visualization of flap coloring, tissue swelling, capillary refill along with doppler pulse checks and Vioptix monitoring. Drainage of flap was maintained by three JP drains. All flap drains were removed prior to patient's discharge. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. On [2102-5-6], patient complained of constipation so his lactulose dosing was increased to 30 cc PO Q8h PRN. By [2102-5-7], patient was able to have a very large bowel movement and felt instant relief. Foley was removed on POD#2. Intake and output were closely monitored. . ID: Post-operatively, the patient was maintained on Voriconazole 200 mg PO TID throughout his inpatient stay. He was also given 10 days of IV Vancomycin per Infectious Disease recommendations. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD# 13, from his original [2102-4-27] surgery, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged to an extended care facility with 1 anterior chest drain to 'pneumostat' device. All of his left sided chest incisions were clean/dry/intact and healing well without signs of infection or breakdown. His left sided chest/axillary flap had good color and warmth and was viable. His left upper thigh split thickness skin graft (STSG) 'donor' site had primary dried xeroform dressings intact which will be left in place and not changed until seen for follow up visit with Dr. [Last Name (STitle) 23606]. His left lateral thigh flap donor site/STSG recipient site appeared to have healthy muscle beneath the pink/warm skin graft site. This site will be smeared with Bacitracin once a day to keep the site moist and then left open to air. Vital signs upon discharge: Temp-->97.8 Pulse-->86 Resps-->17 b/p-->123/83 O2sat-->99% RA Medications on Admission: Buproprion HCL 150 mg tab SR 1 tab PO BID Cycolobenzaprine 10 mg tab 1 tab PO Q12h PRN for muscle spasm Gabapentin 300 mg capsule 1 capsule PO TID Lorazepam 1 mg tab 1 tab PO Q8h PRN anxiety Mirtazapine 15 mg tablet 1 tab PO QHS Oxycodone 5 mg tablet 1-2 tabs PO BID 30-60 min prior to dressing change Oxycodone 10mg tablet SR 12hr 1-2 tabs PO BID PRN for pain Voriconazole (VFEND) 200 mg tablet 1 tab PO TID Multivitamins, TX-Minerals 1 tab PO QD Bactrim reg strength 1 tab PO TID Zocor 40 mg tablet 1 tab PO QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA, T>100 degrees: Do not exceed 4000 mg/day. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [Hospital1 ] (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily) for 30 days. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for muscle spasms. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 17. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: hh Discharge Diagnosis: bronchopleural fistula closing of the [Last Name (un) 72148] window Left chest cavity defect Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Personal Care: 1. Leave your left chest incision site open to air. 2. Your left thigh skin graft DONOR site should be left open to air with primary Xeroform dressings left intact. 3. Your left thigh FLAP site should be dressed with bacitracin ointment once/day and left open to air. 4. Left Pneumostat: drain daily with a syringe. Keep a log of drainage. Cleanse chest-tube site with normal saline and cover with a clean dressing daily. . Activity: 1. You may resume your regular diet and try to eat snacks and take supplemental shakes to improve your nutrition. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [First Name (STitle) ]. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 6. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1216] [Last Name (NamePattern4) 2612], MD Phone:[Telephone/Fax (1) 6331] Date/Time: [2102-5-12] 11:15 . Provider: [Name10 (NameIs) 1532] [Name11 (NameIs) 1533], MD Phone:[Telephone/Fax (1) 2348] Date/Time: [2102-5-16] 9:30 in [Hospital Ward Name 121] Building [Hospital1 ] I Chest Disease Center. Chest X-Ray [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology 30 minutes before your appointment . Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 16976], MD Phone:[Telephone/Fax (1) 457] Date/Time: [2102-6-12] 11:00 Completed by:[2102-5-11]	[ "117.3", "300.00", "510.0", "311" ]	icd9cm	[ [ [] ] ]	[ "34.72", "33.22", "86.69", "33.23", "33.78", "83.82", "86.74", "34.73", "99.29" ]	icd9pcs	[ [ [] ] ]	13094, 13123	5587, 10867	362, 1180	13263, 13263	3568, 4013	15875, 16549	2830, 2970		11512, 13071	4050, 4382	13144, 13242		10975, 11489			13438, 15852									2985, 3549																				256, 324	4411, 5564								10883, 10949	1208, 1786									13278, 13390					1808, 2703	2719, 2814
30,317	149,968	51074	Discharge summary	report	Admission Date: [2113-12-14] Discharge Date: [2113-12-28] Service: SURGERY Allergies: Ibuprofen Attending:[First Name3 (LF) 4691] Chief Complaint: RLE pain s.p mvx Major Surgical or Invasive Procedure: ORIF R acetabulum ORIF R proximal femur IVC filter placement Tunnelled RIJ fistulogram cardiac cath-no intervention History of Present Illness: 84M unrestrained blood courier had mvc vs wall with LOC. He c/o R hip pain in the trauma bay, and was found to have R acetabular and comminuted R prox femur fx with posteriorly displaced femoral head oblique fractures. He was admitted at [Hospital1 18] for further evaluation and treatment of his injuries. Past Medical History: RUE fistula placed [8-19] at [Hospital1 112], not mature for dialysis yet HTN pacemaker for syncope Social History: married, retired dentist blood courier Family History: non-contributory Physical Exam: VITAL SIGNS:Afebrile, BP well controlled. GEN: Elderly male, sitting up in bed, sleepy. NAD HEENT: NC - top of head with healing skin tear, EOMI NECK: hard collar in place. RIJ in place. RESP: CTA, no wheezes, no crackles, no rhonchi, good air exchange throughout. COR: RRR, 3/6 systolic murmur (old), no gallops, no rubs ABD: soft, non-distended, nontender, no masses, no guarding, BS + PULSES: left 2+ radially, right 1+ radially. 1+ DP pulses bilaterally - feet warm EXT: Edema of bilateral UE, no cyanosis; left knee extender in place. Moves toes bilaterally. Grip strength 4/5 bilaterally. Skin: No heel ulcers. Left side of neck - where hard collar sits - there is skin breakdown. NEURO: Asleep - awakens to voice and touch.A and O x3 Pertinent Results: Cr on discharge =3 Brief Hospital Course: Briefly, Dr. [Known lastname 106077] was admitted to [Hospital1 18] after sustaining R pelvis and proximal femur fx s/p mvc vs. pole/wall. neuro: somewhat confused, Ox1 to person only; mental status cleared on [12-22], mentated well, A+Ox3, telling jokes. MS stable since then card: Pt has pacer for syncope.Pt had NSTEMI w/ peak troponin on [12-14] -0.16. He underwent cath on [12-14] which revealed a right dominant system with non obstructive CAD. The LMCA had no angiographically apparent disease. The LAD had mild diffuse disease with a discrete 40% proximal LAD lesion and a 40% mid D1 stenosis. The LCX was noted have one large OM branch without significant disease. The RCA had no angiographically apparent diease. Overall, it revealed non-obstructive CAD and nl ventricular function. No stents were placed. Blood pressures were initially difficult to control requiring nitro gtt and labetolol. pulm: Initially intubated; otherwise uncomplicated pulmonary course. renal: baseline Cr of 2.4-4; HD was eventually initiated due to non-oliguric ARF. A right IJ tunnelled HD line was placed on [12-27] in order to continue HD going forward as necessary. RUE fistula (placed [8-19] at [Hospital1 112]) was never effectively used for HD. Fistulogram on [12-27] showed mild narrowing of AV anastomosis and proximal draining vein in this right brachiobasilic AV fistula and patent flow including central veins. Pt had HD on [12-28] prior to discharge and tolerated it well. musculoskeletal: On [12-17], pt went to OR w/ orthopedic surgery to have removal of traction pin, open reduction right fib dislocation, open reduction internal fixation right subtrochanteric femur fracture with gamma nail, Open reduction internal fixation posterior wall posterior column acetabular fracture, Open reduction internal fixation right patella. He tolerated these procedures well and has since been non-weight bearing on RLE since then FEN/GI: tolerating regular diet. Patient had diarrhea and was (+) for c-diff. Placed on a 10 day flagyl course to be finished on [12-4] GU: no active issues heme: IVF filter placed because of patients certainty of being bedridden for a prolonged period due to his long bone and C-spine fractures. endo: no active issues On [12-21] he was transferred from the SICU to the surgical floor. He is being discharged from [Hospital1 18] to rehab today [2113-12-28] in stable condition, tolerating a regular diet and po medication. Medications on Admission: clonidine 0.2 [Hospital1 ] nifedipine 90 Qday colace asa iron aranesp Vit D Ca Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Breakthrough Pain. 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 7. 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 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please continue until [2114-1-4]. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Shattered R acetab and comm prox femur w/post displaced fem head. 2. Teardrop-type fx through inf base C2, lat mass fx C1 NON-OP SPINE 3. R Transverse Patellar Fracture disrupted ext mechanism 4. nondisplaced R rib fractures 7, 8, 9 5. Acute on chronic renal insufficiency Discharge Condition: stable. afebrile, tolerating PO Discharge Instructions: You were brought to the hospital after after your car accident. While you were here, you were found to have a fracture of your right hip and leg. You have a fracture in one of your spinal bones in your neck which does not need an operation. You also have rib and knee fractures which do not require operations. Please do not put weight on your right leg until further notice and do not remove your hard neck collar until directed to do so by a doctor. Please take your medications as directed below. Please return to the ER if you have chest pain, shortness of breath, confusion, weakness, uncontrolled pain, or any concnerns. Followup Instructions: Follow up with Dr. [Last Name (STitle) ]/Orthopaedic Surgery in [2-14] weeks. Call [Telephone/Fax (1) ] to schedule this appointment. Please follow up with Dr. [Last Name (STitle) 106078] at [Telephone/Fax (1) 106079] in [2-14] weeks; we will fax him your discharge summary and fistulogram report. Please keep your hard cervical collar on for now and follow up in [5-19] weeks with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007]. Please call [Telephone/Fax (1) 1228**] for an appointment.	[ "822.0", "008.45", "403.91", "585.5", "293.0", "427.1", "807.03", "808.0", "820.22", "584.5", "805.01", "835.01", "805.02", "E815.0", "V45.01", "518.81", "285.21", "410.71" ]	icd9cm	[ [ [] ] ]	[ "38.7", "79.35", "99.04", "38.95", "79.39", "39.95", "79.36", "96.04", "37.22", "96.71", "88.56", "99.07" ]	icd9pcs	[ [ [] ] ]	5724, 5803	1734, 4250	235, 353	6125, 6159	1691, 1711	6836, 7387	897, 915		4383, 5701		5824, 6104		4276, 4360			6183, 6813									930, 1672																				179, 197										381, 694														716, 825	841, 881
40,000	132,265	22615	Discharge summary	report	Admission Date: [2188-4-14] Discharge Date: [2188-5-7] Date of Birth: [2137-12-1] Sex: F Service: SURGERY Allergies: NSAIDS Attending:[First Name3 (LF) 695] Chief Complaint: HCV/ETOH Cirrhosis here for liver transplant Major Surgical or Invasive Procedure: [2188-4-14]: Orthotopic liver transplant portal vein to portal vein,common bile duct to common bile duct (no T tube), supraceliac conduit to celiac axis of the donor. [2188-4-29]:ERCP with 10 Fr biliary stent [2188-4-29]: 8 Fr drain to R subhepatic fluid collection [2188-4-30]: Angiogram History of Present Illness: Ms. [Known lastname ] is a 50 year old female with history of decompensated alcoholic and HCV cirrhosis, HRS, hyponatremia, SBP, ascites, grade 1 varices, recently admitted to the [Hospital 18] medical liver service for acute renal failure who presents today for a liver transplant. She was sent to [Hospital 58633] Rehabilitation 3 days ago following a hospitalization at [Hospital1 18] for [Last Name (un) ] and Hyponatremia. The [Last Name (un) ] was thought to be due to HRS and the Hyponatremia was hypervolemic hyponatremia due to fluid excess, likely related to her cirrhosis as well. She was started on octreotide and midodrine while in the hospital. She has not required dialysis to date. They were planning serial paracenteses every 1-2 weeks and she has been taking cipro empirically for SBP prophylaxis. When we learned that a liver became available her rehab was contact[Name (NI) ] and she was admitted directly to the floor, anticipating a liver transplant. . Currently she is complaining of a persistent abdominal pain (states same as last hospitalization). The pain is around her umbilicus, sharp, [10-13] and worse with movement. Other than this she states she is ready for surgery but is clearly frightened of the procedure. She has no other complaints at this time. . ROS: Full review of systems was performed and negative except as per HPI. Past Medical History: Decompsenated cirrhosis Chronic HCV ETOH abuse Knee surgery Depression, with a suicide attempt one and a half years ago Social History: The patient is single, has never been married, has four children and ten grandchildren, oldest child is 27. She currently lives with her mother, who is her healthcare proxy (Faith [Name (NI) ] [Telephone/Fax (1) 58631]). -Tobacco history: Quit [10/2187]; used to smoke less than one pack a day for 43 years. -ETOH: She does not drink alcohol currently over the past 25 years, but for 20+ years, she was drinking a bottle plus of vodka daily. -Illicit drugs: She also used heroin, cocaine, and marijuana last approximately four years ago. She is not currently in a program. Family History: No family history of liver disease or hepatitis Physical Exam: Gen: Hiding under covers, appears older than stated age, frightened VS: T: 98.4 P: 91 BP: 147/76 RR: 20 O2sat: 100RA HEENT: NCAT, EOMI, MMM, palate midline, pallor present NECK: Supple, no LAD noted CARD: RRR, systolic murmur heard best on this exam in noisy environment over LUSB PULM: Lungs are very wheezy bilaterally, L>R, good air entry, some accessory muscle use ABD: soft, distended with fluid wave and shifting dullness present, diffusely tender, voluntary guarding in all guadrants, no rebound, no guarding, pain not distractable EXT: WWP, [3-7]+ B/L LE edema to thighs NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: On Admission: [2188-4-14] WBC-6.1 RBC-1.93* Hgb-7.5* Hct-22.6* MCV-117* MCH-39.2* MCHC-33.3 RDW-19.1* Plt Ct-59* PT-20.3* PTT-35.4 INR(PT)-1.9* Glucose-121* UreaN-120* Creat-4.4* Na-138 K-3.8 Cl-107 HCO3-18* AnGap-17 ALT-35 AST-83* AlkPhos-46 TotBili-4.2* Lipase-43 Albumin-3.8 Calcium-8.9 Phos-4.9* Mg-1.8 HBsAg-NEGATIVE HBsAb-NEGATIVE HIV Ab-NEGATIVE At Discharge: [2188-5-7] WBC-7.0 RBC-2.49* Hgb-7.8* Hct-24.2* MCV-97 MCH-31.5 MCHC-32.4 RDW-18.6* Plt Ct-225 PT-11.5 PTT-27.8 INR(PT)-1.1 Glucose-133* UreaN-36* Creat-1.4* Na-141 K-3.4 Cl-106 HCO3-22 AnGap-16 ALT-20 AST-19 AlkPhos-490* TotBili-2.1* Calcium-8.3* Phos-3.4 Mg-1.5* Prograf pending at time of discharge. Brief Hospital Course: 50 y/o female with HCV and ETOH cirrhosis who underwent Orthotopic deceased donor liver transplant (piggyback) portal vein to portal vein, common bile duct to common bile duct (no T tube), supraceliac conduit to celiac axis of the donor. The surgeon was Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The donor was a CDC high-risk because of the possibility of the donor trading sex for drugs. The patient was informed of these high-risk behaviors and accepted the liver. HBSAg, HBSAb, HIV of recipient were negative at the time of transplant. The HBcAb of the donor was positive, and the patient has received HBIg per protocol with subsequent HBsAb titers > 500, and negative HBsAg. Due to the level of her renal dysfunction, she required CVVHD during the transplant. She required one further day of CVVH. She was extubated on POD 1. She remained in the ICU and while off renal replacement therapy, her BUN and creatinine continued to rise, however her urine output was approximately 1.5 liters daily. On POD 3 her BUN was 117, and prograf level was 15. The patient was noted to start having tonic-clonic seizures, Neuro was consulted, she was started on Keppra and received an additional hemodialysis treatment. Following that treatment, the BUN was in the 70s or less, and creatinine, which peaked at 4.1 has slowly but steadily declined to less than 2. Once these interventions were complete, the patient did not appear to have further seizure activity, however the neurology recommendations are to continue the keppra for 6 months. The patient was transferred out of the ICU on POD 7. Appetite was poor, and feeding tubes have been placed. She has intermittently pulled the tubes out, despite bridling. The patients mental status does not appear to be at baseline, she is noted to be very quiet and uninvolved in personal care and learning medications. TSH was sent, result was 7.4 and levothyroxine was started. AST and ALT have trended down to normal, however the alk phos which initially w starting to normalize, had started to trend back up into the 400s, and the total bilirubin which peaked at 16.1 while in the ICU, has trended down, but not normalized. On POD 14, due to these findings, an ERCP was performed showing mild diffuse dilation at the biliary tree with the CBD measuring 10 mm. The duct-to-duct anastomosis site appeared patent. A balloon sweep was performed through the anastomotic site with minimal resistance. An occlusion cholangiogram revealed extravasation of contrast most likely from the right hepatic system consistent with a high grade bile leak. The rest of the bile duct appeared unremarkable. A 10 Fr biliary stent was placed. Of note, there was a 3mm stomach body ulcer noted. Famotidine was switched to [Hospital1 ] protonix. Mental status continued as flat and disengaged. TSH was checked and found to be elevated at 7.3 with T4 of 7.1. Levothyroxine was started. An ultrasound/duplex of liver was done to assess for collection. Findings were notable for high velocity in hepatic artery concerning for hepatic artery stenosis, large sub-hepatic fluid collection, large amount of abdominal and pelvic ascites adn small right pleural effusion. She then underwent US guided drainage of subhepatic/paracentesis fluid drainage (2 liters of biliuous fluid)with placement of an 8 Fr drain. Cell count had wbc of 2750 with 82 polys. This fluid bilirubin level was 17. Culture was negative. Zosyn was started for infected bile collection. She was given 25grams of Albumin. Another 2 liters of bilious fluid drained out with patient becoming tachycardic. Albumin 5%/500ml was administered with resolution of tachycardia. On [4-30] hepatic angiogram was performed via right groin approach with limited contrast used due to creatinine elevation of 1.7. She was prehydrated with IV bicarb fluid overnight prior to study. Findings were notable for moderate stenosis just beyond anastomosis. IR was unable to stent. On [5-1], repeat angiogram was done with successful stent placement. Aspirin and Plavix were started for the stent. Total bilirubin continued to decrease, however, alk phos continued to remain in the mid 400 range. On [5-3], Hct had decreased to 20.9 from 25.6. Two units of PRBC were transfused with Hct increase to 27. An abdominal CT was done to evaluate for bleeding. CT demonstrated the following: Large subcapsular liver collection that is likely not being drained by the pigtail catheter in place at the inferior aspect of the liver. Air within this collection likely is due to communication with the biliary tree. However, superinfection cannot be excluded. 2. Generalized anasarca with intra-abdominal ascites and multiple collections identified, the largest of which is in the pelvis, as described above. 3. No evidence for intra-abdominal or pelvic bleed to explain the patient's recent drop in hematocrit. On [5-5], CT guided placement of an 8 French drain was placed into the the right perihepatic collection. Per report, 100 mL of blood-tinged fluid removed. No further fluid could be aspirated despite the drain being in satisfactory position, which raises the possibility of a loculated collection. 100 mL of straw-colored fluid was aspirated through the existing right-sided 8French pigtail catheter, which was left in place. Gram stain of fluid was no organisms or PMNs, culture was negative. Drain continued to have thin, yellow colored drainage averaging 50 -150 ml daily. On [5-6], Zosyn was discontinued and Cipro started for peritonitis prophylaxis. Repeat culture was sent on drain fluid showing 1+ PMN with culture negative to date. Mental status was much improved. She was more interactive, animated and able to participate in care. She was ambulating with walker with supervision. PT continued to recommend rehab. Hepatitis B immune globulin was administered IM on [5-6] per protocol (postop day 21)as liver donor was HB core positive. She will receive this on postop day 29 at her next appointment at [Hospital 18] [Hospital 1326] Clinic. HBSAb titer was greater than 500 and HBSAg remained negative. She will continue to receive this per protocol arranged by [Hospital1 18] Transplant. On [5-6], a bed was available at [Hospital ] Rehab in [Location (un) 701]. She was transferred there on [5-7]. Medications on Admission: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. octreotide acetate 500 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY(Daily). 11. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 12. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 13. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 15. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 16. albumin, human 25 % 25 % Parenteral Solution Sig: One (1)Intravenous DAILY (Daily). Discharge Medications: 1. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 5. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day. 6. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): started [4-29]. TSH in 6 weeks. 13. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: no more than 2000mg per day. 16. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): decrease per taper [5-15]. 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 18. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 19. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): peritonitis prophylaxis while drains in place. Do Not discontinue. 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 22. insulin regular human 100 unit/mL Solution Sig: follow sliding scale units Injection four times a day. 23. Outpatient Lab Work Friday [5-9] then every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, t.bili and trough tacrolimus level with stat results. fax results to [Hospital1 18] Transplant [Telephone/Fax (1) 697] see printed recs and labels 24. Hepatitis B Immune Globulin postop day 28-to be given at [Hospital 1326] Clinic on [5-14] 25. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 26. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day: Hold for SBP < 120 or HR < 60. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: HCV/ETOH Cirrhosis now s/p Liver transplant with conduit Bile Leak s/p biliary stent placement infected abdominal bile collections Hepatic artery stenosis Seizures Acute on chronic kidney failure Hypothyroid malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be transferred to [Hospital ] Rehab in [Location (un) 701] Please call the [Hospital 18] [Hospital 1326] Clinic at [Telephone/Fax (1) 673] if the patient has fever of 101 or greater, chills, nausea, vomiting,jaundice, diarrhea, constipation, increased abdominal pain, inability to tolerate food, fluids or medications, incisional redness, drainage or bleeding, or abdominal drain outputs increase or stop. Please empty and record all drain outputs every shift and as needed. Send copy of drain output log to the transplant clinic. Labs Friday [5-9] then every Monday and Thursday for CBC, Chem 10, AST, ALT, Alk Phos, T bili, Trough Prograf level with results faxed to transplant clinic at [Telephone/Fax (1) 697] Please do not add, or take away, or adjust medication dosages without first consulting with the transplant team. Patient may shower, do not allow drains to hang freely. No tub baths or swimming No lifting greater than 10 pounds Followup Instructions: Please call [Hospital1 18] Transplant Coordinator for f/u appointment week of [793-5-12] Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & TARULLA (Neurology)Phone:[Telephone/Fax (1) 44] Date/Time:[2188-6-3] 2:30, [Hospital1 18] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2188-5-7]	[ "263.9", "584.9", "303.93", "296.23", "790.4", "789.59", "277.89", "585.6", "571.2", "567.81", "345.50", "305.93", "493.20", "041.04", "531.90", "707.05", "790.01", "567.23", "276.69", "780.09", "276.1", "V05.3", "572.4", "576.8", "440.8", "403.91", "289.51", "707.22", "572.3", "070.70", "456.21", "E878.0", "997.49", "V15.82" ]	icd9cm	[ [ [] ] ]	[ "88.47", "54.91", "50.59", "39.90", "51.98", "00.45", "96.71", "51.87", "00.40", "39.95", "39.50", "51.85", "00.44", "00.93" ]	icd9pcs	[ [ [] ] ]	14641, 14713	4231, 10591	309, 616	14978, 14978	3529, 3529	16166, 16590	2813, 2863		12013, 14618		14734, 14957		10617, 11990			15161, 16143									2878, 3510												3900, 4208								225, 271										644, 2049							3543, 3886		14993, 15137					2071, 2193	2209, 2797
29,623	116,536	18280	Discharge summary	report	Admission Date: [2183-8-14] Discharge Date: [2183-8-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13541] Chief Complaint: Fever, rigors Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [Known lastname 1005] is an 89yo spanish speaking female with PMH significant for multiple ESBL UTIs, lumbar osteomyelitis, and psoas abcess who was admitted to the MICU with a UTI and transient hypotension concerning for urosepsis. Of note, the patient was recently hospitalized in [2183-5-20] for E coli and K. pneumo UTI ([1-17] BCx + for K. pneumo), tx with cephalexin/cefpodoxime for 14d. Her osteomyelitis was unchanged per MRI at this time. In addition, a PICC was placed on [7-31] to administer a 7d course of Imipenem (500mg q8h, [Date range (1) 50412]) for an ESBL E. coli UTI [2-15] foley catheter (d/c'd [7-31]). The PICC was kept until f/u urine studies could be performed 1 wk post-abx. This morning at the patient's NH, she was noted to have fevers and rigor. Her vitals at this time were T 100.0 BP 160/90 AR 130 RR 30 O2 sat 90% RA. ? if she was on carbapenem for a UTI. She was then transferred to [Hospital1 18] for further work-up. In the ED, initial vitals were T 99.1 Tmax 101.8 BP 120/80 AR 92 RR 16 O2 sat 99% RA. Foley placed without any complications. She received Flagyl 500mg, Linezolid 600mg, and Meropenem 500mg. Her BP dropped to 90/68. She also was given 2L NS. Upon arrival to the MICU and in the presence of the spanish translator, the patient denies any acute complaints. She denies any chest pain, SOB, abdominal pain, or any other concerning symptoms. She does admit to some low back pain, which is chronic for her. She was hemodynamically stable in the MICU, and so she was called out to the floor. She is being followed by ID in-house and is on meropenem and daptomycin (changed from linezolid [2-15] serotonin syndrome concern). On the floor, she only c/o generalized weakness. Past Medical History: 1)VRE stump infection [1-21] 2)Klebsiella pneumonia and bacteremia 3)Multiple UTIs including ESBL E. coli [2183-7-30] in setting of foley 4)Lumbar osteomyelitis L2-L3 s/p daptomycin and meropenem x8 weeks; biopsy cultures were negative 5)Psoas/iliacus abscesses [1-21] 6)Hypertension 7)Type 2 diabetes 8)Stomach carcinoma s/p resection 9)Hx of gastritis/esophagitis 10)Chronic anemia 11)PVD s/p common femoral to left common femoral bypass with PTFE in [2181-6-14] 12)L AKA in [12-21] c/b klebsiella PNA, VRE UTI, presumed c. diff tx'ed with abx 8 wks 13)Hx urinary incontinence status post collagen injections to bladder neck 14)s/p hysterectomy 15)s/p oophorectomy 30 years ago Social History: She is originally from [Country 26231]. She is not employed. She does not use tobacco. She does not use alcohol nor any drugs. Lives at NH. Family History: n/c Physical Exam: VS: 98.9 71 135/44 18 99%RA Gen: Pleasant female, well appearing, alert and oriented to person, place day and month (year - [2145]). HEENT: MMM, anicteric sclera Heart: RRR, no m,r,g Lungs: CTAB, few scattered crackles at posterior lung bases Abdomen: Soft, mild tenderness in RLQ, +BS; G-tube in place without any surrounding erythema or tenderness. No CVAT. Extremities: L AKA, no edema of RLE, 2+ DP/PT pulses; quarter sized sacral ulcer with mild surrounding tenderness Pertinent Results: [2183-8-14] 09:15AM WBC-13.2* RBC-3.71* HGB-10.0* HCT-30.0* MCV-81* MCH-27.1 MCHC-33.5 RDW-14.8 [2183-8-14] 09:15AM PLT SMR-HIGH PLT COUNT-470* [2183-8-14] 09:15AM SED RATE-120* [2183-8-14] 09:15AM CRP-177.7* [2183-8-14] 09:15AM GLUCOSE-106* UREA N-17 CREAT-0.5 SODIUM-130* POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-13 [2183-8-14] 09:47AM LACTATE-3.3* [2183-8-14] 10:17AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.008 [2183-8-14] 10:17AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2183-8-14] 10:17AM URINE RBC-[6-24]* WBC->50 BACTERIA-MANY YEAST-FEW EPI-[3-19] [2183-8-14] 11:02AM LACTATE-2.2* URINE CULTURE (Final [2183-8-17]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| KLEBSIELLA PNEUMONIAE \| \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I =>32 R CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 128 R PIPERACILLIN/TAZO----- <=4 S 32 I TOBRAMYCIN------------ 4 S 8 I TRIMETHOPRIM/SULFA---- <=1 S <=1 S . Urine cx ([8-15]): negative Blood cx ([8-14]): negative x2 Blood cx ([8-15]): NGTD x2 Cdiff toxin neg x1 . CT abd/pelvis ([8-14]): IMPRESSION: 1. No acute finding to explain source of infection. 2. Stable destruction of L2 and L3 vertebral bodies. 3. No CT evidence of pyelonephritis. 4. No evidence of intraabdominal or pelvic abscess. . MRI pelvis ([8-18]): IMPRESSION: 1) Severely limited study for reasons stated above. [claustrophobia] 2) Bilateral femoral avascular necrosis with severe underlying osteoarthritis. 3) Prominent bilateral subcutaneous edema and edema tracking along the adductor musculature bilaterally. 4) Study not of diagnostic quality to assess the psoas muscles or exclude deep abscess. . MRI T/L spine ([8-17]): Impression: Essentially no change in the appearance of the inflammatory changes at L2-L3. . KUB with oral contrast via J tube ([8-16]): Single portable radiograph of the abdomen demonstrates oral contrast within a catheter projecting over the left upper and lower quadrants. There is oral contrast within the small bowel. No extravasation is seen. Surgical staples project over the right upper quadrant. There is a non-obstructive bowel gas pattern. No pneumoperitoneum is evident. The appearance of the osseous structures is unchanged compared with [2183-7-3]. Surgical staples projecting over the left upper and lower quadrants remain similar in appearance as well. Brief Hospital Course: ## UTI/urosepsis: Patient was initially febrile to 101.8 and hypotensive to 90/68 on admission. She was given flagyl, linezolid, and meropenem in the ED, as well as 2L NS. Foley was placed with purulent urine return. She was initially continued on meropenem and linezolid, but the linezolid was switched to daptomycin on [8-15] due to concern for serotonin syndrome given venlafaxine use. Daptomycin d/c'd on [8-18] as osteo stable (see below). Urine culture grew E coli and Klebsiella, sensitive to meropenem and bactrim. Due to this, meropenem was switched to bactrim on [8-19] to complete a 14 day course. Pt transitioned from Foley to straight cath q8h due to retention to help prevent UTI recurrence (no bladder scan at nursing facility). Since her initial ED presentation, she has remained without hypotension or fevers. She was restarted on lisinopril and metoprolol XL after 24hrs w/o hypotension. ## Osteomyelitis: No complaints of back pain. MRI T/L spine showed stable appearance, so daptomycin was stopped on [8-18]. MRI pelvis was attempted, but pt did not tolerate due to claustrophobia (even with ativan). CRP was much decreased on discharge. She will followup in [Hospital ] clinic. ## Rash Erythematous unilateral macular flank rash w/ small pustules noted. No pain, confirms pruritis. No eos on CBC. Started on 7d course valacyclovir to end [8-24] for possible zoster. ## Type 2 DM: Held oral hypoglycemics and had reasonable glucose control with insulin sliding scale. ## FEN Pt gets supplemental tube feeds overnight. Her sutures came loose on [8-16], but were reattached by IR. Plain film w/ contrast showed proper positioning, so feeds resumed. ## Decubitus ulcer Known prior to admission. Wound care consulted and pt was repositioned and cleansed per their recs. No e/o communication w/ osteo on MRI. ## Bilateral AVN of femoral head Noted on brief images obtained on MRI pelvis study. Pt asymptomatic and would likely need conservative management. Can consider bisphosphonates in the outpatient setting. ## Dispo All other chronic problems remained stable and treated as prior. She is being discharged back to her [Hospital1 1501]. Medications on Admission: Pioglitazone 7.5mg PO daily Fluticasone-salmeterol Omeprazole 20mg PO BID Tiotropium MDI Aspirin 81mg PO daily Metoprolol XL 50 mg PO daily Docusate 100 mg 100mg PO BID Senna PO BID Venlafaxine 25mg PO BID Oxycodone PO Q6H PRN Acetaminophen 650mg PO Q6H Vitamin D PO daily Lisinopril 20mg PO daily Immodium PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Venlafaxine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 5 days: Last day of 7d total course is [2183-8-24]. 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Actos 15 mg Tablet Sig: [1-15] Tablet PO once a day. 13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO after each loose stool as needed for diarrhea. 15. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: To finish 14d total course on [2183-8-27]. Discharge Disposition: Extended Care Facility: [Hospital1 ] - [Location 4288] Discharge Diagnosis: Primary: Urosepsis, Stage IV decubitus ulcer Lumbar osteomyelitis. Secondary diagnoses: Diabetes mellitus type 2, controlled with complications Hypertension Peripheral vascular disease status post left above knee amputation Discharge Condition: Stable hemodynamics, alert and interactive, afebrile. Discharge Instructions: You were admitted to [Hospital1 18] because of a bladder infection. This caused you to have low blood pressure, which we fixed with fluids. We started you on intravenous antibiotics for 14 total days for the infection. We imaged your spine with an MRI to see if your previous bone infection had changed, and it looked stable from your last MRI. We have removed the catheter that stays in your bladder because this would make treating the infection difficult. Instead, we will use intermittent catheters, "straight cath," as needed. Also, you have a rash on your back that may be herpes zoster, which is a virus. We will treat you with antibiotics for this as well. Please take all medications as prescribed and follow-up at all appointments. If you notice any problems urinating, fevers, chills, night sweats, weakness, changes in mental status, or any other concerning symptoms, please seek medical attention or come to the emergency department immediately. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD, Infectious Disease Phone:[Telephone/Fax (1) 457] Date/Time:[2183-8-27] 11:30 Dr. [First Name (STitle) 17832] [Name (STitle) 16365], Primary Care, Phone:[Telephone/Fax (1) 17826] [8-22] at 2:45pm. [Street Address(2) ] [Location (un) 577], [Numeric Identifier 4544] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 13546] Completed by:[2183-8-20]	[ "715.35", "041.4", "401.9", "733.42", "730.18", "707.03", "458.9", "V10.04", "041.3", "053.9", "V49.76", "599.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10755, 10820	6802, 8998	277, 284	11089, 11145	3496, 6779	12158, 12699	2978, 2983		9359, 10732		10841, 10909		9024, 9336			11169, 12135									2998, 3477	10930, 11068																			224, 239										312, 2075														2097, 2799	2815, 2962
5,544	174,069	491	Discharge summary	report	Admission Date: [2124-2-12] Discharge Date: [2124-2-16] Date of Birth: [2047-10-15] Sex: M Service: MEDICINE Allergies: Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit Extracts / Nafcillin / cefazolin Attending:[First Name3 (LF) 759] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 76 y/o male with sCHF (EF 35-40%), AS s/p biologic AVR, CAD, pAF, DMII c/b neuropathy, hypothyroidism and stage III/IV CKD, with a recent admission for [Female First Name (un) 564] fungemia, who presented from [Hospital1 ] [Location (un) 620] with SOB and altered mental status. He was recently hospitalized at [Hospital1 18] from [Date range (1) 4108] with [Female First Name (un) 564] fungemia (no evidence of endophthalmitis and TEE without evidence of Endocarditis) with a hospital course complicated by a left IJ DVT (for which he was bridged to Coumadin with Heparin), acute on CKD (CKD [1-20] AIN, most likely [1-20] Nafcillin, with baseline creatinine of ~ 2.3, 2.9 at discharge on [2124-2-3]), and a systolic CHF exacerbation. . He was discharged to [Hospital ] Rehab on [2124-2-3]. He states that since his discharge he has been profoundly short of breath with minimal exertion, especially over the last few days. He states that initially he was making good urine to his Lasix 100 mg [Hospital1 ] but that one to two days ago he stopped making urine. He was also noted to be increasingly confused at [Hospital1 ]. . On [2124-2-11], he was taken to [Hospital1 ] [Location (un) 620] Emergency Department for severe SOB and altered mental status. On arrival to [Hospital1 ] [Location (un) 620] he was noted to be hypotensive. A right IJ central line was placed and he was given Zosyn and started on Levophed prior to transfer. A BNP was reportedly 34,000. He was transferred to [Hospital1 18] [Location (un) 86] for concern for hypotension from CHF vs. sepsis. . On arrival to [Hospital1 18] ED, his initial vitals were 97.5, 60, 96/54, 25, 91%on RA. The Levophed was discontinued but his blood pressure subsequently dropped to 56/46 and the Levophed was restarted. His CBC was notable for a WBC of 17.9 with 82.1% PMNs but no bands. His extended chemistry was notable for a potassium of 5.6, HCO3 of 20, a BUN of 85, a Cr of 4.7, a calcium of 7.6, and a phosphorus of 9.5. His lactate was 5.2 and his INR was 4.1. A CXR was consistent with pulmonary edema. He received Vancomycin, zosyn and 100 cc of NS. His vital signs at transfer were 99/50, 62, 17, 94 on 4L. . On arrival to the MICU, his vitals were 96, 64, 113/56 (on 0.12 mcg/kg/min), 24, 97% on 4L. He looked uncomfortable but was in no apparent distress. He reported the history as detailed above. He additionally reported a nagging non-productive cough in addition to his worsening DOE. He denied any recent fevers, chills, chest pain, palpitations, nausea, vomiting, abdominal pain, diarrhea, dysuria or hematuria. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -Chronic Systolic Heart Failure (EF 35% to 40% in [2119]) -s/p biologic AVR [2119] -CABG: -s/p CABG in [2113] and [2119] -PERCUTANEOUS CORONARY INTERVENTIONS: -multiple stents [10/2123] -PACING/ICD: -pacer insertion [2119] ([Company 1543] Sensia dual-chamber pacemaker) [1-20] transient heart block post-op AVR 3. OTHER PAST MEDICAL HISTORY: - DM type II c/b neuropathy - HTN - HLD - CAD - Paroxysmal Atrial Fibrillation - h/o epistaxis requiring blood transfusion while on coumadin - BPH - Hypothyroidism - CKD stage III/IV - H/o AIN - ? history of stroke - anemia of chronic disease (baseline between 27-30) Social History: Prior to his admission at [Hospital1 ], He lived at home with his wife. [Name (NI) ] ambulates with a walker. He has had multiple hospitalizations since the fall requiring a stay at NewBridge on the [Doctor Last Name ]. He was discharged 3 days ago. He denies tobacco, alcohol, illicit drug use. Family History: Mother died at 81 and had a brain tumor. Sibling with Alzheimer disease. There is also thyroid and lung cancer in other family members. Brother with pancreatic and liver cancer. No family history of CAD or sudden cardiac death. Physical Exam: ADMISSION EXAM: T 96 BP 121/61 HR 67 O2 sat 95% 4L NC RR24 General: uncomfortable, NAD HEENT: MMM, OP clear, RIJ in place, unable to assess JVP CV: RRR, distant heart sounds, unable to appreciate any m/r/g, normal S1 and S2 Lungs: labored, crackles to the mid-posterior lung fields bilaterally Abdomen: distended but soft, BS+, NT/ND GU: foley in place Ext: warm, arterial ulcers on pedal surface of feet bilaterally, [1-21]+ pitting edema in bilateral lower extremities tapering to trace pitting edema at the sacrum Neuro: AAOx3 (person, place and time), right facial droop, strength not assessed Pertinent Results: ADMISSION LABS [2124-2-12] 01:25AM BLOOD WBC-17.9* RBC-3.95* Hgb-8.8* Hct-31.3* MCV-79* MCH-22.2* MCHC-28.1* RDW-17.3* Plt Ct-296 [2124-2-12] 01:25AM BLOOD Neuts-82.1* Lymphs-14.5* Monos-3.1 Eos-0 Baso-0.2 [2124-2-12] 02:21AM BLOOD PT-41.4* PTT-42.0* INR(PT)-4.1* [2124-2-12] 01:25AM BLOOD Glucose-130* UreaN-85* Creat-4.7# Na-140 K-5.6 Cl-103 HCO3-20* AnGap-23* [2124-2-12] 01:25AM BLOOD ALT-793* AST-[2092]* LD(LDH)-1394* CK(CPK)-127 AlkPhos-430* TotBili-0.5 [2124-2-12] 01:25AM BLOOD CK-MB-12* MB Indx-9.4* [2124-2-12] 01:25AM BLOOD cTropnT-0.17* [2124-2-12] 06:00PM BLOOD CK-MB-12* MB Indx-8.7* cTropnT-0.16* [2124-2-12] 01:25AM BLOOD Albumin-2.7* Calcium-7.6* Phos-9.5# Mg-2.3 [2124-2-12] 08:36AM BLOOD Type-ART pO2-31 pCO2-47* pH-7.20* calTCO2-19* Base XS--10 PERTINENT LABS AND STUDIES [2124-2-12] 01:43AM BLOOD Lactate-5.2* [2124-2-12] 10:44AM BLOOD Lactate-5.8* [2124-2-13] 12:54AM BLOOD Lactate-3.4* [2124-2-12] 04:57AM BLOOD O2 Sat-39 [2124-2-12] 06:06PM BLOOD freeCa-0.93* [2124-2-13] 12:54AM BLOOD freeCa-0.70* MICROBIOLOGY: Urine cx [2-12]: negative Blood cultures 2/25: pending, negative to date [2124-2-12] ECHO: The left atrium is markedly dilated. The right 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 size is normal. There is mild to moderate regional left ventricular systolic dysfunction with infero-lateral akinesis and inferior hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CXR [2124-2-12]: 1. Right internal jugular central venous catheter with tip in the right atrium. Consider retraction by approximately 2-3 cm. 2. Mild interval improvement of pulmonary edema. 3. Bilateral collapse/cponsolidation and possible small effusions. Brief Hospital Course: 76M with sCHF (EF 35-40%), AS s/p biologic AVR, CAD, pAF, DMII c/b neuropathy, hypothyroidism and stage III/IV CKD, with a recent admission for [Female First Name (un) 564] fungemia, who presented from [Hospital1 ] [Location (un) 620] with hypotension and initial concern for sepsis vs. CHF. Given concern for possible sepsis, he was continued on fluconazole, and also started on broad spectrum antibiotics (vanco/meropenem). However, further work-up revealed his clinical picture was more suggestive of cardiogenic shock in the setting of decompensated sCHF. The patient's physical exam and CXR were consistent with left and right heart failure. A repeat TTE showed worsened right heart failure. His central venous O2 was 36 and his CVP 23. As he was hypotensive with evidence of significant end-organ damage, diuresis was not an option. The patient was continued on norepinephrine for blood pressure support. Renal was consulted, and the patient was initiated on CVVH. With CVVH, approximately 6.5L of fluid were removed, with improvement in patient's respiratory status. He was weaned off pressors. However, the patient continued to have profoundly altered mental status and tenuous respiratory status. After further discussion between the MICU team and the patient's family, a decision was made to transition to comfort focused care. Dialysis was stopped, and his HD line was removed. A-line removed. Antibiotics were stopped, and all other medications were discontinued. The patient was called out to floor. Palliative care and social work were consulted. The patient was started on morphine as needed for dyspnea, lorazepam as needed for anxiety, and a scopolamine patch to help with secretions. The patient expired on [2124-2-16]. Medications on Admission: 1. Aspirin 81 mg Tablet qd 2. Vitamin D 1,000 unit Tablet qd 3. clopidogrel 75 mg Tablet qd 4. Lasix 100 mg [Hospital1 ] 5. Lantus 100 unit/mL Solution Sig: Twenty (20) units HS 6. insulin aspart 100 unit/mL QID 7. levothyroxine 50 mcg qd 8. metoprolol tartrate 50 mg [Hospital1 ] 9. multivitamin 10. pantoprazole 40 mg Tablet, 11. tamsulosin 0.4 mg Capsule HS (at bedtime). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID 14. warfarin 2 mg q4 PM. 15. fluconazole 200 mg Tablet q24 16. ferrous sulfate 325 mg qd 17. albuterol sulfate neb q4 prn 18. ipratropium bromide q6prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Systolic congestive heart failure exacerbation End stage renal disease Discharge Condition: Patient expired. Discharge Instructions: N/A Followup Instructions: N/A	[ "285.21", "584.5", "585.3", "785.51", "276.2", "428.0", "250.60", "440.23", "V45.81", "272.4", "V42.2", "244.9", "357.2", "V49.86", "707.14", "403.90", "427.31", "276.7", "428.23" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	10241, 10250	7739, 9513	365, 383	10382, 10400	5047, 7716	10452, 10458	4177, 4409		10212, 10218		10271, 10361		9539, 10189			10424, 10429									4424, 5028		3188, 3531																		318, 327										411, 3080											3562, 3831			3102, 3168	3847, 4161
63,360	133,983	35191	Discharge summary	report	Admission Date: [2119-3-6] Discharge Date: [2119-3-11] Date of Birth: [2047-4-26] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: Fall from ladder Major Surgical or Invasive Procedure: Left eye partial tarsorrhaphy History of Present Illness: 71M patient was reportedly at work up on a ladder when he fell 5 feet. The patient was able to walk and went home after falling. He then had several drinks due to the severe pain that he was in. Subsequently he was sent to the ER at [Hospital1 18]. Here he was found to have the following injuries: 1. Lat, Med, Inf orbital wall fractures 2. Left corneal abrasion, subconjuntival hemorrhage, Upper eyelid laceration 3. Nasal laceration and nasal bone fracture 4. C5 comminuted spinous process fracture that extends to canal 5. T11 compression fx - duration unknown Past Medical History: ETOH abuse HTN GERD Gout Ezcema Left tibia fracture [2118-10-7] Social History: ETOH abuse (daily, ?amt), no tob, no drugs. Lives with wife. Family History: NC Physical Exam: Upon Discharge: VS: 97.6, 83, 126/58, 17, 96% on RA Gen: NAD, confused at times, but oriented to person and place. HEENT: C-collar in place in good position. The left eye is markedly swollen and ecchymottic with a suture in place s/p tarsorraphy. There is marked generalized facial swelling with several abrasions througout. CV: RRR, S1S2 Lungs: CTAB Abd: Soft, NTND Ext: LLE - moderate ecchymossis in popliteal fossa. wound near left fibular head is c/d/i with minimal erythema. Pertinent Results: [2119-3-6] 09:10PM BLOOD WBC-14.4* RBC-3.96* Hgb-12.2* Hct-36.9* MCV-93 MCH-30.8 MCHC-33.1 RDW-14.7 Plt Ct-234 [2119-3-7] 04:00AM BLOOD WBC-12.9* RBC-3.65* Hgb-11.7* Hct-34.3* MCV-94 MCH-32.1* MCHC-34.1 RDW-14.8 Plt Ct-235 [2119-3-8] 05:01AM BLOOD WBC-7.3 RBC-3.04* Hgb-9.9* Hct-29.0* MCV-95 MCH-32.4* MCHC-34.0 RDW-15.0 Plt Ct-161 [2119-3-9] 01:17AM BLOOD WBC-8.7 RBC-2.91* Hgb-9.1* Hct-27.8* MCV-95 MCH-31.3 MCHC-32.8 RDW-15.1 Plt Ct-183 [2119-3-10] 04:44AM BLOOD WBC-10.4 RBC-2.94* Hgb-9.6* Hct-28.0* MCV-95 MCH-32.6* MCHC-34.1 RDW-15.4 Plt Ct-183 [2119-3-6] 09:10PM BLOOD PT-14.1* PTT-25.7 INR(PT)-1.2* [2119-3-7] 04:00AM BLOOD PT-13.2 PTT-26.6 INR(PT)-1.1 [2119-3-7] 04:00AM BLOOD Glucose-103 UreaN-10 Creat-1.0 Na-136 K-3.1* Cl-105 HCO3-18* AnGap-16 [2119-3-8] 05:01AM BLOOD Glucose-78 UreaN-9 Creat-0.9 Na-139 K-3.0* Cl-107 HCO3-25 AnGap-10 [2119-3-8] 12:55PM BLOOD K-3.3 [2119-3-8] 09:14PM BLOOD K-3.2* [2119-3-9] 03:14AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-140 K-4.1 Cl-108 HCO3-22 AnGap-14 [2119-3-10] 04:44AM BLOOD Glucose-85 UreaN-9 Creat-0.9 Na-139 K-3.7 Cl-106 HCO3-25 AnGap-12 [2119-3-7] 04:00AM BLOOD Calcium-7.1* Phos-3.2 Mg-1.5* [2119-3-8] 05:01AM BLOOD Calcium-6.9* Phos-2.0* Mg-1.3* [2119-3-8] 09:14PM BLOOD Mg-1.8 [2119-3-9] 01:17AM BLOOD Calcium-6.6* Phos-1.2* Mg-2.4 [2119-3-9] 03:14AM BLOOD Calcium-7.0* Phos-1.3* Mg-2.4 [2119-3-10] 04:44AM BLOOD Calcium-7.3* Phos-2.1* Mg-1.7 [2119-3-6] 09:10PM BLOOD ASA-NEG Ethanol-225* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS CT Face [3-6]: IMPRESSION: 1. Left orbital blowout fractures involving the superior, inferior, medial, and lateral walls. Fracture of the left zygomatic process and bilateral nasal fractures. 2. Inferior rectus muscle swelling and displacement inferiorly without overt evidence of muscle entrapment. 3. Left periorbital and left frontal subgaleal hematomas. CT C-spine [3-6]: IMPRESSION: Comminuted fracture of the C5 spinous process extending into the left lamina and associated central canal hematoma. The hematoma appears to impinge on the adjacent spinal cord. MRI is recommended for further evaluation of the cord and the adjacent ligaments. Grade 1 retrolisthesis of C5 on C6 is also identified. CT Torso [3-6]: IMPRESSION: 1. No definite intra-abdominal, intrapelvic or intrathoracic injury. 2. Bilateral old rib fractures and old pelvic fractures. 3. T11 compression fracture, chronicity unknown. MRI C-spine [3-7]: 1. Possible small spinal canal epidural hematoma without evidence of change in spinal cord signal. Also seen are the previously detailed spinous process fracture and degenerative changes in the cervical spine. Left Tib/Fib xrays [3-7]: IMPRESSION: S/p ORIF with advanced healing of tibial and fibular fractures. No hardware loosenig or conclusive evidence for osteomyelitis. CT head [3-8]: IMPRESSION: 1. Interval development of prominent frontal extra-axial space filled with simple fluid, concerning for acute subdural hygromas. These measure approximately 7 mm in greatest diameter. No evidence of shift of normally midline structures. 2. Unchanged appearance of left-sided facial fractures, left periorbital swelling, and left frontal subgaleal hematoma. 3. Left maxillary opacification, stable. 4. No evidence of acute hemorrhage within the brain parenchyma. CXR [3-9]: FINDINGS: In comparison with study of [3-8], the right subclavian catheter has been extended at least to the right atrium. No change in the appearance of the heart and lungs. There is a vague suggestion of some increased opacification at the left base, which could reflect atelectasis or even pneumonia in the region of multiple lower left rib fractures. CT head [3-10]: IMPRESSION: Stable acute subdural hygromas. Brief Hospital Course: Mr. [Known lastname 12056] was admitted to the Trauma Surgery service on [2119-3-6]. He was placed in the trauma SICU for close monitoring. He was stabilized in the ICU and transferred to the floor on [3-7]. However, he was having signs and symptoms of ETOH withdrawal and was transferred back to the ICU for closer monitoring. He was again stabilized in the ICU, tolerating a regular diet with well controlled pain. He was again transferred to the floor. On the floor he was seen and evaluate by plastic surgery, orthopaedic surgery, neurosurgery, and ophthalmology for his myriad injuries. Ortho: WBAT, continue dicloxacillin. Will follow up in 1 month. Plastics: performed left lateral tarsorraphy [3-10]. Placed a single stitch with xeroform dressing. Will have patient come to clinic on [Last Name (LF) 2974], [3-17]. Will likely treat facial fractures operatively Ophtho: Recommended erythromycin to eye q2hrs. Patching eye at night, and taping eyelid at night if not closing properly. Will f/u in [12-16] weeks for further eval. Neurosurgery: Hard collar at all times x 3 months. Will follow up in 3 months for c-spine fracture, and 4 weeks for hygromas. UTI: The patient was found to have a UTI on [3-6] and was started on a 5day course of cipro, which he completed prior to discharge. He was asymptomatic at that time. He was tolerating a regular diet throughout his hospital course. His pain was well controlled with IV and then PO pain medications. He was discharged to rehab on [3-11] in stable condition. ETOH withdrawal: He was placed on a CIWA scale with valium for DT prophylaxis Medications on Admission: acamprosate 2tab''', allopurinol 200hs, dicloxacillin 500'''', doxepin 200hs, folic acid 1', lisinopril 5', metoprolol succinate 100', omeprazole 40', MVI' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) inj Injection ASDIR (AS DIRECTED): see printed sliding scale. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, HA. 7. Erythromycin 5 mg/g Ointment Sig: One (1) app Ophthalmic Q2H (every 2 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Doxepin 25 mg Capsule Sig: Eight (8) Capsule PO HS (at bedtime). 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Diazepam 5-10 mg IV Q2H:PRN per CIWA>10 16. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO three times a day. 17. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital 169] Center Discharge Diagnosis: Primary: 1. Lat, Med, Inf orbital wall fractures 2. Left corneal abrasion, subconjuntival hemorrhage, Upper eyelid laceration 3. Nasal laceration and nasal bone fracture 4. C5 comminuted spinous process fracture that extends to canal 5. T11 compression fx - duration unknown Secondary: 1. ETOH abuse 2. Left tibia/fibula fracture c/b infection and removal of hardware Discharge Condition: Stable. Hard collar in place. [Last Name (un) ] in left eye brow. Discharge Instructions: Please wear the hard collar around your neck at all times for 3 months. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Other: Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day Followup Instructions: Follow up with Dr. [Last Name (STitle) ] (Trauma Surgery) in [2-15] weeks [Telephone/Fax (1) 600] Follow up with Dr. [Last Name (STitle) ] (orthopaedic surgery) in 4 weeks for your left leg. ([Telephone/Fax (1) 2007]. Follow up with Dr. [Last Name (STitle) 739] (Neurosurgery) in 4 weeks. You will need a head CT at that time. You will also need to see him in 3 months with repeat xrays of your cervical spine. ([Telephone/Fax (1) 18865]. Follow up in the plastic surgery clinic on [Last Name (LF) 2974], [3-17]. Please call ASAP to make your appointment. ([Telephone/Fax (1) 7138]. Follow up with the ophthalmology clinic in [12-16] weeks for evaluation of your eye. Call [Telephone/Fax (1) 253] to make an appointment. Completed by:[2119-3-11]	[ "870.8", "E884.9", "918.1", "852.21", "802.6", "873.20", "303.00", "805.05", "291.0", "802.0", "599.0" ]	icd9cm	[ [ [] ] ]	[ "08.83", "21.81", "08.52" ]	icd9pcs	[ [ [] ] ]	8855, 8907	5527, 7166	330, 362	9320, 9392	1667, 5504	10659, 11464	1148, 1152		7372, 8832		8928, 9299		7192, 7349			9416, 10636									1167, 1167																				274, 292									1183, 1648	390, 961														983, 1052	1068, 1132
28,261	118,906	34803	Discharge summary	report	Admission Date: [2174-6-25] Discharge Date: [2174-7-4] Date of Birth: [2097-4-30] Sex: M Service: CARDIOTHORACIC Allergies: Keflex / Erythromycin Base Attending:[First Name3 (LF) 922] Chief Complaint: chest discomfort Major Surgical or Invasive Procedure: [2174-6-28] Aortic valve replacement (25mm [Company 1543] ultra porcine), coronary artery bypass graft History of Present Illness: Mr. [Known lastname 79702] is a 77 year old gentleman who presented to the emergency department with left arm and left facial weakness and numbness accompanied by chest discomfort. These symptoms were relieved with nitroglycerin. Work-up for this complaint revealed aortic stenosis and coronary artery disease, for which he was referred to cardiac surgery. Past Medical History: reflux left facial neuralgia TURP 10 years ago glaucoma Left eye with lens replacement detached retina right eye Social History: Mr. [Known lastname 79702] works as a consultant. Family History: Mr. [Known lastname 79703] brother passed away at age 16 of heart disease. Physical Exam: At the time of discharge Mr. [Known lastname 79702] was awake, alert, and oriented. His lungs were clear to ausculatation bilaterally. His heart was of regular rate and rhythm. His abdomen was soft, non-tender, and non-distended. His incision was clean, dry, and intact. His sternum was stable. Pertinent Results: [2174-6-30] 06:03AM BLOOD WBC-19.3* RBC-3.53* Hgb-10.6* Hct-30.5* MCV-86 MCH-30.1 MCHC-34.8 RDW-13.7 Plt Ct-169 [2174-6-30] 06:03AM BLOOD Glucose-117* UreaN-18 Creat-1.1 Na-134 K-4.5 Cl-102 HCO3-19* AnGap-18 [2174-6-27] 05:30AM BLOOD ALT-22 AST-31 LD(LDH)-214 AlkPhos-94 TotBili-0.5 [2174-7-4] 05:25AM BLOOD WBC-10.7 RBC-3.39* Hgb-10.2* Hct-28.8* MCV-85 MCH-30.0 MCHC-35.4* RDW-13.4 Plt Ct-319# [2174-7-4] 05:25AM BLOOD Glucose-96 UreaN-16 Creat-1.1 Na-136 K-4.1 Cl-104 HCO3-23 AnGap-13 [Known lastname ],[Known firstname ] [Medical Record Number 79704] M 77 [2097-4-30] Radiology Report CHEST (PA & LAT) Study Date of [2174-7-2] 3:53 PM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2174-7-2] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 79705] Reason: increase size in pneumo post chest tube removal [Hospital 93] MEDICAL CONDITION: 77 year old man with s/o left ct removal / previos small apical pnuemo / please evaluate REASON FOR THIS EXAMINATION: increase size in pneumo post chest tube removal Final Report HISTORY: To evaluate size of pneumothoraces. FINDINGS: In comparison with the earlier study of this date, there is no change in the degree of pneumothorax bilaterally. The left chest tube has been removed. There is some increasing elevation of the left hemidiaphragmatic contour. DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Approved: SAT [2174-7-2] 5:23 PM [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 79706] (Complete) Done [2174-6-28] at 2:37:37 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] C. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2097-4-30] Age (years): 77 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Preoperative assessment. Shortness of breath. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [2174-6-28] at 14:37 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 168], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: 4.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 80 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 75 mm Hg Aortic Valve - LVOT pk vel: 0.80 m/sec Aortic Valve - LVOT diam: 1.8 cm Aortic Valve - Valve Area: 0.5 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. [Male First Name (un) ] of the mitral chordae (normal variant). No resting LVOT gradient. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventicular systolic function. There is a well seated, well functioning bioprosthesis in the aortic position. No aortic insufficeincy is visualized. The study is otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [Last Name (NamePattern4) ] [2174-6-28] 15:02 Brief Hospital Course: Mr. [Known lastname 79702] [Last Name (Titles) 1834] a aortic valve replacement with a 25 mm [Company 1543] ultra porcine valve and coronary artery bypass graft times one (LIMA to LAD) on [2174-6-28]. He tolerated this procedure well and was able to be transferred in critical but stable condition to the surgical intensive care unit. He was placed on amiodarone for atrial fibrillation and converted first to a junctional and then sinus rhythm. He was extubated and his vasoactive drips were weaned. Chest tubes were removed. He was transferred to the surgical step-down unit. His wires were removed and he was seen in consultation by the physical therapy service. The remainder of his hospital course was essentially unremarkable. He progressed well and on POD#6 was discharged to home with VNA. He was instructed on all neccessary follow up appointments. Medications on Admission: aciphex 20mg daily aspirin 81mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Date Range ]:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Date Range ]:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. [Date Range ]:45 Tablet(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:0 5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [Date Range ]:30 Tablet(s) Refills:0 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg po BID x 6 days, then decrease to 200mg po BID x7 days, than decrease to 200 mg PO once daily x 7 days [Name6 (MD) ] [Name8 (MD) ] MD. [Last Name (Titles) ]:120 Tablet(s) Refills:0 7. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (). [Last Name (Titles) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: aortic stenosis, coronary artery disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 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 see [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 914] in [1-25] weeks. Please see Dr. [Last Name (STitle) 8051] in [11-24] weeks. Please see Dr. [Last Name (STitle) ] in [11-24] weeks. Completed by:[2174-7-4]	[ "427.31", "E878.2", "424.1", "327.23", "512.1", "351.8", "530.81", "414.01", "411.1" ]	icd9cm	[ [ [] ] ]	[ "36.15", "35.21", "39.61", "34.04", "39.63", "88.72" ]	icd9pcs	[ [ [] ] ]	9382, 9477	7265, 8146	308, 421	9562, 9569	1454, 2414	10081, 10342	1036, 1116		8234, 9359	2454, 2546	9498, 9541		8172, 8211			9593, 10058								5991, 7242	1131, 1435																				252, 270	2578, 5942									449, 813														835, 949	965, 1020
14,269	106,979	1827+55323	Discharge summary	report+addendum	Admission Date: [2156-6-24] Discharge Date: [2156-7-2] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: hypoxia and hypotension Major Surgical or Invasive Procedure: right femoral line placement History of Present Illness: [Age over 90 ]F with [Hospital 10224] medical problems including diastolic CHF (EF 55%), CAD, CRI, Afib who presented to ED in acute respiratory distress. The patient was recently hospitalized several times at [Hospital1 2177], including in [2156-5-9], during which time she underwent cardiac catheterization for CHF, s/p stent to 90% mid-LAD lesion. Most recently, pt was in hospital [Date range (1) 10232] for CHF exacerbation. Pt reports doing well at home since discharge but does report mild URI Symptoms (rhinorrhea and nonproductive cough) and some "sweats" during the past few nights (but no "sweats" during the day). . For the past 1-2 days, the pt missed all of her medications including lasix because her daughter, who keeps track of her medications, was out of town. Last night, the patient was breathing comfortably when she was going to bed but awoke at midnight with diaphoresis and shortness of breath which improved somewhat with albuterol and pt was able to fall back asleep. Pt then awoke numerous times throughout the night due to SOB and this progressed despite using albuterol MDIs so pt called EMS. . EMS noted BP 180/110, HR 104, RR 32, sat 94% on NRB. En route to ED, received 3 SL NTG and 80 IV lasix with minimal improvement and only diuresed 200 cc. In [Name (NI) ], pt was unable to speak in full sentances. CXR confirmed increased perihilar haziness and interstitial prominence, bilateral effusions consistent with CHF but also with right lung haziness concerning for PNA. Pt was placed on nitro gtt, given 2 mg morphine, Levofloxacin and Ceftriaxone for empiric coverage and placed on BIPAP. Pt felt symptomatically improved with BIPAP, then changed to 50% ventimask with sats low 90s, ABG 7.39/40/101. Pt then admitted to [Hospital Unit Name 153] for further monitoring. . Upon arrival to [Name (NI) 153], pt reported feeling "much better" and her breathing was "almost normal." Pt denied F/C, diarrhea (is in fact constipated), CP, palpitations, orthopnea (sleeps on 2 pillows but prefers to sleep flat), PND, or increased LE edema. Denied dietary indiscretions. Denied DOE & is able to walk (w/walker) about her apt w/o stopping. . ICU course: ~ Respiratory distress thought to be multifactorial with pulmonary edema secondary to discontinuation of lasix being the main triggering factor. Other factors included COPD exacerbation in setting of volume overload and possible pneumonia. Her pneumonia was treated with ceftriaxone and azithromycin which was later changed to levaquin/azithro. She was started on solumedrol and standing nebulizers. Pt had several episodes of respiratory distress, all of which improved with nebs and BiPAP. She was given prn Lasix with a goal of keeping patient one liter negative per day. ~ Her BP ran low thought to be due to poor forward flow but she was never on pressors. ~ Creatinine rose and urine output fell despite lasix. Urine lytes revealed a FeNa of <1% indicating that pt's CHF was likely contributing to poor renal perfusion. Further lasix doses were held given that pt appeared intravascularly dry. ~ Pt's hct remained low during her ICU but pt refused PRBC transfusion because of an episode of respiratory distress that the pt had after receiving a transfusion at [Hospital1 2177]. Past Medical History: -CHF- ECHO [12-12] EF 50-55% with mild MR [First Name (Titles) ] [Last Name (Titles) 10225] -Coronary Artery Disease- s/p atheterization [2153]: Left dominant system; PCI LCx, LPDA, 50% RCA -Paroxysmal Atrial Fibrillation- treated w/ amiodarone, off coumadin due to risk of falls -Asthma -s/p thyroid sx -Diverticulitis -Hypercholesterolemia -Right Hip Fracture -History of [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears -Chronic Renal Insufficiency- baseline creatinine low 2's Social History: -The patient lives alone but with full-time aide. Daughter is main caregiver in terms of administering medications. Ambulates with a walker. Smoked in her teens but none since. Rare EtOH use. Family History: Non-contributory Physical Exam: temp 98, BP 113/50 (90-120/40-60), HR 80 (60-80), R 20, O2 94% on 3 L n/c I/O: 900/650, total ICU LOS: +3.2L Gen: NAD, able to speak in full sentences HEENT: PERRL, EOMI, MMM Neck: JVP 2 cm below angle of mandible CV: irreg irreg, grade 2-3/6 systolic murmur at apex Chest: poor movement of air, crackles B Abd: +BS, slightly tender and distended Groin: femoral line site intact, no erythema or tenderness noted Ext: no edema, 1+ DP Neuro: Alert and Oriented, good cognitive function. Right eyelid sightly drooped; right leg, right hand, left hand 5/5 strength; left leg 4/5 strength; no DTR on left patella; downgoing toes bilaterally. Pertinent Results: (at admission) -WBC 13.9, 54N, 42L, 2M, 3E -Hct 31.4, Plt 579 -Na 141, K+ 4.3, Cl 105, bicarb 21, BUN 24, creat 2.0 -CXR in ED: cardiomegaly; prominent pulm vasculature; L-lung with diffuse haziness throughout; flat diaphragm w/small bilat pleural effusions. -ECG: sinus @ 83 bpm, L-axis, LBBB pattern, no ST/TW-changes compared to old. -ABG @ 6 pm: 7.36/41/361 on hi-flow FM -CK 54->51; MB not done; TropT 0.03->0.04. -INR 1.0 . CXR: Findings consistent with CHF with small bilateral pleural effusions. . ECHO: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 55%). [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: [Age over 90 ] yr old female with hx of CAD, dCHF, COPD, anemia, CRF admitted for respiratory distress. . 1. Respiratory Distress: Etiology likely multifactorial including acute pulm edema, asthma/bronchospasm and tracheobronchomalacia. There was initally concern for pneumonia so she was given several days of ceftriaxone and azithromycin for CAP. These were stopped once it was clear that she had no pneumonia. There was also a question of upper airway obstruction given pt's multiple prior intubations so PFTs were done but were unrevealing as pt was unable to cooperate with testing. A CT of the trachea showed moderate to severe tracheobronchomalacia. Given her tracheobronchomalacia and CHF, she was given BiPAP at night in the ICU to relieve episodes of respiratory distress. She was started on steroids for a COPD flare but these were stopped soon after her transfer to the floor. She was continued on her flovent and nebs. To treat her CHF, she was diuresed gently in the ICU but this was held once her creatinine started to rise. Diuresis was reinitiated on the floor and she diuresed approximately one liter per day. On HD #7, she was breathing comfortably on room air. . 2. CHF: An echocardiogram during this admission showed an EF of 55% but an E/A ratio of 2.8 indicating diastolic heart failure. As above, she was diuresed to her dry weight and she was continued on her beta-blocker. . 3. Paroxysmal Afib: Pt has not been coumadinized in past due to risk for falls. She was rate controlled with metoprolol and she continued her amiodarone. . 4. CAD: Pt with recent cath with stent to LAD. Pt did not report any chest pain and on admission, her cardiac enzymes were flat x 3. ECG unchanged but LBBB pattern so could mask subtle changes. She was continued on her ASA, plavix, BB and statin. . 5. Acute on chronic renal failure/oliguria: On admission, pt's creatinine was at baseline of 2.0 but with diuresis, her creatinine started to rise and urine output dropped. A FeNa indicated prerenal azotemia so she was given gentle fluid boluses to maintain urine output. Once her creatinine stabilized, she was again diuresed and her urine output remained >25cc/hr. . 6. Normocytic Anemia: Baseline hct appears to be 27-28 and pt slightly lower than baseline at 25. Given her CAD, we preferred to transfuse to >30 but pt refused given resp distress following a transfusion at [Hospital1 2177]. Iron studies on this admission indicate iron def anemia so she was started on iron. She should start epogen as an outpatient. . 7. UTI: UA was grossly positive with bacteria and yeast. She was started on treatment with cefpodoxime and her foley was discontinued. . 8. Diarrhea: Due to diarrhea, c. difficile was checked and found to be positive so she was treated with Flagyl, which she must continue after discharge for seven more days. . 9. Disposition: Per family meeting on [6-24], pt expressed her desire to be DNR/DNI but then when the medical team accepting the pt asked her again, she stated that she would like to have the breathing tube if necessary to keep her alive until she can see her great-grandchildren. Per the daughter's request, a palliative care consult was placed and the pt restated that she was not ready for DNR/DNI yet. The patient is being discharged to an extended care facility (Scherrill). Medications on Admission: -Advair 500/50 1 puff [Hospital1 ] -Albuterol prn -Plavix 75 qd -Lipitor 20 qd -amiodarone 200 qd -ASA 325 qd -metoprolol 50 [Hospital1 ] -lasix 60 qd -levothyroxine 75 mcg qd -Flonase 2 sprays qd -MVI 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for loose stools. 5. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed: hold for loose stools. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation [Hospital1 ] (2 times a day). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Diastolic congestive heart failure, ejetion fraction 55% Emphysema Tracheobronchomalacia Acute on Chronic Renal Failure Urinary Tract Infection Clostridium Difficile Colitis [Female First Name (un) 564] of the groin Secondary: Paroxysmal Atrial Fibrillation Coronary Artery Disease, status post stent of the Left Anterior Descending Iron Deficiency Anemia Discharge Condition: Good, breathing well on room air Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Call your PCP or go to the ED if you experience worsening shortness of breath, chest pain, fevers, chills or anything else that concerns you. Walk only with the help of an ambulatory device. Followup Instructions: Please follow-up with your PCP [Name Initial (PRE) 176] 1-2 weeks of discharge Name: [Known lastname ],[Known firstname 1440] Unit No: [Numeric Identifier 1436] Admission Date: [2156-6-24] Discharge Date: [2156-7-2] Date of Birth: [2061-3-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 175] Addendum: 2. Congestive Heart Failure: Outpatient furosemide dose of 60 mg once daily was resumed on discharge. Further increase may be warranted in the future; she was treated with 40 mg IV once daily with good diuretic effect at the end of her hospital course. Beta-blocker dose was increased to 25 mg TID and should be titrated up (or possibly decreased) as tolerated by heart rate and blood pressure. . 3. Atrial Fibrillation: The patient ambulated safely with the use of a walker and did not appear to be a fall risk. Warfarin was therefore added to her list of discharge medications and will be begun on discharge. If she is deemed to be a fall risk in the future, the use of warfarin should be reconsidered, but at this point the risk:benefit ratio appears to favor anti-coagulation given her 5% annual stroke risk. . 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for loose stools. 5. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed: hold for loose stools. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation [Hospital1 ] (2 times a day). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day. 13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 18. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [Hospital1 ] (2 times a day) for 4 days. 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 20. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 21. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital3 163] - [Location (un) 164] Discharge Diagnosis: Principal: 1. Diastolic CHF, EF 55% 2. Emphysema 3. Tracheobronchomalacia 4. Acute on Chronic Renal Failure 5. Urinary Tract Infection 6. C diff colitis 7. [Female First Name (un) 1441] of the groin Secondary: 1. Paroxysmal atrial fibrillation 2. CAD s/p LAD stent 3. Iron deficiency anemia Discharge Condition: Good, breathing well on room air Discharge Instructions: Take all medications as prescribed and go to all follow-up appointments. Call your PCP or go to the ED if you experience worsening shortness of breath, chest pain, fevers, chills or anything else that concerns you. Walk only with the help of an ambulatory device. Followup Instructions: Please follow-up with your PCP [Name Initial (PRE) 1091] 1-2 weeks of discharge [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 181] MD [MD Number(1) 182] Completed by:[0-0-0**]	[ "280.9", "112.3", "414.01", "008.45", "519.1", "599.0", "428.33", "272.0", "427.31", "428.0", "493.22", "V45.82", "584.9", "593.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "93.90" ]	icd9pcs	[ [ [] ] ]	15406, 15478	6670, 10027	283, 313	15818, 15852	5107, 6647	16166, 16405	4416, 4434		13557, 15383		15499, 15797		10053, 10264			15876, 16143									4449, 5088																				220, 245										341, 3647														3669, 4191	4207, 4400
13,259	113,514	7393+7400	Discharge summary	report+report	Admission Date: [2104-12-8] Discharge Date: [2104-12-15] Date of Birth: [2026-12-30] Sex: F Service: VASCULAR SURGERY CHIEF COMPLAINT: Patient with peripheral vascular disease, respiratory-cardiac arrest prior to arteriogram. HISTORY OF PRESENT ILLNESS: This is a 77-year-old female, well known to the vascular surgery, who presented to preop holding area for an arteriogram. She received her medications, Xanax, hydralazine and dilaudid, and then proceeded to have mental status changes, respiratory depression and bradycardia. The patient was coded in a respiratory-cardiac arrest, was intubated and epi was given. The patient's O2 sat postintubation was 28%, and a heart rate of 100 after 2 of epi. Neo was instituted during the code, and the patient's blood pressure was 110/80, with a heart rate of 110. Cardiology was consulted because the patient had ST changes. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Aortic regurgitation. 4. Peripheral vascular disease. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Percocet. 2. Plavix 75 mg qd. 3. Aspirin 325 mg qd. 4. Isordil 30 mg tid. 5. Losartan 10 mg qd. 6. Lopressor 50 mg [Hospital1 ]. 7. Nifedipine 60 mg qd. 8. Reglan 10 mg qd. 9. Lasix 80 mg qd. PAST SURGICAL HISTORY: 1. Right fem-[Doctor Last Name ] bypass graft. 2. Left BKA. 3. Status post CABG. 4. Status post thrombectomy of right graft. PHYSICAL EXAM - VITAL SIGNS: Temperature 101, blood pressure 110/60, PA 34/16, respirations on CPAP, pulmonary CVP 12. The patient is responsive. Heart is regular rate and rhythm. Lungs are clear to auscultation but diminished sounds at the bases. The abdominal exam is unremarkable. Extremities are unremarkable. There are no carotid bruits. There are nonpalpable femoral pulses. In the right lower extremity, DP and PT were not palpable. LABS: Serial enzymes - total CK-MB and troponin levels were elevated. The troponins peaked at 0.68. CT of the chest and abdomen were obtained. There was no aortic dissection or pulmonary embolism. Acute infarcts were seen in the spleen, right kidney, as well, with completion occlusion of the distal abdominal aorta just superior to the bifurcation. There was no significant collateral vessel formation identified, and a feeling that this is an acute etiology. Head CT was negative for intracranial hemorrhage. HOSPITAL COURSE: The patient proceeded to the OR on an urgent basis. Thrombectomy was attempted but not successful, and the patient underwent a left axillobifemoral bypass with the left ileofemoral bypass graft thrombectomy. The patient tolerated the procedure well and was transferred to the SICU for continued monitoring and care. Postop hematocrit remained stable. BUN and creatinine remained stable. On postop day #1, the patient ruled-in for MI by enzymes. She remained hemodynamically stable. Postop hematocrit was 34.1, BUN 28, creatinine 1.2. Initial CK was 156 and the patient peaked at 3379, and CK-MB 14 and peaked at 52. The patient remained intubated, on Nipride for systolic blood pressure control. The patient was continued on perioperative Kefzol and remained in the SICU for continued care. On postoperative day #2, there were no overnight events. The patient was weaned off Nitroglycerin. She continued on CPAP. Hydralazine was given for her hypertension. Hematocrit drifted to 27.1. BUN and creatinine 23 and 0.7. Plans were to wean to extubate, DC Nitroglycerin once the patient was extubated. She continued to remain NPO and remained in the ICU. On postoperative day #3, the patient was extubated. She did require diuresis with lasix IV 20 mg x 2. She was transfused for hematocrit of 26.2 with a post-transfusion crit of 28.2, BUN 16, creatinine 0.5. K was supplemented. The patient's PA line was changed to CVL without incident. Diet was advanced as tolerated. The patient continued to do well and was transferred to the VICU on postoperative day #4. By postoperative day #6, the patient was allowed to transfer to chair. Physical therapy evaluated the patient. They recommended rehab because the patient is functioning well below baseline. The patient was transferred to the regular nursing floor on postoperative day #7. She was continued on Ancef until all lines were removed. Plavix was resumed. Anticoagulation was continued with an INR of 1.7. Rehab screening was begun. Central line was converted to a peripheral line. Remaining hospital course was unremarkable. The patient was discharged in stable condition. Wounds were clean, dry and intact. The patient had bifemoral dopplerable pulses and dopplerable left axillary pulse. DISCHARGE MEDICATIONS: 1. Acetaminophen 625-650 mg q 4-6 h prn pain. 2. Isosorbide dinitrate 30 mg tid. 3. Nifedipine CR 60 mg qd. 4. Atorvastatin 10 mg qd. 5. Aspirin 325 mg qd. 6. Lasix 40 mg [Hospital1 ]. 7. Metoprolol 50 mg [Hospital1 ]--hold for systolic blood pressure less than 100, heart rate less than 60. 8. .........100 mg qd. 9. Reglan 10 mg qid ac and hs. 10.Oxybutynin 5 mg tid. 11.Hydralazine 25 mg qid. 12.Plavix 75 mg qd. DISCHARGE DIAGNOSES: 1. Cardiac-respiratory arrest, resuscitated. 2. Peripheral vascular disease. 3. Blood loss anemia, corrected. SECONDARY DIAGNOSES: 1. A myocardial infarction by enzymes. 2. Coronary artery disease. 3. History of hypertension. 4. History of aortic valvular disease. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with Dr. [Last Name (STitle) ] in [1-17] weeks. 2. Skin clips remain in place until seen. 3. Ambulation as tolerated essential distances. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2104-12-15] 10:48 T: [2104-12-15] 11:25 JOB#: [Job Number 27179] Admission Date: [2104-12-8] Discharge Date: [2104-12-18] Date of Birth: [2026-12-30] Sex: F Service: Vascular surgery #58 This is a stat ADDENDUM to the discharge summary dictated on [2104-12-15]. The patient complained of hoarseness postoperatively. She was seen by Ear, Nose and Throat specialist on [2104-12-16], who felt that there was no vocal cord paralysis. If the hoarseness persisted more than one week, then a fiberoptic examination was recommended. The patient had small amounts of drainage from her groin incision sites. She was started on Kefzol. She was screened and accepted by [Hospital ] Rehabilitation on [2104-12-18]. She was discharged on Keflex until she followed up with Dr. [Last Name (STitle) ] in the office in two weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 3954] MEDQUIST36 D: [2105-1-5] 11:55 T: [2105-1-6] 04:51 JOB#: [Job Number 27198]	[ "285.1", "424.1", "440.0", "V45.81", "410.71", "427.5", "996.74", "E878.2", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.29", "39.49", "96.71", "99.60", "96.04" ]	icd9pcs	[ [ [] ] ]								5169, 5280	4723, 5148					2422, 4700		5460, 7016							1309, 2404			5301, 5436																			168, 260										289, 910														932, 1286
19,038	133,453	51566	Discharge summary	report	Admission Date: [2180-11-9] Discharge Date: [2180-12-5] Date of Birth: [2133-12-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: C4-6 corpectomy Washout of cervical spine surgical site History of Present Illness: 46 yo M s/p renal transplant 17 yrs ago and ESRD on HD secondary to focal glomerulosclerosis status post deceased donor kidney transplantation on [2163-5-13] withgraft loss in [2179-12-10], with multiple placements of HD catheters and recent transposition of right upper arm arteriovenous fistula on [2180-11-8]. He was found on the bathroom floor w/ blood on face and in the mouth by family. Per EMS the patinet was hypertensive, tachycardiac and intially unresponsive but MS improved on way to [Hospital3 3583]. On arrival to OSH, his MS declined and he had a witnessed seized. He was then intubated with vecuronium and loaded with fosphenytoin at that time. BO was recorded as high as 220/110. Electrolytes were WNL and TnI was positive. . Per report, episdoe of arrythmnia (?afib) in field, terminated w/ diltiazem. Rec'd dilantin. Head CT no bleed at OSH. Neck CT: cervical fx, transferred to [Hospital1 18]. . Of note urine tox was positive for cocaine and opiates. Past Medical History: -Cadaveric Renal Transplant 16 yrs ago on immunosuppressants -HTN poorly controlled -Anemia on Procrit -Chronic Allograft Nephropathy baseline Cr 4.2 ([2179-1-10]) -Admitted last [Month (only) 1096] to MICU with acute on chronic renal failure, coagulase negative staphylococcal bacteremia, community acquired pneumonia, duodenal ulcers status post thermal therapy/injection and pericardial effusion No history of seizures. Social History: lives with 2 children and mother Family History: unknown Physical Exam: Vitals - T:97.9 BP:131/91 HR:99 RR:16 VENT SETTINGS: AC 600x14 80% PEEP5 GENERAL: intubated and sedated SKIN: palpable thrill in RUE, warm and well perfused, no excoriations or lesions, no rashes HEENT: AT, dried blood in right nare, small contusion on L maxilla, anicteric sclera, pink conjunctiva, no JVD CARDIAC: RRR, blowing holosystolic 2/6 SEM @ apex, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact Pertinent Results: Admission Labs: Ca: 7.0 Mg: 2.9 P: 9.9 D LDH: 332 [Doctor First Name ]: 84 Lip: 36 . WBC 11.2 Hct: 40 Plt: 205 N:80.7 L:11.4 M:5.7 E:2.0 Bas:0.2 . PT: 14.2 PTT: 28.6 INR: 1.3 ABG: 7.38/54/204/33 Lactate 1.2 . U/A: opiates and cocaine positive initially. . 136 91 47 --------------< 117 5.9 26 10.2 CRP: 48.3 ESR: 80 . Trends: Hct: 42 - 40 - 34 - 33 - 29 - 30 ([11-21]) CK: [Telephone/Fax (1) 106885] - 2960 - 2967 - 1717 - 5493 - 5378 - 1591 Trop: 0.15 - 0.18 - 0.16 . Imaging: [11-9] KUB: NG tube in the stomach. No metal is seen in the abdomen and pelvis . [11-9] CT Head/Neck: 1. Compression fractures of C4 and C5 with fracture lines extending through the right transverse foramen of C5. Vascular injury cannot be excluded at this level. 2. Grade I retrolisthesis of C4 on C5 with likely ligamentous disruption is identified. 3. Fracture of the posterior-superior facet of C6. . [11-9]: CT Head: No intracranial hemorrhage or edema. No fracture . [11-10]: MRI/MRA head/neck: BRAIN: IMPRESSION: No evidence of acute infarct. Small vessel disease and chronic right-sided lacunar infarct. Soft tissue changes right-sided maxillary, frontal, and ethmoid sinuses. NECK IMPRESSION: The right vertebral artery is small in size which could be congenital variation as the vertebral artery is not occluded or affected at the site of abnormality seen at C4-5 level. However, the MRA is limited by motion and for better evaluation repeat MRA or CT angiography are recommended. MRA OF THE HEAD: IMPRESSION: Except for nonvisualization of distal right vertebral artery, no other abnormalities are seen. . [11-10]: ECHO: IMPRESSION: suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Dilated ascending aorta. No structural cardiac cause of syncope identified. Compared with the prior study (images reviewed) of [2179-12-23], the seveirty mitral regurgitation is reduced and a resting LVOT gradient is no longer identified. . [11-11] MRI thoracic and lumbar spine: FINDINGS: There is no evidence to support the presence of either discitis or osteomyelitis within either the thoracic or lumbar spine. The visualized spinal cord, conus medullaris, and cauda equina appear within normal limits. Within the limitations of coverage of this study, there are no overt paraspinal abnormalities discerned, either. CONCLUSION: No evidence for discitis or osteomyelitis, or other causes for spinal cord compression are seen. . [11-11]: EEG: This is an abnormal portable EEG due to bursts of generalized mixed frequency slowing in the setting of a slow, disorganized, poorly reactive background with the tracing also notable for triphasic waves. This constellation of findings is consistent with a moderate encephalopathy suggesting dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbance, infections, and anoxia are among the common causes of encephalopathy. There were no clearly focal or lateralized features although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features and no electrographic seizures were noted. . [11-12]: Prevertebral pathology: A. Prevertebral tissue: Fibrovascular and adipose tissue with reactive vascular and fibroblastic proliferation and mild chronic inflammation. B. C4 vertebral body: 1. Fragments of reactive bone. 2. Maturing trilineage hematopoiesis. 3. No malignancy identified. . [11-14]: CT Sinus: There is complete opacification of the right frontal sinus, ethmoid air cells, and near complete opacification of the sphenoid sinus and the right maxillary sinus. Moderate mucosal thickening and retention cysts versus polyps of the left maxillary sinus are seen. The OMUs are obstructed bilaterally. High- density material is seen within the sphenoid sinus, which may represent inspissated secretions versus fungal colonization and less likely hemorrhage. . [11-14] CT Chest w contrast: 1. No central or segmental pulmonary emboli, however, subsegmental emboli in the lower lobes cannot be excluded due to atelectasis in the lower lobes. 2. Atelectasis and consolidation at the lung bases as described above. Subcentimeter ground-glass opacity in the right middle lobe is likely infectious or inflammatory. 3. Extensive atherosclerosis is present in the coronary arteries 4. Findings concerning for pulmonary artery hypertension. . [11-14] ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a mild resting left ventricular outflow tract obstruction (measurement of gradient was technically suboptimal; ?peak of 11 mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is a no significant aortic stenosis (slightly increased velocities due to left ventricular outflow gradient). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . [11-19]: LENI: no DVT . MR CERVICAL SPINE W/O CONTRAST [2180-11-29] IMPRESSION: Anterior and posterior cervical fusion as described above. There is fluid within the bone graft and surrounding the bone graft in the corpectomy defect extending from C3 to C5 without adjacent bone marrow edema which likely represents postoperative change. There is a large superficial fluid collection dorsal to the cervical spine which likely represents a postoperative seroma, although an infected fluid collection cannot be excluded. Brief Hospital Course: Mr. [Known lastname 1445] is a 46 y.o. M s/p fall with resultant C4-6 nonsurgical fracture s/p corpectomy now being treated for cervical osteomyelitis and pneumonia, s/p recent fever and leukocytosis with fluid collection around cervical surgical site that had 2+ PML, s/p [Known lastname ] spine washout of cervical lesion. . #S/P fall: Unclear etiology but felt that it may be that the patient had a seizure vs. syncope in the setting of arrythmia. Patient was also noticed to have high BPs and suggests hypertensive encephalopathy, which could be related to cocaine use (pt had one positive tox screen). A definitive cause was not determined; however these were all treated as below. . #Seizure: On arrival to OSH, the patients mental status declined and he had a witnessed seizure. He was initially loaded with Dilantin. The possible precipitants included cocaine use and/or hypertension. Head imaging was negative. An LP did not show evidence of infection. Neurology followed for the seizure and dilantin levels and the dilantin was adjusted to goal level of [10-28]. The patient was continued on maintenance doses of dilantin throughout his hospital stay. No further seizures occured. He was discharged with dilantin for an additional 4 weeks and instructions to follow up with neurology as an outpatient. . #Osteomyelitis and C4-6 Fracture: Patient sustained C4-6 acute fracture, although CT scan suggested ? infection vs fluid collection. [Month/Year (2) 1957] was consulted who recommended MRI head/neck which showed chronic-appearing endplate changes at C4-5 level which could be trauma related vs ligament injury vs chronic disckitis or spondylarthritis without spinal cord compression. MR T/L/S was also performed which showed no evidence for discitis or osteomyelitis, or other causes for spinal cord compression are seen. [Month/Year (2) 1957] spine was following, and on [2180-11-12], pt underwent C4-C5 corpectomy and reconstruction. In the OR, C4-C6 appearance was suspicious for infection/osteomyelitis, and prevertebral tissue biopsy, bone biopsy, prevertebral fluid culture were obtained. THe patient was intially started on Ceftriaxone and vancomuycin started on the night of [11-12]. As there was a concern for ?TB per surgery, so consulted ID for abx and planted ppd on [11-13] which was negative. Pt remained in collar and continued prednisone for cervical swelling. On [11-13], pt had a temp to 102 and later on [11-14] became hypotensive requiring a pressor. ABX was broadened to Zosyn and vanc, and also stress dose steroid was started given his chronic steroid use for renal transplant. Later on [11-14], tissue culture grew GP bacteria. On [11-16] patient went back to OR for posterior fusion. Patient was followed by ID and [Month/Day (4) 1957] thorughout his stay. ID felt the patient needed 8-12 weeks of Vancomycin to cover the osteomyelitis and he will follow up with ID as an outpatient. [Month/Day (4) 1957] felt the surgery was successful and patient will follow up as an outpatient. However, post-operatively, his incision site began to drain some yellowish fluid and he had a low grade fever. Blood cultures were obtained and pending at this time. Wound culture showed 2+ PML with no organisms. Orthopedic spine felt that the area needed to be washed out. The patient was taken to the OR on Friday, [12-1] for cervical spine washout. Samples of the bone, soft tissue, and superficial and deep fluid were obtained that showed [1-11]+ PML without organisms. Cultures negative. He remained afebrile. Pt has follow up with orthopedic spine ~2 weeks after discharge. . #Ventilator Associated Pneumonia-Patient had an episode of hypontension thought to be due to sepsis from E.Coli VAP and was started on pressors as well as Vanc and Zosyn; later changed to Cipro for pna coverage. The hypotension resolved and he was quickly weaned off pressors. He also was found to have pansinusitis on CT. Patient was continued on Cipro for the pneumonia to complete a 10 day course. . #AFib: PT had AF with RVR right before going to OR for spine reconstruction as well as when febrile and hypotensive. Although he responded with IV beta blocker and diltiazem. On [11-14], he had a hypotensive episode and amiodarone was started in the setting of septic shock picture. A CTA chest done on [11-14] to rule out PE in the setting of AF with RVR post-operatively which was negative. Amioradone was loaded and then changed to PO. This was discontinued on [11-22] and Lopressor was titrated up. The patient was subsequently in sinus rhythem and did not require further amiodarone. . # Melena: On [11-21] pt had episode of melena. He had received stress dose steroids and motrin intermittently for fevers and has a history of PUD. GI was consulted and the patient had an EGD which showed antral erosions but no active bleeding. THe patient was placed on a PPI which was continued throughout his stay and upon d/c. No further intervention was needed. . #Renal: Patient is s/p failed transplant with recent revision of AV fisula. Transplant team followed the patient while in the hospital. HIs was Cr 10.2 on admission. He was continued on dialysis during his stay. He was continued on Bactrim prophylactically and once the stress dose steroids were discontinued as above, he was placed on his home dose of Prednisone for the rest of his stay. He was also started on Lanthanum. He continued dialysis while in the hospital and will return to his home schedule on discharge. He will need to remain on vancomycin per HD schedule until [2181-1-22]. . #Respiratory: Patient was intially intubated on admission for airway protection. He was extubated on [11-20] and did well on room air. He was weaned off of nasal canula adn his respiratory status remained stable . #HTN: Patient was hypertensive when he was transferred from the ICU to the floor. His medications were changed from Captopril to Lisinopril. He is Metoprolol wasincreased to 125 mg TID. . #Hypothyroid: Patient was continued on home Synthroid. . #Delirium-Patient was agitated while on the floor, most notably he tended to sundown in the evening. In addition, he was not oriented This was initially treated with Haldol. Psychiatry was consulted and felt the delirium was normal given the patients long ICU stay. Patient was continued on Haldol and his MS improved over time. Medications on Admission: - metoprolol 50mg TID - sulfamethoxazole TMP 1 tab MWF - prednisone 10mg QOD - lisinopril 20mg QD - levothyroxine 75mcg QD - diltiazem 90mg QID - omeprazole 20mg [Hospital1 ] - mirtazapine 7.5mg QPM - Renagel 800mg TID W/MEALS Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMWF (). 2. Levothyroxine 25 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Outpatient Lab Work please draw weekly CBC, chem 7, LFTs, and vanc trough while on IV therapy. Please fax results to [Telephone/Fax (1) 457] 7. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 11. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO three times a day. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO qAM for 4 weeks: last day of therapy [12-31]. 14. Phenytoin Sodium Extended 100 mg Capsule Sig: Four (4) Capsule PO qPM for 4 weeks: last day of therapy [12-31]. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 16. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) injection Injection Q4H (every 4 hours) as needed. 18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 20. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous qHD: per HD protocol last dose [2181-1-22]. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: C4-6 Fracture Vertebral Osteomyelitis Ventilator Associated Pneumonia Seizure Disorder NOS Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital after a fall. It is unclear what caused the fall but it is thought that it might be due to a seizure or an arrhythmia in your heart. You sustained a fracture to your cervical spine which was operated on by orthopedic surgery. You were also found to have an infection of the bone at this site. You will need to continue IV antibiotics to complete a [8-20] week course. Your surgical site started to drain some fluid, and you were taken back to surgery by the orthopedic surgeons where the fluid was drained out successfully. You were also treated for a pneumonia. You complete the antibiotics while you were in the hospital. You were evaluated by neurology and you were started on a medicine called Dilantin. You will need to continue this medication for 1 month and follow up with them as an outpatient. You will need to follow up with neurology, infectious disease and your PCP as below. If you have any fever,chills, pain in your neck, neck stiffness, headache, nausea, vomiting, abdominal pain, or any other concerning symptoms, please call your PCP or return to the ED. Followup Instructions: Please call to make an appointment with neurology: ([Telephone/Fax (1) 8951] Please follow up with infectious disease:Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 22367], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2180-12-25] 11:00 Please follow up with [Month/Day/Year ] spine: Provider: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] on [2180-12-13]. Please arrive at 11:40 for your 12PM appointment Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2180-12-13] 11:40 Provider: [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2180-12-13] 12:00	[ "348.30", "578.1", "518.81", "427.31", "998.31", "998.12", "805.06", "996.81", "582.9", "304.21", "518.0", "403.91", "E849.7", "585.6", "E888.9", "999.9", "730.18", "737.10", "722.71", "805.05", "E849.9", "E878.0", "998.59", "995.91", "E878.8", "535.50", "E849.8", "482.82", "304.01", "244.9", "V15.81", "805.04", "038.42", "780.39" ]	icd9cm	[ [ [] ] ]	[ "96.72", "39.95", "81.02", "81.03", "77.49", "81.62", "38.93", "80.51", "45.13", "83.02", "86.22", "77.79", "88.72", "80.99", "83.21" ]	icd9pcs	[ [ [] ] ]	17474, 17571	8754, 15223	325, 383	17706, 17715	2602, 2602	18883, 19694	1928, 1937		15505, 17451		17592, 17685		15249, 15482			17739, 18860									1952, 2583																				277, 287										411, 1405		3532, 4105		4122, 8731	2618, 3523									1427, 1861	1877, 1912
8,701	118,367	25292	Discharge summary	report	Unit No: [Numeric Identifier 63292] Admission Date: [2197-11-29] Discharge Date: [2197-12-13] Sex: F Service: VSU CHIEF COMPLAINT: Epigastric pain. HISTORY OF PRESENT ILLNESS: An 82-year-old, with a 2-month history of epigastric pain with a known thoracoabdominal aneurysm of 11-cm status post rupture--she is now without complaints of pain of shortness of breath, who was admitted to the emergency room and then transferred to the vascular service for definitive care. ALLERGIES: No known drug allergies. MEDICATIONS: Include hydrochlorothiazide 12.5 mg once daily, Norvasc once daily, Lopressor, ferrous and Prilosec. ILLNESSES: Include hypertension. PAST SURGICAL HISTORY: Cholecystectomy. PHYSICAL EXAM: VITAL SIGNS: 97.1, 72, 121/78, 18, 99% O2 sat on room air. GENERAL APPEARANCE: This is a [Location 7972] speaking female, oriented x3 in no acute distress. Heart is a regular rate and rhythm. Chest is clear to auscultation bilaterally. Abdomen is soft, nontender with a palpable, pulsatile epigastric mass. Pulse exam shows palpable femorals, popliteals, DPs and PTs 2+ bilaterally. HOSPITAL COURSE: The patient was initially evaluated in the emergency room. She underwent a CT scan which showed a large saccular aneurysm from the aortic root 5-cm through the celiac and renal arteries with a large superceliac thrombus with a contrast extravasation with multiple liver and kidney cysts. The patient's admitting white count was 8.3, hematocrit 32, platelet count 190. Coags were normal. BUN 40, creatinine 1.7, K 4.3. Patient was begun on antihypertensives to maintain her systolic blood pressure at less than 130. After a long discussion with the family, the risks and benefits of undergoing repair, it was the decision of the patient and family to proceed with anticipated necessary surgery. The patient was evaluated by cardiology for perioperative risk assessment. The patient underwent a P-MIBI. The stress portion of the P-MIBI was absent for EKG changes or symptoms. The patient had a moderate reversible defect involving the left circumflex territory. Left ventricular cavity size and function was normal with an ejection fraction of 64%. An echo was obtained which demonstrated that the left atrium was elongated. There was mild symmetric left ventricular hypertrophy with normal cavity and systolic function. The right ventricular chamber size, freewall motion were normal. The aortic root is moderately dilated. The ascending aorta is markedly dilated. The abdominal aorta was markedly dilated. The aortic valves are 3 or mildly thickened, but aortic stenosis is not present. There is no aortic valve stenosis. There is mild to moderate aortic regurgitation of 2+. The left ventricular inflow pattern suggests impaired relaxation. The tricuspids are mildly thickened. There is moderate 2+ TR, and there is mild pulmonary artery systolic hypertension with significant pulmonic regurgitation. The main pulmonary artery is dilated. There is no pericardial effusion. Cardiology felt that the patient's cardiac function would be improved with planned surgery, in addition to blood pressure control, and effective beta blockade, and nitroglycerin afterload to improve coronary perfusion. The patient proceeded on [12-5] and underwent a repair of a thoracoabdominal aortic aneurysm (descending thoracic aorta to renals) with a beveled anastomosis. The patient tolerated the procedure well and was transferred to the PACU in stable condition. Postoperatively, the patient was transferred to the ICU for continued care. Postoperative day 1, there were no acute events. The patient was afebrile. Hematocrit was 31.2, BUN 32, creatinine 1.3. Physical exam was unremarkable. Postoperative day 2, there were no overnight events. The patient was begun on respiratory weaning to extubate. From a cardiac standpoint, she did well, although she had a right bundle branch block change on her EKG on postoperative day 2. Her hematocrit was 27.7. Recommendations were to maintain a hematocrit greater than 30, increase her beta blockade, and repeat an EKG to see if there was resolution of her right bundle branch block. Her cardiac enzymes were unremarkable. Postoperative day 3, the patient was extubated overnight, was satting well on 4 liters nasal prongs at 98%, remained afebrile. Epidural remained in place. Patient's chest tubes remained in place, and Foley remained in place. Chest tubes were discontinued. Beta blockade was increased. Her hydralazine was increased for rate and systolic blood pressure control. She was transfused platelets prior to epidural being discontinued. Her diet was advanced as tolerated, and she was transferred to the VICU for continued monitoring and care. Postoperative day 4, she remained afebrile. White count was 11.6, hematocrit 33.1, BUN 60, creatinine 2.4 down from 2.5, lactate 1.3. Fasting glucoses were 58-127. Exam showed 1+ edema in the lower extremities. The patient was begun on Percocet for analgesic control, incentive spirometry and pulmonary toiletry. She was continued on Lopressor, Norvasc and hydralazine. Aspirin was added to her diet. She continued to be diuresed. She was started on insulin regular sliding scale as needed. She remained in the VICU. Patient's blood pressure improved by postoperative day 4 with a systolic of 125. Her A-line was discontinued. Her electrolytes were repleted. Ambulation was begun. Physical therapy was requested to see the patient and felt that she would be able to be discharged to home when medically stable. Renal function continued to be monitored. The remaining hospital course was unremarkable. The patient was afebrile on postoperative day #5. The patient did have a significant amount of pleural drainage from the chest tube site. Repeat chest x-ray showed significant improvement in her pleural effusion. The chest tube site continued to drain. She was placed on Keflex 250 q. 24 h for a total fo 2 weeks until she is seen in follow-up with Dr. [Last Name (STitle) ]. The patient will be instructed to change her chest dressing as needed to keep the site dry. She will continue on the Keflex until seen in follow-up. At the time of discharge, wounds were clean, dry and intact. Chest site was without erythema. The drainage was serosanguineous. They have been instructed to call his office if she develops fever greater than 101.5, develops shortness of breath, if she develops change in character in her pleural fluid drainage. The patient has also been instructed to continue her antihypertensive medications as prescribed and to follow-up with her primary care physician for continued blood pressure management. DISCHARGE DIAGNOSES: 1. Thoracoabdominal aortic aneurysm--ruptured. 2. Hypertension, uncontrolled. 3. Postoperative pleural effusion, resolving. 4. Blood loss anemia--transfused. 5. Positive P-MIBI for moderate lateral wall reversible defect and an echo ejection fraction of 55%. Patient should follow-up with Dr. [Last Name (STitle) ] in 2 week's time. She should call for an appointment at [Telephone/Fax (1) 2625]. SURGICAL PROCEDURE: Repair of thoracoabdominal aneurysm on [2197-12-5]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(2) 6039] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2197-12-13] 11:32:36 T: [2197-12-13] 12:21:44 Job#: [Job Number 63293]	[ "511.9", "285.1", "401.9", "997.3", "441.6" ]	icd9cm	[ [ [] ] ]	[ "38.45", "38.44" ]	icd9pcs	[ [ [] ] ]								6691, 7462						1144, 6670									704, 722		738, 1126																				149, 167										196, 680
62,921	164,926	36930	Discharge summary	report	Admission Date: [2193-4-8] Discharge Date: [2193-4-12] Date of Birth: [2140-3-17] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 9160] Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 83339] is a 53 year old man with h/o EtOH abuse, HCV, anxiety/depression, who was BIBEMS after being found down, observed in the ED overnight, now exhibiting signs of withdrawal. The patient was found down behind a Stop and Shop in a hospital gown with a bottle of Listerine at his side. He was lethargic, difficult to arouse. Denied ingesting any other substances. The patient notes that he has been drinking heavily and has had daily ED visits for the past week at different hospitals. He typically exhibits this behavior once every few months, then seeks help at a detox center. He started drinking last week, typically vodka and Listerine. He also wasn't able to get his Klonopin from his case worker on [Last Name (LF) 2974], [First Name3 (LF) ] drank more to compensate for that as well. In the ED, initial VS were: 97.4 80 121/70 14 98%. Labs notable for EtOH level 463, anion gap 17, serum Osms 361, salicylates negative. CT head was negative for acute process. The patient was observed overnight, but then showed signs of EtOH withdrawal this morning. Upon further questioning, he reports h/o EtOH withdrawal seizures. He was given Diazepam 10mg PO x3, Lorazepam 2mg x2, but continued to be tachycardic and tremulous. Also given 4L NS, folate, MVI. VS prior to transfer: 98.0 132/64 125 15 98%RA. On arrival to the MICU, patient's VS 97.7 115 140/76 20 97%RA. He continues to be anxious and tremulous. He also notes some palpitations and generalized weakness. Has R sided abdominal pain that is worse with coughing and movement. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure. Denies constipation, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: EtOH abuse - h/o withdrawal seizure x1 at [Hospital3 ] Hepatitis C Asperger's Anxiety Depression OCD Social History: Patient stays at the Pilgrim Shelter. Smokes tobacco [11-19] ppd. Heavy EtOH use, typically vodka and Listerine, couple pints/day. Past h/o crack cocaine use, last used [8-29]. Family History: Patient does not know of any relevant family history Physical Exam: Vitals: 97.7 115 140/76 20 97%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, right periorbital ecchymosis, small superficial abrasion above the R eyebrow Neck: supple, JVP not elevated, no LAD CV: tachycardic, S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, tenderness to palpation on the R lateral abdomen/chest wall, negative [Doctor Last Name 515], no ecchymosis GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; 2cmx2.5cm superficial abrasion on the L anterior knee, 2cmx3cm superficial abrasion on the R anterior knee, superficial abrasions L lateral ankle Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, +tremor Pertinent Results: ADMISSION LABS: [2193-4-8] 10:00PM BLOOD WBC-8.3 RBC-4.99 Hgb-15.3 Hct-48.7# MCV-98 MCH-30.6 MCHC-31.4 RDW-14.3 Plt Ct-341 [2193-4-8] 10:00PM BLOOD Neuts-60.3 Lymphs-34.3 Monos-4.3 Eos-0.4 Baso-0.7 [2193-4-8] 10:00PM BLOOD Glucose-103* UreaN-7 Creat-0.8 Na-144 K-3.7 Cl-99 HCO3-28 AnGap-21* [2193-4-9] 06:50AM BLOOD Osmolal-361* [2193-4-8] 10:00PM BLOOD ASA-NEG Ethanol-463* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2193-4-9] 12:00PM BLOOD Type-[Last Name (un) ] pO2-58* pCO2-36 pH-7.47* calTCO2-27 Base XS-2 Comment-GREEN TOP [2193-4-9] 12:00PM BLOOD Lactate-3.1* STUDIES: [2193-4-8] CT head: No acute intracranial pathology. Brief Hospital Course: Mr. [Known lastname 83339] is a 53 year old man with h/o EtOH abuse, who was brought to the hospital intoxicated, admitted to the ICU for EtOH withdrawal. ## EtOH withdrawal: Patient admitted with EtOH level 463, exhibited signs of withdrawal (tachycardia, anxiety, tremulousness). Initially on Diazepam 10mg PO q2h, then transitioned to q4h dosing for CIWA>10. Received 110mg Diazepam in the ICU. Patient also given MVI, Thiamine, and Folate. Upon transfer to the floor, he remained stable with low scores on the CIWA scale, only requiring 2 doses of Diazepam over span of 36 hours. Social Work was consulted and assisted with resources and counseling. Patient was encouraged to abstain from drinking. Continued on MVI, Thiamine, and Folate. ## R sided chest/abdominal pain: Patient with R sided point tenderness on exam, found to have acute 9th rib fracture on rib films. He was given NSAIDs for pain control. ## Anxiety/depression: Continued on home Paxil and Seroquel. Klonopin held while on Diazepam for EtOH withdrawal but restarted on discharge due to significant anxiety. ## Communication: Mother [Name (NI) 2127] ([Telephone/Fax (1) 83340]) and Case worker [Doctor Last Name 10378] @ [Location (un) 33316] House ([Telephone/Fax (1) 83341]) were notified of admission. Medications on Admission: Klonopin 1mg PO BID Seroquel 100mg PO BID Paxil 40mg PO daily Bentyl prn (infrequent) Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication Alcohol withdrawal Anxiety Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the Intensive Care Unit for treatment of withdrawal from alcohol. You should avoid drinking to the best of your ability. You were continued on your home medications and also started on Thiamine, Folic acid, and a Multivitamin. Followup Instructions: Name:[Name6 (MD) ] [Name8 (MD) ], NP Location: [University/College ] ST [Hospital ] HEALTH CENTER Address: [Hospital3 ], [Location (un) ],[Numeric Identifier 81399] Phone: [Telephone/Fax (1) 35879] When: Wednesday, [4-17] at 7:00pm [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 9162] Completed by:[2193-4-13]	[ "291.81", "807.01", "303.91", "E888.9", "276.52", "070.54", "300.00", "311", "305.1", "276.2", "300.3", "299.80", "V60.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6421, 6427	4362, 5668	288, 295	6530, 6530	3664, 3664	6953, 7344	2653, 2707		5804, 6398		6448, 6509		5694, 5781			6681, 6930									2722, 3645																1917, 2306				232, 250										323, 1898		4303, 4339			3680, 4294				6545, 6657					2328, 2435	2451, 2637
5,188	139,738	49347	Discharge summary	report	Admission Date: [2153-8-12] Discharge Date: [2153-8-29] Date of Birth: [2072-6-16] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Bactrim Attending:[First Name3 (LF) 2972] Chief Complaint: Right shoulder pain, fever Major Surgical or Invasive Procedure: Intubation . Urethral dilatation for foley placement . [8-27]: Right shoulder MRI IMPRESSION: 1) Tendinosis in the distal supraspinatus and infraspinatus tendons without evidence of tearing. 2) Edema in the medial aspects of the supraspinatus and infraspinatus muscles without associated atrophy, which is nonspecific. 3) Mild acromioclavicular osteoarthritis. . [8-28]: Thoracic spine MRI IMPRESSION: Multilevel degenerative disease with at least moderate spinal canal narrowing as above. No abnormal signal within the cord. Study is severely limited due to patient motion artifact. However, given the absence of abnormal T2 signal in the disc spaces or within the vertebral bodies, osteomyelitis is considered unlikely. . [8-23] Abd US IMPRESSION: Unremarkable abdominal ultrasound. No evidence of cholecystitis, cholangitis, or focal mass lesion identified. No fluid collection or source of MRSA identified. . TEE [8-23] Conclusions: 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. The ascending aorta is mildly dilated. 4. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. No obvious vegetations are seen. 7. Compared with the prior study (images reviewed) of [2153-8-13], LV function may have improved. . Video speech and swallow ([8-21]) FINDINGS: Oropharyngeal swallowing evaluation was performed today in collaboration with speech and swallow pathologist. The thin liquid, nectar thick, pureed, and [12-27] of cookie were administered. There were moderate defects with decreased bolus control and premature spillover of thin and thick liquids to the valleculae and piriform sinuses. There was a decreased high laryngeal excursion, laryngeal valve closure, and only partial epiglottic deflection. There was mild-to-moderate deep penetration that occurred during the swallow with both thin and nectar thick liquids. However, though barium was seen on the vocal cords, no aspiration below the vocal cords was definitively demonstrated. IMPRESSION: A moderate dysphasia with deep penetration to thin and nectar thick liquids. . Shoulder XRAY [8-16] No fracture or dislocation is detected. No bony destructive changes are seen. No obvious soft tissue abnormalities are appreciated. Minimal degenerative changes of the acromioclavicular joints are present. . CTA [8-13] IMPRESSION: 1. No aortic dissection or pulmonary embolism. 2. Coronary artery bypass graft. Severe coronary artery calcifications. 3. Unchanged cardiomegaly. Trace bilateral pleural effusions, decreased from the prior study. 4. Unchanged compression deformities of the thoracic spine . CT Head [8-13] IMPRESSION: No acute intracranial hemorrhage. No change compared to the prior study. History of Present Illness: Pt is an 81 yo priest w/ h/o CAD s/p MI, HTN, DM2, who p/w altered mental status, R shoulder pain x 5d and fever spike to 99.9 at home. He had apparently had worsening shoulder pain for five days, wincing when the shoulder was touched. Pt initially treating shoulder pain at [Hospital3 ] w/ ASA, heat pack per his PCP. [Name10 (NameIs) 2772], noted to have altered MS changes by his [Last Name (LF) ], [First Name3 (LF) ] he was brought to [Hospital1 18] ED. In [Name (NI) ], pt noted to be febrile to 101.9, other VSS. Labs notable for WBC 14.2, lactate 2.4. LP normal. While in the ED, he became increasingly hypertensive, up to the 230's systolic, difficult to control with a NTG-gtt and eventually became increasingly hypoxic. There was questionable seizure activity, and the patient was intubated for acute respiratory failure. At this point, he underwent CTA showing no PE, dissection, or pulmonary abnormality, as well as no soft tissue or osseous abnormalities that could explain his shoulder pain. He also received ceftriaxone, metronidazole, vancomycin, and furosemide 40mg IV x 1. . Past Medical History: -HTN -DM2 -Hypercholesterolemia -CAD with 4 prior MIs, prior PTCA, s/p CABG in [2136] with LIMA to LAD, SVG to D2/Om3, SVG to RCA; cath [11/2152] with stent to SVG-RCA, 40%LMCA lesion, patent LIMA-LAD, diffusely disease LCX. -Bladder outlet obstruction and BPH -Multiple prior UTIs -Depression -Tardive dyskinesia -Anxiety -status post TKR [9-23] . Social History: Reverend. Lives in [Hospital3 ] facility at JP. History of tobacco in the past. No alcohol or IVDU history. His niece is his HCP. . Family History: Non-contributory. . Physical Exam: t 100.0 (rectal), bp 135/72, hr 87, rr 17, spo2 98% Vent- A/C 600/5/14/1.00 peak 25/plateau 14 gen- sedated, intubated; non-acutely-ill appearing heent- anicteric, op with mmm cv- rrr, s1s2, no m/r/g; cabg scar pulm- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm dry, full dp pulses bilat nails- no clubbing, no pitting/color changes/indentations neuro- sedated, not following commands, perrl, mae . Pertinent Results: [2153-8-12] 03:20PM BLOOD WBC-14.2# RBC-5.40 Hgb-16.8 Hct-46.3 MCV-86 MCH-31.1 MCHC-36.2 RDW-14.8 Plt Ct-166 [2153-8-13] 03:21AM BLOOD WBC-17.6* RBC-5.59 Hgb-17.0 Hct-47.7 MCV-85 MCH-30.4 MCHC-35.7* RDW-14.6 Plt Ct-164 [2153-8-15] 05:34AM BLOOD WBC-9.3 RBC-5.14 Hgb-15.3 Hct-44.9 MCV-87 MCH-29.8 MCHC-34.1 RDW-14.6 Plt Ct-199 . [2153-8-12] 03:20PM BLOOD Glucose-261* UreaN-14 Creat-0.9 Na-131* K-3.5 Cl-92* HCO3-27 AnGap-16 [2153-8-13] 12:20PM BLOOD Glucose-153* UreaN-21* Creat-1.0 Na-135 K-3.6 Cl-96 HCO3-27 AnGap-16 [2153-8-15] 05:34AM BLOOD Glucose-142* UreaN-33* Creat-0.8 Na-140 K-4.0 Cl-101 HCO3-30 AnGap-13 . [2153-8-12] 03:20PM BLOOD CK(CPK)-69 [2153-8-12] 03:20PM BLOOD cTropnT-<0.01 [2153-8-12] 11:55PM BLOOD CK(CPK)-261* [2153-8-12] 11:55PM BLOOD CK-MB-3 cTropnT-<0.01 [2153-8-13] 03:21AM BLOOD CK(CPK)-102 [2153-8-13] 03:21AM BLOOD CK-MB-4 cTropnT-0.06* [2153-8-13] 12:20PM BLOOD CK(CPK)-109 [2153-8-13] 12:20PM BLOOD CK-MB-4 cTropnT-0.02* . Brief Hospital Course: Pt is a 81 yo man with PMH CAD s/p MI, HTN, DM2, who p/w altered mental status, R shoulder pain x 5d and fever. . #Respiratory failure -- Given overall story, normal initial CXR, lack of presenting respiratory complaints, pre- and post-intubation CXR's, and post-intubation CTA, it seems the most likely diagnosis was acute pulmonary edema secondary to a hypertensive emergency. He has known depressed systolic function and MR and likely could not tolerate the elevated afterload, causing sudden fluid back-up into the pulmonary tree. This scenario is further supported by his rapid improvement (in terms of o2 sats, abg, and post-intubation cxr) as the positive-pressure ventilation likely dropped both his preload and afterload. There was probably a modest contribution from his RUL pneumonia, seen on the next day's CXR as well. Other possibilities, such as aspiration and PE were excluded his post-intubation CTA. No known history of obstructive lung disease and was moving air well on exam. On the second day of admission, he was easily reduced to minimal ventilatory settings and then extubated with the use of a nitroglycerin drip to control both preload and afterload. A moderate diuresis was He did quite well afterwards, quickly being weaned down from a 70% face-mask to 4L NC with good o2 saturations. On the floor he was satting in the mid 90s on room air and did not have any further respiratory difficulties. He was found to have a RUL pneumonia (likely MRSA). Will continue furosemide 40mg PO. WBC stable and afebrile. . #CHF -- Pt seems to have experienced acute pulmonary edema as above. Has baseline systolic dysfunction, last EF [12/2152] was 30-40%, and current EF on [2153-8-23] after acute exacerbation was 50-55%. Continued on lisinopril, metoprolol for afterload reduction and isosorbide dinitrate for afterload/preload reduction. Arrempted to keep balance -500cc per day. . #. HTN -- Unclear cause of sudden elevation in ED, possibly [1-25] to pain, confusion, anxiety. Better controlled on the floor with no issues in terms of hypertension. Continued home meds. . #. Fever/leukocytosis -- Although it's of unclear etiology, clinically the only presenting symptom was his right shoulder pain. ID work-up in ED included: CSF negative, CXR with RUL pneumonia, blood cxs positive for MRSA (last +bcx was on [8-12]), 3/4 bottles with MRSA, urine culture negative. C. Diff was negative. ID consulted while in house. Shoulder MRI did not show any evidence of osteo, and neither did thoracic MRI. RUQ ultrasound and repeat echo did not show a source. The plan is to treat him for four weeks (started [8-13] should end vancomycin course on [9-11]). He will need weekly CBC, LFT, BUN/Cr, Vanc trough, which should be faxed to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (ID fellow) at ([Telephone/Fax (1) 1353]. . #Right shoulder pain -- As above, main clinical sx. . #MS changes -- Likely [1-25] underlying infectious process, possibly pain. LP negative for infection. He was mentating well on the floor. Haldol was given as needed for agitation. . #CAD -- No evidence of active ischemia on ECG or by cardiac enzymes. Pt on numerous cardiac meds. MI was ruled out with enzymes. Con't asa, clopidogrel, atorvastatin, metoprolol. He had multiple episodes of chest pain while in house with negative ECGs. The pain was reproducible on palpation and likely secondary to sternotomy scar. . # DM: Pt on glyburide as outpt. He was kept on an insulin sliding scale while in house and his glyburide should be restared once at the rehab facility. (He was taking glyburide 5 mg po qd). . # Anxiety/OCD: Pt on numerous anxiolytics. Continue home meds. . # BPH: Patient had urethral dilatation by GU and foley was left in place for duration of his hospital stay. He should have his Foley in place on discharge to the rehab facility. He has an outpatient follow up with Dr. [Last Name (STitle) 4229] on [9-4] (from URology) for a voiding trial. He was started on Flomax and continued his Proscar while in house. . # FEN: Video speech and swallow done in house. Recommended nectar prethickened liquids Please crush PO meds, assist patient with feeding. Cue patient to swallow every [1-26] bites/sips, and cute patient to clear cough and swallow every [1-26] bites. . # PPX: SC heparin, ppi . # Code status: Presumed full . # Dispo: To rehab facility. . # PCP (Gershegorn [2153]) Medications on Admission: Lisinopril 20 mg PO DAILY (Daily). Finasteride 5 mg PO DAILY (Daily). Folic Acid 1 mg PO DAILY (Daily). Glyburide 5 mg PO DAILY (Daily). Clopidogrel 75 mg Tablet PO DAILY Hydrochlorothiazide 25 mg PO DAILY Furosemide 40 mg PO BID Aspirin 325 mg PO DAILY (Daily). Atorvastatin 10 mg PO DAILY Isosorbide Mononitrate 240 mg PO HS Trazodone 50 mg PO HS Metoprolol Tartrate 25 mg PO TID Nitroglycerin 0.3 mg Sublingual PRN Bisacodyl 10 mg Tablet, PO DAILY (Daily) as needed. Ferrous Sulfate 325 (PO DAILY (Daily). Multivitamin PO DAILY Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops TID Docusate Sodium 100 mg PO BID Lorazepam 0.5 mg PO Q4-6H (every 4 to 6 hours) as needed. Clonazepam 0.5 mg PO BID Fluvoxamine 50 mg PO TID Mirtazapine 15 mg PO HS Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for chest pain. 15. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. 17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Continue through [2153-9-13]. 22. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 103373] Discharge Diagnosis: . MRSA bacteremia: You have a bloodstream infection with MRSA (a resistant bacteria). You need treatment with Vancomycin intravenously for at least four weeks (Started on [8-13], need to continue through [9-13]). . Flash pulmonary edema: You had a sudden increase in fluid in your lungs because of your high blood pressure. You need to keep your blood pressure under control. Discharge Condition: Good Discharge Instructions: Please call your PCP if you have high fevers, chills, chest pain uncontrolled with nitro. Followup Instructions: Dr. [Last Name (STitle) 4229], urologist, as an outpatient for a voiding trial. You will be discharged with a Foley in place. - [Telephone/Fax (1) 10941]; Tuesday, [9-4] @ 8:15, [Hospital Ward Name 23], [Location (un) ], surgery specialty . Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], ID specialist will follow up on Mr. [Known lastname 103374] labs, to be drawn by Rehab facility. They should include a weekly CBC, LFTs, BUN/Cr and Vanc trough. They should be faxed to ([Telephone/Fax (1) 1353] . Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of ID will follow up with him in clinic prior to antibiotic completion on [9-4] @ 10am. [Last Name (NamePattern1) ], [Hospital Unit Name ], [Hospital ] medical building. ([Telephone/Fax (1) 4170]	[ "412", "250.00", "038.11", "V45.82", "726.10", "482.41", "518.81", "V43.65", "V45.81", "715.91", "428.0", "401.9", "600.01" ]	icd9cm	[ [ [] ] ]	[ "59.8", "96.04", "96.71", "96.6", "03.31", "58.6", "88.72", "38.93" ]	icd9pcs	[ [ [] ] ]	13851, 13949	6620, 11110	318, 3387	14379, 14386	5582, 6597	14525, 15373	5092, 5113		11949, 13828		13970, 14358		11136, 11926			14410, 14502									5128, 5563																				252, 280										3415, 4538														4560, 4923	4939, 5076
15,264	163,220	45433	Discharge summary	report	Admission Date: [2110-4-15] Discharge Date: [2110-4-30] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: transfer from outside hospital with head bleed Major Surgical or Invasive Procedure: Right parieto-occipital craniotomy for evacuation of an intracerebral hemorrhage. History of Present Illness: HPI: 88yo F, fell yesterday in a parking lot, able to walk home. She fell again at home this morning, was found by friend/neighbors to be less alert, speech difficulty and left-sided weakness. Uncertain the reason for the falls. She was sent to OSH, CT showed IPH/IVH/SAH, patient was txfed to [Hospital1 18]. Per OSH record, pt was A+O x2 and follow commands at initial eval, but became less responsive, was intubated for airway protection/transfer. Past Medical History: PMHx: h/o left breast Ca s/p mastectomy 15yr ago, no h/o of recurrence; COPD; hypothyroidism. All: unknown. Social History: Social Hx: lives alone and independent prior to this admission. No immediate family available. Has a Niece and a great niece, [Name (NI) ] [Name (NI) ] who is a doctor and can be reached at [Telephone/Fax (1) 96968] (c) or [Telephone/Fax (1) 96969] (pg). Family History: Family Hx: unknown Physical Exam: PHYSICAL EXAM ON ADMISSION: T:afebrile BP: 150/60 HR: 76 R 14 on vent O2Sats 100% Gen: intubated, sedated with propafol. large ecchymosis around left eye. No otorrhea, no rhinorrea. No battle sign. HEENT: Pupils: round, R slightly larger than L at 1-1.5mm, sluggish reactive to light. EOMs unable to assess Neck: intubated unable to assess Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: soft, BS+ Neuro: Mental status: intubated and sedated. Cranial Nerves: I: Not tested II: Pupils round, R slightly larger than L at 1-1.5mm, sluggish reactive to light. The rest of CNs unable to assess. Motor: no posturing, no spontaneous movemnet. RUE and both LE withdrawal to noxious stimuli. Sensation: unable to assess. Reflexes: diminished throughout. Toes upgoing bilaterally Pertinent Results: CT/MRI: CT head:(final read pending) 1. Large intraparenchymal hemorrhage with subarachnoid components involving the right frontoparietal region extendinginto the right temporal lobe with intraventricular hemorrhage and mild dilatation of the left occipital [Doctor Last Name 534]. Multiple smaller areas of subarachnoid hemorrhage throughout both cerebral hemispheres with more focal collection noted paramedially adjacent to the left frontal lobe. 2. Approximately 7 mm of leftward subfalcine herniation without evidence of uncal herniation. 3. Left periorbital soft tissue edema. No evidence of underlying fractures. CT C-spine: (final read pending) no fx or dislocation. labs: PT/PTT/INR: 12.7/26.2/1.1 Brief Hospital Course: Pt was admitted and emergently brought to the OR where under general anesthesia a right parieto-occipital craniotomy for evacuation of an intracerebral hemorrhage was performed. Pt tolerated this procedure, was kept intubated and transferred to TICU. Her SBP was maintained 90-140. Her vital signs were stable. On POD#1 she was following some commands on the right but continued with left weakness. Post op CT showed good appearance with decreased amount of hemorrhage. She did spike a temperature and fever work up revealed pneumonia and she was begun on antibiotics. She had many secretions and in addition to her depressed mental status she was not able to be extubated. There was a family meeting with Dr. [Last Name (STitle) 548] and Dr. [Last Name (STitle) ] of TICU. Pt's family appreciated information and decided to make the patient DNR. She was placed on comfort measures only on the evening of [2110-4-29]. She passed away in the AM of [2110-4-30]. Medications on Admission: Medications prior to admission: Lipitor, synthroid, fosamax, advair, ASA, Aldactone, benadryl, Calcium supplement. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: cerebral hemorrhage pneumonia Discharge Condition: Death Discharge Instructions: none Followup Instructions: none Completed by:[2110-4-30]	[ "276.1", "496", "V10.3", "853.01", "E885.9", "V15.88", "V45.71", "599.0", "507.0", "438.20", "244.9", "518.5" ]	icd9cm	[ [ [] ] ]	[ "33.24", "38.93", "96.72", "01.39", "96.6" ]	icd9pcs	[ [ [] ] ]	4073, 4082	2896, 3879	313, 397	4155, 4162	2155, 2163	4215, 4250	1320, 1341		4044, 4050		4103, 4134		3905, 3905			4186, 4192									1356, 1370								3937, 4021												227, 275										425, 882	1821, 2136	2171, 2873					1384, 1767		1782, 1805					904, 1015	1031, 1304
12,688	111,686	8125+55912	Discharge summary	report+addendum	Admission Date: [2192-2-3] Discharge Date: [2192-2-20] Date of Birth: [2120-8-26] Sex: M Service: [Location (un) 259] HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old man with a history of stage IV bladder cancer status post neobladder reconstruction in [2191-2-19] and four cycles of Gemcitabine and cisplatin in [2191-7-19], chronic progressive bilateral hydronephrosis, and moderate alcohol use, approximately three to four beers daily. Otherwise, the patient was relatively well until about two weeks prior to admission when he developed a fever of approximately 101.4 at home. Additionally, the patient described decreased p.o. intake and decreased urine output. He developed persistent nausea, vomiting, and inability to take p.o. one day prior to admission. He had coffee ground emesis at home on the day of admission. He was sent to the Emergency Department for evaluation of bilateral hydronephrosis. In the Emergency Department, the patient was noted to be tachycardiac and complaining of diffuse abdominal pain. His laboratory data was significant for acute renal failure with a BUN of 226, creatinine 15, and a bicarbonate of 7. His amylase and lipase were also elevated between 400 and 600. The ABGs were notable for a pH of 7.22 on 2 liters nasal cannula. After insertion of a Foley, 200 cc of cloudy urine were obtained. NG suction was notable for coffee grounds with dark blood. In the Emergency Department, he received Zosyn for broad coverage and aggressive fluid hydration to approximately 5 liters of normal saline as well as bicarbonate. His urine output increased to 600 cc and he was sent to the MICU for further evaluation of acute renal failure and acidemia. In the MICU, the patient's BUN and creatinine improved steadily with IV fluid hydration. A CT study was performed to evaluate possible fluid collections around the neobladder which was drained percutaneously, revealing a creatinine of 8 which suggested that the fluid collection was not from urine leakage. A right percutaneous nephrostomy tube was also placed while the patient was in the MICU for persistent right-sided hydronephrosis and elevated BUN and creatinine. The patient had an EGD performed on [2192-2-6] after an acute episode of upper GI bleed and a hematocrit drop of 9 points, revealing a duodenal ulcer. The patient is status post cauterization. He was hemodynamically stable and transferred to the floor for further evaluation, status post 5 units PRBCs. PAST MEDICAL HISTORY: 1. Stage IV bladder cancer. 2. Chronic hydronephrosis. 3. Hypercholesterolemia ALLERGIES: The patient has no known drug allergies. The patient does report an intolerance to Cipro. ADMISSION MEDICATIONS: 1. Lipitor. 2. Ditropan. 3. Vitamin C. 4. Multivitamins. 5. Folic acid. SOCIAL HISTORY: The patient lives with his wife at home. He drinks approximately four beers daily and denied any tobacco use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 95.3, heart rate 106, blood pressure 144/68, respiratory rate 29, 98% on 2 liters nasal cannula. General: The patient is an elderly pleasant man in no apparent distress. HEENT: Normal. Cardiac: Regular, tachycardia, no murmurs. Lungs: Clear. Abdomen: Notable for moderate distention, diffuse abdominal tenderness, mostly involving the left upper quadrant, decreased bowel sounds, voluntary guarding in the lower quadrants bilaterally. Extremities: No edema, Guaiac positive. Neurologic: Grossly intact. LABORATORY/RADIOLOGIC DATA: On admission, sodium 128, potassium 6.7, BUN 226, creatinine 15.1, anion gap 35. Amylase 418, lipase 635, lactate 2.3, albumin 3.6. White blood cell count 23.2, hematocrit 37.2. The urinalysis showed moderate leukocyte esterase, 100 protein. Studies performed during the admission revealed a CT of the abdomen without contrast showed mild wall thickening within the cecum and ascending colon, fluid tracking along the left pericolic gutter into the pelvis was noted. Right-sided hydronephrosis and hydronephrosis within the left renal collecting system were noted. Unchanged tiny noncalcified pulmonary nodule within the right anterior middle lobe was also noted. EKG showed sinus tachycardia with a rate of 102, normal axis, normal intervals. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient presented with fevers, acidemia, and acute renal failure. Blood cultures as well as fluid aspirated from the pericolic gutter collection and a collection anterio to the neobladder within the abdomen all grew E. coli ( no other organisms) which was pan sensitive. The patient was treated with multiple antibiotic regimens during his hospital course including ceftriaxone, Flagyl, vancomycin, ampicillin, clarithromycin, and Zosyn. These were directed at sepsis until a diagnosis was established and then at E coli and H pylori noted in the context of the duodenal ulcer. Eventually, his antibiotic regimen was tapered to include Levo, Flagyl, and Clarithromycin which coveredc E coli and H pylori. Additionally, the patient was noted to be H. pylori positive, status post cauterization of his duodenal ulcer and, therefore, he was also treated with a PPI plus antibiotics as noted above.. 2. ABDOMINAL PAIN: The patient presented with abdominal pain, urinary retention, and acute renal failure upon presentation. Interventional Radiology as well as the CT body team evaluated the patient and were able to use CT-guidance to drain the intra-abdominal collection as well as place a right percutaneous nephrostomy tube. Eventually, the left pericolic gutter and the anterior perineobladder collection were also drained with CT-guidance. Fluid from all of these culture samples grew E. coli. The patient's abdominal examination improved throughout his hospital course. He was able to take p.o. An MR urogram was performed on [2192-2-11] which did not reveal any extravasation of contrast. The patient had repeat CT drainage of three of the five pockets involving the left pericolic gutter collection. Follow-up CT on [2192-2-16] revealed re-accumulation of the other abscesses, however, the left lower quadrant drain was able to be pulled. The suprapubic drain was kept intact as there was fluid and air still around it as evident by CT. Overall, the repeat CT appeared to show some improvement in the fluid collection intra-abdominally and the patient's examination reflected this. 3. ACUTE RENAL FAILURE: The patient presented with elevated BUN and creatinine as well as urinary retention and urosepsis. The patient was started on multiple antibiotic regimens and remained afebrile throughout the majority of his hospital course. His BUN and creatinine slowly began to trend down after placement of the right percutaneous nephrostomy tube and with aggressive IV fluid hydration. Renal consult services were following the patient throughout his hospital course; however, the patient did not require hemodialysis during this hospital stay. 4. METABOLIC ACIDOSIS: The patient's metabolic acidosis resolved in the MICU after bicarbonate repletion and IV fluid hydration. 5. HYDRONEPHROSIS: The patient is status post right kidney drainage through percutaneous nephrostomy tube and he is status post dilatation procedure on the 22nd on the right with increased urine output. Left nephrostomy tube was not placed during this hospitalization. 6. GASTROINTESTINAL BLEED: The patient presented with coffee ground emesis and Guaiac positive stool. The GI service was consulted early in his hospital course. EGD was performed with cauterization of his duodenal ulcer. H. pylori was treated with Clarithromycin and PPI and Levo. The patient persistently had melenic stools throughout his hospital course and his hematocrit hovered between 28 and 32. Repeat endoscopy is scheduled to be performed as an inpatient on [2192-2-20] to ensure no further bleeding of the duodenal ulcer. 7. CODE STATUS: Code status was addressed during this hospital course. The patient confirmed that he would like to be full code. 8. ACTIVITY: The patient was able to ambulate with physical therapy and was able to take p.o. intake of a renal diet. Discharge planning, medications, and diagnoses will follow in an addendum. [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. [MD Number(1) 28963] Dictated By:[Last Name (NamePattern1) 1600] MEDQUIST36 D: [2192-2-17] 05:07 T: [2192-2-17] 18:56 JOB#: [Job Number 28964] Name: [Known lastname 5057], [Known firstname ] P Unit No: [Numeric Identifier 5058] Admission Date: [2192-2-3] Discharge Date: [2192-2-20] Date of Birth: [2120-8-26] Sex: M Service: [Location (un) 571] THIS IS A DISCHARGE SUMMARY ADDENDUM TO BE ADDED TO A PREVIOUS DISCHARGE SUMMARY WITH A JOB NUMBER [Numeric Identifier 5059]. The patient underwent a repeat endoscopy on [2192-2-20] to follow-up on a prior diagnosed duodenal ulcer. A repeat endoscopy was done since the patient had been experiencing continued melena. The endoscopy showed that the prior diagnosed duodenal ulcer was healing. Recommendations were made for a colonoscopy. As per the patient's attending, given that the patient had remained stable and had had a prior colonoscopy two years ago which had showed polyps, he felt as though the patient could be discharged home and have the colonoscopy as an outpatient. The patient was to continue his antibiotics which consisted of Levaquin and Flagyl on an outpatient basis. He complained of minimal abdominal pain on the day of discharge. He was discharged home with his drains in place. He was also able to tolerate solid foods. DISCHARGE DIAGNOSES: 1. Urosepsis complicated by intraabdominal abscesses. 2. Stage 4 bladder cancer. 3. Chronic urinary incontinence. 4. Bleeding duodenal ulcer with H. pylori. 5. Acute renal failure. 6. Status post percutaneous nephrostomy tube placement. 7. Status post percutaneous drainage of intraabdominal abscesses. 8. Central venous line placement. 9. Status post esophagogastroduodenoscopy with cauterization of duodenal ulcer. DISCHARGE MEDICATIONS: 1. Metronidazole 500 mg po q. 12 hours times seven days. 2. Levofloxacin 250 mg tablet po q. 24 hours times 14 days. 3. Pantoprazole 40 mg po q. 12 hours. 4. Ferrous gluconate 300 mg po q.o.d. 5. Lipitor 10 mg po q.d. DISCHARGE INSTRUCTIONS: The patient was told to call Urology, specifically, Dr. [Last Name (STitle) 5060], for an appointment in two weeks. Prior to his appointment with Urology, he was told to call Radiology for a time slot to have a repeat CT scan to assess the size of the fluid collections. The patient was also told to call Dr. [Last Name (STitle) ] for an appointment in approximately four weeks. He was also told to call Dr. [First Name4 (NamePattern1) 5061] [Last Name (NamePattern1) 5062] office to schedule a colonoscopy within the next one to two months. The patient was provided with phone numbers for all three of these doctors. The patient was sent home with visiting nurse nursing services. The Visiting Nursing Association was instructed to monitor daily output from the patient's drain and to maintain a clean drain site. They were also told to check a CBC, BUN, and creatinine every three days for the next two weeks and to fax these results to Dr.[Name (NI) 5063] office. They were also told to flush the drain with 10 cc of normal saline once a day. DISCHARGE STATUS: Home with services. DISCHARGE CONDITION: Stable. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-663 Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2192-2-21] 12:58 T: [2192-2-21] 13:21 JOB#: [Job Number 5064] cc:[Name (STitle) 5065]	[ "567.2", "041.4", "038.42", "593.3", "997.5", "590.10", "584.5", "591", "995.92" ]	icd9cm	[ [ [] ] ]	[ "45.13", "38.93", "55.03", "54.91", "99.04", "44.43", "38.95", "97.62", "59.8", "38.91" ]	icd9pcs	[ [ [] ] ]				11775, 12021			2993, 3032	9939, 10366	10389, 10613					4387, 9918		10638, 11753	2769, 2847																																													3047, 4369							2560, 2746	2864, 2976
43,571	110,230	41282+58443	Discharge summary	report+addendum	Admission Date: [2141-4-18] Discharge Date: [2141-5-15] Date of Birth: [2075-9-6] Sex: M Service: MEDICINE Allergies: Penicillin G / Azithromycin Attending:[Last Name (NamePattern4) 290] Chief Complaint: transfer from OSH for multiple issues Major Surgical or Invasive Procedure: C1-2 posterior decompression, evacuation abcess Ventriculostomy placement History of Present Illness: 65 yo M with PMHx of asthma who presented to OSH for confusion and bizzare behavior, found to have fevers, neck stiffness, abnormal LP, MSSA bacteremia with hospital course c/b aspiration event and intubation and acute hemiparesis episode concerning for CVA now transferred for ongoing management for medical issues. . Patient was admitted to [Hospital3 10310] on [4-12] after friends found him confused in his home after not showing up to work for 2 days. Friends report he was confused with slurred speech, unsteady on feet, and letting something burn on his oven. Per report of brother, pt had visited PCP twice in prior 10 days for neck pain and apparently co-workers and reported he was feeling less well, complaining of neck pain, and perhaps acting more confused or unusual than normal. PCP is reported to have treated neck pain with flexeril, benzos, and vicodin. When arrived at [Hospital3 10310] on [4-12], temp was 101.2 and pt was confused. Zosyn was started emperically but on HD #2 pt appeared worse and LP was done showing high protein, low glucose, with elevated WBC of PMN predominance but gram-stain showed no organisms and CSF Cx was still negative at time of transfer. Gram-stain from Bcx on admission grew GPCs and Vancomycin started -> cultures ultimately grew 4/4 bottles MSSA on [4-14] and ID saw pt in consult and started cefazolin to which the MSSA was sensative. Later on HD #3 ([4-14]), he had an aspiration event that required intubation and transfer to MICU although hemodynamically stable at time. Pt was placed back on Vancomycin and started on Cefepime (unclear but zosyn possibly stopped somewhere in this interval). Highest temp of hospitalization was also on this day to 104.0 in AM [4-14]. On intubation and ICU transfer, pt given propofol with resulting BP drop and was started on dopaminem with RIJ CVL placed. He underwent TTE which showed small hyperechoic 3mm lesion in RV trabeculations and 1.5 cm isoechoic RV apical septum lesion. Neither were thought suggestive of a vegetation/endocarditis and no left-sided valvular lesions were noted. He was also noted to have infiltrate on CXRs during admission and sputum Cx from [4-14] grew MSSA. He was maintained on [Month/Day (4) 621] but failed extubation on [4-17] with immediate reintubation. [Month/Day (4) ] changed to Vanc/Meropenem on [4-17] but continued to spike fevers. On early Tues ([4-18]) he developed right arm weakness and a CT head was noted to have new right cerebellar infarcts (one hypodense lesion in pons and one large non-hemorrhagic R cerebellar infacrtion with partial effacement of 4th ventricle). No hemorrhage or midline shift. Hard to oxygenate since requiring Fi02 of 100% and Peep of 12 to maintain sats in the 80s. Receiving SQH only for DVT ppx. . Brother [Name (NI) ] speaks to pt every few weeks. Confirms that pt is somewhat of a recluse but reports that he volunteers some at a senior center. Confirms that sent co-workers of pt to find him on [4-12] due to pt seeming confused via phone and due to reports that pt was confused at the senior center where he volunteered. for neck pain but brother did not recognize torticollus. Brother mentioned that two weeks prior pt had reported a rash on his body but did not give further discription. Pt also says that he did not recognize the name torticollus in reference to his brother's neck problem. . In the ICU, pt minimally responsive to some questions and commands but unable to speak due to endotracheal tube so further information could not be elicited. . Review of sytems (unable to obtain due to intubated state): Past Medical History: (per OSH records and brother) -asthma/allergic rhinitis -depression -dyslipidemia -question of intermittent torticollus since a teenager Social History: (some per OSH records, some per brother): Works as a technician at [Name (NI) 2475]. Apparently also volunteers at a elder center. Single. Reported to be somewhat reclusive and lives alone. No reported history of smoking, alcohol, or drug use per brother. Family History: (per OSH records) One sister died of lung CA. Brother with asthma and some mental health issues as well. Mother died at 87 and Father died at 52 (either liver or kidney CA) Physical Exam: Admission Physical Exam Vitals: T: 100.5 / BP: 123/57 / P: 79 / R: 19 / O2: 99% on vent General: opening eyes and responsive to some simple comands, intermittently losing concentration on surroundings HEENT: Sclera anicteric, no evidence of conjunctival hemorrhage, MMM, ET in place, tongue questionably deviated to the L Neck: supple, R IJ in place but kinked Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: soft heart sounds difficult to hear above ventilatory, RRR, soft S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Skin: no rashes or areas of skin break noted GU: no foley Ext: very arm, well perfused, 2+ pulses bounding pulses at DP and radial, no clubbing, cyanosis or edema, no evidence of [Last Name (un) 62745] lesions or Osler's nodes on exam. Neuro: 4+/5 strength to grip in L hand, 3/5 strength to grip in L hand, able to squeeze hands on command (L>R) and able to move L toes but not R toes to command, difficulty with eye tracking but unsure if due to CN deficits or concetration issue, pupils equal and reactive, tounge questionably deviated to the left Pertinent Results: [2141-4-18] 11:40PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.035 [2141-4-18] 11:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2141-4-18] 11:40PM URINE RBC-7* WBC-3 BACTERIA-NONE YEAST-NONE EPI-1 [2141-4-18] 11:40PM URINE GRANULAR-4* HYALINE-1* [2141-4-18] 11:40PM URINE MUCOUS-RARE [2141-4-18] 10:36PM GLUCOSE-115* UREA N-21* CREAT-0.7 SODIUM-149* POTASSIUM-4.1 CHLORIDE-117* TOTAL CO2-28 ANION GAP-8 [2141-4-18] 10:36PM estGFR-Using this [2141-4-18] 10:36PM ALT(SGPT)-54* AST(SGOT)-67* LD(LDH)-287* ALK PHOS-101 TOT BILI-0.8 [2141-4-18] 10:36PM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.5 IRON-19* CHOLEST-65 [2141-4-18] 10:36PM calTIBC-140* FERRITIN-720* TRF-108* [2141-4-18] 10:36PM TRIGLYCER-156* HDL CHOL-11 CHOL/HDL-5.9 LDL(CALC)-23 LDL([Last Name (un) ])-<50 [2141-4-18] 10:36PM WBC-15.3* RBC-2.88* HGB-9.0* HCT-27.1* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 [2141-4-18] 10:36PM NEUTS-89.3* LYMPHS-6.7* MONOS-2.7 EOS-0.9 BASOS-0.3 [2141-4-18] 10:36PM PLT COUNT-321 [2141-4-18] 10:36PM PT-14.9* PTT-32.7 INR(PT)-1.3* [2141-4-18] 10:30PM TYPE-ART PO2-285* PCO2-41 PH-7.43 TOTAL CO2-28 BASE XS-3 Brief Hospital Course: 65 year-old M with high grade MSSA bactermia, MSSA positive sputume with CXR concerning for infiltrate, LP concerning for bacterial meningitis, and new posterior circulation cerebellar infarcts with background story and diagnostics unclear as to where is initial location of infection. . # Respiratory Failure: Seems to have been triggered by aspiration event on [4-14] per OSH records. CXR showing bilateral lung field opacifications most pronounced at bases concerning for consolidation plus pleural effusions. In setting of MSSA in sputum, likely has staph aureus PNA as this is rarely a contaminant/colinizer although likely that this bug seeded from another source or from bacteremia. Had reported difficulties ventilating at OSH, but gas on arrival to [Hospital1 18] on 100% FiO2 and PEEP 12 was pH 7.43 pCO2 41 pO2 285 HCO3 28 and pt tolerated initial wean to PEEP 10 and FiO2 50% with sats in high 90s. Pt has history of significant asthma which may contribute to difficulty weaning off vent down the road. Infectious Disease was consulted and recommended..... . # Fevers with MSSA bacteremia: Known MSSA 4/4 bottles from OSH Bcx on [4-12] although only reported in transfer summary and no attached micro cultures. TTE questionably negative for endocarditis at OSH. Supposedly surveliance cultures negative since [4-12] although no lab reports. Pt has been on Vanco since [4-12], [4-13], or [4-14] and received doses of zosyn before then. Has also received cefepime or meropenem over last few days but still febrile. Unclear if CNS infection primary with later bacteremia and possible heart valve seeding or if primary endocarditis with septic embolic causing CNS seeding and positive LP. Despite fact that all inital symptoms CNS in nature, more likely that primary endocarditis with CNS seeding as could have sub-clinical symptoms for endocarditis and MSSA endocarditis much more common than MSSA meninigitis. Depending on location of heart involvement could also better explain lung seeding. Other possiblity is that MSSA bactermia was primary even (although no obvious portals of entry on history/exam) and heart, lung, and CNS are all [2-15] areas of seeding. ID contact[Name (NI) ] overnight for initial [Name (NI) ] recs - Will continue Vanco/Meropenem (at increased Vanco dose) due to concern for nafcillin CNS penetration if meningitis were primary insult. Is suboptimal of MSSA endocarditis but will still cover organism and reasonable to continue in short term while CNS issues clarified (Vanco 1g IV Q12 and Meropenem 1000mg IV Q8). Lactate 0.9 - ID consult team will see in AM - TTE [4-19] since none here and desire to eval R heart which TEE won't - Plan for TEE tomorrow if possible by cards (ID strongly recommends) - NPO for possible TEE in AM - Survelliance Bcx and initial Ucx and Sputum Cx - Holding tylenol initially to eval fever curve - Card TEE c/s in AM . # LP suggestive of meningitis with new head CT findings: As mentioned above, unclear if meningitis primary event or seeding although think seeding more likely. LP very suggestive of bacterial process with high WBC with PMN predominance, low glucose, and high protein. Very unlikely viral process and less likely that had full-blown meningitis in [7-23] days of symptoms Concern that new CT findings at OSH from AM [4-18] along with R sided weakness caused by new stroke or mycotic aneurysm. However, CNS findings of R sided weakness do not correlate with R sided cerebellar findings on head CT so picture repains unclear. Images sent with patient on transfer do not include most recent head CT. - MRI/MRA of brain to eval reported acute head CT findings at OSH - Per neuro, if will take any time to get MRI/MRA, would get head CT here since we do not have image and picture per report unclear - Checking FLP and [Name (NI) ] with next labs per neuro recs - Neuro c/s in AM - ID c/s and infectious management as above . # Anemia: Hgb on admission at 9.0. No prior records to compare for baseline. No evidence of bleeding on exam and no suggestive reports on history. Lactate 0.9 indicating that anemia likely not causing significant hypoperfusion. LDH slightly up which could be indicative of mild hemolysis especially if invoking endocarditis. However, may have underlying issues that explain anemia more than acute illness. - iron studies - check hapaglobin and retic count with AM labs - trend Hct and maintain active T&S . # Hypernatremia: Sodium on admission is 149. Was trending up at OSH from 134 on [4-14] likely because pt NPO and not receiving fluid. Free water defecit 2.5-3.0L based on todays labs/weights. - Start D5W at 125ml/hr for 1.5L and recheck AM labs - Plan to correct total deficit over 24hrs . # Anxiety/Depression: long history of anxiety and depression that apparently also runs in family. Pt is somewhat of [Initials (NamePattern4) ] [Last Name (NamePattern4) 68185] per reports and may be component of personality disorder although no way to evaluate this at this time. On significant home regimen of anti-anxiety and anti-depressant medications and would be at risk for withdrawal if all stopped suddently. - cont buproprion 200mg [Hospital1 ] (home dose) -> low threshold to stop if any concerning seizure activity in light of new CNS findings - cont buspar at 15mg daily - hold home celexa, aderal, and xanax . FEN: No IVF, replete electrolytes, regular diet Prophylaxis: Subcutaneous heparin Access: IJ [4-14] from OSH Code: Full presumed Communication: Next of [Name (NI) ] - Brother [Doctor First Name ] Cell:[Telephone/Fax (1) 89897] / Work: [Telephone/Fax (1) 89898] PCP: [Name10 (NameIs) 13309], [Name11 (NameIs) ] [Name Initial (NameIs) ].D. phone: [Telephone/Fax (1) 8572] Disposition: ICU pending clinical improvement . MICU Green Course [Date range (1) 89899]: 1. Hemoptysis: Patient had bronch on admission which demonstrated no active bleeding in lungs but significant secretions LMSB with all subsegments plugged. Suctioned for many thick plugs until subsegments distally were patent. Source felt to be nasopharyngeal given reports of NGT attempts and bleeding from trach just after cuff dropped. - Recommend frequent suctioning due to mucous plugging and coughalator - NAC prn for secretions . 2. Pneumonia: Cultures have repeatedly grown out Enterobacter Aerogenes, pan-sensitive. - Continued Cefepime for total 2 weeks of therapy . 3. C2-C3 Abscess: Per ID discontinued Nafcillin and started Vancomycin (due to lowering the seizure threshold with 2 B-lactam agents) . 3. Shoulder pain: Mild pain with passive range of motion bilaterally. No localized tenderness or overlying erythma. - If worsens consider imaging for ? effusion and tap due to MSSA infection . 4. Nutrition: Recommend S&S consult and consideration of PEG if appropriate. . Otherwise prior care continued and patient transferred back to Neurology team. Medications on Admission: Home medications: -Simvastatin 40mg -Advair 250/50 [Hospital1 ] -Zolaire Q month (anti-IgE) -Singular 10 -Flonase -Celexa 20mg Qd -Bupropion 200mg [Hospital1 ] -Xanax 0.5mg qd -Aderal XR 15mg qd -Buspar 15mg qd -Albuterol PRN . Transfer meds: 1. D5 1/2NS with 20KCL at 125ml/hr 2. [Last Name (un) ] 500mg Q6 3. Vanco 750mg Q12 4. Aderal 10mg in AM and 5mg in PM 5. Buspar 15mg 6. Singular 10mg 7. Bupropion 200mg [Hospital1 ] 8. Simva 40mg Qd 9. Protonix 40mg IV BID 10. SQH 5000 units Q8 11. Propofol gtt 12. Ativan 1-2mg PRN 13. Advair 250/50 [Hospital1 ] 14. Morphine 1-2mg PRN Discharge Medications: 1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. buspirone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours). 4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 5. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 10. bupropion HCl 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for skin lesion. 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 18. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. Vancomycin 1000 mg IV Q 12H 22. CefePIME 2 g IV Q8H 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 24. Morphine Sulfate 2-4 mg IV Q4H:PRN pain 25. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 26. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN pain 27. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 28. Outpatient Lab Work Chem 7, ESR, CRP, LFTs Weekly Please fax results to Dr. [Last Name (STitle) 9461] Fax [Telephone/Fax (1) 1419] 29. Outpatient Lab Work Vancomycin trough on [2141-5-15] please fax results to Dr. [Last Name (STitle) 9461] [Telephone/Fax (1) 89900] 30. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every four (4) hours: **THIS MEDICATION IS TO BEGIN ON [5-5] of Vancomycin and Cefepime. 31. MRI C spine with and without contrast Re epidural abscess. This should be done in 4 weeks. Ordered as an outpatient in the [Hospital1 18] system. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: Epidural Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the [Hospital1 18] an episode of confusion and bizarre behavior. Your PCP said that you had been experirncing neck pain for approximately 10 days. You had a a lumbar puncture that was suggestive of a bacterial meningitis and you were started on broad spectrum antibiotics. On examination you were found to have R>L sided weakness and ataxia. An MRI revealed a cerebellar infarct in addition to an epidural abscess. Neurosurgery evacuated your abscess posteriorly but could not access the anterior portion. Infectious disease was involved and kept you on antibiotics for treatment. A follow-up MRI showed possible worsening of the abscess, however it was felt by neurosurgery to be related to granulation tissue and they wished for you to receive a longer course of antibiotics and follow-up as an outpatient. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 548] on [2141-5-30] at 11:15am in Spine Center on [Hospital Ward Name 516], [Hospital Ward Name 23] 2. If you need to change this appt, please call [Telephone/Fax (1) 2992]. You will also need a repeat cervical MRI with and without gadolinium when you finish your course of antibiotics, this can be arranged by calling Dr [Name (NI) ] office. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2141-5-22] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6214], MD Phone:[Telephone/Fax (1) 3736] Date/Time:[2141-5-30] 11:15 Provider: [Name10 (NameIs) 9462] FLASH, MD Phone:[Telephone/Fax (1) 457] Date/Time:[2141-6-14] 11:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2141-5-15] Name: [Known lastname 11884],[Known firstname 2147] Unit No: [Numeric Identifier 14251] Admission Date: [2141-4-18] Discharge Date: [2141-5-15] Date of Birth: [2075-9-6] Sex: M Service: NEUROLOGY Allergies: Penicillin G / Azithromycin Attending:[Last Name (NamePattern1) 4697] Addendum: Abscess: After coming out of the unit, his antior epidural abscess was being conservatively with antibiotics. Initially it was treated with Nafcillin, however when he developed a pneumonia, he was switched over to Vancomycin and cefepime. His vancomycin trough was monitored. He had a follow up MRI done which demonstrated that the abscess was radiographically worse. However, Neurosurgery (Dr. [Last Name (STitle) 752] felt that some of the changes were related to granulation tissue. He suggested continuation of antibiotics with weekly ESR and CRP, and follow up in clinic after follow - up MRI. Strength continued to improve. However, he was also deconditioned from prolonged hospitalization. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 95] ([Hospital3 96] Center) [First Name8 (NamePattern2) 77] [Last Name (NamePattern1) ] [Last Name (NamePattern4) 4698] MD [MD Number(2) 4699] Completed by:[2141-5-15**]	[ "324.1", "276.0", "E879.8", "300.4", "730.08", "493.00", "518.81", "038.11", "331.4", "995.92", "997.31", "519.19", "507.0", "482.41", "041.85", "325", "348.5", "272.4", "336.8", "320.3", "421.0", "344.00", "383.00", "285.9", "276.8", "434.91" ]	icd9cm	[ [ [] ] ]	[ "31.1", "43.11", "33.21", "03.09", "96.72", "03.31", "33.24", "02.39", "96.6" ]	icd9pcs	[ [ [] ] ]	21194, 21515	7254, 14223	333, 409	18047, 18047	5958, 7231	19088, 21171	4543, 4717		14874, 17827		18007, 18026		14249, 14249			18230, 19065									4732, 5939			14267, 14851																	255, 295										437, 4090									18062, 18206					4112, 4250	4266, 4527
71,520	129,270	40253	Discharge summary	report	Admission Date: [2123-12-14] Discharge Date: [2123-12-15] Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 2534] Chief Complaint: pelvic fracture with hematoma Major Surgical or Invasive Procedure: Embolization of branch of left internal iliac artery History of Present Illness: [Age over 90 ] year old Chinese-speaking female presents after an unwitnessed fall from standing at home, with a television landing on her as she fell. Her daughter was in the next room, and came in immediately, reporting that she cried out immediately for help, with no loss of consciousness. Her daughter believes that she stumbled, then grabbed the TV for support, pulling it onto her as she fell. Past Medical History: PMH: HTN PSH: Left hip surgery 4 years ago Social History: Lives with daughter. [Name (NI) ] EtOH, Non-smoker. Family History: Non-contributory Physical Exam: On Admission: General Appearance: thin, frail, pail, Cantonese-speaking only HEENT: PERRL Cardiovascular: RRR Respiratory / Chest: clear to auscultation bilaterally, minimal crackles bilaterally Abdominal: Soft, Non-distended, Non-tender Ext: warm, no edema, pain to palpation over left hip Skin: no groin hematoma of pulsatile mass Pertinent Results: [2123-12-14] 02:30PM WBC-22.8* RBC-4.06* HGB-12.0 HCT-36.9 MCV-91 MCH-29.5 MCHC-32.5 RDW-14.7 [2123-12-14] 02:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2123-12-14] 02:30PM LIPASE-15 [2123-12-14] 02:30PM UREA N-28* CREAT-1.3* [2123-12-14] 02:39PM HGB-12.5 calcHCT-38 [2123-12-14] 02:39PM GLUCOSE-201* LACTATE-7.3* NA+-143 K+-4.5 CL--106 TCO2-22 [2123-12-14] 04:50PM PLT SMR-LOW PLT COUNT-161 [2123-12-14] 04:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2123-12-14] 04:50PM NEUTS-82* BANDS-6* LYMPHS-5* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-2* [2123-12-14] 04:50PM WBC-25.5* RBC-2.96# HGB-8.9# HCT-27.1# MCV-92 MCH-29.9 MCHC-32.6 RDW-14.9 [2123-12-14] 04:58PM HGB-9.1 calcHCT-27 [2123-12-14] 10:30PM PT-16.6* PTT-33.2 INR(PT)-1.5* [2123-12-14] 10:30PM PLT COUNT-110* [2123-12-14] 10:30PM WBC-24.4* RBC-3.67* HGB-11.0* HCT-32.5* MCV-89 MCH-29.9 MCHC-33.8 RDW-15.0 [2123-12-14] 10:30PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-2.1 Brief Hospital Course: Pt admitted from IR at 9pm S/P coiling of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of the left internal iliac artery. Pt initially stable, HR from 80-90??????s SR and SBP 100-110. Pt very HOH and Cantonese speaking only and her only complaint on admission was that she was hungry per grandson, [Name (NI) ], who was present and translating. Pt with expiratory wheezes throughout early in the shift and Grandson reports that pt uses an inhaler at home. Pt did not respond when asked if she was having any difficulty with breathing with Grandson translating. Pt O2 sats initially 89-95% on 3 liters NC, Face tent at 40% added w/ sats improving to 93-98%, RR 18-22 non labored. Pt angio groin site intact and pulses dobblerable, Pt in reverse trendelenberg per post-angio orders. Pt gradually settling yet then became less responsive yet arousable, she then became more hypotensive, and aline was placed and repeat Hct and ABG sent. Pt??????s Hct came back stable at 30.9 yet ABG with hypercarbia and resp acidosis. Code status was readdressed with family and at this time family wished all efforts to be made. Patient was given 0.5mg of atropine initally becuase patient was hypotensive and bradycardic. Patient was intubated on first pass with 7.0 tube without sedation. Dopamine wide open was given through peripheral line and and pacing was attempted. Patient rapidly went into PEA arrest and was given 3 rounds of atropine and 4 rounds of epi, 1 amp of bicarb, 1 amp of D50, 1 g CaCl, and 1 gram of magnesium. time of death 118AM. no objections to ending code. Pt was coded for 20minutes yet in PEA, unable to capture with transcutaneous pacing, compressions and pharmacological treatment as per code sheet, despite these efforts we were unable to resuscitate pt and she was pronounced at 1:18 am. Family in to see patient, and spoke to RN and MD. Medications on Admission: unknown BP meds Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Pelvic Hematoma, subsequent cardiopulmonary arrest Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased	[ "E888.1", "427.5", "808.2", "958.2", "276.2", "458.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.79", "88.47", "99.60" ]	icd9pcs	[ [ [] ] ]	4447, 4456	2457, 4348	274, 328	4550, 4560	1311, 2434	4617, 4628	924, 942		4414, 4424		4477, 4529		4374, 4391			4584, 4594									957, 957																				205, 236										356, 765							971, 1292							787, 835	851, 908
12,645	122,982	25282	Discharge summary	report	Admission Date: [2131-10-16] Discharge Date: [2131-11-5] Date of Birth: [2055-10-20] Sex: F Service: SURGERY Allergies: Flagyl / Metformin / Tequin Attending:[First Name3 (LF) 1] Chief Complaint: sepsis Major Surgical or Invasive Procedure: exploratory laparotomy with peritoneal washout ([2131-10-17]), closure of abdominal wound ([2131-10-22]) History of Present Illness: 75 F transferred from [Hospital 4068] hospital after presenting from rehab with fever (100), hypotension (sbp 60), tachycardia, diffuse abdominal pain and UTI. patient was also vomiting. Patient received large amounts of volume and was started on dopamine and levophed. Patient was aphasic but able to point to RLQ and nods when asked if she has pain in the region. NGT was placed with non-bloody bilious return. Past Medical History: CVA [2120] IDDM HTN COPD s/p trach/peg history of GI bleed hypothyroidism UTI Physical Exam: 100.8 hr-124 bp-86/45 rr-20 100% on 40% fm gen-alert, lying in bed cor-rapid rate, regular rhythm lungs-coarse bs b/l abd-distended, tympanitic, RLQ tenderness, +rebound, PEG in place guiac + Pertinent Results: [2131-10-16] 11:44PM GLUCOSE-267* LACTATE-7.5* [2131-10-16] 11:20PM TYPE-ART PEEP-5 PO2-95 PCO2-32* PH-7.24* TOTAL CO2-14* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED [2131-10-16] 08:25PM ALT(SGPT)-19 AST(SGOT)-30 CK(CPK)-167* ALK PHOS-60 AMYLASE-35 TOT BILI-0.3 [2131-10-16] 08:25PM NEUTS-46* BANDS-29* LYMPHS-10* MONOS-11 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [2131-10-16] 08:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2131-10-16] 08:25PM URINE RBC-[11-25]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 Brief Hospital Course: After the patient was stabilized a CT scan was obtained which showedno signs of ischemic bowel a distended GB with no signs of cholecytitis. Vancomycin, Zosyn, Flagyl were given and due to the amount of abdominal tenderness, elevated lactate, and spetic physiology it was decided to take the patient to the operating room. An exploratory laparotomy was performed and a large amount of pus in the abdomen was found. There was no perforation or ischemia or any bowel. The abdomen was left open. The remainder of the hosptial course is listed below by systems. 1. Neuro- Initially propofol and fentanyl gtts were used for sedation. As she began to wake up, she required minimal amounts of morphine for pain control 2.CV-Initially a Swan-Ganz catheter was in place and levophed was used to blood pressure support. Gradually the pressor was weaned and the Swan was removed. Patient was started on Lopressor when she was able to tolerate it. 3.Pulm-Initially lung protective ventilation was used. Vent was weaned to CPAP. Trach collar trials were done for approximately 4 hours a day the week prior to discharge. 4.GI-promote with fiber tube feeds (full strength) were advanced to a goal of 70 cc/hr. 5.GU-The initial acidosis and renal failure responded to volume resuscitation. The patient was up in weight by about 15 kilograms and aggressive diuresis was used to help return the patient to her dry weight. 6.Heme-Occasional transfusion of PRBC were given, however a hematocrit of around 25 was tolerated. A HIT antibody test was negative. 7.ID-Patient was on Vancomycin and Zosyn. The OR culture grew VRE, therefore she was treated for 2 weeks with Linazolid. Zosyn was continued for Pseudomonas in her sputum. She also received a course of acyclovir for severe herpes of her lips. The open abdomen was closed in the OR on [2131-10-22]. Her temp and WBC were elevated for 2 days, however these improved upon evacation of a wound hematoma. A vac dressing was placed on the wound. 8.Prophylaxis-prevacid, sc heparin 9.PICC line in place. Medications on Admission: synthroid 50 mcg qd fosamax 70 mg q week zantac 150 qd iron 225 mg [Hospital1 ] oscal 500 mg tid combivent prn loperamide prn temazepam 15 qhs prn atrovent prn lantus 30 u sc qd Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): g tube. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-7] Puffs Inhalation Q6H (every 6 hours) as needed. 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 160 mg/5 mL Solution Sig: [1-7] PO Q4-6H (every 4 to 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 10. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO TID (3 times a day). 11. Piperacillin-Tazobactam Na 2.25 gm IV Q8H for 2 weeks 12. Magnesium Sulfate 2 gm / 100 ml NS IV PRN MG<2 13. Calcium Gluconate 2 gm / 100 ml NS IV PRN ionCa<1.12 14. Potassium Chloride 40 mEq / 100 ml SW IV PRN K<4 15. Furosemide 10 mg/mL Cartridge Sig: Two (2) Injection every twelve (12) hours. 16.NPH insulin and humalog sliding scale as shown on insulin order flowsheet 16. Synthroid 50 mcg Tablet Sig: One (1) Tablet PO once a day. 17. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: exploratory laparotomy with peritoneal washout ([2131-10-17]) closure of abdominal wound ([2131-10-22]) CVA [2120] IDDM HTN COPD s/p trach/peg history of GI bleed hypothyroidism UTI Discharge Condition: stable Discharge Instructions: please change vac dressing every four days PICC line care Followup Instructions: f/u Dr. [Last Name (STitle) ] 1 month	[ "511.9", "584.9", "276.2", "V44.0", "599.0", "995.92", "482.1", "785.52", "583.81", "280.9", "518.84", "428.0", "250.40", "707.14", "V44.1", "496", "V58.67", "054.9", "567.29", "998.12", "244.9", "038.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "00.17", "54.63", "38.93", "96.6", "54.11", "99.15", "00.14", "96.72", "89.64", "86.04" ]	icd9pcs	[ [ [] ] ]	5588, 5667	1821, 3875	293, 407	5904, 5912	1187, 1798	6018, 6062			4107, 5565		5688, 5883		3901, 4084			5936, 5995									975, 1168																				247, 255										435, 855														877, 960
9,967	171,327	29321	Discharge summary	report	Admission Date: [2126-1-14] Discharge Date: [2126-2-2] Date of Birth: [2061-12-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: scheduled cathetirization Major Surgical or Invasive Procedure: cardiac cathetirization History of Present Illness: 64 y old F hx AF, severe pulmonary artery hypertension (4+ TR, gradient 94mm Hg), 1+ MR, HTN. She presents today for a scheduled admission for scheduled cardiac cathetirization tomorrow in order to further evaluate her PAH. . Ms [Known lastname ] has been followed by Dr. [Last Name (STitle) ] in Pulmonary Clinic, seen by Dr. [First Name (STitle) 437] during last hospitalization. As per Dr.[Name (NI) 70440] summary, she initially presented with SOB, which worsened in [3-1]. In [10-1] she presented severely hypoxemic, with an elevated BNP and bilateral pleural effusions, an echocardiogram demonstrated severe PH (pulmonary hypertension) with a TR gradient of 58 mmHg as well as markedly dilated RV, severe RV hypokinesis, moderately dilated RA, and moderate symmetrical LVH with a normal ejection fraction. She was aggressively diuresed and underwent cardiac catheterization which demonstrated elevated right-sided filling pressures with a RA mean pressure of 13, RV diastolic pressure of 18. Her pulmonary artery pressure (PAP) was 82/27 with a mean of 46 and the mean wedge pressure was 12. The PVR was 777. With the addition of 100% FiO2 and inhaled nitric oxide her PAP did not significantly change, 78/27 with mean 43, but the wedge pressure rose to 16. The PVR dropped to 480 due to the rise in cardiac output from 3.5 to 4.5 (cardiac index from 1.9 to 2.5). She was started on sildenafil 50 mg three times daily. She initially improved, but then became progressively short of breath and more hypoxemic despite no change in her weight. Repeat echo demonstrated worsened TR with gradient worsened to 94 mm Hg. Pt notes increase in 7 lbs in weight over last 2 weeks, some increased abdominal girth associated with it. She notes very mild increase in orthopnea, although still using only 1 pillow, no PND. Her functional status includes ambulation around her house to the batroom, she is able to climb 6 stairs at a time before having to stop. She lives by herself, performs ADLs. She also notes that ocassionaly her HR is in the 40s during which times she hold her digoxin. She took her coumadin 2.5mg this morning. Past Medical History: # Atrial fibrillation - s/p several failed attempts at cardioversion - currently rate controlled and anticoagulated on coumadin # h/o EtOH abuse # Idiopathic pulmonary hypertension # Raynaud's syndrome - (+) [Doctor First Name ] (1:1280), (+) anti-centromere antibodies. - (-) negative SSA, SSB, Scl-70, Sm, RNP antibodies # HTN # s/p hysterectomy Social History: Retired nurse, Catholic. Former smoker, stopped 30 years ago, 30 pack year history of smoking. Quit drinking [3-1], former heavy alcohol use with up to a [11-30] of vodka a day or 1 bottle of wine. Never had withdrawl or withdrawl seizures. Lives at home alone, able to perform all ADLs on her own, recently more difficult with shortness of breath. Family History: no hx of pulmonary hypertension or similar lung diseases. Physical Exam: Temp 97.4, BP 130/60, HR 80, RR 12, O2 sat 95% on 4L Gen: pleasant elderly female, speaks in full sentences HEENT: anicteric, OP claer Neck: supple, JVD to jaw at 90 degrees Lungs: minimal crackles at bases Abd: soft, + large umbilical hernia, + BS Extr: tr edema, 1+ pulses b/l Neuro: non-focal Pertinent Results: LABS on admission: WBC-4.8 Hct-31.4* MCV-90 Plt Ct-165 PT-23.4* PTT-35.9* INR(PT)-2.3* Glucose-110* UreaN-24* Creat-1.1 Na-138 K-4.1 Cl-100 HCO3-27 AnGap-15 ALT-9 AST-21 LD(LDH)-233 AlkPhos-46 TotBili-0.8 proBNP-[Numeric Identifier ]* Albumin-4.0 Calcium-9.7 Phos-3.6 Mg-2.1 Digoxin-1.3 . LABS on discharge: WBC-4.3 Hct-27.3* MCV-89 Plt Ct-233 PT-28.8* PTT-46.1* INR(PT)-3.0* Glucose-88 UreaN-13 Creat-0.8 Na-140 K-3.8 Cl-104 HCO3-25 AnGap-15 Calcium-9.5 Phos-3.8 Mg-2.0 proBNP-6740* . LABS during hospitalization: [Doctor First Name ]-POSITIVE Titer-1:640 Cntromr-POSITIVE C3-119 C4-19 HIV Ab-NEGATIVE DNA AUTOANTIBODIES, SSDNA IGG ANTIBODY <69 (negative) SM/RNP ANTIBODIES (WITHOUT [Doctor First Name ]) SM ANTIBODY negative SM/RNP ANTIBODY negative . MICRO: [2126-1-21]: urine cx enterococcus 10-100,000 org/mL, pansensitive [2126-1-21]: urine cx enterococcus 10-100,000 org/mL, pansensitive [2126-1-22]: blood cx x2 no growth [2126-1-23]: urine cx: enterococcus 10-100,000 org/mL, 2nd isolate <10,000 . IMAGING: [2126-1-16] ETT: The patient exercised for 3 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) 4001] protocol and stopped due to progressive shortness of breath. This represents a poor functional capacity for age. The patient denied any arm, neck, back or chest discomfort throughout the study. There were no significant ST segment changes noted over baseline abnormalities. The rhythm was atrial fibrillation with intermittent VPBs (which tended to decrease with exercise) and a rare vent couplet. The HR response to exercise was exaggerated and there was an abnormal blood pressure response to exercise. . [2126-1-16] ECHO: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated. There is moderate global right ventricular free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. . [2126-1-18] CATH: PA sat 49% AO sat 99% RA 22/15/14, HR 51 RV [2109-2-5], max dP/dt [2134], HR 48 PCW 25/25/10, HR 59 PA 78/23/39, HR 53 . [2126-1-21] FOOT XR: 1. Possible erosion medially at the left first TMT joint involving the distal aspect of the medial cuneiform. 2. Soft tissue swelling at the level of the right ankle, particularly laterally. 3. No acute fracture or dislocation. . [2126-1-28] CXR: The right transjugular Swan-Ganz line loops in the right atrium and passes into the right ventricle where the course is obscured by cardiac motion, but I suspect it is still below the pulmonary outflow tract unchanged since 1:58 a.m. Moderate cardiomegaly is stable. There is no pulmonary edema. Small left pleural effusion is probably present. No pneumothorax. Lungs are essentially clear. . [2126-1-29] CXR: Tunneled catheter terminates in SVC at level of carina. Catheter has not been advanced into the pulmonary artery. . [2126-2-1] 6 MIN WALK TEST: Results pending at time of discharge Brief Hospital Course: Ms. [Known lastname ] is a 64yo F with a PMH of afib, severe pulmonary artery hypertension (4+ TR, gradient 94mm Hg), 1+ MR, and HTN. She presented on [2126-1-14] for scheduled R sided cardiac catheterization to further evaluate her pulmonary artery hypertension. On admission, patient had a supratherapeutic INR from her coumadin and was felt to be volume overloaded (~7lbs up from her dry weight. She was gently diuresed while her INR trended down. Once her volume status was stable and her INR was normal, she underwent catheterization on [2126-1-18] which revealed severe pulmonary hypertension, but essentially unchanged from prior catheterization. She was kept on a heparin gtt (as anticoagulation for her afib) while a decision was made regarding next step in her evaluation for pulmonary artery hypertension. She was transferred to the CCU on [1-21] for placement of a Swan cathether and a trial of flolan. However, she developed a fever of 101.3 on the evening of [1-21]. The team decided to hold off on central line placement given her fever, so she was transferred back to [Hospital Ward Name 121] 6 for further fever workup. Pulmonary continued to follow the patient. . Of note, the patient developed bilateral foot pain on [1-21]. She was noted to have low grade fevers the previous night, but had been receiving tylenol for her foot pain. She described the foot pain along the medial aspect of her left foot and up the Achilles tendon on her left, as well as across the dorsal aspect of her right foot, along the anterior aspect of her ankle joint. The pain was so severe that it took her breathe away upon standing. At rest, it was more dull, but was worsenend simply by palpation. She was able to roll her ankles, but felt that her ROM was limited by pain. She notes that the pain was reproduced upon dorsiflexion and plantarflexion of her feet. She noted that they both hurt equally and that she had never had pain like this before. She has had a previous episode of plantar fasciitis. She developed a fever on the night that she first noticed the pain, once the tylenol was stopped. In the CCU, after she spiked a temperature, she was restarted on tylenol and ibuprofen with improvement in her pain. Her fevers then resolved, as did her pain. Her urine cultures revealed 10-100,000 colonies of pan-sensitive enterococcus which was never treated given that her UAs showed few bacteria and minimal if any WBCs. . She was also noted to be in acute renal failure on [2126-1-23], with a creatinine of 1.8 (up from 1.2). It was felt that this was possibly due to over-diuresis. Her diuretics were held and ibuprofen was discontinued, in case of interstitial nephritis. UA and urine lytes were checked and revealed a FeNa of 2.4% (Una 55, Uosm 204) and FeUrea of 24.8%, confirming a prerenal state. discontinuation of her medications and gentle fluid resuscitation resulted in improvement in her creatinine. At discharge, her creatinine had returned to 0.8. . Ms. [Known lastname ] was transferred back to the CCU on [2126-1-23]. A central line was placed on [2126-1-23] and an attempt was made to float a Swan Ganz catheter, but the catheter was unable to be passed into the PA. She underwent PA catheter line placement under fluoroscopic guidance. Flolan was initiated on [2126-1-25] and it was determined that she was a responder to pulmonary vasodilation as her PA pressure went from 83/26/48 -> 67/33/46 on 4 ng/kg/min. However, she developed an increased wedge pressure (10 -> 13), pressure on her chest, crackles on exam and dyspnea, raising concern for diastolic dysfunction. The dose of flolan was decreased to 2ng/kg/min with resolution of her symptoms. A second trial was attempted, but this time flolan was increased at a slower rate. On [2126-1-28], Ms. [Known lastname 62372] readings were suspicious for a misplaced PA line and CXR showed that the line was coiled in RV. The line was pulled back into the RA and was refloated. Flolan continued to be uptitrated. Ms. [Known lastname ] attempted a trial of ambulation (she was asymptomatic at rest with sats 88-100%) but dropped her O2 sats to the 70's with ambulation). Flolan was increased to 7ng/kg/min on [2126-1-29], up to 8ng/kg/min on [2126-1-30], then up to 9ng/kg/min prior to transfer from the CCU. . Trials of diuresis (lasix) and afterload reduction (captopril) were also simultaneously attempted. Afterload reduction was eventually abandoned in favor of optimizing diuresis. She was continued on lasix with a goal of I/O even daily. Her aldactone, however, was held. She began to develop a pancytopenia felt to be either a medication effect or part of a rheumatologic process. She also began to complain again of toe pain, as tylenol was being held, so tylenol was restarted RTC and she was also given oxycodone prn for pain. Her renal function returned to baseline. A digoxin level was checked and was 1.4. Lopressor was held due to bradycardia and she remained in afib with good rate control on digoxin alone. She continued on a heparin gtt until she had a tunnelled line placed on [2126-1-29]. She was then started on coumadin. She developed a pancytopenia that was felt to be either due to medication or perhaps her rheumatologic condition. Her anemia workup revealed anemia of chronic disease. On discharge, her WBC and Hct were both stable and her platelets remained normal. . Rheumatology consulted on the patient and felt that she may have a CREST type syndrome or mixed connective tissue disorder given her pulmonary hypertension, Raynaud's syndrome, rheumatological telangectasias, + [Doctor First Name ], and + anticentromere antibodies. The etiology to her foot pain was unclear, and given that it was completely resolved by the time rheumatology was able to evaluate her, they were unable to tell if it was related. Repeat serologies were sent and showed: [Doctor First Name ] + with a 1:640 titer, centromere + C3 119, C4 19 ssDNA IgG Ab <69 (negative) Sm Ab negative Sm/RNP Ab negative . Ms. [Known lastname ] was transferred back to [Hospital Ward Name 121] 6 on [2126-1-30]. At that time, she denied any fevers or chills, chest pain or pressure, SOB at rest, cough, URI sx, nausea, vomiting, abdominal pain or diarrhea. She had been constipated but was taking colace and senna prn. She had no dysuria or frequency and no back pain. She had been up to a chair and ambulating w/ assistance. She has mild DOE but notes she is most SOB after having ambulated, when she is recovering from that activity. Upon transfer to the floor, her flolan dose was 9ng/kg/min. She was slowly titrated up to 11ng/kg/min, but she then developed diarrhea so her dose was decreased to 10.5ng/kg/min which she appeared to tolerate well. She was ultimately discharged on this dose. A 6 minute walk test was performed on [2126-2-1], but results were pending at time of discharge. She appeared euvolemic on discharge and was able to ambulate with only mild DOE. She continued to be in atrial fibrillation, with HR in the 50s-60s. Her toprol was held upon discharge because of bradycardia, but she was maintained on digoxin. Her INR was 3.0 upon discharge. She remained afebrile when tylenol was changed from RTC to prn, so she was not discharged on any antibiotics. . Of note, a CT scan performed earlier this year revealed enlarged paratracheal and mediastinal lymphadenopathy. No further workup of this lymphadenopathy was performed during this hospitalization and should be performed as an outpatient. . Her code status was FULL throughout her hospitalization. She was discharged home with services with a plan to follow up with Dr. [Last Name (STitle) ] in one week. Medications on Admission: Lasix 80 mg daily aldactone 25 mg daily Toprol XL 12.5 mg daily Coumadin 2.5/5mg (WeFri) qAM digoxin 0.125 daily Celexa 20 mg daily sildenafil 50 mg three times daily Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Epoprostenol 0.5 mg Recon Soln Sig: 10.5 ng/kg/min Intravenous INFUSION (continuous infusion). Disp:1 month supply Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Pulmonary hypertension Atrial fibrillation Discharge Condition: Good. BP 123/54, HR 60, RR 18, sats 98% on 4L. Flolan at 10.5 units. Discharge Instructions: You were admitted to the hospital for a cardiac catheterization. You were diuresed and then had to start a heparin drip for the procedure, given that you are in atrial fibrillation. The procedure showed that you have severe pulmonary hypertension so you were brought to the CCU, had a central line and Swan catheter placed, and were initiated on Flolan. Your hemodynamics improved while on flolan so a tunneled line was placed and your flolan dose was titrated up to the dose of 10.5 ng/kg/min upon discharge. . Please follow all instructions as provided by the Flolan company and nurses. . Please resume your INR checks as you had been doing prior to your hospitalization. Your coumadin dose has had to be adjusted prior to your discharge. Your INR upon discharge is 3.0. . Please continue to take all your medications as prescribed. You are no longer taking TOPROL or ALDACTONE or SILDENAFIL. You are instead taking FLOLAN. You should continue to take LASIX at 40mg daily and DIGOXIN at 0.125mg daily. Your COUMADIN dose will need to be monitored and titrated based on your INR. . Please follow up with your PCP [Last Name (NamePattern4) ] [12-30] weeks. . You also need to follow-up with Dr. [Last Name (STitle) ] within 1 week. Please call Dr.[Name (NI) 70440] office on Monday and speak to [Doctor Last Name 2048] to set this appointment up, preferably on Wednesday. Her office number is [Telephone/Fax (1) ]. . 3 lbs. Please adhere to a no-added salt diet. . Please call your PCP or go to the nearest ER if you develop any of the following symptoms: fever, chills, chest pain, SOB, difficulty breathing, headaches, dizziness, worsening diarrhea, jaw pain or joint aches, leg swelling, or any other worrisome symptoms. Followup Instructions: Please have your INR checked on Monday, [2-4]. . You also need to follow-up with Dr. [Last Name (STitle) ] within 1 week. Please call Dr.[Name (NI) 70440] office on Monday and speak to [Doctor Last Name 2048] to set this appointment up, preferably on Wednesday. Her office number is [Telephone/Fax (1) ]. . Please call to make an appointment with a rheumatologist in your area. The rheumatology team here recommended Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 67929] who is located in [Location (un) 3320]. His office number is ([Telephone/Fax (1) 70441]. You will likely need a referral from your PCP to make this appointment. . Please call to make an appointment with Dr. [First Name (STitle) 437] (cardiology) here at [Hospital1 18]. You should see him in [12-30] weeks. His office number is ([Telephone/Fax (1) 13786]. . Please follow-up with your PCP in the next 1-2 months.	[ "428.0", "719.07", "V58.61", "780.6", "584.9", "428.31", "276.52", "416.8", "710.1", "427.31", "518.89", "443.0" ]	icd9cm	[ [ [] ] ]	[ "89.64", "38.93", "37.21" ]	icd9pcs	[ [ [] ] ]	16290, 16351	7666, 15417	340, 365	16438, 16509	3702, 3707	18305, 19257	3311, 3370		15635, 16267		16372, 16417		15443, 15612			16533, 18282									3385, 3683																				275, 302						4014, 7643				393, 2544							3721, 3995							2566, 2920	2936, 3295
3,266	156,533	1734+1735+55275	Discharge summary	report+report+addendum	Admission Date: [2137-3-27] Discharge Date: [2137-4-5] Date of Birth: [2065-1-15] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old man with past medical history significant for coronary artery disease status post coronary artery bypass graft, hypertension, hypercholesterolemia, and diabetes who was transferred from an outside hospital after having a large right-sided MCA stroke in the setting of a cardiac catheterization on [2137-3-20], having subsequent cerebral edema with midline shift of 1 cm requiring Mannitol administration. On [2137-3-19] Mr. [Known lastname ] was admitted to an outside hospital with acute coronary syndrome as he was having intermittent chest pain at rest. He ruled out for an myocardial infarction and was taken to the catheterization lab on [2137-3-20]. During the catheterization all grafts were found and his coronary artery bypass graft was found to be patent, but there was a 70% circumflex stenosis and an 80% stenosis posterolateral branch and circumflex with a 70% stenosis between two lateral left ventricular branches of the circumflex. During catheterization patient became less responsive. No intervention was performed. After catheterization patient was noted not to be moving left arm. Head CT was performed which showed a large right MCA stroke. On [2137-3-21] Mr. [Known lastname ] was intubated for airway protection given decreased mental status, nausea, vomiting, and a question of aspiration. Neurologic exam at that time revealed left hemiplegia, eyes deviated to the right, probable field cut and .......... to the left side. Head CT showed increased edema. Patient was started on Mannitol as well as antibiotics for a possible pneumonia. From that date until transfer patient remained intubated, and head CT revealed a slightly increasing edema with a 1 cm midline shift as well as a right inferior posterior cerebellar infarct. Mannitol and Lasix were continued. Patient was also started on tube feeds and given some free water boluses for hypernatremia of 150. He was transferred to [Hospital6 256] on [2137-3-27], intubated, for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2131]. 2. Percutaneous transluminal coronary angioplasty with stenting in [2126]. 3. Hypertension. 4. Hypercholesterolemia. 5. Gastroesophageal reflux disease. 6. Peptic ulcer disease. 7. Anemia. 8. Gout. 9. Status post appendectomy. 10. Status post multiple herniorrhaphies. 11. Diabetes. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Zocor 80 mg q.d. 2. Gemfibrozil 600 mg q.d. 3. Mannitol. 4. Lasix. 5. Aspirin. 6. Cefotaxime. 7. Regular insulin sliding scale. 8. Heparin subcutaneously. 9. Norvasc. 10. Metoprolol. 11. Nystatin swish and swallow. 12. Tylenol p.r.n. SOCIAL HISTORY: Quit tobacco in [2108]. One alcoholic drink per day. Retired pension administrator. Very independent. FAMILY HISTORY: Diabetes and heart attack in father. Diabetes and heart disease in mother, as well. Cerebrovascular accident in brother, also coronary artery disease in other brothers. PHYSICAL EXAMINATION ON TRANSFER: Temperature 101.1, blood pressure 157/37, heart rate 62, respiratory rate 16, oxygen saturation 100%, intubated. General: He is intubated; not opening eyes spontaneously but intermittently to commands. HEENT: Mucous membranes moist; oropharynx clear; no scleral icterus or injection. Neck: Supple; no lymphadenopathy or carotid bruits appreciated. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm; S1, S2; no murmurs. Abdomen: Soft, nontender; no distention; normal bowel sounds. Extremities: Warm; some mild edema in the lower extremities. Mental status: Intubated; does follow some axial and appendicular commands; opens eyes to command; will fix and follow; tries to lift right arm and leg when asked to raise both arms or legs; moves toes to command; positive grasp, reflex on right; not moving left hand. Reflexes brisk throughout. Sensation: Withdraws to painful stimuli in all extremities. Motor: Left upper and left lower extremity notably weak. Cranial nerves: Patient does not follow past midline to the left; positive gag. Rest of facial: Moves difficult to assess due to intubated. Gait and coordination could not be assessed. LABORATORY VALUES ON ADMISSION: White count 10.2, hematocrit 30.9, platelets 256, INR 1.4, sodium 150, potassium 4.0, chloride 116, CO2 23, BUN 41, creatinine 1.6, glucose 124. Head CT on admission showed a large right MCA stroke with edema and right to left subfalcine herniation with effacement of right lateral ventricle. Supracellular cistern normal unchanged from prior data from [2137-3-23]; slightly more edematous compared to films from [2137-3-21] and [2137-3-22]. Also, evidence of right cerebellar infarct. HOSPITAL COURSE BY SYSTEM: 1. Pulmonary: Patient's respiratory status improved and he was able to be extubated on [2137-3-28]. He was diagnosed with a left lower lobe pneumonia which was felt to be either ventilator associated or aspiration. He was started on Cefepime, Vancomycin, and Levofloxacin by Neurology for this. His fever curve slowly resolved, as well, on these antibiotics, and his respiratory status improved both clinically and radiographically. Patient has had no new underlying lung disease. Patient did not require reintubation and was gradually transferred from face mask to shovel mask to nasal cannula. Patient also had some mild pulmonary edema for which he was diuresed approximately 1500 ml with good response. 2. Cardiovascular: Patient's hypertension was difficult to control throughout much of the hospitalization. He was kept on the Amlodipine as from outside hospital. Metoprolol was titrated up to 100 mg t.i.d. He was also started on Captopril and this was titrated up to 25 mg t.i.d. as well as started on Hydrochlorothiazide 25 mg q.d. With this combination his blood pressure was well controlled. 3. Ischemia: Patient complained of no further chest pain during the hospitalization. He continued on aspirin, Plavix, statin, beta blocker, and angiotensin-converting enzyme inhibitor. EKGs remained unchanged throughout the hospitalization and further cardiac workup was deferred pending neurologic resolution. 4. Rhythm: Patient was in sinus rhythm throughout hospitalization. Well controlled on beta blocker. 5. Hematologic: Patient had a mild hematocrit drop from low 30s to 26 during hospitalization. He responded well to two units of packed red blood cells and his hematocrit then remained stable at 32. No hemolysis or signs of overt blood loss were found. 6. Neurologic: Patient was transferred from the Neurology service to the Medical Intensive Care Unit due to respiratory distress likely secondary to mild pulmonary edema and pneumonia. Per Neurology, the Mannitol was stopped and he was kept on aspirin, Plavix, and statin for stroke prevention. His neurologic status improved gradually throughout the hospitalization. However, at time of dictation he is still not able to ambulate or swallow safely. 7. Gastrointestinal: Patient had no significant gastrointestinal complications during hospitalization. He was kept on a proton pump inhibitor, and a percutaneous endoscopic gastrostomy was placed prior to transfer to Rehab for nutrition as he was not able to swallow effectively. 8. Endocrine: Patient was kept on insulin drip until [2137-4-4] for optimal insulin control. He was then switched to NPH and regular insulin sliding scale. Glucose was maintained within good range with these. 9. Rheumatologic: Patient also was found to have a swollen knee. Rheumatology was consulted and tapped the knee and found noninfective arthritis consistent with gout. He was started on Prednisone for this and then Colchicine, to which he had good effect. He also had a gout flare in his right elbow. 10. Infectious Disease: Patient was continued on the Cefepime, Vancomycin, and Levofloxacin for a 10-day course for a left lower lobe pneumonia. He responded well to these. 11. Renal: Patient's renal function was stable on Captopril. He does have chronic renal insufficiency with a baseline creatinine going back in the records from 1.7 to 2.0. Again, patient was kept on tube feeds throughout the hospitalization. He was at goal of 75 to 80 ml per hour throughout much of hospitalization. Electrolytes were followed routine. CODE: Full. DISPOSITION: To rehab. DISCHARGE DIAGNOSES: 1. Large MCA cerebrovascular accident. 2. Left lower lobe pneumonia. 3. Hypertension. 4. Diabetes. 5. Coronary artery disease. 6. Gout flare. DISCHARGE MEDICATIONS: 1. Captopril 25 mg t.i.d. 2. Hydrochlorothiazide 25 mg q.d. 3. Insulin standing 70/30 NPH and sliding scale. 4. Metoprolol 100 mg t.i.d. 5. Plavix 75 mg q.d. 6. Amlodipine 10 mg q.d. 7. Aspirin 81 mg q.d. 8. Colace. 9. Simvastatin 80 mg q.d. 10. Protonix 40 mg p.o. q.d. 11. Cefepime. 12. Levofloxacin. 13. Vancomycin. 14. Heparin subcutaneously. DISCHARGE CONDITION: Good. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-AAD Dictated By:[Last Name (NamePattern1) 1737] MEDQUIST36 D: [2137-4-5] 15:24 T: [2137-4-9] 15:03 JOB#: [Job Number 9883] Admission Date: [2137-3-27] Discharge Date: Date of Birth: [2065-1-15] Sex: M Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: The patient is a 72-year-old gentleman with a history of coronary artery disease, status post CABG, hypertension, and hypercholesterolemia originally admitted to the Neurology Service after experiencing a large right MCA stroke in the setting of a cardiac catheterization on [2137-3-20]. Following catheterization, the patient was noted to not be moving his left arm. The head CT at that time at the outside hospital showed a right MCA stroke by report. On [2137-3-21], the patient was intubated secondary to poor mental status. There was also a question of a possible aspiration pneumonia for which the patient was started on antibiotics. The patient was transferred to our hospital to the Neurologic ICU and the antibiotics, Mannitol, and Lasix were continued. The patient was extubated on day number two here at our hospital and the Mannitol was discontinued as well then. On day number three, the patient was doing reasonably well and transferred out to the Neurologic floor. A NG tube was put in place for feeding. While on the floor, the patient became tachypneic and went into respiratory distress. The patient was subsequently transferred to the MICU and started on vancomycin, cefepime, in addition to the Levaquin he had already been on. On hospital day number 11, the patient's respiratory status improved. He was transferred out to the floor in stable condition on Captopril for better blood pressure control. PAST MEDICAL HISTORY: 1. History of hypertension. 2. Hypercholesterolemia. 3. Diabetes. 4. Gastroesophageal reflux disease. 5. Peptic ulcer disease. 6. Anemia. 7. Gout. MEDICATIONS ON TRANSFER TO THE FLOOR: 1. Zocor 80 mg once a day. 2. Gemfibrozil 600 mg once a day. 3. Lasix 10 mg twice a day. 4. Mannitol 20 mg q.i.d. 5. Aspirin. 6. Regular insulin sliding scale. 7. Norvasc. 8. Metoprolol. 9. Nystatin swish and swallow. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: No recent history of tobacco. He quit in [2108]. He drinks one alcoholic beverage per day. He is a retired pension administrator. PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICINE SERVICE: Vital signs: Temperature 96.8, blood pressure 144/58, heart rate 57, respirations 18, 96% on room air. General: The patient was lying in bed with NG tube in place, in no acute distress. HEENT: Rosy cheeks. The mucous membranes were clear with dry mucus in the mouth. The pupils were equal, round, and reactive to light. His neck was supple. Chest: Decreased breath sounds at the lower left base. He had an occasional rale. Cardiac: Regular rhythm with a I/VI systolic ejection murmur heard best at the upper sternal border. Abdomen: Soft, nontender, bowel sounds present. Extremities: Warm. He had good pulses with no edema. Neurologic: He knows that he is at [Hospital1 18]. He knows that it is [2136] and that it was [Month (only) 547]. He did not know the exact date or month. He will not look past the left midline. He does not recognize his left arm as his own. He did not respond to tactile stimuli on the left arm. He did not show any nystagmus. LABORATORY/RADIOLOGIC DATA ON TRANSFER: White count 7.3, crit 33.2, platelets 437,000. His coagulations revealed PTT of 26.4, INR 1.5. Potassium 5.1. BUN 52, creatinine 1.5, glucose 282 on the Chem-7. Calcium, magnesium, and phosphorus normal. The patient had a chest x-ray on [2137-4-4] that showed slightly improved left lower lobe opacity over the prior study, no new consolidation was appreciated. He had an echocardiogram on [2137-4-1] that showed a left atrium that was moderately dilated, mild left ventricular hypertrophy, septal hypokinesis. His LV function was grossly depressed but unable to be quantified. His ascending aorta was moderately dilated. Blood cultures, urine cultures, and joint fluid up to date had not grown anything. HOSPITAL COURSE: This is a 72-year-old gentleman with a history of right MCA stroke, status post cardiac catheterization procedure transferred to the MICU, Neurologic ICU, back to the floor, back to the MICU for respiratory distress, pneumonia and now being transferred back to the Medicine Floor stable, afebrile, and with an improved mental status. In terms of his pulmonary status, the patient was originally on triple antibiotic coverage with Levaquin, cefepime, and vancomycin. Subsequently, peeled back the cefepime and vancomycin and left the patient on Levaquin for a total of a 14 day course. His white blood cell count continued to trend down throughout the remainder of his admission and he remained afebrile once on the floor. The patient's oxygenation status remained very well, saturating 95-99% on room air. Aggressive chest PT was begun to help the patient with secretions and that improved his respiratory status as well. In terms of the patient's neurologic status, he was status post the right MCA stroke now with a mild left hemineglect. His overall mental status continued to improve throughout the course of his admission to where he could easily relate to the team the date and the year and where he currently was. He still remains with some residual weakness in the left upper extremity as well as inability to look past the left midline. In terms of his cardiovascular status, the patient has a significant CAD history. However, throughout the remainder of his admission, he never complained of chest pain. We continued him on his Amlodipine, titrated up his Captopril to maximum blood pressure benefit, in addition to slightly titrating up metoprolol for better heart rate control. In terms of his rheumatologic status, the patient has a history of gout. He was treated with prednisone and colchicine. We began to taper his prednisone slowly throughout the remainder of the admission and the colchicine was continued for low-dose prophylaxis. In terms of FEN/GI, a Speech and Swallow evaluation was obtained of the patient and determined that the patient was at great risk for aspiration. A PEG tube was placed in the patient on [2137-4-8] and tube feeding was begun via the PEG. The patient's nutritional status remained stable. In terms of the patient's prophylaxis, he was maintained on subcutaneous heparin, regular insulin sliding scale, and pneumoboots. He had a proton pump inhibitor as well. CONDITION ON DISCHARGE: Stable, afebrile, tolerating tube feeds. DISCHARGE STATUS: To an acute rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Stroke. 2. Pneumonia. 3. Hypertension. 4. Gout. DISCHARGE MEDICATIONS: 1. Amlodipine 10 mg once a day. 2. Aspirin 81 mg once a day. 3. Captopril 50 mg three times a day. 4. Levaquin 500 mg once a day. 5. Colchicine 0.6 mg once a day. 6. Heparin 5,000 units twice a day. 7. Hydrochlorothiazide 25 mg once a day. 8. Insulin sliding scale. 9. Lansoprazole 30 mg once a day. 10. Metoprolol 125 mg twice a day. 11. Prednisone 15 mg once a day. 12. Simvastatin 40 mg once a day. 13. Plavix 75 mg once a day. FOLLOW-UP PLANS: The patient is to follow-up with his primary care physician within one week. He will also need neurologic follow-up. The remainder of her course, from [4-10] onward, will be dictated in an addendum. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 3809] MEDQUIST36 D: [2137-4-9] 05:07 T: [2137-4-9] 17:20 JOB#: [Job Number 9884] Name: [Known lastname 1058], [Known firstname ] Unit No: [Numeric Identifier 1059] Admission Date: [2137-3-27] Discharge Date: [2137-4-12] Date of Birth: [2065-1-15] Sex: M Service: The date of this discharge summary addendum will cover [2137-4-11] to [2137-4-12]. HOSPITAL COURSE: Over the course of the next two days of the patient's hospitalization, he had a PEG tube placed. On [2137-4-11], the patient was noted to have slight abdominal pain and was noted to be tender to palpation. We checked a serum amylase and lipase levels, which were mildly elevated. We decided given that this pancreatitis picture, to keep the patient NPO over the course of the next day and to watch the patient's abdominal exams. The following day on [2137-4-12], the patient was entirely pain free. His enzymes had trended down for the past two days, and he began on his tube feeds without incident. The patient was being discharged today in stable condition afebrile with no abdominal pain and with stable hematocrit. DISCHARGE DIAGNOSES: As outlined in the prior discharge summary. DISCHARGE MEDICATIONS: To be addendum as follows: The metoprolol is 100 mg twice a day. All the other medications are the same. FOLLOW-UP PLANS: The follow-up plans still remains the patient is to followup with his primary care physician within one week. He will also need a follow-up appointment with Neurology with Dr. [First Name (STitle) 1060] within 3-4 weeks. DR.[Last Name (STitle) 1035],[First Name3 (LF) 1034] 12-AAD Dictated By:[Last Name (NamePattern1) 1061] MEDQUIST36 D: [2137-4-12] 10:27 T: [2137-4-12] 10:40 JOB#: [Job Number 1062]	[ "276.0", "403.91", "577.0", "518.82", "413.9", "518.0", "599.0", "507.0", "997.02" ]	icd9cm	[ [ [] ] ]	[ "96.71", "46.32", "96.6", "99.04", "38.91", "81.91", "38.93" ]	icd9pcs	[ [ [] ] ]				9223, 11058			3059, 3843	18206, 18251	18275, 18383		16112, 16168			17450, 18184						5013, 8651																				18401, 18866															155, 2203	4279, 4470						4485, 4986		3859, 4262				2668, 2915	11080, 11555	11571, 13519	15992, 16091
6,366	157,176	49645	Discharge summary	report	Admission Date: [2189-4-30] Discharge Date: [2189-5-15] Date of Birth: [2133-7-18] Sex: M Service: [Company 191] IDENTIFYING DATA: Mr. [Known lastname 103812] is a 54-year-old male transferred out of the intensive care unit status post delirium tremens and left lower lobe pneumonia status post intubation for airway protection, now extubated completing a course of antibiotics for pneumonia. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 103812] is a 54-year-old male with a history of bipolar disorder, alcohol abuse, hypertension, and hypothyroidism who was admitted to the [Hospital3 8063] for manic symptoms, disorganized behavior, and aggressiveness. The patient was transferred to [Hospital1 346] for further evaluation of mental status changes, delirium, chest pain/shortness of breath on [2189-4-29], two days after presentation to [Hospital1 ]. The patient was admitted to the medical floor. He had received ceftriaxone/acyclovir for concern for meningitis/encephalitis. The patient had ruled out for myocardial infarction on admission and had been initiated on CIWA scale. The patient was determined to be in active delirium tremens while on the medical floor and was transferred to the [Hospital Unit Name 153] for frequent sedation requirements and a level of nursing care that could not be provided on the medical floor. The patient had received Ativan at 2 mg q. one hour plus additional 6 mg of Ativan and Valium 10 mg pushes x 3 with persistent agitation, tachycardia, and hypertension. He was initiated on an Ativan drip, was titrated up to 10 mg per hour for persistent agitation which led to respiratory depression and Ativan was subsequently discontinued. The patient was started on BiPAP and this was quickly titrated off as the benzodiazepines had worn off. He continued to be agitated with increased blood pressures and tachycardia and the Ativan was changed to Valium per CIWA scale. Of note, the patient had spiked a temperature to 101.8 degrees on [2189-5-3] and he was pancultured and a chest x-ray was performed. The patient's sputum had Gram-positive cocci in pairs and clusters and he was initiated on Levaquin therapy for a tracheobronchitis. On [2189-5-4] the patient had persistent thick secretions requiring frequent suction, and he had a large liquid stool which was tested for C. difficile as a cause for his fevers. This culture returned negative for C. difficile. The patient was also noted to have decreasing urine output requiring several fluid boluses. The psychiatrist who had been following this patient since admission recommended a quick taper with Valium secondary to his increased sedation at that time. Haldol was given for agitation and the patient's QTC was followed closely. On [2189-5-5] the patient's CIWA scale was discontinued and Haldol was used preferentially for agitation. The sputum returned with speciation of Staphylococcus aureus and his levofloxacin was changed to vancomycin on this date until the sensitivities returned. He had been transiently started on tube feeds which were subsequently held secondary to agitation. As the sensitivities from his sputum culture returned on [2189-5-7] as oxacillin sensitive, his antibiotics were change to oxacillin at that time. The patient also had received approximately 30 mg of Haldol for agitation and his O2 requirement subsequently increased over this day which led to his intubation on [2189-5-8] for respiratory distress and airway protection. He remained on a propofol drip for sedation while he was intubated. Repeat head CT and EEG were performed for his persistent mental status changes. The CT scan of his head was negative and his EEG ultimately returned with results consistent with encephalopathy. The patient was successfully extubated on [2189-5-11] without difficulty. His mental status continued to improve and his oxacillin was subsequently changed to levofloxacin on [2189-5-13]. The patient completed a 10-day course of antibiotics on [2189-5-14] prior to transfer to the medical floor. Of note, the patient was found to have significant liver function test abnormalities on admission with an ALT of 383, AST 615, alkaline phosphatase of 206, total bilirubin of 0.7 with normal pancreatic enzymes. This was felt to be consistent with alcoholic hepatitis, with the transaminases significantly decreased to within normal limits prior to his transfer. Hepatitis serologies were checked and were determined to be negative. Mr. [Known lastname 103812] had received a total of 275 mg of Valium while admitted and has not required any Haldol since [2189-5-10]. Currently the patient is not agitated and he denies any current complaints. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Hypertension. 3. Hypothyroidism. 4. Bipolar disorder. 5. Peripheral vascular disease. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT HOME: 1. Lithium 300 mg p.o. q.a.m./600 mg p.o. q.p.m. 2. Seroquel 300 mg p.o. q.h.s. 3. Levoxyl 0.1 mg p.o. q.d. 4. Ziac 10 mg p.o. b.i.d. MEDICATIONS ON TRANSFER: 1. Tylenol p.r.n. 2. Guaifenesin 10 mg p.o. q. 4 hours. 3. Albuterol 2 puffs q. 4 hours. 4. Atrovent 2 puffs q. 4 hours. 5. Levoxyl 100 mcg p.o. q.d. 6. Famotidine 20 mg p.o. b.i.d. 7. Thiamine 100 mg p.o. q.d. 8. Folic acid 1 mg p.o. q.d. 9. Lopressor 12.5 mg p.o. q.d. 10. Albuterol/Atrovent nebulizers p.r.n. 11. Levofloxacin 500 mg p.o. q.d. - last dose to be administered on [2189-5-14]. SOCIAL HISTORY: The patient presented from [Hospital3 103813], had lived alone and has a significant alcohol history as noted in the history of present illness. PHYSICAL EXAMINATION: Vital signs - temperature 97.1, blood pressure 134/80, oxygen saturation 96%, heart rate 88. General: Chronically ill appearing, no acute distress, older than stated age, calm, confident and alert. HEENT: Mucous membranes moist, oropharynx clear, extraocular movements intact. Neck: No jugular venous distension, supple, full range of motion. Chest: Clear to auscultation bilaterally, no dullness to percussion, symmetric excursion, expiratory phase not prolonged. Cardiovascular: Regular rate and rhythm, normal S1 and S2, no S3 or S4, no murmurs or rubs, no RV heave, point of maximal impulse not appreciated. Abdomen: Soft, nontender, nondistended, normal active bowel sounds, no hepatosplenomegaly nor masses. Extremities: 2+ pedal pulses, warm. Neurological: Cranial nerves II-XII were intact, motor [4-13] in the upper and lower extremities bilaterally, reflexes were 2+ for quadriceps, ankles, biceps. Distal sensation was intact. The patient was alert and oriented x 3. LABORATORY DATA: Laboratory studies on transfer showed a white blood count of 10.5, hematocrit 33.5, left circumflex coronary artery 261, sodium 138, potassium 3.9, chloride 103, bicarbonate 27, BUN 10, creatinine of 0.7, glucose 97, calcium 8.4, magnesium 1.9, phosphorous 4.1. PT, PTT and INR were 13.5, 28.2 and 1.2 respectively. NOTABLE MICROBIOLOGY: Sputum - samples from [2189-5-1] and [2189-5-2] were poor samples demonstrating oropharyngeal growth. Sputum sample from [2189-5-4] demonstrated 3+ Gram-positive cocci in pairs and clusters which speciates as Staphylococcus aureus sensitive to oxacillin, resistant to penicillin. Sputum sample from [2189-5-10] demonstrated no microorganisms on Gram stain and no growth. Blood - [2189-5-1] (two sets) and [2189-5-2] were negative for growth. Urine - urine culture from [2189-5-2] was negative. Stool - C. difficile negative on [2189-5-4]. NOTABLE STUDIES DURING ADMISSION: 1. Chest x-ray from [2189-4-29] demonstrated no infiltrates or effusions. 2. Chest x-ray from [2189-5-5] demonstrated a left retrocardiac opacity and possible layering of left pleural effusion. 3. Chest x-ray from [2189-5-14] demonstrated improvement of the left retrocardiac opacity. 4. CT scan of the head from [2189-4-29] and [2189-5-9] were significant for no intracranial or extracranial hemorrhage. There were no significant white/[Doctor Last Name 352] matter abnormalities. 5. Lower extremity Doppler ultrasound of left lower extremity on [2189-4-29] were negative for DVT. ASSESSMENT: Mr. [Known lastname 103812] is a 54-year-old male with a past medical history significant for alcohol abuse, hypertension, hypothyroidism, bipolar disorder and a prolonged medical intensive care unit admission for delirium tremens, left lower lobe pneumonia, now stable with no evidence of delirium tremens - the patient has not required Haldol since [2189-5-10]. Mr. [Known lastname 103812] is completing a 10-day course of antibiotics for Staphylococcus aureus pneumonia currently doing well clinically with a normal oxygen saturation on room air. Clearly, Mr. [Known lastname 103812] will require psychiatric placement at a dual-diagnosis unit upon discharge. HOSPITAL COURSE: 1. Left lower lobe pneumonia: Mr. [Known lastname 103814] oxygen saturations were only 96% on room air. His chest x-ray demonstrated resolution of the left retrocardiac opacity. He is currently completing a 10-day course of antibiotics upon transfer to the medical floor. We will continue to follow his temperature curve, will titrate his supplemental oxygen as needed to keep his O2 saturations greater than 93%. Will continue metered dose inhalers/nebulizer treatments as needed. 2. Delirium tremens: The patient is post the time period for delirium tremens to be occurring. He had been treated with a substantial amount of benzodiazepines, including 275 mg of Valium and was treated with p.r.n. Haldol with his last dose required was on [2189-5-10]. The patient may have become oversedated on the Haldol versus substantial worsening of his pneumonia which led to his intubation. Currently, the patient is alert and oriented to person, time and place. If he has further episodes of agitation, will use low doses of Haldol p.r.n. 3. Psychiatric: As Mr. [Known lastname 103814] psychiatric medications had been held since his admission, he has received only benzodiazepines and Haldol for agitation. As his mental status has cleared, he will be restarted on standing Zyprexa. He will clearly need placement in an inpatient dual-diagnosis unit upon discharge. Further medication additions will be directed by his psychiatrist at the inpatient psychiatric facility. The patient had been treated with lithium for his bipolar disorder which has been held since admission. DISCHARGE DIAGNOSES: 1. Left lower lobe pneumonia. 2. Delirium tremens. 3. Alcoholic hepatitis. 4. Hypertension. 5. Hypothyroidism. 6. Anemia. 7. Bipolar disorder. 8. Alcohol withdrawal. DISCHARGE MEDICATIONS: 1. Tylenol 325-650 mg p.o./p.r. q. 4-6 hours p.r.n. 2. Levothyroxine sodium 100 mcg p.o. q.d. 3. Famotidine 20 mg p.o. b.i.d. 4. Thiamine 100 mg p.o. q.d. 5. Folic acid 1 mg p.o. q.d. 6. Lopressor 25 mg p.o. b.i.d. DISCHARGE STATUS: The patient is being discharged to an inpatient psychiatric facility. CONDITION ON DISCHARGE: Medically stable. DISCHARGE INSTRUCTIONS: The patient is to take his medications as prescribed. Return for increased shortness of breath, chest pains, fevers to greater than 101 degrees Fahrenheit. PHYSICIAN FOLLOW UP: The patient should follow up with his primary care physician within one to two weeks. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 20054] MEDQUIST36 D: [2189-5-15] 00:51 T: [2189-5-15] 06:24 JOB#: [Job Number 103815]	[ "291.0", "401.9", "303.91", "571.1", "296.7", "244.9", "482.41", "285.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "94.62", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]								10678, 10845	10868, 11174					9060, 10657		11243, 11411					5005, 5143										11423, 11757				5764, 9042																				465, 4795													5169, 5574	4818, 4983	5591, 5741	11199, 11218
31,260	131,762	2721	Discharge summary	report	Admission Date: [2110-12-8] Discharge Date: [2110-12-26] Date of Birth: [2045-4-2] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[Last Name (NamePattern1) 1167] Chief Complaint: lower extremity edema Major Surgical or Invasive Procedure: placement of temporary dialysis catheter PICC line placement right upper arm Left wrist arthrocentesis History of Present Illness: The patient is a 65 year old female with a past medical history of longstanding right heart failure with severe right ventricular contractile dysfunction and severe tricuspid regurgitation, atrial fibrillation not on warfarin due to GI bleed in [2107] but no known history of coronary artery disease who presents from home with several weeks of progressively worsening lower extremity edema and fatigue. . She has longstanding right sided heart failure, which in the past has been refractory to diuresis and during a previous admission in [2108-3-21] required ultrafiltration due to poor response to IV diuresis. At the time, she was diagnosed with a PFO and left-to-right shunting that was percutaneously closed on [2108-3-14]. Her most recent RHC was on [2108-3-23] and showed no shunt, RAP 30 mmHg, mean PAP 38 mmHg, and wedge pressure 30 mmHg. At the time, ultrafiltation resulted in improved forward flow and improvement in renal function. CT chest in the past was negative for thromboemboli. . She appears to have been fairly well compensated over the past 18 months, on medical therapy (torsemide 40mg [Hospital1 ], metoprolol 25mg [Hospital1 ], spironolactone 25mg daily) without hospitalization. However, over the last 2-3 weeks, she has noted significantly worsening lower extremity edema (legs doubling in size), fatigue, exertional dyspnea, and poor urine output, despite minimal diet changes and medication compliance. She reports mechanical fall this past Friday landing on her right side (knee, shoulder). Following this she took 4 tablets of ibuprofen. Reports dry weight in 140lb range, currently 185lbs. . In the ED, initial vitals were 97.5 58 83/45 (basline early [Month (only) ] ~100-110 systolic) 28 100% RA. Systolic blood pressure transiently down to the high 60s. Exam notable for 4+ bilateral lower extremity edema, sacral edema, JVP to jaw, clear lungs. Labs notable for creatinine of 6.7 (baseline of ~1.5), sodium 131, BNP [Numeric Identifier 13476] (was 6666 in [2108]), troponin of 0.03, lactate 1.2. CXR showed cardiomegaly with small bilateral pleural effusions. EKG showed atrial fibrillation, rate 65, RBBB, unchanged compared to prior. Echocardiogram showed RV dilatation and hypokinesis,4+ TR and failure of the TV leaflets to coapt, LVEF still preserved at >55% with moderate MR (unchanged compared to prior). She was given 250cc IVF initially for hypotension but cardiology fellow stopped. She was given 80IV lasix total. Vitals on trasfer: 97.8 56 98/48 16 94 2LNC. Has 2PIV for access. Foley catheter placed after multiple attempts. . 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 recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -severe diastolic dysfunction of left ventricle -severe pulmonary hypertension -right ventricular contractile dysfunction and dilatation with recurrent right heart failure, requiring ultrafiltration in past -severe tricuspid regurgitation -atrial fibrillation not on coumadin [1-22] GI bleed -Patent foramen ovale (closed [3-/2109]) prior to closure, was allowing right to left shunting at the atrial level during periods of aggressive pressure and volume unloading 3. OTHER PAST MEDICAL HISTORY: - ulcerative colitis - angioectasia of entire colon (last colonoscopy [2108]) - chronic renal insufficiency (baseline 1.5) - history of ETOH abuse with current ETOH use - Chronic massive leg edema with recurrent leg cellulitis - Ventral hernia status post repair Social History: - separated from husband - lives alone, ambulates unassisted, drives - four children, son [Name (NI) ] is health care proxy - [Name (NI) 1139] history: denies - ETOH: [1-23] drinks daily, denies history of withdrawal symptoms. Prior heavy EtOH use. - Illicit drugs: denies Family History: -Father with MI at age 68 -Mother breast cancer at age 52 No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM VS: afebrile, 99/52 50 (irregular) 20 100%4L NC GENERAL: 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 to jawline at 45 degrees, prominent V waves. CARDIAC: S1, S2 irregular rhythm, normal rate, systolic murmur LLSB radiating to apex worse with inspiration 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: [2-22]+ pitting edema bilaterally up to thigh, dependent sacral and thigh edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM Tm/Tc:98.5/97.9 HR: 82-104 BP: 88-100/43-51 RR:18 02 sat:98 GENERAL: 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 to jawline at 45 degrees, prominent V waves. CARDIAC: S1, S2 irregular rhythm, normal rate, systolic murmur LLSB radiating to apex worse with inspiration LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: no edema, tender to palpation on wrist at and around incision site. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS [2110-12-8] 02:10PM BLOOD WBC-4.0 RBC-3.32* Hgb-10.9* Hct-33.3* MCV-100* MCH-32.7* MCHC-32.6 RDW-14.9 Plt Ct-164 [2110-12-8] 02:10PM BLOOD Neuts-72* Bands-0 Lymphs-4* Monos-19* Eos-1 Baso-4* Atyps-0 Metas-0 Myelos-0 NRBC-1* [2110-12-8] 02:10PM BLOOD PT-10.6 PTT-30.5 INR(PT)-1.0 [2110-12-8] 02:10PM BLOOD Glucose-102* UreaN-153* Creat-6.7# Na-131 K-4.9 Cl-95* HCO3-18* AnGap-23* [2110-12-8] 02:10PM BLOOD ALT-14 AST-53* LD(LDH)-311* AlkPhos-230* TotBili-0.9 [2110-12-8] 02:10PM BLOOD proBNP-[Numeric Identifier 13477]* [2110-12-8] 02:10PM BLOOD cTropnT-0.03* [2110-12-8] 02:10PM BLOOD Calcium-9.3 Phos-6.8# Mg-2.3 [2110-12-9] 05:34AM BLOOD Albumin-4.0 Calcium-9.3 Phos-7.1 Mg-2.3 DISCHARGE LABS [2110-12-26] 07:12AM BLOOD WBC-5.6 RBC-2.54* Hgb-8.2* Hct-24.8* MCV-98 MCH-32.4* MCHC-33.2 RDW-14.6 Plt Ct-328 [2110-12-26] 07:12AM BLOOD PT-11.3 INR(PT)-1.0 [2110-12-26] 07:12AM BLOOD ESR-137* [2110-12-26] 07:12AM BLOOD Glucose-89 UreaN-46* Creat-2.8* Na-134 K-3.8 Cl-98 HCO3-26 AnGap-14 [2110-12-26] 07:12AM BLOOD ALT-7 AST-32 LD(LDH)-228 AlkPhos-272* TotBili-2.5* [2110-12-26] 07:12AM BLOOD Mg-1.8 [2110-12-25] 06:15AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 [2110-12-26] 07:12AM BLOOD CRP-PND [2110-12-26] 07:12AM BLOOD CRP-PND [2110-12-26] 07:12AM BLOOD Vanco-20.3* [2110-12-18] 04:16AM BLOOD Type-CENTRAL VE pH-7.44 Comment-GREEN TOP [2110-12-19] 05:14AM BLOOD Type-CENTRAL VE Temp-37.0 pH-7.51* Comment-GREEN TOP PERTINENT LABS AND STUDIES [2110-12-8] ECHOCARDIOGRAM The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The 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 leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. Pulmonary artery hypertension (not quantified). [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Severe tricuspid regurgitation. Right ventricular cavity enlargement with free wall hypokinesis. Moderate mitral regurgitation. Pulmonary artery hypertension.Compared with the prior study (images reviewed) of [2110-4-1], the findings are similar. [2110-12-8] CXR The heart size is enlarged. The mediastinal contours demonstrate engorgement of the central venous vasculature. Additionally small bilateral pleural effusions are present with basilar atelectasis. There does not appear to be appreciable interstitial edema. There is no pneumothorax. IMPRESSION: Cardiomegaly and small bilateral pleural effusions but no evidence of CHF. [2110-12-9] RENAL ULTRASOUND The right kidney measures 10.1 cm and the left kidney measures 9.0 cm. There is no hydronephrosis. No cyst or stone or solid mass is seen in either kidney. The bladder could not be evaluated as a Foley catheter is in place. IMPRESSION: Unremarkable renal ultrasound with no hydronephrosis identified. [2110-12-19] ECHOCARDIOGRAM Moderate to severe tricuspid regurgitation. Mild-moderate mitral regurgitation with normal valvular morphology. Pulmonary artery hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [2110-12-8], the overall findings are similar. An ASD occluder is better defined on the current study [2111-12-21] RENAL USS 1. No evidence of renal artery stenosis. No hydronephrosis. 2. Incompletely assessed hypoechoic nodule (22 mm) along or near the upper pole of the left kidney, for which repeat ultrasound is suggested versus CT or MR imaging. [2110-12-24] RUQ USS WITH DOPPLERS 1. Dilated hepatic veins consistent with right-sided heart failure. 2. No intra- or extra-hepatic duct dilation. 3. Mild splenomegaly. 4. Mild cortical thinning of the renal cortices bilaterally. [2110-12-24] LEFT HAND AP, LATERAL, OBLIQUE 1. Severe osteopenia and severe osteoarthritis. 2. Dislocation at the first CMC joint, of indeterminate acuity. No obvious fracture. 3. Scapholunate widening, with bordelrine DISI configuration. [2110-12-12] 4:12 am BLOOD CULTURE Source: Line-right a line. FINAL REPORT [2110-12-14] Blood Culture, Routine (Final [2110-12-14]): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [2110-12-12]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 13478] @1504, [2110-12-12]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [2110-12-12]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 394] ON [2110-12-12] @ 510 PM. [2110-12-19] 4:53 am BLOOD CULTURE Source: Line-RIJ TLC- brown port. FINAL REPORT [2110-12-25] Blood Culture, Routine (Final [2110-12-25]): NO GROWTH. [2110-12-21] 10:42 am STOOL CONSISTENCY: FORMED Source: Stool. FINAL REPORT [2110-12-21] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2110-12-21]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: 65 year old female with a past medical history of longstanding right heart failure with severe right ventricular contractile dysfunction and severe tricuspid regurgitation, atrial fibrillation (not on warfarin due to GI bleed in [2107]) but no known history of coronary artery disease who presents from home with several weeks of progressively worsening lower extremity edema and fatigue found to be in decomensated heart failure and oliguric acute renal failure. Became septic during this admission with MSSA in her blood. # SEPSIS: On HD4, [1-24] blood cultures returned positive with speciation to MSSA. She was initially treated with vancomycin empirically, which was narrowed to nafcillin when sensitivities showed MSSA. Her A-line (from which the positive cultures were drawn), right IJ and left temp dialysis line were removed and a new right IJ was placed after 3 days of antibiotics. During the time when she was septic, her pressor requirements increased and her WBC was elevated to a peak of 22.2. A TTE showed no evidence of vegetations and there was little concern for endocarditis (of note, she does have an Amplatzer PFO closure devive in place). Blood cultures grew MSSA. She was treated with vanc/zosyn empirically, and changed to nafcillin following culture speciation and sensitivity testing, but developed leucopenia and diarrhea. She was successfully weaned off pressors. Given concern that this might be due to a reaction to nafcillin, her antibiotics were changed to vancomycin. She completed her antibiotic course in hospital. # ACUTE ON CHRONIC DIASTOLIC HEART FAILURE WITH PRESERVED EJECTION FRACTION: The patient has a longstanding history of right heart failure with a dilated, hypocontractile right ventricle and severe tricuspid regurgitation. It is presumed that chronic severe diastolic dysfunction of her left ventricle (no mitral valve disease, no evidence of chronic thromboembolic disease, normal LVEF), possibly with contribution for patent foreamen ovale, led to increased pulmonary artery systolic pressures leading to her right ventricle dysfunction. Her dry weight is thought to be around 140-145lbs based on prior records and she was 186 pounds at admission. We initially tried a lasix gtt with metolazone and she had poor diuresis. Given the poor result with IV diuretics and her markedly elevated creatinine at admission, she was started on CVVHD and she was initially 11 liters negative by HD4 when CVVHD was stopped in the setting of sepsis with hypotension on increasing doses of pressors. Until her sepsis physiology resolved, she was kept at an even fluid balance daily. Following resolution of sepsis, she was diuresed to dry weight with eventual removal of around 20L of fluid. At the time of discharge she was at her dry weight of 144 pounds with no evidence of fluid overload. . AGITATION/DELIRIUM ?????? Initially, the patient was oriented, calm and appropriate. By HD3 to HD4, she became increasingly agitated, disoriented and appeared to have visual hallucinations. Possible etiologies include EtOH withdrawal (unclear history of alcohol consumption), infection (MSSA bacteremia, UTI), toxic-metabolic, or ICU delirium. Given that she was initially agitated, tachycardic, hallucinating and relatively hypertensive, we thought alcohol was a large component. Her agitation improved when she was able to take PO valium, however she was often too agitated to take PO and intermittently received Ativan IV and Haldol IV. Her mental status improved gradually following the resolution of sepsis, and she was at her baseline at the time of discharge. . # ATRIAL FIBRILLATION: Patient with a history of permanent atrial fibrillation not anticoagulated due to history of GI bleed despite CHADS2 score of 2. HR previously increased with agitation, switched from dopa to levophed and vasopressin for less chronotropy. INR at admission was 1.0. Her beta blocker was also held in the setting of hypotension. Her HR remained relatively well controlled, she would be tachy to the 110-120s when agitated. # ACUTE ON CHRONIC RENAL FAILURE: At admission, her Cr was 6.7, up from baseline of approximately 1.5. She also had limited urine output with FeNa of 0.47. This was most likely a consequence of decompensated heart failure with poor forward flow although it is also possible that initial insult was acute renal failure that then led to this cycle of decompensated failure. Her Cr initially improved when she was started on CVVHD and started to trend up again once this was stopped. Renal was consulted and felt that she may be a candidate for outpatient HD given her poor renal function. Vancomycin was dosed renally. At the time of discharge, her creatinine remained elevated at 2.8 # GIB/diarrhea: stools formed. She developed diarrhea starting [2110-12-14]. Possible etiologies included a flare of her long standing UC, antibiotic toxicity due to nafcillin. C-diff toxin x2 was negative. She also developed some maroon stols with possible melena on [2109-12-22], and was transfused 1 unit PRBC. Her Hct remained subsequently stable. She was seen by gastroenterology, but she and her son declined [Date Range ]/colonoscopy. She was given IV protonix, and changed to PO PPI prior to discharge. . # Hand: She developed pain in her left wrist starting [2109-12-24]. ESR was elevated, but no fevers or WBC count. Orthopedics was consulted who attempted a tap of the carpometacarpal joint, which was dry. Gout, and Ulcerative Colitis related arthropathy are also possible etiologies for her wrist pain. She was initiated on prednisone with a taper at the time of discharge. If the prednisone does not improve her pain in [2-22] days, please consider d/c. She has a f/u appt with orthopedics. Medications on Admission: -torsemide 20mg [Hospital1 ] -spironolactone 25mg daily -buproprion 150mg daily (not taking) -folic acid 1mg daily (not taking) -mesalamine 0.750mg daily (not taking) -neurontin 200mg QHS PRN pain (infrequently taking) -metoprolol tartate 25mg [Hospital1 ] -omeprazole 20mg daily -oxycodone 5mg QID PRN pain -potassium 20mg daily -aspirin 81mg daily -ferrous sulfate 325mg [Hospital1 ] -albuterol PRN -miconazole cream Discharge Medications: 1. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime as needed for pain. 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 15. triamcinolone acetonide 0.025 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): apply to left leg as needed for rash. 16. prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 2 days: give [12-27] and [12-28]. 17. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days. 18. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. 19. prednisone 10 mg Tablet Sig: 0.5 Tablet PO once a day for 3 days. Discharge Disposition: Extended Care Facility: [Hospital ] Health Care Center - [Location (un) ] Discharge Diagnosis: Acute on Chronic Diastolic congestive heart failure Cardiogenic/Septic shock Left wrist gout vs inflammation Ulcerative colitis with GI bleed Methacillin sensative staph aureus bacteremia 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 had an acute exacerbation of your congestive heart failure. We used ultrafiltration and medicines to get rid of about 25 pounds of fluid. Your weight at discharge is 144 pounds and we think this is your dry weight. You have some residual swelling in your legs but the TEDS stockings should help to mobilize this fluid. Weigh yourself every morning, call Dr. [First Name (STitle) 437] at [Telephone/Fax (1) 62] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . You also had a bacteria in your blood that was treated with 2 weeks of antibiotics. You need to be monitored for a fever or rising white blood cell count to make sure it does not return. A PICC line was placed and removed. You had some diarrhea and bleeding that we think was your ulcerative colitis. The gastrointestinal doctors recommended [Name5 (PTitle) ] [Name5 (PTitle) ] and colonoscopy in the near future. You have decided against this for now but can contact Dr. [Last Name (STitle) 2987] to arrange if you like. We have not started any blood thinners for your atrial fibrillation because of this. Your left wrist and hand became very painful and you were evaluated by the orthopedic hand team. A tap was attempted but there was no fluid in the wrist joint. It is unlikely that there is an infection given the long course of antibiotics. Prednisone was started for a presumed gout attack and will be tapered over the next week. This should help the pain in [12-22] days. Your liver function tests were elevated because of the heart failure. An ultrasound did not show any acute changes and the liver tests are improving. . We made the following changes to your medicines: 1. Change metoprolol to a long acting version for your heart failure 2. Change torsemide to 40 mg daily in the morning 3. Change omeprazole to pantoprazole while you are in the rehab, you can go back to omeprazole at home 4. Take tylenol every 8 hours to left wrist pain 5. Increase the oxycodone for your left wrist pain 6. START taking prednisone for your left wrist pain, it will taper down over 9 days. 7. STOP taking potassium as your kidney function is still poor. 8. START lomotil as needed for your diarrhea Followup Instructions: Nephrology: Dr. [First Name4 (NamePattern1) 429] [Last Name (NamePattern1) 118], MD [Hospital1 18] [Location (un) ], [Location (un) 86] Office Location: [Street Address(2) 8667] - [Hospital Ward Name ] 1 clinic Office Phone:([Telephone/Fax (1) 10135] Office Fax:([Telephone/Fax (1) 11957] Office will call you with an appt in about 2 weeks. . Orthopedic Surgery: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Hospital1 18] [Hospital Ward Name 23] Clinical Center, [Location (un) ] [Location (un) ], [Location (un) 86] Best parking: [Hospital Ward Name 23] garage Monday [1-12] at 11:50am . Department: CARDIAC SERVICES When: MONDAY [2111-1-26] at 2:30 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2111-1-12] at 4:00 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2110-12-26]	[ "427.31", "556.9", "293.0", "599.0", "428.0", "584.9", "785.51", "038.11", "403.90", "291.81", "274.01", "585.4", "995.92", "530.81", "416.8", "397.0", "272.4", "785.52", "276.1", "428.33" ]	icd9cm	[ [ [] ] ]	[ "38.91", "39.95", "81.91", "38.95", "38.97" ]	icd9pcs	[ [ [] ] ]	21965, 22049	13964, 19762	364, 469	22281, 22281	6811, 13941	24684, 26006	4844, 5017		20243, 21942		22070, 22260		19788, 20220			22457, 24661									5032, 6792		3744, 4219																		303, 326										497, 3650									22296, 22433		4250, 4525			3672, 3724	4541, 4828
11,991	138,800	46152+46153	Discharge summary	report+report	Admission Date: [2187-1-5] Discharge Date: Date of Birth: [2122-4-3] Sex: M Service: [Last Name (STitle) ] DR.[Last Name (Prefixes) 413],[First Name3 (LF) 412] 02-351 Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2187-1-10] 09:14 T: [2187-1-10] 09:25 JOB#: [Job Number 98168] Admission Date: [2187-1-5] Discharge Date: [2187-1-10] Date of Birth: [2122-4-3] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a 64 year-old gentleman who had been admitted previously for cardiac catheterization following a positive ET test. Catheterization done on [12-28] showed an EF of 65%, left main of 60 to 70%, left anterior descending coronary artery 70% and LVEDP of 22. Please see catheterization report for full details. The patient is admitted to the Cardiothoracic Service as an outpatient admission and admitted directly to the Operating Room on [1-5]. At that time the patient came to the Operating Room where he underwent coronary artery bypass grafting times two. Please see the operative report for full details. In summary, the patient had a coronary artery bypass graft times two with a left internal mammary coronary artery to the left anterior descending coronary artery and an saphenous vein graft to the obtuse marginal. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient had an arteriole line, two atrial pacing wires, two mediastinal and one left pleural chest tube. He was transferred with Propofol infusing at 30 mics per kilogram per minute. His mean arteriole pressure was 85. His CVP was 5. He was in normal sinus rhythm. The patient did well in the immediate postoperative period. He was allowed to awaken from his anesthesia and was appropriately responsive weaning from the ventilator at which time the patient was noted to have increasing frequency of premature ventricular contractions and increasing episodes of premature ventricular contractions quickly accelerated to ventricular tachycardia and then to ventricular fibrillation. The patient was resuscitated from his ventricular fibrillation. Please see the resuscitation report for full details. Following resuscitation the patient was transferred to the Cardiac Catheterization Laboratory where he underwent cardiac catheterization to assess the patency of his new coronary artery bypass graft. Once in the Catheterization Laboratory the patient was found to have a widely patent left internal mammary coronary artery to the left anterior descending coronary artery and the saphenous vein graft to left circumflex was patent with an 80% narrowing immediately antegrade and distal to the anastomosis. This narrowing improved, but did not fully normalize with intragraft intravenous nitroglycerin and Diltiazem. An intra-aortic balloon pump was also placed while the patient was in the Cardiac Catheterization Laboratory. The patient was transferred from the Catheterization Laboratory back to the Cardiac Surgery Recovery Unit. The patient returned to the Cardiac Surgery Recovery Unit in good condition. At the time of transfer his medications included neo-synephrine and Propofol. He remained hemodynamically stable overnight without any further episodes of ventricular ectopy. On the morning of postoperatively day one his Propofol was weaned to off. He was weaned from the ventilator and extubated. Following that the intra-aortic balloon pump was weaned and ultimately discontinued also on postoperative day one. The patient remained hemodynamically stable without any further episodes of ventricular ectopy throughout the remainder of postoperative day one. On postoperative day two the patient was transferred from the Cardiac Surgery Recovery Unit to Far Six for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient's activity level was progressively increased with the assistance of physical therapy and the nursing staff. His diet was advanced to regular. He remained hemodynamically stable with no further episodes of ventricular ectopy. On postoperative day five the patient's activity level had progressed to a level five, which is ambulating 500 feet and up a flight of stairs. He remained hemodynamically stable and it was decided that he was stable and ready for discharge. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting times two with a left internal mammary coronary artery to the left anterior descending coronary artery and a saphenous vein graft to obtuse marginal. 2. Hypertension. 3. Chronic left shoulder pain. 4. Cataracts. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature 98.9. [Doctor Last Name ] rate 74 sinus rhythm. Blood pressure 110/60. Respiratory rate 18. O2 sat 94% on room air. Weight preoperatively is 73.8 kilograms, at discharge is 76.2 kilograms. Laboratory data as of [1-9] hematocrit 28, potassium 4.6, BUN 14, creatinine 0.8. Neurological, alert and oriented times three, conversant, moves all extremities, nonfocal examination. Respiratory breath sounds clear to auscultation bilaterally. Heart sounds regular rate and rhythm. S1 and S2. No murmurs, rubs or gallops. Sternum is stable. Incision with Steri-Strips open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well profuse with no edema. Right lower extremity incision just above the knee with Steri-Strips open to air clean and dry. DISCHARGE MEDICATIONS: Lasix 20 mg q.d. times seven days, potassium chloride 20 milliequivalents q.d. times seven days, Colace 100 mg b.i.d., aspirin 325 mg q.d., Imdur 60 mg q.d. times three months, Lopresor 25 mg b.i.d., Amiodarone 400 mg t.i.d. through [1-13] and then 400 mg b.i.d. for one week and then 400 mg q.d. Percocet 5/325 one to two tabs q 4 hours prn. Motrin 400 mg q 6 hours prn. Th[Last Name (STitle) 1050] is to have follow up in wound clinic in two weeks. He is also to have follow up with Dr. [Last Name (Prefixes) ] in one month. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2187-1-10] 09:39 T: [2187-1-10] 10:31 JOB#: [Job Number ]	[ "401.9", "458.2", "997.1", "427.41", "427.5", "411.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "37.61", "88.55", "36.15", "36.11", "39.61", "37.23", "37.64" ]	icd9pcs	[ [ [] ] ]								4518, 4865	5760, 6550																													4880, 5736																	538, 4497
21,218	122,056	23441	Discharge summary	report	Admission Date: [2198-11-17] Discharge Date: [2198-11-26] Service: HISTORY OF PRESENT ILLNESS: This is an 80-year-old female nursing home resident with Parkinson's disease who was found down at the nursing home with blood around her forehead area, was brought by Emergency Medical Services in a hemodynamically stable condition to the emergency room. Her baseline neurologic status is unclear. The patient was noted to not be communicating at this time with anyone. PAST MEDICAL HISTORY: Significant for Parkinson's disease as stated above, degenerative joint disease, narcolepsy, hypercholesterolemia, cataract surgery. PHYSICAL EXAMINATION: On admission temperature 99.6, heart rate 77, blood pressure 182/76, respiratory rate 24. Breathing at 98 percent on room air. An elderly appearing woman not following commands. Staying in a contracted state with her eyes closed and noted to be moving all extremities. Pupils equal, round and reactive to light and accommodation. There was a small amount of blood noted in her right ear. Her head tilted to the right. She is noted to be in a neck collar at this time. Heart was in regular rate and rhythm. Lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, nondistended with normal active bowel sounds. Pelvis was noted to be stable. Her rectal examination noted her to have good tone, no masses felt. Her pulses were palpable throughout. She had good dorsalis pedis and posterior tibial pulses. HOSPITAL COURSE: At this time 81-year-old woman was admitted status post fall with a right forehead laceration that was sutured in the emergency room and studies were performed Head CAT scan revealed a temporal/sub-arachnoid bleed and likely brain contusion. Showed chronic sinusitis and some motion artifact. CAT scan of her spine showed anterior displacement of C3/4 questionable whether this was an old result or new one. Extensive degenerative changes were also noted in her cervical spine and anterior effusion of C5 and C6 was also noted. Her lumbosacral spine noted chronic changes and loss of height at L1 without obvious fracture. Her chest x-ray done at an outside hospital and here showed no pneumothorax. This pa had been transferred from an outside hospital to the [Hospital3 ]. The patient was admitted for neuro checks, was admitted to the ICU, at this time was made NPO, received intravenous fluids. Old records were obtained. Tetanus had been given at an outside hospital. The patient was placed on a Dilantin load as seizure prophylaxis and a repeat head CT was performed the following morning. The patient received chest x-ray and Pelvic films that were negative for fracture and it was at this time questionable in terms of the etiology of this fall and that was pursued as well. The patient was seen by Neurosurgery at this time who noted the patient to be minimally compliant with the exam without focal deficits and to be moving well. They suggested maintaining a systolic blood pressure less than 140 and repeating the Cat scan as was planned an agreed with the Dilantin load. On hospital day two, the patient received another head CAT scan that was noted to be stable and it was noted that the MRI was unable to be read due to poor quality. Neurosurgery then suggested to leave the patient in hard collar for two weeks from this point on and repeat flexion and extension films at that point and for her to follow-up with Dr. [Last Name (STitle) 1327]. The patient at this time was also seen by Neurology for decrease in mental status after this fall and advised on her Parkinson's medication doses. She had not yet regained her baseline mental status at this point, was predominantly nonverbal and rarely interactive and non cooperative following a few commands. They suggested we continue Dilantin for ten days total which was done and taper off accordingly and to continue Amantadine and Sinemet at the current doses that she was taking. A TSH was checked which came back normal at 0.41, in light of an enlarged thyroid seen on CAT scan of the neck. An infectious workup was pursued as well. Chest x-rays were negative. This time urine cultures were sent that came back with fecal contamination however, urinalysis was likely positive and patient was started on Ciprofloxacin at this time. They suggested no further imaging studies and to continue to follow the patient's neurologic status. The patient was also seen by the Nutritional Service and a Debove tube was placed. On hospital day three Impact of Fiber was started at 60 cc per hour. The patient was also seen by the Geriatric Service during this time. The patient was also given a swallowing evaluation and they suggested for us to maintain her NPO with nasogastric tube feedings at this time for safety reasons and that she was not ready to engage in the act of eating and drinking. The patient was also seen by Occupational Therapy and Physical Therapy throughout her stay who worked on increasing her mobility and her ability to perform daily tasks though she was still minimally interactive and on [2198-11-23] the patient was brought to the operating room and received percutaneous endoscopic gastrostomy tube placement for purpose of feedings. The following day the patient was started on Impact with Fiber at 45 cc an hour tube feeds to be run continuously. The patient received tube feeds until the point of discharge and on the day of discharge 125 cc of free water twice a day was added to her tube feeds for the purposes of continued hydration. Neurology continued to follow the patient and noted the patient to be improving in terms of responding to commands. On postop day one, [2198-11-24], hospital day 8 the patient's cognitive status seemed to improve and the patient was now responding to voice with conversation, was able to identify where her sons were from, was able to describe how she was feeling at that time and noted to be still somewhat hard of hearing. Orthopedics was also consulted at this time for right shoulder pain. The patient had received shoulder x- rays and CAT scans of the right shoulder which showed soft tissue swelling and no obvious fracture. Orthopedics determined this was likely bursitis and for pain control and for her to be treated conservatively at this point. On the day of discharge the patient was noted to be stable, vital signs were stable, the patient was receiving tube feeds. There were no other active issues at this time and the patient was to be discharged to rehabilitation facility. DISCHARGE INSTRUCTIONS: The patient is to wear cervical collar until cleared by Neurology. Was to wear this collar for two weeks from the date of [2198-11-20]. The patient is to be discharged to a rehabilitation facility. The doctor is to be made aware of having worsening pains, fever, chills, nausea, vomiting, lightheadedness, dizziness or if there were any questions or concerns. RECOMMENDATIONS: The patient is to follow-up with Trauma Clinic in two weeks and to call for a scheduled appointment at [Telephone/Fax (1) 2359]. The patient is to follow-up with Neurology in two weeks and to have flexion and extension films of her neck and to call to schedule an appointment at [Telephone/Fax (1) 44] and for cervical collar to be possibly removed at this time. DISCHARGE MEDICATIONS: 1. Amantadine 100 mg p.o. twice a day in syrup form. 2. Colace 100 mg p.o. twice a day. 3. Parva dopa/Levodopa 25/100 mg one tablet every four hours. 4. Phenytoin 100 mg three times a day for three days in syrup form. 5. Metoprolol 25 mg p.o. twice a day, hold for systolic blood pressure less than 100 or heart rate less than 60. 6. Acetaminophen 325 mg one to two tablets p.o. q six hours as needed for pain. 7. Lansoprazole 30 mg p.o. once daily to be put through the tube. 8. Hydralazine 10 mg q 4 hours p.r.n. for blood pressure greater than 150 systolic. 9. Regular insulin sliding scale as directed. DISPOSITION: The patient is to be discharged to rehabilitation facility. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5732], [MD Number(1) 5733] Dictated By:[Last Name (NamePattern1) 15912] MEDQUIST36 D: [2198-11-26] 09:17:09 T: [2198-11-26] 10:25:31 Job#: [Job Number 60094]	[ "293.0", "851.80", "347.00", "E888.9", "715.90", "401.9", "332.0", "599.0", "783.7", "873.42", "726.10", "310.2", "285.9" ]	icd9cm	[ [ [] ] ]	[ "43.11", "96.6" ]	icd9pcs	[ [ [] ] ]									7395, 8368					1520, 6588		6613, 7372																			669, 1502																				115, 489														512, 646
2,809	100,426	43278	Discharge summary	report	Admission Date: [2131-11-16] Discharge Date: [2131-11-23] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4219] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, 85 yo woman w/ transfusion dependant myelofiborisis, diastolic CHF, small bowel AVM's, chronic venous insufficiency who was transferred from rehab for anemia on [11-16] (HCT 21). In ED CXR showed early RLL infiltrate w/ pulm edema and she was admitted to Medicine w/ dx of symptomatic anemia, aspiration PNA, and CHF. She was treated w/ IVF's, PRBCs, and 40mg lasix IV, and was placed initially on levoflox and flagyl for presumed aspiration PNA. On HD #2 patient found to be hypotensive, tachycardic, febrile, increasing O2 requirement after receiving 40 mg IV lasix, and was treated with IVF's, dopamine, ceftaz and levo and transferred to the MICU. Concern was for sepsis (fever, low WBC, tachycardia thought to be sedondary to PNA) vs hypotension, but the patient responded well to IVF boluses and PRBC's, and pressors were weaned off by HD #3. The pt denies dyspnea, chest pain. She does report recent increase in LE edema and orthopnea. She denies any recent fever, chills, weight loss, chest pain, palps, cough, abd pain, dysuria, melena, and hematochezia. Past Medical History: 1. Myelofibrosis with myeloid metaplasia, diagnosed [2124]. The patient has been transfusion dependent, requiring frequent admissions for transfusions. She was managed with prednisone 20 mg qod and thalidomide but now on hold per by Dr. [Last Name (STitle) ]/[Last Name (STitle) ] 2. AVMs in the small bowel diagnosed by capsule endoscopy, but she has been guaiac negative during her admissions in the past. EGD in [5-/2130] was normal. 3. H/O left pleural effusion of unknown etiology 4. Spinal stenosis 5. Glaucoma 6. Synovial cyst- This was visualized by ultrasound and CT on [2130-6-24]. 7. H/O CHF - TTE [2131-2-9] mild LA enlargement, LVEF > 55%, 1+ MR, mild PA systolic HTN, minimal AS, trace AR 8. Lung nodules Social History: The patient lives in a second-floor apartment in a subsidized housing. She has not wanted to pursue nursing home options. She has a son who is involved in her care. Pt also has a home health aide and housekeeper who come on a regular basis for a total of about 3 hours per day. No ETOH, tobacco, or drug use. Family History: Mother had gastric cancer. Physical Exam: VITALS: 98.1, 100/50, 96, 20, 96% 2L GEN: cachectic appearing woman breathing uncomfortably HEENT: anicteric, OP clear w/ MMM PULM: crackles 1/2 up bilaterally, no wheezes CV: reg s1/s2, +3/6 systolic murmur at apex0 ABD: +BS, soft, NT, ND EXT: warm, [2-1]+ pitting edema to the thighs B NEURO: CN 2-12 intact, a/o x 3 Pertinent Results: [2131-11-15] 03:00PM WBC-1.3* RBC-2.68* HGB-7.9* HCT-21.7* MCV-81* MCH-29.6 MCHC-36.6* RDW-15.3 [2131-11-15] 03:00PM PLT SMR-VERY LOW PLT COUNT-14* LPLT-3+ [2131-11-15] 03:00PM PT-14.2* PTT-34.7 INR(PT)-1.4 [2131-11-15] 03:00PM GRAN CT-740* [2131-11-15] 03:00PM ALBUMIN-3.2* CALCIUM-7.2* PHOSPHATE-3.7 MAGNESIUM-2.2 [2131-11-15] 03:00PM CK-MB-1 cTropnT-<0.01 [2131-11-15] 03:00PM GLUCOSE-95 UREA N-20 CREAT-0.7 SODIUM-138 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13 [2131-11-16] 06:40AM CK-MB-NotDone cTropnT-<0.01 proBNP-9785* [2131-11-16] 06:40AM CK(CPK)-9* [2131-11-16] 03:53PM LACTATE-1.3 [2131-11-16] 05:06PM LACTATE-2.5* [2131-11-16] 08:42PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2131-11-16] 08:42PM URINE [Month/Day/Year 3143]-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2131-11-16] 08:42PM URINE RBC-[3-3]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2131-11-16] 08:42PM CK-MB-NotDone cTropnT-<0.01 [2131-11-16] 08:42PM CK(CPK)-7* Brief Hospital Course: The patient is an 85 yo woman w/ transfusion dependant myelofiborisis and diastolic CHF was sent from rehab to ED for treatment of HCT 21. On arrival in the ED, T 96.3, BP 104/54, HR 95, O2 sat 92% RA-->98% 2L/m. A CXR showed an early RLL infiltrate and pulmonary edema. She was admitted to Medicine with a diagnosis of symptomatic anemia, aspiration PNA, and CHF. She was treated w/ 3L NS, 2units PRBCs, and 40mg lasix IV. The day after admission, she had temp of 100.0 and was treated with levoflox 250mg IV and flagyl 500mg IV. UOP was 1600cc overnight. At 3:45pm the next day, the patient was given lasix 40mg IV. 35 minutes later she was found to have BP 75/39, HR 120, RR 24, and O2 sat 96% on 2L--> 100% NRB. Temp at that time was 101.8 rectal. She was treated w/ 1L NS, dopamine by PIV, and ceftaz 2gm, and levaquin 500mg. Within the hour, BP increased to 92/34, HR 110. The MICU team was then consulted for evaluation. The patient was transferred to the MICU for treatment of possible sepsis thought most likely secondary to PNA. She was treated with vanocmycin and ceftaz. The patient was transferred out the floor. Her antibiotics were switched to vancoycin and ceftriaxone with a plan to treat for a 10 day course. She was gently diuresed with lasix 10mg IV QD. We continued to transfuse for hct<21 and platelets<15. The patient continued to have increasing amounts of rectal bleeding thought secondary to internal hemorroids in the setting of platelets <20. A GI consult was called. The patient refused an exam, but the GI team advised continuing to give platelets and PRBC. On [2131-11-20], the patient chose to change her code status from full code to DNR/DNI. Later that day, the patient began to have hematuria and [Date Range ] tingled sputum. Her breathing became more labored. She improved with lasix and morphine, but continued to become intermittently hypotensive and was again spiking fevers. A family meeting with the patient and her son lead to a decision to make the patient CMO. All treatments other than lasix/morphine/and ativan were stopped. The patient was started on a morphine drip on [2131-11-22] and passed away on [2131-11-23]. The family was notified and refused autopsy. Medications on Admission: Tucks Hemorrhoidal Oint 1% 1 Appl PR [Hospital1 ]:PRN Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR [Hospital1 ]:PRN Vancomycin HCl 1000 mg IV Q 12H Ceftazidime 2 gm IV Q12H Pantoprazole 40 mg PO Q24H Heparin 5000 UNIT SC TID Docusate Sodium 100 mg PO BID:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN traZODONE HCl 25 mg PO HS:PRN Senna 1 TAB PO BID:PRN Zinc Sulfate 220 mg PO DAILY Ascorbic Acid 500 mg PO DAILY Vitamin D 400 UNIT PO DAILY Calcium Carbonate 1000 mg PO TID W/MEALS Alendronate Sodium 70 mg PO QWED Cyanocobalamin 50 mcg PO DAILY Folic Acid 1 mg PO DAILY Discharge Medications: Expired Discharge Disposition: Extended Care Facility: Meadowbrook - [Location (un) 2624] Discharge Diagnosis: Myelodyplastic Sepsis Discharge Condition: Expired [2131-11-23] Discharge Instructions: Expired [2131-11-23] Followup Instructions: Expired [2131-11-23] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231]	[ "428.0", "507.0", "995.91", "038.9", "733.00", "724.00", "428.33", "284.8", "459.81", "289.89", "455.2", "727.40", "365.9", "276.52", "537.82", "424.0" ]	icd9cm	[ [ [] ] ]	[ "00.17", "99.05", "99.04" ]	icd9pcs	[ [ [] ] ]	6941, 7006	4038, 6283	271, 277	7072, 7098	2889, 4015	7171, 7290	2503, 2531		6909, 6918		7027, 7051		6309, 6886			7122, 7148									2546, 2870																				225, 233										305, 1389														1411, 2156	2172, 2487
21,139	196,515	291	Discharge summary	report	Admission Date: [2169-2-13] Discharge Date: [2169-3-2] Service: MEDICINE Allergies: Iodine-Iodine Containing / Ampicillin / Phenergan Plain / Zaroxolyn / Ambien Attending:[First Name3 (LF) 2763] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [Known lastname 2749] is a [Age over 90 ]yoF with severe diastolic HF NYHA class IV with multiple exacerbations in past year, HTN, HLD, Afib, and gait abnormality related to ?DM who presented from home on [2-13] after sustaining a fall 3 day before. Her fall was unwitnessed, but was thought to be mechanical, as pt tripped while getting out of bed to the commode. L hip pain developed over the next few days, and her family brought her to the ED. CT scans of the cervical spine and head were negative for fracture or bleed. A plain film of the hip showed chronic fractures of the left superior and inferior pubic rami but no new fractures. UA was concerning for UTI, she was started on macrobid. She was subsequently transferred to the floor. . On transfer to the floor, her VS were 98.2 128/70 98 18 98/4L. She was without acute complaints initially. Her antibiotics were broadened to linezolid and cipro on [2-15]. On the evening of [2-15], she triggered on the floor for desaturation to 88% on 2-3L; came up to 94-95% with 5L O2. At baseline, she is in the low 90s on 2-3L at home. She got lasix 60 IV x1 (takes torsemide 100 [Hospital1 ] at home, but has been off since presentation due to hypotension), mucomyst, morphine 0.5, and nebs. Repeat lasix 40mg IV x1. ABG 7.51/45/51/37. HR was noted to be in the 120-130s (home B-blockers also stopped secondary to hypotension), got lopressor 5mg IV x 2 with little effect. Attempted to put her on face mask for mouth breathing, but patient kept ripping it off. Pt was also complaining of chest pain, and was felt to have altered mental status and increased agitation. Pt was trasferred to the MICU for further management. Of note, she is [Hospital1 ] speaking only; per her daughter, she has not had any decreased interaction or confusion. The patient lives in subsidized senior housing and has 24/7 care. The daughter notes a slow decline in her functional status since a [2169] admission for MRSA pneumonia in which she was temporarily intubated. She was recently admitted in [Month (only) 1096] for CHF, and per the daughter, has not fully recovered functionally since. She has had multiple previous falls in the past related to neuropathy and already unsteady gait. Past Medical History: - Chronic diastolic heart failure, last EF 65% ([7-/2168]) - Hypertension - Dyslipidemia - Atrial fibrillation (not anticoagulated due to fall risk) - Microvascular disease - Extensive basal ganglia disease - Gait disorder - Advanced degenerative joint disease - Meniere's disease - Hard of hearing Social History: Patient lives at home by herself at subsidized senior housing in [Location (un) ] with assistance from family. She has a 24 hour care worker that watches her 5 days a week. Her daughter watches her the other 2 days each week. Her Grandson [Name (NI) 382] is an interpreter at [Hospital1 18] and is very active in her care. Granddaughter is ?also HCP. Aids help her with cleaning and shopping. No smoking or drinking. Family History: NC Physical Exam: Admission Physical Exam: VS - Temp 98.2F, BP128/70 , HR98 , R18 , O2-sat98 % 4LNC dry weight 60.4 kg GENERAL - fatigued appearing elderly female in NAD HEENT - bruising around right orbit with swelling, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, JVD to 8cm LUNGS - bibasilar crackles appreciated HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs). Pain on palpation of the feet bilaterally. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, alert, oriented to person and place. Poor compliance with neurologic exam, though CN were intact bilaterally. Strength 5/5 in all extremities. Normal sensation to light touch in all extremities. Patient declined getting out of bed for gait assessment and orthostatic vital signs. Pertinent Results: Admission Labs: [2169-2-13] 09:58PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 [2169-2-13] 09:58PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [2169-2-13] 09:58PM URINE RBC-16* WBC-92* BACTERIA-FEW YEAST-NONE EPI-<1 [2169-2-13] 09:58PM URINE HYALINE-18* [2169-2-13] 09:58PM URINE MUCOUS-RARE [2169-2-13] 01:30PM GLUCOSE-117* UREA N-32* CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-33* ANION GAP-13 [2169-2-13] 01:30PM estGFR-Using this [2169-2-13] 01:30PM cTropnT-<0.01 [2169-2-13] 01:30PM PHENYTOIN-8.1* [2169-2-13] 01:30PM WBC-7.0 RBC-3.50* HGB-11.0* HCT-32.2* MCV-92 MCH-31.5 MCHC-34.1 RDW-18.3* [2169-2-13] 01:30PM NEUTS-75.2* LYMPHS-16.4* MONOS-4.5 EOS-2.8 BASOS-1.2 [2169-2-13] 01:30PM PLT COUNT-218 Discharge Labs: Notable Labs: [2169-2-13] 01:30PM BLOOD cTropnT-<0.01 [2169-2-14] 06:50AM BLOOD CK-MB-2 cTropnT-<0.01 [2169-2-16] 12:10AM BLOOD CK-MB-1 cTropnT-<0.01 [2169-2-16] 05:01AM BLOOD CK-MB-2 cTropnT-<0.01 [2169-2-18] 03:34AM BLOOD proBNP-5862* [2169-2-14] 06:50AM BLOOD calTIBC-373 VitB12-1327* Folate-GREATER TH Ferritn-41 TRF-287 EKG [2169-2-13]: Atrial fibrillation with a rapid ventricular response. Variation in precordial lead placement as compared to the previous tracing of [2169-1-14]. The inferior ST-T wave changes are slightly more prominent. Otherwise, no diagnostic interim change. TWO VIEWS OF THE LEFT TIBIA AND FIBULA [2169-2-13]: Diffuse demineralization limits [Month/Day/Year 2742] of the osseous structures. No fracture or dislocation is present. The left knee is partially imaged and demonstrates mild-to-moderate degenerative changes within the medial and lateral compartments. No focal lytic or sclerotic osseous abnormality is seen. There are no radiopaque foreign bodies. No focal lytic or sclerotic osseous abnormalities are present. . PELVIS PLAIN FILMS [2169-2-13]: Limited [Month/Day/Year 2742]. Chronic fractures of the left superior and inferior pubic rami. No definite new fractures seen. If there is continued clinical concern for a pelvic fracture, a CT of the pelvis can be obtained for further [Month/Day/Year 2742]. . CT C-SPINE [2169-2-13]: preliminary read shows no fracture or subluxation of the cervical spine . CT HEAD W/O CONTRAST [2169-2-13]: preliminary read shows no acute intracranial pathology, chronic small vessel ischemia and atrophy stable. Sinus mucosal thickening new compared with prior, correlate for sinusitis . CXR [2169-2-13]: No acute traumatic injury identified. Enlargement of the hila likely reflective of underlying pulmonary arterial hypertension. Hiatal hernia with adjacent atelectasis. . Brief Hospital Course: Medicine Floor Course: Ms. [Known lastname 2749] is a [Age over 90 ]yo [Age over 90 595]-speaking female with severe dCHF, HTN, HLD, neuropathy, gait abnormalities who presents 3 days after likely mechanical fall without evidence of significant trauma. # RESPIRATORY FAILURE: She developed hypoxia to the low 80s on 3LNC on HD3 with significant resipiratory distress and tachypnea. CXR showed mild fluid overload. She was given albuterol and ipratropium nebulizers and IV lasix with rebounding of her sats to the upper 90s on 5LNC. She was agitated and refused to wear an oxygen mask or complete her neb treatments. She calmed with IV morphine which likewise lessened her tachypnea. She again decompensated with respiratory distress that evening and was subsequently transferred to the ICU for further care. The etiology was felt likely combination of pneumonia plus flash pulmonary edema in the setting of elevated HR in DHF, also possible aspiration in the setting of AMS. Pt was intubated and sedated. She was started on Meropenam and Linezolid for a 10d abx coverage and underwent significant diuresis with lasix gtt. She became afebrile, leukocytosis resolved and resp secretions decreased. There were ongoing discussions with palliative care regarding goals of care and eventually family decided to extubate without reintubation. Soon after, patient's oxygenation deteriorated on NC and face mask and goals of care were shifted towards comfort measures only. Non essential medications were discontinued and she was put on a morphine drip. She passed away secondary to hypoxemic respiratory failure on [2169-3-2] at 1:15AM with her daughter at her bedside. . # S/P FALL: She is a poor historian but states that she did not lose consciousness or suffer any prodromal syncopal or presyncopal symptoms. She sustained no major trauma from her fall aside from right eye echymoses, and CT of the head and cervical spine revealed no fractures or bleeds. She was admitted for a syncope workup. Her EKG and cardiac enzymes ruled out MI. She had no abnormalities on telemetry. She was mentating normally on admission. She did not start new medications recently. She was not orthostatic. Her daughter relates a progressive functional decline over the last year since being intubated in [2169] for MRSA pneumonia. She had fallen a number of times since. Mechanical fall was suspected given her history of lower-half parkinsonism, previous cerebellar strokes, severe arthritis, unstable gait, and neuropathy. Her family had previously decline rehab admission and had chosen to keep her home with 24 hour care. # ATRIAL FIBRILLATION: she has been rate controlled with diltiazem and metoprolol, which were continued on admission. These were continued on admission but were intermittently held due to hypotension. She is not on coumadin given her repeated falls. Her rates ranged from the 90s to low 100s, but climbed to the 110s-120s at the time of her respiratory distress. Metoprolol was continued during ICU stay at 12.5mg TID, dilt was held. # SEIZURE DISORDER: She has been on phenytoin since her CVA about 10 years ago which was accompanied by severe seizures. Phenytoin was continued until goals of care shifted. #) Altered mental status / agitation - differential includes hypoxia, infection, MI, PE, antibiotic side effect, delirium. Pt apparently had normal MS when she presented. MS appears to be altered in the setting of hypoxia and respiratory distress. Infection is also a possibility with known UTI and question of PNA in the setting of worsened respiratory status. MI was considered as possibility as pt complained of chest pain, although she has had negative CE x 2 since admission. Pt was started on cipro for UTI, which is known to cause AMS in elderly patients. Pt was subsequently intubated and therefore it was difficult to assess her status, however she alternated between more agitated and more lethargic. She was started on seroquel 25mg [Hospital1 ] with some improvement of agitation. As goals of care shifted, she was put on a morphine drip and agitation resolved. #) Hypernatremia: Pt developed hypernatremia to 150 in setting of lasix gtt with inability to take PO. Pt was started on free water flushes with TF with resolution of hypernatremia. #) Hypotension: Pt became hypotensive in setting of intubation and sedation. She was started on neo for pressure support given tachycardia from a.fib. This was then transitioned to levophed to improve peripheral perfusion. With decreasing sedation and decreasing diuresis patient was able to be weaned off pressure support. Medications on Admission: 1. diltiazem HCl 240 mg Capsule, Sustained Release daily 2. metoprolol succinate 150 mg daily 3. phenytoin sodium extended 300 mg daily 4. aspirin 325 mg daily 5. ursodiol 300 mg [Hospital1 ] 6. polyethylene glycol 17grams daily prn constipation 7. senna 8.6 mg [Hospital1 ] as needed for constipation. 8. docusate sodium 100 mg [Hospital1 ] 9. torsemide 100 mg Tablet [Hospital1 ] 10. potassium chloride 20 mEq daily Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Congestive Heart Failure Pneumonia Discharge Condition: Deceased. Discharge Instructions: None. Followup Instructions: None. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2764] Completed by:[2169-3-2]	[ "345.90", "781.2", "584.9", "428.0", "585.9", "599.0", "719.45", "780.2", "293.0", "518.84", "427.31", "486", "921.0", "E885.9", "428.33", "507.0", "403.90", "276.0" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.6" ]	icd9pcs	[ [ [] ] ]	12343, 12352	7186, 11829	291, 303	12431, 12443	4358, 4358	12497, 12625	3393, 3397		12313, 12320		12373, 12410		11855, 12290			12467, 12474		5245, 7163							3437, 4339																				244, 253										331, 2605					4374, 5228									2627, 2931	2947, 3377
15,758	154,952	44962	Discharge summary	report	Admission Date: [2167-9-19] Discharge Date: [2167-10-2] Date of Birth: [2115-8-22] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is a 52 year old male who presents now with a three day history of nausea, vomiting, fever and chills. Reports that the pain started three days prior which was sharp pain, crampy in nature, that was periumbilical but did radiate to his back. He reports a similar history of pain about a month ago which was less severe and managed by his primary care physician who found some transiently elevated liver function tests. He reports that he is still passing gas. His last bowel movement was yesterday but has noticed decreased P.O. intake with some nausea and emesis. PERTINENT LABORATORY DATA: White count of 26.5, his lipase was 1701. Chem-7 was normal. An ultrasound showed cholelithiasis with gallbladder wall thickening and edema consistent with acute cholecystitis. HOSPITAL COURSE: Patient was admitted to the Gold Surgery Service, was given aggressive intravenous hydration, Foley placed, was empirically started on levothyroxine, ampicillin and Flagyl with bowel rest, remaining n.p.o. and endoscopic retrograde cholangiopancreatography. Consultants were called to help assist with what appears to be gallstone pancreatitis. On hospital day one the patient did well overnight but did continue to have mid epigastric pain which was tender on palpation. His liver function tests were amylase 1214, lipase 1701. Patient underwent an MRCP to evaluate the bowel ducts and common bile duct stones which showed an acute pancreatitis with non-loculated fluid collections extending around the pancreatic tail and left anterior parenchymal space, large gallstone with some increased signal in the wall concerning for possible hemorrhagic cholecystitis. No choledocholithiasis. The patient was transferred to the Intensive Care Unit for closer monitoring because of a history of confusion and disorientation. The patient responded appropriately over the next one to two days and was transferred from Intensive Care Unit to the floor. Patient was continued on ampicillin, Levaquin and Flagyl on [9-23]. Patient remained in Intensive Care Unit due to lack of beds but was on floor status, had a low grade temperature of 100.6, was started on clears, had good urine output. On hospital day six the patient was continued on just Levaquin and Flagyl and was tolerating some P.O. However, began to have an increase in tenderness in his mid-epigastric region and increased abdominal pain. The patient remained n.p.o. and plan was for laparoscopic cholecystectomy in approximately three to four days. PICC line was placed. Total parenteral nutrition was started. On [9-27] patient had a temperature of 102.2, was pancultured, continued on total parenteral nutrition. On hospital day 11, [2167-9-29] patient underwent a laparoscopic cholecystectomy with intraoperative cholangiogram and a primary umbilical hernia repair. Patient was transferred to the floor postoperatively and had an unremarkable postoperative course and advanced from n.p.o. to clears to full diet without abdominal pain or nausea or vomiting. Total parenteral nutrition was halved and then stopped. Patient was discharged in good condition to home. DISCHARGE DIAGNOSIS: 1. Laparoscopic cholecystectomy with intraoperative cholangiogram on [2167-9-29]. 2. History of obstructive sleep apnea and uses CPAP at home. 3. Depression. 4. Hypothyroidism. MEDICATIONS ON DISCHARGE: Lamotrigine 100 mg P.O. q day, albuterol and Atrovent, Percocet 5/325 1 to 2 tablets P.O. q 4 to 6 hours, dispense 60, beta blocker metoprolol 25 mg P.O. q day, levothyroxine 25 mcg P.O. q day and Colace 100 mg P.O. B.I.D, dispense 60. Patient is to follow with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 468] in one to two weeks. [Name6 (MD) ] [Last Name (NamePattern4) 7542], [MD Number(1) 7543] Dictated By:[Name8 (MD) 96147] MEDQUIST36 D: [2167-10-18] 14:07:42 T: [2167-10-18] 15:28:59 Job#: [Job Number 38827]	[ "553.1", "574.20", "576.1", "244.9", "577.0" ]	icd9cm	[ [ [] ] ]	[ "87.53", "99.15", "51.23", "38.93", "93.90", "53.49" ]	icd9pcs	[ [ [] ] ]											3357, 3543	3570, 4159		984, 3336																																									183, 966
6,473	166,876	28720	Discharge summary	report	Admission Date: [2136-9-22] Discharge Date: [2136-10-3] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Back pain Major Surgical or Invasive Procedure: [9-26] Endovascular stent graft(L subclav->distal thoracic aneurysm) History of Present Illness: 83 yo M presented to LGH with 2 months of back pain, transferred to [Hospital1 18] after CT scan showed aortic aneurysm from distal arch to suprarenal. Past Medical History: CAD HTN Prostate Ca ?CVA HOH Social History: [Last Name (un) ] Family History: [Last Name (un) ] Physical Exam: VS: 97.1 65 153/69 18 (&RA General: NAD w/o complaints Heart: RRR, -murmur Lungs: CTAB -w/r/r Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused Pertinent Results: Chest CTA [9-22]: Diffusely ectatic aorta throughout its entire course. Severe dilatation between the aortic arch and level of T6 with maximal diameter of 7.6 cm and significant atherosclerotic plaque burden. Aortic ectasia extends into the innominate artery and the common iliac arteries. Common origin of left common carotid artery and the innominate artery. Echo [9-26]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is markedly dilated. There are complex (>4mm)atheroma in the descending thoracic aorta. An echogenicity consistent with large plaque/intramural thrombus was noted in the descending thoracic aorta, it measured 1.0 cm in its largest diameter. Mild (1+) aortic regurgitation is seen. Post endovascular stenting, an echogenic material consistent with an endostent is seen in the distal arch and descending thoracic aorta. Visualization was incomplete, but no endoleak was identifited. Chest CTA [9-30]: Type III endoleak at the level of the arch. Question endoleak in the distal thoracic aorta at the level of T7. No significant changes in the maximum diameters of the aneurysmal sac. Abdominal aortic ectasia and the common iliac arteries. Short segment of possible dissection in the left external iliac artery. Short segment of dissection in the right external artery is unchanged. [2136-9-22] 01:25AM BLOOD WBC-5.7 RBC-4.61 Hgb-12.9* Hct-35.9* MCV-78* MCH-28.0 MCHC-35.9* RDW-13.9 Plt Ct-203 [2136-9-25] 04:18AM BLOOD WBC-6.2 RBC-3.96* Hgb-11.0* Hct-30.9* MCV-78* MCH-27.7 MCHC-35.6* RDW-14.1 Plt Ct-132* [2136-10-3] 11:15AM BLOOD WBC-8.6 RBC-3.42* Hgb-9.8* Hct-27.3* MCV-80* MCH-28.5 MCHC-35.7* RDW-14.2 Plt Ct-275 [2136-9-22] 01:25AM BLOOD PT-12.4 PTT-26.6 INR(PT)-1.1 [2136-9-25] 04:18AM BLOOD PT-12.3 PTT-29.4 INR(PT)-1.1 [2136-10-3] 11:15AM BLOOD PT-13.4* INR(PT)-1.2* [2136-9-22] 01:25AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [2136-9-25] 04:18AM BLOOD Glucose-89 UreaN-25* Creat-1.3* Na-138 K-4.3 Cl-106 HCO3-25 AnGap-11 [2136-10-3] 11:15AM BLOOD Glucose-119* UreaN-21* Creat-0.9 Na-133 K-4.3 [2136-10-1] 04:32AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.5 [2136-9-25] 07:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 69435] was transferred from OSH after CT showed a large aortic aneurysm. Upon admission he was immediately evaluated by both Cardiac and Vascular Surgery. He underwent another chest CT upon admission. With ultimate MMS reconstruction. Please see pertinent results. Over the next several days his blood pressure and hemodynamics were tightly managed. Once MMS reconstruction was completed it was determined he would undergo Endograft stenting of aorta. On [9-26] he was brought to the operating room where he underwent Endograft stenting from his mid arch/left subclavian to his distal thoracic aorta. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and was extubated. Lumbar drain was removed on post-op day two. He did require Nitro or Nicardipine secondary to hypertension several days post-op. He was then converted to oral hypertensive meds and on post-op day three he was transferred to the step-down floor. On post-op day four he had a bradycardic and hypotensive event. He did remain alert and oriented. He underwent a chest CT and then brought to the CSRU for closer observation. Bradycardia seemed to be from second degree heart block. The next day, post-op day five, he appeared stable and was transferred back to the step-down floor. Over the next couple of days he continued to look stable and good clinically. Physical therapy followed him during entire post-op course for strength and mobility. He was discharged home on post-op day seven with VNA services and the appropriate follow-up appointments. He will return in 2 weeks for staple removal from groin. Medications on Admission: Norvasc, Digoxin, Enalapril Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Thoraco-Abdominal Aortic Aneurysm s/p Endovascular stent graft(L subclav->distal thoracic aneurysm) PMH: Coronary Artery Disease, Hypertension, s/p prostatectomy Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision, or weight gain more than 2 pounds in one day or five in one week. Shower, no baths. No heavy lifting. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ]/[Doctor Last Name ] with CT Scan in 2 weeks Dr. [Last Name (STitle) ] 2 weeks Left groin staple removal 2 weeks Completed by:[2136-10-24]	[ "996.74", "E878.1", "414.01", "401.9", "366.9", "E849.7", "426.11", "441.7" ]	icd9cm	[ [ [] ] ]	[ "39.73", "39.71", "88.44" ]	icd9pcs	[ [ [] ] ]	6091, 6174	3553, 5363	278, 352	6379, 6385	843, 3530		644, 667		5441, 6068		6195, 6358		5389, 5418			6409, 6564			6615, 6798						682, 824																				229, 240										380, 537														559, 589	605, 628
54,563	175,019	41807	Discharge summary	report	Admission Date: [2148-7-22] Discharge Date: [2148-7-30] Date of Birth: [2089-6-20] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[First Name3 (LF) 3705] Chief Complaint: Difficulty ambulating, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 59yoM with multiple medical problems including CAD s/p stent, CVA x2, DM2, OSA, HTN, HLD, and advanced renal disease who is presenting for evaluation of difficulty walking and fatigue. He repeatedly falls asleep during our interview and requires redirection on every question. He fully alerts and answers questions appropriately, though his somnolence limited the history-taking substantially. . He describes a chronic decline in function over the past few months, noting that it has been more difficult to rise out of chairs and ambulate. He at times attributed this to right hip pain as the limiting factor, though later suggested the hip is not painful. He feel fatigued throughout the daytime and has a general lack of energy. He does carry a diagnosis of OSA and has not been compliant with CPAP recently. He was unfortunately also inconsistent with symptoms of lightheadedness during these episodes of difficulty walking- He has been nauseated and has not been drinking as much recently. He denies any trauma. . On arrival to the ED, his initial vitals were 98.8 56 117/52 20 95% 2L Nasal Cannula. He complained of severe back pain. There was no concerning EKG findings, and a CXR revealed no acute cardiopulmonary process. There was no fracture on a left hip plain film as well. . On arrival to the floor, his initial vitals were T100 BP196/77 P72 RR20 Sat95RA. He recalled having told the ED about a bout of tachypnea last night that was self limiting, but he has no further chest symptoms. He mentions that he thinks he has been sleeping poorly. He mentions right hip pain, though the left hip was examined and radiographed downstairs. A broad review of systems yields no focal weakness, no fevers/chills, no nausea or vomiting, no chest pain or pressure, no abdominal pain, dysuria, hematuria, no hematochezia or melena, no coughing or wheezing, no weight gain or loss. Past Medical History: -diastolic CHF-weight [2148-6-27] 295 lbs, up from 286 lbs [2148-5-9] -CAD s/p LAD stent x2 (unclear date) -CVA x 2 15ya and 2 [Last Name (un) ] -Back pain -Obstructive sleep apnea on CPAP -Retinopathy, diabetic, bilateral -Obesity, morbid -DM (diabetes mellitus), type 2 with renal complications, last A1c 7.3 -CKD (chronic kidney disease), stage IV s/p L AVF not on dialysis -h/o C. difficile diarrhea -Vitreous hemorrhage -Pseudophakia -Cataract -Hyperkalemia -Gout -Hyperlipidemia LDL goal < 70 -Proteinuria Social History: Lives in [Location (un) 90795] with a roommate, he apparently has 24hr home care. No smoking or ETOH. Family History: mom died of MI, father died of old age. Physical Exam: Admission: VITALS: T100 BP196/77 P72 RR20 Sat95RA GENERAL: somnolent, falls asleep between questions though easily arousable HEENT: PERRL, EOMI NECK: no carotid bruits, JVD LUNGS: CTAB on limited anterior exam, could not comply with posterior HEART: RRR, normal S1 S2, 3/6 SEM at the R 2nd ICS with carotid radation, apical murmur also radiating to the axilla. ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: 2+ edema to midleg. Full ROM without pain in the R and L hip. NEUROLOGIC: A+OX3 strength full in UE and LE bilaterally Discharge: VS T98.2-98.5 HR55-72 BP 157-159/76-79 RR18 O2Sat 98% RA General: Morbidly obese, A&Ox3, Denies current VH/AH. CV: Regular rate and rhythm, II/VI systolic murmur. Lungs: CTAB, no wheezing, crackles; moderate air movement Abdomen: soft, obese, non-distended; slightly tender is epigastrum. Ext: warm, well perfused, 2+ pulses, 1+ bilateral pitting edema to the shin, LUE fistula Pertinent Results: [2148-7-22] 06:35PM BLOOD WBC-7.9 RBC-3.82* Hgb-12.0* Hct-36.0* MCV-94 MCH-31.3 MCHC-33.2 RDW-13.4 Plt Ct-208 [2148-7-22] 06:35PM BLOOD Neuts-61.8 Lymphs-24.9 Monos-9.5 Eos-3.1 Baso-0.7 [2148-7-22] 06:35PM BLOOD PT-10.8 PTT-43.6* INR(PT)-1.0 [2148-7-22] 06:35PM BLOOD Glucose-132* UreaN-88* Creat-4.2# Na-141 K-5.3 Cl-110* HCO3-22 AnGap-14 [2148-7-22] 06:35PM BLOOD ALT-18 AST-19 AlkPhos-90 TotBili-0.3 [2148-7-23] 05:50AM BLOOD CK-MB-7 cTropnT-0.04* [2148-7-23] 10:27AM BLOOD CK-MB-7 cTropnT-0.14* [2148-7-23] 04:55PM BLOOD CK-MB-8 cTropnT-0.24* [2148-7-24] 03:56AM BLOOD CK-MB-5 cTropnT-0.23* [2148-7-23] 05:50AM BLOOD Calcium-8.5 Phos-7.1* Mg-2.1 [2148-7-22] 06:35PM BLOOD TSH-5.9* [2148-7-23] 10:27AM BLOOD T3-93 Free T4-1.1 [2148-7-23] 07:38AM BLOOD Type-ART Temp-38.3 FiO2-91 O2 Flow-6 pO2-75* pCO2-50* pH-7.16* calTCO2-19* Base XS--10 AADO2-532 REQ O2-88 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2148-7-23] 10:42AM BLOOD Type-[Last Name (un) ] pO2-170* pCO2-39 pH-7.22* calTCO2-17* Base XS--11 Comment-GREEN TOP [2148-7-22] 08:37PM BLOOD Lactate-1.4 [2148-7-23] 10:38AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.011 [2148-7-23] 10:38AM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2148-7-23] 10:38AM URINE Eos-NEGATIVE [2148-7-23] 10:38AM URINE Hours-RANDOM UreaN-490 Creat-151 Na-24 K-36 Cl-28 [7-22] CXR: Patchy opacity in the lingula, which is not specific as to etiology; pneumonia is not excluded, but the area is not well evaluated and opacity may be due to atelectasis. Noting the technical limitations of the film followup PA and lateral radiographs may be helpful if pulmonary symptoms were to persist. 7/16 L Hip film: No acute abnormality. If there is concern for an occult fracture, recommend MRI. [7-23] CXR: As compared to the previous radiograph, there is unchanged evidence of lower lung volumes and moderate cardiomegaly with signs of minimal fluid overload. No pneumonia, no larger pleural effusions. No lung nodules or masses. Renal U/S: No hydronephrosis. [2148-7-26] 07:20AM BLOOD WBC-5.9 RBC-3.59* Hgb-11.1* Hct-32.8* MCV-92 MCH-30.9 MCHC-33.8 RDW-13.2 Plt Ct-194 [2148-7-26] 07:20AM BLOOD Glucose-109* UreaN-108* Creat-5.0* Na-141 K-4.0 Cl-109* HCO3-23 AnGap-13 [2148-7-25] 08:12AM BLOOD Glucose-99 UreaN-110* Creat-5.5* Na-141 K-4.3 Cl-109* HCO3-21* AnGap-15 [2148-7-24] 03:56AM BLOOD Glucose-86 UreaN-95* Creat-4.9* Na-143 K-4.8 Cl-114* HCO3-15* AnGap-19 [2148-7-23] 04:55PM BLOOD Glucose-113* UreaN-96* Creat-4.6* Na-142 K-4.9 Cl-114* HCO3-14* AnGap-19 [2148-7-23] 04:55PM BLOOD Glucose-113* UreaN-96* Creat-4.6* Na-142 K-4.9 Cl-114* HCO3-14* AnGap-19 [2148-7-29] 06:00AM BLOOD Glucose-118* UreaN-80* Creat-3.5* Na-142 K-3.8 Cl-108 HCO3-25 AnGap-13 [2148-7-28] 07:00AM BLOOD Glucose-127* UreaN-86* Creat-3.7* Na-144 K-3.9 Cl-112* HCO3-21* AnGap-15 [2148-7-27] 08:48AM BLOOD Glucose-113* UreaN-97* Creat-4.2* Na-141 K-4.2 Cl-109* HCO3-20* AnGap-16 Brief Hospital Course: 59M with dCHF, stage IV CKD, HTN, DM who presented with subacute weakness and fatigue, found to have [Hospital 90796] transferred to ICU for hypoxia and AMS, most likely from flash pulmonary edema and uremia. . . # Hypoxia: Was oxygenating well on room air/2L NC at presentation and now requiring 6L NC with pO2 75. A-a gradient approx. 150. CXR with equivocal findings for PNA, also febrile with increasing WBC though no left shift or leukocytosis at admission. Some evidence of volume overload on exam with elevated JVP and bibasilar crackles, also with evidence on CXR, and SBP almost 200 at admission so may have had flash pulmonary edema. ACS also on differential, EKG unchanged. PE also a possibility though no evidence of significant hypoventilation given pCO2 of 50 in patient with OSA and likely elevated pCO2 at baseline. Uncontrolled OSA may also have been contributing. Mr. [Known lastname ] was transferred to ICU and received BiPAP for four hours and his respiratory and mental status improved. After BiPAP, he was able to maintain oxygenation on 3L NC. He received course of levofloxacin for possible PNA and was diuresed to relieve pulmonary edema. At time of discharge, he was satting well on RA and his respiratory exam was normal. # Altered Mental Status: Oriented to person, place, ?time at admission, was only oriented to person in context of changing clinical status next morning. After receiving BiPAP, antibiotics, and diuresis, patient was A&Ox3 and remained so for the remained of his stay. Differential diagnosis of altered mental status includes hypercarbia, uremia, sepsis. PCO2 only mildly elevated, so hypercarbia unlikely to cause this degree of altered mental status. Chest x-ray questionable for pneumonia. Urinalysis not convincing for infection. It is likely that all of these conditions combined to produce altered mental status. Patient had persistent hallucinations admission. Patient had excellent insight into his hallucinations. Per his roommate and sister, he hallucinates at baseline. # Acid/Base Status: ABG 7.16/50/75/19, AG 13 on day of admission. Most likely represents respiratory acidosis with superimposed AG and non-AG metabolic acidosis vs primary metabolic acidosis with respiratory compensation in the setting of chronically elevated pCO2 >50, though serum HCO3 22 in 2/[2148]. Per Winter's formula, expected pCO2 would be 30 with HCO3 15. Delta delta=8. AG acidosis could be due to hyperlactatemia. Non-AG acidosis most likely due to AoCRF. PH returned to [Location 213] during stay in the ICU with treatment of pneumonia and acute kidney injury. # Acute on chronic renal failure: Worsening Cr most likely due to obstruction or prerenal in setting of poor PO intake. FeNa 15%. Renal service was consulted and recommended holding ACE inhibitor. Hemodialysis was not initiated. Patient was fluid resuscitated and subsequently diuresed. Creatinine improved and was nearing baseline at time of discharge. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Furosemide 40 mg PO DAILY hold for SBP<100 2. Carvedilol 12.5 mg PO BID hold for SBP<100, HR<60 3. NIFEdipine CR 60 mg PO DAILY hold for SBP<100 4. Lisinopril 5 mg PO DAILY hold for SBP<100 5. Acetaminophen-Caff-Butalbital [1-8] TAB PO Q6H:PRN HA 6. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Isosorbide Dinitrate 60 mg PO DAILY hold for SBP<100 8. Gabapentin 600 mg PO DAILY 9. Gabapentin 300 mg PO BID in afternoon and evening 10. Allopurinol 100 mg PO DAILY 11. Simvastatin 20 mg PO DAILY 12. LaMOTrigine 100 mg PO BID 13. Aspirin 325 mg PO DAILY 14. Amitriptyline 20 mg PO HS 15. Clonazepam 1 mg PO DAILY 16. Ranitidine 150 mg PO BID 17. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Allopurinol 100 mg PO DAILY 2. Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. LaMOTrigine 100 mg PO BID 4. Ranitidine 150 mg PO BID 5. Simvastatin 20 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Aspirin 325 mg PO DAILY 8. Furosemide 40 mg PO DAILY hold for SBP<100 9. Isosorbide Dinitrate 60 mg PO DAILY hold for SBP<100 10. NIFEdipine CR 60 mg PO DAILY hold for SBP<100 Discharge Disposition: Extended Care Facility: [Hospital 4542] Rehabilitation and Nursing of [Location (un) 38] Discharge Diagnosis: Pneumonia Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Visual hallucinations with insight Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname ], You were admitted to the hospital for difficulty breathing and confusion. Your chest x-ray showed a possible pneumonia, so you were treated with antibiotics. Your lab tests showed that your kidneys suffered some damage, so you were given IV fluids and diuretics and your kidney function improved. Your trouble breathing improved with oxygen and CPAP. The following medications were changed: 1. Lisinopril - do not take this medication until instructed to do so by your nephrologist. 2. gabapentin - please discuss when to restart this medication with your primary physician. 3. clonazepam - please discuss when to restart this medication with your primary physician 4. Lasix - your dose of this medication was changed 5. Amitriptyline - this medication was stopped 6. Acetaminophen-Caff-Butalbital - this medication was stopped Please be sure to schedule and keep all of your follow-up appointments. And please take your medications as directed. It was a pleasure taking part in your care. We wish you a quick recovery. Followup Instructions: Please follow-up with your primary care doctor. Please call your nephrologist to make a followup appointment: - Dr. [Last Name (STitle) ] - [Location (un) 2274] [Hospital1 392] - Call [Doctor First Name ] to schedule appointment at [Telephone/Fax (1) 90797]	[ "272.4", "V12.54", "348.31", "428.0", "278.01", "414.01", "V85.42", "584.9", "327.23", "403.90", "250.40", "585.4", "428.33", "V45.82", "518.81", "276.7" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	11347, 11446	7087, 8357	320, 327	11520, 11520	3955, 7064	12813, 13095	2954, 2995		10921, 11324		11467, 11499		10092, 10898			11731, 12790									3010, 3936																				250, 282										355, 2268									11535, 11707					2290, 2815	2831, 2938
54,777	127,689	53667	Discharge summary	report	Admission Date: [2132-4-13] Discharge Date: [2132-4-18] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 983] Chief Complaint: abdominal pain, n/v Major Surgical or Invasive Procedure: ERCP History of Present Illness: Patient is a [Age over 90 ] year old woman with PMH of atrial fibrillation (not on coumadin), CHF, HTN, and rheumatoid arthritis (on prednisone) who presented to [Hospital6 33] on the morning of the day of transfer with nausea and vomiting. Patient was last in her usual state of health two days prior to presentation when she began to feel mild malaise with loss of appetite. On the day early morning hours of the day of admission, the sensation progressed to frank nausea with vomiting. The vomit did not have blood or dark material but patient admits that she would not be able to see this well, owing to her macular degeneration. Leading up to this she did not notice a change in her bowel habits. She denies fevers but reports feeling very cold in the two days preceding admission. Initial laboratory investigation revealed elevated ALT/AST 418/315, TBili 4.0, lactate 1.6. CT abdomen revealed choledocholithiasis. She received 2L of NS, with subsequent hypotension (BP 80/50). Another 1L NS was given with improvement of blood pressures BP 130/90s. Vancomycin, metronidazole and levofloxacin were given for suspected ascending cholangitis. Zofran was given for nausea. She was transferred for further management and likely ERCP. Vitals prior to transfer: BP 133/92, 96% RA. . On arrival to the ICU, Vital signs T: BP:136/97 P:107 R:22 O2:92%. She has no pain, no shortness of breath, no nausea, but endorses a feeling of "sour stomach". She feels no fever and has been having diarrhea for the day which she attributes to the antibiotics she is receiving. Past Medical History: Atrial fibrillation - not on coumadin Congestive heart failure - normal EF per cardiology note from [Hospital6 ], no record of echo Hypertension Rheumatoid arthritis - on prednisone Anxiety Gout macular degeneration Social History: - Tobacco: denies - Alcohol: denied - Illicits: denies Family History: noncontributory Physical Exam: ADMISSION EXAM: Vitals: afebrile BP:136/97 P:107 R:22 O2:92% General: Alert, oriented, no acute distress HEENT: Sclera very mildly icteric, MMM, oropharynx clear Neck: supple, JVP to angle of jaw, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: irregularly irregular rate and rhythm, normal S1 + S2, [4-1] systolic murmur heard best at the LUSB, no rubs, no gallops Abdomen: soft, non-tender, mild gaseous distension, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Exam VSS GEN: Patient lying comfortably in bed nad a+ox3 HEENT: MMM oropharynx clear NECK: supple no thyromegaly CV: rrr no m/r/g RESP: ctab no w/r/r ABD: soft nt nd bs+ EXTR: no le edema good pedal pulses bilaterally DERM: no rashes, ulcers or petechiae neuro: cn 2-12 grossly intact non-focal PSYCH: normal affect and mood Pertinent Results: ADMISSION LABS: [2132-4-13] 01:45PM BLOOD WBC-9.2 RBC-4.28 Hgb-13.6 Hct-42.1 MCV-98 MCH-31.7 MCHC-32.2 RDW-13.7 Plt Ct-319 [2132-4-13] 01:45PM BLOOD Neuts-90.6* Lymphs-7.0* Monos-2.1 Eos-0.3 Baso-0.1 [2132-4-13] 01:45PM BLOOD PT-12.2 PTT-26.4 INR(PT)-1.1 [2132-4-13] 01:45PM BLOOD Glucose-126* UreaN-14 Creat-0.9 Na-141 K-3.4 Cl-104 HCO3-24 AnGap-16 [2132-4-13] 01:45PM BLOOD ALT-338* AST-433* LD(LDH)-332* AlkPhos-423* TotBili-3.4* [2132-4-13] 01:45PM BLOOD Lipase-17 [2132-4-13] 01:45PM BLOOD Albumin-3.5 Calcium-8.2* Phos-2.0* Mg-1.6 [2132-4-13] 01:53PM BLOOD Lactate-2.1* MICROBIOLOGY: BCx pending UCx pending From OSH: [4-13] CT Abdomen/Pelvis with contrast: stones in the distal common bile duct and gallbladder with dilatation of the common bile duct and central intahepatic bile ducts EKG: afib with rate to 126, LAD, diffuse ST-depressions in inferior, lateral, and anterior leads ERCP: Impression: Two large periampullary diverticula were found at the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in opacification - A full cholangiogram was not done given cholangitis. The bile duct was severely dilated to 18 mm with multiple large filling defects consistent with CBD stones noted. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Pus was noted to drain from the biliary orifice. Given cholangitis, decision was made to place a stent rather than attempt lithotripsy and stone extraction in the current setting. A 5cm by 10FR double pigtail biliary stent was placed successfully. Discharge Labs: [2132-4-18] 06:50AM BLOOD WBC-8.5 RBC-3.67* Hgb-12.0 Hct-37.9 MCV-103* MCH-32.6* MCHC-31.6 RDW-14.1 Plt Ct-340 [2132-4-18] 06:50AM BLOOD PT-13.2* INR(PT)-1.2* [2132-4-18] 06:50AM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-139 K-3.1* Cl-101 HCO3-29 AnGap-12 [2132-4-18] 06:50AM BLOOD ALT-61* AST-29 AlkPhos-192* TotBili-0.9 [2132-4-17] 06:40AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7 Brief Hospital Course: Patient is a [Age over 90 ] yo female with PMH of afib with RVR, CHF, and RA on prednisone who is transferred here from OSH for choledocholithiasis with concerns for ascending cholangitis. She is hemodynamically stable, afebrile on abx, and awaiting ERCP for stone removal. # Choledochilithiasis/Ascending cholangitis: Patient presented to OSH with two days of malaise culminating in nausea and vomiting of unrelenting nature. Concerned for dehydration, her family brought her to the hospital where she was found to have elevated LFT's of a cholestatic picture, and hypotension initially not responsive to fluids. CT showed choledocholithiasis with CBD dilation. Patient was started on abx (vanc, levofloxacin, flagyl) and was given IVF with stabilization of BP. She was transferred to [Hospital1 18] for ERCP and stone removal. Currently, BP stable at 130's systolic with HR 120-130 and without fever, pain, and with mild jaundice. Her antibiotics was changed to ciprofloxacin and metronidazole for abdominal flora. She was given 500 cc NS bolus for her BP. She was kept NPO for ERCP. Following ERCP, she tolerated clear liquids without issue. Her diet was tolerated and she had no further abd pain and her lft/bili continued to improve. She was discharge on cipro/flagyl to complete a 7 day course(end [4-22]) and had a follow up with Dr. [Last Name (STitle) ] on [6-12] at 245 pm to discuss further intervention. # Afib with RVR: Patient has a history of afib with RVR for which she is on rate control with metoprolol and diltiazem at home. Holding home dose for now in the setting of hypotension related to N/V and infection. She received a dose of digoxin at OSH but will hold here. ECG reveals afib with RVR. She is not on anticoagulation at home because of significant vaginal bleeding that she experienced on coumadin. She was given metoprolol 12.5 mg PO as one time doses to control her HR and her diltiazem was held. Following her ERCP, her Metoprolol and Diltiazem were restarted with improvement in her heart rate. Anticoagulation was deferred given expected procedures during the hospital stay. Her metoprolol and dilt were continued. She would have episodes of asymptommatic hypotension at night for which her meds were held, but then her hr would increase. She was discharged on metoprolol 50 tid and dilt 30 [Hospital1 ] with good hr control. BP will have to be monitored at rehab. She was restarted on aspirin on discharge(she previously had not been on coumadin) # CHF: Patient has a known history of chronic CHF of unknown type. She is on home Lasix and beta blocker. Currently she is not showing signs of heart failure, but did receive large amounts of fluids for volume depletion/hypotension at OSH. Cardiology consultation note obtained from [Hospital6 ] noted that she had "normal ejection fraction," but no report of echo was sent. As patient had evidence of pulmonary congestion on CXR, she was diuresed with home dose of lasix. With episode of hypotension on the floor, her lasix was held and will be held on discharge. Please evaluate clinically to decide when to restart lasix. # Arthritis: Patient has rheumatoid arthritis and gouty arthritis and is currently experiencing pain in her knee. She is on allopurinol and prednisone at home and those medications were continued. Medications on Admission: Medications (HOME): lasix 40mg PO daily potassium 20meq PO daily metoprolol 50mg PO BID prednisone 3mg PO daily aspirin 81mg PO daily cardizem 30mg PO BID tylenol prn stool softener daily ferrex 150mg PO daily claritin 1 daily allopurinol 150mg PO daily Vitamin D 50,000 units once weekly . Medications (UPON TRANSFER): allopurinol 150mg PO daily aspirin 81mg PO daily diltiazem 30mg PO BID hydrocortisone 100mg IV Q8H levofloxacin 500mg IV daily lopressor 50mg PO BID flagyl 500mg IV Q8H morphine 2mg IV prn zofran 4mg IV Q6H prn protonix 20mg IV BID prednisone 3mg PO daily vancomycin 1250mg IVx1 Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. Discharge Disposition: Extended Care Facility: [Location (un) 25112] at [Doctor Last Name ] Ponds Discharge Diagnosis: Cholangitis 2nd diagnosis: afib chf htn 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 increased abd pain and found to have an infection of your bile ducts(cholangitis). An ERCP was performed and a stent was placed to drain the bile and antibiotics were given. Your infection improved and your symptoms resolved. You were deconditioned after your hospitalization and will need to go to acute discharge for rehab. New medications 1. Ciprofloxacin end [4-22] 2. Flagyl end [4-22] Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: THURSDAY [2132-6-12] at 2:45 PM With: [Name6 (MD) ] [Name8 (MD) ], M.D. [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	[ "401.9", "V15.82", "V58.65", "428.0", "362.50", "714.0", "V49.86", "574.50", "458.9", "300.00", "428.33", "427.31", "621.2", "274.00", "576.1" ]	icd9cm	[ [ [] ] ]	[ "51.85", "51.87" ]	icd9pcs	[ [ [] ] ]	9978, 10063	5327, 8672	238, 245	10146, 10146	3182, 3182	10778, 11113	2177, 2194		9321, 9955		10084, 10125		8698, 9298			10329, 10755		4908, 5304							2209, 3163																				179, 200										273, 1846					3198, 4891				10161, 10305					1868, 2089	2105, 2161
27,597	130,946	34482	Discharge summary	report	Admission Date: [2199-12-23] Discharge Date: [2200-1-1] Date of Birth: [2139-4-7] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 613] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 60 yo M with a history of Wegeners granulomatosis, presents with fever and cough. He has a [First Name3 (LF) ] cough, but notes worsening x 3 days. He also reports shortness of breath and fatigue. He denies chest pain, nausea or vomiting. He also notes an increase in the [First Name3 (LF) ] swelling of his B/L LE. He was seen by his PCP 4 days PTA with increasing DOE and tachycardia; a CXR, labs and a BNP were checked at that point, all of which were unremarkable. He reports that his symptoms have gotten significantly worse since then. He did not want to come to the ED over the weekend, so waited until this morning. He reports he spiked a temp to 104 at home this morning. He feels short of breath and generally tired and fatigued, but denies myalgias. The patient did have a flu shot this year. . In the ED, initial vs were 102.2 132 107/70 30 93 RA, 98 on 4L NC. Patient was given Azithromycin 500 mg, Ceftriaxone 1g, stress dose steroids (Hydrocortisone 100mg), Albuterol and Ipratropium Nebs, and Acetaminophen 1000mg. He was given 2L IVF, however HR remained 130s and the patient had an increased work of breathing, therefore he was admitted to the ICU. . On arrival to the ICU, the patient was tachypnic and complaining of shortness of breath. . Past Medical History: - Wegener's granulomatosis - Latent Tb -- Ruled out for active infection in [7-5], currently on INH and pyridoxime with LFT monitoring - h/o Aspergillosis of sinuses (treated w/ voriconazole) - CKD Stage III ([12-30] Wegner's) -- baseline creatinine 2.8 - Secondary hyperparathyroidism - [Month/Day (2) 8304] AFlutter - Anemia - Diastolic CHF Social History: Born in [Country 6257], moved to USA in [2170]. He used to work as a machine operator until the recent illness. He is divorced and has two children. He lives with his sister, and his niece [Name (NI) 19313] comes by daily and partipates actively in his care. He smoked 1.5 packs cigs/day for 40-years, quit in [2194]. He used to drink one or two drinks per day but not anymore since this illness. He denies any drug use. Family History: Family History: -Mother -- died of CVA age 85 -Father died in 70s, unknown cause. Had active TB. -No history of CAD, cancer, autoimmune, kidney, or lung disease in family. No known cancer, autoimmune disease, kidney or lung disease in his family. Physical Exam: General Appearance: tachypnic, uncomfortable, moderate distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), tachycardic Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: 2+, Left: 2+ Skin: Warm Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Normal Pertinent Results: [2199-12-23] 11:10AM WBC-1.9* RBC-2.69* HGB-8.6* HCT-25.3* MCV-94 MCH-32.1* MCHC-34.0 RDW-15.7* [2199-12-23] 11:10AM NEUTS-85* BANDS-2 LYMPHS-4* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-2* PROMYELO-1* NUC RBCS-1* [2199-12-23] 11:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL [2199-12-23] 11:10AM PLT SMR-LOW PLT COUNT-104* [2199-12-23] 10:53AM LACTATE-1.2 [2199-12-23] 11:10AM HAPTOGLOB-476* [2199-12-23] 11:10AM ALT(SGPT)-20 AST(SGOT)-29 LD(LDH)-404* ALK PHOS-53 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [2199-12-23] 11:10AM GLUCOSE-66* UREA N-91* CREAT-2.9* SODIUM-144 POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-18 [2199-12-23] 02:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2199-12-23] 07:03PM TYPE-[Last Name (un) ] PO2-27* PCO2-49* PH-7.24* TOTAL CO2-22 BASE XS--7 . [12-23] CT CHEST - 1. New moderately severe widespread bronchocentric process, suspect virus, mycoplasma or H. influenza infection, or atypical edema. 2. Left upper lobe pneumonia cleared since [7-31]. Severe emphysema. 4. Adjacent right upper lobe scar-like lesions and right lower lobe nodule need continued followup to exclude active processes. 5. Persistent central adenopathy in all mediastinal stations and both hila. 6. Persistent small bilateral pleural effusions, decreased on the left. 7. Probable anemia. Brief Hospital Course: 60M with Wegener's granulomatosis admitted with respiratory distress found to have Parainfluenza, now with ARF. . # Respiratory distress: The patient was admitted to the ICU with increased work of breathing, tachycardia and fever. Rapid respiratory viral screen revealed parainfluenza infection. CT chest was consistent with bronchiolitis. Given the patient's history of immunosuppression he was evaluated by the ID service. Additional workup including cryptococcal antigen, urine legionella were negative. Glucan and galactomannan were negative. Sputum culture final pending. He completed a 7 day course of ceftriaxone/azithro for possible additional CAP given [Month (only) ] steroid use. He is continued on expectorants and nebulizers. Nystatin was initiated prior to discharge for oral thrush. . # Pancytopenia: Patient had a history of pancytopenia, thought to be due to myelosuppression from cytoxan and possibly Bactrim. He has an unexplained low CD4 count, most recently 4 on [11-6]. HIV was negative as recently as [10-5]. BM biopsy in past w/ normocellular marrow, thought toxin induced suppression. Rectal guaiac on admission was negative. He was seen by the heme/onc service for consideration of eventual repeat BM biopsy if his counts failed to improve. His bactrim was changed to atovoquone for PCP prophylaxis and PPI was discontinued. No further interventions were made. The patient should follow up with the hematology service as an outpatient. . # Acute on [Month/Year (2) 8304] Renal Failure: The patient had a history of CKD due to vasculitic renal complications from Wegners/RPGN with a baseline Cr 2.0-2.3. On admission, the patient was noted to have a creatinine of 3.8. The nephrology service was consulted and the patient was noted to have urine sediment inconclusive for Wegeners. It was felt that the patient's renal failure was more likely ATN related to [Month/Year (2) ] hypoperfusion with acute exacerbation in the setting of illness. His renal function improved mildly with hydration and at the time of discharge, the patient's creatinine was 1.8. His lisinopril was restarted on day of discharge with instructions to stop if creatinine >3, per renal recommendations. . # Wegener's granulomatosis: Had incomplete induction therapy with Cytoxan (aborted due to side effect), currently on prednisone 50 daily as outpatient, no current evidence of wegener??????s flare. He was started on stress dose steroids on admission to the ICU, which was tapered to 40mg [Hospital1 ] in the setting of infection. Renal and rheumatology were consulted. It was recommended that azathioprine therapy be considered as an outpatient. In addtion, TPMT enzyme activity was evaluated and was normal (19.7 U/mL). . # Atrial Filbrillation ?????? Pt initially with RVR in setting of illness to 130s. He was started on metoprolol 75mg po QID. Diltiazem 60mg QID added with improved rate control. . # Latent Tb: continued INH and pyridoxine . # Code: full . # Communication: Patient, neice [Name (NI) 19313] (HCP) [Telephone/Fax (1) 79235] #Follow-up: appointments have been set up for rheumatology and renal clinic follow-up. Medications on Admission: CALCITRIOL - 0.25 mcg daily GLIPIZIDE - 2.5 mg daily COMBIVENT - 18 mcg-103 mcg PRN ISONIAZID - 300 mg Tablet daily LISINOPRIL - 10 mg Tablet daily METOPROLOL TARTRATE - 100 mg [Hospital1 ] NYSTATIN - 100,000 unit/mL - one tsp PO QID PANTOPRAZOLE - 40 mg Tablet, daily PREDNISONE - 50 mg Tablet daily BACTRIM DS - 800 mg-160 mg Tablet qMWF CALCIUM CARBONATE 1500 mg TID FERROUS SULFATE 325 mg [Hospital1 ] PYRIDOXINE 25 mg daily THIAMINE HCL - 100 mg Tablet daily Colace PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Pyridoxine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily). 13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 15. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q6h PRN (). 16. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 18. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 19. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 3 days: started [2199-12-28] for 7 day course. 20. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 22. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 3894] Nursing & Rehabilitation Center - [Location (un) 5503] Discharge Diagnosis: Respiratory Distress secondary to Parainfluenza possible community-acquired pneumonia Wegener's granulomatosis Latent Tb Acute on [Location (un) 8304] Kidney Disease (Stage III) Secondary hyperparathyroidism [Location (un) 8304] AFlutter Anemia of [Location (un) ] disease [Location (un) ] diastolic CHF Discharge Condition: The patient was hemodynamically stable, afebrile and without pain. Oxygen prior to discharge is 93% on RA Discharge Instructions: You were admitted for evaluation and treatment of fevers and cough. Your symptoms were felt to be due to infection with a virus known as Parainfluenza. In addition, you were felt to have a pneumonia. During this hospitalization, you were treated with antibiotics and oxygen to help your breathing and your symptoms improved. . You are being discharged to [Hospital 3894] Rehabilitation where you will continue to receive care and physical therapy. . The following changes have been made to your regular medications: metoprolol and diltiazem for blood pressure and irregular rhythm bactrim for prophylaxis atovaquone, prednisone for Wegener's fluconazole for urinary tract infection (7 day course) Please take all medications as directed by your physician. Followup Instructions: Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2200-1-6] 3:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2200-1-6] 3:00 Provider: [Name10 (NameIs) ] [Last Name (STitle) ]/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2200-1-6] 4:00 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], Rheumatology [2200-1-20] at 10:30am Provider: [Last Name (NamePattern4) ].[Last Name (STitle) 1366], Renal, [Telephone/Fax (1) 60], [2200-2-6] at 1:00pm [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "465.9", "112.2", "284.1", "584.5", "585.3", "250.00", "285.29", "428.32", "486", "079.89", "446.4", "428.0", "427.32" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10588, 10694	5014, 8193	290, 297	11058, 11167	3428, 4991	11980, 12797	2471, 2704		8729, 10565		10715, 11037		8219, 8706			11191, 11957									2719, 3409																				230, 252										325, 1605														1627, 1984	2000, 2439
76,262	150,891	37539	Discharge summary	report	Admission Date: [2137-11-26] Discharge Date: [2137-12-4] Date of Birth: [2116-3-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 22864] Chief Complaint: Altered mental status, acute hepatitis. Major Surgical or Invasive Procedure: -intraamniotic Digoxin injection ([12-2]) -dilation and evacuation of intrauterine pregnancy in pieces ([12-3]) History of Present Illness: Patient is a 21 yo W G3P1, now 22w6d with PMH of ETOH and vicodin abuse found at home in bathtub with altered mental status. She was brought to OSH agitated and hypoxic, intubated and transferred for management of fulminant hepatic failure. Initial labs include the following: AST 897, ALT 1022, Alk phos 119 T bili 5.5, Alb 2.7, lipase 48, ammonia 157, hct 28.4, plt 304, INR 2.7, Cr 1.4, tylenol<10, neg salicylate level, urine tox positive for opiates. CT head was without any abnormalities. Past Medical History: Asthma G3P1 Etoh abuse since age 15 Social History: Lives with her grandmother, smoker, heavy Etoh abuse w/ daily bourbon. Abuses vicodin which she buys on the street. Has a 2.5 yo son who lives with Father. [Name (NI) ] history of prior SI or HI. Recent breakup with BF. Family History: Non-contributory. Physical Exam: Vitals - T: 98.8 BP: 131/80 HR: 91 RR: 30 02 sat: 100% on 50% FIO2 PEEP 5 GENERAL: Sedated on vent, withdraws from painful stimuli HEENT: No icterus, scleral hemorhage on R, MMM, ETT in place with dried blood on tube CARDIAC: Tachycardic, REgular, No MRG LUNG: CTAB ABDOMEN: Gravid, soft, NT, BS+ EXT: No edema, 2+ DP/PT pulses NEURO: pupils equal and reactive to light, no clonus, Knee reflexes hyperreflexic bilaterally. DERM: No rashes Pertinent Results: Labs at Admission: [2137-11-26] 11:45PM BLOOD WBC-5.9 RBC-2.93* Hgb-8.9* Hct-27.2* MCV-93 MCH-30.3 MCHC-32.6 RDW-17.9* Plt Ct-250 [2137-11-26] 11:45PM BLOOD Neuts-67 Bands-0 Lymphs-21 Monos-3 Eos-5* Baso-0 Atyps-0 Metas-3* Myelos-1* [2137-11-26] 11:45PM BLOOD PT-17.1* PTT-28.8 INR(PT)-1.5* [2137-11-26] 11:45PM BLOOD Glucose-115* UreaN-15 Creat-0.5 Na-146* K-3.9 Cl-123* HCO3-18* AnGap-9 [2137-11-26] 11:45PM BLOOD ALT-439* AST-111* LD(LDH)-228 AlkPhos-69 TotBili-4.3* [2137-11-26] 11:45PM BLOOD Albumin-2.4* Calcium-7.1* Phos-1.4* Mg-1.5* [2137-11-26] 11:45PM BLOOD Hapto-28* [2137-11-27] 05:45AM BLOOD calTIBC-247* Ferritn-288* TRF-190* [2137-11-26] 11:45PM BLOOD Triglyc-204* [2137-12-1] 05:06AM BLOOD Triglyc-145 [2137-11-27] 06:02AM BLOOD Ammonia-59* [2137-11-27] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2137-11-27] 11:58AM BLOOD Smooth-NEGATIVE [2137-11-27] 11:58AM BLOOD [Doctor First Name ]-NEGATIVE [2137-11-27] 05:45AM BLOOD IgG-736 [2137-11-27] 05:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2137-11-27] 05:45AM BLOOD HCV Ab-NEGATIVE [2137-11-29] 08:35AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM-PND Labs at Discharge: [2137-12-4] 07:22AM BLOOD WBC-11.3* RBC-2.40* Hgb-7.7* Hct-23.5* MCV-98 MCH-32.0 MCHC-32.8 RDW-17.2* Plt Ct-385 [2137-12-4] 07:22AM BLOOD Glucose-77 UreaN-5* Creat-0.4 Na-140 K-4.4 Cl-107 HCO3-27 AnGap-10 [2137-12-4] 07:22AM BLOOD ALT-73* AST-40 AlkPhos-72 TotBili-1.7* [2137-12-3] 06:20AM BLOOD Lipase-931* [2137-12-2] 05:45AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.6 Iron-115 Microbiological Data: Sputum culture ([11-28]) [2137-11-28] 9:59 pm SPUTUM Source: Endotracheal. FINAL REPORT [2137-12-1] GRAM STAIN (Final [2137-11-29]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2137-12-1]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([6-/2434]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Imaging Studies: TTE ([11-27]): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). 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 estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Abdominal ultrasound with doppler ([11-27]): 1. Normal grayscale appearance of the liver without biliary ductal dilatation. 2. Normal Doppler interrogation of liver. 3. Small right pleural effusion and trace right perinephric fluid. EEG ([11-28]): IMPRESSION: Abnormal portable EEG due to the slow background with bursts of additional generalized slowing. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. There were no areas of focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. CXR ([11-28]): Portable AP chest radiograph was reviewed in comparison to prior study obtained the same day earlier at 05:09 a.m. The ET tube tip is 4 cm above the carina. The NG tube tip is in the stomach. There is no change in the left retrocardiac consolidation with air bronchogram that might be consistent with infectious process. There is slight interval improvement of pulmonary edema which is currently mild to moderate. Bilateral pleural effusions are present. Brief Hospital Course: In summary a 21 year-old woman with past medical history of ETOH and vicodin abuse, now presenting 22-weeks gravid with acute hepatitis, believed due to alcohol and acetaminophen toxicity. # Liver failure, hepatitis. Regarding her liver failure, her LFTs peaked at 1022 (ALT) and then trended down. T Bili peaked around 5.5. Hep serologies and autoimmune panel were negative. Pt was seen by liver service who felt underlying etiology was secondary to chronic tylenol in setting of ETOH abuse. She was treated with NAC and started on lactulose. RUQ u/s was negative for abnormalities. Her INR though elevated at OSH normalized at time fo discharge. HSV serology is the only test still pending. When she follows up in clinic on [Last Name (LF) 766], [12-9] liver enzymes should be rechecked to assess for resolution of hepatitis. # Respiratory status, intubation, pneumonia. She was initially on propafol for sedation but this was discontinued due to elevated lipase. Her lipase trended up for several days, peaking at 1046, then downtrending at time of discharge. She was extubated [11-29]. A CXR was obtained that showed RLL opacity and sputum cultures grew out MRSA. She was treated with a 7-day course of vancomycin and cefepime for healthcare-associated pneumonia. She denied respiratory complaints at time of discharge; she was afebrile with a white count of 11. # Mental status, psychiatric status. After extubation, patient was noted to be sleepy though able to answer questions appropriately. The ICU team started CIWA scale for concern of withdrawal as patient became agitated overnight with tachycardia. Psychiatry evaluated pt and felt initially that intent of overdose was unclear, but recommend continued 1:1 sitter while mental status was being evaluated. She did report to psych resident that she took a lot of tylenol and vicodin. She had a recent arrest for illegally obtaining vicodin for which she has an upcoming court date. Gradually her mental status cleared. Psych re-evaluated her and felt that there was no need for 1:1 sitter. Per their note, she continues to minimize her substance abuse, particularly around the need for ongoing treatment for substance abuse once she leaves the hospital. She was agreeable to getting into therapy. Per their note, she did not appear to be at increased risk of harm to self or others and did not meet section 12 criteria for psych admission. Arrangements have been made for patient to follow-up for therapy and substance abuse treatment in [Doctor Last Name ]. # Pregnancy, therapeutic abortion, birth control. Patient underwent therapeutic abortion on [12-3] (dilation and evacuation). This was preceded by intraamniotic injection of 1 mg Digoxin on [12-2]. Obstetrics service has arranged for patient to have follow-up at [Hospital1 18] for [Hospital1 ] placement. Of note, GC and CT swabs during this admission were negative. # Pain control. After the TAB, patient had significant pelvic cramping. This was treated initially with Ketorolac and switched to ibuprofen at time of discharge. Breakthrough pain was treated with oxycodone. Patient in total received four doses of 5 mg oxycodone on [12-3] and [12-4]. # Anemia. Patient was noted to be anemic with hct ranging in mid to high 20s during this admission. Iron studies were negative. MCV was 98. The anemia was felt to be secondary to marrow suppression from acute hepatitis and inflammation, in addition to blood loss from the therapeutic abortion (approximately 600 ccs). She should have a CBC rechecked during her follow-up appointment on [Last Name (LF) 766], [12-9]. # Elevated lipase. As per above, this was felt secondary to propofol she received in the ICU. The lipase was downtrending at discharge. It could be rechecked at follow-up. # Smoking cigarettes. Per her report, patient smokes 1 pk every 2-3 days. She did not smoke any cigarettes during this admission. She is requesting Rx for nicotine patch, which has been provided at discharge. # Social work. Patient and family met with our social worker. [Name (NI) ] SW note, she was amenable to outpatient counseling as well as outpatient addictions treatment. Pt needs to call the following for intake appointment: For out patient Counseling: Tri Town Community Action Center: [0-0-] For structured out pt addictions program/intensive out pt: [Name (NI) 789] [Name (NI) ], [Street Address(2) 84284] [Hospital1 789]: [Telephone/Fax (1) 84285] # FEN: regular, replete electrolytes PRN. # Code: full. Medications on Admission: None. Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain/cramping. Disp:30 Tablet(s) Refills:0 2. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. Disp:30 qs Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Acute hepatitis Intrauterine pregnancy at 23 weeks gestation Discharge Condition: Vital signs stable. Mental status: alert and oriented x3. Ambulating without difficulty. Discharge Instructions: You were admitted to the hospital for evaluation of hepatitis and altered mental status. We believe that the hepatitis was due to Tylenol (from taking too much Vicodin) and alcohol. We have followed your liver enzymes during this admission and they are trending down towards normal. Your hematocrit, or red blood cell count, has been low, which we suspect is due to the hepatitis and the blood loss from the abortion. It is important that you follow-up at [Hospital 84286] Community Health Center next week (an appointment has been scheduled) so that you can have the complete blood count and liver enzymes checked. Additionally, you underwent therapeutic abortion during this admission. The obstetricians have scheduled a follow-up for you (provided below) at [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] placement. Followup Instructions: -TRI-TOWN COMMUNITY ACTION CENTER / HEALTH CENTER - appointment with Dr. [Last Name (STitle) 84287] on [Last Name (LF) 766], [12-9] at 1:30PM. Phone number is [0-0-]. -FAMILY PLANNING CLINIC at [Hospital1 ] Phone:[Telephone/Fax (1) 2664] or [Telephone/Fax (1) 84288] Date/Time:[2137-12-16] at 2PM. -INTAKE FOR OUTPATIENT ADDICTIONS TREATMENT PROGRAM at [Hospital1 ] CENTER at [Street Address(2) 84289] in [Hospital1 789], RI. Appointment is scheduled for Tuesday [2137-12-17] at 10:00AM, [Telephone/Fax (1) 84285]. Completed by:[2137-12-4]	[ "997.31", "648.23", "649.03", "285.1", "965.4", "041.12", "E850.4", "311", "647.93", "570", "577.0", "648.43", "305.01", "646.73", "305.50", "305.90", "518.81" ]	icd9cm	[ [ [] ] ]	[ "75.0", "96.71", "69.01", "96.6" ]	icd9pcs	[ [ [] ] ]	12555, 12561	7389, 11957	356, 478	12684, 12704	1812, 3081	13670, 14270	1318, 1337		12013, 12532		12582, 12663		11983, 11990			12799, 13647									1352, 1793																				277, 318							3101, 5312			506, 1002									12719, 12775					1024, 1061	1077, 1302			5330, 7366
14,073	104,347	29830	Discharge summary	report	Admission Date: [2181-4-24] Discharge Date: [2181-4-27] Date of Birth: [2113-2-10] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2297] Chief Complaint: Capsular hematoma and pneumothorax post liver biopsy. Major Surgical or Invasive Procedure: percutaneous liver biopsy History of Present Illness: 68 year-old male with recently diagnosed HTN and liver mass admitted for hemodynamic monitoring from intraperitoneal bleed after liver biopsy. Mass was incidentally discovered on a CT for nephrolithiasis [2113], and initially believed to be in pancreas. CT and MR of the abdomen showed 4x3cm mass to be in caudate liver. He presented for IR liver biopsy on [4-24], which was complicated by small RUL ptx. He was under observation when HCT dropped from 53 (admit) to 41 this morning. Of note, HCT was 45 post bx-->41 14 hrs later. CT abd/pelvis showed subcapsular hematoma, retroperitoneal bleed, blood in pelvis. On transfer to MICU for close observation hemodynamically stable and normal. Denies SOB, dizziness, abd pain. Had stopped baby ASA one week prior to liver bx. Past Medical History: 1. Liver mass as above 2. AAA 3x3 with minimal prior dissection 3. Nephrolithiasis (fall [2179]) 4. Hypertension (diagnosed two weeks prior, no medications) 5. Right inguinal hernia status post repair [5-/2180] 6. Arthritis 7. Alcohol abuse Social History: Retired school teacher, lives in [Hospital1 1562] currently with dying brother. [Name (NI) ] reports smoking [5-31] cigs/day for 40 years and 2 drinks/week. However, cousin told nurse that patient drinks and smokes much more than he admits. No prior blood transfusions. Family History: Brother has prostate Ca, colon cancer, CAD s/p bypass, now dying from cancer metastases. No family hx of pancreatic/liver disease. Physical Exam: 98.8 HR 82-88NSR BP 159/65(not accurate) RR24-28 O2sat 91-96% on room air Gen: AOX3. NAD HEENT: anicteric, PERRL, OP clear, no JVD Chest: RRR, nml S1 S2 Pulm: CTAB Abd: +Bs, NT, soft, tympanitic, no guarding, mildly distended Extr: No edema Pertinent Results: Labwork on admission: [2181-4-24] WBC-6.8 HGB-17.9 HCT-53.0* MCV-102* MCH-34.5* MCHC-33.8 PLT 178 [2181-4-27] WBC 5.2 Hgb 11.2 Hct 32.5 Plt Ct 120 [2181-4-24] 09:15AM PLT COUNT-192 [2181-4-24] 09:15AM PT-11.2 INR(PT)-0.9 [2181-4-24] 04:30PM WBC-8.8 RBC-4.46* HGB-15.5 HCT-45.1 MCV-101* MCH-34.7* MCHC-34.3 RDW-14.0 [2181-4-24] 04:30PM PLT COUNT-178 [2181-4-24] 04:30PM cTropnT-<0.01 . CT LIVER BX [2181-4-24] IMPRESSION: 1. Technically successful CT fluoroscopic-guided biopsy of periportal/caudate lobe lesion. 2. Small right (10-15%) pneumothorax. . CHEST (PA & LAT) [2181-4-24] 3:19 PM CHEST, TWO VIEWS, PA AND LATERAL History of liver biopsy with pneumothorax on post-scan radiograph. The previous chest radiographs are not on PACS for review. There is a small right pneumothorax. . CHEST (PA & LAT) [2181-4-24] 5:02 PM CONCLUSION: Stable right apical pneumothorax as compared to earlier today at 3:30 p.m. . LIVER OR GALLBLADDER US (SINGLE ORGAN) [2181-4-24] FINDINGS: This study was performed in conjunction with the CT fluoroscopic-guided biopsy done on same day ([2181-4-24]). Study was performed to assess feasibility to see if the lesion could be biopsied by ultrasound or CT fluoroscopy. Again seen is a periportal echogenic vascular lesion measuring approximately 2.2 cm in size. However, based on its location, it was decided that the best approach for sampling this lesion would be performed by CT fluoroscopy. . ECG Study Date of [2181-4-24] 4:16:14 PM Sinus rhythm. Biatrial enlargement. Non-specific inferolateral ST-T wave flattening. Delayed precordial R wave progression. No previous tracing available for comparison. . CT ABD W&W/O C [2181-4-25] IMPRESSION: 1. Unchanged right hepatic hematoma. No active extravasation. Increased prominence of the segment VII and VIII hepatic artery branch could reflect that this was the prior source of bleeding, though this is uncertain. 2. Heterogeneous perfusion of the liver likely related to _____ hematoma and the fact that the patient had heterogeneous perfusion prior to the procedure. No narrowing or thrombosis of hepatic or portal veins. 3. Large lesser sac hematoma and hemoperitoneum, as before. 4. Unchanged appearance of mass adjacent to the caudate lobe. 5. Decreased size of right pneumothorax with small remaining pneumothorax. 6. High-grade right renal artery stenosis. . CHEST (PA & LAT) [2181-4-25] REASON FOR EXAMINATION: Followup of pneumothorax after liver biopsy. PA and lateral upright chest radiograph compared to [2181-4-24]. The small right apical pneumothorax is stable or slightly decreased compared to the previous study giving the expiratory technique of the current exam. The marked emphysema and subpleural bullae are unchanged in appearance. The cardiomediastinal silhouette is stable. . CHEST (PA & LAT) [2181-4-26] CHEST TWO VIEWS PA AND LATERAL History of liver biopsy and pneumothorax. There is a persistent small right apical pneumothorax essentially unchanged since the previous film of [2181-4-25], there are new lung lesions. Brief Hospital Course: 68 year old male with incidentally discovered liver mass who presented to CT guided liver biopsy, compicated by right apical pneumothorax and peri-hepatic/intrapelvic hematoma, transferred to the ICU for closer monitoring. 1) Liver mass: As above, the patient underwent CT guided biopsy on arrival. The pathology is still pending at the time of discharge. Complicated by pneumothorax and bleeding (see below). The patient will follow up with his home GI doctor, Dr. [Last Name (STitle) ], who should call Dr. [Last Name (STitle) ] for results of the liver biopsy. 2) Peri-hepatic hematoma/intra-pelvic bleed: Secondary to liver biopsy. His hematocrit on arrival was 53, declining to 45 post-procedure, and then slowly trending down by a couple of points an hour to a nadir of 31.5. He did not require any red blood cell transfusions, and his hematocrit stabilized at around 32; 32.5 on the day of discharge. His aspirin had been discontinued 7 days prior to admission, and should not be restarted for at least a week, possibly longer, pending repeat hematocrit check by his PCP. 3) Pneumothorax: He developed a small right apical pneumothorax secondary to the procedure. His oxygenation was never impaired (>95% on room air throughout). He was given high flow O2 to speed the resolution. Followup chest x-rays demonstrated improvement/resolution of the pneumothorax. 4) Alcohol abuse: Though he denied significant alcohol use, his platelet count was on the low side, with elevated MCV, and his family reported significant use. He was therefore placed on a CIWA scale and required only one 10 mg dose of valium. He was not tachycardic, and appeared comfortable on discharge. He had a social work consult who spoke to him about both his alcohol use and smoking. He would like to try the patch and he was given a prescription for this. He is somewhat in denial about having a problem with drinking. 5) Hypertension: He was normotensive during the admission. This will be followed by his PCP. Medications on Admission: ASA 81 mg daily MVI Discharge Medications: 1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Disp:30 patches Refills:2 Discharge Disposition: Home Discharge Diagnosis: Intrabdominal bleed (subcapsular hematoma of liver, pelvis) Right upper lobe pneumothorax secondary to liver biopsy complications. Hepatic mass Alcohol withdrawal Discharge Condition: stable, no signs/symptoms of further bleeding Discharge Instructions: You had a liver biopsy which resulted in minor collapse of your R lung which is resolving, and some internal bleeding. You were monitored with serial checks of blood levels which were fine. Please seek medical attention immediately if you experience any symptoms of further bleeding such as shortness of breath, dizziness or chest pain. Because of your bleeding, you should not take your baby Aspirin for at least the next week, and probably not until you see your primary care doctor, who should recheck your blood level. Followup Instructions: Follow up with PCP (Dr. [Last Name (STitle) 71330] in [12-26] weeks. Please see Dr. [Last Name (STitle) ] in the next 1-2 weeks. He should call Dr. [Name (NI) 71331] office at [Telephone/Fax (1) 1983] to get the report from your liver biopsy.	[ "291.81", "V13.01", "998.12", "E878.8", "285.1", "235.3", "998.11", "303.90", "401.9", "305.1", "512.1" ]	icd9cm	[ [ [] ] ]	[ "50.11" ]	icd9pcs	[ [ [] ] ]	7594, 7600	5305, 7327	326, 354	7807, 7855	2158, 2166	8429, 8697	1750, 1882		7397, 7571		7621, 7786		7353, 7374			7879, 8406									1897, 2139																				233, 288										382, 1163							2180, 5282							1185, 1435	1451, 1734
28,424	179,065	43129	Discharge summary	report	Admission Date: [2145-10-29] Discharge Date: [2145-11-9] Date of Birth: [2066-12-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Colon polyp with high grade dysplasia. Major Surgical or Invasive Procedure: s/p Right laparascopic colectomy s/p Electrical cardioversion History of Present Illness: Mrs. [Known lastname 31738] is a 78yo female with a h/o AFIB c/b embolus to L arm, s/p cardiac ablation, s/p pacemaker, HTN, CRI. She underwent routine colonoscopy and extensive flat polyp at hepatic flexure seen. Biopsy showed adenoma with some dysplastic features. This is not amenable to resection via the endoscope. The patient was given her options and wished to have surgical treatment at this point in time, via laparoscopic approach. Past Medical History: PMH: Paroxysmal A. fib h/o embolus to L arm s/p cardiac ablation s/p pacemaker placement [1-15] sick sinus syndrome HTN CRI PSH: s/p hysterectomy Social History: Lives alone. Supportive daughter. Denies use of ETOH, tobacco, and illicit drugs. Family History: Non contributory No history of cardiac disease No diabetes Physical Exam: VS - 98.0 130/82 hr 98 (100-130s) 98% ra I/O @ MN - + 1200; I/O @ noon today + 1100 Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no JVD CV: irreg irreg. 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, mildly tender over sugical scars; purple band of eccyhomoses on lower abdomen; OBSESE. + bowel sounds. surgical incisions covered w/ steri strips, healing well, c/d/i. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: IMAGING: CHEST (PA & LAT) [2145-10-31] 5:45 PM [Hospital 93] MEDICAL CONDITION: 78 year old woman with s/p R lap colon HISTORY: Elevated white count. IMPRESSION: PA and lateral chest compared to [2140-11-9]: Mild cardiac enlargement, with substantial left atrial enlargement, accompanied by mild vascular engorgement but no edema, new since [2139]. Pleural effusion, if any, is minimal. Transvenous right atrial and right ventricular pacer leads are continuous from the right pectoral pacemaker. No pneumothorax. Supine intact. . ABDOMEN (SUPINE & ERECT) [2145-11-1] 8:42 AM [Hospital 93] MEDICAL CONDITION: 78 year old woman with polyps s/p Right Lap colon REASON FOR THIS EXAMINATION: Complaints of nausea. Rule out obstruction. HISTORY: Nausea, evaluate for obstruction. IMPRESSION: Findings highly suspicious for mid-distal small bowel obstruction. LABS: [2145-11-5] 01:30PM BLOOD WBC-8.0 RBC-3.32* Hgb-10.1* Hct-29.6* MCV-89 MCH-30.3 MCHC-33.9 RDW-15.7* Plt Ct-271 [2145-11-4] 05:47PM BLOOD Neuts-65.7 Lymphs-25.8 Monos-6.5 Eos-1.8 Baso-0.1 [2145-11-5] 01:30PM BLOOD Plt Ct-271 [2145-11-5] 01:30PM BLOOD PT-24.0* PTT-30.6 INR(PT)-2.3* [2145-11-5] 02:41AM BLOOD Glucose-106* UreaN-29* Creat-1.6* Na-137 K-3.6 Cl-100 HCO3-30 AnGap-11 [2145-11-5] 02:41AM BLOOD CK(CPK)-57 [2145-11-4] 05:47PM BLOOD CK(CPK)-66 [2145-11-4] 09:40AM BLOOD CK(CPK)-65 [2145-11-4] 03:15AM BLOOD CK(CPK)-69 [2145-11-3] 08:35PM BLOOD CK(CPK)-87 [2145-10-30] 06:05PM BLOOD CK(CPK)-338* [2145-11-5] 02:41AM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-4] 05:47PM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-4] 09:40AM BLOOD CK-MB-NotDone cTropnT-0.17* [2145-11-4] 03:15AM BLOOD CK-MB-NotDone cTropnT-0.17* [2145-11-3] 08:35PM BLOOD CK-MB-NotDone cTropnT-0.16* [2145-11-5] 02:41AM BLOOD Calcium-7.3* Phos-4.7# Mg-2.0 Brief Hospital Course: Mrs. [Known lastname 31738] underwent a right laparoscopic colectomy [2145-10-29] without complications. Subsequently she developed atrial flutter with rapid ventricular response and was transferred to [Hospital Unit Name 196] service. . # Adenoma w/ atypia Patient underwent right laproscopic ileocolectomy for adenoma that was not amenable to resection via colonoscopy. She tolerated the procedure well. Post-operatively she developed an ileus however soon thereafter she tolerated clear and then full diet. Her bowel function also normalized as well. . # Atrial fibrillation / Flutter Patient has known hx of aflutter / fibrillation. She underwent right sided aflutter ablation in [2138]. On post-op day 5 she entered what was considered left sided atrial flutter with RVR to 120-140s. EP was consulted and her HR was controlled initially w/ IV nodal agents. She was subseqeuntly transferred to the [Hospital Unit Name 196] service for afib/flutter management. She was treated with amiodarone, digoxin and metoprolol, and finaly underwent successfull electrical cardioversion . . # Troponin Elevation In the setting of aflutter w/ RVR her CE's were checked. Troponin reached peak 0.17 despite flat CKs. In the setting of somewhat decreased GFR, the trop elevation was considered secondary to demand ischemia. She was chest pain free during the episodes and EKG showed aflutter w/o ekg changes. . # Hypothyroidism Home dose levothyroxine was continued. . # COPD Patient experienced baseline SOB, worse w/ ambulation. She has known hx of COPD, w/ worsened PFT's most recently in [Month (only) 216] [2144]. Inhalers were initially deferred, especially given lack of bronchodilation on PFTs. She was counseled to follow up w/ her pulmonologist. . # Anemia: most likely anemia of chronic disease, no source of bleed, and HCT stable with normal B12/folate and iron. Medications on Admission: Fosamax 70mg q/week Spironolactone 25mg qday Synthroid 75mg qday Cozaar 50mg qday Amiodarone 100mg qday Lasix 80mg qday Coumadin 3.5 2xweek, 5mg 5x week Lipitor 20qday Toprol 50mg qday Biotin Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): this is ongoing Amiodarone after she tapered 400 to 200 too 100 mg daily. Disp:30 Tablet(s)* Refills:2 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 5. Levothyroxine 50 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 8. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: please start with this dose after discharge and continue for seven days, then 200 mg for seven days, then 100 mg. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: continue after 400mg course finished for seven days then 100 mg. 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): decrease dose for SBP <90. 16. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: 1. colon adenoma 2. Colectomy 3. Post-op ileus 4. Atrial fibrilation 5. Hypertension 6. Obstructive sleep apnea 7. Sick sinus syndrome 8. Chronic diastolic dysfunction 9. Cervical spondylosis 10. left meralgia paresthetica Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) ] in [1-16] weeks. 2. Please follow-up with PCP, [Last Name (NamePattern4) ].[First Name (STitle) 971] [Last Name (NamePattern4) 92972],[Telephone/Fax (1) 3393] in 1 week or as needed. 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2145-12-29] 2:30 4. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2145-12-29] 3:00	[ "285.29", "427.31", "428.32", "244.9", "E878.2", "V45.01", "427.32", "211.3", "780.57", "560.1", "997.4", "428.0", "496", "401.9", "593.9" ]	icd9cm	[ [ [] ] ]	[ "45.93", "54.21", "99.61", "45.73" ]	icd9pcs	[ [ [] ] ]	7678, 7750	3990, 5897	358, 422	8017, 8095	2081, 2134	9311, 9856	1189, 1249		6139, 7655	2716, 2766	7771, 7996		5923, 6116			8119, 8949						8964, 9288			1264, 2062																				279, 320	2795, 3967									450, 899														921, 1074	1090, 1173
3,866	154,922	48986	Discharge summary	report	Admission Date: [2132-10-21] Discharge Date: [2132-10-24] Date of Birth: [2084-5-28] Sex: M Service: MEDICINE Allergies: Codeine / Enalapril Attending:[First Name3 (LF) 3984] Chief Complaint: Admit to ICU for code sepsis Major Surgical or Invasive Procedure: tPA instillation in dialysis catheter History of Present Illness: 48 y.o. male with complicated medical history, notable for ESRD s/p failed renal transplant in [2130] complicated by collapsing glomerulonephritis, and recent complicated lengthy admit which included MRSA line sepsis, who presents from dialysis with chills and tachycardia. Just after dialysis he experienced chills, with HR 140s. Blood cultures were drawn and he was given vancomycin 1 g. The patient says he was in his usual state of health prior to this, and denies any recent fevers, chills, shortness of breath, cough, abdominal pain, or dysuria. Per report from his girlfriend he has been on prednisone 5 mg daily for a failed cortisol stimulation test during the last admission, however he has forgotten to take this for the last few days. . His last admit was from [Date range (1) 102854] with high grade MRSA bacteremia, presumed line sepsis, treated with 2 weeks of vancomycin and removal of R SC tunneled HD line with placement of new L femoral tunneled line after being afebrile x 48 hours. Of note, prior to this hospitalization he had a long admission from [3-11] to [2132-4-28] during which time he had, among other things, pancreatitis, lower and upper extremity deep venous thrombosis, C. diff, epistaxis requiring intubation, pneumonia, failed PD cath c/b purulent ascites of unknown etiology and failing renal graft. . In the ED his vitals were 101.5, HR 140s, BP 78/52, RR 18, 100% on RA. Labs notable for a WBC count of 13.9, 87% PMNs, 3% bands, lactate 2.7. He was given 2L of fluid, and started on a dopamine drip peripherally, up to 10mcg/kg/min. His only site of access is a L dialysis cath - he has demonstrated clots in his IJ and SC veins bilaterally, and R femoral vein, therefore a central line was not able to be placed. He was given one dose of levaquin. Past Medical History: 1. ESRD s/p transplant on [7-4] now collapsing glomerulonephritis 2. Amyloidosis 3. Sarcoidosis 4. Hx of pulmonary aspergillosis 5. Hx of hyperkalemia 6. Hep B, C, D 7. HTN 8. Hx of IV drug use 9. sinusitis requiring drainage 10. recent epistaxis requiring intubation 11. SPEP/UPEP positive 12. paroxysmal atrial fibrillation 13. recent C diff 14. MRSA 15. h/o purulent ascites Social History: Lives with girlfriend, on disability; 1 packper day x30 years of tobacco use, still currently smoking.No alcohol, but previous history of abuse. Family History: Diabetes Physical Exam: PE: 98.5, 100, 125/62, 16, 98% on RA Gen: Slim african american male resting comfortably in bed, appearing tired but alert, responding to questions. HEENT: Anicteric, PEARL. Neck: No bruits, no JVD. Cor: RR, tachycardic, hyperdynamic precordium, 1/6 systolic flow murmur. Lungs: Rales at R base, otherwise CTA. Abd: NABS, soft, mild RUQ tenderness, no [Doctor Last Name ] sign, no rebound or guarding, no hepatosplenomegaly. Extr: No c/c/e. Dialysis line in place in L groin without exudate/erythema/tenderness. Pertinent Results: [2132-10-21] 06:51PM PT-18.4* PTT->150* INR(PT)-2.4 [2132-10-21] 06:42PM LACTATE-2.7* [2132-10-21] 06:25PM GLUCOSE-74 UREA N-23* CREAT-6.8# SODIUM-141 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-22 ANION GAP-25 [2132-10-21] 06:25PM ALT(SGPT)-28 AST(SGOT)-34 LD(LDH)-263* ALK PHOS-173* AMYLASE-95 TOT BILI-0.7 [2132-10-21] 06:25PM LIPASE-34 [2132-10-21] 06:25PM ALBUMIN-3.6 [2132-10-21] 06:25PM WBC-13.9# RBC-4.62 HGB-14.4# HCT-41.7# MCV-90 MCH-31.1# MCHC-34.4 RDW-15.5 [2132-10-21] 06:25PM NEUTS-87 BANDS-3 LYMPHS-4* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [2132-10-21] 06:25PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2132-10-21] 06:25PM PLT SMR-NORMAL PLT COUNT-240 EKG: NSR at 100 bpm, normal axis, normal intervals, no ST/TW changes. R atrial enlargement. Unchanged from prior of [2132-5-12]. . CXR: No interval change in biapical pleural thickening and patchy opacities within both upper lobes. Given the stability of these findings and history of prior infection within these areas, these changes may likely represent scarring from prior infection. [2132-10-24] 04:35AM BLOOD WBC-8.3 RBC-3.34* Hgb-10.5* Hct-31.0* MCV-93 MCH-31.4 MCHC-33.8 RDW-15.3 Plt Ct-168 [2132-10-24] 04:35AM BLOOD Plt Ct-168 [2132-10-24] 04:35AM BLOOD Glucose-134* UreaN-32* Creat-6.4# Na-137 K-3.9 Cl-101 HCO3-25 AnGap-15 [2132-10-24] 04:35AM BLOOD Calcium-9.9 Phos-4.3 Mg-1.7 [2132-10-22] 01:20AM BLOOD Hapto-127 [2132-10-22] 02:57AM BLOOD Cortsol-5.7 [2132-10-22] 01:20AM BLOOD Cortsol-4.4 [2132-10-23] 09:30AM BLOOD Vanco-15.0 [2132-10-24] 04:35AM BLOOD FK506-2.7* [2132-10-23] 09:40PM BLOOD FK506-2.9* [2132-10-22] 08:11AM BLOOD Lactate-1.1 [2132-10-22] 12:39AM BLOOD Lactate-1.5 [2132-10-21] 06:42PM BLOOD Lactate-2.7* Brief Hospital Course: A/P: 48 year old male with complicated PMHx, multiple problems notably including ESRD s/p renal transplant complicated by collapsing FSGS, recent MRSA line sepsis, here with fevers and hypotension at dialysis, code sepsis. . 1) Sepsis: Met criteria with fever, tachycardia and likely source of infection at site of tunneled dialysis catheter. Also had leukocytosis with L shift. CXR clear, urine not produced for sample. No central line placed [3-5] lack of access. Treated with 2 doses linezolid PO given previous vanco use and poor IV access; d/w Dr. [Last Name (STitle) ] and renal team - preferred vanco use, pt. switched to vanco by level and d/c on vanco at HD. Underwent [Last Name (un) 104] stim test; failed, started on hydrocort at stress dose levels (50 q6), d/w renal, felt uneccessary, pt. started on prednisone taper back to home dose of 5 mg PO qd. Held HTN meds in setting of sepsis. Received dose of vanco on [10-24] prior to d/c. . 2. Dialysis Catheter - noted morning after admission to be clotted; question whether this was related to blood draw. Instilled tPA in catheter overnight; were able to use cath in AM for HD. . 3. ESRD s/p txp - Started on prograf; monitored levels, d/c on home dose. As per pharm, must continue to monitor levels in context of using itraconazole. Continued pt. on bactrim for prophylaxis given tacrolimus use. To go to dialysis 9/24,11 AM, [Location (un) 4265]. 7 point HCT drop noted during admission; thought [3-5] elevated HCT [3-5] hemoconcentration. Hemolysis labs neg, no stool to guiaic. Hct at baseline in 30s-pt. returned to this baseline. . 4. PTT elevation - noted on admission, resolved in ICU. DIC labs negative. PT/PTT elevation at discharge c/w warfarin/SC heparin use. . 5. Hypertension: History of HTN, on lopressor and diltiazem, however hasn't been taking these medications, per girlfriend. [Name (NI) ] in setting of hypotension/possible sepsis. . 6. Pulmonary Aspergillus: Stable. On itraconazole and followed by pulmonary as an outpatient. Continued in house 7. Atrial fibrillation: He is normally rate controlled with metoprolol and anticoagulated with coumadin, however he hasn't been taking metoprolol. NSR on EKG here, continued warfarin, held beta blocker. Medications on Admission: MEDS: 1. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 2. Thiamine HCl 100 mg PO DAILY 3. Folic Acid 1 mg PO DAILY 4. Itraconazole 200 mg PO BID 5. Calcium Acetate 1200 mg PO TID W/MEALS 6. Pantoprazole Sodium 40 mg PO Q24H 7. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO DAILY 8. Prednisone 5 mg PO DAILY 9. Tacrolimus 0.5 mg daily 10. Docusate Sodium 100 mg PO BID 13. Sevelamer HCl 1600 mg PO TID 14. Lactulose 30 ML PO TID 15. Warfarin Sodium 1 mg PO every other day. Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Sertraline 50 mg Tablet Sig: 1-2 Tablets PO once a day: take 1.5 tablets daily. Tablet(s) 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Prednisone 10 mg Tablet Sig: as per taper Tablet PO qd () for 1 doses: take 30 mg of prednisone on [10-25] mg on [10-26] mg on [10-27], and then on [10-28] back to your usual dose of 5 mg a day. Disp:6 Tablet(s) Refills:0 10. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD (). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO Monday-Wednesday-Friday. 14. Vancomycin HCl 1000 mg IV QHD to be administerd after HD 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (): to start after finishing taper. Discharge Disposition: Home Discharge Diagnosis: Primary 1. MRSA line sepsis 2. End Stage Renal Disease on Hemodialysis Secondary 1. Paroxysmal atrial fibrillation Discharge Condition: Good Discharge Instructions: You were admitted for sepsis, a blood infection that was treated with antibiotics. You will continue to get these antibiotics with dialysis. . Call your PCP or return to the ED for fevers/chills/shakes, chest pain, shortness of breath, pain at the site of your dialysis catheter, nausea, vomiting, or swelling in your legs/feet. You were admitted for sepsis, a blood infection that was treated with antibiotics. You will continue to get these antibiotics with dialysis Followup Instructions: Your next dialysis appointment is at the [Location (un) 4265] center tomorrow at 11:00 AM. You should contact Dr. [Last Name (STitle) 1366] ([Telephone/Fax (1) 773] to schedule a follow-up appointment in the next two weeks. Your PCP is [First Name8 (NamePattern2) 2426] [Last Name (NamePattern1) 2427] ([Telephone/Fax (1) 1300]; you can contact Dr. [Last Name (STitle) 2427] for routine health maintenance. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "427.31", "070.30", "070.70", "995.91", "135", "996.62", "E878.2", "996.73", "038.11", "403.91" ]	icd9cm	[ [ [] ] ]	[ "39.95", "00.17", "99.10", "00.14" ]	icd9pcs	[ [ [] ] ]	9456, 9462	5258, 7546	312, 351	9621, 9628	3343, 5235	10147, 10712	2775, 2785		8071, 9433		9483, 9600		7572, 8048			9652, 10124									2800, 3324																				243, 274										379, 2190														2212, 2596	2612, 2759
12,776	106,422	25250	Discharge summary	report	Admission Date: [2169-6-2] [Month/Day/Year ] Date: [2169-6-10] Date of Birth: [2088-3-1] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: Malaise Major Surgical or Invasive Procedure: Placement of Left SC central catheter Placement of PICC line, removed by patient Replacement of PICC line Transesophageal Echocardiogram History of Present Illness: HPI: 81 year old female with medical history significant for HTN and LE edema p/w lethargy, malaise. Her grandson forced her to go to the [Name (NI) ]. She states that for days she states that she has had decreased appetite and feeling not "her normal self" over the past few days. She states that she has also noted diarrhea over the past few days but not watery. Grandson called EMS. Pt was found to be hypotensive in the ED with vitals in ED T 97.2 p 72 bp 62/31. Later had fever to 100.8 in ED, with a lactate, 3.5. She was treated per sepsis protocol. L subclavian was placed, she received 4L NS, vanc, levo, flagyl. She has only made 10 cc of UOP in the past hour and transferred ot the ICU on neosynephrine. Cr also noted to increase from baseline 1.1 to 3.1. Her UA was positive. Transferred to MICU for further evaluation and code sepsis protocol. Past Medical History: 1. HTN 2. LE edema 3. Atrophic dermatitis Social History: SOCIAL HISTORY: Patient is [Initials (NamePattern4) ] [Last Name (NamePattern4) 3064] survivor who lives by herself. She lives near her grandson who is involved in her care. The patient is noted to have poor compliance with hygiene, she has not bathed within weeks. The patient likely needs assistance at home with either home VNA or home health aides. Family History: FAMILY HISTORY: No history of DVT, does note a family history of breast cancer. Physical Exam: Vitals: 100.1 107/65, 82, 17, 100% on 2L NC, CVP 7 . General - elderly appearing female lying flat in bed in NAD HEENT- PERRL, EOMI CHEST- CTAB, breast ulcerations CV - RR, no M Abd - midline abdominal scar with ulcerations, soft, NT/ND, +BS Ext - trace le edema Skin - no cellulitis Pertinent Results: Admission Labs: . [2169-6-1] 07:30PM PLT COUNT-317 [2169-6-1] 07:30PM HYPOCHROM-1+ [2169-6-1] 07:30PM NEUTS-74.7* LYMPHS-19.6 MONOS-3.5 EOS-2.0 BASOS-0.3 [2169-6-1] 07:30PM WBC-15.9* RBC-4.52# HGB-13.1# HCT-39.4 MCV-87 MCH-29.0 MCHC-33.3 RDW-14.5 [2169-6-1] 07:30PM LIPASE-22 [2169-6-1] 07:30PM ALT(SGPT)-24 AST(SGOT)-41* ALK PHOS-146* AMYLASE-22 TOT BILI-0.5 [2169-6-1] 07:30PM GLUCOSE-171* UREA N-38* CREAT-3.1# SODIUM-144 POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-20 [2169-6-1] 08:46PM LACTATE-3.5 [2169-6-1] 08:46PM TYPE-ART PO2-137* PCO2-33* PH-7.51* TOTAL CO2-27 BASE XS-4 [2169-6-1] 09:15PM URINE TRICH-OCC [2169-6-1] 09:15PM URINE HYALINE-[6-17]* [2169-6-1] 09:15PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 [2169-6-1] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [2169-6-1] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2169-6-1] 09:15PM PT-13.9* PTT-24.4 INR(PT)-1.2* [2169-6-1] 09:15PM URINE UHOLD-HOLD [2169-6-1] 09:15PM URINE HOURS-RANDOM [2169-6-1] 09:15PM TOT PROT-5.9* ALBUMIN-2.0* GLOBULIN-3.9 [2169-6-1] 09:15PM TOT BILI-0.5 [2169-6-1] 09:15PM GLUCOSE-133* UREA N-37* CREAT-2.8* SODIUM-149* POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-26 ANION GAP-17 [2169-6-2] 03:11AM HCT-30.7* [2169-6-2] 03:11AM CORTISOL-13.4 [2169-6-2] 03:11AM CORTISOL-22.1* [2169-6-2] 03:11AM CORTISOL-25.5* [2169-6-2] 03:11AM CALCIUM-6.3* PHOSPHATE-2.8 MAGNESIUM-1.6 [2169-6-2] 03:11AM LD(LDH)-292* [2169-6-2] 03:11AM GLUCOSE-75 UREA N-30* CREAT-2.2* SODIUM-147* POTASSIUM-2.8* CHLORIDE-116* TOTAL CO2-22 ANION GAP-12 [2169-6-2] 03:40AM LACTATE-2.0 [2169-6-2] 03:40AM TYPE-MIX TEMP-36.6 O2 FLOW-2 PO2-129* PCO2-42 PH-7.35 TOTAL CO2-24 BASE XS--2 INTUBATED-NOT INTUBA [2169-6-2] 07:52AM PLT COUNT-258 [2169-6-2] 07:52AM WBC-16.7* RBC-3.70* HGB-10.6* HCT-32.7* MCV-89 MCH-28.8 MCHC-32.6 RDW-14.5 [2169-6-2] 07:52AM CALCIUM-6.6* MAGNESIUM-1.6 [2169-6-2] 07:52AM POTASSIUM-4.4 [2169-6-2] 08:13AM freeCa-1.05* [2169-6-2] 08:13AM LACTATE-1.3 [2169-6-2] 08:13AM TYPE-[Last Name (un) ] TEMP-35.6 PO2-44* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 [2169-6-2] 03:38PM URINE RBC-[11-27]* WBC-[6-17]* BACTERIA-FEW YEAST-NONE EPI-[3-12] [2169-6-2] 03:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2169-6-2] 03:38PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2169-6-2] 03:38PM URINE HOURS-RANDOM CREAT-117 SODIUM-77 [2169-6-2] 03:39PM CALCIUM-7.3* PHOSPHATE-2.7 MAGNESIUM-2.4 [2169-6-2] 03:39PM GLUCOSE-220* UREA N-25* CREAT-1.8* SODIUM-143 POTASSIUM-4.2 CHLORIDE-118* TOTAL CO2-18* ANION GAP-11 Pertinent Labs/Studies: . ECG: Sinus tach at 110 bpm. nl axis, borderline QT prolongation. QT 360. No ST/T changes. . Imaging: [2169-6-2] - Portable Chest The left subclavian line tip is in the level of the junction of brachiocephalic vein and superior vena cava. There is no pneumothorax or apical hematoma. The heart size is normal. Mediastinal widening seen on the current chest x-ray is most probably due to supine position and relatively low lung volumes. To exclude hematoma, an erect chest PA and Lat films should be obtained. The lungs are clear. There is no pleural effusion. . [2169-6-2]: Portable Chest - IMPRESSION: No acute cardiopulmonary process. . [2169-6-6]: Transesophageal Echocardiogram: Intravenous sedation was administered as described above. The patient developed asymptomatic hypotension with a systolic blood pressure of 70 mm Hg. The patient remained alert and interactive and did not appear to be sedated. Blood pressure normalized quickly with intravenous fluids. The patient requested that we try to complete the test. One attempt was made at passing the TEE probe, however, the patient was unable to swallow it. The test was terminated. If a TEE is still clinically necessary, an anesthesiologist will be needed to provide deeper sedation and blood pressure support. . [2169-6-6] - Echocardiogram (TTE) Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. 6. No evidence of endocarditis seen. 7. Compared with the prior study (images reviewed) of [2169-5-3], there is no significant change. . [2169-6-7]: IMPRESSION: Successful placement of a 40cm single lumen left brachial vein PICC line. The tip is in the SVC. The line is ready for use. . [2169-6-7]: Chest Pa/Lat - IMPRESSION: Small right pleural effusion. Prominent mediastinum likely due to mediastinal fat. . [2169-6-8]: IMPRESSION: Successful placement of a 46 cm single-lumen PICC through the left brachial vein with the tip in the superior vena cava. The line is ready for use. . . Microbiology: Blood cultures: [2169-6-1]: 4/4 Bottles growing MRSA [2169-6-3]: NGTD [2169-6-4]: NGTD [2169-6-5]: NGTD [2169-6-6]: NGTD [2169-6-6]: (central line tip) - Coag Pos Staph . Urine: [2169-6-1]: 10K-100K STREPTOCOCCUS MILLERI [2169-6-2]: No growth [2169-6-3]: No growth [2169-6-6]: No growth . Relevant Labs: [2169-6-1] 08:46PM BLOOD Lactate-3.5* [2169-6-2] 03:40AM BLOOD Lactate-2.0 [2169-6-2] 08:13AM BLOOD Lactate-1.3 . [2169-6-2] 03:11AM BLOOD Cortsol-25.5* [2169-6-2] 03:11AM BLOOD Cortsol-22.1* [2169-6-2] 03:11AM BLOOD Cortsol-13.4 . [2169-6-6] 06:42AM BLOOD TSH-5.8* [2169-6-7] 02:06PM BLOOD Free T4-0.8* . [2169-6-6] 06:42AM BLOOD calTIBC-83* Ferritn-425* TRF-64* [2169-6-6] 06:42AM BLOOD Triglyc-77 HDL-40 CHOL/HD-2.1 LDLcalc-28 [Month/Day/Year ] Labs: . [2169-6-9] 09:45AM BLOOD WBC-15.2* RBC-3.14* Hgb-8.9* Hct-27.5* MCV-88 MCH-28.4 MCHC-32.4 RDW-17.1* Plt Ct-398 [2169-6-9] 05:46AM BLOOD WBC-13.7* RBC-2.79* Hgb-8.2* Hct-24.7* MCV-88 MCH-29.3 MCHC-33.1 RDW-16.6* Plt Ct-371 [2169-6-9] 05:46AM BLOOD Glucose-104 UreaN-6 Creat-0.9 Na-142 K-4.6 Cl-113* HCO3-21* AnGap-13 [2169-6-9] 05:46AM BLOOD Mg-1.8 [2169-6-10] 06:00AM BLOOD WBC-13.3* RBC-2.91* Hgb-8.4* Hct-25.7* MCV-88 MCH-29.1 MCHC-32.9 RDW-17.1* Plt Ct-441* [2169-6-10] 06:00AM BLOOD Glucose-82 UreaN-6 Creat-0.8 Na-142 K-4.5 Cl-114* HCO3-22 AnGap-11 Brief Hospital Course: The patient is an 81 year old female with medical history significant for LE edema and HTN who was admitted to the MICU with lethargy and hypotension, eventually discovered to have MRSA sepsis from unknown source. . # Sepsis/MRSA bacteremia - As per H+P, the patient presented with lethargy and hypotension found to be febrile with elevated lactate. A central line was placed, the patient was started on broad-spectrum antibiotics with vancomycin, levofloxacin, and Flagyl and volume resuscitation was initiated. The patient was transferred to the ICU on Neosynephrine and was rapidly weaned off pressors within 24 hours. The patient's MICU course was complicated by ARF likely secondary to ATN in the setting of hypotension with eventual complete recovery of renal function with adequate treatment of infection and volume resuscitation. The patient was Blood cultures revealed 4/4 bottles from admission growing MRSA. Initally it was thought that the source of infection may have been from the urine as the patient had a positive UA on admission, however, subsequent cultures revealed Streptococci Milleri rather than MRSA. The patient's antibiotics regimen was tailored to IV Vancomycin, dosed per renal function, as monotherapy. Given that urine did not grow MRSA, it was not clear what the patient's source of infection was. Of note, the patient is noted to have many cutaneous wounds and excoriations. Although no area of frank cellulitis or fluctuance was idenitified, it is suspected this to be the most likely source currently. However, given high grade bacteremia on admission with MRSA, there was clinical concern that the patient may have seeded her cardiac valves. The patient underwent attempted TEE but was unable to tolerate the procedure. The patient developed hypotension in the setting of sedation with rapid resolution with fluid bolus and trendelenberg. Subsequent attempt with less sedation was not tolerated by the patient secondary to discomfort. It was recommended that if TEE were necessary the patient would require anesthesia to be involved. Given that the patient rapidly cleared her cultures with therapy, it was thought that a TTE should first be attempted. TTE demonstrated a hyperdynamic LV with EF > 75% but no vegetations or evidence for endocarditis. The patient remained afebrile for the remainder of her hospital course with decrease in leukocytosis since admission from 16 to 12. On [Month/Day/Year ] the patient continues to have a mild leukocytosis, ranging between [12-21] generally but clinically appears quite well. Despite negative blood cultures, tip culture from the patient's central line has since grown MRSA. Blood surveillance cultures drawn the same day are negative however, signifying the patient was not experiencing significant bactermia from the central line. Subsequent surveillance cultures continue to be culture negative and additional surveillance culture was drawn on morning of [Month/Year (2) ] given positive CL tip. This will continue to be monitored and facility would be made aware if any cultures turn positive. Given documented bacteremia the patient will require IV antibiotics with Vancomycin, with plans for total duration of 4 weeks given no definite source was identified. The patient started antibiotic therapy with Vancomycin on [2169-6-4]. Because of hypotension, the patient's home medications of Valsartan and Lasix were held. The patient is currently normotensive but not hypertensive. The patient therefore is being discharged without these medications, with instructions to follow up with her PCP upon [Date Range ] from extended care facility to determine when or if she should restart these medications. . # ARF: As above, the patient developed acute renal failure during the ICU course, likely secondary to hypotension with subsequent ATN. The patient's creatinine returned to [Location 213] with normalization of blood pressure with volume support, antibiotics, and treatment as above. The patient continues to produce good urine and is currently at her baseline creatinine on [Location ]. . #. Wounds/ Skin ulcerations - The patient on presentation was wound to have a number of cutansous wounds over her extremities and trunk, mostly healed and scabbing, with some more recent excoriations. The patient had been prescribed protopic cream and petroleum jelly as an outpatient but was not using these regularly per family report. The patient overall was admitted with generally poor hygiene and suspicion that the patient's MRSA may have been introduced via cutaneous injury. The patient continued to receive wound care throughout her hosptialzation with daily cleansing and Aloe Vesta. The patient should continue to receive wound care at the extended care facility as detailed in page 1. . #. LE Edema - The patient on admission was reported to have a history of CHF. However, review of OMR notes reveals echocardiogram was ordered to rule out CHF with plan for ongoing work-up of LE edema given lack of evidence for CHF by recent echocardiogram. Prior to admission, the most recent echocardiogram reveale an EF > 55% without comment on evidence of diastolic dysfunction. Repeat echocardiogram this admission revealed a hyperdynamic LV with EF 75%. The patient was treated with volume as above initially given evidence of sepsis. With normalization of pressures fluid balance was allowed to equilibrate. Physical exam was remarkable for mild LE edema as has been previously documented, but the patient otherwise appears relatively euvolemic. The patient maintained good oxygen saturation on room air. As an outpatient the patient was on a medical regimen including Diovan 160 mg po qd as well as lasix 40mg po qd. These medications have been held throughout the [Hospital 228] hospital course as her pressures have generally ranged from 100-120. On further exam the patient was noted to have mild diffuse edema. The patient's Albumin was noted to have fallen from 3.0 one month prior to 1.6. This was thought likely to be secondary to geenrally poor po intake and previous sepsis. The patient was written for boosts and nutritional support was continued. Urine dip revealed no proteinurea and the patient had a normal cholesterol. TSH was mildy elevated and free T4 was just below the lower limit of normal. Given the patient's recent illness however decision was made not to initiate thryroid replacement at this time as this more likely represents sick euthyroid than true hypothyroidism. . #. Anemia - the patient was noted to have an anemia on admission. Iron binding studies were consistent with anemia of chronic disease. The patient had a single OB positive stool on transfer with all subsequent negative. The patient's Hct remained stable throughout the course with some expected fluctuation within lab error and volume status. . #. Tachycardia - On [Hospital ] the patient is known to have mild persistent sinus tachycardia with HR ranging from 70 to 120. THe etiology is not clear but the patient is doing clinically well, afebrile, not in pain, and hemodynamically stable. As above, the patient's labs trend towards hypo rather than hyperthyroidism. The patient is with excellent O2 sats. The patient was taking [Doctor First Name ] daily previously. This was discontinued recently given thought that anti-cholinergic effect may be contributing to tachycardia. If the patient's tachycardia persists after [Doctor First Name ] from extended care facility she should have ongoing evaluation with PCP. . # CODE status - As per discussion with ICU team, the patient was maintained as DNR/DNI Medications on Admission: Diovan 160 mg a day, Aspirin 81 mg a day, [Doctor First Name ] 180 mg a day Lasix 40 mg a day [Doctor First Name ] Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection every eight (8) hours: please continue while patient is generally bed bound. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours): First dose [2169-6-4]. Patient should complete a 4 week course until [2169-7-5]. Patient will require monitoring of Vanc trough q week as per instructions. 9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): 2ml IV daily:PRN 10ml NS followed by 2ml of 100U/ml Heparin each lumen daily and PRN. [Month/Day/Year ] Disposition: Extended Care Facility: [Location (un) 11729] Home - [Location (un) 686] [Location (un) ] Diagnosis: MRSA Bacteremia/Sepsis [Location (un) ] Condition: Stable. Patient hemodynamically stable, afebrile. Upon [Location (un) ], patient has known sinus tachycardia, with rates 100-125 without obvious cause with basic workup. Patient should receive ongoing outpatient evaluation upon [Location (un) ]. Patient has known persistent mild leukocytosis with white count [12-21]. Patient is receiving antibiotics x 4 weeks for her infection. [Month/Year (2) ] Instructions: 1. Please take all medications as prescribed from this [Month/Year (2) ]. You were previously taking Diovan and Lasix. These medications were stopped during this admission because of low blood pressure. Your blood pressure is currently normal, but not elevated. Because of this, you should not take these medications again until you see your primary care doctor. [First Name (Titles) 616] [Last Name (Titles) ] from rehab, please see your PCP to discuss when or if you should restart these medications. . 2. Please keep all outpatient appointments . 3. Please return to the hospital or seek medical attention for any symptoms of chest pain, shortness of breath, fever/chills, nausea/vomiting, or any other concerning symptoms. Followup Instructions: You should continue to receive care at your extended care facility. . After [Last Name (Titles) ], it is very important you have follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. After [Last Name (NamePattern1) ] from the extended care facility you should make an appointment to be seen within one to two weeks with Dr. [Last Name (STitle) ]. If he is not available please ask to be seen by any available physician at [Name9 (PRE) 191]. PLease call [Telephone/Fax (1) 250] to make this appointment . The following medications have been held this admission: Diovan and Lasix. You should discuss with your primary care doctor during your visit whether or not you should restart these medications. Until then, do not take these medications	[ "428.30", "995.92", "V09.0", "599.0", "285.9", "584.9", "785.52", "038.11", "428.0", "276.51" ]	icd9cm	[ [ [] ] ]	[ "88.72", "38.93" ]	icd9pcs	[ [ [] ] ]		9029, 16663	333, 471		2225, 2225	19383, 20237	1840, 1905						16689, 18099												1920, 2206																			18131, 18156	286, 295			18188, 19360							499, 1361					2241, 9006									1383, 1427	1460, 1807
11,318	122,038	50714	Discharge summary	report	Admission Date: [2124-10-27] Discharge Date: [2124-11-6] Date of Birth: [2052-2-14] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 4765] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary catherization w/ stent placement to RCA on [10-28] PICC line placement on [2124-11-6] for IV antibiotics Left leg cast placement for tib/fib fracture Intubation for respiratory failure History of Present Illness: 72 yo with extensive PMH, to include h/o CAD s/p PTCA to RCA, diastolic CHF (EF 70-80%), chronic afib on Coumadin who presented to her PCP with leg pain and SOB. At her PCPs office, she was found to be cyanotic and to have agonal breathing, at which point she was sent to the ER. . In the ER, patient was found to be afebrile, tachycardic to 140s hypertensive then hypotensive to SBP of 62 and O2 of 92% on 4L. EKG showed STE in III and AVF and ST depressions in I and AVL. Pt. was intubated and taken to cath lab where she was found to have no disease in her LMCA, modest disease in the LAD and LCx and hazy 70% occlusion of the mid RCA, PA 63/33 (49), RV 58/12, PCWP of 24, RA 21(A), 26 (V). Past Medical History: PMH: 1. CHF with diastolic dysfunction- Last LVEF was 65% with a normal MIBI in 01/[2123]. 2. Type 2 diabetes mellitus 3. Atrial fibrillation 4. Anemia 5. CAD s/p PTCA x3- Pt had a stent to her RCA in [2109], LCx in [2110], and RCA in [2113]. 6. Pulmonary HTN 7. COPD/[Name (NI) 105500] Pt is on intermittent oxygen at home. 8. Thyroid CA s/p resection- Pt is now hypothyroid. 9. Myoclonic tremors 10. H/O PE 11. OSA on CPAP 12. Depression 13. Anxiety 14. H/O MRSA and [Name (NI) 105501] Pt has two past ICU admissions for MRSA aortic valve endocarditis and pseudomonal sepsis. She has had two intubations. 15. S/P laproscopic cholecystectomy [34]. S/P right throcoscopy and decortication 17. S/P right lung biopsy 18. S/P right hip ORIF 19. S/P right ankle ORIF 20. s/p right AKA Social History: Social: Pt lives at [Hospital1 100] Senior Life. Divorced and has three children. She quit smoking in [2104] but has a history of 1 PPD for 15 years. No ETOH or drugs. . Family History: FHx: F: died at 47 of MI; M: died colon ca; B: DM Physical Exam: Vitals: T: 100.5, HR: 110, BP: 148/75, RR: 22, O2: 99%, AC/550/23/1.0/5 General: Intubated, but responsive, in NAD HEENT: NC/AT, PERRLA Neck: Supple, no JVD appreciated Chest/CV: S1, S2 nl, no m/r/g appreciated, but difficult to auscultate [3-9] [Month/Day (2) 1440] sounds Lungs: Harsh BS with diffuse crackles, b/l Abd: soft, NT, ND, minimal BS Ext: right leg amputated below knee, 1+ pitting edema on left leg Skin: warm, dry, no lesions Pertinent Results: [2124-10-27] 10:25PM TYPE-ART PO2-86 PCO2-48* PH-7.35 TOTAL CO2-28 BASE XS-0 [2124-10-27] 10:25PM GLUCOSE-222* LACTATE-3.0* NA+-142 K+-3.0* CL--105 [2124-10-27] 10:25PM freeCa-1.02* [2124-10-27] 10:06PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2124-10-27] 10:06PM URINE RBC-[12-25]* WBC-21-50* BACTERIA-FEW YEAST-NONE EPI-0 [2124-10-27] 10:05PM GLUCOSE-234* UREA N-26* CREAT-1.1 SODIUM-142 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-25 ANION GAP-16 [2124-10-27] 10:05PM CALCIUM-7.9* PHOSPHATE-3.9# MAGNESIUM-1.9 [2124-10-27] 10:05PM TSH-0.28 [2124-10-27] 10:05PM WBC-31.3# RBC-4.71 HGB-12.8 HCT-37.3 MCV-79 MCH-27.1 MCHC-34.2 RDW-15.9* [2124-10-27] 10:05PM PLT SMR-NORMAL PLT COUNT-275 [2124-10-27] 10:05PM PT-16.4* PTT-38.2* INR(PT)-1.5* [2124-10-27] 06:50PM GLUCOSE-470* UREA N-26* CREAT-1.0 SODIUM-145 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-18 [2124-10-27] 06:50PM WBC-17.2* RBC-4.18* HGB-11.4* HCT-34.1* MCV-82 MCH-27.2 MCHC-33.4 RDW-15.8* [2124-10-27] 06:50PM NEUTS-87* BANDS-4 LYMPHS-6* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2124-10-27] 06:00PM CK(CPK)-110 [2124-10-27] 06:43PM LACTATE-3.9* [2124-10-27] 06:00PM CK-MB-3 cTropnT-<0.01 [2124-10-27] 06:00PM PT-23.4* PTT-49.7* INR(PT)-2.3* . LLE XRAY: Age indeterminate fracture involving the lateral malleolus as described above. Question possible nondisplaced fracture of the distal tibia. Given severity of osteoporosis, MR is recommended over CT if further imaging is required to corroborate finding. . [10-28] Echo: Image quality is suboptimal due to body habitus, supine position, and mechanical ventilation. The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. The overall left ventricular ejection fraction appears relatively well-preserved (at least 50%); the inferior and posterior walls may be hypokinetic. Due to suboptimal technical quality, other focal wall motion abnormalities cannot be fully excluded. 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 no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([2-7]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2124-6-27], the inferior and posterior walls may now be hypokinetic. . [10-27] Cath: . Selective coronary angiography revealed a right dominant system with LMCA free of obstructive disease. The LAD and LCX had modest diffuse disease. RCA had a hazy mid vessel 70% lesion. 2. Left ventriculography was deferred. 3. Hemodynamic assessment revealed atrial fibrillation at 130 with hypotension. PCWP was elevated at 30 mm Hg and RAp 19 mm Hg. There was moderate pulmonary hypertension. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe systolic ventricular dysfunction and shock. 3. Acute inferior myocardial infarction, managed by acute ptca. 4. PTCA of vessel. . ECG Study Date of [2124-10-28] 9:18:20 AM Atrial flutter with 2:1 block. No change compared to the previous tracing of [2124-10-27]. Rate PR QRS QT/QTc P QRS T 133 0 66 [Telephone/Fax (2) 105504]4 178 . CHEST (PORTABLE AP) [2124-10-29] 7:04 AM IMPRESSION: Improved fluid balance with moderate-to-severe persisting interstitial and alveolar edema. The more confluent opacity in the left lung base also persists. Again, this may be manifestation of confluent edema or focus of pneumonia. Continued radiographic followup with progressive diuresis recommended to assess for underlying infection. . PICC LINE PLACMENT SCH [2124-11-6] 7:27 AM IMPRESSION: Successful placement of 30-cm single-lumen 4 French PICC line from right basilic vein with the tip terminating in distal SVC. The line is ready for use. . CHEST (PORTABLE AP) [2124-11-1] 7:06 AM IMPRESSION: AP chest compared to [10-27] through 26: . Mild pulmonary edema has improved, particularly in the right lung. Mild cardiomegaly is chronic. Pleural effusion if any is minimal, on the left. No pneumothorax. . ANKLE (2 VIEWS) LEFT [2124-11-1] 8:24 PM FINDINGS: Two portable radiographs of the left ankle were reviewed. There is a distal fibular fracture with posterior angulation. There is no marked interval change from [10-29], [2124]. There is also abnormal angulation of the distal tibia suggesting buckle fracture. Age is indeterminate, but unchanged from [2124-10-29]. Given severe osteopenia, evaluation is limited. . IMPRESSION: Unchanged appearance of distal tibia and fibula with angulated fibular fracture and possible tibial fracture. Severe osteopenia. Brief Hospital Course: 72 yo with extensive PMH, to include h/o CAD s/p PTCA to RCA, diastolic CHF (EF 70-80%), chronic afib on Coumadin who presented with L fibula fracture and SOB, found to have STE in III and AVF, s/p PCI to RCA for hazy 70% occlusion. . CARDIAC #Ischemia: CAD, s/p stent of RCA Patient s/p inferior wall MI with 70% occlusion of RCA. Patient was intubated for respiratory failure secondary to pneumonia and pulmonary edema. She was placed on beta blocker and lisinopril for optimal BP control and to improve survival post MI. Plavix was added for coronary stent. Aspirin and statin were continued given risk factors for CAD. Patient remained free of chest pain after catherization. She had intermittent episoded of bradycardia but remained asymptomatic and without abnormal rhythms on telemetry. . #Pump: Hyperdynamic LV systolic function with EF of 70-80%, elevated RHC pressures. Patient's volume status was closely monitored and she was diuresed with lasix to remove excess fluid from lungs and lower extremities, with goal of reducing afterload post MI. BP remained stable and normotensive. Patient was euvolemic at discharge and lasix dose was lowered to 40mg [Hospital1 ] from outpatient regimen of 80mg [Hospital1 ] to prevent volume depletion. She will continue lisinopril for afterload reduction. . #Rhythm: Patient w/ hx of atrial fibrillation/atrial flutter. Digoxin was continued and she was placed on coumadin with a therapeutic INR, temporarily bridged with heparin. . # Pulm Patient w/ history of pseudomonas PNA and went into respiratory failure upon admission. She was intubated in the coronary care unit and extubated two days later once able to [Hospital1 1440] on own during trials of pressure support. Daily CXR revealed resolution of pulmonary edema with diuresis. Blood cultures from [10-27] grew coag neg staph., G+ rods, Veillonella species, suspected to be likely contaminants, vancomycin was administered and d/c'd [11-3] once blood cultures remained negative. At discharge, she was on meropenem IV given h/o pseudomonas PNA day 10 of 14. She has remained afebrile without elevations in WBC ct after initial leukocytosis. She had a PICC line placed by IR on day of discharge to complete remaining course of meropenem. . # Fibula Fracture: Patient suffered a left leg fracture after bumping wheelchair into wall. She has been in severe pain throughout hospital course with intractable leg pain. Xrays revealed fracture of distal left tibial/fibula near ankle. Orthopedics was [Month/Year (2) 4221] and did not recommend immediate intervention. Half-cast and splint was placed and orthopedics will follow ankle films outpatient to determine appropriate management. Pain control has not been adequate with fentanyl, dilaudid, neurontin, and morphine. She was placed on PCA dilaudid prior to discharge for pain relief. She will need acute rehabilitation for leg fracture. Wound care was [Month/Year (2) 4221] for sore at heel and dressing changes were done daily to prevent expansion into ulcer. . # Anemia: Patient had baseline low hematocrit with wide fluctuations. Transfused 1 unit PRBCs [11-1] with Hct stable at 28.8. She was guiaic negative. Groin checks post catherization did not reveal hematoma/bruit/oozing on exam. Hemolysis workup was normal and iron studies were negative for deficiency. . # Hyperglycemia: Mildly elevated BG, now taking PO. Patient was placed on sliding scale insulin with adequate FSBG control. Continued glargine 16 QHS (taking 16 at [Hospital1 1501]). . # Neuro/psych Patient emotionally labile, not content w/ overall care provided, secondary to severe leg pain from fracture. She was alert/oriented and aware of medical issues but required constant reassurance to relieve frustrations. Patient may benefit from psychiatry evaluation outpatient given complexity of medical problems. . # Code status: Full Code . # Communication: [First Name5 (NamePattern1) ] [Known lastname 105375] - ([Telephone/Fax (1) 105505] . # Dispo: PT/OT consult done, pt cleared for acute care rehabilitation. DC to [Hospital 100] Rehab Medications on Admission: ASA 325 mg QD Coumadin Lopressor 25 mg [Hospital1 ] Lasix 80 mg [Hospital1 ] SImvastatin 20 mg QD Glargine 16 units HS, Humulin SS Neurontin 600 mg QHS Neurontin 300 mg [Hospital1 ] Klonopin 0.5 mg [Hospital1 ] prn, 1mg QHS Levothyroxine 175 mcg QD Lidocaine Patch MVI Fluticasone 2 P [Hospital1 ] Magnesium hydroxide 30 ml PRN COmbivent IH 2P Q12 hr prn Morphine 4 mg Q4 Buproprion 100 mg QD Magnesium gluconate 500 mg [Hospital1 ] Oxycodone 5 mg Q4 PRN KCl 20 meq QD Citalopram 20 mg QD Quetiapine 25 mg QHS Discharge Medications: 1. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Hospital1 ]: [2-7] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 Refills:2 3. Citalopram 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Bupropion 100 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Month/Day (2) ]: One (1) Adhesive Patch, Medicated Topical QD (). Disp:30 Adhesive Patch, Medicated(s) Refills:2 6. Digoxin 125 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Acetaminophen 650 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:120 Tablet(s) Refills:2 10. Potassium Chloride 20 mEq Packet [Last Name (STitle) ]: One (1) PO DAILY (Daily): Hold for K>5. Disp:30 Refills:2 11. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 2 Refills:2 12. Atorvastatin 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Gabapentin 300 mg Capsule [Last Name (STitle) ]: Two (2) Capsule PO HS (at [Last Name (STitle) 21013]). Disp:60 Capsule(s) Refills:2 14. Gabapentin 300 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 15. Citalopram 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at [Last Name (STitle) 21013]). Disp:60 Tablet(s) Refills:2 16. Warfarin 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Morphine 10 mg/5 mL Solution [Last Name (STitle) ]: One (1) PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:2 2 Refills:0 18. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 19. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR [Last Name (STitle) ]: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:90 Tablet Sustained Release 24HR(s) Refills:2 20. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at [Last Name (STitle) 21013]) as needed for anxiety. Disp:30 Tablet(s) Refills:0 21. Lisinopril 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 22. Magnesium Hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:1 ML(s) Refills:0 23. Fentanyl 75 mcg/hr Patch 72HR [Last Name (STitle) ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 24. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 25. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 26. Hydromorphone 4 mg/mL Solution [Last Name (STitle) ]: One (1) Injection ASDIR (AS DIRECTED). Disp:1 mg/ml Refills:2 27. Meropenem 1 g Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 5 days. Disp:15 Recon Soln(s) Refills:0 28. Insulin Glargine 100 unit/mL Cartridge [Last Name (STitle) ]: One (1) 16 units Subcutaneous at [Last Name (STitle) 21013]. Disp:1 units Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnoses: s/p STEMI stent to RCA for 90% occlusion Left tibia/fibula fracture near ankle . Secondary diagnoses: CHF EF 50% PVD AF CAD DM Pulmonary HTN COPD Hypothyroidism OSA Hx of PE Hx of MRSA Aortic Valve Endocarditis Pseudomonal Sepsis PNA (multiple ICU admissions; RML PNA on Meropenem since [Month (only) ]) Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. . Please see your PCP or return to the ED if you experience chest pain, shortness of [Name8 (MD) 1440], increase swelling in your hands/feet. You had a heart attack and had a stent placed in the occluded coronary artery which supplies blood to the heart muscle. You also had a left leg cast placed by orthopedics for a fracture near your ankle. Antibiotics were continued for presumed pseudomonas pneumonia and you will need to finish the remaining course after discharge. Followup Instructions: Provider: [Name10 (NameIs) 5865] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2124-11-21] 3:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2124-11-21] 3:20 . Provider: [Name10 (NameIs) 9977] Phone:[Telephone/Fax (1) 327] Date/Time:[2125-1-22] 3:20	[ "300.4", "285.9", "824.2", "518.81", "428.30", "427.31", "410.41", "428.0", "496", "V58.61", "E884.3", "414.01", "E849.7", "250.00" ]	icd9cm	[ [ [] ] ]	[ "00.66", "36.06", "88.56", "37.22", "99.20", "88.53", "96.71", "38.93", "96.04", "00.45", "00.40" ]	icd9pcs	[ [ [] ] ]	16719, 16785	7932, 12055	337, 541	17156, 17165	2846, 6038	17792, 18171	2310, 2361		12640, 16696		16806, 16906		12081, 12617		6055, 7909	17189, 17769									2376, 2827	16927, 17135																			287, 299										569, 1265														1287, 2098	2114, 2294
13,566	163,488	49970	Discharge summary	report	Admission Date: [2159-1-14] Discharge Date: [2159-2-17] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5827] Chief Complaint: Hypoxic respiratory insufficiency. Major Surgical or Invasive Procedure: MICU monitoring History of Present Illness: This is a [Age over 90 ] y/o, Russian-speaking only, male with a PMH of interstitial lung disease, Alzhemier's dementia, PUD, who presents from the NH with hypoxia. He was found to be in his room earlier today, appearing pale with O2 sats from 74-84 on 2LNC. He is normally on O2 2-4L NC at the NH [1-25] to his ILD. He was brought into the ED for further evaluation. Per his grandchildren, the pt has not been well for the past 3 days - not eating or drinking, looking pale and weaker than usual. He was recently started on Levaquin for PNA on [2159-1-12]. Family denies pt having a cough, fevers, chest pain, or any other symptoms although pt is unreliable in giving ROS. At his baseline, he is not very communicative and is confused most of the times, per his grandchildren. Pt has become increasingly more confused and combative over the last few days, refusing medications and food. Unable to assess ROS as patient not responding to questions. . On admission, pt started on vancomycin and levaquin. This was changed to vanco, ceftriaxone, azithro and flaygl today as pt had increasing hypoxia and increasing opacity on R lung on CXR from early this AM. MICU called to evaluate for persistent O2 sat in mid 80s on 100% NRB. Antibiotics then changed to Vanco, Zosyn, Azithro for coverage of MDR pseudomonas. He was tx'd to the MICU for worsening hypoxia. Past Medical History: 1. Alzheimer's dementia 2. PUD 3. Atypical psychosis 4. Macular degeneration 5. Interstitial lung disease Social History: SHx: Resident of nursing home. Tobacco use unknown but denies asbestos, Tb exposure. Family History: Non-contributory Physical Exam: PE: 96.6----131/77---98----93-95% on 100% NRB Gen: lethargic but responsive to voice. HEENT: NCAT, pupils min reactive and equal. Anicteric. OP shows dry MM. Lungs: CTA b/l with limited air movement due to pt effort. CV: RRR, nml S1S2, no mrg Abd: soft, NT, ND, naBS Ext: no c/c/e; no calf tndr or cords Neuro: confused and lethargic. Pertinent Results: LABS ON ADMISSION: [2159-1-14] 02:45PM BLOOD WBC-16.9* RBC-4.14* Hgb-13.3* Hct-37.6* MCV-91 MCH-32.0 MCHC-35.2* RDW-13.6 Plt Ct-290 [2159-1-14] 02:45PM BLOOD Neuts-89.6* Bands-0 Lymphs-7.6* Monos-2.6 Eos-0.1 Baso-0.1 [2159-1-14] 02:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2159-1-14] 02:45PM BLOOD PT-11.9 PTT-25.5 INR(PT)-0.9 [2159-1-14] 02:45PM BLOOD Glucose-85 UreaN-54* Creat-1.9* Na-147* K-3.9 Cl-108 HCO3-25 AnGap-18 [2159-1-14] 02:45PM BLOOD CK(CPK)-57 [2159-1-14] 07:30PM BLOOD CK(CPK)-56 [2159-1-15] 06:00AM BLOOD CK(CPK)-117 [2159-1-17] 11:48AM BLOOD CK(CPK)-82 [2159-1-14] 02:45PM BLOOD cTropnT-0.05* [2159-1-14] 07:30PM BLOOD cTropnT-0.05* [2159-1-15] 06:00AM BLOOD CK-MB-3 cTropnT-0.04* [2159-1-17] 11:48AM BLOOD CK-MB-NotDone cTropnT-0.04* [2159-1-15] 06:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.3 [2159-1-14] 03:03PM BLOOD Lactate-4.0* [2159-1-14] 07:56PM BLOOD Lactate-2.0 [2159-1-15] 06:18AM BLOOD Glucose-118* Lactate-2.0 Na-147 K-4.1 Cl-109 [2159-1-15] 08:10AM BLOOD Lactate-1.4 IMAGING: Admit CXR ([1-14]): IMPRESSION: Limited by rotation. Probably unchanged appearance of peripheral reticular pattern predominantly in the lower lobes. No pneumonia or CHF. New right- sided lower rib fractures. Bilateral LENI's: IMPRESSION: No evidence of deep vein thrombosis. . Chest CT ([1-16]): IMPRESSION: 1. No evidence of pulmonary embolism. 2. Fractures of the 9th and 10th ribs on the right, nondisplaced. 3. Bilateral posterior atelectasis and pleural effusions. 4. Mediastinal and hilar lymphadenopathy. 5. Ulcerated plaques in the descending aorta. 6. Possible right adrenal adenoma. . Follow Up CXR ([1-19]): IMPRESSION: Improved aeration of the right lung base. Otherwise, no significant change from prior study. . CXR [2159-1-19] IMPRESSION: Improved aeration of the right lung base. Otherwise, no significant change from prior study. . CXR [2159-1-23] IMPRESSION: 1. Findings consistent with CHF. 2. Bilateral pleural effusions. . CXR [2159-1-28] There is mild-to-moderate congestive heart failure superimposed on underlying emphysema, which is associated with cardiomegaly and moderate-sized pleural effusion. There are continued opacities in both lower lobes indicating atelectasis versus aspiration pneumonia. No evidence of pneumothorax is identified. Again, note is made of tortuosity of the thoracic aorta. . CXR [2159-1-29] IMPRESSION: Moderate bilateral pleural effusions unchanged. . CXR [2159-1-31] IMPRESSION: 1. Mild improvement of pleural effusion on the right. 2. Bibasilar consolidations which may reflect atelectasis or pneumonia, especially on the left. 3. Radiological evidence of mild congestive heart failure. . CXR [2159-2-4] FINDINGS: Bilateral effusions are much more prominent on the current study. Positioning differences could contribute. Appears to be more prominence of the upper lobe pulmonary vasculature and decompensation of fluid status seems likely. Bibasilar atelectatic changes are noted, greater than that seen previously. Upper lungs are clear of consolidations. IMPRESSION: Worsened fluid status versus prior study. . CXR [2159-2-5] IMPRESSION: 1. Partial improvement in congestive heart failure. 2. Unchanged moderate left and small right pleural effusions. 3. Persistent right basilar atelectasis. Superimposed aspiration cannot be excluded. . CXR [2159-2-6] IMPRESSION: 1. Congestive heart failure with bilateral pleural effusions, increased effusion on the right in the interval. A superimposed aspiration cannot be excluded. . CXR [2159-2-10] Heart size cannot be accurately evaluated, but there is probably some cardiomegaly. There are bilateral pleural effusions with possible underlying pulmonary edema, essentially unchanged since the prior film of [2159-2-10]. Tip of PICC line overlies mid SVC. No pneumothorax. . CXR [2159-2-13] FINDINGS: A left-sided PICC is in unchanged position with tip in the SVC. Bilateral pleural effusions, moderate-to-large in size, appear stable. There is improvement in underlying pulmonary edema and stable bibasilar atelectasis. No pneumothorax. Brief Hospital Course: Mr. [Known lastname ] was a [Age over 90 ] yo Russian-speaking man with history of interstitial lung disease, Alzheimer's dementia, and peptic ulcer disease, who presented from his nursing home with hypoxia. Per his family for about 3days prior to admission he was less interactive than usual and was not taking food. He seemed weak and on the day of admission did not even raise his head up when his daughter came to visit. She called this to the attention of the NH, who noted the pt was hypoxic to 74-84% on 2LNC, and started him on Levaquin on [1-12] for possible RLL pneumonia. Per family, no cough, fever, SOB, or CP. He was pale appearing. . At baseline the pt used O2 2-4L for his interstitial lung disease. He was minimally interactive, did not speak very much even in Russian, and his overall health had had been declining over the last year. Prior to that time he used to try to run out of his nursing home and build barricades to keep workers out. He was a slow walker with assist. He was, however, strong, and had been combative requiring restraints in the ICU, and per his granddaughter he [Name2 (NI) ] her the day prior to admission. He was noted to have been reluctant to eat for the last year, only taking food when fed by his family, and occasionally refusing to eat. . On admission, the patient was started on vancomycin and continued on levofloxacin for pneumonia. His chest x-rays gradually evolved to a picture consistent with RLL and LLL opacities, likely pneumonia. The pt was treated with ceftriaxone, azithromycin and Flagyl, but on the second hospital day he was transferred to the ICU after an acute episode of desaturation on the floor thought to be secondary to mucus plugging or aspiration. In the ICU the patient was kept on levofloxacin, and after 5 days total, the vancomycin was discontinued. The patient initially passed swallow study but there was concern for possible aspiration after the family's attempts to feed the pt. The family was instructed to not force in food. . The pt's remaining hospital course was significant for multiple episodes of desaturation, requiring deep suctioning and supplemental oxygen. During his worst episodes, he was requiring oxygen levels of 6L nasal cannula and 100% face mask; some of these episodes were precipitated by repeated attempts of the pt to manually remove oxygen supply despite wrist restraints and mitts. During one of the acute episodes of desaturation the pt underwent a chest x-ray which showed bilateral pleural effusions. The pt was diuresed with interval improvement of the effusions. The pt's underlying pneumonia was treated with Vancomycin, Levofloxacin and Flagyl (for empiric coverage of aspiration pneumonia). The pt remained stable in the [Hospital1 ] with eventual improvement of oxygen saturations to low 90s on 50% face mask. After multiple family meetings, the health care proxy decided that they would like to continue medical care and they chose to change the pt's code status to DNR/DNI. . During this admission, it was noted that the pt refused to eat anything unless fed by family, including medications. The pt's PO intake continue to decline during the hospital admission and due to a risk for aspiration, the attending, Dr. [First Name8 (NamePattern2) 335] [Last Name (NamePattern1) 5351], decided that the pt should not have a feeding tube placed. The pt was evaluated by the gastroenterology team and they felt that the pt was a poor candidate for PEG placement (of note the [Hospital 228] health care proxy also refused this procedure). . During the hospitalization the patient had numerous episodes of desaturation which were precipitated by his attempts to remove his face mask. He was placed in restraints (after discussion with the family)to prevent him from pulling off his face mask. The pt was also assigned a 1:1 sitter. The pt was noted to maintain an oxygen saturation of 89-95% on face mask (with intermittent requirement of supplemental oxygen delivered via nasal cannula). Mr.[Known lastname ] also needed frequent suctioning due to accumulation of copious thick secretions. His oral intake gradually declined and he refused to take food. At that time he was treated with supplemental IV fluids. Mr [Known lastname ] gradually developed frequent episodes of hypoxia and tachycardia which were responsive to diuresis, suctioning and IV Lopressor. However,in the last few days prior to his death, his oxygen saturation status deteriorated and he was unable to maintain oxygen saturation above late 80s on 6L nasal cannula and 80% face mask. Mr. [Known lastname ] was also noted to be intermittently tachycardic and he was frequently in respiratory distress with respiratory rate up to 40. He was treated for respiratory distress with low dose morphine and with diuresis. On the day Mr.[Known lastname ] [Last Name (Titles) ], he was noted to desaturate down to 50 and would not respond to deep suctioning or medical measures. He ultimately went into respiratory distress and had pulseless electrical activity and passed away. Medications on Admission: CURRENT MEDS: 1) Vancomycin 1 gram q48h (day 2) 2) Zosyn 2.25 gram q6h (day 1) 3) Azithro 500mg daily (day 2) 4) Protonix 40mg IV daily Discharge Medications: none (pt passed away) Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: none (pt passed away) Discharge Condition: pt [Location (un) ] Discharge Instructions: none Followup Instructions: none Completed by:[2159-2-26]	[ "428.0", "362.50", "276.51", "933.1", "515", "507.0", "593.9", "533.90", "331.0", "294.11", "518.81", "584.9", "427.89" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11961, 12031	6612, 11728	297, 314	12096, 12121	2351, 2356	12174, 12209	1962, 1980		11915, 11938		12052, 12075		11754, 11892			12145, 12151									1995, 2332																				223, 259										342, 1713							2371, 6589							1735, 1843	1859, 1946
31,044	184,171	11179	Discharge summary	report	Admission Date: [2121-5-3] Discharge Date: [2121-5-6] Date of Birth: [2082-8-31] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: etoh intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 38 yo female with pmhx etoh abuse, depression, suicide attempts, h/o domestic abuse here with etoh intoxication. Per family, patient was sober for 6 years and then started drinking again a year ago before she was married. She has had a number of recent hospitalizations for etoh intoxication but has never required intubation per her mother. Today, pt was reportedly talking to her sister and sounded intoxicated. A friend tried to call and when he got no answer called the police and went to the house where she was found to be unresponsive with bottles of vodka next to her. Her sbp was in the 70s and she had no gag and was intubated in the field. At osh, tox screen was negative although she had empty seroquel and oxycodone bottles in her house but these were apparently there earlier in the week. Etoh level > 700 at osh and 614 here at 7 pm. Unclear if this was a suicide attempt as brother states that she has stated recently that she wishes she wasnt alive. She was given NS and 1 mg ativan for agitation and was transferred to [Hospital1 18] for further management. . In the ED, initial vs were: 97.6, 85, 95/66, RR 16 on vent, 100% on vent. Currently in ED, P 89, 100/64, R12 and 100% vent with settings Fio2 50%, peep 5, Tv 450 and RR 20. Pt was gagging on NG tube in the ED and they gave her 2 mg midazolam. NG tube in esophagus and they advanced NG tube further. She also received NS. EKG unremarkable. . In the ICU, initial vs were: T 99.7, HR 114, BP 112/85, O2 sat 100% and RR 17. Patient was unresponsive and would not follow commands. Past Medical History: etoh abuse depression h/o suicide attempts h/o domestic abuse ? h/o eating disorder Social History: Patient lives with roomate. She is separated from her second husband and was divorced in [2113]. First husband was physically abusive. Long history of etoh abuse. Sober x 6 yrs. Started drinking last year before she got married. Husband cheating on her. Had restraining order against him but this may be removed now. ? whether there is phsyical abuse in this relationship as well but she denied to her family. Reportedly he was slipping her etoh. Multiple recent hosp for etoh intox and was court ordered to go to sobriety program but the judge who knows her excused her yesterday. H/O suicide attempts and has been making si comments to family members recently. [Name2 (NI) ] tobacco or drug use. Pt is a public defender (attorney) in [Location (un) 1110]. Family History: NC Physical Exam: VS: T 99.7 BP 112/85 HR 114 O2 sat 100% Tv 450, RR 20, Fi02 50%, peep 5 GEN: intubated and sedated HEENT: AT, NC, PERRLA, no conjuctival injection, anicteric, OP clear difficult to see because tongue is swollen, MMM, no LAD, no carotid bruits CV: mild tacchycardia, RR, nl s1, s2, no m/r/g PULM: CTAB ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL NEURO: sedated without medication, does not withdraw to nail bed pressure or abg, downgoing toes on babinski, left L5 reflex slightly more brisk at 2+ than right, all other reflexes 2, could not assess the rest of the neuro exam Pertinent Results: Labs: pH 7.37 pCO2 42 pO2 229 HCO3 25 Lactate:2.0 Serum EtOH 614 Serum ASA, Acetmnphn, [Last Name (LF) 2238], [First Name3 (LF) ], Tricyc Negative 153 121 5 -------------< 121 3.6 22 0.5 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative wbc 3.7 hgb 11.8 hct 36.9 plt 373 N:72.3 L:24.2 M:2.1 E:0.5 Bas:1.0 PT: 11.9 PTT: 24.4 INR: 1.0 UA negative . STUDIES: . ekg: nsr at 88, nl axis and intervals, no qt prolongation, no st-t wave changes. . cxr: The cardiomediastinal silhouette is within normal limits. Endotracheal tube is in satisfactory position 3 cm from the carina. Endotracheal tube is within the distal esophagus. There is a calcified granuloma within the left lung base. No effusion or pneumothorax is present. The lungs are overall clear. There is a metallic side plate and screws fixing the left clavicle. IMPRESSION: Satisfactory position of endotracheal tube. Nasogastric tube is in the distal esophagus and recommend advancing it at least 14 cm. repeat cxr shows good placement of ng tube. . CT head negative per osh report Brief Hospital Course: A/P: Pt is a 38 yo female with pmhx depression, etoh abuse who presents with etoh intoxication. 1) Etoh intoxication- Patient has h/o etoh abuse with several recent hospitalizations for intoxication but has never been intubated. Found unresponsive without gag reflex and it is unclear exactly how long she was this way. She was intubated for airway protection given her marked obtunded state. Her serum ethanol level was markedly high. There was no QT prolongation to suggest seroquel overdose. She was mechanically ventilated easily and eventually extubated without difficulty. She recived nutritional support with thiamine, folate, and multivitamins. Once extubated she was monitored on CIWA scale (minimal diazepam requirements) and evaluated by the psych and social work departments. She is currently stable from a medical standpoint. At the time of admission she had a section 35 from [Location (un) 1110] police and discharge will be to [Location (un) 1110] police departement for mandatory inpatient substance abuse care. 2) Depression: In speaking with the family, the patient had made comments about suicide prior to this admission. The patient denied desire to harm herself. Psychiatry was consulted and followed her here. She remained on a 1:1 sitter for suicide precautions while here. Medications on Admission: None Discharge Medications: 1. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for for CIWA >12. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol Intoxication Respiratory Depression Suicidal Ideation Discharge Condition: Good, breathing well on room air, vital signs stable, no further signs of active withdrawal Discharge Instructions: You were admitted with alcohol intoxication and poor mental status as a result of your alcohol intake. While in the hospital, you were given a medication to help curb alcohol withdrawal symptoms. You were also seen by social work and psychiatry. You are being discharged to a mandatory substance abuse treatment program. Followup Instructions: Please follow-up as per inpatient rehab's instructions. You will need to follow-up with your PCP [Name Initial (PRE) 176] 2 weeks. Completed by:[2121-5-6**]	[ "515", "303.00", "V15.41", "311", "276.0", "V62.84", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	6274, 6280	4585, 5904	330, 336	6405, 6499	3481, 4562	6872, 7038	2843, 2847		5959, 6251		6301, 6301		5930, 5936			6523, 6849									2862, 3462																				273, 292										364, 1932						6320, 6384								1954, 2039	2055, 2827
53,310	198,605	40002	Discharge summary	report	Admission Date: [2137-2-11] Discharge Date: [2137-2-22] Date of Birth: [2076-6-15] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1253] Chief Complaint: SOB Major Surgical or Invasive Procedure: Thoracenteses x2 Pleurex catheter placement History of Present Illness: 60 y/o female with recently dx metastatic breast presents with fatige and SOB. Last chemo was 3 days ago (paclitaxel. Sudden onset of SOB over 1.5 days prior to admission. No F/C, no cough, no chest or abd pain. No sick contacts. + orthopnea. She has not had further thoracentesis or paracentesis performed since discharge. . She was originally sent to [Hospital3 ] where labs were collected and she was sent to [Hospital1 18] without intervention. Her BP was 100s/70s, HR 100s and 96% on 3.5 L. . On arrival to the [Hospital1 18] ED T 98.2, HR 118, BP 102/67, 15, 98% on 4L NC. After arrival she desated to 64% on RA. Her oxygen requirement increased to non-rebreather. On exam she has decreased BL BS and dullness to purcussion. CXR showed L > R pleural effision and possible RLL PNA. EKG showed sinus tach and RBBB of unclear chronicity. Labs significant for WBC of .6 with ANC of 420. She was started on Vanco and Cefepime. She had transient hypotension to 92/55. She received 2L of NS. VS prior to transfer HR 107, BP 105/67, R 14, 100% Non Re-breather. ED talked with pt regaurding code status and confirmed that pt is DNR/DNI but that she would be ok with non-invasive ventilation. Pt with exsisting double lumen port for access. . She was recently admitted to [Hospital1 ] from [1-1] to [2137-1-18] after presenting to on OSH with abd pain and a right adnexal mass with ascites. Gastric bx confirmed dx of metastatic breast ca and she was started on paclitaxel. She developed BL pleural effusions which required thoracentesis x 2 (lasat [2137-1-15] for 1200cc). Cytology confirmed it is a malignant effusion. She was empiric treated for SBP at the OSH although para later in the [Hospital1 ] course was not consistent with infection. . On arrival to the floor she is drowsy but arousable and oriented. Past Medical History: - History of breast cancer. In [2125], initially right sided (ER/PR+ lobular). Tx with neoadjuvant chemo then modified radical mastectomy and postop radiation. While on tamoxifen in [2127], she developed a left-sided tumor and had a modified radical mastectomy with TRAM flap. She then took Arimidex until [2132]. Followed closely by her oncologist at [Hospital6 5016]. - [12-14] [Hospital1 18] hospitalization dx with poorly differentiated adenocarcinoma on gastric bx consistent with met breast ca. ER pos, Her 2 negative. Presented with lichen planus, adenexal mass, malignant pleural effusion and evidence of bone mets consistent with stage 4. s/p Pacitaxil [1-12] and [1-18] - Hypothyroidism - Hypertension - Hyperlipidemia . SurgHx: Bilateral modified radical mastectomies with reconstruction. Social History: Lives at home currently alone, previously with husband who recently had a stroke and is in a nursing facility. Has support from friends and [Name2 (NI) 9259]. Former [Name2 (NI) 1818] x 15 years, not since dx of breast cancer. Occ wine. No drugs. Works as a substitute teacher. Family History: Cousin with breast cancer. No first degree relatives with breast, ovarian, colon, endometrial cancers. Physical Exam: Admission: VS: Temp: 95.8 BP: 108/69 HR: 109 RR: 23 O2sat 92% on nonrebreather GEN: cachetic and drowsy but NAD HEENT: PERRL, EOMI, anicteric, pale conjuctiva, DMM, op with whitelesions, no jvd RESP: Anteriorly decreased BS at the bases. CV: tachy, S1 and S2 wnl, no m/r/g ABD: nd, decreased b/s, soft, nt, no masses or hepatosplenomegaly. No significant ascites EXT: 2+ edema in BL UE and BL LE to knee, 2+ radials and DPs SKIN: no rashes/no jaundice/no splinters. Skin cool. NEURO: drowsy but arousable to verbal stimulus. AAOx3. Cn II-XII intact. 4/5 strength throughout UE, [3-9] in hip flexors. No sensory deficits to light touch appreciated. Pertinent Results: [2137-2-11] 01:20AM BLOOD WBC-0.6# RBC-3.31 Hgb-9.7* Hct-29.2* MCV-88 MCH-29.1 MCHC-33.1 RDW-15.7* Plt Ct-216# [2137-2-11] 01:20AM BLOOD Neuts-70 Bands-0 Lymphs-21 Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-18* [2137-2-12] 04:53AM BLOOD WBC-0.8* RBC-3.14* Hgb-9.1* Hct-28.3* MCV-90 MCH-29.1 MCHC-32.2 RDW-15.8* Plt Ct-147* [2137-2-12] 04:53AM BLOOD Neuts-58 Bands-12* Lymphs-12* Monos-0 Eos-2 Baso-0 Atyps-0 Metas-16* Myelos-0 NRBC-9* [2137-2-17] 06:05AM BLOOD WBC-7.9 RBC-3.03* Hgb-8.9* Hct-28.4* MCV-94 MCH-29.4 MCHC-31.4 RDW-17.7* Plt Ct-178 [2137-2-18] 05:53AM BLOOD Glucose-92 UreaN-18 Creat-0.6 Na-138 K-4.2 Cl-107 HCO3-30 AnGap-5* [2137-2-14] 05:07AM BLOOD ALT-15 AST-18 AlkPhos-108* TotBili-0.3 [2137-2-18] 05:53AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.7 . Stool C-diff negative x 3 . Blood, urine, and pleural fluid cultures: negative . Left Pleural Fluid for cell block; C11-3953A DIAGNOSIS: Left pleural fluid, cell block: Positive for malignant cells, consistent with metastatic adenocarcinoma. . Cardiac Echo Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). A sessile 12 by 16 mm globular apical mass is seen in the left ventricle. The mass enhances during Definity contrast infusion suggesting a vascularized tissue mass rather than thrombus. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . CTA CHEST W&W/O C&RECONS, NON-CORONARY IMPRESSION: 1. New subsegmental right and left lower lobe pulmonary arterial filling defect consistent with acute pulmonary embolism. 2. Interval decrease in size of left pleural effusion and new extensive left lower lobe consolidation. 3. Stable moderately large right pleural effusion with associated compressive atelectasis. 4. Apparent filling defect in the right internal jugular vein may represent thrombus or a flow artifact and could be further evalutaed with ultrasound, if clinically appropriate. 5. New left ventricular apical filling defect, most likely represents a thrombus as it was not present on the CTA of [2137-1-2] but a cardiac metastasis could also have this appearance. 6. Multiple stable lytic bone metastases, the involvement of the right T6 pedicle raises the possibility of impingement of the right transverse foramen and thecal sac, this would be better evaluated with MRI, if clinically appropriate. . MR HEAD W & W/O CONTRAST Study Date of [2137-2-12] IMPRESSION: Possible focus of abnormal enhancement identified in the right frontal lobe, involving the right straight gyrus, measuring approximately 2.8 x 3.3 mm in size, with no evidence of mass effect or shifting of the adjacent structures. Given the clinical history, the possibility of a metastatic lesion is a strong consideration; however, dural enhancement or vascular enhancement cannot be completely ruled out, correlation with a dedicated MRI of the orbits and frontal lobe with high-resolution and gadolinium is recommended. . CHEST (PA & LAT) Study Date of [2137-2-17] FINDINGS: Catheters overlie both hemithoraces. The left pleural effusion is decreased in size compared to prior. The right effusion is slightly larger. There is some residual volume loss/infiltrate in the left lower lobe. There is also some volume loss/infiltrate in the right lung. Right Port-A-Cath is still present. Compared to the prior study, the upper lung aeration is similar. It is difficult to compare the lower lobes secondary due to change in size of the effusions. Brief Hospital Course: 60 y/o female with metastatic breast cancer presents with hypoxia and fatigue. . 1. Hypoxia / hypercarbia: She initially required a non-rebreather to keep her O2 sats >90%. She had bilateral, recurrent malignant pleural effusions, likely leading to significant restrictive physiology and reduced ventilation. Since her CXR showed a possible RLL PNA, we did cover for a simultanous HCAP with Vancomycin and Cefepime. She received 2 thoracenteses during her ICU stay, 1 on each side, with good effect and improvement in her oxygen saturation. IP was consulted regarding pleurx catheter placement, which was done on [2-15] on the right side, without complication. A left pleurex catheter was placed on [2-17] without complications. She will need follow-up with IP in 2 weeks with a repeat CXR in 2 weeks. Her oxygenation gradually improved, and she was successfully weaned to room air. All cultures are negative and finalized. Her Pleurex catheters were drained daily, with alternating sides each day. She should continue this alternating drainage daily after discharge. . 2. Low urine output: This was likely [2-6] to low intravascular volume due to hypoalbuminemia and third spacing. She has been total body overloaded and responding well to IV furosemide. She tolerated gentle diuresis and was started back on her home dose of furosemide prior to transfer to the floor with resultant tachycardia, which responded to NS bolus. Her lasix was subsequently discontinued given the tachycardia, and may be restarted if O2 requirement worses. She may not need continued diuresis with her new pleurx catheters. . 3. Subsegmental PE: CTA showed a RLL subsegmental PE as well as a "LLL pulmonary arterial filling defect." LENIs were negative. MRI brain showed a likely metastatic lesions, and she was therefore not anticoagulated. She did not have any further respiratory compromise and not further treatment was initiated. . 4. Metastatic breast cancer : Imaging cosistent with stage 4 disease with mets in adnexa, stomach, bone, and malignant effusion. Her neutropenia, secondary to previous chemotherapy, was treated with good effect with Neupogen. Echocardiogram showed a mass suggesting vascularized tissue in left ventricle (a likely metastasis). Palliative care was consulted to help patient to better cope with her illness, address goals of care, and provide an effective pain regimen. She is currently on both long-acting morphone and short-acting doses for breakthrough pain, but her pain has been very well controlled on the MSContin with minimal breakthrough requirements. Her goals of care were discussed at length and she is DNR/DNI. She has chosen to pursue hospice care at a hospice house. Medications on Admission: Levothryoxine 88 mcg PO daily simvasatin 10mg PO daily colace 100mg PO BID lorazepam 0.5 mg PO q12h prn anxiety mirtazapine 7.5mg PO hs metoprolol tartrate 25mg PO BID oxycodone 5-10mg PO q6h prn senna 8.6 [1-6] tab qhs prn constipation zofran 4-8mg PO q8h prn lasix 20-40mg PO daily as needed fro wt gain > 2 lb. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for anxiety. 4. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constapation. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 10. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital3 ]Hospice House Discharge Diagnosis: ## Widely metastatic breast cancer, with new evidence for probable intracranial and intracardiac metastatic foci ## Cachexia secondary to above ## Pulmonary emboli - right and left subsegmental branches, not on anticoagulation due to concerns re: brain metastases ## s/p recent neutropenic episode s/p Taxol therapy ## Febrile with neutropenia - no clear source of infection identified, treated empirically with vanco/cefepime ## diarrhea ## Hypothyroidism ## Hypertension ## Unstageable sacral ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a low white blood cell count and fatigue after getting chemotherapy. You also had shortness of breath. You were found to have fluid around your lungs related to spread of breast cancer. You also had a blood clot in your lungs. After a full discussion of your prognosis with your doctors, it was decided to continue to support you but avoid further chemotherapy as well as heroic measures and you asked to be discharged to hospice. Followup Instructions: Department: Radilogy When: THURSDAY [2137-3-7] at 9:00 AM Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage NOTE-You can just walk in to obtain this xray. Let them know you have an appt at 9:30am Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2137-3-7] at 9:30 AM With: [First Name8 (NamePattern2) 828] [Name8 (MD) 829], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "198.5", "V49.86", "458.9", "486", "288.03", "401.9", "415.19", "787.91", "707.03", "197.8", "E933.1", "244.9", "707.22", "V45.71", "272.4", "198.3", "V10.3", "511.81", "198.89", "197.2" ]	icd9cm	[ [ [] ] ]	[ "34.09", "34.91" ]	icd9pcs	[ [ [] ] ]	12111, 12167	8016, 10744	309, 354	12712, 12712	4201, 7993	13386, 13980	3406, 3511		11112, 12088		12188, 12691		10770, 11089			12888, 13363									3526, 4182																				265, 271										382, 2226									12727, 12864					2248, 3082	3098, 3390
23,282	128,978	27928	Discharge summary	report	Admission Date: [2102-9-29] Discharge Date: [2102-9-30] Date of Birth: [2041-11-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: s/p cath with hypotension Major Surgical or Invasive Procedure: Cardiac catheterization with placement of drug eluting stents History of Present Illness: 60 yo M with h/o diet controlled DM, hypercholesterolemia. Pt was transferred to [Hospital1 18] from an OSH [2102-8-21] after c/o chest pain on and off throughout the day and a Trop of 0.73. Cardiac catheterization showed CAD and he underwent POBA of the RCA. He had a post-cath echo which demonstrated EF=60% and no wall motion abnormalities, mild LVH. In order to begin cardiac rehab he had a follow up stress test, with no symptomatic or EKG ischemic changes, but moderate reversible anterior and distal lateral wall defect on nuclear imaging. Normal LV wall thickness, cavity size and function, EF=62%. The patient had no symptoms of chest pain, SOB, PND, edema, lightheadedness or palpitations between the time of first cath and current admission. He exercises by walking and has had no DOE. The patient underwent cardiac catheterization, which showed LAD 40% stenosis proximal, 60-70% mid vessel, and 90% at origin of D2. His Lcx was diminutive with origin having 60% stenosis. His RCA was not evaluated. Cypher stents were placed into the D2 and LAD with "Culotte" stenting), with good result. Angioseal was used for closure. Patient developed a 8-10 cm soft hematoma and manual pressure was applied. At this point patient states he felt lightheaded for the first time in hospitalization. BP decreased to 60/palp, HR decreased to 40s, in sinus brady. 1.5 mg of atropine was given as well as 10 mcg/kg/min dopamine drip started, with SBP responding to 150. Dopa was turned off and bp decreased to 91/70, hr 73, then to 80/50, hr 80. Foley was inserted and dopa restarted at rate of 10. BP increased to 110/70 and foley yielded 400cc. He was sent to holding area with BP 150/80, which decreased to 79/40 off dopa drip. He was put on [2-13] NS open, received 1500 cc, and dopa drip restarted. He had a CT scan, which showed no pericardial effusion, no retroperitoneal bleed, and right femorral hematoma with no focal site suggestive of active bleed. Hematoma was soft and did not expand, and ultrasound of right groin demonstrated no pseudoaneurysm or AV fistula. He was transferred to floor on dopa drip of 2. At no time during the procedure or after did patient develop CP or SOB. On the floor, patient states that he is symptom free. Denies lightheadedness, palpitations, chest pain, dyspnea. His dopa rate was increased from 2 to 3 due to SBP <90 with good response. He developed some nausea about 3 hours after arriving on floor and received anzemet IV. At the same time, he had hypotension, and required Dopa drip at 5-7. Past Medical History: borderline DM -Diet controlled Osteoarthritis right hip hyperlipidemia Tobacco-quit with a 60 ppy history CAD s/p POBA of RCA s/p NSTEMI Kidney stones: previous intervention for stone removal hernia repair Social History: Smokes one and one-half packs per day for 40 years (60 pack years). drinks 3-4 vodka and club sodas roughly every other weekend. no illicit drug use. . Lives alone; adult children live in the area. Retired from [Company 22916] 5 years ago; patient states that he receives all of his medical care in the clinic at [Company 68023] factory in [Location 9104]. Family History: Mother 92; living. Has Alzheimer's-type dementia. Father died at 72 of brain aneurysm. . 1 older brother had quadruple bypass surgery one year ago. 7 other siblings healthy. Physical Exam: PE: VS: T-96.8, HR 71, BP 94/54, MAP 67, RR 21, O2 sat: 98, Wt 86.2 kg Gen: AAO x3 HEENT: PERRL CV: distant heart sounds, no m/r/g Lungs: cta bilaterally anterior Abd: Soft, NT, NABS Ext: no lower ext edema. Rt tibial pulse palp, DP notpalp. Left poorly palp. Neurological: CN grossly intact Pertinent Results: [2102-9-29] 04:05PM HCT-36.5* [2102-9-29] 04:05PM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-2.0 [2102-9-29] 04:05PM GLUCOSE-116* UREA N-15 CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-24 ANION GAP-11 [2102-9-29] 07:12PM HCT-38.4* [2102-9-29] 07:12PM CK(CPK)-62 C.Cath: PTCA COMMENTS: Initial angiography revealed a 60-70% mid LAD lesion at the origin of D2 which had a 90% stenosis. The proximal LAD had a 40% lesion and the CX was a small vessel with a 60% lesion. The RCA was not injected. We planned to treat the mid LAD/D2 bifurcation lesion with stenting and rescue. Heparin and integrilin were used for anticoagulation. The 7F XBLAD3.5 guiding catheter provided good support. A BMW wire was crossed the LAD lesion without difficulty. A Whisper wire crossed the D2 lesion without difficulty. The D2 lesion was predilated with a 2.0x15 mm Voyager balloon at 6 ATM. A 3.0x23 mm Cypher stent was deployed across the mid LAD lesion (jailing the D2) at 16 ATM. D2 was recrossed with the Whisper wire and redilated with a 2.25x15 mm Quantum Maverick balloon at 8, 11, and 17 ATM. The origin of D2 still had a 70% stenosis so the decision was to perform bifurcation "Culotte" stenting. A 2.5x18 mm Cypher stent was deployed in the ostial D2 at 15 ATM. The LAD was then recrossed with the Choice PT XS wire. "Kissing balloon" inflation was performed with a 3.0x15 mm Quantum Maverick balloon in the LAD and a 2.5x15 mm Quantum Maverick balloon in the D2 both at 14 ATM. Final angiography revealed normal flow, no dissection, and TIMI 3 flow in the stents. The right femoral arteriotomy site was closed with an 8F Angioseal device. After successful deployment the patient developed a hemotoma inferior to the puncture site and hemostasis was achieved with manual pressure. The patient developed multiple presumed vagal episodes during pressure hold and afterwards requiring atropine, IVF, and intermittently dopamine. Further evaluation was performed due to hypotension including abd/pelvic CT, right femoral ultrasound which showed no active bleeding with non-organized hemotoma, and no pericardial effusion. Patient was transferred to the CCU for further monitoring. COMMENTS: 1) Initial angiography revealed a 60-70% mid LAD lesion at D2 which had a 90% ostial lesion. 2) Successful PTCA and stenting of the mid LAD and D2 bifurcation using the "Culotte" technique with a 3.0x23 mm Cypher stent in the LAD and a 2.5x18 mm Cypher stent in the D2. Post-dilation was performed with a 3.0 mm balloon in the LAD and a 2.5 mm balloon in the D2 using a "kissing" technique. Final angiography revealed 0% residual stenosis, no dissection, and TIMI 3 flow. (see PTCA comments) 3) Right femoral arteriotomy site closed with an 8F Angioseal closure device. 4) Post-procedure hypotension evaluated without obvious source other than vagally mediated. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stenting of the mid LAD and D2 bifurcation lesion using "Culotte" technique. . . CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: There is dependent atelectasis at the lung bases bilaterally. There are no pleural effusions. There is no pericardial effusion on visualized images through the heart. The liver, gallbladder, pancreas, adrenal glands, abdominal loops of large and small bowel are unremarkable on this non-contrast enhanced study. There are vascular calcifications present in the aorta. There is diverticulosis of the descending colon without evidence of acute diverticulitis. Contrast administered during the catheterization procedure is seen excreted by kidneys normally. There is mild bilateral perinephric fat stranding. There is an exophytic right renal cyst, measuring approximately 51 x 44 mm in size. There is a 13-mm parapelvic cyst in the mid pole in the right kidney. There is no evidence of retroperitoneal bleeding. There is no free air, and no free fluid in the abdomen. CT PELVIS WITHOUT IV CONTRAST: The rectum, prostate, seminal vesicles are unremarkable. There is diverticulosis of the sigmoid colon, without evidence of acute diverticulitis. A Foley catheter is seen in the bladder that is partially collapsed. There is no free fluid, and no pathologically enlarged pelvic or inguinal lymphatic nodes. There is a large hematoma in the right inguinal area, extending to the proximal thigh. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified in visualized osseous structures. Coronal and sagittal reconstructed images were reviewed, and confirmed the findings seen on the axial images. IMPRESSION: 1. No evidence of retroperitoneal bleed. 2. Large hematoma in the inguinal region, extending to proximal thigh. Ultrasound can be performed to assess for active bleeding. Femoral U/S FINDINGS: Targeted ultrasound of the right groin deep to the patient's recent arterial puncture was performed. Color flow and Doppler analysis of the right common femoral artery and vein were performed demonstrating normal arterial and venous waveforms. There was no evidence for pseudoaneurysm or AV fistula. Hematoma is demonstrated along the right groin, as better quantified on the concurrent CT scan. Note is made of partially visualized shadowing material in the right groin which may relate to surgical material if there is history of prior inguinal hernia repair. IMPRESSION: No evidence of pseudoaneurysm or AV fistula. Of note, noncontrast ultrasound is not sensitive for active bleeding. . ECHO [2102-9-30]: MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.2 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.49 (nl >= 0.29) Left Ventricle - Ejection Fraction: 65% to 70% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 1.33 Mitral Valve - E Wave Deceleration Time: 241 msec TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [2102-8-22]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Mildly dilated ascending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). 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. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2102-8-22], no change. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD on [2102-9-30] 16:45. Brief Hospital Course: The patient presented for elective catheterization following reversable perfusion changes on nuclear stress test. Catheterization revealed 60-70% mid LAD lesion and D2 90% ostial lesion, and a Culotte technique was used to stent the two vessels with Cypher drug eluting stents with good result. An angioseal device was used for closure. As described in the HPI section, the patient developed hypotension post procedure. He received atropine and was put on a dopamine drip. A abdominal CT scan was performed which showed no retroperitoneal bleed and also visualized enough of heart to rule out a pericardial effusion. A femoral doppler was negative for pseudoaneurysm. He was continued on the dopamine drip at a low rate while his systolic blood pressure remained stable ranging from 85 to 100. His low blood pressure was considered most likely due to a prolonged vagal response. The dopamine drip was discontinued roughly 12 hours after the procedure with no decrease in SBP. His urine output remained normal throughout and he had no symptoms of presyncope, chest pain or SOB. His post cath EKG was unremarkable. His hematocrit also remained stable. An echocardiogram was performed as well, which demonstrated normal EF and no wall motion abnormalities and no pericardial effusion. The patient was discharged on his outpatient doses of plavix, aspirin and metoprolol. His ACE inhibitor was held and could be restarted on follow up with reassessment of the patient's blood pressure. The patient's statin dose was decreased to 40 mg and can be reassessed in the future. Medications on Admission: Lipitor 80mg daily Plavix 75mg daily Lisinopril 5mg daily Metoprolol 25mg [Hospital1 ] ASA 325mg daily MVI Discharge Medications: 1. Cardiac rehab program 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Coronary artery disease Secondary: Hyperlipidemia Borderline DM Discharge Condition: The patient was discharged hemodynamically stable, afebrile with appropriate followup. Discharge Instructions: You have had two coronary drug eluting stents placed to fix a partial blockage in your coronary arteries. Take your medications as follows: 1) You should continue taking your aspirin (325 mg), plavix (75 mg), and metoprolol (25 mg twice a day) as you had previously. Because you have coronary stents, it is absolutely essential that you continue taking both aspirin and plavix for one year. If you have difficulty getting supplies of Plavix for any reason, you should contact your cardiologist. 2) Your lisinopril was temporarily discontinued while in the hospital due to low blood pressure. You should restart this medication after seeing your primary care physician or cardiologist. 3) Your lipitor dose was reduced to 40 mg every day. 4) Continue taking your multivitamin. . Talk with your cardiologist about when to start your cardiac rehabilitation program. . If you feel lightheadedness, chest pain, or shortness of breath, call your physician or go to the emergency room. Followup Instructions: Please call your primary care physician, [Name10 (NameIs) 68024],[Name11 (NameIs) ] [Name Initial (NameIs) ]. at [Telephone/Fax (1) 68025], to schedule an appointment in one to two weeks time. You have an appointment with your cardiologist, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1989], scheduled for [2102-11-27] at 11:40. He will be contact[Name (NI) ] about your admission. If you do not see your PCP in one week, please see Dr. [Last Name (STitle) 171] in about 1 week to address re-starting one of your medications, Lisinopril. Completed by:[2102-10-2]	[ "250.00", "401.9", "276.51", "458.29", "414.01" ]	icd9cm	[ [ [] ] ]	[ "00.46", "88.56", "36.07", "37.22", "00.66", "99.20", "00.41" ]	icd9pcs	[ [ [] ] ]	14401, 14407	12212, 13782	342, 406	14525, 14614	4115, 7018	15642, 16295	3613, 3788		13944, 14378		14428, 14504		13808, 13921		7035, 12189	14638, 15619									3803, 4096																				277, 304										434, 2981														3003, 3210	3226, 3597
11,171	110,132	12326	Discharge summary	report	Admission Date: [2192-8-29] Discharge Date: [2192-9-5] Date of Birth: [2134-5-4] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: VF arrest Major Surgical or Invasive Procedure: [2192-8-31] 1. Urgent coronary artery bypass graft x5; left internal mammary artery to left anterior descending artery and saphenous vein sequential grafting to posterior descending artery and posterior left ventricular branch and saphenous vein grafts to diagonal and distal circumflex. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: Mr. [Known lastname 38430] is a 58 year old man with a history of tobacco abuse and coronary artery disease who was found unresponsive by his wife. His family performed CPR, EMS arrived and administered amio and epinepherine and shocks. He was brought to [Hospital6 3105] emergency department where he went into PEA arrest and CPR/hypothermia were administered. He was intubated and admitted. After two days he was extubated, but then experienced acute renal failure, acidemia, and anuria. Past Medical History: CAD with stent placement in [2183] Hyperlipidemia Tobacco Abuse L subpectoral hematoma s/p CPR, now with penrose drain bilateral rib fractures s/p CPR Past Surgical History kidney stone removal abdominal surgery after gunshot Cardiac Procedures CAD with stent placement in [2186] Social History: Lives with:wife and children Contact:[Last Name (NamePattern4) 38433] (wife) Phone #([Telephone/Fax (1) 38434] Occupation:fork-lift operator Cigarettes: Smoked no [] yes [x] last cigarette Current smoker, smoked 2 packs per every 3 days for many years ETOH: < 1 drink/week [x] [12-27] drinks/week [] >8 drinks/week [] Illicit drug use (none) Family History: No coronary artery disease Physical Exam: Pulse: 49 Resp: 16 O2 sat: 96%RA B/P 105/67 Height:68 inches Weight:170 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [x] 1+ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left:1+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:1+ Radial Right: 1+ Left:1+ Carotid Bruit Right:- Left:- Pertinent Results: Intra-op TEE [2192-8-31] Conclusions Pre-Bypass: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A small patent foramen ovale is present by color flow doppler. Left ventricular wall thickness, cavity size and global systolic function are normal (LVEF >55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter with simple atheroma. 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. Moderate [2+] tricuspid regurgitation is seen. Post-bypass: The patient is A-paced on a phenylephrine infusion. The left ventricular function is preserved with an estimated ERF-55%. No apparent wall motion abnormalities. TR remains 2+. There is no echocardiographic evidence of an aortic dissection s/p decannulation. The remainder of the exam is unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [Last Name (NamePattern4) ] [2192-9-3] 15:47 ?????? [2182] CareGroup IS. All rights reserved. . [2192-9-5] 07:25AM BLOOD WBC-9.6 RBC-3.29* Hgb-8.8* Hct-27.3* MCV-83 MCH-26.9* MCHC-32.4 RDW-15.9* Plt Ct-360 [2192-9-4] 07:25AM BLOOD WBC-13.5* RBC-3.18* Hgb-8.7* Hct-26.4* MCV-83 MCH-27.3 MCHC-32.8 RDW-15.6* Plt Ct-298 [2192-9-3] 03:20AM BLOOD WBC-11.7* RBC-3.11* Hgb-8.4* Hct-25.8* MCV-83 MCH-27.1 MCHC-32.7 RDW-15.6* Plt Ct-311 [2192-9-5] 07:25AM BLOOD Glucose-121* UreaN-22* Creat-1.2 Na-137 K-3.7 Cl-96 HCO3-31 AnGap-14 [2192-9-4] 07:25AM BLOOD Glucose-107* UreaN-24* Creat-1.3* Na-133 K-3.7 Cl-94* HCO3-29 AnGap-14 [2192-9-3] 05:09PM BLOOD Glucose-110* Na-134 K-3.9 Cl-92* Brief Hospital Course: The patient was brought to the Operating Room on [2192-8-31] where the patient underwent CABG x 5 with Dr. [First Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. He did develop bradycardia on POD 1, requiring Atrial pacing. He was hyperkalemic with Potassium 6.7. This was treated with insulin and D50 and resolved. 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 developed acute kidney injury with a peak creatinine of 2.6. It would trend down to baseline prior to discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO DAILY 2. Naproxen 375 mg PO Q12H Discharge Medications: 1. Simvastatin 20 mg PO DAILY RX simvastatin 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Aspirin EC 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. HYDROmorphone (Dilaudid) 2-6 mg PO Q4H:PRN pain RX hydromorphone [Dilaudid] 2 mg [11-21] tablet(s) by mouth q3h Disp #60 Tablet Refills:0 4. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Ranitidine 150 mg PO DAILY RX ranitidine HCl [Acid Control] 150 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 7. Furosemide 40 mg PO DAILY Duration: 7 Days RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 8. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily Disp #7 Packet Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: CAD with stent placement in [2183] Hyperlipidemia Tobacco Abuse L subpectoral hematoma s/p CPR, now with penrose drain bilateral rib fractures s/p CPR Past Surgical History kidney stone removal abdominal surgery after gunshot Cardiac Procedures CAD with stent placement in [2186] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170], [2192-9-11] 11:45 Surgeon Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2192-10-9] 2:00, [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) 4922], [2192-9-25] at 1:45pm Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] [Telephone/Fax (1) 29068] in [2-23] 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:[2192-9-5]	[ "584.5", "414.01", "922.1", "E879.8", "427.89", "427.31", "276.8", "V12.53", "272.4", "V45.82", "305.1", "807.09", "285.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.14", "39.61" ]	icd9pcs	[ [ [] ] ]	7434, 7509	4834, 6192	318, 685	7840, 8008	2617, 4811	8796, 9615	1925, 1954		6359, 7411		7530, 7819		6218, 6336			8032, 8773									1969, 2598																				268, 280										713, 1214														1236, 1526	1542, 1909
17,002	133,974	23179	Discharge summary	report	Admission Date: [2153-4-16] Discharge Date: [2153-4-22] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6088] Chief Complaint: retroperitoneal hematoma Major Surgical or Invasive Procedure: Evacuation of left retroperitoneal hematoma and arterial exploration. Return to the operating room for control of bleeding History of Present Illness: :85F with significant CAD and s/p CABG in [2148] hx of diastolic heart failure presents from OSH for cardiac catheterization for planned stenting of LM to LCx. During procedure patient recieved 7000U hep bolus and had a 6F Arterial sheath and 5 french venous sheath. The arterial site was closed with perc close device. Pt was out of the room at 5pm and between 7 and 9 pm patient was hypotensive to systolic of 70-80 and dropped her HCT to 19 from a pre-op HCT of 30. These issues prompted a CT scan which revealed a large left-sided RP hematoma. Patient received 2 units of blood and the patients BP rose to 100 systolic. vascular surgery consulted for RP hematoma. Past Medical History: CABG x 4 ([2148]) LIMA -> LAD, SVG to Ramus, SVG to OM and PDA HTN PVD DMII Diastolic Dysfunction Sleep apnea on bipap at night ? Mild Dementia (alert and oriented x 3) Social History: Social history is significant for the absence of current tobacco use. There is minimal history of alcohol abuse. Family History: Family hx is non-contributory. Physical Exam: 94.6 56 105/40 12 97% on 5L NC NAD CTAB RRR S, TTP in Left lower quadrant, obese mild ecchymosis over both groin sites Pulses palp fem to dp/py bilaterally Pertinent Results: [2153-4-16] 11:43PM HCT-35.0# [2153-4-16] 10:48PM HCT-20.7 [2153-4-16] 10:48PM PT-16.1* PTT-150* INR(PT)-1.4* [2153-4-16] 10:45PM GLUCOSE-158* UREA N-29* CREAT-0.9 SODIUM-141 POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-11 [2153-4-16] 10:45PM CALCIUM-5.8* PHOSPHATE-3.0 MAGNESIUM-1.4* [2153-4-16] 08:45PM UREA N-34* CREAT-1.0 POTASSIUM-3.8 [2153-4-16] 08:45PM estGFR-Using this [2153-4-16] 08:45PM CK(CPK)-10* [2153-4-16] 08:45PM CK-MB-NotDone [2153-4-16] 08:45PM PLT COUNT-128* [2153-4-16] 07:30PM HCT-19.3# [2153-4-16] 02:00PM INR(PT)-1.2 Brief Hospital Course: Cardiac catheterization was performed via arterial and venous punctures in the left groin. COMMENTS: 1. Planned PCI of Left Main and LCX. 2. Stenting of LM and LCX with Xience 4x28mm stent posted to 4.5 mm in left main ostium. 3. Groin closure with Mynx device. Post cath patient had a vagal episode during venous sheath removal. She remained with borderline BP for several hours and a repeat HCT went from 26 to 19. A CT scan confirmed retroperitoneal bleed and she was transferred to CCU for transfusion and monitoring. The decision to explore the patient initially was based on continued hemodynamic instability requiring pressors. Hct remianed 20 despite total of 8 units of blood transfused over approximately 4-6 hours. She had a noncontrast CT after 2 units that showed the beginnings of a retroperitoneal hematoma. Her groin had no hematoma so my thought was that the only place to sequester that many transfused units was in the retroperitoneum. She was quite obese. In the OR she had a relatively small RP hematoma and after underway her 1st intraop Hct came back at 35 (despite no further transfusions). There was no external iliac artery injury and no arterial bleeding coming from under the inguinal ligament. We controlled some minor venous bleeding points and closed with the supposition that based on now stable hemodynamics, Hct of >35 that there was no ongoing source and that the 2nd Hct was likely in error. Soon postop, her JP drain began to put out large quantities despite attempts to correct coagulopathy. She was immediately re-explored. She was more unstable this time and nearly arrested in the OR. Large retorperitoneal hematoma encountered this time with bleeding coming from under inguinal ligament (still no groin hematoma). Groin was opened and small arterial puncture site just under the lower edge of the inguinal ligament (no sign of Mynx closure device) was repaired with single prolene stitch. The inguinal ligament was mobilized slightly to get at it. She was able to wean off of most pressors and eventually all pressors by 48 hrs after she was cardioverted out of Afib. We had discussion about Plavix / ASA and this was restarted by consensus 24 hours postop. No further bleeding. Oliguria / ATN renal failure attributed to recent dye load and shock. Echo showed good left heart function. Seemed to be about to turn the corner until 24 hours prior to death when she started to behave more septic, again into afib with more pressor requirements. CT showed bilateral pneumonias as only potiential source for infection. ABX were changed accordingly. Patient had persistant thrombocytopenia of unclear etiology. Final event was rapid Afib (previously rate controlled), hypotension that ensued quickly degraded to non-cardiovertable asystole. Resuscitation efforts were stopped when echo showed no heart movement (~15minutes total). Medications on Admission: Medications (date/ time last taken): Did not get plavix. Asa 81mg (this am) Mucomyst Protonix Miralax 17gm Spiriva Norvasc 5mg Daily Imdur heparin 5000 SQ given at 9am Requip 4mg Lasix 40mg (this am) Potassium 10meq Exelon 6mg (dementia) Eye gtts Namenda 10mg (dementia) Metoprolol 25 Lovastatin 50. . Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: cardiac failure and death Discharge Condition: death Discharge Instructions: none Followup Instructions: Patiet's family declined autopsy. Completed by:[2153-5-1]	[ "790.92", "428.33", "287.5", "E870.6", "250.00", "285.9", "427.31", "V45.81", "413.9", "E879.0", "584.9", "996.72", "491.21", "E849.7", "518.81", "995.92", "785.52", "414.01", "441.3", "428.0", "998.12", "785.51", "998.2", "038.9" ]	icd9cm	[ [ [] ] ]	[ "99.61", "88.72", "37.22", "39.31", "38.93", "96.72", "88.56", "33.23", "96.04", "36.07", "00.40", "00.45", "00.66", "54.0", "99.60" ]	icd9pcs	[ [ [] ] ]	5613, 5622	2330, 5231	286, 411	5691, 5698	1683, 2307	5751, 5814	1458, 1491		5584, 5590		5643, 5670		5257, 5561			5722, 5728									1506, 1664																				222, 248										440, 1115														1137, 1312	1328, 1442
4,155	135,302	43939	Discharge summary	report	Admission Date: [2154-6-11] Discharge Date: [2154-6-28] Date of Birth: [2071-8-19] Sex: F Service: MEDICINE Allergies: Bactrim Ds / Lisinopril Attending:[First Name3 (LF) 4760] Chief Complaint: Progressive dyspnea x 5 days Major Surgical or Invasive Procedure: [2154-6-11] Thoracentesis/ Left Pleural tap (dx) [2154-6-17] Thoracentesis/ Left Pleural tap (~1400cc) [2154-6-26] Pleurex Catheter Placement with 1100 cc removed [2154-6-26] Transthoracic Ultrasound [2154-6-26] Bronchoscopy History of Present Illness: Ms [Known lastname ] is an 82 year old female with history of COPD not on home O2, CAD s/p CABG ([2147]), CHF (EF 40-50%), s/p BiV ICD who presents from home with progressive dyspnea x 5 days. She also reports cough productive of brown sputum over this period of time. She denies any fevers, chills or night sweats. She had no chest pain, diaphoresis, or headache. She did occasionally feel lightheaded. She also had decreased PO intake over the past week. She had been using her inhalers at home with only minimal relief. The shortness of breath has been progressive and worsened with any exertion to the point where she became dyspneic while eating her cereal this morning. Her son had encouraged her to go to the ED yesterday but she refused, finally agreed to present today. . In the ED the patient's vital signs were T 97.7, BP 80/38, HR 70, RR 17, O2sat 88% on RA improved to 95% on 2L. She was given 500cc NS for low blood pressure with good response to systolic 100-110. One hour later BP trended down to systolic 80s and another 500cc NS was given again with good improvement in BP to systolic 110. She was started on maintenance IVF at 100cc/hr. She had 300cc of urine output. She was given albuterol and ipratroprium nebulizers with symptomatic improvement in shortness of breath. CXR showed new LLL opacity concerning for PNA with adjacent parapneumonic effusion. UA negative for infection. Blood and urine cultures were drawn. She was given ceftriaxone and levofloxacin. Consideration was given to CTA to rule out PE, however given patient's acute renal failure and low suspicion for PE the study was deferred for now. The patient is being admitted to the ICU due to labile blood pressure in the ED. . On arrival to the floor, the patient is feeling well. She feels that her breathing is much improved. She continues to have cough. She has no chest pain, shortness of breath or dizziness. She is A&Ox3. She is speaking in full sentences without difficulty. Ms. [Known lastname ] reports a 20lb unintentional weight loss over the past several months. . ROS: The patient denies fevers, chills, chest pain, diaphoresis, lightheadedness, dizziness. No orthopnea, PND, LE edema. Past Medical History: COPD, 100 PYH, quit [2132] CHF, weight @ baseline 160 lbs Ischemic cardiomyopathy, EF 40% (TTE [2151-10-11]) CAD, s/p MIs and CABG ([2147]) CAD history: - Patient states that she had an MI ~15 years ago - s/p EPS with AVRNT ablation in [2139] - She [Year (4 digits) 1834] RCA stenting in [2140], after a positive ETT-thal - MI & CABG in [2147]: LIMA-LAD (done in [Country 4754]) - Cath in [4-/2148] after drop in EF by ECHO - LM disease, EF 20% on left ventriculography. Patent LIMA, patent native vessels - P-MIBI [2151-7-15]: No definite evidence of reversible ischemia, calculated LVEF of 39%. BIV/ICD pacer, ICD device change [2154-4-17] Valvular Disease: Mild AS/AI, Mild-to-mod MR & TR Hypertension Hyperlipidemia Anemia Renal insuff Hypothyroidism, [1-19] XRT for Pituitary tumor [2094]-50 GERD Carpal tunnel Spinal stenosis Chronic lower back pain, followed by pain clinic Greater trochanteric bursitis bilaterally Osteoarthritis, back, hips, legs per OMR Polyarthritis, ? RA, seen by [Name8 (MD) ], MD Hard of hearing h/o pos PPD, no CXR abnl, started on INH in [2134] c/b acute INH hepatitis h/o psoriasis . PSHx: [2151-9-2] s/p Right TKR [2151-5-24] s/p cataract O.S. w/ implant [2148-4-29] s/p 1V CABG (mammary to LAD) [2147-8-14] s/p R Knee Arthroscopy, subtotal medial meniscectomy & lateral meniscectomy foot neuropathy hernia repair Social History: Widowed & lives w/ son and daughter in her own home in [Location (un) 14307], 2 other children live in the same home in separate apartments. Retired house cleaner. No current EtOH or smoking (2ppd+ x 40yrs, quit 24 yrs ago) or EtOH. Uses walker for ambulation. Is independent in feeding and dressing Meals are made for her, she does her own shopping weekly with transportation. Family History: NC Physical Exam: 96.1, BP 130/49, HR 60, RR 16, O2 sat 94% on 3L NC. Gen: Elderly female in NAD, speaking in full sentences, in NAD. No accessory muscle use. HEENT: Dry MM, EOMI, PERRL. Neck: JVP flat, no HJR. Supple. CV: Regular rate and rhythm, soft [1-23] holosystolic murmur at the apex without radiation. Pulm: Scattered rhonchi diffusely with decreased breath sounds at the LLL. +egophony. Dull to percussion at left base. Abd: Soft, NT, ND, +BS. Ext: No edema bilaterally, 2+ DP pulses Neuro: A&Ox3, nonfocal neuro exam Guaiac: Negative in the ED Pertinent Results: Admission Labs: =============== [2154-6-11*] BLOOD WBC-8.7 RBC-4.14 Hgb-12.6 Hct-38.0 MCV-92 MCH-30.4 MCHC-33.1 RDW-13.9 Plt Ct-281 [2154-6-12] BLOOD WBC-7.4 RBC-3.76* Hgb-11.8* Hct-35.5* MCV-94 MCH-31.3 MCHC-33.1 RDW-13.2 Plt Ct-245 [2154-6-11] BLOOD Neuts-64.1 Lymphs-25.2 Monos-5.7 Eos-4.7* Baso-0.3 [2154-6-11] BLOOD Glucose-117* UreaN-43* Creat-1.7* Na-136 K-4.9 Cl-105 HCO3-21* AnGap-15 [2154-6-12] BLOOD Glucose-90 UreaN-39* Creat-1.6* Na-140 K-5.2* Cl-110* HCO3-20* AnGap-15 [2154-6-11] BLOOD LD(LDH)-441* CK(CPK)-47 [2154-6-11] BLOOD cTropnT-0.08* [2154-6-11] BLOOD TotProt-6.2* Albumin-3.5 Globuln-2.7 Calcium-8.8 Phos-3.8# Mg-2.2 [2154-6-11] BLOOD TSH-0.29 [2154-6-11] BLOOD Lactate-1.3 [2154-6-11] URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2154-6-11] URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 [2154-6-11] PLEURAL TotProt-3.6 Glucose-93 LD(LDH)-716 . Microbiology: ============= Blood culture ([2154-6-11]): No growth Pleural fluid ([2154-6-11]): No growth [2154-6-11] PLEURAL FLUID GRAM STAIN (Final [2154-6-11]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. . Imaging: ======== CXR ([2154-6-11]): New left lower lung opacity concerning for pneumonia with adjacent parapneumonic effusion. . CXR ([2154-6-12]): In comparison with the study of [6-11], there is little change. Opacification in the left lower lung consistent with the clinical diagnosis of pneumonia. The degree of left effusion cannot be evaluated since the outer aspect of the image on this side has been excluded. Right basilar opacification persists. . CXR ([2154-6-23]): As compared to the previous examination, there is no major change. The pre-existing areas of parenchymal consolidation that presumably represent pneumonia are unchanged in extent and distribution. Unchanged position of the defibrillator leads. Unchanged size of the cardiac silhouette. CT Torso ([2154-6-24]): 1. Moderate-to-large left pleural effusion as described above. No definite cause is identified. However, there is a patch of consolidation/atelectasis within the left upper lobe, which cannot be further characterized for underlying neoplasm given the collapse and inability to administer IV contrast. Consider follow-up imaging after therapy or thoracentesis for further evaluation. 2. Mediastinal lymphadenopathy. 3. Emphysema with interstitial lung disease and calcified pleural plaques, probably asbestos related. CT Head ([2154-6-24]): No definite intracranial metastatic lesions. Please note that the non-contrast technique of this head CT is significantly limited for assessment of intracranial metastatic disease. If the patient cannot tolerate MR imaging with gadolinium due to implanted pacemaker/defibrillator or for other reasons, further evaluation with contrast-enhanced head CT is suggested as this is a more sensitive means of evaluation. Other: ====== Transthoracic Echo ([2154-6-18]): The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %) secondary to hypokinesis of the inferior septum and inferior free wall. Right ventricular chamber size is normal. with borderline normal free wall function. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Discharge Labs: =============== COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2154-6-28] 06:00AM 13.9* 3.01* 9.3* 28.3* 94 30.7 32.7 13.3 393 RENAL & GLUCOSE Glu UreaN Creat Na K Cl HCO3 AnGap [2154-6-28] 06:00AM 78 52* 1.7* 141 5.0 103 30 13 [2154-6-21] 05:50AM BNP 2536* Brief Hospital Course: This is an 82 year old woman with a history of CAD, CKD, and COPD who was initially admitted with a pneumonia and hypotension. She was in the ICU upon admission, and then transferred to the floor. . ICU Course: Ms. [Known lastname ] was admitted with hypoxia and a new infiltrate on CXR. She was admitted to the ICU due to fluid-responsive hypotension while in the ED. She received ceftriaxone and levofloxacin while in the ED and was continued on levofloxacin monotherapy while in the ICU. She [Known lastname 1834] thoracentesis revealing an uncomplicated exudative para pneumonic effusion. Cultures of the blood and pleural fluid were without growth at the time of transfer to the floor, but as per below the cytology was later found to be positive for malignant cells. The patient's hypoxia resolved, saturating in the low-mid 90's% on room air. The following is the pts course while on the floor: #. LLL Pneumonia (community acquired and likely obstructive) with effusion and hypoxia. The effusion was tapped by IP on [6-11] (dx) and [6-17] (1400 cc). She remained satting at around 92% on 4-5L of O2 by nasal cannula. She was treated with Levofloxacin 750 mg PO Q48H for 9 days but did not improve. She was started on Zosyn on [2154-6-20] after CXR showed a new R base pulmonary infiltrate. She continued to receive nebulizers with albuterol and atrovent q 6 hours and frequent incentive spirometry. CXR on [6-23] showed no improvement over CXR on [6-19]. She was started on prednisone 30 mg daily on [2154-6-21] with some improvement in the patients breathing. WBC rose to 16 possibly from steroids, but blood cultures were repeated. Sputum culture was sent on [6-23] which was negative. WBC on [6-24] increased again to 16.4, blood cultures were drawn. As the patient remained afebrile and WBC was trending down, antibiotics were stopped on [2154-6-25] (for a total of 5 days of Zosyn). . # NSCLC: Pleural fluid cytology was found to be positive for non-small cell lung cancer, confirmed on [2154-6-25]. Chest/abdomen/pelvis CT ordered for further evaluation of showed no metastases outside the lungs. Head CT without contrast also showed no metastases. A family meeting was held on [2154-6-25] to discuss the patient's diagnosis and plan of action. She [Date Range 1834] bronchoscopy and L sided Pleurex catheter placement by IP on [2154-6-26]. No endobronchial lesions were noted, but a large amount of mucus was removed from the L bronchus. 1100cc of blood fluid was removed on this tap. 600cc removed on [6-27]. Seen by oncology who felt it was stage IIIB vs IV. No surgical intervention as no clear mass. No xrt at this time as no symptoms to improve. [Month (only) 116] be eligible for palliative [Doctor Last Name 360] +/- EGFR inhibitor depending on functional status. Will see thoracic oncology [7-11] to further evaluate. . #. Acute on CKD Stage III (baseline creat ~1.6) After lasix 10 mg IV on [6-19] and [6-20] her Creat did rise to 1.9 with BUN of 55. With some improvement in output. Her Creat peaked at 2.2 with K+ of 5.4 on [6-16] after lasix 20 mg IV on [6-15] and she was given Sodium Polystyrene Sulfonate 30 gm daily x's 2d. Her creatinine trended down to her baseline of [12-23]. Her weight continued to creep up even with multiple pleural taps and she had early satiety so her furosemide was restarted at 20mg. . #. Hypotension on admission: Treated by holding Imdur and Valsartan. Remain on hold at discharge. . #. COPD - Wheezing was prominent for several days. She was transitioned from tiotropium to duonebs due to inability to correctly deliver inhaler meds. On [2154-6-21] she was started on Prednisone 30 mg daily for wheezing with prompt improvement and albuterol and atrovent nebs were scheduled. She will be discharged on slow taper, q 7 days by 10mg. Starting 20mg on [6-28]. #. CHF - lasix was on hold for hypotension & inc creat after lasix 20 mg IVP x's 1 on [6-15]. Lasix 10 mg IV was given on [6-19] and [6-20] for increased congestion with moderate output and subsequent rise in BUN/Cr. Lasix was restarted at 20mg on [6-27] as her weight increased to 168 lbs (baseline 160) and without improvement in her 02 sat s/p thoracentesis. Her weight on [2154-6-28] was 165.8 lbs. Cr slightly increased to 1.7 and K 5.0. Lasix changed to 10mg daily. #. CAD, s/p MIs & CABG, chronic Troponin elevation (~0.04), has ICD : The pt was continued on ASA, beta blocker dose was decreased due to hypotension. She remained off isordil and valsartan. Had one episode of SBP to 160 on day of discharge. If needed please increase metoprolol as she was on higher dose as outpatient. #. Nausea and vomiting, long-standing (years)in AM without weight loss: Has worsened with constipation. Had severe cramping after lactulose and dulcolax po. On the night of [2154-6-24] the patient has numerous episodes of emesis. She was treated with IV Zofran and IV compazine. LFTs were all WNL. CT abdomen with diffuse stool but no obstruction. Her symptoms improved after several bowel movements. She responded well to Miralax. No further nausea after relief of constipation. #. Osteoarthritis - followed by pain clinic and had injections, currently minimal pain at rest (L knee), some L knee pain with ambulation. Seen by geriatrics and suggested stopping neurontin. On scheduled tylenol. - continue Lidocaine 5% Patch 1 PTCH TD DAILY #. Constipation: was significantly constipated requiring attempts at tap water enema. Stopped any meds contributing to constipation including calcium. This can be restarted at pcp [Name Initial (PRE) 8469].. #. Hypothyroidism, TSH = 0.29 ([2154-6-11]) . Free t4 0.98. [Month (only) 116] be slightly overrepleted. Consider decreasing dose. #. Hyperlipidemia: Her Statin was stopped as inpatient in setting of persistent nausea and new NSCLC. [Month (only) 116] consider restarting as outpatient. #. GERD: - continue home prilosec #. Anemia - baseline Hct ~33%, has been as low as 28 on [6-23] after IVF. Anemia profile not consistent with either chronic disease or iron deficiency. Stool guiaic negative. Remained stable at 29. # Advance Directives: Currently Full Code but should be further addressed. She was not prepared to discuss as she was dealing with the new diagnosis of NSCLC. She has a large supportive family. They mentioned they would be open to hospice in the future. Palliative Care consult as needed. Medications on Admission: Centrum 1 tab daily Lipitor 40 mg daily Valsartan 80 mg daily Triamcinolone topical cream Aspirin 81 mg daily Lasix 40 mg daily Omeprazole 20 mg [Hospital1 ] Isosorbide mononitrate SR 30 mg daily Percocet 1-2 tabs Q6H PO PRN for left CP Tramadol 50 mg q6H PRN Unithroid 100 mcg daily Neurontin 300 mg [Hospital1 ] Toprol XL 50 mg daily Ipratroprium 2 puff INH QID TEDS Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO daily prn as needed for constipation. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: 2 tabs (20mg) daily until [7-4] then one tab (10mg) daily x 7 days- until [7-11] then stop. Disp:30 Tablet(s) Refills:0 6. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) gms PO DAILY (Daily). Disp:510 gms Refills:0 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 8. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on 12 in am off at hs. Disp:30 Adhesive Patch, Medicated(s) Refills:0 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Zofran 4 mg Tablet Sig: One (1) Tablet PO q6h prn as needed for nausea. Disp:30 Tablet(s) Refills:0 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 17. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 18. Furosemide 20 mg Tablet Sig: one half tab (10mg) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: NSCLC found in pleural fluid, consistent with adenocarcinoma Left pleural effusion, malignant Pneumonia COPD, 100 PYH, quit [2132] CHF, EJ 40%, weight @ baseline 160 lbs Acute on Chronic Kidney Disease stage III Secondary Diagnoses: Ischemic cardiomyopathy, EF 40-50% (TTE [2154-6-18]) CAD, s/p MI and CABG ([2147]) BiV ICD device change [2154-4-17] S/p EPS with AVRNT ablation in [2139] Valvular Disease: Mild AS/AI, Mild-to-mod MR & TR Hypertension Hyperlipidemia Anemia Hypothyroidism, [1-19] XRT for Pituitary tumor ~[2094] GERD Carpal tunnel Spinal stenosis Chronic lower back pain, followed by pain clinic Greater trochanteric bursitis bilaterally Osteoarthritis, back, hips, legs per OMR Polyarthritis, ? RA, seen by [Name8 (MD) ], MD Hard of hearing h/o pos PPD, no CXR abnl, started on INH in [2134] c/b acute INH hepatitis h/o psoriasis . PSHx: [2151-9-2] s/p Right TKR [2151-5-24] s/p cataract O.S. w/ implant [2148-4-29] s/p 1V CABG (mammary to LAD) [2147-8-14] s/p R Knee Arthroscopy, subtotal medial meniscectomy & lateral meniscectomy Discharge Condition: Stable * Home meds on hold or stopped * - Neurontin stopped due fatigue - Furosemide 40 mg qd- changed to 20mg daily - Valsartan 80 mg qd- on hold due to low bp - Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr (more below)- on hold due to low bp - Toprol XL dose decreased to 25mg Discharge Instructions: You had a collection of fluid in the lining of your lung. You had a catheter placed to help drain the fluid and improve your breathing. You are now requiring oxygen to help your breathing. This should be on at all times. You are also on steroids to help your breathing and it should be tapered off over next two weeks. You were diagnosed with lung cancer. You need to follow-up with the lung cancer specialists on [7-11]. Take the medications as listed on your discharge paperwork. Your lasix dose has been changed and your calcium is currently on hold due to your constipation. Do not restart any old medications until you follow-up with Dr. [Last Name (STitle) 4026]. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2000cc/day Followup Instructions: Thoracic Oncology -Provider: [Known firstname ] [Last Name (NamePattern1) 19895], MD Phone:[0-0-] Date/Time:[2154-7-11] 10:30 PCP- [Name Initial (NameIs) 2169]: [First Name8 (NamePattern2) 11136] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Date/Time:[2154-7-23] 10:30 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2154-8-7] 9:30 Completed by:[2154-6-28]	[ "486", "389.9", "412", "724.5", "199.1", "492.8", "724.2", "414.8", "530.81", "V45.81", "715.09", "424.0", "416.8", "799.02", "244.9", "426.3", "354.0", "458.29", "V45.02", "285.29", "276.7", "564.00", "787.01", "584.9", "585.3", "726.5", "197.2", "338.29", "162.5", "414.00", "428.23", "428.0", "724.00", "272.4", "403.90", "397.0", "696.1" ]	icd9cm	[ [ [] ] ]	[ "33.23", "86.07", "96.05", "34.91" ]	icd9pcs	[ [ [] ] ]	18612, 18678	9754, 13223	313, 560	19844, 20145	5269, 5269	21005, 21460	4687, 4691		16727, 18589		18699, 18935		16326, 16704			20169, 20982		9404, 9731							4706, 5250	18956, 19823																			245, 275										588, 2814					5285, 9388		13237, 16300							2836, 4271	4287, 4671
29,633	139,497	34189	Discharge summary	report	Admission Date: [2181-5-12] Discharge Date: [2181-5-14] Date of Birth: [2109-10-29] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 800] Chief Complaint: fall off ladder Major Surgical or Invasive Procedure: none History of Present Illness: 71M with Afib on coumadin, CAD s/p 1 vessel CABG, presenting s/p fall off a ladder earlier today. He was disassembling an awning outside his house and was on the 4th or 5th stair of his ladder. Noted that the ladder was on a slippery surface, and seemed to lean over to the left and he fell on his left side. Does not recall exact details of the actual fall. Unsure if he lost consciousness. Unwitnessed but his wife heard the fall. Able to get up immediately after and walk into his house. Denied any preceding dizziness, LH, CP, palps. Denied any HA, visual changes, pain in extremities; did note a feeling of muscle pull on his left torso/flank. Brought to OSH hospital, imaging suggestive of tiny SDH. Transferred to [Hospital1 18] for neurosurgical evaluation. . In the ED, initial vs were: T99.1 72 134/85 15 98% on RA. CT head confirmed tiny SDH, no change from this afternoon's OSH study; also possible tiny SAH. Neurosurgery consulted, recommended phenytoin for tiny subarachnoid. Also repeat head CT in AM. Needs Q2H neuro checks. Per ED, since no neurosurgical managment anticipated, neurosurg recommended admission to trauma ICU; TICU service refused admission and recommended admit to medicine. Patient was given phenytoin and oxycodone. Past Medical History: - Aortic stenosis s/p tissue AVR [9-/2179] - CAD s/p single vessel CABG (LIMA to LAD) during AVR [2179] - Afib on coumadin - s/p PPM (bradycardia) ~ [2174] - Hyperlipidemia - GERD - BPH Social History: Lives with wife. Retired drafting technician. Does all ADLs and fair amount of handy work around house. Goes to gym regularly and walk/jogs for 1 hour. - Tobacco: Never - Alcohol: None - Illicits: none Family History: NC Physical Exam: General: Alert, oriented, very pleasant, no acute distress. HEENT: Sclera anicteric, PERRL 3->2, EOMI, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Mostly regular with occ irreg beats, normal S1 + S2, 2-3/6 SM best at RUSB. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. No focal TTP over left sided ribs; describes whole area as mildly sore. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Hips with full painless ROM in flexion, int/ext rotation. LUE with significant edema and mild ecchymosis near elbow. Elbow with full active and passive ROM; painless but notes "tightness of skin". Neuro: Alert and oriented x3. CN II-XII intact. Sensation grossly intact. Muscle bulk and tone normal. Strength 5/5 in all UE and LE muscle groups. Gait not tested. Pertinent Results: ADMISSION LABS: [2181-5-12] 07:45PM BLOOD WBC-9.1 RBC-5.25# Hgb-15.4# Hct-46.8# MCV-89 MCH-29.4 MCHC-33.0 RDW-14.0 Plt Ct-141* [2181-5-12] 07:45PM BLOOD Neuts-78.6* Lymphs-14.6* Monos-4.9 Eos-1.1 Baso-0.8 [2181-5-12] 07:45PM BLOOD PT-21.4* PTT-30.8 INR(PT)-2.0* [2181-5-12] 07:45PM BLOOD Glucose-104* UreaN-20 Creat-1.1 Na-145 K-4.2 Cl-109* HCO3-26 AnGap-14 DISCHARGE LABS: [2181-5-14] 09:30AM BLOOD WBC-7.3 RBC-5.21 Hgb-15.7 Hct-46.3 MCV-89 MCH-30.1 MCHC-33.9 RDW-14.6 Plt Ct-138* [2181-5-14] 09:30AM BLOOD Glucose-164* UreaN-16 Creat-1.1 Na-140 K-4.3 Cl-102 HCO3-30 AnGap-12 [2181-5-13] 01:57AM BLOOD Phenyto-8.2* [2181-5-14] 09:30AM BLOOD Phenyto-6.7* CT HEAD #1 [2181-5-12]: Tiny subdural hematoma layering along the left tentorium, not progressed compared to images from outside hospital performed four hours prior. Scalp swelling along the left parietooccipital region, without underlying skull fracture. CT HEAD #2 [2181-5-13]: No interval change. CT HEAD #3 [2181-5-14]: No intracranial hemorrhage identified. L Elbow [2181-5-12]: Mineralization and alignment are within normal limits. No fracture or dislocation is evident. No joint effusion is noted. Soft tissue swelling is noted along the dorsal aspect of the distal upper arm. No embedded radiopaque foreign bodies are seen. Incidental note is made of a small enthesophyte at the distal insertion of the triceps tendon. Correlate clinically. CT C-SPINE [2181-5-12]: No fracture or malalignment involving the cervical spine. Multilevel spondylosis, causing moderate canal narrowing, particularly from C3 through C6. Consider MRI if there is concern for cord contusion or ligamentous injury. L RIBS [2181-5-14]: There is an equivocal nondisplaced fracture involving the anterolateral aspect of the left tenth rib. Brief Hospital Course: 71M with Afib on coumadin, CAD s/p CABG, s/p tissue AVR, presenting with fall and small tentorial SDH. . # SDH: No change on 3 serial Head CTs. Remained neurologically intact. No HA or visual changes. Loaded with dilantin and continued on 100mg TID which he will continue for total 3 days. Warfarin and ASA held on admission. ASA restarted on day of admission. Instructed pt to restart warfarin on [2181-5-16] and will continue going to [Hospital3 4107] to have INR followed. He was given phone number to schedule an appointment with Dr. [Last Name (STitle) ] in 8 weeks and will have repeat Head CT at that time. # Mechanical Fall: Per patient, ladder gave out. He was seen by PT who reccommended home,no PT. # Non-displaced L 10th Rib Fx: Pt noted to have tenderness and mild swelling of left flank. Prescribed percocet for pain control and advised pt not to drink ETOH or drive while taking this medication. # Afib: Rate controlled. Holding coumadin till [5-16]. Continued diltiazem, atenolol, digoxin. . # CAD: No active issues. ASA held initially as above but ok for pt to restart at DC. Continued on crestor and atenolol. Medications on Admission: warfarin 2.5 mg 4times weekly, 5 mg 3xweekly ASA 81 mg daily digoxin 250 mcg daily atenolol 100 mg [Hospital1 ] diltiazem 240 mg daily crestor 10 mg daily prilosec 20 mg daily flomax 0.4 mg daily vit C 1000 mg daily vit D 1000 units daily Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 8 days. Disp:24 Capsule(s) Refills:0 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 6. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for severe pain: do not drive or drink alcohol while taking this medication. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Subdural hematoma, Non-displaced fracture of left 10th rib Secondary: Atrial fibrillation, s/p Aortic Valve Repair Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to this hospital for to manage a blood collection under your skull which you sustained after falling from a ladder. You had multiple Head CT scans that indicated that this blood collection is stable and not getting larger. You were seen by the neurosurgery team who suggested that you begin a medication called phenytoin to prevent seizures. We also found that you have a rib fracture on the left. This can take a few weeks to heal. You may take percocet as needed for severe pain. STOP TAKING: -Coumadin. You may restart this medication on [2181-5-16]. You should have an INR checked 2-3 days after you restart this medication to assure that you are becoming therapeutic. NEW MEDICATIONS: -Phenytoin (Dilantin) you will need to take this medication for a total of 10 days. You last doses of medication will be on [2181-5-22]. -Perocet: you can take 1 tablet every 4 hours as needed for pain. Do not drive or drink alcohol will taking this medication. We would suggest that you avoid using ladders. Because you take coumadin you are at increased risk of bleeding. Followup Instructions: You should go to your coumadin clinic at [Hospital3 ] [2-14] days after your restart your coumadin on [5-16]. Follow-up with Dr. [Last Name (STitle) ] in 8 weeks. Call [Telephone/Fax (1) 1669] to schedule an appointment. His assistant with also schedule you for a repeat Head CT. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811] Completed by:[2181-5-14]	[ "807.01", "427.31", "287.5", "600.00", "V58.61", "272.4", "V45.81", "530.81", "852.26", "E881.0", "852.06", "414.00", "V45.01", "V42.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7297, 7303	4866, 6016	284, 291	7471, 7471	3001, 3001	8743, 9202	2031, 2035		6309, 7274		7324, 7450		6042, 6286			7622, 8720		3392, 4843							2050, 2982																				229, 246										319, 1575					3017, 3376				7486, 7598					1597, 1796	1812, 2015
7,275	114,690	43680	Discharge summary	report	Admission Date: [2139-8-26] Discharge Date: [2139-8-27] Date of Birth: [2078-11-11] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[First Name3 (LF) 2901] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: Hemodialysis. History of Present Illness: The patient is a 60 yo man with h/o ESRD on HD, ESLD [3-16] HepC, seizure d/o, who presented to the ED with bradycardia. The patient states that he was in his normal state of health until three days ago, when he began to develop increased shortness of breath. He stated that he felt subjective fevers at home; however, he never documented a fever. He normally has HD on M/W/F, but he rescheduled today's HD session for tomorrow. This afternoon, the patient began to feel weak and dizzy at home and found that his pulse was significantly slower (30s-40s). He has experienced a similar situation approximately 3 times over the past year, so he presented to the ED for further workup and evaluation. In the ED, the patient's VS were T 97.9 BP 164/75 P 37 O2 96% on RA. His pulse was persistently in the 30s-40s. He complained of lightheadedness and dizziness, but no CP. ECG showed junctional rhythm with retrograde P waves. Trop is at baseline. Labs were drawn which showed a K of 6.7. He was given Calcium gluconate, Kayexelate, D50, Sodium Bicarbonate, and insulin, and his ECG converted to sinus bigeminy. He then became increasingly hypertensive to 220/130s and reportedly complained of active chest pain. He was given NTG SL, which did not alleviate his pain, and he was then started on a nitro gtt. EKG at this time showed ST depressions in V4-V6. He was then transferred to the CCU for emergent HD and further observation. On arrival to the CCU, the patient states that he does not currently feel any chest pain and he solely felt "chest pressure" in the ED, which was not concerning to him. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. 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: 1. Epilepsy: began in childhood w/ generalized tonic-clonic seizures. previously treated with phenobarbitol, mysoline, depakote, dilantin, trileptal, tegretol, keppra; most recently Keppra + Lamictal. usual seizure characterized by confusion, disorientation, rare generalized tonic-clonic, followed by Dr. [First Name (STitle) 437] 2. ESRD on HD; due to idiopathic glomerulonephritis, s/p failed renal Tx x 2 3. Hypertension 4. Hypothyroidism 5. Peripheral [First Name (STitle) 1106] disease s/p stenting of bilateral common iliac arteries 6. ESLD [3-16] Hepatitis C, on liver xplant list, followed by [Doctor Last Name 497] 7. CHF - systolic w/ EF 45% and diastolic dysfunction (echo [12/2135]) 8. h/o SVT/AVNRT s/p ablation 9. h/o MRSA line infection 10. h/o VRE infection 11. ? amyloid masses b/l shoulders Social History: Lives at [Hospital3 ] facility on Mission [Doctor Last Name ] called [Hospital1 ] at [Hospital1 1426], on disability, has two sons. smokes 1ppd x 40 yrs, no etoh, drugs. . Family History: Mother with breast CA; father alive with CAD & CHF; sons healthy. Physical Exam: VS: T 95.4, BP 185/92 HR 72 RR 16 O2 sat 91% on 4L GENERAL: Middle aged man, cantankerous, in NAD. AAO x3. Depressed affect. [Hospital1 4459]: PERRL, EOMI. Oropharynx clear and without exudate. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 13 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Occasional S3. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar rales to mid-way up lung. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [2139-8-26] 10:04PM K+-5.6* [2139-8-26] 07:00PM K+-6.8* [2139-8-26] 06:50PM GLUCOSE-94 UREA N-56* CREAT-7.8* SODIUM-137 POTASSIUM-6.7* CHLORIDE-97 TOTAL CO2-24 ANION GAP-23* [2139-8-26] 06:50PM CK(CPK)-57 [2139-8-26] 06:50PM cTropnT-0.05* [2139-8-26] 06:50PM WBC-5.8 RBC-3.98* HGB-10.5* HCT-33.3* MCV-84 MCH-26.5* MCHC-31.6 RDW-21.0* [2139-8-26] 06:50PM NEUTS-53 BANDS-0 LYMPHS-34 MONOS-12* EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2139-8-26] 06:50PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL OVALOCYT-2+ TEARDROP-1+ [2139-8-26] 06:50PM PLT COUNT-223 Chest Portable (AP) Comparison is made with prior study performed a day earlier. Mild-to-moderate cardiomegaly is unchanged. Moderate pulmonary edema has improved. Aeration in the bases of the lungs has also improved. There is no evidence of pneumothorax. Small right pleural effusion is more conspicuous on today's exam. Central venous catheter is in a standard position. Brief Hospital Course: The patient is a 60 yo man with h/o End Stage Renal Disease on hemodialysis, Hepatits C cirrhosis, and Seizure disorder, who presents with bradycardia and hypertensive emergency in the setting of a missed HD session. # Bradycardia: The patient presented with symptomatic junctional bradycardia with a long QT and a rate of 30s-40s. His K on admission was 6.7 Emergent HD was performed in the CCU, with an output of 2.5 liters. After the procedure, the potassium decreased to 4.7. He was monitored on telemetry and did not have any further episodes of bradycardia. It is likely that the patient was hyperkalemic because he missed a session of hemodialysis the morning prior to admission. His hyperkalemia was the etiology behind his bradycardia. He is advised to make all of his hemodialysis appointments. # Hypertensive Urgency/Emergency: The patient's BP in the ED increased to 230s/130. He had concomitant chest pain, and there was concern for ACS. His EKG during this episode did not show ischemic changes, but a chronic strain pattern seen with chronic severe hypertension. The patient was given Nitroglycerin SL and was started on a nitroglycerin drip, which decreased his BP and relieved his CP. The patient has a history of labile BPs, and this current episode is most likely related to his fluid overload. After the nitro drip was weaned down, the patient was restarted on his home medications of lisinopril, clonidine, metoprolol, and nifedipine. He is to follow up closely with his nephrologist and primary doctor for further managment. # Pneumonia: Patient complained of a new productive cough and subjective fever. On chest xray it appeared that an infiltrate was forming. Since the patient is at high risk for infection on hemodialysis, he was started on a five day course of Azithromycin for community acquried pneumonia. He is to follow-up with his primary care doctor next week and have a repeat chest x-ray in [3-17] weeks. # End Stage Renal Disase: The patient has a history of ESRD, for which he receives hemodialysis on M/W/F. He received HD overnight and 2.5 liters were taken off. He remained hemodynamically stable throughout and his potassium decreased to a normal level. He is to continue follow-up with his nephrologist next week. # HepC Cirrhosis: The patient has a history of HepC cirrhosis, and he recently took himself off of the [Date Range ] list. His liver function appeared stable throughout this admission. He is currently taking Rifaximin 200 mg TID, he is to continue this medication and follow up with his PCP for further management. # Seizures: The patient has a history of epilepsy, for which he takes Lamotrigine, Phenytoin, and Keppra daily. The patient did not have a seizure during this hospital stay, and appears stable on his medication. He is to continue these medications and follow-up with his Neurologist for futher management. Medications on Admission: B-Complex with Vitamin C daily Cinacalcet 90 mg daily Clonidine 0.1 mg [Hospital1 ] Clopidogrel 75 mg daily Lamotrigine 250 mg [Hospital1 ] Lansoprazole 30 mg daily Lisinopril 20 mg daily Metoprolol Tartrate 50 mg TID Rifaximin 200 mg TID Aspirin 81 mg daily Phenytoin Sodium Extended 200 mg [Hospital1 ] Levetiracetam 375 mg [Hospital1 ] Levetiracetam 250 mg after HD Calcium Carbonate 500 mg qid prn Nifedipine 60 mg Sustained Release TID Discharge Medications: 1. Clonidine 0.1 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Rifaximin 200 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 5. Lamotrigine 100 mg Tablet [Hospital1 ]: 2.5 Tablets PO BID (2 times a day). 6. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 7. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 8. Phenytoin Sodium Extended 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO BID (2 times a day). 9. Levetiracetam 250 mg Tablet [Hospital1 ]: 1.5 Tablets PO BID (2 times a day). 10. Keppra 250 mg Tablet [Hospital1 ]: One (1) Tablet PO As directed: To be taken three times weekly after hemodialysis. 11. Calcium Carbonate 500 mg Tablet, Chewable [Hospital1 ]: Two (2) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 12. Nifedipine 60 mg Tablet Sustained Release [Hospital1 ]: One (1) Tablet Sustained Release PO TID (3 times a day). 13. Azithromycin 250 mg Tablet [Hospital1 ]: One (1) Tablet PO Q24H (every 24 hours) for 4 days: Start [2139-8-28], [Month/Day/Year 2974] morning. Disp:4 Tablet(s) Refills:0 14. B Complex Plus Vitamin C Oral 15. Cinacalcet 30 mg Tablet [Month/Day/Year ]: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Bradycardia, community acquired pneumonia, end stage renal disease requiring dialysis Secondary: Hypertension, Hypothyroidism, Peripheral [Month/Day/Year 1106] disease s/p stenting of bilateral common iliac arteries, End stage liver disease secondary to Hepatitis C, CHF systolic with EF 45% and diastolic dysfunction, Seizures Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted after developing shortness of breath, cough and then chest pain. This was in the setting of missing a hemodialysis session. You were found to have slow heart rate (bradycardia) and electrolyte abnormalities due to missing dialysis. You were also found to have pneumonia. Given your severe reaction from missing hemodialysis, you must attend every session or risk life threatening medical consequences. Please take all medications as prescribed. - In addition to your regular medications, you have been started on a 5 day course of antibiotics for your pneumonia. You must pick this medication up from the pharmacy upon discharge. - You were previously on a medication called Lansoprazole. This medication interacts with your Clopidogrel, please discuss changing it to a different medication at your next primary care visit. You have not been discharged on this medication given this interaction. - You were found to have low calcium. Given this, you should increase your Calcium Carbonate (Tums) intake to 2 tabs (1000 mg total) four times daily. Please keep all outpatient appointments. Your next hemodialysis appointment is at [Location (un) ] [Location (un) ] tomorrow [Location (un) 2974] at 11am. Please keep this appointment. Seek medical advice if you develop fever, chills, difficulty breathing, chest pain, persistent productive cough, abdominal pain, weakness, lightheadedness or any other symptom that is concerning for you. Followup Instructions: You have an appointment scheduled with [First Name4 (NamePattern1) 402] [Last Name (NamePattern1) 93901], NP, who works with Dr. [First Name8 (NamePattern2) 4320] [Last Name (NamePattern1) 4321] at the same office in Jamaice Plain. This appointment is [2139-9-2] at 11:00 AM. You should discuss your hospitalization and pneumonia symptoms at this appointment. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2139-8-28] 8:40 Your next dialysis session is [2139-8-28] at 11AM at [Location (un) ] [Location (un) ]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "V45.12", "428.42", "571.5", "V49.83", "070.54", "244.9", "403.01", "486", "428.0", "276.7", "585.6", "427.89", "345.90" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10475, 10481	5563, 8463	329, 345	10868, 10907	4498, 5540	12435, 13203	3568, 3636		8971, 10452		10502, 10847		8489, 8948			10931, 12412									3651, 4479																				278, 291										373, 2492														2514, 3346	3362, 3552
82,681	124,146	4960	Discharge summary	report	Admission Date: [2167-7-17] Discharge Date: [2167-7-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: AICD firing Major Surgical or Invasive Procedure: cardioversion with sedation History of Present Illness: He presented to [Hospital6 17032] [7-13] with nausea, vomitting, chills and stable VTach on ECG. He became hypotensive, was loaded and put on a drip of amiodorone for TVach, and was admitted to the ICU. 1/4 bottles were positive for E. coli. CXR showed an early right base infiltrate. ICD was interrogated, programmed to a lower pacing rate of 75bpm, and the VT detection was increased to cycle lengths of 420msec. BBlocker was stopped that admission per Dr. [Last Name (STitle) 1911]. He was d/c home [2167-7-16] on levofloxacin 500mg daily with an expected 14 day total course, and Lasix 40mg daily for 1 week. He returned to the NVMC ED late that evening due to 9 episodes of ACID firing. On his arrival with EMS he had witnessed VTach and appropriate AICD shock. He was afebrile, HR 117, RR 22, BP 157/80, and sat 94%; labs were unremarkable. Patient states that there was no "warning" and felt well before ACID firing. He was amiodorone loaded, started on a drip, and transefered to [Hospital1 18] for further management. AICD fired 3 times in the ED, but there were not further episodes as of 7am [7-16]. ECG showed AFib with HR in the 120s. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, s/p left carotid endarterectomy, CAD s/p MI '[54] 2. CARDIAC HISTORY: Afib -CABG: 4 vessel in [2156] -PERCUTANEOUS CORONARY INTERVENTIONS: [2161] -PACING/ICD: AICD place in [2151] after an episode of VFib arrest 3. OTHER PAST MEDICAL HISTORY: chronic renal insufficiency (baseline Cr 1.3), AAA s/p endovascular repair in [2163], s/p cholecysectomy, BPH s/p TURP, chronic anemia (early myelodysplasia). Social History: Live with wife. -Tobacco history: nonsmoker -ETOH: 1 glass of wine daily -Illicit drugs: denies Family History: no history of sudden/early cardiac death. Physical Exam: VS: T=96.7 BP=104/68 HR=84 RR=20 O2 sat= 100% GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no JVP noted CARDIAC: S1, S2, irregular, no m/r/g LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND EXTREMITIES: warm, no edema noted PULSES: distal 2+ pulses b/l Pertinent Results: [2167-7-17] 12:55AM WBC-6.7 RBC-2.71* HGB-9.8* HCT-29.4* MCV-109* MCH-36.1* MCHC-33.2 RDW-15.8* [2167-7-17] 12:55AM NEUTS-78.2* LYMPHS-15.8* MONOS-4.7 EOS-0.8 BASOS-0.5 [2167-7-17] 12:55AM PLT COUNT-191 [2167-7-17] 12:55AM GLUCOSE-123* UREA N-40* CREAT-1.6* SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16 [2167-7-17] 12:55AM CK(CPK)-61 [2167-7-17] 12:55AM cTropnT-0.05* [2167-7-17] 12:55AM PT-23.7* PTT-28.3 INR(PT)-2.3* [2167-7-17] 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2167-7-17] 05:45PM TSH-1.4 . [2167-7-20] 04:40AM BLOOD WBC-6.0 RBC-2.50* Hgb-9.2* Hct-27.0* MCV-108* MCH-36.7* MCHC-34.1 RDW-15.4 Plt Ct-185 [2167-7-20] 04:40AM BLOOD Plt Ct-185 [2167-7-20] 04:40AM BLOOD PT-22.9* PTT-30.0 INR(PT)-2.2* [2167-7-20] 04:40AM BLOOD Glucose-81 UreaN-28* Creat-1.1 Na-142 K-4.4 Cl-110* HCO3-28 AnGap-8 [2167-7-20] 04:40AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3 . CXR [2167-7-17] No pneumonia or CHF. Appearance of right upper lung vague nodule. Recommend repeating the study with standard PA and lateral view when the patient can tolerate. CXR [2167-7-19] In comparison with study of [7-17], there is little change. Again there is the vague suggestion of a right upper lung nodule that could well represent progressive scarring. Further evaluation would require CT scanning. . Blood Cx [7-13] at NVMC: [1-19] bottle (+) for E coli; sensative to TMP/SMX, Amox/clavulonate, amp/sulbactam, cipro and levo; resistant to amp, cetriaxone, cefzolin, and cefuroxime Brief Hospital Course: 89yo M with AICD placed s/p VFib arrest, CAD s/p CABG, and AFib recently d/c from OSH after being treated for E. coli bacteremia who presented after multiple AICD firings. #AICD firings: Subsided after initiation of amiodorone drip. Pt switched to home dose of po amiodorone after drip completed. 3 sets of cardiac enzymes have been unremarkable and there were no new ECG changes. It was suspected that episodes of AFib were triggering VTach and thus the AICD shocks were appropriate. He had perviously been cardioverted to NSR. He is on longstanding anticoagulation and is therapeutic on coumadin, so cardioversion in the setting of sedation was considered safe. Pt was successfully cardioverted day 2 of admission. Patient will be d/c home with f/u with Dr. [Last Name (STitle) 1911]. . # E. coli bateremia: Switched from Levaquin to Unasyn to avoid risk of QT prolongation. Right lung process noted on CXR is unlikely to be a source of a gram (-) bacteremia. Urine was negative. Intrabdominal process was suspected at OSH, but no abdominal imaging done. ID recommended changing to abx to better cover ESBL. Called micro lab at OSH and E. coli was sensative to ertapenam. Patient felt well throughout admission. PICC was placed for a 2 week course of IV abx at home. Home VNA will be arranged. . # amiodorone - Mr. [Known lastname ] has had multiple IV doses of amio as well as his home po dose over the past few days. Normal TSH. Patient will be d/c on his prior home dose of amiodorone. . # CAD: S/p CABG. No c/o chest pain or SOB. No increase incardiac enzymes as noted above. Continue home statin and ASA. . # CRF: Cr was at baseline of low 1s throughout admission . # lung nodule: First incidentaly found on CXR at OSH. Was stable on lung films x2 during admission here. Pt should have CT scan as an outpatient for further evaluation. Medications on Admission: Amiodorone 200mg daily ASA 81mg daily Pravastatin 20mg daily Courmadin, 5mg on day 1 and 4 and 2.5mg other days Ascorbic acid 500mg daily Folic acid 2.5mg daily multivitamins 1 tablet daily Vitamin B6 50mg [Last Name (un) ] Lasix 40mg daily Levofloxacin 500mg daily Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS ([Doctor First Name ],WE). 3. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,TU,TH,FR,SA). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Recurrent Ventricular tachycardia successfully terminated by ICD Atrial Fibrillation E.Coli bacterimia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You were transferred to the [Hospital1 18] CCU because your debrillator (ICD) shocked you numerous times. We cardiovertered you because we believe that this will prevent the heart rhythms which caused the shocks. We have not changed any of your heart medications. You should continue to take them as prescribed. We obtained records pertaining to your blood infection and changed your antibiotics. Please start taking ertapenem and please discontinue levofloxacin. Please make an appointment with Dr. _____ for further evaluation of the source of this infection. Followup Instructions: Dr. [Last Name (STitle) 1918] [Name (STitle) ] [2167-11-3] 10:20AM Phone:[Telephone/Fax (1) 11767] Completed by:[2167-7-21]	[ "585.3", "412", "427.1", "272.4", "427.31", "425.4", "041.4", "414.00", "403.90", "238.75", "V45.81", "518.89", "496", "V45.02", "790.7" ]	icd9cm	[ [ [] ] ]	[ "99.62", "38.93" ]	icd9pcs	[ [ [] ] ]	7167, 7235	4321, 6174	273, 303	7382, 7382	2656, 4298	8160, 8306	2132, 2175		6494, 7144		7256, 7361		6200, 6471			7532, 8137									2190, 2637		1653, 1807																		222, 235										331, 1504									7397, 7508		1838, 2003			1526, 1633	2019, 2116
14,583	118,099	25739	Discharge summary	report	Admission Date: [2166-7-25] Discharge Date: [2166-8-7] Date of Birth: [2109-2-10] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Atrovent / Peanut Oil Attending:[First Name3 (LF) 14964] Chief Complaint: SOB, abdominal bloating CAD Major Surgical or Invasive Procedure: Cardiac Catherization [2166-7-29] CABG x 3 (LIMA->LAD, SVG->OM,PDA) History of Present Illness: 57 yo with EtOH abuse, COPD, PVD, DM, h/o hiatal hernia who presented to OSH on [2166-7-22] for abd bloating and dyspnea x6-7 weeks. The symptoms started immediately after he quit smoking. He had mild DOE at baseline, but now becomes severely dyspneic with minimal activity such as speaking. He also notes new orthopnea and episodic LE edema bilaterally. . At OSH he had negative cardiac enzymes and a stress test which showed reversible septal defect and partially fixed inferior defect. EF was 18%. EGD demonstrated gastritis and duodenitis and his ASA was d/c'd. He also had CT abd which showed possible pancreatitis and followed up with MRCP which demonstrated no evidence of gallstone pancreatitis but some fluid around liver possibly c/w hepatitis. . He was transferred for cardiac cath which showed LAD 100%, D1 diffuse 60%, LCirc 90% ulcerated, and RCA diffuse 90% mid and distal . ROS on admission: No CP. +chronic cough which worsened after quitting smoking. +phlegm, no hemoptysis. +claudication R>L LE. No regular exercise. No recent URI symptoms Past Medical History: 1. PVD with angiogram at [Hospital3 3583] showing LLE disease > RLE (per patient) 2. DM, diet controlled,noncompliant 3. Hypertension 4. Hyperlipidemia 5. COPD 6. hiatal hernia 7. gastritis 8. EtOH abuse Social History: Tob: >60pack years, quit 7 weeks ago EtOH: [6-20] drinks/night 4 nights a week. No h/o alcoholism, w/d, or blackouts. Works as traveling salesman Family History: Father: died MI in 40s Mother: CHF in 80s Physical Exam: On admission: VS: afebrile, 142/110, 100, 99%RA GEN - frequent cough, NAD HEENT - MMM, anicteric CHEST - diminished BS throughout, no focal rales, no wheezes CV - reg rate, no MRG ABD - soft, NT/ND, +BS, ?mild ascites, no stigmata of chronic liver dz Ext - no edema, superficial ulcer Right shin Neuro - A&O x3 On discharge: VS: afebrile, 104/73, 73,95%RA GEN-NAD CHEST - diminished BS throughout, no focal rales, no wheezes CV - reg rate, no MRG ABD - soft, NT/ND, +BS Ext - no edema, superficial ulcer Right shin Neuro - A&O x3 Skin - MSI C/D/I, no erythema, drainage. LLE SVG sites C/D/I Pertinent Results: Carotid U/S [7-27]: Significant bilateral superficial femoral artery occlusive disease. On the left, there may be some component of proximal common femoral artery or iliac artery disease in addition. [2166-7-25] 05:45PM BLOOD WBC-5.3 RBC-4.51* Hgb-13.6* Hct-40.3 MCV-89 MCH-30.1 MCHC-33.7 RDW-14.4 Plt Ct-178 [2166-8-6] 06:20AM BLOOD WBC-8.6 RBC-3.59* Hgb-10.6* Hct-33.1* MCV-92 MCH-29.5 MCHC-32.0 RDW-14.3 Plt Ct-298 [2166-7-25] 05:45PM BLOOD PT-13.9* INR(PT)-1.3 [2166-8-7] 05:58AM BLOOD PT-15.5* INR(PT)-1.6 [2166-7-25] 05:45PM BLOOD Glucose-181* UreaN-16 Creat-1.1 Na-135 K-4.0 Cl-101 HCO3-24 AnGap-14 [2166-8-7] 05:58AM BLOOD Glucose-84 UreaN-19 Creat-1.2 Na-139 K-4.3 Cl-95* HCO3-33* AnGap-15 [2166-8-5] 05:45AM BLOOD Mg-1.8 [2166-7-28] 11:55AM BLOOD %HbA1c-10.9* [Hgb]-DONE [A1c]-DONE [2166-7-26] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG Brief Hospital Course: Pt. was initially seen on HD #2. Felt pt would be best suited for bypass surgery, but first needed work-up. Work-up included PFT's, Carotid U/S, Echo, ABI, and heart failure consult. After work-up, pt was brought to the OR on HD #4 and underwent a CABG. Please see op note. Pt. tolerated the procedure well and was transferred to the CSRU in stable condition. After surgery, he was extubated by post op day 1. He remained on Levophed and milrinone, which were weaned to off by post op day three. Chest tubes, pacing wires, and Foley catheter were all removed per protocol. He was transferred to the step down unit on post op day 5. An echocardiogram on POD #6 showed severe left ventricular hypokinesis, and mildly dyskinetic apex and EF 20% (improved from pre-op by 5%). He was started on anticoagulation with Coumadin for low EF on POD #7. He improved slowly with no complications and was ready for discharge on POD #9. Medications on Admission: Meds (at home): 1. Albuterol prn Meds (transfer): 1. Lopressor 25 daily 2. lipitor 10 daily 3. protonix 40 [Hospital1 ] 4. albuterol prn 5. ASA (d/c'd [3-19] gastritis) 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. 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 4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): x1, check INR friday [2166-8-8]. Disp:30 Tablet(s) Refills:2 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 6138] Home Care Services Discharge Diagnosis: Cornary Artery Disease s/p Coronary Artery Bypass Graft PMH: Hypertension, Hyperlipidemia, Chronic Ostructive Pulmonary Disease, Diabetes Mellitus, Peripheral Vascular Disease, Gastritis, Pancreatitis, hiatal hernia, ETOH abuse. Discharge Condition: Good. Discharge Instructions: Shower daily,wash incision with mild soap and water, pat dry No lifting more than 10 pounds.No driving until follow up appointment,or while taking narcotics. Call with temperature greater than 101.5, redness or drainage from incision, or weight gain greater 2 pounds in one day or five in one week. Followup Instructions: Dr. [Last Name (STitle) 70] 6 weeks Dr. [First Name (STitle) 5700] @ [Last Name (un) ] 2 weeks [Telephone/Fax (1) 2384] Dr. [Last Name (STitle) ] 1-2 weeks Dr. [Last Name (STitle) 5310] 1-2 weeks Completed by:[2166-8-8]	[ "401.9", "414.01", "428.0", "250.02", "577.1", "411.1", "553.3", "496" ]	icd9cm	[ [ [] ] ]	[ "37.23", "36.15", "36.12", "88.53", "39.61", "88.56" ]	icd9pcs	[ [ [] ] ]	5648, 5722	3560, 4484	330, 404	5994, 6001	2582, 3537	6348, 6597	1911, 1955		4713, 5625		5743, 5973		4510, 4690			6025, 6325									1970, 1970													2296, 2563							263, 292										432, 1330							1984, 2282							1518, 1727	1743, 1895
18,194	152,192	22633	Discharge summary	report	Admission Date: [2120-4-1] Discharge Date: [2120-4-11] Date of Birth: [2051-6-19] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Status post fall Major Surgical or Invasive Procedure: 1. Left tube thoracostomy History of Present Illness: 68-year-old male status post 7-foot fall from roof. Patient fell while working on construction site, denies LOC, complained of left-sided [Last Name (un) 58668] shoulder pain and shortness of breath. O2 sat 88% on RA and 96% on NRB as per EMS. Left chest crepitus. Taken to OSH where chest tube was placed. Transferred in stable condition to [Hospital1 18] for further care. In ED, GCS 15, AVSS, sat 94% NRB, no respiratory distress. Imaging showed left rib fractures [2-2], left scapular and clavicular fracture, a small left pneumothorax and a left kidney hematoma. The patient was admitted to the TSICU for respiratory monitoring. Past Medical History: 1. Coronary artery disease Social History: 1. 1 PPD tobacco abuse 2. Denies EtOH abuse Family History: NC Physical Exam: On arrival: VS: T 98.0 BP 143/80 HR 72 RR 16 sat 98 NRB GEN: NAD HEENT: PERLA, EOMI, trachea midline, c-collar, small abrasion left eyebrow CARDIO: S1S2, RRR PULM: CTAB, left chest crepitus, left chest ube in place [Last Name (un) ]: soft, NT/ND, FAST neg, rectal normal tone, guaiac neg ORTHO: TLS spine nontender, no stepoffs, pelvis stable NEURO: GCS 15, moves all extremities, no focal deficit Pertinent Results: [2120-4-1] 01:20PM WBC-19.5* RBC-5.03 HGB-16.0 HCT-47.1 MCV-94 MCH-31.8 MCHC-34.0 RDW-13.0 [2120-4-1] 01:20PM PLT COUNT-209 [2120-4-1] 01:20PM PT-13.9* PTT-24.9 INR(PT)-1.2 [2120-4-1] 01:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2120-4-1] 01:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2120-4-1] 08:23PM GLUCOSE-109* UREA N-23* CREAT-1.4* SODIUM-142 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12 [2120-4-1] 08:23PM ALT(SGPT)-25 AST(SGOT)-40 ALK PHOS-66 AMYLASE-61 TOT BILI-0.9 ## CT chest/[Last Name (un) 103]/pelvis [2120-4-1]: 1) Small left anterobasal pneumothorax with pneumomediastinum and a large amount of left chest wall subcutaneous emphysema. 2) Bibasilar consolidation/collapse. 3) Left clavicular, left scapular, fracture and fractures through the left 1st through 7th ribs. 4) Left renal hematoma, primarily intraparenchymal/subcapsular in location. Left renal hilar vessels are intact. Both kidneys enhance symmetrically. 5) Small high density left pleural fluid collection, which may represent hemothorax. 6) Left hepatic low density round lesion, which may represent a simple hepatic cyst. ## CXR [2120-4-7]: There has been interval removal of the left chest tube. No pneumothorax is identified. The right lateral lung is off the film. However, in the right lower lobe is new alveolar infiltrate. Brief Hospital Course: NEUROLOGY: Mr. [Known lastname 58669] was admitted to the TSICU for close monitoring of his respiratory function following the diagnosis of extensive left-sided chest injuries. The patient's mental status remained stable throughout his hospital stay. His pain was controlled with fentanyl as needed. This was supplemented by the placement of an epidural on HD#3 once his spine was cleared. ## ORTHO: The patient injuries were mainly localized at the left side of his chest with multiple rib fractures, a clavicular and scapular fracture. This was managed with agressive pain control as discussed above and a sling to control the clavicular fracture. ## PULMONARY: The patient's oxygen saturation fluctuated during the course of his ICU stay and he often required CPAP at night when his saturations would drop to the mid-high 80s. He otherwise did well on a NRB mask with saturations in the high 90s. The patient also had difficulty coughing and required regular physical therapy support. This improved after removal of his chest tube on HD#7. On day of discharge, the patient had saturations in the mid-90s on 5L NC. ## CARDIAC: The patient's coronary artery disease was stable during his hospital stay. He was initially placed on iv metoprolol and subsequently on his usual regimen of carvedilol, losartan, lipitor when he was able to take oral medications. His ECGs and enzymes remained within normal range during his stay with us. ## INFECTIOUS DISEASE: The patient developed a mild RLL infiltrate on HD#9 which was treated with levofloxacin. The patient remained afebrile throughout his stay. He will continue his antibiotic therapy for 6 days after discharge. ## The patient was discharged on HD#11 in stable condition, able to ambulate on his own and with oxygen saturations in the mid-high 90s on 5L NC. He will transition in a rehabilitation facility prior to returning home. Instruction were given to return to the Trauma, Orthopedic and Ophthalmology clinics for follow up. Medications on Admission: 1. Benicar 1 tab once daily 2. Coreg 6.25 mg twice daily 3. Lipitor 10 mg once daily Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Discharge Disposition: Extended Care Facility: [Hospital1 ] Cape & Islands Discharge Diagnosis: 1. Left rib fractures [2-2] 2. Left non-displaced scapular fracture 3. Left clavicular fracture 4. Left pneumothorax 5. Left kidney hematoma 6. Right lower lobe pneumonia Discharge Condition: Good Discharge Instructions: you were hospitalized in the trauma service for injuries you sustained after your fall. you were found to suffer from multiple rib fractures, a fractured left shoulder blade and collar bone, a collapsed left lung and a bruised left kidney. you were initially placed in the intensive care unit to better monitor you respiratory function. you were given pain medications including an epidural to control your symptoms. please call the Orthopedic Surgery Clinic to schedule a follow up visit with Dr. [Last Name (STitle) 1005] [Telephone/Fax (1) 5499]. You should be seen in [3-29] weeks. please call the Trauma Clinic to be seen in [3-29] weeks [Telephone/Fax (1) 2359]. also, call the [Hospital 8183] Clinic to schedule a follow up visit with Dr. [Last Name (STitle) ] for a repeat eye exam [Telephone/Fax (1) 253]. continue to take your medications as prescribed. Followup Instructions: 1. Trauma Clinic in [3-29] weeks [Telephone/Fax (1) 2359] 2. [Hospital ] Clinic in [3-29] week with Dr. [Last Name (STitle) 1005] [Telephone/Fax (1) 5499] 3. [Hospital 8183] Clinic with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 253] Completed by:[2120-4-11]	[ "860.4", "E882", "807.07", "811.00", "486", "958.7", "810.00", "866.00", "414.01" ]	icd9cm	[ [ [] ] ]	[ "38.91", "03.90", "34.09" ]	icd9pcs	[ [ [] ] ]	6223, 6281	3079, 5068	330, 358	6499, 6505	1601, 3056	7451, 7755	1160, 1164		5203, 6200		6302, 6478		5094, 5180			6529, 7428									1179, 1582																				274, 292										386, 1033														1055, 1083	1099, 1144

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