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train · 26.9k rows

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27,860	136,466	33640	Discharge summary	report	Admission Date: [2148-3-23] Discharge Date: [2148-3-24] Date of Birth: [2082-1-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3326] Chief Complaint: ICH Major Surgical or Invasive Procedure: None. History of Present Illness: Pt is a 66 yo man, h/o HTN, AFib, DM2, CAD, ESRD s/p xplant, presents with ICH. Pt initially presented to [Hospital 1474] hospital after being found down at 3AM at home - ?length of time down. Of note, pt had had episode of dizziness, HA and ?L arm sxs approximately 1 week ago, presented to an ED where was noted to have elevated diastolic BP to > 100, had head CT which was unremarkable. D/ced home, f/u in clinic w/ PCP yesterday where noted to have BP 128/85, felt fine. Overnight, per pt's wife, pt awoke and went to sleep on couch (he does this frequently as he gets hot at night). His wife awoke sometime after this to go to the bathroom and heard that his breathing "sounded weird" - went to see him and found him unresponsive on floor, labored breathing, called 911. Presented to [Hospital 1474] hospital, where GCS reportedly was 3. BP notabley 194/104. Labs noted for INR 2.8. Intubated using succinylcholine, receiving no additional sedation. Head CT there showed large L IPH around basal ganglia w/ extension into ventricles. He received dilantin and manitol, as well as rocephin, zithromax, labetalol, SC Vit K. Pt transferred to [Hospital1 18]. In our ED, initial vitals were: T 97.8, HR 61, BP 154/85, RR 12, O2 100% on vent settings. His BP dropped to SBP 40-50, BP improved slightly with IVF to SBP in 80's. He was also given profilin, vitamin K, FFP and dilantin. Neurosurgery was consulted. The physical exam was significant for lack of purposeful movement and fixed and dilated pupils. Here, the head CT shows "Extensive left-sided intraparenchymal hemorrhage with extensive intraventricular hemorrhage. Hemorrhage does appear to extend to brainstem. Uncal, subfalcine and transtentorial herniation are evident. Hydroscephalus." Neurosurgery felt that any further intervention is medically futile. His family was at the bedside and, per report, understand the severity of the situation and are waiting for other family to arrive prior to withdrawel of care. Neurology also consulted w/ repetition of mortality = 100%. Family aware. Past Medical History: - DM2 diet controlled - pacemaker for complications s/p stent - CAD s/p Stents in [9-11] - AFib - ESRD s/p Renal tx - HTN - legally blind Social History: Lives at home w/ wife. Family History: NC Physical Exam: Vitals - HR 61, BP 89/63, O2 100% on AC/FiO2 1.0/TV 500/RR 12/PEEP 0 Gen - intubated, unresponsive HEENT - pupils fixed, dilated, non-responsive CVS - RRR, no noted m/r/g Lungs - CTA b/l Abd - soft Ext - warm Neuro - unresponsive, no movements, full neuro exam per neuro note Pertinent Results: . Brief Hospital Course: Assessment/Plan: 66 yo man p/w large intraparenchymal hemorrhage w/ uncal herniation, admitted for awaiting family members prior to w/drawl of care. . # Intraparenchymal hemorrhage - Pt was found down at home, initially presented to [Hospital ] hospital, transferred to [Hospital1 18], with extensive IPH w/ brain herniation, w/ no purposeful movements and fixed dilated pupils on exam. Patient was initially maintained on ventilatory support, with plans to withdraw care one family arrived. Neurology saw in MICU - given neurological status, ICH findings on CT scan, mortality is 100%, mannitol not initiated. Likely etiology of bleed was HTN along w/ coum. Discussed w/ family at bedside. Decision was made to keep pt on ventilator, IVF PRN to maintain BP, otherwise no escalation of care, no pressors, DNR if develops heart arrythmia, no lab draws. On afternoon of [3-24] with family at bedside, patient was discontinued from ventilatory support. At 4:44, pt pronounced dead at bedside. Family denied autopsy. . Contact numbers: Wife - [Name (NI) ] - (c) ([Telephone/Fax (1) 77894], (h) ([Telephone/Fax (1) 77895] Sister - [Name (NI) ] - (c) ([Telephone/Fax (1) 77896] Medications on Admission: Coumadin 6mg daily Cyclosporine 100mg [Hospital1 ] Prednisone 10mg daily celexa 20mg daily protonix 40mg daily lipitor ?dose Plavix 75mg daily atenolol 25mg daily ?more meds Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage Respiratory failure Coronary Artery Disease Diabetes Mellitus Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired.	[ "518.81", "403.91", "348.4", "V45.01", "V42.0", "427.31", "414.01", "431", "585.6" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	4443, 4452	2997, 4214	319, 326	4582, 4592	2971, 2974	4649, 4660	2655, 2659				4473, 4561		4240, 4420			4616, 4626								2674, 2952																							276, 281									354, 2433															2455, 2599	2615, 2639
31,033	151,287	48640	Discharge summary	report	Admission Date: [2200-3-30] Discharge Date: [2200-4-2] Date of Birth: [2136-2-28] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 826] Chief Complaint: tongue swelling Major Surgical or Invasive Procedure: Intubation History of Present Illness: 64 yo male with history of ESRD s/p living unrelated kidney transplant in [2196] presented to the ER in the middle of the night with tongue swelling. Per report, the pt noted he woke up from his sleep at 3 Am and felt that his mouth had been forced open. In the ER he was statting 93% on RA and could barely speak. He received 125 mg IV solumedrol, 50 mg IV benadryl, 20 mg IV pepcid and 0.3 cc of 1:1000 epinephrine sc, but his symptoms only got worse. He was thought to have angioedema and fiberoptically intubated by anesthesia. . Upon arrival to the floor the pt was intubated and sedated. Additional history obtained from his mother who lives with him. She did not know his medication list, but stated this had never happened to the pt before and she did not think there had been any recent medication changes. Only notable thing was that pt ate "hot sauce" last night which was different for him. . Medications brought in by family following admission, includes (recently added) benazepril. Past Medical History: HTN ESRD s/p living unrelated kidney transplant in [2196] sleep apnea on CPAP DM2 H./o colon cancer s/p right colectomy by Dr. [Last Name (STitle) ] [2196-3-23]. No chemotherapy. History of bilateral lower extremity edema. s/p L AV fistula hypercholesterolemia admission for LE cellulitis ion '[96] h/o GIB Social History: 2 daughters, 1 son. Lives with family. Non-smoker. Occ etOH. No illicit drug use. Family History: unknown Physical Exam: VS: T: 06.9 HR: 71 BP: 120/79 RR: 14 O2 Sat: 100% on vent AC: 600x14 FIO2 1 PEEP 5 GEN: intubated, moving around, couging HEENT: intubated, edematous tongue Neck: supple Cardio: RRR, nl S1 S2, no m/r/g Pulm: CTAB ant, no w/r/r,no stridor Abd: soft, NT, ND, + BS Ext: no edema, 2+ DP pulses Neuro: sedated, moving around, grimacing and coughing, moving upper and lower ext; PERRL Skin: no rashes or hives Pertinent Results: [2200-4-2] 06:15AM BLOOD WBC-4.9 RBC-3.86* Hgb-13.3* Hct-39.0* MCV-101* MCH-34.3* MCHC-34.0 RDW-14.9 Plt Ct-58* [2200-4-1] 06:14AM BLOOD WBC-7.1# RBC-4.06* Hgb-14.0 Hct-40.2 MCV-99* MCH-34.4* MCHC-34.8 RDW-15.4 Plt Ct-67* [2200-3-31] 12:27AM BLOOD WBC-3.4* RBC-4.20* Hgb-14.9 Hct-41.9 MCV-100* MCH-35.4* MCHC-35.5* RDW-14.6 Plt Ct-64* [2200-3-30] 05:04AM BLOOD WBC-3.6* RBC-4.07* Hgb-14.4 Hct-41.0 MCV-101* MCH-35.4* MCHC-35.1* RDW-14.7 Plt Ct-78* [2200-4-2] 06:15AM BLOOD Glucose-223* UreaN-48* Creat-2.2* Na-141 K-3.5 Cl-101 HCO3-29 AnGap-15 [2200-4-1] 06:14AM BLOOD Glucose-267* UreaN-38* Creat-2.0* Na-143 K-4.3 Cl-102 HCO3-29 AnGap-16 [2200-3-31] 12:27AM BLOOD Glucose-268* UreaN-35* Creat-1.9* Na-139 K-4.1 Cl-103 HCO3-24 AnGap-16 [2200-4-2] 06:15AM BLOOD tacroFK-10.4 [2200-3-30] 08:55AM BLOOD Type-ART FiO2-100 pO2-443* pCO2-40 pH-7.43 calTCO2-27 Base XS-2 AADO2-252 REQ O2-48 Intubat-INTUBATED Brief Hospital Course: # Angioedema: Initially unclear precipitant for angioedema, however, after family brought in meds following admission, an ACE inhibitor was among them (had not previously been known to be on ACE) and most likely due to this. No family or personal history of angioedema. No rash or hypotension. IV steroids (with transition to PO taper) started along with benadryl and pepcid. He was extubated easily on [2200-3-31] following resolution of the swelling. ACE inhibitor was added to his allergy list. He was discharged on a prednisone taper. # ESRD s/p txplnt in [2196]: Pt with unrelated living donor txplnt. Azathioprine and prograf were continued. The renal transplant team followed him during admission. # HTN: Rrestarted home regimen with exception of ACE inhibitor. # DM: SSI and qid FS. # Sleep apnea: not using CPAP regularly at home. Medications on Admission: (meds brought in by family) Benazepril-HCTZ 1 tablet PO QD Bactrim SS PO QD Vitamin D 1.25 MG PO QD HCTZ 25 mg PO QD Azathioprine 100 mg PO QD Prograf 3 mg PO BID (vs. 1 mg PO BID - unclear) Amlodipine 10 mg PO QD Carvedilol 25 mg PO BID Lipitor 80 mg PO QD Aspirin 81 mg PO QD Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Azathioprine 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Prednisone 10 mg Tablet Sig: as below Tablet PO Daily () for 3 days: Take 3 tablets for one day (30mg), followed by 2 tablets for one day (20mg) and 1 tablet for one day (10mg). Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Angioedema likely secondary to ACE-I Secondary: ESRD s/p living transplant on chronic immunosupression Type II Diabetes Hypertension Discharge Condition: Stable with decreased tongue swelling Discharge Instructions: You were admitted to the hospital with a likely allergic reaction to a medication you were taking, benzapril. While you were in the hospital, you required intubation to help you breath because of your swollen tongue. We treated you with steroids and your tongue swelling improved. If you develop any shortness of breath, chest pain, swelling, rash or any other concerning symptoms, you should call your doctor or come to the emergency room. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] within one to two weeks of discharge. The phone number is [Telephone/Fax (1) 7728]. Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2200-4-25] 8:50 AM. Please follow up with Dr. [First Name (STitle) 805], [2200-4-7] 10:30 AM. The phone number is [Telephone/Fax (1) 3637]. Completed by:[2200-9-8]	[ "V10.05", "272.0", "287.5", "401.9", "995.1", "250.00", "E942.9", "V42.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	5476, 5482	3208, 4068	289, 302	5668, 5708	2245, 3185	6200, 6700	1796, 1805		4397, 5453		5503, 5647		4094, 4374			5732, 6177								1820, 2226																							234, 251									330, 1332															1354, 1679	1695, 1780
21,138	109,343	8894+8895+55985	Discharge summary	report+report+addendum	Admission Date: [2193-4-7] Discharge Date: [2193-5-2] Date of Birth: [2117-1-19] Sex: M Service: Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 76 year old man with a history of chronic obstructive pulmonary disease, coronary artery disease, status post four vessel coronary artery bypass graft, mitral valve replacement, left ventricle pseudoaneurysm with thrombus who was admitted to the Medical Intensive Care Unit with respiratory distress and hypercarbic respiratory failure. Four days prior to admission the patient began to have progressively worsening shortness of breath with increasing oxygen requirement and orthopnea. The patient went to the Emergency Room where he was found to be afebrile and had diffuse wheezes. He was admitted to the hospital with a presumptive diagnosis of chronic obstructive pulmonary disease exacerbation. On the medical floor he was treated with Solu-Medrol 60 mg intravenously for five doses and Albuterol, Atrovent nebulizers without significant improvement for two days. His oxygen saturation was decreased to 86% with exertion, so he was started on empiric Levofloxacin given his slow improvement. On the morning of [4-10], the patient began to have chest pain and shortness of breath. The chest pain was 4 out of 10, typical for his angina and had desaturations into the 70s on 2 liters by nasal cannula, increased to 6 liters, improved to 84% oxygen saturation and 90% on 100% nonrebreather. An electrocardiogram showed questionable MATs with heart rate in the 120s and possible ST depressions in V3. He received sublingual nitroglycerin with resolution of chest pain. Chest x-ray was obtained that showed a right lower lobe consolidation that was initially thought to be fluid overload. He was subsequently given a total of 160 mg of intravenous Lasix but continued to desaturate with fluctuating oxygen requirement and arterial blood gases. Arterial blood gases was obtained with values of pH 7.33, pCO2 57 and pO2 of 64 on 6 liters by nasal cannula. He was then transferred to the Medical Intensive Care Unit for further management of his respiratory failure. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post four vessel coronary artery bypass graft, porcine mitral valve replacement in [2189], complicated by mediastinitis. 2. Left ventricular pseudoaneurysm with thrombus diagnosed by transesophageal echocardiogram, [4-4]. 3. Chronic obstructive pulmonary disease on home oxygen at 2 liters, baseline carbon dioxide in the 48 to 52 range. Multiple hospital admissions, last in [2193-2-7]. Pulmonary function tests in [2189-12-9] revealed an FVC of 1.84 (41 percent), FEV1 0.94 (32 percent), FEV/FVC 51 (77%). 4. Atrial fibrillation. 5. Peptic ulcer disease. 6. Bilateral carotid stenosis, status post stent placement in the left carotid in [2192-9-7]. 7. Gastrointestinal bleed in [2191-4-8], large lower gastrointestinal bleed with angiectasias in the cecum, also found to have internal hemorrhoids and diverticuli. Esophagogastroduodenoscopy showing hiatal hernia and gastritis, the patient has had multiple bleeds on Plavix in [2191] and [2192] resulting in melena. 8. Pulmonary hypertension. 9. Chronic renal insufficiency, baseline creatinine 1.3 to 1.5. 10. Gastroesophageal reflux disease. 11. Status post polypectomy and cholecystectomy. ALLERGIES: Penicillin, Ancef, Vancomycin, question of anaphylaxis, Procainamide. MEDICATIONS ON TRANSFER: Levofloxacin 250 mg p.o. q.d. day #2, Prednisone 60 mg q.d., Lasix 40 mg q.d., Albuterol, Atrovent nebulizers q. 6 hours, subcutaneous heparin, Protonix 40 mg q.d., Fluticasone 110 mcg 2 puffs b.i.d., Salmeterol 50 mcg b.i.d. Regular insulin sliding scale. Senna and Colace. SOCIAL HISTORY: The patient lives with his wife, remote smoking history, 40 pack years and no alcohol use. He is a retired firefighter with possible asbestos exposure in the past. PHYSICAL EXAMINATION: On transfer to medicine Intensive Care Unit - Temperature 98.1, blood pressure 144/75, heart rate 87, respiratory rate 20 to 30. Oxygen saturation 92% on 50% facemask. Head, eyes, ears, nose and throat showed equal pupils, round and reactive to light. Dry mucous membranes. Neck was supple with no jugulovenous distension. Jugulovenous pressure was approximately 6 cm. The patient was tachycardiac with a III/VI holosystolic murmur heard at the left upper sternal border radiating to the axilla. Lungs had diffuse expiratory wheezes with decreased air movement. Abdomen was soft, normal bowel sounds, well healed scar. Extremities had 2+ pitting edema, left greater than right, but were warm with strong pulses. Neurologically, he was oriented to self and date. He was minimally cooperative with the examination but was able to follow simple commands. LABORATORY DATA: Pertinent laboratory values on transfer to the Medicine Intensive Care Unit showed laboratory data notable for a white count of 23.1 and arterial blood gases with a pH of 7.31, pCO2 59, pO2 of 62 on 10 liters, saturating 93%. Pertinent imaging - Chest x-ray showed bilateral pleural effusions, left greater than right, hyperinflation with cardiomegaly and pleural thickening with a possible left lower lobe consolidation with no evidence of pulmonary edema. An electrocardiogram showed inconsistent P wave morphology with right bundle branch block, [Street Address(2) 1766] depression in V3 and minimal T wave inversion in V1 and V2. HOSPITAL COURSE: (In the medical Intensive Care Unit by issue) 1. Respiratory failure - On arrival in the Medicine Intensive Care Unit, the patient was placed on BiPAP and continued to have relatively good arterial blood gases. The patient continued to improve and was on antibiotics and continued steroid treatment and was returned to the Medical Floor on [2193-4-13]. Later that night the patient began to desaturate again on the medical floor to the 90s. A blood gas was drawn that showed a pH of 7.25, pCO2 of 76 and pO2 of 90. The patient appeared to be tiring and was intubated. An earlier sputum culture grew out Methicillin-resistant Staphylococcus aureus and the patient was started on Linezolid due to his Vancomycin allergy. He continued to improve and was extubated on [4-19]. He remained on BiPAP for a short period of time and was soon transitioned oxygen by facemask and subsequently nasal cannula. The patient was initially on intravenous steroids for chronic obstructive pulmonary disease exacerbation which was changed to Prednisone and slowly tapered over his hospital course. 2. Atrial fibrillation/atrial flutter - The patient had brief episodes of atrial fibrillation upon arrival into the Medical Intensive Care Unit with pressure drops to systolics of 80s. The rate was controlled with a Diltiazem drip at this time. Upon returning to the floor on [4-13], he again went into atrial fibrillation with difficulty in controlling his rate despite being on the Diltiazem drip. He became hypotensive and was transferred back to the Medicine Intensive Care Unit. He continued to have a high heart rate in the 140s with hypertension. Electrophysiology was consulted and it was decided that the patient should be cardioverted. He was placed on Amiodarone and remained in normal sinus rhythm until [4-22], when he was transferred back to the Medical Floor. Shortly thereafter the patient again went into atrial fibrillation with heart rate in the 140s and systolics in the 70s. Cardiology was again consulted and it was decided to transfer the patient back to the Medicine Intensive Care Unit for possible cardioversion. Upon arrival in the Medicine Intensive Care Unit the patient's blood pressure had improved and he was placed on a Diltiazem drip, but again became hypotensive, so the Diltiazem drip was discontinued. The patient was then placed on Digoxin the following day when electrophysiology was consulted. The patient was cardioverted, remained on Amiodarone and Digoxin. Following this he remained in normal sinus rhythm until he was transferred back to the Medical Floor. 3. Thrombocytopenia - The patient's platelets continued to dwindle down to a level of 53,000. His antibodies were negative. Proton pump inhibitor was held briefly. The patient developed melena so it was restarted. Hematology was consulted and thought that the Linezolid might be the leading candidate for thrombocytopenia. Since the patient had finished a ten day course of Linezolid the antibiotic was discontinued. 4. Gastrointestinal bleed/anemia - The patient had multiple episodes of melena with guaiac positive stools and received multiple transfusions with a goal of hematocrit above 30%. The patient remained on his home regimen of Nexium. Gastroenterology was initially consulted and deferred doing an esophagogastroduodenoscopy unless the patient began to have a brisker bleed. By the end of the Medicine Intensive Care Unit stay the hematocrit was remaining stable. 5. Chronic obstructive pulmonary disease - The patient received frequent Albuterol/Atrovent nebulizers and was treated with steroids initially intravenous that was changed to Prednisone and tapered. 6. Left superficial femoral vein thrombosis - The patient had very edematous lower extremities. Ultrasound was obtained which showed a new left superficial femoral vein thrombosis. Although the patient had three indications for anticoagulation with atrial fibrillation, thrombosis in the left ventricle thrombus, the patient could not be anticoagulated prior and continued with gastrointestinal bleed. On [2193-4-11], an inferior vena cava filter was placed by Dr. [First Name (STitle) ], left ventricular pseudoaneurysm. Thoracic surgery and Dr. [First Name (STitle) ] followed the patient while in the Medicine Intensive Care Unit. Repair of mitral valve leak and pseudoaneurysm was deferred until after recovery from current illness. For the remainder of this discharge summary, please see the addendum on [2193-4-28], dictated by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404]. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Last Name (NamePattern1) 30936] MEDQUIST36 D: [2193-5-1] 19:58 T: [2193-5-1] 20:18 JOB#: [Job Number 30937] Admission Date: [2193-4-7] Discharge Date: [2193-5-2] Date of Birth: [2117-1-19] Sex: M Service: [Hospital1 ] CHIEF COMPLAINT: Shortness of breath times four days. HISTORY OF PRESENT ILLNESS: This is a 71 year-old male with a history of coronary artery disease status post coronary artery bypass graft and mitral valve prosthetic replacement, chronic obstructive pulmonary disease, who presents with shortness of breath progressive over the past four days after undergoing a transesophageal echocardiogram several days prior to admission. He denies orthopnea, reports increased O2 requirement at home now. Use to use it intermittently now 24 hours a day. He also reports a chronic cough with yellow sputum, which is mostly unchanged. He denies fevers or chills, nausea. He has not slept well in the past couple of nights, because he has been huffing and puffing. He notes that his chronic lower extremity edema is unchanged. He denies chest pain, palpitations, diaphoresis, nausea, vomiting, rhinorrhea or sore throat. He states his weight is stable. In the Emergency Department the patient received Atrovent and Albuterol nebulizers times three, Solu-Medrol, aspirin and Lasix 40 po. PAST MEDICAL HISTORY: 1. Coronary artery disease, myocardial infarction in [2189], coronary artery bypass graft times four in [State 108] in [2189]. 2. Mitral valve replacement with a bioprosthetic valve in [2189]. 3. Atrial fibrillation. 4. Chronic obstructive pulmonary disease with an FEV1 in [2189] of .3 on 2 liters home O2. 5. Peripheral vascular disease. 6. Bilateral carotid stenosis status post percutaneous transluminal coronary angioplasty and stent to the left ICA. 7. History of gastrointestinal bleed with an arteriovenous malformation. 8. Gastroesophageal reflux disease. 9. Diverticulosis. 10. Gastric ulcer. 11. History of mediastinitis secondary to coronary artery bypass graft. 12. Pulmonary hypertension. 13. Polypectomy. 14. Chronic renal insufficiency with a baseline creatinine of 1.3 to 1.5. 15. Anemia secondary to chronic disease. MEDICATIONS ON ADMISSION: 1. Aspirin 81 once a day. 2. Albuterol. 3. Vitamin C. 4. Flovent two puffs twice a day. 5. Nexium 40 twice a day. 6. Simvastatin 20 once a day. 7. Lasix 40 once a day. 8. Colace b.i.d. 9. Prednisone 10 once a day. ALLERGIES: Penicillin, Vancomycin, Ancef, Procainamide, which dropped his platelets. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is independent of his activities of daily living. He quit tobacco, but has a 40 pack year history. He does not drink. He is a retired firefighter. He has a positive asbestos exposure. He lives with his wife. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.6. Blood pressure 122/54. Heart rate 60. Respiratory rate 26. Oxygen saturation 99% on 2 liters. General, this si a pleasant elderly gentleman in mild respiratory distress who can speak in full sentences. HEENT anicteric sclera. Mucous membranes are moist. Neck no LAD. JVP 8 to 9 cm. Cardiovascular regular rate and rhythm. Normal S1 and S2 with a 2 out of 6 systolic murmur at the left lower sternal border. Chest decreased breath sounds on the right, diffuse wheezes, increased expiratory phase. Abdomen soft, nontender with positive bowel sounds. Liver edge is 2 cm below the costal margin. Extremities with 2 to 3+ pitting edema left greater then right to the knees with good dorsalis pedis pulses. Neurological alert and oriented times three. Pupils are equal, round and reactive to light. 5 out of 5 strength throughout and downgoing toes. LABORATORIES ON ADMISSION: White blood cell count 7.4, hematocrit 33.1, platelets 100, sodium 142, potassium 5.0, which was hemolyzed, BUN 25, creatinine 1.5, glucose 183. Chest x-ray showed a right pleural effusion unchanged, possibly a small left pleural effusion. Electrocardiogram showed sinus tachycardia with frequent premature atrial contractions, left axis deviation of the right bundle branch block and a left anterior vesicular block. T wave inversions in V1 and V2 all unchanged. HOSPITAL COURSE ON THE MEDICINE [Hospital1 ]: 1. Chronic obstructive pulmonary disease flare: The patient was treated with nebulizer and intravenous steroids. Left ventricular pseudoaneurysm with thrombus as noted on transesophageal echocardiogram. Anticoagulation was held, because of recent gastrointestinal bleed. 2. Mitral valvular regurgitation with mild paravalvular leak: CT surgery was consulted and they did not advise any acute intervention. 3. Coronary artery disease: The patient did not have evidence of ischemia by history or electrocardiogram, but he was ruled out for a myocardial infarction by enzymes and he was continued at this point on his aspirin and statin as beta-blocker was held, because of his chronic obstructive pulmonary disease flare. 4. Carotid stenosis with left stent: The patient was continued on a baby aspirin, but [Name (NI) ] was held, given the history of gastrointestinal bleed. On [2193-4-10] the patient developed the acute onset of chest pain and shortness of breath with oxygen saturations in the 70s. The patient was subsequently transferred to the Medical Intensive Care Unit for management of his respiratory failure. This portion of his hospital course is detailed in a separate discharge summary addendum. HOSPITAL COURSE FROM DAY [2193-4-29] TO [2193-5-2]: At this time the patient is back on the Medicine Floor and his clinical condition is improving. 1. Anemia and blood loss: As noted the patient had a history of gastrointestinal bleed on anticoagulation in the past and had a slew of heme positive stools, melena and hematocrit drop, which required approximately one unit of packed red blood cells per day for several days to maintain his hematocrit above 28. His stools became heme negative and his blood count stabilized at approximately 32. He underwent esophagogastroduodenoscopy with push enteroscopy on [2193-5-1]. No clear source of his bleeding was found. He was noted to have significant chronic gastritis, but without acute bleeding. He was also noted to have a small red vessel in his jejunum that was not currently bleeding. No interventions were undertaken. GI's recommendation was that if the patient continued to have a stable hematocrit over time consideration could be given to restarting anticoagulation with the risk that he may bleed again. At the time of discharge his hematocrit was stable at 32 and he had a guaiac negative stool. 2. Thrombocytopenia: Stopping the Linezolid correlated with improvement in the patient's platelet count up to 69 on the day of discharge. He had been restarted on his Nexium several days before discharge and this did not seem to impact his platelet counts. It was felt that Linezolid was the culprit. It is expected that his platelet counts will continue to rise over time. 3. Atrial fibrillation: As noted the patient had recurrent atrial fibrillation with rapid ventricular rate and hypotension in the MICU. He was continued on his Amiodarone and Digoxin. The Amiodarone was decreased from 400 b.i.d. to 300 b.i.d. on [2193-5-1]. He should continue on 300 b.i.d. for a total of 14 days at which time he should be changed to 400 q.d. recommended for one month, but in fact the patient should probably see his cardiologist before stopping this dose of 400 q day. He will continue on the Digoxin 0.125 q.d. His Digoxin level had been stable at therapeutic range at 1.2 as of a couple of days ago. Beta-blocker is being held at this time given the patient's chronic obstructive pulmonary disease though since his flare seems to have resolved one could consider restarting a beta-blocker in the near future. He is not anticoagulated at this time given his risk of gastrointestinal bleeding, though he obviously remains at risk for clot given his known left ventricular thrombus, known left superficial femoral vein deep venous thrombosis status post IVC filter and his atrial fibrillation. 4. Diarrhea: Appears to have resolved at this time. There was high suspicion for C-diff, but eh was negative for C-diff times three test. At this time a C-diff B toxin was pending. If he should develop diarrhea again C-diff would be a likely culprit. 5. Status post MRSA pneumonia: The patient remained afebrile with a normal white blood cell count at this time. His respiratory status is gradually improving. Antibiotic course completed. 6. Congestive heart failure with an EF of 35% on his echocardiogram on [2193-4-10]: The patient was diuresed with Lasix 40 mg intravenously b.i.d. for several days. This tended to produce a net negative 1 to 1.5 liters per day. The day prior to discharge he was switched to a more stable regimen of Lasix 40 po and Aldactone 25 po. We feel that he may have several more pounds of fluid to come off with a gentle diuresis over the next week and he should certainly not become fluid positive at this time. Diuresis was slowed just because his bicarbonate had creeped up to 38 though his BUN and creatinine had remained relatively stable at 34 and 1.1. His weights and Is and Os should be followed closely. 7. Chronic obstructive pulmonary disease: The patient is on a Prednisone taper from his chronic obstructive pulmonary disease flare. He is to receive 10 mg per day through [2193-5-3] and then he can be decreased to 5 mg per day for a three day taper and then probably can be tapered off as his respiratory status will tolerate. 8. Left superficial femoral deep venous thrombosis: The patient has an IVC filter in place, but as noted above is not on anticoagulation given his risk of gastrointestinal bleeding. 9. Chronic renal insufficiency: The patient's creatinine has actually improved over his baseline in the mid 1s with a creatinine of 1.1 on discharge. 10. Coronary artery disease: The patient is continued on his statin and ace inhibitor. 11. Diabetes mellitus type 2: The patient is controlled in the hospital on NPH and a regular insulin sliding scale. 12. Carotid stenosis: The patient is status post left carotid stent. Ideally he wold be on [Month/Day/Year ], but again this is being held given his recent gastrointestinal bleeding and hematocrit drops. 13. FEN: The patient has been on a cardiac and [Doctor First Name ] diet, however, he certainly could use nutritional consultation and supplementation given his low albumin of 2.6 recently and his mild whole body edema. 14. Access: The patient is a very difficult to place an IV in and has a right double lumen PICC line in place. DISCHARGE DISPOSITION: To extended care facility. DISCHARGE INSTRUCTIONS: 1. He should contact his primary care physician or come to the Emergency Department with any chest pain, worsening shortness of breath, bleeding from your bottom or coughing up blood. 2. Please check daily weights and adjust diuretic regimen accordingly. We feel the patient can diurese several more pounds. 3. Adhere to a 2 gram sodium diet. 4. Two liter fluid restriction. 5. You should have your Digoxin level checked in one week. 6. You should have your hematocrit and platelets checked in three days. 7. You should have your potassium and chem 7 checked in three days as you have recently started on Spironolactone. 8. If your hematocrit remained stable for a week you could consider adding back aspirin to your regimen. 9. You have an appointment with Dr. [Last Name (STitle) 30938] cardiology on [2193-6-18] at 11:30. 10. Vascular steady [2193-7-16] 2:00. 11. Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ] [2193-7-16] at 3:30. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease exacerbation. 2. MRSA pneumonia. 3. Chronic renal insufficiency. 4. Anemia with presumed gastrointestinal bleeding source. 5. Atrial fibrillation with rapid ventricular rate. 6. Gastritis. 7. Diverticulosis. 8. Coronary artery disease. 9. History of left upper extremity deep venous thrombosis. MAJOR SURGICAL AND INVASIVE PROCEDURES: 1. Cardioversion. 2. Central line placement. 3. Intubation. 4. Esophagogastroduodenoscopy. 5. Transfusions. DISCHARGE MEDICATIONS: 1. Atorvastatin 20 mg once a day. 2. Maalox prn. 3. Fluticasone two puffs twice a day. 4. Artificial tears one to two drops prn. 5. Albuterol nebulizer every four hours. 6. Atrovent nebulizer every four hours. 7. Captopril 6.25 t.i.d. 8. Digoxin 0.125 q.d. 9. Nexium 20 mg po b.i.d. 10. Prednisone 10 mg q.d. for two days, on [5-4] change to 5 mg q.d. times three days and then to 2.5 mg q.d. times two days and then stop. 11. Spironolactone 25 mg q.d. 12. Lasix 40 mg q.d. 13. Insulin NPH 20 units q.a.m. 14. Insulin NPH 10 units q.p.m. 15. Regular insulin sliding scale. 16. Bisacodyl 10 mg suppository prn. 17. Amiodarone 300 mg b.i.d. until [2193-5-16] for a total of 14 days and then change to 400 mg q.d. for one month, but this dose should be continued until the patient is seen by a cardiologist. DISCHARGE CONDITION: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8708], M.D. [MD Number(1) 10932] Dictated By:[Last Name (NamePattern1) 6006] MEDQUIST36 D: [2193-5-2] 11:45 T: [2193-5-2] 11:48 JOB#: [Job Number 30939] Name: [Known lastname 5405], [Known firstname ] Unit No: [Numeric Identifier 5406] Admission Date: [2193-4-7] Discharge Date: [2193-4-28] Date of Birth: [2117-1-19] Sex: M Service: HOSPITAL COURSE: 1. Atrial fibrillation, atrial flutter - The patient returns to the floor from the Intensive Care Unit on [4-24], status post DC cardioversion for the second time following a Digitalis load. The patient remained in normal sinus rhythm. He was monitored on telemetry with no events. His Digoxin was increased from .0625 to .125 with plan to check a level q. 3 days. Additionally, he was treated with Amiodarone 400 b.i.d. for a total of 14 days, thereafter 300 b.i.d. times 14 days and then 400 q. day times one month, no anticoagulation was given due to the patient's history of a gastrointestinal bleed. 2. Methicillin-resistant Staphylococcus aureus pneumonia - The patient completed a ten day course of Linezolid. The patient antibiotics were stopped due to thrombocytopenia which was felt to be possibly due to Linezolid, though it was felt that a ten day course was sufficient. The patient remained afebrile with an increased white count and his respiratory status continued to improve. 3. Thrombocytopenia - The patient's platelets dropped as low as 21,000, requiring one transfusion. Hematology was following and felt that Linezolid was the leading candidate which was then stopped. The patient's proton pump inhibitor was held. The Serotonin release assay was sent to evaluate for HIT, results of which are pending at the time of this dictation. At the time of this dictation, the patient's platelets continued to be low despite the cessation of Linezolid. The plan was to transfuse for platelets less than 20,000 in the setting of bleeding. 4. Congestive heart failure - The patient with an ejection fraction of 35% on an echocardiogram from [4-10] with an ejection fraction of 55% on the prior echocardiogram on [4-4]. In addition the patient has a bioprosthetic mitral valve with paravalvular leak seen on transesophageal echocardiogram. On transfer from the unit the patient appeared fluid overloaded, mostly right-sided heart failure. The patient was started on ACE inhibitor at a low dose and Lasix was used 40 mg intravenously b.i.d. to diurese with good effect. 5. Anemia, blood loss - The patient continued to have a drop in his hematocrit requiring approximately 1 unit of packed red blood cells per day. The patient's stools were heme positive as well as melanotic at times. At the time of this dictation the Gastrointestinal Team was consulted for possible endoscopy. 6. Chronic obstructive pulmonary disease - The patient was treated with a Prednisone taper and nebulizer treatments. 7. Left superficial femoral vein deep vein thrombosis - The patient is status post inferior vena cava filter, no anticoagulation given gastrointestinal bleed. The remainder of this discharge summary including the remainder of hospital course as well as diagnoses and medications will be dictated as part of an addendum to this summary. [Name6 (MD) ] [Name8 (MD) 5407], M.D. [MD Number(2) 3608] Dictated By:[Name8 (MD) 5408] MEDQUIST36 D: [2193-4-28] 14:41 T: [2193-4-28] 15:13 JOB#: [Job Number 5409]	[ "453.8", "518.81", "428.0", "584.9", "482.41", "578.9", "V42.2", "491.21", "287.5" ]	icd9cm	[ [ [] ] ]	[ "45.13", "38.93", "96.04", "00.14", "96.72", "99.61", "38.7", "99.04" ]	icd9pcs	[ [ [] ] ]	21196, 21224			23635, 24170			12933, 12951	22259, 22759	22782, 23613				12605, 12916	24188, 27300		21248, 22238																						4020, 5539									10616, 10654									10683, 11686							14136, 21172							3537, 3814	11708, 12579	12968, 13214
19,470	115,735	52014	Discharge summary	report	Admission Date: [2205-5-2] Discharge Date: [2205-5-15] Date of Birth: [2150-7-11] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Morphine / bee sting Attending:[First Name3 (LF) 1406] Chief Complaint: Angina, Shortness of breath Major Surgical or Invasive Procedure: [2205-5-8] Re-do sternotomy. Coronary artery bypass grafting x1 with saphenous vein graft to the right coronary artery. Mitral valve replacement with a 25/33 On-X mechanical valve, serial #[Serial Number 107678], reference #[Serial Number 101277]. Aortic valve replacement with a 19 mm On-X mechanical valve, serial #[Serial Number 107679], reference #[Serial Number 42227]. History of Present Illness: 54F with hx of CAD s/p CABG x 2, prior stents, CHF, and severe MR referred here by her primary cardiologist for one month of intermittent chest pain and increasing shortness of breath. Patient states that for the past month she has had increasingly severe DOE with occasional pre-syncopal symptoms and light-headedness. She also describes experiencing a dull, squeezing sensation in her chest about a month ago and since has had intermittent sharp central chest pain that has crescendo quality with exertion and resolves after seconds with rest. She also describes occasional onset of chills without fevers, 3-pillow orthopnea, PND, frequent bedtime urination, and waxing and [Doctor Last Name 688] LE swelling. She was to undergo coronary cath today for evaluation primarily of her MV as she has been undergoing outpatient planning for possible MVR but is thought to be higher risk given her past history of bleeding (nose bleeds requiring ED visit and cautery) and prior CABG prompting a trial of medical management. Of note, she does not take aspirin or plavix currently due to her history of bleeding. Her baseline creatinine is in the high 1.0's per report but was 2.0 this AM so his cath was deferred and she was transferred. Goal of transfer also include coronary cath, C-[Doctor First Name ] evaluation, diuresis, and ACS rule-out. In the ED, initial vitals were 98.5 71 130/66 18 100% Labs and imaging significant for negative troponin, creatinine 2.0, BNP of 2374, HCT of 33.7, UA negative, CXR c/w mild fluid overload ECG showed SR @ 70, NA, NI, TWI in V1-V2 Patient given Aspirin 325mg PO x 1, Hydromorphone 0.5 mg IV x 1, humalog 14units x 1 for fingerstick of 300. Vitals on transfer were P 66, BP: 114/93, RR: 12, 95% on RA On arrival to the floor, patient initially feeling well and recounting her history as above but became acutely diaphoretic, anxious, described chest pressure and shortness of breath. Vital signs unchanged, satting 100%RA, EKG unchanged, FSBS 54 following 1 glass of juice 10 minutes prior. REVIEW OF SYSTEMS: Cardiac review of systems is notable for intermittent chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, but no palpitations, Also denies fevers, abdominal pain, N/V/D, urinary symptoms, or localized numbness, weakness, or tingling. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: CABG x2 [2199-7-26] (LIMA-LAD, SVG-OM) -PERCUTANEOUS CORONARY INTERVENTIONS: Prior stenting (anatomy not presently known) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -Non-Hodgkin's lymphoma dx [2175] s/p splenectomy/partial pancreatectomy along with XRT/chemotherapy -COPD/asthma -Heliohepatitis -Hyperlipidemia -NIDDM -GERD c/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] esophagus -Bipolar disorder, depression/anxiety -Retinal artery stenoses -Hypothyroidism -Prior shoulder injury -3+ Mitral valve regurgitation Past Surgical History: -CABG -shoulder surgery -splenectomy -distal pancreatectomy '[94] for duct stricture Social History: Lives with boyfriend, 20 pack-year smoking history, quit a few years ago, prior modest ETOH but none now, no illicts. Family History: Father died of MI at 47 Brother with PTCA at 50 Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS- T= 97.8 BP= 132/76 HR= 67 RR= 16 O2 sat= 99RA GENERAL- WDWN woman in NAD, AOx3, tearful when recounting PMHx HEENT- NCAT. Sclera anicteric. PERRL, EOMI. NECK- Supple without JVD. CARDIAC- RRR, normal S1, S2. [1-29] holosystolic mumur loudest lower left sternal border. No thrills, lifts. No S3 or S4. Some tenderness to palpation of her sternum which she describes as reproducing her sharp chest pain LUNGS- Soft expiratory wheezes diffusely, no rales appreciated on exam ABDOMEN- Soft, obese, ND, mildly tender to palpation in epigastrium. EXTREMITIES- 1+ pitting in BLE's. Non-tender. 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 PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: --------------- [2205-5-2] 10:15AM BLOOD WBC-9.3 RBC-3.58* Hgb-10.9* Hct-33.7* MCV-94# MCH-30.3# MCHC-32.2 RDW-14.7 Plt Ct-354 [2205-5-2] 10:15AM BLOOD Neuts-74.0* Lymphs-14.0* Monos-5.1 Eos-5.9* Baso-1.1 [2205-5-2] 10:15AM BLOOD PT-11.3 PTT-34.8 INR(PT)-1.0 [2205-5-2] 10:15AM BLOOD Glucose-252* UreaN-64* Creat-2.0* Na-138 K-5.1 Cl-101 HCO3-24 AnGap-18 [2205-5-2] 10:15AM BLOOD CK-MB-2 proBNP-2374* [2205-5-2] 10:15AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.6 [2205-5-2] 10:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2205-5-2] 10:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2205-5-2] 10:45AM URINE Hours-RANDOM UreaN-557 Creat-49 Na-45 K-51 Cl-39 [2205-5-2] 10:45AM URINE Osmolal-392 DISCHARGE LABS: --------------- MICRO/PATH: ----------- -MRSA SCREEN (Final [2205-5-6]): No MRSA isolated. -URINE CULTURE (Final [2205-5-4]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING/STUDIES: ---------------- ECG [2205-5-2]: Sinus rhythm. Mild P-R interval pro0longation. RSR' pattern in leads VI-V2 is likely a normal variant. Minor non-specific ST-T wave abnormalities. Compared to the previous tracing of [2202-6-5] no significant changes. . CXR PA/LAT [2205-5-2]: IMPRESSION: Unchanged, small right pleural effusion with mild pulmonary edema. . TTE [2205-5-3]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([11-26]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened and mildly retracted. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. There is a minimally increased gradient consistent with trivial mitral stenosis. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened and mildly retracted. Moderate [2+] tricuspid regurgitation is seen (may be significantly underestimated due to the technically suboptimal nature of this study). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2202-4-26], the pulmonary artery pressure is increased. IMPRESSION: Suboptimal image quality. The multiplicity and morphology of valve lesions suggests radiation-induced or, less likely, rheumatic valve disease . L-Spine XR AP/LAT [2205-5-3]: FINDINGS: Comparison is made to the CT scan of the abdomen and pelvis from [2199-8-1]. There is slight scoliosis of lumbar spine convexity to the left side centered at L3-L4. There are no compression deformities. There are degenerative changes of the lower facet joints. No compression deformities or antero- or retrolisthesis is seen. There are abdominal aortic calcifications. The sacroiliac joints and bilateral hip joints are grossly preserved. . CT CHEST Non-Con [2205-5-4]: IMPRESSION: 1. Status post CABG and median sternotomy with intact sternotomy wires. 2. Several stable pulmonary nodules, some of which are calcified. 3. Hepatomegaly, similar to prior. 4. Status post splenectomy with splenules. . TEE [2205-5-6]: Conclusions The left atrium is minimally enlarged. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic function may be depressed given the severity of mitral regurgitation and aortic regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are moderately thickened. No masses or vegetations are seen on the aortic valve. At least moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse or mass/vegetation Systolic flow reversal is seen in the pulmonary veins. Moderate to severe (3+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Moderate to severe mitral regurgitation without discrete vegetation or systolic prolapse. At least moderate aortic regurgitation. Preserved global left ventricular systolic function. If clinically indicated, cardiac MR would be better able to quantify the severity of valvular regurgitation and to assess effective left ventricular ejection fraction. . C. Cath [2205-5-6]: COMMENTS: 1. Selective angiography of this right dominant system demonstrated native LMCA and three-vessel coronary artery disease. The LMCA is diffusely diseased with distal haziness; caliber of LMCA similar to LCx so likely 70% ostial lesion with diffuse disease throughout. The LAD had a mid total occlusion after S1 and branching D2; D2 proximal 50%. The LCx had a mid AV groove CX lesion of 80% supplying grafted tortuous LPL. The RCA had stent(s) ostially and proximally; difficult to engage RCA selectively, likely severe ostial in-stent restenosis with unequivocal diffuse 60% in-stent restenosis with diffuse mid 60% stenosis beyond with TIMI 2 flow. 2. Selective arterial conduit angiography demonstrated a patent LIMA to LAD graft. 3. Selective venous conduit angiography demonstrated patent SVG to OM graft with tapering at the distal anastamosis (but taper approximates the caliber of the grafted LPL/OM). 4. Subclavian artery angiography showed no obvious proximal subclavian artery stenosis. 5. Although not imaged in detail, the left vertebral artery is tortuous at its origin and significant stenosis cannot be excluded. FINAL DIAGNOSIS: 1. Native LMCA and three vessel coronary artery disease with severe in-stent restenois. 2. Prominent PCW v waves consistent with significant mitral regurgitation. 3. Moderate to severe pulmonary arterial hypertension. 4. Moderate to severe left and severe right ventricular diastolic heart failure. 5. Sheaths to be removed in holding. 6. Additional plans per Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) ], and Dr. [Last Name (STitle) ]; likely benefit from MVR+CABG (SVG-RPDA). 7. Reinforce secondary preventative measures against CAD. Brief Hospital Course: 54F with hx of CAD s/p CABG x 2, prior stents, dCHF, and severe MR referred here by her primary cardiologist for one month of intermittent chest pain and increasing shortness of breath concerning for ACS overlying diastolic CHF exacerbation. ACTIVE DIAGNOSES: ----------------- # Subacute Diastolic CHF Exacerbation/Severe Aortic and Mitral Regurg: Patient was admitted following a month of severe CHF symptoms such as orthopnea, PND, frequent night time urination and was found to have an elevated BNP and evidence of fluid overload on admission CXR concerning for worsening CHF likely related to her severe known MR. [First Name (Titles) ] [Last Name (Titles) 1834] TTE and then TEE which showed moderate to severe mitral regurgitation without discrete vegetation or systolic prolapse and at least moderate aortic regurgitation with preserved global left ventricular systolic function. She was diuresed with IV lasix and maintained on metoprolol (lisnipril initially held given need for contrast with C. cath and fear of precipitating CIN). She had a coronary catheterization which showed in-stent restenosis with a 60% ostial RCA lesions. She was evaluated by cardiac surgery who felt she would benefit from AVR/MVR/RCA CABG. On [5-8] she [Month/Year (2) 1834] a redo sternotomy, aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting times one. This procedure was performed by Dr. [Last Name (STitle) ], please see the operative note for details. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. She was extubated by the following day and weaned from vasopressor and inotropic support over the next two days. Her chest tubes were removed. On post-operative day three she transferred to the step down unit and coumadin was begun for her double mechanical valves. She quickly became supertherapeutic so her epicardial wires were cut at the skin and several doses of coumadin were held. She was discharged to home on post-operative day seven with low dose coumadin and INR/CBC follow-up arranged with VNA and Dr. [Last Name (STitle) 29478], her PCP. . # Unstable Angina/CAD/HTN/HLD: Patient with increasing anginal symptoms at home over the past month. Chest pain has features of classic angina but also has aytpical features including reproducibility on palpation and sharp nature. EKG with TWI in V1-V2 which are minimally changed from her prior EKG's in our system 3 years ago. She ruled-out for MI with CE's x 3 which were negative. CXR without significant thoracic process other than mild fluid overload. CT chest non-con without significant findings that may explain cause. Cardiac cath showing 60% ostial RCA in-stent restenosis. She was initially treated with aspirin 325mg daily but then switched to 81mg daily following rule-out. She was continued on her crestor and metoprolol (switched to tartrate in-house) with holding of her lisinopril prior to and following catheterization given concerns for [Last Name (un) ] and CIN. . # Acute on Chronic Kidney Injury: Patient with CKD Stage III at baseline. She was admitted with a Cr of 2.0 with FENa and FEUrea in indeterminant ranges. Her Cr improved to 1.5 with initial diuresis and witholding her lisinopril. Following surgery her creatinine stabilized and lisinopril was restarted. . # Low Back Pain: Patient with a couple weeks of low back pain localized mostly to the low lumber paraspinal muscles but also including the central back. No radiculopathy, localized weakness, or other concerning symptoms. She recounts history of falling when getting out of bath tub which may correlate. L-spine XR 2 views was without significant pathology. Her pain was managed with tylenol and dilaudid PO PRN. Post operatively her pain was adequately managed with percocet. . CHRONIC DIAGNOSES: ------------------ # COPD/Radiation-related Lung Disease: Patient with history of COPD related to smoking and radiation relatd lung disease from non-hodgkins lymphoma treatment 30 years ago. She had intermittent diffuse expiratory wheezes on exam which improved with nebs. Her CT non-con of her chest showed parenchymal scarring and volume loss within the medial portion of both lungs, likely related to previous radiation therapy as well as post-CABG, post-sternotomy, and post-splenectomy changes. She was maintained on nebs PRN as well as her home montelukast, inhaled steroid, and [Last Name (un) ] regimen. # DM2: A1c 7.5. She was hyperglycemic on admission to 300's for which she recieved 14 units of humalog which percipitated a hypoglycemic episode with significant symptoms at a BSL of 49. She was started on her home regimen of humalog 75/25 with improved control in her BSL's. Her home glipizide was held while in-house given [Last Name (un) ]. It was restarted at discharge with stablilization of her creatinine. # Anemia: Chronic anemia with prior workup 4 years ago with normal iron studies and B12/folate. Likely related to CKD and stable. Further workup was deferred to the outpatient setting. Her hematocrit was 27 on the day of discharge, she will have a CBC drawn the day after discharge. # Bipolar Disorder: Stable. She was continued on her home sertraline 150mg PO daily, seroquel 25 mg PO bid, and 50mg PO QHS. She was followed by social work in-house. Medications on Admission: - Albuterol Neb Q4-6hrs PRN - Clonazepam 1mg TID - Rosuvastatin 5 mg PO DAILY - Fluticasone 220 mcg inhaler 2 puffs [Hospital1 ] - Furosemide 80mg PO daily - Lamotrigine 100mg Tab PO DAILY - Lamotrigine 100mg Tab x 2 PO QHS - Levothyroxine 88 mcg PO DAILY - Lisinopril 20mg PO daily - Metoprolol Succinate 25mg PO BID - Protonix 40mg PO BID - Albuterol Inhaler 2 puffs Q4hrs PRN - Serevent Diskus 50mcg 1 puff [Hospital1 ] - Singulair 10mg PO daily - Colace 100mg PO daily - Ascorbic Acid 1000mg PO DAILY - Sertraline 150mg PO daily - Glipizide 10mg PO daily - Quetiapine 25 mg PO BID - Quetiapine 50 mg PO QHS - Insulin (Humalog) 75/25 15units [Hospital1 ] Discharge Medications: 1. Furosemide 80 mg PO DAILY 2. Rosuvastatin Calcium 5 mg PO DAILY 3. Levothyroxine Sodium 88 mcg PO DAILY 4. Quetiapine Fumarate 25 mg PO BID 5. GlipiZIDE 10 mg PO DAILY 6. fluticasone NF 220 mcg Inhalation 2 puffs [Hospital1 ] 7. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing/dyspnea 8. Clonazepam 1 mg PO TID 9. LaMOTrigine 100 mg PO DAILY 10. LaMOTrigine 200 mg PO QHS 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/dyspnea 12. Docusate Sodium 100 mg PO DAILY 13. Ascorbic Acid 1000 mg PO DAILY 14. Montelukast Sodium 10 mg PO DAILY 15. Pantoprazole 40 mg PO Q12H 16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 17. Sertraline 150 mg PO DAILY 18. Aspirin EC 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg daily Disp #30 Tablet Refills:2 19. Metoprolol Tartrate 6.25 mg PO BID Hold for HR <60 or SBP <95 RX metoprolol tartrate 25 mg two times daily Disp #30 Tablet Refills:2 20. Oxycodone-Acetaminophen (5mg-325mg) [11-26] TAB PO Q4H:PRN pain RX Percocet 5 mg-325 mg every four hours Disp #40 Tablet Refills:0 21. Warfarin 0.5 mg PO ONCE Duration: 1 Doses do not take until as directed by the office of Dr. [Last Name (STitle) 29478] RX Coumadin 1 mg once Disp #30 Tablet Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: mitral regurgitation coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound check [2205-5-23] at 10:00am at Cardiac Surgery Office [Telephone/Fax (1) 170] Surgeon Dr. [Last Name (STitle) ] [2205-6-20] at 1:00pm [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) ] [2205-6-3] 2:20p Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 29478] in [2-28] 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/CBC Coumadin for mechanical aortic and mitral valves Goal INR 2.5-3.5 First draw day after discharge Thursday [2205-5-16] Then please do INR checks daily until stablized and then Monday, Wednesday, and Friday for 2 weeks then decrease frequency as directed by Dr. [Last Name (STitle) 29478] ([Telephone/Fax (1) 35953]. Check a CBC during the first INR check. Plan confirmed with Dr. [Last Name (STitle) 29478] on [2205-5-15]. Results to phone fax ([Telephone/Fax (1) 107680] Completed by:[2205-5-15]	[ "396.8", "V12.59", "414.02", "428.33", "E942.9", "416.8", "584.9", "E879.2", "V13.89", "V87.41", "288.60", "V15.82", "585.3", "530.85", "998.2", "V45.79", "E934.2", "V10.79", "998.01", "244.9", "508.1", "E870.0", "E888.1", "411.1", "250.80", "909.2", "440.8", "V45.82", "790.92", "E932.3", "403.90", "362.13", "V88.12", "428.0", "E849.0", "724.2", "V17.3", "V58.67", "493.20" ]	icd9cm	[ [ [] ] ]	[ "88.56", "37.23", "35.22", "36.99", "38.97", "35.24", "36.11", "88.72", "39.61", "88.44" ]	icd9pcs	[ [ [] ] ]	19213, 19272	11864, 12107	322, 719	19361, 19517	4912, 4912	20388, 21505	4002, 4051		17959, 19190		19293, 19340		17265, 17936		11284, 11841	19541, 20365		5756, 11267				3761, 3851		4066, 4076				3184, 3335										4098, 4867					2806, 3076				255, 284									747, 2787					4928, 5740					3366, 3738			12125, 17239		3098, 3164	3867, 3986		4893, 4893
7,192	190,739	24529	Discharge summary	report	Admission Date: [2153-6-29] Discharge Date: [2153-7-3] Date of Birth: [2075-5-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Paracentesis x 2 EGD Blood transfusion x 4 units History of Present Illness: 78 yo male with CHF, severe TR, cardiac cirrhosis, multiple episodes of GIB secondary to AVM's who presented to the ED on [6-29] for routine paracentesis. He complained of dyspnea and was found to be have a hct of 18 and melenic stool on rectal exam. He noticed increasing abdominal distension and tried to schedule a paracentesis (he routinely gets at least 2 per month) but was unable to, so he came to the ED instead for the procedure. He noted there that he had been weak and fatigued for the past two weeks and was found to have a hct of 18. . In the ED, rectal exam revealed dark, guaiac positive stool; he refused NG-lavage or placement of central line or peripheral IV's. He denied lightheadedness or dyspnea, his SBP's were initially in the 110's but drifted down to the 90's, and his ECG was unchanged. He also denies recent f/c, uri, chest pain, dyspnea (though has had orthopnea for past few weeks), n/v/d, melena (stool is always dark from iron), hematochezia, or urinary sx. . He was admitted to the MICU for further management. He was transfused a total of 3 units PRBC's with increase in hematocrit from 18 -> 25. Paracentesis was peformed with removal of 4.8 liters of serous fluid. He remained hemodynamically stable. GI was consulted and is planning for EGD and colonoscopy on Monday. Past Medical History: -HTN -CAD: CABG [2140], cath [2151] with patent lima-lad, occluded svg-om, near occluded svg-rca -CHF: TTE [9-/2151] with EF 40-50%, mild LVH and LV-HK, 2+MR, 4+TR -Severe TR -Moderate MR [Name13 (STitle) ] -Cardiac cirrhosis: Requiring repeat sx paracenteses -Recurrent GIB [3-2] AVMs -Colon polyps -HBV -CRI: cr 1.5-1.8 -Hypothyroidism -OA Social History: Originally from [Country 3397]. Previously living with wife in [Name (NI) 3146], but has been at rehab since recent hospitalization. Quit smoking 15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but used to work as a machinist. Unable to walk. Needs wheelchair/walker to get around his house. Family History: Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no FH of cancer Physical Exam: PE: T 98, BP 100/60, HR 70, RR 18, SpO2 97% on RA Gen: pleasant, chronically-ill male, fair function, non-toxic, NAD HEENT: anicteric, op clear with dry mucosa Neck: distended ej's that fill from above, not below, no lad, no thyromegaly CV: rrr, soft s1s2, [3-6] llsb systol murmur PULM: no resp distress or accessory muscle use, fair air movement, decreased breath sounds at bases ABD: firm, distended but not tense with positive fluid wave, large ventral hernia (pt states chronic), mild diffuse tenderness BACK: no cva/vert tendrn, no sacral edema EXTREM: chronic venous stasis changes with scars from previous grafts, no edema NEURO: a&ox3, no focal cn/motor defect Pertinent Results: [2153-6-29] 04:40PM BLOOD WBC-8.2 RBC-1.84# Hgb-5.8# Hct-18.2# MCV-99 MCH-31.7 MCHC-32.0 RDW-22.9* Plt Ct-272 . [2153-7-3] 06:09AM BLOOD Hct-28.1* . ECG: difffuse low voltage, sinus, sl rightward axis, rbbb, no st-t changes; no major change from prior . PA AND LATERAL CHEST [2153-6-29]: Patient is status post sternotomy and CABG, and the heart again appears enlarged. Compared to the prior study, there is persistent pulmonary congestion with blunting in the the left costophrenic angle again noted and persistent fluid within the right horizontal fissure. A right subclavian central venous catheter is unchanged in position. IMPRESSION: Persistent mild to moderate CHF. . TTE [2153-6-30]: The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is >20 mmHg. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate global left ventricular hypokinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is markedly dilated with prominent 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 aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened and fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2151-9-30], the estimated pulmonary artery systolic pressure and right ventricular cavity size have increased and global left ventricular systolic function is slightly worse. The severity of tricuspid regurgitation is similar. . EGD [2153-7-2]: Esophagus: Normal esophagus. Stomach: Normal. Duodenum: A few small non-bleeding angioectasias were seen in the 3rd and 4th portions of the duodenum. [Hospital1 ]-CAP Electrocautery was applied for hemostasis with success. Jejunum: Flat Lesions Several small angioectasias that were not bleeding were seen in the proximal jejunum, mid jejunum and 3rd/4th portion of Duodenum. [Hospital1 ]-CAP Electrocautery was applied for hemostasis successfully. Ileum: Not examined. Impression: Angioectasias in the proximal jejunum and mid jejunum and 3rd portion of duodenum (thermal therapy). Otherwise normal EGD to mid jejunum. Brief Hospital Course: 78m with cad, chf, tr, cardiac cirrhosis, reccurent avm-related gi bleeds, cri here with increasing abominal distension, fatigue, and a hct of 18. . 1) Anemia: Patient is chronically transfusion-dependent secondary to multiple AVM's. Bleed is known to be slow and chronic, and patient maintains symptomatic and hemodynamic tolerance of low hematocrit. Patient was initially admitted to the medical ICU for close hemodynamic monitoring. There, he refused multiple interventions, including foley to monitor u/o, NG-lavage, and peripheral IV's, stating he's aware that he may become very ill or die without these interventions. In the MICU, he received 3 units PRBC's with increase in hematocrit from 18.2 to 25.7. He was subsequently transferred to the medicine unit and under went enteroscopy which revealed multiple non-bleeding AVM's; cautery was performed. Mr. [Known lastname ] was transfused an additional unit of PRBC's prior to discharge (total of 4 units this admission). His hematocrit was 28.1 on the morning of discharge. . 2) Cirrhosis with ascites: Patient routinely requires paracenteses bimonthly due to rapid reaccumulation of fluid in the setting of right heart failure. INR 1.1, indicating preserved synthetic liver function. Of note, patient is on regimen of furosemide 120 mg [Hospital1 ] as outpatient. Spironolactone was recently discontinued due to hyperkalemia during previous hospitalization. A therapeutic paracentesis was performed on [6-30] with removal of 4.8 liters of serous fluid and no complications. Given residual ascites and persistent abdominal discomfort, a second paracentesis was performed on [7-2] with removal of an additional 3 liters of serous fluids. . 3) Cardiac: (a) Pump: Patient with known right side CHF, and as a result, much of his total body fluid likely contained within the abdomen. TTE was repeated during this hospitalization, revealing an ejection fraction of 35% with unchanged severe (4+) tricuspid regurgitation. This reflects increased pulmonary artery systolic pressure and right ventricular cavity size with slight worsening of global left ventricular systolic function. He was continued on digoxin and furosemide. (b) Vessels: Patient with known CAD and slight troponin leak of 0.26 in the setting of severe anemia. This leak was consistent with known baseline. ASA has been held indefinitely in the setting of chronic bleed. (c) Rhythm: Continue amiodarone for rate control. Anti-coagulation contraindicated in the setting of high bleeding risk. . 4) Chronic renal insufficiency: Creatinine ~1.2 was at baseline during this hospitalization, improved from previous hospitalization. . 5) UTI: UA on [6-29] with 11-20 WBC's, 0 epi's. He was started on Bactrim for UTI, but this was disconinued after urine culture returned with no growth. . 6) Hypothyroidism: h/o thyroid goiter s/p thyroidectomy. Continued levothyroxine. . 7) Code status: DNR/DNI. Medications on Admission: 1) Amiodarone 200 mg daily 2) Levothyroxine 150 mcg daily 3) FeSO4 325 mg daily 4) Pantoproazole 40 mg [Hospital1 ] 5) Digoxin 125 mcg 3x/wk (MWF) 6) Furosemide 120 mg [Hospital1 ] Discharge Disposition: Extended Care Facility: [Hospital ] Nursing Home Discharge Diagnosis: Anemia Chronic GI bleed secondary to arteriovenous malformations Recurrent ascites Right heart failure Severe tricuspid regurgitation Discharge Condition: Stable Discharge Instructions: You were admitted with ascites (collection of fluid in your abdomen) and lower extremity swelling. A paracentesis was done to take some of the fluid off of your abdomen. In addition, you were transfused a total of 4 units of blood for your anemia. You underwent an EGD with cautery of several blood vessels. . You should be sure to continue taking all your medications, as prescribed. Also please be sure to follow-up with Dr. [Last Name (STitle) ] (see appointments below). Given your history of heart failure and swelling, you should weigh yourself every morning and call Dr. [Last Name (STitle) ] if you weight increases by 3 pounds or more. In addition, adhere to a 2 gram/day sodium diet. Followup Instructions: You are scheduled to undergo an outpatient paracentesis on [7-17] at 10:30 a.m. Please come to the Radiology Department on the [Location (un) 470] of the [Hospital Unit Name 1825] on the [Hospital1 18] [Hospital Ward Name 516]. Please call [Telephone/Fax (1) 327] with questions. . Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] HEALTH CARE [Location (un) 2352] Address: 1000 [Last Name (LF) ], [First Name3 (LF) 2352],[Numeric Identifier 9121] Phone: [Telephone/Fax (1) 1144] Appt time/date: [7-27*] at 9:30 a.m. .	[ "244.0", "599.0", "394.0", "414.00", "715.90", "V45.81", "789.5", "070.30", "398.91", "276.7", "V12.72", "585.9", "427.31", "403.90", "276.1", "569.85", "397.0", "280.0", "571.5" ]	icd9cm	[ [ [] ] ]	[ "44.43", "54.91", "99.04" ]	icd9pcs	[ [ [] ] ]	9383, 9438	6189, 9144	333, 384	9616, 9625	3246, 6166	10382, 11056	2457, 2536				9459, 9595		9170, 9360			9649, 10359								2551, 3227																							274, 295									412, 1727															1749, 2113	2129, 2441
15,841	192,311	4509	Discharge summary	report	Admission Date: [2158-6-8] Discharge Date: [2158-6-12] Date of Birth: [2100-10-3] Sex: F Service: MEDICINE Allergies: Codeine / Demerol / Plavix / Percocet Attending:[First Name3 (LF) 6195] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation History of Present Illness: 57 y.o. female with hx asthma, CAD, DM II, hypothyroidism, anxiety/agarophobia and depression, who presented to the ED today with SOB and agitation. Patient is unable to provide history as she is intubated at this time. History is obtained from patient's daughter who does not live with the patient. According to the patient's daughter the patient has been in her USOH until a few days ago when she started complaining of SOB initially relieved with Albuterol inhaler. Daughter reports speaking with pt on the phone day prior to admission and pt has not mentioned any complaints to her. Her SOB has been getting progressively worse and this morning she developed increased WOB and had to come in to the ED. In the ED, the patient was noted to have increased WOB and was very agitated. ED initial vitals 98.3 108 207/78 20 100% on NRB and 88% on RAHer lung exam was described as having bilateraly wheezing and crackles. She was given nebs, 125 mg of Solumedrol IV, Levofloxacin for presumed UTI, 5 units of insulin, a total of 3 mg of Ativan and Valium 5 mg for anxiety, and was placed on oxygen. She then was noted to be somnolent and difficult to arouse. Patient was intubated and placed on AC 500x15; peep 5; FiO2 100%. ABG was checked post-intubation and was 7.06/98/374. CXR and CTA done (see below). . Per family, no fevers, chills recently. No cough. No ill contacts. Bloody stools recorded in ED record. Patient's SO reports that she ran out of Levothyroxine x 2 wks recently. . Of note, the patient was recently seen in PCP's office. Her TSH was noted to be 9 and Levothyroxine dose was increased. She was also started on Bactrim for presumed UTI. . Called out to floor on [2158-6-10] - patient reports that she is feeling well. SOB is significantly improved, no cough. No chest pain, abdominal pain. Eating well. Urinating without difficulty after removal of foley. Past Medical History: 1. Diabetes Type II on NPH and SS at home, last HgbA1C 9.4% ([5-11]) 2. HTN 3. Hypothyroidism, last TSH 9.3 ([5-11]) 4. Major depressive disorder 5. Anxiety with agoraphobia 6. CAD, s/p stent in [2153] mid LCx, mid and distal RCA and LVEF 58% LV-gram 7. Two prior episodes of confusion with abnormal EEG findings (evidence of focal irritability). She was started on Tegretol [9-/2157] and recent level was 6.2. 8. Asthma. On Flovent and Albulterol at home. No PFTs on record. Never hospitalized for asthma exacerbation. Never intubated. 9. s/p hysterectomy Social History: Widow. Lives at home with boyfriend. [Name (NI) 1403] as a secretary at a red cross. Has a daughter. Alcohol: occasionally. Tobacco: a few cigs/day. Has smoked x 35 years and "much more" than just a few cigs in past. Family History: FX of DM II and heart disease, no asthma hx known of relatives Physical Exam: VS: 97.8 78 (78-80) 145/65 92% on a vent current vent AC 500x20; PEEP of 5; FiO2 30% GENERAL: intubated, sedated, follows some simple commands, does not appear to focus HEENT: NC, AT, PER sluggishly reactive from 3 mm to 2 mm, no scleral icterus, MM sl dry NECK: supple, no elevated JVP appreciated CV: regular, nl S1S2, no m/r/g PULM: soft crackles bilterally ABD: + BS, soft, obese, NT, ND, well healed vertical midline scar c/w prior C-section EXT: trace LE edema, no pretibial myxedema, extremities are cool to touch NEURO: moving all 4 xtr; lightly sedated SKIN: maculopapular rash with excoriated papules on abdomen and arms Pertinent Results: EKG: sinus rate 116, ST depressions in V4-V6 and II, III, aVF (new c/w prior). . CXR [2158-6-8]: Persistent bilateral interstitial pattern. This could represent recurrent interstitial pulmonary edema, but differential diagnosis includes interstitial infection and a more chronic interstitial infiltrative process. If there is clinical evidence of volume overload, initial evaluation with follow up chest x-rays after diuresis would be suggested. If persistent, high-resolution CT may be helpful for better characterization if warranted clinically . CTA [2158-6-8]: 1. No evidence of pulmonary embolism or aortic dissection. 2. Focal opacity seen at the anterior aspect of the left and right lungs, possibly representing focal area of atelectasis versus infection. . PRIOR STUDIES: Exercise-MIBI [12/2157]: 4.8 Mets Probable reversible defect involving the basal inferior wall. Moderately depressed left ventricular function with inferior hypokinesis. . Brief Hospital Course: 1. Hypercarbic respiratory failure: Etiology is not entirely clear - ? CHF exacerbation and/or asthma causing development of initial respiratory symptoms, further exacerbated by multiple doses of benzodiazepines given for anxiety in the ED. Also has history of hypothyroidism - abnormal TFTs but no bradycardia, hypothermia, or other symptoms that suggest myxedema coma. CXR with interstitial infiltrate vs. pulmonary edema. Patient required intubation in the ED for respiratory distress. She was able to be extubated on hospital day 2 and was transferred to the floor. Asthma exacerbation was treated with Solu-Medrol and then was switched to a prednisone taper. Patient received albuterol and ipratropium inhalers. She was also started on Levofloxacin and Azithromycin empirically to cover for a URI. A nasopharyngeal aspirate for viral pathogens was negative. Patient was started on furosemide and diuresed. WBC elevated during her stay although most likely secondary to steroids - WBC were WNL on admit, increased after getting Solu-Medrol, and trended down as steroid dose was decreased. Antibiotics were discontinued. On discharge patient was continued on albuterol and ipratropium, a prednisone taper, and furosemide. . 2. Pleural effusions: Etiology unclear. [Name2 (NI) ] fevers, chills to suggest infection. Profound hypothyroidism may results in pleural effusion but unlikely to be the case here. Most likely can be attributed to her CHF. ECHO on [2158-6-9] with EF of 40 % (this is unchanged from exercise mibi in [12-10] with calculated EF of 40%). Patient will be discharged on standing furosemide. She will follow-up with her PCP next week who will repeat her CXR and adjust her furosemide dose as necessary. She should also have her electrolytes checked at that time. . 3. Anemia: Acute HCT drop from 35.8 on admission to 28. ED chart has documented blood in stool. Recent colonoscopy negative. No bowel movements during admission. No obvious source of bleeding. Gastric lavage was negative. No recent instrumentation to be concerned about retroperitoneal bleed. Bilateral pneumothoraces unlikely. HCT stable since admission. Coags WNL. No transfusions during this admission. Anemia may be related to hypothyroidism and should be followed up in out-patient setting. . 4. CAD s/p stents: ST depressions in lateral and inferior leads on EKG changes. CK slightly elevated, but MB and trop negative. Patient with recent stress mibi in [12-10] and seen by cardiology in [4-10], recommended ongoing medical management. No chest pain during this admission. Patient was continued on ASA, atorvastatin, metoprolol and lisinopril. . 5. UTI: Treated with a course of levofloxacin. . 6. Hypothyroidism: TSH up to 17 from 9.4 recently. Discussed with endocrine fellow: no indications for T3 at this time. Levothyroxine 150 mcg po daily, per endocrine - recheck TFTs in one month. . 7. DM: Poorly controlled, was initially on insulin gtt when on the ICU. Seen by endocrine who made recommendations for a home regimen of NPH and a regular insulin sliding scale. Patient was discharged on NPH and regular insulin. . 8. Depression/anxiety/psych: Continued on home regimen of Paxil, Klonopin, and Valium. Medications on Admission: ALBUTEROL inh 1 puff qid prn wheezes ASPIRIN 325MG every day ATENOLOL 50MG every day ATORVASTATIN CALCIUM 10 MG daily CARBAMAZEPINE XR 400 MG daily DIAZEPAM 5 MG qhs FLOVENT 2 puff twice a day Insulin KLONOPIN 0.5MG [Hospital1 ] prn LEVOTHYROXINE SODIUM 150 mcg daily LISINOPRIL 10 MG po daily Nortriptyline 50 mg po qhs PAXIL 20 mg po qd Bactrim (started [6-4]) x 7 days Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:2 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as needed for constipation. Disp:60 Tablet(s) Refills:3 6. Carbamazepine 100 mg/5 mL Suspension Sig: Two (2) PO BID (2 times a day). Disp:qs qs Refills:2 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. Disp:qs qs Refills:3 8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs qs Refills:2 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:qs qs Refills:3 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:qs qs Refills:2 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 15. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: take 50 mg (5 pills)on [6-13] mg (4 pills)on [6-14] mg (3 pills)on [6-15] - you should discuss further dosing with your PCP [Last Name (NamePattern4) ] [6-15]. Disp:30 Tablet(s) Refills:2 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 40 units in AM, 20units at bedtime Subcutaneous QAM and QHS. Disp:qs qs Refills:2 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per sliding scale Subcutaneous 4 x daily per sliding scale: sliding scale as recommended by the endocrinologist will be provided in your discharge paperwork. Disp:qs qs Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses congestive heart failure asthma exacerbation * Secondary diagnoses coronary artery diease hypothyroidism depression anxiety Discharge Condition: good Discharge Instructions: Please take all of your medications as prescribed. You were started on a new medication called furosemide (Lasix) - your PCP will adjust the dosage of this as needed. You were also given a prescription for prednisone. You should take this as prescibed until your see your PCP in clinic. He will then advise when to stop the prednisone. . Please call your doctor or return to the emergency department if you develop chest pain, shortness of breath, if you cannot eat, drink, or take your medications, or you develop any other symptoms that are concerning to you. Followup Instructions: Please follow-up with your PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (PRE) ].D. on Thursday [2158-6-15] - please call to confirm your appointment [Telephone/Fax (1) 250]. You should have your electolytes checked then, and you should have your thyroid function checked again in two weeks. * You also have the following apointments coming up: 1. Provider: [Name10 (NameIs) 19240],[Name11 (NameIs) 19241] PSYCHIATRY OPD Phone:[Telephone/Fax (1) 1387] Date/Time:[2158-6-27] 5:00 . 2. Provider: [Name10 (NameIs) 19240],[Name11 (NameIs) 19241] PSYCHIATRY OPD Phone:[Telephone/Fax (1) 1387] Date/Time:[2158-7-18] 5:00 . 3. Provider: [Name10 (NameIs) ] [Name11 (NameIs) 540], MD Phone:[Telephone/Fax (1) 8302] Date/Time:[2158-7-20] 3:15 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6198] MD, [MD Number(3) 6199]	[ "493.20", "300.01", "428.0", "296.20", "518.81", "250.92", "511.9", "305.1" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	10895, 10901	4794, 8026	301, 313	11087, 11094	3804, 4771	11706, 12670	3073, 3137		8457, 10872		10922, 11066		8052, 8434			11118, 11683								3152, 3785																							258, 263									341, 2222															2244, 2819	2835, 3057
2,543	106,163	21557+57258+57248	Discharge summary	report+addendum+addendum	Admission Date: [2114-9-17] Discharge Date: [2114-10-15] Date of Birth: [2057-11-29] Sex: F Service: NEUROLOGY Allergies: Percodan / Percocet / Cerebyx / Phenytoin Attending:[First Name3 (LF) 618] Chief Complaint: Right facial droop, left face and arm numbness Major Surgical or Invasive Procedure: -Status post tracheostomy -Status post PEG -Status post dental extraction of 3 teeth History of Present Illness: Patient is a 56 year old right handed female with pastmedical history of breast cancer 10-15 years ago, pleural effusion, DVT and PE who presented to [Hospital1 18] on [2114-9-17] for evaluation of left face and arm numbness and right facial droop. Patient was in her usual state of health until about one week ago when she reports having "the flu". She then had several days of nausea and vomiting and malaise. Two days prior to admission her daughter her right eye was "droopy". On evening prior to admission, her whole right face was drooped. Then, on morning of admission, she awoke at 6am with left arm and face numbness. This was associated with a vertiginous sensation as well. Daughter noted that her speech was slurred. No nausea or vomiting, headaches, blurry vision, double vision, lightheadedness, paresthesias, weakness or incoordination. She went to [Hospital1 56809] for evaluation. Head CT there with pontine hemorrhage. Transferred to [Hospital1 18] for further evaluation. On initial arrival, heart rate 70-80s and sinus, BP 138/90, oxygen 93/RA and 98%/2L. While in ED, she received 2 units of FFP. However, she reported that her symptoms worsened. She felt that her speech was more slurred, she was having difficulty managing her saliva and secretions, and had vertical diplopia. Repeat head CT showed interval worsening in the size of her bleed, from 8-12 mm. While in ED, she went into atrial fibrillation with rapid ventricular response; Diltiazem 20mg IV resulted in rate control. After arrival to the neurology floor, she continued having difficulty managing her secretions. On several occasions, her oxygen saturation drooped into the 80s. She was transferred to the ICU for closer monitoring. She received Factor VIIa. She was electively intubated in early am on [9-18]. Past Medical History: 1. Breast cancer status post right mastectomy and chemotherapy 15 years ago 2. Pleural effusion 3. DVT and PE 7 years ago Social History: Married, with 3 children. Lives with husband,daughter, son and grandchildren. She is a homemaker. No tobacco,valcohol, drug use. Family History: Mother with stroke in her 70s. Sister with history of breast cancer, died from brain mets. Physical Exam: Tm: 99.0 Tc: 98.4 BP: 97/69 (97-150/66-87) HR: 78 (76-140s) Vent AC 600x12 ([11-14]) with FiO2 0.40 Gen: WD/WN, sitting up in bed comfortably, NAD. HEENT: NC/AT. Anicteric. MMM. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: Decreased breath sounds over right hemithorax. Coarse breath sounds on left. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Sleepy but arousable. Cooperative with exam. Able to follow simple midline and appendicular commands. Able to make needs known by writing on pad of paper. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: On neutral gaze, eyes are deviated to the left with right beating nystagmus. On right lateral gaze, eyes do not cross midline. Upgaze impaired with vertical nystagmus, some rotatory component. V, VII: Unable to fully assess with ETT but appears to have right UMN palsy. Decreased sensation left hemiface. VIII: Unable to fully assess. IX, X: Unable to assess with ETT. [Doctor First Name 81]: Shoulder shrug strong. XII: Tongue to right around ETT. Motor: Normal bulk and tone. No abnormal movements or tremors. Strength full. Sensation: Decreased to light touch over left hemibody. Reflexes: B T Br Pa Ac Right 1 1 1 0 0 Left 1 1 1 0 0 Grasp reflex absent. Right toe upgoing. Left toe equivocal. Coordination: Slowed but accurate on left FNF. Dysmetric right FNF. Gait: Unable to assess. Pertinent Results: [2114-9-17] 12:20PM WBC-8.1 RBC-4.15* HGB-12.1 HCT-35.0* MCV-84 MCH-29.1 MCHC-34.5 RDW-14.1 [2114-9-17] 12:20PM NEUTS-74.4* LYMPHS-21.2 MONOS-3.5 EOS-0.5 BASOS-0.5 [2114-9-17] 12:20PM PLT COUNT-258 [2114-9-17] 12:20PM PT-18.9* PTT-29.3 INR(PT)-2.2 [2114-9-17] 12:20PM GLUCOSE-107* UREA N-15 CREAT-0.6 SODIUM-141 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-32* ANION GAP-12 [2114-9-17] 12:20PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9 ----- CT head w/o contrast [2114-9-17]: A rounded hyperdensity is again noted in the right pontomedullary junction. This is slightly larger than on the prior study, now measuring 12 x 11 mm in size. In addition, this extends slightly more superiorly into the pons and slightly more inferiorly into the medulla. No new areas of hemorrhage are identified. Streak artifact is again identified within this area which limits evaluation of surrounding edema. There is no mass effect or hydrocephalus. [Doctor Last Name ]-white matter differentiation remains preserved. The osseous structures are normal. ----- MRI head w/o contrast and MRA head [2114-9-17]: Multiplanar T1 and T2W images of the brain was obtained. MRA of the Circle of [Location (un) 431] was performed. Correlation is made to the CT examination dated [2114-9-17]. As seen on the CT examination, there is a small 1 cm lesion of increased T2 signal along the right pontomedullary junction which demonstrates magnetic susceptibility on gradient echo images suggestive of a small cavernoma or a calcified lesion due to the increased density seen on the CT exam and magnetic susceptibility. FLAIR images demonstrate a similar but smaller lesion near the left middle cerebellar peduncle. Additional evaluation of the brain with Gadolinium enhanced MRI in both axial and coronal planes would be recommended. The ventricular system is symmetrical without hydrocephalus. The 4th ventricle is in the midline. There is normal signal flow void within the intracranial portions of the carotid and basilar arteries. MRA of the Circle of [Location (un) 431] demonstrates patent distal vertebrobasilar circulation. No aneurysms are seen along the posterior circulation. The visualized anterior, middle, and posterior cerebral arteries are patent. The exam is insensitive to detect tiny aneurysms less than 3 mm in diameter. ----- CT Chest, Abdomen, Pelvis [2114-9-20]: CT OF THE CHEST WITH IV CONTRAST: There are multiple enlarged lymph nodes in the left supraclavicular and prevascular regions, the largest is in the left supravicular region measuring approximately 12 x 19 mm. The patient is intubated. The trachea and left main stem bronchi and its tributaries are widely patent. There is obstruction within the central right airways with complete opacification of the more distal airways and the entire right lung. There is a mixed low and high attenuation density of the collapsed right lung. There is a small loculated effusion at the posterior inferior right thoracic cavity with a thickened wall. The distal right main pulmonary artery is obstructed. Posterior atelectatic changes are noted within the left lung. At the superior aspect of the superior segment of the left lower lobe there is a pleural based nodular density measuring approximately 6 x 10 mm. The patient is status post right mastectomy and surgical clips are noted in the right axilla consistent with lymph node dissection. A porta cath is noted in the superior left chest wall. CT OF THE ABDOMEN WITH IV CONTRAST: The liver, pancreas, spleen, adrenal glands, kidneys, ureters, and small/large bowel loops are unremarkable. There is layering high attenuation material within the gallbladder suggestive of layering sludge. There is gallbladder wall thickening or gallstones. There is no lymphadenopathy or free fluid. CT OF THE PELVIS WITH IV CONTRAST: The uterus, adnexa, sigmoid colon, rectum, distal ureters, and urinary bladder are unremarkable. Surgical clips are noted adjacent to the uterine fundus. There is no lymphadenopathy or free fluid. There are no suspicious lytic or sclerotic osseous lesions. ----- MRI head with and without contrast [2114-9-22]: Since the previous MRI study there is now evidence of subacute hemorrhage with increased T1 and decreased T2 signal identified in the right side of the pontomedullary junction. The previously seen surrounding edema has also increased which involves now the medulla and the posterior portion of the pons. No distinct enhancement is seen in this region. A second area of increased T2 signal with subtle enhancement is identified in the left middle cerebral peduncle which is unchanged from the previous study. No midline shift or hydrocephalus is seen. There are no other distinct areas of abnormal enhancement noted. IMPRESSION: Interval new hemorrhage with subacute characteristics in the right pontomedullary junction with increased edema. No distinct enhancement is seen in this region given the presence of blood products. However in the presence of a second small enhancing lesion in the left middle cerebral peduncle, and given the patient's clinical history, these findings are suggestive of metastatic lesions. No hydrocephalus is seen. Brief Hospital Course: Patient is a 56 year old female with past medical history of breast cancer 15 years ago, DVT/PE admitted on [2114-9-17] after 2 day history of right facial droop, left hemibody numbness. Exam with left gaze preference, impaired right lateral gaze with nystagmus, impaired upgaze with vertical and rotatory nystagmus, right central 7th palsy, altered palatal and gag function, diminished sensation over left hemibody and right dysmetria. In terms of localization, her findings point to lesion in right lower pons/upper medulla. Indeed, she has hemorrhage at right pontomedullary junction, 12x11mm. In light of location and history of breast ca, hemorrhagic transformation of underlying mass was a concern. She was admitted to the Neurology/Neurosurgical ICU. Neuro checks were performed every hour. Initially, she was started on Mannitol and Decadron. These were both weaned [2114-9-19]. Goal systolic blood pressure was <130. All antiplatelets and anticoagulant agents were held. Repeat MRI with gadolinium to assess for underlying mass demonstrated enhancement of hemorrhagic mass and second enhancing lesion in cerebellum. Oncology was consulted. Patient actively refusing chemotherapy and/or radiotherapy but is actively discussing other treatment options with Oncology. On hospital day #1, she was intubated for inability to protect airway and difficulty handling secretions. Chest XRay showed opacification of right hemithorax and mediastinal shift. She underwent flexible and rigid bronch with tissue biopsies samples taken. Chest CT demonstrated multiple enlarged lymph nodes, collapsed right lung and left sided pleural based density concerning for malignancy. Pathology from her right mainstem tumor mass was consistent with metastatic adenocarcinoma of breast origin. We were unable to wean patient from ventilator, likely related to collapsed right lung and poor lung volumes. Tracheostomy was performed [2114-9-25]. Patient continues to rely on mechanical ventilation. While on telemetry monitoring, patient was noted to have intermittent rapid atrial fibrillation alternating with sinus bradycardia. She was seen by cardiolgoy. Esmolol or diltiazem was recommended as needed for rate control. TSH was within normal limits. PEG tube was placed [2114-9-26]. Due to location of her hemorrhagic tumor, patient is likely to have difficulties with swallowing and speech function as she has decreased palatal, tongue, and gag functions. In terms of infectitious disease issues, patient spiked a temperature on [2114-9-26]. Sputum culture showed S. Aurea. Urine culture had gram positive bacteria. She was started on Vancomycin empirically while identification and sensitivities were pending on cultures. The day prior to discharge she was started on a right eye patch to be used intermittently to alleviate her diplopia. She also has a right conjunctivitis that is being treated with drops. We discussed the patient's disposition with oncology, who stated that they had had a lengthy conversation with the patient and her daughter on [9-28], at which time the patient had adamantly refused any chemotherapy or further therapeutic interventions. Arimidex or tamoxifen are not therapeutic candidates because they have already been used in her treatment regimen in the past. Oncology requested that she make a follow up appointment with Dr. [Last Name (STitle) ] if she is interested in further therapy. Medications on Admission: 1. Coumadin 10 mg po qHS 2. Arimidex 1 mg po qd 3. Lasix 40 mg po qd 4. Potassium KCL Discharge Medications: 1. Vancomycin 1000 mg iv q12 2. Reglan 10 mg po qid 3. senna 1 tab po bid prn constipation 4. prochlorperazine 10 mg IV q6 hours prn nausea 5. magnesium sulfate 2 gm IV qday prn Mg<2 6. Potassium chloride 40 meq IV qday prn K<3.5 7. Tocopheryl 400 ml pg qday 8. Esmolol 25 mcg/kg/min titrate to HR<110 9. Dulcolax 100 mg po bid 10. Insulin sliding scale Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Metastatic breast cancer, with hemorrhage in right pontomedullary junction, likely secondary to metastasis. Discharge Condition: Stable Discharge Instructions: Neuro: Neuro checks, supportive care Onc: Pt should follow up with oncology (Dr.[Name (NI) 8949] office) as an outpatient if she wishes to pursue therapy Optho: Pt needs eye patch on R eye intermittently to alleviate diplopia, also eye drops for conjunctivitis CV: Continue esmolol for rate control. Pt has hx of intermittent rapid atrial fibrillation, but has been stable from that perspective for many days Resp: Follow O2 sats, continue ventilation through trach ID: Continue vancomycin x14 day course (last day will be [10-10]), recommend reculturing if she spikes HEME: follow hematocrit, transfuse for hematocrit <30, last transfusion was [9-28] GI: continue PEG tube feeds, follow electrolytes Prophylaxis: pneumoboots, insulin sliding scale, proton pump inhibitor Followup Instructions: Follow up with oncology: Call Dr.[Name (NI) 8949] office at [Telephone/Fax (1) 6568] to schedule appointment [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Name: [Known lastname 10601],[Known firstname 511] Unit No: [Numeric Identifier 10602] Admission Date: [2114-9-17] Discharge Date: [2114-10-15] Date of Birth: [2057-11-29] Sex: F Service: NEUROLOGY Allergies: Percodan / Percocet / Cerebyx / Phenytoin Attending:[First Name3 (LF) 608] Chief Complaint: Facial droop and L sided sensory loss Major Surgical or Invasive Procedure: none Brief Hospital Course: Addendum: Oncology service met with Pt and her daughter on [10-1] and discussed the therapeutic options. They recommended radiation therapy, but also gave the option of [Last Name (LF) 10644], [First Name3 (LF) ] anti-estrogen therapy given qmonth. Ms. [Known lastname ] expressed her wishes to discuss the options with her family before deciding on therapy. She will follow up with her outpatient oncologist (not Dr. [Last Name (STitle) ] when she feels prepared to do so. Discharge Disposition: Extended Care Facility: [Hospital1 49] - [Location (un) 50] Discharge Diagnosis: Metastatic Breast Cancer Pontomedullary junction hemorrhage Discharge Condition: fair Discharge Instructions: see prior instructions [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 610] Completed by:[2114-10-2] Name: [Known lastname 10601],[Known firstname 511] Unit No: [Numeric Identifier 10602] Admission Date: [2114-9-17] Discharge Date: [2114-10-15] Date of Birth: [2057-11-29] Sex: F Service: MEDICINE Allergies: Percodan / Percocet / Cerebyx / Phenytoin Attending:[First Name3 (LF) 10603] Chief Complaint: here for XRT Major Surgical or Invasive Procedure: XRT History of Present Illness: 56 yo F with metastatic breast cancer to brain and lung presented to [Hospital1 8] [2114-9-17] with L face/arm numbness, R facial droop, found to have pontine hemorrhage likely [12-18] pontinemedulary met. She was initially treated with mannitol, decadron and fiven FFP, factor VIIa and electively intubated for difficulty in managing secretions. Head imadging revealed hemorrhage in the R pontomedullary junction and a met in the cerebellum. Bronch with lung/LN mediastinum bx revealed adenocarcinoma of breast origin. Due to a collapsed lung ([12-18] tumor invasion) the patient could not be weaned and a trach was placed on [2114-9-25]. Also PEG placed the following day due to difficulty swallowing. On [9-26] the pt spiked a fever growing MRSA in her sputum and GPC in her urine (likely skin contam). 3 teeth were extracted [12-18] decay. Pt also started on vanc [9-26] for a 14 day course. Pt also had been having intermittant episodes of A-fib which were controled with dilt and prn esmolol. TSH normal. She initially declined any further treatment from the hospital and was almost discharged. However the pt decided that she would like to have palliative XRT. She will receive 1 dose a day x 5 days starting [10-4]. On presentation to the micu the pt was comfortable. She complained of mild jaw pain from where her teeth had been extracted. This has been treated well with tylenol/codeine. No CP/SOB/HA. Her last BM was today. Has back pain when lays flat for long periods. She is able to transfer OOB to chair [12-19] hours/day. Past Medical History: 1. Breast cancer status post right mastectomy and chemotherapy 15 years ago 2. Pleural effusion 3. DVT and PE 7 years ago Social History: Married, with 3 children. Lives with husband,daughter, son and grandchildren. She is a homemaker. No tobacco,valcohol, drug use. Family History: Mother with stroke in her 70s. Sister with history of breast cancer, died from brain mets. Physical Exam: PE - T 100 P 45-79 BP 108/60 PS 8/5/30% with TV 350/RR 24/O2 sat 96% Gen- A+Ox3, not able to speak b/c trach, lying in bed comfortably HEENT - Patch or R eye, MMM, s/p R lower jaw extraction no bleeding Cor- RRR no murmur Chest- decreased BS at based b/l Abd- S/NT/ND +BS Ext- 1+ edema b/l, DP 2+ b/l Neuro- L pupil round reactive, left lateral gaze, R facial droop, R eye injected, strength 5/5 b/l, sensation R>L mild dysmetria finger to nose on the R Pertinent Results: Labs [10-3] WBC 9.9 Hct 31 Plt 317 PT 13.7 PTT 22.0 INR 1.2 Na 140 K 3.8 Cl 102 HCO3 33 BUN 26 Cr 0.5 Glu 123 Ca 8.9 Mg 2.0 PO4 5.4 CXR - [9-25] opacification of R hemithorax [12-18] obstructing tumor. MRI head [9-22] - R pontomedullary hemorrhage, L middle cerebral peduncle c/w met CT chest [9-20] - There are multiple enlarged lymph nodes in the left supraclavicular and prevascular regions, There is obstruction within the central right airways with complete opacification of the more distal airways and the entire right lung. There is a mixed low and high attenuation density of the collapsed right lung. There is a small loculated effusion at the posterior inferior right thoracic cavity with a thickened wall. The distal right main pulmonary artery is obstructed. Posterior atelectatic changes are noted within the left lung. At the superior aspect of the superior segment of the left lower lobe there is a pleural based nodular density measuring approximately 6 x 10 mm. Brief Hospital Course: A/P 56 yo F with met breast cancer who is chronically intubated due to difficult managing secretions. Transfered to [Hospital Unit Name ] inorder to receive palliative XRT to head and chest. 1) Metastatic Breast [Name (NI) 10604] Pt has stable neurological status. Pt was followed by XRT and received 1 dose per day x 5 days to head and chest. She was placed on decadron 4mg [Hospital1 ] to avoid swelling. Upon discharge the pt decided she may attempt to try further palliative chemo. She will go to rehab and contact her primary oncologist Dr. [Last Name (STitle) ]. 2) MRSA pna- Pt completed her 14 day course of vanc. She has remained afebrile. However as the XRT progressed she did produce more purulent sputum. The medical team felt that this was from her collapsed lung which had been partially opened up due to the XRT. 3) s/p trach and mech vent - Pt has been stable on the vent since admission. On [10-6] she was given a passy-muir valve to allow her to speak. She was able to tolerate this for 9 hours and spoke with ease. The pt was placed back on pressure support at night. She was then tired the next day and could only tolerate being off the vent for 2-3 hours at a time. She has been allowed to dictate her care of when she would like to be on the vent. Her settings are pressure support [8-21] with an FiO2 of 30%. 4) Afib - HR remained stable throughout admission. Ca channel blocker and beta blocker held since HR is decreased. 5) R eye conjunctivitis and diplopia - Artificial tears and tear ointment were used to keep her eye protected. She has baseline diplopia from her dysconjugate gaze. When she wanted to watch TV she would wear a patch. 6) Prophylaxis - pneumoboots, Insulin Sliding Scale, Protonix 7) Communication - with patient and daughter DNR/DNI Medications on Admission: Medications on Admission: 1. Coumadin 10 mg po qHS 2. Arimidex 1 mg po qd 3. Lasix 40 mg po qd 4. Potassium KCL Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs PO Q4H (every 4 hours) as needed for pain. 3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 6. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for nausea. 11. Morphine Sulfate 2 mg/mL Syringe Sig: Two (2) mg Injection Q3-4H () as needed for pain. 12. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four (4) mg Injection Q12H (every 12 hours): please give 4mg [Hospital1 ] for 1 week then 2 mg [Hospital1 ] for one week then 2 mg qday for one week. Then stop. 13. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H (every 4 hours) as needed for anxiety. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) see sliding scale Injection ASDIR (AS DIRECTED): Please see attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital1 49] - [Location (un) 50] Discharge Diagnosis: Metastatic Breast Cancer Discharge Condition: stable Discharge Instructions: [Name (NI) 10605] Pt is on pressure support [8-21] with FiO2 30%. She uses the vent at night to sleep and when she feels tired during the day. Otherwise the pt uses a passy-muir valve to talk and can breathe on her own. She needs an oxygen mask for her trach when she off the vent. Please titrate to O2 sat >95%. Pt also needs frequent suctioning due to her colapsed lung. She has just finished treatment for a pneumonia. If she starts spiking fevers or has an increased WBC please consider a relapse of the pneumonia. Eyes - Pt has a dysconjugate gaze from her brain metastases. She has diplopia at base line. She needs atrificial tears drops or ointment applied to her eyes at least tid. She wears a patch over her right eye when she watches tv. Glucose - the pt has increased blood sugar from her steroids. She needs qid finger sticks. Follow the insulin sliding scale provided. Neuro - please follow the patient's neuro exam q12h as she has brain mets. Nutrion - please continue tube feeds as written below. Followup Instructions: Contact Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 10606] for initial appointment. [Name6 (MD) 3359] [Last Name (NamePattern4) 3360] MD [MD Number(1) 3361] Completed by:[2114-10-15]	[ "197.0", "V12.51", "198.3", "523.3", "263.9", "427.81", "518.0", "V10.3", "372.30", "518.81", "431", "482.41", "285.9", "599.0" ]	icd9cm	[ [ [] ] ]	[ "43.11", "96.04", "92.24", "99.04", "38.93", "99.07", "23.09", "33.24", "96.72", "31.1" ]	icd9pcs	[ [ [] ] ]	23732, 23802	20225, 22053	16648, 16653	23871, 23879	19196, 20202	24961, 25240	18605, 18698		22216, 23709		23823, 23850		22105, 22193			23903, 24938								18713, 19177																							16596, 16610									16686, 18296	3386, 4341								3214, 3370						18318, 18442	18458, 18589
74,820	159,924	42182	Discharge summary	report	Admission Date: [2148-10-13] Discharge Date: [2148-10-31] Date of Birth: [2075-8-27] Sex: F Service: NEUROLOGY Allergies: Cipro / Quinolones / Cephalosporins / Gammagard Liquid Attending:[First Name3 (LF) 2090] Chief Complaint: Weakness and hallucinations Major Surgical or Invasive Procedure: Intubation [10-15] Pheresis catheter placed [10-15] Plasmapheresis D1=[10-16], D2=[10-18] D3=[10-21] D4=[10-23] D5=[10-25] Extubation [10-26] History of Present Illness: 73y F with longstanding history of [First Name9 (NamePattern2) ] [Last Name (un) ] who presents with hallucinations, confusion, slurred speech, and generalized fatigue. She has never been seen here at [Hospital1 18] before transferring into our ED this evening "for Neuro eval." She presented to an OSH ED after what her daughters think is an acute-on-chronic [Hospital1 15099] exacerbation. Apparently, her outpatient Neurologist, Dr. [Last Name (STitle) 63296], advised them to have her brought to either [Hospital1 112] or [Hospital1 18] for Neurologic evaluation and care. She has been breathing comfortably and her vitals have been rather unremarkable at the OSH and here. Her labs in both hospitals are notable for intracellular dehydration with what appears to be a "contraction alkalosis" (hypernatremic, hypokalemic, hyperHCO3/~alkalotic), and for possible UTI (dirty UA). The patient is currently an unreliable historian -- confused and inattentive and tangential, prone to rambling about unrelated topics, interspersed with appropriate information. Her daughters know some, but not all historical details, and there are some sparse notes available from the outpatient provider (see chart). From what I can gather from the above sources, she has long-standing MG s/p thymectomy in [2124], and last immunosuppresion Tx was [2143]-[2145] with CellCept. She has never needed immunomodulatory treatment besides then. That course was started after an ICU/intubation crisis that occurred after she had her gallbladder removed at an OSH. She has not required intubation except for a series of intubation/extubation episodes related to that [2143] hospitalization. Her MG symptoms primarily involve ptosis and LE weakness, and are best in the morning and worst later in the day and with exercise. She was doing very well, off all MG medication from [2145] until roughly six months ago, which is the last time she considers she was in her USOH. Six months ago, she developed LE weakness and SOB with extended walks and R>L eyelid drooping as before, so her Neurologist restarted her Mestinon at 60mg q4h. This caused nausea, so they reduced it to 15mg q4h. This dose has been relatively ineffective, so just a day or two ago it was increased to 30mg, and then again to 45mg on the day of presentation (Sat AM clinic visit). At that time, she was still able to walk and talk normally per her daughters, although they did not witness this. Instead of going home from the clinic visit, she stopped at her daughter's workplace because she had to urinate and it was closer than home. Her daughter says she was weak and had difficulty walking to the bathroom, with her neck slumped forward. She was behaving oddly, confused, and slurring her speech. She slumped over before she made it to the toilet, and had an episode of incontinence on the floor. The daughter called the Neurologist to reprimand him for allowing her to leave in this condition, but he said she was behaving normally and walking fine in his office. He recommended that they take her to the ED, and later that they transfer to our hospital for better Neurologic evaluation. Prior to this, the patient denies any recent illness, although she got a flu vaccine sometime earlier in the month. She says she has been eating and drinking enough recently, but on her daughter's reminder agrees that sometimes she is afraid to eat and skips meals because food can be difficult to swallow. Of note, for the past few days, she has been complaining of a bat in her house which the daughters say is not there, and a mouse in her bed, also not there. She insisted on sleeping at a neighbor's house recently due to these ?hallucinations/delusions. At the OSH today, her daughter says the pt said there was a bug or spider crawling up the IV tubing towards her, which clearly was not there. The patient remains adamant for me that she saw all these things, and then tells me she has episodes at night recently where she feels like all her "hearing goes away" for a few minutes and she asks whether it may be related to anxiety. She says she is feeling much better now (IVF with KCl running in her IV), but still "I'm not myself." The daughters say the speech is less slurred, but still not normal. Review of Systems: negative except as above; difficult to obtain thorough ROS due to tangential/inattentive patient. No pain or paresthesias currently. Endorses weakness everywhere, nowhere in particular. Past Medical History: . HTN 2. HL 3. ?afib (not A/C, need to clarify afib hx which was only noted on OSH ED sheet) 4. [First Name9 (NamePattern2) ] [Last Name (un) ], as above; s/p thymectomy [2124]; antibody status unknown; Neurologist is Dr. [Last Name (STitle) 10653]; intubated in ICU [2143]; last on immunosuppression [2143]-[2145] (CellCept); back on Mestinon past 6mos, decreased [1-24] nausea, then recent up-titration [1-24] increased fatigue. 5. s/p cholecystectomy [2143] 6. Pt endorses history of recurrent UTI and outpatient abx from PCP for this; details are unclear Social History: Lives alone with brother in [Name2 (NI) ] above her. Independent in most/all activities. Retired. h/o learning disability, unclear details. Denies tob/EtOH/illicits. Family History: Daughter also with MG Physical Exam: Admission General Physical Examination: Vital signs: T: 97.9 F HR: 60s initially, 80s later in interview BP: 122/51 RR: 15-17 at rest; mid-20s, non-labored with prolonged speaking General: Lethargic, tangential/inattentive/confused, NAD. HEENT: Normocephalic and atraumatic. Thinned short white hair. No scleral icterus. Mucous membranes are moist. No lesions noted in oropharynx. Neck: Slumped forward, but supple, with no meningismus. Pulmonary: Lungs CTA bilaterally. Non-labored breathing, mildly tachypneic at times. Cardiac: RRR. Abdomen: Soft, non-tender, and non-distended, + normoactive bowel sounds. Extremities: Warm and well-perfused. Pitting edema up to knees bilaterally (pt unsure how new this is). 2+ radial, DP pulses bilaterally. Skin: no gross rashes or lesions noted. *************** Neurologic examination: Mental Status exam: Lethargic, but easily arousable. Oriented to person, year ([2138]? [2148]. No, it's 11 -- [2147]), month, date, not day of week "Friday" (it's Sat), season, city, location. Inattentive, tangential; cannot perform MOYbw (gets 0 or 1 in order, then goes forward). Speech was mildly slurred. Language is fluent with intact repetition and comprehension, normal prosody, and normal affect. There were no paraphasic errors. Naming is intact to low frequency objects. Able to follow both midline and appendicular commands with coaching. Memory - registers 3 objects and recalls [1-25] at 5 minutes. Calculation was impaired (answers five quarters in $1.75). There was no evidence of apraxia or neglect or ideomotor apraxia; the patient was able to reproduce and recognize hammering a nail and brushing teeth with both hands. -Cranial Nerves exam: I: Olfaction not tested. II: PERRL, 3.5 to 2mm and brisk. Visual fields are grossly full. III, IV, VI: EOMs full and conjugate. Frequent saccadic intrusions during smooth pursuits horizontally. Patient able to sustain up-gaze for over 60sec, but quits several times in-between and asks if she has to continue (no clear sag during compliance with task, however). V: Facial sensation intact and subjectively symmetric to light touch V1-V2-V3. VII: Bilateral ptosis, Right > left. Flattening of the Left NLF which her daughters agree is long-standing. Accordingly asymmetric facial elevation with smile (R>lt). Brow elevation is symmetric. Eye closure is strong and symmetric. VIII: Hard of hearing, but grossly intact to finger rub bilaterally. IX, X: Palate elevates symmetrically with phonation. [Doctor First Name 81]: [4-25] equal strength in trapezii bilaterally. XII: Tongue protrusion is midline. -Motor exam: No drift. No tremor or fasciculations were observed. No asterixis. Normal muscle bulk and tone, no flaccidity, hypertonicity, or spasticity noted. full power in nearly every muscle group tested, although exam required continuous coaching due to give-way weakness and lack of effort Delt Bic Tri WE FF FE IO \| IP Q Ham TA [Last Name (un) 938] Gastroc L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5- 5 5 5 5 5 5 4+ 5 5 5 5 5 Neck flexors -- poor effort, 3 to 4- out of 5, give-way Neck extensors -- 4+/5 (breakable), give-way Left-deltoid power after 40 pumps (patient kept stopping saying she is too tired, and I could only get her up to 40) was give-way, then on immediate re-test it was briefly [4-25], then partial give-way, then [4-25] at 45 degrees, then total give-way. -Sensory exam: No gross deficits to light touch, pinprick, cold sensation, or vibratory sensation in either distal lower extremity; possible mild L>r vibratory deficit. At most mild proprioceptive deficit (JPS) in the R>lt great toe. Eyes-closed Finger-to-nose testing revealed mild proprioceptive deficit on the left UE. Cortical sensory testing: Stereoagnosia and graphesthesia are preserved in the palms. -Reflex exam (left; right): Pec/delt (+++;+++) Biceps (++;++) Triceps (++;++) Brachioradialis (++;++) Quadriceps / patellar (++;++) Gastroc-soleus / achilles (+;+) Plantar response was withdrawal/?flexor bilaterally. -Coordination exam: Finger-nose-finger testing with no gross dysmetria. Heel-knee-shin testing with no dysmetria. No dysdiadochokinesia noted on rapid-alternating hand movements. -Gait: patient says she is too tired to get up; deferred. ---------------- DISCHARGE EXAM: Awake, alert, conversant, speech fluent, follows commands. PERRL, EOMI, no fatigability or diplopia, bilateral 5- deltoids, soft abdomen, gait stable. Pertinent Results: [2148-10-12*] 10:05PM WBC-5.2 RBC-4.06 HGB-12.0 HCT-35.3* MCV-87 MCH-29.6 MCHC-34.0 RDW-12.9 [2148-10-12] 10:05PM PLT COUNT-219 [2148-10-12] 10:05PM NEUTS-60.1 LYMPHS-30.3 MONOS-6.6 EOS-2.2 BASOS-0.8 [2148-10-12] 10:05PM PT-12.6 PTT-24.8 INR(PT)-1.1 [2148-10-12] 10:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [2148-10-12] 10:05PM URINE RBC-33* WBC-14* BACTERIA-FEW YEAST-NONE EPI-0 [2148-10-12] 10:05PM CK-MB-3 cTropnT-<0.01 [2148-10-12] 10:05PM ALT(SGPT)-13 AST(SGOT)-18 CK(CPK)-105 ALK PHOS-29* TOT BILI-0.6 [2148-10-12] 10:05PM GLUCOSE-106* UREA N-7 CREAT-0.8 SODIUM-147* POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-36* ANION GAP-10 [2148-10-13] 10:23AM TYPE-ART PO2-103 PCO2-81* PH-7.28* TOTAL CO2-40* BASE XS-8 INTUBATED-NOT INTUBA DISCHARGE LABS [2148-10-30]: WBC 21.8 (thought to be due to Prednisone therapy at 60mg), Hgb 10.9, Plt 882 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2148-10-30] 06:13 1131 30 1.0 139 4.4 97 28 18 Calcium 12.1 (being followed by Endocrinology) TSH 0.46 Urine Cultures NTD Blood Culture NTD Sputum Culture respiratory commensals Brief Hospital Course: 73 RHF with MG sx past 30+ years AChR Ab and +ve with markedly elevated binding, blocking and modulating AChR Ab in combination with markedly elevated anti-striated muscle Ab titre s/p thymectomy for thymoma on bx [2124], prior crisis following acute cholecystitis and emergent cholecystectomy with ICU admission requiring intubation for neuromuscular weakness in [2143] treated with plasmapheresis and complicated by CHF and pleural effusions presents with recent worsening of myasthenic symptoms on [10-12] from OSH with myasthenic crisis and confusion/disorientation/hallucinations likely secondary to hypercarbia. Baseline FVC 1.47 in [2140]. Patient had initially self-restarted pyridostigmine at 90mh qid herself 6 weeks prior after she had diffiuclty holding her head. She saw her o/p neurologist and he decreased this to 15mg qid (had not been on since [2145]) due to conerns for overmedication. He then followed her closely increasing to 30mg and then 45mg qid but patient decompensated precipitating admission. CXR was clear at OSH and due to hallucinations, she had a CT head which was normal. Patient was transferred to [Hospital1 18] for fiurther management. Patient was initially admitted to the neurology floor and started on IVIg on [10-13] at 0.4g/kg on [10-13] however, ABG showed hypercarbia pCO2 81 and she was transferred to the ICU for a trial of BiPAP. She had a low grade fever to 100.4F in the setting of her first IVIg dose. She had been treated for a presumptive UTI with Bactrim at this point. On initial assessment in the ICU on [10-14], patient had reduced sniff and cough, significant neck flexion weakness, dysarthria, mild bilateral ptosis and bilateral facial weakness in addition to fixed mild proximal UE>LE weakness which was fatiguable and mild disorientation. She initially did well on BiPAP with normalising CO2 on [10-14] and spent most of the day off NIV. Patient passed swallow assessment and was started on a soft diet and CXR showed a left base opacity concerning for possible pneumonia although given clinical stability and that she had no stigmata of infection, was afebrile, additional antibiotics were held. During the day, pCO2 rose to 50s but patient remained stable, however, she unfortunately vomited in the evening of [10-14] and refused 2x doses of pyrodostigmine and at this point was treated with nasal BiPAP out of concern for aspiration pCO2 worsened during the night and due to worsening pCO2 to 71 on the morning of [10-15], she was electively intubated and pyridostigmine was stopped. Immediately post intubation CXR showed R>L base opacities and in the setting of a fever to 101.1 she was started on IV meropenem and vancomycin for HAP. Neuromuscular were consulted post intubation and recommended plasmapheresis. She had a reaction to IVIg on [10-15] with tachycardia and hypotension and this settled after brief treatment with pressors. She had no further episodes. She proceeded with her first plasmapheresis session on [10-16]. The patient remained clinically stable, did not appear septic and had no further fevers and given that all cultures were negative, antibiotics were discontinued on [10-17]. She had very poor tidal volumes on the ventilator and restarted pyridostigmine 30mg Q4H on [10-17] however this was stopped due to greatly increased oral secretions on [10-21]. She was started on steroids at prednisone 60mg qd on [10-21] due to continued poor tidal volumes and she had no untoward sequelae from this. Her strength improved but her respiratory functioning and NIFs lagged behind this. Patient had a frankly blody urine in her catheter which was felt to be trauimatic and resolved on changing her catheter. UA was positive but UCx was negative and no treatment was instituted. Patient had transient hypotensive episodes with her plasmapheresis which improved with IV fluid boluses and latterly the decision was made to hold her metoprolol before plasmapheresis days which improved this. She was aslo noted to have hypercalcemia to 11.4 and PTH was normal. Endocrine were consulted and followed her calcium level and this was felt to be secondary to mild hyperparathyroidism in the setting of a calcium challenge following calcium gluconate infusion with plasmapheresis and this was stopped on further sessions and her calcium improved but did not normalise. She was restarted on vit D as she was vit D deficient and will follow-up with endocrine as an o/p. She slowly improved with better tidal volumes and pyridostimine was restarted at a lower dose [10-23] to augment respiratory function in preparation for extubation. She remained stable without any complications from intubation and had an uneventful last plasmapheresis session on [10-25]. Strength and NIFs improved such that she was able to be extubated on [10-26]. She did well on face tent following extubation and latterly was saturating well without oxygen although she still had oral secretions which were manageable by the patient. After discussion with neuromuscular team she was restarted on mycophenolate 500 mg [Hospital1 ] on [10-29] for 1 week, and then the mycophenolate should be increased to 1000mg [Hospital1 ] thereafter. She conditionally passed speech and swallow and was started on thin liquids with pureed solids, but she did still have some coughing up of residuals so the NGT was left in with Speech Therapy continuing to reassess every day or every other day. Vitals were stable and NIF was -24 FVC was 0.9L and was transferred to the stepdown unit on [10-28]. She remained clinically stable and improving with NIFs and FVCs rising steadily. We rechecked a CT Chest to look for thymoma which shows no infiltrates but the final read is pending. We rechecked a UA and urine culture prior to discharge with the result thus far showing a contaminated sample not consistent with a UTI. TRANSITIONAL CARE ISSUES: [ ] Mycophenolate - Please increase mycophenolate to 1000 mg [Hospital1 ] after 5 more days on the 500mg [Hospital1 ] dosing. [ ] Please f/u the CT Chest and UA/Urine Culture. [ ] Please follow the patient's NIFs and FVCs to monitor for improvement. [ ] Speech Therapy - please have Speech evaluate her frequently in anticipation of discontinuing the NG tube. She is not overtly aspirating but occasionally coughs up residuals from her purees. [ ] Please encourage her to speak with her primary neurologist and primary care physician to setup followup appointments at her convenience within 4-6 weeks from her hospitalization. [ ] Please follow her fingerstick glucose and start an insulin sliding scale if needed. Medications on Admission: 1. Mestinon (pyridostigmine) 15mg --> 30mg --> 45mg PO q4hrs (doses increased once each over the past two days; only one dose of 45mg was given today in OSH ED by family; pt had been cutting her pills into 1/4s, so the aforementioned doses to her are approximate -- equivalent to one, two, or three of her cut-up pieces of pill). 2. doxepin 10mg qhs for sleep (she says she took ??4 tabs of this every night up until recently, when her MD reduced it to 1 3. omeprazole 20mg [Hospital1 ] 4. colace 100mg [Hospital1 ] 5. senna [Hospital1 ] 6. Fosamax 70mg qWk 7. metoprolol 50mg [Hospital1 ] 8. amlodipine 5mg daily 9. vitD [Hospital1 ]; MVI daily * pt thinks one of these two BP meds were stopped recently Discharge Medications: 1. alendronate 70 mg Tablet [Hospital1 ]: One (1) Tablet PO QFRI (every Friday). 2. prednisone 20 mg Tablet [Hospital1 ]: Three (3) Tablet PO DAILY (Daily). 3. pyridostigmine bromide 60 mg/5 mL Syrup [Hospital1 ]: One (1) PO Q6H (every 6 hours). 4. metoprolol tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 5. cholecalciferol (vitamin D3) 1,000 unit Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. simethicone 80 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for flatulence. 7. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 8. polyethylene glycol 3350 17 gram/dose Powder [Hospital1 ]: One (1) PO DAILY (Daily). 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Ondansetron 4 mg IV Q8H:PRN nausea 11. docusate sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: One (1) PO BID (2 times a day). 12. senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution [Last Name (STitle) ]: One (1) PO BID (2 times a day) for 10 doses. 15. mycophenolate mofetil 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO twice a day: after the once daily dosing is complete. 16. acetaminophen 650 mg/20.3 mL Solution [Last Name (STitle) ]: One (1) PO Q6H (every 6 hours) as needed for fever. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Primary Diagnosis: Myasthenic crisis Secondary Diagnosis: Hypertension, Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neurologic: Awake, alert, conversant, can count to 22 in one breath, NIF -34/VC 900cc. Discharge Instructions: Dear Ms. [Known lastname 91475], You were hospitalized due to your symptoms of difficulty breathing and confusion. This was due to a MYASTHENIC CRISIS, an exacerbation of your MYASTHENIA [Last Name (un) ] with resulted in an abnormally high level of carbon dioxide in your blood stream (HYPERCAPNEA). You required intubation and care provided in an intensive care unit. For treatment of your myasthenic crisis, you required both plasmapheresis and IVIG to remove the culprit antibodies that likely were causing the exacerbation. You were restarted on a medication called CellCept (Mycophenolate Mofetil) which will help reduce your risk of developing further myasthenic crises. You will take the following medications: 1. You will take MYCOPHENOLATE MOFETIL (CELLCEPT) 500 MG by mouth TWICE DAILY for 5 more days, and then 1000 MG by mouth TWICE DAILY afterwards as directed by the [Hospital 18] [Hospital 7817] clinic (Drs. [Last Name (STitle) 1206] and [Name5 (PTitle) ]). 2. You will take PREDNISONE 60 MG by mouth DAILY for your myasthenia [Last Name (un) 2902]. 3. You will take PYRIDOSTIGMINE 15 MG by mouth EVERY 6 HOURS for treatment of your symptoms of myasthenia [Last Name (un) 2902]. 4. You will take VITAMIN D 1000 MG by mouth TWICE DAILY until changed by the [Hospital1 18] Endocrinology physicians. Please followup with your primary neurologist Dr. [Last Name (STitle) 70173], [Hospital1 18] Endocrinology, and the [Hospital1 18] Neuromuscular physicians as listed below. If you experience any of the following symptoms, please seek medical attention. It was a pleasure providing you with medical care during this hospitalization. Followup Instructions: Please keep the following appointments: 1. Neurology/Neuromuscular follow up DRS. [Name5 (PTitle) ] & [Doctor Last Name 37664] on [2148-12-19] at 11:30AM Phone:[Telephone/Fax (1) 2846] 2. Primary Neurology Followup DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], please call him at [Telephone/Fax (1) 91476] per his instruction to set up a followup appointment at your earliest convenience, preferably within 4-6 weeks from your hospital discharge 3. Endocrinology follow up [First Name11 (Name Pattern1) 1409] [Last Name (NamePattern4) 91212], MD on [2148-11-6] at 3:20PM [Hospital1 18] [Hospital Ward Name 516], [Hospital Ward Name 23] Building [Location (un) ] Phone:[Telephone/Fax (1) 1803] Fax: [Telephone/Fax (1) 3541] * Please contact your PCP to have your medical records faxed over before your appointment. 4. Please call your primary care physician to schedule [Name Initial (PRE) ] followup appointment within 4-6 weeks from your date of discharge from the hospital. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43] MD [MD Number(1) 2107]	[ "358.01", "401.9", "518.81", "V03.82", "733.00", "599.0", "276.1", "276.52", "276.3", "276.8", "E934.6", "348.30", "458.29", "272.4", "733.90", "785.0" ]	icd9cm	[ [ [] ] ]	[ "99.55", "96.72", "38.91", "38.97", "96.04", "99.14", "99.71", "93.90", "96.6" ]	icd9pcs	[ [ [] ] ]	20920, 21017	11703, 17650	346, 521	21148, 21148	10469, 11680	23109, 24300	5880, 5903		19178, 20897		21038, 21038		18426, 19155			21386, 23086								5918, 5936							10298, 10450							5959, 6728					4866, 5053				279, 308			17676, 18400						549, 4847			21096, 21127			21057, 21075			21163, 21362		6753, 10282				5075, 5676	5692, 5864
40,059	110,385	41619	Discharge summary	report	Admission Date: [2138-10-6] Discharge Date: [2138-11-3] Date of Birth: [2062-3-23] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4616] Chief Complaint: Confusion Major Surgical or Invasive Procedure: Left Craniotomy for resection of brain mass One CyberKnife treatment ([2138-11-3]) History of Present Illness: This is a 76 year old Creole speaking man who was found wondering around his senior center with new confusion. Family saw him last week and he was his normal self. He was taken by EMS to LMH and CT head showed a large Left frontal cystic lesion and a small area of edema in the left cerebellum. CXR showed a 5 cm left peri-hilar mass. He was given 10 mg of Decadron and was transferred to [Hospital1 18] for further management. Past Medical History: HTN, prostate CA s/p seed treatment and chemotherapy in [2134] with a urologist at [Hospital3 ], GERD Social History: He is a right handed Creole man. His family reports that he was a marine and worked in metal welding. He has a long history of Tobacco use 1ppd but now smoke about 10 cigarettes daily. Family History: unknown Physical Exam: Upon Admission: PHYSICAL EXAM: O: T:99.7 102 137/79 18 99% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:[4-13] EOMs intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, interpretation by family. Orientation: Oriented to person, hospital, month and day Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4to3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-15] throughout. Mild right pronator drift Coordination: normal on finger-nose-finger. At transfer, he speaks French-Creole, is oriented to self, follows commands readily, PERRL 4-2mm, Incision is clean/dry/intact. No drift, no clonus, reflexes are 2+ throughout. tongue is at midline. . DISCHARGE EXAM: VS: 98.6, 122/70, 90, 20, 95% RA, BG 103-241 General: Elderly man in NAD, comfortable, appropriate HEENT: Longitudinal scar over the left frontal area. PERRL, sclerae anicteric, MMM, OP clear Neck: Supple. Lungs: CTA bilat, no r/rh/wh Heart: RRR, nml S1-S2, no MRG Abdomen: +BS, soft/NT/ND, no palpable masses or HSM Extrem: WWP, no c/c/e Skin: no concerning rashes or lesions Neuro: grossly non-focal Pertinent Results: [2138-10-6] 06:05PM URINE RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE EPI-<1 [2138-10-6] 06:35PM PT-13.3 PTT-29.7 INR(PT)-1.1 [2138-10-28] LENIs - negative for DVT DISCHARGE LABS: [2138-11-3] 07:55AM BLOOD WBC-8.9 RBC-4.30* Hgb-12.2* Hct-37.1* MCV-86 MCH-28.3 MCHC-32.8 RDW-15.9* Plt Ct-339 [2138-11-3] 07:55AM BLOOD Glucose-87 UreaN-15 Creat-0.7 Na-136 K-4.3 Cl-95* HCO3-32 AnGap-13 [2138-11-3] 07:55AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.0 MRI brain [2138-10-8] 1. Left frontal and left cerebellar hemispheric enhancing lesions demonstrating marked slow diffusion. In the setting of the findings on the recent chest CT, these intracranial lesions would be most suggestive of metastases from primary small cell carcinoma of the lung. 2. Additional round focus of slow diffusion and relatively [Name2 (NI) 15403] [Name (NI) 90467] in the medial left temporal lobe, without convincing enhancement. Although a focal infarct, particularly embolic, is not entirely excluded, given the signal characteristics similar to the other lesions, above, this is concerning for a third metastatic deposit. 3. Relatively T1-hypointense regional bone marrow signal; while this may simply represent red marrow reconversion in response to anemia or systemic treatment, this finding should be correlated with clinical and laboratory data. CT torso:[2138-10-7] 1. Large 4.4-cm left perihilar mass concerning for primary lung cancer. There is associated left hilar and mediastinal lymphadenopathy. 2. Severe right hydronephrosis with cortical atrophy and a 9-mm calculus in the proximal right ureter. This represents a chronic process, likely secondary to UPJ obstruction from a crossing vessel. 3. No evidence of osseous metastatic disease CT head [10-10]: expected postoperative changes, moderate pneumocephalus. no hemorrhage MRI Brain with and without contrast [10-11]: expected postoperative changes with good resection of left frontal lesion. No acute infarcts. stable left cerebellar lesion. Lower Extremity Dopplers [10-13]: No right- or left-sided lower extremity DVT. Lower Extremity Dopplers [10-20]: No DVT of the bilateral lower extremity. [2138-10-25] Abd XR - Nonspecific air-fluid levels within non-distended loops of small and large bowel. Although nonspecific, this could potentially be related to gastroenteritis, considering the provided clinical history. 18 mm and 3 mm diameter calcifications located in the right abdomen may be related to renal and ureteral calculi considering presence of right ureteral calculus on CT of [2138-10-7]. Brief Hospital Course: This is a 76 year old Croele-speaking man who was found confused wandering around his Senior Center, and was taken to an OSH, where CT showed multiple brain lesions including a large left frontal lesion and a small area of edema in the left cerebellum. # Brain Mets: Originally admitted to neurosurgery under the care of Dr. [Last Name (STitle) 65817]. He was getting Q4 hr neuro checks on the floor. MRI brain was ordered as was a CT torso. He was on Keppra. Decadron was held for possible lymphoma. He was started on Bactrim for a slightly positive UA. Neuro-onc and neuro-radation services were consulted. MRI revealed a large Left frontal tumor and a small cerebellar mass. He had an fMRI and was taken to the OR with Dr. [Last Name (STitle) ] on [2138-10-10]. The patient was extubated in the OR. Immediately post-operative the patient was opening his eyes to voice and moving all extremities. There was some soft tissue edema noted above the left ear and an Ace wrap was applied for 1 hour. The patient was started on Decadron 4 mg every 6 hours. Keppra was continued. Ancef was continued post operativly for three doses. The patient was brought to the SICU for recovery and a post operative Head Ct was performed which was consistent with expected post-operative change with some pneumocephalus. On [2138-10-11], a MRI with and without constrast was performed which was consistent with expected post-op changes. He was deemed fit for transfer to the floor and PT and OT consults were ordered. The patient was then transferred to the oncology service for cyberknife therapy. # Lung Mass: CT chest showing 4.4cm left peri-hilar mass concerning for primary lung cancer. Hematology-oncology consulted and wanted to see him as an outpatient after final pathology from brain lesion was confirmed. Discharged with outpatient follow up. # Right Renal Calculus: Urology consult was called for right renal calculus. Imaging indicates that this is a longstanding process for him and recommended nonurgent follow up as an outpatient. Urinalysis and urine culture were sent [10-7] and urine culture was negative. During his hospital stay he completed a 7 day course of Bactrim for WBCs in urine and altered mental status suspiscious for UTI. Discharged with outpatient follow up with urology. # Hyponatremia: On [10-14] the patient's serum Na was 130 and so he was placed on a fluid restriction and started on salt tabs. Patient was continued on fluid restriction on day of discharge, and salt tabs were discontinued. Labs to be rechecked 1 week post discharge. # Physical Therapy and Placement: He was seen and evaluated by physical therapy and occupational therapy who felt that he would benefit from rehab. He remained afebrile and stable during his course on the floor. Screening lenis continued to be done Q7 days and were negative as of [10-20]. # Goals of Care: Multiple family meetings occurred with social work, case management and the neurosurgery team. The family stated that they could not provide 24 hour supervision at home and evaluation for placement was initiated. On [10-28] patient had a LENIs for surveillance which was essentially negative. OMED was consulted to management while receiving cyberknife treatment. On [10-30] he underwent mapping for his cyberknife treatment and was transferred to OMED in stable condition. He completed 1 cycle of cyberknife on day of discharge and tolerated the procedure well. He will have 4 more treatments. TRANSITION OF CARE: -continuation of Cyberknife treatment as an outpatient. To be completed on [2138-11-5]. -continue 1L fluid restriction for treatment of hyponatremia. Hyponatremia has been improving with fluid restriction. Would re-evaluate the need for fluid restriction in the near future. Re-check sodium within 1 week from discharge. Medications on Admission: Norvasc 2.5 QD, Flomax 0.4mg QD, HCTZ 25 QD, Vit D 1000 Units QD, Prilosec 20 QD, APAP Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): Hold for SBP < 100. 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 9. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/ha. 13. insulin regular human 100 unit/mL Solution Sig: Per insulin sliding scale units Injection ASDIR (AS DIRECTED): Please see the attached sheet for the patient's regular insulin sliding scale. Discharge Disposition: Extended Care Facility: [Location (un) 582] of [Location (un) 583] Discharge Diagnosis: Brain Tumor Lung Mass Large Kidney stone with hydronephrosis Hyponatremia Dysphagia Malnutrition hyperkalemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known firstname 90468], It was a pleasure taking care of you during your stay at [Hospital1 18]. You presented to [Hospital1 18] for treatment of metastatic lung cancer to your brain. You had brain surgery followed by 1 day of CyberKnife therapy. You will continue to have CyberKnife therapy for another 4 treatments while you are outside fo the hospital. The following changes were made to your medication: ADDED: -Bisacodyl 10mg po daily -docusate sodium 100mg by mouth daily -Dexamethasone 2mg orally twice a day -Insulin sliding scale -Levetiracetam 750mg by mouth twice a day -Ondansetron 4mg po every 8 hours as needed for nausea -senna 1 tab by mouth daily -Vitamin D 800units by mouth daily -Trazadone 25mg by mouth as needed for insomnia -acetaminophen 325-650mg every 6 hours as needed for pain CHANGED: - Increased your dose of norvasc from 2.5mg daily to 5mg daily by mouth STOPPED: none We are in the process of arranging follow-up. The patient will need to have follow-up in the following clinics: 1. Hematology-Oncology Thoracics Division- please call ([2138] to arrange an appointment for a new patient at the next earliest available new patient appointment. The clinic is located in [Hospital Ward Name 23] Clinical Center on the [Location (un) 24]. 2. Brain [Hospital 341] Clinic- please call ([Telephone/Fax (1) 27543] to arrange an appointment for 1-2 weeks after discharge. You will also need to follow-up with the neurosurgeons during this appointment. The clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. 3. The patient will also need to follow-up with Urology in [1-12] weeks from discharge for hydronephrosis and right kidney stone. To make an appointment, their number is [Telephone/Fax (1) 164]. Followup Instructions: We are in the process of arranging follow-up. The patient will need to have follow-up in the following clinics: 1. Hematology-Oncology Thoracics Division- please call ([2138] to arrange an appointment for a new patient at the next earliest available new patient appointment. The clinic is located in [Hospital Ward Name 23] Clinical Center on the [Location (un) 24]. 2. Brain [Hospital 341] Clinic- You will be contact[Name (NI) ] with this appointment after you complete CyberKnife Treatment. Please call ([Telephone/Fax (1) 27543] if you need to change this appointment date. The clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. 3. The patient will also need to follow-up with Urology in [1-12] weeks from discharge for hydronephrosis and right kidney stone. To make an appointment, their number is [Telephone/Fax (1) 164]. . Patient will need to have 3 more CyberKnife treatments for which he will need to return to [Hospital1 18] ([Location (un) ]. [Location (un) 86]) to the [Hospital Ward Name 332] Basement ([Hospital Ward Name 516]) for treatment: Tuesday, [2138-11-4] at 9:15, Wednesday [2138-11-5] at 9:15, and Thursday [2138-11-6] at 10:15.	[ "V10.46", "V58.65", "198.3", "786.39", "530.81", "162.2", "591", "V06.6", "593.4", "401.9", "305.1", "348.5", "780.09", "196.1" ]	icd9cm	[ [ [] ] ]	[ "93.59", "92.29", "01.59", "02.12" ]	icd9pcs	[ [ [] ] ]	10709, 10786	5440, 9296	314, 403	10940, 10940	2808, 2982	13022, 14340	1218, 1227		9434, 10686		10807, 10919		9322, 9411			11122, 12999		2998, 5417						1273, 1411							2385, 2789																265, 276									431, 865	1566, 2369						1258, 1258		10955, 11098						887, 999	1015, 1202
22,896	170,020	50940	Discharge summary	report	Admission Date: [2144-1-15] Discharge Date: [2144-1-19] Date of Birth: [2087-5-17] Sex: F Service: CARDIOTHORACIC Allergies: Nifedipine / Iodine; Iodine Containing / Dicloxacillin / Azithromycin / Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion, fatigue Major Surgical or Invasive Procedure: s/p redo sternotomy, MVrepair (#28mm Rigid saddle ring) History of Present Illness: 56 year old female s/p CABG'[35] presented with shortness of breath secondary to Mitral Regurgitation. She was evaluated for redo sternotomy/ Mitral valve repair with Dr.[Last Name (STitle) ]. Past Medical History: s/p OPCABG x1 '[35] (LIma-LAD) s/p right femoral pseudoaneurysm repair '[35] CAD HTN hypercholesterolemia anemia asthma allergic rhinitis depression osteoarthritis uterine myomectomy knee surgery Social History: works as a project manager denies tobacco lives with mother [Name (NI) ]. ETOH Family History: noncontributory Physical Exam: General: NAD VSS Skin: well healed sternotmy scar HEENT:AT/NC, carotids:2+ CHEST: CTA (B) CVS:RRR +sem ABD:benign EXT: NO cyanosis/clubbing/edema Pertinent Results: [2144-1-15] 02:02PM BLOOD WBC-11.5* RBC-2.67# Hgb-7.9# Hct-22.6# MCV-84 MCH-29.5 MCHC-35.0 RDW-14.7 Plt Ct-139# [2144-1-17] 06:45AM BLOOD WBC-13.9* RBC-3.31* Hgb-10.1* Hct-28.6* MCV-87 MCH-30.6 MCHC-35.3* RDW-14.9 Plt Ct-107* [2144-1-15] 02:02PM BLOOD PT-16.5* PTT-31.1 INR(PT)-1.5* [2144-1-16] 03:35AM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2* [2144-1-17] 06:45AM BLOOD Glucose-129* UreaN-12 Creat-1.0 Na-136 K-5.5* Cl-104 HCO3-26 AnGap-12 [Known lastname ],[Known firstname ] [Age over 90 105868] F 56 [2087-5-17] Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [2144-1-15] 4:58 PM [Last Name (LF) ],[First Name3 (LF) ] R. CSURG CSRU [2144-1-15] SCHED CHEST PORT. LINE PLACEMENT Clip # [Clip Number (Radiology) 105869] Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax. [Hospital 93] MEDICAL CONDITION: 56 year old woman with redo MVR REASON FOR THIS EXAMINATION: Pleural effusion, pulmonary edema, tamponade, pneumothorax. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14777] [Numeric Identifier 72690] with issues. Pt will be in CSRU in 120 mins. Final Report REASON FOR EXAM: Assess line placement. Patient S/P redo MVR. Comparison is made with preop evaluation, [1-9]. ET tube is 3.9 cm above the carina. NG tube tip is out of view below the diaphragm. Swan-Ganz catheter tip is in the right pulmonary artery. Sternal wires are aligned. Mediastinal and chest tubes are in place. There is no pneumothorax. There is no overt CHF. There is no evidence of pneumothorax. Bibasilar opacities are likely atelectasis. MVR is in place. jr DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: [First Name8 (NamePattern2) ] [2144-1-16] 9:23 PM Imaging Lab Brief Hospital Course: [1-15] Ms.[Known lastname ] was taken to the operating room and underwent redosternotomy Mitral valve repair with a # 28mm Rigid saddle ring. Please refer to Dr[Last Name (STitle) 105870] operative report for further details. Pt intubated and sedated transferred to CVICU hemodynamically stable. She awoke neurologically intact and was extubated in a timely fashion. All lines and drains were discontinued with appropriate criteria met.POD#1 She was transferred to the step down unit for further telemetry monitoring. Beta-blocker, ACE-Inhibitor, aspirin, and statin were initiated. The remainder of her postoperative course was essentially uneventful. She continued to progress and was ready for discharge on POD# 4. All follow up appointments were advised. Medications on Admission: Lipitor 80(1) Lasix 20(1) Lisinopril 40(2) Toprol XL 200(1) asa 325(1) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: S/p redo sternotomy, MVrepair (#28mm Rigid saddle ring) CAD s/p LCx stent '[33] s/p OPCAB (Lima->LAD)'[35] HTN hypercholesterolema anemia asthma allergic rhinitis depression s/p right femoral pseudoanyrsm repair'[35] uterine myomectomy knee surgery Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) ], cardiology, in 1 week please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2144-1-19]	[ "V45.82", "311", "401.9", "493.90", "285.9", "272.0", "V45.81", "424.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "35.12", "39.61" ]	icd9pcs	[ [ [] ] ]	5181, 5239	3238, 4011	379, 437	5544, 5551	1209, 2077	6063, 6383	1010, 1027		4133, 5158	2117, 2149	5260, 5523		4037, 4110			5575, 6040								1042, 1190																							311, 341	2181, 3215								465, 667															689, 894	910, 994
42,340	110,126	34002	Discharge summary	report	Admission Date: [2148-11-29] Discharge Date: [2148-12-3] Date of Birth: [2101-3-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: S/p fall from horse Major Surgical or Invasive Procedure: None History of Present Illness: 47 y/o M s/p fall off horse onto fence Past Medical History: Hyperlipidemia, Gout Family History: Noncontributory Physical Exam: Upon admission: T:98.9 BP:160/91 HR:92 RR:18 O2Sat: 100% 2L NC General: Appear comfortable. HEENT: Pupils:PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Spine: Generalized tenderness throughout his back extending laterally to the right. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-22] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally No clonus Good rectal tone Pertinent Results: [2148-11-29] 04:39PM WBC-11.0 RBC-4.54* HGB-14.0 HCT-37.8* MCV-83 MCH-30.7 MCHC-36.9* RDW-14.3 [2148-11-29] 04:39PM PLT COUNT-202 [2148-11-29] 04:39PM PT-13.1 PTT-19.1* INR(PT)-1.1 [2148-11-29] 04:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2148-11-29] 09:30PM GLUCOSE-137* UREA N-14 CREAT-1.0 SODIUM-142 POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-22 ANION GAP-14 [2148-11-29] CT CHEST W/CONTRAST; CT ABD W&W/O C; CT PELVIS W/CONTRAST IMPRESSION: 1. Right lower lobe consolidation/contusion with small to moderate sized right hemothorax. 2. Non-enhancing bilateral hyperdense adrenal nodules possibly representing small adrenal hematomas. A follow up MRI can be performed to assess for interval change and full characterization. 3. Right psoas intramuscular hematoma. No evidence of active arterial or venous extravasation. 4. Eccentric wall thickening of the aorta and its infrarenal portion which is likely atherosclerotic, but a tiny intramural hematoma is not excluded. 5. Multiple right-sided rib fractures, transverse processes and spinous fractures as described above. Brief Hospital Course: 47 y/o transferred from referring hospital after falling off horse onto fence. There imaging showed no fractures on CXR or pelvis, normal head and c-spine CT. Torso CT demonstrated small right hemothorax, right [4-29] rib fracture, right T8-T9 transverse process fracture, right L1-L5 transverse process fracture, T6-T11 spinous process fracture, ? fracture right T4 lamina and right T11 lamina, right psoas muscle hematoma. Repeat CT ([11-29])here showed no lamina fracture, psoas hematoma w/no extravasation, and aorta w/atherosclerotic calcification. Hematocrits remained stable. Patient was evaluated by Neurosurgery; no surgical intervention warranted. He was transitioned from IV to PO pain medications with good pain control and was able to ambulate and was cleared by physical therapy. He was discharged to home with specific instructions for follow up. Medications on Admission: indomethacin 50 tid, lipitor 40 Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Three (3) Adhesive Patch, Medicated Topical Q24 HRS () as needed for pain: Apply to right thorax as directed. Disp:90 Adhesive Patch, Medicated(s) Refills:0 7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). Disp:90 Tablet Sustained Release 12 hr(s) Refills:0 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for breaktrhough pain. Disp:90 Tablet(s) Refills:0 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Fall Small right pneumothorax Right rib fractures [4-29] Right transverse process and lumbar fractures (T8-T9; L1-L5) Spinous process fractures T6-T11 Right psoas muscle hematoma Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: It is importnat that you cough, deep breathe and use the incentive spirometer at least every hour while you are awake to avoid complications from rib fractures, e.g. pneumonia. Return to the Emergency room if you develop feers, chills, productive cough, pain not relieved by your by the pain medication when taken as prescribed, shortness of breath, chest pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Take your pain medication as prescribed. Continue with the stool softeners and laxatives in order to avoid constipation. Followup Instructions: Follow up in [12-20] weeks with Dr. [Last Name (STitle) ], Trauma Surgery for evaluation of your rib fractures, right pneumothorax and psoas muscle hematoma. Call [Telephone/Fax (1) 6429] for an appointment and to make an appointment for a chest xray which needs to be done on same day right before you see Dr. [Last Name (STitle) ]. Completed by:[2148-12-6]	[ "860.4", "805.4", "805.2", "868.01", "807.08", "E884.9", "959.12" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5166, 5172	2981, 3855	334, 341	5403, 5484	1808, 2958	6098, 6479	469, 486		3937, 5143		5193, 5382		3881, 3914			5508, 6075								501, 503																							275, 296									369, 409	1093, 1789						517, 841		856, 1077						431, 453
4,828	115,113	19074	Discharge summary	report	Admission Date: [2163-8-30] Discharge Date: [2163-9-2] Date of Birth: [2137-10-22] Sex: M Service: MED Allergies: Penicillins Attending:[First Name3 (LF) 3326] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 25 yo male with a hx of AML s/p failed BMT x2 admitted for worsening shortness of breath x 1 day. Pt was recently d/c from [Hospital1 18] for shortness of breath and pleuritic chest pain, productive cough with sputum, thrombocytopenia, and low-grade temperature. He was treated for community acquired pneumonia and atypical pneumonia w/ vancomycin, cefepime, levofloxacin, caspofungin, and pentamidine. He was d/c to home on vanco/levo/caspofungin. All culture data in the hospital was negative. Pt was also started on serevent w/ symptomatic improvement. He had been improving until [8-31] when his previous symptoms returned acutely and worsened throughout the day. Pt was seen in clinic [8-29] where his white blood cell count had increased from 8.0 to 26.0. Past Medical History: AML Aspergillosis HTN [2-21] cyclosporine Social History: Pt's family is quite supportive of his condition. He has a girlfriend. [Name (NI) ] does not smoke, drink alcohol or do drugs. He is much less physically active than in the past Family History: No cancer/leukemia. Physical Exam: Gen - skin dry and pale, cachectic, mild distress HEENT - PERRL dry mucus membranes Neck - no JVD Chest - rhonchi b/l . CV - tachy, Normal S1/S2 no murmurs, rubs, or gallops Pulses - + pulsus paradoxus Abd - Soft, nontender, nondistended, with normoactive bowel sounds. No HSM. Extr - 2+ bipedal edema to ankles. Neuro - Alert and oriented x 3, cranial nerves [3-3] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact. Pertinent Results: [2163-8-30] 08:50PM GLUCOSE-157* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-5.9* CHLORIDE-104 TOTAL CO2-19* ANION GAP-18 [2163-8-30] 08:50PM ALT(SGPT)-55* AST(SGOT)-29 LD(LDH)-506* CK(CPK)-40 AMYLASE-20 TOT BILI-0.6 [2163-8-30] 08:50PM LIPASE-12 [2163-8-30] 08:50PM CK-MB-NotDone cTropnT-<0.01 [2163-8-30] 08:50PM CALCIUM-9.1 PHOSPHATE-3.8 MAGNESIUM-2.1 [2163-8-30] 08:50PM WBC-32.7# RBC-3.37# HGB-10.1# HCT-28.6 MCV-85 MCH-30.0 MCHC-35.3* RDW-14.2 [2163-8-30] 08:50PM NEUTS-7* BANDS-1 LYMPHS-10* MONOS-25* EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 BLASTS-55* [2163-8-30] 08:50PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [2163-8-30] 08:50PM PLT SMR-RARE PLT COUNT-14# LPLT-2+ [2163-8-30] 08:50PM PT-14.2 PTT-39.9* INR(PT)-1.3 [2163-8-30] 11:57AM WBC-18.6* RBC-2.64* HGB-8.0* HCT-24.0* MCV-91 MCH-30.4 MCHC-33.5 RDW-14.6 [2163-8-30] 11:57AM PLT COUNT-60# [2163-8-30] 11:57AM GRAN CT-1420 [2163-8-29] 04:54PM PLT COUNT-34* [2163-8-29] 11:58AM GLUCOSE-105 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [2163-8-29] 11:58AM ALT(SGPT)-72* AST(SGOT)-28 LD(LDH)-218 ALK PHOS-72 TOT BILI-0.4 DIR BILI-0.2 INDIR BIL-0.2 [2163-8-29] 11:58AM ALBUMIN-3.6 CALCIUM-8.7 MAGNESIUM-1.4* [2163-8-29] 11:58AM WBC-28.4# RBC-3.38 HGB-10.2* HCT-28.9* MCV-86 MCH-30.1 MCHC-35.3* RDW-13.9 [2163-8-29] 11:58AM NEUTS-5* BANDS-3 LYMPHS-20 MONOS-21* EOS-0 BASOS-0 ATYPS-4* METAS-3* MYELOS-0 BLASTS-44* [2163-8-29] 11:58AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL FRAGMENT-OCCASIONAL [2163-8-29] 11:58AM PLT COUNT-<5*# Brief Hospital Course: 25 yo male w/ refractory AML, now in blast crisis tachycardic w/ large pericardial effusion Blast crisis - bone marrow transplant attending was following the patient. It was deemed that his condition was not amenable to any treatment at this time. He was given hydroxyurea as a palliative measure. Cadiac Tamponade - was thought to arrive most likely source is a malignant effusion from tumor on the pericardium. The pericardium was likely fibrosed and treatment would involve pericardial stripping which was deemed too invasive for the patient and the family at the point of his disease. Palliative pericardiocentesis was offered to the patient but he declined. Dyspnea - He has several etiologies for his shortness of breath. leukostasis vs aspergillus vs pna. The patient was continued on levofloxacion, vancomycin, bactrim, caspofungin, and acyclovir. These were eventually dicharged as he was made palliative care. He was also maintained on Bipap in order to keep him comfortable from a respiratory standpoint. Pain control - The patient was eventually placed on a morphine drip as his code status was DNR/DNI. He was made comfort measures and passed away surrounded by his family. Discharge Disposition: Expired Discharge Diagnosis: AML Discharge Condition: deceased	[ "518.81", "996.85", "287.5", "486", "205.00", "E878.0", "285.9", "423.8" ]	icd9cm	[ [ [] ] ]	[ "99.05", "99.04", "93.90" ]	icd9pcs	[ [ [] ] ]	4955, 4964	3732, 4932	271, 277	5011, 5022	1888, 3709		1373, 1394				4985, 4990													1409, 1869																							228, 233									305, 1089															1111, 1158	1174, 1357
5,266	134,352	16662+16663	Discharge summary	report+report	Admission Date: [2159-11-30] Discharge Date: [2159-12-1] Date of Birth: Sex: F Service: Hepatobiliary Surgery Service REASON FOR ADMISSION: Jaundice and bile ascites. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 47171] is a 56-year-old Caucasian female with a past medical history significant for hypothyroidism and a large hepatic cyst. She was taken to underwent appears to be cystectomy of this large hepatic cyst and marsupialization of the lesion. Postoperatively, she returned to the hospital 72 hours later where she was found to have significant jaundice and ascites. An ERCP was attempted and paracentesis was performed demonstrating a large amount of bile and peritoneal fluid. placed. Despite this, she accumulated the ascites at a short period of time, and a HIDA scan was performed which demonstrated a bile duct obstruction as well as frank extravasation of the contrast material. She underwent a re-ERCP with replacement of a stent as well as redrainage of the ascites fluid. Despite this, she continued to accumulate the ascites fluid, and remained jaundice. At this time, she is transferred to [Hospital1 ] Hospital for further management. PAST MEDICAL HISTORY: 1. Hepatic cystectomy. 2. Hypothyroidism. 3. Atrial fibrillation as a postoperative complication of above. 4. Clostridium difficile colitis as a complication of above. 5. Hypertension. CURRENT MEDICATIONS ON TRANSFER: 1. Aldactone. 2. Metamucil. 3. Protonix. 4. Flagyl po. 5. Levofloxacin. 6. Digoxin. 7. Cardizem. 8. Zosyn. Her blood pressure is 110/70, heart rate is 80. Her temperature is 98.6. Her respiratory rate is 18. She is markedly jaundice. Her sclerae are icteric. She has no cervical or supraclavicular lymphadenopathy. No carotid bruits. She has a right IJ central venous line in place. Her abdomen is protuberant. She has a subcostal incision on the right side which has healed nicely. There is no drainage. A right sided lower abdominal catheter is in the peritoneal cavity, and is draining a very small amount of bile stained fluid. Her abdomen is distended. There is a positive fluid wave. There is no significant peritoneal irritation or tenderness. She has some anasarca. Cardiac examination reveals a regular, rate, and rhythm without murmur. Her laboratory studies are significant for a total bilirubin of 7.3, a white count of 33,000, BUN and creatinine of 18 and 0.9. Her lactate is down to 4.2. CT scan of the abdomen was obtained this morning which demonstrated some large amount of ascites as well as a large pleural effusion. There is no intrahepatic ductal dilatation. IMPRESSION: Ms. [Known lastname 47171] is a 56-year-old Caucasian female who underwent an attempt at a marsupialization of a hepatic cyst that was complicated by the development of a bile leak. At this point in time, our findings are consistent with what appears to be a transected proximal bile duct that appears to be in communication with the extrahepatic biliary tree as based upon the ERCP, but there also appears to be some findings with common bile duct obstruction as noted by the persistent jaundice and the elevation in the alkaline phosphatase, and transaminases. At this point in time, the best means to manage this would be by proximal route where a PTC catheter is to be placed in the right main and main left ducts to further identify the proximal anatomy. In all likelihood, she has a common bile duct obstruction related to the surgical procedure as well as a partially transected proximal bile duct. Placement of the tube caused a leak may in-fact resolve the leak and bypass the obstruction allowing the leak to heal without surgical intervention. We also will need to perform a paracentesis and a thoracentesis to drain with in all likelihood is bile ascites as well as the possibility of a bile pleural effusion. These findings and plan were discussed with Mrs. [Known lastname 47171], who agreed with the plan. This will be undertaken. DR.[Last Name (STitle) ],[First Name3 (LF) ] 02-366 Dictated By:[Last Name (NamePattern1) 30156] MEDQUIST36 D: [2159-12-1] 09:37 T: [2159-12-5] 07:37 JOB#: [Job Number 47172] Admission Date: [2159-11-30] Discharge Date: [2160-1-17] Date of Birth: Sex: Service: ADMITTING DIAGNOSES: 1. Jaundice. 2. Intra-abdominal abscess. 3. Bile leak status post hepatic cystectomy. DISCHARGE DIAGNOSES: 1. Right and left main hepatic duct structure status post dilation and placement of transhepatic catheter. 2. Intra-abdominal abscess. 3. Gram negative sepsis. 4. Prolonged mechanical ventilation. 5. Malnutrition. 6. Intrahepatic abscess. PROCEDURES: 1. Exploratory laparotomy. 2. Drainage of abdominal abscess. 3. Placement of a J-tube. 4. Percutaneous transhepatic cholangiogram. 5. Right and left catheter placement on [11-30] as well as on [12-2]. 6. Multiple CT scans and cholangiograms. 7. Placement of a drainage catheter in the intrahepatic abscess. 8. Mechanical intubation and ventilation. 9. Placement of post-pyloric feeding tube. CONSULTATIONS: Gastroenterology. Radiology. Infectious disease. Critical care. HISTORY OF PRESENT ILLNESS: The patient is a 56 year old Caucasian female with a history of hypothyroidism, atrial fibrillation and a large hepatic cyst, who underwent attempted laparoscopic cystectomy and marsupialization of the cyst at an outside institution. This was complicated by conversion to an open procedure secondary to difficult dissection, but the open procedure was complicated by a large hemorrhage presumably from the hilar area of the liver. This required massive resuscitation and blood transfusion. Eventually patient was discharged home and returned several weeks later with jaundice and ascites. A bile leak was identified. Bile was aspirated from the peritoneal cavity and a transampullary stent was placed. Despite this she continued to have ongoing jaundice and biliary leak and she was transferred to this facility for further management. HOSPITAL COURSE: She arrived on [11-29] late in the evening. She was admitted to the intensive care unit. At that time she had marked ascites and jaundice. She underwent a CAT scan of the abdomen which demonstrated a large cystic appearing lesion within the medial segment of the left lobe and the anterior segment of the right lobe of the liver as well as a large amount of ascites. The following day she was taken to the interventional suite where she underwent placement right and left percutaneous transhepatic catheters. These were unable to cross the stenosis located in the hilum. The following 48 hours later she was taken back to the interventional suite where the catheters were advanced across the stenosis in the right main and left main hepatic duct and the catheters transversed the stenosis and entered the duodenum. At this time she was unable to aspirate the fluid in the peritoneal cavity and due to continued fever and elevated white count, she was taken to the operating room on the 10th where 5 liters of free flowing bile was found in the peritoneal cavity. There was also a large abscess located in the right subphrenic space. A J-tube was placed at this time as well as multiple catheters in the subphrenic space on the right side as well as in Morison pouch to collect any residual abscess. She tolerated this well and was extubated and taken to the surgical intensive care unit where she remained. Over the next several days she required increasing oxygen support and eventually was placed on a ventilator. Cultures of the abscess and the bile grew out Enterococcus that was sensitive to vancomycin. She had multiple episodes of diarrhea which had been treated for C.diff colitis at the outside institution and the cultures did not grow Clostridium difficile at this institution. Five days postoperatively the J-tube fell out and attempts were made to percutaneously replace it in interventional radiology and these were unsuccessful. During the remainder of her hospital course she had several episodes of fever and elevated white count that prompted further imaging studies and no residual abscess within the peritoneal cavity could be documented. The [Location (un) 1661]-[Location (un) 1662] drains located inferior to the lateral segment of the left lobe of the liver and in Morison pouch were removed, leaving only the abscess drain in the subphrenic space. The transhepatic catheters continued to remain open to gravity drainage. Strictures were identified in the right main and left main hepatic ducts. These were balloon dilated with minimal residual stenosis. Due to continued fever and chills, she was taken back to the interventional suite where an 8 French pigtail catheter was placed into the remnant cyst cavity. This presumably had become the source of the bile leak as well as abscess. The catheter drained approximately 40 to 50 cc of bile stained fluid on a daily basis, the cultures of which also grew Enterococcus and gram negative rods. She remained on IV antibiotic therapy and supportive treatment for some time. Eventually she was able to be weaned from the ventilator and extubated. She was transferred to the floor where she remained on the floor for approximately seven to 10 days where she received physical therapy. The transhepatic catheters were internalized and her bilirubin remained slightly elevated, but did not bump any higher. On [2160-1-18] she was able to be discharged home. She was discharged home with followup instructions by Dr. [First Name (STitle) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1331] Dictated By:[Last Name (NamePattern1) 30156] MEDQUIST36 D: [2160-3-31] 09:17 T: [2160-4-1] 16:47 JOB#: [Job Number 47173]	[ "997.4", "038.9", "486", "789.5", "427.31", "998.59", "518.81", "567.8", "511.9" ]	icd9cm	[ [ [] ] ]	[ "34.04", "96.6", "54.91", "33.22", "38.93", "54.0", "46.01", "51.98", "89.64", "34.91" ]	icd9pcs	[ [ [] ] ]								4508, 5260						6149, 9974																																										5289, 6131														1452, 4487	1233, 1427
109	131,345	15330	Discharge summary	report	Admission Date: [2141-9-5] Discharge Date: [2141-9-8] Date of Birth: [2117-8-7] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 348] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [Known lastname ] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [2141-9-4]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [2134] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([2139]) and ESRD ([2135]) 2. CKD/ESRD: - Diagosed [2135] - Initiated dialysis [2137] - PD catheter placement [5-18] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([2139]); related to a catheter - Negative lupus anticoagulant ([4-/2138], [8-/2138], [9-/2140]) - Negative anticardiolipin antibodies IgG and IgM x4 ([2137]-[2140]) - Negative Beta-2 glycoprotein antibody ([4-/2138], [8-/2140]) 6. HOCM: Last noted on echo [8-17] 7. Anemia 8. History of left eye enucleation [2139-4-20] for fungal infection 9. History of vaginal bleeding [2139] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [6-16] and [5-17] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [2140-4-10]. 4. PD catheter placement in [2141-5-11]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [2141-9-8] 07:30AM BLOOD CK(CPK)-126 [2141-9-5] 02:50PM BLOOD HCG-<5 . [2141-9-8] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [2141-9-8]): 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 . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [9-8]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [Known lastname ] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [2-11] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [Hospital1 ] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:20 Capsule(s) Refills:0 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:270 Tablet(s) Refills:0 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [9-10]. Disp:30 Tablet(s) Refills:0 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [1-11] soft bowel movements per day. Disp:500 ml Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [2-11] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [2-11] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2141-9-12] 5:00 Provider: [Name10 (NameIs) 706] NURSE Phone:[Telephone/Fax (1) 327] Date/Time:[2141-9-14] 2:00 Provider: [Name10 (NameIs) 7548] Phone:[Telephone/Fax (1) 327] Date/Time:[2141-9-14] 3:00 Please followup with your nephrologist and PCP. [Name10 (NameIs) ] would like you to see your nephrologist within the next 1-2 weeks.	[ "275.41", "276.2", "425.4", "403.01", "582.81", "585.6", "V45.1", "V12.51", "275.3", "959.6", "599.0", "287.5", "E928.9", "787.02", "276.7", "458.9", "588.81", "E942.6", "710.0", "285.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10471, 10477	6687, 9105	308, 331	10812, 10908	4851, 6664	12024, 12531	3794, 3905		9350, 10448		10498, 10791		9131, 9327			10932, 12001						3402, 3566		3920, 4832																							240, 270									359, 2069															2091, 3379	3582, 3778
7,618	180,256	14248	Discharge summary	report	Admission Date: [2113-5-28] Discharge Date: [2113-6-2] Date of Birth: [2053-4-13] Sex: M Service: MEDICINE Allergies: Atorvastatin Attending:[First Name3 (LF) 2901] Chief Complaint: Arm tingling, numbness Major Surgical or Invasive Procedure: left internal carotid artery stent placement. History of Present Illness: Mr. [Known lastname 5936] is a 60 yo M w/PMHx sx for CAD s/p CABG ([2103]), DM, hyperlipidemia, HTN who presents with right arm tingling, numbness, and difficulty closing his hand into a fist upon wakening this morning. . Patient has known CAD, and is asymptomatic with his heart disease. He has yearly stress tests, and states that his stress test in [Month (only) 956] of this year was abnormal. He does note gradual increase in his exertional dyspnea over the course of the past year, and this past Thursday, developed a sharp midsternal chest pain, without associated nausea, diaphoresis, radiation, or SOB, relieved by SL nitro. He then saw his cardiologist on [Month (only) 2974], who performed an echo, and requested that he have a repeat catheterization done this Wednesday. Patient then developed the right arm tingling and presented to the OSH ED ([Hospital3 ]). Patient has chronic visual blurriness from cataracts. He has chronic numbness and swelling of his legs from Charcot foot. . Of note, he had left arm shaking for 20 minutes one week ago after having lifted his arm during house work. Disappeared on its own. No tingling or weakness associated. . Patient was initially seen at an OSH, with an unchanged EKG, negative head CT (per pt), and was given aspirin, plavix load, nitroglycerin, and started on a heparin gtt. His first set of CE there were negative. He was then transferred here where his sx did not seem compatible with ACS, and his heparin gtt was discontinued. . On admission, the patient denied any CP, SOB, palpitations, tingling/pain/numbness in his arms, trauma to his neck or arm. Past Medical History: - CAD s/p 2v CABG in [2104-4-18] (at [Hospital1 112] by Dr. [Last Name (STitle) 1683]; angina equivalent in the past: right arm pit discomfort; now SSCP - Stent to LAD in [2103] (at [Hospital1 18] cath with 90% mid-LAD and 89%diag lesion; EF 45%, apical hypokinesis; cath c/b dissection in distal LAD which was stable on re-cath); on ASA/Plavix since [2103] - HTN - Type II DM with neuropathy and retinopathy; since age 40; strong FHx; FS run in low 200s and HbA1c 8-9 per patient - s/p III degree burn on L foot [1-20] diabetic PNP (per pt) - s/p unnoticed fractures of R foot [1-20] diabetic PNP/charot's foot (per pt) - Hyperlipidemia - OSA - GERD Social History: lives with wife, daughter (33) and son (35), VP of sales, no tobacco, no EtOH Family History: Father died of malignant hypertension in 40s, father's brothers died of heart disease in 50s, mother died of aneurysm rupture at 76, several family members on mothers side with DM Physical Exam: VS: 97.5 BP 157/60 HR 67 RR 14 O2sat 100% RA Gen: well appearing. HEENT: MMM. Hrt: RRR. 2/6 SEM. Lungs: CTAB no RRW. Abd: S/NT/ND. Ext: Warm. Sensation to LT diminished below ankles. 1+ edema at ankles bilaterally. 1+ pulses bilaterally. No femoral bruits. Neuro: Strength full bilaterally. Alert and oriented. Sensation diminished as above. Pertinent Results: 141 103 19 --------------< 171 3.5 26 1.4 14.5 6.1 >----< 215 41 N:71.3 L:19.8 M:4.4 E:4.0 Bas:0.5 . PT: 11.9 PTT: 49.9 INR: 1.0 . Trends: WBC: 6.1 - 7.7 Hct 41 - 36 Creatinine 1.4 - 1.4 CK 98-73-67 Trop 0.02-0.01-0.01 . EKG: NSR. TWI I, AVL. PRWP. Q III, AVF c/w old inferior MI. (no olds to compare). . Echo [2112-12-2] (per outside records): Inferobasilar hypokinesis, EF 50%, mild MR, LAE . Stress test [2110]: partially reversible infero-apical defect . MRI MRA brain: FINDINGS: Circle of [Location (un) 431] is normal with no evidence of aneurysms. There is a predominantly fetal circulation to the right posterior cerebral artery. There is a hypoplastic right A1 segment. IMPRESSION: Normal time-of-flight MRA of the Circle of [Location (un) 431]. . Carotid ultrasound: Significant left-sided plaque with 80-99% carotid stenosis. Of note, this extends fairly distally in the cervical internal carotid artery. On the right, there is less than 40% carotid stenosis. . MR spine: Right paracentral and foraminal disc herniation at C6-7 could be causing neural impingement. This would correlate with patient's clinical symptoms. Mild degenerative changes otherwise. Brief Hospital Course: Mr. [Known lastname 5936] is a 60 yo M w/PMHx sx for CAD s/p CABG, HTN, hyperlipidemia, and DM who presents with sharp shooting pain down arm concerning for TIA. hosp course by problem: . # Neuro/TIA: Patinet had neuro workup as above. He was evaluated by neurology and sx were concerning for a TIA. Given the carotid findings it was deemed that the source of the TIA was likely carotid in origin. He was taken to the cath lab for stent placement in the left ICA on [6-1]. Procedure was tolerated well without complication. He was monitored in the CCU postprocedure. His groin site was stable and his neuro exam remained nonfocal. He was treated with a nitro gtt temporarily given that many of his antihypertensives had been on hold. This was weaned as his meds were titrated up. His goal SBP was 110-170 given recent carotid manipulation. After remaining stable overnight, he was evaluated by neuro again and there were no deficits. He was stable for d/c to home. He has f/u with neuro/stroke attng within one month. . #. Cardiac. a. Ischemia. Patient's EKG without active ischemic changes, and CE negative. However per patient report abnormal stress and scheduled for cath this week given SSCP last Thursday, relieved by SL nitro. The cath was put on hold given neuro workup. Patient will f/u with cardiologist and will likely have elective cath in 1 month. We continued ASA 325, Plavix, metoprolol, statin b. Rhythm. NSR. Monitor on telemetry. c. Pump. euvolemic. EF 50% on last Echo in [11-23]. . #. HTN. His home meds were adjusted pre-stent to allow for some autoregulation. Postprocedure, we gradually added back some antihypertensives but held the HCTZ and verapamil on discharge given the new carotid stent will likely decrease BP. He will have close f/u with his PCP and will contact him sooner if develops dizziness, lightheadedness, headache, or low BP on self-exam. . #. Hyperlipidemia. Continued statin. . #. DM2. Continued home insulin. . #. CRI. GFR 54. Cr 1.3-1.4 and stable. He received pre-carotid stent hydration . #. Dispo status: well. ambulating without issue. no neuro deficits. Medications on Admission: ASA 325 QD Plavix 75 QD Omeprazole 20 mg QD Insulin 70/30 40 U QAM, 55 U QPM Verapamil SR 240 mg QPM Welchol 625 mg [Hospital1 ] Diovan 160/12.5 QD Tricor 145 QD Zetia 10 mg QD Norvasc 2.5 mg QD Metoprolol 100 [Hospital1 ] Niacin 50 QD Vit E Fish oil Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 2. insulin 70/30 Sig: variable units twice a day: take 40 U every morning and 55 units every pm. Take as previously instructed. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Colesevelam 625 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Niacin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 12. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Arm numbness, tingling - TIA - carotid stenosis left sided s/p stent - CAD, s/p 2 vessel CABG in [2103] - HTN - Type II diabetes Secondary: - hyperlipidemia - OSA - GERD Secondary Diagnosis: 1. Hyperlipidemia Discharge Condition: Afebrile. Hemodynamically stable. Ambulating. Tolerating PO. Discharge Instructions: You have been evaluated for arm tingling and numbness. You have been found to have a transient ischemic attack. You had a carotid stent placed which you tolerated well. . We made some adjustments to your medications. Please take them as instructed. If you experience any lightheadedness, dizziness, or headache your blood pressure medications may need to be adjusted. Check your blood pressure and contact your PCP if necessary. . The adjustments to your meds are as follows: 1. Decreased metoprolol to 50mg [Hospital1 ] 2. holding diovan/hctz 3. starting losartan 160mg daily 4. holding verapamil SR . If you experience any chest pain, shortness of breath, neurological findings, or palpitations please contact your PCP, [Name10 (NameIs) 2085], or emergency department. . It is very important for you to continue taking your plavix daily. . Please followup with Dr. [Last Name (STitle) 11493] in preparation for a cardiac cath as previously discussed Followup Instructions: Please follow up with [Last Name (LF) ],[First Name3 (LF) 1955] F. [Telephone/Fax (1) 20587] [Last Name (LF) 2974], [6-9] at 9:45. . Please also follow up with your neurologist, Dr. [Last Name (STitle) 1693]. His number is ([Telephone/Fax (1) 22692]. Your appointment is [7-6] at 9:30. [Hospital Ward Name 23] building [Location (un) ]. . Please followup with Dr. [Last Name (STitle) 11493] on [6-16] at 11:15am. Please followup with Dr. [Last Name (STitle) 911] in [5-26] weeks. His office number is ([Telephone/Fax (1) 24798]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "250.50", "357.2", "411.1", "530.81", "433.10", "585.9", "362.01", "327.23", "V45.81", "272.4", "403.90", "713.5", "250.60" ]	icd9cm	[ [ [] ] ]	[ "00.61", "00.63", "00.40", "00.45" ]	icd9pcs	[ [ [] ] ]	8216, 8222	4611, 6748	295, 343	8501, 8564	3386, 4588	9580, 10305	2828, 3009		7058, 8193		8243, 8243		6774, 7035			8588, 9557								3024, 3367																							233, 257									371, 2010			8460, 8480			8262, 8439									2032, 2717	2733, 2812
47,937	169,115	39451	Discharge summary	report	Admission Date: [2120-1-13] Discharge Date: [2120-1-16] Date of Birth: [2044-7-10] Sex: M Service: MEDICINE Allergies: Lactose Attending:[First Name3 (LF) 6565] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Three units of blood transfusion ([2120-1-13]) Esophagealgastroduodonoscopy with placement of a clip on duodenal ulcer ([2120-1-13]) Abdominal Ultrasound History of Present Illness: This is a 75 year old male with PMH of diffusely metastatic prostate cancer s/p orchiectomy and his 5th cycle of Taxotere chemotherapy/Neulasta in [12-21], diabetes, and h/o MSSA bacteremia s/p antibiotic treatment in [8-21] presenting with 1 episode of black stools this AM, hct drop from 25.7 to 19.6, and a small amount of dark emesis this AM. The patient does not have any prior history of upper or lower GI bleeding, no EtOH history, or liver disease and has never been scoped at [Hospital1 18]. The patient reports that he had a normal bowel movement at 5:30 AM and then again at 7:30 AM. At the time of his 7:30 AM bowel movement, the patient became nauseous and vomited a small amount of dark emesis. He does report some wretching, but denies any bright red blood in the emesis. Following the emesis he was given Gatorade, a cookie, and Zofran which helped his nausea. He did report some lightheadedness when he was walking back to his room from the bathroom using his walker. At 9:30 AM he called out from his room and his family found him lying in a pool of black liquid stool. He had never been incontinent of stool in the past. He also reported lightheadedness and dizziness if he sat up straight after this episode. Of note, the patient took a 2 week course of naproxen for joint pain, but has not taken any naproxen or other NSAIDs for the last week. He also takes ASA 81mg daily and receives steroids with his chemo cycles. He also took his home beta blocker this morning. He does not report having any abdominal pain and has not had a bowel movement since his dark black stool this AM. He is followed by Dr. [Last Name (STitle) ] and [Doctor Last Name ] from hem/onc. . In the ED, initial vs: T=97.8, HR=80, BP=116/43, RR=16, POx=98% on RA. An NG lavage was performed which revealed coffee grounds that cleared after 500cc of lavage. A rectal exam revealed melena. He remained HD stable and GI was consulted. An EKG showed NSR at 84 with poor R wave progression but no acute ischemia. He received 1 unit of pRBCs in the ED and has 2 peripheral IVs (an 18g and a 20g). He also was started on a Protonix drip. His HCP who is his son confirms that the patient is full code. His transfer vitals was BP=120/40, HR=81, and POx=99% RA. . On the floor, the patient reports no abdominal pain or repeat nausea, vomiting, or bowel movements. He remains lightheaded when sitting upright. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies abdominal pain, dysuria, frequency, or urgency. Denies rashes or skin changes. Past Medical History: Past Oncologic History: Metastatic prostate cancer . Other Past Medical History: Mitral valve prolapse Diabetes Hyperlipidemia MSSA BSI [8-/2119] Past surgical history: s/p orchiectomy . Social History: He emigrated from [Country 11150] on [2119-8-20] in order to be closer to his sons. [Name (NI) ] is a retired corporate attorney, a business executive and a diplomat. He currently lives with his son in [Name (NI) ], [State 350]. His son is a professor [First Name8 (NamePattern2) ] [Name (NI) ] Business School. He has never smoked or drank alcohol and has never used recreational drugs. He is vegetarian. He plans to reside in the United States for this foreseeable future. Family History: There is no known family history of cancer. His father died at the age of 78 from an MI. His mother died at the age of 69 of an MI and was obese. He has three brothers who are all healthy. He has two sisters, one who died in her 60s. He has two sons who are both healthy. Physical Exam: Admission Exam Vitals: T: 96, BP: 109/41, P: 82, R: 18, O2: 99% RA General: Alert and oriented; chronically ill appearing, cachectic male in no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, 2/6 SEM radiating to axilla Abdomen: soft, non-tender, non-distended, loud abdominal bruit and pulsations felt centrally in his abdomen, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused; no clubbing, cyanosis, or edema Neuro: A+Ox3, CN II-XII intact, motor strength and sensory grossly equal and intact bilaterally . Discharge Exam Vitals: Tm:98.9 Tc: 98.2, BP: 110/58 (98-121/48-62), P: 76 R: 16, O2: 99-100% RA General: Alert and oriented; chronically ill appearing, cachectic male in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, 2/6 SEM radiating to axilla Abdomen: soft, non-tender, non-distended, loud abdominal bruit and pulsations felt centrally in his abdomen, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused; no clubbing, cyanosis, or edema Neuro: A+Ox3, CN II-XII intact, motor strength and sensory grossly equal and intact bilaterally Pertinent Results: Admission Labs [2120-1-13] 11:35AM BLOOD WBC-21.6* RBC-2.16* Hgb-6.4* Hct-19.6* MCV-91 MCH-29.8 MCHC-32.9 RDW-15.3 Plt Ct-172 [2120-1-13] 11:35AM BLOOD Neuts-90.8* Lymphs-7.6* Monos-1.3* Eos-0.1 Baso-0.2 [2120-1-13] 11:35AM BLOOD PT-14.9* PTT-24.3 INR(PT)-1.3* [2120-1-13] 11:35AM BLOOD Glucose-206* UreaN-45* Creat-1.0 Na-136 K-4.8 Cl-105 HCO3-19* AnGap-17 [2120-1-13] 11:35AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.3 . EGD ([2120-1-13]) Impression: Ulcers in the antrum and stomach body (endoclip) Erosions in the antrum Ulcers in the duodenal bulb Otherwise normal EGD to second part of the duodenum Recommendations: Numerous ulcers and erosions noted in gastric body, antrum and duodenal bulb. Ulcer with visible vessel noted in pyloric channel non bleeding s/p endoclip. Consistent with NSAID induced peptic ulcer disease as culprit for bleed. Please continue IV BID PPI. Hold NSAIDs. Check H-pylori antibody and treat if positive. . ECG Study Date of [2120-1-13] 11:28:16 AM Normal sinus rhythm. Borderline atrio-ventricular conduction delay. Non-specific T wave flattening. Compared to the previous tracing of [2119-10-10] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 196 74 400/442 53 73 31 . AORTA AND BRANCHES Study Date of [2120-1-15] 11:04 AM FINDINGS: The visualized abdominal aorta is normal in caliber throughout its length. The maximum measured diameter is 1.6 cm. Bilateral pleural effusions are noted, as seen on the recent CT chest. The right kidney measures 10.1 cm, the left kidney measures 10 cm. The right kidney in particular demonstrates a somewhat echogenic cortex, however, no focal lesions are seen. No hydronephrosis. IMPRESSION: 1. The aorta is normal in caliber. 2. Bilateral pleural effusions. 3. Echogenic renal corex suggestive of medical renal disease . Discharge Labs: [2120-1-16] 07:10AM BLOOD WBC-11.4* RBC-3.02* Hgb-9.2* Hct-27.0* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.3 Plt Ct-167 [2120-1-15] 01:40PM BLOOD Hct-29.6# [2120-1-15] 08:15AM BLOOD Neuts-82.5 Lymphs-12.2* Monos-4.7 Eos-0.4 Baso-0.2 [2120-1-16] 07:10AM BLOOD Plt Ct-167 [2120-1-16] 07:10AM BLOOD PT-14.8* PTT-28.2 INR(PT)-1.3* [2120-1-15] 08:15AM BLOOD Plt Ct-155 [2120-1-15] 08:15AM BLOOD PT-14.9* PTT-27.5 INR(PT)-1.3* [2120-1-16] 07:10AM BLOOD Glucose-84 UreaN-22* Creat-1.1 Na-139 K-3.7 Cl-112* HCO3-19* AnGap-12 [2120-1-15] 08:15AM BLOOD Glucose-100 UreaN-30* Creat-1.1 Na-140 K-3.9 Cl-111* HCO3-19* AnGap-14 [2120-1-16] 07:10AM BLOOD ALT-13 AST-47* AlkPhos-1508* TotBili-0.4 [2120-1-16] 07:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.2 Brief Hospital Course: Assessment and Plan: This is a 75 year old male with PMH of diffusely metastatic prostate cancer s/p orchiectomy and his 5th cycle of Taxotere chemotherapy/Neulasta in [12-21], diabetes, and h/o MSSA bacteremia s/p antibiotic treatment in [8-21] presenting with 1 episode of black stools this AM, hct drop from 25.7 to 19.6, and a small amount of dark emesis this AM s/p an EGD on admission which revealed multiple gastric ulcers. . #. UGIB. The patient had one episode of dark emesis and dark liquid stools. He had an EGD on admission revealing multiple gastric ulcers with one visible vessel that was clipped. There was no active bleeding and the patient received 3 unit of pRBCs with appropriate rise in his HCT. He was started on protonix gtt which was transitioned to pantoprazole IV BID. Aspirin and NSAIDs were discontinued on admission while beta blocker was held in the setting of upper GI bleed. Pt's HCT was monitored and stablized. Pt was continued on IV PPI and then switched to PO PPI [Hospital1 ] prior to discharge (to be continued as outpt) w/GI follow-up in 6-8wks for repeat EGD. Pt will need to have H pylori serologies followed up as these are still pending. Pt's diet was advanced and he was able to be d/c'ed home. . #. Pulsatile abdominal mass and bruit. Likely consistent with a AAA. Low likelihood that the patient has an aortoenteric fistula given that he is HD stable and has multiple GI ulcers that are the likely culprit for his GI bleeding. US of the abdomen was order for futher workup; this showed that caliber of Aorta was w/in normal limits. . #. Metastatic prostate cancer. Defer further management to the outpatient setting and his primary oncologists Dr. [Last Name (STitle) ] and [Doctor Last Name ]. Continued on Zofran/compazine PRN nausea . # SVT with ? rate related ST changes: HCP/son reports history of SVT during his admission in [Month (only) 216]. Wife also acknowledges hx of SVT in past. During initial episode patient was sleeping and aysmptomatic. Resolved with carotid massage. Pt had several repeat episodes of SVT. Metoprolol was restarted and increased to 12.5mg TID from 12.5mg [Hospital1 ] (equivalent to home dose of metoprolol succinat 25mg daily). Pt's SVT spontaneously resolved or resolved w/carotid massage and pt remained asymptomatic. . #. Communication: Patient and [Name (NI) ] (HCP/son) [Telephone/Fax (1) 87169] (cell), [Telephone/Fax (1) 87170] (home), [Telephone/Fax (1) 87171] (2nd cell) . Outpt follow-up arranged w/pt's oncologist and GI. Pt will need to have H pylori serologies followed up as these are still pending. Medications on Admission: -NAPROXEN 250 mg by mouth twice a day -ONDANSETRON 8 mg by mouth three times a day as needed for nausea -OXYCODONE 5 mg by mouth every 4 hours as needed for moderate pain -PROCHLORPERAZINE MALEATE 10 mg by mouth four times a day as needed for nausea -RACECADOTRIL 100 mg daily prn diarrhea -ACETAMINOPHEN -ASCORBIC ACID -ASPIRIN 81 mg by mouth daily -VITAMIN B COMPLEX -DOCUSATE SODIUM 100 mg by mouth twice a day -FOLIC ACID -METOPROLOL SUCCINATE 25mg daily Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 2. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. 5. RACECADOTRIL Sig: 100mg once a day as needed for diarrhea. 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Do not take more than a total of 4g of tylenol per day. 7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Do not take if you are having diarrhea/loose stool. 11. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis 1. NSAID induced gastritis and ulcer disease 2. Prostate cancer (metastatic) 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 because you were noted to have dark bowel movements indicating blood in your stool and dizziness with standing as well as some blood in your vomit. You were found to have a low blood volume for which you were given three units of packed red blood cells. . Gastroenterology performed an esophagealgastroduodenoscopy which showed several ulcers seen in your gut but no active source of bleeding. One clip was placed on one of the ulcers. Your aspirin and all other NSAIDS (e.g., ibuprofen, naproxen, etc.) were stopped as these likely contributed to the development of the ulcers. You will need to have a repeat endoscopy in 6 to 8 weeks with the GI doctors (see below for appointment details). . You also had an ultrasound of your abdomen which showed that your aorta had a normal diameter. Bilateral pleural effusions were noted which have previously been seen on CT scan. Echogenic renal corex was suggestive of medical renal disease. You kidney function in the hospital remained stable. . You also had several episodes of fast heart rate but did not experience any symptoms. For this we gave you metoprolol; please continue to take metoprolol at home. . The following changes were made to your medications: - Please START taking omeprazole twice daily. - Please STOP taking aspirin and all other NSAIDS (e.g. iburprofen, (Advil), naproxin (Alleve)). - Please STOP taking Naproxen (Alleve) - For pain you can take tylenol but do not take more than 4mg of tylenol per day; if your pain is still not controlled, you can take oxycodone - Please continue to take all of your other home medications as prescribed. . Please be sure to keep all follow-up appointments with your PCP oncologist, gastroenterologist and other healthcare providers. . It was a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: Please be sure to keep all follow-up appointments with your PCP oncologist, gastroenterologist and other healthcare providers. . You will need to have a repeat endoscopy in 6 to 8 weeks with the GI doctors (see below for appointment details). . Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2120-1-25] at 2:00 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2120-1-25] at 2:00 PM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2120-1-25] at 3:00 PM With: [Name6 (MD) 8111] [Name8 (MD) 8112], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Name:[First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Specialty: Gastroenterology Location: [Hospital1 18]-DIVISION OF GASTROENTEROLOGY/GI WEST Address: [Doctor First Name ], STE 8E, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 463] When: Please call office to book a repeat endoscopy procedure with Dr [First Name (STitle) 2643] in [6-19] weeks. [First Name4 (NamePattern1) 2946] [Last Name (NamePattern1) ] MD [MD Number(1) 3218] Completed by:[2120-1-17]	[ "E935.9", "532.40", "V85.0", "427.89", "424.0", "535.40", "250.00", "V10.46", "198.5", "272.4" ]	icd9cm	[ [ [] ] ]	[ "44.43" ]	icd9pcs	[ [ [] ] ]	12732, 12790	8408, 11053	277, 441	12928, 12928	5742, 7594	14968, 16690	3997, 4276		11563, 12709		12811, 12907		11079, 11540			13110, 14945		7611, 8385				3435, 3454		4291, 5723																			2902, 3240				229, 239									469, 2883									12943, 13086						3343, 3412	3470, 3981
55,245	129,246	37997	Discharge summary	report	Admission Date: [2131-9-11] Discharge Date: [2131-9-19] Date of Birth: [2057-5-14] Sex: F Service: ORTHOPAEDICS Allergies: Demerol / Albuterol Attending:[First Name3 (LF) 3190] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior/posterior lumbar fusion with instrumentation. History of Present Illness: Ms. [Known lastname 12056] has a long history of back and leg pain. She has attempted conservative therapy including phyisical therapy and has failed. She now presents for surgical intervention. Past Medical History: 1) Rheumatoid Arthritis 2) Hypertension 3) Hypothyroidism 4) Degenerative disc disease L2-S1 Social History: Not currently working. Lives with her husband. [Name (NI) ] 8 children and 24 grandchildren Family History: N/C Physical Exam: Gen: NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, mucous membranes dry, NGT in place in right nostril Neck: Supple, JVP not elevated, no [Doctor First Name ] CV: Rate normal with some irregularity to rhythm, normal S1, S2. No M/R/G Chest: CTAB anteriorly aside from occasional coarse breath sounds on right. No wheezing. Resp were unlabored, no accessory muscle use. Ext: Trace bilateral non-pitting edema of lower extremities, no cyanosis or clubbing Skin: No rashes seen, fingernails without pathology Neuro: Alert, oriented to self and hospital, though some impairment of concentration Pertinent Results: [2131-9-17] 12:35PM BLOOD WBC-9.5 RBC-3.18* Hgb-9.6* Hct-27.2* MCV-85 MCH-30.1 MCHC-35.2* RDW-15.2 Plt Ct-190 [2131-9-17] 05:35AM BLOOD WBC-9.1 RBC-3.25* Hgb-9.8* Hct-27.8* MCV-86 MCH-30.0 MCHC-35.1* RDW-15.4 Plt Ct-159 [2131-9-16] 06:00AM BLOOD WBC-9.5 RBC-3.35* Hgb-10.2* Hct-28.5* MCV-85 MCH-30.4 MCHC-35.8* RDW-15.6* Plt Ct-138* [2131-9-15] 02:30AM BLOOD WBC-6.4 RBC-3.21# Hgb-9.4# Hct-26.5* MCV-83 MCH-29.3 MCHC-35.5* RDW-16.2* Plt Ct-117* [2131-9-11] 04:11PM BLOOD WBC-11.8* RBC-3.39* Hgb-10.8* Hct-31.4* MCV-93 MCH-31.9 MCHC-34.4 RDW-14.5 Plt Ct-216 [2131-9-17] 12:35PM BLOOD Glucose-108* UreaN-12 Creat-0.5 Na-136 K-3.9 Cl-103 HCO3-26 AnGap-11 [2131-9-17] 05:35AM BLOOD Glucose-108* UreaN-12 Creat-0.6 Na-135 K-4.0 Cl-101 HCO3-27 AnGap-11 [2131-9-16] 06:00AM BLOOD Glucose-109* UreaN-15 Creat-0.7 Na-133 K-4.2 Cl-103 HCO3-23 AnGap-11 [2131-9-17] 12:35PM BLOOD Calcium-7.5* Phos-2.9 Mg-2.0 Brief Hospital Course: Ms. [Name13 (STitle) 7049] was admitted to the [Hospital1 18] Spine Surgery Service on [2131-9-11] and taken to the Operating Room for L1-S1 interbody fusion through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#4 ([2131-9-14]) she returned to the operating room for a scheduled L1-S1 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was low and she was transfused PRBCs with good effect. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop check when it was removed due to a LLE motor block. She developed a post-op ileus and an NGT was placed until bowel sounds were present. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. She developed intermittent tachycardia and a medicine consult was obtained. Multifocal atrial tachycardia was diagnosed and her beta blocker was increased. She is to follow up with her PCP. [Name10 (NameIs) 8389] was removed on POD#4 from the second procedure. She was fitted with a lumbar warm-n-form brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Alendronate 70 mg weekly Methotrexate 2.5 mg daily, except 5 mg once weekly Hydroxychloroquine 200 mg [Hospital1 ] (lunch and dinner) Synthroid 50 mcg daily Folic acid 1 mg [Hospital1 ] Metoprolol Succinate 25 mg daily Irbesartan 300 mg daily Gabapentin 300 mg daily Multivitamin 1 tab daily Oscal 500 + D3 tabs daily Metamucil daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Methotrexate Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO 1X/WEEK (WE). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO Daily (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Watch [Doctor Last Name ] rehab Discharge Diagnosis: Lumbar spondylosis and disc degeneration Post-op ileus Multifocal atrial tachycardia Post-op acute blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Lumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Out of bed w/ assist Lumbar corset for ambulation; may be out of bed to chair without. Treatments Frequency: Please continue to change the dressing daily with dry, sterile gauze. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 363] in his clinic in 10 days. Please follow up with your PCP regarding your multifocal atrial tachycardia within 2 weeks. Completed by:[2131-9-19]	[ "244.9", "427.89", "E849.7", "V12.01", "997.4", "737.30", "285.1", "401.9", "721.3", "714.0", "733.00", "599.72", "338.18", "E878.1", "560.1" ]	icd9cm	[ [ [] ] ]	[ "80.99", "84.52", "81.63", "81.06", "81.08", "84.51" ]	icd9pcs	[ [ [] ] ]	5727, 5789	2441, 4362	302, 359	5950, 5957	1482, 2418	8157, 8361	835, 840		4757, 5704		5810, 5929		4388, 4732			5981, 6080								855, 1463	7942, 8041	8063, 8134															6116, 6309						245, 264					6345, 6812		6824, 7924		387, 589															611, 706	722, 819
30,078	100,036	13877+56489	Discharge summary	report+addendum	Admission Date: [2187-7-13] Discharge Date: [2187-7-23] Date of Birth: [2104-8-30] Sex: F Service: CARDIOTHORACIC Allergies: Penicillin V / Methyldopa Attending:[First Name3 (LF) 165] Chief Complaint: general malaise Major Surgical or Invasive Procedure: dental extractions [2187-7-15] redo sternotomy/AVR (#19 CE Magna)-[2187-7-17] History of Present Illness: 82 yo F s/p CABG [2177] now with severe AS and recent NSTEMI, preop for [Hospital 1291] transferred from [Hospital3 ] with SOB, recurrent pulmonary edema. Past Medical History: Right carotid endarterectomy CABG at [Hospital6 ] in [2181] (LIMA to LAD, SVG to RCA, SVG to first diagonal, SVG to OM2) NSTEMI in [2187-5-1] Renal insufficiency (baseline creatinine 1.5) Hypertension Severe Aortic stenosis Dementia Peripheral Vascular Disease Anemia (baseline hematocrit 32-34) Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Her mother died of a heart attack at age 61. Her dad died of a CVA at age 47. Her sister has diabetes. She has a son who passed away. She had six miscarriages. Physical Exam: HR 64 RR 20 BP 129/44 NAD Lungs with scattered rales Heart RRR 3/6 SEM radiating to neck Extrem warm 62" 72 kg Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT 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. Resting bradycardia for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. A left atrial appendage thrombus cannot be excluded. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area 0.5 cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. There is a small left pleural effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the OR. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and was AV paced. 1. A well-seated bioprosthetic valve is seen in the mitral position with normal leaflet motion and gradients (mean gradient = 11 mmHg and cardiac output of 2.6 L/min). Trivial central aortic regurgitation is seen. 2. Regional and global left ventricular systolic function are normal. 3. Right ventricular systolic function post-bypass is moderately hypokinetic. 4. The intra-atrial septum is dynamic. 5. Aortic contours are intact post-decannulation. [Known lastname ],[Known firstname 24357] L [Medical Record Number 41597] F 82 [2104-8-30] Radiology Report CHEST (PORTABLE AP) Study Date of [2187-7-19] 2:14 PM [Last Name (LF) ],[First Name3 (LF) ] CSURG CSRU [2187-7-19] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 41598] Reason: ? ptx s/p ct removal [Hospital 93] MEDICAL CONDITION: 82 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ? ptx s/p ct removal Final Report STUDY: Single portable AP chest radiograph. INDICATION: 82-year-old female status post CABG and chest tube removal. COMPARISON: [2187-7-18]. FINDINGS: Patient has been extubated with removal of right basilar chest tube and Swan-Ganz catheter/NG tube. Atelectasis at the left lower lobe has improved. Small left pleural effusion remains. The upper lungs remain clear. Bilateral subclavian artery calcifications are again noted. Median sternotomy wires remain in stable condition. IMPRESSION: 1. Interval removal of multiple lines and tubes without pneumothorax. 2. Improvement of left lower lobe atelectasis. 3. Residual small left pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name 4391] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: [Doctor First Name ] [2187-7-19] 4:49 PM Imaging Lab Brief Hospital Course: She was admitted to cardiac surgery. Dental consult was called and tooth extractions were recommended. On [7-15] she had 5 teeth extracted. On [7-17] she was taken to the operating room on [7-17] where she underwent a redo sternotomy and AVR. She was transferred to the ICU in stable condition. She as extubated on POD #1. Chest tubes removed and she was transferred to the floor on POD #2 to begin increasing her activity level. She was gently diuresed toward her preop weight. Beta blockade was titrated. Pacing wires removed on POD #3.She had several episodes of A fib and coumadin was started. Target INR 2.0-2.5. She continued to make good progress and was cleared for discharge to rehab on POD #6. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: ASA 325, lopressor 25", lipitor 10, lovenox 40, norvasc 5, diovan 160,acidophilus [Hospital1 ] Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) units SC Subcutaneous once a day. 10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: 3 mg today only [7-23]; all further dosing per rehab provider;target INR 2.0-2.5. 11. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO BID (2 times a day): hold for K >4.8.[Month (only) 116] DC when lasix is stopped. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: AS s/p AVR R CEA, CABG at [Hospital6 ] in [2181] (LIMA to LAD, SVG to RCA, SVG to first diagonal, SVG to OM2), NSTEMI in [Month (only) 547] [2187], Renal insufficiency (baseline creatinine 1.5), Hypertension, Severe AS, dementia, PVD, Anemia (baseline hematocrit 32-34) ;postop A Fib 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. No driving until follow up with surgeon or at least one month. Followup Instructions: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10543] 2 weeks Dr. [First Name (STitle) ] 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2187-7-23] Name: [Known lastname ],[Known firstname 7506] L Unit No: [Numeric Identifier 7507] Admission Date: [2187-7-13] Discharge Date: [2187-7-23] Date of Birth: [2104-8-30] Sex: F Service: CARDIOTHORACIC Allergies: Penicillin V / Methyldopa Attending:[First Name3 (LF) 265] Addendum: Please note this addendum to past medical history and discharge diagnoses: Acute on chronic diastolic heart failure Discharge Disposition: Extended Care Facility: [Location (un) ] Manor - [Location (un) ] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2187-8-17]	[ "585.9", "403.90", "428.33", "E878.2", "414.01", "443.9", "285.21", "428.0", "427.31", "276.2", "294.8", "414.02", "410.72", "997.1", "433.30", "521.00", "424.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21", "23.19" ]	icd9pcs	[ [ [] ] ]	8522, 8718	5041, 5824	307, 395	7415, 7425	1379, 3910	7747, 8499	1065, 1230		5974, 7018	3950, 3982	7092, 7394		5850, 5951			7449, 7724								1245, 1360																							252, 269	4014, 5018								423, 591															613, 923	939, 1049
77,511	161,615	28271	Discharge summary	report	Admission Date: [2192-12-14] Discharge Date: [2192-12-19] Date of Birth: [2149-9-12] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine / Platinum Complexes / Aspirin / Shellfish Derived Attending:[First Name3 (LF) 18369] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: Ms. [Known lastname 45419] is a 43yo female with a history of recurrent stage IIIC adenocarcinoma of the ovary who presented today with a GI bleed. She arrived to [Hospital Ward Name 23] 9 today for C1D1 of oral topotecan. She was recently transitioned off gemcitabine when a CT scan demonstrated and interval increased size of left pelvic mass, which invaded the pelvic sidewall and likely the small bowel. She was feeling well today, except for a report of fatigue, most specifically when walking. She had her blood counts checked and her hematocrit returned at 21.1 from 28.2 on [2192-12-6]. She was treated with topotecan. She noted darker stool over the last 24-36 hours, which she attributed to spinach. She went to work after the chemotherapy and had another bowel movement that was described as "sticky." It was a small formed stool, dark/black in color with red/maroon streaks. She discussed this development with her oncologist and was referred to the ED. In the ED, vitals were 125/73 95 18 99% 2L. She was given 1 liter normal saline and 10 units of regular insulin and admitted to the OMED team. On the floor, she did well. She was seen by the GI and surgery consult teams. She was transfused 1 unit of blood. The surgical team felt the patient should be monitored in the ICU overnight and she was transferred. This evening, she has no specific complaints. She has noted the onset of some chemotherapy side effects, which is typical for her. She denies headache, orthostasis, vision changes, mouth sores, chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, further ostomy output, rectal bleeding, joint pain or rash. Past Medical History: [Known firstname ] is 43 yo woman with advanced ovarian ca. She is s/p debulking surgery and hysterectomy and bilateral salpingo-oopherectomy. She received iv and intraperitoneal chemotherapy as part of her adjuvant chemotherapy ending in [2192]7. She was enrolled in study getting oral [Doctor Last Name 360] AZD2171 until [12-11]. She resumed tx with single [Doctor Last Name 360] [Doctor Last Name ] as of [2191-5-12]; but had reaction with dose 6/08. Started doxil [2191-7-21]. Had evidence of disease progression so tx changed to Alimta on [2191-11-17] till [2-13]. Tx changed to Weekly taxol with Avastin on [2192-3-8]. Due to neuropathy from taxol; tx changed to weekly taxotere on [2192-6-28]. She had sigmoid colon perforation and had colon ressection and colonostomy on [2192-7-6]. She has been slow to heal and resumed chemo with gemzar on [2192-10-11]. Tx changed to Topotecan on [2192-12-14]. Past Medical History: Diabetes Hypothyroidism HTN (improved- no meds since [Month (only) ]) Clear cell ovarian Cancer s/p TAH-BSO, appendectomy, omentectomy [2189] s/p sigmoid resection [7-12] Social History: Lives by herself in [Hospital1 8]. No tobacco, alcohol, or illicit drugs. Family History: Many women on mother's side with cancers including lung, colon, gastric, ovarian. Physical Exam: VS: 98.5 106/54 89 18 98% RA GEN: Comfortable appearing female, sitting up in bed, in NAD HEENT: NC/AT, EOMI, pale conjunctiva, MMM, clear oropharynx, no LAD CV: RRR, normal S1/S2, no m/r/g PULM: CTAB, no wheezing, rubs or rales ABD: Normoactive bowel sounds, nontender, nondistended, ostomy clear --guaiac positive, dark black stool in ostomy (guaiac reported in OMED admit exam) LIMBS: Strength 5/5 in all extremities SKIN: No skin lesions or rashes noted NEURO: CN II-XII grossly intact Pertinent Results: Admission Labs: [2192-12-14] 08:00AM WBC-12.9* RBC-2.85# HGB-6.5# HCT-21.1# MCV-74 MCH-23.0* MCHC-31.0 RDW-21.2* [2192-12-14] 08:00AM PLT COUNT-584* [2192-12-14] 12:30PM GLUCOSE-369* UREA N-12 CREAT-0.8 SODIUM-133 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-23 ANION GAP-19 [2192-12-14] 05:40PM FIBRINOGE-700* [2192-12-14] 12:30PM PT-10.8 PTT-20.6* INR(PT)-0.9 [2192-12-14] 05:40PM HAPTOGLOB-476* [2192-12-14] 05:40PM ALT(SGPT)-9 AST(SGOT)-13 LD(LDH)-188 ALK PHOS-109 TOT BILI-0.3 [2192-12-14] 05:40PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-2.3 Hct trends: [2192-12-14] 08:00AM Hct-21.1# [2192-12-14] 12:30PM Hct-21.7 [2192-12-14] 05:40PM Hct-20.3* [2192-12-15] 01:01AM Hct-22.7* [2192-12-15] 06:09AM Hct-28.7# [2192-12-15] 12:32PM Hct-24.8 [2192-12-15] 12:32PM Hct-26.7* [2192-12-15] 08:07PM Hct-32.1* [2192-12-16] 03:59AM Hct-30.1* [2192-12-16] 09:45AM Hct-29.6* [2192-12-16] 04:40PM Hct-28.5* [2192-12-17] 01:55AM Hct-29.6* [2192-12-17] 05:00PM Hct-31.2* [2192-12-18] 06:25AM Hct-27.1* [2192-12-18] 01:50PM Hct-28.3* [2192-12-18] 09:35PM Hct-27.8* [2192-12-19] 07:10AM Hct-28.3* [2192-12-19] 04:35PM Hct-27.3* Discharge labs [12-19]: WBC-8.3 RBC-3.54* Hgb-9.1* Hct-28.3* MCV-80* MCH-25.7* MCHC-32.1 RDW-18.4* Plt Ct-381 Glucose-74 UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-100 HCO3-30 AnGap-14 Calcium-9.9 Phos-3.7 Mg-2.1 Microbiology: MRSA screen positive Imaging: EKG [12-14]: Sinus tachycardia. Late R wave progression. Since the previous tracing of [2192-7-16] T wave abnormalities are less prominent. Clinical correlation is suggested. EGD [12-15]: There was a 5 mm inlet patch in the proximal esophagus. In addition, the was a very small (3-4 mm) mucosal erosion in the proximal esophagus that was likely due to the passage of the endoscope. There was no blood in the esophagus or duodenum. Otherwise normal EGD to fourth part of the duodenum Colonoscopy [12-17]: Pus lining the crypt lines on one large fold but no obvious inflammation in the cecum (biopsy) Cecum pathology [12-17]: Cecum, biopsy: Colonic mucosa, no diagnostic abnormalities recognized. Brief Hospital Course: 43yo female with a history of recurrent stage IIIC adenocarcinoma of the ovary who presents with a GI bleed. #. GI bleed: Her hematocrit on admission was 20.1 which was decreased from her recent baseline of about 28. She remained hemodynamically stable but was transferred to the ICU for monitoring. She was given 4 units of PRBCs and had an appropriate hematocrit increase post-transfusion. There was concern that her pelvic mass had invaded her bowel mucosa and vasculature causing a GI bleed. GI was consulted who did an EGD and colonoscopy both not revealing for a source of bleeding. Patient then had a capsule endoscopy and was discharged home with close follow-up with oncology. She was counseled on warning signs of further bleeding and fatigue. #. DM: She was continued on lantus and SSI. #. Recurrent ovarian cancer: She was given her dose of topotecan prior to admission. There was concern for continued growth of her pelvic mass despite recent chemotherapy. She is to follow-up with her primary oncology team a few days after discharge. #. Hypothyroidism: Continued on home levothyroxine. #. Code Status: She was full code during this admission. Medications on Admission: Tricor 145mg daily Lantus 80U daily Humalog sliding scale Levothyroxine 100 mcg daily Lorazepam 0.25-0.5mg qhs PRN insomnia Prochlorperazine Maleate 10mg po q8 PRN nausea Crestor 40mg daily Tylenol PRN Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lantus 100 unit/mL Solution Sig: Eighty (80) units Subcutaneous once a day. 4. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per sliding scale. 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 7. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. Discharge Disposition: Home Discharge Diagnosis: Primary: Melena Secondary: Ovarian adenocarincoma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital for dark stools and a low blood count. You had endoscopies of your upper and lower GI tracts that did not find a source of your bleeding. You had a capsule endoscopy for which we do not yet know the results. No new medications started. Followup Instructions: You will need to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4149] and Dr. [First Name8 (NamePattern2) 7019] [Last Name (NamePattern1) ] this coming Friday [2192-12-21]. You will be contact[Name (NI) ] with the exact time. Provider: [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2193-1-14] 10:30	[ "197.6", "V44.3", "272.0", "578.1", "V87.41", "244.9", "V58.67", "250.00", "V10.43", "401.9", "790.01" ]	icd9cm	[ [ [] ] ]	[ "45.25", "45.13" ]	icd9pcs	[ [ [] ] ]	8330, 8336	6230, 7401	344, 372	8430, 8430	3999, 3999	8871, 9295	3391, 3474		7653, 8307		8357, 8409		7427, 7630			8575, 8848								3489, 3980																							296, 306									400, 2084					4015, 6207				8444, 8551						3095, 3279	3295, 3375
76,479	147,232	49726	Discharge summary	report	Admission Date: [2176-8-12] Discharge Date: [2176-8-21] Date of Birth: [2124-6-21] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[First Name3 (LF) 1936] Chief Complaint: diarrhea, fevers Major Surgical or Invasive Procedure: flex sigmoidoscopy History of Present Illness: Ms. [Known lastname 1007] is a 52 year-old female with past medical history significant Crohn's Disease with multiple prior fistulas and corrective surgeries who presented to ED after complaining of severe abdominal pain, nausea, dry heaving, and nonbloody diarrhea with fevers x 2 days to 101F range. She states that she is still passing gas and localizes her abdominal pains to her mid and lower left quadrant. Pains are sharp, [2177-8-14] severity and come in "crampy waves". In ED, she had initial hypotension to a low of 70/34, HR into 120-140s with notable atrial fibrillation, and she was resuscitated with 4L IVFs per ED records. She was also given IV flagyl 500mg x1, Cipro 400mg IV x1, surgery consult called and seen by GI fellow. A left IJ was placed and blood pressures improved to the low 100s systolic. She was also given IV Zofran 4mg IV and Hydromorphone 1mg IV x2. Of note, she gave herself her last Humira dose on Friday morning and states she last took Asacol on Saturday. She also notes that she noticed a small developing 1" sized sore that she describes as a painful, red area with additional draining yellowish discharge along the edge of her left groin region. Per OMR, she has been evaluated over the past month by Dr. [Last Name (STitle) 1120] and Dr. [First Name (STitle) ] for consideration of joint surgeries to include ventral herniorrhaphy, proctosigmoidectomy and end colostomy. She is followed regularly by Dr. [Last Name (STitle) 1120] for her longstanding history of Crohn's disease. Prior surgical history includes several fistula reconstructions, bowel resections, and temporary ostomies in the past. She has known severe proctosigmoiditis which was corroborated on prior CT this past winter [2175]. On arrival to the ICU she was in no apparent distress but had several bowel movements immediately on arrival, was afebrile with BP 132/76, HR 125s with atrial fibrillation noted on telemetry. Past Medical History: Crohn's disease (diagnosed in [2167]): on Humira weekly therapy. On prior Remicade. Prednisone caused enterocutaneous fistulas. Did not tolerate prior azathioprine Rx. Pre-diabetes Hyperlipidemia Benign multinodular goiter (followed by Dr. [Last Name (STitle) ] Cervical cancer GERD Paraspinal cyst (followed by Dr. [Last Name (STitle) 575] Atrial fibrillation: developped 10 months ago. Per patient, her cardiologist, Dr. [Last Name (STitle) 5874] ([Hospital ] Medical Center), has opted to defer cardioversion and coumadin therapy until a later date after she has surgery for her hernia and Crohn's disease. s/p L tib/fib fixation Surgical History: [2167] - Temporary colostomy [2168] - reversal of colostomy [2169] - reconstruction of fistulas [2172] - bowel resection [2173] - repair of ventral hernia with allograft [2174] - patient reports 7 operations, to fix hernias, had a abscess under her allograft Social History: On leave now but had been working as a physical therapist. She smoked intermitently in college but no current or recent tobacco use. No ETOH, no illicit drug use. Family History: Her father has ulcerative colitis. On her father's side, she has an aunt who was diagnosed at 70 with Crohn's, and a cousin who was diagnosed at 14 with IBD. There might be more; she says that her family is very private and likely wouldn't share about their condition. Her father had esophageal cancer, her maternal grandfather liver cancer and her maternal grandmother lung cancer. A paternal aunt had breast cancer and her mother had basal and squamous cell carcinoma. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Temp 98F, BP 132/76, HR 125s, RR 18, O2 Sat 98% RA GEN: obese female in no apparent distress, A&Ox3 HEENT: OP clear, PERRL, EOMI CVS: S1/S2 appreciated and regular, rapid irregularly irregular rate, no rubs, no overt murmurs but exam limited due to rapid rate RESP: CTA bilaterally, no wheezes or crackles ABD: obese, soft, left sided tenderness at mid-left and left lower quadrant, no guarding and no rebound tenderness. Normoactive bowel sounds throughout. SKIN: pale complexion, no bruises noted, small left groin region 1" furuncle noted with erythematous margins and central yellowish purulent draining discharge. EXT: 2+pedal pulses, 1+ bilateral edema bilaterally . Note: Rectal exam per surgical assessment with normal rectal tone with no blood in vault Pertinent Results: [2176-8-12] 12:11PM LACTATE-3.6* [2176-8-12] 12:00PM GLUCOSE-99 UREA N-13 CREAT-1.1 SODIUM-137 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-29 ANION GAP-16 [2176-8-12] 12:00PM ALT(SGPT)-14 AST(SGOT)-11 ALK PHOS-159* TOT BILI-0.5 [2176-8-12] 12:00PM LIPASE-12 [2176-8-12] 12:00PM ALBUMIN-2.9* [2176-8-12] 12:00PM WBC-14.6* RBC-4.79# HGB-12.0 HCT-39.7 MCV-83 MCH-25.1* MCHC-30.3* RDW-15.3 [2176-8-12] 12:00PM NEUTS-74.6* LYMPHS-20.4 MONOS-3.6 EOS-1.0 BASOS-0.4 [2176-8-12] 12:00PM PLT COUNT-833# [8-12] CXR: There is moderate cardiomegaly. Left IJ catheter tip is in the confluence of the brachiocephalic vein. There is no pneumothorax or pleural effusion. The lungs are clear. The trachea is deviated towards the left, at the thoracic inlet due to enlarged thyroid. [8-12] PLAIN ABD: There is a nonobstructive bowel gas pattern. Fecal loading is seen in the ascending colon. Surgical clips at the left lower abdominal quadrant. Air seen within the rectum. No definite evidence of free air under the hemidiaphragms. Nonobstructive bowel gas pattern. [8-12] EKG: rate 140s, atrial fibrillation, slight borderline ST depressions in V4-V5 distribution, normal axis [8-12] CT abdoman and pelvis: \ 1. Diffuse thickening of the descending colon, sigmoid and rectum, with increased thickening in the descending and proximal sigmoid region and possible developing fistula between the sigmoid colon and small bowel. Increase in size of pericolonic lymph nodes. 2. Stable dilatation of the extrahepatic bile duct, without obvious cause. [8-16] Flex Sig Findings: Mucosa: Erythema, punched out ulceration, cobblestoning and exudate were noted from anus to about 42cm. Above this area the visualized mucosa just had scattered erythema and was relatively normal. Much of the mucosa was not seen. Biopsies were sent for histology and cmv.The biopsy for CMV was done at about 35cm where there were ulcerations. Cold forceps biopsies were performed for histology at the 55cm. Cold forceps biopsies were performed for histology at the 40cm. Cold forceps biopsies were performed for histology at the 15cm. Impression: Erythema, punched out ulceration, cobblestoning and exudate in the colon (biopsy, biopsy, biopsy) Otherwise normal sigmoidoscopy to splenic flexure at 55cm Recommendations: Follow-up biopsy results TPN. Surgery in the future. Continue current therapy Additional notes: It was discussed with the patient that abnormalities including polyps and colorectal cancer can rarely be missed. The medications were verified and appended to the report. Brief Hospital Course: 52 year old woman with refractory Crohn's disease, admitted with hypotension and Crohn's flare. #Crohn's Flare: The patient presented with abdominal pain and >15 loose, bloody bowel movements daily. Her CT abdomen was unrevealing but a flex sig was consistent with active Crohns, with unremarkable stool studies. She was initially placed on broad spectrum antibiotics with cipro + vanco + zosyn; this was narrowed to cipro/flagyl once her initial hypotension resolved and there was no longer a concern concern for sepsis passed. GI was consulted and recommended bowel rest and holding steroids, especially steriods in light of the patient's upcoming surgery. Pain was adequately controlled using dilaudid. She is tentatively scheduled for ventral herniorrhaphy, proctosigmoidectomy and end colostomy with Drs. [Last Name (STitle) 13543] and [Name5 (PTitle) 103973] [9-2]. She was sent home on asacol and a course of cipro/flagyl. Aspirin and humera were discontinued for now. #Atrial fibrillation: The patient has a one year history of atrial fibrillation and presented with AF with RVR, with a ventricular rate in the 150s. At baseline, she is not a candidate for cardioversion/anticoagulation given her active Crohns, and she takes diltiazem and metoprolol for rate control at home. Her rate was initially difficult to control, but she eventually responded to titration of her metoprolol and diltiazem. On discharge, she was placed back on her home regimen. #Hypotension The patient presented with hypotension on [8-12] in the setting of AF with RVR and was admitted to the intensive care unit. Her hypotension was responsive to fluid resuscitation and was thought to be secondary to hypovolemia due to massive GI losses and diminished cardiac output from atrial fibrillation with RVR. The patient was initially treated with fluid boluses and rate control using B-blockers and calcium channel blockers. She remained clinically stable with no dizziness, SOB, AMS, or chest pain and was transferred to the medical floor on [8-15]. Her blood pressure remained stable while on the floor. #Anemia of chronic disease: Her hematocrit remained stable during hospitalization. #Skin boil/furuncle - The patient presented with a small, draining furuncle in her left labia. This remained stable and was managed with local wound care. Medications on Admission: Humira - 40 mg x2 pen injections qweekly Diltiazem ER -180 mg qdaily Nexium 40mg qdaily Advair Diskus - 250 mcg-50 mcg -1 puff inh twice a day Lisinopril 30 mg Tablet qdaily Ativan - 2 mg Tablet [Hospital1 ] Asacol 2400 mg [Hospital1 ] Metoprolol Tartrate - 100 mg PO TID Folic Acid tablet qdaily Aspirin - 325 mg Tablet qdaily - (stopped on [2176-8-10]) Calcium Carbonate and Vitamin D3 - dosage uncertain Vitamin B12 - 1,000 mcg Tablet daily VITAMIN D2 - 1,000 unit Capsule daily Ferrous Sulfate supplement qdaily Discharge Medications: 1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Six (6) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:180 Tablet, Delayed Release (E.C.)(s)* Refills:2 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Folic Acid 1 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for abd pain . Disp:60 Tablet(s) Refills:0 13. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO three times a day for 5 days. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: - Crohn's disease flare - Atrial fibrillation with rapid ventricular response Secondary: - Hyperlipidemia - Anemia of chronic disease - Skin furuncle Discharge Condition: Home in good condition. Discharge Instructions: You were admitted on [2176-8-12] with a Crohn's flare. You were managed with IV fluids, bowel rest, and antibiotics. A sigmoidoscopy was performed, which showed erythema, ulceration, cobblestoning and exudate in the colon. Biopsies were taken, and the results are pending at time of discharge. While you were hospitalized, your heart was beating at a fast rate due to your atrial fibrillation. We managed this condition with medication. Please continue taking your home medications as prescribed. Please keep all of your follow-up appointments. -Stop taking aspirin for now -Stop taking lisinopril for now -Continue ciprofloxacin and flagyl for five more days Please see your primary physician or return to the emergency room immediately if you experience abdominal pain, severe nausea or vomiting, bloody diarrhea, black stools, chest pain or shortness of breath. Followup Instructions: Your new surgery date for ventral herniorrhaphy, proctosigmoidectomy and end colostomy is [9-2] with Dr. [Last Name (STitle) 1120]. Please keep all of your scheduled appointments: # Provider ULTRASOUND Phone:[Telephone/Fax (1) 327] Date/Time:[2176-12-9] 11:00 # Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5340], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2177-1-13] 10:00 Completed by:[2176-8-22]	[ "285.29", "276.52", "300.00", "427.31", "V10.41", "780.60", "555.1", "458.9", "569.82", "272.4", "241.1", "250.00", "288.60", "530.81", "787.91", "616.4" ]	icd9cm	[ [ [] ] ]	[ "99.15", "45.25", "38.93" ]	icd9pcs	[ [ [] ] ]	11699, 11705	7409, 9770	290, 310	11908, 11933	4776, 7386	12857, 13319	3473, 3946		10350, 11676		11726, 11887		9796, 10327			11957, 12834								3986, 4757																							234, 252									338, 2297															2319, 3276	3292, 3457
70,476	118,218	29719	Discharge summary	report	Admission Date: [2133-5-14] Discharge Date: [2133-5-23] Date of Birth: [2051-9-30] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2279] Chief Complaint: Delirium. Major Surgical or Invasive Procedure: PICC line placement [2133-5-21], removed on [2133-5-23] History of Present Illness: Please see the medicine nightfloat admission note for full details. In brief, this is an 81yo man w/ systolic/diastolic CHF (EF 45%, dry weight 215lbs in [Month (only) ]), HTN, Afib on coumadin and vascular dementia, admitted for altered mental status, this morning being transferred to the MICU for hypoxia. . He was last well about 10 days ago when he initially had urinary retention c/b UTI and altered mental status. He improved quickly with antibiotics and went to rehab on PO antibiotics. [2133-5-8] he had low BPs and altered mental status. CXR showed PNA, and he was started on ceftriaxone/azithro with improvement. Yesterday morning he was again altered, could not get out of bed, and was transferred to the [Hospital1 ]. . In the ED he triggered for hypoxia that improved with 6L O2 by NC. Given vanc/levo/flagyl. Trop 0.08 and BNP >9000. Given ASA, but not Lasix because of concern for infection/sepsis. On the floor overnight he was appearing improved and was given lasix 20mg IV x1. He had an unwitnessed fall early this morning and was found on the ground. At 7am he was again hypoxic with an arterial P02 59 on a non-rebreather. He is profoundly confused, oriented x0 and having trouble speaking. . Speaking with his wife, he usually lives in [Hospital3 ] with her, is oriented x3, walks with a walker, and had been hospitalized very little before the last 3 weeks. He had never been hospitalized before 3 weeks ago. He is DNR/DNI, but she would like him to get all of the care necessary to improve his current status short of intubation. Past Medical History: 1.) Chronic permanent AF, on warfarin/BB. 2.) Combined systolic/diastolic heart failure 3.) Presumed CAD, s/p inferior MI by imaging. 4.) Vascular dementia. 5.) HTN 6.) Recent urosepsis precipitated by urinary retention s/p hospitalization at [Hospital3 ] with Foley catheter in place Social History: Retired. Married to [Doctor First Name ] [Known lastname 71190], [Name Initial (MD) ] retired RN. Children live in [Hospital1 ] and [Hospital1 1474]. Lives in [Hospital3 ] in [Location (un) 5087], but most recently in rehab. Walks with a walker at baseline. - Tobacco: Previous smoker - Alcohol: None currently - Illicits: None Family History: Father: Deceased age 79 with cardiac problem Mother: Deceased age 82 with stroke Brother: Deceased age 78 colon cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.1 BP 120/53 HR 79 RR 18 O2 93-96 on 2-3LNC General: Alert but very confused, nearly non-verbal. Mild respiratory distress. HEENT: NC/AT, sclera anicteric, dry mucous membranes, oropharynx clear with dentures in place. Neck: supple, JVP elevated to 10cm when upright, no LAD though he does have a ? lipoma at the neck base on the left. Lungs: Initially diffusely rhoncorus, now improving with diuresis. Crackles at bilateral bases. CV: tachycardic, irregular, no audible murmurs or gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing. Ecchymoses on hands and forearms. DISCHARGE PHYSICAL EXAM: VS: T 97.7 Tmax 98.4 BP 121/76 (100-121) HR 78 (65-82) RR 18 O2 91-96 on RA I&O: 650/700 (+0) General: Alert, oriented to person and place. Responsive, hard of hearing. HEENT: NC/AT, edentulous, oropharynx clear Neck: with JVP of approximately 5 cm CV: Irregular, no murmurs Pulm: CTAB. Otherwise lungs clear to auscultation, no wheezes or rhonchi Abd: Soft, non-tender, non-distended. Ext: Warm and well-perfused, no LE edema, 2+DP pulses Pertinent Results: ADMISSION LABS: [2133-5-14] 04:35PM BLOOD WBC-6.8 RBC-3.16* Hgb-9.9* Hct-29.7* MCV-94 MCH-31.4 MCHC-33.4 RDW-18.1* Plt Ct-207 [2133-5-14] 04:35PM BLOOD PT-35.0* PTT-35.6* INR(PT)-3.5* [2133-5-14] 04:35PM BLOOD Glucose-98 UreaN-20 Creat-0.9 Na-144 K-3.4 Cl-108 HCO3-27 AnGap-12 [2133-5-15] 06:15AM BLOOD CK(CPK)-72 [2133-5-14] 04:35PM BLOOD cTropnT-0.08* [2133-5-14] 04:35PM BLOOD Calcium-7.8* Phos-2.8 Mg-2.0 [2133-5-15] 06:51AM BLOOD Type-[Last Name (un) ] pO2-44* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 DISCHARGE LABS: [2133-5-23]: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.3 3.20* 9.7* 30.7* 96 30.4 31.6 18.0* 167 INR: 1.6 Glucose UreaN Creat Na K Cl HCO3 AnGap 93 32* 1.6* 148* 3.5 113* 26 13 PERTINENT RESULTS: [2133-5-14] 04:35PM BLOOD cTropnT-0.08* [2133-5-15] 06:15AM BLOOD CK-MB-4 cTropnT-0.10* [2133-5-15] 04:05PM BLOOD CK-MB-5 cTropnT-0.08* [2133-5-16] 02:25AM BLOOD CK-MB-4 cTropnT-0.09* [2133-5-15] 06:15AM BLOOD VitB12-587 Folate-7.8 MICRO: [2133-5-14]: Blood cultures no growth x 2 sets [2133-5-15]: Blood cultures no growth x 2 sets [2133-5-14]: Urine culture no growth [2133-5-15]: C. diff toxin A & B negative [2133-5-20] 5:20 pm SPUTUM Source: Expectorated. FINAL REPORT [2133-5-22] GRAM STAIN (Final [2133-5-20]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. QUALITY OF SPECIMEN CANNOT BE ASSESSED. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2133-5-22]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. YEAST. MODERATE GROWTH. SECOND MORPHOLOGY. CXR Portable [2133-5-14]: FINDINGS: Lung volumes are profoundly diminished. The patient was imaged in a somewhat lordotic position. There is diffuse interstitial opacity with cephalad flow most consistent with volume overload likely due to congestive heart failure. Aortic tortuosity is present with calcified plaque seen at the arch. The cardiac silhouette size is difficult to assess but is enlarged. There is right pleural effusion with fluid tracking within the minor and major fissures. A left pleural effusion cannot be entirely excluded. There is poor visualization of the retrocardiac lung, possibly due to atelectasis and/or edema. No pneumothorax is noted. The bones are diffusely osteopenic with degenerative changes noted in both shoulder joints. IMPRESSION: Findings most compatible with congestive heart failure. Correlate clinically. Repeat radiography after appropriate diuresis recommended to assess for underlying infection. CT HEAD NON-CONTRAST [2133-5-16]: FINDINGS: No hemorrhage, edema, mass effect, or evidence for acute vascular territorial infarction is present. There is no shift of normally midline structures and [Doctor Last Name 352]-white matter differentiation appears well preserved. There is prominence of the ventricles and the sulci compatible with parenchymal atrophy. There are periventricular white matter hypodensities compatible with small vessel microvascular disease. However, no acute infarcts are present. Osseous structures appear intact and the visualized sinuses are clear. IMPRESSION: 1. Parenchymal atrophy and small vessel microvascular disease but no acute intracranial findings. SWALLOWING VIDEO FLUOROSCOPY [2133-5-21]: Swallowing videofluoroscopy was performed in conjunction with the speech and swallow department. Multiple consistencies of barium were administered. There was aspiration and penetration to thin liquids. ECG, [2133-5-14]: The underlying rhythm is probably atrial fibrillation. Left axis deviation. Intraventricular conduction defect. One ventricular premature beat is seen. Lateral ST-T wave changes likely due to left ventricular hypertrophy. Cannot exclude ischemia. Clinical correlation is suggested. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 81 [Telephone/Fax (3) 71191]/464 134 -40 118 ECG, [2133-5-19]: Atrial fibrillation with occasional ventricular premature beats. Intraventricular conduction delay. Left axis deviation. Late transition. Rate PR QRS QT/QTc P QRS T 76 0 150 446/474 0 -41 134 Brief Hospital Course: 81 year-old man w/ systolic/diastolic CHF (EF 45%, dry weight 215 lbs. in [1-/2132]), HTN, atrial fibrillation on Coumadin and vascular dementia, admitted for altered mental status, transferred to the MICU for altered mental status and hypoxia. . # Hypoxia: Most likely due to combination of acute decompensation of his CHF in the setting of diastolic dysfunction secondary to afib with RVR, as well as healthcare acquired pneumonia. HCAP: Patient completed a 8-day course of cefepime/vancomycin and was afebrile with normal WBC on discharge. Acute on chronic CHF: He received several doses of 40 IV Lasix. Subsequently, his exam appeared more dry so lasix was held. On discharge, he weighed 185 lbs and was 93-96% on RA. He will require daily standing weights, ins/outs monitoroing, volume assessment, and every other day (until stabilized) electrolytes monitoring. He can be restarted on his home dose of furosemide 40 mg daily for a goal of maintaining euvolemia. . # Toxic metabolic encephalopathy: Patient is extremely sensitive to metabolic insult, and has had wide fluctuations in his mental status with his recent infections and CHF exacerbation. CT head w/o contrast did not show acute process. Scopolamine patch was apparently given at rehab facility, and also likely contributed; this was discontinued. When he was able to take POs, home doses of Donepezil and Memantine were restarted. . # Afib on coumadin: Coumadin initially held for supertherapeutic INR (3.5). He was started on IV Metoprolol as he was unable to take POs. He was then transitioned to PO metoprolol (increased from 12.5 mg [Hospital1 ] to 25 mg [Hospital1 ]), and his heart rate remained well-controlled. His Coumadin was re-started at home dose of 2.5 mg, then increased to 3 mg on [2133-5-22]; INR at discharge is 1.6. INR will need to be checked on [5-25] and thereafter as needed for goal of INR [1-8]. . # Urinary Retention: Patient underwent Foley catheter placement after repeatedly failing voiding trials. Etiologies include BPH vs recent scopolamine patch. He underwent and failed a repeat voiding trial with PVR 700 [2133-5-22], and underwent TID straight catheterization thereafter. He was continued on Flomax with up-titrated dose (0.8 mg). As straight catheterization not available at rehab, a foley catheter was placed prior to transfer and will remain in place until follow-up with Dr. [Last Name (STitle) ] in Urology on [2133-6-2]. . #) Acute renal failure: His creatinine trended up from a baseline of 1.0 to 1.6 in the setting of aggressive diuresis. FeNa of 0.45% was consistent with pre-renal intravascular depletion. He was hydrated with gentle IVF. ACE inhibitor and furosemide were held and medications renally dosed. Creatinine was stable (1.6) at time of discharge, up from baseline of 1.0. His ACE-I may be restarted as outpatient when his creatinine returns to baseline. His renal function should be monitored at the rehab every other day as needed until improved. . #) Nutrition: Due to suspicion of aspiration, the patient was evaluated by speech and swallow and underwent a video swallowing study that showed evidence of aspiration with thin liquids. He was started on a Pureed (dysphagia) diet with Nectar prethickened liquids, which he tolerated. His medications were crushed. \ . # S/p fall: patient found down [5-15] on the floor. Not complaining of focal pain, but he has difficulty cooperating fully with a neurologic exam. He does open eyes to command and squeeze fingers when asked. CT head without acute ICH. . #) Hyperlipidemia: Patient was continued on home dose of 5mg simvastatin when able to tolerate POs. . #) Gout: Allopurinol renally dosed. Can increase to usual 400 mg daily as renal function improves. . #) Outpatient management: Once admitted to rehab, the patient needs every other day blood labs to monitor serum electrolytes, creatinine, INR, and daily weights. Plan to monitor volum status clinically to reach a balance between his CHF and renal failure. Outpatient urology follow-up as above. Medications on Admission: - Allopurinol 400mg daily - Vitamin C 500mg daily - benefiber - lasix 40mg daily - Vitamin D [2121] daily - Pantoprazole 40mg [Hospital1 ] - Namenda 10mg [Hospital1 ] - Donepezil 10mg daily - Simvastatin 5mg daily - Tamsulosin 0.4mg daily - Warfarin 2.5mg daily (INR on [2133-5-11] 2.6) - Miralax - Azithromycin 500mg daily X 7 days last day was day of admission - Lopressor 12.5mg [Hospital1 ] - CTX 1gm IV daily X 10 days - Scopalamine patch Discharge Medications: 1. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:0 Refills:0 2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:0 Refills:0 3. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical HS (at bedtime). Disp:0 Refills:0 5. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 8. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:0 Refills:0 11. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:0 Refills:0 12. Benefiber (guar gum) Packet Sig: Two (2) tsp PO once a day. 13. Miralax 17 gram Powder in Packet Sig: Seventeen (17) gm PO once a day as needed for constipation. 14. Outpatient Lab Work Please check Chem 10 and INR on Monday [5-25], Wednesday [5-27], Friday [5-29], and thereafter as needed [Name6 (MD) ] rehab MD. 15. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day. 16. Foley placement Pt was straight-cathed tid at [Hospital1 18]; please place foley catheter on arrival to rehab facility 17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 25112] in [Location (un) 5087] Discharge Diagnosis: Primary diagnosis: Heart failure exacerbation with acute renal insufficiency Healthcare-associated pneumonia Secondary diagnosis: Chronic systolic/diastolic heart failure Atrial fibrillation Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. O2 saturation: 93-95% on RA at rest. Discharge Instructions: You were admitted to [Hospital1 18] with altered mental status and shortness of breath. You were found to have a pneumonia and too much fluid in your lungs (heart failure exacerbation). You were given antibiotics for 8 days for the pneumonia, as well as medication to help remove the extra fluid. Your symptoms improved and you were discharged to a rehab facility. We also monitored you for worsened kidney function; this was stable on discharge. In the setting of your acute illness, there was concern for your ability to swallow liquids/food without aspirating. You were evaluted by the swallowing team and underwent a swallowing study. You aren't able to swallow well when you drink thin liquids (water), so you will need to continue to crush your pills and stay on a puree diet. We made the following changes to your home medications: 1. We increased Tamsulosin (Flomax) to 0.8 mg instead of 0.4 mg 2. We increased Metoprolol to 25 mg twice daily instad of 12.5 mg twice daily 3. We have held your furosemide (Lasix) for now; this can be restarted as needed at your rehab. 4. We decreased your allopurinol to 150 mg daily instead of 400 mg daily until your kidney function improves 5. We stopped your scopalamine patch Followup Instructions: Urology Follow-Up Name: [Last Name (LF) ], [First Name7 (NamePattern1) 122] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: UROLOGY PRACTICE ASSOCIATES Address: [Street Address(2) 18723], [Location (un) ],[Numeric Identifier 18724] Phone: [Telephone/Fax (1) 18725] When: Tuesday, [2132-6-2]:30AM Neurology Follow-Up: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8384], MD Phone:[Telephone/Fax (1) 1690] Date/Time:[2133-5-27] 1:00 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2285]	[ "600.91", "799.02", "V49.86", "414.01", "290.40", "458.29", "428.0", "787.22", "349.82", "E941.1", "788.21", "276.52", "780.97", "428.43", "E884.4", "584.9", "V15.82", "401.9", "412", "486", "437.0", "272.4", "V58.61", "427.31", "274.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	14516, 14596	8314, 12394	282, 348	14832, 14907	4770, 8291	16307, 16954	2651, 2771		12908, 14493		14617, 14617		12420, 12885			15054, 15881		4569, 4751						2811, 3530					15899, 16284																		233, 244									376, 1948			14748, 14811		4032, 4553	14636, 14727			14922, 15030						1970, 2261	2277, 2635		3555, 3997
23,278	132,250	47136	Discharge summary	report	Admission Date: [2166-6-19] Discharge Date: [2166-6-26] Date of Birth: [2115-6-25] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Codeine / Bactrim Ds / Keflex / Iodine Attending:[First Name3 (LF) 2181] Chief Complaint: nausea and vomitting with abd pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy intubation and ventilation History of Present Illness: Pt is a 50 yo woman who developed n/v on [2166-6-16] with resolution of sxs. Sxs redeveloped [6-18] around noon. She had [5-18] bouts of n/v subsequently and she presented to [Hospital1 18] for evaluation. Past Medical History: thyroid cancer s/p partial thyroidectomy 20 yrs ago GERD asthma IBS allergic to cipro and codein Social History: lives in [Hospital3 ] with son former portrait photo shop worker Family History: noncontributory Physical Exam: admission 98.5 136/93 105 96% RA 18 uncomfortable appearing but not in acute distress no carotid bruits CTA bilaterally tachycardic, nl S1 and S2, no murmurs nbs, soft, nondistended, moderate bilateral upper quad tenderness, positive [Doctor Last Name ] sign, no rbd no c/c/e Pertinent Results: [2166-6-19] 05:25AM GLUCOSE-117* UREA N-16 CREAT-0.9 SODIUM-141 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [2166-6-19] 05:25AM ALT(SGPT)-169* AST(SGOT)-83* ALK PHOS-149* AMYLASE-1120* TOT BILI-0.3 [2166-6-19] 05:25AM LIPASE-1299* [2166-6-19] 05:25AM TSH-0.020* [2166-6-19] 05:25AM WBC-12.2* RBC-4.24 HGB-12.2 HCT-37.2 MCV-88 MCH-28.7 MCHC-32.7 RDW-13.7 [2166-6-19] 05:25AM PLT COUNT-256 [2166-6-19] 12:02AM URINE HOURS-RANDOM [2166-6-19] 12:02AM URINE GR HOLD-HOLD [2166-6-19] 12:02AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2166-6-19] 12:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2166-6-18] 09:00PM PT-11.5 PTT-20.6* INR(PT)-1.0 [2166-6-18] 08:50PM GLUCOSE-129* UREA N-16 CREAT-1.0 SODIUM-139 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-31 ANION GAP-11 [2166-6-18] 08:50PM estGFR-Using this [2166-6-18] 08:50PM ALT(SGPT)-235* AST(SGOT)-133* LD(LDH)-231 ALK PHOS-173* AMYLASE-2479* TOT BILI-0.5 [2166-6-18] 08:50PM LIPASE-2709* [2166-6-18] 08:50PM CALCIUM-9.6 PHOSPHATE-3.0 MAGNESIUM-2.1 [2166-6-18] 08:50PM WBC-12.3# RBC-4.74 HGB-13.9 HCT-40.6 MCV-86 MCH-29.2 MCHC-34.1 RDW-14.0 [2166-6-18] 08:50PM NEUTS-88 BANDS-4 LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2166-6-18] 08:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2166-6-18] 08:50PM PLT SMR-NORMAL PLT COUNT-263 Brief Hospital Course: In the ED, labs were notable for elevated lipase and amylase in excess of 2K. Ultrasound revealed dilated CBD with evidence of stones. She was given abx, admitted to 12R. GI and surgery consulted. Pt went to ERCP initially on [2166-6-19] and thept acutely desaturated her O2 to the 60's. Anesthesia was summoned and she received positive pressure ventilation with resolution of her desaturation. She had repeat ERCP on [2166-6-20] with scheduled anesthesia and she was found to have tracheal stenosis. She had an aspiration event during intubation. At ERCP, they removed a small stone and performed a sphinterotomy. She was sent to the [Hospital Unit Name 153] post procedure while remaining intubated late [2166-6-20]. on arrival to the [Hospital Unit Name 153], she was noted to be febrile to 101.5. She was restarted on Zosyn. She was extubated [6-21]. Given lasix in ICU. Developed yeast vaginitis in ICU. Amylase and lipase began to normalize after ERCP. Tx'ed to 12R on [6-22] at 1900. Pt's respiratory rapidly improved and she did not need supplemental O2 after arrival to 12R. She remained on abx until discharge. She gradually was able to tolerate more po's and at discharge, she was eating a BRAT diet without any pain. I spoke with Dr. [Last Name (STitle) ] and he recommended that she f/u in one week for elective CCY. I reviewed this with pt and her partner. They had previous plans for a vacation at the end of [Month (only) ] and preferred to delay surgery until [Month (only) 205]. Dr. [Last Name (STitle) ] reviewed this with them in person. I advised her to f/u in [Hospital 3782] clinic with both Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 62932]. She received nystatin throughout her stay for yeast vaginitis. Her thyroid function tests were checked in the ICU and they were not normal. I reviewed this with pt and advised her to f/u with her pcp for recheck when she was not acutely ill. I also asked her to f/u with pcp to discuss the tracheal stenosis. Medications on Admission: Prilosec TUMS synthroid 125 mcg daily Pepcid Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 1 Refills:0 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: aspiration pneumonia bile duct obstruction due to stones yeast vaginitis tracheal stenosis hypokalemia hypothyroidism Discharge Condition: stable Discharge Instructions: Seek medical attention if you are not feeling well or if you develop any abd pain or n/v or fever Followup Instructions: followup with your pcp, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 62932] at [Hospital 778] clinic and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Hospital1 ] surgery clinic	[ "V10.87", "560.1", "507.0", "616.10", "576.1", "574.51", "577.0", "244.9", "112.1", "276.8", "519.19" ]	icd9cm	[ [ [] ] ]	[ "51.85", "97.56", "51.88", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	5323, 5329	2794, 4838	350, 404	5491, 5500	1209, 2771	5646, 5915	877, 894		4933, 5300		5350, 5470		4864, 4910			5524, 5623								909, 1190																							276, 312									432, 655															677, 775	791, 861
58,460	168,951	52497	Discharge summary	report	Admission Date: [2182-8-3] Discharge Date: [2182-8-20] Service: MEDICINE Allergies: Nsaids Attending:[First Name3 (LF) 2297] Chief Complaint: Generalized weakness Major Surgical or Invasive Procedure: ERCP Upper endoscopy Colonoscopy Endotracheal intubation PICC line Right IJ CVL Righ wrist arthrocentesis History of Present Illness: 88 year old female with multiple medical problems including dementia, hypothyroidism, rheumatoid arthritis, and A.Fib on coumadin presents with one week of generalized weakness and not feeling well. Pt also c/o vague abdominal discomfort and, today, nausea and anorexia. In ED noted to have an inflamed wrist joint - this was tapped and there was no evidence of infection. Wrist films showed a wrist fracture and she was placed in a splint. On further history-taking the pt does recall falling on the right hand "a couple of weeks ago". She was also noted to have elevated LFTs and an abdominal CT and ultrasound showed choledocholitiasis without acute cholecystitis. The studies were not changed since [2181-12-8]. She received a dose of Zosyn in the ED as "empiric therapy for presumed intra-abdominal pathology". She was seen by Surgery in the ED, and no surgical problems were identified. GI Consultation was suggested. Was last admitted here from [2182-7-5] through [2182-7-7] for mental status changes, which were thought to be due to Ultram +/- Detrol (both were stopped) in the setting of probable [Last Name (un) 309] body dementia. ROS: denies SOB, chest pain, bowel or bladder problems, currently denies abdominal pain or nausea. Asks for a drink of water. Pain in right wrist region is tolerable. All other systems negative. Past Medical History: Atrial fibrillation Hypothyroidism Hypertension H/o Diastolic Dysfunction Hypercholesterolemia Gastroesophageal reflux disease Arthritis - severe degenerative; ? RA - on low dose prednisone Status post hysterectomy Rheumatic fever Chronic renal insufficiency: baseline creat 1.4-1.6 Dementia - ? early [Last Name (un) 309] body type Hypothyroidism Menigioma Social History: Social History: lives [Location 6409] w/ her daughter and grandson. Retired [Name2 (NI) ]. No tobacco or alcohol use. Has a PCA/HHA. Family History: Gastric CA - father at 83 [Name2 (NI) ] Physical Exam: T-96.0 BP-121/57 HR-70 RR-16 SaO2- 96 %RA Pleasant and cooperative. Morbidly obese. A & O x 3. HEENT-Negative. Neck-supple, non-tender, no JVD. Lungs-CTAB CV-RR, grade II/VI systolic murmur at apex, no rubs or gallops Abd-soft, obese, NT, ND, NABS, no HSM Extr-Right wrist in a splint. Fingers warm, sensation intact. No evidence of active joint inflammation elsewhere. No peripheral edema or calf tenderness. Neuro-Moves all 4 extremities equally against gravity (albeit with some difficulty in the LE). Sensation intact throughout. Pertinent Results: [2182-8-2] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 [2182-8-2] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [2182-8-2] 07:35PM JOINT FLUID WBC-2375* RBC-[Numeric Identifier 108444]* POLYS-85* BANDS-2* LYMPHS-1 MONOS-0 MACROPHAG-12 [2182-8-2] 07:17PM LACTATE-2.2* [2182-8-2] 07:05PM GLUCOSE-123* UREA N-21* CREAT-1.4* SODIUM-145 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-18 [2182-8-2] 07:05PM ALT(SGPT)-65* AST(SGOT)-121* CK(CPK)-72 ALK PHOS-142* TOT BILI-3.3* [2182-8-2] 07:05PM LIPASE-750* [2182-8-2] 07:05PM cTropnT-<0.01 [2182-8-2] 07:05PM WBC-12.7# RBC-4.01 HGB-12.1 HCT-36.6 MCV-91 MCH-30.2 MCHC-33.1 RDW-17.1* [2182-8-2] 07:05PM NEUTS-90.8* LYMPHS-6.0* MONOS-2.1 EOS-0.8 BASOS-0.3 [2182-8-2] 07:05PM PT-26.2* PTT-26.9 INR(PT)-2.5* [2182-8-2] 07:05PM PLT COUNT-231 [2182-8-2] Wrist XRAY RIGHT WRIST, FOUR VIEWS: There is a fracture of the distal radius with minimal distraction of a 4-mm fragment. There is mild positive ulnar variance. There is extensive soft tissue edema. There is an amorphous density in the region of the triangular fibrocartilage which may indicate chondrocalcinosis. There is degenerative change of the first CMC and triscaphe joints. IMPRESSION: Distal radius fracture with mild positive ulnar variance. [2182-8-5] ERCP Report Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Two regular stones ranging in size from 4mm to 6mm were seen at the biliary tree. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. The stones were extracted successfully using a balloon. Otherwise normal ercp to third part of the duodenum [2182-8-8] EGD The biliary sphincterotomy was identified and appeared normal. No bleeding was noted. No ulceration or erythema was noted. The sphincterotomy was observed for about 5 minutes - no bleeding was noted. Impression: Polyp in the stomach body Erythema and friability in the antrum No fresh or old blood was found in the stomach or duodenum. The biliary sphincterotomy was identified and appeared normal. No bleeding was noted. No ulceration or erythema was noted. The sphincterotomy was observed for about 5 minutes - no bleeding was noted. Otherwise normal ercp to third part of the duodenum Recommendations: No source for melena was found. Give Vit K and FFPs to keep INR < 1.5. [2182-8-12] Colonoscopy Large amount of stool was found in the whole colon. About 33% - 50% of the colonic mucosa was obscured by stool. Protruding Lesions A single sessile 10 mm polyp of benign appearance was found in the cecum. This involved the appendiceal orifice. Given patient's co-morbidities and poor bowel prep this was not removed. Impression: Polyp in the cecum - this was not removed. Poor bowel preparation Otherwise normal colonoscopy to cecum [2183-8-14] Transesophageal Echo Mild spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are thickened/deformed. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Significant aortic stenosis is present (not quantified). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. There is moderate-to-severe (3+) tricuspid regurgitation. IMPRESSION: No definite vegetations identified; thickened and calcified aortic valve leaflets, with aortic stenosis present (not quantified). [8-16] MRI C - T - L Spine IMPRESSION: 1. Markedly limited examination with no obvious findings to suggest vertebral body/disk/epidural infection. 2. Interval increase in size of extramedullary intradural soft tissue mass at the C7-T1 interspace, resulting in rightward cord deviations/mass effect. The lesion is most likely a meningioma. If alteration in care will occur, can consider repeat dedicated target imaging through this region once patient is able to tolerate exam. 3. Mild anterior wedge compression deformity involving T5 which appears new from [2174] exam but not acute. Additional multilevel cervical and lumbar spondylosis is not significantly changed. [8-17] CT ABD/PELVIS: IMPRESSION: 1. Normal appearance to the spleen. 2. Air and contrast in the gallbladder and left biliary system related to prior sphincterectomy and ERCP. No pericholecystic fluid or inflammatory changes to suggest cholecystitis. 3. Focal stranding of the right pannicular fat may represent asymetric edema or panniculitis . 4. Moderate bilateral pleural effusions with bibasilar atelectatic changes. [8-19] CT Head w/o contrast: Study severely limited by motion artifact. A contrast-enhanced MRI, or contrast-enhanced CT if the patient cannot tolerate MRI, would be more sensitive for an abscess. [8-20] CXR: The ET tube tip is 5 cm above the carina. Tube tip is in the mid low esophagus and should be advanced 10-15 cm. The cardiac silhouette is enlarged, unchanged since the prior study. The bibasal atelectasis is present but there is no evidence of overt failure. The left internal jugular line tip is at the junction of the brachiocephalic vein and SVC. The left basal opacity most likely represents area of atelectasis and is unchanged since the prior study. Brief Hospital Course: 88 year-old woman with history of morbid obesity, HTN, atrial fibrillation on warfarin, and diastolic heart failure who presented with gallstone pancreatitis and a right wrist fracture. She underwent ERCP and sphincterotomy which was complicated by hypoxia and hypotesnion. She was transferred to [Hospital Unit Name 153] and remained there for less than 24 hours and was called out to medical floor on [2182-8-6]. Her post-procedure course was complicated by multiple episodes of melena with progressive anemia. Her course was further complicated by: NSTEMI, MRSA and Coag negative staph bacteremia and septicemia and Acute Renal Failure. Hospital course by problem is as follows. # Fevers/bacteremia: Pt was febrile on [8-9] to 100.9 and BCx were positive for MRSA. Repeat U/A was negative for UTI. Cipro was discontinued and vancomycin was started at 1500mg q24h. Pt had mild temp (100-101) on [8-10]. PICC line was pulled, and central line was placed. BCx prelim on [8-10] & [8-11] show gram (+) cocci, coag negative. On [8-13], pt had Tm 100.2. Concern for subacute endocarditis (staph viridans vs staph epidermidis), but TEE negative for endocarditis. On [8-15], pt complained of back pain. MRI of spine did not reveal epidural abscess/osteo/diskitis. CT abd only shows panniculitis of the right pannicular fat. CT scan of head was negative. From [8-17] to [8-20], pt became intermittently hypotensive. Empiric treatment with Zosyn was started. She received 3L IVF from [Date range (1) 9458], and 500cc on 7/14am. Pt BP responded initially, but now 90s/60s. Lactate level increased to 4.0 on [8-20] (venous blood). Pt was transferred to [Hospital Unit Name 153], upon arrival the patient's condition appeared to be stable but she quickly decompensated. She was bolused 4L NS w/ little response, a CVL was introduced for monitoring and she was started on pressors. She was intubated shortly after. She continued to decompensate and a decision to make her DNR was taken by the family. The patient became progressively bradycardic and died of cardiorespiratory failure at 8:25 pm. Most likely cause of death was felt to be overwhelming sepsis causing severe acidosis. # Gallstone pancreatitis: She presented with abdominal pain, low-grade fevers, and an elevated lipase in the setting of choledolithiasis. She underwent ERCP with sphincterotomy and removal of two stones. Her lipase trended down afterward. She was evaluated by surgery who felt that she was not currently a candidate for cholecystectomy given her co-morbidities but recommended she follow-up as an outpatient. As noted above, she had multiple episodes of melena post procedure. On [2182-8-20], however patient LFTs increased. Concern for toxic shock liver versus recurrence of biliary obstruction. # Acute Renal Failure: On [8-17], pt's creatinine increased from 1.0 to 2.1. This was initially attributed to hypovolemia. However, despite fluid resuscitation, creatinine continued to increase to 3.9 on [8-20]. # Progressive anemia with melena: She had three episodes of melena after ERCP with a four point hematocrit drop, but her hematocrit later stabilized at 25-26 g/dl without transfusion. She was thought to have bleeding from her sphincterotomy but no active bleeding was visualized on EGD, and the only pathological findings were a beefy antrum and a gastric polyp with a non-bleeding ulcer. Vitamin K was administered to correct her coagulopathy (INR 2) and her melena resolved, with brown stools that were still guaiac positive as of [2182-8-11]. Coumadin was stopped despite the high risk of stroke because of the GI bleeding. # Meningioma: MRI revealed increase in mass, likely a meningioma, in her her T-spine. Neurosurgery consulted. They had no recommendations at this time beyond outpatient follow-up when patient is medically stable. # Atrial fibrillation: She was on warfarin at home but this was held at the time of admission because of the need for a procedure (ERCP). She will be discharged without warfarin because of her high risk of bleeding, despite her high CHADS score, and this was discussed with her family and her home nurse. Wafarin can be restarted as an outpatient after her hematocrit stabilizes. # Right wrist fracture: She fell at home and suffered a non-displaced distal radius fracture. She was seen by ortho in the ED and a splint was placed. On [8-9], pt's fingers of R hand became more swollen. Ortho repeated XR, which revealed no change from previous image. On [8-16], pt removed splint on own. Complains of worsening wrist pain. Ortho consulted. Repeat films show fx healing. OT consult on [8-19] for short open splint for wrist, and ROM as tolerated. OT was consulted, and a custom short splint was placed. Needs follow up in ortho clinic in 3wk with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 1228]). # Chronic diastolic heart failure: She was continued on lasix and had no acute issues. Medications on Admission: Atenolol 50 mg PO Daily, Furosemide 40mg PO Daily, Lovastatin 20 mg PO Daily, Omeprazole 20 mg PO Daily, Prednisone 5 mg PO Daily, Tramadol 50 mg PO prn pain, Synthroid 50 mcg PO Daily, Alendronate 35 mg PO Qweekly, Aspirin 81 mg PO Daily, Colace 100 mg PO BID, [Doctor First Name ] 325 mg PO Daily, Warfarin 4 mg PO Daily except for Saturday and Sunday 5 mg PO. Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "707.03", "428.32", "211.1", "244.9", "574.50", "847.0", "285.1", "410.71", "531.90", "714.0", "211.3", "038.19", "414.01", "E928.9", "274.9", "428.0", "307.81", "707.22", "E888.9", "V58.61", "530.81", "511.9", "570", "998.11", "577.0", "E878.8", "276.2", "995.92", "585.2", "403.90", "813.42", "584.9", "112.9", "562.10", "038.12", "427.31" ]	icd9cm	[ [ [] ] ]	[ "81.91", "88.72", "38.93", "51.85", "45.23", "45.13", "51.88" ]	icd9pcs	[ [ [] ] ]	14243, 14252	8777, 13825	234, 341	14303, 14312	2915, 8754	14369, 14379	2290, 2335				14273, 14282		13851, 14220			14336, 14346								2350, 2896																							174, 196									369, 1726															1748, 2112	2145, 2274
2,291	121,937	23510	Discharge summary	report	Admission Date: [2139-10-5] Discharge Date: [2139-10-14] Date of Birth: [2071-10-20] Sex: F Service: MEDICINE Allergies: Hydrocodone Attending:[First Name3 (LF) 330] Chief Complaint: worsening shortness of breath Major Surgical or Invasive Procedure: Intubation and Mechanical Ventilation History of Present Illness: 67 /o F w/ PMHx of COPD on home O2, Lung cancer s/p resection presented with worsening SOB. Initially admitted for SOB worse than baseline occuring at rest and limiting activity for [5-1] days. She had low grade fevers associated with this SOB and a mild episodic cough with production of yellowish sputum. She also complained of substernal chest pain on admission. . She was admitted for evaluation, she was ruled out for MI. A chest CT was performed to rule out PE which showed chronic emphysema. . Overnight prior to transfer she had episodes of shortness of breath with desaturations into the 80s. She was given multiple nebulizers with some minor improvement. She was noted to be choking and some food was found in her mouth. She was suctioned and her secretions were noted to be thick. On the floor she had increased shortness of breath and was in severe respiratory distress. An ABG was sent and was 7.33/79/84, the quantity of FIO2 was decreased and a repeat ABG was 7.29/88/80. Based upon this it was felt she was tiring so she was transfered to the ICU and intubated for respiratory distress. Past Medical History: 1. Lung cancer, s/p partial resection of left lung (?left upper lobe) and radiation therapy. No chemotherapy. Treatment was at [Hospital1 336]. 2. Emphysema, on home O2 3. Chronic hoarseness secondary to radiation therapy 4. Hypothyroidism 5. s/p tonsillectomy and adenoidectomy 6. Early menopause (age 28), never on hormones 7. On diltiazem, unknown why. Patient denies hypertension, irregular heart rate. Social History: Divorced woman, currently living at [Hospital3 2558]. Has brother in [Name (NI) 3146] and son in [State ]. Used to work as private nurse's aide. Reports 2 ppd since age 7 (~60 years) and now down to 1 cigarette per day x7 months (since moving in to [Hospital3 2558]). Says she takes off oxygen when she smokes. Used to drink alcohol 3-4 times per week, and would have [6-7] cans of beer at one time. No alcohol for 3 years. Denies any other recreational drugs. Family History: Doesn't know any other family history because "I never see them." Physical Exam: Temp 98, Pulse 93, BP 136/80, Sats 95% on 100% face mask Post extubation P 97, BP 91/50 RR 16 O2 sat 100% Gen: cachectic female in clear respiratory distress unable to complete full sentences. HEENT: MM dry, OP clear Heart: RRR, nl S1S2, no m/r/g Lungs: distant sounds, decreased air movement bilaterally, no wheezing abd: s/NT/ND Ext: no edema Pertinent Results: Lung VQ Scan Diffuse airway disease. With this degree of disease manifest by clumping it is likely that a perfusion scan would be nondiagnostic. CTA Chest 1. No acute pulmonary embolus. 2. Moderate mainly centrilobular emphysema throughout. 3. A least 2 small(sub 6mm) areas of nodularity m nonspecfic, and unlikely to be clinically significant, but interval follow up in 6 months should be considered to ensure stability. Chest Xray [10-13] Interval collapse of the left lung, most likely from an obstructing mucus plug given the acuity. Chest Xray [10-14] Expansion of left upper lobe [2139-10-13] 12:40PM BLOOD WBC-14.9* RBC-3.26* Hgb-9.6* Hct-29.7* MCV-91 MCH-29.5 MCHC-32.3 RDW-16.0* Plt Ct-332 [2139-10-13] 12:40PM BLOOD Neuts-91* Bands-0 Lymphs-1* Monos-6 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [2139-10-13] 12:40PM BLOOD Plt Ct-332 [2139-10-8] 03:44PM BLOOD PT-12.8 PTT-36.3* INR(PT)-1.1 [2139-10-5] 04:15PM BLOOD D-Dimer-1078* [2139-10-13] 12:40PM BLOOD Ret Aut-0.4* [2139-10-13] 04:46AM BLOOD Glucose-89 UreaN-21* Creat-0.8 Na-141 K-4.4 Cl-99 HCO3-38* AnGap-8 [2139-10-13] 12:40PM BLOOD LD(LDH)-222 [2139-10-8] 11:55PM BLOOD CK(CPK)-41 [2139-10-8] 03:44PM BLOOD CK(CPK)-69 [2139-10-6] 06:00AM BLOOD CK(CPK)-264* [2139-10-6] 12:53AM BLOOD CK(CPK)-300* [2139-10-5] 04:15PM BLOOD CK(CPK)-422* [2139-10-8] 11:55PM BLOOD CK-MB-NotDone cTropnT-0.08* [2139-10-8] 03:44PM BLOOD CK-MB-NotDone cTropnT-0.07* [2139-10-6] 06:00AM BLOOD CK-MB-7 cTropnT-0.01 [2139-10-6] 12:53AM BLOOD CK-MB-8 cTropnT-0.03* [2139-10-5] 04:15PM BLOOD CK-MB-7 cTropnT-0.02* [2139-10-13] 12:40PM BLOOD Iron-77 [2139-10-13] 12:40PM BLOOD calTIBC-198* VitB12-991* Folate-9.3 Hapto-329* Ferritn-332* TRF-152* [2139-10-6] 06:00AM BLOOD TSH-0.86 [2139-10-11] 03:35AM BLOOD Theophy-3.9* [2139-10-9] 05:38AM BLOOD Theophy-4.3* [2139-10-12] 06:12AM BLOOD Type-ART pO2-134* pCO2-63* pH-7.40 calHCO3-40* Base XS-11 Brief Hospital Course: # Respiratory distress - Patient with known baseline emphysema and lung resection p/w with worsening shortness of breath. CTA showed no evidence of PE, also has been ruled out for MI. Most likely this is COPD exacerbation with possible aspiration pnemonia vs. viral illness. She had fever, cough, sputum w/ elevated white counts with no infiltrate on CXR. During the hospital stay, developed aspiration PNA and was intubated and ventilated. She had a favorable recovery post-intubation. She was continued on Combivent nebs, Prednisone, Theophylline (levels were monitored). She was also started on Levofloxacin for presumed PNA (to be continued for 5 days after discharge). Pt to benefit from Chest PT. . # Speech and Swallow eval: done and S&S suugested pureed solids and thin liquids and to advance diet cautiously. . # Lung Collapse: She developed total left lung collapse on [10-13] most likely secondary to mucus plugs. Respiratory suctioned her and repeat Xray the next day showed interval expansion of left lung. . # ARF: Creatinine elevated to 1.6 on admission which eventually trended down. . # UTI: intial UA showed RBC [11-15], WBC >50, Epi [2-28]; likely contaminated. A repeat Cx negative. . # Hypothryoidism: TSH levels normal, was continued on levothyroxine . # Dispo planning: the patient will benefit from chest PT as she is prone to mucus plugging. PT was involved w/ patient while in hospital. Also continue Levofloxacin for 5 days post-discharge. . # Code Status: was discussed w/ patient and she wanted to be DNR/DNI after she came out of the intubation in intensive care unit. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 6. Insulin injection Please continue insulin regimen as before 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2H (every 2 hours) as needed. 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q2H (every 2 hours) as needed. 9. Albuterol 90 mcg/Actuation Aerosol Sig: 4-8 Puffs Inhalation Q6H (every 6 hours). 10. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation QID (4 times a day). 11. Theophylline 100 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QAM (once a day (in the morning)). 12. Theophylline 200 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO QPM (once a day (in the evening)). 13. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for aggitation. 14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 20. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 21. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 22. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 23. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: COPD excerbation Aspiration Pneumonia Collapse of left lung secondary to mucus plug Discharge Condition: all vitals are stable Discharge Instructions: Please take all your medications and follow up with your appointments. Please report to the ED or to your physician if you have any concerns at all. . Please continue with Chest physical therapy Followup Instructions: Please make an appointment to see your primary care physician [Last Name (NamePattern4) ] [7-5] days. Completed by:[2139-10-14]	[ "599.0", "V10.11", "518.81", "507.0", "934.9", "276.2", "584.9", "491.21", "244.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	8736, 8806	4884, 6497	303, 343	8934, 8958	2875, 4861	9201, 9343	2428, 2495		6520, 8713		8827, 8913					8982, 9178								2510, 2856																							234, 265									371, 1479															1501, 1914	1930, 2412
303	103,013	12016	Discharge summary	report	Admission Date: [2163-3-29] Discharge Date: [2163-4-4] Date of Birth: [2142-4-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10293] Chief Complaint: 20 year old male s/p unintentional APAP overdose. Major Surgical or Invasive Procedure: None History of Present Illness: 20 year old male transferred from [Hospital1 112] for liver transplant evaluation after percocet overdose. On Sunday [3-27] had a stressful day and pt took approximately 20 percocet (5/325) throughout the day after a series of family arguments. Denies trying to hurt himself. Parents confirm to suicidal attempts in the past. Pt felt that he had a hangover on Monday secondary to "percocet withdrawal" and took an additional 5 percocet. Pt was admitted to the SICU and followed by Liver, Transplant, Toxicology, and [Month/Year (2) ]. He was started on NAC q4hr with gradual decline in LFT's and INR. His recovery was c/b hypertension, for which he was started on clonidine. Pt was transferred to the floor on [4-1]. Past Medical History: Bipolar D/o (s/p suicide attempts in the past) ADHD S/p head injury [2160]: s/p MVA with large L3 transverse process fx, small right frontal epidural hemorrhage-- with post-traumatic seizures (was previously on dilantin, now dc'd) Social History: Father is HCP, student in [Name (NI) 108], Biology major, parents and brother live in [Name (NI) 86], single without children, lived in a group home for 3 years as a teenager, drinks alcohol 1 night a week, denies illict drug use, pt in [Location (un) 86] for neuro eval Family History: no liver disease Physical Exam: VS. 96, 154/90, 67, 20, 97%RA Gen. comfortable, appears combative at times, using swears words, then appreciative at other times Heent. MMM Chest. CTA ant Cor. RR, nl s1 s2 Abd. +BS, soft, slight tenderness to palpation, improved overall, no rebound or guarding. Ext. no edema Pertinent Results: [2163-3-29] 11:53PM BLOOD WBC-6.4 RBC-4.71 Hgb-14.0 Hct-41.6 MCV-88 MCH-29.8 MCHC-33.7 RDW-14.2 Plt Ct-50# [2163-3-29] 11:53PM BLOOD Plt Smr-VERY LOW Plt Ct-50# [2163-3-29] 11:53PM BLOOD PT-23.7* PTT-28.9 INR(PT)-3.6 [2163-3-29] 11:53PM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137 K-4.7 Cl-98 HCO3-30* AnGap-14 [2163-3-30] 03:36AM BLOOD ALT-[Numeric Identifier 37727]* AST-9060* LD(LDH)-5544* AlkPhos-75 Amylase-49 TotBili-5.0* [2163-3-29] 11:53PM BLOOD Lipase-32 [2163-3-29] 11:53PM BLOOD Albumin-3.4 Calcium-8.0* Phos-1.0# Mg-1.5 [2163-3-30] 03:36AM BLOOD Hapto-275* [2163-3-30] 04:49PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE [2163-3-30] 12:11PM BLOOD [Doctor First Name ]-NEGATIVE [2163-3-30] 04:49PM BLOOD HIV Ab-NEGATIVE [2163-3-30] 03:36AM BLOOD Phenyto-<0.6* Valproa-<3.0* [2163-3-29] 11:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2163-3-29] 11:53PM BLOOD HCV Ab-NEGATIVE [2163-3-30] 10:53AM BLOOD Type-[Last Name (un) ] pO2-45* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 CT Abd: LLL PNA There is a confluent air space opacity within the left lower lobe consistent with pneumonia. The right lung is grossly clear. There are no pleural effusions. The liver, gallbladder, spleen, pancreas, adrenal glands, and right kidney appear grossly normal. There are at least two (2) tiny low attenuation foci arising from the left kidney which are too small to characterize further. Stomach and visualized loops of small and large bowel are unremarkable. No pathologically enlarged retroperitoneal or mesenteric lymph nodes are present. There is no free fluid. Head CT: There is no intracranial hemorrhage. C-spine CT: There is no evidence of fracture or dislocation. There are numerous cervical lymh nodes seen and thickening of the adenoidal/nasopharyngeal soft tissues. Clinical correlation recommended. Brief Hospital Course: [Known firstname 20069] [Known lastname 37728] ia a 20 yo male with h/o bipolar disease, ADHD, h/o seizures p/w acute hepatitis due to unintentional percocet overdose. Acute Hepatitis due to APAP overdose: He was initially admitted to the SICU where he was evaluated by the liver transplant team. Luckily, his ALT/AST trended down with 17 doses of N-Acetylcysteine from a peak of 22,000/14,00 respectively, and an INR peak of 6.6. With his improvement, he was transferred to the floor on [4-1], with continued improvement of his LFT's. An abd CT was not surprising, showing expected signs of inflammation around the liver. Pt's abdominal pain was improving on discharge. Hypertension: in setting of acute hepatitis. Pt was treated with clonidine in house with. Anticipate resolution with resolution of acute process. ?Bipolar Disease/ADHD: Followed by psychiatry in house. They recommend not medically treating his reported diagnoses given pt could not provide names of any psychiatrists, and the psychiatry team questioned the pt's diagnoses. Pt will follow up with outpatient psychiatry, and was given the number of a psychiatry practice near his home. LLL PNA: Likely due to aspiration while pt was acutely sick. Pt spiked to 101.9, with evidence of LLL PNA on abd CT. He was started on Levo/Flagyl [4-2] for 1 week. He remained comfortable on room air and afebrile. ? H/O Seizures d/t subdural hemorrhage in setting of CVA in [2160]: Pt reported being on dilantin and depakote for seizures/mood stabalization. However, I spoke with both his PCP and primary neurologist who have no record of him being on either medication, and no record of him ever having a seizure. Further, he had an EEG for headaches on [2163-4-22] that was normal. Pt's dilantin and depakote levels on admission were below assay. Pt was not place on either dilantin or depakote. He remained seizure free in house and head CT showed no evidence of subdural hematoma as present three years ago after his car accident. He will follow up with outpatient neurology. Drug seeking behavior: Pt was clearly pain med seeking, being verbally abusive to staff. His episode of falling off the toilet [4-2] was likely due to opioid overuse, with no subsequent evidence of trauma on exam or CT. With some struggle, we have negotiated switching him from IV to PO dilaudid. He will be d/c'd off dilaudid, with a few oxycodones for breaktrough pain. Comm: PCP [Name9 (PRE) ] [Name (NI) ] [Telephone/Fax (1) 8539], Neuro [Doctor Last Name 10653] [Telephone/Fax (1) 37729] in [Location (un) ]. Dispo: Pt was discharge home with PCP, [Name10 (NameIs) ], GI, and neuro followup plans. Medications on Admission: Per patient: Dilantin (for seizure prophylaxis) Depakote Dexedrine Percocet prn Wellbutrin Xanax Neurontin --doses unknown Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:15 Tablet(s) Refills:0 3. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [5-4] hours for 3 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Acute Hepatitis d/t Tylenol Overdose 2. Hypertension 3. Drug seeking behavior 4. ?Bipolar Disease 5. LLL Pneumonia Discharge Condition: Pt was in good condition, afebrile, on room air, with stable vital signs. Discharge Instructions: Follow up with Dr. [Last Name (STitle) ] on Friday. Please call your other doctors at the [Name5 (PTitle) 37730] provided so that you may follow up with them. Do not take any medications with Tylenol, including Percocet, until directed otherwise by your doctor. Followup Instructions: See you primary care doctor, Dr. [First Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 8539] (phone), on Friday at 1pm (appointment made). Call Dr.[Name (NI) 37731] office at [Telephone/Fax (1) 37732] for a follow up GI visit in 2 weeks. Call your neurologist, Dr. [Last Name (STitle) 10653] [Telephone/Fax (1) 37729], for an appointment next week. Call [Hospital 86] Health Care at [Telephone/Fax (1) 37733] for a follow up psychiatric appointment in 2 weeks.	[ "V65.2", "296.80", "E849.9", "965.09", "401.9", "E950.0", "486", "780.39", "790.92", "314.01", "965.4", "305.90", "570" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7268, 7274	3993, 6716	365, 371	7435, 7510	2041, 3721	7830, 8337	1711, 1729		6889, 7245		7295, 7414		6742, 6866			7534, 7807								1744, 2022																							276, 327									399, 1137				3730, 3970											1159, 1395	1411, 1695
78,983	178,660	38785	Discharge summary	report	Admission Date: [2180-3-24] Discharge Date: [2180-4-1] Date of Birth: [2125-7-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: Left Empyema Major Surgical or Invasive Procedure: [2180-3-27] Left thoracoscopy and partial decortication of left lung. [2180-3-30] Flexible bronchoscopy History of Present Illness: The patient is a 54-year-old male with an approximately 12 cm loculated empyema in the left chest. He was treated initially with a chest tube that evacuated over a liter of frank pus. A post chest tube CT scan demonstrated markedly improved expansion of the left lung but there were some residual fluid collections within the pleural space. He was taken to the operating room for debridement and decortication. Preoperatively, we reviewed the risks of the operation with the patient and his sister. We discussed the risk of bleeding, reoperation, recurrence of the pleural effusion and death. Past Medical History: Obesity Social History: Lives alone Never smoked. ETOH once a week Family History: non-contributory Physical Exam: T 98.3, HR 86, BP 130/82, RR 18, O2Sa 95%RA GEN - NAD, A&O HEENT - NCAT, EOMI, MMM, trachea midline, neck supple CVS - RRR, nl S1 and S2 PULM - CTAB, no W/R/R, no respiratory distress ABD - S/NT/ND, no massess EXTREM - warm/dry Pertinent Results: [2180-3-31] WBC-16.6* RBC-2.76* Hgb-8.0* Hct-24.6 Plt Ct-661* [2180-3-30] WBC-21.2* RBC-2.88* Hgb-8.1* Hct-25.7* Plt Ct-713* [2180-3-24] WBC-23.3* RBC-3.35* Hgb-9.4* Hct-28.3* Plt Ct-578* [2180-3-29] Neuts-84.5* Lymphs-10.8* Monos-3.2 Eos-1.1 Baso-0.4 [2180-3-31] Glucose-112* UreaN-22* Creat-2.8* Na-143 K-3.3 Cl-107 HCO3-26 [2180-3-30] Glucose-114* UreaN-21* Creat-3.1* Na-142 K-3.6 Cl-107 HCO3-25 [2180-3-29] Glucose-120* UreaN-20 Creat-2.9* Na-139 K-4.1 Cl-104 HCO3-24 [2180-3-29] Glucose-101* UreaN-18 Creat-2.6# Na-136 K-4.0 Cl-105 HCO3-24 [2180-3-28] Glucose-88 UreaN-12 Creat-1.2 Na-135 K-3.7 Cl-102 HCO3-24 [2180-3-24] Glucose-99 UreaN-13 Creat-0.8 Na-130 K-3.8 Cl-94* HCO3-27 [2180-3-31] Calcium-8.2* Phos-4.2 Mg-2.3 [2180-3-25] calTIBC-122* Hapto-472* Ferritn-GREATER TH TRF-94* [2180-3-25] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2180-3-27] IgG-1611* IgA-390 IgM-96 Micro: [2180-3-30] BAL G/S -> no orgs [2180-3-29] renal u/s No hydro, bladder appears nl [2180-3-28] DFA Negative for Influenza A & B [2180-3-27] Pleural Tissue Final- no growth [2180-3-25] Urine Cx Negative [2180-3-25] Pleural Fluid Strep Milleri, GNR [2180-3-24] Blood Cx Negative CXR: [2180-3-31] FINDINGS: In comparison with the study of [5-29], the right IJ catheter has been removed. Post-surgical changes are again seen on the left with two chest tubes in place. Little overall change in the extent of the left pleural thickening or residual effusion. Chest CT [2180-3-26] IMPRESSION: 1. Marked decrease in the size of multiloculated left pleural fluid collections following placement of a left pleural drain. Small amount of loculated fluid and extensive pleural thickening persists. 2. Slight interval increase in the size of pericardial effusion. These findings should be closely followed clinically for the possibility of developing tamponade physiology. 3. Persistent left lobe dependent consolidation. 4. Mild gallbladder mural thickening. Would correlate this finding to physical examination for upper abdominal pain. If absent, could correlate to an outpatient abdominal ultrasound [2180-3-29] Renal US: 1. Patent hepatic vasculature. 2. No significant ascites is seen. 3. Multiple gallbladder calculi and moderately thickened gallbladder wall as identified on prior ultrasound scan [2180-3-24]. Brief Hospital Course: 54M admitted on [2180-3-24] from the ED after as a transfer from [Hospital3 3583] ED where he was found to have six weeks of fatigue, decreased energy. At [Hospital1 18] he was found to have a leukocytosis and on CT had a large left sided empyema occupying >50% of the left chest cavity. He was immediately started on Vanc and Zosyn and on HD 2 he underwent placement of a left sided pigtail catheter with the immediate outflow of thick pus > 1L. The patient did complain of some abdominal pain and was found to have cholelithiasis with thickening of the gallbladder wall on ultrasound, but there was no intrahepatic or extrahepatic biliary dilatation. An MRCP was performed because of the ultrasound findings and the patient's elevated biliruben to 3.4 at the time of admission, but his pain had begun to subside by HD 2 and his LFTs were all down trending. There was much less of a concern for acute cholecystitis. He was otherwise stable and tolerating a regular diet. On HD 3 a repeat CT of the chest confirmed that much of the empyema had drained but there was a persistent left lobe dependent consolidation and and extensive pleural thickening. On HD 4 he was taken to the operating room for a L VATS decortication, washout and chest tube placement. This procedure went well without surgical complication; for more information please see separate op note. During extubation the patient did become agitated and resultantly pulled out his IV access and dislodged the ET tube. The tube was promptly replaced but becuase the patient remained agitated, IM sedation was given including 5mg midazolam and 60mg ketamine. He was also hypertensive into the 200s systolic and given 10 labetolol. A central line was placed in the PACU and the patient remained intubated. His pressures then began to drift downward with MAPs 60-65. He was then started on phenylephrine drip up to 2mcg/kg/min. He was transferred to the ICU for monitoring, weaning of the pressors and respiratory managment. Overnight POD 0 he required a 500cc bolus of LR and 250 of 5% albumin as his Urine output was borderline low. On the morning of POD 1 he was alert, responsive to commands and down on his pressor to 0.8mcg/kg/min of phenylephrine. At 5pm his pressors were weaned off and he was extubated without event. He was comfortable and tolerating a regular diet On POD 2 he transferred to the floor. Renal was consulted for ATN pk CRE 3.1 base 0.8. They felt his acute renal failure was secondary to ischemic ATN during his period of hypotension requiring pressors. His creatinine continued to improve and on POD#5 it was 2.4. It was decided that since the patient had no insurance and was paying out of pocket for his hospital stay that it would be ok to discharge him home. The nephrology team was comfortable with sending him home with a Cr of 2.4 as well as long as the patient was set for follow-up soon after discharge where a chem panel could be checked. Therefore, his chest tubes were switched out for pneumostats. He and his sister received [Name2 (NI) 84856] teaching and home VNA was set up for him since he started an application for Mass Health. On the day of discharge, he was afebrile with stable vital signs. He was tolerating a regular diet. He had no complaints of pain, shortness of breath, cough, or chest pain. He was able to get out of bed and ambulate independently. Medications on Admission: None Discharge Medications: 1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day: Continue antibiotics until seen in [Hospital ] clinic on [2180-4-28]. Disp:30 Tablet(s) Refills:0 2. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO four times a day: Continue taking this medication until seen in [Hospital ] clinic on [2180-4-28]. Disp:360 Capsule(s) Refills:0 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Left empyema Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or sputum production -Chest tube site: ([Telephone/Fax (1) ]) change dressing daily -Drain [Telephone/Fax (1) ] daily and keep a record of output. -If the chest tube falls out cover site with dressing and call immediately -Continue to take the antibiotics as directed until you are seen in infectious disease clinic Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2180-4-13] 3:00 in the [Hospital Ward Name 121] Building Chest Disease Center [Location (un) 24] Chest X-Ray at 2:30 (before your appt) in the [Location (un) 861] Radiology Deparment Blood draw ground floor [Hospital Ward Name 516] Shapior Clinical Center (behind the information desk) You have an appointment for follow-up in the Infectious Disease clinic on [2180-4-28] at 9:30am. Call [Telephone/Fax (1) 457] to confirm or reschedule your appointment as needed. The [Hospital ] clinic is located on the ground floor of the [Hospital ] Medical Office Building, which is located on [Last Name (NamePattern1) ]. Please call ([Telephone/Fax (1) 10135] to schedule an appointment with Dr. [First Name (STitle) 30217] [Name (STitle) 28760] in nephrology clinic within 2 weeks of discharge.	[ "519.19", "458.29", "584.5", "276.1", "285.9", "486", "510.9" ]	icd9cm	[ [ [] ] ]	[ "96.05", "33.24", "34.52", "34.04" ]	icd9pcs	[ [ [] ] ]	8130, 8191	3903, 7289	333, 447	8248, 8248	1459, 3880	8891, 9867	1178, 1196		7344, 8107		8212, 8227		7315, 7321			8396, 8868								1211, 1440																							281, 295									475, 1070									8263, 8372						1092, 1101	1117, 1162
23,582	105,770	19708	Discharge summary	report	Admission Date: [2197-12-1] Discharge Date: [2197-12-4] Date of Birth: [2136-3-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 45] Chief Complaint: STEMI now s/p stents in LCx (100% - culprit lesion) and OM1 (70%) with temp wire in for pre-cath brady in ED and with post-cath hypotension on dopa drip. Major Surgical or Invasive Procedure: Coronary catheterization with stenting of the LCx and OM1. History of Present Illness: 61 yo male smoker h/o hypercholesterolemia p/w CP and found to have STEMI at [Hospital1 18]. Pain was substernal, heavy and crushing, [11-13] and different than any other pain he has had. Works as mechanic -initially attributed pain to lifting, but not as it increased in intensity. Developed diaphoresis, SOB, lay on ground and lost consciousness. Awoke and called EMS - got NTG in ambulance without relief. EKG showed 4mm STE in III, aVF and ST depressions in V1-V4. In the ED a temp wire was placed for brady in the 20's. Pain to balloon time roughly 2.5 hours. After cath the pt was hypotensive and put on a dopa drip. Currently being weaned. In unit after procedure, pain free and no groin or back pain. . Post-cath the patient had N/V x 1 with ? dark emesis. No guaiac was done. HCT decreased 41 -> 34 but was then stable at 33. Past Medical History: hyperlipidemia Social History: Married with three children (35, 32, 25) who live in area. Works as mechanic (heavy lifting). Weekend social etoh of a few drinks. Smokes PPD x 20yrs. No illicits Family History: No CAD, MI, Sudden Death, DM Physical Exam: V: 95/51 (dopa at 3), 69, 16, 95% RA G: NAD, lying flat, interactive H: EOMI, PERRL, neck supple, no LAD, OP clear, no JVD, no bruits C: RRR, no murmurs, physiologic split S2, good distal pulses L: Clear bilaterally A: Soft, NT, ND, nml BS E: R groin with sheath in place, no hematoma, no ecchymosis. Distal pulses symm. Feet WWP bilat N: AandOx3, CN II-XII intact, MAE, sensation intact, no drift Pertinent Results: EKG: prior to cath: ST elevations III, aVF. ST depr V1-3, 5. after cath: nsr with no ST/TW changes . [2197-12-1] Hct-41.3 [2197-12-1] 02:01PM Hct-34.6* [2197-12-1] 05:26PM Hct-33.3* [2197-12-2] 01:19AM Hct-32.6* [2197-12-2] 06:28AM Hct-32.8* Plt Ct-302 [2197-12-3] 07:00AM Hct-38.8* . [2197-12-4] 06:10AM BLOOD Glucose-98 UreaN-10 Creat-0.9 Na-143 K-4.4 Cl-108 HCO3-25 AnGap-14 . [2197-12-1] 09:50AM BLOOD CK(CPK)-199* [2197-12-1] 02:01PM BLOOD CK(CPK)-330* [2197-12-1] 05:26PM BLOOD ALT-29 AST-61* LD(LDH)-203 CK(CPK)-609* AlkPhos-70 TotBili-0.4 [2197-12-2] 01:19AM BLOOD CK(CPK)-652* [2197-12-2] 06:28AM BLOOD CK(CPK)-632* [2197-12-3] 07:00AM BLOOD CK(CPK)-283* . [2197-12-1] 09:50AM BLOOD CK-MB-3 [2197-12-1] 09:50AM BLOOD cTropnT-<0.01 [2197-12-1] 02:01PM BLOOD CK-MB-33* MB Indx-10.0* [2197-12-1] 05:26PM BLOOD CK-MB-49* MB Indx-8.0* cTropnT-1.88* [2197-12-2] 01:19AM BLOOD CK-MB-38* MB Indx-5.8 cTropnT-1.53* [2197-12-2] 06:28AM BLOOD CK-MB-30* MB Indx-4.7 [2197-12-3] 07:00AM BLOOD CK-MB-8 . Coronary Cath COMMENTS: 1. Selective coornary angiography of this codominant system revealed single vessel coronary artery disease. Te LMCA had no angiographically apparent flow limiting lesions. The LAD had mild diffuse disease. The LCX was a large vessel and was codominant. The LCX was totally occluded after the OM2. The OM1 was a large branch with an 80% proximal stenosis. The RCA was a codominant vessel with no angiographically apparent flow limiting stenosis. 2. Resting hemodyncamics revealed elevated right snd left sided pressures with a PA pressure of 50mmHgand a PCWP of 25mmHg. The cardiac output was 3.41l/min and the cardiac index was 1.91l/min/m2. 3. Left ventriculography was deferred. 4. Successful predilation using a 2.0 X 15 Voyager balloon, stenting using a 2.5 X 28 Cypher stent of the acutely occluded CX with lesion reduction from 100% to 0%. The final angiogram showed TIMI III flow with no dissection and no embolisation. There was jailing of the OM2 with <50% residual stenosis. 5. Successful direct stenting of the proximal OM1 stenosis using a 2.5 X 18 Cypher stent with lesion reduction from 80% to 0%. The final angiogram showed TIMI III flow with no dissection and no embolisation. ( see PTCA comments) FINAL DIAGNOSIS: 1. Angiographic evidience of single vessel coronary artery disease. 2. Elevated right and left sided pressures. 3. Acute inferior myocardial infarction PCI with drug-eluting stenting of the mid co-dominant LCx. 4 Successful drug-eluting stenting of the OM1 . [2197-12-4] Echo Conclusions: EF > 55% 1.The left atrium is mildly dilated. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.There is borderline pulmonary artery systolic hypertension. 7.There is no pericardial effusion. Brief Hospital Course: BRIEF OVERVIEW: 61 yo smoker with dyslipidemia presented with STEMI stented x2 in LCX (culprit 100-0%) and OM1 (70% - 0%) with a pacer wire placed in cath lab for bradycardia from CHB that resolved after cath. Hypotensive post-cath and put on dopamine for 12 hours then weaned with good pressure. Also had a HCT drop post cath, which then stabilized and increased. He remained symptom free and had no arrhythmias on telemetry. He was placed on BB, acei, plavix, aspirin, high-dose statin and discharged home in stable condition. ## CV: -CAD: The patient had 3 risks (age, lipid, smoker) and was found to have 2VD on coronary catheterization. LCx was the culprit lesion and was stented open with a DES. In addition, OM1 was stented. In the ED the patient was bradycardic to 20bpm and a temporary pacer wire was placed in the cath lab. Post-stenting, ST changes resolved and the pt's bradycardia also resolved. CE's trended down. However, the patient remained hypotensive and he received a dopamine drip for 12 hours. Thereafter his BP climbed and he was weaned off pressors and started on both metoprolol and captopril (followed by lisinopril prior to discharge). Toprol was not used in this patient as he chews his pills prior to swallowing them. . -Pump: The patient had a post-even echocardiogram that showed an EF of 55% that was suggestive of little decrease in stroke volume/CO. . -Rhythm: The patient was brady in ED with temp wire placed at the cath lab. Had CHB, but resolved with stenting. The patient continued to be mildly bradycardic after the MI initially, however there was no evidence of a bundle block or AV slowing or continued CHB. . ##Anemia - drop in HCT after procedure not uncommon - will tx for <30. Would continue to monitor HCT [Hospital1 ] or qd. Could be dilutional. No hematoma, only small amt oozing at groin site that cleared by the second day post-MI. ##Smoking - The patient was encouraged to quit. Initially there was no nicotine patch as he was recently stented. However, he was counselled to use assistive devices PRN at home. He suggested that he would do everything he could to stop smoking. The pt was counselled on this topic foer at least 30 minutes. . ## Dispo - the patient was discharged home after being cleared by PT with good follow-up. Medications on Admission: Atorvastatin 10mg Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take EVERY DAY as directed to prevent stent closure. Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take daily to decrease cholesterol and prevent coronary artery narrowing. Disp:30 Tablet(s) Refills:0 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina: Take one tablet for Chest Pain and wait 5 minutes. If the pain does not resolve, repeat up to 2 times. Disp:30 Tablet, Sublingual(s) Refills:0 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Take daily for blood pressure control and heart protection. Disp:30 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day: Take as prescribed for Blood Pressure control and to protect your heart. Disp:180 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute Myocardial infarction Hypercholesterolemia Hypotension Discharge Condition: Stable Stable Stable Stable Discharge Instructions: You were admitted to the hospital because of a myocardial infarction, also called "MI," or "heart attack." You were taken to catheterization, which opened the artery in your heart that had clogged. You are now going home. You will need to follow up with your Dr. [Last Name (STitle) 11679], your primary care doctor/cardiologist within 1 week. Please call him for an appointment [Telephone/Fax (1) 2394]. You will be taking some new medications because of your MI. Because you had stents placed in your heart during the catheterization, you will need to take aspirin and plavix EVERY DAY. Be sure not to miss a day. If you have any medical problems including chest pain, groin pain, groin bleeding, cold leg, lightheadedness, feeling like you are going to pass out, or any other worrisome symptoms, please seek immediate medical attention. Followup Instructions: Dr. [Last Name (STitle) 11679] in one week - pt to call for appointment. Will need K and Cr checked as he has recently been started on an ACEI. Cardiac rehab to start in appx 6 weeks. (Will need to be arranged through Dr. [Last Name (STitle) 11679] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63] Completed by:[2197-12-6]	[ "305.1", "426.0", "285.9", "458.29", "410.11", "414.01", "272.0" ]	icd9cm	[ [ [] ] ]	[ "99.20", "88.56", "37.78", "00.46", "36.07", "37.23", "00.41", "00.66" ]	icd9pcs	[ [ [] ] ]	8881, 8887	5439, 7748	466, 527	8992, 9025	2109, 4456	9928, 10344	1645, 1675		7816, 8858		8908, 8971		7774, 7793		4473, 5416	9049, 9905								1690, 2090																							273, 428									555, 1409															1431, 1447	1463, 1629
10,628	152,850	26366	Discharge summary	report	Admission Date: [2159-10-30] Discharge Date: [2159-11-14] Date of Birth: [2097-5-6] Sex: F Service: CARDIOTHORACIC Allergies: Fish Product Derivatives Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2159-10-31] Mitral Valve Repair with 26 millimeter [Doctor Last Name 405] Annuloplasty Band and Three vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending; with saphenous vein grafts to obtuse marginal and posterior descending artery. History of Present Illness: This is a 62 year old schizophrenic female who was admitted to [Hospital1 ] with congestive heart failure of unknown etiology. Noted to have significant left pleural effusion on chest x-ray for which she underwent thoracentesis. She was concomitantly started on empiric antibiotics for presumed community acquired pneumonia. An echocardiogram showed an LVEF o f 20% with global hypokinesis and moderate mitral regurgitation. Cardiac catheterization on [2159-10-30] revealed severe three vessel coronary artery disease with severe LV systolic dysfunction. Left ventriculography showed at least moderate MR with an ejection fraction of 25%. Coronary angiography revealed a right dominant system with 95% stenosis in the LAD with proximal occlusions in the circumflex and right coronary arteries. Based on the above results, she was urgently transferred to the [Hospital1 18] for cardiac surgical intervention. Past Medical History: Coronary artery disease, mitral regurgitation, congestive heart failure, active smoker, chronic obstructive lung disease, schizophrenia, osteoporosis, history of ETOH abuse, history of panic attacks, s/p cesarean section Social History: Active smoker - 40 pack year history. History of ETOH abuse in the past, currently sober. She has been in various institutions and group home for several years - currently in group home. She says she is married, husband lives in [Name (NI) 65230]. Denies history of IVDA. Family History: Significant for heart disease. No history of diabetes. Physical Exam: Vitals: BP 98/57, HR 80, RR 20, SAT 93% on 3L General: well developed female in no acute distress HEENT: oropharynx benign, no carotid bruits Neck: supple, no JVD, no murmur Heart: regular rate, normal s1s2, 2/6 systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2159-10-31] 12:39AM BLOOD WBC-14.9* RBC-3.81* Hgb-12.3 Hct-35.3* MCV-93 MCH-32.2* MCHC-34.8 RDW-14.5 Plt Ct-451* [2159-11-8] 07:25AM BLOOD WBC-19.5* RBC-3.61* Hgb-11.4* Hct-32.8* MCV-91 MCH-31.4 MCHC-34.6 RDW-14.2 Plt Ct-363 [2159-10-31] 12:39AM BLOOD Glucose-78 UreaN-21* Creat-0.9 Na-138 K-4.3 Cl-101 HCO3-28 AnGap-13 [2159-11-8] 07:25AM BLOOD UreaN-20 Creat-0.7 K-3.8 [2159-11-8] 07:25AM BLOOD Mg-2.1 [2159-10-31] 12:39AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE Brief Hospital Course: Patient was admitted and underwent routine preoperative evaluation. Workup was unremarkable and she was cleared for surgery. She remained stable on medical therapy. The following day, she underwent a mitral valve repair and coronary artery bypass grafting by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1290]. The operation was uneventful. Postoperative transesophageal echocardiogram demonstrated good mitral valve repair with no leak and improved left ventricular ejection fraction with ejection fraction of about 40%. She was taken to the CSRU on moderate inotropic support. Within 24 hours, she awoke neurologically intact and was extubated. On postoperative day one, she experienced acute respiratory distress secondary to aspiration and required re-intubation. By postoperative day four, she was re-extubated and successfully weaned from inotropic support. She otherwise maintained stable hemodynamics and transferred to the SDU on postoperative day five. Given her pulmonary status, she required aggressive pulmonary toilet and diuresis. She was maintained on MDI and nebulizer therapies in addition to steroids and antibiotics. Over several days, medical therapy was optimized. She remained in a normal sinus rhythm without atrial or ventricular arrhythmias. She tolerated low dose beta blockade. She was noted on POD#9 to have an elevated white blood sell count and was found to have a cellulitis in her left lower extremity vein harvest site, which responded to levofloxacin. By POD#14, her WBC had decreased to 13K, she was approaching her preoperative weight with oxygen saturations of 95% on room air. All surgical wounds were clean, dry and intact. she was cleared for discharge to home. Medications on Admission: Protonix 40 qd, Metoprolol 25 [Hospital1 ], Lisinopril 5 qd, Haldol 5 qpm, Lamictal 75 qd, Colace, Fosamax 70 qweek, Lovenox SC daily, Clozapine 700 qd Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Clozapine 100 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily). 5. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 7. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Rehab & Nursing Center - [Location (un) 47] Discharge Diagnosis: Coronary artery disease, mitral regurgitation, congestive heart failure, chronic obstructive lung disease, schizophrenia, osteoporosis, history of ETOH abuse, history of panic attacks, steroid induced leukocytosis Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [2-27] weeks. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [12-28] weeks. Local cardiologist in [12-28] weeks. Completed by:[2159-11-14]	[ "934.1", "305.03", "428.0", "496", "998.59", "414.01", "424.0", "733.00", "305.1", "682.6", "E932.0", "295.90", "288.8", "518.5" ]	icd9cm	[ [ [] ] ]	[ "36.15", "88.72", "89.68", "35.33", "36.12", "39.61", "96.04", "99.04", "96.05", "96.71" ]	icd9pcs	[ [ [] ] ]	6166, 6306	3095, 4822	312, 611	6564, 6571	2582, 3072	6890, 7127	2113, 2169		5028, 6143		6327, 6543		4848, 5005			6595, 6867								2184, 2563																							253, 274									639, 1560															1582, 1804	1820, 2097
9,870	186,267	4264	Discharge summary	report	Admission Date: [2111-10-20] Discharge Date: [2111-11-12] Date of Birth: [2072-8-3] Sex: M Service: MEDICINE Allergies: Latex Attending:[First Name3 (LF) 99] Chief Complaint: Transfer from OSH for Intracranial hemorrhage Major Surgical or Invasive Procedure: Tracheostomy Percutaneous IVC filter placement Bronchoscopy Central Venous Line Placement History of Present Illness: 39 yo male with h/o C5/6 traumatic injury with quadriplegia in [2102] and complicated by recurrent UTIs, DVTs, PNAs, and he is s/p IVC filter who presents from OSH with a left putamenal ICH. On admission, he was somnolent and unable to give any history. His PCA then noted at night that his normal speech had become dysarthric. He was still somewhat awake and alert. When cleaning him, she noted a right facial droop and weakness of his minimally functional right side. He went to the OSH and was found to have O2 sats in the 80s and by report a fever, although there is only documentation of normal temp. He was given Zosyn for possible resp problem. [Name (NI) ] then had head CT which showed 2.2x2.6x5 cm left basal ganglia bleed. At that time, he was apparently sleepy, but alert and making decisions well. He initially refused transfer to [Location (un) 86] and refused surgery. He also said he would want resuscitation, but not intubation and recounted that he was on a chronic vent in the past. He did not sign anything formally, but the MD there did indicate this on the [Hospital3 ] documentation. He was then sent to [Hospital1 18]. INR was found to be 1.9 as he is on coumadin for DVT ppx. He got dilantin 1 g, ativan 1 mg, and Zosyn at the OSH. . On admission, he was much more somnolent and not able to answer any questions. He constantly fell asleep during examination. He also has BP of Systolic in the 95 range. this then normalized to the 150 range with IVFs. . MICU Transfer: On [2111-10-25], called by primary Neuro team for increasing respiratory distress though to be secondary to LLL PNA (? CAP or aspiration PNA). Patient was given an IV on [10-24] and this was his first dose of Levofloxacin as well as Vancomycin. This was delayed due to the patient's reluctance to have the IV placed. The patient has been having increased O2 requirements since [10-22] and has currently progressed to 100% non-rebreather. He has required more frequent suctioning and an escalation of nursing needs. He has been having low grade fevers and spiked to 102. . On [10-24], the patient was assess by Psychiatry and found to be delirious, and as such with limited decision making capacity. On examining the patient today, he knows his name, his location, but does not know the date. His response to other questions is incomprehensible at times and non-sensical at other times. Given his previous reluctance for escalation of care in the recent past, the legal department at [Hospital1 18] was consulted who clarfied that in his current delirious state, his capacity for decisions was reduced and as such, his HCP (mother) would be the person to help guide his decision making. In speaking to her, she states that it would be reasonable to transfer him to the ICU for escalated nursing care and for more frequent suctioning. But she states that in the event that he does not improve and he starts to suffer, that we should try to make him comfortable. She maintained that he should not be intubated, consistent with his DNI status. . ROS: Patient unable. Past Medical History: -C5/6 traumatic injury with quadriplegia in [2102] and complicated by recurrent UTIs, DVTs, PNAs -s/p IVC filter -indwelling suprapubic catheter Social History: He is estranged from his mother. [Name (NI) ] has a 14 yo daughter who is not living with him. He has 24 hr caregivers. [Name (NI) ] EtOH/smoking. He apparently has a drug use/abuse history. Family History: Father is deceased, unknown why. Mother living. Physical Exam: On Admission: Exam:Vitals:99.9, 113/71-->95/60s, 82, 14, 95% on 5L Gen:NAD. HEENT:MMM. Sclera clear. OP clear Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Rhonchi throughout Ext:No cyanosis/edema Neurologic examination: Mental status: Somnolent and needs constant stimulation to stay awake. Orientation: Oriented to person, place, ?/[2084] Attention: Very inattentive Registration: Unable Language: Fluent with poor comprehension and able to do repetition for [3-14] words. Naming intact to high freq only. Significant dysarthria No apparent neglect, but difficult to assess Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields grossly intact, but no BTT overall. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial with right facial droop and unable to discern if he has sensation change. VIII: Hearing grossly intact bilaterally. IX, X: Palatal elevation symmetrical XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and increased tone bilaterally in LEs. Mild RUE tremor D T B WE FiF [Last Name (un) ] IP Q H DF PF TE([Last Name (un) 938]) Right 0---------------- -----------------> Left 5 4+ 5 5- 4- 3 0----------------> Sensation: Difficult to assess, but pt reports no feeling in LEs. He says he that feels LT in UEs. Reflexes: B T Br Pa Ankle Right 3 2 2 0 0 Left 3 2 2 0 0 Toes were mute bilaterally Coordination: Pt unable at this time. Gait: Unable Pertinent Results: ADMISSION LABS: [2111-10-20] 06:20PM BLOOD WBC-12.1* RBC-4.72# Hgb-12.0* Hct-36.4* MCV-77# MCH-25.4 MCHC-32.9 RDW-17.0* [2111-10-20] 06:20PM BLOOD Neuts-82.7* Bands-0 Lymphs-10.7* Monos-4.9 Eos-1.3 Baso-0.4 [2111-10-20] 08:19PM BLOOD PT-17.3* PTT-28.9 INR(PT)-1.6* [2111-10-20] 08:19PM BLOOD Glucose-112* UreaN-13 Creat-0.5 Na-144 K-4.3 Cl-107 HCO3-25 AnGap-16 [2111-10-20] 08:19PM BLOOD CK(CPK)-64 [2111-10-21] 07:18AM BLOOD CK(CPK)-68 [2111-10-20] 08:19PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2111-10-21] 07:18AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2111-10-20] 08:19PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.4 [2111-10-20] 08:19PM BLOOD Phenyto-6.3* [2111-10-23] 09:23PM BLOOD Type-ART Temp-37.0 Rates-/20 pO2-65* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2111-10-20] 08:32PM BLOOD Lactate-1.4 . CT HEAD W/O CONTRAST [2111-10-20] 5:59 PM CT HEAD W/O CONTRAST Reason: More lethargic [Hospital 93] MEDICAL CONDITION: 39 year old man with Head bleed from osh REASON FOR THIS EXAMINATION: More lethargic CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Intracranial hemorrhage, now more lethargic. NON-CONTRAST HEAD CT: No prior for comparison. An intraparenchymal hemorrhage centered in the left lentiform nucleus measures 24 x 29 mm in greatest axial dimension, with surrounding edema. No extension into the lateral ventricles is identified. There is no hydrocephalus. The hemorrhage exerts some mass effect, however, there is negligible shift of septum pellucidum to the right. No acute major vascular territorial infarct is identified, though evaluation of the inferior cranial structures is somewhat limited due to motion. No fractures are seen. Imaged sinuses are clear. IMPRESSION: Left lentiform nucleus intraparenchymal hemorrhage with very mild mass effect. No extraaxial hemorrhage seen. . CTA CHEST W&W/O C &RECONS [2111-10-21] 11:35 AM CTA CHEST W&W/O C &RECONS Reason: Assess for PE. PE protocol CT scan. [Hospital 93] MEDICAL CONDITION: 39 year old man with desaturation, cxr concerning for pe REASON FOR THIS EXAMINATION: Assess for PE. PE protocol CT scan. CONTRAINDICATIONS for IV CONTRAST: None. STUDY: CTA of the chest. CLINICAL HISTORY: 39-year-old man with history of quadriplegia, cerebral hemorrhage, now with desaturation. Chest radiograph concerning for pulmonary embolism. TECHNIQUE: Multiple transaxial images of the chest were obtained after administration of intravenous contrast, utilizing the pulmonary embolism protocol. Multiple coronally and sagittally reformatted images were also obtained. No prior CT study is available. Comparison made to chest radiograph dated [2111-10-21]. FINDINGS: Images are somewhat degraded secondary to patient body habitus and the fact that the patient's arms are by his side during scanning. There are no intraluminal filling defects within the main pulmonary artery or its proximal branches. There is dense air space disease involving the dependent portion of the left lower lobe. This most likely presents pneumonia; given patient's clinical history, aspiration is a possibility. There are two regions of linear atelectasis in the left upper lobe and left lower lobe. The right lung is clear. No pleural or pericardial effusions. There is a prominent prevascular lymph node, measuring up to 9 mm in short axis diameter (sequence 2, image #88). There are no pathologically enlarged hilar, mediastinal, or axillary lymph nodes. There are degenerative changes of the spine, including exuberant osteophytes of lower thoracic vertebral bodies. No suspicious osseous lesions. Findings were discussed with [Last Name (LF) ], [First Name4 (NamePattern1) 1059] [Last Name (NamePattern1) ]. IMPRESSION: 1. No evidence of pulmonary embolism, as clinically questioned. 2. Left base airspace disease, likely representing pneumonia. . CT HEAD W/O CONTRAST [2111-10-21] 11:35 AM CT HEAD W/O CONTRAST Reason: Assess for progression of bleed. [Hospital 93] MEDICAL CONDITION: 39 year old man with intracranial bleed, worsening neurologic exam REASON FOR THIS EXAMINATION: Assess for progression of bleed. CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 39-year-old man with intracranial hemorrhage and worsening neurological examination. COMPARISONS: Prior day CT scan. TECHNIQUE: Non-contrast head CT. FINDINGS: The appearance of a intraparenchymal hemorrhage, centered at the left lentiform nucleus, and measuring 2.4 x 3.1 cm is not significantly changed since the prior study. There is mild surrounding edema with a similar appearance, as well. Bilaterally symmetric, subcentimeter ovoid hypodensities in the basal ganglia on both sides may relate to prior episode of hypoxic injury and are also unchanged. There is no hydrocephalus or shift of the normally midline structures. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Stable appearance of left basal ganglia hemorrhage. See above report for additional findings. . [Last Name (un) ]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [2111-11-4] 12:08 PM [Last Name (un) ]-INTESTINAL TUBE PLACEMENT Reason: placement [Hospital 93] MEDICAL CONDITION: 39 year old man with C5-C6 quadriplegia REASON FOR THIS EXAMINATION: placement HISTORY: 39-year-old man with C5-6 quadriplegia, status post Dobbhoff tube placement on the floor. FINDINGS: The patient was placed supine on the fluoroscopy table. Initial fluoroscopic image demonstrated positioning of the Dobhoff tip in the third portion of the duodenum. This was confirmed with injection of 5 mL of contrast. [Initials (NamePattern4) ] [Last Name (NamePattern4) 7648] wire was subsequently advanced through the Dobbhoff, and the tube was advanced to the distal fourth portion of the duodenum, at the level of the ligament of Treitz. The tube was secured with tape. Note also is made of [Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter which is tilted and on the left side of the abdomen. Its location is uncertain and does not appear to be within the IVC. It may be within the left renal vein. Its location could be confirmed by CT. . CT ABDOMEN W/O CONTRAST [2111-11-5] 5:03 PM CT ABDOMEN W/O CONTRAST Reason: Per Interventional Radiology Fellow, to assess location of m [Hospital 93] MEDICAL CONDITION: 39 year old man with C5-C^ paraplegia, migrated IVC filter (? to renal vein per recent fluoroscopic procedure) REASON FOR THIS EXAMINATION: Per Interventional Radiology Fellow, to assess location of migrated IVC filter; per IR fellow, no need for contrast CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Migrated IVC filter. TECHNIQUE: Axial non-contrast images through the abdomen. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Within the right middle lobe and lower lobe are patchy airspace opacities. There are small bilateral pleural effusions. There is bibasilar atelectasis, left greater than right. Within the left atelectasis is a 1 cm area of focal fluid. This could represent necrosis or loculated pleural effusion. There is a small pericardial effusion. A feeding tube is within the stomach. On this unenhanced scan, the liver, gallbladder, spleen, pancreas, adrenal glands, large and small bowel are normal. There are scattered small subcentimeter mesenteric lymph nodes. Within the mid pole of the right kidney is an exophytic 1.8 cm isoattenuating lesion measuring approximately 30 Hounsfield units, and is not characteristic of a simple cyst. Within the left kidney upper pole is a wedge-shaped area within the cortex, which could represent focal fat or scarring from prior infection. The [Location (un) 260] inferior vena cava filter is seen located in the left renal vein. The struts have migrated outside the renal vein. One of these struts appears to be abutting the duodenum. There is no free air or free fluid. Without IV contrast, the vascularity to the left kidney cannot be assessed. Both kidneys appear to be symmetric in size. New suspicious osseous lesions. IMPRESSION: 1. [Location (un) 260] IVC filter within the left renal vein, with the struts migrated external to the renal vein, one abutting the duodenum. Without contrast, the perfusion to the left kidney cannot be assessed. 2. A 1.8 cm isoattenuating lesion in the right kidney, which does not meet characteristics of a simple cyst. An ultrasound is required to evaluate this lesion to exclude malignancy. 3. Wedge-shaped deformity in the left kidney could represent fat or scarring, and can also be assessed on renal ultrasound. 4. Patchy airspace consolidation in the right lobe is nonspecific, and could represent infection or inflammatory etiologies. 5. Small bilateral pleural effusions. Loculated fluid versus evolving necrosis within the left lower lobe atelectasis. . C1880 VENA CAVA FILTER [2111-11-6] 7:47 AM Reason: had IVC filter placed, per IR yesterday filter has migrated, Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 39 year old man with C5-C6 paraplegia, recent stroke REASON FOR THIS EXAMINATION: had IVC filter placed, per IR yesterday filter has migrated, please re-place or re-position INDICATION OF THE EXAM: 39-year-old man with C5-C6 paraplegia that needs IVC filter placed, previous filter is located in the renal vein. RADIOLOGISTS: The procedure was performed by Drs. [Last Name (STitle) 15785] and [Name5 (PTitle) 380], the attending radiologist who was present and supervising throughout the procedure. PROCEDURE AND FINDINGS: After informed consent was obtained from the [Hospital 228] healthcare proxy explaining the risks and benefits of the procedure, the patient was placed supine on the angiographic table and the right groin was prepped and draped in standard sterile fashion. Using ultrasound guidance, the right common femoral vein was accessed with a 21-gauge needle and a 0.035 [Last Name (un) 7648] wire was advanced into the inferior vena cava under fluoroscopic guidance. The needle was then removed over the wire and a 5 French vascular sheath was then advanced over the wire. A 4 French Omni Flush catheter was then advanced over the wire and under fluoroscopic guidance and a venogram was performed. Venogram showed single inferior vena cava as well as the level of the renal veins. Note is made of another filter in the left renal vein location. Based on the diagnostic findings, it was determined that the patient would benefit from the placement of an inferior vena cava filter. The 5 French vascular sheath as well as the Omni Flush catheter were then removed and a 9 French filter deployment sheath was then advanced over the wire into the inferior vena into the level low of the renal vein under fluoroscopic guidance. The wire was then removed and a VenaTech filter was then deployed under fluoroscopic guidance below the renal veins. A final abdominal x-ray was obtained to document the position and adequate deployment of the IVC filter. The sheath was then removed and pressure was held until hemostasis was achieved after five minutes. COMPLICATIONS: There were no immediate post-procedural complications. IMPRESSION: Successful placement of a permanent inferior vena cava filter below the renal veins. Note is made of another previously placed filter located in the left renal vein. . RADIOLOGY Final Report FEMORAL VASCULAR US [2111-11-11] 11:42 AM FEMORAL VASCULAR US Reason: r/o groin abscess v/s hematoma [Hospital 93] MEDICAL CONDITION: 39 year old man with R groin swelling s/p IVC filter placed , now c fever REASON FOR THIS EXAMINATION: r/o groin abscess v/s hematoma INDICATIONS: Right groin swelling after IVC filter placed, now with fever. Assess for brain abscess versus hematoma. RIGHT GROIN ULTRASOUND: Using the linear and curved probes, the right groin was imaged. There is a large fluid collection with internal echoes and septations which measures up to 13.2 x 6.5 x 12.2 cm. Assessment of the right femoral vessels shows normal venous waveforms on pulsed Doppler, without evidence of spectral broadening or arterialization. The femoral artery is patent. IMPRESSION: Large right groin hematoma measuring up to 13.2 cm. No evidence of AV fistula or pseudoaneurysm. Whether or not this fluid is infected cannot be determined by this study. . CHEST (PORTABLE AP) [2111-11-11] 3:57 AM CHEST (PORTABLE AP) Reason: interval change [Hospital 93] MEDICAL CONDITION: 39 year old man s/p tracheostomy and bronchoscopy for left lung collapse REASON FOR THIS EXAMINATION: interval change AP CHEST 4:08 A.M. ON [11-11] HISTORY: Tracheostomy and bronchoscopy. IMPRESSION: AP chest compared to [11-8] through 31: Left lung is now completely collapsed producing marked leftward mediastinal shift. Right lung is clear. Tracheostomy tube is in standard placement. Feeding tube passes into the stomach and is either looped there or passes into the jejunum. Tip of the right subclavian line projects over the anticipated location of the displaced superior vena cava. . MICROBIOLOGY: [2111-10-26] 6:16 pm SPUTUM Source: Induced. FINAL REPORT [2111-10-30] GRAM STAIN (Final [2111-10-26]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2111-10-30]): SPARSE GROWTH OROPHARYNGEAL 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . [2111-11-1] 11:30 am SPUTUM Source: Endotracheal. FINAL REPORT [2111-11-5] GRAM STAIN (Final [2111-11-1]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2111-11-4]): SPARSE GROWTH OROPHARYNGEAL FLORA. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R . DISCHARGE LABS: WBC 6.3 Hct 27.2 MCV 79 PLT 185 INR 1.1 Glu 106 Na 140 K 3.8 Cl 107 Hco3 25 BUN 10 Cr 0.3 Ca 8.2 Mg 1.8 Po4 3.1 Brief Hospital Course: Pt is a 39 yo quadriplegic (C5/6 injury), w/ h/o recurrent UTIs, DVTs (s/p IVC filter), PNA (including Klebsiella and MRSA) who presented from OSH on [2111-10-20] with [Hospital 18505] transferred to MICU for pna, worsening resp status. . # Repiratory Failure/PNA: He initially came to ICU after increasing resp distress on neuro floor, was found to have pna on CXR, sputum cx from [10-26] grew MRSA, and [11-1] grew out Klebsiella. During ICU course, he was intubated [10-26], extubated [11-3], re-intubated [11-5] due to continuing lung collapse, likely [2-12] poor cough reflex, poor respiratory effort. Pt has h/o difficulty weaning from vent, requiring trach [2111-11-9]. Completed 14 day course of Vancomycin for MRSA PNA (started [10-26]). Currently on day 10 of meropenem (originally ceftazidime) for Klebsiella PNA (started [11-3]) to complete 14 day course. Will need surveilance CXR and likely frequent bronchoscopy to clear secretions from left lung which is completely atelectatic and given his poor cough reflex. . # IVC filter: He came in with existing IVC filter for h/o DVT in past. IVC filter was noted to have migrated to the left renal vein. He had a new permanent IVC filter placed while at [Hospital1 18] on [2111-10-31]. . # Fever: Pt w/ low grade fever from time to time. Blood cxs and urine cxs drawn were negative. Moniter and reculture if he spikes greater than 101.4. . # ICH: Pt presented with a ICH in left basal ganglia. His hemorrhage was likely due to coumadin (although also possibley due to HTN). Bleed is stable by repeat head CT. All anticoagulation has been held, and should be held in the future due to head bleed. . # Paraplegia: Patient at baseline able to move upper extremities, but not lower. After this recent head bleed, he had decreased strength in his R arm (L sided bleed). Pt on neurontin and baclofen as outpt, held early in his at some point during hospital admission, and was re-started once his mental status cleared. . # Leg ulcers: Pt with left leg and heel ulcers. He has dry dressings in place. Wound care per protocol. . # H/o recurrent UTIs: Likely due to paraplegia/neurogenic bladder. He has a superpubic catheter in place. . # Right groin hematoma: He developed a right groin hematoma after IVC filter placement. Documented by Ultrasound. . # Code status: Full Code. . # Access: Peripheral IV. He had a R subclavian CVL, placed [10-26] and removed on [2111-11-11]. . # Nutrition: Post pyloric feeding tube in place. Tube feeds, replete with Fiber, at. goal of 80 cc/hr. . # communication: HCP is pt's mother, [Name (NI) ] [Name (NI) 18506] (h) [Telephone/Fax (1) 18507], (c) [Telephone/Fax (1) 18508] Medications on Admission: Coumadin Neurontin Baclofen Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Left lentiform nucleus intraparenchymal hemorrhage Klebsiella/MRSA Pneumonia Respiratory Failure Requiring Tracheostomy Recurrant Left Lung Collapse from mucous plugging requiring multiple bronchoscopies Right Groin Hematoma History of Deep Vein Thrombosis History of Cervical Injury with resulting Paraplegia Discharge Condition: Stable Discharge Instructions: Please follow up with Dr. [Last Name (STitle) ] (the neurologist), and your primary care doctor. Followup Instructions: Neurology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], stroke service, [Telephone/Fax (1) 1694], [12-1], 10am [Hospital Ward Name 23] [Location (un) ]. PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 6330] [Last Name (NamePattern1) ], [Telephone/Fax (1) 18509]. [11-25] at 12noon. Fax: [Telephone/Fax (1) 18510]. Completed by:[2111-11-12]	[ "V09.0", "707.14", "276.0", "344.00", "780.09", "998.12", "401.9", "707.03", "482.0", "278.01", "518.0", "518.81", "998.11", "V12.51", "431", "276.2", "482.41", "934.1", "V44.59", "996.1" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.04", "33.21", "38.93", "99.07", "96.72", "38.7", "96.6", "33.23", "96.56", "31.1" ]	icd9pcs	[ [ [] ] ]	24319, 24391	21487, 24241	312, 404	24745, 24754	5607, 5607	24903, 25328	3953, 4002			18123, 18196	24412, 24724		24267, 24296			24778, 24880		21350, 21464						4017, 4017																							226, 274	18225, 21334								432, 3544	4650, 5588			6839, 7647	5624, 6595		4031, 4246		4285, 4634		4270, 4270				3566, 3716	3732, 3937
20,124	108,521	49720	Discharge summary	report	Admission Date: [2191-5-24] Discharge Date: [2191-5-28] Date of Birth: [2133-2-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 58yo M with DM, HTN, CHF, ESRD on peritoneal dialysis, h/o necrotizing E.coli PNA in [9-8] resulting in LUL scar and chronic volume overload presents with hemoptysis and hypoxia x 1day. Pt was feeling generally well until 7:30 pm on [5-23] when he coughed up ~ [1-7] cup of hemoptysis with some blood clots. Denies any sob, palpitations, chest pain, no cough prior to hemoptysis, rhinorrhea, nasal congestion, sore throat, fevers, but felt somewhat LH and chills/cold. Denies any recent sick contact or travel. Never been in prison, TB exposure or homeless. Pt still smokes 1.5pack per day. Had some weight loss but gained it all back. Denies night sweats. . In [Name (NI) ], pt was afebrile, 90-92% on RA and 97% with 2L via NC. Pt had another episode of hemoptysis ~[1-6] cup. . On ROS, denies any chosking/cough after eating, abdomianl pain, constipation, n/v, nose bleeds, easy bleeding, hematochezia, melena, diarrhea, orthopnea, PND and recently lost weight which he gained all his weight back, worsening back pain, or LE weakness. Denies skipping peritoneal dialysis. Past Medical History: 1. ESRD: [2-5] anti-GBM disease, on HD since [3-8], then PD since [9-10] 2. DM2 3. HTN 4. Chronic low back pain [2-5] herniated discs 5. diastiolic CHF- TTE [12-10] EF 75%, LVH 6. Peripheral neuropathy 7. Anemia 8. h/o nephrolithiasis 9. s/p cervical laminectomy; ?osteo in past 10. h/o depression 11. h/o MSSA bacteremia ([3-10]-infected HD catheter), E. coli bacteremia 12. s/p L AV graft: [7-8] 13. h/o [12-8] of L4-5 diskitis, osteo, epidural abscess 14. MRSA cath tip infection 15. MSSA peritonitis [6-11] 16. thyroid nodule on u/s [6-11], recommended f/u 1 yr 17. wheelchair bound due to knee/muscle contraction since had a PNA and ICU admission in [2187] 18. h/o IJ clot Social History: Lives w/ wife and son. Daughter-in-law, and three grandchildren in [Location (un) 86] area, has been unemployed [2-5] disability, smokes tobacco 2 ppd x45 years, past alcohol, denies current, no recreational drug use. Does not walk due to knee contraction, spinal disease. WC bound since [2187]. Wife manages his medications. Family History: NC Physical Exam: VS: 98.3 148/78 80 19 100% on 3L, 89-90 on RA. FS 97. GEN: Appears NAD, no tachypneic, no visible blood around mouth HEENT: [Year (4 digits) 3899], PERRL, no oropharyngeal lesions, erythema. No LAD, no JVD but difficult to assess COR: distant HS RR PULM: diffuse mild expiratory wheezing throughout ABD: obese NT, BS+, + distension, L PD catheter NT, c/d/i EXT: [2-6]+ edema to knees LEs NEURO: Alert, oriented. CNs intact. Intact FTN. [5-9] UE strength. Able to lift b/l legs partially, limited by pain. Pertinent Results: GLUCOSE-64* UREA N-43* CREAT-11.7* SODIUM-139 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-27 CALCIUM-8.5 PHOSPHATE-5.6* MAGNESIUM-1.7 WBC-6.8 RBC-2.74* HGB-8.9* HCT-26.6* MCV-97 MCH-32.3* MCHC-33.4 RDW-16.1* PLT COUNT-365 PT-13.2 PTT-31.9 INR(PT)-1.1 . CXR (prelim read): PA AND LATERAL CHEST RADIOGRAPH: Cardiac and mediastinal contours appear stable allowing for low lung volumes. Pulmonary vascularity is within normal limits. There are no focal consolidations or pleural effusions. Persistent streaky opacity in the left mid lung is again identified, likely representing residual scar or atelectasis from the previously seen airspace disease. IMPRESSION: No evidence of acute cardiopulmonary process. Persistent streaky opacity in the left lung likely representing atelectasis, or scar from prior infection. . CTA chest (wet read): No PE. Increased opacity in region of left upper lobe scar/cavity, concerning for possible superimposed infection, or scar carcinoma. opacity in left bronchus possibly blood or secretion. evidence of fluid overload. [2191-5-25] 03:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- Negative . [5-24] Sputum - [2191-5-24] 5:53 am SPUTUM Site: EXPECTORATED Source: Expectorated. GRAM STAIN (Final [2191-5-24]): [10-29] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. SMEAR REVIEWED; RESULTS CONFIRMED IN PAIRS. RESPIRATORY CULTURE (Final [2191-5-26]): MODERATE GROWTH OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. . Time Taken Not Noted Log-In Date/Time: [2191-5-24] 3:22 pm BRONCHIAL WASHINGS GRAM STAIN (Final [2191-5-24]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2191-5-26]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000 ORGANISMS/ML.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2191-5-25]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2191-5-24] 9:29 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [2191-5-24]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2191-5-27]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Time Taken Not Noted Log-In Date/Time: [2191-5-25] 2:21 pm BRONCHIAL WASHINGS GRAM STAIN (Final [2191-5-25]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2191-5-27]): ~1000/ML OROPHARYNGEAL FLORA. BETA STREPTOCOCCI, NOT GROUP A. >100,000 ORGANISMS/ML.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2191-5-25]): TEST CANCELLED, PATIENT CREDITED. Brief Hospital Course: A/P: 58yo M with ESRD on PD, h/o E.coli pneumonia resulting in LUL scar p/w hemotpysis and hypoxia. . 1) Hemoptysis: The patient was admitted with hemoptysis. He was admitted to the medical service and was stable overnight. On the morning of [5-24] he had another episode of hemoptysis. He was taken to the IP suite for bronchoscopy where he was found to have large clot in the apico-posterior segment of his left upper lobe. BAL/wash from the LUL was performed and sent for gram stain & culture, fungal culture, and cytology. No intervention was performed due to concern for bleeding. He was transferred to the MICU for closer monitoring. He underwent a embolization of the artery in LUL under IR and tolerated procedure well. Pt was stable for transer to medical service. Hematocrit stable at ~29, compared to most recent value in OMR dated [3-11]. In terms of understanding what may have precipitated bleeding into the mainstem bronchus, there is some increased opacity in the LUL on CT scan which may represent superimposed infection vs. malignancy. Patient also has a history of necrotizing pneumonia with scarring in LUL; this may be a complication of chronic scarring of this old lesion, causing in erosion of bronchial artery, similar to [Doctor Last Name ] aneurysm seen in TB patients. At time of presentation, patient was notably afebrile with normal WBC, prompting some concern for malignancy in this gentleman with a long smoking history. Gram stain from BAL with GPC and GNR, also sputum culture with GPC so pt started on vanco and levofloxacin-in setting of changes on CT asl well. The patient stable and was discharged home to complete a course of levafloxacin. He was schedued to follow up in Pulmonary Clinic for a repeat CT chest. . 2) ESRD on PD: On admission the pt had abdominal tenderness on exam and a sample of peritoneal fluid was sent for evaluation revealing 2 WBC, no evidence for infection. He was continued on PD with a 2.5 L/exchange, 6 exchanges/day, dwell time 4 hours each. He was also continued on sevelamer, cinecalcet, calcitriol. . 3) DM: he was continued on neurontin for peripheral neuropathy . 4) Hypertension: BP well controlled with PD. . 5) Pain: Continued with management of chronic back pain on q4 hour methadone with PRN oxycodone. . 6) Depression: Continued Paxil. . Medications on Admission: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 3. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO Qdinner. Disp:180 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 7. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 12. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO EVERY OTHER DAY (Every Other Day). 13. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. Nifedical 60mg qday Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 8 days: First day = [5-24]. Disp:2 Tablet(s) Refills:0 2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours. 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO WITH LUNCH AND DINNER (). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 12. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 13. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Hemoptysis Secondary: 1. ESRD on Peritoneal Dialysis Discharge Condition: Afebrile, VSS Discharge Instructions: You were admitted after coughing up blood and were found to have a scar and bleeding blood vessel in your left upper lung. You underwent a bronchoscopy and cultures were taken to rule out infection. You are being treated with levaquin for a lung infection. Please complete your course of antibiotics as directed. . It is very important that you undergo a CT scan of your chest to monitor for resolution of your infection. You should follow up in Pulmonary Medicine as scheduled. . Please continue to take your medications as directed. . Please return if you develop fever/chills. You should return immediately if you begin to cough up blood again. Followup Instructions: Please follow up for your Chest CT scan on [2191-7-11] 10:00am in the [Hospital Unit Name 1825] on the [Location (un) 470], on [Hospital1 18] [Hospital Ward Name 516] Building. You should fast for three hours prior to your test. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2191-7-11] 10:15 . Please follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4507] in Pulmonary Medicine on [2191-7-13] at 10:30am. Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2191-7-13] 10:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2191-7-13] 11:00 . Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1366] in Nephrology on [2191-6-29] at 9:00am. Provider: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2191-6-29] 9:00 . You need to obtain a new primary care provider at [Name9 (PRE) 191]. Please call [Telephone/Fax (1) 250] after [6-5] to schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673]	[ "444.89", "583.1", "250.60", "311", "285.21", "241.0", "585.6", "428.30", "428.0", "403.91", "V13.01", "357.2", "786.3" ]	icd9cm	[ [ [] ] ]	[ "32.28", "39.79", "88.49", "99.04", "33.24", "54.98" ]	icd9pcs	[ [ [] ] ]	11179, 11185	6560, 8894	325, 339	11294, 11310	3139, 4730	12006, 13362	2582, 2586		10037, 11156		11206, 11273		8920, 10014			11334, 11983								2601, 3120								6414, 6537														5522, 5763	275, 287									367, 1464								5799, 5814							1486, 2210	2226, 2566
30,169	196,878	33494	Discharge summary	report	Admission Date: [2156-4-6] Discharge Date: [2156-4-23] Service: SURGERY Allergies: Percocet / Percodan Attending:[First Name3 (LF) 2777] Chief Complaint: Contained rupture of an infrarenal abdominal aortic aneurysm Major Surgical or Invasive Procedure: Repair of ruptured abdominal aortic aneurysm, repair of ventral hernia. 1.Placement of open tracheostomy 2.therapaeutic bronchoscopy 3. esophageoscopy History of Present Illness: This is an 83-year-old woman who presented emergently to [Hospital 29158] Hospital with abdominal and back pain and tenderness who was noted on CT to have a likely contained rupture of an abdominal aortic aneurysm. She was transferred to [Hospital1 18] where contrast CT was performed, again showing likely contained rupture of an infrarenal abdominal aortic aneurysm. She was not a candidate for an Endograft repair due to severe angulation of the proximal neck, inadequate neck below the renal arteries and very small iliac arteries. She was taken emergently to the operating room for aneurysm repair Past Medical History: PMH: HTN, AAA, COPD, Cerebrovascular aneurysms x2 s/p clipping, Hypothyroid PSH: Open CCY, Tonsillectomy Social History: pos smoker non drinker Family History: n/c Physical Exam: a/o nad supple farom neg lyphandopathy neg supraclavicular nodes decreased bs at bases pos bs / surgical inc c/d/i Pulses Fem [Doctor Last Name ] DP PT R 2+ 1+ 2+ M L 2+ 1+ 2+ - Pertinent Results: [2156-4-23] 06:30AM BLOOD WBC-10.3 RBC-3.94* Hgb-12.0 Hct-35.7* MCV-91 MCH-30.4 MCHC-33.6 RDW-15.8* Plt Ct-485* [2156-4-23] 06:30AM BLOOD Plt Ct-485* [2156-4-17] 02:44AM BLOOD PT-12.8 PTT-33.4 INR(PT)-1.1 [2156-4-23] 06:30AM BLOOD Glucose-136* UreaN-28* Creat-1.1 Na-140 K-4.5 Cl-99 HCO3-36* AnGap-10 [2156-4-23] 06:30AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2 [2156-4-17] 09:07AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD URINE RBC-0-2 WBC-[6-1]* Bacteri-NONE Yeast-NONE Epi-0-2 URINE CastHy-0-2 [2156-4-17] 9:43 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2156-4-17]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2156-4-19]): OROPHARYNGEAL FLORA ABSENT. ESCHERICHIA COLI. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S [2156-4-17] 9:51 AM CHEST (PORTABLE AP) CHEST: Comparison is made with the prior chest x-ray of [4-16]. There has been no significant change since this time. Atelectasis at both bases persists. No definite infiltrates are present. IMPRESSION: No change. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 2671] [Hospital1 18] [Numeric Identifier 77658]Portable TTE (Complete) Results Measurements Normal Range Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm Left Ventricle - Ejection Fraction: >= 60% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A ratio: 0.67 Mitral Valve - E Wave decel time: 310 ms 140-250 ms TR Gradient (+ RA = PASP): >= 37 mm Hg <= 25 mm Hg Findings LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. AORTIC VALVE: Aortic valve not well seen. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality - ventilator. Conclusions There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Cannot exclude basal inferior hypokinesis; image quality technically suboptimal for assessment of regional wall motion. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion Brief Hospital Course: Pt admitted Emergent AAA repair - intra op recieved PRBC / PLT / FFP / Fluid resusitation Sent to the CVICU in critical condition Presuure support and resusitation while in the CVICU While in the CVICU multiple atempts to wean patient. Could not Thoracics consulted. Trach and peg placed. Pt also experienced in crease in WBC / febrile / All lines changed out. Pan cx'd. Pos urine and sputum. Pan sensitive to cipro. Sputum - E Coli treated with cipro, urine - Morganelli also sensitive Cipro. Pt to be on Cipor for 14 days upon DC. Pt also had agitatiion. Haldol given with good results Pt also had elevation in cardiac enzymes. Cardiology consult - demand ischemia, cardiology followed. On Enzymes are decreasing. Pt needs full Cardiac work-up as an out patient. Treated for hyponatremia with free water Once completely resusitated from CVICU. Pt sent to the VICU for further care. PT consult and Case Management involed Recommended rehab Medications on Admission: [Last Name (un) 1724]: Plavix 75', quinapril 5', lasix 40''', levoxyl (unknown dose), combivent [Hospital1 ], serevent 50mcg [Hospital1 ] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 8. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] (). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Ruptured AAA Demand Ischemia with troponin leak Anemia requuiring blood products UTI Respiratory distress requiring trach / unable to wean from vent post operative FTT postoperative requiring PEG placement PNA / E Coli Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [5-30] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [1-25] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr [Last Name (STitle) ] office and schedule an appointment for [2-24] weeks. He can be reached at [Telephone/Fax (1) 2625]. Pt had demand ischemia post operative period. Needs full cardiac workup when stable. [Last Name (un) 77659],[Last Name (un) ] A [Telephone/Fax (1) 9674], Immediatly when discharged from rehab. Completed by:[2156-4-23]	[ "997.1", "997.3", "401.9", "244.9", "441.3", "553.20", "997.5", "276.0", "599.0", "285.9", "041.4", "496", "482.82", "518.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "45.13", "31.1", "38.91", "38.44", "96.6", "53.59", "33.21", "96.72" ]	icd9pcs	[ [ [] ] ]	7633, 7705	5556, 6509	287, 441	7968, 7975	1504, 5533	10716, 11096	1267, 1272		6709, 7610		7726, 7947		6535, 6686			7999, 10263	10289, 10693							1287, 1485																							186, 249									469, 1082															1104, 1211	1227, 1251
9,182	186,395	21217	Discharge summary	report	Admission Date: [2133-5-20] Discharge Date: [2133-5-27] Date of Birth: [2060-11-16] Sex: F Service: CSU CHIEF COMPLAINT: Mrs. [Known lastname 56184] is a 73 year old woman referred by Dr. [Last Name (STitle) 11493] for cardiac catheterization to further evaluate her critical aortic stenosis and evaluate for coronary artery disease prior to the repair of her aortic valve. HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 56184] reports shortness of breath starting two years ago. She recently reports worsening shortness of breath with stair climbing and occasionally at rest. She also reports occasional PND, two pillow orthopnea and bilateral ankle edema, right greater than left. Furthermore, she reports a few episodes of sharp pains especially in her right chest while at rest. An echo done on [2133-5-8] revealed preserved LV function with tight AS and a peak gradient of 110 and mean gradient of 80 with an aortic valve area of 0.4 cm2. There was no significant AI, MR [First Name (Titles) ] [Last Name (Titles) 56185]. PAST MEDICAL HISTORY: Past medical history is significant for hypertension, hypercholesterolemia, non insulin dependent diabetes mellitus, chronic renal insufficiency, mild anemia. PAST SURGICAL HISTORY: Appendectomy, tonsillectomy, eye surgery. ALLERGIES: Penicillin. MEDICATIONS PRIOR TO ADMISSION: Lasix 20 mg qd, Avandia 8 mg qd, Zocor 40 mg qd, Avapro 300 mg qd, Prempro 0.625 mg qd and aspirin 81 mg qd. LABORATORY DATA: White count is 7.1, hematocrit 28.8, platelets 206, sodium 130, potassium 4.2, chloride 102, CO2 28, BUN 27, creatinine 1.5, INR 1.1. SOCIAL HISTORY: Mrs. [Known lastname 56184] lives with her husband. She denies tobacco and alcohol use. As stated previously, Mrs. [Known lastname 56184] was a direct admission to the Cath Lab. Please see cath report for full details. In summary, she had a cath that showed critical AS with an aortic valve area of 0.4 cm2, a mean gradient of 76 and normal coronaries. PHYSICAL EXAMINATION: Heart rate is 72, blood pressure 110/50, respiratory rate 16, O2 sat 99 percent on 2 liters. Neurologically, she is awake, alert and oriented times three with nonfocal exam. HEENT - pupils are equally round and reactive to light. Mucous membranes are moist, normal mucosa and no lymphadenopathy. Cardiovascular - regular rate and rhythm, harsh 4/6 systolic ejection murmur radiating to the neck. Respiratory - clear to auscultation bilaterally. Abdomen - obese, soft, nontender, nondistended, normoactive bowel sounds. Extremities are cool with 2+ edema. Pulses - femoral on the left is 2+, the right is cath site, dorsalis pedis 1+ bilaterally, radial 2+ bilaterally, carotids with bruits versus radiating murmur bilaterally. HOSPITAL COURSE: The patient was accepted for cardiac surgery and was preopped for an AVR on [5-21]. Please see the OR report for full details. In summary, the patient had an aortic valve replacement with a No. 21 Mosaic Porcine valve. The bypass time was 79 minutes with a cross-clamp time of 57 minutes. The patient tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the night of his surgery and on postoperative day 1, he was weaned from all cardioactive medications, but remained in the Cardiothoracic Intensive Care Unit for close hemodynamic monitoring. On postoperative day 2, the patient remained hemodynamically stable. His Swan-Ganz catheter and central venous access were removed and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. On postoperative day 3, the patient continued to progress in his activity level. His chest tubes were discontinued. His wires were removed and with the assistance of Physical Therapy and the nursing staff, his activity level was further advanced. Throughout the remainder of the patient's postoperative course, it was uneventful. On postoperative day 6, it was decided that the patient was stable and ready to be discharged to home. At this time, the patient's physical examination is as follows: Vitals signs - temperature 98.4, heart rate 76, sinus rhythm, blood pressure 150/60, respiratory rate 20, O2 sat 94 percent on room air. Weight preoperatively was 73.6 kg and at discharge 76.4 kg. Lab data reveals a white count of 7.2, hematocrit 27.4, platelets 260, sodium 136, potassium 4.4, chloride 97, CO2 29, BUN 19, creatinine 1.1, glucose 128. On physical examination, he is neurologically alert and oriented times three. He move all extremities, follows commands. Respiratory - clear to auscultation bilaterally. Cardiac - regular rate and rhythm, S1 and S2. Sternum is stable. Incision is with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm, well-perfused with 1+ edema bilaterally. DISCHARGE MEDICATIONS: Metoprolol 50 mg [Hospital1 ], aspirin 325 mg qd, Zocor 40 mg qd, Avandia 8 mg qd, Lasix 20 mg qd times two weeks, Prempro. The patient is to resume preoperative schedule and Percocet 5/325 one to two tabs q4h, prn. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: AS, status post aortic valve replacement with a No. 21 Mosaic Porcine valve. Hypertension. Hypercholesterolemia. Chronic renal insufficiency. Non insulin dependent diabetes mellitus. Status post appendectomy. Status post tonsillectomy. Status post eye surgery. DISCHARGE INSTRUCTIONS: The patient is to be discharged home with visiting nurses. She is to follow up with Dr. [Last Name (STitle) 1159] and/or Dr. [Last Name (STitle) 11493] in [1-22] weeks and follow up with Dr. [Last Name (STitle) 70] in 6 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2133-5-27] 12:44:49 T: [2133-5-27] 14:30:10 Job#: [Job Number ]	[ "593.9", "250.00", "428.0", "272.0", "285.9", "424.1", "401.9" ]	icd9cm	[ [ [] ] ]	[ "35.21", "89.68", "39.61", "88.72", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]								5429, 5698	5154, 5375					2809, 5130		5723, 6234						1297, 1365												1398, 1661				2063, 2791									155, 417									446, 1090															1113, 1273	1678, 2040	5400, 5407
28,073	140,509	20877	Discharge summary	report	Admission Date: [2176-4-23] Discharge Date: [2176-4-28] Date of Birth: [2095-5-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2344] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 7716] is an 80 year-old man with a history of CHF and COPD who presents with dyspnea. At baseline, patient is able to walk 20-30 feet or one flight of stairs. Over the last few days, this has worsened. Per his wife, he spent most of the day prior to admission in bed with little interest in food and only toast taken in. The patient does report baseline 1 pillow orthopnea and has had increasing PND over the last few nights, awakening at 3am with acute shortness of breath, relieved with sitting at the bedside. This is often accompanied by chest discomfort, especially when coughing. He also reports, as above, poor appetite with abdominal distension, chronic cough (production of phlegm). There has been on weight change. Also with chills two days prior to admission, without recorded fever, one episode of diarrhea one day prior to admission, and dysuria (on and off for a year). For these symptoms, he has been using an occasional tylenol and advil. Given the worsening and his wife's urgings, he presented to the ED for futher evaluation. In the ED, initial temperature was 98.0, HR 103, BP 92/55, RR 25, 89% on room air. Blood pressure fell as low as 80/48 and O2 improved to 94% on 4 liters. He was given Levofloxacin 750mg IV, Aspirin 325mg, Vancomycin 1gram and Decadrom 10mg IV. For the hypotension, a sepsis line was placed. 2+ liters of NS were also given. Past Medical History: 1. Congestive heart failure - Echo ([9-26]) with Mild symmetric LVH with normal cavity size and global systolic function (LVEF>55%). Mild MR; Moderate TR - Cath ([1-28]) with dilated left ventricle with significant generalized hypokinesis and a global ejection fraction of 28% (while the patient is in atrial flutter). 2. COPD 3. Hypertension 4. s/p AVR for aortic stenosis 5. Atrial fibrillation, cardioversion ([5-25]) 6. s/p splenic artery aneurysm resection/splenectomy ([7-26]) 7. GERD 8. History of RCC s/p left nephrectomy ([8-26]) 9. History of colon cancer status post colostomy ([9-/2160]) 10. History of B12 deficiency 11. History of ITP Social History: Lives with his wife in [Location (un) 538]. He quite smoking in [2172]. He has 5 to 7 beers three to four times per week. Retired electrician. Family History: Noncontributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals T 97.2, BP 120/67, HR 91, RR 32, 94% on 4 liters via NC GEN - Lying in bed, coughing during exam. In no distress, able to complete sentences. HEENT - Unable to assess JVP in setting of RIJ. OP is clear. Mildly dry MM. CV - Regular. Systolic murmur heard over aortic site. PULM - Bronchial breath sounds on left. Crackles at right base. ABD - Soft and distended. Midline ventral hernia, reproducible. Non-tender. EXT - Warm. Trace edema. NEURO - Alert. Oriented. PHYSICAL EXAM ON TRANSFER TO MEDICAL FLOOR: ============================================ VS: T 98.0 BP 118/54 HR 80 RR 22 95% 4L NC CVP 15 I/O: 220/590 GEN: NAD, elderly, pleasant male sitting up in bed, able to answer in complete sentences HEENT: EOMI, PERRL, OP - no exudate, no erythema, no LAD NECK: CVL bandage on R neck CHEST: poor air movement throughout lung fields, + wheezes heard in right upper and middle lobe, decreased BS in RLL, no crackles. CV: irregularly irregular, II/VI SEM at RUSB, II/VI SEM at LLSB, no r/g ABD: NDNT, soft, NABS, vertical abdominal scar noted, reducible abdominal hernia along right side of midline. EXT: no c/c/e Pertinent Results: ADMISSION LABS: =============== Lactate: 3.0 -> 1.9 -> 2.3 140 106 44 ------------ 137 4.8 23 2.5 WBC: 33.3 --> 35.7 HCT: 36.3 --> 32.6 PLT: 132 --> 127 N:89.9 Band:0 L:3.3 M:6.5 E:0 Bas:0.3 Poiklo: 1+ Macrocy: 1+ Polychr: OCCASIONAL Ovalocy: 1+ Burr: 1+ Plt-Est: Low UA: 1.021 / 5.0 Urobil 4 Bili Sm Leuk Mod Bld Lg Nitr Neg Prot 30 Glu Neg Ket Tr RBC [12-12] WBC >50 Bact Many Trop-T: 0.04 CK: 129 MB: 3 Ca: 8.8 Mg: 2.2 P: 1.2 PT: 28.3 PTT: 51.0 INR: 2.9 ABG 7.41 / 70 / 38 / 25 PERTINENT LAB DURING HOSPITALIZATION: ===================================== Lactate trend: 3.8 - 1.9 - 2.3 - 1.6 - 1.8 - 1.5 WBC trend: 33.3 - 35.7 - 27.7 - 24.8 - 15.6 - 10.9 - 12.6 INR trend: 2.9 - 3.8 - 3.9 - 4.1 - 3.3 - 2.9 Cr trend: 2.6 - 2.5 - 2.3 - 1.9 - 1.8 - 1.7 - 1.6 BNP: [Numeric Identifier 34892] MICROBIOLOGY: ============= [2176-4-23] Blood Cultures x 2: No growth [2176-4-23] 12:00 pm URINE Site: CATHETER FINAL REPORT [2176-4-26] URINE CULTURE (Final [2176-4-26]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S [2176-4-26] 2:21 pm SPUTUM Source: Expectorated. FINAL REPORT [2176-4-26] GRAM STAIN (Final [2176-4-26]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. STUDIES: ======== CHEST (PORTABLE AP) [2176-4-23] FINDINGS: Allowing for differences in technique, there appears to be increased cardiomegaly. There has been interval development of interstitial and alveolar opacities, most prominent in a bibasilar distribution. The lung volumes appear increased suggesting underlying obstructive lung disease. There has been aortic valve replacement and median sternotomy wires remain in place. The thoracic aorta is calcified and tortuous. IMPRESSION: Increased cardiomegaly and interval development of bibasilar interstitial and alveolar opacities most suggestive of CHF; however, underlying infection cannot be entirely excluded. PORTABLE ABDOMEN [2176-4-23] FINDINGS: There is no evidence of free intra-abdominal air. There is a nonspecific bowel gas pattern with air-filled loops of colon. No dilated loops of small bowel are identified to suggest small bowel obstruction. Left paraspinal clips noted consistent with previous left nephrectomy. Diffuse degenerative changes are present throughout the thoracolumbar spine, not well evaluated on this radiograph. IMPRESSION: Nonspecific bowel gas pattern. No evidence of free intra- abdominal air. EKG [2176-4-23] Sinus rhythm Leftward axis Intraventricular conduction delay ST-T wave changes Since previous tracing of [2172-10-5], no significant change Portable TTE (Complete) Done [2176-4-24] The left atrium is elongated. The right atrium is markedly 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. Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2172-10-6], the degree of pulmonary hypertension detected has increased. CHEST (PORTABLE AP) [2176-4-25] The cardiac silhouette remains enlarged and shifted towards the right. Interstitial edema has slightly improved. Confluent right retrocardiac opacity with some associated volume loss appears slightly decreased, but adjacent right pleural effusion is minimally increased in the interval. Brief Hospital Course: Mr. [Known lastname 7716] is an 80 y.o. M with diastolic and systolic CHF (EF 60% during this admission), atrial fibrillation on Coumadin, hypertension and COPD, admitted on [2176-4-23] for sepsis due to RLL PNA and UTI. # Sepsis: The patient initially presented with hypotension, mildly elevated lactate, and leukocytosis in the ED. He improved with gentle IVFs. Did not require pressors while in the hospital, but was admitted to the MICU for closer monitoring. Blood cultures were negative, but urine culture did grow pseudomonas. CXR with retrocardiac opacity, concerning for possible pneumonia. Lactate trended down during MICU course. Hypotension resolved. # Dyspnea: Initially, the patient was noted to be 89% O2 on RA, which improved with 4 L NC to 94%. At baseline, he does not need oxygen. [Month (only) 116] have been due to both pneumonia and acute on chronic CHF as pt intermittently took his home Lasix, presented with an elevated BNP, and his CXR was suggestive of failure. Diuresis was held as he was septic on presentation. On transfer to floor, he did not appear volume overloaded clinically, and diuresis continued to be held. His oxygen saturation improved while he was on his antibiotics for pneumonia. By discharge, the patient was maintaining mid 90% oxygen saturation during rest and ambulation without any supplemental oxygen. # Pneumonia: Treated with both Levofloxacin and Ceftriaxone for CAP coverage. Discharged with Levofloxacin and Cefpodoxime to complete a 7 day course. NC was weaned. Leukocytosis trended down with antibiotics. # UTI: Grossly positive UA x 2. Urine culture with pan-sensitive pseudomonas. Treated in hospital with ceftriaxone and levofloxacin. He was discharged with cefpodoxime to complete a 7 day course. # Leukocytosis: WBC markedly elevated on admission and trended down during hospitalization with antibiotic treatment of his UTI and PNA. Blood cultures negative. Urine culture as above. # CHF, systolic and diastolic, chronic: BNP elevated on admission. Echo showed EF 60%. Patient admits to intermittently taking his Lasix. However, CXR on medical floor did not support volume overload nor did physical exam. Continued to hold diuresis while on medical floor. Held [Last Name (un) ] as BP on the low range. # Acute on CKD: Cr elevated on admission at 2.6 and trended down to 1.6 on discharge. Most recent baseline of 1.7-1.8 in [2173]. All medications were renally dosed. # Anemia: Has intermittently been macrocytic; current MCV 97. Appears to be roughly at baseline. Likely at least in part due to CKD. Also has a history of B12 deficiency though most recent value is within normal limits. # COPD: Albuterol and Atrovent prn. # s/p AVR: On Coumadin as outpatient. INR trended during hospitalization to keep within goal of 2.5-3.0. Held Coumadin as needed particularly since patient was on antibiotics that interacted with Coumadin. Outpatient lab work and INR follow up arranged upon discharge. # Atrial fibrillation: Held metoprolol as patient with low blood pressures. Also held Coumadin as needed as stated above. Continued digoxin. # h/o ITP: Platelet count remained stable during hospitalization. # Code: Full code # Contact: Wife [Name2 (NI) ] [Telephone/Fax (1) 55568] # Dispo: Home with close monitoring of INR. Pt cleared to go home by PT. Medications on Admission: 1. Digoxin 0.125mcg daily 2. Coumadin 2.5mg and 5mg alternating 3. Cozaar 50mg [Hospital1 ] 4. Metoprolol 50mg [Hospital1 ] 5. Lasix 40mg daily (does not take frequently) Not on aspirin because of ulcer Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 doses. Disp:1 Tablet(s) Refills:0 3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 inahler Refills:3 4. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 days. Disp:4 Tablet(s) Refills:0 6. Outpatient Lab Work Please check PT/PTT on [Last Name (LF) 766], [4-29] and fax results to patient's PCP (Dr. [First Name (STitle) ] at fax #[Telephone/Fax (1) 28310]. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Pneumonia 2. Urinary Tract Infection Secondary Diagnosis: 1. Congestive Heart Failure 2. Acute on Chronic Kidney Disease 3. Anemia 4. Atrial fibrillation 5. COPD Discharge Condition: Stable. Afebrile. Comfortable on room air. Discharge Instructions: You were admitted with pneumonia and a urinary tract infection. You were intitially in the ICU due to your respiratory status, but you improved and were transferred to the medical floor. You were given IV antibiotics during your hospitalization. Physical therapy also saw you. You no longer need supplemental oxygen. Please take all your medications as prescribed. The following changes have been made: 1. Please take your levofloxacin and your cefpodoxime for another 2 days to complete a 7 day course. A prescription has been given to you. 2. Please hold your coumadin until your doctor says you can take it. 3. Please hold your Lasix, metoprolol, and Cozaar until your doctor tells you to restart it. Please keep all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, bright red blood in the toilet bowel, lightheadedness, dizziness, or any other concerning symptoms. Followup Instructions: You have an appointment with Dr. [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ] on Tuesday, [2176-4-30] at 12:15 pm. If you cannot make this appointment, please call [Telephone/Fax (1) 18145] to reschedule. The home nursing company will check your bloodwork to evaluate your INR (how thin your blood is). These results will be sent to your primary care physician. (fax #[Telephone/Fax (1) 28310]) Completed by:[2176-5-5]	[ "038.9", "428.42", "V10.52", "995.91", "V10.05", "593.9", "285.21", "496", "428.0", "V45.73", "599.0", "427.31", "V43.3", "486" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13118, 13176	8641, 12016	324, 331	13405, 13450	3890, 3890	14505, 14969	2650, 2668		12277, 13095		13197, 13197		12042, 12254			13474, 14482								2708, 3871																							276, 286									359, 1769			13278, 13384		3906, 8618	13216, 13257									1791, 2466	2482, 2634
28,082	153,645	28155	Discharge summary	report	Admission Date: [2191-11-27] Discharge Date: [2191-12-6] Date of Birth: [2115-9-25] Sex: F Service: MEDICINE Allergies: Metronidazole / Tape Attending:[First Name3 (LF) 3276] Chief Complaint: seizure Major Surgical or Invasive Procedure: Tracheal intubation Inferior vena cava filter placement Whole brain irradiation History of Present Illness: 76-year-old woman with history of recently diagnosed lung adenoca, protein-losing enteropathy, afib, was transferred from [Hospital 1562] hospital after having seizure at home. . Per son, patient was eating at home when she suddenly had leftward gaze, slurred speech, and confusion. Son called EMS. During the ambulance ride to [Hospital 1562] hospital, she again had leftward gaze and slurred speech and at one time was unresponsive. Upon arrival to [Hospital1 1562] ED, she was reportedly responsive again, however. Was given lorazepam in [Hospital1 1562] ED. WBC 8.9, Hct 42, plt 413, IRN 1.0. Cr 0.54. CE neg. Head CT at [Hospital1 1562] revealed 3-cm lesion in the right frontal parietal region with no midline shift. Patient was intubated for airway protection. Was given dexamethasone 40 mg IV x 1, loaded with fosphenytoin and transferred to [Hospital1 18]. . On arrival to [Hospital1 18] ED, afebrile, HR 80s, BP 120s/80s, vented. Repeat head CT showed 3-cm right frontal mass with surrounding edema but no midline shift. CXR showed possible developing pneumonia the in the RUL; therefore, the patient was given pip-tazo 4.5 mg IV x 1 and levoflox 750 mg IV x 1. Neurosurg was consulted, recommending dex 4 mg q6h and levetiracetam 1000 mg [Hospital1 ]. Heme-onc fellow was aware, recommending [Hospital Unit Name 153] admission. . ROS: not obtained due to patient's being intubated . Past Medical History: * Lung cancer: adenocarcinoma, followed by Drs. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10919] and [Name5 (PTitle) 3274] - [2191-1-25]: admitted for SBO, imaging revealed pulmonary nodules in RUL and RLL as well as possible spine mets with a collapsed T10 and a partially collapsed T12; work-up delayed due to poor clinical status - [2191-6-26]: PET revealed that RUL and RLL nodules were FGD avid; considered poor surgical candidate - [2191-8-26]: seen by Dr. [Last Name (STitle) 548] in spine center, perc biopsy of spine lesions suggested to rule out mets - [2191-11-18]: transbronchial bx performed by Dr. [Last Name (STitle) ], positive for adenocarcinoma * Atrial fibrillation. * Protein-losing enteropathy on TPN for about a year and a half. Last TPN was in [2191-5-26]; has been having PO food since. Her course with her protein losing enteropathy and TPN was complicated by line infections and several hospitalizations. * Right torn rotator cuff. * Status post removal of basal cell carcinoma. * Small bowel obstruction managed conservatively in [2190]. * Small bowel obstruction in [2191-2-25] requiring exploratory laparoscopic lysis of adhesions and ileocecal bypass. . Social History: The patient lives with one of her daughters and her son and his children. She continues to smoke less than half a pack per day over the past several months. She previously smoked about two packs a day for about 60 years. She does not drink alcohol. Her husband passed away several years ago of leukemia. She has eight children, four sons and four daughters, all within the [Name (NI) ] area or in [Hospital3 ]. She has 17 grandchildren and has very good family support. Family History: Mother had breast cancer in her 60s. Father died of MI at 59, sister with post-polio syndrome, brother with status post CABG, but is very active and has no further heart problems. [Name (NI) ] one in the family with any bowel problems or lung cancer or any other cancers. Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: Elderly woman, intubated, nonresponsive HEENT: PERRL, sclera anicteric, ET tube in place NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy COR: nl rate, reg rhythm, nl S1/S2, no m/r/g PULM: coarse breath sounds bilaterally from anterior ABD: Soft, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords, 2+ DP pulses bilaterally SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission labs [2191-11-27] 08:39PM BLOOD WBC-5.8 RBC-4.28 Hgb-12.3 Hct-36.6 MCV-85 MCH-28.7 MCHC-33.6 RDW-16.1* Plt Ct-347 [2191-11-27] 08:39PM BLOOD Neuts-83.6* Lymphs-14.7* Monos-1.4* Eos-0.1 Baso-0.1 [2191-11-27] 08:39PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2* [2191-11-27] 08:39PM BLOOD Glucose-153* UreaN-10 Creat-0.6 Na-137 K-3.8 Cl-106 HCO3-22 AnGap-13 [2191-11-27] 08:39PM BLOOD ALT-5 AST-8 LD(LDH)-245 AlkPhos-145* TotBili-0.4 [2191-11-27] 08:39PM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.2 Mg-1.9 [11-27] CT head: IMPRESSION: Right frontal lobe 3 cm mass with surrounding edema. Given history, this is a presumed metastasis. No evidence of hemorrhage, shift of midline structures, or herniation. Findings were posted to the ED dashboard. [11-28] Bilat Venous dopplers: IMPRESSION: DVT involving the right superficial femoral vein. [11-28] MRI head: IMPRESSION: 1. Three enhancing lesions in the brain compatible with metastatic disease. Suggestion of leptomeningeal seeding by location of 1 or 2 of these lesions. 2. Other nonspecific white matter FLAIR abnormalities in the periventricular white matter as well as the left brachium pontis. . KUB: 1. Nonspecific bowel gas pattern. No evidence for obstruction or ileus. No intraperitoneal free air or pneumatosis. 2. IVC filter. . CXR [12-3]: IMPRESSION: Development of pleural effusions and volume loss in the left lower lobe. Brief Hospital Course: 76-year-old woman with recently diagnosed lung adenocarcinoma with mediastinal node mets, history of protein-losing enteropathy, presented with seizure from home, found to have likely new brain mets. . Plan: # Seizure with altered mental status: Most likely from new brain lesion, which is concerning for brain mets from her lung ca. Neurosurgery, oncology were called and patient started on levetiracetam 1000 mg [Hospital1 ], dexamethasone 4mg q6h. MRI showed 3 enhancing lesions c/w metastases. Patient was extubated on day 2 of hospital stay and transitioned well. Family meeting was held and it was decided to make patient DNR/DNI, but offer whole brain radiation for palleation. Rad-onc consulted and patient received WBR. XRT completed and the patient was alert, oriented, and ambulating well prior to discharge. After discharge the patient is to continue a steroid taper to be followed by primary oncology as outlined on discharge medications. . # Lung cancer: Recent transbronchial biopsy of mediastinal node revealed adenocarcinoma.Biopsy of spinal lesion revealed no tumor and now with new brain mets/ stage IV. Completed WBR. Further management as per primary oncology. . # Right lower extremity DVT: bilateral LENIs showed DVT and IVC filter was placed. Anticoagulation was not started as patient is at risk for bleed with new brain mets. . # Possible pneumonia: with opacity in RUL, concerning for aspiration in the setting of seizure. Patient does have a history of MRSA bacteremia and VRE from abdominal wound. Empiric pip-tazo and vanco were transitioned to ceftriaxone on hospital day 1 as patient was at home prior to this episode. Cultures without growth. Mrs [Last Name (STitle) ] remained afebrile and was transitioned to PO cefpodoxime and completed a 7 day course of antibiotics. . # Atrial fibrillation: Remained in sinus rhythm. Continued dilt 60 mg q8h. Hold off on warfarin given risk of intracranial bleeding. . # Protein-losing enteropathy: most recently on TPN in [2191-5-26]. S/p abd surgeries for SBO. Tolerated PO after extubation. . # FEN: Regular diet, passed speech and swallow eval . #Thrush: Discharged on Nystatin solution. . # Code: DNR/DNI . # Comm: son [Name (NI) ] and daughter [Name (NI) ] [Name (NI) 4027] are HCPs, [Telephone/Fax (1) 68438] Medications on Admission: diltiazem 60 mg q8hrs furosemide 40 mg [Hospital1 ] warfarin: held since late [Month (only) ] due to bronch Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 2. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours for 30 doses: take 4 mg (2 tabs) every 8 hours for 4 days, then 4 mg (2 tabs) every 12 hours for 4 days, then 4 mg in the morning and 2 mg in the evening for 4 days, 2 mg every 12 hours for 4 days and then discuss with your Oncologist Dr. [Last Name (STitle) 3274] how long you should continue to take this medication. Disp:60 Tablet(s) Refills:0 3. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:90 Tablet(s) Refills:2 4. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed for thrush for 1 months. Disp:1000 ML(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Primary: Seizure Metastatic lung cancer to the brain Community-acquired pneumonia Deep venous thrombosis . Secondary: * Lung cancer: adenocarcinoma * Atrial fibrillation. * h/o protein-losing enteropathy requiring TPN. * Right torn rotator cuff. * Status post removal of basal cell carcinoma. * h/o recurrent small bowel obstructions requiring exploratory laparoscopic lysis of adhesions and ileocecal bypass. Discharge Condition: Good, tolerating POs Discharge Instructions: You were admitted after having a seizure and found to have a brain mass from your lung cancer. You were started on steroids and anti-seizure medications and will need to continue these after discharge. Initially you required mechanical ventilation due to your change in mental status. You were also found to have a blood clot in your leg and a filter was placed to protect against the blood clot from traveling to your lungs. In addition, you were diagnosed with pneumonia and completed a course of antibiotics. . Please take all medications as prescribed. New medications: keppra, dexamethasone, nystatin Discontinued medications: Lasix (measure your weight daily and call your doctor if it increases more than 2 pounds, they may want to restart this medication) . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, abdominal pain, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: Follow up with Dr. [Last Name (STitle) 3274] and Dr. [Last Name (STitle) 10919], your Oncologists, the first week in [Month (only) 1096]. ([Telephone/Fax (1) 3280]. . Call your PCP: [Name10 (NameIs) 7726],[Name11 (NameIs) 177] [Name Initial (NameIs) ]. [Telephone/Fax (1) 7728] to schedule an appointment in [1-26] weeks. In addition to your recent hospitalization, please discuss whether you should restart lasix. . Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2192-1-2] 10:35 Provider: [Name10 (NameIs) 5005] [Last Name (NamePattern4) 5342], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2192-1-2] 11:30 [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282] Completed by:[2191-12-17]	[ "196.1", "427.31", "198.3", "579.8", "V85.0", "112.0", "162.9", "453.41", "486", "780.39" ]	icd9cm	[ [ [] ] ]	[ "92.29", "38.7", "96.71" ]	icd9pcs	[ [ [] ] ]	9155, 9206	5847, 6078	290, 372	9660, 9683	4395, 4935	10707, 11549	3621, 3901		8342, 9132		9227, 9639		8201, 8319			9707, 10684								3916, 4376																							243, 252									400, 1832		4944, 5824							6093, 8175						1854, 3103	3119, 3605
54,265	142,230	13895+56497	Discharge summary	report+addendum	Admission Date: [2194-7-4] Discharge Date: [2194-7-15] Date of Birth: [2110-2-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Right Upper Quadrant pain Major Surgical or Invasive Procedure: [First Name3 (LF) ] with stent placement [2194-7-8] Laparoscopic cholecystectomy History of Present Illness: Ms. [Known lastname ] is an 84-year-old woman with a history of coronary artery disease s/p CABG, AVR, hypertension. She was in her usual state of health until [7-2]. She ate an english muffin in the morning, felt mild malaise throughout the day, and after seeing her cardiologist for a routine appointment in the afternoon became acutely nauseas. She vomitted 5-7 times, nonbloody, nonbilious. The was accompanied by [9-15] upper abdominal and bilateral scapular pain. She presented to [Hospital 1562] hospital ED. There she received antiemetics and pain control. Ultrasound showed a thick-walled gallbladder with cholelithiasis and a dilated CBD. She was admitted. She was started on empiric Zosyn. She was anemic to an unclear nadir and received 2 units of pRBC. There was no melena or hematemesis. Her coumadin was held. Given concern for GI bleed, her cardiologist recommended reversing her coumadin with Vit K and possibly FFP, although it is unclear if this was done. By report, overnight, she developed chest pain with troponin elevation to .55 without EKG changes. She was hemodynamically stable. The patient does not recall chest pain. Her abdominal exam and pain improved, but she was becoming more jaundiced with a rising bilirubin to >7. Thus, she was transferred to the [Hospital1 18] ICU. Past Medical History: - CAD - CABG (SVG-->LAD, OM, RCA in [9-/2180]) - atrial fibrillation (apparently chronic) - AVR, on Coumadin - HTN - hypothyroid - history of bleeding peptic ulcer in [2180] Social History: The patient is a widow after her husband died from pancreatic cancer 15 years ago. She is independent in her ADLs and ambulatory with a walker. She has 3 children, 8 grand-children, and 8-great-grandchildren who live in the area and are involved in her care. Lifetime non-smoker. No EtOH. Family History: Non-contributory Physical Exam: VS: T 98.4 HR 98 Afib BP 118/61 RR 24 96% RA GEN: NAD, pleasant, conversive HEENT: no scleral icterus CHEST: CTA B/L, A fib, no murmurs, mechanical heart valve ABD: soft, NT, ND, no rebound/guarding, BS present EXT: warm, no edema, DP/PT palp B/L Neuro: AAOx3 Pertinent Results: [Year (4 digits) ] [2194-7-5] 1. Innumerable filling defects within the common duct, consistent with stones. There is moderate duct dilatation. 2. Placement of common bile duct stent, with numerous residual retained common duct stones present at the termination of procedure. Brief Hospital Course: A 84 year-old woman with a history of coronary artery disease s/p CABG, atrial fibrillation, was transferred from an outside hospital with choledocholithiasis and cholangitis. She was initially admitted to the MICU where she underwent an [Month/Day/Year ] with stent placement. No stones were visualized and likely already passed. Her antibiotics were switched from Zosyn to PO Cipro and Flagyl for a 1 week course and she will need to follow up for stent removal in 4 weeks. On [2194-7-8] she underwent a laparoscopic cholecystectomy by Dr. [Last Name (STitle) ]. She tolerated the procedure well and returned to the PACU in stable condition. She was subsequently sent to the surgical floor where she continued to make good progress. Her would as healing well, she was tolerating a regular diet and she was able to ambulate without difficulty. She was placed on IV heparin post op for her atrial fibrillation and aortic valve as a bridge until a therapeutic INR was achieved with Coumadin. Dr. [Last Name (STitle) ] will continue to monitor this after discharge. After an uneventful post operative course she was discharged to home with VNA services. INR on [2194-7-15] was 1.9. Medications on Admission: Medications on transfer: Zosyn 2.25 g IV BID protonix 40 mg IV q12h lopressor 2.25 mg IV q3h enalapril 20 mg PO bid synthyroid .088 mg PO daily Coumadin on hold. Home Medications: Coumadin 2.5 mg daily Lipitor 40 mg daily Zetia 10 mg daily Levoxyl 75 mcg daily Enalapril 20 mg [Hospital1 ] Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:8 Tablet(s) Refills:0 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:12 Tablet(s) Refills:0 5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Bayada Nurses Inc Discharge Diagnosis: 1. Acute cholecystitis/cholangitis 2. Choledocholithiasis Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with gallstones and bile duct stones and infection from it. You underwent an [Hospital1 ] procedure during which a bile duct stent was placed and some stones were removed. You were seen by surgeons and underwent removal of gallbladder... Your coumadin was held for procedures/surgery. You were placed on heparin drip and coumadin restarted after surgery. Please have your primary care doctor check your InR within 1-2 days after discharge from hospital You will need to come back for repeat [Hospital1 ] to remove the stent and stones in your bile duct Please finish your antibiotic course as prescribed Please return to ED for fevers, chills, abdominal or chest pain, shortness of breath Followup Instructions: Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2194-9-4] 12:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2194-9-4] 12:00 Patient does not currently have a PCP. [Name10 (NameIs) ] Cardiologist is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 41632] in [Hospital1 1562] and he regulates her Coumadin ([Telephone/Fax (1) 19666]) Dr. [Last Name (STitle) ] on Friday [2194-7-25] at 3:45pm [Hospital Ward Name 516], Shariro [Location (un) 470] ( [Telephone/Fax (1) 3201] ) Completed by:[2194-7-15] Name: [Known lastname ],[Known firstname ] Unit No: [Numeric Identifier 7539] Admission Date: [2194-7-4] Discharge Date: [2194-7-15] Date of Birth: [2110-2-28] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3524] Addendum: Pt with small volume loose stool, guiac positive x1. Pt hemodynamically stable, loose stool resolving, no abdominal pain, nausea, lightheadedness/dizziness, hematocrit stable. Pt to be followed up by Dr. [Last Name (STitle) 1825] with GI. Will continue with anti-coagulation. Discharge Disposition: Home With Service Facility: Bayada Nurses Inc [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2207] MD [MD Number(1) 3525] Completed by:[2194-7-15]	[ "576.1", "997.1", "401.9", "V58.61", "427.31", "782.4", "574.00", "576.2", "285.9", "V45.81", "244.9", "E879.9", "414.00", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "51.87", "51.85", "51.88", "51.23" ]	icd9pcs	[ [ [] ] ]	7673, 7878	2969, 4179	339, 430	5533, 5542	2656, 2946	6321, 7650	2334, 2352		4524, 5360		5452, 5512		4205, 4205			5566, 6298								2367, 2635					4386, 4501																		274, 301									458, 1802														4230, 4368	1824, 2008	2024, 2318
3,009	176,442	12292	Discharge summary	report	Admission Date: [2168-3-27] Discharge Date: [2168-4-1] Service: MICU/[Hospital1 ] MEDICINE CHIEF COMPLAINT: Delta MS. HISTORY OF PRESENT ILLNESS: This is an 82 year old male admitted on transfer from outside hospital with change in mental status, positive blood cultures, recent intraventricular hemorrhage and urosepsis. Mr. [Name14 (STitle) 38369] was admitted to [Hospital6 302] [2168-1-31], and a CT scan there showed a left basal ganglion hemorrhage secondary to hypertension. The course of his stroke was complicated by diffuse hemorrhage into the ventricular system and acute hydrocephalus. A ventriculostomy was placed and was eventually removed at a later time. He never regained his baseline neurologic function which included being independent, quite healthy and traveling to Europe on his own several times a year. However, there are no accurate assessments of his pre-morbid and post-morbid course in the outside hospital records. His family, however reports that he was making progress at Rehabilitation, able to read and communicating with them, although he had not yet walked. A PEG was placed and he was discharged to a [Hospital ] Hospital [2168-3-4]. He ostensibly did "well" there but on [3-21], he reportedly had another episode of delta MS. The family states that he was not easily arousable and was sleepy and was transferred to [Hospital3 ]. Repeat CT scan [3-21] showed a question of increased size of lateral and third ventricles compared with prior study, however, the Neurosurgical consultant was not concerned. An EEG was obtained on [3-22], reportedly negative for seizure activity. He had been discharged on Tegretol with a therapeutic level, but there is no known history of a prior seizure disorder. Also, his white blood cell count was 14.5 on admission to [Hospital3 ] and blood cultures and urine cultures were sent. He was started on Ceptaz/Gentamycin/Flagyl/Unasyn, on [3-22]. He was also started on Clonidine (?), which was tapered off rapidly after Neurologic consultant recommended against it. On [2168-3-24], the urine cultures returned with 75,000 colony-forming units of Enterococcus fecalis sensitive to Ampicillin and nitrofurantoin. On [3-24], stool culture returned positive for C. difficile toxin. Ceptaz was discontinued and nitrofurantoin was started; p.o. Flagyl was discontinued and p.o. Vancomycin was started for unclear reasons. Gentamicin and Unasyn were continued. He apparently was observed to be returning to his baseline mental status at the rehabilitation facility when, today at 10 or 11 a.m., he reportedly suddenly became obtunded. He has been switched from Unasyn to Ceftriaxone for "better central nervous system penetration for concern of central nervous system infection". At 6 p.m., he became febrile to 101.0 F., by report. White blood cell count was 13.8. He was seen by his primary care physician's coverage and the family re-iterated that he wanted to be Full Code and requested a transfer to [Hospital1 69]. A CT scan was performed which showed mild hydrocephalus and no acute changes. Blood cultures returned one out of two bottles positive for Gram positive bacilli, Neisseria species, and presumptive lactobacilli and Diphtheroids. He was therefore considered to have "poly-microbial sepsis". PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. Hypertension. 3. "Cardiac arrhythmia secondary to complete heart block". 4. Pacemaker placement. 5. Hernia repair. 6. Bilateral cataract surgery. 7. Transurethral resection of the prostate. MEDICATIONS ON TRANSFER: 1. Colace 100 q. day. 2. Zantac 150 twice a day. 3. Lopressor 25 twice a day. 4. Nitrofurantoin. 5. Vancomycin 125 mg p.o. four times a day. 6. Gentamicin 225 intravenously q. day. 7. Tylenol. 8. Regular insulin sliding scale. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with his wife. [Name (NI) ] has a very large supportive family. He does not drink or smoke. PHYSICAL EXAMINATION: 98.2 F.; 125/70; 73; 16; 100% saturations. In general, this is an elderly frail appearing man lying in bed in no acute distress with his eyes closed. HEENT: Oropharynx dry. Mucous membranes clear of lesions. Neck was supple; there was no jugular venous distention. Lungs were clear to auscultation bilaterally although he would not take deep breaths for us. Cardiac: He had a regular rate and rhythm with normal S1 and S2. Abdomen soft, nontender, with normoactive bowel sounds. He was incontinent of stool. Extremities with no cyanosis, clubbing or edema. He has a bruise on his right hip which is without explanation. He has a sacral decubitus ulcer which is dressed. Neurologic: He is not oriented; he is somnolent. There is no spontaneous speech, although he speaks to his family when they prompt him. He does gesture with his hands. He is unable to keep his arms suspended in the air. He rarely moves his lower extremities bilaterally. Reflexes are one to two plus diffusely. Babinski's downgoing bilaterally. LABORATORY: From outside hospital, white blood cell count 13.8. Chem-7 notable for a BUN of 20 and creatinine of 0.3. Glucose 137, albumin 2.8. Blood cultures showed Gram positive bacilli, identified as Neisseria species and "presumptive lactobacilli and presumptive diphtheroids. Urine cultures from the 19th showed 75K CFU Enterococcus fecalis sensitive to Ampicillin, nitrofurantoin; resistant to Ciprofloxacin and Streptomycin. Stool was C. difficile positive on [3-24]. Labs on admission to [Hospital1 69]: White blood cell count 11.1; 78 neutrophils, 5 bands, 11 lymphocytes, 3 atypical and 3 meta. Chem-7 was normal. Tegretol was 4.1. Chest x-ray was without infiltrates or effusions. There was some question of deviation of the trachea but the patient was malpositioned. Cerebrospinal fluid showed three white cells, one red cell, 100% lymphocytes. Protein increased at 72; glucose 63. Urine culture was pending; blood culture was pending. Cerebrospinal fluid Gram stain was negative. Cerebrospinal fluid culture was without growth. CT scan showed prominent ventricles, out of proportion to sulci, focally dilated left frontal [Doctor Last Name 534] secondary to prior bleed with punctate foci consistent with hemorrhage versus calcifications versus post-ventricular drain changes and a low density subdural collection along the right frontal lobe. An EEG was obtained several days later which was read as diffuse encephalopathy with no evidence of seizure activity. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and observed overnight with neurologic consultation. His lumbar puncture was negative. Head CT scan was without acute change. The EEG showed only encephalopathy; no evidence for seizure. He was treated with Zantac and heparin prophylaxis, Tegretol, his anti-hypertensives, Regular insulin sliding scale and Ampicillin for his Enterococcal urinary tract infection as well as Flagyl p.o. for his C. difficile colitis. He also received a dose of Ceftriaxone until his lumbar puncture could be performed. He was transferred to the Floor on [2168-3-28]. His antibiotics were continued. After discussion with the Floor Team, the patient was made "DO NOT RESUSCITATE", "DO NOT INTUBATE", by his family in accordance with prior stated wishes. Because he had been started on Tegretol, his liver transaminases were checked and showed AST mildly elevated at 52 and ALT mildly elevated at 46, with an alkaline phosphatase of 87, a total bilirubin of 0.6. Urine cultures and blood cultures remained negative. He was continued on his tube feeds and free water boluses for nutrition and was evaluated by Physical Therapy and screened for Rehabilitation. This completes his hospital course up to the evening of [2168-3-30]. The remainder of his hospital course will be dictated by the accepting intern. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2168-3-30] 16:21 T: [2168-3-31] 10:10 JOB#: [Job Number ]	[ "250.00", "401.9", "599.0", "707.0", "285.9", "331.4", "348.3", "038.8", "008.45" ]	icd9cm	[ [ [] ] ]	[ "96.6", "03.31" ]	icd9pcs	[ [ [] ] ]														6627, 8249																								4076, 6609									130, 141									170, 3379														3656, 3931	3401, 3631	3948, 4053
69,162	133,316	42580	Discharge summary	report	Admission Date: [2150-3-11] Discharge Date: [2150-3-19] Service: SURGERY Allergies: Keflex / Benadryl Attending:[First Name3 (LF) 598] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: PROCEDURES: 1. Open reduction internal fixation, left anterior column posterior hemi-transverse acetabular fracture. 2. Open reduction position of left bimalleolar ankle fracture. 3. Left chest thoracostomy tube History of Present Illness: 89F with history of a-fib on coumadin and previous CVA w/o deficits presents to [Hospital1 18] as transfer from OSH s/p fall with multiple fractures. She was reportedly found down at her home after fall from [7-9] feet from interior balcony in her home when she was last seen normal. Patient states she remembers the entire episode and falling to the floor, with no LOC. At OSH had neg CT head, cxr showing rib fracture, and hct down 10pts from three weeks ago. She was given 1 unit of PRBC's and Vitamin K to reverse anticoagulation prior to transport. There was report of impacted hip fracture as well as left ankle fracture. She was transferred to [Hospital1 18] for further management. Past Medical History: - Atrial fibrillation on coumadin - HTN - Osteoarthritis - Glaucoma - RIGHT total hip replacement - Hysterectomy Social History: Lives at home on her own Family History: Noncontributory Physical Exam: (On presentation to ER) Temp: 97.0 HR: 142 BP: 148/92 Resp: 18 O(2)Sat: 99 Normal Constitutional: Opens eyes to commands HEENT: Ecchymosis on right cheek, Pupils equal, round and reactive to light, Extraocular muscles intact, no proptosis c-collar placed on arival, no tenderness Chest: Clear to auscultation; no chest wall crepitus or ttp Cardiovascular: irregular, tachy Abdominal: Soft, Nontender, Nondistended Extr/Back: Left ankle swelling/injury without deformity, equal radial pulses, dopplerable DP and PT pulses bilaterally Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation (alert and oriented though slightly slow to open eyes and follow commands) Pertinent Results: [2150-3-11] 05:00PM GLUCOSE-149* UREA N-29* CREAT-0.8 SODIUM-133 POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13 [2150-3-11] 05:00PM WBC-12.1* RBC-3.75* HGB-10.4* HCT-31.1* MCV-83 MCH-27.8 MCHC-33.6 RDW-14.1 [2150-3-11] 05:00PM PT-21.6* PTT-36.3 INR(PT)-2.1* IMAGING: Xray Left Ankle [3-11]: Acute fractures involving the medial malleolus, distal fibula ([Doctor Last Name 11586] B) with syndesmotic disruption and widened medial mortise. Xray Pelvis [3-11]: Multiple pelvic fractures detailed above including right superior and inferior pubic ramus fractures, left acetabular fracture with protrusio defect and left inferior pubic ramus fractures. CT C-spine [3-11]: No acute fracture CT Chest w/contrast [3-11]: Multiple pulmonary nodules, nondisplaced posteriorlateral 8th and 9th rib fx CT Abd/Pelvis [3-11]: Hepatic cyst, L psoas hematoma 8.7 by 4.6 by 11.7cm, intermuscular hematomas of the pelvic girdle w/o active extravasation CT head w/o contrast ([3-16]): negative for ischemia or hemorrhage Brief Hospital Course: Her Emergency Department course as follows: On arrival to [Hospital1 18] ED she had a GCS 15 with dopperable pulses in both lower extremities. She underwent CT imaging - CT c-spine was negative but cervical collar was left in place initially due to potential of orthopedic injuries being a distracting factor; the collar was eventually removed. CT scan of the chest, abdomen and pelvis confirming rib fractures on left [9-10] non-displaced and complex pelvic fracture without evidence of active extravasation. It should also be noted that there were 4-mm pulmonary nodules in the left lower lobe and lingula for which follow up with a repeat chest CT in one year is being recommended. Hematocrits in ED remained stable. Her CK and lactate were initially elevated which was concerning for rhabdomyolysis but her creatinine remained stable; she was given fluid resuscitation. She was noted to be in atrial fibrillation with HR up to 120's and was given Diltiazem and started on a drip. No other hemodynamic instability was noted. Two Units of FFP were given to reverse her INR in the ED. Orthopedic consultation was obtained. ICU course as follows: She was admitted to the Acute Care Surgery team and transferred to the Trauma ICU for close monitoring and stabilization prior to orthopedic repair of her injuries. She was taken to the operating room on [3-13] for open reduction internal fixation, left anterior column posterior hemi-transverse acetabular fracture and open reduction position of left bimalleolar ankle fracture. There were no intraoperative complications. Postoperatively she had significant pain control issues prompting Acute Pain Service consultation. Her hematocrit dropped from admission value of 31.1 to 21.2 on [3-12] and she was transfused with 4 units PRBC's for anemia due to acute blood loss which was felt likely due to her pelvic fracture. She also received 3 units of FFP to correct her Coumadin-induced coagulopathy. She was also started on Zosyn for treatment of a recent complicated UTI that had failed Bactrim therapy as outpatient. On POD#2 she was transferred to a surgical floor, however after only a short time she was found to be minimally responsive and was transferred back to the ICU for further workup. By the time of arrival back to the ICU her mental status began to show some improvement as she was waking up more. A CT scan of the head was done and revealed no acute processes; her change in mental status was felt likely due narcotic medication. A chest x ray obtained on POD#3 was concerning for left pleural effusion and an ultrasound supported this. A chest tube was placed with drainage of ~400cc serosanguinous fluid. She was started on a Ketamine drip and clonidine patch for pain control. The following day POD#4 her chest xray was markedly improved and the chest tube was removed with concomitant improvement in pain. The Ketamine was weaned off and pain control accomplished with clonidine patch, gabapentin, and oxycodone for breakthrough. By POD#4 she underwent a swallow evaluation and her diet was upgraded to mechanical soft and thin liquids. Her floor course as follows: She was transferred from the ICU to the floor for ongoing care. She underwent left lower extremity ultrasound to assess for DVT given swelling but no evidence of clot was found. She did however have a significant cellulitis near her left ankle surgical site and was recommended for Vancomycin IV. A formal Infectious Disease consult was obtained who recommended continuation of the Vancomycin through [3-26]. A PICC line was placed. She will need her ESR and CRP checked on [3-26]; Vanco levels will also need to be followed and dosing adjusted accordingly. Next Vanco trough to be done [3-20]. Her INR was noted to be elevated and her home dose of 6.5 mg Coumadin was held on [3-18] for an INR 3.2. Her INR will need to be followed closely and when restarting it is being recommended that she be given at least half of her usual home dose. Physical and Occupational evaluations were obtained and she is being recommended for acute level rehab after her hospital stay. Medications on Admission: - coumadin 6.5 mg daily - metoprolol 50 mg [Hospital1 ] - diltiazem 120 mg daily - digoxin 0.125 mg daily - lisinopril 5 mg daily - xalantan eye gtt Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: One (1) Dose Injection four times a day as needed for per sliding scale. 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): both eyes. 3. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. metoprolol tartrate 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). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply over left chest region rib fx site [9-10]. 12. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 13. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: New dose being recommneded - home dose previously 6.5 mg but stopped d/t elevated INR. . 14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) GM Intravenous Q 24H (Every 24 Hours) for 7 days. 15. 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. 16. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 17. Ultram 50 mg Tablet Sig: 0.5 Tablet PO four times a day as needed for pain. 18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Hospital Discharge Diagnosis: s/p Fall Injuries: 1. Left anterior column posterior hemi-transverse acetabular fracture 2. Left bimalleolar fracture 3. Rib fractures on left [9-10] (non-displaced) 4. Moderate left pleural effusion 5. Wound cellulitis left ankle 6. [Hospital Ward Name 4675] cyst left popliteal fossa 7. Acute blood loss anemia 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 following a fall where you sustained multiple injuires including rib fractures and fractures of your pelvic/hip, fibula (lower leg) and ankle bones. You required surgery to fix the broken bones and now being recommended for a rehabilitation facility to help strengthen you. During your hospital stay you also developed an infection on the leg where your fractures are located. Intravenous antibiotics were recommended and a special intravenous catheter line called a PICC was placed into your veins to deliver the medications. Your blood thinning medication called Coumadin required some adjustments while you were in the hospital based on your INR blood levels. You are being discharged to rehab on a lower dose than you were on at home. The rehab facility will be able to monitor your blood levels closely and will adjust the dose accordingly. Followup Instructions: * Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2150-4-9] at 1:15 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 Department: Orthopedics When: Thursday [2150-4-9] at 12:00 PM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 15942] Phone: [Telephone/Fax (1) 1228] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2150-3-19]	[ "682.6", "V43.64", "401.9", "427.31", "V13.02", "824.4", "E878.4", "780.09", "511.9", "793.11", "V15.88", "V58.61", "727.51", "E884.9", "807.02", "E849.0", "808.2", "599.0", "285.1", "808.0", "922.31", "041.12", "338.11", "E935.9", "998.59" ]	icd9cm	[ [ [] ] ]	[ "79.19", "79.36", "34.91" ]	icd9pcs	[ [ [] ] ]	9374, 9430	3186, 7329	232, 454	9794, 9794	2106, 3163	10880, 11518	1379, 1396		7533, 9351		9451, 9773		7355, 7510			9974, 10857								1411, 2087																							184, 194									482, 1185									9809, 9950						1207, 1321	1337, 1363
42,752	167,897	38366	Discharge summary	report	Admission Date: [2110-7-8] Discharge Date: [2110-7-20] Date of Birth: [2048-2-28] Sex: F Service: CARDIOTHORACIC Allergies: Erythromycin Base / Hydroxychloroquine Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram, left ventriculogram [2110-7-8] Coronary Artery bypass grafts x 4(LIMA-LAD.SVG-dg,SVG-oOM,SVG-LPDA) [2110-7-16] History of Present Illness: This 62 year old white female with history of infarction in [2099] with LAD stent, LAD stent [2105] presented elsewhere with a week history of chest and arm pain with radiation to neck and jaw. She was transferred from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Hospital for catheterization after ruling out for an infarction and remained stable. Past Medical History: s/p MI with LAD stent (99), LAD stent (05) hypertension Hyperlipidemia Peripheral artery disease Aortic atheroma -- on Coumadin noninsulin dependent Diabetes mellitus Rheumatoid arthritis s/p Hysterectomy Pulmonary nodules (being followed) Social History: married, works as hairdresser smoker Family History: strong family history of premature cardiac disease Physical Exam: admission: Pulse:56 Resp:16 O2 sat:99% RA B/P Right:132/59 Left:138/61 Height:5'0" Weight:112 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 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Dressing in place Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2110-7-20] INR 2.5 ECHO: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. During prep and drape the patient became ischemic with new inferior, lateral and RV HK. There was new moderate TR and moderate to severe MR. The patient was aggressively treated with nitrates and heparin and the ischemia completely resolved. Post-CPB: The patient is on NTG and is A-Paced. Preserved biventricular sysolic fxn. No AI, trace MR, trace TR. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2110-7-16] 16:07 Brief Hospital Course: Following transfer she remained stable. Cardiac catheterization on [7-9] revealed triple vessel disease and some in stent restenosis. She was referred for cardiac surgical evaluation, which was completed. Plavix was stopped and washout allowed. On [7-16] she went to the Operating Room where quadruple bypass was undertaken. She weaned from bypass on Neo Synephrine, insulin and Propofol infusions. She was weaned and extubated easily and all infusions discontinued. Beta blockade and diuresis were begun and she was transferred to the floor. Chest tubes were removed according to protocol. Physical Therapy worked with her for strength and mobility. She was cleared for discharge to home on POD#4 by Dr. [First Name (STitle) ]. All follow up appointments and instruction advised. Medications on Admission: Coumadin 5mg po daily (followed by Dr. [Last Name (STitle) 13517]/[First Name4 (NamePattern1) 803] [Last Name (NamePattern1) ] NP) Atenolol 12.5mg po daily Protonix 40mg po daily iron 65 mg po daily Imdur 60mg po daily Plavix 75mg po daily Metformin 1000mg po BID Avandia 4mg po qPM Lipitor 40mg po daily Zetia 10mg po daily ASA 81mg po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: INR goal 2.5-3.0 for PVD. Disp:60 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY AT 1600 (). 11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Home Health of [Location (un) 5028] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts x 4 hypertension hyperlipidemia peripheral vascular disease noninsulin dependent diabetes mellitus rheumatoid arthritis s/p hysterectomy pulmonary nodules Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with ultram Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace edema Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([Telephone/Fax (1) 170]). Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. Please call cardiac surgery office with any questions or concerns ([Telephone/Fax (1) 170]). Answering service will contact on call person during off hours. Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[First Name8 (NamePattern2) ] [Name (STitle) ] ([Telephone/Fax (1) 170]) on [Last Name (LF) 766], [8-18] at 1:30pm Please call to schedule appointments with: Primary Care: Dr. [Last Name (STitle) ] [Name (STitle) 13517] ([Telephone/Fax (1) 75761]) in [1-4] weeks Cardiologist: Dr. [Last Name (STitle) 83355] [Name (STitle) 77919] ([Telephone/Fax (1) 65733]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 peripheral vascular disease Goal INR: 2.5-3.0 First draw: [2110-7-21] Results to:Dr. [Last Name (STitle) 13517] phone fax [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2110-7-20**]	[ "411.1", "272.0", "414.01", "272.4", "V45.82", "305.1", "714.0", "412", "443.9", "401.9", "V58.61", "250.00", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "36.13", "88.53", "36.15", "37.22", "88.56", "39.61" ]	icd9pcs	[ [ [] ] ]	5770, 5840	3204, 4008	314, 484	6097, 6323	1963, 3181	7183, 8205	1226, 1278		4414, 5747		5861, 6076		4034, 4391			6347, 7160								1293, 1943																							264, 276									512, 892															914, 1155	1171, 1210
72,202	112,225	39166	Discharge summary	report	Admission Date: [2187-12-17] Discharge Date: [2187-12-24] Date of Birth: [2112-12-2] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2187-12-18] 1. Mitral valve repair with a 3-D [Company 1543] annuloplasty ring, 28 mm and a cleft repair of A2. 2. Tricuspid valve repair with 30 mm MC3 annuloplasty ring. History of Present Illness: 75 year old female c/o dyspnea on exertion since summer [2186]. Developed congestive heart failure which required diuresis and multiple thoracentesis for recurrent pleural effusions. Most recent right thoracentesis at [Hospital3 418] [2187-12-14] for 1 liter. Work-up revealed severe mitral regurgitation and she is admitted for heparinization for MV surgery [2187-12-18]. Past Medical History: Mitral Regurgitation Congestive heart failure, recurrent effusions s/p thoracentesis x 4 (most recent was last week, also had PTX after thoracentesis) Moderate pulmonary hypertension Atrial Fibrillation (on Coumadin) Diabetes Mellitus Hypertension Hyperlipidemia Hypothyroidism ?COPD Colon Cancer s/p resection Social History: Race: Caucasian Last Dental Exam: [2187-11-27], cleared Lives: alone Occupation: Secretary Tobacco: Quit 50 yrs ago ETOH: Occ. Family History: non-contributory Physical Exam: Physical Exam Pulse: 107- irreg Resp: 20 O2 sat: 88% on RA B/P Right: 107/59 Left: 105/63 Height: 170cm Weight: 72kg General: well-developed female in no acute distress Skin: Dry [X] - dime sized area of blanching erythema on right buttock. HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Bilateral rales at the bases with right>left Heart: RRR [] Irregular [X] Murmur [1-19] holosystolic heard loudest at the apex Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: +2 Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 2+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [2187-12-24] 05:30AM BLOOD WBC-6.1 RBC-3.13* Hgb-8.8* Hct-28.1* MCV-90 MCH-28.1 MCHC-31.2 RDW-15.6* Plt Ct-301# [2187-12-21] 06:05AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.7* Hct-27.2* MCV-89 MCH-28.7 MCHC-32.1 RDW-15.7* Plt Ct-168 [2187-12-20] 03:57AM BLOOD WBC-11.1* RBC-3.27* Hgb-9.3* Hct-28.5* MCV-87 MCH-28.5 MCHC-32.8 RDW-15.6* Plt Ct-157 [2187-12-24] 05:30AM BLOOD PT-14.1* INR(PT)-1.2* [2187-12-23] 06:10AM BLOOD PT-13.4 INR(PT)-1.1 [2187-12-22] 07:50AM BLOOD PT-12.8 INR(PT)-1.1 [2187-12-24] 05:30AM BLOOD Glucose-103* UreaN-12 Creat-0.6 Na-140 K-4.5 Cl-104 HCO3-33* AnGap-8 [2187-12-23] 06:10AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-141 K-4.6 Cl-104 HCO3-32 AnGap-10 PREBYPASS The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets do not fully coapt. An eccentric, posteriorly directed jet of Severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. POSTBYPASS LV systolic function is preserved. The is a ring prosthesis in the mitral position . MR is now mild. RV systolic function remains mildly depressed. There is a ring prosthesis in the tricuspid position. TR is mild. The remaining study is unchanged from the prebypass period. Brief Hospital Course: The patient was admitted one day prior to surgery for pre-admission testing and heparin bridge. She was brought to the operating room on [2187-12-18] where she underwent mitral valve repair and tricuspid valve repair with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition on neo and propofol for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. She was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Chest tubes and pacing wires were discontinued without complication. Coumadin was resumed for atrial fibrillation. She was diuresed toward her preoperative weight and beta-blockade was initiated. She does have a history of chronic pleural effusions, and this was closely followed by CXR following removal of chest tubes. Diuresis was adjusted accordingly for pleural effusions and significant lower extremity edema. She will follow up in one week with a chest x-ray. The patient progressed without complication, and was cleared by Dr. [Last Name (STitle) ] for discharge to ** on POD **. Medications on Admission: Cardizem CD 120mg QD Lasix 40mg 5x/day Synthroid 75mcg QD Metformin 500mg qd Metoprolol XL 100mg QD KCl 10mEq QD Simvastatin 20mg qd Diovan 80mg QD Coumadin 2.5mg QD- last dose [2187-12-12] levaquin 750mg daily- started at [Hospital3 ] [2187-12-14]- unknown infectious process Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: dose will change daily for goal INR 2-2.5, Dr. [Last Name (STitle) *] to manage. Disp:30 Tablet(s)* Refills:2 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 7. Metoprolol Succinate 100 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:0 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:120 Tablet(s) Refills:2 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2 Discharge Disposition: Extended Care Facility: Life Care Center of [Location 15289] Discharge Diagnosis: Mitral Regurgitation Congestive heart failure, recurrent effusions s/p thoracentesis x 4 Moderate pulmonary hypertension Atrial Fibrillation (on Coumadin) Diabetes Mellitus Hypertension Hyperlipidemia Hypothyroidism ?COPD Colon Cancer s/p resection Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] Thursday, [2188-1-17] 1:15pm [Telephone/Fax (1) 170] Primary Care Dr. [First Name8 (NamePattern2) 1059] [Last Name (NamePattern1) ] [Telephone/Fax (1) 19470] in [11-17] weeks Cardiologist Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 8725] in [11-17] weeks CXR [2187-12-31] to follow up on pleural effusions, with film emailed to [University/College 86751], for Dr. [Last Name (STitle) ] Completed by:[2187-12-24]	[ "V10.05", "424.0", "428.0", "244.9", "401.9", "416.8", "V58.61", "427.31", "V58.66", "397.0", "272.4", "250.00", "428.33" ]	icd9cm	[ [ [] ] ]	[ "35.12", "39.61", "35.14", "35.33" ]	icd9pcs	[ [ [] ] ]	7083, 7150	4143, 5364	343, 530	7443, 7539	2305, 4120	8163, 8770	1449, 1467		5705, 7060		7171, 7422		5390, 5682			7563, 8140								1482, 2286																							284, 305									558, 949															971, 1284	1300, 1433
60,637	188,101	12823	Discharge summary	report	Admission Date: [2122-9-10] Discharge Date: [2122-9-28] Date of Birth: [2061-9-1] Sex: M Service: SURGERY Allergies: Benzodiazepines Attending:[First Name3 (LF) 4691] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [2122-9-11] Cervical decompression and instrumented fusion laminectomy C2-C7 [2122-9-15] Tracheostomy and gastrostomy (PEG) History of Present Illness: 61 y.o. male with history of mental retardation, cerebral palsy with spastic quadriplegia, and h/o central cord syndrome presents after a fall. Pt reportedly had a fall in his wheelchair, with the patient falling head first approximately [4-13] feet into rocks. The wheelchair reportedly came to rest on top of the patient. The patient was found to be moaning immediately after the fall. The patient was brought to the emergency department by EMS, and was unable to provide a ROS. He was found to have multiple facial lacerations, including an approximately 5cm laceration of his forehead and a 1cm laceration of the bridge of his nose. The patient Once in the SICU, the patient was intubated fiberoptically as he could not protect his airway. At baseline, the patient is reportedly unable to move his legs, although he does move his arms and is normally able to feed himself. Past Medical History: (1) quadraplegia with worse function in his LE than UE (per caretakers has good strength in hands and is able to feed himself) (2) Cerebral Palsy h/o premature birth associated with CP manifesting in spastic quadplegia, was ambulatory with walker until [2107] when he fell with nasal bone fracture and subsequently noticed urinary retention and decreased gross motor strength and coordination (CT and MRI showed no cord compression, Dx of central cord syndrome made primarily in c5-c6 region R>L (3) DJD disease of spine lumbar and thoracic (4) s/p left hip fixation with ORIF (81) (5) On exam from [2122-5-26] motor exam has [2-10] in UE and 1-2/5 in LE. (6) Increased tone in L 2+ in UE reflexes, [1-9]+ in knees, toes chronically flexed, o/w normal exam (7) osteoporosis with some cervical degeneration (8) Recurrent Nummular eczema (9) Hypothyroidism (10) GERD with hiatal hernia, swallowed foreign body ([2115]) (11) chronic constipation [2-9] central cord syndrome (12) Neurogenic bladder [2-9] central cord syndrome treated medically Social History: Patient lives in the Ferald Center for Mental Retardation in [Hospital1 ], and has reportedly been at the center for many years. Family History: 4 brothers with unknown health. Physical Exam: Tmax 99.3 Tcurrent 99.2 HR59 BP105/55 CVP 11 RR14 Sp02 95% Vent: CMV via Tracheostomy tube, VT 500 (399-467ml) PEEP 12, FiO2 0.60 ABG 7.44/33/97/21/0 General: No acute distress, Obses HEENT: EOMI Cardiovascular: RRR PULM: symmetric expansion with rhonchorous breath sounds diffusely Abd: Soft/non-distended/non-tender Extremities: warm Neuro: Follows simple commands Pertinent Results: [2122-9-10] 06:00PM GLUCOSE-156* UREA N-17 CREAT-0.4* SODIUM-138 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-22 ANION GAP-11 [2122-9-10] 06:00PM CALCIUM-8.3* PHOSPHATE-2.0* MAGNESIUM-1.7 [2122-9-10] 06:00PM WBC-11.8# RBC-3.70 HGB-10.8* HCT-33.9* MCV-92 MCH-29.3 MCHC-31.9 RDW-14.2 [2122-9-10] 06:00PM NEUTS-89.7* LYMPHS-5.3* MONOS-4.3 EOS-0.6 BASOS-0.1 [2122-9-10] 06:00PM PLT COUNT-229 [2122-9-10] 04:18PM TYPE-ART PO2-92 PCO2-48* PH-7.33* TOTAL CO2-26 BASE XS--1 INTUBATED-NOT INTUBA [2122-9-10] 06:00PM PT-12.4 PTT-29.3 INR(PT)-1.0 [2122-9-10] 04:18PM O2 SAT-96 [2122-9-10] 01:20PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2122-9-10] 01:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2122-9-10] 01:12PM GLUCOSE-92 LACTATE-1.1 NA+-135 K+-4.0 CL--101 TCO2-25 [2122-9-10] 01:12PM GLUCOSE-92 LACTATE-1.1 NA+-135 K+-4.0 CL--101 TCO2-25 [2122-9-10] 01:00PM estGFR-Using this [2122-9-10] 01:00PM LIPASE-20 [2122-9-10] 01:00PM WBC-6.0 RBC-3.83* HGB-11.6* HCT-35.1* MCV-92 MCH-30.2 MCHC-33.0 RDW-14.3 [2122-9-10] 01:00PM PT-12.2 PTT-27.6 INR(PT)-1.0 [2122-9-10] 01:00PM PLT COUNT-267 [2122-9-10] 01:00PM FIBRINOGE-444* [2122-9-28] 02:38AM BLOOD WBC-7.3 RBC-3.11* Hgb-9.4* Hct-28.5* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.5 Plt Ct-517* [2122-9-27] 02:24AM BLOOD WBC-8.0 RBC-3.15* Hgb-9.3* Hct-28.8* MCV-92 MCH-29.6 MCHC-32.2 RDW-15.6* Plt Ct-542* [2122-9-26] 04:02AM BLOOD WBC-6.7 RBC-3.32* Hgb-9.8* Hct-30.1* MCV-91 MCH-29.5 MCHC-32.5 RDW-15.7* Plt Ct-560* [2122-9-25] 02:53AM BLOOD WBC-8.7 RBC-3.23* Hgb-9.6* Hct-30.2* MCV-94 MCH-29.8 MCHC-31.8 RDW-15.9* Plt Ct-499* [2122-9-24] 02:17AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.1* Hct-28.2* MCV-90 MCH-28.9 MCHC-32.2 RDW-15.9* Plt Ct-475* [2122-9-23] 03:29AM BLOOD WBC-10.1 RBC-3.37* Hgb-10.3* Hct-30.3* MCV-90 MCH-30.5 MCHC-33.9 RDW-15.5 Plt Ct-415 [2122-9-22] 04:31AM BLOOD WBC-9.0 RBC-3.20* Hgb-9.7* Hct-29.4* MCV-92 MCH-30.4 MCHC-33.1 RDW-16.0* Plt Ct-338 [2122-9-21] 06:39PM BLOOD WBC-8.4 RBC-3.21# Hgb-9.3# Hct-29.3# MCV-92 MCH-29.2 MCHC-31.8 RDW-15.6 Plt Ct-324 [2122-9-26] 04:02AM BLOOD Neuts-78.7* Lymphs-15.1* Monos-3.9 Eos-1.9 Baso-0.4 [2122-9-20] 02:39AM BLOOD Neuts-78.1* Lymphs-17.0* Monos-4.1 Eos-0.6 Baso-0.2 [2122-9-11] 05:31PM BLOOD Neuts-88.9* Lymphs-6.9* Monos-4.0 Eos-0.1 Baso-0.1 [2122-9-28] 02:38AM BLOOD Plt Ct-517* [2122-9-27] 02:24AM BLOOD Plt Ct-542* [2122-9-26] 04:02AM BLOOD Plt Ct-560* [2122-9-28] 02:38AM BLOOD Glucose-104 UreaN-27* Creat-0.4* Na-135 K-4.1 Cl-103 HCO3-24 AnGap-12 [2122-9-27] 02:31PM BLOOD Glucose-93 UreaN-25* Creat-0.5 Na-139 K-3.9 Cl-103 HCO3-24 AnGap-16 [2122-9-27] 02:24AM BLOOD Glucose-94 UreaN-26* Creat-0.5 Na-137 K-4.2 Cl-107 HCO3-21* AnGap-13 [2122-9-26] 04:02AM BLOOD Glucose-101 UreaN-23* Creat-0.5 Na-136 K-4.0 Cl-106 HCO3-22 AnGap-12 [2122-9-25] 02:53AM BLOOD Glucose-98 UreaN-22* Creat-0.5 Na-136 K-4.1 Cl-104 HCO3-24 AnGap-12 [2122-9-21] 04:04AM BLOOD ALT-90* AST-46* AlkPhos-188* Amylase-53 TotBili-0.2 [2122-9-21] 04:04AM BLOOD Lipase-37 [2122-9-10] 01:00PM BLOOD Lipase-20 [2122-9-28] 02:38AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.1 [2122-9-27] 02:31PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2 [2122-9-27] 02:24AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2 [2122-9-27] 02:31PM BLOOD TSH-8.0* [2122-9-26] 04:02AM BLOOD TSH-6.9* [2122-9-23] 03:29AM BLOOD TSH-8.9* [2122-9-22] 06:00AM BLOOD Vanco-12.4 [2122-9-16] 06:15AM BLOOD Vanco-7.8* [2122-9-27] 02:37PM BLOOD Type-ART pO2-332* pCO2-36 pH-7.45 calTCO2-26 Base XS-2 Intubat-INTUBATED Vent-SPONTANEOU [2122-9-27] 02:42AM BLOOD Type-ART pO2-97 pCO2-33* pH-7.44 calTCO2-23 Base XS-0 [2122-9-26] 01:00AM BLOOD Type-ART pO2-135* pCO2-28* pH-7.45 calTCO2-20* Base XS--2 [2122-9-25] 05:03PM BLOOD Type-ART pO2-98 pCO2-35 pH-7.42 calTCO2-23 Base XS-0 [2122-9-24] 05:01PM BLOOD Lactate-0.6 [2122-9-27] 02:42AM BLOOD freeCa-1.21 [2122-9-24] 05:01PM BLOOD freeCa-1.19 [2122-9-23] 03:47AM BLOOD freeCa-1.19 Brief Hospital Course: # Fall from Wheelchair Imaging: CT-C-spine ([2122-9-10]) REASON FOR EXAM: Status post trauma. COMPARISON: None. TECHNIQUE: Multidetector axial CT images of the cervical spine as well as coronal and sagittal reformatted images were submitted for interpretation. FINDINGS: There is a 0.6-cm inferiorly displaced fracture of the anteroinferior portion of the C6 vertebral body without dislocation or subluxation. Fracture involves the anterior column and anterior middle column of the verterbal body. Mild diffuse vertebral body height loss is likely degenerative in nature. Diffuse narrowing of the cervical spinal canal, as well as severe degenerative changes with posterior osteophyte formation, places the patient at high risk of cord injury. Normal alignment of the cervical spine is maintained. There is mild swelling of the prevertebral soft tissues. Stylohyoid ligament calcification and areas of fragmentation, more on the right than left, likely chronic. Mild atelectatic changes within bilateral lung apices are noted. IMPRESSION: Mildly displaced fracture of the anteroinferior portion of the C6 vertebral body without subluxation. Diffuse narrowing of the cervical spinal canal in addition to severe degenerative changes, including posterior osteophytes, put the patient at risk for cord injury. MRI is a better modality to evaluate for spinal cord or ligamentous injury. CT-Head w/o Contrast ([2122-9-10]): REASON FOR EXAM: Status post trauma. COMPARISON: None. Multidetector CT images of the head with coronal and sagittal reformatted images were submitted for interpretation. FINDINGS: There is no intracranial hemorrhage, mass effect, or [Doctor Last Name 352]-white matter differentiation, abnormality. The ventricles and extra-axial spaces are appropriate for age. There is a mildly displaced right nasal bone fracture. The adjacent inflammatory changes extend into the forehead. Hyperdense punctate material in the subcutaneous soft tissues likely represents foreign body. The orbits are unremarkable. No skull fracture is seen. The left mastoid air cells are sclerotic and asymmetric to the right, query for prior mastoiditis is suggested. Mild mucosal thickening within the ethmoid sinus air cells is also noted. There is a small mucous retention cyst within the right maxillary sinus. IMPRESSION: No intracranial abnormality. Right nasal bone fracture with adjacent soft tissue swelling and punctate foreign bodies within anterior subcutaneous tissues. Left mastoid air cell sclerosis, clinically correlate with prior bouts of mastoiditis. Mucosal sinus disease as described above. CT-Abd/Pelvis ([2122-9-10]) Final Report REASON FOR EXAM: Status post trauma. COMPARISON: None. Multidetector axial CT images of the chest, abdomen, and pelvis were obtained after administration of IV contrast. Coronal and sagittal reformatted images were also submitted for interpretation. FINDINGS: CHEST CT WITH CONTRAST: The aorta, pulmonary, heart, pericardium are normal. There is mediastinal lipomatosis. Visualized thyroid is unremarkable. No mediastinal, hilar, or axillary lymphadenopathy is seen. Dependent atelectasis of bilateral lungs and low lung volumes are noted. Subtle patchy ground- glass opacities throughout bilateral lungs are likely related to expiratory phase of scanning. The tracheobronchial tree is patent. CT ABDOMEN WITH CONTRAST: The liver demonstrates mild periportal edema. A large gallstone measuring approximately 1.9 cm is present. There is no pericholecystic fluid. The spleen, pancreas, adrenal glands, and kidneys are unremarkable. The stomach is collapsed. The colon contains a large amount of stool. Abdominal aorta and iliac vessels are normal in size. No lymphadenopathy is noted. PELVIC CT WITH CONTRAST: There is trace free fluid adjacent to the appendix with appendix measuring upper limits of normal. The rectosigmoid colon, prostate gland, seminal vesicles are unremarkable. The urinary bladder contains a Foley catheter, with small amount of air, likely related to instrumentation. No free pelvic fluid is seen. There are small bilateral fat- containing inguinal hernias. OSSEOUS STRUCTURES: No fracture is seen. The bones are osteopenic. Severe degenerative changes of the spine are noted. Multiple Schmorl's nodes are noted with the largest at L2-L3. Hardware noted in the left proximla femur. IMPRESSION: 1. No acute sequelae of trauma. 2. Cholelithiasis. 3. Marked constipation. Final Report EXAMINATION: Cervical spine MRI ([2122-9-10]) HISTORY: A 61-year-old male with prior history of central cord syndrome presents with new C6 fracture and new onset upper extremity weakness. COMPARISON: None. TECHNIQUE: Sagittal T1, T2 FSE, STIR, axial T2-weighted sequences of the cervical spine were obtained. FINDINGS: Sagittal views demonstrate severe multilevel degenerative changes superimposed upon what likely represents a congenitally narrow spinal canal resulting in severe cord compression from C2-C3 down to C6-C7. Associated with this is markedly abnormal cord signal, with T2 prolongation, this is perhaps most severe at the C3-4 level, where there is approximately 3 mm of residual spinal canal patency. There appears to be a minimally displaced fracture extending to the anterior aspect of the C6 vertebral body, turning inferiorly and extending to the disc space with no obvious associated retropulsion. Additionally, there is marrow edema involving the C3 and C4, to a lesser extent C2 vertebral bodies, likely representing acute trabecular injury in this context. There is an associated large heterogeneous fluid collection anteriorly centered at C3 and predominantly residing within the retropharyngeal space. No contiguity of the anterior longitudinal ligament is identified at the C3-4 level, highly concerning for ligamentous disruption. Additionally, there is some increased signal within the posterior soft tissues, interdigitating into the interspinous ligaments at C3 and C4. The severe degree of diffuse canal narrowing is worsened at the C3-C4 level by what may represent an acute superimposed disc protrusion related to the mechanism of injury. There is a well-defined cystic region within the C2 vertebral body which is likely of no clinical significance. There is severe multilevel foraminal narrowing. The atlanto-occipital articulation is intact. Wackenheim's clival line, however, does not intersect with the posterior aspect of the dens, which is situated approximately 7-8 mm anterior to the line. No basilar impression is identified. IMPRESSION: 1. There has been an acute traumatic injury, likely representing hyperextension, superimposed upon advanced preexisting degenerative changes resulting in severe cord compression from C2-C3 through C6-C7 and associated abnormal cord signal. 2. Minimally displaced fracture through C6, as well as trabecular fractures involving the C3 and C4 vertebral bodies. 3. Extensive heterogeneous fluid collection, part of which may represent a hematoma with, within the retropharyngeal space with disruption of the anterior longitudinal ligament. Mildly increased signal within the posterior ligamentous structures at C3-C4. On [2122-9-11], the patient was taken to the operating room and underwent C3-C6 laminectomy, medial facetectomy, posterior instrumentation segmental C2-C7 (EBI Altius), local autograft, posterolateral arthrodesis C2-C7. A hard collar was maintained at all times after the procedure. #Cardiology Echo ([2122-9-23]): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Normal regional and global biventricular systolic function. No pathologic valvular abnormality seen. No evidence of endocarditis or abscess seen. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. #Neuro The patient was maintained on regular neuro checks, he began to track and move extremities when rolled/stimulated. #Pulmonary Due to the patient's multiple cervical fractures, he was intubated and became vent dependent. He was initially managed with fentanyl and propofol. On [2122-9-15], the patient underwent tracheostomy. CXR on [2122-9-14] showed increase right pleural effusio, LLL atelectasis, and small left PTX. #GI On [2122-9-15], the patient underwent tracheostomy and percutaneous endoscopic gastrostomy. He was started on tube feeds (Nutren 25g beneprotein) and advanced to goal @ 50ml/hr. #Renal He required diuresis during his hospitalization for peripheral edema and pulmonary edema. #Endocrine The patient was maintained on a RISS. He also received levothyroxine 100mcg daily for hypothyroidism. #ID On [2122-9-13] blood cultures were obtained that grew gram positive cocci in clusters. All lines were changed and he was started on cefazolin and vancomycin. Tips were sent for culture. Patient had bronchoscopy performed on [2122-9-19] that showed frank pus. BAL grew enterobacter and H. flu. He continued to have fevers. Throught his hospitalization he received many different antibiotics. Vancomycin (started [2122-9-19]), Zosyn ([Date range (1) 39485]), Meropenem (started [9-20]), Cipro ([9-20]), Cefepime (started [9-21]). #Prophylaxis Patient was maintained on pneumoboots and famotidine intially. Later in hospitalizaiton received subcutaneous heparin. Medications on Admission: Tylenol 650mg tabs [Hospital1 ] benefiber powder 2tsbp oral in morning Calcium-OYST 500mg [Hospital1 ] Docusate 250mg QD Levothyroxine 100mcg QD MVI QD Omeprazole 20mg QD Miralax 17gm in water [Hospital1 ] Senna 1 tab Every M,W,F in AM Terazosin 2mg QHS Vit D 400IU 2 tabs WD Benadryl PRN Guaifenesin PRN Pink Bistmuth PRN loose stools Discharge Medications: Erythromycin 250mg PO q 6 hours for GI motility Vancomycin 1000mg IV q 12 hours Cefepime 1gm IV q day albuterol inhaler 4 puffs IH every four hours PRN wheeze Levothyroxine 100 mcg PO q day Cipro 500mg PO/NG q 12 hours Tylenol 650mg tabs [Hospital1 ] Simethicone 40 mg PO QID Docusate 100mg NG/OG [Hospital1 ] Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: severe stenosis cervical fracture of the C6 vertebral body Discharge Condition: Fair, Stable Discharge Instructions: You are being discharged to a rehabilitation center. Please return to the emergency department/your PCP for worsening of respiratory status, fever, or any other new or concerning symptom. Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED CERVICAL XRAYS PRIOR TO YOUR APPOINTMENT Completed by:[2122-9-28]	[ "997.39", "721.2", "E884.3", "721.3", "E929.3", "873.42", "530.81", "596.54", "788.39", "952.08", "482.2", "344.89", "518.0", "733.00", "723.0", "806.06", "518.5", "244.9", "E878.8", "564.09", "319" ]	icd9cm	[ [ [] ] ]	[ "81.03", "96.72", "96.6", "77.79", "38.91", "33.21", "81.63", "96.04", "86.59", "33.24", "31.1", "38.93", "43.11", "33.23" ]	icd9pcs	[ [ [] ] ]	17985, 18056	7223, 17243	283, 417	18159, 18173	3028, 7200	18410, 18618	2593, 2626		17642, 17962		18077, 18138		17269, 17619			18197, 18387								2641, 3009																							235, 245									445, 1334															1356, 2427	2443, 2577
80,410	183,251	41265	Discharge summary	report	Admission Date: [2187-3-30] Discharge Date: [2187-4-23] Date of Birth: [2130-6-28] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: nephrotoxicity from nafcillin therapy ongoing in community for known MSSA bacteremia; also question of worsening AV function as sequella of infective endocarditis. Cardiac surgery to evaluate for surgical correction. Major Surgical or Invasive Procedure: Urgent aortic valve replacement for aortic valve endocarditis with a size 25-mm St. [Male First Name (un) 923] Regent mechanical valve. History of Present Illness: 56 y/o man with recent admission for MSSA bacteremia with AV endocarditis, septic left prosthetic hip, sent home on nafcillin hepatotoxicity and nephrotoxicity from nafcillin therapy ongoing in community for known MSSA bacteremia; also question worsening AV function as sequella of infective endocarditis. Cardiac surgery consulted for aortic valve replacement. Past Medical History: MSSA Aortic valve endocarditis s/p Aortic Valve Replacement (#25mm St.[Male First Name (un) 923] Mechanical Valve) Secondary: - Left paravertebral abscess - Left prosthetic hip septic arthritis - Transaminitis secondary to rifampin - Diabetes mellitus type 2 - Hyperlipidemia - History of renal cyst - ATN secondary to nafcillin Hepatic and nephro-toxicity from nafcillin and or rifampin antibiotics. Social History: Patient lives with his wife and daughter. [Name (NI) ] is self-employed in consulting. Tobacco: never ETOH: 5 drinks per week - reports not having had any alcohol since last hospitalization. Wife is present on exam and corroborates this. Family History: No history of heart attack or heart failure in either parent Physical Exam: Physical Exam on Admission Pulse: 78 Resp: 24 O2 sat: 95% RA 97.1 B/P: 138/44 Height: 69" Weight: 245 BSA: 2.25m2 General: WDWN in NAD. Appears older then stated age. Skin: Warn, dry and intact. No [Last Name (un) ] lesions, osler nodes or splinter hemorrhages. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in fair repair. Neck: Supple [X] Full ROM [X] Mild JVD Chest: Bibasilar rhonchi/crackles Heart: RRR. Normal S1-S2. 3/6 systolic murmur loudest on the RUSB with radiation to the carotids. [1-12] diastolic murmur loudest over apex. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Obese, mild hepatomegally Extremities: Warm [X], well-perfused [X] [12-10]+ peripehral Edema Varicosities: None noted. Pt unable to stand. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit Pertinent Results: [2187-4-23] 06:25AM BLOOD WBC-6.5 RBC-2.94* Hgb-9.1* Hct-28.1* MCV-96 MCH-30.9 MCHC-32.3 RDW-17.4* Plt Ct-316 [2187-4-21] 05:00AM BLOOD WBC-8.9 RBC-3.05* Hgb-9.6* Hct-29.3* MCV-96 MCH-31.5 MCHC-32.8 RDW-17.1* Plt Ct-242 [2187-4-20] 04:13AM BLOOD WBC-11.4* RBC-3.22* Hgb-9.9* Hct-31.1* MCV-97 MCH-30.8 MCHC-31.8 RDW-17.5* Plt Ct-239# [2187-4-23] 06:25AM BLOOD Plt Ct-316 [2187-4-23] 06:25AM BLOOD PT-22.7* PTT-45.5* INR(PT)-2.1* [2187-4-22] 09:35AM BLOOD PT-19.4* PTT-28.8 INR(PT)-1.8* [2187-4-22] 12:01AM BLOOD PT-19.5* PTT-31.1 INR(PT)-1.8* [2187-4-21] 05:00AM BLOOD PT-19.8* INR(PT)-1.8* [2187-4-20] 04:13AM BLOOD PT-24.7* INR(PT)-2.3* [2187-4-19] 02:15AM BLOOD PT-16.8* PTT-29.5 INR(PT)-1.5* [2187-4-17] 12:58PM BLOOD PT-17.5* PTT-30.4 INR(PT)-1.6* [2187-4-17] 12:18PM BLOOD PT-18.0* PTT-30.3 INR(PT)-1.6* [2187-4-16] 04:37AM BLOOD PT-16.9* PTT-69.3* INR(PT)-1.5* [2187-4-15] 05:42AM BLOOD PT-17.4* PTT-51.4* INR(PT)-1.6* [2187-4-14] 05:48AM BLOOD PT-17.5* PTT-54.4* INR(PT)-1.6* [2187-4-13] 06:41AM BLOOD PT-17.2* PTT-79.9* INR(PT)-1.5* [2187-4-12] 04:45AM BLOOD PT-17.6* PTT-77.1* INR(PT)-1.6* Admission labs: [2187-3-30] 03:55PM BLOOD WBC-6.8 RBC-3.12* Hgb-10.0* Hct-29.9* MCV-96 MCH-31.9 MCHC-33.4 RDW-17.8* Plt Ct-250# [2187-3-30] 03:55PM BLOOD Neuts-71.6* Lymphs-18.7 Monos-7.8 Eos-1.3 Baso-0.4 [2187-4-2] 03:03PM BLOOD PT-20.5* PTT-29.6 INR(PT)-1.9* [2187-3-30] 03:55PM BLOOD Glucose-111* UreaN-27* Creat-2.0* Na-137 K-3.0* Cl-100 HCO3-21* AnGap-19 [2187-3-30] 03:55PM BLOOD ALT-256* AST-209* AlkPhos-115 TotBili-0.7 [2187-3-30] 03:55PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.4 TTE (Complete) Done [2187-4-2] Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. A mass is present on the aortic valve. There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a mass on the tricuspid valve. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Vegetations seen on aortic and tricuspid valves. There is severe aortic regurgitation, directed towards the anterior leaflet of the mitral valve. There is moderate tricuspid regurgitation. Mild mitral regurgitation - a focal vegetation cannot be excluded. Normal left ventricular systolic function. Dilated and hypokinetic right ventricle with evidence of pressure/volume overload and at least moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [2187-2-15] (TEE) and [2187-2-14] (TTE), there is significant AR seen on both prior echoes. It is shadowed near the valve but can be clearly delineated from the mitral inflow jet on multiple views. On the TEE, the anterior leaflet of the mitral valve does not open properly due to the eccentric nature of the regurgitant jet. On today??????s study, the AR is much more apparent. There is also a mass on the TV. I think this was present on the TTE (image #54). The TEE did not capture enough clear pictures of the TV to be able to say whether or not a vegetation was present but image #36 suggests there may have been something there. The right ventricle is now dilated and hypokinetic. Pulmonary pressures are higher. CAROTID SERIES COMPLETE Study Date of [2187-4-4] Impression: Right ICA with no stenosis. Left ICA with no stenosi LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [2187-4-4] IMPRESSION: Congestive hepatomegaly with mild ascites and bilateral pleural effusions. [2187-4-17] Intra-op TEE Conclusions PRE BYPASS The left atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is severely dilated. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). The right ventricular cavity is dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. The left coronary cusp is prolapsing into the left ventricular outflow tract resulting in severe eccentric aortic regurgitation. There may be a vegetation on the aortic valve. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is receiving milrinone by infusion. There is normal right ventricular systolic function. There is somewhat more anterior and anteroseptal hypokinesis of the left ventricle relative to the other walls. Miold global hypokinesis of the other segments remains. Overall LV ejection fraction remains in the 40 to 45% range. There is a bileaflet prostheis located in the aortic position. It appears well seated and displays normal leaflet motion. The maximum pressure gradient across the aortic valve is 17 mmHg with a mean gradient of 7 mmHg at a cardiac output of 6.5 liters/minute. There are two jets of trace aortic regurgitation that likely represent normal washing jets but cannot completely rule out a paravalvular source for one or both of the jets. The tricuspid regurgiation is now mild. The thoracic aorta appears intact after decannulation. Brief Hospital Course: 56 y/o man with recent admission for MSSA bacteremia with AV endocarditis, septic left prosthetic hip, sent home on nafcillin acute hepatotoxicity and nephrotoxicity from nafcillin and or rifampin. On admission, he was noted to have significant renal failure and transaminitis, which was initially attributed to antibiotics. Accordingly, his rifampin and nafcillin were discontinued and he was started on IV Daptomycin per ID recommendations. His LFT's and renal function were followed closely. Due to his known endocarditis and the potential for heart failure to be causing his current presentation, a cardiac echo was obtained to reevaluate his valvular function. He was found to have very significant heart failure due to worsening valve function with severe AR and moderate TR. Cardiology and Cardiac Surgery were therefore consulted to assist with management of his heart failure. He was subsequently restarted on IV lasix, as well as nitrates and hydralazine to reduce afterload. A RUQ ultrasound was obtained which showed hepatic congestion. It remains unclear if the major precipitant of his tranaminitis was due to antibiotics (rifampin and/or nafcillin) or whether this was due to congestive hepatopathy. He remained afebrile, without evidence of any untreated infections. He was subsequently transferred to the Cardiology service for ongoing treatment of his heart failure in preparation of valve replacement surgery. Prior to AVR, he had a cardiac catheterization which showed non-flow limiting lesion of <30% in the mid LAD, and unobstructed coronary flow. Patient was also started on levofloxacin as per recommendation of infectious disease team for suppression, and was subsequently stopped on therapy. He continued daptomycin until the time of his valve replacement. On [2187-4-17] he was taken to the operating room and underwent an urgent aortic valve replacement for aortic valve endocarditis with a size 25-mm St. [Male First Name (un) 923] Regent mechanical valve, with Dr.[First Name (STitle) ]. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. He was weaned off inotropy and pressors, awoke neurologically intact and was extubated without incident. Beta-blockade/Aspirin/ and diuresis were initiated. All lines and drains were discontinued in a timely fashion. He continued to progress and on POD# 2 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. He was placed on anticoagulation for his mechanical AVR. The remainder of his postoperative course was essentially uneventful. ID continued to follow postoperatively with antibiotic recommendations. Final blood cultures were negative. On POD 6 he was cleared for discharge to [Location (un) 246] Nursing and Rehab. All follow up appointments were advised. Medications on Admission: Medications at home: Nafcillin 2g Q4 Rifampin 300mg TID Metformin 500 mg [Hospital1 ] Metformin reportedly discontinued by pcp. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 4. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? mechanical aortic valve Goal INR 2.5 - 3 First draw [2187-4-24] 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 8. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Duration- indefinitely, per ID. 14. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM as needed for mech AVR: dose will change daily for goal INR 2.5-3, dx: mech. aortic valve. 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 16. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 17. Outpatient Lab Work Weekly CBC, Chem 7, AST, ALT, Alk Phos, CRP, ESR All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] Discharge Disposition: Extended Care Facility: [Location (un) 246] Nursing Center - [Location (un) 246] Discharge Diagnosis: MSSA Aortic valve endocarditis s/p Aortic Valve Replacement (#25mm St.[Male First Name (un) 923] Mechanical Valve) Secondary: - Left paravertebral abscess - Left prosthetic hip septic arthritis - Transaminitis secondary to rifampin - Diabetes mellitus type 2 - Hyperlipidemia - History of renal cyst - ATN secondary to nafcillin Hepatic and nephro-toxicity from nafcillin and or rifampin antibiotics. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - deconditioned 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: Department: ORTHOPEDICS: TUESDAY [2187-5-1] at 8:40 AM with: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD [Telephone/Fax (1) 1228]-Building: [Hospital6 29] [Location (un) 551] Campus: EAST,Best Parking: [Hospital Ward Name 23] Garage Surgeon: Dr.[First Name (STitle) ], [Telephone/Fax (1) 170], on [2187-5-14] at 2:15p Cardiologist:Dr.[First Name8 (NamePattern2) ] [Name (STitle) ] on [2187-5-15] at 8:50a [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2187-5-16] 10:00 Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) 2563] [Last Name (NamePattern1) 1004] ([Telephone/Fax (1) 89874] in [3-13] 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 ?????? mechanical aortic valve Goal INR 2.5 - 3 First draw [2187-4-24] Outpatient Lab Work Weekly CBC, Chem 7, AST, ALT, Alk Phos, CRP, ESR All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 10739] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2187-4-23]	[ "570", "414.01", "790.4", "424.2", "424.1", "421.0", "E930.6", "324.1", "V43.64", "573.0", "041.11", "428.0", "E878.1", "996.66", "272.4", "E930.0", "790.7", "250.00", "287.5", "428.21", "584.5", "711.05" ]	icd9cm	[ [ [] ] ]	[ "37.22", "88.56", "35.22", "39.61" ]	icd9pcs	[ [ [] ] ]	14406, 14497	9233, 12210	526, 668	14946, 14946	2868, 4036	15998, 17508	1770, 1833		12394, 14383		14518, 14925		12236, 12236			15098, 15975				12257, 12371				1848, 2849																							270, 488									696, 1060					4052, 9210				14961, 15074						1082, 1490	1506, 1754
31,408	178,297	46595	Discharge summary	report	Admission Date: [2149-1-17] Discharge Date: [2149-2-5] Date of Birth: [2080-7-16] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 898] Chief Complaint: Progressive weakness Major Surgical or Invasive Procedure: 1. Anterior cervical diskectomy, C4-C5 and C5-C6. 2. Anterior cervical arthrodesis, C4-C5 and C5-C6. 3. Anterior instrumentation, C4 to C6. 4. Application, interbody device (VG2 graft), C4-C5 and C5-C6. History of Present Illness: Mr. [Known lastname 98931] is a 68-year-old man with a history of cervical myelopathy and CIDP who presents with worsening weakness. He has a long-standing polyradiculoneuropathy, which began in [2135] or [2136] with numbness over his right 4th finger. This has been most recently treated with Prednisone. He has in the past been treated with CellCept, but this was ineffective, and Imuran caused a flu-like reaction. He has also recently been treated with IVIg, but this has had to be held due to an acute worsening of his chronic renal insufficiency - last treatment was [2148-12-26]. Plasmapheresis has been tried in the past, as well, but this was also ineffective. He had been doing well in [Month (only) 1096], and his prednisone dose was decreased at that time from 15 mg daily to 10 mg daily. However, at the beginning of [Month (only) 404], he developed tingling in his nose and hands, and his prednisone was increased to 10 mg daily alternating with 15 mg daily. This improved his symptoms. He was due for an IVIg treatment on [1-8], but at that appointment, it was noted that his Creatinine had risen up to 1.9, which had been a gradual increase over the prior 6 months. The decision was made then to hold his IVIg until the etiology could be determined. He believes that he has been becoming progressively weak over the last 1-2 months, though it has been worse in the last week or so, with today being particularly bad. His proximal arm weakness was noted to be worse at his visit on [1-9]. At the time, this was thought perhaps due to his cervical myelopathy. However, he has progressed further since that time to the point of being unable to get up the stairs to his apartment without assistance; as recently as one month ago he was walking up 46 steps at the [Location (un) ] T station without help. As his neuromuscular fellow points out, "All this has occured in the setting of prednisone weaning, making steroid induced myopathy less likely." He did have a C-spine MRI last week that showed a large disk compressing the cord at C4/5. His orthopedic spine surgeon is aware of his admission. Mr. [Known lastname 98931] [Last Name (Titles) 15797] headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. [Last Name (Titles) ] difficulties producing or comprehending speech. [Last Name (Titles) ] focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. [Last Name (Titles) ] difficulty with gait. On general review of systems, he reports some recent diarrhea, consistent with his alternating constipation and diarrhea of IBS. He [Last Name (Titles) 15797] recent fever or chills. No night sweats or recent weight loss or gain. [Last Name (Titles) ] cough, shortness of breath. [Last Name (Titles) ] chest pain or tightness, palpitations. [Last Name (Titles) ] nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. [Last Name (Titles) ] arthralgias or myalgias. [Last Name (Titles) ] rash. Past Medical History: 1. Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) as above. 2. Chronic renal insufficiency, baseline Cr 1.2-1.4, but with elevation of his creatinine over the last month, now up to 2.0. 3. Possible myelodysplastic syndrome (persistently low blood counts), followed by Dr. [Last Name (STitle) ] 4. Diabetes Mellitus 5. T8 compression fracture. 6. Squamous cell carcinoma 7. Cervical myelopathy 8. Irritable bowel syndrome, with chronic constipation alternating with diarrhea Social History: He has a remote alcohol and smoking history, none now; and no illicits. Formerly worked for the USPS. Family History: Father died age 57 of CAD, mother in 80s with Alzheimers. No one with other neurologic disease. Physical Exam: Vitals: T: 98.5 P: 64 R: 18 BP: 139/87 SaO2: 99%RA FS 147 General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Bandages over forehead lesion. Slight edema around eyes. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. Good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VFF to confrontation. III, IV, VI: EOMI with 3 beats of bilateral end-gaze nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Subtle pronator drift bilaterally. No adventitious movements noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5- 4+ 4+ 4+ 4 4 4 5 5 5 5 4 4+ R 5 4 5 5 5 5 5 4- 5- 4+ 5- 5 4 4 -Sensory: Diminished sensation to pinprick over medial forearm and medial fingers on right. Diminished cold sensation and vibratory sense over bilateral feet to ankles. Proprioception intact throughout. No extinction to DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 tr tr 0 0 R 1 tr tr 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Slightly wide-based with short stride. Dorsiflexes toes while walking. Unable to walk in tandem. Romberg mildly positive. . MICU Txfer PE: VS - Tm 102.7ax, Tc 100.4, BP 112/54 (112-164/54-70), HR 106 (58-106), RR 20, sats 100% on NRB. FS 140 I/O: incont today I/O: [1-29]: 240 PO + 2275 IV/1485; [1-30]: 480PO + 1600/800 + BM x1; [1-31]: 760 + 1800/1350 Gen: Obese, older male, in NAD. In c-collar and using NRB. Not dyspneic or tachypneic. Talking in full sentences. Oriented x3. HEENT: Sclera anicteric. PERRL. Slightly edematous L eyelid. Skin flushed. MMM. Unable to assess for JVD due to collar. CV: Tachy, regular, normal S1, S2. No murmurs appreciated but difficult to hear due to rhonchorous breath sounds. Lungs: Diffuse, rhonchorous breath sounds throughout the anterior chest. No crackles appreciated at the bases. Abd: Soft, NTND. + BS. No masses. No HSM appreciated. Ext: No edema. Negative [Last Name (un) 5813] sign bilaterally. LE in pneumoboots bilaterally. 2+ DP pulses. + erythema, warmth of L knee. Pertinent Results: Radiologic Data: MRI C-spine: Extensive degenerative changes of the cervical spine with severe canal stenosis at C4/5. Although the cord is compressed at this level, there are no cord signal abnormalities. These findings are not significantly changed compared to [2147-5-22]. . Bone Marrow Biopsy: [2149-1-21]: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: 1. Fragmented bone marrow biopsy with maturing trilineage erythroid dominant hematopoiesis. 2. Absent iron stores . Renal US: LIMITED LIVER ULTRASOUND: The liver shows no focal or textural abnormalities. The gallbladder appears normal without evidence of stones on this non-fasting study. There is no intra- or extra-hepatic biliary dilatation; the CBD measures 4 mm in diameter. Color Doppler demonstrates patent and anterograde portal venous flow. Patency is also demonstrated in the right and left portal veins, the hepatic veins, and the splenic vein. There is no ascites. IMPRESSION: Normal-appearing liver and gallbladder with patent portal veins. . CTA Chest: IMPRESSION: 1. No pulmonary embolism. 2. Bilateral lower lobe consolidation and small bilateral pleural effusions. Patchy right upper lobe airspace opacity. Differential diagnosis includes infectious etiology. Followup is recommended. 3. Mid thoracic vertebral body compression deformity of unknown chronicity. . CT NEck: CLINICAL INFORMATION: Patient with acute hypoxia and tachypnea. There is slight thickening of the right aryepiglottic fold identified. The trachea and subglottic space is well maintained. The nasopharynx is also well maintained. There are postoperative changes in the lower cervical region with patient status post anterior discectomy. There are degenerative changes visualized in the cervical spine. No definite focal abscess identified. Soft tissue changes are seen in the partially visualized right sphenoid sinus and a retention cyst is seen in the left maxillary sinus. At the right lung apex, linear opacities are identified with opacities at the posterior lung base which could be due to atelectasis. Correlation with chest CT recommended. IMPRESSION: Status post anterior discectomy. Soft tissue changes identified at the level of upper aspect of the postoperative change with indentation on the posterior aspect of the oropharyngeal airway, thickening of the right aryepiglottic fold, and obliteration of the right piriform sinus could be related to surgery but are slightly unusual in position and direct inspection is recommended to exclude focal abnormality. This finding is new since the previous cervical spine MRI of [2149-1-11]. . [2-2]: CXR: Comparison is made with prior study performed a day earlier. Left lower lobe retrocardiac opacity has improved, right lower lobe atelectasis/consolidation is unchanged, ill-defined opacity in the right upper lobe is also stable. Mild cardiomegaly is unchanged. Small bilateral pleural effusions are stable. . [2149-1-17] 09:50AM BLOOD WBC-4.5 RBC-3.92* Hgb-10.7* Hct-33.0* MCV-84 MCH-27.2 MCHC-32.3 RDW-17.6* Plt Ct-96* [2149-1-24] 06:55AM BLOOD WBC-1.9* RBC-3.61* Hgb-9.7* Hct-30.1* MCV-83 MCH-26.8* MCHC-32.2 RDW-17.2* Plt Ct-67* [2149-2-1] 06:30AM BLOOD WBC-3.8* RBC-3.32* Hgb-9.0* Hct-27.6* MCV-83 MCH-27.2 MCHC-32.7 RDW-19.3* Plt Ct-72* [2149-2-5] 05:40AM BLOOD WBC-2.8* RBC-3.15* Hgb-9.4* Hct-26.5* MCV-84 MCH-29.8 MCHC-35.4* RDW-20.0* Plt Ct-85* [2149-1-17] 09:50AM BLOOD UreaN-40* Creat-2.0* Na-139 K-4.5 Cl-106 HCO3-24 AnGap-14 [2149-1-31] 05:50AM BLOOD Glucose-86 UreaN-21* Creat-1.4* Na-138 K-3.5 Cl-101 HCO3-29 AnGap-12 [2149-2-5] 05:40AM BLOOD Glucose-103 UreaN-16 Creat-1.3* Na-139 K-3.4 Cl-104 HCO3-28 AnGap-10 Brief Hospital Course: Mr. [Known lastname 98931] is a 68-year-old man with a history of cervical myelopathy and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) who presents with progressive weakness over the last month. His neurologic exam is notable for diffuse weakness, worse distally than proximally though with bilateral IP involvement. He also has sensory loss distally. These findings are consistent with a neuropathy, although the progressive weakness may be a result of his myelopathy. 1. Cervical myelopathy: The patient was admitted to the neurology service as his exam suggested an upper motor neuron pattern of weakness (consistent with spinal cord compromise more than his known CIDP), for consideration of surgery. Orthopedics evaluated him (Dr. [Last Name (STitle) 1352]) after an MRI showed cord compression in the upper cervical cord. Surgery was recommended, but as his platelets dropped during the admission, surgery was felt to be unsafe until his platelets could be stablized. Eventually, after IVIG infusions and transfusions of several packs of platelets immediately afterwards, his platelets rose to >100,000 and he was taken to the OR on [2149-1-30] for anterior discectomy and fusion. Stress dose steroids were given perioperatively. Surgery was uncomplicated and blood loss was only 50cc. Dilaudid PCA was used postoperatively to control pain, then transitioned to oral narcotics. Strength in the arms improved during admission (residual C7 weakness bilaterally) and strength in the legs also improved to 4+/5 at the right IP and [4-28] at the left IP, 5-/5 at bilateral hamstrings. He was followed by the Neuromuscular service while he remained in house. His platelets remained stable for 48 hours after the procedure (80-100,000 range) but on post-op day three dropped to 72,000... Physical therapy followed him both pre- and postoperatively and recommended rehab. 2. CIDP Prednisone was continued initially at his home dose. Lower motor neuron signs of weakness consistent with the CIDP were quite mild throughout the admission, and in fact, as his renal function improved (initial reason IVIG was stopped), IVIG was re-initiated, both for CIDP and for platelet dysfunction. Stress dose steroids were given perioperatively, as above. He gets 35g IVIG q day x 2 days every two weeks. He will be due for his next dose of IVIG early next week. In the past he has been receiving his IVIG infusinons at the infusion clinic at [Hospital1 18]. The number for that clinic where he is known is : [Telephone/Fax (1) 98932]. If you are not able to get in contact with then, please call Dr. [Last Name (STitle) 7673] at Pager: [Telephone/Fax (1) 8717], [Numeric Identifier 58341] (however, the infusion clinic will be better able to assist with the specifics of his infusions). He is also maintained on prednisone for this, which at time of discharge is being administered at doses of 10mg and 15mg on alternative days (please restart this regimen on day #2 of [Hospital1 ] as he is to get 1 more day of 40mg prednisone for a gout flare). 3. Acute on chronic renal insufficiency FENa was checked and was 0.3, suggesting an element of pre-renal failure, likely due to poor po intake and chronic diarrhea from IBS. He was hydrated and electrolytes normalized, as renal function overall improved. Renal consults followed him initially and renal u/s was normal; they signed off once renal function improved with hydration.On discharge, his Cr returned to its baseline. 4. Respiratory illness On post-op day 3 following the discectomy and fusion (decompression of spinal cord), he was found to be febrile to 103.5 axillary, with low level of responsiveness and sats in the low 80s (80-82%), tachypneic on exam with rhonchorous lung sounds, and no improvement with high-flow nasal cannula. He was placed on non-rebreather O2 and sats increased to high 90s; ABG was: pH 7.40 pCO2 46 pO2 123 HCO3 30 BaseXS 2. He was started on broad-spectrum antibiotics (vanco, levaquin and flagyl), and maintained on nonrebreather as this was unable to be weaned without substantial drop in oxygen saturations. CTPA and CT of the neck were ordered which showed no post-surgical abscess and no PE but confirmed a bilateral consolidation consistent with a significant aspiration pneumonia. As he could not maintain his SaO2 without the 100% Non-rebreather, a MICU consult was initiated and transfer to that service was effected. He was started on Vancomycin, Levofloxacin and Flagl to cover for aspiration pneumonia and also to cover for MRSA given his long hospital course. He did not require intubation; his O2 requirement was decreased after 2 days in the ICU and he was able to breath on room air >48 hours prior to discharge. We plan to continue him for 7 additional days with Vancomycin and Flagyl. The Flagyl can be transitioned to PO. 5. Hematology/? Myelodysplastic syndrome: Platelets dropped during the admission and after consult with hematology, etiology was felt to be chronic ITP, likely kept at bay with the IVIG infusions he had received as an outpatient for the CIDP. Platelets were felt to be sequestered in the spleen, and he was advised to ambulate with nursing three times daily to limit this complication pre-op. Platelets rose to an acceptable level for operation by [1-30] and he was taken to the OR after IVIG and platelet infusion. Platelets dropped to 72,000 on [2-1]. In addition to his thrombocytopenia, he was anemic, felt to be severe iron deficiency-related. He was treated with IV Fe Gluconate. he had a bone marrow biopsy on this admission - this was not consistent with a myelodysplastic syndrome. 6. Diabetes Team held metformin in preparation for possible surgery and imaging studies, continued glyburide, while covering with ISS. He was switched to glipizide at the recommendation of the Renal team. Blood sugars were within goal range, in general. 7. HTN: the patient was changed from atenolol to metoprolol given his renal insufficiency. He was still hypertensive to the 160s-170s - hence amlodipine 5mg daily was added onto his regimen prior to discharge. 8. Gout Flare: Post op he developed gouty flares in his L knee, L 1st MTP and L wrist. Rheumatology was consulted who recommended: - 2 days of prednisone 40mg - colchicine 3x/week - recheck his uric acid level in 1 month (it was 7.1 on [2149-2-3]) - by discharge, his knee and L 1st MTP were improved. 9. CODE: FULL Medications on Admission: ATENOLOL 50 mg--1 tablet(s) by mouth a.m. Caltrate-600 Plus Vitamin D3 600 mg-400 unit--1 tablet(s) by mouth twice a day GLYBURIDE 2.5 mg--2 tablet(s) by mouth daily LORAZEPAM 0.5 mg--Tablet(s) by mouth as needed for 3 times a day prn METFORMIN 500 mg--2 in am; 3 in pm twice a day PREDNISONE 10 mg--1 tablet(s) by mouth 10mg alternating with 15mg daily PROTONIX 40 mg--1 tablet(s) by mouth a.m. TERAZOSIN 2 mg--twice a day one in the am and two at bedtime VITAMIN B-12 1,000 mcg--once in am once in pm twice a day XALATAN 0.005 %--1 drip instill each eye at night Allergies: Penicillins Discharge Medications: 1. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 2. Vancomycin in Dextrose 1 gram/250 mL Solution Sig: One (1) Intravenous twice a day for 7 days. 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO 3x/week for 1 months: Please give every other day. Hold for diarrhea. . 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 15. Terazosin 1 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-25] Puffs Inhalation Q6H (every 6 hours) as needed. 19. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-25] Sprays Nasal QID (4 times a day) as needed. 20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 21. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 days. 22. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO QOD: To restart alternating between 15mg and 10mg daily. To start after 1 more dose of 40mg is given. 23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD: To restart taking this. His typical prednisone dose is alternating between 10mg and 15mg. (He has to get 1 more dose of 40mg before enacting this regimen). 24. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Heparin, Porcine (PF) 5,000 unit/0.5 mL Syringe Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Cervical stenosis with myelopathy. 2. Cervical spondylosis. 3. Chronic inflammatory demyelinating polyneuritis. 4. Thrombocytopenia with idiopathic thrombocytopenic purpura. Discharge Condition: Stable to rehab Discharge Instructions: You were admitted for a fall and found to have compression of your spinal cord. You underwent surgery for this. During your hospitalization, you had an aspiration pneumonia. . Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [Telephone/Fax (1) ]. Please resume all home mediciation as prescribed by your primary care physician. Followup Instructions: Please follow up the Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352] at two weeks from the date of your surgery. If you need to make this appointment, please call [Telephone/Fax (1) ]. . You have the following premade appointments: Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2149-2-27] 11:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7476], MD Phone:[Telephone/Fax (1) 7477] Date/Time:[2149-3-28] 1:00 Completed by:[2149-2-5]	[ "507.0", "238.75", "403.90", "584.9", "721.1", "518.0", "287.31", "286.9", "789.2", "357.81", "274.9", "284.1", "787.20", "250.00", "585.3" ]	icd9cm	[ [ [] ] ]	[ "84.51", "99.05", "99.14", "81.62", "80.51", "41.31", "81.02" ]	icd9pcs	[ [ [] ] ]	21103, 21182	11516, 18001	292, 497	21407, 21425	7794, 11493	22033, 22633	4351, 4449		18641, 21080		21203, 21386		18027, 18618			21449, 22010					5423, 7775			4464, 5038																							231, 254									525, 3695									5053, 5406						3717, 4215	4231, 4335
13,752	185,633	26091	Discharge summary	report	Admission Date: [2152-6-15] Discharge Date: [2152-6-29] Date of Birth: [2075-8-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Fever Major Surgical or Invasive Procedure: Removal of Tunneled hemodialysis line Placement of temporary HD line Replacement of tunneled HD line History of Present Illness: HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 64743] is a 76 year-old African-American male with ESRD on hemodialysis, long-standing hypertension and DM type 2, status post left BKA on [2152-5-9], who presents with a 1-day history of fever. * According to his wife, he went for his usual dialysis session on [2152-6-13]. After dialysis, she notes that he was more sleepy. They were planning to return to [Location (un) 5622] on [6-14], but he did not feel well enough to travel. Last night, he developed a fever to 102, with associated chills. His wife also reports that his sugar at that time was low at 62. He remained sleepy during the course of the day today. Mr. [Known lastname 64743] [Last Name (Titles) ] chest pain, no shortness of breath, no cough, no abdominal pain. He is anuric. No diarhrea. He did have emesis X1 this AM after taking his medications. Mild headache last night, resolved. His wife adds that she found him to be confused today, not knowing the date or year. No recent fall. He was seen by the VNA nurse, who recommended evaluation in the ED. * In ED, vitals T 100.2, HR 118, BP 104/65, RR 12, Sat 99% on 2L. CXR unremarkable. Blood cultures were drawn, and he was empirically given Vancomycin 1gm IV and Ceftriaxone 2 gm IV X1. He was also given Motrin 600 mg PO X1. A lumbar puncture was performed, with 0 WBC, 0 RBC, elevated total protein 91, and normal glucose. He was admitted to [Hospital1 18] for further work-up and management. . ................................................................ On [2152-6-16], the patient was found to have GPC in his blood and Coag + Staph Aureus. The decision was made to keep in his dialysis line, have him dialyzed and then changed by IR after dialysis. However, his R dialysis catheter was not changed. 1.8L of fluid was taken off by dialysis. He also received 1g of Vancomycin with dialysis. Throughout the day, the patient has had low grade fevers to the low 100s. This evening, a trigger was called for hypotension and tachycardia. The patient's systolic blood pressure dropped to the 70s and his heart rate went to the 140s-150s briefly. Social History: He shares his time between [Location (un) 5622] and [Location (un) 86]. He has been in [Location (un) 86] since his discharge from the hospital on [5-30] following his amputation. He currently lives with his daugther and wife. Ex-[Name2 (NI) 1818], quit many years ago. No EtOH. He moves around with a wheelchair, and is able to transfer. Physical Exam: PE on Admission: VITALS: T 100.0, BP 102/70, HR 92, RR 18, Sat 98% on 2L. FS 109. GEN: In NAD. Oriented to name only. Shivering. HEENT: Anicteric. MMM. NECK: EJV distended. CHEST: Right IJ tunneled dialysis catheter: erythema at exit site, no purulence, slight tenderness. RESP: Bibasilar inspiratory crackles, L>R. No bronchial breathing. CVS: RRR. Normal S1, S2. GI: BS NA. Abdomen soft, non-tender. EXT: Left BKA site: Sutures still in place, no erythema, no tenderness, no collection, no drainage. RLE: Unable to palpate pedal pulses. EXT: RUE AV fistula and graft, no thrill or bruit. LUE AV fistula, no thrill or bruit. No erythema. Tremulous. Pertinent Results: [2152-6-15] 03:36PM WBC-8.4 RBC-3.69* HGB-10.1# HCT-30.3# MCV-82# MCH-27.2# MCHC-33.2 RDW-15.5 [2152-6-15] 03:36PM NEUTS-90.3* BANDS-0 LYMPHS-6.8* MONOS-2.2 EOS-0.6 BASOS-0.1 [2152-6-15] 02:25PM GLUCOSE-80 UREA N-51* CREAT-8.9# SODIUM-138 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-19 [2152-6-15] 02:25PM ALT(SGPT)-22 AST(SGOT)-14 CK(CPK)-30 ALK PHOS-83 AMYLASE-93 TOT BILI-0.9 [2152-6-15] 02:25PM LIPASE-26 [2152-6-15] 07:00PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0 LYMPHS-56 MONOS-44 [2152-6-15] 07:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-91* GLUCOSE-5407/19/06 05:25AM BLOOD WBC-6.1 RBC-3.22* Hgb-8.6* Hct-26.3* MCV-82 MCH-26.6* MCHC-32.6 RDW-15.7* Plt Ct-223 [2152-6-28] 05:25AM BLOOD Glucose-79 UreaN-34* Creat-7.7# Na-138 K-5.1 Cl-104 HCO3-20 AnGap-19 [2152-6-28] 05:25AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.5* [2152-6-28] 05:25AM BLOOD Vanco-13.5* Brief Hospital Course: 76 year-old male with ESRD on HD, long-standing HTN, DM type 2, status post recent BKA [2152-5-9] and status post right IJ tunneled dialysis catheter placement on [2152-5-28] admitted with MRSA bacteremia. * 1) MRSA Bacteremia: Pt initially presented with fever and bacteremia which was eventually diagnosed MRSA. Throughout hospital course he was treated with Vancomycin after dialysis (with 7 days of Gentamicin). The initial line (later found to be infected) was removed on [6-16] and a temporary line was replaced. This second line was the removed after pt had repeat blood culture positivity found on [6-21] (4/4 bottles MRSA). Repeat blood cultures from [Date range (1) 5882] were negative. In the last 10 days, pt has been afebrile without leukocytosis. However, Pt was with fever to 102.8 when briefly transfered to the MICU on [6-16]. Echocardiogram showed no signs of endocarditis, but patient was found to have atheromatous plaques in aorta with thrombi in Right IJ and cephalic vein. ID was consulted and given the patient's high grade bacteremia. After extensive surveillance for sites of additional infection (MRI, CT, WBC scan), they recommended 6 weeks of antibiotics with goal level not less than 15-20. Additionally they requested an additional [Month/Day (4) 950] evaluation of the clots to be performed prior to follow up. * 2) ESRD- Patient on chronic hemodialysis for 8-9 years. Admitted with infected hemodialysis catheter. Now with replaced HD catheter. Pt last dialyzed on [6-28]. PT originally on Tu.Th.Sa dialysis schedule. * 3) Atheroma, R IJ thrombus, Cephalic vein thrombus- These lesions discovered on echocardiogram, [Month/Year (2) 950] and IR angiogram. Cardiology recommended anticoagulation as an outpatient. * 4) Tachycardia: Pt had several episodes of tachycardia initially. These episodes were interpreted as afib and SVT, but resolved once infection cleared. -Continue Metoprolol * 5) Change in MS: Pt initially presented with mental status changes, but thought to be secondary to acute infection. Pt was alert and oriented without changes in MS in the week prior to d/c. - LP showed no signs of infection on admission: No PMNs, No organisms * 6) CV: Multiple cardiovascular risk factors. No documented history of CAD, but EKG with probable old IMI and known PVD. Troponin elevated at 0.60 on admission, but no acute EKG signs of ischemia. Troponin elevation thought to be secondary to renal insufficiency. Pt was monitored on TELE 3 days after MICU transfer and had no acute ST changes. Additionally, pt required no oxygen supplementation. Echo showed normal EF and no signs of endocarditis. - Place on ASA 325 mg PO QD, already on BB. * 7) DM type 2: Pt was managed on Insulin sliding scale while inpatient with [Doctor First Name ] diet. He will be discharged on Glipizide PRN for FS >200. * 8) PVD status post left BKA: Incision site clean. Sutures were removed without complication. [Doctor First Name ] showed no area of fluid collection. Pt to follow up with vascular surgery to evaluate for prosthesis placement. - continue pletal for claudication * 9) Chronic anemia: Continue with EPO at hemodialysis. Currently on Fe SO4 supplementation * 10) Pulmonary nodule: CT showed 5 mm left lower lobe nodule with recommendation for repeat CT in 1 year. * 11) Code: Full. Confirmed with patient Medications on Admission: Percocet prn Metoprolol 100 mg PO BID Nephrocaps 1 tab PO QD Renagel 1600 mg PO with meals Cilostazol 100 mg PO BID Protonix 40 mg PO QD Epo 8000 units TIW with dialysis Glipizide prn for FS>200 Discharge Medications: 1. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp:30 Capsule(s) Refills:0 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:60 Tablet(s) Refills:0 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 11. Vancomycin HCl 1250 mg IV QHD 12. Giplizide Sig: One (1) once a day as needed for hyperglycemia >200. Disp:60 Refills:0 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): At dialysis. Discharge Disposition: Home Discharge Diagnosis: Primary: 1) Septicemia 2) MRSA line infection, high grade bacteremia, presumed septic thrombophlebitis of Right IJ and cephalic vein 3) Delirium, resolved Secondary: 4) ESRD on HD 5) DM- Type 2, controlled with complications 6) Incidental Pulmonary Nodule 7) Iron Deficiency Anemia and Anemia of chronic kidney disease 8) Atheroma of the aorta Discharge Condition: Good Discharge Instructions: Please take all medications as prescribed. Follow up with scheduled appointments. Followup Instructions: 1) Continue vancomycin for at least 6 weeks to ensure resolution of bacteremia; this antibiotic will need to be redosed when its level falls below 20. This level should be dosed at dialysis, probably 1250 mg at HD 2) While you are on vancomycin, you will need weekly laboratory work, including liver function tests, complete blood counts and this laboratory work should be faxed to your primary care doctor and to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] in the [Hospital ] clinic ([Telephone/Fax (1) 1419]) 3) Follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] on [8-1] at 10 AM ([Telephone/Fax (1) 457]). 4) Follow up [Telephone/Fax (1) 950] at [Hospital3 ] on the [Hospital Ward Name 517] on [7-29] at 9:00. (You should have an [Month (only) 950] of your internal jugular vein and cephalic vein before this appointment.) Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 327] Date/Time:[2152-7-31] 5) You have been restarted on coumadin (also called warfarin). This is a blood thinning medication. You will need to have your INR checked periodically to ensure your blood is appropriately thinned (INR [1-14]). Your primary care doctor (Dr. [First Name8 (NamePattern2) 698] [Last Name (NamePattern1) 64744]) can do this in [Location (un) 5622]. Dr. [Last Name (STitle) 64744] is aware of this. The lab levels should be faxed to [Telephone/Fax (1) 64745] 6) You had a CT scan of your chest while here to look for evidence of infection. No infection was found but an incidentally noted pulmonary nodule was found. As per the Radiologist's report: 'A 5-mm nodule within the left lower lobe. In the absence of a known primary malignancy, followup evaluation should be obtained in one year.' Dr. [Last Name (STitle) 64744] can help arrange for this to ensure there is no growth of this nodule or evidence of cancer IN 1 YEAR. 7) You are anemic. It is likely related to a combination of iron deficiency as well as your chronic kidney failure. You should probably have a colonoscopy and perhaps an upper endoscopy to make sure you are not losing blood through your bowels. Dr. [Last Name (STitle) 64744] can arrange for this. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "451.89", "785.52", "996.62", "427.31", "451.82", "038.11", "250.40", "V09.0", "V49.75", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95", "03.31", "86.05", "88.72" ]	icd9pcs	[ [ [] ] ]	9561, 9567	4617, 6812	320, 422	9956, 9963	3670, 4593	10093, 12511			8266, 9538		9588, 9935		8046, 8243			9987, 10070								2999, 3002																							275, 282									478, 2608							6826, 8020									2624, 2984
55,519	106,294	19535	Discharge summary	report	Admission Date: [2131-8-12] Discharge Date: [2131-8-24] Date of Birth: [2061-5-31] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Lisinopril / Ibuprofen / Metoprolol Tartrate Attending:[First Name3 (LF) 1505] Chief Complaint: Angina Major Surgical or Invasive Procedure: [2131-8-20] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with vein grafts to obtuse marginal and PLV History of Present Illness: Mr. [Known lastname ] is a 70 year old Russian speaking male with h/o 3 vessel coronary artery disease on cath [2126] s/p DES to mid LAD, who presented to PCP [Name Initial (PRE) 151] 1 month of exertional angina. Pt sent for stress test and it was stopped d/t fatigue and patient was sent home. Shortly after the stress test, pt was called by a doctor to return to the ED. Past Medical History: Coronary Artery Disease s/p stent mid LAD [2126] Hypertension Hyperlipidemia Gastroesophageal reflux disease Bilateral Knee pain Chronic breathing problems/[Name2 (NI) ] d/t Chernobyl - pt worked close Social History: Lives with: wife [Name (NI) ]: Caucasian Tobacco: quit [2108], 22 pack year hx ETOH: social Family History: denies Physical Exam: Pulse:72 Resp:16 O2 sat: 100% RA B/P Right:180/85 Left: 160/85 Height:5'7" Weight:210 LBS, 95.3 KG General: NAD, alert, cooperative 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 [] NO Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: NONE Left: NONE Pertinent Results: [2131-8-13] Cardiac Cath: 1. Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a distal 20% stenosis. The proximal LAD had 90% ostial in-stent restenosis with mild luminal irregularities. There was 60% stenosis of the mid-LAD. The distal wraparound LAD was 30% stenosed. The proximal LCx had a 90% lesion at the bifurcation of OM1, the mid LCx had 60% stenosis. The OM2 was 90% occluded. The RCA had 50% mid and 60% distal disease. The RPDA was occluded at the origin and supplied by right to right collateral. 2. Limited resting hemodynamics revealed a central aortic pressure of 164/86mmHg. 3. Left ventriculography was deferred. [2131-8-14] Carotid Ultrasound: Less than 40% stenosis in the right and left internal carotid arteries. [2131-8-15] Echocardiogram: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. [2131-8-23] CXR: PA and lateral chest radiographs are compared to [2131-8-21]. The cardiomediastinal contours are stable. Bilateral pleural effusions are probably unchanged in size. Bibasilar atelectasis and overall lung aeration compared to the examination from two days prior have improved. Median sternotomy wires appear vertically oriented and intact. [2131-8-12] 11:30AM BLOOD WBC-8.1 RBC-4.25* Hgb-13.8* Hct-39.6* MCV-93 MCH-32.4* MCHC-34.7 RDW-13.6 Plt Ct-237 [2131-8-24] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1* MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193 [2131-8-12] 11:30AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1 [2131-8-20] 04:54PM BLOOD PT-15.8* PTT-63.8* INR(PT)-1.4* [2131-8-12] 11:30AM BLOOD Glucose-105 UreaN-15 Creat-0.9 Na-139 K-4.3 Cl-106 HCO3-24 AnGap-13 [2131-8-24] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135 K-3.9 Cl-98 HCO3-28 AnGap-13 [2131-8-14] 06:40AM BLOOD ALT-13 AST-15 AlkPhos-81 TotBili-0.9 [2131-8-13] 06:30AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0 [2131-8-23] 05:46AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 [2131-8-14] 10:05AM BLOOD %HbA1c-5.7 [2131-8-24] 05:05AM BLOOD WBC-7.0 RBC-2.79* Hgb-9.0* Hct-26.1* MCV-93 MCH-32.1* MCHC-34.4 RDW-13.9 Plt Ct-193 [2131-8-24] 05:05AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-135 K-3.9 Cl-98 HCO3-28 AnGap-13 Brief Hospital Course: Mr. [Known lastname ] was admitted and underwent cardiac catheterization which revealed severe three vessel coronary artery disease - see result section for details. Prior to catheterization, he underwent Aspirin desensitization. Following cardiac cath he underwent pre-operative work-up for bypass surgery. Prior to surgery though he required Plavix washout. On [2131-8-20] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. He remained stable during his post-operative course and was seen by physical therapy for strength and mobility. There were no significant post-op events besides a rise in his WBC that trended back down to 7 by discharge. Also, all cultures taken were negative. On post-operative day four he appeared to be doing well and was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Medications at home: Nifedipine SR 60mg daily Simvastatin 40mg qHS HCTZ 25 mg qHS Inhouse: ASA (desensitized [2131-8-13]) Heparin SC TID Colace PRN Plavix 75 mg daily Plavix - last dose:300mg [8-12] + 75 mg [8-13] 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:1 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. 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 5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:1 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary Artery Disease, s/p Coronary Arteyr Bypass Graft x 3 Hypertension Dyslipidemia Gastroesophageal reflux disease s/p Stent placement to LAD [2126] Bilateral knee pain Chronic breathing problems/[Name2 (NI) ] d/t living near Chernobyl s/p Appendectomy Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [Telephone/Fax (1) 170]. 6)Call with any additional questions or concerns Followup Instructions: [Hospital Ward Name 121] 6 in 2 weeks for wound check Dr. [Last Name (STitle) ] in [5-6] weeks, call for appt Dr. [Last Name (STitle) 3357] in [3-6] weeks, call for appt Dr. [Last Name (STitle) 52994] in [3-6] weeks, call for appt Completed by:[2131-8-24]	[ "272.4", "788.43", "V07.1", "401.9", "411.1", "530.81", "E929.8", "909.2", "V45.82", "508.1", "414.01", "V58.61", "719.46" ]	icd9cm	[ [ [] ] ]	[ "36.15", "88.56", "36.12", "37.22", "39.61" ]	icd9pcs	[ [ [] ] ]	7515, 7590	4882, 6147	328, 505	7899, 7905	2005, 4859	8447, 8736	1286, 1294		6426, 7492		7611, 7878		6173, 6173			7929, 8424				6194, 6403				1309, 1986																							282, 290									533, 920															942, 1153	1169, 1270
63,685	198,093	54517	Discharge summary	report	Admission Date: [2132-6-11] Discharge Date: [2132-6-16] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2132-6-11] Aortic Valve Replacement with [First Name8 (NamePattern2) 17167] [Male First Name (un) 923] Epic Bioprosthetic History of Present Illness: 89 year old male who has been followed with several echo's for aortic stenosis over the past year or more. He has slowly developed worsening symptoms over the last 3-4 months of dyspnea on exertion. He describes this as only being mild. In addition he has had some atypical chest pain. He presented for surgical evaluation for an aortic valve replacement. Cardiac Catheterization: Date:[2132-5-28] Place:[Hospital1 18] LMCA: normal LAD: 30% proximal LCX: normal RCA: minimal luminal irregularity RA=11 PCW=15 PA=44/14 [2131-5-24] Cardiac Echocardiogram: LVEF 60-65%, Severe AS ([Location (un) 109] 0.6, pk/mn 65/44), mild MR, Trace TR/PR Past Medical History: Hyperlipidemia Hypertension BPH LBBB Anemia Low back pain Past Surgical History: none Social History: Race: Caucasian Last Dental Exam: Many years ago Lives: alone Occupation: Retired Tobacco: Denies ETOH: 2/day Family History: Non-contributory Physical Exam: Pulse: 58 Resp: 16 O2 sat: 9/RA B/P Right: 168/70 Left: 159/77 Height: 5'2" Weight: 143 lb General: Well-developed elderly male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 3/6 systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: Trans murmur Pertinent Results: [2132-6-12] 03:10AM BLOOD WBC-12.3* RBC-3.24* Hgb-10.5* Hct-30.0* MCV-92 MCH-32.3* MCHC-34.9 RDW-15.2 Plt Ct-126* [2132-6-12] 03:10AM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-135 K-4.7 Cl-108 HCO3-22 AnGap-10 TEE [6-11] Brief Hospital Course: Patient was admitted as same day admission and taken to the operating room on [2132-6-11] where he underwent an Aortic Valve Replacment with [First Name8 (NamePattern2) 17167] [Male First Name (un) 923] Epic Bioprosthetic. 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 on no inotropic or vasopressor support. Percocets were stopped due to confusion and Ultram was started for pain control. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Lopressor was titrated up on POD#1 for better blood pressure control. The patient was transferred to the telemetry floor for further recovery. Wires and chest tube were removed per protocol. Lopressor was uptitrated as tolerated for sinus tachycardia. His foley was removed and he was able to void- he was mainatined on high dose tamsulosin for his known prostate enlargement. He was discharged [Hospital 108453] Rehab on POD# 5. Medications on Admission: Tamsulosin 0.8mg daily Atenolol 75mg daily Simvastatin 40mg daily Aspirin 81mg daily Zolpidem 10mg daily Multivitamin daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 10. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: 7 days or until lower extremity edema resolved or at pre-op weight. Discharge Disposition: Extended Care Facility: [Hospital 66] Rehab & Nursing Center - [Hospital1 392] Discharge Diagnosis: Aortic Stenosis Hyperlipidemia Hypertension Benign Prostatic Hypertrophy Left bundle branch block Anemia Low back pain Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] on [7-3] at 2:45pm [Last Name (un) 2577] Building [Last Name (NamePattern1) 10357] Cards: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [7-30] at 3:50pm in [University/College ] office. Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 4509] in [3-25] weeks [Telephone/Fax (1) 111541] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2132-6-16]	[ "401.9", "426.3", "427.89", "600.00", "272.4", "285.9", "424.1", "724.2" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61" ]	icd9pcs	[ [ [] ] ]	4946, 5035	2352, 3543	278, 415	5198, 5367	2095, 2329	6208, 6869	1359, 1378		3718, 4923		5056, 5177		3569, 3695			5391, 6185						1208, 1215		1393, 2076																							218, 240									443, 1104															1126, 1185	1231, 1343
27,530	115,116	6210	Discharge summary	report	Admission Date: [2111-10-16] Discharge Date: [2111-10-20] Date of Birth: [2051-12-5] Sex: M Service: MEDICINE Allergies: Codeine / Percocet Attending:[First Name3 (LF) 1145] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with stenting History of Present Illness: Mr. [Known lastname 24214] is a 59 yo man with history of HTN and s/p renal transplant for polycystic kidney disease who presenting with substernal crushing chest pressure that began while building a gazebo. When the pain failed to subside with rest, he went to [Hospital1 18] ED. In the emergency room, he was diaphoretic with blood pressure 114/70, pulse 70, respiratory rate 16, and oxygen saturation 100% on room air. He was given full dose aspirin and EKG showedhyperacute t-waves, questionable ST changes. Repeat EKG showed ST elevations V3-V5, and the patient was taken to cath lab. In the cath lab, Mr. [Known lastname 24214] was found to have 90% lesion of LAD with thrombus at D1, and a 70% lesion with filling defect after D2. He was stented with 2 overlapping Diver bare metal stents with normal flow. Subsequently, he did have marked oozing around femoral sheath; the sheath was upsized and integrilin was stopped with good effect. The patient was admitted to the CCU for further care. 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. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Does note slightly increased DOE over the past few weeks. He does note feeling lightheaded over the past few days, and attributed this to working in the heat. Past Medical History: 1. polycystic kidney disease, s/p R-sided transplant in [2103] 2. HTN 3. Anemia- prior to kidney transplant Social History: Mr. [Known lastname 24214] is a prior smoker of 44 pack years. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. His mother died from brain cancer, and his father died from cirrhosis. Physical Exam: Exam in CCU Vital signs Gen: Lying flat, appears well, NAD, resp or otherwise. 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, unable to assess JVP secondary to positioning CV: PMI non-displaced, normal s1/s2, no murmurs, rubs, or gallops Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: soft, NTND, no tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: mild stasis dermatitis, no 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: [2111-10-16] 02:00PM WBC-9.6 RBC-3.81# HGB-8.5# HCT-27.5# MCV-72# MCH-22.3# MCHC-30.8 RDW-17.6* [2111-10-16] 02:00PM NEUTS-76.3* LYMPHS-15.6* MONOS-6.7 EOS-1.2 BASOS-0.2 [2111-10-16] 02:00PM PLT COUNT-361# [2111-10-16] 02:00PM PT-13.5* PTT-26.8 INR(PT)-1.2* [2111-10-16] 02:00PM RET AUT-1.7 [2111-10-16] 02:00PM calTIBC-333 HAPTOGLOB-207* FERRITIN-17* TRF-256 [2111-10-16] 02:00PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.1 IRON-15* [2111-10-16] 02:00PM CK-MB-4 [2111-10-16] 02:00PM cTropnT-<0.01 [2111-10-16] 02:00PM LD(LDH)-187 CK(CPK)-140 TOT BILI-0.8 [2111-10-16] 09:23PM CK(CPK)-3349* [2111-10-16] 09:23PM CK-MB-387* MB INDX-11.6* [2111-10-16] 02:54PM TYPE-ART O2 FLOW-3 PO2-122* PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0 COMMENTS-NASAL [Last Name (un) 154] . CATH [2111-10-16]: 90% lesion of LAD with thrombus at D1, 70% lesion with filling defect after D2. 60% stenosis of RCA. . TTE [2111-10-17] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with septal, anterior, distal LV/apical akinesis. The remaining segments are hyperdynamic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve 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 mild pulmonary artery systolic hypertension. There is no pericardial effusion. EF 30% . CXR [2111-10-16] Left costophrenic sulcus is excluded from the radiograph, precluding assessment of small left pleural effusion. Right cardiophrenic angle is clear. The heart is mildly enlarged and there is mild CHF with vascular engorgement and minimal interstitial pulmonary edema. . Lower extremity ultrasound [2111-10-19] IMPRESSION: No evidence of DVT on the left or right legs. . CXR [2111-10-19] 1. No evidence of CHF. 2. Small focal patchy opacity in the anterior aspect of one of the lower lobes seen only on lateral view. This may be due to atelectasis or early focus of infection. Followup radiographs may be helpful in this regard. . Microbiology [2111-10-18] urine culture: NEGATIVE [2111-10-18] blood culture: no growth as of [2111-10-20] Brief Hospital Course: 1. STEMI - The patient underwent bare metal stent placement of his LAD. He continued his beta blocker and was started on high dose statin, plavix, and aspirin. We added a low dose ACE inhibitor as well after discussion with his outpatient nephrologist Dr. [First Name (STitle) 805]. He will follow up with cardiology clinic on [2111-11-2]. A repeat TTE to assess LV function should be done in [5-15] weeks from discharge. . 2. Fever - Mr. [Known lastname 24214] developed a fever to 102 with chest film showing question of retrocardiac infiltrate. Although he had minimal symptoms, given his immunosuppression his team felt that he should receive empiric treatment for pneumonia. He was started on ceftriaxone and azithromycin, and will complete a 7 day course of cefpodoxime and azithromycin. He knows to seek medical attention should he develop worsening fevers, chills, or coughing at home. He did also have lower extremity ultrasound studies to assess for DVT as the cause of his fevers; this study showed no evidence of DVT. His urine culture from [10-18] was negative, and his blood culture from [10-18] was negative as of the date of discharge [10-20]. . 3. CRI s/p renal transplant - The patient continued his home immunosuppressants. . 4. Microcytic anemia - The patient had iron studies suggestive of iron-deficiency anemia. He was started on iron supplements. He will need followup endoscopy as an outpatient to assess for sources of gastrointestinal bleeding. . Code: The patient was full code Medications on Admission: cellcept [Pager number ] mg PO BID cartia 300 mg PO daily gengraf 75 mg PO BID prednisone 5 mg PO daily metoprolol 50 mg PO BID lasix 40 mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gengraf 25 mg Capsule Sig: Three (3) Capsule PO twice a day. 7. CellCept [Pager number ] mg Tablet Sig: One (1) Tablet PO twice a day. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 11. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 13. Outpatient Lab Work Please have blood drawn for a complete metabolic panel (including potassium, creatinine, and BUN) in one week and have the results sent to your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 24215] ([Telephone/Fax (1) 24216]) and Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 4022]) Discharge Disposition: Home Discharge Diagnosis: 1. Myocardial infarction 2. Iron deficiency anemia 3. Pneumonia Discharge Condition: good Discharge Instructions: You came to the hospital after developing chest discomfort. This was caused by a heart attack. You had a stent placed in one of the arteries supplying your heart. Please be sure to take all of your medicines as directed and follow up with both your primary care doctor and your cardiologist. Please do not stop taking aspirin or Plavix unless told to do so by your cardiologist. While in the hospital, you had some fevers and sweats that may have been due to pneumonia. Please continue to take the entire course of antibiotics as directed even if you are feeling well. You have an iron-deficiency anemia. It is very important that you let your doctor know about this. You will need a colonoscopy as an outpatient to further address this anemia. Call your doctor or seek medical attention at once if you develop: Recurrent chest discomfort that is severe or persistent, shortness of breath, lightheadedness, fevers, shaking chills, sweats, worsened cough, or other symptoms that worry you Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Phone:[Telephone/Fax (1) 4022] Date/Time:[2111-11-2] 1:40 Please follow up with your primary care doctor [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 24215] at [Hospital ] Medical Group ([Telephone/Fax (1) 24217] on Monday [10-26**] at 2pm. Please bring all new medications with you, so that they can be entered into the Caritas records.	[ "V42.0", "285.21", "585.9", "410.11", "403.90", "414.01" ]	icd9cm	[ [ [] ] ]	[ "37.22", "00.46", "88.55", "88.52", "99.20", "00.40", "36.06", "00.66" ]	icd9pcs	[ [ [] ] ]	9210, 9216	5925, 7460	292, 331	9324, 9331	3216, 5902	10373, 10871	2243, 2396		7663, 9187		9237, 9303		7486, 7640			9355, 10350								2411, 3197																							242, 254									364, 1970															1992, 2105	2121, 2227
72,336	125,453	53039	Discharge summary	report	Admission Date: [2178-2-26] Discharge Date: [2178-3-3] Date of Birth: [2129-1-3] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 4760] Chief Complaint: hypotension, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: This is a 49 year old male with no PMH other than a three month history of diarrhea of unclear etiology who presents with fever, leukocytosis, and hypotension. Patient's symptoms started in late [12-5], with significant weight loss. Patient has been followed at [Company 191] and has had no clear etiology to his diarrhea. In [1-5] patient had negative stool studies (culture, O&P, c. diff toxin). Patient had seen his PCP this morning at [Company 191] because of n/v with minimal PO intake during the past 2 days, and intermittent fever. Patient was evaluated in at [Company 191] and was found to be significantly dehydrated, BP 84/64 supine, p120 regular, with temp 94.5. . Patient was transferred to the ED from [Company 191]. In the emergency department, patient's vital signs were 99.0, 140 94/65, 16, 98. Patient received 4L NS and SBPs improved to 110, BPs intermittently dropped to low 90s. Baseline SBPs 140s. Patient was started on Cipro/Flagyl and had stool sent for cx. . Patient states that he has [1-29] [Last Name (un) 940] BM daily and has had an associated weight loss (15 lbs) over the past month. He states that he can typically eat a small meal (soup with rice) but notes that he has some diarrhea post meals. Additionally, he states that he has some abdominal pain (mid epigastic) occassionally throughout the day. Currently denies any nausea, vomiting, chest pain, shortness of breath. . Review of systems is otherwise negative. Past Medical History: None Social History: Non-smoker. Denies heavy alcohol drinking. In committed homosexual relationship for 20 years. Family History: Mother and a few other relatives had cerebral aneurysm. No cancer in the family. Physical Exam: GENERAL: Pleasant, well appearing male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Tachycardic, Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. No JVD. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft. Mild diffuse tenderness in lower quadrants, ND. No HSM. No guarding or rebound. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [11-28]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs on admission: [2178-2-26] 10:40AM BLOOD WBC-18.8* RBC-5.07 Hgb-12.2* Hct-35.6* MCV-70* MCH-24.1* MCHC-34.3# RDW-18.2* Plt Ct-231 [2178-2-26] 10:40AM BLOOD Neuts-54 Bands-19* Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-7* Metas-5* Myelos-2* [2178-2-26] 10:40AM BLOOD Glucose-124* UreaN-21* Creat-1.1 Na-130* K-4.1 Cl-98 HCO3-20* AnGap-16 [2178-2-26] 10:40AM BLOOD ALT-15 AST-29 LD(LDH)-263* AlkPhos-44 Amylase-205* TotBili-0.5 [2178-2-26] 06:27PM BLOOD Calcium-5.8* Phos-2.4* Mg-1.8 [2178-2-27] 03:35AM BLOOD TSH-2.3 [2178-2-27] 03:35AM BLOOD Osmolal-267* [2178-2-26] 10:36AM BLOOD Lactate-2.5* . Microbiology: 4/2 blood cultures - no growth to date [2-26] stool culture - positive c diff [2-26] HIV viral load -223,000 [2-27] Stool culture -fecal bacterial culture neg, O and P neg x 2, cyclospora neg, microsporidum neg, cryptosporidium/giardia neg, isospora neg, AFB pending, Viral culture neg so far [2-27] CMV viral load - negative, CMV IgG/IgM both positive HCV viral load 20,900 . Imaging: [2-26] Chest x-ray: IMPRESSION: No acute cardiopulmonary abnormality. . [2-26] KUB: IMPRESSION: Thumbprinting in the transverse and descending colon is nonspecific, with the differential includeing ischemic, inflammatory, or infectious colitis. . [2-28] Abdominal CT scan: CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: There are small-to-moderate simple bilateral pleural effusions. Bibasilar atelectasis. Mild intra-abdominal ascites. Within the right lobe of the liver is an irregular large hypoattenuating region with lobulated margins measuring 6.3 x 5.5 x 4.3 cm not compatible with a simple cyst. Hepatic [Month/Day (4) 56207] course through this lesion with minimal to no mass effect demonstrated. Several adjacent subcapsular hypoattenuating foci are also present within the posterior right lobe (series 2:image 21), the largest measuring 1.1 cm, the smaller measuring 0.6 cm. The left lobe is clear. The portal vein, splenic vein and SMV are patent. The gallbladder is distended without wall thickening or pericholecystic fluid/stranding to suggest acute cholecystitis. Several gallstones are present within the gallbladder. Diffuse pancolitis with wall thickening and surrounding inflammatory change with an appearance suggestive of infectious etiology such as pseudomembranous colitis. The kidneys enhance and excrete symmetrically without hydronephrosis. Cortically based cyst at the upper pole of the left kidney measures 2 x 0.8 cm. No retroperitoneal lymphadenopathy per CT size criteria. CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: The bladder is minimally distended and thus not well evaluated. The rectum and sigmoid colon are diffusely wall-thickened with surrounding hyperemia and inflammation. No inguinal or pelvic adenopathy per CT size criteria. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions detected. Schmorl's nodes with sclerosis noted at multiple inferior and superior endplates within the lower thoracic and upper lumbar spines. IMPRESSION: 1. Severe pancolitis including the rectum consistent with an infectious etiology, likely pseudomembranous colitis. 2. Large irregular hypoattenuating focus within the right lobe of the liver with two adjacent satellite lesions. Given HIV positive status, the differential diagnosis is broad. Given lack of displacement of hepatic [Last Name (LF) 56207], [First Name3 (LF) ] infectious process with developing abscess should be strongly considered. Lymphoma and primary hepatic tumors are also possibilities. Recommend ultrasound evaluation after trial of antibiotic therapy, at which time abscess drainage versus biopsy may be performed as discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2418] at the time of dictation. 3. Small intra-abdominal ascites. Small-to-moderate bilateral pleural effusions. . RUQ US [2178-3-2]: FINDINGS: Corresponding to the lesion seen on CT, there is a predominantly hyperechoic lesion within the right lobe measuring approximately 6.1 cm transverse x 7 cm AP x 5.9 cm CC. There is no demonstrable through transmission. The lesion does not appear to be hypervascular by Doppler imaging. Based on the ultrasound appearance alone, a large hemangioma could have a similar appearance. However, the CT appearance is not typical. Perihepatic ascites is again identified. IMPRESSION: Lesion within the right lobe of the liver is not consistent with abscess. Differential considerations are broad, and include primary as well as secondary solid neoplasms. MRI is recommended for further Brief Hospital Course: This is a 49 year old male with a three month history of diarrhea of unclear etiology who presents with fever, leukocytosis, and hypotension found to have c diff infection, and incidental new diagnosis of HIV and hepatitis C. Also found to have a liver mass. . # Diarrhea/C diff Colitis/sepsis: Patient presented with leukocytosis, hypothermia, tachycardia, hypotension, elevated lactate with work up demonstrating stool culture positive for c diff, consistent with picture of sepsis. However, this is in setting of 3 months of diarrhea and new diagnosis of HIV (see below). He was initially admitted to the intensive care unit where he received 8 liters of IV fluids and was started on IV flagyl, oral vanc for the c diff infection with decreasing WBC, normalized lactate, improved blood pressure and heart rate, and therefore was called out to the regular medical floor.KUB demonstrated thumbprinting in the transverse and descending colon which is nonspecific. Abdominal CT scan demonstrated pancolitis and a liver mass (see below). ID was consulted and was involved during his hospital course. He was maintained on IV flagyl, oral vancomycin, and also was started on oral ciprofloxacin in case of other underlying infection.Stool studies were also sent for O+P x 2, cyclosporidia, microsporidia, cryptosporidium, isospora, and giardia which were negative. Fecal bacterial culture was negative. Viral culture and AFB smear were pending at discharge. CMV serologies and viral load were also sent. Viral load was negative and CMV IgG/IgM indicating recent infection. On day 5, cipro was discontinued and pt was just continued on oral flagyl and vancomycin (oral). He will complete a 14 day course of flagyl and will complete 3 more weeks of oral Vancomycin taper (already completed 5 days prior to discharge). Pt was only having [11-28] very small loose stools a day at the time of discharge. . # New diagnosis HIV: Patient had HIV test and CD4 count sent at clinic on [2-24] prior to admission. CD4 count low at 187, HIV viral load was 233,000. HIV ab pending at discharge. Patient was started on oral bactrim for PCP [Name Initial (PRE) 1102]. ID was consulted during his hospital course regarding these issues and will be sending HIV genotyping after discharge to start HAART therapy in the near future. The pt has follow up arranged with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of ID. RPR was pending at discharge. . # Liver mass: Patient underwent an abdominal CT scan that demonstrated a large liver mass in the R lobe of the liver (approx 5 cm). RUQ US was performed and showed this was a solid mass. AFP was 2.4. Pt will require an outpatient MRI to further delineate this lesion (ie, if looks malignant then needs biopsy; if looks benign then potentially can be followed with serial imaging). Pts PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 9006] is aware of this finding and MRI is already scheduled for [3-17]. . # Hepatitis C: HCV viral load was measure at 20,900. Again, will need outpatient ID follow up. . # Diastolic HTN/Tachycardia: Noted HR in low 100s to 110s intermittently while here. Noted in OMR from prior visits HR have been up to 120, and pt states his HR has always been high. EKG showed sinus tachycardia at 112 bpm. Pt has no symptoms of dizziness, palpitations, etc. TSH is normal. No evidence for PE (no SOB, chest pain, hypoxia, EKG changes). Seems chronic. Given baseline tachycardia and DBP in 90s often while here (pt had diastolic HTN), started atenolol at 12.5 mg daily which can be titrated further as an outpatient. . #. Microcytic Anemia: Patient's hematocrit was baseline on admission and remained stable. Is noted to be microcytic (old finding since [2175]). Iron studies are consistent with anemia of chronic disease. . # Oral thrush: This was treated with Nystatin swish and swallow. . #. Hyponatremia: Patient's sodium trended down on admission with nadir of 124. Giving presenting sespis/volume depleted state, initially believed hypovolemic hyponatremia. However, serum osms were measured to be low/normal at 267, urine osms were inappropriately elevated at 698, urine specific gravity inappropriately elevated at 1.020. Urine sodium was measured at 22. His hyponatremia self resolved prior to discharge. Ultimately felt to be hypovolemic in etiology. . Medications on Admission: None Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:27 Tablet(s) Refills:0 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day) as needed for thrush. Disp:100 ML(s) Refills:0 4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as directed: Take 1 tablet three times a day for 1 week, then 1 tablet 2 times a day for 1 week, then 1 tablet daily for a week. Disp:42 Capsule(s) Refills:0 5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day. Disp:15 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: C diff colitis Diarrhea NOS Sepsis HIV Hepatitis C Liver Mass NOS Discharge Condition: Stable. Vitals signs stable, diarrhea improving. Discharge Instructions: You were admitted with an infection in the colon called c diff colitis, and were initially in the intensive care unit. You were treated for this, as well as evaluated for a new diagnosis of HIV, and were seen by infectious disease. You will need to complete your course of antibiotics. . Medication Changes: you were started on bactrim to protect you from infections with your low CD4 counts. You were started on nystatin for the thrush in your mouth. You are being treated for your diarrhea with vancomycin and flagyl. For the oral Vancomycin: Take 1 tablet three times a day for 1 week, then 1 tablet 2 times a day for 1 week, then 1 tablet daily for a week. Given that your blood pressure has been elevated (the low number is often in the 90s) and your heart rate runs in the 110s, you have been started on a medication called atenolol. You have follow up with Dr. [Last Name (STitle) 9006] next week, at which time she will need to check your heart rate and blood pressure. . You were diagnosed with a liver mass. This appears to be a solid mass and requires further work up. You will need a follow up MRI of this (this has already been scheduled by Dr. [Last Name (STitle) 9006]. Dr. [Last Name (STitle) 9006] is aware of this. . Please follow up with appointments as directed. . Please contact physician if develop fevers/chills, dizziness/lightheadedness, worsening of diarrhea, abdominal pain, blood in stool, shortness of breath, chest pain/pressure, any other questions or concerns Followup Instructions: 1. Infectious Disease: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2178-3-17] 11:00. [Hospital Unit Name ], Ground floor, [Hospital Ward Name 517] [Hospital1 18], [Last Name (NamePattern1) 439], [Location (un) 86], MA. . 2. MRI of the liver: Provider: [Name10 (NameIs) 7548] Phone:[Telephone/Fax (1) 327] Date/Time:[2178-3-17] 3:00 PM. Please call ahead for directions. . 3. Please follow up with Dr [First Name8 (NamePattern2) ] [Last Name (STitle) 9006] on Tuesday, [3-10] at 9:50 AM	[ "285.9", "038.9", "042", "276.1", "275.41", "273.8", "275.3", "112.0", "070.70", "995.91", "008.45", "288.60" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12710, 12716	7575, 11959	301, 307	12826, 12878	2936, 2941	14431, 15056	1990, 2073		12014, 12687		12737, 12805		11985, 11991			12902, 13191								2088, 2917																					13211, 14408		240, 263									335, 1835							2955, 7552								1857, 1863	1879, 1974
20,747	192,314	4050	Discharge summary	report	Admission Date: [2132-3-29] Discharge Date: [2132-4-18] Date of Birth: [2086-3-6] Sex: M Service: [Doctor Last Name 1181] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 17839] is a 46-year-old man with an extensive medical history, including coronary artery disease, diabetes mellitus Type 1, peripheral vascular disease, and end stage renal disease status post living related donor renal transplant, who was admitted on [2132-3-29], to the Medical Intensive Care Unit after presenting with a headache, right leg pain, and confusion. These symptoms began on the morning of presentation. Upon arrival to the [Hospital1 69] Emergency Department, the patient's blood pressure readings were noted to be erratic, with systolic blood pressures ranging from the 50s to the 140s over a five minute period. His temperature was noted to be 105 degrees Farenheit. PAST MEDICAL HISTORY: 1. Diabetes mellitus Type 1 2. Coronary artery disease status post myocardial infarction x 3, status post coronary artery bypass graft in [2125] 3. Peripheral vascular disease status post femoral-popliteal bypass x 2 and numerous amputations 4. Peripheral neuropathy 5. Retinopathy 6. End stage renal disease status post second living related renal transplant in [2122] 7. Pseudomonal wound infections 8. Left femoral artery injury, status post IABP placement in [2125] 9. Hypertension 10. Gout ALLERGIES: Erythromycin and protamine. OUTPATIENT MEDICATIONS: 1. Enteric-coated aspirin 2. Allopurinol 3. Lopressor 50 mg twice a day 4. CellCept [Pager number ] mg twice a day 5. Lasix 80 mg once daily 6. Darvocet/percocet as needed 7. Insulin 8. Rapamune 9. Diovan 80 mg once daily 10. Advicor (?) 500 mg once daily 11. Colchicine 12. Univasc 7.5 mg once daily 13. Zantac 14. Prednisone 5 mg once daily 15. Neurontin 16. Zaroxolyn 2.5 mg as needed SOCIAL HISTORY: The patient is married. He quit tobacco. He denies alcohol use. PHYSICAL EXAMINATION: On presentation (per admitting [Male First Name (un) 1573] Intensive Care Unit resident), vitals: Temperature 105 degrees, blood pressure 55 to 148 systolic/18 to 110 diastolic, heart rate 110, oxygen saturation 98%. General: Man who appears older than stated age, able to answer questions, alert and oriented x 3. Head, eyes, ears, nose and throat: Extraocular movements intact, pupils equal, round and reactive to light and accommodation, mouth clear, poor dentition, sclerae anicteric, no conjunctival petechiae. Neck: Supple. Cardiac: Heart sounds regular rhythm, with no S3 or S4, II/VI systolic ejection murmur radiating to the axilla. Lungs: Bilateral rales at the bases. Abdomen: Soft, nontender, positive bowel sounds. Extremities: Numerous amputations of digits. Right hand with necrotic fingertips. Several full and partial finger amputations bilaterally. Right leg with erythema and tenderness to distal one-third, especially over the heel. Left foot with TMA. LABORATORY DATA: On presentation, CBC revealed a white count of 7.4, hematocrit 36.9, platelets 265. Coag studies revealed an INR of 1.3, PT 13.7, PTT 33.1. Chem 7 revealed a sodium of 141, potassium 4.7, chloride 101, bicarbonate 16, BUN 7.4, creatinine 3.8, glucose 131. Urinalysis revealed [5-5] white blood cells and bacteria. Albumin was 3.6, calcium 10.0, magnesium 1.7. Arterial blood gas revealed a pH of 7.57, PCO2 20, PO2 192, lactate 6.3. Electrocardiogram obtained upon admission revealed sinus rhythm at a rate of 143 beats per minute, left atrial enlargement, left axis deviation, Q waves in Leads II, III, AVF, question marked ST elevations at Leads I, AVL, poor R wave progression. Subsequent electrocardiogram (also obtained on [2132-3-29]) revealed sinus rhythm at a rate of 97 beats per minute, some resolution of ST elevations at lower heart rate. Chest x-ray obtained upon admission revealed the pulmonary vasculature to be normal. There was no evidence of overt cardiac failure or pneumonia. There were no effusions. HOSPITAL COURSE: The patient, as noted above, was initially admitted to the Medical Intensive Care Unit. The first two weeks of the patient's approximately [Hospital 17840] hospital stay were spent in the Intensive Care Unit. The patient was admitted to the Medical Intensive Care Unit on pressor support and started on ceftriaxone for presumed sepsis. The ensuing workup of the patient's fever included blood cultures that would later grow out methicillin-sensitive staphylococcus aureus, as would tissue samples from the patient's right lower extremity. Cerebrospinal fluid and joint fluid from the patient's right knee did not yield any cultured organisms. The Vascular Surgery and Infectious Disease services were consulted and followed the patient throughout the remainder of his hospital course. The patient's antibiotic regimen underwent several iterations following admission. The [Hospital 228] Medical Intensive Care Unit course was notable for the following events: [3-29]: The patient ruled in for a myocardial infarction, with a maximum CK of 1284, and a maximum troponin of greater than 50. He was intubated for respiratory failure. The patient's creatinine also reached its zenith at 3.3. The patient underwent right lower extremity biopsy of his fascia, which was ultimately deemed to be necrotizing fascitis per pathology report. [2132-4-2]: The patient went into diabetic ketoacidosis. He was also taken to the operating room for emergent debridement and exploration of his right lower extremity. Per report from the Vascular Surgery service, there was no significant evidence of necrotizing fascitis in the operating room. [2132-4-9]: The patient developed perioral HSV-like lesions. These were later confirmed to be herpes simplex virus Type I by monoclonal fluorescent antibody tests. Consequently, the patient was started on acyclovir, in addition to his other antibacterial medications. [2132-4-10]: The patient was extubated. He was transfused two units of packed red blood cells. Following extubation, the patient continued to have occasional fevers, with vancomycin being restarted and discontinued on several occasions. Ultimately, the patient's antibiotic regimen upon discharge from the Medical Intensive Care Unit consisted of oxacillin, levofloxacin, and acyclovir. The patient's renal function improved following admission, with a creatinine of 1.1 noted on [2132-4-13]. Following extubation, the patient exhibited good oxygen saturation on room air. The patient's diet was advanced, and he tolerated this well. The patient was called out to the Medicine floor on [2132-4-13]. Following transfer to the Medicine [Hospital1 ] floor, plain films and CT scans of the patient's right lower extremity were obtained. These revealed evidence of osteomyelitis in the third metatarsal. Because of the patient's poor vascular status, the Surgery service opted not to pursue any surgical intervention at that time. Lower extremity arterial Doppler examination on [2132-4-17], revealed significant and widespread vascular disease, especially at the superficial femoral artery and popliteals bilaterally. As no operative intervention could be pursued, the patient was maintained on intravenous oxacillin, per the recommendations of the Infectious Disease service. They further recommended that the patient remain on intravenous oxacillin for four weeks following discharge from [Hospital1 346] (the patient has already been on the intravenous oxacillin for two weeks during his hospitalization, so he will ultimately receive a six week course of the antibiotic). The patient's right lower extremity pain was controlled with a morphine patient-controlled analgesia for a time. This was ultimately changed to oral Oxycontin, with MSIR being used on an as needed basis for breakthrough pain. Diabetes mellitus Type 1 issues: The patient's finger stick blood sugars were checked four times a day. He is being maintained on a regimen of Lantus insulin, with a regular insulin sliding scale four times a day. Cardiac issues: As noted above, the patient has an extensive history of coronary artery disease. Additionally, the patient suffered a myocardial infarction at the beginning of his hospital course. Ultimately, the patient would benefit from cardiac catheterization, however, at this time, given his ongoing infection as well as other medical issues, this has been deferred. Also, the patient should continue taking his lipid-lowering [Doctor Last Name 360], Advicor, which is a combination of niacin and a statin. The patient has his own supply of this medication. Renal issues: As noted above, the patient is status post his second living related renal transplant. The patient's Rapamune was restarted during his hospitalization. Also, his prednisone is being tapered. Physical therapy issues: The patient would benefit from physical therapy and rehabilitation. His right foot should only be used for partial weight bearing, to optimize healing. Pulmonary issues: Also of note, during the [Hospital 228] Medical Intensive Care Unit course, he was noted to have a left lower lobe pneumonia by chest x-ray on [2132-4-12]. The patient was thus placed on a course of levofloxacin, which he has finished. The patient is breathing comfortably currently, with good oxygen saturation on room air. CONDITION AT DISCHARGE: Vital signs stable, afebrile. DISCHARGE DIAGNOSIS: 1. Right lower extremity cellulitis and osteomyelitis, with positive methicillin-sensitive staphylococcus aureus grown in wound and blood cultures 2. Status post non-Q wave myocardial infarction [2132-3-29] 3. Diabetes mellitus Type 1 4. Status post diabetic ketoacidosis 5. Perioral herpes simplex virus Type I 6. Status post intubation for respiratory failure, with subsequent extubation on [2132-4-10] 7. Status post debridement of right lower extremity [2132-4-2] 8. End stage renal disease status post second renal transplant in [2122], on immunosuppressive therapy 9. Peripheral vascular disease DISCHARGE MEDICATIONS: 1. Allopurinol 100 mg by mouth twice a day 2. Gabapentin 100 mg by mouth twice a day 3. Tylenol 325 mg to 650 mg by mouth every four to six hours as needed 4. Bisacodyl 10 mg by mouth or per rectum twice a day as needed 5. Heparin 5000 units subcutaneously every 12 hours 6. Aspirin 325 mg by mouth once daily 7. Valsartan NS 80 mg by mouth once daily 8. Miconazole powder 2% applied topically three times a day as needed to the groin 9. Amlodipine 10 mg by mouth once daily 10. Metoprolol 150 mg by mouth three times a day 11. Bacitracin ointment one application topically three times a day to wounds 12. Colace 100 mg by mouth twice a day 13. Acyclovir 400 mg by mouth every eight hours until the patient's oral HSV lesions are completely gone 14. Sirolimus 2 mg by mouth once daily 15. Furosemide 80 mg by mouth once daily 16. Glargine 6 units subcutaneously daily at bedtime 17. Regular insulin sliding scale four times a day, to be administered subcutaneously. The sliding scale begins at the 151-200 range of glucose, for which 2 units of regular insulin is to be given subcutaneously. Thereafter, the glucose dose increases by 2 units for every increase of 50 (e.g., for a range of 201-250, 4 units of regular insulin should be given subcutaneously). 18. Oxacillin 2 grams intravenously every four hours x four more weeks 19. Morphine sulfate SR 60 mg by mouth every 12 hours 20. MSIR 15 mg by mouth every four to six hours as needed for breakthrough pain 21. Prednisone taper: 15 mg by mouth once daily for three days, then 10 mg by mouth once daily for three days 22. The patient should take his own Advicor as directed by its prescriber. DIET: The patient should be maintained on a diabetic, cardiac and renal diet. PHYSICAL THERAPY: The patient, as noted above, should practice partial weight bearing only on his right foot, to facilitate healing of his right lower extremity. FOLLOW UP: The patient is to be discharged to a rehabilitation center. He should follow up with his primary care physician in the next seven to ten days. Additionally, the patient has been encouraged to follow up in the Infectious Disease Clinic. [Name6 (MD) 251] [Last Name (NamePattern4) 11865], M.D. [MD Number(1) 11866] Dictated By:[Last Name (NamePattern1) 1550] MEDQUIST36 D: [2132-4-17] 23:44 T: [2132-4-18] 00:43 JOB#: [Job Number 17841]	[ "038.11", "250.61", "V42.0", "250.11", "410.71", "486", "518.81", "730.26", "682.6" ]	icd9cm	[ [ [] ] ]	[ "83.44", "96.6", "83.21", "96.72", "96.04", "03.31", "38.93" ]	icd9pcs	[ [ [] ] ]									10224, 11965		9573, 10201			4094, 9506											11984, 12129								12141, 12646			1514, 1916		2023, 4075	9521, 9552																	189, 909															931, 1490	1933, 1999
32,424	124,515	33891	Discharge summary	report	Admission Date: [2152-8-29] Discharge Date: [2152-9-7] Date of Birth: [2094-12-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Adenocarcinoma of the esophagus with Barrett's esophagus. Major Surgical or Invasive Procedure: Transhiatal esophagectomy with esophagogastroduodenoscopy, pyloroplasty and placement of a feeding duodenostomy tube. History of Present Illness: The patient is a 57-year-old gentleman with a long-standing history of untreated reflux disease who was diagnosed with a long segment Barrett's on recent EGD. The patient also had 2 polyps at 30 and 34 cm, the biopsy of which showed adenocarcinoma. The patient had a clinic stage of T1a N0 before this elective surgery. Past Medical History: GERD, nephrolithiasis PSH: L thoractomy & blebectomy '[27] Social History: Former smoker-quit [2127] Alcohol [3-7] glasses/week-stopped [2152-6-4] Family History: non-contributory Physical Exam: VS: T: 98.6 HR: 87 SR BP: 110/58 Sats: 95%RA NAD, Alert RRR, S1/S2 Lungs clear bilaterally Abd soft, J tube in place Extr: warm 1+ pedal edema bilaterally Incisions: neck, abdomen(w/staple & steri-strips) and J-tube site, clean dry intact. Neuro: non-focal Pertinent Results: Pathology: ESOPHAGUS AND PROXIMAL STOMACH, LEFT GASTRIC LYMPH NODES. DIAGNOSIS: I. Esophagogastric resection (A-AK): 1. Extensive glandular dysplasia, ranging from low to high grade, involving the distal 8.4 cm of the esophagus. The dysplasia is more prominent in the proximal part. 2. Barrett's esophagus with intestinal metaplasia. 3. Normal esophagus at the proximal margin, and normal gastric corpus at the distal margin. 4. Regional lymph nodes (8): No tumor. II. Left gastric lymph nodes ([Doctor Last Name ]-AT): Multiple lymph nodes (13): No tumor. Note: There is no residual invasive carcinoma in this specimen. VIDEO OROPHARYNGEAL SWALLOW-ASPIRATION/PENETRATION: No episodes of penetration or aspiration were noted IMPRESSION: No evidence of aspiration or penetration. [2152-9-4]: Chest X-Ray: IMPRESSION: Small pleural effusions. Subsegmental atelectasis. No significant change. [2152-9-5] WBC-4.8 RBC-3.86* Hgb-11.3* Hct-33.9* Plt Ct-228 [2152-8-29] WBC-10.1# RBC-4.61 Hgb-13.5* Hct-38.6* Plt Ct-164 [2152-9-7] Glucose-126* UreaN-14 Creat-0.6 Na-135 K-4.5 Cl-100 HCO3-32 [2152-8-29] Glucose-138* UreaN-13 Creat-0.8 Na-139 K-3.9 Cl-106 HCO3-24 [2152-9-7] Calcium-8.4 Phos-2.1* Mg-2.2 Brief Hospital Course: Pt was admitted post Transhiatal esophagectomy with esophagogastroduodenoscopy, pyloroplasty and placement of a feeding duodenostomy tube. A Jp drain was placed intra-op at the cervical anastomosis. An epidural was attempted for pain control but unable to be placed. Pain was managed w/ a PCA. Post operatively pt was extubated and transferred to the ICU for ongoing resp and hemodynamic monitoring. On POD#1 pt was transferred from the ICU to the surgical floor for ongoing post-op care. He remained NPO on IVF w/ J-tube to gravity. POD#2 trophic tube feeds initiated. POD#3 NGT d/c'd. Hoarse voice noted. ENT eval'd pt w/ bedside laryngoscopy. Left cord in paramedian position. right cord normal mobility. Unable to void after foley removed. straight cath'd. POD#4 TF advancing to goal. passing flatus. Ambulating. foley replaced for failure to void, subsequently removed and was able to void. PCA d/c'd; pain control on roxicet. C/o reflux symptoms. KUB w/ normal gas/stool pattern. POD#5 Modified barium swallow to eval for aspiration showed no evidence of aspiration. He was seen by speech who recommended PO intake of thin liquids and regular solids, Pills may be taken whole with water as tolerated. POD#6 JP drain was removed. Staples were removed from the cervical incision. He was gently diuresed and discharge to home on POD#7. He will follow-up with Dr. [Last Name (STitle) ] as an outpatient. Medications on Admission: Prilosec 20', Zantac 150qhs, Tylenol prn Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:60 Tablet,Rapid Dissolve, DR(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Colace 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) mls PO twice a day. Disp:60 doses Refills:2 4. Dulcolax 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: [1-5] Tablet, Delayed Release (E.C.)s PO qd prn. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Hydromorphone 2 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:90 Tablet(s) Refills:0 6. Ativan 0.5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO once a day as needed for insomnia. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: Adenocarcinoma of the esophagus with Barrett's esophagus. GERD, nephrolithiasis PSH: Left thoractomy & blebectomy [2127] Discharge Condition: stable Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 78322] if experience: -Fever > 101 or cough -Increased shortness of breath, or cough -Chest pain -Incision develops drainage -Difficulty swallowing, diarrhea or nausea/vomiting or abdominal pain J-tube: If your feeding tube sutures become loose or break, please tape tube securely and call the office [Telephone/Fax (1) 4741]. If your feeding tube falls out, save the tube, call the office immediately [Telephone/Fax (1) 4741]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours if not in use and before and after every feeding. Follow-up visit on [9-19] your diet will be advanced to soft solids and decrease your tube feeds to 5 cans if weight stable. Take liquid tylneol for pain Followup Instructions: You have a follow up appointment with Dr. [Last Name (STitle) ]/[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4129] NP/[First Name8 (NamePattern2) 1439] [Last Name (NamePattern1) ] [MD Number(3) 78323] [Hospital Ward Name ] [Hospital Ward Name ] building [Location (un) 448] in the Chest Disease center on [First Name9 (NamePattern2) ] [9-19] at 1:00 pm. Report to the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiololgy for a Chest X-Ray 30 minutes before your appointment. Please follow-up by Otolaryngology-Dr. [Last Name (STitle) 18622] on [11-8] at 1PM ([Telephone/Fax (1) 41]). Arrive 15-20 minutes early. You will need a referral from your primary care physician before this appointment. Completed by:[2152-9-11]	[ "458.29", "478.31", "V85.1", "V13.01", "530.81", "788.20", "E878.6", "785.0", "530.85", "150.5", "997.1" ]	icd9cm	[ [ [] ] ]	[ "45.13", "40.3", "42.52", "46.39", "96.6", "31.42", "42.42" ]	icd9pcs	[ [ [] ] ]	5008, 5059	2638, 4050	380, 500	5228, 5237	1374, 2615	6216, 7033	1056, 1074		4141, 4985		5080, 5207		4076, 4118			5261, 6193								1089, 1355																							282, 342									528, 852															874, 939	955, 1040
11,138	147,854	53478+59531	Discharge summary	report+addendum	Admission Date: [2153-11-29] Discharge Date: [2153-12-11] Date of Birth: [2082-8-18] Sex: M Service: MEDICINE Allergies: Aspirin / Lipitor / Transpore Surgical / amlodipine Attending:[First Name3 (LF) 633] Chief Complaint: hip fracture Major Surgical or Invasive Procedure: hip hemiarthroplasty History of Present Illness: Mr. [Name13 (STitle) ] is a 71-year-old man with a hx of follicular lymphoma and a remote history of high-grade lymphoma, CAD, CABG, AVR on coumadin, HTN, CKD III who is transferred from [Hospital3 ] with a hip fracture. He was found to have interval progression of his lymphoma and started Rituxan-Bendamustine C1D1 [2153-11-26]. On [11-29] he sustained a mechanical fall on ice and sustained a right proximal femur fracture. He did have any prodrome of chest pain, chest tightness, shortness of breath, palpitations, lightheadedness, dizziness; he did not hit his head or have LOC. He presented to [Hospital3 ] and was transferred to [Hospital1 18] where his INR was 4.7. He received Vitamin K 5mg IV, Morphine. Patient also states that he experiences shortness of breath whenever he has his chemotherapy. On days he has it, he takes Lasix twice a day; othewise, he does not require this. He states that he has a cough for the last day but he feels the phlegm is caught in his throat. He denies orthopnea, PND, LE swelling, sick contacts, fevers, chills. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGY HISTORY: Significant for non-Hodgkin lymphoma w diffuse mixed cell histology diagnosed in [2130], status post six cycles of CHOP. Status post laparotomy in [2134] that showed that he was in remission. Relapsed in the form of abdominal LAD in [2150] causing hydronephrosis (has a ureteral stent), path showed follicular lymphoma, treated with 6 x RCVP resulting in PR, last cycle was in [12-28]. - He was found to have interval progression of his lymphoma and started Rituxan-Bendamustine C1D1 [2153-11-26]. PMH: -CAD status post CABG in [2144]. -History of aortic valve replacement with a mechanical valve in [2144]. -Hernia repair. -Correction of an undescended testis in childhood and appendectomy. -C. diff diarrhea. -S/p nephrostomy tube placement for right ureter obstruction by lymphoma. - Cavitating lesion found in left lung in [2150] on CT scan, underwent bronchoscopy after which revealed a likely a BOOP-like reaction although unclear to what (transient infection vs medication reaction). He was never required to see pulmonology in follow-up - Hypersensitivity skin reaction and pruritis secondary to increased dose of amlodipine, [2-/2153] - left urethral stricture repair [2153-7-3] - hypertension - hyperlipidemia - CKD Stage III with GFR 43 Social History: Lives with wife. Retired police officer. Denies smoking, alcohol, recreational drug usage. Family History: Father died at 89 of old age; mother died of surgical complications of stone removal; sister with unspecified cancer at shoulder. Family h/o heart disease. Physical Exam: VS: T 98.1 HR 67 bp 150/81 RR 20 SaO2 95 5L GEN: Elderly man, uncomfortable, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP slightly dry and without lesion NECK: Supple, no JVD CV: Reg rate and rhythm, mechanical click, I/VI systolic murmur, no r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi on anterior and lateral fields ABD: Soft, NT, ND, no HSM, bowel sounds present MSK: normal muscle tone and bulk EXT: right LE shortned and internally rotated with normal perfusion, no other abnormalities SKIN: No rash, warm skin NEURO: oriented x 3, normal attention, intact sensation to light touch PSYCH: appropriate Pertinent Results: EKG: Sinus rhythm. Left axis deviation. Right bundle-branch block. Consider inferior myocardial infarction, age undetermined. Since the previous tracing of [2153-7-2] the Q-T interval is shorter. ST-T wave abnormalities are less prominent . CXR: [11-30] IMPRESSION: 1. Elevated venous pressures and mild pulmonary edema. 2. Stable cardiomegaly. 3. No evidence of pneumonia. . [2153-11-30]: DIAGNOSIS: 1. Right femoral neck lesion: - [Month/Day/Year ] clot and bone fragments with features consistent with fracture; a Hematopathology Note will follow as addendum. 2. Right femoral neck: - Features consistent with fracture; a Hematopathology Note will follow as addendum. 3. Right femoral head:: - Features consistent with fracture; a Hematopathology Note will follow as addendum. HEMATOPATHOLOGY: Right femoral neck and head, hemiarthroplasty: Cellular bone marrow with no diagnostic morphologic evidence of lymphoma. See note. Note: Sections of cortical and trabecular bone and bone marrow with extensive crush artifact. Focally, trabecular bone has osteopenic features. Marrow elements have maturing trilineage hematopoiesis. No lymphoid aggregates or atypical lymphoid infiltrates are seen. Hematopathology added by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 3157]/gapa Date: [2153-12-11] . [11-30] hip: FINDINGS: The prosthetic device appears well seated without evidence of hardware-related complication. Post surgical changes in the soft tissues. . [2153-12-1] Radiology CT HEAD W/O CONTRAST IMPRESSION: 1. There is no evidence of acute intracranial hemorrhage. 2. Chronic involutional changMes with low attenuating white matter disease in the periventricular and subcortical white matter likely represents sequelae of chronic small vessel ischemic disease. 3. Bilateral lacunes in the basal ganglia. 4. MRI is more sensitive for the detection of acute infarct and should be considered in the correct clinical setting if there are no contraindications to the use of MRI. . [2153-12-2]: Sinus rhythm. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing ST segment changes in lead III are less prominent. . [2153-12-2] Radiology CT ABD & PELVIS W/O CON IMPRESSION: No focal fluid collection or evidence of large hematoma to explain hematocrit drop. Diffuse asymmetric enlargement of the right thigh relative to the left, likely representing postoperative edema with areas of intra- and inter-muscle postoperative hemorrhage; however, no large collection identified. . [2153-12-4] EKG: Sinus rhythm. Right bundle-branch block. Left anterior fascicular block. Old inferior myocardial infarction. Compared to the previous tracing no clear change. . [2153-12-5] Radiology CHEST (PORTABLE AP) IMPRESSION: No evidence of acute cardiopulmonary process. . [2153-12-6] investigation of transfusion reaction: DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [Known lastname 109953] experienced a temperature increase of 2.6 degrees F over the first 100 minutes of a leukoreduced compatible red [Known lastname ] cell transfusion. Laboratory workup revealed no evidence of hemolysis and the patient has had fevers during his hospital course that were not in the setting of transfusion. . As such and given that leukoreduction significantly reduces the incidence of febrile nonhemolytic transfusion reactions, the patient's fever is most likely due to his underlying illness and not the transfusion. No change in transfusion practice is recommended at this time in this patient . [2153-12-6] CT leg: IMPRESSION: 1. Stable-appearing right hip hemiarthroplasty. 2. Post-operative changes with edema and small post-operative seroma, as described above. 3. No definite intra- or inter- muscular hematoma. . [12-9] CXR: IMPRESSION: Right subclavian PICC line continues to have its tip in the proximal to mid superior vena cava. Status post median sternotomy with aortic valve replacement and stable postoperative cardiac and mediastinal contours. Lungs appear well inflated without evidence of focal airspace consolidation to suggest pneumonia. No pleural effusions. No evidence of pneumothorax. No evidence of pulmonary edema. . Microbiology: [2153-12-8] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2153-12-8] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-PENDING INPATIENT [2153-12-8] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-PENDING INPATIENT [2153-12-6] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-PENDING INPATIENT [2153-12-6] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-PENDING INPATIENT [2153-12-5] URINE URINE CULTURE-FINAL INPATIENT [2153-12-5] URINE URINE CULTURE-FINAL INPATIENT [2153-12-5] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-FINAL INPATIENT [2153-12-5] [Numeric Identifier 3143] CULTURE [Numeric Identifier ] Culture, Routine-FINAL INPATIENT [2153-12-2] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2153-11-29] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] . [2153-12-11] 06:00AM [Month/Day/Year 3143] WBC-4.4 RBC-2.68* Hgb-8.3* Hct-24.5* MCV-91 MCH-31.1 MCHC-34.1 RDW-14.8 Plt Ct-167 [2153-12-10] 01:24PM [Month/Day/Year 3143] Hct-25.7* [2153-12-10] 04:55AM [Month/Day/Year 3143] WBC-5.6 RBC-2.78* Hgb-8.6* Hct-25.0* MCV-90 MCH-31.0 MCHC-34.4 RDW-14.9 Plt Ct-155 [2153-12-9] 03:30PM [Month/Day/Year 3143] Hct-27.8* [2153-12-9] 02:05AM [Month/Day/Year 3143] WBC-4.4 RBC-2.77* Hgb-8.6* Hct-24.7* MCV-89 MCH-31.2 MCHC-35.0 RDW-14.6 Plt Ct-143* [2153-12-8] 06:15AM [Month/Day/Year 3143] WBC-7.2 RBC-3.00* Hgb-9.3* Hct-27.6* MCV-92 MCH-31.0 MCHC-33.7 RDW-14.9 Plt Ct-155 [2153-12-7] 07:30AM [Month/Day/Year 3143] WBC-8.8 RBC-2.93* Hgb-9.2* Hct-26.4* MCV-90 MCH-31.5 MCHC-35.0 RDW-15.0 Plt Ct-117* [2153-12-6] 10:28PM [Month/Day/Year 3143] Hct-24.9* [2153-12-6] 09:25AM [Month/Day/Year 3143] Hct-23.6* [2153-12-6] 06:33AM [Month/Day/Year 3143] WBC-9.3 RBC-2.93* Hgb-9.2* Hct-25.8* MCV-88 MCH-31.3 MCHC-35.6* RDW-14.9 Plt Ct-105* [2153-12-5] 03:02PM [Month/Day/Year 3143] Hct-28.1* [2153-12-5] 04:04AM [Month/Day/Year 3143] WBC-6.2# RBC-3.01* Hgb-9.3* Hct-28.1* MCV-93# MCH-30.8 MCHC-33.1# RDW-15.0 Plt Ct-95* [2153-12-4] 11:04PM [Month/Day/Year 3143] Hct-28.3* [2153-12-4] 03:53PM [Month/Day/Year 3143] Hct-30.2* [2153-12-4] 05:10AM [Month/Day/Year 3143] WBC-4.1 RBC-2.99* Hgb-9.5* Hct-25.7* MCV-86 MCH-31.7 MCHC-36.8* RDW-15.1 Plt Ct-78* [2153-12-3] 08:25PM [Month/Day/Year 3143] Hct-23.6* [2153-12-3] 04:00PM [Month/Day/Year 3143] Hct-25.7* [2153-12-3] 10:18AM [Month/Day/Year 3143] Hct-22.6* [2153-12-3] 03:43AM [Month/Day/Year 3143] WBC-6.2 RBC-2.88# Hgb-9.4# Hct-24.3* MCV-84 MCH-32.6* MCHC-38.6* RDW-14.9 Plt Ct-93* [2153-12-2] 11:33PM [Month/Day/Year 3143] Hct-22.1* [2153-12-2] 05:30PM [Month/Day/Year 3143] Hct-20.1# [2153-12-2] 12:35PM [Month/Day/Year 3143] WBC-9.9 RBC-1.85 Hgb-6.0* Hct-15.9* MCV-86 MCH-32.3* MCHC-37.7* RDW-15.1 Plt Ct-120* [2153-12-2] 10:49AM [Month/Day/Year 3143] WBC-8.6 RBC-1.84* Hgb-5.9* Hct-15.8* MCV-86 MCH-32.3* MCHC-37.7* RDW-15.4 Plt Ct-126* [2153-12-2] 07:25AM [Month/Day/Year 3143] WBC-9.8 RBC-2.01# Hgb-6.5# Hct-17.3# MCV-86 MCH-32.5 MCHC-37.7* RDW-15.3 Plt Ct-117* [2153-12-1] 07:52AM [Month/Day/Year 3143] WBC-10.8 RBC-2.95* Hgb-9.5* Hct-26.0* MCV-88 MCH-32.3* MCHC-36.6* RDW-14.7 Plt Ct-146* [2153-11-30] 07:50AM [Month/Day/Year 3143] WBC-7.5 RBC-3.56* Hgb-11.2* Hct-31.6* MCV-89 MCH-31.6 MCHC-35.5* RDW-14.9 Plt Ct-123* [2153-11-30] 01:20AM [Month/Day/Year 3143] WBC-12.8* RBC-3.90* Hgb-12.3* Hct-34.8* MCV-89 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-141* [2153-11-29] 06:42PM [Year/Month/Day 3143] WBC-13.6# RBC-4.09 Hgb-12.4* Hct-36.3* MCV-89 MCH-30.3 MCHC-34.1 RDW-14.9 Plt Ct-161 [2153-12-5] 04:04AM [Month/Day/Year 3143] Neuts-92.8* Lymphs-1.7* Monos-4.4 Eos-1.0 Baso-0.1 [2153-12-11] 06:00AM [Month/Day/Year 3143] Plt Ct-167 [2153-12-11] 06:00AM [Month/Day/Year 3143] PT-13.6* PTT-97.2* INR(PT)-1.3* [2153-12-10] 04:55AM [Month/Day/Year 3143] Plt Ct-155 [2153-12-10] 04:55AM [Month/Day/Year 3143] PT-12.9* PTT-76.7* INR(PT)-1.2* [2153-12-9] 11:47PM [Month/Day/Year 3143] PTT-88.6* [2153-12-9] 02:05AM [Month/Day/Year 3143] Plt Ct-143* [2153-12-9] 02:05AM [Month/Day/Year 3143] PT-13.4* PTT-55.4* INR(PT)-1.2* [2153-12-8] 06:15AM [Month/Day/Year 3143] Plt Ct-155 [2153-12-8] 06:15AM [Month/Day/Year 3143] PT-13.3* PTT-69.2* INR(PT)-1.2* [2153-12-7] 12:22PM [Month/Day/Year 3143] PTT-73.6* [2153-12-7] 07:30AM [Month/Day/Year 3143] Plt Ct-117* [2153-12-7] 07:30AM [Month/Day/Year 3143] PT-12.8* PTT-62.7* INR(PT)-1.2* [2153-12-6] 10:28PM [Month/Day/Year 3143] PT-13.5* PTT-53.4* INR(PT)-1.3* [2153-12-6] 08:17AM [Month/Day/Year 3143] PT-13.3* PTT-71.0* INR(PT)-1.2* [2153-12-6] 06:33AM [Month/Day/Year 3143] Plt Ct-105* [2153-12-6] 06:33AM [Month/Day/Year 3143] PT-13.2* PTT-60.1* INR(PT)-1.2* [2153-12-5] 11:29PM [Month/Day/Year 3143] PT-13.2* PTT-45.4* INR(PT)-1.2* [2153-12-5] 03:03PM [Month/Day/Year 3143] PTT-146.9* [2153-12-5] 04:04AM [Month/Day/Year 3143] Plt Ct-95* [2153-11-30] 07:50AM [Month/Day/Year 3143] PT-13.4* PTT-30.3 INR(PT)-1.2* [2153-11-29] 06:42PM [Year/Month/Day 3143] PT-47.2* PTT-48.7* INR(PT)-4.7* [2153-12-4] 05:10AM [Month/Day/Year 3143] Fibrino-735* [2153-12-2] 12:35PM [Month/Day/Year 3143] Fibrino-647* [2153-12-3] 03:43AM [Month/Day/Year 3143] Ret Aut-1.3 [2153-12-11] 06:00AM [Month/Day/Year 3143] Glucose-114* UreaN-25* Creat-1.3* Na-136 K-4.1 Cl-103 HCO3-25 AnGap-12 [2153-12-10] 04:55AM [Month/Day/Year 3143] Glucose-118* UreaN-25* Creat-1.3* Na-135 K-4.2 Cl-103 HCO3-25 AnGap-11 [2153-12-9] 02:05AM [Month/Day/Year 3143] Glucose-107* UreaN-26* Creat-1.4* Na-135 K-3.9 Cl-103 HCO3-25 AnGap-11 [2153-12-8] 06:15AM [Month/Day/Year 3143] Glucose-108* UreaN-24* Creat-1.4* Na-135 K-3.8 Cl-101 HCO3-24 AnGap-14 [2153-12-7] 07:30AM [Month/Day/Year 3143] Glucose-112* UreaN-22* Creat-1.4* Na-134 K-3.9 Cl-103 HCO3-24 AnGap-11 [2153-12-6] 06:33AM [Month/Day/Year 3143] Glucose-110* UreaN-20 Creat-1.4* Na-133 K-3.9 Cl-102 HCO3-25 AnGap-10 [2153-12-4] 05:10AM [Month/Day/Year 3143] Glucose-107* UreaN-27* Creat-1.6* Na-134 K-3.8 Cl-106 HCO3-21* AnGap-11 [2153-12-3] 04:00PM [Month/Day/Year 3143] Creat-1.7* Na-133 K-4.1 Cl-103 [2153-12-3] 03:43AM [Month/Day/Year 3143] Glucose-103* UreaN-33* Creat-2.1* Na-126* K-3.5 Cl-96 HCO3-23 AnGap-11 [2153-12-2] 12:35PM [Month/Day/Year 3143] Glucose-126* UreaN-31* Creat-2.3* Na-128* K-4.1 Cl-97 HCO3-23 AnGap-12 [2153-12-2] 07:25AM [Month/Day/Year 3143] Glucose-124* UreaN-27* Creat-2.3* Na-128* K-4.0 Cl-95* HCO3-22 AnGap-15 [2153-11-30] 04:54PM [Month/Day/Year 3143] Na-137 K-4.0 Cl-103 [2153-11-30] 07:50AM [Month/Day/Year 3143] Glucose-96 UreaN-28* Creat-1.7* Na-137 K-4.4 Cl-105 HCO3-25 AnGap-11 [2153-11-29] 06:42PM [Year/Month/Day 3143] Glucose-110* UreaN-33* Creat-1.7* Na-140 K-4.0 Cl-107 HCO3-24 AnGap-13 [2153-12-11] 06:00AM [Month/Day/Year 3143] ALT-23 AST-24 AlkPhos-125 TotBili-1.2 [2153-12-8] 06:15AM [Month/Day/Year 3143] ALT-20 AST-29 AlkPhos-116 TotBili-1.0 [2153-12-4] 05:10AM [Month/Day/Year 3143] LD(LDH)-169 [2153-12-3] 03:43AM [Month/Day/Year 3143] LD(LDH)-167 [2153-12-2] 11:33PM [Month/Day/Year 3143] CK(CPK)-157 [2153-12-2] 12:35PM [Month/Day/Year 3143] ALT-14 AST-22 LD(LDH)-155 CK(CPK)-150 AlkPhos-49 TotBili-0.7 [2153-12-1] 07:52AM [Month/Day/Year 3143] CK(CPK)-118 [2153-12-1] 12:22AM [Month/Day/Year 3143] CK(CPK)-167 [2153-11-30] 04:54PM [Month/Day/Year 3143] CK(CPK)-189 [2153-11-30] 07:50AM [Month/Day/Year 3143] LD(LDH)-291* [2153-11-29] 06:42PM [Year/Month/Day 3143] ALT-21 AST-27 AlkPhos-73 TotBili-0.6 [2153-11-29] 06:42PM [Year/Month/Day 3143] Lipase-278* [2153-12-2] 11:33PM [Month/Day/Year 3143] CK-MB-2 cTropnT-<0.01 [2153-12-2] 12:35PM [Month/Day/Year 3143] CK-MB-3 cTropnT-<0.01 [2153-12-1] 07:52AM [Month/Day/Year 3143] CK-MB-3 cTropnT-<0.01 [2153-12-1] 12:22AM [Month/Day/Year 3143] CK-MB-4 cTropnT-<0.01 [2153-11-30] 04:54PM [Month/Day/Year 3143] CK-MB-5 cTropnT-<0.01 [2153-12-11] 06:00AM [Month/Day/Year 3143] Calcium-7.9* Phos-3.2 Mg-2.0 [2153-12-2] 12:35PM [Month/Day/Year 3143] Albumin-2.6* Calcium-7.0* Phos-3.9 Mg-1.6 Iron-11* [2153-12-4] 05:10AM [Month/Day/Year 3143] Hapto-214* [2153-12-3] 03:43AM [Month/Day/Year 3143] Hapto-174 [2153-12-2] 12:35PM [Month/Day/Year 3143] calTIBC-178* Hapto-150 Ferritn-202 TRF-137* [2153-11-29] 06:42PM [Year/Month/Day 3143] Osmolal-300 [2153-11-30] 04:54PM [Month/Day/Year 3143] TSH-1.8 Brief Hospital Course: Mr. [Name13 (STitle) ] is a 71-year-old man with a hx of follicular lymphoma and a remote history of high-grade lymphoma, CAD, CABG, AVR on coumadin, HTN, CKD III who was transferred from [Hospital3 ] with a hip fracture. # Right proximal femoral fracture: Pt had a mechanical slip-and-fall resulting in a right femoral neck fracture on [2153-11-29]. Pt was transferred from [Hospital3 ] and had an open biopsy of right femoral neck and a right hip hemiarthroplasty (press-fit) on [2153-11-30]. Pt was controlled with IV Dilaudid (avoided metabolites with morphine in CKD). Per ortho, procedure went well and Pt is weight bearing as tolerated on R lower extremity. Was given linezolid x1 for prophylaxis. On the second day post op ([12-2]), Pt had a large hematocrit drop from 26.0 -> 17.3 (see below). Per ortho, wound looked good with obvious major bleeding. Pathology from the site returned negative for malignancy. Staples were removed on [2153-12-11] and pt will be following up in orthopedic clinic on [2153-12-25] with Dr. [Last Name (STitle) 109958]. Wound does not appear infected. Pain was controlled with oxycodone, standing tylenol, lidocaine patch. Dressing should be dry sterile dressing to wound site. PT is on DVT ppx see below. He is WBAT. . # Hct drop/hypotension/anemia: Pt was transferred to the MICU for hypotention and a large 9 point hematocrit drop as well as confusion and word finding difficulty. Most likely explanation was an acute bleed, especially given that he has been on a heparin ggt and coumadin post-op, in combination with recent Chemo txt, suppressing bone marrow production. Non-con CT of abdomen and pelvis did show bleeding through right thigh, but no large hematoma or collection that could explain the degree of Hct drop. Pt's heparin drip was stopped. Pt recently received chemotherapy 1 week prior, which may explain platelet drop but less likely to affect Hct. No sign of GI bleed. GI service was consulted, who felt that GI bleed was very unlikely and that scoping was unwarranted right now. No DIC (fibrinogen 735). Unlikely to have been acute hemolysis since LDH and haptoglobin were normal. Transfused a total of 4 units [Last Name (STitle) ] on [12-2], during which hct increased but not appropriately. Transfused 2 units [First Name9 (NamePattern2) ] [12-3], with more appropriate increases in Hct. Hapto 214, fibrinogen 735, retic 1.3% on [12-3], which was low given hct drop. Hematology was also consulted, who felt that hemolysis was unlikely. Direct coombs negative. Pt's Hct was stable at ~28 for 2 days, even after restarting his anticoagulation, initially with heparin drip, for his aortic mechanical valve (see below), and Pt was transferred back out to the floor on [12-5]. Pt had another HCT drop on [12-6], On the [Hospital1 ], his hct continued to fall and his rt thigh was very painful, so a CT was repeated of the thigh, but no bleeding was evident. Transfusion was ordered, however, the pt. had a febrile transfusion reaction and the transfusion had to be aborted. Pathology ultimately determined that this was unlikely to be a transfusion reaction and pt was continued on heparin gtt. After ensuring HCT stability, coumadin was restarted on [2153-12-10] at 7.5mg daily. Heparin should continue until INR therapeutic. Would monitor daily CBC and INR for now. Could use transfusion criteria for HCT <25, given heart disease, however given recent acute illness and ?transfusion reaction, would consider more conservative approach and transfuse for HCT drop and/or symptoms. HCT on day of discharge 24.5. . #Mechanical Aortic valve on Coumadin (INR Goal [12-21]). Patient's INR in ED 4.7 --> received Vitamin K 5mg IV x1. He was on a heparin drip after his orthopedic procedure, but this was stopped after he developed a large Hct drop (see above). His outpatient cardiologist felt that it would be fine to stop anticoagulation since this is an aortic mechanical valve until his Hct stabilizes for 24 hours. His heparin drip was restarted on [12-5], then intermittantly stopped [12-6] (see above) and then again resumed when CT did not show evidence of acute bleeding. Heparin drip continued and coumadin was added on [2153-12-10] after ensuring HCT stability. Would continue heparin gtt until INR is therapeutic. . # Fever: 101.3F on [12-5] morning. WBCs 6.2k. No focal symptoms. Repeat UCx, BCx, CXR were sent. Ortho re-evaluated wound and felt it was fine. Pt did have a pyuria on his admission UA for which empiric Levofloxacin was started, but this was stopped after his urine cultures were negative after 2 days. Pt spiked more fevers throughout [12-5] and had significant shaking chills, and vancomycin and cefepime were started empirically. His foley was also changed. Given that CXR and cx's remained negative without further fevers, these antibiotics were dc'd and pt has remained afebrile without a leukocytosis for >48hours. Ucx revealed some yeast, but foley was subsequently removed. . # Delirium/word-finding difficulty: Pt triggered for word finding difficulty [12-1] evening. Neurology was consulted, who felt his symptoms were most likely due to pain medications in the setting of hypotension and severe anemia. CT head did not show any concerning process. Neurology evaluated and recommended MRI w/ DWI to rule out stroke, however patient and family have declined the study due to his severe claustrophobia and resolution of his symptoms. Patient has returned to baseline MS per wife and remained at baseline while on the medical floor. . # Acute on chronic renal insufficiency: Baseline Cr 1.3-1.5. CKD III Cr 2.3 upon admission to MICU, likely in setting of pre-renal state from anemia/hypotension. Resolved back to 1.4 with fluids and clinical improvement overall including [Month (only) ] transfusion following hct of 17 (see above). Creatinine remained at baseline while on the medical floor. Cr 1.3 on day of DC. . #Lymphoma. Pt has follicular lymphoma and a remote history of high-grade lymphoma who was found to have interval progression and started Rituxan-Bendamustine C1D1 [2153-11-26]. Pt reports that he is due for his next cycle of chemotherapy in [Month (only) ]. Appointment scheduled, see below. #thrombocytopenia-appeared intermittent upon review of prior labs. Overall improved compared to early in admission. Likely due to recent chemo/acute illness. Improved. 167 on day of DC. . . #CAD, s/p CABG: HTN, HL, afib- unclear why on both bb and ccb, had post-op afib that resolved. Restarted BB, and uptitrated to home dose. Home diltiazem was not given during admission as pt did not require this for BP or HR control. . #FEN: --cardiac diet . #PPX: --on heparin gtt, started coumadin . access-PICC. . Communication-with patient. . Full Code HCP [Name2 (NI) ] [Name (NI) 109953] (wife) [Telephone/Fax (1) 109959] Medications on Admission: Diltiazem CR to 240 mg daily. FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth on days with chemotherapy PROPRANOLOL - 80 mg Capsule,Extended Release 24 hr - one Capsule(s) by mouth once a day WARFARIN - 10mg PO on Tuesday, Friday; 7.5mg all other days Discharge Medications: 1. propranolol 80 mg Capsule,Extended Release 24 hr Sig: One (1) Capsule,Extended Release 24 hr PO DAILY (Daily). 2. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: for PICC. 3. IV Heparin drip IV heparin drip according to guidelines for bridging therapy while on coumadin and awaiting therapeutic INR for mechanical aortic valve. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 (). 8. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for pain. 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. warfarin Warfarin 10mg tuesday and friday, 7.5mg on all other days 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO prn chemotherapy: lasix 20mg prn chemotherapy. 12. NOT TAKING Pt is on diltiazem CR 240mg at home. This medication was NOT given during admission and was not required. Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: R.hip fracture s/p hemiarthroplasty anemia fever CAD s/p CABG s/p mechanical AVR 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 for repair of a hip fracture. However, your course was complicated by significant anemia requiring an ICU stay and [Hospital1 ] transfusions. A CT of your thigh did not show any bleeding or other post-operative complication and your anemia improved with [Hospital1 ] transfusions. Your anemia was thought to be secondary to your recent chemotherapy. Your [Hospital1 ] thinners were restarted. You also developed a fever and were placed on antibiotics until your cultures and a chest-xray returned negative. . Medication changes: 1.Restart coumadin 2.start heparin while in rehab 3.start oxycodone and acetaminophen for pain 4.stop diltiazem and lasix for now 5.start medications for constipation . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: You have a follow up appointment with Dr. [Last Name (STitle) ] for your Right Hip on [2153-12-25] at 8:15 AM in the [Hospital 23] [Hospital ] Clinic Please all [Telephone/Fax (1) ] to confirm and speak with his office. Thank you. . Department: ORTHOPEDICS When: TUESDAY [2153-12-25] at 1:25 PM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2153-12-25] at 1:45 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: BMT CHAIRS & ROOMS When: MONDAY [2153-12-24] at 11:00 AM Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2153-12-24] at 11:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13863], RN [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: TUESDAY [2153-12-25] at 10:30 AM With: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 9816], RN [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Known lastname 18037] JR,[Known firstname ] B Unit No: [Numeric Identifier 18038] Admission Date: [2153-11-29] Discharge Date: [2153-12-11] Date of Birth: [2082-8-18] Sex: M Service: MEDICINE Allergies: Aspirin / Lipitor / Transpore Surgical / amlodipine Attending:[First Name3 (LF) 467] Addendum: Pt is on warfarin for CAD. He was not on asa therapy prior to admission. Given anemia and requirement for transfusions, he was not started on aspirin in addition to the coumadin therapy he is on Discharge Disposition: Extended Care Facility: [Hospital1 ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 468] MD [MD Number(2) 469] Completed by:[2153-12-11]	[ "E885.9", "593.3", "458.29", "780.62", "E935.2", "293.0", "272.4", "202.00", "285.1", "V43.3", "276.1", "584.9", "V45.81", "285.3", "287.49", "403.90", "585.3", "E878.1", "820.03", "E933.1", "427.32" ]	icd9cm	[ [ [] ] ]	[ "81.52", "77.45" ]	icd9pcs	[ [ [] ] ]	29613, 29812	17740, 24686	326, 349	26417, 26417	4412, 17717	27445, 29590	3540, 3697		24989, 26217		26304, 26396		24712, 24966			26600, 27139								3712, 4393																			1488, 2076		27159, 27422		274, 288									377, 1469									26432, 26576						2098, 3415	3431, 3524
31,133	161,127	32784	Discharge summary	report	Admission Date: [2106-5-18] Discharge Date: [2106-7-15] Date of Birth: [2032-12-19] Sex: M Service: SURGERY Allergies: Bactrim / Ace Inhibitors Attending:[First Name3 (LF) 974] Chief Complaint: Mental status change, chronic left pleural effusion Major Surgical or Invasive Procedure: [2106-5-19]: Ultrasound-guided left-sided diagnostic and therapeutic thoracentesis. [2106-5-20]: Ultrasound guided pleural pigtail catheter placement on the left. [2106-6-8]: Flexible bronchoscopy, Left thoracotomy, Decortication of left lung. History of Present Illness: 73 yo M with multiple medical issues, who is admitted in transfer from [Hospital1 ] for concerns of mental status changes and increasing ventilator dependence. He was recently discharged to rehab after being hospitalized from [2106-3-12] to [2106-4-13] following treatment of a LLL pneumonia, respiratory failure (already with tracheostomy as of [6-21]), acute renal failure for which he is now on HD 3 times a week, C. difficile colitis and malnutrition (he has been on TF's since [6-21]). Sputum cultures during his last hospitalization grew Pseudomonas and He was discharged on Ceftazidime, Linezolid, and Fluconazole, but was transitioned to Meropenem at [Hospital1 ] based on sensitivities. He was on a slow ventilator wean since he was at rehab, however over the last week he was tolerating less trach collar. He also has had progressivly worsening mental status changes, including confusion and aggitation. He has had a chronic L pleural effusion and has undergone serial thoracenteses by Dr. [Last Name (STitle) 957] over the last year. His most recent thoracentesis was on [4-6], for which the pleural fluid cytology was negative for malignant cells and cultures did not show any growth. His pulmonary history also includes a RUL lung resection for CA in [2094] at MSK, cell type unknown. He had a prolonged and complicated hospitalization in mid-[2104] that resulted in respiratory failure requiring tracheostomy. Reports from [Hospital1 ] did not note increased secretions, fevers, or chills. Past Medical History: CABG x 3 vessel [2090], RUL lobectomy [2094], Right hemicolectomy w/ primary anastomosis ([4-21]), LGIB requiring end ileostomy and colonic mucus fistula ([6-21]), trach/PEG for prolonged hospital stay ([6-21]), ileostomy takedown ([10-22]) c/b anastomotic leak requiring anastomotic resection and revision 3 days later. Percutaneous drain placed in abdominal fluid collection [2105-12-16]. Parapneumonic effusion thoracentesis [3-23] ESRD on HD M/W/F via tunneled catheter Paroxysmal atrial fibrillation Social History: Pt is married for 54 years. Has 2 grown children. Spends 3months a year in [State 108]. He lives with his wife in [Name (NI) 5936], MA. Denies ETOH since [2105-5-15], Quit Tobacco in [2091]. Family History: Non-contributory Physical Exam: On Discharge: Tcurrent 98.7 HR 75 BP 109/60 RR 20 SaO2 99% PS AAO x 2 RRR no MRG B/L Rales and Wheezes likely due to ventilatory support. Trach midline. soft, NT, ND, + BS + 1 edema Pertinent Results: [2106-5-18] (CXR): Tracheostomy tube is again noted to the midline. Two right central lines terminates in the mid and distal SVC (PIC line and subclavian line accordingly). Left Large pleural effusion appears slightly smaller than previous study. Left basilar atelectasis remains. No pneumothorax is detected. Median sternotomy wires and mediastinal clips are consistent with previous coronary artery bypass grafting. . [2106-5-18] (head CT): IMPRESSION: No acute intracranial abnormalities. Minimal amount of chronic microscopic change in small lacune versus perivascular space of the left basal ganglia. . [2106-5-18] (carotid ultrasounds): IMPRESSION: There is less than 40% stenosis within the right internal carotid artery. There is no evidence of stenosis within the left carotid artery. . [2106-5-19] (CTA chest): 1. Large left basal effusion with atelectasis of the left lower lobe and scattered patchy opacities in both lungs, likely infectious or inflammatory. Air fluid level overlying the right upper lobe posteriorly, this may be related to thoracentesis. 2. No pulmonary embolism or aortic dissection. Extensive coronary atherosclerosis is noted. 3. There is small trace of ascites noted. . [2106-5-19] (bilat lower ext. ultrasounds): IMPRESSION: No DVT in left or right lower extremity . [2106-5-19] (ECHO): The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %) with global hypokinesis. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial pericardial effusion. Compared with the prior study (images reviewed) of [2106-4-1], LV and RVEF are now significantly depressed. . Brief Hospital Course: 73 yo M with multiple medical issues, who is admitted in transfer from [Hospital1 ] for concerns of mental status changes and increasing ventilator dependence (HPI as above). Initial work-up on admission included evaluating for infectious and cardiovascular etiologies of his mental status changes. Brief course by system: Neuro: Head CT on day of admission was negative for acute process. Of note, the pt had been getting a significant amount of haldol at the rehab facility, approximately 12mg per 24hr period. The haldol was slowly weaned off and during the day he was much more alert. He has had mild deficits initially with only mild changes at the time of readmission on [5-18]. The patient had a moderate mental status that worsened somewhat with regards to attentitiveness on [6-6] but stayed stable until recently. He would wax and wane with some days walking around the ICU and other days being really lethargic and unattentive. Then on [2106-6-30] he had a marked decrease in ability to follow commands and inattentiveness. This occured with a decrease in saturation. He also had tremors of his entire body. Work-up including EEG, MRI of the brain and of the arteries, CT scan of the head, and lumbar puncture were negative except for a hypoplastic vetebral right artery which was felt to be old and neurology recommended not doing anything about it. All sedatives were withheld and he is slowly recovering his mental status. He improved significantly over the remainder of the course of his hospitalization, although it was slow progress daily. He is, at the time of discharge, appropriate and able to follow commands. He is able to converse somewhat and understands what we are telling him. Over the last week of his hospitalization, there was a lot of discussion about his plan and goals of care. It was decided between his wife, the ethics committee here in the hospital as well as the nursing team, that his surgical candidacy was remote at this time. It was therefore decided that he should go to rehab, with further follow up by the geriatrics department. This was set up for [2106-7-15]. Respiratory: Pt initially kept on ventilator CPAP+PS. this was slowly weaned and by hospital day 6 and he was tolerating trach collar. Admission CXR and chest CTA revealed his known large left pleural effusion. Thoracic surgery and interventional pulmonology (IP) were consulted. On HD2 IP performed Ultrasound-guided left-sided diagnostic and therapeutic thoracentesis. Approximately 1300cc of fluid were removed. This revealed [2097] WBC, [Numeric Identifier 18318] RBC (w/ 34polys, 35 lymphs, 23 macros; total protein 3.3, LDH 201, amylase 39, albumin 2.1). On HD3, IP then placed an Ultrasound guided pleural pigtail catheter in this effusion. Speech services fitted him with a PMV and he was able tolerate this for several hours per day. He still require being on the pressure support and he had a chronic Left pleural effusion so thoracic surgery on [2106-6-8] took him to the OR for flexible bronchoscopy, left thoracotomy and decortication of the left lung. He has a chest tube left in place and thoracic surgery and have converted it to an empeyema tube. He has since improved dramatically, although continues to require ventilatory support with PS of 8 and PEEP of 5. Cardiovascular: On admission, carotid doppler study and EKG were unremarkable with respect to causation of his symptoms. His HR was controlled with lopressor (and also initially with his Norvasc, although this was discontinued on HD6). GI: the pt was immediately restarted on goal tubefeeds but switched to Impact given that he was already on dialysis, and adequate protein supplementation was felt to be more important than a renal TF regimen. He is now at his goal Tube feeds at full strength running at 100cc/hr to give him a total of 32kcal/kg/day. His tube feeds were switched to replete with fiber because it was thought that the osmolarity in the impact was giving him uncontrolled diarrhea. This improved over the course of his hospital stay, patient was howeve, changed to replet with fiber. He Tolerated goal TF's by the last week of his hospitalization with reolution of his diarrhea. GU: Pt is a dialysis pt. Renal HD was consulted and helped manage his HD 3x/wk. He recieves HD on Monday, Wednesday and Friday. He has been stable on this regimen. Transplant was consulted for placement of AV fistula and it felt that it would better for his care to wait for him to get over his acute issues and to have him less edematous prior to placing AV fistula. He should follow up with Dr [Last Name (STitle) 816] as an outpatient. He continued to require hemodialysis while he was with us in the hospital. Heme/ID: On admission, the pt was afebrile, normal WBC. Blood cx from day of admission were negative, although his sputum grew pan-sensitive serratia. He was initially kept on his inhalational colistin, but this was d/c'ed. Endocrine: pt was kept on insulin SS per ICU routine upon admission. Fingerstick glucose was adequately controlled. Proph: Subcutaneous heparin was used for DVT proph. Bilateral lower extremity ultrasound were neg. for DVT on HD2 ([2106-5-19]). Continued on prophylaxis of SQH, PPI and boots thorughtout his hospitalization. Medications on Admission: Tylenol, Mucomyst, Norvasc 5mg daily, Colace 100mg daily, Folic Acid 1mg daily, Haloperidol 1-2mg IV tid prn, Haldol 3mg po qhs, Heparin 5000 SC tid, SSI, Atrovent nebs 6h, Levothyroxine 30mcg daily, Lopressor 37.5mg [Hospital1 ], Meropenem 500mg IV q24, Sertraline 50mg [Hospital1 ] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for fever pain. mL 6. Insulin Regular Human 100 unit/mL Solution Sig: per f/s Injection ASDIR (AS DIRECTED). 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 8. Melatonin 3 mg Tablet Sig: One (1) Tablet PO daily (). 9. Levothyroxine 300 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 14. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed. 17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Location (un) 32674] Discharge Diagnosis: 1. Respiratory distress 2. left empyema 3. Malnutrition Discharge Condition: stable on ventilatory support and dialysis Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Followup Instructions: Please follow-up with Geriatrics Department of Medicine. Appointment has been made for Monday [2106-7-26] at 3 pm. Please call to confirm appointment: [Telephone/Fax (1) 719]	[ "707.07", "V44.2", "511.8", "518.89", "427.32", "510.9", "263.9", "V46.11", "276.1", "V45.81", "V44.0", "511.9", "512.8", "585.6", "348.30", "414.00", "427.31", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.72", "34.91", "03.31", "34.04", "38.95", "96.6", "33.21", "99.10", "34.51", "39.95" ]	icd9pcs	[ [ [] ] ]	12817, 12869	5458, 10783	336, 594	12969, 13014	3221, 5435	13384, 13570	2976, 2995		11126, 12794		12890, 12948		10809, 11103			13038, 13361								3010, 3010																3024, 3202							245, 298									622, 2173															2195, 2734	2750, 2960
59,832	111,144	35754	Discharge summary	report	Admission Date: [2109-1-8] Discharge Date: [2109-2-1] Date of Birth: [2055-2-17] Sex: M Service: MEDICINE Allergies: Nortriptyline Attending:[First Name3 (LF) 2745] Chief Complaint: aspiration s/p intubation for [First Name3 (LF) ] Major Surgical or Invasive Procedure: [2109-1-8] [Month/Day/Year ] and intubation [2109-1-11] Placement of post pyloric Doppoff feeding tube [2109-1-16] Dobhoff replacement in post pyloric position [2109-1-19] Extubation [2109-1-20] Pulled Dobhoff feeding tube History of Present Illness: This is a 53 year-old male with a history of depression who was admitted to the [Hospital Unit Name 153] after [Hospital Unit Name ] complicated by aspiration and hypoxic respiratory failure. Briefly, this patient was admitted to an outside hospital initially with abdominal pain and concern for choleycystitis. He was transferred to [Hospital1 18] on [2108-12-31] for [Date Range ] as there was a presumed stone in the CBD, but no stone was seen. Therefore, he was transferred back to [Hospital1 392] and underwent a laparascopic choleycystectomy. This procedure was complicated by a very friable gallbladder and a persistent by duct leak. He was then transferred back to [Hospital1 18] for stenting. He was intubated for his procedure. During a successful stent placement he vomited and aspirated. Anesthesia performed a bronchoscopy and there was a significant quantity of bile in the RML. He was transferred to the ICU on a ventilator given concern he would develop [Doctor Last Name ]/ARDS after his severe aspiration event. His vent settings at the time of transfer were AC, Tv 600,RR 14,PEEP 8,FiO2 100%. ABG was 7.42/45/207. Review of Systems: Unobtainable at presentation Past Medical History: Depression Social History: He does not use tobacco and rarely uses alcohol. He works at [Hospital6 ] Health Center. He is recently divorced. He has two brothers from whom he is somewhat estranged. Family History: Non-contributory Physical Exam: On Presentation: ----------------- Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 37 ??????C (98.6 ??????F) HR: 93 (93 - 94) bpm BP: 94/51(62) {94/51(62) - 99/54(65)} mmHg RR: 17 (17 - 25) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 73 Inch Gen: intubated; appears comfortable HEENT: PEERL; NGT in place; intubated. Bilious fluid in NGT CV: RRR no murmurs Lungs: BS heard throughout, coarse rhonci bilaterally R>L Abd: distended, hypoactive BS; incision sites C/D/I. JP drain in place, bilious fluid; no grimace to palpation. No guarding Ext: no edema Neuro: sedated; normal tone. No clonus Pertinent Results: Admission labs: ---------------- [2109-1-8] 06:05PM BLOOD WBC-19.7* RBC-3.60* Hgb-10.8* Hct-32.5* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.4 Plt Ct-218 [2109-1-8] 06:05PM BLOOD Neuts-93.4* Lymphs-2.9* Monos-2.9 Eos-0.7 Baso-0.1 [2109-1-8] 06:05PM BLOOD PT-13.6* PTT-27.1 INR(PT)-1.2* [2109-1-8] 06:05PM BLOOD Plt Ct-218 [2109-1-8] 06:05PM BLOOD Glucose-109* UreaN-6 Creat-0.7 Na-136 K-3.4 Cl-99 HCO3-28 AnGap-12 [2109-1-8] 06:05PM BLOOD ALT-16 AST-20 LD(LDH)-332* AlkPhos-77 Amylase-94 TotBili-0.6 [2109-1-8] 06:05PM BLOOD Lipase-46 [2109-1-8] 06:05PM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0 [2109-1-8] 05:09PM BLOOD Type-ART pO2-207* pCO2-45 pH-7.42 calTCO2-30 Base XS-4 [2109-1-8] 05:09PM BLOOD Na-130* K-3.0* Cl-98* [2109-1-8] 11:11PM BLOOD Lactate-1.4 [2109-1-8] [Month/Day/Year ]: IMPRESSION: 1. Persistent bile leak from the cystic duct stump with contrast directed away from the drainage catheter. 2. Status post cholecystectomy with cholecystectomy clips and drainage catheter at the end of the cystic duct remnant. 3. On this study the tip of the endotracheal tube is near the right main stem bronchus however on radiographs from subsequent days, the tip of the endotracheal tube is appropriately positioned. [2109-1-10]: CT Abdomen and Pelvis: IMPRESSION: 1. Necrotizing pancreatitis characterized by lack of enhancement of the pancreatic head, neck and proximal body with marked peripancreatic inflammatory stranding. 2. No evidence of hematoma in the abdomen or pelvis. The previously described abnormality in Morison's pouch likely represented the surgical drain in this region. 3. Multifocal nodular opacities throughout the bilateral lung fields, near- complete consolidation of the bilateral lower lobes and small bilateral pleural effusions. These findings are suspicious for an infectious etiology and given the bibasilar consolidation, aspiration pneumonia is suspected. 4. Colonic diverticulosis without evidence of diverticulitis. [2109-1-14]: CT Torso IMPRESSION: 1. Interval worsening of diffuse patchy alveolar opacities throughout both lungs and persistent bibasilar consolidations concerning for pneumonia. Aspiration pneumonia remains a diagnostic consideration. 2. CT evidence of necrotizing pancreatitis as previously described. Although the study was not specifically tailored to assess the enhancement of the pancreas, decreased areas of enhancement in the head and body are again evident. Enlarged mesenteric lymph nodes likely reactive and related to ongoing inflammatory and/or infectious process. Markedly attenuated SMV. 3. Prominence of the left intrahepatic biliary ducts in the setting of a biliary stent, could represent obstruction, but unchanged. 4. Anasarca and increase in bilateral pleural effusions and small amount of intra-abdominal ascites. [2109-1-14] CT Head: IMPRESSION: No evidence of acute intracranial abnormalities. [2109-1-25] TTE: Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No apparent valvular vegetations identified. Mild left ventricular hypertrophy with preserved biventricular regional and global systolic function. [2109-1-28] 3:41 pm STOOL CONSISTENCY: NOT APPLICABLE FINAL REPORT [2109-1-29] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2109-1-29]): REPORTED BY PHONE TO [Initials (NamePattern4) ] [Last Name (NamePattern4) 76625] ON [2109-1-29] AT 0540. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). [2109-1-23] 10:30 am BLOOD CULTURE FINAL REPORT [2109-1-29] Blood Culture, Routine (Final [2109-1-29]): [Female First Name (un) ] ALBICANS. FINAL SENSITIVITIES. Fluconazole = Sensitive , sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060] This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [Hospital1 69] Clinical Microbiology Laboratory.. Aerobic Bottle Gram Stain (Final [2109-1-25]): REPORTED BY PHONE TO DR. [Last Name (STitle) 81313],[First Name3 (LF) ] @ 0700 ON [2109-1-25]. BUDDING YEAST. [2109-1-21] 5:09 pm CATHETER TIP-IV Source: Right IJ. FINAL REPORT [2109-1-23] WOUND CULTURE (Final [2109-1-23]): [Female First Name (un) ] ALBICANS, PRESUMPTIVE IDENTIFICATION. >15 colonies. Brief Hospital Course: This is a 53 year-old male with a history of depression transferred to the [Hospital1 18] with a persistent bile leak after laparoscopic choleycystectomy. Current active issues are treatment for line-associated fungemia, c.difficile colitis and recurrent ileus. 1) Hypoxia: The patient was intubated for [Hospital1 ] after being somewhat hypoxic during his procedure. The primary etiology of his initial respiratory failure was considered to be aspiration pneumonia/pneumonitis after having frank bile in the lung on bronchoscopy. As his hospitalization progressed he required large amounts of IV fluids for volume resuscitation in the context of vasodilatory shock. Initially, the patient was kept on AC and low volume settings given the high perceived risk of developing ARDS. His PaO2/FiO2 ratio never dropped below 100, however, and he was eventually successfully weaned to pressure support in the context of initiating diuresis. He had been advanced to minimal settings with good oxygenation and ventilation but was maintained on CPAP for [1-1] more days while his mental status resolved. On [2109-1-19] he was extubated and maintained good O2 saturations and showed no signs of hypercarbia thereafter. 2) Vasodilatory Shock: The patient was not hypotensive on his initial presentation to the [Hospital Unit Name 153] but over his first night in the unit developed severe hypotension with persistently low CVP's so that over his first two nights in the unit he required >15 L of NS and then LR in order to aim for a goal CVP of 15 and a MAP of >60. This shock was considered likely to be septic/inflammatory and due to cholangitis +/- pancreatitis. Surgery strongly recommended avoiding the pressors in the setting of known pancreatitis and these were never required except for briefly on the night of [2109-1-15] when he received norepinephrine briefly in order to get enough blood pressure to allow furosemide bolusing. His hypotension resolved and he required no further fluid boluses after [2109-1-15]. 3)Choleycystitis/Cholangitis: The patient was febrile shortly after his arrival in the ICU and given his complicated procedure and the sequelae he was placed on pipercillin-tazobactam and vancomycin for cholangitis in this heavily instrumented patient. The patient completed a 10 day course of pipercillin-tazobactam/meropenem and vancomycin for this problem. 4)Fevers/VAP: Despite being well covered for cholangitis and HAP organisms the patient remained febrile. Numerous blood and urine cultures remained negative but the patient did have growth of E. coli 2 in his sputum. After the second of these showed resistance to pipercillin-tazobactam the patient was switched to meropenem on [2109-1-15]. He defervesced slightly thereafter and he completed a 10 day course of meropenem for VAP. 5) Pancreatitis: CT scan on [2109-1-10] showed necrotizing pancreatitis. Surgery was consulted and recommended NPO status, avoiding pressors, and supportive care. The patient had a repeat scan on [2109-1-14] to rule out subdiaphragmatic abscess as he had persistent hiccups on the ventilator; this showed no interval change. Surgery recommends outpatient follow up in order to rescan his abdomen weeks in the future to look for developing phlegmon that may need eventual drainage. -Patient will need f/u with Dr. [Last Name (STitle) 1924] in surgery clinic [Telephone/Fax (1) 7508] on Tuesday, [2-12] at 9am, [Last Name (un) 469] [Location (un) 470]. He will perhaps form a pseudocyst that may potentially need drainage in the future. 6) Ileus: The patient developed a functional ileus presumably due to his pancreatitis and inflammatory stunning of his bowel. This led to persistently high NG tube outputs on low intermittent suction. By the day he was transferred from the ICU on [2109-1-22] he was only putting out a liter/day. This decreased subtsantially and his NG tube was removed, however the patient was not able to comfortably tolerate full liquids and after replacement of the NG tube on [1-31], the patient started have further bilious NG tube drainage. The patient will be discharged with a NG tube with plan for enteral feeding via J-tube. -Can remove NG tube when drainage significantly decreases and patient's nausea and vomiting improves. 7) Altered Mental Status: The patient was slow to wake up after sedation was stopped. He was extubated when he was able to regularly follow commands. He remained persistently confused with waxing and [Doctor Last Name 688] mental status but no focal findings consistent with ICU delirium. After his arrival on the floor, the patient's delirium significantly improved. 8)Nutrition: The patient was started on PPN on [2109-1-10] and then advanced to TPN on [2109-1-11]. The patient then had a post-pyloric feeding tube and was advanced to tube feeds on [2109-1-12]. Unfortunately, we had repeated issues with the patient pulling out post-pyloric feeding tubes so he was put back on TPN on [2109-1-20]. Due to the patient's fungemia, his TPN was discontinued on [1-31]. Interventional radiology placed a J-tube on [2-1]. -Initiate tube feeds and advance as tolerated. . 9) Line-associated [Female First Name (un) 564] Albicans Fungemia) The patient is on a 2 week course of IV fluconazole to be completed on [2-8]. Surveillance cultures to date had no growth. . 10) Clostridium difficile) The patient had a positive [1-28] stool cx for c.difficile. The patient was treated with IV flagyl with improvement in his symptoms. With J-tube placement on [2-1], this can be changed to oral flagyl. Full Code Medications on Admission: Medications at home: per records Cymbalta 60 mg daily . Medications on transfer from OSH: Heparin sc Flagyl 500 mg IV q8H Ambien 10 mg QHS PRN Zofran 4 mg IV q6h PRN Famotidine 20 mg [Hospital1 ] Duloxetine 60 mg QHS Hydromorphone 1-2 mg IV q4h PRN Zosyn 4.5 gm q6H Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q24H (every 24 hours) for 7 days. 3. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 12 days. 4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 5. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush. 10. Morphine 10 mg/mL Solution Sig: 1-2 mg Intravenous Q4H (every 4 hours) as needed. 11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 12. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. 13. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous three times a day: Use per sliding scale. 14. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Hypoxemic respiratory failure from aspiration Severe Sepsis Cholangitis Cystic Duct Stump Leak Ileus Vent-associated pneumonia Line-associated fungemia C. difficile colitis Delirium Discharge Condition: Vital Signs Stable Discharge Instructions: Patient is to return to the ED if he is having high fevers, confusion, symptomatic hypotension. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 1927] Date/Time:[2109-2-12] 9:00 Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2109-2-26] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2839], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2109-2-26*] 8:30	[ "293.0", "238.71", "995.92", "038.9", "997.31", "112.5", "008.45", "E878.1", "997.4", "276.4", "E878.8", "560.1", "518.81", "507.0", "576.1", "482.82", "311", "285.9", "999.31", "577.0", "785.52" ]	icd9cm	[ [ [] ] ]	[ "51.87", "33.23", "43.11", "96.04", "99.15", "38.93", "96.6", "96.72" ]	icd9pcs	[ [ [] ] ]	15975, 16057	8418, 12784	327, 575	16283, 16303	2727, 2727	16447, 16896	2071, 2089		14448, 15952		16078, 16262		14153, 14153			16327, 16424				14174, 14425				2104, 2708																			1798, 1828				233, 289									603, 1779		5595, 8395			2743, 5586				12799, 14127						1850, 1863	1879, 2055
29,851	184,844	31083	Discharge summary	report	Admission Date: [2100-8-19] Discharge Date: [2100-8-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 29767] Chief Complaint: Melena Major Surgical or Invasive Procedure: Upper endoscopy (EGD) Colonoscopy History of Present Illness: PCP: [Name Initial (NameIs) ] . [Age over 90 ] y/o male with MMP including CAD, atrial fibrillation on Coumadin, T2DM, and CHF EF 35% who presented to the ED with 2 loose bloody stools and poor appetite. Of note, he recently started taking meloxicam (Mobic) 1 week prior to presentation for OA. Pt is a poor historian so most of history obtained through records. He is a resident of the [Hospital3 ] and lives there with his wife. [Name (NI) ] normally wears a diaper as he is incontinent of urine and staff noticed melena x 2. He was sent to the [Hospital1 18] ED for further evaluation. He was seen recently by Dr. [Last Name (STitle) 73399], cardiology, at [Hospital1 18]. He recently moved to the area from [Location (un) ] so he has very few records at [Hospital1 18]. He had a recent ED visit ([2100-8-15]) s/p mechanical fall in the bathtub and was sent home with normal imaging. . Vitals upon presentation to the ED: T 98.2 HR 96 BP 144/48 RR 18 98%RA. . ED course: He was to be guaiac positive with maroon stool in vault on exam. NG lavage was performed which revealed maroon stomach contents and small amount of coffee grounds which cleared after 150 mL of NS. 2 large bore PIV were placed. He was T&S for 3 units. He was given Protonix 40 mg IV x 1. He was found to be hyperkalemic, K of 6, and was given 1 amp of D50, 10 units regular insulin, kayexelate 30 mg PO x 1, and 1 amp of bicarb. Repeat K was 5.5 and repeat HCT was 28.4. EKG did not reveal any peaked T waves. He was given Vit K 5 mg SC for an INR of 6. CXR did not reveal any acute abnormalities. He was given IVF. . ROS: Denies F/C. Denies N/V/D or abdominal pain. No CP or SOB. He denies PND, orthopnea, or worsening LE edema. He has had a rash recently that he states is not pruritic. No hematochezia or hematemesis. Past Medical History: CHF EF 35% Atrial fibrillation s/p pacemaker insertion ([2091]) and generator replacement ([2095]) s/p fall in [2100-2-18], [1-22] to CVA Dx at [University/College ], [Location (un) 73400] T2DM, Dx [2085], recent HbA1c in [4-26] was 7.8 Obesity Hyperlipidemia CAD OA Undescended testis CRI ([2100-4-20] was 44/1.7) Mild dementia s/p appendectomy s/p radical prostatectomy over 20 yrs ago s/p left TKR [2089] Colonoscopy in [2092], s/p polypectomy Social History: Recently moved from [Location (un) ] to [Hospital3 537] to live with his wife near his family. He lives with his wife at [Name (NI) ]. His daughter, [Name (NI) ], lives in [Name (NI) 745]. He quit smoking in [2057] and does not drink significant alcohol. Family History: N/C. Physical Exam: Vitals: T 98 HR 90 BP 117/91 RR 24 95%RA General: [Age over 90 ] y/o male NAD, poor historian. HEENT: NC/AT. MM dry. OP clear. NGT in place. Neck: No JVD. CV: Irregularly irregular rhythm, S1, S2 with Grade III/VI holosystolic murmur, best heard at apex. Pulm: Bibasilar crackles, otherwise CTAB, no wheezes. Abd: Soft, NT, ND with normoactive BS. Ext: No c/c/e. Skin: Warm, evidence of scattered ecchymosis, large left thigh. Small erythematous papules on B/L UE. Neuro: A/O x 1. Confused. Good ROM and strength in all 4 extremities. No focal deficits. Pertinent Results: TTE [2097] Mildly increased LV size with normal wall thickness and an ejection fraction of 35%. There was a moderately enlarged left atrium. There was evidence of mild-to-moderate mitral regurgitation, severe tricuspid regurgitation and a moderately dilated ascending aorta measuring 4.1 cm. . [2100-7-21]: Pacemaker interrogation was performed of the patient's St. [Male First Name (un) 923] Identity SR model 5172 single chamber pacemaker (serial #[Serial Number 73401]). His ventricular lead is a St. [Male First Name (un) 923] model 1346T with serial number [Serial Number 73402]. The device was implanted on [2096-12-6]. Underlying rhythm is atrial fibrillation with a well-controlled ventricular response rate. He is paced 48% of the time. Heart rate histogram is normal. The ventricular lead has an impedance of 390 ohms, a sensed R-wave of 3.5 millivolts and a threshold of 1.25 volts at 0.4 milliseconds. Minor programming changes today were made to the device. He remains programmed VVIR at 60 beats per minute. . CXR [2100-8-19] No acute cardiopulmonary process. Moderate cardiomegaly. Calcified granuloma of the left upper lobe. . EKG on admission: Atrial fibrillation, RBBB, no peaked T waves, no acute ST changes, demand paced. Brief Hospital Course: [Age over 90 ] y/o male with MMP including CAD, atrial fibrillation on Coumadin, T2DM, and CHF EF 35% who presented to the ED with 2 loose bloody stools and poor appetite. He was intially admitted to the MICU for closer monitoring given UGIB. . # UGIB The patient was admitted after two episodes of melena. He had further episodes of melena in the MICU in the setting of receiving Kayexelate for hyperkalemia. An NG lavage in the ED was positive for coffee grounds. His INR was also supratherapeutic. GI was consulted given need for EGD. He was managed initially on a Protonix gtt until the pt's INR decreased. An EGD was performed on [2100-8-20] which revealed hypertrophic gastric mucosa, likely source of his bleeding. He later had a colonoscopy on [2100-8-24]; findings included grade I internal hemorrhoids and sigmoid diverticulosis with no areas of active bleeing. He was transitioned to a PPI PO BID. His HCT was monitored and remained stable after his MICU course. The etiology for his UGIB was most likely the above EGD findings in the setting of new NSAID use and supratherapeutic INR. . # Atrial fibrillation His BP meds (beta blocker, lisinopril and digoxin) were initially held in the setting of a UGIB. He was then started on low dose BB with gradual titration up for HR control and his digoxin was also restarted. His metoprolol remains at 50 mg daily, decreased from his previous dose of 100 mg daily. This can be increased as needed for BP and HR control following discharge. Lisinopril was also restarted. His Coumadin was initially held [1-22] to UGIB; in light of upper extremity DVT, ongoing Afib, and no active bleeding on EGD/colonoscopy, he will be restarted on coumadin with Lovenox bridge with goal INR 1.8-2. . # Supratherapeutic INR He was given Vitamin K and his INR gradually decreased to normal (1.1). He will be restarted on Coumadin as above. . # Hyperkalemia This was most likely in the setting of aldactone and Mobic. Resolved with hydration, Kayexalate, improvement in renal function as above. . # T2DM He was covered with a HISS while NPO and then once eating restarted his NPH and continued HISS. His glucoses were mildly elevated (150-250) here. He will be discharged on his home dose of NPH with sliding scale prn; this can be adjusted as needed at rehab. . # CHF EF 35% His BP meds were initially held on admission [1-22] to UGIB and gradually restarted. There was no evidence of volume overload on admission; however, he was given IVF while NPO and became volume overload without any evidence of respiratory compromise. He was diuresed gently for one day with good response. He remains on his home dose of spironolactone and an increased dose of Lasix (40 once daily). He is on beta blocker and lisinopril. Lisinopril is currently at decreased dose (10mg daily vs home dose of 20mg daily); this can be adjusted as needed. . # CRI Baseline Cr of ~ 1.7 per records; improved during admission to creatinine 1-1.1. . # Code - DNR/DNI Medications on Admission: Warfarin 4 mg PO QHS Spironolactone 25 mg PO BID Metoprolol 100 mg PO daily Digoxin 0.125 mg PO daily (Sun, Tues, Thurs, Sat) Lisinipril 20 mg PO daily Lasix 20 mg PO daily Meloxicam 7.5 mg PO daily NPH 18 units QAM Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK ([Doctor First Name ],TU,TH,SA). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<95. 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<95. 4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eighteen (18) units Subcutaneous once a day: By subcutaneous injection. In the morning. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Goal INR 1.8 - 2.2.;. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP <95. 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: please hold for SBP <90 or HR<55. 9. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous twice a day: Please D/C once INR is 1.8. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 5 days. 11. Insulin Humalog insulin per sliding scale Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: GI bleed Upper extremity deep venous thrombosis Atrial fibrillation Congestive heart failure Diabetes Discharge Condition: Stable Discharge Instructions: You were admitted after having bloody stools and bleeding from your stomach. We admitted you to the intensive care unit for close monitoring. You had an upper endoscopy (looking at your stomach with a camera) and colonoscopy. We temporarily stopped your blood thinning medication (Coumadin). . Please return to the hospital or call your doctor if you have any further blood in your stools, if you vomit blood, if you have abdominal pain, dizziness, or any new symptoms that you are concerned about. . Please keep all of your appointments with your doctors. Please continue to take all of your medications. We are restarting coumadin at a lower dose (2 mg daily). Until your INR (coumadin levels) are high enough, we will give you Lovenox injections twice daily. We have also temporarily lowered your Metoprolol dose; this can be increased in the future if needed for high blood pressure. We have also decreased your dose of lisinopril. You should also continue to take Cipro for 5 more days. Omeprazole is a new medication for your stomach, please take as directed. Followup Instructions: You will be followed at [Hospital3 537] by [Hospital3 4262] Group; they will come to see you once you are back there. You do not need to call to set this up. . You have the following upcoming appointments at [Hospital1 18]: DEVICE CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2101-1-24] 2:30 DR. [First Name11 (Name Pattern1) 275] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone:[Telephone/Fax (1) 2934] Date/Time:[2101-1-24] 3:00 . At rehab, please check hematocrit twice weekly for two weeks and INR daily for 5 days (and as needed thereafter). Coumadin adjustment as needed by the physicians at rehab. Please D/C Lovenox when INR is 1.8. Insulin adjustment as needed by the physicians at rehab.	[ "562.10", "250.00", "414.01", "715.90", "585.9", "V58.61", "272.4", "428.0", "788.30", "535.21", "V45.01", "427.31", "276.7", "453.8", "455.0" ]	icd9cm	[ [ [] ] ]	[ "45.23", "45.13" ]	icd9pcs	[ [ [] ] ]	9279, 9350	4896, 7898	270, 306	9496, 9505	3597, 4777	10629, 11388	2997, 3003		8165, 9256		9371, 9475		7924, 8142			9529, 10606								3018, 3578																							224, 232									334, 2169							4791, 4873								2191, 2685	2701, 2981
19,396	101,325	13884	Discharge summary	report	Admission Date: [2149-10-21] Discharge Date: [2149-10-27] Date of Birth: [2085-5-16] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1283] Chief Complaint: Chest Discomfort Major Surgical or Invasive Procedure: s/p Redo-Sternotomy/Coronary Artery Bypass Graft x 2 on [2149-10-21] History of Present Illness: Mr. [Known lastname ] is a 64 yo male with significant cardiac past medical history who was experiencing chest discomfort with minimal activity. He had a positive exercise tolerance test and was referred for a cardiac cath. On cath he had a patent LIMA but occluded native and vein graft vessels. He was then referred for redo bypass surgery. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 [2138] Hypercholesterolemia Hypertension Diabetes Mellitus Factor VII Deficiency s/p Colectomy Social History: Live alone Quit 15 yrs ago after 3ppd x 30years, Occ. Pipe 1 drink ETOH/day Family History: Mother and Father both with CAD Physical Exam: General: NAD, Lying supine after cath HEENT: EOMI, PERRL, NC/AT Skin: Well healed MSI, L GSV harvest ankle to thigh Heart: RRR, +S1S2 -c/r/m/g Lungs: CTAB -w/r/r Abd: Soft NT/ND, +BS Ext: cool, decreased pp, -varicosisties Neuro: A&O x 3, non-focal, MAE Pertinent Results: [2149-10-26] 06:15AM BLOOD WBC-5.3 RBC-3.17* Hgb-10.0* Hct-27.0* MCV-85 MCH-31.4 MCHC-36.8* RDW-13.6 Plt Ct-233 [2149-10-26] 06:15AM BLOOD UreaN-19 Creat-0.9 K-4.2 [2149-10-24] 01:25PM BLOOD Glucose-119* UreaN-25* Creat-1.0 Na-138 K-3.9 Cl-103 HCO3-26 AnGap-13 [2149-10-21] 12:28PM BLOOD PT-17.3* PTT-31.5 INR(PT)-2.1 [2149-10-24] 11:41AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2149-10-24] 11:41AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Brief Hospital Course: Patient was a same day admit and on [2149-10-21] he was brought directly to the operating room where he underwent a redo coronary artery bypass graft x 2. Please see op note for surgical details. Pt. tolerated the procedure well and was transferred to the CSRU in stable condition receiving Neo-Synephrine and Propofol. Later on op day pt was weaned from mechanical ventilation and sedation and was extubated. He was neurologically intact. By post-operative day one he was weaned from any Inotropes and diuretics and b-blockers were initiated per protocol. His chest tubes were removed on post op day 1 and epicardial pacing wires on day 2. He was transferred to the telemetry floor on post-op day 1. Patient had no post op complications and made a rather swift recovery. He cleared level 5 on post op day 3. He did however have a slight temperature and remained in the hospital until post op day six when he was discharged home with vna services and the appropriate follow-up appointments. Medications on Admission: Metformin, Glipizide, Lopid, Lipitor, ASA, Atenolol, Lisinprol Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary Artery Disease s/p Redo-Sternotomy/Coronary Artery Bypass Graft x 2 on [2149-10-21] Hypercholesterolemia Hypertension Diabetes Mellitus Factor VII Deficiency s/p Coronary Artery Bypass Graft x 3 [2138] Discharge Condition: good Discharge Instructions: Can take shower. Wash in incisions with warm water and gentle soap. Gently pat dry. Do no bath or swim. Do not apply lotions, creams, ointments, or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you notice any sternal drainage or fever greater than 101 please contact office. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 16004] in [11-17] weeks Dr. [Last Name (STitle) ] in [12-19] weeks Completed by:[2149-10-27]	[ "414.04", "V17.3", "401.9", "414.01", "250.00", "272.4", "780.6", "286.3", "424.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "88.72", "36.12" ]	icd9pcs	[ [ [] ] ]	4207, 4262	1935, 2931	297, 371	4524, 4530	1361, 1912		1039, 1072		3044, 4184		4283, 4503		2957, 3021			4554, 4884			4935, 5116					1087, 1342																							241, 259									399, 747															769, 930	946, 1023
12,412	138,544	50960	Discharge summary	report	Admission Date: [2176-1-13] Discharge Date: [2176-1-19] Date of Birth: [2124-9-13] Sex: M Service: Medicine, [Hospital1 ] Firm HISTORY OF PRESENT ILLNESS: This is a 51-year-old gentleman who is known to our service from his admission in late [Month (only) 1096] and early [Month (only) 404] with diabetic dermopathy, Child class C cirrhosis complicated by hepatic encephalopathy, chronic renal failure, gastroparesis, and type 1 diabetes mellitus with recently malfunctioning insulin pump. The patient was admitted on [2176-1-13] and transferred to the Medical Intensive Care Unit in diabetic ketoacidosis; likely secondary to spontaneous bacterial peritonitis (ascitic fluid with 1600 white blood cells and 93% polymorphonuclear leukocytes on [2176-1-14]). He has also had hepatic encephalopathy. He is currently receiving ceftriaxone for empiric treatment of spontaneous bacterial peritonitis (culture negative) as well as vancomycin for an alpha-streptococcal bacteremia noted on culture on [2176-1-13]. His course has also been complicated by pancytopenia (nadir white blood cell count of 2, hematocrit of 22.8, and a platelet count of 70 on [1-15]) for which Hematology has been consulted. He is status post transfusion of 2 units of packed red blood cells with a resultant increase in his hematocrit to 30.5. Currently, Mr. [Known lastname 19672] notes the sensation of increased abdominal girth and pain at the site of his previous thoracentesis. He is breathing well, and he has decreased weeping from his lower extremity bullae. He has been off an insulin drip since [2176-1-14] with resolved hyperglycemia and anion gap. PAST MEDICAL HISTORY: 1. Cirrhosis secondary to hepatitis C; complicated by a grade 2 esophageal varices, portal hypertension with ascites complicated by spontaneous bacterial peritonitis, anasarca, and hepatic encephalopathy. 2. Celiac disease. 3. Diastolic cardiac dysfunction. 4. Type 1 diabetes mellitus; complicated by gastroparesis. 5. Chronic renal failure. 6. Osteoporosis. 7. Diverticulitis; status post hemicolectomy. MEDICATIONS ON TRANSFER: 1. Ceftriaxone 1 g intravenously q.24h. (day number 2). 2. Vancomycin by level (day number 3). 3. Metronidazole 500 mg p.o. twice per day (day number 10); for encephalopathy. 4. NPH insulin 30 units q.a.m. and 20 units q.p.m. 5. Regular insulin sliding-scale. 6. Mupirocin cream. 7. Betamethasone cream. 8. Sarna lotion. 9. Metoclopramide lotion 10 mg four times per day. 10. Furosemide 40 mg intravenously twice per day. 11. Spironolactone 100 mg p.o. q.a.m. 12. Lactulose 30 cc four times per day and q.4h. as needed (titrate to four to five bowel movements per day). 13. Pantoprazole 40 mg p.o. once per day. 14. Neutra-Phos. 15. Multivitamin one tablet p.o. every day. 16. Thiamine. 17. Folate. 18. Oxycodone as needed. 19. Docusate 20. Ondansetron as needed. 21. Guaifenesin as needed. 22. Cepacol as needed. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 97.3, heart rate was 88, blood pressure was 106/74, and respiratory rate was 18. Head, eyes, ears, nose, and throat examination revealed sclerae were anicteric. The oral mucosa were moist. The lungs were clear to auscultation bilaterally. Heart was regular in rate and rhythm. Normal first heart sounds and second heart sounds. A 2/6 systolic ejection murmur over the right upper sternal border. The abdomen was tense and moderately distended. Positive bowel sounds. Tender in the right lower quadrant at the site of previous paracentesis. Umbilical hernia unchanged. Extremity examination revealed 1-cm bilateral pitting edema to the waist. Sterile/dry dressings over the shins bilaterally. Neurologic examination revealed alert and appropriately interactive; attentive to questions. No asterixis. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count 2.4, hematocrit was 30.5, and platelets were 73. Sodium was 135, potassium was 4.1, chloride was 107, bicarbonate was 18, blood urea nitrogen was 73, creatinine was 1.6, and blood glucose was 57, and anion gap was 10. Calcium was 8.2, phosphate was 3.9, and magnesium was 2.1. Vancomycin level was 16.2. Cryoglobulin was pending. Rheumatic factor was negative. Blood cultures from [1-15] no growth to date from 4/4 bottles; [1-14] no growth to date from 4/4 bottles. Nasal swab culture from [1-15] was pending. Methicillin-resistant Staphylococcus aureus was pending. Blood culture from [1-13] grew 2/2 bottles of alpha hemolytic streptococcus. Ascites fluid revealed negative culture, negative acid-fast bacillus, negative fungal culture. Urine culture from [1-14] was negative. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. INFECTIOUS DISEASE ISSUES: The patient continued to receive empiric treatment for spontaneous bacterial peritonitis with ceftriaxone. His vancomycin was discontinued; per Infectious Disease consultation recommendations as the ceftriaxone was felt to be adequate coverage for the alpha-streptococcal bacteremia. The Infectious Disease Service also recommended increasing the dose of ceftriaxone to 2 g intravenously once per day; completion of a two weeks total of ceftriaxone, and discontinuation of the patient's metronidazole. It was recommended that the speciation of the alpha-streptococcal be followed, as the presence of S. Sanguis would indicate recurrence of an infection with this organism and could represent endovascular infection. In this case, the Infectious Disease Service recommended a transesophageal echocardiogram evaluate for the presence of endocarditis. In the case of a different type of alpha-streptococcus, the Infectious Disease Service recommended that the patient receive an outpatient colonoscopy to evaluate for a colonic lesion or source of bacteremia. At the time of discharge, the speciation of the streptococcus had yet to be determined. 2. GASTROINTESTINAL ISSUES: The patient's symptoms and physical examination indicated worsening ascites. On [1-16], the patient was converted from intravenous furosemide to oral furosemide at a dose of 40 mg p.o. once per day. On the afternoon of [1-17], a therapeutic paracentesis was attempted. This procedure was unsuccessful because the needles in the thoracentesis tray were insufficiently long to access the patient's peritoneal fluid despite multiple attempts and angles. The patient was subsequently scheduled for an ultrasound-guided therapeutic paracentesis, and 3 liters of fluid were removed from his peritoneum. On [1-18], the patient's dose of furosemide was increased to 80 mg p.o. once per day. This was the dose on which the patient was discharged. 3. ENDOCRINE ISSUES: At the time of transfer out of the Medical Intensive Care Unit, the patient had well controlled blood sugars. The patient's endocrinologist (Dr. [Last Name (STitle) 16258] followed the patient during this admission, and the patient's insulin regimen was adjusted according to Dr.[Name (NI) 16259] recommendations. As of [1-16], the patient was on a regimen of 34 units of NPH insulin at breakfast and dinner as well as 10 units of Humalog at breakfast, lunch, and dinner. On [1-18], this regimen was changed to 32 units of NPH insulin at breakfast and dinner with the same doses of Humalog. The patient was discharged on this regimen of NPH and Humalog insulin. 4. NEUROLOGIC ISSUES: The patient notably had recent and recurrent hepatic encephalopathy. He was continued on lactulose titrated to four to five stools per day. The patient maintained a nonfluctuating level of consciousness and good attention throughout the remainder of his admission after transfer from the Medical Intensive Care Unit. He did not manifest asterixis on examination. 5. HEMATOLOGIC ISSUES: As aforementioned, the patient had pancytopenia. The Hematology Service was consulted. In their impression, the patient's pancytopenia was chronic in nature and could entirely be explained by hypersplenism. They did not make any diagnostic or therapeutic recommendations. 6. LINE ISSUES: Prior to discharge on [1-19], the patient received placement of a peripherally inserted central catheter line for intravenous ceftriaxone to complete his course. This procedure was successful, and the patient was discharged with plans to complete 14 days of ceftriaxone. He was to resume taking ciprofloxacin for prophylaxis after the ceftriaxone was completed. He was also to receive visiting nurse twice per day for dressing changes on his lower extremities. DISCHARGE DIAGNOSES: 1. Status post diabetic ketoacidosis. 2. Spontaneous bacterial peritonitis. 3. Status post hepatic encephalopathy. 4. Child class C cirrhosis secondary to hepatitis C virus infection; complicated by portal hypertension with esophageal varices and hypersplenism. 5. Chronic renal failure. 6. Type 1 diabetes complicated by autonomic neuropathy with gastroparesis and diabetic dermopathy causing lower extremity bullae. 7. Pancytopenia secondary to hypersplenism. 8. Celiac disease. 9. Left ventricular diastolic dysfunction. 10. Osteoporosis. 11. Diverticulitis; status post hemicolectomy. 12. Alpha-streptococcal bacteremia. CONDITION AT DISCHARGE: Condition on discharge was fair. DISCHARGE STATUS: Discharge status was to home with [Hospital6 3429] and followup with Dr. [Last Name (STitle) 497] and Dr. [Last Name (STitle) 16258]. MEDICATIONS ON DISCHARGE: 1. Ceftriaxone 2 g intravenously once per day. 2. NPH insulin 32 units subcutaneously at breakfast and dinner. 3. Humalog insulin 10 units with [Last Name (STitle) 16429]. 4. Furosemide 80 mg p.o. every day. 5. Spironolactone 100 mg p.o. once per day. 6. Lactulose 30 cc p.o. four times per day and q.4h. as needed. 7. Mupirocin cream. 8. Betamethasone cream. 9. Sarna lotion. 10. Metoclopramide 10 mg four times per day. 11. Pantoprazole 40 mg p.o. once per day. 12. Multivitamin one tablet p.o. once per day. 13. Folate. 14. Thiamine. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7619] Dictated By:[Last Name (NamePattern1) 5596] MEDQUIST36 D: [2176-5-14] 18:46 T: [2176-5-18] 04:45 JOB#: [Job Number 105898]	[ "790.7", "567.2", "428.0", "284.8", "584.9", "585", "070.41", "250.13", "789.5" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]								8764, 9420				9662, 10487																							4887, 8742				9435, 9635																	189, 1706														2168, 4853	1728, 2142
9,592	174,215	45970	Discharge summary	report	Admission Date: [2152-11-30] Discharge Date: [2152-12-1] Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 5893] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] year old female discharged [2152-11-28] presenting to ED with shortness of breath, chest congestion and hypoxia starting at 7:30 pm on [2152-11-30]. She was hospitalized from [Date range (1) 97882] for altered mental status in the setting of a Proteus UTI and hyponatremia. She was felt to be volume deplete and was volume expanded. The discharge summary notes difficulty with fluid balance from presumed age-associated aortic-sclerosis or CHF. The patient developed anasarca, but not thought to be intravascularly volume overloaded. The team uptitrated her enalapril to improve afterload reduction in an attempt to improve forward flow. The patient also required escalation of antibiotics from ciprofloxacin to vancomycin/meropenem before she clinically improved (mental status and leukocytosis). At discharge, she was transitioned back to ciprofloxacin to complete a 14 day course. On the day of admission, she had acute onset shortness of breath with desaturation to 83% on 2L NC, RR 40. She was given Lasix 40 mg po, Morphine 1 mg sq, and one duoneb. Following the neb, her oxygenation improved to 90-91% on 4L NC, but proceeded to drop to 70-80%. When EMS arrived she was satting 60% on 4L and they placed her on a NRB with nasal trumpet airway. Upon arrival in the ED, vitals were 100.2 102/70 80 26 92% NRB. BP in ED 90-106/44-71. Her lowest O2 was 86% on NRB, but she mostly was 100%. She was given 40 mg IV Lasix with 200+ cc UOP at 1 hour and improvement in her tachypnea to a RR of 24. She was given a dose of levofloxacin for presumed pneumonia. At transfer, her vitals were 73 105/50 24 98% NRB. Upon arrival to the [Hospital Unit Name 153], patient was in distress. HR in 140s, SBP 80, RR 40, O2 86% NRB. ECG with atrial fibrillation, spontaneously converted into NSR and BP improved to 90s. Nephew/HCP contact, does not want aggressive/invasive measures, but wants attempt at stabilization. Past Medical History: 1. Hypertension. 2. Arthritis, gout 3. Hypothyroidism (Hashimoto's) and thyroid nodule. 4. Waldenstrom's globulinemia. 5. Anemia, with a work-up at [Hospital6 ] Center that revealed a negative colonoscopy, and the patient was started on iron sulfate three times a day 6. Thrombocytopenia 7. s/p fall [5-2], subdural hematoma 8. s/p [2153], colles fracture 9. s/p cataract surgery [53]. hip fxr s/p ORIF [9-/2149] Social History: Currently was staying at [Hospital ] nursing home, nephew is HCP. Family History: NC Physical Exam: VS: 97.7 75 88/66 97% on 100% cool neb Gen: comfortable, responds to name and answers questions appropriately, difficult to understand, follows commands HEENT: MM dry, PERRL Neck: JVP not seen (pt at 90 deg angle and slouched to side) Car: Regular, distant, difficult to hear due to very loud lung sounds, III/VI SM c/w AS Resp: Coarse ronchi bilaterally with insp and exp wheeze throughout, decreased at bases bilaterally Abd: s/nt/nd/nabs Ext: 2+ pitting edema to knees, symmetric Skin: bruising and skin tears on arms/legs Neuro: unable to cooperate with exam, moves extremities, responds to name, difficult to understand. Pertinent Results: [2152-11-30] 10:30PM GLUCOSE-143* UREA N-53* CREAT-1.3* SODIUM-142 POTASSIUM-5.4* CHLORIDE-111* TOTAL CO2-18* ANION GAP-18 [2152-11-30] 10:30PM CK(CPK)-40 [2152-11-30] 10:30PM CK-MB-NotDone cTropnT-0.05* proBNP-GREATER TH [2152-11-30] 10:30PM WBC-22.3* RBC-5.13 HGB-15.1 HCT-46.4 MCV-90 MCH-29.3 MCHC-32.5 RDW-14.3 [2152-11-30] 10:30PM NEUTS-94* BANDS-0 LYMPHS-3* MONOS-0 EOS-1 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [2152-11-30] 10:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [2152-11-30] 10:30PM URINE RBC-[10-19]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2152-11-30] 10:43PM LACTATE-2.6* Studies: CXR: Findings compatible with moderate congestive heart failure and bilateral pleural effusions, right greater than left. Bibasilar opacities likely represent atelectasis; however, developing infection or aspiration cannot be completely excluded. ECG: -Initial: NSR at 77 bpm, LAD/LAFB, no ischemic changes -[Hospital Unit Name 153] arrival: AF wtih RVR at 144 bmp, rate related ST cahnges in I, aVL, V5/V6 Brief Hospital Course: [Age over 90 ] year old female with a history of HTN/Waldenstrom macroglobulinemia presenting with respiratory distress and hypoxia now deceased due to respiratory failure secondary to congestive heart failure and volume overload. The patient was admitted with hypoxia from a nursing home. She had evidence of volume overload by CXR and a BNP > 70,000. She had a recent hospital admission for a UTI and was volume resusitated during the stay and was volume overload on discharge. She has a history of heart failure so presentation was consistent with an acute heart failure exacerbation. Given her recent hospitalization requiring broad spectrum antibiotics for response she was treated with vancomycin and meropenem initially. She was DNR/DNI on admission and was placed on a 100% NR in the ED which was continued in the ICU. The patient??????s respiratory status has continued to worsen over the course of her admission. She was continued on the nonrebreather at 100% as her family did not want more invasive measures taken. As she continued to due poorly and did not respond to lasix for gentle diuresis, further family discussion in the afternoon resulted in the patient being changed to CMO. Her antibiotics were stopped and a morphine drip was started for comfort. The patient was pronounced dead at 2120. Her nephew (health care proxy), Mr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 97857]), was called and informed of her death at 2135. The ICU covering fellow, Dr. [Last Name (STitle) ], was called and informed of her death and the attending of record, Dr. [Last Name (STitle) ], was also informed. As she had been admitted less then 24 hours ago the medical examiner??????s office was called and they waived the autopsy. Mr [Name13 (STitle) ] was asked if the family wanted an autopsy which he declined. Her cause of death was reported as respiratory failure secondary to congestive heart failure and volume overload. Medications on Admission: Enalapril 5 mg in am 2.5 mg qhs Ciprofloxacin 500 mg tab one tab daily (last dose due [2152-12-9]) MVI daily Calcium carbonate 500 mg po three times dailyl Vitamin D3 800 mg daily Senna [Hospital1 ]:prn Colace 100 mg [Hospital1 ] Metoprolol 12.5 mg po bid Acetaminophen prn Levothyroxine 137 mcg daily Discharge Disposition: Expired Discharge Diagnosis: Primary - Respiratory failure Congestive heart failure Secondary - Hypothyroidism Atrial fibrillation Discharge Condition: Expired Followup Instructions: None Completed by:[2152-12-1]	[ "424.1", "518.81", "244.9", "V66.7", "401.9", "428.0", "276.2", "273.3", "427.31", "276.7", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6971, 6980	4598, 6607	237, 244	7127, 7137	3449, 4575	7160, 7196	2783, 2787				7001, 7106		6633, 6948											2802, 3430																							177, 199									272, 2223															2245, 2679	2695, 2767
11,269	163,226	3394	Discharge summary	report	Admission Date: [2196-5-2] Discharge Date: [2196-5-7] Date of Birth: [2149-5-24] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old male with a history of HIV/AIDS, last CD4 count in [2194-12-9] of 34 with a viral load greater than 100,000, who presented to an outside hospital with a complaint of shortness of breath and fatigue. The patient was feeling relatively well until one week prior to his presentation when he had dyspnea on exertion and increasing shortness of breath. He was evaluated at [Hospital3 417] Hospital and started on treatment for suspected pneumonia. Of note, the patient has had a slight cough for one week with production of clear sputum, but he denies any fevers. During this outside hospitalization, the patient experienced sharp, burning chest pain radiating to the back which was constant in nature. A chest x-ray at the time demonstrated a left lower lobe pneumonia, and he was started on levofloxacin, ceftriaxone, and azithromycin. A chest CT scan and transthoracic echocardiogram demonstrated a large pericardial effusion with tamponade physiology. The patient was transferred to [Hospital1 69] for intervention. Upon arrival, the patient had a temperature of 100.0, heart rate 100, blood pressure 130/90, respiratory rate 23, and oxygen saturation of 98% on room air. A pulsus paradoxus of 20 mm Hg was noted. Also significant on physical exam was an elevated JV distention and crackles bilaterally. Electrocardiogram on presentation demonstrated a sinus tachycardia with no electrical alternans or ST-T wave changes. The patient was taken for pericardiocentesis with removal of 900 cc of bloody pericardial fluid, and resolution of his chest pain and of the pulsus paradoxus. Repeat transthoracic echocardiogram demonstrated no tamponade, and the patient was transported to the CCU for observation. PAST MEDICAL HISTORY: 1. HIV diagnosed in [2181]. Studies in [2195-7-9] noted CD4 34, viral load greater than 100,000. 2. No history of opportunistic infections other than thrush. 3. Hypertension. 4. Acute renal failure with glomerulonephritis, proteinuria, and hematuria. ALLERGIES: Erythromycin causes eye swelling. MEDICATIONS: 1. Dapsone 100 mg po q day. 2. Univasc 15 mg po q day. 3. Hydrochlorothiazide 12.5 mg po q day. 4. Atenolol 100 mg po q day. 5. Trizivir 1 mg po bid. 6. Biaxin 500 mg po q day. 7. Mycelex 10 mg po tid. PHYSICAL EXAMINATION: On physical exam, the patient was afebrile with a temperature of 99.1, heart rate 110, blood pressure 145/95, respiratory rate 28, and oxygen saturation 93% on room air. In general, the patient is a thin, pleasant male in no apparent distress. Oropharynx was clear with no evidence of thrush. Lungs had decreased breath sounds on the left base with egophony. Cardiovascular examination revealed tachycardia with a normal S1, S2 and no murmurs or rubs. Jugular venous distention was elevated at 10 cm. Abdomen was benign. Extremities had no edema. LABORATORIES: Laboratory studies was significant for a white blood cell count of 1.3 with 65% neutrophils and an absolute neutrophil count of 720. Hematocrit was 29.0, and platelets were 100. The MCV was 109. Panel 7 was significant for a BUN of 23, and creatinine of 1.3. Magnesium was low at 1.3. Albumin was 2.0. Cardiac catheterization demonstrated a cardiac output of 4.32 and cardiac index of 2.44. These rose respectively to 5.54 and 3.12 after pericardiocentesis. Pulmonary capillary wedge pressure was 22, right atrial pressure was 20, PA pressure was 35/20, and RV pressure was 35/8. HOSPITAL COURSE: 1. Pericardial effusion: The differential diagnosis in this patient with HIV and AIDS is wide, including multiple infectious causes such as tuberculosis, bacterial infection, fungal infection, or viral infection. Also in the differential was neoplasm. Pericardial fluid was sent for evaluation and revealed a white blood cell count of 4,000, red blood cell count of 4,500, with 5 polys, 5 lymphocytes, and 80 atypicals. Total protein was 5.8, and glucose was 34, LDH was 2,217, amylase was 54, and albumin was 1.5. Initial Gram stain showed 1+ polys with no organisms, and at the time of discharge, AFB stain was negative and bacterial cultures were negative. The AFB culture of the pericardial fluid was pending. Cytology of the pericardial fluid was pending at the time of discharge as well, and this should be followed up by the patient's PCP. [Name10 (NameIs) ] is concerning for a neoplasm such as lymphoma given the atypical cells noted on initial smear. Post-pericardiocentesis, the patient had a pericardial drain which produced 30 cc over 24 hours, and was discontinued without further events. Serial transthoracic echocardiograms on postdrainage day one and two showed a stable, small pericardial effusion. The patient did not have a further pulsus paradoxus or pericardial rub during the remainder of his hospitalization, and a repeat echocardiogram several days after discharge should be obtained to evaluate for reaccumulation of pericardial fluid. 2. Pneumonia: The patient was changed from ceftazidime to cefepime given his low white blood cell count and possible functional neutropenia. He was maintained on cefepime for several days for febrile neutropenia, though sputum cultures were negative. An induced sputum from [2196-5-5] demonstrated a Gram stain with oropharyngeal flora, culture with rare oropharyngeal flora as well as yeast, and negative PCP. [Name10 (NameIs) ] was switched to oral levofloxacin, and should complete a total 14 day course for pneumonia. 3. HIV: Patient had recently restarted his HIV medications after self discontinuing in the prior month. His Trizivir was held during his hospitalization as per the patient's primary care provider. [Name10 (NameIs) ] should follow up with his primary care provider for determination of continuation of HIV treatment in the near future. A repeat CD4 count demonstrated an absolute CD4 count of 27 during his hospitalization. 4. Pancytopenia: The cause of his pancytopenia was thought to be malignancy. Although the patient is HIV positive, he had maintained stable counts and this is an acute decrease in all cell lines. CMV viral load was negative. The patient was started on filgrastim and responded well with a rise in his white blood cell count to 5.5. The patient's white count was 4.1 at the time of discharge. Following rehydration, the patient's hematocrit was 25, and he was transfused with 2 units of packed red blood cells for this anemia. Further workup of the pancytopenia should proceed as an outpatient following results from the pericardial fluid cytology. The patient's primary care physician may determine the need for filgrastim treatment as an outpatient. 5. ID: The patient did not have diarrhea during this hospitalization, however, he did complain of diarrhea at the outside hospital. A Clostridium difficile toxin was positive, and he was started on po Flagyl. He remained without abdominal pain or diarrhea during his hospitalization, and he should complete a two week course of Flagyl. 6. Hypertension: The patient was initially normotensive following his pericardiocentesis. His antihypertensive medications were held initially, but they were restarted as he became hypertensive during his hospitalization to a maximum pressure of 170/120. He will be discharged on a half dose of his antihypertensives until followup by his primary care provider. DISCHARGE DISPOSITION: The patient was discharged in stable condition to home. DISCHARGE DIAGNOSES: 1. Pericardial effusion. 2. Pneumonia. 3. Pancytopenia. 4. HIV/AIDS. 5. Clostridium difficile colitis. 6. Hypertension. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg po q day x10 days. 2. Metronidazole 500 mg po tid x12 days. 3. Biaxin 500 mg po q day. 4. Mycelex 10 mg po tid. 5. Univasc 7.5 mg po q day. 6. Atenolol 50 mg po q day. 7. Dapsone 100 mg po q day. DISCHARGE PLAN: 1. The patient should follow up with his primary care provider in one week for followup of the cytology studies on the pericardial fluid specimen. Primary care provider should decide whether to continue filgrastim treatment as well as re-instituting HIV medications. 2. A repeat transthoracic echocardiogram should be performed on [5-9] or [5-10] for evaluation of any reaccumulating pericardial fluid. This is to be raised by the primary care [Provider Number 15725]. The patient's complete blood count with differential and SMA-10 should be drawn in the next week to evaluate for pancytopenia. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 6916] MEDQUIST36 D: [2196-5-7] 13:05 T: [2196-5-10] 10:40 JOB#: [Job Number 15726]	[ "042", "008.45", "486", "423.9", "284.8", "401.9" ]	icd9cm	[ [ [] ] ]	[ "88.55", "37.0", "37.21" ]	icd9pcs	[ [ [] ] ]	7588, 7645							7666, 7787	7810, 8030					3654, 7564																								2480, 3637																		154, 1911												8046, 8946			1933, 2457
14,761	107,887	48925+59123	Discharge summary	report+addendum	Admission Date: [2193-4-26] Discharge Date: [2193-5-8] Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is an 82 year old white female with a history of severe scoliosis, osteoporosis, hypertension, status post T3-T12 fusion on [2193-4-26], status post compression fracture one to two years ago. The patient was doing well after her operation on the orthopedic service, apart from self-extubating herself on [2193-4-27], requiring increasing amounts of oxygen on the floor. On [2193-5-1], the patient had a fever of 101.4 and chest x-ray showed left lower lobe collapse with a right greater than left effusion. Blood cultures, one out of four, were positive for gram positive rods, thought to be a contaminant, and gram positive cocci. On [2193-5-3], overnight, the patient had acute onset shortness of breath with an increase in oxygen requirement with an oxygen saturation of 93% on a 40% face mask. Arterial blood gases at that point were 7.45, 50 and 65 at 1:00 a.m. and then later, at 5:00 a.m., 7.41, 57 and 128 on 40% to 50% face mask. Electrocardiogram was read as stable. A chest x-ray showed no congestive heart failure, with right sided effusion and left lower lobe collapse, unchanged from prior. CT was negative for pulmonary embolus but also saw bilateral effusions. The patient's mental status was deemed stable, as she was alert and oriented times three, with some inappropriateness. A medicine consult was called for this desaturation at 1:00 a.m. on [2193-5-2] and then on [2193-5-2] for falling. For the fall, she possibly hit her head and fell on her right side and also had a transient desaturation, for which were arterial blood gases were 7.41, 57 and 124. She had a CT of her chest and head which showed no bleed and no fracture. She was put in a collar until she was cleared and, at that point, because a urinalysis was found to be positive for 46 white blood cells and greater than 1,000 red blood cells on [2193-5-2] at 9:00 a.m. The patient was started on ciprofloxacin and then transferred to the medical service. PAST MEDICAL HISTORY: 1. Osteoporosis, status post compression fracture in last one to two years, here with T3-T12 fusion done on [2193-4-26]. 2. Severe scoliosis. 3. [2193-4-22] echocardiogram, concentric left ventricular hypertrophy, left atrial enlargement, 1+ mitral regurgitation, no wall motion abnormalities, normal left ventricular ejection fraction. 4. Hypertension times two years. 5. Hiatal hernia/gastroesophageal reflux disease. 6. Question of mitral valve prolapse but negative on echocardiogram. ALLERGIES: The patient has no known drug allergies except for morphine, which causes her to get very sick, nausea apparently. MEDICATIONS ON ADMISSION: Iron supplements, Zantac 150 mg p.o.q.d., Tenormin 25 mg p.o.q.d., Os-Cal 500 mg p.o.b.i.d.; on transfer, albuterol and Atrovent nebulizers, Zantac 150 mg p.o.b.i.d., Lopressor 12.5 mg p.o.t.i.d., Colace 100 mg p.o.t.i.d., and p.r.n. Lasix, Zofran, codeine, Haldol and Tylenol. PHYSICAL EXAMINATION: On physical examination on transfer, the patient's vital signs were 96.1, 66 to 80, 160 to 174/63 to 72 and 96% on 50% shovel mask, 84% in room air. Overnight ins and outs were 760 and 1,553, and urine output was 300 cc over the last eight hours. General: In no acute distress. Head, eyes, ears, nose and throat: Moist mucous membranes, oropharynx clear, no jugular venous distention, no point tenderness. Chest: Clear to auscultation bilaterally, slight crackles at right base, scattered. Cardiovascular: Regular rate, S1 and S2 normal, II/VI systolic murmur at left upper sternal border, no gallops or rubs. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no masses. Extremities: No cyanosis, clubbing or edema. Neurologic examination: Alert and oriented times three, recall [5-1] immediately and [1-31] in five minutes, strength 5/5 throughout, sensation to light touch intact throughout, finger-to-nose bilaterally intact, gait not tested, reflexes 1+ throughout bilaterally. LABORATORY DATA: White blood cell count was 11.7, hematocrit 37.7, down from 39.6, platelet count 256,000, and coagulation profile normal. Urinalysis showed specific gravity of 1.040, large blood, positive nitrite, greater than 300 protein, greater than 1,000 red blood cells, 46 white blood cells, many bacterial and no epithelial cells. Chem-7: Sodium 144, potassium 3.8, chloride 101, bicarbonate 32, BUN 22, creatinine 0.4 and glucose 127. The patient was ruled out with CKs of 252, 262 and 213 with negative MB, troponin less than 0.3. Arterial blood gases: As above. CT scan of head and chest: Negative for bleed and fracture respectively. CTA: Negative for pulmonary embolus and bilateral pleural effusions with question of left lower lobe loculation. Chest x-ray: Bilateral effusions as on [2193-4-28]. HOSPITAL COURSE: 1. The patient was thought to have had flash pulmonary edema, possibly due to arrhythmia given her diastolic dysfunction by echocardiogram. The patient was given 20 mg of Lasix. Lopressor was increased, eventually to 50 mg twice a day. Aspirin was given. The patient was put on telemetry. 2. Pulmonary: The patient's effusions were thought likely due to her flash pulmonary edema and were considered stable. Left lobe loculation was not considered accessible by ultrasound guided tap with risk of pneumothorax significant enough to cause her significant clinical deterioration. 3. Infectious disease: The patient's urinary tract infection was treated with five days of ciprofloxacin. Blood cultures were negative and urine culture was pending at this time. 4. Hematology: The patient's hematocrit remained stable during her hospitalization, ranging from 33 to 39 and, on discharge, was 37.2. Her white blood cell count continued to climb during her hospitalization, although she remained afebrile after transfer to medicine. It was thought possible that she could have a pneumonia given her effusions and difficult chest x-ray assessment based on her skeletal changes. Ceftriaxone was started upon discharge for seven days, 1 gram daily. Her wounds did not look infected. 5. Fluids, electrolytes and nutrition: The patient initially had a BUN to creatinine ratio that was elevated but, during her hospitalization, her creatinine remained stable at 0.4 to 0.5 and her BUN fell from a peak of 23 on [2193-5-2] to 15 on discharge. The patient was intermittent getting intravenous fluids but mostly taking orals and, by the end of her hospitalization, the patient was taking adequate oral intake. 6. Neurology: The patient's mental status fluctuated day to day and, as a result, she had a CT scan of her head initially on transfer that was negative, and then another one on [2193-5-7] that was also negative for a subdural hematoma. Her mental status changes were thought possibly due to ciprofloxacin but, also, her family said that this was her baseline. She was off codeine and only on Tylenol for her pain. 7. Renal: As above, the patient's BUN to creatinine ratio reduced over time. Orthopedic surgery followed her after her transfer to the medicine service and after her fall. The patient had a thoracic spine film, read by orthopedic surgery who said that the alignment of the rods had shifted status post the fall and still was adequate in terms of stabilization of her spine. Another read on the thoracic spine was a left eighth rib fracture, unclear when that occurred based on this one film. There were no management issues for that other than to heal spontaneously. DISCHARGE STATUS: The patient was discharged to rehabilitation in stable condition. DISCHARGE DIAGNOSES: Thoracic compression fracture, status post T3 to T12 spinal fusion. Acute desaturations secondary to possible congestive heart failure with diastolic dysfunction. Hypertension. Gastroesophageal reflux disease. Scoliosis. Concentric left ventricular hypertrophy. Osteoporosis. DISCHARGE MEDICATIONS: Ceftriaxone 1 gm i.v.q.24h. times seven days, until [2193-5-16]. Lactulose 15 cc p.o.b.i.d.p.r.n. Lopressor 50 mg p.o.b.i.d. Multivitamins one p.o.q.d. Zantac 150 mg p.o.b.i.d. Tylenol p.r.n. Colace 100 mg p.o.b.i.d. Aspirin 81 mg p.o.q.d. Dulcolax 10 mg p.r.n. Haldol p.r.n. Heparin 5,000 units s.c.b.i.d. FOLLOW-UP: The patient is to follow up with orthopedic surgery as an outpatient and is to have her white blood cell count checked at [Hospital ] Rehabilitation to see if it resolves with the ceftriaxone. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 102750] MEDQUIST36 D: [2193-5-8] 10:19 T: [2193-5-8] 11:14 JOB#: [Job Number 27840] Name: [Known lastname 12003], [Known firstname 6532] Unit No: [Numeric Identifier 16591] Admission Date: [2193-4-26] Discharge Date: Date of Birth: [2110-8-25] Sex: F Service: ADDENDUM: Her follow up should be with Dr. [Last Name (STitle) 16592] in a month or so. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1743], M.D. [MD Number(1) 1744] Dictated By:[Last Name (NamePattern1) 16593] MEDQUIST36 D: [2193-5-8] 10:21 T: [2193-5-8] 12:15 JOB#: [Job Number 16594] cc:[Telephone/Fax (1) 16595]	[ "737.30", "997.3", "401.9", "424.0", "428.0", "518.0", "737.10", "599.0", "486" ]	icd9cm	[ [ [] ] ]	[ "81.04" ]	icd9pcs	[ [ [] ] ]								7788, 8065	8088, 9513				2799, 3078	4963, 7767																								3101, 4945																		122, 2114															2137, 2772
46,116	156,119	54790	Discharge summary	report	Admission Date: [2153-8-21] Discharge Date: [2153-9-1] Date of Birth: [2127-8-19] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2736] Chief Complaint: Chest Pain, Shortness of breath Major Surgical or Invasive Procedure: 1. [8-21]: Pericardiocentesis 2. [8-22]: Thoracentesis 3. [8-24]: Pericardial window History of Present Illness: [Known firstname ] is a 26 year old female who was transferrd from [Hospital1 5109] with CP and possible pericarditis for evaulation and cardiac echo. Patient reports development of shooting [9-10] precordial chest pain approximately 1.5 months ago. She reports that the pain was worse inspiration and lying down. She also notes shortness of breath. She reports that she was originally seen at [Hospital1 2436] 1 month ago and admitted to the hospital for 5 days for same pain. She reports that at that time she was told that she had a small amount of fluid around her heart. She denies any GI or URI syndrome prior to the onset of the pain. She reports that at [Hospital1 2436] she was treated empirically for lyme disease (even though her tests were "negative") with doxycycline. Was discharged about 3 weeks ago and pain has been worsening. She reports that she completed her 14 day course of doxycycline. She again went to [Hospital1 2436] today for shortness of breath where an CXR was concerning for pericardial effusion and she was transferred to [Hospital1 ] for echocardiogram given concern for worsening endocarditis. Over the past month, has continued to have night sweats, fevers, SOB, pleuritic/positional CP (worse with lying flat). Denies any recent tick bites, rashes, IVDA. Reports being in a shelter for several weeks in the past, but currently lives with her mother (her mother denies this and say that she does not know where she is living). She denies recent travel or recent weight loss. . In the ED, initial vitals were 98.3 98 106/75 18 96% 2L nc Labs and imaging significant for CXR Left pleural effusion, lactate 2.6, WBC 11.7, and BNP 1030. Troponin flat. EKG: NSR at 98. Diffuse TWI in I, II, III, IVL, IVF, V3,-V6 . She was given 30mg Ketorolac for the pain in ED. . Vitals on transfer were 98.9 89 95/63 21 92% 2L NC . On arrival to the floor, patient was laying in bed in no acute distress. She reports continued 7/10 chest pain unchanged from above. Past Medical History: 1. CARDIAC RISK FACTORS: None 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: HPV with cervical dysplasia. Social History: -Tobacco history: [1-1] ppd -ETOH: Denies -Illicit drugs: Denies current use. hx of IVDU 6 months yr ago (heroin). Mother reports that [Name (NI) ] had been using as recently as a month ago and believes that she may currently be using. She has 2 children that live with her mother. Family History: Non-contributory Physical Exam: Admission Physical: VS: T=95.9 BP=91/65 HR=86 RR=21 O2 sat= 92% on 3L NC GENERAL: WDWN Woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at the angle of the jaw when sitting up. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Discharge Physical: 98.5 102/70 80 16 GENERAL: WDWN Woman 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 without JVD. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Dressing on left where chest tube has been removes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [8-20]: EKG Sinus rhythm. There are diffuse ST-T wave abnormalities suggestive of myocardial ischemia. Clinical correlation is suggested. No previous tracing available for comparison. [8-21]: Pericardial fluid cytology: NEGATIVE FOR MALIGNANT CELLS. Abundant neutrophils and proteineous debris. No mesothelial cells identified. [8-21]: Cardiac Echo: The left atrium is normal in size. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is abnormal septal motion. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber size is normal with mild global free wall hypokinesis. There is abnormal septal motion/position, potential consistent with constrictive physiology. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a large (up to 3.2cm) partially echodense pericardial effusion primarily anterior to the right ventricle and right atrium with extensive fibrinous stranding/organization. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Large loculated/organized anterior pericardial effusion with evidence for increased pericardial pressure/early tamponade physiology. Large left pleural effusion. Normal biventricular cavity sizes with abnormal septal motion and biventricular hyopkinesis. [8-21]: Cardiac Cath: Attempted access using hemodynamic, ultrasonographic and fluoroscopic guidance using a micropuncture needle would not enter the fluid filled space and only entered the RV (x1) as confirmed by agitated saline injection. Using the blunt tipped needle, access to the pericardial space was obtained but could only be confirmed with agitated saline since no fluid could be aspirated. Hemodynamic measurement confirmed that there was a pericardial pressure tracing that was slightly higher but entrained with the RA tracing. As such, a dilator was placed and then over a Amplatz SuperStiff wire, an 8 French drainage catheter was passed back and forth in an effort to break apart loculations. 90 cc of cloudy, brown, tan fluid was removed with echocardiographic confirmation of all fluid but persistent thick gelatinous material remained with pericardial pressure decreasing to 0 to -3 mm Hg. [8-21]: CXR 1. Opacification of the left hemithorax concerning for empyema with pneumonia. 2. Prominent cardiac silhouette concerning for pericardial efffusion. Recommend CT scan for further evaluation. [8-21]: Chest CT with contrast: 1. Relatively extensive pericardial effusion that might be partly hemorrhagic. Air inclusions in the chest wall and effusion suggest prior pericardiocentesis. The pericardium shows no focal thickening but minimally increased contrast uptake. Minimal compression of the right heart. 2. Extensive left pleural effusion with subsequent areas of atelectasis at the level of the left lower lobe. 3. Moderate mediastinal lymphadenopathy. 4. No evidence of TB in the well-ventilated right lung and in the ventilated areas of the left lung. 5. No other parenchymal abnormalities, except for the pre-described atelectasis. In particular, no evidence of focal or diffuse lung disease. 6. No bony or upper abdominal changes. [8-24]: Chest CT without contrast: Decrease in size in pericardial effusion with a hemorrhagic component. Focal thickening of the pericardium previously seen cannot be evaluated in this non-contrast study. Decrease in size in loculated left pleural effusion. New right pleural effusion. Right middle lobe and right lower lobe and left lower lobe lymphangitic engorgement. Mediastinal lymphadenopathy, unchanged from [8-23]. [2153-8-21] 12:40AM BLOOD WBC-11.7* RBC-4.36 Hgb-12.7 Hct-38.2 MCV-88 MCH-29.1 MCHC-33.3 RDW-13.6 Plt Ct-490* [2153-8-22] 06:00AM BLOOD WBC-11.4* RBC-4.19* Hgb-12.2 Hct-36.8 MCV-88 MCH-29.2 MCHC-33.3 RDW-13.6 Plt Ct-460* [2153-8-23] 03:15AM BLOOD WBC-11.4* RBC-4.14* Hgb-12.1 Hct-36.8 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.7 Plt Ct-219# [2153-8-24] 01:55AM BLOOD WBC-9.3 RBC-3.91* Hgb-11.4* Hct-34.8* MCV-89 MCH-29.2 MCHC-32.8 RDW-13.7 Plt Ct-416# [2153-8-21] 05:37AM BLOOD PT-15.7* PTT-26.4 INR(PT)-1.5* [2153-8-24] 11:06AM BLOOD PT-14.7* PTT-27.2 INR(PT)-1.4* [2153-8-22] 06:00AM BLOOD ESR-70* [2153-8-21] 12:40AM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-139 K-4.6 Cl-102 HCO3-26 AnGap-16 [2153-8-25] 04:32AM BLOOD Glucose-96 UreaN-14 Creat-0.6 Na-135 K-5.0 Cl-107 HCO3-21* AnGap-12 [2153-8-21] 12:40AM BLOOD ALT-35 AST-30 LD(LDH)-200 AlkPhos-152* TotBili-0.6 [2153-8-23] 03:15AM BLOOD TotProt-6.0* Albumin-2.8* Globuln-3.2 Calcium-8.0* Phos-4.2 Mg-2.3 [2153-8-23] 03:15AM BLOOD %HbA1c-5.7 eAG-117 [2153-8-21] 12:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2153-8-21] 11:11PM BLOOD [Doctor First Name ]-NEGATIVE [2153-8-21] 11:11PM BLOOD RheuFac-4 CRP-39.7* [2153-8-21] 11:11PM BLOOD C3-138 C4-45* [2153-8-23] 06:30PM BLOOD HIV Ab-NEGATIVE [2153-8-21] 12:40AM BLOOD HCV Ab-POSITIVE* [2153-8-22] 06:00AM BLOOD QUANTIFERON-TB GOLD-Test Brief Hospital Course: 26 yo female with no significant past medical history with 1 month of chest pain initally empirically treated for Lyme who represented with continued chest pain and SOB with cardiac echo that demonstrated large pericardial effusion with tamponade physiology. The pericardial effusion was found to be infectious and secondary to MRSA. . # MRSA Pericardial Effusion/Tamponade: [Known firstname ] presented from an outside hospital over concern for tamponade physiology after re-presenting to the OSH for chest pain and shortness of breath. She had been hospitalized there 1 month prior for work up for the same complaints. At that time she was thought to have pericarditis due to Lyme disease and was discharged on 14 days of doxycycline for treatment. The pain and shortness of breath did not resolve and continued to progress and so she presented to the OSH again; she was transferred to [Hospital1 18] for further work-up and management. On admission to [Hospital1 18] an echo was performed that was consistant with tamponade physiology with a large pericardial effusion. She underwent pericardial drainage that resolved the tamponade features, but was found to have MRSA in the pericardial fluid. She was started on IV vancomycin. Given the extensive loculations/adhesionsa and purulent nature of the pericardial fluid the patient was taken to the OR for pericardial window and wash-out. She did well post-operatively. The pericardial drain was removed on [8-27] once drainage had stopped. A repeat cardiac echo was notable for abnormal septal motion suggestive of possible constrictive physiology, trivial MR, but pericardial effusion had largely resolved. Blood cultures were negative during her entire hospitalization. . Given the finding of MRSA pericarditis the patient was evaluated for endocarditis. Her blood cultures remained negative and cardiac echo did not find any evidence of valvular vegetation or abscess formation. She will follow-up with Cardiology for repeat Echo in [4-6] weeks. She will continue on vancomycin at a rehab facility for 4-6 weeks, as per the recommendations of ID. She will follow up in the [Hospital 4898] clinic. . # Pleural Effusion: She also was noted to have a large left-sided pleural effusion on imaging. Given concern for empyema a chest tube was placed and the pleural effusion was drained and cultures were sent that came back negative. Fluid was serosanginuous without purulence. On the 3rd day of the chest tube, Interventional Pulmonology felt there were likely loculations and TPA and DNAse were flushed into the pulmonary effusions with signifanct drainage following these flushes. The chest tube was removed on [8-30]. Lorazepam and oxycodone was weaned following removal of the chest tube. . # Hepatitis C: On this admission during work-up of the cause of the pericardial effusion a hepatitis C antibody was sent. This came back positive and a hepatitis C RNA viral load was sent that was also positive. There was no note of liver pathology on imaging. She should follow up with liver clinic regarding the hepatitis C once this acute infection has resolved. . #Transitional Issues: # Hepatitis C: Please see above for work-up. [Known firstname ] will require out-patient follow up with hepatology. . # IV Antibiotics: For the above pericardial abscess [Known firstname ] will require 4-6 weeks of IV Vancomycin. She will follow-up in [Hospital 4898] clinic. . # Mediastinal Lymphadenopathy: On CT scan [Known firstname ] had mediastinal lymphadenopathy that may be reactive in nature due to the pericardial infection. She will require outpatient follow-up imaging to evaluate for resolution of the lymphadenopathy following completion of the antibiotics course. She was evaluted for TB with sputum x 3 which were negative. She also had a negative quantiferon gold to rule out TB. Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE Negative test result. M. tuberculosis complex infection unlikely. Test Result Reference Range/Units NIL 0.03 IU/mL MITOGEN-NIL 0.88 IU/mL TB-NIL <0.00 IU/mL [2153-8-22] 6:51 am SPUTUM Source: Induced. GRAM STAIN (Final [2153-8-22]): [10-25] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2153-8-24]): SPARSE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final [2153-8-23]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [2153-8-23] 8:27 am SPUTUM Source: Induced. GRAM STAIN (Final [2153-8-23]): <10 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 [2153-8-23]): TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final [2153-8-24]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [2153-8-23] 9:15 pm SPUTUM Source: Induced. GRAM STAIN (Final [2153-8-23]): <10 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2153-8-25]): MODERATE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [2153-8-30]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2153-8-23]): SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. Less than 2 ml received. PLEASE SUBMIT ANOTHER SPECIMEN. TEST CANCELLED, PATIENT CREDITED. Reported to and read back by [Doctor First Name ] [Doctor Last Name ] @ 2255, [2153-8-23]. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [2153-8-24]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED Medications on Admission: None Discharge Medications: 1. Outpatient Lab Work Weekly CBC, CMP, and vanc level 30 minutes before dose starting on [9-7] with results sent via fax to [First Name8 (NamePattern2) 2808] [Last Name (NamePattern1) 1352] and [Name6 (MD) 111987] [Name8 (MD) ], MD at ([Telephone/Fax (1) 1353]. ICD 9 code: 420.0 2. 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. 3. Ibuprofen 800 mg PO Q8H pain 4. Mirtazapine 15 mg PO HS 5. Ranitidine 150 mg PO BID 6. Vancomycin 1000 mg IV Q 8H 7. Zolpidem Tartrate 5 mg PO HS Discharge Disposition: Extended Care Facility: [Hospital 671] [Hospital 4094] Hospital - [Location (un) 86] Discharge Diagnosis: Pericarditis (Inflammation and infection around the heart) Left-sided Pleural effusion (Fluid in the left lung) Anxiety/Impaired coping Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [Hospital1 18] from [Hospital3 ] on [8-21] with complaints of chest pain and were found to have inflammation and fluid around your heart and lungs. The fluid from your heart and lungs were infected with staphylococcus aureus and requires treatment with antibiotics through an IV. A drain was placed in the cavity around your heart to drain the fluid. You also had a chest tube place to drain the fluid and infection from your lungs. You were discharged to [Hospital 671] Healthcare Center where you will recieve antibiotics for a total of 6 weeks. You will follow-up with cardiology and infectious disease as an outpatient to monitor your recovery. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2153-9-11] at 2:00 PM With: [Name6 (MD) ] [Name8 (MD) 10828], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2153-9-18] at 11:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: TUESDAY [2153-10-9] at 11:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "V60.0", "300.00", "423.3", "041.12", "305.1", "790.92", "511.9", "070.70", "785.6", "305.51", "420.99" ]	icd9cm	[ [ [] ] ]	[ "38.93", "37.21", "34.04", "37.0", "37.12" ]	icd9pcs	[ [ [] ] ]	17341, 17440	10016, 13164	303, 401	17620, 17620	4563, 9993	18489, 19436	2974, 2992		16698, 17318		17461, 17599		16669, 16675			17771, 18466								3007, 4544				2512, 2588		16616, 16643		16469, 16580										13185, 14938					232, 265									429, 2440									17635, 17747	2619, 2649					2462, 2492	2665, 2958
17,599	136,999	28962	Discharge summary	report	Admission Date: [2175-8-7] Discharge Date: [2175-8-18] Date of Birth: [2104-2-8] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Mr. [Known lastname ] presented to [Hospital1 18] after cardiac arrest Major Surgical or Invasive Procedure: cardiac catheterization [8-7] emergent CABGx5 [8-7] History of Present Illness: Mr. [Known lastname ] is a 71 yo who became unresponsive on [8-7] and was resuscitated by his son and EMS. Past Medical History: Hypertension Social History: married, visiting from [Country 4754] Family History: unknown Physical Exam: His initial physical exam was significant for patient being unresponsive, intubated. PERRL, trachea midlinie, equal breath sounds, irregular, palpable pulses, abdomen soft non-tender, and no extremity movement noted. BP 100/60 in cath lab Pertinent Results: [2175-8-17] 02:44AM BLOOD WBC-25.4* RBC-2.73* Hgb-8.7* Hct-24.6* MCV-90 MCH-32.0 MCHC-35.5* RDW-14.6 Plt Ct-372 [2175-8-17] 02:44AM BLOOD UreaN-33* Creat-0.8 Na-140 Cl-111* HCO3-22 [2175-8-17] 02:44AM BLOOD Plt Ct-372 [2175-8-16] 02:03AM BLOOD Neuts-88.1* Bands-0 Lymphs-5.7* Monos-5.0 Eos-1.1 Baso-0.1 [2175-8-17] 02:44AM BLOOD UreaN-33* Creat-0.8 Na-140 Cl-111* HCO3-22 [2175-8-14] 02:27AM BLOOD ALT-62* AST-39 LD(LDH)-605* AlkPhos-57 Amylase-133* TotBili-0.4 [2175-8-13] 03:06AM BLOOD Lipase-416* [2175-8-17] 02:44AM BLOOD Phos-2.6* Mg-2.2 [2175-8-17] 10:26AM BLOOD freeCa-1.15 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 69833] (Complete) Done [2175-8-7] at 4:26:03 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division of Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2104-2-8] Age (years): 71 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Chest pain. Hypertension. Mitral valve disease. ICD-9 Codes: 410.91, 402.90, 427.89, 424.1, 424.0 Test Information Date/Time: [2175-8-7] at 04:26 Interpret MD: [Known firstname ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5209], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2006AW3-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 39% >= 55% Aorta - Valve Level: 2.4 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 3.4 cm <= 3.0 cm Aortic Valve - Valve Area: 4.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. No spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Mild-moderate regional LV systolic dysfunction. Moderately depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV chamber size. Normal RV systolic function. Prominent moderator band/trabeculations are noted in the RV apex. AORTA: Normal aortic root diameter. Simple atheroma in aortic root. Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Moderate mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB: The left atrium is normal in size. No thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size are normal.. There is mild to moderate regional left ventricular systolic dysfunction with focalities. Overall left ventricular systolic function is moderately depressed LVEF is 35-40%. Resting regional wall motion abnormalities include mid anterior and anteroseptal hypokinesis, apical anterior hypokinesis. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. Right ventricular systolic function is normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. The IABP was repositioned to 2 cm below the LSCA. POST-CPB: Pt on epi, neo, dobutamine. Preserved LVEF = 35-40% with wall motion abnormalities as described. During period of volume resuscitation, there was transient decreased RV systolic function to mildly depressed with mild TR, improvement was seen following dobutamine therapy. Mild MR, mild AI as described. IABP well-positioned below the LSCA. Normal aortic contours post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Known firstname ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Known lastname ],[Known firstname ] [Male First Name (un) ]: [Hospital1 18] Neurophysiology Detail - CCC Record #[Numeric Identifier ] [5-/2422]R - CCC REPORT APPROVED DATE:[2175-8-17] TEST DATE: [2175-8-16] INTERPRETED BY: [Last Name (LF) ],[First Name3 (LF) ] W. FINDINGS: ABNORMALITY #1: Throughout the recording the background rhythm remained of extremely low voltage such that no clear cortical activity was evident, at least for a few seconds at a time. These low voltage periods were punctuated by high voltage generalized sharp waves occurring every two to four seconds. The pattern did not vary over the course of the recording. There is no apparent response to external stimuli. Propofol had been discontinued 20 minutes earlier. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a frequently regular wide complex rhythm with some episodes of tachycardia to about 120. IMPRESSION: Markedly abnormal portable EEG due to the profoundly suppressed background rhythm with no clear cortical activity evident for seconds at a time and due to the sharp wave discharges every two to four seconds throughout the recording. This finding indicates a severe encephalopathy affecting both cortical and subcortical structures. The discharges were not so frequent as to suggest seizure activity. Following over a week after anoxic injury, the recording suggests a very poor prognosis. OBJECT: ANOXIC INJURY AFTER CARDIAC ARREST. ?????? [2171] CareGroup IS. All rights reserved. Brief Hospital Course: Mr. [Known lastname ] was admitted to [Hospital1 18] after cardiac arrest and was taken to the cardiac catheterization lab where it was found that he had left main and severe 3 vessel disease. An intra-aortic balloon pump was inserted and the patient was taken emergently to the operating room with Dr. [First Name (STitle) ] where he underwent a CABGx5, LIMA-LAD, SVG-Diag, SVG-OM, SVG-PDA, SVG-Diag2. He underwent bronchoscopy in the operating room for hypoxia from presumed aspiration during his arrest. He was also noted to have severe epistaxis which was packed by ENT. Please see operative note for full details. He was transfered to the ICU requiring inotropes and pressors which were weaned off on POD 1. His oxygenation gradually improved and his ventillatory support was weaned down to minimal. He was noted to be febrile and was pan-cultured. He had been placed on antibiotic therapy to cover for his aspiration. An neurology consult was obtained on POD1 as he did not regain consciousness when the sedation was weaned off and was unresponsive to pain. CT scan showed evidence of anoxic injury. Patient developed atrial fibrillation and was treated with amiodarone and beta blockers. He continued to have elevated temperatures with persistently elevated white blood cell counts. He had one blood culture that grew coagulase negative staph and his lines were resited. He was noted to have a large amount of sub cutaneous air on POD #2 which and a R chest tube was placed for a R pneumothorax. He continued to have subcutaneous air without further findings of pneumothoracies, but the patient had multiple broken ribs and segments of flail chest presumably from his resucitation. On POD#4 he was noted to have brief seizure activity and was started on dilantin. On POD #8 the family decided to make him DNR.On POD#10, the family met with the team and neurology, and it was discused that the patient had a less than 1% chance of making a meaningful recovery. It was then decided to extubate the patient and make him CMO. Pt. expired with family at bedside on [2175-8-18] at 14:34. Medications on Admission: diltiazem lipitor omeprazole aspirin Discharge Disposition: Expired Discharge Diagnosis: s/p cardiac arrest s/p CABG anoxic brain injury Afib Discharge Condition: expired [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2175-9-5]	[ "507.0", "348.1", "427.1", "410.01", "401.9", "784.7", "414.01", "790.7", "E879.8", "807.4", "577.0", "512.1", "518.5" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.6", "79.39", "88.56", "37.21", "88.72", "21.01", "36.14", "36.15", "96.05", "99.20", "96.72", "39.61", "99.62", "37.61", "34.04" ]	icd9pcs	[ [ [] ] ]	11072, 11081	8860, 10984	397, 458	11178, 11306	996, 5050		713, 722				11102, 11157		11010, 11049										5099, 8837	737, 977																							279, 359									486, 602															624, 638	654, 697
16,106	184,942	46345+58899	Discharge summary	report+addendum	Admission Date: Discharge Date: Date of Birth: Sex: Service: ADDENDUM: Following transfer to the medical [Hospital1 ], the patient's oxygen supplementation was rapidly titrated down and the patient was eventually placed on room air. Her cough abated. She had no fevers and she maintained adequate pulse oxygenation. Microbiological data was unrevealing and antibiotics were not reinstituted. The patient was evaluated by the physical therapy service. She was deemed to require acute rehabilitation services. Regarding the remainder of her active medical issues, no changes were made to her inhaled bronchodilator therapy for her chronic obstructive pulmonary disease. Her anti-ischemic regimen was not changed either. Her hypertensive medications were also unchanged. She was discharged in stable condition. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg daily. 2. Fluticasone 10 mcg two puffs inhaled twice daily. 3. Albuterol ipratropium six puffs every four hours. 4. Nifedipine 120 mg daily. 5. Clonidine 0.1 transdermal daily. 6. Ranitidine 150 mg twice a daily. 7. Docusate 100 mg twice daily. 8. Heparin 5000 units subcutaneously every 8 hours. This medication may be discontinued once the patient is ambulating satisfactorily. 9. Montelukast 10 mg daily. 10. Prednisone 40 mg daily for 3 days, then 20 mg qd for 3 days, then 10 mg qd for 3 days. 11. Alendrinate 70 mg weekly. 12. Atroven 2 puffs qid [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 27168] Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2125-2-8] 04:06 T: [2125-2-8] 16:31 JOB#: [Job Number 98515] Name: [Known lastname 15720], [Known firstname ] Unit No: [Numeric Identifier 15721] Admission Date: [2125-1-31] Discharge Date: [2125-2-7] Date of Birth: [2039-10-1] Sex: F Service: MICU CHIEF COMPLAINT: Cough, fever, and shortness of breath. HISTORY OF PRESENT ILLNESS: Eighty-five year old female with history of hypertension, colon cancer status post colectomy, COPD/asthma, recent bronchitis treated with Z-Pak 2-3 weeks ago prior to admission to the floor and prior to admission to the MICU, presented with shortness of breath since last night. Patient with fatigue and weakness. No chest pain or pain complaints. Positive cough with minimal white x2-3 days. Has left sided chest tightness with cough, which has all resolved somewhat, worse with deep breath. Patient is also complaining of some urinary frequency changes. She denied any abdominal pain, any chest pain or palpitations, rhinorrhea. She had a fever of 102.3 on [2125-1-30]. No chills, sweats. No weight loss. She had some [Date Range ] contact. Grandson was [Name2 (NI) ] with earache. She has received her influenza and her pneumococcal vaccines this year. She sleeps with two pillows at night in terms of her review of systems. Patient reported to be desatting while ambulating on room air from 96% to the high 80s. No sore throat, no ear pain. In ED, patient was given Levaquin p.o. x1. EKG showed a left bundle branch block which was old, and some ST segment depressions laterally. PAST MEDICAL HISTORY: 1. Hypertension. 2. Colon cancer status post colectomy resection. 3. History of small bowel obstruction status post lysis of adhesions. 4. CHF in [2116] with an EF of 40%. 5. IgA MGUS/anemia. 6. COPD/asthma. 7. Recent colonoscopy with adenomas. 8. Degenerative joint disease. 9. History of bronchitis treated with Z-Pak. 10. Osteoporosis, osteoarthritis. 11. Status post total abdominal hysterectomy. HOME MEDICATIONS: 1. Albuterol MDI. 2. Atrovent MDI. 3. Serevent. 4. Flovent. 5. Aspirin. 6. Clonidine 0.1 mg patch q week. 7. Nifedipine ER 60 mg q.d. 8. Fosamax 70 mg q week. 9. [Doctor First Name 1866]. 10. Lasix 20 mg b.i.d. 11. Quinine 260 mg q.d. 12. Vioxx. 13. Singulair. ALLERGIES: ACE inhibitors, penicillin, beta blocker, and diltiazem per note. Patient has allergies to beta blockers, which causes her bronchospasm. Diltiazem gives her junctional rhythm. Penicillin allergy, ACE inhibitor which causes angioedema, and also an allergy to Bactrim. SOCIAL HISTORY: Lives with granddaughter. [Name (NI) ] history of ethanol use. No history of tobacco use. LABORATORIES ON ADMISSION: White blood cell count 8.8, hematocrit 36.5, platelets 282. Sodium 138, potassium 4.8, chloride 99, bicarb 28, BUN 21, creatinine 1.0, glucose 91. She had 76% neutrophils, 16 bands, 5 lymphocytes, 3 monocytes. Chest x-ray showed no CHF, increased haziness at the right base, and which at that point, pneumonia could not be ruled out. Pleural thickening and right .......... stable. No focal consolidation at the time. Blood cultures x2 were sent and had been negative so far. HOSPITAL COURSE: Since patient had been admitted to the floor, eventually developed hypercapnia, respiratory distress, which developing multilobar pneumonia, although on no microbiological studies, no organism was every cultured. The patient was started on levo and Flagyl for possible aspiration, which she was started on the 27th. Two days after admit to the floor, the patient developed respiratory distress, hypercapnic respiratory distress requiring intubation. Was intubated and was transferred to the unit for further workup and care. While the patient remained in the unit until the 3rd, where she was extubated, and on the 4th, she was transferred to the floor to the Medical service team under attending, Dr. [Last Name (STitle) ]. While in the unit, patient was put on steroids. She was to start on a prednisone taper, starting at 60mg for 3 days. She had developed some hypernatremia, which with fluid boluses, had resolved. In terms of her CAD history, she was continued on her aspirin. The team was mentioned to contemplate of starting statin for patient. Prophylactically, patient was on proton-pump inhibitor and Heparin subQ. On the day transferred to the floor, patient was able to ambulate and also patient was able to take p.o. without any difficulty. Her oxygen requirements had dropped down to 4 liters nasal cannula, and patient had noted to be feeling much better while being transferred back to the floor. On the day of transfer to the floor, after discussing the patient's care with the team, and since there was no organism isolated, Flagyl and Levaquin was stopped. Patient had received about a seven day course of both of those medications, and patient had remained afebrile while in the unit. Although on examination, continues to have some basilar rales right greater than left. In terms of her hypertension, patient had developed some symptoms of rebound hypertension since she was off her clonidine patch. She was restarted on her clonidine patch on [2125-2-5] and also since being extubated yesterday, was able to take her p.o. nifedipine, which further improved her hypertension. Further addendum to be added by Medicine team when transferred to the floor. Discharge medications and status at time of discharge to be added by Medicine team, who is being transferred to. DR. [First Name (STitle) 304] Dictated By:[Name8 (MD) 5105] MEDQUIST36 D: [2125-2-7] 14:15 T: [2125-2-7] 14:12 JOB#: [Job Number 15722]	[ "V10.05", "276.0", "493.20", "276.5", "401.9", "518.81", "507.0", "414.01", "428.0" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "33.24" ]	icd9pcs	[ [ [] ] ]									882, 1985					4922, 7431															3731, 4280																		2003, 2043									2072, 3285							4422, 4904								3307, 3713	4297, 4407
12,508	100,524	7145	Discharge summary	report	Admission Date: [2198-2-11] Discharge Date: [2198-3-14] Date of Birth: [2150-10-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3624] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 1. Intubation/extubation 2. Bronchoscopy 3. PICC placement 4. Right internal jugular placement 5. Blood transfusions 6. [Last Name (un) 1372]-intestinal feeding tube placement 7. Arterial line placement History of Present Illness: Mr. [Known lastname 931] is a 47 yo male with h/o DM, kidney/pancreas transplant in [2183] and recent STEMI that was medically managed in late [12-18] who was transferred from OSH with SOB. Hx was obtained mostly from notes as pt quite somnolent on exam. Pt presented to OSH today with c/o 2 weeks of progressive dyspnea and pedal edema. His sats were 70% on RA and 92% on NRB with RR 40. He was placed on Bipap with sats 94-95% and CXR showed whiteout in his lungs. He was treated with Rocephin,solumedrol 125 mg, 80 mg IV lasix, ativan and nitro gtt. Additionally, his troponin T was noted to be 1.17, proBNP 70,000 (baseline 30,000), WBC 21.8 with a left shift. ABG there was 7.39/32/71. He was then transferred to [Hospital1 ]. . Upon arrival to the ER here his blood pressures were stable. His sats were 98% on 15L NRB. Since he appeared to be using his ascessory muscles he was switched to BIPAP with sats of 95%. An additional 80 of IV lasix was administered at that time and he put out 1.1L over the past 6 hours. CXR was done and showed evidence of PNA. Additionally in the ER troponin was noted to elevated and ST elevations were seen on EKG. After d/w cards it was determined the trop was trending down from previous STEMI and ST changes were residual from previous STEMI. . Currently patient is on BIPAP and answering questions periodically and falling back asleep. Past Medical History: STEMI (admitted [Date range (1) 26574]) decided to medically manage in the setting of renal failure and Cr of 6 and the fact that event had likely occurred several days prior. MIBI showed EF of18%. DM1 x 12 yo- pt has been off insulin and no longer checks BS R toe amputation Osteopenia Urethral stricture Penile implant Sleep apnea history bilateral IVH in [2195] Kidney/pancreas transplant [2183]: His kidney transplant is present in his RLQ, pancreas transplant is in his LLQ (enteric conversion was performed where pancreas was moved from bladder to GI). Rejection [2183] Recent admit for elevated Cr thought [3-16] to lasix and ACEI as well as recent STEMI Social History: No ETOH, 20 pky smoker, quit [2183] before transplant, smokes marijuana rarely, no heroin, no cocaine. Married with 2 children, works for [Company 11293]. Family History: Brother - deceased from MI at age 52, also had diabetes s/p transplant Father - deceased from MI at age 53 Physical Exam: VS:T 97.7 BP 125/83 HR 79 RR 23 O2 94% on bipap 8/10 Fio2 0.5 GEN: somnolent but arousable male, NAD HEENT: bipap in place, unable to open eyes, limited by BIPAP mask Neck: supple, JVP 6 cm Cardio: RRR, 2/6 systolic murmur loudest LUSB, nl S1 S2 Pulm: CTA b/l ant Abd: soft, NT, ND, hypoactive BS Ext: 3+ pitting edemal b/l Neuro: somnolent but arousable, withdraws to painful stimuli, not cooperative with exam Pertinent Results: EKG: NSR with LAD; TWI in I,AVL,V2-V6 (new in V2,V3) q in v2-v5; persistent ST elevations V3-V5 (present previously in V3,V4). . CXR [2198-2-10] prelim read: Worsening airspace opacities likely representing consolidation with some element of edema; pneumonia. No effusions. . Exercise MIBI [12-18]: 1. Moderate, predominantly fixed perfusion defect involving the mid-distal anterior wall, the apex, and the distal septum. 2. Marked left ventricular enlargement. 3. Severe global hypokinesis, with superimposed apical dyskinesis. LVEF=18%. . ECHO [2198-1-1]: Moderate aortic valve stenosis, AoV area 0.8 cm2. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (mid-LAD territory), EF 30%. Moderate pulmonary artery systolic hypertension, PASP 48mm Hg. . LENI [2198-2-13]: Possible old, nonocclusive thrombus within a duplicated left superficial femoral vein. Remainder of the deep veins in the lower extremities bilaterally are unremarkable. . RENAL U/S [2198-2-13]: 1) Tardus parvus waveforms within the segmental arteries supplying the renal parenchyma with decreased resistive indices suggestive of parenchymal hypoperfusion. 2) No hydronephrosis. . TTE [2198-2-13]: The left atrium is moderately dilated. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened with mild to moderate aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral 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. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . CT HEAD [2198-2-28]: 1. No evidence of acute intracranial hemorrhage. Stable appearance of the brain compared to [2195-9-2]. 2. New opacification of the mastoid air cells bilaterally and right middle ear cavity in this intubated patient. . RENAL U/S [2198-3-11]: Overall stable appearance of the renal transplant with tardus-parvus waveforms within the parenchymal segmental arteries suggestive of parenchymal hypoperfusion. Brief Hospital Course: A/P: 47 yo male with h/o DM, kidney/pancreas transplant in [2183] and recent STEMI that was medically managed in late [12-18] who was transferred from OSH with SOB, likely PNA and CHF exacerbation. . 1) Respiratory failure: Patient's sats were in the 70s on RA at OSH. CXR showed whiteout c/w bilateral patchy PNA +/- CHF exacerbation. Following admission, patient was initially maintained on BiPAP for what appeared to be increased work of breathing, though sats were stable at the time. On transfer to [Hospital1 18], patient failed to improve clinically with diuresis, making CHF seem less likely to be the etiology of his respiratory failure. Bilateral patchy infiltrate was visualized; this atypical pattern for community-acquired pneumonia raised concerns for PCP [Last Name (NamePattern4) ]. fungal vs. multifocal bacterial pneumonia in this chronically immunosuppressed host. On HD#2, he was intubated for respiratory distress. Diagnostic bronchoscopy and BAL were performed with unrevealing culture data. He was initially was treated empirically for PCP, [Name10 (NameIs) ] Bactrim discontinued due to nephrotoxicity and highly sensitive BAL negative for PCP. [Name10 (NameIs) ] was treated with a 10-day course of levaquin and vancomycin for broad spectrum coverage as no organism was isolated. Serum fungal markers negative for aspergillus, equivocal for beta-glucan. Patient remained ventilator-dependent from [2-12] - [3-1], on CPAP + PS with ongoing high ventilatory requirements likely due to fluid overload which was compounded by acute oliguric on chronic renal failure. Course was complicated by a MSSA ventilator-acquired pneumonia which was treated with 8 days of vancomycin and zosyn. Following improvement of renal function, we diuresed aggressively with lasix gtt and lasix boluses. On [3-1], he was extubated despite poor prognostic indicators due to the chronicity of his vent-dependence, with plan for tracheostomy if he did not tolerate non-invasive respiratory support. He was transitioned to face-mask O2 and ultimately did not require the planned tracheostomy. . 2) Cardiac: (a) Pump - Patient is s/p STEMI in [12-18] with resultant CHF, last EF measured at 30% in [Month (only) ], now 25% this admission. On admission, the heart failure service was consulted. Because his clinical status early in admission did not improve with diuresis, we did not feel as though heart failure was the predominant precipitating factor for his initial respiratory failure. However, his poor pump function and poor renal function compounded his course significantly and led to a protracted course on the ventilator due to worsening pulmonary edema. He was tried on a trial of nitroglycerin drip for afterload reduction, which was later discontinued in favor of hydralazine. His beta-blockade therapy was uptitrated as tolerated by BP. Throughout the hospital course, he was diuresed only as tolerated, with careful monitoring of his tenuous renal function. (b) Vessels - Per cards, persistent troponin elevation was likely residual from prior STEMI, as CKMB not elevated. Continued medical management with ASA, plavix, statin, BB. ACEI held in the setting of ARF. (c) Rhythm - Previously NSR with new onset paroxysmal atrial fibrillation during this hospitalization. He was initially started on beta-blocker for rate control while in the ICU. On [3-3] went into afib without resolution to Lopressor, then with dropping blood pressure. An amiodarone drip was started, with loading bolus of 150 mg, with improvement. Coumadin initiated on [3-5] for CVA prophylaxis in this relatively young man with [Name (NI) 16064] score of 3 (1 point each for DM, HTN, and CHF); Goal INR [3-17]. There was some difficulty with regulation of his coumadin dosing as the patient became supratherapeutic likely secondary to renal failure. His dose was held for a few days and restarted. However, the patient refused to take the coumadin once reinitiation was recommended because he was concerned about having an elevated INR again. Multiple attempts were made to encourage him to take his medications as recommended. He was eventually started and discharged on daily oral amiodarone for his irregular rhythm. . 4) Anemia: NG lavage gastroccult positive. Stools reported as guiac-negative. GI consulted on [2-24] for ? UGIB and EGD deferred. Consider stress ulcer vs. OG trauma. Iron studies c/w anemia of chronic disease. He was transfused periodically in the setting of his low output state. His hematocrit was stable while on the medicaly floor. . 5) ARF: In the setting of his acute pulmonary illness, patient developed acute on chronic renal insufficiency s/p renal transplant x 14 years. Suspect initially pre-renal picture as precipitant for ARF, given intravascular volume depletion. Renal ultrasound of transplant kidney shows hypoperfusion but no hydronephrosis (which was queried in the acute setting of post-renal obstruction, now resolved). Likely overall picture c/w prerenal azotemia, which resolved throughout the hospitalization with improving Cr and improving UOP. The Renal service followed him throughout his stay and felt that he had no acute HD needs despite his poorly functioning renal graft. He was continued on Vitamin D analogue Calcitriol for secondary hyperparathyroidism (PTH 225). He received Epo 10,000 units 3x/week for anemia of chronic disease. His aAceI in the setting of acute renal failure. He was maintained on prednisone and tacrolimus for chronic immunosuppression. His tacrolimus dose was decreased under the direction of the Nephrology service. . 6) Urinary retention: Patient also has unusual phallic anatomy with penile implant, stricture, ? prostatic enlargement, and it is possible that post-renal obstruction also contributed to the onset of his ARF. Following multiple nursing and house officer attampts at foley placement, Urology was consulted and ultimately were able to place a 12 french Coude catheter. Had no difficulties with urinary retention once foley discontinued. He was restarted on flomax once his hemodynamics were stable and tolerated it well. . 7) FEN: Nutrional support with tube feeds was provided while patient was ventilator-dependent. A S&S evaluation demonatrated possible delayed signs of aspiration. A video swallow study was ultimately performed which revealed moderate silent aspiration with nectar-thick consistencies and multiple episodes of laryngeal penetration, which were able to be cleared with cued cough. He underwent a repeat swallow evaluaiton [3-14] with improved swallowing mechanics. His diet was advanced to regular and he tolerated it well. While on the medical floor, the patient remained stable and was monitored mainly for return of renal function to baseline and medication management. It was recommended to the patient initially that he be discharged to a rehabilitation facility for further PT/OT. However, the patient and his wife felt very strongly that he would be safe at home. He worked with PT throughout his admission who felt that he was improving and was appropriate for home PT. He was discharged home with home PT and VNA for medication teaching. He will follow up with his Renal and Diabetic physicians. Medications on Admission: Tacrolimus 2 mg qAM Tacrolimus 1 mg qPM Atorvastatin 80 mg qd Aspirin 325 mg Tablet qd Ferrous Sulfate 325 [Hospital1 ] Cholecalciferol (Vitamin D3) 400 unit qd Prednisone 12.5 mg qhs Metoprolol Succinate 150 mg qd Calcium Acetate 667 mg 2 tabs PO TID Sodium Citrate-Citric Acid Thirty ml TID Clopidogrel 75 mg Tablet qd Hydralazine 10 mg Tablet q8hours Lasix Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:15 Tablet(s) Refills:1 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:1 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:1 10. 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:1 11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:1 12. Epogen 10,000 unit/mL Solution Sig: Three (3) Injection once a week. Disp:10 Refills:1 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: 1. Congestive Heart Failure 2. Diabetes Mellitus 3. Pneumonia 4. non-St elevation myodardial infarction 5. Atrial Fibrillation Discharge Condition: Stable. Able to walk safely with walker. Tolerating general diet. Discharge Instructions: You should weight yourself every day. If your weight is up more than 3 pounds, you should call your doctor. Adhere to a low sodium diet. Your tacrolimus level was changed. You are now taking 1.5 mg of tacrolimus twice a day. This change was made by the Renal doctors. You also were started on amiodarone for atrial fibrillation (irregular heart rate). You should continue to take that medication until seen by your primary care physician. Contact a physician for fever > 101.5, nausea, vomiting, loss of conciousness, abdominal pain, persistent diarrhea, or any other concerns. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 5003] Date/Time:[2198-3-27] 11:40 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2198-6-12] 10:10 Provider: [Name10 (NameIs) ], [Name11 (NameIs) ] MD Phone: [Telephone/Fax (1) 26575] or [Telephone/Fax (1) 2378]. Follow-up within 2 weeks. You must call to make that appointment. [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629]	[ "518.81", "403.91", "327.23", "250.41", "584.5", "424.1", "410.72", "V42.83", "285.29", "427.31", "585.5", "996.81", "599.60", "428.33", "486", "788.20" ]	icd9cm	[ [ [] ] ]	[ "57.94", "38.93", "96.6", "99.04", "96.72", "96.04", "93.90", "33.24" ]	icd9pcs	[ [ [] ] ]	15075, 15136	6071, 13377	336, 545	15307, 15375	3430, 6048	16005, 16660	2873, 2982		13792, 15052		15157, 15286		13403, 13769			15399, 15982								2997, 3411																							277, 298									573, 1969															1991, 2676	2692, 2857
29,097	134,379	33777	Discharge summary	report	Admission Date: [2183-3-19] Discharge Date: [2183-4-9] Date of Birth: [2157-2-21] Sex: F Service: MEDICINE Allergies: Bactrim Ds Attending:[First Name3 (LF) 613] Chief Complaint: SOB, fever, R flank & chest pain Major Surgical or Invasive Procedure: VATS procedure Chest tube placement x 2 Right pigtail catheter placement Renal biopsy History of Present Illness: [History obtained through telephone interpreter] . 26 yo [Location 7972] woman who came to the United States three days ago for medical care of reportedly newly diagnosed lupus. She presented to [Hospital ] clinic on day of presentation (per her report) and was referred to [Hospital1 18] ED for further evaluation of her current complaints of shortness of breath, fever, right flank pain & chest pain. She describes her c/p is a nonradicular pleuritic without that is worse with cough. She became SOB 1.5 months ago that has progessively worsened. She is now SOB at rest. . The patient reports that she was diagnosed with lupus about 1.5 month ago in [Country 3587], after presenting with joint pains & fever accompanied by rash (peri-orbital). Workup revealed pleural effusion (reportedly drained/tapped), anemia, and renal failure. She was given the dx of SLE. She has som paper work from her [Country 3587] doctors, which she brings with her (in [Country 78113] language). It includes lab tests from [2183-3-14] & a few brief notes. Without the aid of an intrepreter, review of the notes reveal a Hct of 25% (on [2183-3-14]), plt 93, BUN 164mg/dl, Crt 3.5mg/dl (up from 0.6 on [2183-2-20]), albuminuria, slightly elevated transaminases (in 30-40s). C3 of 1.9 g/L & C4 0.2 g/l. It appears that her anti-DS DNS was positive, HIV was negative. Pregnancy tests were negative. She was started on Prednisone (3 tablets daily--?60mg daily); however, she stopped this one day ago. She flew to the US three days prior to presenting b/c she wants to receive medical care in US. She is living with an aunt in the [Name (NI) 86] area. . In the ED, VS Tm 102, HR 100-110s, BP 110-140s/60-70s, RR 20-30s, 100% on 2L. She underwent CT torso which showed large b/l pl effusions, the left pleural effusion has fultiple foci of air within it--this is likely [3-1] to pt's recent tap in [Country ], however, ddx includes infection or possibly bronchopleural fistula. CT also showed small pericardial effusion, trace fluid in the pelvis, and mild anasarca, all possibly associated with lupus. The patient was given 750mg of levoflox for possible PNA. Her UA came back +. Pt being admitted for further w/u of effusions, tachypnea, fevers, & possible lupus. . ROS: Positive for fever, chills, weight loss (4kg 3 months), central chest pain ass'td w/ cough & inspiration. No nausea, vomitting, constipation, diarrhea, melena, BRBPR, dizziness or lightheadedness change in vision. Occas frontal HA. + Rash as noted above (w/scaling), now resolved. ?oral ulcers. No change in hearing. No hematuria, dysuria, LE swelling, numbness, tingling, weakness, Past Medical History: -SLE -Anemia NOS Social History: Just moved to US living w/ Aunt. Sexually active. No etoh, tobacco, or illicits. Family History: No fam h/o SLE. Physical Exam: VS: 99.8-->100.6, 100-120s, 120/60, 20, 100% on 3L Gen: NAD, comfortable, a&ox3 HEENT: NCAT, PERRL, sclera anicteric, OP clear, MMdry Neck: Supple, no LAD, JVP flat CV: tachy, regular S1/S2, no m/r/g Resp: decreased BS bilaterally ~ 1/2way up w/ dullness to percussion over same area Abdomen: Soft, NTND, BS+ Back: CVA tenderness over R flank Ext: No c/c/e. DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [6-2] both upper and lower extremities Skin: Pink, warm, no rashes Pertinent Results: Imaging: . PA & LATERAL CHEST: Increased opacity is seen at the lung bases bilaterally, obscuring both hemidiaphragms and the left heart border. Moderate-sized bilateral pleural effusions are seen, left greater than right, likely with associated atelectasis. Underlying airspace consolidation cannot be excluded, particularly at the left lung base. Apical pleural thickening is seen bilaterally, but the upper lungs are well aerated. The heart does not appear enlarged. The mediastinal and hilar contours are unremarkable. Soft tissue and osseous structures are also unremarkable. IMPRESSION: 1. Moderate-sized bilateral pleural effusions, left greater than right. 2. Bibasilar atelectasis; however, underlying pneumonia cannot be excluded. . CT CHEST WITH CONTRAST: There is a large left pleural effusion. In addition, multiple foci of air are noted within the pleural effusion. The effusion does not demonstrate rim enhancement. There is associated partial collapse of the left lower lobe. The atelectasis enhances uniformly. There is a small pericardial effusion. There is a moderate right pleural effusion with associated atelectasis. The remaining portions of the lung are clear. The heart and great vessels of the mediastinum are unremarkable. Note is made of multiple borderline enlarged lymph nodes in both axilla. No mediastinal or hilar adenopathy is present. CT ABDOMEN WITH CONTRAST: The liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, small bowel loops all appear normal. There is a paucity of intra-abdominal fat, but no pathologic adenopathy is identified. There is no free air. . CT PELVIS WITH CONTRAST: There is small amount of free fluid in the cul-de-sac. The colon appears normal. A Foley catheter is present in a normal- appearing bladder. There is a normal-appearing retroverted uterus. Note is made of mild anasarca. BONE WINDOWS: The osseous structures are unremarkable. IMPRESSION: 1. Multiple foci of air within large left pleural effusion. If this is not secondary to an iatrogenic cause, the differential includes infection or possibly bronchopleural fistula. However, no other good signs of infection are present including rim enhancement of the pleural effusion or obvious associated pneumonia. 2. Large bilateral pleural effusions, small pericardial effusion, trace fluid in the pelvis, and mild anasarca, all possibly associated with lupus. . ECG: sinus tach, no signif ST-T changes . Labs: [2183-4-9] 05:50AM BLOOD Glucose-73 UreaN-11 Creat-0.5 Na-139 K-4.1 Cl-109* HCO3-22 AnGap-12 [2183-4-8] 06:00AM BLOOD Glucose-71 UreaN-12 Creat-0.6 Na-140 K-4.3 Cl-111* HCO3-22 AnGap-11 [2183-3-20] 05:35AM BLOOD calTIBC-137 Hapto-383* Ferritn-534* TRF-105* [2183-3-20] 05:35AM BLOOD TSH-1.2 [2183-3-21] 06:40AM BLOOD RheuFac-15* [2183-3-20] 05:35AM BLOOD [Doctor First Name ]-POSITIVE Titer-1:1280 [MD Number(3) 78114]-POSITIVE [2183-3-20] 05:35AM BLOOD CRP-122.3* [2183-3-21] 06:40AM BLOOD PEP-POLYCLONAL IgG-2736* IgA-272 IgM-98 [2183-4-7] 06:15AM BLOOD C3-48* C4-10 [2183-3-20] 05:35AM BLOOD C3-31* C4-5* [2183-3-21] 04:19PM BLOOD pH-7.24* Comment-PLEURAL FL [2183-3-20] 05:49PM BLOOD pH-6.83* Comment-PLEURAL Brief Hospital Course: # Lupus: The patient's diagnosis of lupus was corroborated through both clinical and auto-antibody testing. The patient had extremely high anti-DS DNA, [Doctor First Name ], and Sm antibodies, confirming the diagnosis. She was restarted on prednisone 60mg daily and slowly titrated down to 35mg daily. The patient was started on bactrim prophylaxis but developed a rash; she was discharged on dapsone. In addition she was found to have lupus nephritis and eventually started on mycophenolate mofetil, once active TB was sufficiently ruled out (see below). She was followed by rheumatology during her stay and will follow up with them as an outpatient. The patient was counseled extensively regarding the necessity of taking her medications regularly and the importance of using birth control or sexual abstinence while taking the MMF. # Nephrotic Syndrome/Lupus Nephritis: The patient had proteinuria upon presentation with a urine protein/creatinine ratio of 5.5, suggesting nephrosis. A renal biopsy was conducted that demonstrated Lupus Nephritis, ISN/RPS Classification mixed Classes III (A) Focal Lupus Nephritis and V Membranous Lupus Nephritis. She was started on mycophenolate mofetil as above and will be considered for ACE inhibitor therapy and further titration of her immunosuppression by renal as an outpatient. # Pleural Effusions/Empyema: The patient had bilateral pleural effusion and a small pericardial effusion upon admission. The pleural fluid was tapped by IP and revealed a low pH and glucose of zero that was concerning for possible tuberculosis infection versus empyema. The patient had two chest tubes placed on the left side and a pigtail catheter on the right side to drain the effusions. In addition she was treated with a 14 day course of vancomycin and Zosyn empirically despite having a negative gram stain and no positive culture data for presumed bacterial empyema. Despite an elevated [Doctor First Name ], the decision was made to follow the patient clinically and not treat for tuberculosis at this time given lack of PCR or culture data. Her TB cultures were pending at the time of discharge. # Anemia: The patient was anemic throughout her stay. Iron studies suggested anemia of chronic inflammation. # Social Coordination: The patient was seen by social work during her stay. We coordinated with the free care pharmacy to ensure the patient's access to her medications and plugged her into the [Company 191] clinical resource specialists for further coordination of her care. Medications on Admission: Prednisone 60 (stopped prior to admission) Omeprazole Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. Disp:100 Tablet(s) Refills:0 4. Prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Disp:100 Tablet(s) Refills:2 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 8. Mag-SR 64 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:60 Tablet Sustained Release(s) Refills:0 9. Dapsone 100mg Daily Discharge Disposition: Home Discharge Diagnosis: lupus lupus pleural effusions complicated by empyema lupus nephritis anemia of chronic disease Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with fluid and a possible infection in your lungs caused by lupus. The fluid was drained and you were treated for an infection with antibiotics. The lupus was also affecting your kidneys. We have started you on medicine to counteract the lupus. It is very important that you take your medications as prescribed. As we discussed before, you must not become pregnant while taking these medicines. Please follow up with your physicians as directed below. You have an appointment with your lupus doctor, primary care physician, [Name10 (NameIs) 1083] disease doctor, and kidney doctors. If you develop shortness of breath, a new rash, fevers that do not go away with tylenol, chest pains, or any other concerning symptoms please contact a physician immediately or return to our emergency room. Followup Instructions: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2183-4-15] 12:00 [2183-4-15] 3:30p [Last Name (LF) ],[First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Hospital6 29], [Location (un) ] RENAL DIV-CC7 (SB) Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2183-4-16] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7380],MD MPH[MD Number(3) 708]:[Telephone/Fax (1) 457] Date/Time:[2183-5-6] 9:00 [2183-5-7] 09:00a [Last Name (LF) ],[First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Hospital6 29], [Location (un) ] RENAL DIV-CC7 (SB) [2183-5-28] 08:30a [Last Name (LF) ],[First Name3 (LF) ] [Hospital6 29], [Location (un) ] [Hospital 191] MEDICAL UNIT [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2183-4-14]	[ "583.81", "581.81", "510.9", "710.0", "518.0", "599.0", "285.29", "511.9" ]	icd9cm	[ [ [] ] ]	[ "34.52", "34.04", "34.09", "34.20", "55.23", "33.22", "34.91" ]	icd9pcs	[ [ [] ] ]	10709, 10715	7057, 9606	302, 390	10854, 10863	3814, 7034	11747, 12817	3253, 3270		9710, 10686		10736, 10833		9632, 9687			10887, 11724								3285, 3795																							230, 264									418, 3098															3120, 3139	3155, 3237
70,433	181,971	32444	Discharge summary	report	Admission Date: [2119-11-20] Discharge Date: [2119-12-12] Date of Birth: [2045-4-23] Sex: F Service: SURGERY Allergies: Lisinopril Attending:[First Name3 (LF) 4748] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: PICC line placement [2119-11-21] Laparoscopic Cholecystectomy Right carotid endartectomy rt. neck exploration left pneumothorax s/p CT placement History of Present Illness: Case discussed with ERCP team 74 y/o F w/ PMH of htn, ETOH, who is admittted for abdominal pain x 2 weeks. ERCP for pancreatic ductal stone deferred today due to ongoing pain control issues. The patient has a history of drinking 3-5 beers per day for several years. Beginning 2 weeks ago she developed epigastric discomfort which was constant in nature, like a band around her abdomen without radiation to the back. Sharp and achy in quality. Associated with nausea and loose bowel movements initially. No associated fever or vomiting. Prior history of fleeting abdominal pains, but never this severe or prolonged in duration. 11 days ago she visited an OSH ER because the abdominal pain was persistent and she was unable to tolerate POs. She was found to have an elevated Amylase to 260, and Lipase at 4600. An abdominal film at that time showed moderate to severe gaseous distension of the transverse right colon. She was discharged home, but abdominal pain continued and on [11-14] days ago, repeat labs revealed persistently elevated pancreatic enzymes with an amylase of 366 and lipase of 4100. She was placed on HCTZ for blood pressure control, and a CT scan was performed which showed pancreatitis and a pancreatic duct calcified stone. Given the large pancreatic calcification, which is partially obstructing the pancreatic duct, she was transferred to [Hospital1 18] today for ERCP. As mentioned above, ERCP deferred today due to pain control issues. ROS: she has been intolerant of POs over the last couple weeks, eating only very small quantities. Feels early satiety, nausea. Has also lost 7lbs over this time frame. Initially with loose BMs, but now notes decreased BM frequency. Denies ETOH over the last 2 weeks. ROS otherwise negative. Past Medical History: htn h/o kidney stones s/p appy s/p partial hysterectomy Social History: widowed, lives alone, independent. smokes 1ppd, drinks 2-5 beers per day (none in last 2 weeks) Family History: mother- died of [Last Name ] problem age 70. father had a deforming arthritis. 1 brother died of throat ca, another of lung ca Physical Exam: vitals- 99.8, 148/72, HR 74, RR 16, 96% RA gen- pleasant, thin female, sitting up in bed, with mild mid-epigastric pain heent- EOMI. non-icteric. MM dry neck- supple pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- active bowel sounds. tender to palpation in mid-epigastric area and right upper quadrant with voluntary guarding. no rebound. ext- no edema. 1+ dp pulses b/l. warm distal extremities skin- no jaundice neuro- alert and oriented x 3. CNII-XII intact. extr [4-29] b/l Pertinent Results: Labs (at OSH): [2119-11-18]- WBC 8.1, HCt 45.0, Plt 592; Na 137, K4.0. Ca 10.2. [2119-11-18]- Lipase 3703, Amylase 236, Tbili 0.1, AST 25, ALT 49 [2119-11-19]- Lipase [2030], Amylase 115, Tbili 0.2, AST 18, ALT 39 Brief Hospital Course: 74 y/o F w/ PMH of htn, ETOH, who is admittted with pancreatic duct calcification for ERCP # Pancreatitis- Secondary to pancreatic calcification (?calcified stone) blocking pancreatic duct. Plan for ERCP pending bowel rest, pain control. No fever, leukocytosis. Hold off on abx. - pain control w/ morphine pca - NPO/IVF hydration - ERCP recs, Dr. [Last Name (STitle) 174] to see. - check calcium (10.2 at OSH), triglycerides - trend amylase/lipase # Htn- ca channel blocker if needed, currently normotensive #PPx- hep SQ, PPI # FEN- 7-10lb wt loss, intolerant of POs. nutrition consult for TPN; PPN for now. PICC request, TPN started on [2119-11-22] and has continued until discharge.Plan is for 2 months of TPN # Code- Full = = = = = = = = = = = = = = = = = ================================================================ She then went to the OR on [2119-11-24] for: Laparoscopic cholecystectomy with cholangiogram. Stroke: Post-op she had transient confusion post op which is resolved. Also had Right sided weakness, which is still there but much improved. noted to be confused and "not making sense". At 22:15 the RN notes report R UE and RLE weakness and no verbal response to questions. The event notes reports her vitals as 98.2 89 160/60 22 96% on 3L NC. Her speech had limited output, answering y/n questions appropriately following simple commands with maximal cuing. It appeared that she couldn't find the right words. She was noted to be very slightly dysarthric due to a severely dry mouth (same as prior) but did not make paraphasic errors. She was only oriented to person. She had R sided neglect but no other CN abnormalities. On motor exam her R arm was not moving "<2/5 strength in biceps/triceps but "full grip strength. Her R leg and foot had no movement. The left upper and lower extremities had full strength. She had intact sensation symmetrically in all extremities. On reflex exam a R down-going toe was noted. The entire episode lasted slightly less than 2 hours. Per PACU records, her BP ranged from 110-160/40-60 with SR but her BP is noted to be quite different in the R and L arm (L < R). Her recollection of the event is somewhat hazy, "what I remember probably isn't worth much". She felt that she may have come out of sedation too quickly, "It seems to me that I came too a little too soon." She recalls trying to speak but finding that "the words wouldn't come out". She was certain that she knew what she wanted to say and that she understood what everyone was telling her. She wanted to say "there's nothing wrong". She does not recall any focal weakness but felt "weak all over". She denied HA, vision changes, CP, palpitations or sensory changes. She had a NCHCT which did not show evidence of an acute infarct. She was then transferred to the [Hospital Ward Name 517] for further monitoring. Currently she reports a bifrontal headache which is moderate and somewhat throbbing. She also reported chills and some SOB. She denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech. Denied focal weakness, numbness, paresthesias. No bowel or bladder incontinence or retention. Denied difficulty with gait. The reported history would be mostly consistent with a L MCA distribution occlusion which resolved. The report of R sided neglect however is inconsistent with this clinical picture. Other etiologies include hypoglycemia (did not see FS at time of event recorded), seizure or stroke. RECOMMENDATIONS: -MRI/MRA brain and MRA neck r/o stroke and evaluate cerebral vasculature -monitor on tele to evaluate for arrythmia's -r/o MI with CE -check TTE -allow BP to autoregulate to SBP autoregulate SBP < 200/100 if appropriate in the context of recent surgery and aortic -check FLP and A1c -Start 40mg Lipitor and ASA 81mg if acceptable in the context -If w/u negative, would check EEG as well -infectious w/u given the R PICC site and chills -Metabolic w/u given recent pancreatitis, surgery, and TPN -maintain euglycemic and normothermic [2119-11-28] Vascular consulted for carotid artery stenosis and recommendations as to timing of CEA.Levo/flagyl discontinued. [2119-11-29] TEE negative for thombus. Proceeded to surgery for Right CEA with dacron patch. Transfered to Dr.[Name (NI) 1392] service. [Date range (3) 75737] postoperative neck wound bleeding requiring transfusion.postoperative hypertension requiring IV NTG.Returned to surgery for neck exploration 12/-[8-1] cvl placed complicated by rt. apical pneumothroax requiring chest tube placement. [2119-12-3] CT to suction with improvment in pneumothorax. [12-4] chest tube to water seal, lung remains expanded. Chest tube removed.episode of pulmonary edema improved with diuresis but EKG changes + enzyme elevation. Cardology consulted. [2119-12-5] enzymes trending down [Hospital1 ]. [12-8] Speech and Swallow eval: 1.Suggest the pt continue with TPN for her primary means of nutrition. 2. Pt can take essential PO medications crushed with moist purees such as apple sauce or jello. 3. Occasional ice chips by mouth are also safe at this time. [Date range (1) ] Patient experience diarrhea and C. diff Cx was negative x 3 [12-8] patient had a PICC line placed for long term TPN. [Date range (1) 62114] patient has been feeling much better. She has been ambulating with PT and the case managers began the rehab screening process [12-12] D/C to Medications on Admission: protonix 40mg PO daily HCTZ daily MVI calcium supplement Discharge Medications: 1. Simvastatin 10 mg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution [Month/Year (2) ]: One (1) Injection TID (3 times a day). 3. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [Month/Year (2) ]: One (1) Appl Rectal PRN (as needed). 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Month/Year (2) ]: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 5. Ipratropium Bromide 0.02 % Solution [Month/Year (2) ]: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. Hydralazine 10 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6h PRN as needed for pain. 11. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID PRN. 12. Ondansetron HCl (PF) 4 mg/2 mL Solution [Last Name (STitle) ]: One (1) Injection Q8H (every 8 hours) as needed for nausea or vomiting. 13. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID PRN. 14. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: SSI Injection ASDIR (AS DIRECTED). 15. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: Cholecystitis, Pancreatitis secondary to Pancreatic Duct stone postoperative stroke carotid stenosis, s/p Rt. CEA,complicated by MI ([12-1]) postoperative carotid wound bleed, post op PTZ secondary to line placement s/p CT placement postoop blood loss anemia s/p transfusion 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. * Continue to amubulate several times per day. Followup Instructions: 1. Please followup with [Name6 (MD) ] [Name8 (MD) ],M.D. in 3 weeks.Call his office at ([Telephone/Fax (1) 10532] for an appointment 2. followup with Dr. [Last Name (STitle) 1391] post d/c from rehab. call for an appointment [Telephone/Fax (1) 1393] 3. Please have carotid ultrasound performed 3 months after discharge from [Hospital1 18] (Mid-[2120-2-24]) 4. Please followup with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],M.D. in 3 weeks.Call his office at ([Telephone/Fax (1) 2363] for an appointment Completed by:[2119-12-12]	[ "433.11", "998.11", "997.1", "575.0", "512.1", "577.8", "410.71", "451.84", "999.31", "285.1", "263.0", "997.02", "577.0" ]	icd9cm	[ [ [] ] ]	[ "00.40", "06.02", "51.23", "34.04", "38.93", "87.54", "99.15", "38.12" ]	icd9pcs	[ [ [] ] ]	10721, 10791	3346, 8900	287, 438	11114, 11121	3091, 3323	12211, 12802	2441, 2573		9007, 10698		10812, 11093		8926, 8984			11145, 12188								2588, 3072																							233, 249									466, 2232															2254, 2312	2328, 2425
26,744	136,707	7594	Discharge summary	report	Admission Date: [2199-7-9] Discharge Date: [2199-7-19] Date of Birth: [2137-9-24] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: ESRD now s/p living related kidney transplant from brother Major Surgical or Invasive Procedure: [2199-7-9]: living related kidney transplant History of Present Illness: 61 y/o male with ESRD currently on hemodialysis x one year. He has undergone extensive workup including cardiac evaluation due to PMH of CAD, s/p CABG and significant family history of heart disease. He is currently dialyzing three days a week and is here for living related donation from his younger brother. [Name (NI) ] current medical issues to prevent transplant. Past Medical History: ESRD CAD s/p CABG [2196] Porcine Aortic Valve replacement [2196] Obesity s/p gastric bypass DM II PVD s/p Right fem-[Doctor Last Name ] bypass HTN Hyperlipidemia Social History: Married with 2 sons Family History: Both parents deceased s/p MI Physical Exam: Post Op: VS: 98.2, 77, 143/55, 22, 100% on shovel mask Gen: A+Ox3 HEENT: EOMI, PERRLA, Anicteric, conjunctiva pink Lungs: CTA bilaterally Card: RRR, III/VI systolic murmur radiating throughout the pericardium Abd: Soft, incision dressed. No drains Extr: No edema Pertinent Results: Post Op Day 0: [2199-7-9] WBC-3.5* RBC-4.55* Hgb-11.9* Hct-37.8* MCV-83 MCH-26.2* MCHC-31.6 RDW-17.2* Plt Ct-118* Glucose-101 UreaN-47* Creat-6.8# Na-137 K-3.8 Cl-99 HCO3-22 AnGap-20 Calcium-8.0 Phos-4.6* Mg-1.3* Brief Hospital Course: 61 y/o male with ESRD who underwent living related kidney transplant from his brother. The patient was taken to the OR by Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Please see the operative note for surgical detail. In summary, the kidney was placed retroperitoneally on the right. There was some delay obtaining the donor kidney, the kidney filled slowly with blood and it took approximately [11-6] minutes for it to pink up normally. The kidney was firm and there was excellent flow in the renal artery. He received routine immunosuppression including MMF 1 gm, solumedrol and thymoglobulin induction of 100 mg. T and B cell flow studies were negative at the time of transplant. Urine output was excellent averaging 4liters to 1800ml. He experienced a slow fall in the serum creatinine to 4.2 on pod 3 despite excellent urine output. Per Dr.[Name (NI) 8385] note a flow crossmatch was suggestive of a new possibly anti-donor IgM antibodies (CDC crossmatch +, turned negative after DTT). He was therefore sent to the SICU on [7-12] for plasmapheresis, IVIG and ATG administration. Rituximab was given on [7-12]. He received a total of 6 doses of ATG in the setting of a known donor specific antibody. Prograf was started on POD 0 and subsequent doses were adjusted based on trough level. This dose settled at 5mg [Hospital1 ] for a trough of 11.2. Cellcept had been increased to 1.5 grams [Hospital1 ] given concern for absorption given h/o gastric bypass. Steroids were tapered per protocol, but prednisone 20 mg qd was continued given higher risk for rejection with h/o preop donor specific antibodies. On [7-16] he was taken back to the OR for drainage of perinephric fluid collection/hematoma seen on U/S and Tru-Cut biopsy of the transplanted kidney to rule out humeral rejection. Per renal's note, the biopsy was negative for cellular or humoral rejection. Postop, Hct remained stable. Urine output remained excellent. Creatinine stayed at 2.0. Diet was advanced and he moved his bowels. Postop, he had edema and lasix 40mg [Hospital1 ] was given. He received extra iv lasix the day of & prior to discharge with u/o ~ 3.5 liters. He was sent home on lasix 40mg po qd. [Last Name (un) ] was consulted for hyperglycemia and insulin (humalog ss & NPH)was given with improved glycemic control. His was discharged home on insulin. [Location (un) 1110] VNA was arranged to assist with JP (2)care and insulin/med management. PT evaluated and felt that he was safe for discharge home. He was ambulating independently at time of discharge. Medications on Admission: Amlodipine 10', Atorvastatin 80', triazolam 2pills hs, Lisinopril 10', Metoprolol 100", Mirtazapine 30 hs, Morphine 15hs, Ropinirole 0.5hs, asa 325, colace Discharge Medications: 1. Glucometer One Touch Ultra 2 2. One Touch Ultra Test Strip Sig: One (1) In [Last Name (un) 5153] four times a day. Disp:01 bottle Refills:2 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 10. Betamethasone Dipropionate 0.05 % Ointment Sig: One (1) Appl Topical QID (4 times a day). 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-23] Sprays Nasal QID (4 times a day) as needed. 12. Ropinirole 0.25 mg Tablet Sig: 2-4 Tablets PO QPM PRN (). 13. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 14. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 18. Triazolam 0.25 mg Tablet Sig: Two (2) Tablet PO qhs (). 19. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) unis Subcutaneous once a day. Disp:1 bottle Refills:2 21. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:1 bottle Refills:2 22. syringes Sig: One (1) four times a day: low dose insulin syringes 1/2 cc, 30gauge needles. Disp:1 box Refills:2 23. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:1 box Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: ESRD now s/p living related kidney transplant perinephric hematoma DM II Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications, decreased urine output, weight gain of 3 pounds in 2 days, dizziness or if your incision is red/bleeding or draining You may shower, allow water to run over incision and pat dry. No tub baths or swimming until directed otherwise by the surgeon No heavy lifting Do not drive if taking narcotic pain medications Labwork to be drawn every Monday and Thursday. Labs are faxed to the transplant clinic at [Telephone/Fax (1) 697] Followup Instructions: [Name6 (MD) 2105] [Name8 (MD) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2199-9-6] 11:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2385], MD Phone:[Telephone/Fax (1) 2386] Date/Time:[2199-11-25] 10:20 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2199-7-23] 11:30 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2199-7-23] 12:45 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2199-8-1] 9:40 Please call [Telephone/Fax (1) 673] to schedule follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 1 week [Hospital ] Clinic [Telephone/Fax (1) 2490] follow up appointment on [2199-7-31] at 10:30 with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 27713] ([Last Name (un) 3911]) [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2199-7-19]	[ "585.6", "403.91", "V45.81", "V45.3", "V42.2", "250.40", "414.00", "998.12" ]	icd9cm	[ [ [] ] ]	[ "55.69", "00.91", "55.24", "55.23", "55.01", "99.71" ]	icd9pcs	[ [ [] ] ]	6540, 6599	1646, 4260	371, 422	6716, 6723	1403, 1623	7362, 8509	1075, 1105		4467, 6517		6620, 6695		4286, 4444			6747, 7339								1120, 1384																							273, 333									450, 825															847, 1022	1038, 1059
21,403	191,245	21660	Discharge summary	report	Admission Date: [2177-12-23] Discharge Date: [2178-1-3] Date of Birth: [2106-8-4] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 74 year old white female has been complaining of left parasternal pain, blurred vision, tinnitus, lightheadedness and dyspnea on exertion for a few weeks. At an outside hospital, she was ruled out for a cerebrovascular accident. She had an echocardiogram, which revealed an aortic valve area of 0.6 centimeter squared with an aortic valve gradient of 69 mmHg. She underwent cardiac catheterization on [2177-12-8], at [Hospital1 190], which revealed an ejection fraction of 70 percent, an 85 percent left anterior descending coronary artery lesion, a 60 percent right coronary artery lesion and aortic valve area of 0.65 centimeter squared and a mean gradient of 29 mmHg. She is now admitted for elective aortic valve replacement and coronary artery bypass graft. PAST MEDICAL HISTORY: History of cerebrovascular accident. History of peripheral vascular disease. History of breast cancer, status post radiation therapy in 09/[2166]. History of heart murmur. Status post right lumpectomy. Status post right carotid endarterectomy in [2174]. Status post right lower extremity bypass. ALLERGIES: She is allergic to Penicillin. She gets hives and gets anxiety from Demerol. MEDICATIONS ON ADMISSION: 1. Ambien 10 mg p.o. daily. 2. Norvasc 5 mg p.o. daily. 3. Lopressor 50 mg p.o. daily. 4. Protonix 40 mg p.o. daily. 5. Zocor 40 mg p.o. daily. 6. Pletal 100 mg p.o. twice a day. SOCIAL HISTORY: She lives with her husband, quit smoking twenty-five years ago and has a less than ten pack year history, and drinks alcohol rarely. FAMILY HISTORY: Significant for coronary artery disease. REVIEW OF SYMPTOMS: Positive for headaches, migraines, sinusitis, hard of hearing in the left ear. PHYSICAL EXAMINATION: On physical examination, she is an elderly white female in no apparent distress. Vital signs are stable, afebrile. Head, eyes, ears, nose and throat examination is normocephalic and atraumatic. Extraocular movements are intact. The oropharynx is benign. The neck was supple with full range of motion. No lymphadenopathy or thyromegaly. Carotids two plus and equal bilaterally with bilateral carotid bruits. The lungs are clear to auscultation and percussion. Cardiovascular examination is regular rate and rhythm, with IV/VI systolic ejection murmur, which radiated to the carotids. The abdomen was soft, nontender, with positive bowel sounds, no masses or hepatomegaly. Extremities were without cyanosis, clubbing or edema. Pulses were two plus and equal bilaterally throughout with the exception of her right dorsalis pedis and posterior tibial, which were one plus. Neurologic examination was nonfocal. HOSPITAL COURSE: When the patient was admitted, she reported that she had had a magnetic resonance imaging at [Hospital 1474] Hospital the week prior because of a question of a transient ischemic attack. Her surgery was canceled and she was admitted for a neurologic workup and to have her magnetic resonance imaging read by the neurologist. They said she had an old right parietal occipital infarct of unclear etiology and her left internal carotid artery stenosis was not related to that. She did have carotid duplex, which showed less than 40 percent right internal carotid artery stenosis and a 60 to 69 percent left internal carotid artery stenosis. She was cleared by neurology and on [2177-12-27], she underwent a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending coronary artery, reversed saphenous vein graft to the right coronary artery and diagonal with an aortic root enlargement and an aortic valve replacement with a 19 millimeter [Last Name (un) 3843]- [Doctor Last Name ] pericardial tissue valve. The cross clamp time was 176 minutes. Total bypass time was 199 minutes. She was transferred to the CSRU on Propofol in stable condition. She was extubated her postoperative night. On postoperative day number one, she was stable. Postoperative day number two, she had her chest tubes discontinued and she was transferred to the floor. She continued to have a stable postoperative course and had her epicardial pacing wires discontinued on postoperative day number three. On postoperative day number seven, she was discharged to home in stable condition. Her laboratories on discharge were hematocrit 32.7, white blood cell count 10.1, platelet count 217,000. Sodium 138, potassium 4.3, chloride 99, CO2 27, blood urea nitrogen 14, creatinine 0.9, blood sugar 111. MEDICATIONS ON DISCHARGE: 1. Potassium Chloride 20 mEq p.o. twice a day for seven days. 2. Colace 100 mg p.o. twice a day. 3. Aspirin 81 mg p.o. daily. 4. Protonix 40 mg p.o. daily. 5. Simvastatin 40 mg p.o. daily. 6. Lasix 20 mg p.o. twice a day for seven days. 7. Toprol XL 100 mg p.o. daily. 8. Vicodin one to two p.o. q4-6hours p.r.n. pain. 9. Ibuprofen 400 mg p.o. q8hours p.r.n. pain. 10. Ativan 0.5 mg p.o. q8hours p.r.n. 11. Pletal 100 mg p.o. twice a day. FO[Last Name (STitle) 996]P: She will be followed by Dr. [Last Name (STitle) 1299] in one to two weeks and by Dr. [Last Name (Prefixes) ] in four weeks. DISCHARGE DIAGNOSES: Coronary artery disease. Aortic stenosis. Peripheral vascular disease. Cerebrovascular accident. Transient ischemic attack. Hypertension. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) 18588] MEDQUIST36 D: [2178-1-3] 13:14:05 T: [2178-1-3] 14:11:35 Job#: [Job Number 56981]	[ "V10.3", "280.9", "414.01", "433.30", "401.9", "440.21", "V17.4", "435.9", "V15.82", "424.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "35.21", "99.05", "99.07", "36.15", "99.04", "36.12", "89.61", "89.68", "39.61", "89.64" ]	icd9pcs	[ [ [] ] ]							1745, 1888	5364, 5763				4724, 5342	1396, 1577	2849, 4698																								1911, 2831																		164, 945															968, 1370	1594, 1728
77,427	163,354	34931	Discharge summary	report	Admission Date: [2139-11-18] Discharge Date: [2139-12-15] Date of Birth: [2077-8-1] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 6346] Chief Complaint: Nectrotizing Fascitis of the LLE and groin. Major Surgical or Invasive Procedure: Operative debridement of Necrotizing fascitis on [11-18]. Second operative debridemnet of necrotizing fascitiis [11-18]. Bedside debridement of Leg wound. Picc line placment. History of Present Illness: 62M transfered from outside hospital with nectrotizing fascitis. Patient was seen at OSH two days ago with "boil" on left leg and was discharged home (unknown whether he was treated with Abx). Patient reports the erythema has spread over last two days and has become painful. Patient presented to OSH ED today secondary to shortness of breath and dysnea. Upon arrival to OSH patient was found to be hypotensive and a soft tissue skin infection was apparent on the left leg. Patient was given Zosyn and Clindamycin, started on Levophed and transferred to [Hospital1 18]. Past Medical History: PMH: DM, COPD, HTN, Hyperlipidemia PSH: Right knee surgery Social History: Tobacco: 1ppd EtOH/drugs: negative Family History: NC Physical Exam: On admission: VS: T 98.0 P 107 BP 95/71 (on levophed) RR 20 O2 98% NC PE: Gen - alert and oriented CV - Tachycardic, no murmurs Pulm - clear to ascultation bilaterally Abd - S/NT/ND, no rebound/guarding GU - Diffuse erythema over scrotum and left inner thigh, with erythema extending below the knee. Skin necrosis found along left inner thigh with multiple skin blisters Pertinent Results: [11-22] CTA; Bibasilar effusions, no definite evidence for pulmonary embolism. Nasogastric tube terminating in the upper stomach, with a sidehole noted at the gastroesophageal junction. [11-26] Echo: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Left atrial enlargement. LVEF 55%. [12-7] CTA: Multifocal segmental and subsegmental pulmonary emboli Improved bilateral small pleural effusions and bilateral lower lobe atelectasis. Small bilateral pulmonary nodules. Left thyroid nodule for which ultrasound is recommended if not already worked up elsewhere. Fatty liver. [12-8] LE U/S: No deep venous thrombosis in the right lower extremity. Limited evaluation of the left lower extremity due to wound vac, no distal thrombus. Brief Hospital Course: [11-18] PT admitted to surgery for nectrotizing skin infection of left leg and sepsis. PT went to OR for debridement. Broad spectrum Abx ( meropenem, Vancomycin and Clindamycin, Flagyl) and IVF resuscitation started. Patient post op pt remained intubated and was transferred to the ICU. Taken back to the OR for further debridment and [Last Name (un) 7162] kept intubated. Infectious disease was consulted. [11-19]: Started vasopressin, placed SVO2 & Quinton cath, bolused bicarb and maintained on bicarbonate gtt. Coagulase negative Staph, Ecoli, Strep ciridans, and Corneybacterium diptheria were cultured from the wound. [11-20]: Renal consulted for Acute renal failure creatinine wtih peak of 4.7. Hd ccathete placed. Pt was rehydrated with NS, All meds were renally dosed. Wound vac applied to wound. [11-21]: Vancomycin q12, Meropenem q6, off vasopressin, HD cath d/c'd. [11-22]: Off levo, acute desat to 84-88%, hypotensive, resumed levo gtt. CTA of the chest performed showed no no PE, moderate b/l pleural effusions. [11-23]: 1/2NS changed to LR, vac changed . [11-24]: Trophic TF started, inc vanc to 1.25 q12 for trough 10.2. Wound care team consulted. [11-25]: Advanced TF, PT given 25% albumin x 3, d/c clinda at the reccommendation of ID. [11-26]: D/c vanc, started dapto, Lasix gtt, [Last Name (un) ] stim test neg. Bedside debridment of necrotic tissue at edge of wound. Plastic surgery consulted re possible flap coverage. Still on pressors. [11-27]: TSH 1.8, Lasix gtt on hold, switched to CPAP + PS [11-28]: Restart Lasix gtt, weaned PS . C difficile checked. [11-29]: A fib with RVR. PT given esmolol and converted spontaneously, trop neg x 2. Cardioloy consult. [11-30]: Extubated, restarted home BB, TTE eprformend w/ LVEF>55%. Per cardiology antiarrythmics held. Pressors continued to wean. [12-1]: Lasix gtt -> 20''', acetazolamide x2, restarted home statin, glyburide, Haldol prn agitation, PICC placed by venous access team. PT consulted for therapy. [12-2]: Lasix 20', d/c acetazolamide, restarted omeprazole [12-3]: [Hospital ] transferred to the floor. Agitated o/n given Haldol x 3 doses. [12-5]: CXR perforemed. Patient continued to be agitated. [12-6] Psychiatry consult: Recs for infection workup and Serum tox screen. Replete thiamine, folate. [12-7] Pt triggered on the floor for SaO2 <90%. PT transferred to the ICU, intubated. CTA chest showed B/l RUL and LUL subsegmental PE. Heparin GGT was started. Plan to skin graft with plastic surgery delayed by anticoagulation. [Date range (1) 25351]: Heparin ggt, Intubated. [12-10]: antibiotics d/c'd ; PT evaluation, lopressor frequency increased TID, PO feeds started and tolerated well, arterial line d/c. Vascular surgery cnsulted regarding IVC filter (decided against placement). [12-11]: Pt extubated. Bridged to coumadin. Transferred to the floor. [Date range (1) 35672]: Pt advanced to regular diet. Mental status cleared. Pt therapuetic on coumadin. Heparin dc'd on the [2142-12-13]: Foley dc'd, Vac changed. Rehab screening. Pt discharged to rehab VSS, Afebrile, Pain well controlled with Po pain medications, off antibiotics, with normal WBC count. Plan to follow up with plastic surgery for skin grafting. Medications on Admission: Lovastatin 20', Lisinopril 20', Metoprolol 25'', ISDN 30', Albuterol, Ipatropium, Combivent, Glyburide 5AM, 2.5HS, Omeprazole 40', Advair 250/50'', [Doctor First Name ] 60'', Ibuprofen 800'', Nicotine Patch Discharge Medications: 1. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:60 Capsule(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 10. 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. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehabilitation Discharge Diagnosis: Left thigh/groin necrotizing fascitis; sepsis, septic shock, Acute renal failure, Pulmonary embolism. Discharge Condition: VSS, Wound vac in place. Pain controlled on Po pain meds. Tolerating a regular cardiac diet. Discharge Instructions: General: * Please look at the wound site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. -Maintain the site clean, dry, and intact. -Avoid swimming, baths, hot tubs-do not submerge yourself in water. -Keep drain attached safely to body to prevent pulling Please call your doctor or return to the ER for any of the following: Increased pain, and erythema of your leg wound. * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: 1. Please Call to schedule follow up with Dr. [First Name (STitle) 2819] in 1 -2 weeks.([Telephone/Fax (1) 6347]. 2. Please follow up with plastic surgery in 1 week [Telephone/Fax (1) 4652]. 3. Please call your primary care to schedule follow up. Completed by:[2139-12-15]	[ "415.19", "276.2", "250.00", "584.9", "496", "995.92", "272.4", "038.9", "682.6", "728.86", "278.01", "401.9", "785.52" ]	icd9cm	[ [ [] ] ]	[ "96.6", "83.39", "38.93" ]	icd9pcs	[ [ [] ] ]	8160, 8221	2539, 5875	317, 502	8367, 8463	1700, 2516	10150, 10441	1258, 1262		6137, 8137		8242, 8346		5901, 6114			8487, 10127								1277, 1277																							233, 279									530, 1106							1292, 1681								1128, 1189	1205, 1242
75,618	110,754	13786	Discharge summary	report	Admission Date: [2102-1-13] Discharge Date: [2102-1-15] Date of Birth: [2017-10-29] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / gabapentin Attending:[First Name3 (LF) 30] Chief Complaint: Need for peritoneal dialysis Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 4135] is an 84 yo M with AF on warfarin, CAD s/p CAB, ESRD on peritoneal dialysis, polyneuropathy, and other medical issues transferred from [Hospital ] Hospital for peritoneal dialysis and recent intraventricular hemorrhage [3-16] fall. . Patient states frequent falls, every other week since back surgery in [2096]. He reports a fall about 10 days ago and caused posterior scalp laceration s/p stapling. His INR was not checked and he had not had Coumadin dose changed for the past several months. He states taking warfarin 4 mg daily except for Friday when he takes 7 mg. About 4 days prior to admission, staples were removed, but has been oozing. He noticed that his pillow was stained with [Last Name (LF) ], [First Name3 (LF) ] he went to [Hospital ] Hospital to get suture where his INR was found to be 9.2 and 10 point Hct drop compared to about 1 week prior. Per report, he received FFP and vitamin K there. However, since [Location (un) ] does not do PD and his wife has not been able to help him with it due to recent hospitalization (d/c'ed home yesterday), he is transferred to [Hospital1 18]. . In the ED, initial VS were: 98.4 60 139/60 16 98% 2L Nasal Cannula. Guaiac negative. He received 1 unit of pRBC, 10 mg IV vitamin K, and about 500 cc NS. Labs were drawn right after the pRBC with Hct 22 and INR of 2.2. CT head showed a small left intraventricular bleed in the posterior [Doctor Last Name 534]. Neurosurgery felt that patient did not require any surgical intervention. Per ED, neurology thought patient was stable. Renal was contact[Name (NI) ] and felt that he could get PD tomorrow. Has 18G x2 IV on the right arm. VS upon transfer were 98.2, 77, 140/63, 18, 95% RA. . On arrival to the MICU, currently feeling well. He states that he falls at least once but no more than 5 times a month. He thinks it is a balance problem, but would lose consciousness and find himself on the ground. He denies prodrome or post-ictal symptoms. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. He denies tingling, numbness, diplopia. Past Medical History: - CAD s/p CABG - Afib on Coumadin - HTN - HLD - ESRD on peritoneal dialysis - Chronic LBP s/p discectomy in [2096] - Chronic anemia - h/o strokes - BPH s/p TURP - psoriasis - carotid stenosis, most recent carotid ultrasound in [12/2101] - h/o GIB - T2DM - anxiety Social History: Lives at home with wife who is the HCP and next of [Doctor First Name ]. Retired engineer. No smoking hx. Rare alcohol use Family History: No premature CAD, brother and sister with DM. DM in aunt, sisters, and brother Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T98.8 HR 76, BP 132/51, RR 21, O2Sat 94% RA General: Alert, oriented, no acute distress HEENT: + hematoma in the posterior occipital scalp, s/p suture, sclera anicteric, PERRLA, MMM, OP clear Neck: supple, JVP not elevated, no LAD, + carotid bruits L>R CV: irregularly irregular, normal S1 and S2, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, dialysis line in place, area clean without erythema or drainage GU: no foley Ext: warm, well perfused, 1+ pulses, no edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, diminished sensation to light touch in the left foot, gait deferred . Pertinent Results: ADMISSION LABS: [2102-1-13] 08:45PM [Month/Day/Year 3143] WBC-9.2 RBC-2.32# Hgb-7.3# Hct-22.5# MCV-97# MCH-31.2# MCHC-32.2 RDW-14.3 Plt Ct-290 [2102-1-13] 08:45PM [Month/Day/Year 3143] Neuts-75.0 Lymphs-16.0* Monos-4.7 Eos-4.1* Baso-0.2 [2102-1-13] 08:45PM [Month/Day/Year 3143] PT-23.4* PTT-31.6 INR(PT)-2.2* [2102-1-13] 08:45PM [Month/Day/Year 3143] Glucose-192* UreaN-52* Creat-5.4# Na-144 K-3.7 Cl-100 HCO3-33 AnGap-15 [2102-1-14] 06:25AM [Month/Day/Year 3143] Calcium-8.0* Phos-3.6 Mg-1.8 [2102-1-14] 11:38AM [Month/Day/Year 3143] Type-ART pO2-81* pCO2-46* pH-7.48* calTCO2-35* Base XS-9 Intubat-NOT INTUBA . IMAGING: [1-13] CT HEAD: FINDINGS: A small amount of intraventricular hemorrhage layers posteriorly in the occipital [Doctor Last Name 534] of the left lateral ventricle. No additional intra- or extra-axial hemorrhage is identified. Ventricular dilatation is unchanged since [2096], with prominence of the sulci, likely due to atrophy. Focal hypodensities in the right thalamus and left lentiform nucleus are unchanged since [2096], and likely reflect lacunes. Confluent periventricular and subcortical white matter hypoattenuation is compatible with the sequela of chronic microvascular infarction. A large posterior parietal subgaleal hematoma is present. No fractures are seen. Visualized paranasal sinuses and mastoid air cells are well aerated. Calcification of the cavernous carotid arteries is present. IMPRESSION: Small amount of intraventricular hemorrhage in the occipital [Doctor Last Name 534] of left lateral ventricle. Large posterior parietal subgaleal hematoma. . [1-14] CXR: IMPRESSION: 1. Status post median sternotomy for CABG with stable cardiac enlargement and calcification of the aorta consistent with atherosclerosis. Relatively lower lung volumes with no focal airspace consolidation appreciated. Crowding of the pulmonary vasculature with possible minimal perihilar edema, but no overt pulmonary edema. No pleural effusions or pneumothoraces. Brief Hospital Course: Mr. [Known lastname 4135] is an 84 year old male with end-stage renal disease (ESRD) on peritoneal dialysis (PD), atrial fibrillation (AFib) on warfarin, coronary artery disease (CAD) status post bypass surgery who presented with intraventricular bleed transferred to MICU for neurological monitoring. . ACTIVE ISSUES BY PROBLEM: # Intraventricular bleed was secondary to recent fall in the setting of being on warfarin and with supratherapeutic INR. Based on CT head without contrast. [Month (only) 116] have some mild sensation deficit in the LE L>R, could be chronic given underlying diabetes. Currently asymptomatic and stable from intraventicular bleed. He did recieve one unit packed RBCs before transfer and his hematocrit was maintained above 25. His warfarin was held and he was given vitamin K which brought his INR to therapeutic levels quickly. Neurosurgery was consulted and they recommended that he be closely monitored. He was discharged with instructions to continue antiepileptic, dilantin x 10days and to follow up with neurosurgery clinic in [5-18] weeks with repeat head imaging. Given multiple falls, would not recommend restarting anticoagulation. . # Anemia: Likely chronic in nature with acute intraventricular bleed as mentioned above. Recieved one unit packed RBCs and warfarin was held. . # Falls/Syncope: Based on history, concerning for cardiogenic arrhythmia given no prodrome with drop attacks in the setting of underlying CAD requiring CABG. Also could be due to gait instability from peripheral neuropathy from T2DM. Also, patient had history of CVA and has carotid stenosis, although symptoms unlikely from TIA. Monitored on tele with no significant arrhythmias. PT saw patient and felt that he could safely be discharged home with services. . # ESRD on PD: Creatinine at 5.4. No significant electrolyte derangement at this time. He did continue on PD while an inpatient. Continued renal cap and calcitriol. He gets epo 20,000 unit every other week. Followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Hospital1 ], [Telephone/Fax (1) ] as an outpatient . # Chronic AF: High risk for bleed given frequency of falls/syncopes; however, with CHADS 5 is also at high risk of stroke. Given ICH, warfarin was stopped and coagulopathy was aggressively reversed in the ED. At time of discharge, INR was 1.0. Decision whether to resume anticoagulation was deferred to cardiologist but is strongly not recommended given frequent falls. at this time. . # CAD s/p CABG/HTN/HLD (hypertension and hyperlipidemia): Continued home Diovan, isosorbide, furosemide, amlodipine. Would recommend switching simvastatin to atorvastatin 40 mg given higher risk of rhabdo with simvastatin on amlodipine. . # Diabetes mellitus type 2 (T2DM): On insulin, continued home regimen. . # Anxiety: continued citalopram 20 mg as at home . TRANSITONAL ISSUES: ICH: antiepileptic x 10 days, follow up with head imaging in neurosurgery clinic in [5-18] weeks afib: stopped coumadin given recent ICH, will need to discuss possible initiation of antiplatelts Medications on Admission: - Diovan 160 mg [Hospital1 ] - isosorbid 30 mg daily - furosemide 40 mg [Hospital1 ] - simvastatin 80 mg daily - amlodipine 10 mg daily - calcitriol 0.25 every other day - renal cap daily - folic acid daily - B6 100 mg daily - vitamin D 1000 IU daily - 20 mg citalopram - ISS with Humalog - 12 units of Lantus qHS - tums 1 TID - Epo 20,000 unit every other week - Ferrex without food daily - warfarin 4 mg every day except Friday, 6 mg on Friday Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. insulin aspart 100 unit/mL Solution Sig: per sliding scale Subcutaneous per sliding scale. 13. phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) for 9 days. Disp:27 tablets Refills:0 14. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) ] Vna Discharge Diagnosis: Primary Diagnosis: intraventricular hemorrhage supratherapeutic INR mechanical fall Secondary Diagnosis: atrial fibrillation end stage renal disease on peritoneal dialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 4135], You were admitted to the hospital after a fall with [Known lastname ] in your brain. You were seen by the neurosurgeons, your coumadin was stopped and you were given products to reverse your [Known lastname ] thinning. The bleeding in your head stopped but you will need to take medications to prevent seizure for the next 9 days. You will also need to follow up with the neurosurgery team with a repeat CT scan of your head in the next 4 -6 weeks. Please make the following changes to your medication regimen: STOP coumadin. Do NOT restart this medication. Talk to your cardiologist about other options, like aspirin, for your atrial fibrillation START dilantin 100mg three times daily for the next 9 days (end date [2102-1-24]) Please take all of your other medications as previously prescribed Followup Instructions: Follow up in [Hospital 4695] clinic in [5-18] weeks with a repeat head CT at that time and appointment with Dr. [Last Name (STitle) ]. Call [Telephone/Fax (1) 1669] to schedule. Follow up with cardiologist on Monday, [1-16] as previously scheduled Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ], in the next 1-2 weeks. Call [Telephone/Fax (1) 41459] to schedule an appointment	[ "851.80", "585.6", "790.92", "403.91", "285.21", "V56.8", "E888.9", "V45.81", "357.2", "427.31", "272.4", "285.1", "250.60", "V58.67", "300.00", "E934.2", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "54.98" ]	icd9pcs	[ [ [] ] ]	11342, 11397	6333, 9467	347, 353	11614, 11614	4247, 4247	12670, 13142	3386, 3467		9973, 11319		11418, 11418		9493, 9950			11796, 12647								3507, 4228																			2440, 2929				279, 309									381, 2421		4944, 6310	11524, 11593		4263, 4935	11437, 11503			11629, 11772						2951, 3225	3241, 3370
12,302	141,429	12302	Discharge summary	report	Admission Date: [2180-11-4] Discharge Date: [2180-11-24] Date of Birth: [2119-2-13] Sex: M Service: SURGERY Allergies: Iodine / Heparin Agents Attending:[First Name3 (LF) 695] Chief Complaint: Thrombosis of distal branch of right portal vein Major Surgical or Invasive Procedure: L 3 Kyphoplasty [2180-11-16] History of Present Illness: Mr. [Known lastname 1140] is a 61M s/p a simultaneous liver and kidney transplant in [2180-2-10]. He was recently hospitalized and had a portal vein shunt placed on [2180-10-10] for portal vein stenosis. On Wednesday [2180-11-2] he states that he experienced the acute onset of sharp, constant, 7 out of 10 left flank pain that radiates down his left side and to his anterior abdomen. He denies any recent trauma or strenuous exertion. Turning his upper body aggravates the pain and tylenol relieves the pain. He underwent a CT scan the next day that revealed a thrombosed distal branch of the right portal vein. No ascites or focal hepatic lesions were seen. No hernias were seen. He denies dyspnea and chest pain. He denies fevers, chills, nausea, vomiting, and diarrhea. He is able to tolerate food. He denies dysuria and hematuria. Past Medical History: -alcoholic cirrhosis -diabetes -hypertension -mild pulmonary artery hypertension -CRI (Baseline Cr. 2.0 up to 2.4) -vitamin B12 deficiency -rectal adenoma -herniated lumbar disk -gastritis -hyperkalemia Social History: Mr. [Known lastname 1140] lives alone in [Hospital3 ]. He quit smoking 16 years ago. He has been sober for 11 years. Family History: -F: Committed suicide at age 34 -M: Colon CA, doing well Physical Exam: VS: Temp 98.1, HR 86, BP 102/60, RR 20, O2 Sat 100% on room air Gen: Alert and oriented, no acute distress, comfortable HEENT: NC/AT, anicteric sclera, mucus membranes moist Neck: no lymphadenopathy CV: RRR, no murmurs, gallops, or rubs Pulm: clear bilaterally Abd: soft, nontender, nondistended, well healed incisions, no CVA tenderness, no palpable masses Ext: no edema, no calf tenderness, 2+ distal pulses Pertinent Results: Admission Labs: [2180-11-4] WBC-2.5* RBC-3.64* Hgb-11.9* Hct-34.4* MCV-94 MCH-32.7* MCHC-34.6 RDW-15.9* Plt Ct-71* PT-14.6* PTT-35.0 INR(PT)-1.3* Glucose-143* UreaN-24* Creat-1.3* Na-141 K-4.4 Cl-107 HCO3-27 AnGap-11 ALT-43* AST-25 AlkPhos-74 Amylase-39 Lipase-8 TotBili-0.4 Albumin-3.9 Calcium-9.1 Phos-2.9 Mg-1.3* [2180-11-24] 09:10AM BLOOD WBC-2.2* RBC-3.23* Hgb-10.1* Hct-29.8* MCV-92 MCH-31.4 MCHC-34.0 RDW-15.6* Plt Ct-105* [2180-11-24] 09:10AM BLOOD Glucose-224* UreaN-25* Creat-1.2 Na-140 K-4.2 Cl-105 HCO3-29 AnGap-10 [2180-11-24] 09:10AM BLOOD ALT-45* AST-33 AlkPhos-122* Amylase-25 TotBili-0.6 [2180-11-23] 06:00AM BLOOD FK506-13.8 MR L SPINE W/O CONTRAST [2180-11-8] 9:00 PM FINDINGS: There is a new compression deformity of the L3 vertebral body (approximately 25% decrease in height) with low signal on T1 and increased signal on STIR imaging, indicating acute etiology. Other chronic compression deformities and degenerative changes are noted. Specifically, at T12-L1, there is a mild posterior disc bulge, but no central cord stenosis or neural foraminal narrowing. There is a chronic anterior compression deformity of the L1 vertebral body with approximately 50% loss of height, unchanged from [2180-10-10]. At the L1-L2 level, there is a mild posterior disc bulge, but no central canal or neural foraminal stenosis. There is a large Schmorl's node along the superior endplate of the L2 vertebral body, unchanged. At L2- L3, there is eccentric left broad-based posterior disc bulge resulting in mild left neural foramen narrowing, there is no central canal stenosis. A compression deformity at L3 as described above. At L3-L4, there is a moderate posterior disc bulge with unfolding of the ligamentum flavum that together cause moderate canal stenosis. There is severe bilateral neural foraminal stenosis. At L4-L5, again there is moderate central canal stenosis secondary to a moderate broad-based posterior disc bulge and thickening of the ligamentum flavum as well as moderate right and severe left neural foraminal stenosis. At L5-S1, there is mild central canal stenosis secondary to mild posterior disc bulge and thickening of the ligamentum flavum and severe bilateral neural foraminal stenosis. There is mild facet hypertrophy from L2- L5. The left psoas muscle is expanded by an intramuscular hematoma. The spleen appears enlarged, but visualization is limited. Please see the CT torso from same day for further details. IMPRESSION: 1. New acute L3 compression deformity. 2. Multilevel degenerative changes that are most severe from L3-S1 with mild- to-moderate canal stenosis and moderate-to-severe neural foraminal narrowing. 3. Chronic L1 compression deformity. 4. Left psoas hematoma. 5. Possible splenomegaly. Brief Hospital Course: Mr. [Known lastname 1140] was admitted on [2180-11-4] after a CT scan of his abdomen, obtained for a chief complaint of left flank pain radiating into his abdomen, revealed that a distal branch of his right portal vein was thrombosed. He was started on therapeutic Lovenox, which for him is 80mg SC injection [Hospital1 ]. On HD2 he stated that the pain now radiated down into his left testicle. On CT scan he does have a non-occlusive renal calculus in his left native kidney. A urinalysis was obtained, which was negative. No blood was seen on microscopic exam. Pelvic and hip plain films were also obtained which were negative. This pain is likely musculoskeletal in origin. He was started on a lovenox bridge and coumadin 5mg for the thrombus in his distal right portal vein. On [2180-11-8] it was noted that his LFT's were starting to trend upwards and a liver biopsy was planned. Coumadin and Lovenox were placed on hold. On that same morning, the patient had an episode of dizziness while shaving and fell in the patient bathroom. He did hit his head and had a scalp laceration that required 4 staples. He was found to be hypotensive so he received a fluid bolus of 3 liters, 1 unit of RBC's and was transferred to the ICU for further care. He underwent total body CT to evaluate for bleeding. Head CT showed no intracranial hemorrhage. In addition, body CT showed a small left retroperitoneal hematoma, no evidence of pulmonary embolism, no significant change in thrombosis of one of the distal right portal vein branches, and a patent portal vein stent. He was also evaluated by Ortho trauma due to continued complaints of back and hip pain. An MRI of his spine was obtained and revealed that he had a compression fracture of L3, although it is unclear if this was acute. He was initially treated conservatively with pain management and was fitted for a LSO brace. On [2180-11-10] the patient was finally able to undergo the liver biopsy. This was done as a transjugular biopsy with no complications. Biopsy results showed features consistent with mild/partially treated acute cellular rejection. It was decided per the transplant team to increase Prograf dosing and not use pulse steroids. In addition he was followed throughout by [Last Name (un) ] for his erratic blood sugars. He continued to have back pain that radiated into his right leg and was found to be unable to put on his LSO brace by himself. He was seen again by Ortho on [11-14] and requested the kyphoplasty procedure. He underwent successful kyphoplasty of L3 on [2180-11-16]. Immediately after the procedure his back pain improved. On POD1 he was re-evaluated by physical therapy and they recommended continuation of physical therapy. He was now having pain in the right hip that was interfering with ambulation, as well he was unable to raise his right leg. He was seen again by the spine service. He underwent a LENI evaluation negative for DVT, pain most likely due to known history of spinal stenosis and compression fractures. Pain management continued to be an issue, patient very reluctant to take PO pain medication due to his fear of becoming addicted. He was counseled regarding ths issue by several members of the transplant team. He was unable to be placed at a rehab facility due to insurance issues. PT cleared him for home after he ambulated 80 feet on [11-23]. Medications on Admission: 1. ASA 81mg daily 2. Bactrim SS daily 3. Cellcept 500mg [Hospital1 ] 4. Florinef 0.1mg daily 5. Gabapentin 300mg TID 6. Humalog SSI 7. Humulin NPH 20units Qam, 14units Qpm 8. Prednisone taper: 10mg ([Date range (1) 38383]), 5mg ([Date range (1) 9649]) 9. Prograf 3mg [Hospital1 ] 10. Protonix 40mg daily 11. Valcyte 900mg daily Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. Disp:10 Suppository(s) Refills:0 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:300 ml Refills:0 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:75 Tablet(s) Refills:0 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous once a day. Disp:15 ml Refills:2 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Nine (9) units Subcutaneous at bedtime. Disp:15 ml Refills:2 14. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:15 ml Refills:2 15. Mycophenolate Mofetil 250 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:180 Capsule(s) Refills:2 16. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 ] Senior Healthcare - [Location (un) 38384] Discharge Diagnosis: Thrombosis of distal branch of right portal vein Compression fracture L3 Discharge Condition: Fair Discharge Instructions: Call the transplant office at [Telephone/Fax (1) 673] if: - you experience a fever > 101.0 - have nausea, vomiting, or diarrhea - unable to take or keep down medications - problems with urination - any infections - persistent or worsening back/hip pain not relieved by your medications Continue outpatient labwork per the transplant clinic recommendations. Followup Instructions: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2180-11-29] 1:30 ORTHO XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2180-11-29] 1:10 Please call transplant clinic to make a follow up appointment [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709]	[ "805.4", "V18.0", "V16.3", "V16.43", "729.5", "287.4", "V42.0", "996.82", "250.80", "V15.82", "V11.3", "E888.9", "593.9", "401.9", "V16.0" ]	icd9cm	[ [ [] ] ]	[ "00.33", "50.13", "99.04", "81.66" ]	icd9pcs	[ [ [] ] ]	10675, 10764	4958, 8366	333, 368	10881, 10888	2151, 2151	11300, 11749	1647, 1705		8761, 10652		10785, 10860		8392, 8738			10912, 11277								1720, 2132																							244, 295									396, 1259					2167, 4935										1281, 1486	1502, 1631
66,804	151,537	41912	Discharge summary	report	Admission Date: [2166-10-23] Discharge Date: [2166-10-25] Date of Birth: [2112-12-23] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: MVC Major Surgical or Invasive Procedure: none History of Present Illness: 56 yo F s/p single car MVC with significant damage to passenger side of vehicle. Pt has history of depression, was found with multiple pill bottles in the car, as well as suicide note. In the field, pt resposive, moving all extremities. On arrival to the [Name (NI) ], pt not speaking or breathing. Intubated for airway protection. FSG normal. EKG unremarkable. ETOH level 212, tox screen otherwise negative. Imaging showed no acute process. Pt given activated charcoal via OGT for possible overdose. Pills found in her belongings included seroquel, amphetamine, citalopram, metadate (methylphenidate). Past Medical History: unknown Social History: unknown Family History: unknown Physical Exam: 97.8, 76, 112/70, 18, 97 % room air alert, oriented, flat affect RRR CTA BL abdomen soft nontender nondistended no peripheral edema Pertinent Results: [2166-10-23] CT C-spine FINDINGS: No acute cervical spine fracture or malalignment is present. Mild degenerative changes are present with disc osteophyte complexes at C5-C6 causing mild canal narrowing at these levels. Pre- and paravertebral soft tissues are not thickened. Retained secretions in the nasopharynx are likely secondary to recent intubation. The visualized lung apices are clear. [2166-10-23] CT Head: FINDINGS: No acute intracranial hemorrhage, major vascular territorial infarction, edema, or shift of normally midline structures is present. The ventricles and sulci have normal size and configuration. Secretions in the nasopharynx are likely secondary to recent intubation. Minimal mucosal thickening is seen in the ethmoid sinuses. Mastoid air cells are well pneumatized. No acute fracture is seen [2166-10-23] CT abdomen/pelvis: IMPRESSION: 1. No evidence of acute traumatic injury in the torso. 2. Bibasilar opacities consistent with aspiration which may be related to recent intubation. 3. Apparent filling defect in the SMV is most consistent with mixing artifact rather than thrombosis. [2166-10-23] CT chest: IMPRESSION: 1. No evidence of acute traumatic injury in the torso. 2. Bibasilar opacities consistent with aspiration which may be related to recent intubation. 3. Apparent filling defect in the SMV is most consistent with mixing artifact rather than thrombosis. Brief Hospital Course: The patient was brought to [Hospital1 18] after her MVC. She had a GCS 15 but was reportedly apneic in the truama bay so was intubated and tranferred to the TSICU. In the TSICU she was hemodynamically stable and extubated uneventfully. She was then transferred to the hospital floor. She had a 1:1 sitter throughout her stay on the floor. Her foley was removed, she voided, tolerated a diet, and vitals remained stable. On [10-25] in the morning, her sitter observed the patient grab her personal belongings and ingest three pills from her large bag of multiple prescription bottles and loose pills. It is unclear why the patient had access to her belongings and why she was not stopped. She ingested three of her "daily pills" per patient but we could not confirm which pills they were. She remained hemodynamically stable and was asymptomatic. Physical exam was unremarkable. The patient was reevaluated by psychiatry who arranged for a transfer to the inpatient psychiatry floor for continued management. Medications on Admission: unknown Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: MVC Suicide attempt Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ] has not sustained any injuries from her recent suicide attempt. She does not require follow up with the surgical service. We recommend close psychiatric monitoring to address her suicidality as well as her polypharmacy and alcohol use and follow up with her primary care provider after discharge from psychiatry inpatient Followup Instructions: Psychiatry inpatient care Primary Care Provider after discharge from psychiatry [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2166-10-25]	[ "305.1", "780.97", "E816.0", "786.03", "305.70", "305.00", "E958.5", "314.01", "507.0", "305.40", "296.90" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	4125, 4170	2641, 3659	309, 315	4234, 4234	1201, 1617	4758, 4977	1025, 1034		3717, 4102		4191, 4213		3685, 3694			4385, 4735								1049, 1182																							266, 271									343, 953		1626, 2618							4249, 4361						975, 984	1000, 1009
25,777	135,680	13147+56425	Discharge summary	report+addendum	Admission Date: [2121-9-22] Discharge Date: [2121-11-4] Date of Birth: [2058-10-21] Sex: M Service: ADDENDUM There were no major changes in the patient's course between previous discharge summary and this addendum. The patient continued on slow CPAP vent wean without much progress. There were several discharge medication changes, including the patient's Protonix which was discontinued. The patient was started on Prevacid 30 mg per PEG q.d. The patient's Lopressor was increased from 25 mg b.i.d. to 50 mg b.i.d. The patient was started on Multivitamin 1 tab q.d., K-Dur 20 mEq per PEG q.other day, Calcium Carbonate 750 mg per PEG b.i.d., and Magnesium Oxide 800 mg per PEG q.d. The rest of the patient's discharge medications remained the same. DISCHARGE DIAGNOSIS: The same. DISPOSITION: The patient was discharged on [2121-11-4], to rehabilitation. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 13625] Dictated By:[Last Name (NamePattern1) 33441] MEDQUIST36 D: [2121-11-4] 12:00 T: [2121-11-4] 11:57 JOB#: [Job Number 40130] Name: [Known lastname 7203], [Known firstname ] Unit No: [Numeric Identifier 7204] Admission Date: [2121-9-22] Discharge Date: [2121-10-30] Date of Birth: [2058-10-21] Sex: M Service: AGE: 62. HISTORY OF THE PRESENT ILLNESS: This is a 62-year-old male with a past medical history of type 2 diabetes mellitus and coronary artery disease. The patient presented with substernal chest pain to [Hospital1 536] on [2121-9-22]. The patient was found subsequently to rule in for an acute myocardial infarction with troponin I levels peaking at greater than 50. The patient went to the Cardiac Catheterization Laboratory. Cardiac catheterization showed severe three-vessel disease. The patient was referred to the Cardiac Surgery Service for coronary revascularization. PAST MEDICAL HISTORY: Type 2 diabetes mellitus currently treated with Insulin. MEDICATIONS: 1. Insulin, preoperatively. 2. Claritin, preoperatively. ALLERGIES: The patient is allergic to ASPIRIN and PENICILLIN, both of which give the patient hives. SOCIAL HISTORY: The patient denied history of tobacco use, alcohol use. The patient is single and lives with his sister. FAMILY HISTORY: The patient has a family history with a brother, who has coronary artery disease status post myocardial infarction at the age of 40. PHYSICAL EXAMINATION: Examination on admission revealed the following: Temperature 100.7; blood pressure 154/91; pulse 97; respiratory rate 24; saturation 95% on three liters nasal cannula. GENERAL: The patient is alert, mildly tachypneic, in no acute distress. HEAD: Examination was unremarkable. NECK: Without JVD. CHEST: Chest was clear to auscultation bilaterally without crackles or wheezes. CARDIOVASCULAR: Regular, normal S1 and S2; no murmurs appreciated. ABDOMEN: Abdomen was soft, nontender, and nondistended; no masses or hepatosplenomegaly noted. EXTREMITIES: Warm with 2+ dorsalis pedis pulses bilaterally; no edema. NEUROLOGICAL: Nonfocal. RECTAL: Rectal examination showed trace-positive guaiac. HOSPITAL COURSE: The patient was initially admitted to the Medical Service. He underwent cardiac catheterization, which showed severe three-vessel disease with a preserved ejection fraction of 50%. The patient subsequently underwent CABG times five on [2121-9-26], LIMA to the LAD, and saphenous vein grafts to obtuse marginal, diagonal, PLE, and PDA. The surgeon was Dr. [First Name (STitle) ]. The patient tolerated the operation well. Of note, the patient's preoperative testing revealed mildly elevated LFTs of unknown etiology. The preoperative pulmonary function tests also showed moderate to severe restrictive pattern, again, of unknown etiology. Postoperatively, the patient's course was complicated initially by respiratory failure requiring re-intubation, initially thought to be secondary to upper-airway edema. The patient's chest tubes and pacing wires were removed earlier in the patient's postoperative course. However, he continued to have respiratory failure requiring mechanical ventilation. The [Last Name (un) 616] Diabetes Service was consulted for the patient's diabetes management and he required Insulin drip intermittently throughout his hospital course. The Pulmonary Service was consulted on the [9-29]. The patient then underwent bronchoscopy, which showed very few thick secretions in the proximal airways, but, otherwise, completely clean airways; BAL was sent for cytology and microbiology. The patient, at that time, was started on broad spectrum antibiotic coverage with Vancomycin, Imipenem and Levaquin. The patient also had CAT scan of the chest, as per the Pulmonary Service, which showed diffuse interstitial changes with ground-glass appearance and areas of alveolar filling process, especially in the left upper lobe. Of note, the patient's cytology from his BAL came back showing atypical cells worrisome for small cell lung cancer. However, this was not immediately followed up as the patient's clinical course started to deteriorate. The patient manifested signs of ARDS, as well as worsening LFTs. As the patient's LFTs worsened, he became somewhat coagulopathic and manifested an upper GI bled with bloody NG-tube drainage, requiring transfusion of several units of packed red cells. The patient's coagulopathy was corrected with vitamin K and FFP initially. The GI bleed was stabilized. The patient underwent a repeat echocardiogram, which showed severe hypokinesis. The patient also had periods of hypotension requiring Neo-Synephrine drip. The patient also began to manifest signs of acute renal failure with worsening creatinine. This eventually peaked at a creatinine of approximately 5.9. However, the patient never required hemodialysis during the hospital course. The patient maintained his electrolytes and never became acidotic and continued to make urine, such that volume overload was not an issue. Multiple sets of cultures were sent including cultures from previous bronchoscopy, blood cultures, and urine cultures. These were sent for bacteria, fungus, and AFB. All of these cultures failed to grow out any organisms, however. After all these cultures came back negative, the patient's broad- spectrum antibiotic coverage was stopped. Given the patient's increased LFTs, hepatitis panel was sent, all of which came back negative. Hepatology service was consulted. After evaluating the patient, it was unclear as to the cause of the etiology of the patient's elevated LFTs. Again, in light of the patient's increased LFTs, a right upper quadrant ultrasound was obtained, which was worrisome for a calculus cholecystitis. General Surgery was consulted and a cholecystostomy tube was placed by Interventional Radiology. On [2121-10-2], cultures from bile obtained from the cholecystostomy tube were negative. During the remainder of the patient's protracted hospital course, he essentially received supportive care, again, never requiring hemodialysis, requiring mechanical ventilation. However, the acute renal failure slowly improved and his LFTs returned close to baseline. The total bilirubin peaked at 16 and again slowly went down to the 4 or 5 level. The patient's respiratory status remained his [Last Name 7205] problem. The patient underwent percutaneous tracheostomy and PEG placement on [2121-10-13]. Tube feeds were continued twenty-four hours after PEG placement. The patient essentially underwent a very slow CPAP wean over the next two weeks. However, the patient was unable to weaned completely from the ventilator. The patient underwent two more bronchoscopies, again, with some suctioning of some thick secretions. Sputum culture was sent after the nurse noted increased frequency of suctioning, which grew MRSA. The patient was started on Vancomycin to treat the MRSA pneumonia for a 14-day course. The patient's mental status during his recovery remained essentially stable, although mental status waxed and waned to some degree. The patient was screened for rehabilitation and was accepted on [2121-10-30]. DISCHARGE MEDICATIONS: 1. Protonix 40 mg per PEG q.d. 2. Vitamin E 400 mg per PEG q.d. 3. Albuterol MDI 2 puffs q.6h. 4. Heparin 5000 units subcutaneously t.i.d. 5. Lopressor 25 mg per PEG b.i.d. 6. Vancomycin 750 mg IV q.24h.to end on [2121-11-5]. 7. Clonidine Patch .2 mg every week. 8. NPH Insulin 8 units subcutaneously q.a.m. and p.m. 9. Ultracal tube feeds at 65 cc an hour. 10. ProMod 10-g in tube feeds q.d. 11. Epogen 40,000 units subcutaneously, every week. 12. Ativan .5 to 1 mg IV q.2-3h.p.r.n. DISCHARGE DIAGNOSES: 1. Severe three-vessel coronary artery disease status post CABG times five, complicated by multi-organ system dysfunction with acute renal failure, ARDS and acute hepatic failure. 2. The patient is also status post tracheostomy and PEG and bronchoscopy times three. The patient was discharge on [2121-10-30]. [First Name8 (NamePattern2) 1523] [Last Name (NamePattern1) 5538], M.D. [MD Number(1) 6443] Dictated By:[Last Name (NamePattern1) 7206] MEDQUIST36 D: [2121-10-30] 12:55 T: [2121-10-30] 14:15 JOB#: [Job Number 7207]	[ "584.9", "250.00", "518.81", "414.01", "410.41", "482.41", "518.5", "575.0", "578.9" ]	icd9cm	[ [ [] ] ]	[ "36.14", "36.15", "96.6", "96.72", "43.11", "96.04", "51.02", "31.1", "39.61" ]	icd9pcs	[ [ [] ] ]							2441, 2575	8909, 9507	8390, 8888		832, 2044			3321, 8367																								2598, 3303																																	2067, 2300	2317, 2424
11,855	197,956	17090	Discharge summary	report	Admission Date: [2103-7-10] Discharge Date: [2103-7-18] Date of Birth: [2029-2-9] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 74 year old woman who has not sought medical treatment in many years and had a recent fall fracturing her right humerus and soon thereafter she was noted to have some irregular heart beat. She took some medication of a neighbor who had a similar problem and ultimately went to be treated in the Emergency Department in [State 108] where the patient lived. She was found at that time to be in atrial flutter with a rapid ventricular response in the 130s. This spontaneously converted to sinus rhythm but she has had bouts of paroxysmal atrial fibrillation since that time. At that time, echocardiogram was obtained which demonstrated significant mitral valve prolapse with severe mitral regurgitation and a large ventriculoseptal defect with a left to right shunt. Left ventricular function was normal. She was also noted to have moderate to severe pulmonary artery hypertension. The patient was discharged from the hospital on beta blocker, Lipitor and Coumadin at that time and she has since come to the [Location (un) 86] area to seek further treatment of this. PAST MEDICAL HISTORY: Significant for at least two previous bouts of endocarditis, one in [2050] and one in [2070] which was treated with antibiotics with no sequelae. She has also had three uneventful pregnancies and has not taken any medications regularly and has not had any medical treatment over the past 20 years or so. The patient was admitted to the hospital [7-10]. ALLERGIES: The patient also states an allergy to Penicillin. MEDICATIONS PRIOR TO ADMISSION: Lipitor 20 mg p.o. q.d., [Month (only) 8863] XL 50 mg p.o. q.d., Coumadin 5 mg Monday, Wednesday and Friday and 2.5 mg alternating four days per week. She was also taking Alprazolam for anxiety. HOSPITAL COURSE: The patient was admitted to the hospital on [2103-7-10] and taken directly to the Operating Room where she underwent mitral valve repair with a #28 mm [Doctor Last Name 405] annuloplasty band as well as tricuspid valve repair with a #32 mm [Last Name (un) 3843] [Doctor Last Name ] annuloplasty ring and a primary closure of ventriculoseptal defect. Postoperatively the patient was transported from the Operating Room to the Cardiac Surgery Recovery Unit in stable condition on Milrinone, Neo-Synephrine and Propofol intravenous drips. She was initially atrioventricularly paced with an adequate blood pressure. The pacemaker was ultimately turned off the following morning and she was in normal sinus rhythm with first degree atrioventricular block. On postoperative day #1, the patient remained with a Swan-Ganz catheter and the Milrinone was weaned off, the Neo-Synephrine had been discontinued, the patient was weaned from mechanical ventilation and successfully extubated to nasal cannula oxygen. Diuretics were begun on postoperative day #1. On postoperative day #2 it was noted that the patient had significant thrombocytopenia, after being started on heparin. The heparin was discontinued. Heparin antibodies were sent and have subsequently come back negative. The patient remained on intravenous Neo-Synephrine throughout the course of postoperative day #2 which was ultimately discontinued late that day. On postoperative day #3, the patient was continued with aggressive diuresis, was hemodynamically stable and remained in normal sinus rhythm at that time. On postoperative day #4 the patient's chest tubes had been removed. The patient remained with adequate heart rhythm and rate and blood pressure and was transferred out from the Cardiac Surgery Recovery Unit to the Telemetry Floor. The patient was begun ambulating with physical therapy and tolerating that well. Her Foley catheter was discontinued and she was voiding without problems. On postoperative day #5, the patient was noted to have some atrial fibrillation with a ventricular response rate between 90 and 125. She was treated with Magnesium and intravenous Lopressor and she was placed on Amiodarone as well. The patient converted to normal sinus rhythm later that day and had had no subsequent atrial fibrillation while on the Lopressor and the Amiodarone. The patient continued to progress with physical therapy on [2103-7-17]. The patient was still unable to be weaned completely from oxygen due to desaturation. Chest x-ray was obtained. She also had symptomatic shortness of breath. The chest x-ray from the previous day revealed a significant left pleural effusion. On [7-17], she underwent a thoracentesis for approximately 400 cc of serosanguinous fluid. The patient tolerated the procedure well and did state symptomatic relief of her symptoms. The subsequent chest x-ray showed decreased pleural effusion although some residual fluid remains with left lower lobe atelectasis and no pneumothorax noted. Today, [2103-7-18], the patient remained off oxygen with adequate oxygen saturation. On room air her Saturday was 93 to 95%. She remains hemodynamically stable and is ready to be discharged home. CONDITION ON DISCHARGE: Good. Temperature is 98.6, blood pressure 110/70, heartrate 87 in normal sinus rhythm with a first degree atrioventricular block, respiratory rate 20. Neurologically, the patient is alert and oriented. Her lungs are clear to auscultation bilaterally, however, diminished lung space. Her heart rhythm is regular with no rub or murmur noted. Abdomen is soft, nontender, nondistended with positive bowel sounds. She has no peripheral edema. The patient is discharged today in good condition. DISCHARGE INSTRUCTIONS: She is to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696], the patient's primary cardiologist in one to two weeks. She is to follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in four weeks for a postoperative check. DISCHARGE MEDICATIONS: Lasix 20 mg one p.o. b.i.d. times ten days Potassium chloride 20 mEq p.o. b.i.d. times ten days Lipitor 20 mg p.o. q. day Ibuprofen 400 mg p.o. q. 8 hours prn pain Amiodarone 200 mg one p.o. q.d. to be continued for one month or as deemed necessary by Dr. [Last Name (STitle) 696] [Name (STitle) 8863] XL 50 mg p.o. q.d. Enteric coated Aspirin 325 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Mitral regurgitation 2. Tricuspid regurgitation 3. Ventriculoseptal defect 4. Status post mitral valve repair 5. Status post tricuspid valve repair 6. Status post ventriculoseptal defect closure [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2103-7-18] 13:40 T: [2103-7-18] 16:05 JOB#: [Job Number 48038]	[ "429.5", "424.0", "511.9", "287.4", "424.2", "518.0", "427.31", "997.3", "429.71" ]	icd9cm	[ [ [] ] ]	[ "34.91", "88.72", "35.14", "35.72", "39.61", "39.63", "35.32", "35.12" ]	icd9pcs	[ [ [] ] ]									6070, 6440		6461, 6914			1978, 5219		5765, 6047																		1759, 1960																						183, 1272															1295, 1726		5244, 5740
23,150	171,705	52200	Discharge summary	report	Admission Date: [2173-2-3] Discharge Date: [2173-2-10] Date of Birth: [2092-2-13] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Carbapenem / A.C.E Inhibitors / Angiotensin Receptor Antagonist Attending:[First Name3 (LF) 14145] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: right heart catheterization, pericardiocentesis History of Present Illness: 80-year-old man with CAD (LAD and OM1 stents in [2167]), systolic CHF (EF 45%), HTN, HL, DM2, CKD (baseline Cr 3.0), who presented with a few days of dyspnea at rest and on exertion. He presented to the ED, was found to be hypotensive with echo showing RV diastolic collapse and respiratory variation in mitral/tricuspid inflows, consistent with impaired filling/tamponade physiology. He was emergently sent to the cath lab, where catheter pericardiocentesis drained out 800 cc of bloody fluid. He was then admitted to the CCU. . 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 chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . On arrival to the CCU, MAP was in the 70s, HR 85, sating well on room air. Patient was pleasantly conversational. Past Medical History: 1. CARDIAC RISK FACTORS:: Diabetes (+), Dyslipidemia (+), Hypertension (+) 2. CARDIAC HISTORY: * Systolic CHF (Echo [Hospital1 18] [6-/2171] with EF 45-50%) * CAD s/p MI in [2166] -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: LAD stent [11/2167], OM1 stent [12/2167], restenosis s/p balloon angio [1-/2169] -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: * Diabetes Type II (on home insulin, with peripheral neuropathy, nephropathy) * Chronic Kidney Disease (baseline Cr 3-3.5) * Type 4 [Year (4 digits) 2793] Tubular Acidosis (hypoaldosteronism, hyperkalemia) * Anemia (baseline Hct 30) * Fulminant C.diff colitis (s/p total colectomy with ileostomy) * [Year (4 digits) 2793] Cell Cancer (s/p partial R nephrectomy [2-/2166]) * Prostate Cancer (s/p XRT) * Depression * OSA on BiPAP at home * Mid-shaft, surgical neck humerus fracture ([7-/2169]) in setting of several falls * Nephrectomy [2-/2166] (for [Year (4 digits) ] cell carcinoma) * Total colectomy with ileostomy [2167](for C. diff colitis) Social History: Pt lives alone. He has a helper who comes by daily. Uses a scooter to get around, but can walk with a rolling walker. Retired attorney (once argued before the supreme court). H/o tobacco, quit 55 years ago. Denies EtOH. . Family History: Father -- CVA, fatal, 49 yo Mother -- MI, fatal, 80s Sister -- breast cancer, 81 yo Physical Exam: General appearance: elderly, alert, oriented x 3, pleasant Vital signs: per R.N. Height: 68 Inch, 173 cm BP right arm: 147 / 64 mmHg T current: 97.1 C HR: 85 bpm RR: 21 insp/min O2 sat: 94 % on Room air Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Right carotid artery: No bruit), (Left carotid artery: No bruit), (Jugular veins: Not visible) Back / Musculoskeletal: (Chest wall structure: WNL) Respiratory: (Effort: WNL), (Auscultation: WNL) Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1: WNL, S2: wnl, S3: Absent, S4: Absent), (Murmur / Rub: Present) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No), (Hepatosplenomegaly: No) Genitourinary: (WNL) Extremities / Musculoskeletal: (Digits and nails: WNL), (Edema: Right: 0, Left: 0) Skin: ( WNL) Pertinent Results: Admission labs: [2173-2-3] 03:30PM GLUCOSE-220* UREA N-74* CREAT-4.6# SODIUM-134 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-20 ANION GAP-17 [2173-2-3] 03:30PM WBC-11.4* RBC-3.37* HGB-9.7* HCT-28.5* MCV-85 MCH-28.9 MCHC-34.1 RDW-15.8* [2173-2-3] 03:30PM NEUTS-76.8* LYMPHS-13.3* MONOS-7.2 EOS-2.0 BASOS-0.8 Cardiac enzymes: [2173-2-3] 03:30PM cTropnT-0.05* [2173-2-3] 03:30PM CK(CPK)-53 [2173-2-4] 04:10AM BLOOD cTropnT-0.15* [2173-2-4] 11:40AM BLOOD CK-MB-NotDone cTropnT-0.13* . Labs on discharge: [2173-2-9] [2173-2-9] 07:25AM BLOOD WBC-12.6* RBC-3.48* Hgb-9.9* Hct-29.4* MCV-84 MCH-28.4 MCHC-33.7 RDW-15.9* Plt Ct-450* [2173-2-9] 07:25AM BLOOD PT-13.8* PTT-27.6 INR(PT)-1.2* [2173-2-9] 07:25AM BLOOD Glucose-125* UreaN-48* Creat-2.6* Na-140 K-5.0 Cl-106 HCO3-24 AnGap-15 [2173-2-9] 07:25AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.4 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2173-2-10] 07:00AM 10.8 3.46* 9.6* 29.7* 86 27.9 32.5 15.7* 471 [Year (4 digits) ] & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2173-2-10] 07:00AM 156* 50* 2.8* 140 5.2* 104 25 16 . [2173-2-3] transthoracic echo: There is mild regional left ventricular systolic dysfunction with thinning and akinesis of the basal to mid inferolateral wall. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is a moderate sized pericardial effusion. The effusion appears circumferential. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [2173-1-25], the pericardial effusion is larger in size and there is now more fluid anterior to the right ventricle. There is RV diastolic collapse and respiratory variation in mitral/tricuspid inflows, consistent with impaired filling/tamponade physiology. . [2173-2-3] cardiac cath: 1. Right heart catheterization demonstrated elevated right sided pressures with diastolic equalization (mean RA 29mmHg, RVEDP 29mmHg) and elevated intrapericardial pressures (24mmHg). Pulmonary arterial pressures were elevated (58/31/39 mmHg) and left sided filling pressures were elevated (mean PCWP 39mmHg). 2. Limited resting hemodynamics after pericardiocentesis demonstrated significant improvement of intrapericardial pressures (to 10mmHg). 3. Pericardiocentesis was performed via a subxiphoid approach. Cloudy serosanguinous pericardial fluid was sent for biochemical, cytological, and microbiological analyses. A pigtail drain was left in situ. 4. An echocardiogram performed after pericardiocentesis demonstrated significant reduction of pericardial effusion and resolution of tamponade physiology. . TTE ([2-9]): There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with dyskinesis of the basal inferolateral wall and akinesis of the basal half of the inferior wall. The remaining segments contract normally (LVEF = 35 %). There is a moderate sized, echo-dense pericardial effusion without echocardiographic signs of tamponade or constriction. Compared with the prior study (images reviewed) of [2173-2-6], the pericardial effusion is similar. The regional left ventricular systolic dysfunction is more pronounced. . RADIOLOGY: CT Head ([2-6]) IMPRESSION: Although the sensitivity of non-contrast CT in the evaluation of intracranial metastases is limited, no obvious metastasis is identified. Consider gadolinium-enhanced MRI for further evaluation as clinically indicated. . CT Torso ([2-6]) IMPRESSION: 1. Heterogeneous, moderate pericardial effusion, somewhat increased from [2172-5-29], containing areas of increased density likely representing hemorrhage secondary to recent pericardiocentesis. 2. Enlarged retroperitoneal lymph node, 12 mm in short axis diameter. No other evidence of residual or recurrent disease. This node is mildly increased compared to [2172-5-29]. 3. Extensive atherosclerotic disease, with involvement of the coronary arteries. 4. Small left pleural effusion with left lower lobe atelectasis. 5. Cholelithiasis. Brief Hospital Course: Mr [Known lastname ] is an 80-year-old man with CAD (LAD and OM1 stents in [2167]), systolic CHF (EF 45%), HTN, HL, DM2, CKD (baseline Cr 3.0) presented with shortness of breath and was found to have cardiac tamponade physiology on echo in the ED. . # Pericardial Effusion: There was tamponade physiology on the initial echo. He underwent pericardial drainage in cath lab with placement of a drain. Potential etiologies included uremia, infections, neoplasm, myocarditis, hypothyroidism (but TSH normal on [2173-1-25]). Fluid gram stain was negative for infection. There was no history of trauma or prior chest XRT. Thus, the most likely cause was uremia secondary to worsening [Date Range ] failure. After the evacuation, blood pressure was stable and pulsus was normal. Repeat echo the following day showed no evidence of tamponade, although an echo-dense moderate effusion persisted. TTE on discharge showed stable moderate effusion and newly-observed wall-motion abnormalities (though pt remained asymptomatic). . Potential etiologies of the pericardial effusion were considered. It was initially thought to be most likely uremic, although BUN was not elevated to the degree one would expect if this was the explanation. Other causes considered included infections (cultures from fluid were negative), neoplasm (no malignant cells on cytology, no malignancy seen on torso/head CT), autoimmune causes ([Doctor First Name ], dsDNA were negative), myocarditis, hypothyroidism (TSH was normal). At discharge the most likely explanation was viral, since he had a PNA in the proceeding weeks. # Coronaries: There was no chest pain or evidence of active ischemia. Aspirin and statin were continued. . # Diabetes: Home dose of Lantus and Humalog sliding scale were given initially, but blood glucose values were frequently in the 300s. Humalog insulin was added with meals, with improvement in control. [Last Name (un) ] saw pt and he was restarted on his regular home mealtime insulin schedule. [Last Name (un) ] follow up scheduled. For neuropathy gabapentin, Tylenol and oxycodone PRN were given. . # Acute on chronic kidney disease: Creatinine was 4.6 on admission, increased from 3.0 at baseline. BUN was also elevated at 74. This was thought to be prerenal in the setting of poor cardiac output from tamponade. Creatinine improved to baseline after pericardiocentesis to baseline. . # Hypertension: Amlodipine and torsemide were held initially out of concern for hypotension. Amlodipine was subsequently restarted and uptitrated for better control. Toresemide restarted at discharge. . # Hyperlipidemia: Statin was continued. . # Enlarge retroperitoneal lymph node- was 12mm, increased from CT scan [5-28]. Will need out pt follow up since pt has hx of malignancy in the past. . Pt will have PCP, [Name10 (NameIs) ], and cardiology follow up including f/u echocardiogram. Medications on Admission: torsemide 20 mg [Hospital1 ] aspirin 81 mg qday simvastatin 40 mg qday paroxetine 30 mg qday calcitriol 0.25 mcg qday amlodipine 2.5 mg [Hospital1 ] gabapentin 300 mg [Hospital1 ] insulin glargine 55 units qhs Humalog s.s. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45) units Subcutaneous once a day. 6. Insulin Lispro 100 unit/mL Solution Sig: As directed Subcutaneous three times a day: 13 units before breakfast, 8 units before lunch and 11 units before dinner. 7. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Do not take more than 8 pills in 24 hours. 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 20 doses. Disp:20 Tablet(s) Refills:0 14. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: cardiac tamponade secondary to pericardial effusion acute on chronic kidney failure . diabetes mellitus, type 2 hypertension hyperlipidemia coronary artery disease chronic systolic congestive heart failure neuropathy Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with shortness of breath. You were found to have pericardial effusion causing tamponade (fluid around your heart compromising your heart function). You were treated with pericardiocentesis and drainage (removal of fluid). You were also found to have an enlarging lymph node of unclear significance for which we recommend imaging followup. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Your home medications were restarted. Your insulin doses were changed. You now take lantus 45 units in the morning for your long acting insulin. . If you have fever, chest pain, shortness of breath or any other concerning symptoms, please call your physician [Name Initial (PRE) 2227]. Followup Instructions: Please call Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office for echocardiogram and followup appointment for Friday, [2-12]. [Telephone/Fax (1) 5768] . Nephrology followup - Dr. [First Name (STitle) 805] at [Last Name (un) ] - Monday, [2-15] at 1:30 pm . PCP followup [Name Initial (PRE) ] Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1728] ([Telephone/Fax (1) 14148]) - Tuesday, [2-16] at 1:30 pm. . Endocrinology followup - [Last Name (un) ] Diabetes Center: [2172-2-17] 8:30 a.m. with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557], NP . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 20430], MD Date/Time:[2173-2-16] 2:00 Provider: [Name10 (NameIs) 1248],CHAIR FOUR [Name10 (NameIs) 1248] ROOMS Date/Time:[2173-2-16] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 20430], MD Date/Time:[2173-3-4] 2:00 . CT Abdomen/Pelvis to follow up 12mm retroperitoneal lymphnode: [2173-6-9] @ 10am in [Hospital Ward Name 23] [Location (un) ]. Completed by:[2173-2-10]	[ "403.90", "428.0", "357.2", "250.60", "584.9", "V10.52", "423.3", "428.22", "414.01", "285.9", "V45.82", "423.9", "585.9", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "37.21", "37.0" ]	icd9pcs	[ [ [] ] ]	13172, 13230	8495, 11421	375, 424	13490, 13498	3938, 3938	14313, 15483	2950, 3035		11707, 13149		13251, 13469		11447, 11684			13522, 14290								3050, 3919				1727, 1985																4277, 4454			316, 337				4473, 8472					452, 1610					3955, 4260					2016, 2694					1632, 1707	2710, 2934
22,289	162,416	2424	Discharge summary	report	Admission Date: [2110-6-4] Discharge Date: [2110-6-28] Service: MEDICINE Allergies: Benadryl Attending:[Last Name (NamePattern4) 290] Chief Complaint: AMS, Hypotension, Acute on Chronic RF Major Surgical or Invasive Procedure: Intubation/Ventilation Tracheostomy PEG CRRT Dialysis catheter placement Central Venous Catheter placement. History of Present Illness: This is an 85 yo m w/ a hx gastric/small bowel AVMs, recently admitted for shock attributed to a GIB, afib, CHF (EF 20%), CRI (stage 4), who was transferred from rehab for altered mental status and worsening renal function. He was noted initially at rehab to have worsening creatinine, and was scheduled to be seen in renal clinic as an outpatient. Then today, he developed AMS, and was transferred to the [Hospital1 18] ED for further evaluation. . In the ED, the patient was altered, with initial vitals found him to be hypothermic, hypotensive to 60-70's, brady to 30-40's. He received a femoral line, calcium, 1500cc NS (not more out of concern for possible cardiogenic shock). A bedside shock u/s did not demonstrate a pericardial effusion but showed global hypokinesis, and a large right sided pleural effusion. A CT torso demonstrated bilateral pleural effusions R>>L with associated atelectasis and cardiomegaly, but no intraabdominal pathology on wet read. A UA was dirty. Lactate was wnl, CE's were within his baseline in the setting of renal failure. EKG was notable for low voltage afib with bradycardia but no ischemic changes compared to prior. BNP was 3200 (which is in the middle of recent values). He received a dose vanco/zosyn. He was guaiac pos brown stool initially. An ABG was notable for a respiratory acidosis and he was intubated with etom and rocuronium for airway protection and increased minute ventilation. Of note, he was a difficult intubation and there was a ?edema in airway. He was also started on levophed after he did not respond to 1.5L NS. Because he was hypothermic, a rectal probe was attempted to be placed, and he then was found to have a "puddle" of BRBPR, but then nothing actively coming out. NG lavage negative. GI was consulted and evaluated him in the ED, but felt that given his stable hct (28 -> 29) that this was unlikely to explain his shock. He was type and screened, and received 2 units in ED. Urine output was poor throughout ED stay. . He is transferred to the MICU for further management of hypotension, acute on chronic renal failure, respiratory failure and hypothermia. Upon transfer, HR 66, BP 113/64 on levophed 0.12mcg, satting 100% on A/C 500x14 peep 5 and FiO2 1.0. . Of note, pt was recently admitted from end of [Month (only) 116] to [5-23] for hypotension, respiratory failure and GIB. Hct did drop at that time to 21 with reports of melena. EGD was normal w/o AVMs seen. Recent [Last Name (un) ] [3-20] normal as well except for some small polyps. During recent hospital course, pt intubated for presumed CHF, had worsening renal failure, and also found to have new parietal CVA. Coumadin held given bleeding and pt d/c'd to rehab on [5-23]. . Review of systems: (+) Per HPI (-) unable to obtain, patient intubated and sedated. Past Medical History: Chronic Systolic CHF - Echo [3-20] with EF 25% Hypertension Dyslipidemia Afib (coumadin d/c'd on last admission) CVA (right parietal [5-20]) CKD IV, baseline 2.1-2.5, sees Dr. [Last Name (STitle) 4883] Anemia - likely mixed, CKD and Iron Deficiency, baseline 35-39 DM, on insulin, hgb A1c 9.2 [3-20] Gastritis - hematemesis [2109-7-12]. EGD with antral erosions, small AVM in duodenum - colonoscopy [12/2108] with single sessile 2 mm polyp of benign appearance in the proximal transverse colon (not removed [1-13] bleeding risk); [Last Name (un) ] [5-/2110] - several small polyps Prior Tobacco use Osteoarthritis Prostate Cancer s/p prostatectomy Urinary incontinence Social History: Widowed and lived with his daughter [Name (NI) 12469], who is his health care proxy, until his recent CVA afterwhich he was staying at a rehab. Wife passed away in the summer of [2108]. Former [Year (4 digits) 1818], smoked 1-2 packs daily for ~40 years. Previously drank one shot of whiskey daily. No known history of illicit drug use. Family History: NC Physical Exam: General: Intubated, sedated, comfortable on vent [Year (4 digits) 4459]: Sclera anicteric, MMM, oropharynx clear, PERRL but small Neck: supple, JVP @ temples Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi - good lung volumes despite large effusion CV: irregularly irregular, bradycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Cool most distally, no clubbing, cyanosis but asymmetric edema R>L, no cords. Pertinent Results: Admission Labs WBC-3.7* RBC-3.09* Hgb-8.8* Hct-28.5* MCV-92 MCH-28.5 MCHC-30.9* RDW-17.5* Plt Ct-143* Neuts-71.4* Bands-0 Lymphs-19.9 Monos-6.1 Eos-2.1 Baso-0.4 PT-15.5* PTT-38.5* INR(PT)-1.4* Glucose-113* UreaN-83* Creat-4.8# Na-135 K-5.8 Cl-101 HCO3-29 AnGap-11 ALT-14 AST-26 CK(CPK)-39 AlkPhos-310* TotBili-0.6 cTropnT-0.12* proBNP-3244* Albumin-3.6 Calcium-10.3* Phos-5.0# Mg-2.8 TSH-4.3* VBG pO2-69* pCO2-79* pH-7.19* calTCO2-32* Base XS-0 ABG (s/p intubation) Rates-14/ Tidal V-500 PEEP-5 FiO2-100 pO2-263* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 AADO2-406 REQ O2-71 -ASSIST/CON Intubat-INTUBATED Echo ([6-5]) The left atrium is mildly dilated. The estimated right atrial pressure is 0-10mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. Compared with the prior study (images reviewed) of [2110-4-2], the left ventricular systolic function is better. The severity of tricuspid regurgitation and detected pulmonary artery systolic hypertension have increased. . The echocardiographic findings are consistent with restrictive cardiomyopathy (? Amyloid, Fabry's). Lower Extrem U/S - IMPRESSION: No evidence of deep vein thrombosis in either leg. [2110-6-28] 04:30AM BLOOD WBC-14.4* RBC-2.61* Hgb-7.4* Hct-23.7* MCV-91 MCH-28.4 MCHC-31.3 RDW-15.8* Plt Ct-251 [2110-6-25] 05:47AM BLOOD PT-14.1* PTT-29.2 INR(PT)-1.2* [2110-6-28] 04:30AM BLOOD Glucose-164* UreaN-62* Creat-3.0* Na-143 K-3.7 Cl-105 HCO3-26 AnGap-16 [2110-6-28] 04:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.3 Brief Hospital Course: # Respiratory Failure ?????? The patient initially presented with a respiratory acidosis and was intubated in the ED. Lower extremity ultrasounds ruled out DVT. He was initially weaned to pressure support with a plan to extubate; however, increased frothy secretions resulted in switching him back to assist control. Further attempts to wean to pressure support have failed with the patient becoming tachypnic. Additionally, after his empiric 7-day course of vancomycin and zosyn, the patient developed a leukocytosis and was started on zosyn, which was switched to meropenem when sputum cultures grew out klebsiella. Percutaneous tracheostomy placed on [6-25]. Pt then transitioned to trach mask without difficulty and has tolerated it well. #. Hypotension ?????? On admission, the etiology was not entirely clear. Despite the patient??????s history of GI bleed, it was felt that hemorrhagic shock from a GI bleed was unlikely. He was initially treated for a mixed septic and cardiogenic shock. He was started on levophed. He was also tried on dobutamine several times in an attempt to increase his cardiac output; however, the dobutamine was ultimately stopped because it resulted in an increased levophed requirement. The patient also received a 7 day course of empiric vancomycin and zosyn on admission. Pt was started on midodrine on [6-24] and increased to 10mg TID on [6-26], and has not required pressor use. . #. Acute on Chronic Renal Failure - The patient had chronic renal failure with a baseline creatinine of 2.0-2.5. He had significant edema in all extremities on admission. Dobutamine was given in an attempt to increase cardiac output and renal blood flow but was stopped as explained above. The patient developed significant edema in his scrotum and sacral area with skin breakdown, requiring wound care consultation. A lasix drip was started but was eventually stopped secondary to hypotension and minimal effect on UOP. CVVH was initiated on [6-11]. The patient has been continued on CVVH with a goal of removing as much fluid as possible and using levophed as necessary to maintain his mean arterial pressures. The patient??????s edema improved significantly with CVVH. Pt was transitioned to HD and was able to tolerate it with borderline BP's. Plan to continue HD for CRF. . # Heart Failure ?????? The patient has known heart failure and presented with significant upper and lower extremity edema. He was initially started on levophed and dobutamine, with the dobutamine eventually being stopped. Echo results showed improvement in systolic function but were indicative of a restrictive cardiomyopathy. As explained above, the patient was also tried on a lasix drip and then started on CVVH for volume overload. After significant volume reduction and initiation of midodrine pressors were d/c'd and pt was able to maintain adaquate BP's. # Anemia ?????? The patient??????s hematocrit was 27-28 on admission. He received 2 units of blood in the ED. During his ICU stay, nursing reported that the patient was having some very dark stools. He was placed on a [Hospital1 ] IV PPI. Also, due to dropping hematocrits, he received blood on several occasions. Given the slow decrease in HCT and multiple other problems management consisted of monitoring and transfusion. HCT has been stable for past three days without need for transfusion. #. Altered Mental Status ?????? Numerous factors that could have contributed to his altered mental status. On arrival to the MICU, the patient was sedated and on a ventilator, making assessment of his mental status difficult. Since tracheostomy and d/c sedation Pt more arousable and is reported to have squeezed [Hospital1 802]'s hand on command. Remains minimally interactive. . #. DM2 ?????? The patient was placed on sliding scale insulin. Increasing blood sugars levels required frequent adjustments to the patient??????s insulin regimen. It was unclear whether this hyperglycemia was secondary to an underlying infection or decreased responsiveness to the insulin. Blood sugars have been controlled on sliding scale with 30units glargine qhs. . #. Atrial Fibrillation ?????? The patient has atrial fibrillation; however, he is not on Coumadin secondary to his recent GI bleed. On admission, his nodal blocking agents were held secondary to his hypotension and were not restarted secondary to his persistent hypotension and borderline pressures. # Pleural Effusion ?????? On admission, the patient had a large pleural effusion. This effusion was monitored through serial chest x-rays with some resolution following volume removal. # Yeast in Urine Cultures ?????? The patient??????s urine cultures consistently grew yeast throughout his hospitalization. His catheter was changed twice and he was also eventually given a 3 day course of fluconazole. This is thought to be a colonization rather than an acute infection. Pt has continued to have dirty UA's and was started on a 7day course of Cipro on [6-27] for empiric coverage of UTI. Medications on Admission: Bisacodyl Senna Heparin 5000 sq TID Carvedilol 3.125 mg [Hospital1 ] Calcitriol 0.25 mcg daily Calcium Acetate 667 mg Capsule 2 capsules TID Acetaminophen 500 mg TID Albuterol nebs q4h prn Ipratropium Bromide nebs q6h Lidocaine 5 %(700 mg/patch) daily Simvastatin 40 mg daily Dulcolax 5 mg Tablet daily prn Omeprazole 40 mg Capsule [Hospital1 ] Insulin Lispro 100 unit/mL Solution Sig: [12-16] units Subcutaneous ASDIR (AS DIRECTED) as needed for hyperglycemia. Miralax PO once a day. Lasix 40 mg PO twice a day. Lisinopril 2.5 mg PO once a day. Discharge Medications: Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Midodrine 10 mg PO TID hold for SBP>170 Albuterol Inhaler [12-13] PUFF IH Q6H Ciprofloxacin HCl 500 mg PO/NG Q24H Docusate Sodium (Liquid) 100 mg PO/OG [Hospital1 ] constipation Senna 1 TAB PO/NG [Hospital1 ] constipation Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose - Glargine 30units qhs Ipratropium Bromide MDI 2 PUFF IH QID Tuberculin Protein 0.1 mL ID ONCE Duration: 1 Doses For intradermal injection, needs to be read in 48-72 hours Order date: [6-27] @ 1615 Oxygen: 35% humidified O2 via trach mask. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital 86] [Hospital ] Hospital Discharge Diagnosis: Chronic Renal Failure Heart Failure Respiratory failure Altered Mental Status Gastrointestinal bleed. Discharge Condition: Stable Discharge Instructions: -Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. -Adhere to 2 gm sodium diet -Finish 7 day course of Cipro for UTI (first dose [2110-6-27]) - Have your PPD read on [6-29] or [6-30] Call your doctor if you experience fever, chills, shortness of breath, chest pain, passing out or any other concerning symptoms. * Hepatitis screening labs pending, have your physician call for results. Followup Instructions: Gastroenterology: Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2110-7-15] 3:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "578.9", "585.4", "250.00", "599.0", "272.4", "428.0", "276.2", "V02.9", "V58.67", "584.9", "403.90", "785.52", "995.92", "511.9", "518.81", "V12.54", "537.82", "V10.46", "428.23", "427.31", "038.9", "285.21", "785.51" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.72", "31.1", "39.95", "96.04", "96.6", "43.11", "38.95", "38.91" ]	icd9pcs	[ [ [] ] ]	13659, 13744	7349, 12425	260, 370	13889, 13897	4925, 7326	14368, 14650	4332, 4336		13034, 13636		13765, 13868		12451, 13011			13921, 14345								4351, 4906																			3155, 3221				183, 222									398, 3136															3243, 3949	3965, 4315
2,558	163,053	28773	Discharge summary	report	Admission Date: [2187-10-2] Discharge Date: [2187-10-9] Date of Birth: [2128-11-20] Sex: F Service: UROLOGY Allergies: Codeine Attending:[First Name3 (LF) 1232] Chief Complaint: Left flank mass Major Surgical or Invasive Procedure: Left nephrectomy History of Present Illness: 58F transferred to medical service from OSH [2187-9-12] for W/[Location 69532] 10X15cm L renal mass. She presented to [Hospital ] Hospital [9-10] c/o B LE swelling, pruritis, dry cough, and urinary retention. The LE swelling began approximately 1 month ago. W/U at OSH included CT A/P, demonstrating 10X15cm L renal mass and multiple small pulmonary nodules. HCT 21, so given PRBC transfusion. OSH oncologist recommended transfer to [Hospital1 18]. Past Medical History: HTN New renal mass, likely metastatic renal cell carcinoma, with associated liver dysfunction CHF, EF 40-55% by report Factor [Hospital1 ] deficiency Social History: Lives at home in [Location (un) ], MA with husband and son. [Name (NI) ] two other children. Smoked <1ppd x 10 years, quit 30 years ago. Denies exposures to dyes, chemicals. Occasional alcohol use. No illicit drugs. Family History: Father d. 59 with brain tumor. Mother died of CVA. Sister with cervical cancer. Brother with CAD. Pertinent Results: [2187-10-6] 04:33AM BLOOD WBC-8.5 RBC-3.91* Hgb-9.9* Hct-32.2* MCV-82 MCH-25.2* MCHC-30.6* RDW-20.4* Plt Ct-736* [2187-10-5] 04:35AM BLOOD WBC-12.8* RBC-3.75* Hgb-9.8* Hct-30.5* MCV-81* MCH-26.1* MCHC-32.1 RDW-19.5* Plt Ct-644* [2187-10-4] 01:54PM BLOOD WBC-19.4* RBC-4.10* Hgb-10.4* Hct-33.8* MCV-83 MCH-25.4* MCHC-30.8* RDW-20.2* Plt Ct-690* [2187-10-4] 01:19AM BLOOD WBC-23.2* RBC-3.88* Hgb-10.0* Hct-31.7* MCV-82 MCH-25.9* MCHC-31.7 RDW-20.1* Plt Ct-679* [2187-10-3] 05:28PM BLOOD WBC-22.3# RBC-3.93# Hgb-10.1# Hct-32.0# MCV-82 MCH-25.8* MCHC-31.7 RDW-20.0* Plt Ct-675* [2187-10-3] 03:35AM BLOOD WBC-13.3* RBC-3.09* Hgb-7.8* Hct-24.3* MCV-79* MCH-25.3* MCHC-32.2 RDW-20.4* Plt Ct-659* [2187-10-2] 01:36PM BLOOD WBC-12.1* RBC-3.24* Hgb-8.5* Hct-25.1* MCV-77* MCH-26.1# MCHC-33.7# RDW-20.3 Plt Ct-661* [2187-10-2] 07:47AM BLOOD WBC-13.3* RBC-3.14* Hgb-7.1* Hct-23.8* MCV-76* MCH-22.6* MCHC-29.8* RDW-21.9* Plt Ct-778* [2187-10-6] 04:33AM BLOOD Plt Ct-736* [2187-10-6] 04:33AM BLOOD PT-14.0* PTT-27.3 INR(PT)-1.2* [2187-10-5] 05:24AM BLOOD PT-14.4* PTT-26.3 INR(PT)-1.3* [2187-10-5] 04:35AM BLOOD Plt Ct-644* [2187-10-4] 01:54PM BLOOD Plt Ct-690* [2187-10-4] 01:19AM BLOOD Plt Ct-679* [2187-10-4] 01:19AM BLOOD PT-15.8* PTT-27.7 INR(PT)-1.4* [2187-10-3] 05:28PM BLOOD Plt Ct-675* [2187-10-3] 05:28PM BLOOD PT-16.1* PTT-28.3 INR(PT)-1.5* [2187-10-3] 03:35AM BLOOD Plt Ct-659* [2187-10-3] 03:35AM BLOOD PT-17.4* INR(PT)-1.6* [2187-10-2] 01:36PM BLOOD Plt Ct-661* [2187-10-2] 01:36PM BLOOD PT-18.5* PTT-30.4 INR(PT)-1.7* [2187-10-2] 10:45AM BLOOD PT-19.0* PTT-31.6 INR(PT)-1.8* [2187-10-2] 07:47AM BLOOD Plt Ct-778* [2187-10-2] 07:47AM BLOOD PT-19.3* PTT-33.8 INR(PT)-1.8* [2187-10-6] 04:33AM BLOOD Glucose-58* UreaN-12 Creat-0.5 Na-136 K-3.9 Cl-98 HCO3-32 AnGap-10 [2187-10-5] 09:23AM BLOOD Na-137 K-4.3 [2187-10-5] 04:35AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-137 K-3.7 Cl-102 HCO3-27 AnGap-12 [2187-10-4] 01:54PM BLOOD Glucose-64* UreaN-10 Creat-0.6 Na-135 K-4.5 Cl-102 HCO3-27 AnGap-11 [2187-10-4] 01:19AM BLOOD Glucose-80 UreaN-7 Creat-0.7 Na-135 K-4.5 Cl-99 HCO3-29 AnGap-12 [2187-10-3] 05:28PM BLOOD Glucose-91 UreaN-8 Creat-0.7 Na-135 K-4.3 Cl-98 HCO3-28 AnGap-13 [2187-10-3] 03:35AM BLOOD Glucose-99 UreaN-12 Creat-0.8 Na-132* K-4.2 Cl-98 HCO3-27 AnGap-11 [2187-10-2] 01:36PM BLOOD Glucose-81 UreaN-13 Creat-0.8 Na-133 K-4.2 Cl-94* HCO3-28 AnGap-15 [2187-10-4] 01:54PM BLOOD CK(CPK)-24* [2187-10-4] 01:19AM BLOOD CK(CPK)-25* [2187-10-3] 06:04PM BLOOD ALT-7 AST-18 LD(LDH)-212 AlkPhos-259* Amylase-17 TotBili-0.8 [2187-10-3] 05:28PM BLOOD CK(CPK)-36 [2187-10-4] 01:54PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2187-10-6] 04:33AM BLOOD Calcium-7.6* Mg-2.2 [2187-10-5] 09:23AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.2 [2187-10-5] 04:35AM BLOOD Calcium-7.8* Phos-4.3 Mg-2.0 [2187-10-5] 04:53AM BLOOD Type-ART Temp-36.7 pO2-108* pCO2-52* pH-7.36 calTCO2-31* Base XS-3 Intubat-NOT INTUBA [2187-10-3] 05:32PM BLOOD Type-ART O2 Flow-3 pO2-90 pCO2-46* pH-7.38 calTCO2-28 Base XS-0 Intubat-NOT INTUBA [2187-10-5] 04:53AM BLOOD Lactate-0.6 [2187-10-3] 05:32PM BLOOD Glucose-87 Lactate-1.3 Na-135 K-3.6 [2187-10-2] 12:40PM BLOOD Glucose-126* Lactate-1.4 Na-132* K-4.2 Cl-95* [2187-10-2] 01:52PM BLOOD O2 Sat-98 [2187-10-2] 12:40PM BLOOD Hgb-8.6* calcHCT-26 [2187-10-2] 11:04AM BLOOD Hgb-8.2* calcHCT-25 [2187-10-2] 09:10AM BLOOD O2 Sat-93 [2187-10-2] 09:05AM BLOOD Hgb-6.6* calcHCT-20 [2187-10-2] 07:45AM BLOOD Hgb-7.6* calcHCT-23 [2187-10-3] 05:32PM BLOOD freeCa-1.09* [2187-10-2] 12:40PM BLOOD freeCa-1.21 [2187-10-2] 11:04AM BLOOD freeCa-1.08* [2187-10-2] 09:05AM BLOOD freeCa-1.08* [2187-10-2] 07:45AM BLOOD freeCa-1.17 Brief Hospital Course: Pt was initially seen by Dr. [Last Name (STitle) ] as inpatient consult on [2187-9-14]. She is a 58 Caucasian F who presents with a 17cm Left renal mass with mets to chest. Her bone scan was negative. Pt was admitted to Urology on same day admissions for Left Radical Nephrectomy/Adrenalectomy on [2187-10-2]. Her surgery was complicated by a pleural leak which was closed with water seal. EBL 300. Pt remained in PACU overnight per cardiology recs for nipride drip. POD#1 Pt did well overnight. Urine out put was intermittens. Pt received 2UPRBCs in PACU. Pt extubated on this day and doing well. Pt developed acute onset of delirium/agitation which resolved with Haldol and Ativan. Change in MS may have been due to nitroprusside toxicity so pt weaned off of nitroprusside and started on oral HTN meds. Per cardiology, pt restarted on digoxin 0.125. Pt transferred to TSICU s/p MS changes. Pt on esmolol drip which was started in PACU. POD#2 Pt unrestrained. Improving MS. Pt complained of chest pain related to inspiration. CXR: mild pulm vascular congestion and free air under R diaphragm. Bilat nodules consistent with mets. Normal EKG. Blood pressure better controlled with oral regimen and pt responding well to Lasix. Pt seen by Heme/Onc to discuss tx options. POD#3 Pt transferred to [Hospital Ward Name 1827] 12. Pt responded well to diuresis, but remains slightly wet. Adv diet to sip from clears. Restart all home meds. Weaning off of O2. Per cards, cont lisinopril and 0.125 dig. POD#4 Pt still with scant bibasilar crackles. Sat @ 97% on 2L NG. Continuing with oral HTN meds and Dig. OOB and ambulating with walker. POD#5 Pt depressed about diagnosis. Sat 98% RA at rest. OOB/AMB with walker. ADAT. Following Dig and BNP levels per cardiology. Dispo planning. Nutrition recommends boots supplements. POD#6 Pt feels anxious this AM. No overnight events. Sat 92% on room air and Sat 86% on RA while ambulating. CXR: consistent with volume overload. EKG: no changes from prior tracings. Pt diuresed per cardiology recommendations. Discussed findings of EKG, CXR and pt's symptoms with cardiology fellow and attending. POD#7 Pt doing much better this AM. Pt [Name (NI) ] 100% while ambulating with PT. PT feels pt no longer needs home PT. Pt safe to be discharged to home with services. Pt discharged on oral HTN meds per cardiology. Discussed with pt the importance of following up with cardiologist. Medications on Admission: furosemide 40a, hydroxyzine 25 mg Q4-6 prn itching, acetaminophen 325 mg Q4-6 prn, zolpidem 5hs PRN insomnia, percocet prn pain, lisinopril 10 qd, spironolactone 25 qd, ferrous sulfate 325 mg qd, phytonadione 10 qd, digoxin 0.25 qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:50 Tablet(s) Refills:0 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety/insomnia. Disp:30 Tablet(s) Refills:0 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take this medication while taking the pain medication. Disp:60 Capsule(s) Refills:0 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: Care Centrix Discharge Diagnosis: Left Renal Cell carcinoma Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please call your doctor if you have any of the following.: -worsening abdominal pain -fever of 101 or more -vomiting -increased drainage coming from your incision -You may see a small amount of clear or slightly red drainage coming from the wound. This is normal. If you have a lot of drainage, you should let your surgeon know. Followup Instructions: Provider: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 276], M.D. Phone:[Telephone/Fax (1) 277] Date/Time:[2187-10-17] 8:40 Provider: [Name10 (NameIs) 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 902] Date/Time:[2187-11-9] 9:40 Completed by:[2187-10-9]	[ "286.3", "997.3", "428.0", "189.0", "197.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "07.22", "55.51" ]	icd9pcs	[ [ [] ] ]	9141, 9184	5224, 7707	284, 303	9254, 9263	1360, 5201	9743, 10058	1241, 1341		7990, 9118		9205, 9233		7733, 7967			9287, 9720																															229, 246									331, 805															827, 983	999, 1225
5,727	152,332	51922	Discharge summary	report	Admission Date: [2154-12-12] Discharge Date: [2154-12-17] Date of Birth: [2096-11-3] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 678] Chief Complaint: PCP: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] . CC: Chest Pain Major Surgical or Invasive Procedure: right external jugular catheter clotted dialysis catheter removal ([2154-12-16]) History of Present Illness: Mr. [Known lastname 107485] is a 58 year old man with history of diabetes, ESRD on HD, CAD s/p MI who presents with left-sided chest pain since dialysis the morning of admission. The chest pain is around the site of his hemodialysis catheter, although the site of the catheter is clean and dry without purulence or erythema. The chest pain is constant and is non-pleuritic; he has had similar episode in the past. He denies fever, shortness of breath, abdominal pain, nausea, and vomiting. He reports that his back is pruritic. He notes recent crack cocaine use in the past three days. . In dialysis the morning of admission, his hematocrit was noted to be 5. He denies bright red blood per rectum and hematemesis, but he had an episode of melena several days ago. In the ED, his vitals were He refused NG lavage but allowed placement of a peripheral IV in the EJ along with another PIV. He was guaiac negative x 2 in the ED. The renal hemodialysis team was consulted in the emergency room. . He has had an extensive workup in the past including (at least) six endoscopies, three colonoscopies, one enteroscopy, and a capsule camera study; all studies have been negative with the exception of small AVM's in the duodenum seen and cauterized on one study, as well as minor jejunal erosions noted on the capsule camera study. During his last admission (end of [Month (only) 359]), he required 7 units of pRBC's. . GI was consulted and given pt's multiple admissions for GI bleed and non-compliance with follow-up and active crack/cocaine use, GI recommended no endoscopies at this time. Pt was transfused 2 units while in the MICu and his Hct stabilized at 26, up from 15 on presentation. Pt's mental status was initially altered and given his substance abuse history he was placed on a CIWA scale. He cleared mentally without benzos and received haldol PRN agitation. He received hemofiltration for fluid overload and pul edema and will continue on his outpt dialysis. His increased troponins were attributed to his renal failure and his CK-MBs remained WNL. Past Medical History: #) ESRD on hemodialysis #) Type II diabetes mellitus #) CAD s/p MI, MIBI in [11-18] showed reversible defects inferior/ latateral #) CHF with EF 30% and severe global hypokinesis #) Hypertension #) Dyslipidemia #) Atrial fibrillation #) History of gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli #) Chronic pancreatitis #) Hepatitis C #) GERD #) Gout, s/p arthroscopy with medial meniscectomy [5-/2149] #) Depression, s/p multiple hospitalizations due to SI #) Polysubstance abuse: crack cocaine, EtOH, tobacco #) Erectile dysfunction, s/p inflatable penile prosthesis [5-/2148] Social History: Smokes 3 cigs/day. Hx of alcohol abuse, with DTs and detoxification. Active crack cocaine use. Family History: Father with alcoholism, cousin with [Name2 (NI) 14165] cell. Mother with renal failure, d. 58. Twin brother and son with kidney disease. Physical Exam: VITALS: T 98.9F, HR 115, BP 134/70, RR 28, Sat 94%2L GEN: Terse, appears older than stated age, no acute distress HEENT: MMM, OP without lesions NECK: No JVD appreciated RESP: Bibasilar crackles, otherwise clear CV: Tachycardic, regular rate, soft systolic murmur at apex-->axilla ABD: Non-distended, soft, + bowel sounds EXT: No edema, L HD catheter clean/dry/intact, without tenderness SKIN: No rashes, L AV fistula + thrill NEURO: A&O x 3 RECTAL: Guaiac negative x 2 in ED (per report) Pertinent Results: . [2154-12-12] 11:27p HCT: 22.5 . [2154-12-12] 8:46p . PT: 17.0 PTT: 150 INR: 1.5 . [2154-12-12] . 141 101 28 =============< 248 3.5 33 3.4 MB: 5 Trop-T: 0.24 . Ca: 8.1 Mg: 1.8 P: 3.3 . Iron: 71 Hapto: 160 . WBC 4.1 Hct 15.3 Plt 258 N:77.3 L:13.0 M:5.9 E:3.7 Bas:0.1 Retic: 5.5 . [2154-12-12] 1:50p . CK: 118 MB: 6 Trop-T: 0.26 . CXR: Chronic small right-sided pleural effusion and tiny left pleural effusion, unchanged. . Removed tunnelled catheter: Successful removal of a left internal jugular vein tunneled line. . . Brief Hospital Course: 58-yo man with diabetes, ESRD on HD, CAD s/p MI, substance abuse, who presented with left-sided chest pain, found at HD to have Hct 15. . #. Atrial fibrillation - Pt has known history of paroxysmal atrial fibrillation and currently in A-fib. Usually well-controlled with HR 90s-110s, but noted to have short episodes of RVR over nights to the 140s-160s, treated with Lopressor IV and PO with good response. No further events with increased dose of labetalol, although pt remains in A-fib at this point. He was discharged on labetalol at 200mg [Hospital1 ], and without anticoagulation given his anemia and GI bleeding. . #. Anemia - Pt reports an episode of melena approx 4-5 days PTA, although he has had no episodes of melena or BRBPR since that time. He has had many prior scopes and is known to have small bowel AVMs. Guaiac negative x2 in the ED, refused NG lavage, no evidence of hemolysis. GI aware, no plan to scope currently. He received 5units PRBCs during his MICU course, as well as DDAVP 25mg IV x1 for uremic bleeding on admission, and his Hct has responded nicely and continues to be stable at 27-30 (baseline Hct 32-36). He was continued on a PO PPI [Hospital1 ], and his ASA and anticoagulation were held. He received Epo at HD. . #. ESRD on HD - Pt has received HD through AVF on this admission, as his HD catheter was known to be clotted and was then removed [12-16]. Renal team aware, appreciate involvement. The patient received ultrafiltration for pulmonary edema, and received Epo as above for his anemia. . #. Altered Mental Status - Pt noted to have AMS by MICU team, felt to be multifactorial due to anemia and cocaine use. Now appears to be at baseline. Patient also advised to see a psychiatrist for treatment of his depression, and to avoid illicit drugs. . #. CAD - Pt was noted to have ECG changes on admission (TWI V5-V6), with last stress test [2152] showing reversible defects inferiorly and laterally. CEs flat x3 on admission. His ASA was held given his anemia / GI bleeding as above, but he was continued on his labetalol and lisinopril. . #. Hypertension - currently stable on home anti-hypertensives. His labetalol was titrated for rate control of his atrial fibrillation. . #. CHF - noted to have decreased EF [9-/2154], currently stable. He was continued on his home BB and ACE-I. . #. Diabetes - Pt is on [Hospital1 ] NPH at home. He was continued on [Hospital1 ] NPH and his doses were titrated. He was also covered with an insulin sliding scale and kept on a diabetic diet. . #. Hyperlipidemia - He was continued on atorvastatin at home dose. . #. Pruritus - DDx for etiology: uremia vs. narcotic effect. He was treated with Sarna lotion. . Medications on Admission: Thiamine 100mg daily Folic acid 1mg daily Iron sulfate Atorvastatin 20mg daily Insulin NPH 30 units qAM, 20 units qPM Sevelamer 800mg TID with meals Labetalol 100mg [Hospital1 ] Pantoprazole 40mg daily Aspirin 325mg daily Lisinopril 40mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Hospital1 ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Hospital1 ]:60 Tablet(s) Refills:2 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. [Hospital1 ]:30 Tablet(s) Refills:2 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous at Breakfast. 8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty Five (25) units Subcutaneous at Dinner. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. anemia 2. h/o gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli 3. atrial fibrillation 4. clotted HD catheter 5. ESRD on HD 6. Type II Diabetes Mellitus 7. Hypertension 8. Depression, s/p multiple hospitalizations due to SI 9. Polysubstance abuse: crack cocaine, EtOH, tobacco Secondary Diagnoses: - CAD s/p MI, MIBI in [11-18] showed reversible defects inferior/lateral - CHF with EF 30% and severe global hypokinesis - Dyslipidemia Discharge Condition: afebrile, vital signs stable, pain free, hematocrit stable, asymptomatic. Discharge Instructions: You were admitted to [Hospital1 69] on [2154-12-12] for anemia, from a hematocrit of 15 that was noted at dialysis. Given your history of bleeding from your intestines, you were admitted to the Medical Intensive Care Unit for transfusions, monitoring, and dialysis. You received 5 units of blood there, and hemodialysis twice. Your clotted dialysis catheter was removed on [12-16] as your AV fistula was well-functioning. You were also monitored on telemetry and noted to be in atrial fibrillation and have increased heart rates to the 140s-160s over nights, which was treated by increasing your dose of labetalol, with definite improvement in your heart rates and blood pressures. You remained stable overnight and were discharged home on [2154-12-17]. . You should continue to take your medications as prescribed below. You should hold your aspirin for now given your bleeding and anemia, and you should take your protonix twice daily at home. You should also take your 200mg of your labetalol, which is twice the dose you were on prior to this hospitalization. You should follow-up with your primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], within 2-3 weeks. You should call [Telephone/Fax (1) 250] to schedule an appointment to see him. . If you develop any further bleeding or black tarry stools, or chest pain, shortness of breath, palpitations, you should call your doctor or return to the emergency room. Followup Instructions: You should follow-up with your primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216], within 2-3 weeks. You should call [Telephone/Fax (1) 250] to schedule an appointment to see him. . Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2155-1-3] 8:20 . [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684]	[ "305.61", "585.6", "996.73", "305.01", "305.1", "428.22", "403.91", "250.42", "070.54", "428.0", "285.1" ]	icd9cm	[ [ [] ] ]	[ "86.05", "39.95" ]	icd9pcs	[ [ [] ] ]	8437, 8443	4586, 7303	361, 448	9000, 9076	4013, 4563	10635, 11172	3346, 3488		7602, 8414		8464, 8816		7329, 7579			9100, 10612								3503, 3994			8837, 8979																				231, 323									476, 2545															2567, 3215	3231, 3330
30,786	125,596	9322+56024	Discharge summary	report+addendum	Admission Date: [2110-9-25] Discharge Date: [2110-10-6] Date of Birth: [2060-5-13] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 2499] Chief Complaint: Lethargy, fever Major Surgical or Invasive Procedure: Esophageal stent placement History of Present Illness: Patient is a 50yo woman with adenoid cystic carcinoma s/p left pneumonectomy, known mets to liver/kidney, PE, presenting with fevers, lethargy, and pleuritic CP. . In ED, T 102.5, SBPs initially 110/62, HR 150, on 2Lnc, received 2L of NS with drop of HR to 110, SBPs 80/40, given CTX for putative PNA. CT (-) for PE but flashed at CT scan, relieved nitro gtt and NIPPV. Received CTX IVx1, combivent nebs, 60poKCl, Mg 5g, 3L NS. . Most recent chemotherapy was cisplatin on [9-9] with 4 clinic visits over next 12 days with Dr. [Last Name (STitle) ]/[Last Name (un) 31899]. Found to be tachycardic at all visits for unknown reason with resolution post fluids. As per primary oncologist, no plans for further chemotherapy with plan for hospice care discussion soon as outpatient. Past Medical History: PMH: 1. Adenoid cystic carcinoma, diagnosed [3-/2103], details below 2. Left vocal cord paralysis 3. GERD 4. History of PE, [2099], [2107] 5. Cerebral vein thrombosis 6. Depression? (found in ED note) 7. CVA? (found in ED note) . Onc Hx: [2102]: diag after work-up 8 months of cough, L pneumonectomy and carinal resection and postop radiation. [2105]: Recurrent dz in pleural space. [2106]: palliative radiation with concurrent low-dose Taxotere. [2107]: Hepatic involvement --> 4 cycles of cisplatin and Adriamycin. [2107]: CT showed progression in lungs/liver. 2 cycles of carboplatin and Taxol given, still with pulm progression. Tx complicated by thrombocytopenia and PE on CT, started on Lovenox. [2108]: Brachial plexus MRI showed tumor L paraspinal region from T2-T5 [2108]: 4 cycles of dose-reduced cisplatin, Navelbine [2108]: CT showed renal hepatic progression. [2108]: started on gemcitabine, held sev times for myelosuppression. [2108]: MRI showed leptomeningeal enhancement L frontal lobe. [2109]: seizure, vein of Trolard thrombosis. [2109]: weekly epirubicin, received 3 cycles, but multiple doses were held because of poor performance status. [2109]: onc team and pt decided upon symptom managment as CT scan showed progression, she received single [Doctor Last Name 360] cisplatin. Social History: She does not smoke cigarettes or drink alcohol. She moved from [Country 3594] to [State 350] in [2091]. She has a daughter who lives in [Name (NI) 17065]. She also has a brother and sister who live in the Greater [Name (NI) 86] area. She denies tobacco or alcohol use and is currently not working. In the past, she has worked in a bakery. Family History: Her mother is alive and healthy. Her father died at age 80 from a stroke and heart attack. She has 5 sisters and 2 brothers, and some of them have hypertension, hypercholesterolemia, and diabetes. She has 6 daughters and a son; they are all healthy. Physical Exam: PE: T 99.7, BP 111/78, HR 136, RR 18, 96% 2L Gen: thin, chronically ill-appearing F in NAD, mostly Spanish speaking. HEENT: EOMi dry mucous membranes, clear oropharynx without thrush. Neck: flat JVP, no LAD. Lungs: good air movement on R, decreased to no movement on left. Cardiac: tachycardic, RRR, S1, S2, no murmurs Abd: SNTND, +bs Extr: thin, warm, well perfused. no clubbing/cyanosis/edema. Skin: no rashes or other lesions. port on right chest c/d/i, no erythema, tenderness to palpation. Neuro: A&O, CNs grossly intact, no focal deficits Psych: pleasant, appropriate Pertinent Results: Admission labs: [2110-9-24] 11:00AM WBC-4.0 RBC-4.00* HGB-11.0* HCT-34.6* MCV-87 MCH-27.5 MCHC-31.8 RDW-16.6* [2110-9-24] 11:00AM GRAN CT-2890 [2110-9-24] 11:00AM PLT COUNT-313 [2110-9-24] 11:00AM GLUCOSE-88 UREA N-5* CREAT-0.7 SODIUM-143 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16 [2110-9-24] 11:00AM ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.2* . CHEST (PORTABLE AP) [2110-9-25] IMPRESSION: Extensive opacification in the right lung, with both alveolar and interstitial characteristics, most likely due to aspiration. Stomach is mildly distended with gas. Left pneumonectomy space is free of gas or other evidence of stump leak. Cardiac silhouette is obscured in the left hemithorax. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [2110-9-25] IMPRESSION: 1. Nodular and patchy opacities in the right lower lobe consistent with aspiration or infection. 2. Enlarging right lower lobe pleural-based mass. 3. Increased paravertebral soft tissue mildly narrowing the right bronchus intermedius. 4. No pulmonary embolism. . EGD [2110-9-30] Impression: 1. Stricture of the middle third of the esophagus probably related to extrinsic compression. 2. A 7cm covered ultraflex metal stent (Lot no. [Serial Number 31900]) was placed successfully across the stricture. This was done under fluoroscopic guidance after placement of a jagwire. The stent placement was confirmed endoscopically. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Patient is a 50 yo woman with metastatic adenoid cystic lung cancer progressing on cisplatin who presents with fevers to 102, productive cough, lethargy. Given the respiratory distress after 2 L of IVFs, episode of hypotension in the ED, and tachycardia, she was admitted to MICU. . Her hypotension resolved with the IVFs prior to arrival to the MICU. Per outpatient notes, her blood pressure does run low with SBPs in the 90s. Her tachycardia was also at baseline. . Her acute respiratory distress resolved after nebulizer treatments and NIPPV. The cause may be due to bronchospasm. She was also found to have a RLL pneumonia. She was started on cefepime and vancomycin. As her respiratory distress resolved, she was transferred to the oncology floor the day after admission. . On the oncology floor, patient's antibiotics were changed to cefepime and metronidazole to cover for aspiration. Recent speech and swallow evaluation did show evidence of mild-moderate oropharyngeal dysphagia with aspiration if not using proper swallowing technique. Her fever did defervesce and her cough is resolving. Blood cultures were negative. She was discharged on levofloxacin and metronidazole to complete 2 weeks of antibiotics. . After discussion with her outpatient oncology team and family, her care was shifted to center on comfort. Her pain was controlled with her outpatient regimen of fentanyl patch and po morphine for breakthrough. She also responded well to Compazine for any nausea. Patient was also discontinued on Coumadin for her h/o PE and cerebral vein thrombosis. . Patient also had an esophageal stent placed to help with her dysphagia. Hopefully this will decrease risk of aspiration. She had some mild neck discomfort from the stent, which resolved with morphine and time. . Patient was comfortable upon discharge and was discharged to home with hospice. Medications on Admission: COMPAZINE 10mg prn COUMADIN 2mg DEXAMETHASONE 4mg during chemo EMEND 125mg 80mg 80mg during chemo. FENTANYL 225 mcg/hr q72 GABAPENTIN 250 tid LANSOPRAZOLE 30mg Megace 400mg OXYCODONE 5mg q6hrs prn ZOFRAN 8mg prn Discharge Medications: 1. oxyfast [Serial Number ]: 1-20 mg q1 hr prn as needed for pain. Disp:30 ml Refills:0 2. 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 3. Fentanyl 100 mcg/hr Patch 72 hr [Last Name (STitle) ]: Two (2) Transdermal Q72H (every 72 hours). Disp:60 Refills:2 4. Fentanyl 25 mcg/hr Patch 72 hr [Last Name (STitle) ]: One (1) Transdermal every seventy-two (72) hours. Disp:30 Refills:2 5. Gabapentin 250 mg/5 mL Solution [Last Name (STitle) ]: One (1) PO Q8H (every 8 hours). Disp:qs x 1 mo Refills:2 6. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Last Name (STitle) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Senna 8.6 mg Tablet [Last Name (STitle) ]: Five (5) ML PO BID (2 times a day). 9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [Last Name (STitle) ]: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:qs x 1 mo Refills:0 10. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 11. Levofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 12. Compazine 5 mg/5 mL Syrup [Last Name (STitle) ]: [4-3] mL PO every 6-8 hours as needed for nausea. Disp:qs x 1 mo Refills:0 Discharge Disposition: Home With Service Facility: Hospice of the Good [Doctor Last Name 9995] Discharge Diagnosis: Metastatic adenoid cystic lung cancer Aspiration pneumonia Esophageal stricture Discharge Condition: Stable Discharge Instructions: You were admitted for difficulty breathing. You were found to have a pneumonia and were treated with antibiotics. . You also had an esophageal stent placed to ease your swallowing. . Please take your medications as prescribed. . If you develop a fever, nausea or vomiting, pain, or any other worrisome symptoms, please call your oncologist. Followup Instructions: Hospice nurse will be taking care of you while you stay at your sister's place. . If you have any concerns or questions, please call your oncologist Dr. [Last Name (STitle) ] at ([2110] or Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 31901]. Name: [Known lastname 5545],[Known firstname 5546] Unit No: [Numeric Identifier 5547] Admission Date: [2110-9-25] Discharge Date: [2110-10-6] Date of Birth: [2060-5-13] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 2808] Addendum: Severe malnutrition: Nutrition was consulted and followed the patient while in the hospital. Discharge Disposition: Home With Service Facility: Hospice of the Good [Doctor Last Name 5548] [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 2809] Completed by:[2110-10-27]	[ "286.7", "261", "530.81", "197.7", "198.0", "507.0", "197.2", "530.3", "197.0", "V10.11", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "42.81" ]	icd9pcs	[ [ [] ] ]	10455, 10705	5350, 7229	339, 368	9274, 9283	3834, 3834	9673, 10432	2973, 3224		7491, 9049		9171, 9253		7255, 7468			9307, 9650								3239, 3815																							284, 301									396, 1187					3850, 5327										1209, 2578	2594, 2957
54,465	193,862	12194	Discharge summary	report	Admission Date: [2106-6-24] Discharge Date: [2106-6-30] Date of Birth: [2048-1-11] Sex: F Service: MEDICINE Allergies: Cipro / Septra Attending:[First Name3 (LF) 602] Chief Complaint: unable to move legs Major Surgical or Invasive Procedure: none History of Present Illness: 58F with history of bipolar disorder and ?polysubstance abuse presents with acute low back pain, lower extremity numbness, urinary incontinence and subjective fevers. Patient presented to [Hospital3 26615] hospital with a 3 day hx of fever (to 102) and worsening back pain with assoicated urinary incontinence and numbess of bilateral lower extremities. Labs were notable for normal WBC, K of 2.7 and Cr elevated at 2.7 from a baseline for approximately 1.1 She was given dilaudid for pain, vancomycin and ceftriaxone and transferred to [Hospital1 18] given concern for potential epidural abscess or cauda equina syndrome. Of note patient was recently discharged from OSH in [4-29] after presenting with weakness and altered mental status. During that hospitalization she was treated for an enterococcal UTI with levaquin with transition to amoxicillin. She was also noted to have acute renal failure (Cr 1.5) and hypokalemia (K 2.9) which were attributed to volume depletion. She had a troponin bump to 0.17 and rule out ultimately thought not to be ACS in addition to a COPD exacerbation treated with steroids. Hospitialization was complicated by hypotension requiring transient dopamine for blood pressure support. Blood pressure improved with IVF and her home clonidine was discontinued. In the ED, initial VS were: 98.3 60 117/72 24 100%. Labs were notable for a normal WBC, Cr of 2.7 from a baseline of 0.7 and K of 2.5 which was repleted with 30 mg PO potassium. A spinal MRI was done given concern for epidural absecess or cauda equina syndrome which was negative for abscess but did show moderate to severe spinal canal narrowing at L3/4 due to lig. flavum hypertrophy, facet arthropathy and disc bulge. UA was unremarkable. The patient was given 1 mg of dilaudid, 5 mg of IV diazepam, and 1 mg of Lorazepam after which she was noted to have increased solmonence and hypotension to the 80s systolic. She was given narcan with improvement to the 110s. She was evalutated by neurology who felt symptoms were most likely reflective of a toxic metabolic encephlopathy and recommened infectious work-up with plan for LP today should symptoms fail to improve in order to evaluate for a potential viral myelopathy. In the ED she remained intermittently hypotensive to the 80s-90s despite 2L IVF. She was therefore admitted to the ICU for further management. On arrival to the MICU, patient's VS. She is agitated and unwilling to participate with the majority of the interview. She was unable to provide details of her back pain but does state it goes all down her spine and that she cannot feel her legs. Symptoms have been ongoing for the past few weeks. She denies recent trauma to her back. She denies associated nausea, vomiting, cough, neck stiffness or headaches. She does state she has not had a BM in 2 weeks though she normally has them daily. The patient further reports decreased PO over the past several days stating "no one would give her food". She denies dysuria but does endorse one urinary incontinence. Review of systems: (+) Per HPI (-) Denies fechills, 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 abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Status post CVA 2. Status post lumpectomy 3. History of renal stones. 4. Abnormal endometrial biopsy in [2094]. 5. Depression 6.?polysubstance abuse 7. Chronic low back pain 8. COPD 9. Arthritis 10. S/p L knee surgery [05]. Chronic back pain Social History: Lives in a sober living house. Former nurse. 1. Used to drink alcohol once a week on the weekend, increased intake to up to a pint of Tequila per night in late [2095]/early [2096]. Has been sober for the past 4 months 2. Smokes one half to one pack of cigarettes per day. 3. No illicit drug abuse. Family History: Father died of multiple myeloma at age 66. Mother passed a way from breast and colon cancer at 92. Brother died of leukemia at age 67. Physical Exam: ADMISSION EXAM General: patient is crying throughout the interview stating no one is willing to help her HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, + asterixis bilaterally Neuro: CNII-XII intact, patient unable to move lower extremities, normal tone, decreased sensation in bilateral lower exremities, 2+ reflexes bilaterally at biceps, unable to elicit LE reflexes, per ED normal rectal tone, gait deferred. Discharge Exam: VS: Tm AFebrile Tc BP 120s-150s/80s-90s HR 60s-90s RR 16-18 SaO2 97%RA GENERAL: [x] NAD [] Uncomfortable Eyes: [x] anicteric [] PERRL ENT: [x] MMM [] Oropharynx clear [] Hard of hearing NECK: [] No LAD [] JVP: CVS: [x] RRR [x] nl s1 s2 [x] no MRG [] no edema LUNGS: [x] No rales [x] No wheeze [x] comfortable ABDOMEN: [x] Soft []nontender []bowel sounds present []No hepatosplenomegaly BACK: very minimal ttp at the midline lumbar spine SKIN: [x]No rashes []warm []dry [] decubitus ulcers: LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [x] Oriented x3 [x] Fluent speech Psych: [x] Alert [x] Calm [x] Mood/Affect: good Pertinent Results: ADMISSION LABS [2106-6-23] 09:50PM BLOOD WBC-4.3 RBC-3.75* Hgb-11.4* Hct-33.6* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.9 Plt Ct-203 [2106-6-23] 09:50PM BLOOD Neuts-44.8* Lymphs-45.4* Monos-6.4 Eos-2.3 Baso-1.1 [2106-6-23] 09:50PM BLOOD PT-10.3 PTT-27.0 INR(PT)-0.9 [2106-6-23] 09:50PM BLOOD Glucose-86 UreaN-27* Creat-2.9# Na-134 K-2.5 Cl-82* HCO3-39* AnGap-16 [2106-6-23] 09:50PM BLOOD ALT-10 AST-20 LD(LDH)-190 AlkPhos-63 TotBili-0.3 [2106-6-23] 09:50PM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2 [2106-6-24] 05:04AM BLOOD VitB12-436 [2106-6-24] 05:04AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2106-6-24] 06:18AM BLOOD Type-ART Temp-38.7 pO2-74* pCO2-61* pH-7.42 calTCO2-41* Base XS-11 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] . URINE [2106-6-24] 02:20AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.007 [2106-6-24] 02:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2106-6-24] 02:20AM URINE Hours-RANDOM UreaN-143 Creat-45 Na-51 K-27 Cl-LESS THAN [2106-6-24] 02:20AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . MICROBIOLOGY Blood Cx negative x 2 Urine Cx negative RPR negative . IMAGING MR T/L spine 1. No evidence of epidural abscess. 2. Multilevel degenerative changes are seen. 3. Moderate spinal canal narrowing at L3-4 level due to ligamentous flavum thickening and facet hypertrophic changes. 4. Postoperative changes in the lumbar region. 5. No acute fracture identified. . CXR Lung volumes are normal. Normal size of the cardiac silhouette. Normal appearance of the hilar and mediastinal structures. Normal structure and transparency of the lung parenchyma. No evidence of pneumonia or other acute lung disease. . EKG Sinus rhythm. Poor R wave progression. Modest ST-T wave changes that are non-specific. No previous tracing available for comparison. Discharge/Notable Labs: [2106-6-27] 11:00AM BLOOD WBC-3.4* RBC-3.77* Hgb-11.5* Hct-34.3* MCV-91 MCH-30.5 MCHC-33.5 RDW-15.0 Plt Ct-194 [2106-6-28] 04:30AM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-142 K-3.5 Cl-108 HCO3-27 AnGap-11 [2106-6-28] 04:30AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.3 [2106-6-24] 05:04AM BLOOD VitB12-436 [2106-6-24] 05:04AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Studies pending on discharge: None Brief Hospital Course: 58 yo female with history of chronic low back pain, bipolar disorder complicated by prior suicidal ideation and psychiatric admission admitted with fever, hypotension, urinary incontinence and back pain. #Hypotension: The patient was initially hypotensive in the emergency department and was therefore admitted to the ICU. Hypotension was felt most likely reflective of volume depletion in the setting of poor oral intake in addition to polypharmacy (requiring narcan). She did report fevers at home which was concerning for sepsis however she was without evidence of infection on exam, WBC was normal, CXR was clear, UA was unremarkable. Blood and urine cultures showed no growth. She was fluid resuscitated with improvement in her BPs. Antibiotics were not started. Her home clonidine was held and opioids were avoided. Blood pressure improved and she was transferred to the floor. Her blood pressures were stable on the floor including >48 hours prior to discharge. # Back Pain: Patient has a long history of chronic back pain with acute worsening with symptoms initially concerning for epidural abscess or cord compression. However MRI spine was without evidence of abscess, cord compression, and Neurology feels that exam is not consistent with primary neurologic etiology. Concern for somatization or other non-organic etiology. Per her daughter she does have a history of similar presentation of lower extremity weakness and numbness felt to be somatization which resolves spontaneously. Pain was managed with lidoderm patch, neurotin and tylenol. She was not complaining of significant back pain at the time of discharge. #Bipolar disorder/substance abuse: Patient has a history of multiple psychiatric issues, including hx of substance abuse, bipoloar d/o/depression requiring ECT, as well as ? of eating disorder. She was extremely upset and tearful on admission. In addition, the patient had many sharp objects such as needles, scisors and a razor all part of a sewing kit which was removed from the patients room. A sitter was placed in the patients room. There was concern that symptoms of numbness and weakness were reflective of somatization (conversion disorder). Psychiatry was consulted and initially felt that the patient warranted psychiatric admission. However, the patient's mood improved over course of hospitalization, and after discussion with the patients PCP and therapist [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] NP ([Telephone/Fax (1) 38156]) the decision was made that it would be in the patient's best interest for her to be discharged back to her sober house ([First Name4 (NamePattern1) 38157] [Last Name (NamePattern1) ]) under close supervision of her therapist. She has appt with therapist the day after admission. Pt also denied severe depressive symptoms on the day and day prior to discharge. . #Encephalopathy/altered mental status: Patient was noted to be very somnolent in the emergency department in the setting of receiving both opioids and benzos. This was felt to be reflective of polypharmacy. She became more alert with administration of narcan. As above infectious work-up was unrevealing. Patient was alert and interactive for >48 hours prior to discharge. . #Possible history of non epileptic seizures: Following severe agitation during her hospitalization, she was given haldol and ativan and had a short episode of twitching witnessed by the sitter. EKG showed a QTC of 432. She did not have post-ictal confusion, had no obvious injuries, had a non focal neuro exam and showed some signs during the episode, such as purposeful movements, that are not consistent with true seizures. It was therefore felt that this was a pseudo-seizure and not true epileptiform activity. She was placed on tele and had no subsequent events to witness. . #Acute renal failrue: Cr was elevated at 2.9 on admission (most recent baseline 0.8 on discharge at OSH in [Month (only) 547]). This was felt to most likely be reflective of pre-renal given significant improvement with administration of IVF. Patient had normal renal function for >72 hours prior to discharge. . # Hypokalemia: Patient has a history of recurrent hypokalemia which has been attributed to poor PO intake in the past. Currently stable levels after repletion and was stable without repletion prior to discharge for >72 hours. STABLE ISSUES # COPD: Patient is not currently on medications. Appears to be in stable respiratory status without evidence of exacerbation. . TRANSITIONAL ISSUES - Patient was full code throughout this admission - Patient discharged home ([First Name4 (NamePattern1) 38157] [Last Name (NamePattern1) ]- sober house) with close PCP/NP/Therapist followup/supervision Medications on Admission: KCl 10mEq albuterol PRN ASA 81 daily gabapentin 600mg TID Seroquel 300mg at HS clonidine 0.1mg QID Discharge Medications: 1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 2. quetiapine 100 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 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). 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Seroquel 25 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for anxiety. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Depression Chronic low back pain possibly due to moderate spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You initially came to [Hospital1 18] for further work up of back pain, urinary incontinence, fevers, and low blood pressure. It was felt that your low blood pressure was due to your clonidine as well as dehydration. Imaging of your back showed moderate narrowing of your spinal canal but no abscess. Your back pain improved during hospitalization and you were discharged home. Please make sure to follow up with your therapist/PCP following discharge. Followup Instructions: Please follow up with your therapist [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] NP ([Telephone/Fax (1) 38156]) on Thurdsday [2106-7-1] at 230pm.	[ "E849.7", "724.02", "458.9", "E939.4", "303.90", "349.82", "V13.02", "V49.87", "496", "788.30", "780.60", "E935.2", "276.8", "584.9", "305.00", "V12.54", "276.51", "296.80" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13906, 13912	8492, 11398	294, 300	14030, 14030	6025, 8449	14663, 14846	4400, 4536		13401, 13883		13933, 14009		13278, 13378			14181, 14640								4551, 5346							5362, 6006									8463, 8469			3391, 3778				235, 256									328, 3372									14045, 14157						3800, 4055	4072, 4384
32,094	146,827	33341	Discharge summary	report	Admission Date: [2151-8-12] Discharge Date: [2151-8-30] Date of Birth: [2085-3-13] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: back and leg pain with ambulation Major Surgical or Invasive Procedure: PLIF L4-5 History of Present Illness: Patient is a 66M who was electively admitted for surgical managment for severe lumbar stenosis Past Medical History: HTN Social History: married resides in [Location (un) 14663], EtOH 3-5 drinks/day Family History: non-contributory Physical Exam: On Admission: Pleasant obese gentleman, AO x3 Heart: RRR Lungs; CTA Abd: Obese, soft NT/ND Ext: warm, perfused Motor: Full Lower Extremites,sensation intact On Discharge: Neuro:AOx3, full motor strength to upper and lower extremites. Sensation intact. Surgical incision is Clean, Dry and Intact. Resp: with mild dyspnea with ambulation, maintaining saturations of 93% or greater. Pertinent Results: Labs On Admission: [2151-8-13] 01:00AM BLOOD WBC-10.6 RBC-3.79* Hgb-11.7* Hct-33.7* MCV-89 MCH-30.8 MCHC-34.6 RDW-13.3 Plt Ct-203 [2151-8-13] 04:42PM BLOOD PT-12.7 PTT-27.3 INR(PT)-1.1 [2151-8-13] 01:00AM BLOOD Glucose-203* UreaN-23* Creat-1.7* Na-137 K-5.1 Cl-106 HCO3-23 AnGap-13 [2151-8-13] 01:00AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.0 Labs on Discharge: [2151-8-28] 07:20AM BLOOD WBC-8.6 RBC-3.63* Hgb-10.7* Hct-31.7* MCV-88 MCH-29.4 MCHC-33.6 RDW-13.3 Plt Ct-414 [2151-8-29] 02:00AM BLOOD PT-20.8* PTT-74.0* INR(PT)-2.0* [2151-8-28] 07:20AM BLOOD Glucose-101 UreaN-15 Creat-1.1 Na-137 K-5.0 Cl-100 HCO3-29 AnGap-13 [2151-8-27] 06:52AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 Radiographic Studies: Lumbar Drain Placement ([8-13]): IMPRESSION: Successful fluoro guided lumbar drain placement. Dr. [First Name8 (NamePattern2) ] [Name (STitle) ], the attending neurointerventionalist, was present supervising throughout the entire procedure. CTA([8-22]): IMPRESSION: 1. Massive bilateral pulmonary emboli. 2. Right atrium and right ventricle appear dilated. Although CT cannot definitively diagnose right heart strain, these findings are supportive of the patient's known right heart strain on EKG. 3. Non-specific ground-glass opacities in the right upper and left lower lobes are likely related to pulmonary emboli. 4. Diffuse idiopathic skeletal hyperostosis of the thoracic spine. Lower Extremity Doppler Study: FINDINGS: There is normal compressibility, waveform, color Doppler signal, and augmentation of the lower extremity veins from the level of the common femoral through the tibial veins. Cardiac Echo([8-25]): The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is markedly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Post-Surgery/Standing Lumbar Films([8-26]): Four radiographs of the lumbar spine demonstrate the patient to be status post L4-L5 posterior metallic spinal fusion and L4 laminectomy. When compared to [2151-6-11], the fusion is new. There is partial interval reduction of the L4-L5 anterolisthesis seen on [2151-6-11]. 4-5 mm of anterolisthesis are present at L4-L5. A radiolucent intervertebral body spacer is seen at L4-L5. Hip and sacroiliac joints are unremarkable. Symphysis pubis is normal. The AP view suggests the L4-L5 intervertebral body spacer device is to the right of midline. Correlation with surgical history is requested. Brief Hospital Course: Pt was admitted and brought to the OR electively where under genaeral anesthesia he underwent PLIF L4-5. He tolerated this procedure well but due to length of case remained intubated post op. he had dural leak intra-op that was repaired. He was transferred to SICU. He was kept flat bedrest. In attempt to extubate on POD#1, HOB was elevated and shortly thereafter, wound was draining what appeared to be CSF. He was taken to IR for placement of lumbar drain. Lumbar drain was not functioning well and this was revised in OR by Dr. [Last Name (STitle) 548] on POD#2. He was extubated later that day without difficulty. His motor exam was full strength. His dressing/wound was monitored, lumbar drain output was controlled. On [8-21], the lumbar drain was removed, as surgical incision remained dry. On [8-22], while getting up from bed for the first time after remaining on bedrest for his dural tear, patient became acutely dyspneic, diaphoretic, tachycardic, and hemodynamically unstable. He was emergently escorted back to the bed, when an EEG, and cardiac consult was emergently obtained. EEG revlead right heart strain, and patient was emergently taken to CT scan for CTA to evaluate for pulmonary embolus. Massive pulmonary embolus was identified, and patient was begun on systemic weight based heparin protocol. He was transferred to the ICU for closer managment during his acute episode and remain in the ICU until [8-24]. He had post op xrays that should good alignment. His incision was well healed and staples were removed. He was begun on coumadin and heparin was maintained until coumadin reached therapeutic goal. He was seen by PT and cleared for home. He was tolerating all PO meds. Medications on Admission: aspirin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release 12 hr(s) Refills:0 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:120 Tablet(s) Refills:0 7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 9. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: You must be seen by your PCP by monday or Tues for managment of your coumadin and INR levels. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: lumbar stenosis Intraoperative dural tear, lumbar drain placement by IR Massive pulmonary embolus Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean and dry / No tub baths or pools until seen in follow up/ begin daily showers [2151-8-16] ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for 2 weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN [3-23] WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT You must be seen by your PCP for management of your Coumadin and INR levels by Tuesday or Wednesday at the latest. Completed by:[2151-8-30**]	[ "415.11", "E870.0", "998.2", "E849.7", "722.10", "416.8" ]	icd9cm	[ [ [] ] ]	[ "77.79", "81.08", "84.52", "81.62", "03.31", "03.09" ]	icd9pcs	[ [ [] ] ]	6987, 6993	4177, 5910	353, 365	7135, 7159	1050, 1055	8368, 8692	615, 633		5968, 6964		7014, 7114		5936, 5945			7183, 8345								648, 648																820, 1031							280, 315				1423, 4154					393, 489							1069, 1404								511, 516	532, 599
481	117,834	15909	Discharge summary	report	Admission Date: [2167-11-29] Discharge Date: [2167-12-2] Date of Birth: [2126-11-29] Sex: M Service: ACOVE CHIEF COMPLAINT: Cough. HISTORY OF PRESENT ILLNESS: This is a 41-year-old man with a history of alcoholism, cirrhosis, with ascites, small varices, alcoholic seizures, and hepatitis C, who has been alcohol free for several months prior to admission. The patient then noted a cough several days prior to admission that he notes to be nonproductive. He stated he was out in the rain all day, then came home, and fell asleep. He woke up with high fever and chills, but could not tell me the temperature. Her also has pain in his left upper chest with inspiration and pain in his back. His mother called EMS. The patient was brought to [Hospital3 3834] [Hospital3 ]. Vital signs were 102.3, 100/38, 112, 100%. White blood cells at that time was 16.6 with 27 bands. He was given ceftriaxone 1 gram IV, Zithromax 500 mg IV. The patient soon dropped his blood pressure to 70 systolic, but was asymptomatic. He was admitted to the Intensive Care Unit. He had a Swan Ganz catheter placed. He was then given Dopamine and switched to Levophed and Neo. The patient was then transferred to [Hospital1 1444] for further evaluation. Upon admission, the patient complained of fever, chills, and slight nausea. Had a nonproductive cough as well as mild back and abdominal pain. PAST MEDICAL HISTORY: 1. Chronic hepatitis C with history of hepatic encephalopathy. 2. Cirrhosis with ascites. 3. Anemia. 4. History of alcohol abuse. 5. History of small varices on esophagogastroduodenoscopy in [2167-9-20]. 6. History of alcoholic seizure disorder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION TO [Hospital1 ]: 1. Ceftriaxone 1 gram q day. 2. Levofloxacin 500 mg IV q day. 3. Lasix 40 mg po q day. 4. Aldactone 100 mg po q day. 5. Protonix 40 mg po q day. 6. Lactulose 30 mg po tid. FAMILY HISTORY: Father died of alcoholism. Mother is alive and living with depression. SOCIAL HISTORY: Patient is currently 1.5 pack per day smoker, and has been so for greater than 20 years. He had a history of heavy alcohol use, but quit three months ago. He lives with his mother and his son. [Name (NI) ] has a history of intravenous cocaine use many years ago. He denies any history of heroin use. PHYSICAL EXAMINATION: Vital signs: 97.8, 103, 107/57, 24, and 98% on room air. In general, this is a pleasant middle-aged man in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Slight icterus. Neck: Right Swan, supple. Lungs are clear to auscultation bilaterally. Cor tachycardia, but regular, rate, and rhythm. No murmurs, rubs, or gallops. Abdomen is soft, moderately distended, decreased bowel sounds, no rebound or guarding, but mild diffuse tenderness. Extremities: 1+ edema. Neurologic is alert and oriented times three. Positive slight asterixis. Many tatoos, mild macular pin-point rash, flushed, spider angiomas. LABORATORIES: White blood cells 30.8, hematocrit 30.3, platelets 173. Chem-7 132, 3.8, 103, 13, 19, 2.6 and 92. Urinalysis negative. Chest x-ray with a question of a left lower lobe infiltrate. Electrocardiogram with normal sinus rhythm at 87, normal axis, intervals, and no ST-T wave changes. HOSPITAL COURSE: 1. Infectious Disease: Patient was admitted to the hospital with sepsis of unclear etiology. Patient was afebrile on admission with stable blood pressure of 107/97, heart rate of 103. His pressors were weaned off. He had a cardiac echocardiogram which demonstrated an ejection fraction of 60%, dilated, [2-18]+ TR, and mild pulmonary hypertension. A right upper quadrant ultrasound demonstrated cholelithiasis, traced perihepatic ascites, hepatosplenomegaly with hepatofugal flow and recanalized umbilical veins consistent with portal hypertension. Paracentesis was attempted, but could not be done secondary to lack of fluid. Chest x-ray with left lower lobe atelectasis versus infiltrate. The patient was given levofloxacin 500 IV and Flagyl 500 IV tid for question of SBP versus pneumonia. After 24 hours in the Intensive Care Unit, the patient was weaned off the pressors. He also remained afebrile on IV antibiotics. Patient was then switched to po antibiotics and transferred to the floor. On the floor, the patient did well with stable blood pressure in the low 100s and he remained afebrile. Repeat chest x-ray demonstrated collapse or consolidation of the left lower lobe as well as patchy infiltrate in the right middle lobe. Linear atelectasis was also visualized consistent with a pneumonia. The patient was discharged on oral antibiotics. 2. GI: The patient was taken off his diuretics for his hypotension. Once the patient's blood pressure stabilized, he was put back on his Lasix 40 po q day and aldactone 100 mg po q day for his portal hypertension. Patient was not started on a beta blocker secondary to his hypotension. This is something that may be considered as an outpatient. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged home with followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 17029] on [12-8] at 2 pm. DISCHARGE DIAGNOSES: 1. Pneumonia complicated by sepsis. 2. Hypotension. 3. Cirrhosis. 4. Alcoholism. 5. Hepatitis C. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2. Aldactone 100 mg po q day. 3. Thiamine 100 mg po q day. 4. Folate 1 mg po q day. 5. Multivitamin one tablet po q day. 6. Protonix 40 mg one tablet po q day. 7. Flagyl 500 mg one tablet po tid. 8. Levaquin 500 mg po q day. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735], M.D. [MD Number(1) 736] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2167-12-2] 14:00 T: [2167-12-5] 09:59 JOB#: [Job Number 45646]	[ "571.2", "038.9", "789.5", "780.39", "397.0", "572.3", "486", "276.1", "456.21" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							1976, 2049	5366, 5464	5487, 6001					3404, 5125																								2398, 3387									154, 162									191, 1429															1451, 1959	2066, 2375	5150, 5345
71,880	190,096	5068	Discharge summary	report	Admission Date: [2114-2-19] Discharge Date: [2114-2-26] Date of Birth: [2048-7-20] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2114-2-19] Coronary artery bypass grafting x3 -- left internal mammary artery graft to left anterior descending and reversed saphenous vein grafts to the marginal branch and the posterior descending artery History of Present Illness: This 65 year old male hyperlipidemia who was seen for the evaluation of his coronary artery disease in early [Month (only) 1096]. At that time a cardiac catheterization revealed three vessel disease with depressed left ventricular function. He has been scheduled for coronary artery bypass surgery on [2114-2-16] and returns today for preadmission testing. In the interim he has felt well without chest pain or significant dyspnea. His chronic edema has been very mild. Past Medical History: Diabetes Mellitus Type 1 2. Coronary artery disease Hypertension Hyperlipidemia Chronic anemia h/o Bursitis Chronic Kidney diease (baseline Cr 1.7) Gastroesophageal reflux disease s/p Carpal tunnel repair s/p Trigger finger sugery s/p Lipoma resection s/p Bilateral foot surgery Social History: Race: Caucasian Last Dental Exam:edentulous Lives with: wife Occupation: disability Tobacco: He is a former smoker, 1PPD for 30 years. Quit 12 years ago. ETOH: Drinks alcohol socially. Family History: CAD in father. Died at 55. Mother died at the age in [2092] at age of 88 secondary to MI. Physical Exam: admission: Pulse: 72 Resp:15 O2 sat:99% RA B/P Right: 132/54 Left 130/54 Height: 5'8" Weight:221 pounds General: WDWN in NAD Skin: Warm, Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Very quiet I/VI systolic murmur at left mid sternal border Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Small, well healed incisions over left mid/upper quadrant. Extremities: Warm [x], well-perfused [x] trace Edema 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: [2114-2-19] Echo: PRE-CPB: Poor image quality. The left atrium is markedly dilated. In limited views of LAA, there is no apparent thrombus is seen. A patent foramen ovale is present with left to right shunt. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened with focal calcifications. There is no AS. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-CPB: The LV remains mildly hypertrophied and moderately dilated with severely depressed EF, estimated at 15-20%. The interatrial septum is hypermobile, but no shunt is seen at rest. There is no dissection. [2114-2-26] 06:30AM BLOOD WBC-8.5 RBC-3.03* Hgb-8.8* Hct-26.4* MCV-87 MCH-29.2 MCHC-33.4 RDW-13.6 Plt Ct-283 [2114-2-25] 04:45AM BLOOD WBC-10.2 RBC-2.84* Hgb-8.5* Hct-24.3* MCV-86 MCH-30.0 MCHC-35.1* RDW-13.4 Plt Ct-248 [2114-2-26] 06:30AM BLOOD Glucose-120* UreaN-82* Creat-2.1* Na-132* K-5.4* Cl-97 HCO3-27 AnGap-13 [2114-2-25] 04:45AM BLOOD Glucose-114* UreaN-84* Creat-2.2* Na-128* K-4.6 Cl-92* HCO3-25 AnGap-16 [2114-2-24] 09:33AM BLOOD UreaN-72* Creat-2.1* Na-128* K-4.5 Cl-91* [2114-2-19] 04:00PM BLOOD UreaN-33* Creat-1.4* Na-138 K-3.9 Cl-106 HCO3-24 AnGap-12 [2114-2-20] 03:27AM BLOOD UreaN-36* Creat-1.8* Na-137 K-4.7 Cl-106 HCO3-25 AnGap-11 Brief Hospital Course: Mr. [Known lastname 1391] was a same day admit after undergoing pre-operative work-up prior to admission. On [2-18] he was taken to the Operating Room where he underwent coronary artery bypass grafting to three vessels. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one, beta-blockade, diuretics and aspirin were started and he was gently diuresed towards his pre-op weight. [Last Name (un) ] followed patient post-op regarding diabetes and insulin pump management. On post-op day two he chest tubes were removed and he was transferred to the stepdown unit for further care. Epicardial pacing wires were removed on post-op day three. He continued to make good progress while working with physical therapy for strength and mobility during his post-op course. He had an acute flare of gout for which the rheumatology service was consulted. His uric acid level was noted to be 11. Colchicine was started with some improvement of his symptoms along with a single dose of intravenous Solumedrol. Arthocentesis of his right wrist was performed by the orthopedic service however no fluid was obtained. Maintenance colchicine was recommended after resolution of his acute flare. On post-op day eight he was discharged to home with VNA services and the appropriate follow-up appointments. Medications on Admission: 1. Pantoprazole 40 mg daily 2. Aspirin 81 mg daily 3. Lisinopril 10 mg daily 4. Pravachol 40mg daily 5. Toprol XL 75 mg daily 6. HCTZ 50 mg daily 7. Lasix 40 mg every other day 8. Insulin pump 9. Vitamin D 10. Folic acid 11. Lisinopril 5mg daily 12. Alpha Lipoic Acid 13. Lasix 40mg daily Discharge Medications: 1. Insulin Pump SC (Self Administering Medication) Continue as per prior to surgery 2. Pravachol 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO as directed: 1 tablet twice daily for 7 adys, then 1 tablet daily for 7 days, then one tablet evry other day. Disp:100 Tablet(s) Refills:2 8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One Dose) for 1 doses. 12. pneumococcal 23-valps vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection NOW X1 (Now Times One Dose). 13. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 15. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 16. insulin pump syringe Miscellaneous 17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass Graft x 3 Acute Gouty arthritis Diabetes Mellitus Type 1 Hypertension Hyperlipidemia Chronic anemia h/o Bursitis Chronic Kidney diease (baseline Cr 1.7) Gastroesophageal Reflux Disease s/p Carpal tunnel repair s/p Trigger finger sugery s/p Lipoma resection s/p Bilateral foot surgery Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right,- healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [3-22] at 1pm Cardiologist: Dr. [Last Name (STitle) ] on [2114-4-2] at 1:40pm Please call to schedule appointments with: Primary Care Dr. [First Name4 (NamePattern1) 1158] [Last Name (NamePattern1) 20893] in [5-1] weeks ([Telephone/Fax (1) 20894]) Endocrinologist Dr. [Last Name (STitle) 10088] in [3-30] weeks. Nephrologist Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10083] in [3-30] weeks. Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2114-2-26]	[ "300.00", "414.01", "272.4", "357.2", "428.0", "403.90", "274.01", "V17.3", "250.41", "585.9", "530.81", "V58.67", "553.3", "V15.82", "V45.85", "413.9", "250.61", "285.9", "428.23", "V13.02" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.12", "38.93", "81.91" ]	icd9pcs	[ [ [] ] ]	7789, 7862	4187, 5685	330, 542	8241, 8460	2456, 4164	9383, 10154	1569, 1664		6024, 7766		7883, 8220		5711, 6001			8484, 9360								1679, 2437																							271, 292									570, 1049															1071, 1351	1367, 1553
26,271	191,492	9071	Discharge summary	report	Admission Date: [2165-7-16] Discharge Date: [2165-7-26] Date of Birth: [2089-10-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: Diarrhea x 8 days Major Surgical or Invasive Procedure: None History of Present Illness: 75 year old man with a history of metastatic colon cancer to liver s/p lobectomy, CAD s/p MI, and CVA with residual weakness who presented to the ED with weakness. Pt was recently admitted to [Hospital1 18] from [7-9] to [7-13] with dx of diarrhea, NSTEMI in setting of hypovolemia and an enterococcal UTI. Pt was discharged after 3 days with a 7-day course of Levaquin. At home, pt's family states that he continued to complain of stomach pressure, "felt like air inside". He also continued to have [3-16] loose bowel movements per day. He was drinking some but not taking good po. On day of admission, pt was noted to be more lethargic, not getting out of bed. Pt's family states that they were taking his temps and he has been afebrile. . On arrival to the ER, pt's HR was in the 140s with an SBP in the 70s. After 2L of fluid, pt's SBP was still in the 70s so a femoral line was urgently placed for pressors. He was then cardioverted with resumption of sinus rhythm and improvement of his SBP to 110s. Pt received a total of 3L in the ED and one dose of Vancomycin. Past Medical History: -Colon cancer status post 5-FU and leucovorin [1-15] and s/p right liver lobectomy for three liver mets in [1-16], complicated by a bile leak with catheter removal in [11-16], persistent sinus tract drainage from the site. -CAD s/p MI -Hypercholesterolemia -HTN x 10 years -CVA (left cerebellar stroke) -Glaucoma resulting in right eye blindness. Both eyes were operated on at some point. Social History: He lives with his wife and daughter; he neither smokes nor drinks alcohol. He formerly worked as a cook. Family History: There are no strokes or neurological disorders in the family. Physical Exam: Exam on Admisison: Vitals: temp 96.8, BP 102/48, HR 98, R 20, O2 ? poor waveform Foley: 150cc Gen: NAD, slightly tachypneic HEENT: MM dry, no appreciable JVD, right eye cloudy (blind) CV: regular, with occasional ectopy Chest: decreased breath sounds at bases, no wheezes, no crackles; biliary drainage from between 8th and 9th ribs on right Abd: hypoactive bowel sounds, distended, tympanic on percussion, tender to deep palpation in RLQ Ext: 2+ edema, dopplerable pulses in all 4 extremities Neuro: moves all extremities on command, strength 4/5 throughout; AO x 2 (person, place) . . Exam on Admission to MICU: VS: T93.9 HR102 afib BP90/55 RR18 o2sat: 98%3L NC UOP 340cc since MN rectal output: 1700cc since MN GEN: NAD, comfortable, mentating HEENT: MM dry NECK: No appreciable JVP CV: Regular, nml s1,s2. No murmurs Chest: CTAB anteriorly. Abd: Normoactive bowel sounds, distended, tympanic on percussion Ext: 2+ edema, pulses symmetric Neuro: moves all extremities on command, strength 4/5 throughout; AO x 3(person, place) Pertinent Results: [2165-7-16] 04:45PM BLOOD WBC-11.5# RBC-4.14 Hgb-12.3* Hct-37.1* MCV-90 MCH-29.7 MCHC-33.2 RDW-14.4 Plt Ct-227 [2165-7-16] 04:45PM BLOOD Neuts-62 Bands-30* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2165-7-16] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-3+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Burr-3+ [2165-7-16] 04:45PM BLOOD PT-15.5* PTT->150* INR(PT)-1.4* [2165-7-16] 04:45PM BLOOD Glucose-256* UreaN-61* Creat-3.1# Na-137 K-3.3 Cl-113 HCO3-11* AnGap-16 [2165-7-16] 04:45PM BLOOD CK(CPK)-137 [2165-7-16] 09:13PM BLOOD Lipase-39 [2165-7-16] 04:45PM BLOOD cTropnT-0.90* [2165-7-16] 04:45PM BLOOD Calcium-6.4* Phos-6.6# Mg-2.2 [2165-7-16] 09:13PM BLOOD Cortsol-33.1 [2165-7-16] 07:46PM BLOOD Type-ART pO2-117* pCO2-24* pH-7.25* calTCO2-11* Base XS--14 [2165-7-16] 04:54PM BLOOD Lactate-1.9 Imaging: CXR [7-20]: There is a right CVL with the tip at the junction of the SVC and right atrium and no PTX. Compared to the prior, the left lung is stable but the right lung shows some density increasing towards the base and laterally suggestive of pleural fluid/thickening and increased atelectasis; followup is recommended to see if there is further progression. The heart and mediastinum are stable. . CT Abd/pelvis s IV contrast (po contrast only): 1. Diffusely edematous small bowel is a nonspecific finding. There is no evidence of bowel obstruction, perforation, or pneumatosis intestinalis. 2. Stable 14 mm left hepatic hemangioma. 3. Small bilateral pleural effusions. 4. Stable subcentimeter bilateral renal hypodensities, too small to characterize, but probably representing cysts. . TTE [7-9] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is small and underfilled. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary gradient is identified (61 mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Brief Hospital Course: 75 year old man with a history of metastatic colon cancer to liver s/p lobectomy, CAD s/p MI, and CVA with residual weakness who presented to the ED on [7-16] with fever, weakness, diarrhea; found to have BPs in the 70s with HR in the 140s. He was found to be in afib with RVR, was cardioverted successfully in the ED. He received 6L NS IVF resuscitation and transferred to the unit for further management. Of note, he had a CT abd in the ED which showed diffusely edematous bowel edema c/w enterocolitis. He was started on levaquin/flagyl to cover GI organisms and cover for ? c.dif given a recent course of Levaquin for an enterococcal UTI. . Pt was continued on IVFs in the ICU, and briefly started on pressors to maintain his MAPs >65. He was quickly weaned off pressors and transferred to the floor on [7-18]. On the floor, he was evaluated by GI who felt it was likely infectious vs ischemic and recommended adding cholestyramine +/- flex-sig if his diarrhea did not resolve. His stool output continued to worsen on [7-20], and the MICU was contact[Name (NI) ] at 1900 regarding a BP of 62/P in a patient who had lost IV access. A R SC line was urgently placed and patient received 1L IVF bolus which raised his BP to 110/68 prior to transfer to the ICU for further observation. . Of note, patient had received Lisinopril 5mg x1 and Metoprolol 12.5gm x1 that AM as well as Lasix 20mg IV x1 at 1440. He otherwise was started on a heparin gtt for atrial fibrillation. # Hypotension: Pt with increased stool output of >2L on readmission to MICU, with poor IV access and negative fluid balance. Pt appeared hypovolemic per exam likely from combination of diarrhea, aggressive diuresis and antihypertensive medications. Placed CVL and given 2L NS resuscitation with improvement of BP to 110/68 prior to tx to ICU. CVP 6cm. Antihypertensives were initially held and IVF resuscitation continued. Once BPs were stable, lopressor 12.5 BIB was started for rate control as this was thought to be contributing to his hypotension. With [Month (only) ]. HR the patient's diastolic dysfunction improved and BP remained stable. The patient failed [Last Name (un) 104] stim test so stress dose steroids were started and cont. for 5 days. . # Diarrhea: Pt with persistant diarrhea that appeared to improve prior to arrival on the floor, with acute worsening prior to returning to MICU. Pt with an extensive infectious workup, including (-) c.diff, O&P, and stool cultures. GI consulted on the floor; believed it represents infectious vs vascular colitis. Despite (-) c.diff, suspicion remained high for c. diff colitis. Pt. was switched to flagyl PO for better c.diff coverage. Unasyn was discontinued. Ceftaz and Vanco were then started for better nosocomial gram (-), gram (+) coverage given recent hospitalizations. c.dif toxin B was sent and is still pending. GI had a high suspicion for c diff despite neg stool cultures and PO vanco was added for additional coverage. Stool output tapered off but diarrhea did not completely resolve. . # Atrial Fibrillation: Pt with known hx of atrial fibrillation in setting of prior dehydration and ? sepsis; has remained in PAF throughout this admission. pt started on anticoagulation on the floor but was held in ICU (pt with documented fall risk in prior d/c summaries). BB was restarted and increased to 37.5mg [Hospital1 ] with good rate control. Patient converted to NSR spontaneouly and remained in sinus for the duration of his admission. . # CAD s/p CABG: Hx of mild troponin leak during this admission in setting of hypotension and ? sepsis. ASA, statin were continued. ACEI was held due to hypotension and ARF. TTE showed a small LV cavity and hyperdynamic LV with EF>75% Patient initially appeared slightly volume overloaded on CXR but was intravascularly dry given hypotension, CVP of 6cm and response to IVF. . # Acute renal failure: Likely [2-14] prerenal azotemia in setting of hypotension and diarrhea. Urine lytes showed FeNa <1% consistent with prerenal azotemia. During admission the patient's Cr trended down to baseline 1.3. . On morning of [7-26] the MICU team was alerted that the patient was becoming SOB with tachypnea into 40s and hypotensive. At this time, BP responded to IVF boluses. Throughout the morning, the patient had more frequent episodes of hypotension and respiratory distress. His hypotension was not responding to IVF and the patient was started on pressors again to maintain SBP>90. The patient was also becoming more SOB with O2 sats decreased into 80s. The patient's family was present during this time and a long discussion occurred with the patient and his family about the patient's worsening respiratory status. With a translator present, the patient clearly stated that he would not want to be intubated if he was unable to breath adequately on his own. After a long discussion, it was decided to make the patient CMO as he did not want to be intubated or resuscitated and he was quickly decompensating. He was given Morphine IV for comfort and he expired on [2165-7-26] with his family present in the room. Medications on Admission: * Methazolamide 50mg [Hospital1 ] * PPI * Atenolol 50mg qd * Lisinopril 5mg qd * ASA 325mg qd * Lipitor 80mg qd * Levaquin 500mg qd Discharge Medications: n/a Discharge Disposition: Home Discharge Diagnosis: Hypotension Diastolic CHF Diarrhea - unknown etiology Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a	[ "272.0", "414.01", "511.9", "038.9", "401.9", "410.71", "197.7", "276.52", "787.91", "153.9", "276.2", "V12.59", "427.31", "518.81", "428.0", "458.9", "785.52", "425.1", "789.5", "995.92", "584.9" ]	icd9cm	[ [ [] ] ]	[ "34.91", "38.91", "38.93", "99.15" ]	icd9pcs	[ [ [] ] ]	11155, 11161	5800, 10940	333, 339	11259, 11269	3151, 5777	11321, 11328	2020, 2084		11127, 11132		11182, 11238		10966, 11104			11293, 11298								2099, 3132																							276, 295									367, 1455															1477, 1880	1896, 2004
22,849	136,445	46933	Discharge summary	report	Admission Date: [2171-9-18] Discharge Date: [2171-9-24] Date of Birth: [2108-11-23] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Clindamycin / Aspirin / Gentamicin / Penicillins Attending:[First Name3 (LF) 348] Chief Complaint: Lethargy, Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 62 year old male with PMH of MS [First Name (Titles) 151] [Last Name (Titles) 78605], [Last Name (Titles) 27285] retention requiring chronic indwelling cath causing recurrent UTI, recent admissions for urosepsis complicated by cholecystitis (treated with cholesystostomy tube, BCx showed Proteus, given 2 weeks aztreonam, 3 weeks Flagyl), re-admission in late [Month (only) ] for continuing fevers found to be vertebral osteomyelitis by MRI (T9-11, biopsy showed no organisms, pt was poor surgical candidate for debridement, currently at the end of 6 week course of [Month (only) ], zosyn, and flagyl due to end on [2171-9-22]), who was admitted to ICU for lethargy and altered mental status. In the ED, patient's initial vs were T 98.6, P 102, BP 101/55, O2 sat 99% on RA. He was noted to be lethargic and disoriented. Patient had a couple episodes of hypotension to the 70's systolic. Right IJ was placed and patient was given 2 Liters of IV NS which brought his pressures up to the 120s systolic. He was noted to be very lethargic during those hypotensive episodes. Past Medical History: -Secondary progressive MS ([2125]): Failed steroids -[Year (4 digits) ] (Decreased UE function: L -Vertebral osteomyelitis -Dementia -GERD -Chronic constipation -[Year (4 digits) ] disorder -Trigeminal neuralgia -[Year (4 digits) ] retention necessitating indwelling Foley -Recurrent UTI, urosepsis (Colonized with VRE) -Decubitus ulcers: Extremities, thoracic spine -Temporomandibular joint pain -Cholecystitis (s/p cholesystostomy tube placement) -Decreased visual acuity Social History: # Personal: Single, chronic nursing home resident. # Professional: Former elementary school math teacher # Tobacco: Never # Alcohol: Rare # Recreational drugs: Never Family History: # M, a: Asthma, macular degeneration # F, d 88: Unknown, possibly had MI's # Siblings (two sisters): One with MS Physical Exam: VS: T 97 ax, BP 126/48, P 101, R 13, 100% on RA Gen- alert and oriented x 1, awake HEENT- NCAT, anicteric, no injections, pupils were small and minimally reactive to light, OP showed dry MMM, poor dentition Neck- right IJ in place, no LAD or thyromegaly, neck supple, no JVD Lungs- CTA b/l Heart- RRR, slightly tacchy, s1s2 no mgr Abd- +bs, soft, nt, nd, no masses or hsm Extrem- no cce, patient's right foot with deformity, cold, pedal pulses 2+ b/l Neuro- difficult to obtain, CN 2-12 intact, strength 5/5 on right UE and [2-28] LUE, very diminished grip strength of left hand, babinski response was extensor, unable to tell sensation, gait not assessed, cerebellar function showed past pointing in R hand on finger to nose, unable to perform finger to nose with L hand. DTRs 0+ uniformly. Pertinent Results: MANDIBLE (PA, [Last Name (un) ] & BOTH OBLS): The right frontal sinus is not pneumatized. No definite air-fluid level seen in the maxillary sinuses. Several small areas of periapical lucency are seen at the base of several mandibular teeth. The maxillary teeth are not well evaluated on this study dedicated for the mandible. No mandibular fracture is seen. . NON CONTRAST HEAD CT: There is no evidence of intracranial hemorrhage, mass effect, shift in mass structures, or acute major vascular territorial infarction. Central atrophy with dilatation of the third and lateral ventricles is displayed with no significant interval change as does periventricular white matter hypoattenuation and scattered periventricular subcortical white matter hypodensities, likely reflect underlying multiple sclerosis. Soft tissues and osseous structures appear unremarkable. There is minimal mucosal thickening within the left posterior ethmoid air cells, unchanged probably with cerumen within the external auditory canals bilaterally. CHEST (PORTABLE AP): No acute cardiopulmonary abnormality. [2171-9-18] 05:41AM GLUCOSE-119* UREA N-17 CREAT-0.6 SODIUM-143 POTASSIUM-3.4 CHLORIDE-110* TOTAL CO2-28 ANION GAP-8 [2171-9-18] 05:41AM ALT(SGPT)-7 AST(SGOT)-13 LD(LDH)-143 ALK PHOS-69 TOT BILI-0.3 [2171-9-18] 05:41AM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-2.2* MAGNESIUM-2.1 [2171-9-18] 05:41AM VIT B12-456 FOLATE-GREATER TH [2171-9-18] 05:41AM TSH-2.9 [2171-9-18] 05:41AM CRP-56.0* [2171-9-18] 05:41AM VANCO-28.3* [2171-9-18] 05:41AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2171-9-18] 05:41AM WBC-5.2 RBC-3.21* HGB-8.0* HCT-26.6* MCV-83 MCH-25.0* MCHC-30.1* RDW-17.2* [2171-9-18] 05:41AM NEUTS-57 BANDS-0 LYMPHS-20 MONOS-12* EOS-5* BASOS-1 ATYPS-5* METAS-0 MYELOS-0 [2171-9-18] 05:41AM PLT COUNT-580* [2171-9-18] 05:41AM PT-13.6* PTT-26.0 INR(PT)-1.2* [2171-9-18] 05:41AM SED RATE-100* [2171-9-17] 08:00PM cTropnT-0.01 [2171-9-17] 08:00PM PHENYTOIN-2.7* [2171-9-17] 08:00PM CARBAMZPN-10.2 [2171-9-17] 08:00PM LACTATE-1.8 [2171-9-17] 08:00PM WBC-6.7 RBC-4.01* HGB-10.3* HCT-32.8* MCV-82 MCH-25.7* MCHC-31.5 RDW-18.2* [2171-9-17] 08:00PM NEUTS-66.1 LYMPHS-19.1 MONOS-12.5* EOS-1.6 BASOS-0.6 [2171-9-17] 08:00PM PT-12.1 PTT-24.2 INR(PT)-1.0 [2171-9-17] 08:00PM PLT COUNT-830* [2171-9-17] 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD [2171-9-17] 08:00PM URINE RBC-21-50* WBC->50 BACTERIA-MOD YEAST-MANY EPI-0 Brief Hospital Course: Altered Mental Status/Lethargy - It was thought the pt's lethargy and altered mental status was likely related to a possible UTI given his history. He was admitted on broad spectrum antibiotic coverage, and he was given a dose of cipro in the ED, but this was not continued on the floor. His foley was changed, and urine culture showed preliminary culture showed >100K yeast, but no bacteria. Other infectious etiologies were evaluated, such as meningitis, but pt was not febrile, WBC was normal, and neck was supple, and pt was already on broad spectrum abx. Other causes of altered mental status were considered. The pt was on several medications which could cause altered mental status, most of which were presecribed by his nursing home and were not on his prior discharge summary dated [2171-8-23]. Specifically, his oxycodone, baclofin and ativan were held. The pt's electrolytes were normal, his bicarb was WNL indicating no acute avid/base dirsorders, and tox screens were drawn and negative. He was not having any acute [Month/Day/Year 862] activity, but his serum dilantin level was low on admission (see below). Head CT was negative. Overall, pt's mental status improved greatly after IVF and holding of the medications which may have had CNS effects, and by [9-19], with pt feeling like he was at his baseline. Pt was more oriented, was able to have a regular conversation, and had an appropriate affect. The patient was also seen by his sister on the day of discharge who felt he was closer to his baseline. Hypotension - Pt had some episodes of hypotension in the ED for which he was given IVF before being sent the the [Hospital Unit Name 153]. He was given an additional 1L, and by [9-18] was able to resume a regular ground diet. His SBP did have some dips into the 90's which was felt to be related to autonomic dysfunction related to long standing MS with very little mobility, along with how the pt was not able to eat and hydrate ad lib due to his non-mobile state. Nursing was notified to have fluid and nutrition by the bedside for po intake as tolerated. Osteomyelitis - The patient was continued on his outpatient regimen of [Month/Year (2) ], Flagyl, and Zosyn. The patient was scheduled to end antibiotics on [9-22] (after a 6 week course), but discussion with ID, the decision was made to continue abx for another 4 weeks. His Zosyn dosing was increased from q 8hrs to q 6hrs. He had a repeat MRI prior to discharge which will be followed up by his infectious disease physicians. Neurosurgery saw the patient and felt that there was no need for surgical intervention at this time. Recurrent UTI - Pt's foley was changed on admission. Prior D/C summaries show that pt should be considered for suprapubic catheter placement at some point. Urine culture showed yeast but no bacterial growth after 1 day. [Month/Year (2) ] Disorder - Pt did not appear to have any [Month/Year (2) 862] activity based upon call to nursing home, nor did he have any in the ED or on admission. His dilantin level was low, even with correction. Prior D/C summary indicates that they had reduced his dosing from 300 mg tid to 100 mg tid. Pharmacy was called, and their recomendation was to increase dosing to 200 mg tid which was done on [9-18]. Levels were not checked on [9-19] due to it being unlikly to have equilibrated so quickly, and should be followed up on at the nursing home facility. Facial Pain - Pt has history of trigeminal neuralgia and TMJ pain. On exam, the pt has very poor dentition, so the idea of oral abscess or other dental conditions was considered. Dental consult was requested, who ordered mandibular films which showed non-specific findings. They otherwise found no signs of acute abscesses on exam, and recomended panorex films when pt was stable for transport for further evaluation. Additionally, they felt that extraction of 4 teeth would be needed. Panorex films were not obtainable as the patient was unable to maintain the proper position. As the patient was comfortable and denying any pain, he was advised to follow this up as an outpatient if necessary. Back Pain - Pt was reporting some back pain on [9-19], which he attributed to lying in bed for the past 2 days. He states he typically spends part of the day in his wheelchair rather than in bed. He states that he does not have any specialized or electric wheelchair and that a regular chair suffices. On the floor, he was transferred to chair for several hours during the day which he tolerated well. GERD - Continued outpatient pantoprazole dose to good effect. Decubitus Ulcers - Pt has old ulcers on his back and extremities. Wound care instructions were on prior D/C summary and were continued on this admission. No acute issues currently. Constipation - Continued most of the pt's outpatient bowel regimen (Held Miralax). From prior d/c summary, pt apparently develops severe constipation if regimen is decreased, but he's doing well currently. Communication - Sister [Doctor First Name 5627] is HCP, [Telephone/Fax (1) 99552] or [Telephone/Fax (1) 99553]. Medications on Admission: Tylenol 325-650mg prn for pain Ascorbic Acid 500 mg po twice a day. Bisacodyl Delayed Release 10 mg by mouth QAM prn constipation Carbamazepine 200 mg by mouth four times a day. Docusate Sodium 50 mg/5 mL Liquid One by mouth twice a day. Heparin 5,000 unit/mL Solution One injection Injection tid Heparin Lock Flush 100 unit/mL Syringe Two (2) ML IV qday prn Hexavitamin Tablet by mouth DAILY. Lactulose Thirty ML by mouth three times a day. Lorazepam 2 mg/mL injection PRN for Seizures. Miconazole Nitrate 2 % Cream Appl Topical four times a day. Pantoprazole Delayed Release 40 mg by mouth q24h hours. Phenytoin Sodium Extended 100 mg three times a day. Polyethylene Glycol 17 g by mouth at bedtime. Sennosides 8.6 mg 1-2 Tablets by mouth twice a day. [Telephone/Fax (1) ] 750mg IV q12h. End on [2171-9-22]. Metronidazole 500mg by mouth three times a day. End on [9-22].07. Piperacillin-Tazobactam 4.5g q8h. End on [2171-9-22]. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [3-1] hours as needed for pain. 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): hold for diarrhea. 8. Lorazepam 2 mg/mL Solution Sig: Two (2) mg Injection once a day as needed for anxiety. 9. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 12. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 weeks: to end on [2171-10-16]. 16. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 g Intravenous Q6H (every 6 hours) for 4 weeks: to end on [2171-10-16]. 17. [Date Range ] in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 4 weeks: to end on [2171-10-16]. 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 86] Home - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Altered mental status Osteomyelitis T9 - T11 Secondary Diagnosis: -Secondary progressive MS ([2125]): Failed steroids -[Year (4 digits) ] (Decreased UE function) -Dementia -[Year (4 digits) ] disorder -Trigeminal neuralgia -[Year (4 digits) ] retention necessitating indwelling Foley -Recurrent UTI, urosepsis (Colonized with VRE) -Decubitus ulcers: Extremities, thoracic spine -Temporomandibular joint pain Discharge Condition: Stable; mental status at baseline. AAO x 3. Discharge Instructions: You were admitted to the ICU with altered mental status. This quickly resolved and you were transferred out to the regular medicine floor. The infectious disease doctors followed [Name5 (PTitle) ] [Name5 (PTitle) 1028] you were in the hospital. Unfortunately, they feel that the infection in your back in not getting better with the antibiotics you have been taking. We have increased the frequency of one of the antibiotics you have been getting. You will also need to continue the antibiotics for another 4 weeks. We are scheduling an outpatient appointment for you to follow up with the infectious disease doctors [Last Name (NamePattern4) ] [2171-10-3] (see below for details). You will likely need a repeat MRI of your back at that time. You will also need to have weekly blood draws (checking vanco trough, BUN, and creatinine). The results should be faxed to Dr [Last Name (STitle) 4020] at [Telephone/Fax (1) 1419]. The following changes were made to your medication: 1. The Zosyn you have been getting every 8 hours; we have increased this to every 6 hours. 2. We held your baclofen, ativan and oxycodone while you were in the hospital because of concern for oversedation. These can be restarted by your primary doctors if they feel if is appropriate. 3. Your dilantin was increased from 100 mg three times a day to 200 mg three times a day Please return to the ED for fevers, chills, shortness of breath, chest pain, worsening back pain or any other symptoms that are concerning to you. Followup Instructions: You have an appointment with Dr [Last Name (STitle) 4020] on [2171-10-3] at 9 am. If you need to change this appointment for any reason please call her office at [Telephone/Fax (1) 457]. You have an appointment with Dr. [Last Name (STitle) 548] in Neurosurgery on [2171-10-30] at 10:15 AM.	[ "530.81", "350.1", "564.09", "788.20", "340", "E935.2", "707.02", "294.8", "276.52", "707.07", "707.09", "996.64", "345.90", "344.1", "730.18", "112.2", "292.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13739, 13818	5800, 10961	364, 371	14306, 14353	3155, 3532	15933, 16247	2209, 2323		11959, 13716		13839, 13839		10987, 11936			14377, 15910								2338, 3136																							293, 326									399, 1495			13925, 14285	3541, 5777		13858, 13904									1517, 2009	2025, 2193
25,803	174,891	12195	Discharge summary	report	Admission Date: [2159-3-26] Discharge Date: [2159-3-30] Date of Birth: [2117-12-22] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 41-year-old gentleman who is completely asymptomatic with a known history of a heart murmur at the age of 18 with echocardiogram and known mitral regurgitation. On his next evaluation, echo after diagnosis showed aortic insufficiency and mild MR. [Name13 (STitle) ] was referred for serial echo's which he has had done over the past several years. He has a known bicuspid aortic valve with a dilated aorta. His exercise tolerance test was negative. He underwent cardiac catheterization on [2159-2-22] which an ejection fraction of 59%, normal coronaries, moderate AI, and mild mitral regurgitation, and dilated ascending aorta. MRI performed in [2157-6-19] showed moderate MR and an ascending aorta of 4.7 cm, with a normal LV ejection fraction. PAST MEDICAL HISTORY: 1. L5-S1 sciatica. 2. Mild lactose intolerance. 3. Remote bilateral arm fractures and left fibular fracture. PAST SURGICAL HISTORY: Includes right inguinal herniorrhaphy and varicocelectomy. MEDICATIONS ON ADMISSION: Claritin 10 mg p.o. daily and p.r.n. antibiotics for dental work. ALLERGIES: He had no known allergies. PREOPERATIVE LABORATORY DATA: White count of 5.9, hematocrit of 44.2, PT of 13.4, PTT of 25.4, INR of 1.1, platelet count of 213,000. Urinalysis was negative. Glucose of 81, BUN of 19, creatinine of 0.9, sodium of 143, K of 3.8, chloride of 103, bicarbonate of 32, anion gap of 12. ALT of 20, AST of 18, alkaline phosphatase of 43, total bilirubin of 0.7, total protein of 7.8, albumin of 4.9, globulin of 2.9, HBA1C of 5.5%. RADIOLOGIC STUDIES: Preoperative chest x-ray showed no abnormalities and was a normal chest x-ray. Preoperative EKG showed a sinus rhythm at 77 with a normal EKG [Location (un) 1131]. PREOPERATIVE PHYSICAL EXAMINATION: The patient was referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] to address aortic valve replacement and possible repair of his ascending aorta. The patient came in to preadmission testing on [2159-3-20] prior to admission, and on exam had a heart rate of 92 and regular. Blood pressure on the right was 132/78. Blood pressure on the left was135/84, 6 feet 6 inches tall, 225 pounds. An active young man in no apparent distress. Skin was unremarkable. His pupils were equally round and reactive to light and accommodation. His EOMs were intact. His eyes were anicteric and noninjected. He had no JVD. His neck was supple. His lungs were clear bilaterally. His heart was regular in rate and rhythm with S1 and S2 and faint diastolic and systolic [1-25] murmurs. His abdomen was soft, nontender, and nondistended with positive bowel sounds. He had no hepatosplenomegaly or CVA tenderness. His extremities were warm and well perfused with no cyanosis, clubbing, or edema. No varicosities were noted. He was grossly neurologically intact with a nonfocal exam. He was moving all extremities with 5/5 strength. Alert and oriented x 3. He had 2+ bilateral femoral, DP, PT, and radial pulses. HOSPITAL COURSE: The patient came in to the hospital on [2159-3-26] and underwent aortic valve replacement by Dr. [First Name (STitle) ] [Last Name (Prefixes) ] with a 29-mm pericardial CE tissue valve and replacement of his ascending aorta with a 28-mm Gelweave graft. He was transferred to the cardiothoracic ICU in stable condition on a titrated propofol drip and a Neo-Synephrine drip at 0.2 mcg/kg/min. On postoperative day 1, the patient had been extubated overnight. He remained on a Neo-Synephrine drip at 0.5 mcg/kg/min and on an insulin drip at 3 units per hour for control of his blood sugars. Postoperatively, his white count was 14.4, hematocrit was 26.8, and platelet count was 158,000. BUN was 17. Creatinine was 1.1. His INR was 1.3. He began Lasix diuresis. His chest tubes remained in place for a little bit of additional drainage, and weaning of Neo- Synephrine began. The patient was transferred out to the floor on the afternoon on postoperative day 1. He had 1 episode of tachycardia in the 90s to 100s, elevating to the 120s when he was out of the bed to the bathroom. He was given additional Lopressor, and this brought his blood pressure down to 80/40 and his heart rate into the 90s. He was asymptomatic with this, and his blood pressures slowly rose back into the normal range over the evening. The patient was able to void after the Foley was discontinued. He was seen on the floor and evaluated by physical therapy. He began to work on ambulation with the nurses. He was also evaluated by case management to arrange for visiting nurse services when he went home. On postoperative day 2, the patient was restarted on aspirin therapy. He was taking Percocet for oral pain management. He was continued with Lasix diuresis. He was doing very well. He was encouraged to ambulate and to use his incentive spirometry. Chest tubes remained in place for continuing drainage. His Lopressor was increased to 25 mg p.o. b.i.d. The patient was very comfortable and continued to work on increasing his ambulation and his activity level. On postoperative day 3, the patient was already doing level IV activity and was started on his iron and vitamin C therapy also. His chest tubes were removed. His pacing wires were removed. His Lopressor was increased to 50 mg p.o. b.i.d. His heart rate was 68, in sinus rhythm, with a blood pressure of 112/50, and discharge planning was begun. On postoperative day 4, the patient was doing extremely well without signs or symptoms of anemia. His hematocrit was 24.0. He was saturating 97% on room air. In sinus rhythm at 90 with a blood pressure of 134/80, respiratory rate of 18. He was 100.3 kilograms. He was alert and oriented with a nonfocal neurologic exam. His lungs were clear bilaterally. His heart was regular in rate and rhythm. He had no sternal drainage or erythema. His extremities were warm with trace peripheral edema. His right groin incision was also clean and dry. DISCHARGE STATUS: The patient was discharged to home in stable condition with VNA services with the following instructions. DISCHARGE INSTRUCTIONS: 1. To follow up with Dr. [First Name (STitle) ] [Name (STitle) ], the primary care physician, [Last Name (NamePattern4) ] 1 to 2 weeks. 2. To follow up with Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5874], his cardiologist, in 1 to 2 weeks post discharge. 3. To follow up with Dr. [First Name (STitle) ] [Last Name (Prefixes) ] in the office for his postoperative surgical visit in 3 to 4 weeks post discharge. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. daily (for 5 days). 2. Potassium chloride 20 mEq p.o. daily (for 5 days). 3. Colace 100 mg p.o. twice a day. 4. Enteric coated aspirin 81 mg p.o. daily. 5. Percocet 5/325 1 to 2 tablets p.o. q.4h. p.r.n. (for pain). 6. Ferrous gluconate 300 mg p.o. daily. 7. Vitamin C 500 mg p.o. twice a day. 8. Metoprolol 50 mg p.o. twice a day. 9. A single multivitamin p.o. daily. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement and ascending aortic repair. 2. L5-S1 sciatica. 3. Mild lactose intolerance. 4. Remote bilateral arm fractures and left fibular fracture. CONDITION ON DISCHARGE: The patient was discharged to home in stable condition with VNA services on [2159-3-30]. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2159-5-3] 17:09:36 T: [2159-5-3] 19:11:49 Job#: [Job Number 38158]	[ "441.2", "724.3", "424.1" ]	icd9cm	[ [ [] ] ]	[ "88.72", "35.21", "39.61", "38.45" ]	icd9pcs	[ [ [] ] ]								7209, 7392				6794, 7188	1179, 1918	3176, 6241		6265, 6768						1092, 1152																1941, 3158																		166, 935															957, 1068		7417, 7761
27,969	156,777	51709	Discharge summary	report	Admission Date: [2190-9-26] Discharge Date: [2190-9-28] Date of Birth: [2121-12-29] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1115] Chief Complaint: Fatigue, weakness, and dizziness. Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Blood transfusion History of Present Illness: 68 year old male with BPH, CAD (IMI [2185] w/ BMS to RCA) who presented with fatigue, lightheadedness and shortness of breath. He first began feeling fatigued two days ago. The day before admission, he was weak in the morning, feeling short of breath and lightheaded while walking up stairs. That day he also noted thick tarry stool. At 5AM this morning sat down on the tiolet to urinate around felt lightheaded, flushed, and chills. Called 911. Felt similar to when had stents placed in [2185] except then had chest pain. This time he reports no chest pain, pressure, or tightness. He denied any shortness of breath at rest. He denies abdominal pain or diarrhea. Denies focal weakness or tingling. The patient has been taking ibuprofen and naproxen in addition to his prescribed ASA 325mg, increased recently after completing a bike trip in [Month (only) 216]. Found by EMS pale, cool, diaphoretic. Orthostatics with SBP seated 102 -> 92 when standing with increased symptoms. More pale and diaphoretic. EKG in field reported as unremarkable. 150cc NS given en route. In the ED, initial VS were: 96.8 63 95/70 18 98% 2L Crit 46.6->36.3, BUN/Cr 62/0.9 Rectal exam showed dark black stool, Guaiac pos. Troponin <0.01, EKG sinus rhythm, rate 65, nl axis, non-specific st-t changes, consistent w/ prior from [7-/2189] unchanged. BPs 80s-100s, baseline BPs are 110-120s. NG lavage was negative no withdrawal of clots or red return with 350cc fluids. He was given 1L IVF, two peripheral IV's were placed, type and cross sent, and was started on protonix gtt. On arrival to the MICU, the patient still feels lightheaded when stands to use bathroom but otherwise feels like his regular self. Denies SOB, chest pain/pressure/tightness. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: CAD: MI [2185], cath with 2 vessel disease and stent placement Stress MIBI in [2-/2187] showed EF of 53% with small inferobasal infarct. Hyperlipidemia Sacral Osteomyelitis BPH s/p TURP Inguinal hernia repair [1-21] Colonoscopy [2189]: Polyp in the proximal ascending colon (polypectomy) Polyp in the transverse colon (polypectomy) Tattoo in the transverse colon from previous polypectomy Otherwise normal colonoscopy to cecum Social History: married, lives with wife + ETOH, denies Tobacco, recreational drug use Family History: Father deceased from "old age" in his 90's, mother deceased 60 years ago from rheumatic fever. One brother, healthy. [Name2 (NI) ] known family history of sudden death or premature cardiac disease. Physical Exam: Admission physical exam Vitals: T:98.2 65 114/70 13 97%RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, Neck: JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: VS: 98.5 77 121/76 15 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated 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 Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: grossly intact Pertinent Results: [2190-9-26] 07:20AM BLOOD WBC-6.9 RBC-3.68# Hgb-11.9# Hct-36.3# MCV-99 MCH-32.4* MCHC-32.8 RDW-12.4 Plt Ct-207 [2190-9-26] 07:20AM BLOOD Neuts-69.7 Lymphs-21.4 Monos-6.9 Eos-1.5 Baso-0.6 [2190-9-26] 07:20AM BLOOD Plt Ct-207 [2190-9-26] 07:20AM BLOOD Glucose-99 UreaN-62* Creat-0.9 Na-143 K-4.4 Cl-110* HCO3-25 AnGap-12 [2190-9-26] 07:20AM BLOOD ALT-18 AST-18 LD(LDH)-117 AlkPhos-46 TotBili-0.3 [2190-9-26] 05:43PM BLOOD CK-MB-3 cTropnT-<0.01 [2190-9-26] 10:44PM BLOOD CK-MB-3 cTropnT-<0.01 [2190-9-27] 03:05AM BLOOD CK-MB-3 cTropnT-<0.01 [2190-9-27] 03:05AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1 [2190-9-26] 08:30AM BLOOD Lactate-2.0 Studies CXR [2190-9-26] FINDINGS: The lungs are clear. Cardiomediastinal silhouette and hilar contours are unremarkable. No effusion or pneumothorax. Aorta is tortuous. IMPRESSION: No evidence of acute cardiopulmonary process. EGD Impression: Mucosa suggestive of short segment Barrett's esophagus. Normal mucosa in the duodenum. Ulcers in the antrum. Otherwise normal EGD to third part of the duodenum. Micro: None DISCHARGE LABS [2190-9-28] 08:20AM BLOOD WBC-5.2 RBC-3.72* Hgb-12.0* Hct-35.6* MCV-96 MCH-32.3* MCHC-33.7 RDW-13.8 Plt Ct-180 [2190-9-27] 03:05AM BLOOD WBC-6.8 RBC-3.70* Hgb-11.9* Hct-35.3* MCV-95 MCH-32.1* MCHC-33.7 RDW-13.9 Plt Ct-172 Brief Hospital Course: 68yoM with history of CAD s/p IMI in [2185] with BMS to RCA and BPH presenting with dizziness/LH and low Hct, found to have GI Bleed with antral ulcers. # GI Bleed: The patient presented with melena, with low Hct and orthostasis. The patient had a history of active NSAID use, and also uses Etoh socially. He was admitted to the MICU. He got 2 units PRBCs without Hct response to the first unit, but with good Hct response to the second unit. EGD showed non-bleeding antral ulcers and possible Barretts esophanus. The patient was stable with no further Hct drop, so he was transfered to the floor. He was counseled to avoid all NSAIDs indefinently, unless told otherwise by GI in the future. GI saw the patient in house and will follow outpatient, with repeat EGD in [6-18] weeks to eval for healing of antral ulcers and possible esophagus biopsy. H pylori blood test was sent and was pending at time of discharge. # CAD: s/p BMS placement in [2185]. No active signs of ischemia now, Troponins negative, EKG unchanged, no chest pain. Dizziness and diaphoresis likely [2-11] anemia from acute blood loss from GI bleed, and does not represent anginal equivalent at this time. ASA 325 was initially held on admission for acute GI bleed. On discussion with outpatient cardiologist, it was decided to decrease ASA to 81 daily. ASA was restarted the morning of discharge since it was felt that the patient was not actively bleeding. # HTN - cont metoprolol, DCed lisinopril per outpatient cardiologist since BP well controlled without it and has normal LV function. # HLD - cont atorvastatin # BPH: no active issues # PPX: pneumatic boots, bowel regimen # CODE STATUS: Full, confirmed # CONTACT: Wife [Name (NI) 107117] [Name (NI) 107118] home [Telephone/Fax (1) 107119] cell [Telephone/Fax (1) 107120] Transitional issues - F/U H pylori, which was pending at time of DC. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Lisinopril 5 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Aspirin 325 mg PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Peptic Ulcer Disease Upper GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you were feeling lightheaded and had were not feeling well. Your symptoms were explained by a bleed in your stomach. The gastroenterologists performed an endoscopy which showed an ulcer in your stomach. This is likely related to the ibuprofen and naproxen use. It is very important that you avoid such medications in the future. You will need a follow up endoscopy in [6-18] weeks. Also, at discharge there is a lab test (which tests if there is bacteria in your stomach causing the ulcers) that is still pending. We will arrive for someone to contact you with the results. Followup Instructions: Please be sure to keep the following appointments: Name: [Last Name (LF) 2539], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] HOSPITAL - [Location (un) ] Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 3002] Phone: [Telephone/Fax (1) 49151] * Appointment Thursday [2190-10-7] 2:30pm* Gastroenterology: will call you with an appointment. If you don't hear from their office by Friday, please call [Telephone/Fax (1) 463]. Department: CARDIAC SERVICES When: MONDAY [2191-8-15] at 12:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "412", "414.01", "531.40", "E935.6", "530.85", "285.1", "276.52", "600.00", "V45.82", "272.4" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	8275, 8281	5775, 7685	339, 385	8360, 8360	4399, 5752	9155, 10030	3196, 3401		7967, 8252		8302, 8339		7711, 7944			8510, 9132								3416, 3880																			2176, 2624				266, 301									413, 2157									8375, 8486						2646, 3091	3107, 3180		3905, 4380
27,002	102,668	5778	Discharge summary	report	Admission Date: [2120-7-7] Discharge Date: [2120-7-22] Date of Birth: [2052-7-8] Sex: M Service: MEDICINE Allergies: Penicillins / Optiray 350 / Clindamycin / Aldactone / IV Dye, Iodine Containing / pyridostigmine Attending:[Last Name (un) 2888] Chief Complaint: Fall and increased weight gain Major Surgical or Invasive Procedure: [2120-7-12] Cardiac catheterization [2120-7-14] Pulmonary arterial catheterization [2120-7-14] Intra-aortic balloon pump insertion [2120-7-15] Dialysis catheter placement [2120-7-15] Arterial line placement [2120-7-17] Intra-aortic balloon pump re-insertion [2120-7-17] Intubation History of Present Illness: 68 year old man with a history of coronary disease status post cabg in [2107] and multiple PCIs since then presenting on the [7-7] with weight gain at home and altered mental status resulting in a fall at home. In the ED he had a possible seizure with dilantin loading. He became hypotensive after that and went to MICU. He was then sent to the medicine service for several days working up neurologic issues and falls. Then the patient began having chest pain, echo showed new acute decrease in the EF from 45->20% and some apical and septal akinesis. Cath showed severe native disease with 2 BMS placed in RCA. RHC showed elevated wedge at 30mmHg. RA pressures 25 and PAP 73. CI 1.5. Then transferred to [Hospital1 1516] for further management. . Patient was given 80mg IV lasix given last night and this morning still volume overloaded and given another 100mg IV lasix and metolazone and lasix gtt. Team is concerned for poor forward flow given LFTs have increased to >1000, creatinine to 3.3, INR >2, and only 600mL UOP with 20mg/hr lasix gtt yesterday. . At this point, he was transferred to the HF service and admitted to the CCU for inotropes, swan, and lasix drip. If non-responsive to this will need IABP. . On arrival to the floor, patient appears somewhat lethargic and uncomfortable but is conversant. He endorses discomfort around his foley site but denies cough, chest pain, sob, abdominal symptoms, fevers/chills. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CAD - Chronic systolic & diastolic CHF, EF 40-50% [5-/2119] - CABG: s/p CABG in [2107] (LIMA-LAD (patent), SVG-PDA (occluded), SVG-OM(occluded)) - PERCUTANEOUS CORONARY INTERVENTIONS: multiple stents (s/p DES to LMCA into LCx, RCA, r-PL) - PACING/ICD: - ?Afib 3. OTHER PAST MEDICAL HISTORY: - Appendicitis (complicated by colectomy & mucocele [2114]) - Depression - Erectile dysfunction - Insulin dependent diabetes mellitus x 30+yrs - ulcerative colitis - Peyronie's disease s/p penile implant - benign Prostatic Hypertrophy - h/o C. Difficile colitis - CKD Social History: A retired Optometrist. -Tobacco history:he quit smoking about 40 years ago, only having smoked for about 5 years,while in his 20's. -ETOH: None. -Illicit drugs: None. Family History: His mother had CAD and a CABG in her 60's. There is a strong family history of premature coronary artery disease, diabetes mellitus, hypertension, and hyperlipidemia. Physical Exam: Admission exam: Vitals: T: BP: 86/62 P: 61 R: 15 O2: 100% on RA General: Oriented, no acute distress, depressed mood and affect, talking extremely slowly HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not visualized, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: B/L crackles at bases, no wheezes, rales, ronchi Abdomen: Soft, non-tender, moderately distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation to light touch . Discharge/Death exam: HEENT: pupils fixed and dilated CV: no heart sounds auscultated, no carotid pulse RESP: no breath sounds Pertinent Results: ADMISSION LABS: [2120-7-6] 10:16PM cTropnT-0.03* [2120-7-6] 06:00PM LACTATE-1.4 [2120-7-6] 05:55PM GLUCOSE-173* UREA N-43* CREAT-2.2* SODIUM-133 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14 [2120-7-6] 05:55PM estGFR-Using this [2120-7-6] 05:55PM ALT(SGPT)-33 AST(SGOT)-36 ALK PHOS-61 TOT BILI-0.8 [2120-7-6] 05:55PM cTropnT-0.05* [2120-7-6] 05:55PM proBNP-7830* [2120-7-6] 05:55PM ALBUMIN-4.5 [2120-7-6] 05:55PM WBC-7.6 RBC-4.08* HGB-10.7* HCT-34.5* MCV-85# MCH-26.3* MCHC-31.1 RDW-15.5 [2120-7-6] 05:55PM NEUTS-68.8 LYMPHS-16.8* MONOS-12.1* EOS-1.9 BASOS-0.4 [2120-7-6] 05:55PM PLT COUNT-232 [2120-7-6] 05:55PM PT-14.7* PTT-30.0 INR(PT)-1.4* . STUDIES: [2120-7-6] CT Head w/o contrast- No acute intracranial process [2120-7-6] C Spine w/o contrast- No acute fractures or malalignment [2120-7-6] CXR Portable AP- Midline sternotomy wires are again noted. Bilateral pleural effusions are noted with probable basilar atelectasis. No overt pulmonary edema. Heart size is top normal. No pneumothorax. IMPRESSION: Bilateral pleural effusions with basilar atelectasis. [2120-7-6] CT Abd/Pelvis-IMPRESSION: 1. Nonspecific mesenteric stranding and small amount of fluid in the abdomen could be secondary to generalized third spacing. 2. Chronic loculated left sided pleural fluid collection/chronic empyema is stable. 3. Gallstones and sludge within the gallbladder. [2120-7-8] EEG- This is an abnormal waking EEG because of diffuse polymorphic arrhythmic theta and delta activity. This background activity improves to theta range activity on stimulation. These findings are suggestive of moderate encephalopathy but of nonspecific cause. There are no epileptiform discharges or focal abnormalities seen. [2120-7-10] MRI Head w and w/o contrast- 1. No acute intracranial abnormality. 2. No pathologic focus of enhancement or anatomic substrate for seizure. 3. Relatively mild global atrophy. 4. Chronic inflammatory changes in the paranasal sinuses; correlate clinically. . [2120-7-11] Portable TTE: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to severe hypokinesis/akinesis of the septum and apex; the rest of the left ventricle appears hypokinetic with regional variation. The aortic valve leaflets are moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([12-18]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2119-5-19], left ventricular systolic function is significantly further compromised. . [2120-7-12] Cardiac Catheterization: 1. Selective coronary angiography demonstrated three vessel disease in the right dominant system The LMCA had a patent stent with mild in stent restenosis, there was a 30-40% distal LMCA stenosis beyond the distal edge of the LMCA stent which was unchanged from prior. The LAD had diffuse severe disease proximally and occludes at the mid vessel after a tiny diagonal branch. The Cx had diffuse disease throughout with serial focal 50% stenoses. The RCA had an ostial 80% stenosis which was heavily calcified. There was also an 80% heavily calcified 80% stenosis in the mid RCA. Diffuse mild to moderate disease was seen throughout the rest of the RCA. 2. Limited resting hemodynamics revealed elevated right and left sided filling pressure with an RVEDP of 24 mmHg and an LVEDP of 26 mmHg. There was pulmonary hypertension with PA pressures of 73/35 mmHg. The cardiac index was depressed at 1.55 L/min/m2. The central aortic pressure was 120/73 mmHg. Upon careful pullback of a pigtail catheter from the LV to the aorta no pressure gradient was seen. 3. Arterial conduit angiography revealed a patent LIMA which supplied a diffusely diseased LAD. The SVGs were not engaged as they were known to be occluded. 4. Successful PTCA and stenting of the ostial RCA with a 3.5x26mm INTEGRITY stent which was postdilated proximally to 4.0mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 5. Successful PTCA and stenting of the mid RCA with a 3.5x12mm INTEGRITY stent which was postdilated to 3.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 6. Successful closure of the 6 French right femoral arteriotomy site with a 6 French ANGIOSEAL VIP device with good resultant hemostasis. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate to severe diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. 4. Successful PTCA and stenting of the ostial RCA with a BMS. 5. Successful PTCA and stenting of the mid RCA with a BMS. 6. Successful closure of the right femoral arteriotomy site with an Angioseal device. . [2120-7-15] EEG: Abnormal EEG due to a low voltage slow background throughout. This indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are the most common causes. Ischemia or hypoxia are other possibilities. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features or electrographic seizures. . [2120-7-15] CT abdomen & pelvis: IMPRESSION: 1. No acute intra-abdominal or intrapelvic hematoma detected. 2. Circulatory assist device within the abdominal aorta. 3. Persistent bilateral nephrograms, compatible with severe renal failure, as the last contrast-enhanced study was performed on [2120-7-10]. 4. Unchanged small left pleural effusion. . [2120-7-19] Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with hypokinesis of the inferior septum, inferior, and inferolateral walls and distal anterior, lateral and apical walls. The remaining segments contract normally (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with extensive regional systolic dysfunction most c/w multivessel CAD (including proximal RCA). Right ventricular cavity enlargement. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [2110-7-11], global left ventricular systolic function is slightly improved. . [2120-7-20] KUB: 1) No dilated loops of large or small bowel to suggest obstruction or ileus. No obvious free air identified. 2) Multiple clustered locules of air in the right mid abdomen may represent stool within the colon in an area of prior surgery and are similar to the appearance on the [2120-7-7] abdominal CT. However, the differential diagnosis for this appearance includes air within an abscess. If there is significant clinical suspicion for intra-abdominal infection, then this area could be further assessed with a CT scan. Brief Hospital Course: Hospital Course: 68 year old man with a history of coronary disease status post cabg in [2107] and multiple PCIs, DM type II, hypertension and depression who presented initially on [2120-7-7] with weight gain at home and altered mental status. He had what appeared to be a possible seizure in the ED, resulting in dilantin loading and subsequent hypotension requiring transfer to the MICU. He was then sent to the medicine service for several days while work up continued on his neurologic issues and falls (work up negative). Then on [2120-7-11], he began having chest pain, and echo showed new acute decrease in the EF from 45->20% with some apical and septal akinesis. Cath the following day showed severe native disease with 2 BMS placed in RCA, and RHC showed elevated wedge at 30mmHg. He was intitially transferred back to the cardiology service for management, however he became increasingly volume overloaded with end organ dysfunction (renal and liver failure) suggestive of cardiogenic shock, necessitating transfer to the CCU under the heart failure service. . CCU Course: On arrival patient was started on inotropes, pulmonary artery catheter was placed, and intra-aortic balloon pump was initiated for support for his cardiogenic shock. Given his renal failure, CVVH was initiated (mostly for ultrafiltration). Despite full support with intermittent pressors, IABP, and CVVH, he failed to improve. On [2120-7-17], he self-discontinued his balloon pump, leading to rapid decompensation necessitating urgent intubation and transfer to the cath lab for IABP re-placement. He was able to wean off the balloon pump on [2120-7-19], however his hemodynamics then worsened again, necessitating the use of pressors. Despite full pressor support, his status continued to worsen. Upon frank discussion with his family regarding his grim prognosis, they felt that he would never want to continue with aggressive care if there was little chance of full recovery. On [2120-7-21], they decided to transition his care to comfort measures only. He died peacefully on [2120-7-22]. . Please see below for details on each of his major active issues: . ACTIVE ISSUES: # [Date Range 7792]/Cardiogenic Shock: On [2120-7-11] while on medicine service, experienced chest pain with troponin of 0.1, negative MB, but echo with new anterior WMA and EF depressed at 25% (down from 40-45%). Cath on [7-12] showed 80% ostial stenosis of the RCA, which was stented with 2 bare metal stents. Following the cath, he continued to decompensate. He appeared to be in decompensated CHF by renal status, crackles on exam, and mild peripheral edema. A TTE showed an EF of 20% from baseline of 40-45% in 6/[2118]. He had 2 BMS placed to his RCA, his LVEDP was elevatd at 30, pulmonary pressures were also elevated so the patient was transferred to the [Hospital1 1516] service. Despite aggresive diuresis, patient continued to [Last Name (un) 22977] clinically, with high filling pressures, low CI, low UOP and was transfered to CCU. Patient was started on dobutamine for inotropic effect (could not do milranone because of [Last Name (un) ]). He was also on lasix drip. Patient had an intra-aortic baloon pump to improve systemic perfusion and coronary artery perfusion. . While in CCU a Swan-Ganz catheter was placed to monitor CO. Dobutamine drip was started in setting of low CO. The patient was also started on CVVH to remove fluid thought to be contributing to decreased CO as renal failure persisted. On [7-17] pt was increasingly delusional and removed his IABP partially. Decision was made to remove pump at this time and heparin ggt d/c and pressure held at site. The patient's o2 sats decreased at this time and lactate increased to over 6. Decision was made to intubate and transfer to cath lab for replacement of pump. Ballon pump was weaned off of IABP on [7-19]. Howver he conintued to have high pressor requirements. . #.Acute on Chronic [Last Name (un) ]: Baseline creatinine 1.1-1.5, on admission 2.2. However after the drop in his blood pressure and after his cath his Cr continued to rise and he stopped making urine. Renal was consulted who started CCVH to remove fluid to help relieve strain on his heart. CCVH was stopped when patient was made CMO by family on [7-21]. . #Transaminitis - On transfer to [Hospital1 1516] service, patients LFTs had noted to increase to ALT 117, AST 418. The day following cath, his LFTs sharply rose to ALT 1200 and AST 1059, LDH 1900, TBili 1.9. Concern was for shock liver vs med effect, Hepatology was consulted who felt this was due to shock liver - they rec'd to hold atorvastatin, obtain RUQ U/S which showed possibly fatty liver with patent vasculature. The following day, he developed encephalopathy and lactulose was started. LFTs trended down throughout his hospital course. . #.Fall at Home- His initial insult was a well-described mechanical fall from slipping on mineral oil, and he did not endorse symptoms consistent with vasovagal syncope. We also considered orthostasis given history of same vs. arrhythmia vs. seizure given possible seizure in CT scan. Patient was not found to be orthostatic. Neurology consulted and had a low suspicion of seizure. MRI with and without contrast was unremarkable. Neurology continued to follow and did not recommend AED's. . IDDM: Patient was kep on insulin sliding scale and hi blood surgars well well ontrolled in the CCU. . Goals of Care dicussion: On [7-21]: Family meeting was held with Dr. [Last Name (STitle) ]??????[Doctor Last Name ], Dr. [Last Name (STitle) 4402], SW [Doctor First Name ], and patient??????s family including: wife [Name (NI) ], daughter [Name (NI) 12983], daughter [Name (NI) 22978], and sister [Name (NI) ]. They were updated on the patient??????s grim prognosis and his continued decline despite maximal support. The family was in agreement that per past discussions they had with the patient, he would not have wanted a prolonged death and would rather be made comfortable at this juncture. In light of this, Mr [Known lastname ]??????s goal of care was focused on comfort only, with cessation of all supportive measures including pressors, CVVH, and the ventilator. After withdawal of all care he passed away on [2120-7-22] at 7:10am. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Atorvastatin 40 mg PO DAILY 2. Bumetanide 1 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Eplerenone 25 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Lorazepam 0.5 mg PO TID 7. Mesalamine DR 1200 mg PO Frequency is Unknown 8. Metoprolol Succinate XL 12.5 mg PO Frequency is Unknown Frequency [Hospital1 ] 9. ranolazine NF 1,000 mg Oral [Hospital1 ] 10. Aspirin 81 mg PO DAILY 11. NPH 28 Units Breakfast NPH 18 Units Bedtime Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Congestive Heart Failure Cardiogenic Shock Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2120-7-22]	[ "V45.02", "V45.81", "414.00", "584.9", "311", "V15.88", "785.51", "V15.82", "780.39", "416.8", "428.43", "V58.67", "250.00", "E936.1", "V66.7", "428.0", "V45.82", "410.71", "287.5", "348.30", "570", "403.90", "585.9", "V70.7", "458.29" ]	icd9cm	[ [ [] ] ]	[ "89.64", "88.56", "96.71", "89.68", "00.46", "00.40", "39.95", "38.95", "36.06", "37.61", "37.21", "38.91", "96.04", "00.66" ]	icd9pcs	[ [ [] ] ]	18860, 18869	11839, 11839	385, 696	18955, 18964	4044, 4044	19020, 19058	3051, 3221		18828, 18837		18890, 18934		18257, 18805	11856, 14005	8969, 11816	18988, 18997								3236, 4025				2275, 2545																			314, 347		14037, 18231							724, 2167					4060, 8952					2576, 2850					2189, 2255	2866, 3035
16,342	170,526	45681	Discharge summary	report	Admission Date: [2115-2-15] Discharge Date: [2115-2-21] Date of Birth: [2048-5-19] Sex: M Service: MEDICINE Allergies: Tetanus Diphtheria / Lisinopril / Mavik Attending:[First Name3 (LF) 9853] Chief Complaint: COPD exacerbation/hyponatremia Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: This is a 66 year-old Male w/ Stage IV COPD on home O2, HTN, h.o. UGI bld, + MRSA and Pseudomonas in sputum during recent admission at [Hospital1 ] [Location (un) 620] who presented to the ED from rehab for suspected COPD exacerbation. Pt was recently discharged from [Hospital1 18] [Location (un) 620] for complaints of wheezing and worsening dyspnea. His dyspnea was attributed to COPD exacerbation likely [3-4] tracehobronchitis. Following + culture of Pseudomonas pt was treated with a 10 day course of [Name (NI) 97361], pt also had sputums + for MRSA that was thought to be a colonizer. It does appear though that he was discharged on a 5 day course of Bactrim per ID recs for MRSA. Pt was initially noted to be on Prednisone 60mg daily upon that admission that was self-titrated without consulting a physician, [Name10 (NameIs) ] discharge he was given a steroid taper. Since his discharge on [2-11], the patient had been reporting increasing tightness in his chest and shortness of breath. His wife notes that he had not slept for at least 48 hours due to his persistent respiratory discomfort. Additionally, he had been eating minimally, and had begun to develop increased lower extremity, worse than ever in the past. Of note, lasix had been discontinued during his most recent admission due to hyponatremia to 133 and hypovolemia. However, the patient's wife believes it was restarted yesterday due to his progressive lower extremity edema and decreased urine output. Records from the nursing home are not available at this time. The patient's family also notes that he had been mildly confused, even before discharge from [Hospital1 ] [Location (un) 620], however, this has worsened in the last 24 hours. He had been having hallucinations and talking to people who were not in the room. Additionally, he had been "pretend eating," and not fully oriented. Of note, he had also been complaining of back pain, so had been receiving increased doses of percocet since his discharge as well. In the ED, initial vitals showed T 97.6 BP 162/85 HR 98 RR 18 satting 97% on 2L NC. He was noted to have increased work of breathing. Initially this was thought to be related to a CHF exacerbation so nitropaste was placed on the patient without improvement. He was trialed on CPAP which he did not tolerate, and he was satting 100% on NRB. 80 mg lasix were given without improvement, so patient was intubated due to increased work of breathing after discussing intubation with his wife and daughter (however, patient has been DNI in the past). He was then placed on a Nitro gtt which was discontinued prior to arrival to the ICU. He was also given ctx and levaquin for possible infection. CTA was done which showed no PE and a possible recent aspiration on prelim read. He was observed having myoclonic jerking during his CTA scan, and neurology was curbsided to ensure that this was not seizure activity due to his hyponatremia. A CT scan of the head was done to look for possible etiology. He also rec'd 1/2 L of NS for his hyponatremia prior to transfer. Patient arrived to the ICU intubated and sedated. ROS: Unable to obtain. Laboratories: Notable for ?????? . See below for rest. . ECG: Sinus tach at 124, occasional pvcs, PR wnl, biphasic TW in V4-V6, q waves in II, III, avF that are old compared to prior . Imaging: CXR: no evidence of infiltrate . CT head: Motion limited study, but no obvious acute process. . CTA chest prelim read: no PE RLL atelectasis, and mild bronchiolar impaction, ? recent aspiration T8 compression fx, new from 8/[2114]. no signif. retropulsion. . . Past Medical History: 1) CAD s/p MI [8-5] 2) Hypertension 3) ? H/O CHF x2: EF 60% on echo [11-6], moderate symmetric LVH 4) Severe COPD on Home O2: FEV1 29% [2113-8-30], FEV1/FVC 52% predicted, reduced FVC 5) OSA not on CPAP 6) h/o MRSA + sputum 7) Anemia 8) s/p Rectus Sheath Hematoma 9) Alcohol Abuse/dependence s/p multiple rehab stays 10) Cervical Radiculopathy 11) Chronic Pancreatitis 12) Diverticulosis (last scope [7-1]) PAST SURGICAL HISTORY: s/p knee surgery s/p LE venous stripping age 28 Social History: Per OMR history pt was a heavy drinker (8-10 beers per day), no history of severe withdrawals, reportedly now limits his drinking to 2/night. Smokes 6 cigarettes per day, former 80 pack year history of smoking. He is married and lives with wife with no drug use. Family History: Mother had a DVT and diabetes. Father died of coronary artery disease at age 35. Physical Exam: GEN: NAD / well-appearing EYES: EOMI / conjunctiva clear / anicteric ENT: moist mucous membranes NECK: supple CV: RRR s1s2 II/VI SEM LUSB PULM: diffuse inspiratory and expiratory wheezes but improved, decreased breath sounds GI: NABS / ND / soft / nontender BACK: no paraspinal tenderness EXT: warm , 4+ pedal edema bilaterally SKIN: erythematous healing vesicular rash on left buttock NEURO: alert / oriented x 3/ answers ? appropriately / follows commands / normal gait PSYCH: appropriate / pleasant Pertinent Results: [2115-2-15] 11:45AM GLUCOSE-89 UREA N-21* CREAT-0.9 SODIUM-118* POTASSIUM-5.3* CHLORIDE-81* TOTAL CO2-25 ANION GAP-17 [2115-2-15] 11:45AM CK(CPK)-77 [2115-2-15] 11:45AM cTropnT-<0.01 [2115-2-15] 11:45AM CK-MB-NotDone proBNP-364* [2115-2-15] 11:45AM WBC-12.6* RBC-3.95* HGB-11.1* HCT-32.5* MCV-82# MCH-28.0# MCHC-34.1# RDW-15.9* [2115-2-15] 11:45AM NEUTS-95.4* LYMPHS-3.0* MONOS-1.5* EOS-0.1 BASOS-0.1 [2115-2-15] 11:45AM PLT COUNT-264 [2115-2-15] 11:45AM PT-13.1 PTT-28.7 INR(PT)-1.1 [2115-2-15] 11:52AM LACTATE-1.3 [2115-2-15] 01:26PM TYPE-ART TIDAL VOL-550 PEEP-5 O2-50 PO2-190* PCO2-52* PH-7.36 TOTAL CO2-31* BASE XS-3 INTUBATED-INTUBATED [2115-2-15] 04:47PM freeCa-1.03* [2115-2-15] 04:47PM GLUCOSE-101 NA+-118* K+-4.5 CL--81* TCO2-29 [2115-2-15] 07:18PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2115-2-15] 07:18PM URINE RBC-34* WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 [2115-2-15] 07:18PM CK-MB-6 cTropnT-0.07* [2115-2-15] 07:18PM CK(CPK)-62 [2115-2-16] 12:00AM CK-MB-5 cTropnT-0.04* [2115-2-16] 12:00AM CK(CPK)-45 Imaging: CXR ([2-15]): No acute intrathoracic process. CTA ([2-15]): (replim) no PE; RLL atelectasis, and mild bronchiolar impaction, ? recent aspiration; T8 compression fx, new from 8/[2114]. no signif. retropulsion. Head CT ([2-15]): Motion limited study, but no obvious acute process. Brief Hospital Course: 66 year-old male with severe COPD and recent admission for COPD exacerbation who was admitted intubated after experiencing increased WOB and hyponatremia. #. Respiratory failure: Pt presented to the ED with complaints of dyspnea, upon assessment required intubation currently on ventilatory support. Pt has a history of dyspnea that improves only with an increase in his steroid doses. His last spirometry in [2114-12-26] showed Stage IV COPD with an FEV1 28%; FEV1/FVC 55%. He did not improve with diuresis, nitro page or nitro gtt, so this did not likely represent a CHF exacerbation. Also BNP was low at 364. Had recent admission for COPD exacerbation and was treated with 10 days of ceftaz and 5 days of Bactrim for pseudomonas/MRSA + sputum. Patient presumed to have COPD exacerbation wasn was treated with iv solumedrol and transitioned to po prednisone. Patient did not appear to have much of a cough or sputum production prior to intubation. However, he does have evidence of infiltrate on CT scan, ? new aspiration. He was treated with vanc/zosyn for PNA given gram + rods in his sputum cx and hx of MRSA in his sputum. MRSA was felt to be a colonizer and Vanc was discontinued on discharge. Pseudomonas was pan-sensitive so Zosyn was changed to Cipro and he will complete a 14-day course. This antibiotic treatment plans was discussed with his outpatient pulmonology team. He was also treated with IV steroids, atrovent nebs, advair, albuterol prn, and guafenesin. He was discharged on a slow steroid taper and will follow up with his pulmonologist as an outpatient. # Hyponatremia: Unclear what precipitated such as drop, likley [3-4] to significnat home lasix dose (60mg [Hospital1 ]) Had been slightly hyponatremic during his admission at [Hospital1 ] [Location (un) 620] and lasix had been discontinued. His family believes lasix was restarted, and the patient had been eating and drinking minimally since his discharge. Also given his chronic steroid use, there is a question of possible adrenal insufficiency (elevated potassium/hyponatremia) though chronic steroid use does not cause primary adrenal insufficiency so mineralocorticoid axis should be intact. His Na began correcting after he was given IVF and his hypovolemia was fully corrected once he was extubated and was able to control his po intake. He received one dose of po lasix in order to restart him on his home medications and Na dropped to 132, so it was discontinued. He was advised to remain off Lasix for the time being. # Delirium: Resolved. Multifactorial. Likely acutely worsened by his hyponatremia. However, he had also been taking increased narcotic medication, had minimal sleep over multiple days and had not been eating or drinking. His mental status cleared once his hyponatremia was partially corrected and he was alert and oriented x3 by the time he was called out to the floor, and remained so until discharge. # Lower extremity edema: Per the family, this has been an ongoing problem, never any definitive etiology. He has diasolic heart failure, but no pnd/orthopnea or other symptoms suggestive of acute CHF. Also, BNP was less than 400. There may also be a contribution from his recent steroid use. His lasix was held as above due to hyponatermia. He was also given compression stockings to wear and instructed to elevate his legs as much as possible. # Hypertension: his BP regimen was continued with slight changes to his doses of verapamil and amlodipine while in-house. He was advised to follow up with his PCP for [Name9 (PRE) 35455] management. ## rash on buttock: The patient had a vesicular-appearing rash on his left buttock. He stated this is herpes that breaks out intermittently and has been treating it with fluocinonide ointment which clears it up. He reports his PCP prescribed it but he has also been to a dermatologist. Although the rash had a somewhat vesicular appearance (but no open or draining vesicles), it would not be expected to heal with topical steroids if it were herpes, so this diagnosis is in question. His dermatologist's office was [Name (NI) 653], but there was no clear reference in the records by review of a nurse to indicate herpes; he has had an irritant dermatitis treated with topical steroids including clobetasol. Topical steroids were not given in-house, and he was advised to follow up with his dermatologist as an outpatient. # Code: FULL CODE. The patient had been DNR/DNI in the past, appears family made a quick decision to intubate while he was in the ED and now wish him to be full code. Medications on Admission: Medications on discharge [2115-2-11]: ? Lisinopril 10 mg daily (has documented allergies) Ambien 10 mg prn Spiriva 18 mcg daily Bupropion 150 mg SR [Hospital1 ] Fexofenadine 60 mg [Hospital1 ] Folic Acid 1 mg daily Calcium +D Duonebs q4H prn Percocet Q6H prn Senna Colace Fluticasone-Salmeterol 250 mcg-50 mcg 1 puff [Hospital1 ] Prednisone taper, 35 mg for now Verapamil 240 mg daily ASA 81mg daily Discharge Medications: 1. Cipro 750 mg Tablet [Hospital1 ]: One (1) Tablet PO every twelve (12) hours for 8 days. [Hospital1 ]:16 Tablet(s) Refills:0 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device [Hospital1 ]: Eighteen (18) mcg Inhalation once a day. 3. Bupropion 150 mg Tablet Sustained Release [Hospital1 ]: One (1) Tablet Sustained Release PO BID (2 times a day). 4. Fexofenadine 60 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day. 5. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Calcium+D 500 (1,250)-200 mg-unit Tablet [Hospital1 ]: One (1) Tablet PO once a day. 7. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization [Hospital1 ]: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. Oxycodone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. [Hospital1 ]:30 Tablet(s) Refills:0 9. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Capsule [Hospital1 ]: One (1) Capsule PO once a day. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Hospital1 ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 12. Verapamil 180 mg Tablet Sustained Release [Hospital1 ]: Two (2) Tablet Sustained Release PO Q24H (every 24 hours). [Hospital1 ]:60 Tablet Sustained Release(s) Refills:2 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). [Last Name (STitle) ]:30 Tablet,Rapid Dissolve, DR(s) Refills:2 14. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 15. Guaifenesin 600 mg Tablet Sustained Release [Last Name (STitle) ]: One (1) Tablet PO Q12H (every 12 hours). 16. Amlodipine 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). [Last Name (STitle) ]:60 Tablet(s) Refills:2 17. Prednisone 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily) for 8 days: Take four tablets for two days, then three tablets for two days, then two tablets for two days, then 1 tablet for two days, then stop. [Last Name (STitle) ]:20 Tablet(s) Refills:0 18. Outpatient Physical Therapy outpatient pulmonary PT Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: respiratory failure, pneumonia, severe COPD Secondary: hypertension, hyperlipidemia, coronary artery disease, anemia, hyponatremia Discharge Condition: good, stable, at baseline oxygen requirement of 1-2L NC Discharge Instructions: You were evaluated for respiratory distress. You were intubated for a short period of time and have improved since then. You should continue antibiotics for eight more days. You may take tylenol and oxycodone for your back pain. Do NOT drive or operate heavy machinery while taking oxycodone due to the risk of sedation. Do NOT take Lasix for the time being, as it has led to low sodium levels that can be dangerous. Follow up with your primary care physician for consideration of restarting this or an alternative medication. Our physical therapists have recommended home physical therapy, although you would probably benefit from outpatient pulmonary physical therapy in the future. If you have worsening shortness of breath, fevers, chills, chest pain, lightheadedness or episodes of loss of consciousness, call your doctor or seek medical attention immediately. Followup Instructions: Follow up with your pulmonary physician [Last Name (NamePattern4) ] [2-1] weeks. Dr. [Last Name (STitle) 14827] office will call you with an appointment. If you do not hear from them, call them at ([Telephone/Fax (1) 513]. Follow up with your primary care provider [Name Initial (PRE) 176] 1-2 weeks. Call Dr.[Name (NI) 2935] office at [Telephone/Fax (1) 2205] for an appointment. Follow up with your dermatologist, Dr. [First Name8 (NamePattern2) 233] [Last Name (NamePattern1) ], regarding the rash on your left buttock. Call her office at [Telephone/Fax (1) 97362] to make an appointment. Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2115-4-3] 11:10 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2115-4-3] 11:30 Provider: [Initials (NamePattern4) ] [Last Name (NamePattern4) 4506] NP/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2115-4-3] 11:30	[ "562.10", "276.52", "482.1", "518.81", "782.1", "327.23", "E944.4", "782.3", "428.32", "780.09", "E932.0", "577.1", "276.1", "414.01", "491.21", "428.0", "412", "401.9", "288.60", "303.90", "285.29", "V02.54" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.07", "96.04" ]	icd9pcs	[ [ [] ] ]	14448, 14497	6996, 11595	331, 359	14681, 14739	5477, 6973	15656, 16728	4857, 4939		12061, 14425		14518, 14660		11621, 12038			14763, 15633						4509, 4559		4954, 5458																							261, 293									387, 3806		3815, 4040													4062, 4486	4575, 4841
13,502	136,314	7721+55869	Discharge summary	report+addendum	Admission Date: [2180-2-8] Discharge Date: [2180-2-25] Date of Birth: [2112-3-15] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old diabetic male with known coronary artery disease transferred in from ______ ______ presenting with flash pulmonary edema. He was in the catheterization laboratory where an intraaortic balloon pump was placed and he has been pain free since. He was admitted to our Intensive Care Unit where he was put on a heparin nitroglycerin drip. PAST MEDICAL HISTORY: Significant for insulin dependent diabetes mellitus, hypercholesterolemia, hypertension, glaucoma. He denies stroke, transient ischemic attacks or claudication. SOCIAL HISTORY: He stopped smoking tobacco 35 years ago according to him. PHYSICAL EXAMINATION: Significant for an augmented diastolic pressure of 120 to 130 with the pump and pressors set on admission. There was no JVD. There were no bruits. His abdomen was soft and obese. He was regular rate and rhythm. His catheterization found an EF of 55% with occlusion of the left internal mammary coronary artery 40%, left anterior descending coronary artery of 70%, left circumflex of 100%, right coronary artery 100%. He was in cardiogenic shock on admission. He was taken to the Operating Room on [2180-2-9] with Dr. [Last Name (STitle) 1537]. Please see the operative note for full details of that. Postoperatively, he was transferred back to the Intensive Care Unit on pressor support and had a continued and the intraaortic balloon pump was discontinued. Physical examination in the Intensive Care Unit was significant for 1 to 2+ edema bilaterally. On [2-11] we were called. It was noted that the patient had a drop in blood pressure and diaphoresis and the patient showed signs of hemodynamic compromise on [2-11]. This is after the surgery on [2-8]. The patient was in the Intensive Care Unit at this time. The patient was taken into the catheterization laboratory where it was discovered that his grafts had all fallen and went down. Basically the LMCA was 40% occluded, the left anterior descending coronary artery stent. He continued to have worsening inferolateral ST depressions. The patient was taken back to the Operating Room on [2180-2-11] for clotted vein graft. He had a thrombectomy of such with Dr. [Last Name (STitle) 1537] and Dr. [Last Name (STitle) 28037]. He was transferred back to the Intensive Care Unit. Hematology/Oncology was contact[Name (NI) ] for evaluation of a possible hypercoagulable state, which upon further workup could not be evaluated, because he was on Coumadin and heparin. However, tests sent off preliminary came back negative for protein, CS, lupus, anticoagulant. The patient continued in the Intensive Care Unit where he was extubated, weaned off pressors and was eventually transferred out to the floor on [2180-2-16]. The patient on arrival to the floor still had chest tubes in place. Hematology/Oncology continued to follow along and advised us that the patient was not in a hypercoagulable state and tests came back negative. They will follow on an outpatient basis with Dr. [Last Name (STitle) ]. The patient was manifesting odd behavior per his primary cardiologist and a neurology evaluation was conducted during the first week of [Month (only) 956] as well as a head CT. The CT of the head was negative for any signs of stroke or mass effect and neurology concurred with this and stated that his personality changes are most likely due to being sent on bypass twice as well as having a code when his grafts went down on the 25th. On the floor the patient had some blood sugar management issues for which [Last Name (un) ] was contact[Name (NI) ] and his sliding scale was adjusted appropriately and the scale is the one he will be sent to rehab on. The patient was noted to have an edematous leg and his leg harvest site was oozing as well as slight erythema with no discharge consistent with any type of cellulitis of his sternal wound and he was started prophylactically on Levaquin on [2180-2-23]. The patient is tentatively being discharged on [2180-2-25] in no acute distress. His physical examination revealed some mild erythema, noninfected, noncellulitic of his sternum and his leg wound has some discharge of clear fluid from his edematous leg noninfected looking. He has no JVD or signs of hemodynamic instability. DISPOSITION: Rehabilitation. Addendum to follow with final discharge medications and physical examination prior to discharge. [First Name4 (NamePattern1) 275] [Last Name (NamePattern1) 28038] M.D.02-248 Dictated By:[Name8 (MD) 16758] MEDQUIST36 D: [2180-2-24] 13:40 T: [2180-2-24] 14:35 JOB#: [Job Number 28039] Name: [Known lastname 4888], [Known firstname ] Unit No: [Numeric Identifier 4889] Admission Date: [2180-2-8] Discharge Date:[2180-2-25] Date of Birth: [2112-3-15] Sex: M Service: DISCHARGE SUMMARY ADDENDUM: DISCHARGE MEDICATIONS: 1. Levaquin 500 milligrams po q day. 2. Lipitor 40 milligrams po q day. 3. Lasix 40 milligrams po q day. 4. K-Dur 20 milliequivalents po every other day. 5. Colace 100 milligrams po q day. 6. Aspirin 325 milligrams po q day. 7. Plavix 75 milligrams po q day. 8. Coumadin 5 milligrams po q day check INR and to be dosed by Dr. [Last Name (STitle) ]. 9. Insulin NPH 40 units in the A.M., 30 units in the P.M. Hold K-DUR for a potassium level of greater than 4.5. 10. Lopressor 12.5 milligrams po q day. 11. Alphagan 2 milligrams to each eye [Hospital1 ]. 12. Motrin 600 milligrams po q h prn. The patient will receive wet to dry dressing changes to the left leg wound saphenectomy site. Have VNA instructed on dressing changes. Tegaderm dressing to any other area. He is in good condition upon discharge. [First Name4 (NamePattern1) 63] [Last Name (NamePattern1) 4890] M.D.02-248 Dictated By:[Name8 (MD) 2965] MEDQUIST36 D: [2180-2-25] 13:21 T: [2180-2-25] 13:26 JOB#: [Job Number 4891]	[ "996.72", "414.01", "250.01", "428.0", "272.0", "530.81", "785.51", "E878.2", "401.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "37.22", "36.14", "39.49", "88.56", "88.53", "37.61", "37.23" ]	icd9pcs	[ [ [] ] ]									5165, 6232																													809, 5141																		159, 524															547, 710	727, 786
76,558	119,695	1163	Discharge summary	report	Admission Date: [2160-8-4] Discharge Date: [2160-8-12] Date of Birth: [2099-6-29] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 3853] Chief Complaint: "Diabetic ketoacidosis and CP." Major Surgical or Invasive Procedure: Cardiac catheterization [2160-8-7] with stent placement in LAD History of Present Illness: Mr. [Known lastname ] is a 61-year-old insulin-dependent diabetic type I, with history of coronary artery disease, transferred from [Hospital1 ] [Location (un) 620] by life flight for DKA associated with chest pain. The patient describes a week of intermittent chest pain, associated with progressive lethargy and poor PO intake. The patient's wife called the patient on the phone today, and the patient was belligerent and altered. The patient checked his blood sugar and it was 500. The patient was seen at [Hospital1 ] [Location (un) 620], and found to have a HR 40, BP 70s/30s. EKG showed peaked T waves. The patient was found to have a potassium of 8.0. He was given 2 g of calcium gluconate, 10 units of IV insulin, 50 of bicarbonate, and an aspirin. The patient's EKG changes normalized and the patient became hemodynamically more stable. He was life-flighted to [Hospital1 18] for further management. In the [Hospital1 18] ED, initial vitals were: 94 127/54 12 100% 15L Non-Rebreather. He denied chest pain, fevers, abdominal pain upon transfer. Patient's glucose remained 500. He was given 20 units i.v. insulin, and the rate of his insulin drip was increased to 10/hr. He was given 5 L IVF. The patient's potasium improved to 5. However, his glucose remained critically high. The patient was seen by cardiology, who recommended a stat ECHO. . In the MICU, initial vitals are: 99.3 80 98/53 11 100% 2LNC. The patient states that he continues to be fatigued. He endorses thirst and polyuria. He states that he has also had diarrhea for the past 2 days. Over the past day, he has had a non-productive cough. He denies chest pain, fevers, dyspnea, abdominal pain. Past Medical History: 1)Type 1 diabetes a. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension b. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA at [Hospital1 336] in [2152] 2) CAD s/p MI and [Last Name (un) 2435] in [2152] 3) Sleep apnea 4) Hiatal hernia s/p surgical repair, 5) Depression 6) GERD 7) Retinopathy 8) Gastropathy 9) Nephropathy (Baseline 1.6) 10) PVD s/p status bilateral infrapopliteal revascularization 11) Critical PT lesion successfully treated with athrectomy and PTA. 12) cognitive/memory issues since MI [61]) obesity Social History: -Tobacco history: Not a current smoker, Quit smoking: in the [2118] -ETOH: Does not drink alcohol -Illicit drugs: None -Retired courier, married with one son. Family History: Father: previous MIs Physical Exam: On Admission: VS:99.3 80 98/53 11 100% 2LNC Gen: Alert, oriented x 3 (knows president was on [Location (un) 7453] this weekend), slurred speech HEENT: PERRL, EOMI, MM dry, cervical lymphadenopathy R>L, no thyromegaly Card: Normal S1, S2, no murmurs, rubs or gallops Resp: Clear to auscultation bilaterally Abd: Obese, mildly distended, soft, non-tender; +BS Ext: Dry, 1+ DP pulses Skin: Dry, spider angioma on face Neuro: CN II - XII grossly intact; alert, interactive . On Discharge: ****** VS:98.3 56 126/70 18 95%RA Gen: Pleasant patient lying flat in bed in not acute distress HEENT: PERRL, EOMI, MMM, OP without erythema or exudate, upper dentures appreicated. no thyromegaly Card: RRR. Normal S1, S2, no murmurs, rubs or gallops Resp: Crackles at the basese bilaterally. No wheezes. Abd: Overweight. mildly distended, soft, non-tender; +BS Ext: 1+ DP pulses. 1+ pitting edema bilaterally to the knee Skin: Dry, pealing skin of the LE bilerally. Neuro: CN II - XII grossly intact; alert, interactive and answering questions appropriately. 5/5 strength through all muscle groups of the LE bilaterally. Pertinent Results: On Admission: . [2160-8-4*] 03:30PM BLOOD WBC-11.1 RBC-3.28* Hgb-10.6* Hct-31.4* MCV-96# MCH-32.2* MCHC-33.6 RDW-12.9 Plt Ct-248 [2160-8-4] 03:30PM BLOOD Neuts-92.6* Lymphs-3.9* Monos-3.0 Eos-0.2 Baso-0.3 [2160-8-4] 03:30PM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1 [2160-8-4] 03:30PM BLOOD UreaN-68* Creat-2.6* [2160-8-4] 08:49PM BLOOD Glucose-807* UreaN-71* Creat-2.9* Na-139 K-5.0 Cl-103 HCO3-23 AnGap-18 [2160-8-4] 03:30PM BLOOD cTropnT-0.04* [2160-8-4] 08:49PM BLOOD Calcium-8.8 Phos-2.1# Mg-2.8 [2160-8-4] 03:38PM BLOOD Glucose-GREATER TH Lactate-2.4* Na-135 K-5.3 Cl-100 calHCO3-15* . CE Trend: [2160-8-4] 03:30PM BLOOD cTropnT-0.04* [2160-8-4] 08:49PM BLOOD CK-MB-9 cTropnT-0.25* [2160-8-5] 0.35 [2160-8-5] 21:16 0.42 [2160-8-5] 13:00 0.56 [2160-8-5] 06:27 0.61 [2160-8-5] 02:25 0.51 . On Discharge: [2160-8-12] 06:20AM BLOOD WBC-9.5 RBC-3.43* Hgb-10.8* Hct-31.1* MCV-91 MCH-31.5 MCHC-34.7 RDW-13.2 Plt Ct-359 [2160-8-12] 06:20AM BLOOD Glucose-93 UreaN-50* Creat-2.1* Na-137 K-4.8 Cl-102 HCO3-28 AnGap-12 [2160-8-12] 06:20AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.3 . Imaging: [8-4] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior wall. The remaining segments contract normally and global systolic function is preserved (LVEF = 60 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction c/w CAD. . [8-5] CXR: IMPRESSION: AP chest compared to [8-4]: Moderate pulmonary edema has developed in both lower lungs. Moderate cardiomegaly is stable, but mediastinal and hilar vascular engorgement have worsened. Pleural effusions are small if any. No pneumothorax. . [2160-8-7] CARDIAC CATH: 1. Severe 2 vessel CAD with occluded RCA proximally and 80% mid LAD hazy lesion. 2. Successful PTCA and stenting of the mid LAD with a 2.5x15mm Promus DES, postdilated to 2.75mm with excellent results. 3. Successful closure of the RCFA with a 6F angioseal. 4. Dual anti-platelet treatment with plavix (600mg PO one-time, then 150mg daily x1 week, then 75mg daily for a minimum of 1 year) and ASA 325 mg daily x 3 months, then 162 mg daily. 5. Global CV risk reduction strategies. . MICRO: Urine cultures: NO GROWTH FINAL Blood cultures: [8-4] and [8-5]: NO GROWTH FINAL [8-8]: PENDING Brief Hospital Course: Mr. [Known lastname ] is a 61-year-old insulin-dependent diabetic type I, with history of coronary artery disease, transferred from [Hospital1 ] [Location (un) 620] for DKA associated with chest pain. In summary, his DKA and hyperkalemia were treated successfully in the MICU. Upon callout to the floor, he was found to have chest pain and unstable angina with possible NSTEMI. He was placed on a heparin gtt and then received cardiac cath, during which he received a drug-eluting stent in his mid-LAD. His condition improved throughout the rest of admission. . ACTIVE ISSUES: . #DKA - Patient transferred from OSH with elevated glucose to 500 despite 20 units of IV insulin and 10u/hr IV drip. Anion gap on admission 17. Patient was bolused with insulin in the ICU. His insulin drip was titrated up and his blood sugar values decreased. He was given NS boluses with potassium repletion and converted to 1/2NS for rising sodium level. While in ICU, anion gap closed, glucose remained between 150-200 and patient was weaned off drip to S.C. dosing. Fingersticks checked q1hr; electrolytes q2hrs and potassium repleted accordingly. Etiology of DKA likely due to insulin non-adherence in the setting of poor PO intake, exacerbated by recent gastroenteritis. CXR with possible new LLL opacity, U/A negative. EKG and Echo similar to prior, though patient felt to have unstable angina per Cardiology team (see below). Once the patient was stablized, he was seen by the [Last Name (un) ], who recommended a more stringent insulin regimen given his level of insulin resistance. [Last Name (un) ] followed the patient through his hospital course. He is being discharged on a [Last Name (un) ] 70units after breakfast and sliding scale insulin with Humalog at meals and before bedtime. Insulin regimen should be adjusted, possibly splitting up [Last Name (un) ] dose, as does spike to glucoses in the 200-300 range in the afternoons. . #NSTEMI/CAD - Per report, patient had short episode of chest pain on admission associated with peaked T waves, and lateral lead ST depressions. Patient was given Aspirin 325mg PO. Cardiac enzymes cycled, and showed rise in trop to peak of 0.61, with flat CK MB. Cardiology was [Name (NI) 653], who initially felt EKG changes and troponin elevation likely due to demand ischemia in the setting of DKA. ECHO with normal systolic function and old area of hypokinesis was consistent with past inferior MI. Following transfer from ICU to floor, patient had two further episodes of substernal CP, relieved with SL nitro x1. ECG unchanged, and cardiac enzymes continued to trend down. Cardiology felt presentation concerning for unstable angina, and recommended initiation of heparin gtt and cardiac cath for further evaluation. He was continued on aspirin, plavix, statin, and beta blocker. Lasix and lisinopril initially held in setting of volume depletion and hyperkalemia. Patient went for cath on [2160-8-7], which showed severe 2 vessel CAD with occluded RCA proximally and 80% mid LAD hazy lesion. A DES was placed in the mid-LAD and patient was transferred to cardiology post-cath. Loaded with plavix (600mg PO one-time, then 150mg daily x1 week, then 75mg daily for a minimum of 1 year) and ASA 325 mg daily x 3 months, then 162 mg daily. He had no further CP throughout the remainder of admission. He was restarted on ACEi, and the patient will need to have follow-up labs within 1 week of discharge to monitor potassium and serum creatinine. . #Hyperkalemia - Patient admitted to OSH with K+ of 8.0 with peaked T waves. He was given 50 of bicarbonate and K+ improved to 5. Peaked T waves resolved. K+ repleted to keep between 3.3 and 5 while correcting DKA. Potassium remained stable for the remainder of admission. . #Cognitive deficits: He has had episodes of DKA in the past, and this episode appears to have been precipitated in part by lack of taking his lantus. His recent neuropsychology testing suggests that he may benefit from rehab or another structured living situation and will require help monitoring his glucose and administering medications. Please refer to Neuropsychology Report from [2160-7-31] for further details. Patient has follow-up with Neuropsychology on [2160-9-4]. . #Hypernatremia: In setting of free water loss from DKA. He was given D5 1/2NS with insulin drip which was changed to D5W and encouraged free water intake. AM of MICU d/c to floor he had a 3.5 L free water defecit which was being actively corrected with D5W. This hypernatremia resolved on the floor. On day of discharge, the patient's sodium was 137. . #Acute on Chronic kidney injury - Baseline creatinine from recent records 1.5. Elevated to 2.9 on admission. [Last Name (un) ] likely prerenal secondary to fluid depletion, and was slowly trending down with fluid administration. Patient received pre-cath hydration. Patient's serum creatinine 2.1 on day of discharge, stable. He was restarted on ACEi, and the patient will need to have follow-up labs within 1 week of discharge to monitor potassium and serum creatinine. . #Gastroparesis - Chronic as side effect of DM. Continued on metoclopramide, pantoprazole. . #Depression - Chronic. Continued bupropion, citalopram. Held gabapentin on admission out of concern for mental status, though this was later restarted. . Transitional Issues: . - Adhering to his insulin schedule and a diabetic diet should be readdressed with patient and he should be encouraged to have close follow up. Insulin regimen may need adjustment to achieve better day time euglycemia. - BCx [8-8] pending . The following changes were made to the patient's medications: NEW: - lisinopril: 2.5mg by mouth once a day - Aspirin 325 mg by mouth daily x 3 months, then 162 mg daily - Atorvastatin 80mg by mouth daily - Clotrimazole Cream 1 Application topically twice per day: Apply to right and left inguinal folds for 3 weeks. . CHANGED: - Increased: plavix (150mg daily x1 week (last day at this dose [2160-8-14]), then 75mg daily for a minimum of 1 year) . STOPPED: - Simvastatin 40mg Medications on Admission: BUPROPION HCL [BUDEPRION XL] - 150 mg Tablet Extended Release 24 hr - 3 Tablet(s) by mouth once a day CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day CLINDAMYCIN PHOSPHATE - 1 % Swab - apply affected areas pimples twice a day CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth every other day (to be titrated up and down by doc) GABAPENTIN - (Not Taking as Prescribed: taking 2 capsules bedtime) - 400 mg Capsule - 3 Capsule(s) by mouth at bedtime HYDROCORTISONE - 2.5 % Cream - apply affected area twice a day 2 weeks on, 2 weeks off INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - inject as per outlined sliding scale per meal as needed for prn INSULIN [Year (4 digits) ] [LANTUS] - 100 unit/mL Solution - 70 units once a day KETOCONAZOLE - (Not Taking as Prescribed) - 2 % Shampoo - Wash scalp and face daily LISINOPRIL - (On Hold from [2160-3-5] to unknown for Hypotension) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day prn METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth q.d. NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually PRN (as needed) NYSTATIN - (Not Taking as Prescribed) - 100,000 unit/gram Powder - apply to groin once daily PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day SIMVASTATIN - 40 mg Tablet - one-half Tablet(s) by mouth daily ( to lower cholesterol) ASPIRIN - (Not Taking as Prescribed) - 325 mg Tablet - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) - (Not Taking as Prescribed) - 1,000 unit Capsule - 2 Capsule(s) by mouth once daily Discharge Medications: 1. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Once Daily at 4 PM. 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for nausea. 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold for SBP<100 mm Hg, HR<60. 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Apply to right and left inguinal folds. . 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take 325mg per day for 3 months, then 162mg per day. 13. clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days: (Last day is [2160-8-14]). 14. Humalog 100 unit/mL Solution Sig: Sliding Scale Per Sliding Scale Subcutaneous 4x a day with meals: Morning/Noon/Evening BG Units 71-80mg/dL 0 Units 81-120mg/dL 12Units/10Units/10Units 121-160mg/dL 14Units/12Units/12Units 161-200mg/dL 16Units/14Units/ 14Units 201-240mg/dL 18Units/16Units/16Units 241-280mg/dL 20Units/18Units/18Units 281-320mg/dL 22Units/20Units/20Units 321-360mg/dL 24Units/22Units/ 22Unit/ 361-400mg/dL 26Units/24Units/24Units >400 [Name8 (MD) ] MD NIGHT TIME BG Units 0-70mg/dL 0Units 71-80mg/dL 0Units 81-120mg/dL 0Units 121-160mg/dL 0Units 161-200mg/dL 0Units 201-240mg/dL 2Units 241-280mg/dL 4Units 281-320mg/dL 6Units 321-360mg-dL 8Units 361-400mg/dL 10Units >400mg/dL [Name8 (MD) 138] MD. 15. Outpatient Lab Work Please check full serum chemistry panel (Na, K, HCO3, BUN, Cr) in 7 days from discharge, [2160-8-19] 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day: once a day for 12 months: Take 1 tablet daily after [2160-8-14] for at least 1 year. . 17. insulin [Month/Day/Year ] 100 unit/mL Solution Sig: Seventy (70) Units Subcutaneous qam. 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO every other day: Hold for SBP<100 mmHg. Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: Primary diagnosis: Diabetic ketoacidosis Unstable angina Secondary diagnoses: Chronic kidney disease Gastroparesis Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], It was a privilege to provide care for you here at the [Hospital 61] Hospital. You were transferred here from [Location (un) 620] for treatment of your diabetic ketoacidosis (very high blood sugar). You were treated with insulin and fluids in the intensive care unit, and after your condition stabilized you were transferred to the regular medical floor. You had several episodes of chest pain, and you were given a cardiac catheterization. A stent was placed in one of your coronary arteries. Your condition has stabilized and improved and you can be discharged to your extended care facility. The following changes were made to your medications: NEW: - lisinopril: 2.5mg by mouth once a day - Aspirin 325 mg by mouth daily for 3 months, then 162 mg daily after 3 months - Atorvastatin 80mg by mouth daily - Clotrimazole Cream 1 Application topically twice per day: Apply to right and left inguinal folds for 3 weeks. . CHANGED: - Increased: plavix 150mg daily until Thursday [2160-8-14], then 75mg daily for a minimum of 1 year . STOPPED: - Simvastatin 40mg . Please keep your follow-up appointments as scheduled below. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following doctor appointments: . Department: NEUROSPYCHOLOGY When: THURSDAY [2160-9-4] at 12:00 PM . Department: DERMATOLOGY When: TUESDAY [2161-7-7] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3833], MD [Telephone/Fax (1) 3965] Building: [Street Address(2) 7454] ([Location (un) 620], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site . Please arrange with your rehabilitation facility follow up with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3649], at [Telephone/Fax (1) 3070*].	[ "250.13", "250.63", "599.0", "564.00", "414.2", "585.9", "584.9", "276.7", "300.4", "403.90", "V58.67", "536.3", "412", "276.1", "V45.82", "414.01", "410.71", "530.81", "272.4" ]	icd9cm	[ [ [] ] ]	[ "37.22", "36.07", "00.40", "00.45", "88.56", "00.66" ]	icd9pcs	[ [ [] ] ]	17566, 17643	7113, 7687	300, 369	17814, 17814	4087, 4087	19280, 19900	2902, 2924		15001, 17543		17664, 17664		13252, 14978			17997, 19257								2939, 2939			17743, 17793													5066, 7090		12498, 13226					229, 262		7702, 12477							397, 2113						17683, 17722	4101, 5052		17829, 17973						2135, 2703	2719, 2886
51,216	113,395	37468+58148	Discharge summary	report+addendum	Admission Date: [2197-1-13] Discharge Date: [2197-2-3] Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: chest discomfort and fatigue Major Surgical or Invasive Procedure: Aortic valve replacement (27mm [Company 1543] Mosaic),coronary artery bypass x3(Lima-LAD,SVG-ramus, SVG-OM) and ligation of left atrial appendage [2197-1-17] History of Present Illness: Mr. [Known lastname 84178] is an 86 year old man who has been experiencing increasing episodes of chest discomfort and fatigue over the past month. A recent echocardiogram revealed an EF of 45% with modest aortic stenosis ([Location (un) 109] 1.2) and moderate aortic regurgitation and 2+ mitral regurgitation and modest tricuspid regurgitation. A subsequent cath revealed 90% LM and RCA, LCX, and Ramus lesions. He is admitted for surgical revasularization and aortic valve replacement. Past Medical History: Past Medical History: PAF, HTN, Meniere's, Aortic stenosis, Aortic insufficiency, non-STEMI [12-14], TIA (two episodes ten years ago), AFib Social History: Race:caucasian Last Dental Exam:2 yrs ago Lives with:alone Occupation:retired Tobacco:never ETOH:never Family History: non contributory Physical Exam: Pulse: 77 Resp: 18 O2 sat: 100% RA B/P 137/71 Height: 5'[97]" Weight:150 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 [] Irregular [x] Murmur IV/Vi SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: superficial veins b/l None [] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: Left: transmitted murmur Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 84179] (Complete) Done [2197-1-17] at 1:08:20 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: [2110-1-20] Age (years): 86 M Hgt (in): 70 BP (mm Hg): 110/70 Wgt (lb): 150 HR (bpm): 50 BSA (m2): 1.85 m2 Indication: Coronary artery disease, aortic valve disease ICD-9 Codes: 424.1, 424.0 Test Information Date/Time: [2197-1-17] at 13:08 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3893], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 6.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.2 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: 1.1 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Dilated LA. Moderate to severe spontaneous echo contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Moderately thickened aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The rhythm appears to be atrial fibrillation. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is dilated. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) 914] was notified in person of the results on Mr.[Known lastname 84178] before surgical incision. Post_Bypass: Normal RV systolic function. LVEF 40%. Intact thoracic aorta. The bioprosthetic aortic valve is stable and functioning well. NO periprosthetic leaks. Residual mean gradient is 4mm of Hg. I certify that I was present for this procedure in compliance with HCFA regulations. . Brief Hospital Course: Mr. [Known lastname 84178] was admitted and taken tot he operating room for the following:(see operative note for details) 1. Aortic valve replacement with a 27-mm [Company 1543] Mosaic ULTRA Bioprosthesis. 2. Coronary bypass grafting x3 with the left internal mammary artery, left anterior descending coronary; reversed after sustaining a single graft from the aorta to ramus intermedius coronary artery; as well as reverse saphenous vein single-graft from the aorta to the first obtuse marginal coronary artery. 3. Resection of left atrial appendage. 4. Endoscopic left greater saphenous vein harvesting. Post operatively he remained intubated and was admitted to the CVICU for invasive hemodynamic monitoring and care. He awoke neurologically intact and was weaned from the ventilator and extubated without difficulty. Mr. [Known lastname 84180] chest tubes and temporary pacing wires were removed per protocol. He was started on betablockers, statins and diuresed toward his pre-operative weight however he continues to have 2+ LE edema bilateral which is being treated with IV lasix and zaroxyln. He remains in rate controlled atrial fibrillation. Mr. [Known lastname 84178] was anticoagulated with coumadin. He was evaluated and treated by physical therapy for strength and conditioning. He was noted to have endo-vein harvest site cellulitus on POD 8 and was placed on Vancomycin. Leukocytosis was persistent, and ID was consulted and agreed with vancomycin treatment. He developed loose stools and his laxatives were tapered and C-diff toxin would return negative twice. Cellulitis did improve on vancomycin. Rehab was recommmended upon discharge. Mr. [Known lastname 84178] was discharged to rehab on POD #17 after being cleared for discharge by Dr. [Last Name (STitle) 914]. Medications on Admission: ASA 81mg daily, plavix 75mg daily, lopressor 50mg [Hospital1 ], zocor 20mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take as directed for INR Goal 2-2.5 for afib. 13. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): last dose pm on [2197-2-9]. 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: while on lasix check potassium daily. 17. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): continue diuresis until lower extremity. 18. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [Hospital1 ] (2 times a day): until lower extremity edema resolves. 19. picc picc line care and flushes per facility protocol 20. Outpatient Lab Work check INR daily until stablizes and follow bun/creat and lytes daily while on lasix and vanco Discharge Disposition: Extended Care Facility: [Last Name (NamePattern1) ]Nursing Facility Discharge Diagnosis: post operative left lower extremity cellulitis from saphenous vein graft site Aortic stenosis coronary artery disease s/p aortic valve replacement, coronary artery bypass grafts and ligation of left atrial appendage [2197-1-17] Meniere's disease hypertension hyperlipidemia paroxysmal atrial fibrillation cerebrovascular disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with tylenol and ultram prn Discharge Instructions: 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] When to Call Your Surgeon Call your surgeon ([Telephone/Fax (1) 1504] (24 hours a day, seven days a week) if any of the following occur: Your incision is warm, red or swollen or there is increased tenderness or pain * Any of your incisions have ANY fluid or drainage coming out * You have a fever of 100.5 degrees Fahrenheit or higher * Your weight has gone up more than two pounds in one day or five pounds in a week * You have severe pain or increased swelling in either leg * You have palpitations * You feel dizzy or weak (if severe, call 911) * You notice any of the following, especially if you are on warfarin (Coumadin) o A lot of dark, large bruises o Black or dark bowel movements o Pain, discomfort or swelling in any area, especially after an injury o Severe or unusual headache (if symptoms are severe, please call 911) Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) [2197-2-28] at 1pm Dr. [First Name11 (Name Pattern1) 2174] [Initial (NamePattern1) ] [Last Name (NamePattern4) 656] (primary care) [2-21] at 130 pm plaese call and schedule the following appointments: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4610] (cardiologist) in 2 weeks Completed by:[2197-2-3] Name: [Known lastname 13375],[Known firstname 126] N Unit No: [Numeric Identifier 13376] Admission Date: [2197-1-13] Discharge Date: [2197-2-3] Date of Birth: [2110-1-20] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1543] Addendum: see updated sections regarding left lower extremity spahenous vein graft site. Brief Hospital Course: left lower extremity remains erythematous -area demarkated. SVG harvest site is draining serous fluid. Site is packed with 2x2 [Hospital1 ] and covered with DSD. Discharge Disposition: Extended Care Facility: [Last Name (NamePattern1) 13377]Nursing Facility Discharge Instructions: dressing change to Left LE saphenous vein graft site- dry wicking 2x2 [Hospital1 ] and cover with ABD and flexinet. [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2197-2-3]	[ "V12.54", "412", "416.8", "413.9", "272.4", "424.1", "512.1", "E878.2", "V58.61", "427.31", "386.00", "428.0", "414.01", "998.59", "682.6", "521.00" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61", "36.12", "38.93", "37.36", "36.15" ]	icd9pcs	[ [ [] ] ]	13118, 13197	12928, 13095	252, 420	10533, 10639	1962, 4820	12046, 12905	1253, 1271		8065, 10059		10177, 10512		7956, 8042			13221, 13500							4869, 6069	1286, 1943																							184, 214									448, 948															992, 1116	1132, 1237
67,473	159,400	28536	Discharge summary	report	Admission Date: [2113-11-11] Discharge Date: [2113-11-17] Date of Birth: [2055-11-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo M w hx of COPD (FEV1 24% predicted, 4 L home oxygen), diastolic CHF, presents with two days of increasing DOE and weakness and fatigue. Patient's daughter (also [Name (NI) ]) first called [Name (NI) 191] and then elected to bring patient to [Hospital3 ] ED. She reported that the patient had 2 days of generalized body aches, fatigue, HA, increased SOB (above baseline), low back pain (per OMR is chronic). No cough or fever. At presentation to the [Hospital1 18] ED vitals were: T 98.4, HR 120, BP 146/80, RR 30, O2Sat 96% (10 L neb). CXR was obtained. Patient was started on ceftriaxone and azithromycin. Received several rounds of albuterol and ipratropium as well as methylpred 125 mg IV. Nasopharyngeal swab for influenza rule-out was reportedly sent from ED and patient was started on oseltamivir. An ABG was performed and was 7.16/125/120 (was sent under wrong patient's name). Patient was subsequently started on BiPAP. Patient subsequently became more somnolent and repeat ABG showed 7.21/116/70. Due to somnolence, head CT was performed and prelim negative. Patient subsequently intubated and started on fentanyl and midazolam drips. Vitals prior to transfer to the ICU were: HR 107, BP 122/83, RR 14, O2Sat 98% (CMV, VT 400, RR 14, FiO2 60%, PEEP 7). Past Medical History: 1) COPD, largely emphysema (FEV1/FVC 29, FEV1 24% pred [6-/2113]) - s/p bullectomy with RUL resection in [2106] - 4L of oxygen at baseline 2) Colonic polyps 3) History of embolic stroke which had hemorrhagic conversion s/p heparin [2110-7-22] (frontal and occipital) 4) History of PFO 5) Factor V Leiden heterozygosity 6) Hyperlipidemia 7) Inguinal hernia 8) Right ventricular dysfunction, likely due to pulmonary hypertension 9) Polycythemia, likely due to hypoxemia 10) Eczema Social History: Worked as a security guard (vs computer scientist) at [University/College ] library. Lives with wife in [Name (NI) 3307] and uses wheelchair to get around outside of the home. Also has grown children. Tobacco: The patient stopped smoking in [2108] after his lung resection. He has at least a 40-pack year history. EtOH: Occassional Illicits: Past marijuana, No IVDU Family History: Father: CVAs (or MI?) starting at age 53 (deceased in 70s) Mother: breast cancer Brother: liver cancer Had 4 brothers and 1 sister in good health as of [2109]. Physical Exam: VS: T 99, HR 91, BP 117/65, RR 16, O2Sat 91% (intubated with AC VT 400, RR 14, PEEP 7, FiO2 60%) GEN: NAD HEENT: PERRL, does not track movement, oral mucosa moist, NECK: No [Doctor First Name ], no JVP elevation PULM: Coarse, but diminished breath sounds with crackles and left anterior base, prolonged expiratory phase with inaudible air movement in expiratory, copious thick secretions suctioned from ET tube CARD: RR, nl S1, nl S2, no M/R/G ABD: BS+, soft, non-tender, non-distended EXT: No C/C/E SKIN: Diffuse dry skin with some icthyosis of BLE and some psoriatic skin changes around face NEURO: sedated, pupils reactive Pertinent Results: Admission Labs: 11.8>13.9/44.0<258 N81.0, L8.7, M9.6, E0.4, B0.3 PT 52.8, PTT 46.5, INR 5.8 142/4.4/98/42/17/0.5<132 proBNP 299 Trop T <.01 7.21/116/70 Studies: [2113-11-10] ECG: Sinus tachycardia. Intraventricular conduction delay. Compared to the previous tracing of [2110-8-10] the rate has increased and intraventricular conduction delay is now present. [2113-11-10] Chest xray: 1. Findings consistent with pulmonary edema. 2. Emphysematous changes and post-surgical changes in the right upper lung. [2113-11-11] CT Head: IMPRESSION: No acute intracranial hemorrhage. New hypodensities seen in the current study can be due to evolution of infarcts but an associated acute infarct is difficult to evaluate. MRI can help for further assessment if clinically indicated. [2113-11-15] Chest xray: As compared to the previous radiograph, there is no relevant change. The patient has been extubated, the nasogastric tube has been removed. Pre-existing bilateral opacities are unchanged in extent and severity. The size of the cardiac silhouette, at least its visible parts, are also unchanged. The caudal parts of the left sinus are not included on the image. The presence of a small left-sided pleural effusion cannot be excluded. Brief Hospital Course: 58 yo M w hx of COPD (FEV1 24% predicted), diastolic CHF, presents with two days of increasing DOE and weakness and fatigue. #. Hypercarbic respiratory failure: He was intubated in the emergency room due to hypercarbic respiratory failure with a pCO2 greater than 100. He was felt to have a COPD exacerbation in setting of a likely community acquired pneumonia. His last measured FEV1 was 24% predicted. Though he had no history of fevers, cough, or chills, his elevated WBC count to 11.8 with 81% neutrophils as well as CXR findings of patchy opacities consistent with a pneumonia. He was started on ceftriaxone and azithromycin on [11-11], and completed his course of azithromycin. Ceftriaxone course will end on [2113-11-17]. He was also given Albuterol and ipratropium nebulizer treatments, in addition to being started on IV steroids. He had a negative swab for influenza. His respiratory status improved and he was extubated on [2113-11-14]. Though he continued to have periodic desaturations to the high 80s, he remained stable on face tent. He was also put on a prednisone taper which should be continued after discharge. Prednisone taper can be adjusted per according to patient's clinical presentation (i.e. stop taper and continue steroids if respiratory status worsens). At discharge, he was on face tent with Fi02 55% with O2 sats 89-92%. He desats when eating as he takes off his oxygen. Patient needs repeat CXR at 6 weeks to ensure that bilateral lower lobe opacities seen on imaging this admission resolve. If these imaging abnormalities are not resolved on repeat CXR, he will need high resolution chest CT to further evaluate his lung parenchema. #. Coagulopathy: He had elevation of his INR to 5.8 at admission. he had no evidence of GI bleeding and no history of trauma to cause concern for internal bleeding. Negative head CT for bleed in the ED was reassuring. Hct remained stable and his Coumadin was restarted at his home dose prior to discharge. He is reportedly on Coumadin for a h/o CVA and factor V Leiden heterozygosity. He will need INR checks after discharge and his dose may need to be readjusted. Goal INR is [1-10]. #. Hyperlipidemia: Continued on simvastatin. #. Diastolic heart failure: He was given IV fluids on admission and during his stay for hypotension. He was then aggressively diuresed as his chest xrays looked like pulmonary edema. He was restarted on his home Lasix at discharge, and would likely benefit from an In/Out goal of 1 liter negative per day after discharge as his breathing continues to improve. #. Chest Pain: He had one episode of chest pain during this admission and there was low clinical suspicion for a cardiac source. His ECG was unchanged and he was ruled out for MI. #. Code Status: He was full code during #. Contact: [Name (NI) ] [Name (NI) ], wife, [0-0-] Medications on Admission: MEDICATIONS: (per OMR) 1) Albuterol prn 2) Advair 250mcg/50mcg 1 puff [Hospital1 ] 3) Furosemide 20mg daily 4) Ketoconazole 2% TID 5) 3.5-4L oxygen as needed (saturation 83% without) 6) Simvastatin 40mg daily 7) Spiriva 18 mcg daily 8) Coumadin 7.5mg po daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Sliding scale Check fingerstick glucose and give the following insulin scale using Humalog insulin: Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0 Units 101-150 mg/dL 2 Units 151-200 mg/dL 4 Units 201-250 mg/dL 6 Units 251-300 mg/dL 8 Units 301-350 mg/dL 10 Units 351-400 mg/dL 12 Units > 400 mg/dL Notify M.D. 4. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia. Recon Soln(s) 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for cough, wheeze. 10. Ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 1 days: Please give daily with last dose on [2113-11-17]. 11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Please give 60mg po daily until [2113-11-20]. Then give 50mg po daily for 3 days, then 40mg po daily for 3 days, then 30mg po daily for 3 days, then 20mg po daily for 3 days, then 10mg po daily for 3 days, then 5mg po daily for 3 days, then stop prednisone. 12. Oxygen Patient should be maintained on at least 4 liters of oxygen at all times. He is being discharged on face tent with 55% FiO2 and should be slowly weaned to 4 liters of oxygen as tolerated. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Inhalation every six (6) hours: Can also give as needed for wheezing/SOB in between standing doses. 14. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for eczema. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation Inhalation once a day. 17. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 18. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig: One (1) Inhalation Inhalation every six (6) hours: Can also give prn for wheezing or SOB in between standing doses. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: Hypercarbic respiratory failure Chronic Obstructive Pulmonary Disease Pneumonia Secondary Diagnosis: Chronic diastolic heart failure Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Has transferred from bed to chair since extubation, requires assistance Discharge Instructions: You were admitted to the hospital with shortness of breath. The carbon dioxide level in your blood was very high and you required a breathing tube to help you breathe. It was felt that you had a worsening of your COPD, as well as a pneumonia. You were given antibiotics to treat your pneumonia. The breathing tube was removed on [11-14] without complication. You have been wearing a face mask to help the oxygen levels in your blood. After discharge, it is important that you continue nebulization treatments every day for your wheezing, which you have been requiring 2-3 times per day. You are also being given Lasix for diuresis and your goal for diuresis is approximately 1 liter negative per day. You should have your INR checked after discharge and your Coumadin dose should be changed accordingly. Please hold for INR>3.0 Your foley catheter was removed from your bladder on the day of discharge. You should have a voiding trial this evening. You should have a follow-up chest xray in 6 weeks to assess for resolution of your pulmonary edema or stability of your lung disease. Followup Instructions: You are being discharged to a pulmonary rehabilitation center ([Hospital1 ]) in order to help your breathing. Upon discharge from that facility, please follow-up with your primary care provider as well as your pulmonary specialist, Dr. [Last Name (STitle) 575] (see below for appointment). You have the following appointments scheduled: Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time: [2113-12-12] 10:00 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone: [Telephone/Fax (1) 609] Date/Time: [2113-12-12] 9:40 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2113-12-12] 10:00 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "428.0", "786.51", "790.92", "289.81", "428.33", "348.39", "416.9", "E934.2", "V12.72", "458.9", "491.21", "438.89", "518.81", "250.00", "692.9", "V15.82", "729.89", "486", "238.4", "V58.61" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.04", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	10506, 10585	4694, 7577	332, 338	10782, 10782	3412, 3412	12100, 13038	2580, 2746		7892, 10483		10606, 10606		7603, 7869			10977, 12077								2761, 3393																							285, 294									366, 1653		3961, 4671	10727, 10761		3428, 3952	10625, 10706			10797, 10953						1675, 2168	2184, 2564
79,539	191,126	38575	Discharge summary	report	Admission Date: [2109-7-15] Discharge Date: [2109-7-24] Date of Birth: [2029-7-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 13159] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: This is an 80y/o Male with a history of [Last Name (NamePattern1) 2091], CAD s/p [Name (NI) 7792] (unclear if intervented upon), CVA, dementia who presents with low Hct. Of note patient is a poor historian and is unable to confirm information. On follow up labs for known anemia on [7-15], patient was found to have Hct of 21 down from 28 on [7-1]. Per report, patient did not have any abdominal pain, nausea, vomiting, tarry or bloody stools. He was then sent to [Hospital1 18] for further evaluation. On arrival to ED, initial VS were: 98 66 117/52 20 100%RA. Evaluation was significant for melena on rectial exam. Hct was 21. Patient was ordered for 2 units pRBCs however did not receive any units. He was started on protonix gtt and was admitted to MICU. Prior to transfer GI was consulted who planned to scope in AM. Patient remained hemodynamically stable however given concern for upper GI bleed, patient was admitted to MICU. Past Medical History: PVD s/p multiple toe amputations Encephalopathy (EtOH) Alzheimer's dementia with occasional paranoia and visual hallucinations DM2 with history of DKA CAD s/p [Hospital1 7792] HTN Korsakoff's syndrome PVD with dry gangrene of L toes and transmetatarsal amputation of right foot Social History: History of alcohol abuse with encephalopathy. Living in the [Hospital3 537] nursing home. No history noted of tobacco abuse. He has one living relative, his [Name2 (NI) 802] and health care proxy [Name (NI) 717] [Last Name (NamePattern1) 479]. At baseline oriented to person and occasionally place. He is dependent for nearly all ADLs. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 97.9 BP: 158/82 P: 66 R: 16 O2: 98%RA General: NAD, alert, not oriented HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Deceased Pertinent Results: [2109-7-15] 06:15PM BLOOD WBC-5.5 RBC-2.06# Hgb-7.1 Hct-21.0* MCV-102# MCH-34.3 MCHC-33.7 RDW-13.9 Plt Ct-235 [2109-7-16] 04:09AM BLOOD WBC-7.6 RBC-2.83# Hgb-9.6# Hct-28.0# MCV-99 MCH-33.8* MCHC-34.2 RDW-13.9 Plt Ct-192 [2109-7-16] 12:10PM BLOOD Hct-27.7* [2109-7-16] 07:52PM BLOOD Hct-29.1* [2109-7-15] 06:15PM BLOOD PT-11.0 PTT-31.7 INR(PT)-1.0 [2109-7-15] 06:15PM BLOOD Glucose-264* UreaN-49* Creat-2.2* Na-137 K-4.3 Cl-100 HCO3-29 AnGap-12 [2109-7-16] 12:28AM BLOOD Glucose-477* UreaN-50* Creat-2.3* Na-136 K-4.5 Cl-100 HCO3-26 AnGap-15 [2109-7-16] 04:09AM BLOOD Glucose-419* UreaN-50* Creat-2.2* Na-139 K-3.8 Cl-103 HCO3-28 AnGap-12 ECG [2109-7-19]: Sinus rhythm with premature ventricular complex. Borderline Q-T interval prolongation. Extensive ST-T wave changes in the inferolateral leads consistent with possible ischemia. Clinical correlation is suggested. Compared to the previous tracing of [2109-7-18] the precordial voltage is less prominent. TTE [2109-7-19]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior/infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-24]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT Head [2109-7-20]: Chronic abnormalities, without evidence for acute intracranial process. EEG: [2109-7-23] This telemetry captured no pushbutton activations. The recording showed a slow background in all areas throughout, relatively unchanged over the course of the recording. This suggests a widespread encephalopathy. Medications, metabolic disturbances, and infection among the most common causes. The regularity increases the possibility of medication effect. There were no areas of prominent focal slowing, and there were no clearly epileptiform features or electrographic seizures. [2109-7-24] 06:45AM BLOOD WBC-11.9* RBC-3.39* Hgb-11.2* Hct-35.1* MCV-104* MCH-33.2* MCHC-32.0 RDW-14.2 Plt Ct-285 [2109-7-23] 07:25AM BLOOD Neuts-84.3* Lymphs-8.7* Monos-6.7 Eos-0.2 Baso-0.1 [2109-7-24] 06:45AM BLOOD Glucose-208* UreaN-56* Creat-2.6* Na-149* K-4.1 Cl-116* HCO3-21* AnGap-16 [2109-7-23] 06:22PM BLOOD Type-ART pO2-62* pCO2-33* pH-7.44 calTCO2-23 Base XS-0 Intubat-NOT INTUBA Brief Hospital Course: MICU Green Course 80y/o Male with multiple medical problems including [Name (NI) 2091], CVA, CAD s/p [Name (NI) 7792], PVD, DM, dementia who presented with anemia and melena c/w upper GI Bleed complicated by hyperglycemia and [Name (NI) 7792] # GI bleed/ Macrocytic Anemia: Given melena, appears most c/w upper source. DDx includes gastritis v. PUD v. AVM. Currently HDS. Of course black stools could be confounded from iron supplemenation however that does not explain Hct drop. Macrocytosis could be related to prior ETOHism but has not had ETOH in many years. Vitamin B12 and folate WNL in 12/[2106]. Could also have represented underlying bone marrow process. Two 2 BRBC units were transfused with goal Hct > 24 given CAD, PVD.His Hct remained stable at approx. 28-30 . # Hyperglycemia/Diabetes: On arrival to MICU, fingerstick elevated to 400's. Blood glucose control with insulin drip and he was restarted on home NPH 22 units in the AM and 14 units in the PM with Humalog sliding scale. # Hypertension: Chronic issue. Elevated to 150's systolic at the time of admit. Better control with therapy in MICU.Continued clonidine, metoprolol, and amlodipine and briefly was on nitro drip given [Year (4 digits) 7792] below which was weaned off. # CAD s/p [Year (4 digits) 7792]: Chronic issue. On aspirin and plavix and imdur. No hx of CAD per PCP. [Name10 (NameIs) ] at baseline.Given plavix load, full dose ASA and heparin drip which will be continued for 48 hours. Cardiology consulted and given multiple medical issues and peak in troponin thought to be no role in cardiac catherization. # Dementia: Chronic stable issue. Alzheimer's type dementia with visual hallucinations. Per family between the hours of 3-5PM every day he is unresponsive and sleeping, and barely arousable. - continued with home meds # Glaucoma: Chronic stable issue - continued eye gtts # Prophylaxis: Subcutaneous heparin # Code: DNI/DNR Floor Course: 80m with h/o dementia, CAD s/p [Name10 (NameIs) 7792], [Name10 (NameIs) 2091], admitted [7-15] with anemia and melanotic stool, transferred to MICU [7-18] for DKA, transferred back to floor on [2109-7-19] whose hospital course was complicated by [Date Range 7792] and [Last Name (un) ] with increasing lethargy and altered mental status. He expired on [2109-7-24]. # [Date Range 7792]: Pt had a [Date Range 7792] in the context of DKA/HNK and marked anemia. Denied any symptoms and is was hemodynamically stable in the early post MI period. ECG with lateral TWI, new compared with initial ECG. Biomarkers which were elevated in setting of [Date Range 7792] began to trended down. TTE demonstrated new inferolateral hypokinesis, mild LV systolic dysfunction, mild/moderate MR [First Name (Titles) ] [Last Name (Titles) 114]e pulmonary hypertension. Per Cardiology, opted for medical management of [Last Name (Titles) 7792] given pt poor functional status. It was unclear if plaque-rupture mediated or supply-demand mismatch. Per Cardiology recs pt was put on ASA/Plavix/heparin x 48 hours. He was started on a beta-[Last Name (LF) 7005], [First Name3 (LF) ] ace-inhibitor, and continued statin. Pt was gently rehydrated in setting of new LV hypokinesis. Pt [First Name3 (LF) ] was significant for PVCs (not new) and prolonged QT. # Lethargy/Altered Mental Status - Pt had become progressively more lethargic since returning from the MICU to the floors. He no longer was verbal and did not responde to commands. Studies looking for a cause of the new onset lethargy were obtained but did not reveal a source. TSH was WNL, head CT neg, ABG was wnl, blood sugars were elevated but pt was not in DKA. UA and CXR were also negative. We continued to monitor BS and adminstered insulin as needed. Lactulose enema was also continued as there was a concern for constipation (gets lactulose at home). # DMII: s/p DKA now resolved. Several days with high sugars while getting lower than usual insulin, also likely due to [First Name3 (LF) 7792]. Pt was maintained on SC insulin. Pte as also seen by [Last Name (un) ] to optimize DM management. BS low s/p getting PM NPH without taking POs so pt home insulin regimen was held and he was switched to lantus while NPO. # acute on chronic renal failure: Pt has chronic renal failure with a baseline Cr 2. He acute kidney injury peaked at 3.3 and improved with fluids back to his baseline around 2. Suspect prerenal given elevated Na and poor POs. # GIB: H/H stablized on floor. Please see above MICU note for more details. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from list faxed by PCP. 1. Aspirin 325 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. HumaLOG NF (insulin lispro) 100 unit/mL Subcutaneous per sliding scale QACHS 4. NPH insulin human recomb NF 100 unit/mL (3 mL) Subcutaneous as directed 22 units every morning, and 14 units at dinner 5. OLANZapine 7.5 mg PO DAILY 6. Mirtazapine 15 mg PO HS 7. traZODONE 25 mg PO DAILY BEFORE LUNCH 8. traZODONE 21.5 mg PO Q6H:PRN as needed 9. CloniDINE 0.3 mg PO TID 10. Amlodipine 10 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO BID 12. Tamsulosin 0.4 mg PO HS 13. Isosorbide Mononitrate 20 mg PO BID 14. Vitamin D 50,000 UNIT PO MONTHLY 15. Lactulose 30 mL PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Cal-[Last Name (un) ] Antacid NF (calcium carbonate) 200 mg calcium (500 mg) Oral two tablets [Hospital1 ] 18. Omeprazole 20 mg PO DAILY 19. Docusate Sodium 200 mg PO BID 20. Polyethylene Glycol 17 g PO DAILY 21. Senna 2 TAB PO HS 22. Timolol Maleate 0.5% 1 DROP BOTH EYES [Hospital1 ] 23. Pilocarpine 4% 1 DROP BOTH EYES Q6H 24. Travatan Z NF (travoprost) 0.004 % OU QPM 25. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea/wheeze 26. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea/wheeze 27. Simvastatin 40 mg PO HS 28. Fish Oil (Omega 3) 1000 mg PO DAILY 29. Ferrous Sulfate 650 mg PO BID 30. Bisac-Evac NF (bisacodyl) 10 mg Rectal every 72 hours Discharge Disposition: Expired Discharge Diagnosis: Myocardial Infarction Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None	[ "535.50", "V12.54", "578.1", "414.01", "584.9", "276.0", "403.90", "412", "348.30", "424.0", "564.00", "410.71", "331.0", "V58.67", "V49.72", "276.8", "V49.86", "416.8", "285.1", "365.9", "250.12", "585.9", "303.93", "294.10", "V49.75", "443.9" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	11870, 11879	5752, 10366	320, 326	11944, 11954	2722, 5729	12007, 12014	2003, 2021				11900, 11923		10392, 11847			11978, 11984								2036, 2703																							274, 282									354, 1312															1334, 1617	1633, 1987
57,739	159,802	33333	Discharge summary	report	Admission Date: [2132-10-1] Discharge Date: [2132-10-11] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: abdominal pain, ruptured AAA Major Surgical or Invasive Procedure: 1. Endovascular repair of ruptured abdominal aortic aneurysm 2. Diagnostic laparoscopy, exploratory laparotomy, sigmoid colectomy, 3. cholecystectomy 4. GJ tube History of Present Illness: 87 M with > 1 week back pain, collapsed at rehab taken by EMS to [Hospital1 ] [Location (un) 620]. CT scan w/ ruptured AAA. Transfered to [Hospital1 18] for emergent repair. Past Medical History: Parkinsons dementia BPH hyperlipidemia HTN Social History: No Tob, no EtOH, no IVDU. Lives in [Hospital3 ]. Daughter ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]) is HCP. Retired from retail. Family History: h/o aneurysms in the family Physical Exam: Deceased on discharge Brief Hospital Course: Mr. [Known lastname 77386] was taken to the OR emergently and underwent an endovascular repair of his ruptured AAA. Please see Dr. [Name (NI) 19759] operative note for further detail. Postoperatively, his course was complicated by abdominal pain, a persistently high WBC, and loose bowel movements on POD #2. Given the concern for ischemic colitis, a general surgery consult was obtained -- and the decision was made to take Mr. [Known lastname 77386] to the operating room for an exploratory laparotomy. He was found to have a dead sigmoid and a chronically inflamed gallbladder, and underwent a sigmoid colectomy, Hartmann's procedure, and cholecystectomy. Please see Dr.[Name (NI) 670] operative note for further detail. Now status post an EVAR for a ruptured AAA and an exlap/sigmoid colectomy/CCY, Mr. Latex was aggresively diuresed and eventually extubated. His extubation was initially held off over concerns of his neurologic status, which improved. He did not suffer any adverse cardiac events. While initially he required a nitroglycerin drip for SBP control, this was eventually weaned off. His tube feeds, via a GJ tube were started and gradually advanced to goal feeds of 80cc/hour. He was diuresed with a lasix drip in the postoperative period, and once he neared his baseline weight, this was stopped. He was on perioperative antibiotics following his second operation, of Vanc and Zosyn, which were discontinued after 72 hours. His hematocrits remained stable throughout. On POD 9 and 11 he acutely decompensated from a respiratory standpoint. Family (HCP-daughter) was present and wished to not intubate the patient and make him CMO. Discussion was held with Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] and [Name5 (PTitle) ] was made CMO. He expired a short time later with the family present. Family and ME declined post mortum. Medications on Admission: norvasc 10 budenoside carb/levo 25/100 proscar 5 prilosec 20 paxil 40 simvastatin 20 flomax 0.4 colace ASA Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: ruptured AAA Mesenteric ischemia Respiratory failure Renal failure Discharge Condition: Deceased Discharge Instructions: none Followup Instructions: none	[ "E879.8", "441.3", "401.9", "E849.7", "272.0", "567.89", "574.10", "584.9", "458.29", "401.1", "294.10", "557.0", "331.82" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.93", "51.22", "44.39", "99.15", "39.71", "45.76" ]	icd9pcs	[ [ [] ] ]	3106, 3115	1018, 2916	291, 453	3225, 3235		3288, 3295	928, 957		3073, 3083		3136, 3204		2942, 3050			3259, 3265								972, 995																							223, 253									481, 670															692, 736	752, 912
19,005	111,838	46229	Discharge summary	report	Admission Date: [2151-5-10] Discharge Date: [2151-5-15] Date of Birth: [2093-7-2] Sex: F Service: NEUROLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old left-handed woman with a history of uncontrolled hypertension, never previously on any antihypertensive medications and taking several herbal medications that possibly contribute a bleeding diathesis, who was admitted on [2151-5-10] after presenting to an outside hospital with headache as well as some dizziness and complaints of left arm and leg clumsiness and inability to move them where she wanted to. The patient initially went to [Hospital3 ] where a head CT showed a right thalamic hemorrhage. Her blood pressure at that time was 240/140. She was started on a Nipride drip and transferred to the [Hospital6 256]. At [Hospital3 ], she had a repeat head CT which showed stable size of her right thalamocapsular hemorrhage. She was transferred to the ICU for blood pressure management which was initially very difficult to control requiring a Nipride drip for the first four days after admission. PAST MEDICAL HISTORY: 1. Uncontrolled hypertension. 2. Raynaud's phenomenon. MEDICATIONS ON ADMISSION: 1. Multivitamin. 2. Multiple herbal medications including Coenzyme Q, [Location (un) ], and horse chestnut. 3. Claritin. 4. Aspirin. ALLERGIES: She has a possible allergy to morphine. She also reports multiple sensitivities to multiple chemicals and medications which she cannot clarify further. SOCIAL HISTORY: She lives alone. She denied tobacco or alcohol use. She works for an insurance company. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON TRANSFER TO THE NEUROLOGY FLOOR: Vital signs: Temperature 98.4, blood pressure 146/80, pulse 67, respirations 20, saturating 94% on room air. General: She was awake and alert, in no acute distress. Neck: Supple with no carotid bruits. Lungs: Clear to auscultation bilaterally. Cardiac: Regular. Abdomen: Benign. Mental status: She was awake, oriented times three with normal language, naming, repetition, comprehension. She has no neglect. Cranial nerves: The pupils were 4 mm to 2 mm, round, and reactive to light. The extraocular movements were full. The visual fields were full to confrontation. Facial sensation was equal. Her face was symmetric. Her palate was upgoing and symmetric. The tongue was midline. Motor examination revealed mild upper motor neuron pattern weakness in her left deltoid, triceps, wrist extensors, and finger extensors. She also has mild to moderate weakness in her left iliopsoas, hamstrings, and toe extensors. She has slightly increased tone on the left. Reflexes: 2+ in the right upper extremity, 3+ in the left upper extremity. They were also 3+ at the left patella, 2+ at the right patella, absent at the ankles with an extensor plantar response on the left. Sensation: She had slightly decreased joint position sense in the left upper extremity and left lower extremity, graphesthesia and double-simultaneous stimulation were intact. She was intact to light touch and pinprick throughout. Coordination revealed slow random alternating movements on the left with mild dysmetria on finger-nose-finger, not out of proportion to weakness. LABORATORY DATA ON ADMISSION: White count 10.3, hematocrit 32, platelets 208,000. INR 1.2, PTT 26.3. Sodium 139, potassium 3.7, BUN 22, creatinine 0.7, glucose 105. Her liver function tests were within normal limits. She had a urinalysis which was also within normal limits. The urine culture revealed no growth. She ruled out for a myocardial infarction with serial CKs of 127, 84, and 54. Her troponins were less than 0.3. Hemoglobin A1C was 5.4, total cholesterol 157, triglycerides 49, HDL 59, LDL 88. She had an EKG which showed sinus rhythm at 90 beats per minute with a right bundle branch block. Head CT was done on [2151-5-10] and [2151-5-11] which showed stable size of a 1.5 by 1.7 cm right thalamocapsular hemorrhage with slight surrounding edema with some extension into the right lateral ventricle but no evidence of hydrocephalus. HOSPITAL COURSE: The patient is a 57-year-old left-handed woman with uncontrolled hypertension who presents with left-sided weakness and sensory loss in the setting of excessively elevated blood pressure, most likely hemorrhage is due to uncontrolled hypertension. She had a transthoracic echocardiogram during admission which showed an ejection fraction of greater than 60% with no focal wall motion abnormalities. However, she had evidence of severe left ventricular hypertrophy which was symmetric. She remained in the ICU on Nipride drip for the first four days of admission as her oral blood pressure medications were tapered up. She was discharged to the floor in stable condition on metoprolol, captopril, and hydralazine with her blood pressure of 146/80. She had slight improvement in her left-sided weakness and sensory loss during admission and she is to be transferred to a rehabilitation hospital upon discharge. DISCHARGE DIAGNOSIS: 1. Right thalamocapsular hemorrhage with residual mild left hemiparesis and left-sided sensory loss. 2. Uncontrolled hypertension. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. b.i.d. 2. Captopril 50 mg p.o. t.i.d. 3. Hydralazine 25 mg p.o. q.i.d. 4. Colace 100 mg p.o. b.i.d. 5. Saline nasal spray to each nostril t.i.d. p.r.n. 6. Tylenol 325-650 mg p.o. q. 4-6 hours p.r.n. DR.[Last Name (STitle) ],[First Name3 (LF) ] 13-279 Dictated By:[Last Name (NamePattern1) 1203] MEDQUIST36 D: [2151-5-14] 04:01 T: [2151-5-14] 18:24 JOB#: [Job Number 98287]	[ "431", "342.82", "427.1", "443.0", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							1666, 2162		5289, 5751		5132, 5266		1233, 1541	4195, 5111																																											2179, 3328						3343, 4177								1149, 1207	1558, 1649
81,449	138,178	36700	Discharge summary	report	Unit No: [Numeric Identifier 83001] Admission Date: [2155-7-25] Discharge Date: [2155-8-2] Date of Birth: [2072-2-18] Sex: F Service: At the time of admission the chief complaint was abdominal pain. The patient is an 83-year-old woman with 6 weeks of fatigue, malaise and intermittent abdominal pain. IMAGING: She was evaluated at an outside hospital where she underwent an ERCP with stone extraction, and subsequently laparoscopic cholecystectomy. Postoperatively she was then noted to be distended and hypotensive. She required 1 unit transfusion. Subsequent to that she continued to be febrile, and also developed a left hemiparesis and facial droop, at which time her family requested transfer to [Hospital1 18]. At the time of arrival here she was tachycardic but afebrile. Initially she spiked 101.1, and was complaining of abdominal pain. Her medical history included hypertension, high cholesterol, CVA, anemia, diabetes, PVD, and COPD. Other surgical history aside from lap chole which unclear, although the patient has a midline incision, she did not recall for what operation. At baseline she was living at a rehab facility, but had previously lived with her daughter. Examination on admission was significant for a soft but distended abdomen with diffuse tenderness to percussion with guarding. She had a white blood count of 8.6 but with left shift. The creatinine was 1.4, other electrolytes fairly normal with lactate of 2.1. She underwent an ultrasound of the right upper quadrant which demonstrated an 8 mm common bile duct, and also demonstrated complex collection in the gallbladder fossa. The subsequent CT scan showed the same fluid collection with rim enhancement, containing either gas levels or Surgicel, with a central calcified lesion, possibly stone. There was a slightly nodular contour of the liver. She also underwent HIDA CT which demonstrated a prior infarct in the paracentral region. The patient therefore was first evaluated with abdominal tenderness, a right lower lobe pneumonia, some hepatic fluid collection, pulmonary edema, apparent sepsis. In the emergency department the family was contact[Name (NI) ] to discuss the DNR, DNI, and the DNI was rescinded. She was subsequently intubated for respiratory distress, transferred to the ICU. Antibiotic were initiated. Neurology was involved. She underwent further evaluation with MRI which revealed a possible new embolic stroke. She was therefore begun on anticoagulation. That collection was drained, antibiotic coverage was maintained. Neurology continued to be involved. This was thought to be secondary either to atrial fibrillation or to aortic atheroma. Neurologic status failed to improve and she was unable to be weaned from the ventilator. Neural status failed to improve. The patient, having been intubated by the family's agreement, emergently stayed intubated but remains DNR. DICTATION ENDED [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Dictated By:[Last Name (NamePattern4) 79676] MEDQUIST36 D: [2156-1-19] 11:25:58 T: [2156-1-19] 13:44:51 Job#: [Job Number 83002]	[ "272.0", "496", "342.90", "507.0", "997.02", "427.31", "038.0", "995.91", "285.9", "250.00", "997.39", "351.8", "440.0", "443.9", "784.5", "E878.8", "401.9", "567.22", "998.59", "305.1", "434.11", "427.5" ]	icd9cm	[ [ [] ] ]	[ "54.91", "96.04", "88.72", "38.91", "99.04", "38.93", "93.90", "96.72", "33.24", "99.15" ]	icd9pcs	[ [ [] ] ]
7,299	155,098	2265	Discharge summary	report	Admission Date: [2170-11-13] Discharge Date: [2170-11-16] Date of Birth: [2132-4-17] Sex: F Service: MEDICINE Allergies: Allopurinol / Lisinopril Attending:[First Name3 (LF) 2167] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: Right Internal Jugular Central line History of Present Illness: In summary, this is a 38F PMH DM1, CKD (baseline creatinine 1.7), HTN presenting with nausea/vomiting x 1 week and diarrhea x 1 day. During this time she was unable to tolerate po's for last week. There were no associated fevers, chills, abdominal pain, melena, BRBPR, recent travel, uncooked foods, sick contacts, or recent antibiotic use. At outpatient renal clinic, her creatinine was found to be up to 3.7 on routine laboratories [2170-11-12] and patient advised to present to ED. . In the ED, laboratories were notable for FSG 464, hyponatremia, anion gap 14, creatinine 3.7, dirty urinalysis with trace ketones. VBG 7.26/36/60 with lactate 1.2, no serum/urine ketones were obtained. Patient given unasyn for urinary tract infection and 1L NS. She was started on insulin gtt and admitted to the MICU. A right IJ was placed for access. . In the MICU, she received an insulin gtt overnight with improvement in her fingersticks to 100-140s. Her serum ketones were negative and her gap was followed and remained stable at 10. She received further IVF with improvement in her creatinine and was switch to home NPH w/ insulin sliding scale once she tolerated po intake. She had no further episodes of nausea, vomiting, or diarrhea once she was in the MICU. There was concern for diabetic foot ulcers and she was switched to cipro/vanc. Podiatry was consulted and thought her foot ulcerations were [1-6] gout. Foot xrays were obtained, tissue swab was sent for culture/path for gout. Preliminary swab showing GPCs and GPRs at time of transfer. . On arrival to the floor, patient was noting significant improvement in her nausea/vomiting/malaise and was tolerating po with blood glucose <200. . Please see MICU course for further details. Past Medical History: 1) T1DM: Last A1C 9.7% 12/05, up from 6.6% 2/05. With retinopathy and nephropathy. s/p bilateral vitrectomy, R cataract removal, lens implant L eye. Takes NPH 36U [Hospital1 ], plus Humalog SSI. Followed at [Last Name (un) ]. 2) Migratory arthritis: Being worked up by rheumatology. [Doctor First Name ]+ at 1:160, dsDNA negative. +Family h/o lupus. Has chronically elevated ESR and CRP, no other rheum markers have been positive. Has elevated uric acid, rheum feels symptoms most c/w gouty arthropathy. Pt has been hesitant to start colchicine. Has been using percocet for joint sx's due to problems with NSAIDs with renal dysfunction. 3) Duodenitis - dx on EGD [12-10]. H. pylori seen on biopsy, s/p triple therapy. 4) Pulmonary HTN with elevated R side pressures seen on cardiac cath [2-7]: PA mean 51mmHg, RA mean 16mmHg, RVEDP 25 mmHg, PCW mean 26 mmHg, LVEDP 34 mmHg. HIV neg, rheum w/u as above. Does have OSA. 5) Restrictive lung disease on [3-10] PFTs: FEV1: 1.66 (65%), FVC 1.94 (60%), FEV1/FVC: 86 (109%) 6) Anemia: Unclear etiology, microcytic. Nl hemoglobin electropheresis. Pt has diagnosed gastritis. Possibly [1-6] chronic blood loss. Normal colonoscopy and small bowel follow through. 7) s/p lap chole 8) LBP 9) Chronic renal insufficiency: [1-6] diabetic nephropathy. Baseline Cr 1.3 (GFR 60 per MDRD) 10) h/o Acute liver failure [1-6] allopurinol toxicity 11) s/p TAH-BSO for uterine fibroids in [2161] Social History: Denies tob/EtOH/drug use. Lives at home with husband. Brother and sister both live in building. worked as computer programmer previously, but now on disability. Originally from West Indies and moved to the United States at age 9. No recent travel. Family History: DM, HTN in almost all family members Father with CHF Mother [Name (NI) 5895] disease, Lupus Physical Exam: Vitals: T: 98.2 BP: 156/73 P: 83 R: 20 O2: 98% on RA Fingerstick = 158 General: Alert, oriented, no acute distress, pleasant, morbidly obese Skin: + acanthosis nigricans HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP unable to evaluate [1-6] body habitus, no LAD Lungs: Clear to auscultation bilaterally, BS distant, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, unable to assess for HSM Ext: Warm, well perfused, diminshed pulses distally, b/l charcot feet w/ dressings inplace, did not assess ulcers at this time. Pertinent Results: [2170-11-12] 01:30PM WBC-6.9 RBC-5.11 HGB-11.7* HCT-36.1 MCV-71* MCH-22.8* MCHC-32.3 RDW-17.3* [2170-11-12] 01:30PM UREA N-98* CREAT-3.8# SODIUM-130 POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-21* ANION GAP-19 [2170-11-13] 03:45PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-[10-25] [2170-11-13] 03:45PM URINE BLOOD-SM NITRITE-POS PROTEIN-30 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2170-11-13] 03:45PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.010 [2170-11-12] 01:30PM ALT(SGPT)-19 AST(SGOT)-28 CK(CPK)-458* [2170-11-13] 07:11PM TYPE-[Last Name (un) ] PO2-60* PCO2-36 PH-7.26* TOTAL CO2-17* BASE XS--9 COMMENTS-GREENTOP [2170-11-13] 09:48PM GLUCOSE-194* UREA N-100* CREAT-3.2* SODIUM-134 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-18* ANION GAP-15 [2170-11-13] 09:48PM CK-MB-4 cTropnT-0.03* [2170-11-13] 09:48PM CK(CPK)-332* . [2170-11-16] 06:06AM BLOOD WBC-6.3 RBC-4.11* Hgb-9.2* Hct-29.7* MCV-72* MCH-22.3* MCHC-30.9* RDW-16.8* Plt Ct-301 [2170-11-15] 05:08AM BLOOD ESR-60* [2170-11-16] 06:06AM BLOOD Glucose-63* UreaN-29* Creat-1.5* Na-140 K-4.2 Cl-114* HCO3-20* AnGap-10 [2170-11-14] 03:13AM BLOOD CK(CPK)-306* [2170-11-13] 09:48PM BLOOD CK(CPK)-332* [2170-11-14] 03:13AM BLOOD CK-MB-4 cTropnT-0.03* [2170-11-16] 06:06AM BLOOD Phos-3.4 Mg-1.4* [2170-11-15] 05:08AM BLOOD CRP-11.8* . [2170-11-13] 3:45 pm URINE Site: CLEAN CATCH FINAL REPORT [2170-11-15] URINE CULTURE (Final [2170-11-15]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. . FECAL CULTURE (Final [2170-11-15]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2170-11-15]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2170-11-14]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2170-11-14]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [2171-11-13] Blood cultures x 2: Negative [2171-11-14] Urine culture: Negative . [2171-11-14] Wound culture: +MRSA [2171-11-14] Debridement results: DIAGNOSIS: Hallux, left, debridement: Necrotic tissue with suppurative inflammation, deposits of amorphous material, and bacteria. [2171-11-14] Bilateral x-rays of feet: RIGHT FOOT: There is a prominent amount of soft tissue swelling. This is best seen around the first MTP joint. No soft tissue gas is seen. There is no bony destruction. There is increased density and sclerosis of the midfoot, which is stable since the prior study. LEFT FOOT: There is a prominent amount of soft tissue swelling. There are extensive cystic changes with large spurs and increased density involving the midfoot consistent with neuropathic arthropathy. This is unchanged. There is no soft tissue gas. There are no signs of acute fractures. Brief Hospital Course: A/P: 38F PMH DM1, CKD (baseline Cr 1.7), presenting with acute on chronic renal failure and anion gap metabolic acidosis in the setting of nausea, vomiting, diarrhea, and UTI. . # Acute on chronic renal failure: Creatinine was elevated at 3.7 on admission from baseline 1.7. Likely pre-renal given history of response to fluids. Baseline kidney disease due to diabetes. Continued to trend down with IVF to 2.1 at time of transfer. Cr now 1.8. Pt was tolerating PO intake on day of discharge. Pt was continued on Calcitriol/Aranesp. . # ?diabetic ketoacidosis/DM: Pt had an anion gap in the setting of renal failure. There were trace ketones on urinalysis, and no serum ketones sent. Precipitant is likely hypovolemia versus infection. Gap is now resolved with rehydration and insulin gtt. Pt was continued on her home insulins sliding scale per [First Name9 (NamePattern2) 3782] [Last Name (un) ]. She will be following up with them as outpatient. She was treated for a UTI and possible foot infection. . # Metabolic acidosis: This is likely due to renal failure, with possible component of diabetic ketoacidosis unproven by laboratory values. This resolved with improved creatinine and blood glucose control. She was continued on IVF until tolerating POs, and resumed on her home insulin. . # Possible UTI: She has had E. coli with some resistance patterns and vancomycin-sensitive Enterococcus. Pt has been afebrile without leukocytosis. She was initially started on Ciprofloxacin and vancomycin pending culture sensitivities. Urine culture was eventually positive for E.Coli sensitive to Cipro. She will be completing the course of Cipro as outpatient. Blood cultures are negative x 2. . # Nausea, vomiting, diarrhea: Perhaps due to gastroenteritis versus urinary tract infection with component of uremia/DKA. Pt has been afebrile without leukocytosis. CEs neg x2 in the absence of chest pain or EKG changes. Nausea/diarrhea quickly resolved with IVF/glucose control. Stool cultures negative x1. Questioned if colchicine induced, given worsening renal failure. Pt has not had recurrent n/v/diarrhea. Pt was tolerating PO intake on day of discharge. . # Diabetic foot ulcers vs. gouty erosions: Followed by podiatry as an outpatient. Question pus vs. tophaceous material from left great toe. Recent bilateral foot x-rays [2170-11-5] show stable Charcot deformity. Swab now positive for MRSA. Repeated swab of white, tophi-like material expressed from L hallux, and this culture was negative. X-ray of feet bilaterally were negative for osteo. Rheum was consulted, as pt is normally seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] for migratory arthritis. He will be helping patient to find a better regimen for treatment of gout. Pt was also followed by Podiatry here, who debrided the wound. Pt will be following up with Podiatry and Rheum as outpatient. She will be completing a course of Bactrim for the MRSA wound infection. . # HTN: pt was continued on her home BB, ca-channel blocker. . # Anemia: Baseline 33-36, appeared to be hemoconcentrated on admission. Microcytic; etiologies include chronic kidney disease vs. chronic blood loss/iron deficiency in menstruating female. Normal iron studies from [9-12]. Pt was continued on her home iron supplementation. . # FEN: diabetic, regular diet, monitor and replete lytes prn . # ACCESS: right IJ placed in ED [11-13] . # Proph: Hep sc, bowel regimen . # CODE: FULL . # Dispo: to home with completion of antibiotics, [Month/Day (4) 3782] follow-up with Rheum and Podiatry. Medications on Admission: Iron Polysaccharides Complex 150 mg PO DAILY Metoprolol XL 50 mg PO DAILY Nortriptyline 10 mg PO HSA lbuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze Omeprazole 20 mg PO DAILY Aspirin 325 mg PO DAILY Calcitriol 0.25 mcg PO DAILY Simvastatin 80 mg PO DAILY Colchicine 0.6 mg PO EVERY OTHER DAY Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ] Verapamil SR 120 mg PO Q24H Insulin 75-25 50 units QAM, 32 units QHS Lasix 80 mg QAM Aranesp 100 mcg every other week Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Lopressor 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 11. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 12. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 13. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a day for 10 days. Disp:40 Tablet(s) Refills:0 14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: as directed units Subcutaneous twice a day: 50 units QAM and 32 units Qdinner. 15. Humalog 100 unit/mL Cartridge Sig: as directed units Subcutaneous four times a day: please follow home sliding scale. 16. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1) dose Injection every other week: Please continue to receive as directed at renal clinic. Discharge Disposition: Home Discharge Diagnosis: Mild Diabetic Ketoacidosis Acute on Chronic Renal Failure Urinary Tract Infection, complicated Gouty Arthritis Diabetic Foot Infection Insulin Dependent Diabetes Mellitus with complication Discharge Condition: Hemodynamically stable, tolerating po, with blood glucose well controlled on home insulin regimen. Discharge Instructions: You were treated in the hospital for elevated blood sugars, acute renal failure, nausea, vomiting, and a urinary tract infection. During your stay, you were also found to have severe gout causing open wounds on your feet and were treated for a wound infection and with special foot care by the podiatry team. Please complete the prescribed course of antibiotics for your urinary tract infection and the wound infection. Please apply the following dressings to your foot wounds: 2x2 soaked in betadine to wound, dry sterile dressing, kerlix wrap and ACE daily. You will be followed as an outpatient by the podiatry team for further wound care. Please call your doctor or return to the emergency department if you have any fevers >100.8, chest pain, shortness of breath, or any other concerning symptoms. . You were admitted for treatment of your high blood sugars. The high levels of sugar in your blood as well as dehydration and infection had contributed to your nausea, vomiting, and diarrhea. You were treated with insulin by IV initially in the ICU, and then transferred to the floor when you were doing better. Your sugars have been well controlled. You should follow-up with [Hospital ] [Hospital 11948] Clinic 1 month after discharge. . You were also found to have a UTI. You will be treated with a course of oral antibiotics. . You were also evaluated for an infected diabetic foot ulcer. You were seen by Podiatry here, and they debrided your R foot lcer as well as a gouty joint in your left foot. You were fitted for a boot, and will be following up with Podiatry next week for further foot care. Your wound is infected with MRSA, so you will be completing a course of antibiotics for that infection as well. . You were also seen by Dr. [Last Name (STitle) ], your rheumatologist, for your gout flare. He will be working with you to try a new gout medication to prevent future flares. . If you experience any fever, chill, increasing foot pain or drainage from your ulcers, worsening joint pain or gout flare, or lightheadedness, please call your PCP or go to the nearest ED. . Please continue taking your remaining medications as prescribed except: STOP Lasix Followup Instructions: You have the following appointments arranged for you: PODIATRY Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2170-11-26] 11:50 - They will follow up your final wound cultures . NEPHROLOGY Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 435] Date/Time:[2170-11-26] 9:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2540], RN Phone:[Telephone/Fax (1) 435] Date/Time:[2170-12-12] 8:00 . Your PCP, [Last Name (NamePattern4) ].[Name (NI) 11945] office will be contacting you regarding a follow-up appointment. If you do not hear from them in 1 week, call [Telephone/Fax (1) 250]. - She will review your Lasix medication dosing with you - She will follow up your pending blood cultures . Please follow-up in 1 month with [Hospital ] [Hospital 982] Clinic [Telephone/Fax (1) 2378]. . Please follow-up with Dr. [Last Name (STitle) ], your rheumatologist on [2170-11-21] at 2:00pm. ([Telephone/Fax (1) 1668] - He will be following up your gout Completed by:[2170-12-31]	[ "707.15", "250.43", "390", "041.10", "250.83", "V88.01", "285.9", "599.0", "274.0", "518.89", "041.04", "403.90", "V13.01", "250.13", "V58.67", "585.9", "276.52", "584.9", "716.90" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13664, 13670	7947, 11531	301, 339	13903, 14004	4709, 7924	16240, 17428	3881, 3978		12055, 13641		13691, 13882		11557, 12032			14028, 16217								3993, 4690																							248, 263									367, 2113															2135, 3599	3615, 3865
23,356	149,188	20127+57114	Discharge summary	report+addendum	Admission Date: [2166-12-9] Discharge Date: [2166-12-16] Date of Birth: [2148-10-30] Sex: M Service: Trauma ADMISSION DIAGNOSES: 1. Splenic laceration. 2. Closed head injury. 3. Pelvic fracture. 4. Renal contusion. 5. Pulmonary contusion. SECONDARY DIAGNOSIS: Attention-deficit disorder exacerbated by closed head injury. ADMISSION HISTORY AND PHYSICAL: This is an 18-year-old male who was a restrained driver in a high speed motor vehicle accident with driver compartment intrusion. [Location (un) 2611] coma score was 5 at the scene. He was intubated at that point, transferred via [Location (un) 7622] to [Hospital1 188]. There was no alcohol involved in the accident. PAST MEDICAL HISTORY: 1. Asthma. 2. Bronchial problems. MEDICATIONS: Prednisone taper. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature 98.4, heart rate 103, blood pressure 137/77, respirations 13, satting 100%. General: Intubated and sedated. HEENT shows no blood at the tympanic membranes. Pupils are equal, round, and reactive [1-25]. Chest was clear to auscultation bilaterally. The sternum is stable. The back shows no deformity. He is tachycardic, but regular, no murmurs, rubs, or gallops. Abdomen was soft, nontender, nondistended. Extremities show no gross deformities. Neurologic: [Location (un) 2611] coma score 3. Rectal: Heme negative, normal tone. ADMISSION LABORATORIES: Chemistry: 139/4.2/110/20/17/0.8/184. Blood gas: 7.25/44/302/20/-7. CBC: 18.6/31.9/214. Coags: 15.7/39.3/1.6. Lactate 1.7, calcium 1.1, fibrinogen 224, amylase 100. Serum tox is positive for benzodiazepines, negative for alcohol. Urinalysis is negative. RADIOLOGIC STUDIES: C spine and CT negative. Chest x-ray shows large left basilar contusion. Mediastinum is slightly shifted to the right. Pelvis: Bilateral rami fractures and SI joint diastasis on right fracture. Head CT shows diffuse axonal injury, intraparenchymal petechiae consistent with the above diagnosis. Chest CT shows left lung contusion, right apical pulmonary contusion. Abdominal and pelvic CT scans show grade 2 splenic lacerations with blood, left renal contusion. ......... is positive and CT abdomen shows splenic laceration and the question of bladder rupture. ASSESSMENT: A 16-year-old male status post motor vehicle crash. Plan is to the operating room, 2 units of packed red blood cells and FFP, central venous access. BRIEF HOSPITAL COURSE: Patient was taken to the operating room, where he underwent exploratory laparotomy, splenectomy. At that time, a retroperitoneal pelvic hematoma was observed and was observed to be a renal contusion on the right side. There was no bladder rupture. Please see operative note for details. Patient was transfused 2 units of packed red blood cells at that time. Patient tolerated the procedure well and was taken to the ICU postoperatively. Regarding patient's pelvic injury, Orthopedic consult was obtained, and films were reviewed. Patient had inlet/outlet views to assess for vertical stability. This was done after the patient was eventually weightbearing on the floor. The patient was determined to be vertically stable. He was also seen by Dr. [First Name (STitle) 1022], who will see him in followup and will see him in followup clinic in four weeks. Patient will be touchdown weightbearing on the right side, where the fracture is, and weightbearing as tolerated on the left for transfers only. Regarding patient's general medical care in the Intensive Care Unit, he remained hemodynamically stable. While he was in the unit, his hematocrit was approximately 30. On hospital day two, he remained intubated at that time. He was treated with Ancef perioperatively, and in addition, regarding patient's head injury, Neurosurgery consult was obtained, and they recommended mannitol x1, and close observation. Patient was initially not moving his right lower extremity which was concerning as the patient had a pelvic fracture which involved the sacral neural foramina. However, by day of discharge, he was moving his right lower extremity quite well, although he did have a slight foot drop and loss of everter and inverter muscle function. On hospital day three, the patient's hematocrit dropped from 30 to 27 to 24.6. Concerning an expanding pelvic hematoma. Patient's hematocrit eventually bumped not requiring him to undergo angiography of the pelvis. In order to further investigate the patient's right leg weakness, Neurology was consulted and they suggested that this is a possible upper motor neuron finding due to possible cord contusion. MRI of the spinal cord was obtained revealing no cord contusions. Followup head CT was obtained and that showed no significant evolution in patient's diffuse axonal injury. MRI was obtained verifying diffuse axonal injury. The head MRI showed no stroke. On hospital day five, the patient was finally weaned to CPAP at 5 and 5. His hematocrit remained stable. His pain was well controlled with Dilaudid as needed. SubQ Heparin has been used or was used throughout his hospital course for DVT prophylaxis. On hospital day five, a Dobbhoff was placed for feeding purposes. Patient was extubated and chest x-ray showed Dobbhoff in the stomach. Patient was then transferred to the floor stable. His neurologic examination improved dramatically over hospital days six, seven, and eight. His right lower extremity had regained strength. His attention and alertness improved gradually. Neurobehavioral consult was obtained prior to discharge. He will be following up with them. Neurosurgery recommended the patient can be started on Lovenox within one week of his injury which was started prior to his discharge. DISCHARGE DIAGNOSES: 1. Splenic laceration. 2. Closed head injury. 3. Pelvic fracture. 4. Renal contusion. 5. Pulmonary contusions. RECOMMENDED FOLLOWUP: Trauma Clinic in four weeks. Ortho Trauma Clinic in two weeks. Behavioral Neurology in four weeks. DISCHARGE MEDICATIONS: 1. Albuterol. 2. Bisacodyl. 3. Ambien for sleep. 4. Lovenox 30 mg twice a day. 5. Percocet as needed for pain. 6. Colace for constipation. DISPOSITION: He will be discharged to [Hospital1 ] Traumatic Brain [Hospital 50086] Rehab Unit. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520], M.D. [MD Number(1) 521] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2166-12-16] 10:44 T: [2166-12-16] 11:00 JOB#: [Job Number 54137] cc:[Hospital1 54138] Name: [Known lastname 10046], [Known firstname 2490] [Last Name (NamePattern1) ] Unit No: [Numeric Identifier 10047] Admission Date: [2166-12-9] Discharge Date: [2166-12-16] Date of Birth: [2148-10-30] Sex: M Service: ADDENDUM: On the day of discharge, the patient was given a meningococcal vaccine, hemophilus B vaccine, and pneumococcal vaccine. His staples were removed from his wound, and Steri-Strips were placed. CONDITION AT DISCHARGE: The patient was discharged in excellent condition. DISCHARGE DISPOSITION: The patient was discharged to [Hospital ] [Hospital 10048] Rehabilitation Unit. [First Name11 (Name Pattern1) 1080] [Last Name (NamePattern4) 3711], M.D. [MD Number(1) 3712] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2166-12-16] 12:47 T: [2166-12-16] 19:32 JOB#: [Job Number 10049]	[ "866.01", "E812.0", "808.43", "865.02", "873.0", "314.00", "851.42", "861.21", "952.9" ]	icd9cm	[ [ [] ] ]	[ "99.05", "54.11", "99.04", "99.07", "96.72", "86.59", "41.5", "38.93", "01.18", "96.6" ]	icd9pcs	[ [ [] ] ]	7198, 7567	2496, 5788						5809, 6046	6069, 7107																												158, 269	872, 2472	7122, 7174																				291, 721												743, 849
29,615	118,254	34359	Discharge summary	report	Admission Date: [2103-8-17] Discharge Date: [2103-8-19] Date of Birth: [2035-6-1] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 443] Chief Complaint: exertional angina, hypotension s/p elective cardiac catheterization Major Surgical or Invasive Procedure: left cardiac catheterization s/p placement of [First Name3 (LF) ] x2 right catheterization s/p left inferior epigastric balloon tamponade History of Present Illness: 68 year old female with multiple cardiac risk factors including DM, HTN, Hypercholesterolemia, and prior tobacco abuse, 3 vessel disease s/p multiple presenting s/p cath after re-stenting of proximal and distal circ with complication of a RP bleed. Patient presented to [Hospital1 18] for elective catheterization with 2 week history of exertional CP and negative stress test. Recent catheterization in [2103-5-25] showed new 80% mid lesion LCX and 60% stenosis distal RCA PDA stent, with balloon angioplasty and drug eluting stents in her mid LCX and distal PDA. She was recatheterized, and re-stented in her proximal and distal LCX. As completing the procedure, patient became hypotensive. She was given atropine and pressors and stabilized. However, she again became hypotensive, and dye investigation showed perforation of the inferior epigastric artery. She was given Dopamine and 4 units of blood. Balloon tamponade was performed to stop bleeding, and patient was stabilized, with no other signs of bleeding. On the floor pt was stable. Repeat CT was 35.3. Small amount of oozing was initially seen at sheath sites but this resolved w/pressure. Pt had non-contrast CT of abdomen to assess extent of bleed per attendings request. Pt's blood pressures rose on the floor as she had not had her regular BP meds and thus nitrodrip was added for greater control in the setting of possible rebleed. The patient was seen for multiple episodes of chest discomfort at cardiac rehabilitation on [2103-7-26]. She required a NTG after each machine. patient she states after any exertion like climbing a set of stairs, or making the bed she gets an ache/pressure that starts in her throat and will go to her chest. For the past two weeks her pain has been getting worse. This is accompanied by shortness of breath, she states if she keeps up the activity she will get lightheaded. The pain will last for a few minutes after resting. Patient states the pain has limited her life style. She denies orthopnea, PND, ankle edema, palpitations, syncope. All of the other review of systems were negative. Past Medical History: CAD s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] x 6 hypertension hyperlipidemia diabetes mellitus type 2 (diet controlled) hypothyroidism Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. The patient lives with her husband. She has 6 children from a prior marriage. She currently works part time in real estate. Family History: There is no family history of premature coronary artery disease or sudden death. Mother died of heart disease in her 60s. Father died of heart disease in his 70s. Physical Exam: Physical Exam on Admission: VS: T= afebrile BP=156/89 HR=66 RR=15 O2 sat= 96% GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, tender to light palpation. +BS EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites clean/dry/ intact PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . Physical Exam upon Discharge: . GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, tender to light palpation. +BS EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites clean/dry/ intact, bruising in left groin site PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Skin: Warm and dry, no lesions Pertinent Results: LABS UPON ADMISSION: . [2103-8-17] 01:00PM BLOOD WBC-5.6 RBC-2.92* Hgb-8.0# Hct-23.9 MCV-82 MCH-27.3 MCHC-33.4 RDW-14.7 Plt Ct-285 [2103-8-17] 01:00PM BLOOD Neuts-66.5 Lymphs-24.9 Monos-5.1 Eos-2.7 Baso-0.8 [2103-8-19] 07:00AM BLOOD PT-14.3* PTT-22.5 INR(PT)-1.2* [2103-8-17] 01:00PM BLOOD Glucose-134* UreaN-29* Creat-1.1 Na-139 K-5.1 Cl-110* HCO3-18* AnGap-16 [2103-8-17] 03:22PM BLOOD Calcium-7.8* Phos-5.7# Mg-1.5 [2103-8-18] 12:08PM BLOOD Cholest-202* [2103-8-18] 12:08PM BLOOD Triglyc-397* HDL-36 CHOL/HD-5.6 LDLcalc-87 LDLmeas-114 [2103-8-17] 02:08PM BLOOD Type-ART O2 Flow-4 pO2-201* pCO2-43 pH-7.25* calTCO2-20* Base XS--8 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2103-8-17] 07:36PM BLOOD Type-[Last Name (un) ] Temp-36.4 pO2-31* pCO2-50* pH-7.27* calTCO2-24 Base XS--5 [2103-8-17] 02:08PM BLOOD K-4.9 [2103-8-17] 07:36PM BLOOD Lactate-1.5 K-5.0 [2103-8-17] 02:08PM BLOOD Hgb-9.1* calcHCT-27 O2 Sat-98 . LABS UPON DISCHARGE: . [2103-8-19] 07:00AM BLOOD WBC-7.0 RBC-3.86* Hgb-11.3* Hct-32.6* MCV-84 MCH-29.4 MCHC-34.8 RDW-15.2 Plt Ct-211 [2103-8-19] 07:00AM BLOOD PT-14.3* PTT-22.5 INR(PT)-1.2* [2103-8-19] 07:00AM BLOOD Glucose-108* UreaN-29* Creat-1.4* Na-142 K-4.5 Cl-108 HCO3-27 AnGap-12 [2103-8-19] 07:00AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1 . CARDIAC CATHETERIZATION [2103-8-17]: . 1. Selective coronary angiography in this right dominant system demonstrated single vessel coronary artery disease. The LMCA was normal without significant stenosis. The LAD has insignificant plaquing with widely patent stents. The LCx has a severe 90% mid vessel stenosis with in stent restenosis and the second OM has a 70% stenosis. The RCA has insignificant plaquing. 2. Limited resting hemodynamics revealed elevated left sided filling pressures. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. . CT ABD/PELVIS: [2103-8-17]: Large retroperitoneal hematoma exerting mild mass effect on the bladder as described above, with a small area of hyperdense material which may reflect more acute bleeding. Serial hematocrit checks are encouraged. 2. Prominent portocaval lymph nodes, as above. 3. Probable small right adrenal adenoma, as above. 4. Probable gallbladder sludge. Brief Hospital Course: Madelyne [Known lastname 79054] is a 68 year old female with hypertension, hyperlipidemia, history of smokin, with known 3 vessel disease and history of multiple [Known lastname ], who presented for cardiac catheterization and re-stenting of the proximal and distal circumflex artery. Her procedure was complicated by a retroperitoneal bleed, prompting admission and monitoring in the CCU. . # Retroperitoneal bleed: Patient became hypotensive s/p elective catheterization, and was found to have a laceration of the left inferior epigastric artery. A stat Hct was approx. 24, and contrast study showed laceration and retroperitoneal bleeding. Venous access obtained on right and balloon tamponade was maintained to stop bleeding. ABG demonstrated pH 7.25, with normal CO2/o2 and decreased bicarb, and hct 24. The patient was placed on Dopamine to maintain her pressures, but was quickly weaned with hemostasis. Patient transfused 4U PRBC, post transfusion hct 35. The patient was transferred to the CCU for observation overnight. Blood pressures returned to sBP 150s, and she was started on nitro gtt. A non-contrast CT body was obtained which showed large RP bleed surrounding the rectum. Pain management with Percocet 5/325 PO PRN, with morphine PRN for breakthrough pain. . # CAD s/p [Known lastname ] in LAD and LCX: Ms. [Known lastname 79054] presents with longstanding CAD with multiple stents (app. 6). Patient underwent elective catheterization for 2 weeks exertional CP after negative stress test, which showed 70-80% re-stenosis of LXC [Known lastname ]. Two [Known lastname ] were placed at the distal and mid-portion LXC. Patient noted pre-procedural CP had resolved. She was continued on home ASA, Plavix, Atorvastatin. Her home metoprolol and Imdur were held post-procedurally, and restarted after observation overnight. . # Hypertension: The patient became acutely hypotensive s/p cath, related to bleeding. She was transfused 4 units. She was started on a dopamine drip briefly in lab but was quickly weaned off. After cath, she was hypertensive sBP 150s so a nitro drip was started for better control of BP in setting of possible re-bleed. The nitro drip was weaned and she was restarted on her home doses of metoprolol. She will restart her quinapril and isosorbide the day after discharge. She will need to follow up with her PCP [Name Initial (PRE) ]/or cardiologist for blood pressure monitoring. . # Diabetes: DM typically controlled at home with glipizide and diet. Insulin Sliding Scale started for acute managment in hospital. On discharge, patient was restarted on home medication of glipizide. # Hypothyroidism: Ms. [Known lastname 79054] has a history of hypothyroidism, treated with Synthroid. C/o fatigue for last several weeks, likely related to cardiac symptoms. However, patient should have TSH checked on outpatient basis to make sure Synthroid in therapeutic range. . The patient was full code for this admission. Medications on Admission: CLOPIDOGREL - 75 mg daily GEMFIBROZIL - 600 mg [Hospital1 ] GLIPIZIDE - 5 mg daily ISOSORBIDE MONONITRATE - 10 mg daily LEVOTHYROXINE - 75 mcg daily METOPROLOL TARTRATE - 25 mg [Hospital1 ] NITROGLYCERIN - 0.4 mg Sublingual PRN for chest pain QUINAPRIL - 20 mg daily SIMVASTATIN - 20 mg daily ASPIRIN - 325 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as directed as needed for chest pain: Take 1 pill for chest pain and wait 5 minutes. If chest pain continues, take a second pill and wait another 5 minutes. If chest pain continues, please wait another 5 minutes and take a third pill. 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Percocet 5-325 mg Tablet Sig: 0.5-1 Tablet PO every [5-8] hours for 5 doses. Disp:5 Tablet(s) Refills:0 11. Isosorbide Mononitrate 10 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Retroperitoneal bleed status post catheterization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 79054], You presented to the hospital for chest pain and underwent cardiac catheterization which showed blockages in the blood vessels supplying your heart, and you had stents placed to open the obstructions. The procedure was complicated by bleeding from a blood vessel into the space around your kidney, and a balloon was used to stop the bleed and a plug was placed to prevent further bleeding. You received blood transfusions to replace the blood loss. You were monitored in the cardiac intensive care unit, where you did not have any further bleeding. You were felt safe to go home. The following changes were made to your home medications: - Please continue taking your Plavix and Aspirin every day without missing a dose to ensure the stents in your heart do not become blocked. - Please INCREASE the dose of your Simvastatin to 40mg daily. Please let your doctor know if you have any problems with this new dose of the medication - You may use Oxycodone-Acetaminophen tablets (Percocet) -- half to one tablet AS Needed for pain, no more than one tablet every 6-8 hours as needed. Please do not drive after taking this medication. Please be sure to make your followup appointments with your cardiologist and primary care physician. Followup Instructions: Please follow up with your cardiologist within the next [12-2] weeks. You should also follow up with your primary care physician [Name Initial (PRE) 176] 2-4 weeks. Completed by:[2103-8-20]	[ "790.01", "401.9", "998.2", "E879.0", "414.01", "272.4", "458.29", "414.2", "998.11", "244.9" ]	icd9cm	[ [ [] ] ]	[ "37.23", "00.46", "39.98", "00.66", "00.40", "88.56", "36.07" ]	icd9pcs	[ [ [] ] ]	11285, 11291	6805, 9814	334, 477	11384, 11384	4501, 4508	12834, 13039	3098, 3262		10188, 11262		11312, 11363		9840, 10165		6364, 6782	11535, 12197								3277, 3291					12215, 12811																		227, 296						3902, 4482		5509, 6347	505, 2621							4522, 5493		11399, 11511						2643, 2832	2848, 3082
8,529	112,847	52857	Discharge summary	report	Admission Date: [2148-2-9] Discharge Date: [2148-2-11] Date of Birth: [2091-6-16] Sex: F Service: MEDICINE Allergies: Gold Salts Attending:[First Name3 (LF) 3513] Chief Complaint: palpitations Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: This is a 56 year old woman with history of peptic ulcer disease status post an upper endoscopy in [2141] and [2138](?), rheumatoid arthritis and hypertension who presented with palpitations on day of admission. Patient was concerned because she had palpitations with her prior episodes of GI bleeding. In the ED, she was found to have melena and her Hct was 25 down from her baseline of 31-33. NG lavage was negative and she was given IV fluids. Her heart rate decreased from 130's to 100's. GI was consulted and recommended transfusion 2U PRBCs, PPI and admission to the unit for close monitoring. . Patient denied nausea, vomitting, constipation, chest pain, shortness of breath, abdominal pain. Past Medical History: 1. rheumatoid arthritis 2. peptic ulder disease w/EGD in [2141] and [2138]? 3. hypertension Family History: NC Physical Exam: T97.8 HR 96 BP 108-122/68-72 O2Sat 100% RR 21 GEN pleasant, NAD, looking younger than actual age HEENT PERRL, mmm, OP clear, JVP 9cm CV RRR, nl s1 s2, no murmur/rubs/gallops LUNG CTA b/l at bases, no w/r/r ABD soft ntnd +bs no rebound/guarding EXT nonedematous, 2+ DP pulses, warm NEURO AOx3 nonfocal Pertinent Results: notable for hct drop from 31 (baseline) to 25 . Labs on admission: WBC-7.7 RBC-3.02* Hgb-9.0* Hct-26.5* MCV-88 MCH-29.7 MCHC-33.9 RDW-16.2* Plt Ct-363 . Neuts-84.6* Lymphs-13.1* Monos-1.7* Eos-0.3 Baso-0.3 . Glucose-121* UreaN-35* Creat-0.9 Na-143 K-4.7 Cl-104 HCO3-29 AnGap-15 . PT-12.3 PTT-23.9 INR(PT)-1.1 . Ret Aut-1.5 . URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG . . EGD [2-10]: Esophagus: Normal esophagus. Stomach: Mucosa: Erythema and congestion of the mucosa with no bleeding were noted in the antrum and pylorus. These findings are compatible with mild gastritis. Excavated Lesions A single cratered non-bleeding ulcer was found in the antrum. Cold forceps biopsies were performed for histology at the ulcer periphery. Duodenum: Normal duodenum. Impression: Erythema and congestion in the antrum and pylorus compatible with mild gastritis. Non-bleeding ulcer in the antrum. Clean-based, non-bleeding ulcer likely secondary to patient's ibuprofen use. Biopsy results: Mild hyperplasia of gastric pits . . EKG: Sinus tachycardia with supraventricular extrasystoles. Normal ECG, except for rate. Since the previous tracing of [2141-12-27] supraventricular extrasystoles are seen. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 130 70 298/360 67 -2 62 Brief Hospital Course: Briefly, this is a 56 year old woman with a history of PUD, RA and HTN who p/w melena and Hct drop. Patient status post upper endoscopy [2-10] which revealed gastritis and nonbleeding ulcer in antrum c/w NSAID use. Hct was stable and patient was subsequently transferred to the floor on [2-10]. . . #. Gastrointestinal bleed: Hematocrit drop and melena were suggestive of an upper gastrointestinal bleed or possible but less likely a lower gastrointestinal bleed. Patient received two units of packed red blood cells with a bump in her hematocrit from 25 to 27.7. GI was consulted and performed an upper endoscopy on [2-10] which showed mild gastritis and a nonbleeding ulcer in antrum which was the likely source of the GI bleed. Patient's Hct stabilized and she was transferred to the floor. Patient's diet was advanced as tolerated. She was continued on protonix PO QD and held all NSAIDs. Patient's Hct remained stable and she was discharged home with follow-up with a repeat upper endoscopy in [Hospital ] clinic in 8 weeks time. She will also need to have her biopsy results checked either when she follows up with her primary care physician or at [Hospital ] clinic. . . #. Rheumatoid arthritis: Continued prednisone and enbrel. Continued methotrexate at 10mg every Monday. Held all NSAIDs. . . #. Hypertension: Held outpatient hydrochlorothiazide per unstable blood volume. Resumed blood pressure medication when hematocrit was stable 24-36 hours. . . #. Prophylaxis: Continued Protonix PO daily per GI recs and pneumoboots . . #. FEN: Advanced diet as tolerated. . . #. Code: Full Medications on Admission: 1. prednisone 5 daily 2. methotrexate 10 mg q mon?? f/u with attg 3. leukovorin 4. enbrel 25 mg q mon + friday Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enbrel 25 mg Kit Sig: Twenty Five (25) mg Subcutaneous q monday and friday () as needed for rhuematoid arthritis. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Methotrexate 2.5 mg Tablet Sig: Four (4) Tablet PO QMON (every Monday). Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: upper GI bleed NSAID induced gastritis . secondary diagnosis: rheumatoid arthritis hypertension Discharge Condition: Hct stable Hct stable Discharge Instructions: Please take medications as prescribed. Do not take your blood pressure medication (hydrochlorothiazide) until you follow-up with Dr. [First Name (STitle) 3510] on Tues [2148-2-13]. . Please keep follow-up appointments. . If you have any palpitations, lightheadedness, black tarry or blood stools (guaiac positive), chest pain, abdominal pain or the emergency department. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 3510] on [2148-2-13] for a blood level and blood pressure check. Please call to confirm the time of the appointment. Phone: [Telephone/Fax (1) 3511] . Please call Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] office (Gastroenterology) and schedule a follow-up appointment 8 weeks from discharge date. Phone: [Telephone/Fax (1) 904] Completed by:[2148-6-14]	[ "535.41", "401.9", "531.40", "E935.9", "285.9", "714.0", "427.89", "790.01" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.16" ]	icd9pcs	[ [ [] ] ]	5302, 5308	2928, 4540	283, 300	5467, 5492	1516, 1569	5919, 6414	1176, 1180		4701, 5279		5329, 5329		4566, 4678			5516, 5896								1195, 1497																							231, 245									328, 1036			5410, 5446			5348, 5389	1583, 2905								1058, 1160
18,893	121,663	52152	Discharge summary	report	Admission Date: [2163-1-3] Discharge Date: [2163-1-9] Date of Birth: [2111-9-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 7539] Chief Complaint: SOB, lightheadedness, weakness, leg heaviness Major Surgical or Invasive Procedure: Placement of Right Interior Jugular central line Transesophageal Echocardiogram DC Cardioversion with conscious sedation History of Present Illness: Mr. [Known lastname ] is a 51yo M w/ PMH of HTN and afib dx one week ago who presented to his PCP today [Name Initial (PRE) ]/ SOB, leg heaviness, lightheadedness, weakness and fatigue. Found to be hypotensive (SBP in 60s) and bradycardic (HR 30s). EMS was called and transported him to the [Hospital1 18] ER. In the ER, he was given atropine x2, glucagon, calcium and 1.5L NS. EKGs showed bradycardia at rate of ~30, with no definite P waves, but a baseline suggestive of afib/flutter. No qwaves, no ST or T wave changes. He was still hypotensive so a R IJ was placed and he was started on a dopamine gtt at 15 mcg/hr. . Was diagnosed w/ afib about a week ago. Had a persistent chest cold for approx. 3 weeks, went to see his PCP who examined him and found him to be in rapid afib w/ HR of 170s by EKG. From his PCP's office, he was sent to the ER at [Hospital6 ]. He was admitted and was finally rate controlled in the ED (to HR of 96) after 35mg IV diltiazem and 60mg PO diltiazem. Was d/c on atenolol and diltiazem on [12-29] and represented to the ER on [12-31] via EMS because of SOB, lightheadedness, and 3 episodes of chest pressure at home. He was observed overnight, r/o MI by 3 sets of neg CE and had a stress test which was negative. He was then sent home on [1-1]. He decided at that point that perhaps his symptoms were due to his warfarin so he started taking 2mg QHS instead of 5mg QHS as instructed. He continued to take the atenolol and diltiazem as instructed. Today, he felt well when he woke up but began to have symptoms of lightheadedness, SOB, and leg heaviness about an hour after he took his medications. He went to his PCP's office, as he had a previously scheduled appointment, and she called EMS who brought him here. . ROS: denies CP, palpitations, headache, nausea, vomiting or any sort of pain associated w/ these episodes; no PND, orthopnea currently (though did complain of those a week ago); no f/c, no further symptoms of his chest cold (no cough, rhinorrhea or sore throat); no diarrhea, constipation or BRBPR, no urinary sx Past Medical History: Atrial fibrillation HTN Hypercholesterolemia Social History: Lives alone. Works as a caterer, but took last week and this week off [1-6] newly dx afib and generally not feeling well. No tob, occ EtOH (had been taking shots [Hospital1 ] to help w/ his cold), occ marijuana, no IVDU, no cocaine. Has two brothers, one of whom is his legal next of [Doctor First Name ] ([Doctor Last Name ] #[Telephone/Fax (1) 107905]). Family History: + CAD. M has a pacermaker, F had a CABG around age 60. Physical Exam: VS: T 96.5, BP 115/69 (on dopa gtt), HR 70s, RR 14, sats 98% on 2L Gen: WDWN, middle aged male, lying in bed, in NAD. Ruddy complexion. HEENT: Sclera anicteric. PERRL, EOMI. OP clear, no exudates or lesions. MM dry. Neck: R IJ line in, can not assess for JVD CV: RR, with some premature beats, normal S1, S2. No m/r/g. Lungs: few scattered insp crackles, but otherwise CTAB. Abd: Soft, NTND. + BS. No masses. Ext: Warm, well perfused. 2+ DP, radial pulses bilaterally. No c/c/e. Toes w/ onychomycosis. Skin: Warm, dry. Back is pink, blanching, but pt denies that it's pruritic. Does not extend to chest or abdomen. Neuro: CN II-XII grossly intact. Pertinent Results: Labs on admission: WBC 10.9, Hgb 17.0, Hct 47.5, MCV 88, Plt 360 (DIFF: Neuts-74.2* Lymphs-18.6 Monos-5.2 Eos-0.9 Baso-1.1) PT 13.6, PTT 25.0, INR(PT) 1.2 Na 138, K 5.8, Cl 102, HCO3 28, BUN 32, Cr 1.5, Glu 114 Ca 9.9, Ph 3.8, Mg 1.9 ALT 51, AST 34, AlkPhos 80, TBili 0.5 repeat: ALT 58, AST 31 TSH 1.7 . Cardiac enzymes: [2163-1-3] 11:55AM BLOOD CK(CPK)-52 cTropnT-<0.01 [2163-1-3] 05:45PM BLOOD CK(CPK)-49 CK-MB-NotDone cTropnT-<0.01 . Urinalysis: [2163-1-3] 09:40PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0-2 WBC-[2-6] Bacteri-FEW Yeast-NONE Epi-0-2 [2163-1-3] 09:40PM URINE Hours-RANDOM Creat-15 Na-98 . Labs on discharge: WBC 10.4, Hgb 14.5, Hct 39.4, MCV 84, Plt 244 PT 24.0, INR(PT) 2.4 Na 138, K 4.3, Cl 103, HCO3 25, BUN 21, Cr 1.2, Glu 102, Ca 9.2, Mg 1.9, Phos 4.3 . Imaging: [1-3] CXR - There are no prior studies available for comparison. There is a right internal jugular vein line, with its tip at the superior vena cava/right atrial junction. No pneumothorax is seen. The heart size is at the upper limits of normal for technique. The pulmonary vascularity is normal in appearance without redistribution. No pleural effusions are seen, though the extreme right costophrenic angle has been excluded from the study. There are no focal consolidations. . [2163-1-5] TEE - 1. The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is dilated. 2.The left ventricular cavity size is normal. The left ventricular function is hard to assess given that the ventricular rate is very rapid but there is probably moderate global left ventricular hypokinesis with an EF of 35-40%. 3. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. 6.There is no pericardial effusion. . IMPRESSION: No thrombus in the left or right atria. Moderate global left ventricular hypokinesis. Brief Hospital Course: 51yo M w/ hypotension and bradycardia, likely in setting of CCB and BB for his newly diagnosed afib. . # CV: * Rhythm: Mr. [Known lastname 107906] bradycardia was likely due to excessive nodal blockade from CCB and BB since he recovered his rate and BP off all nodal blocking agents. He then went back into rapid afib, with HR up to 160s despite the addition of BB. His BP remained stable so the decision was made to attempt cardioversion. TEE showed no clot and DCCV was attempted but he was only able to maintain NSR for ~30 sec. He continued to be in afib w/ RVR, with a rate as high as 160-170. Diltiazem 30mg PO QID was added, still with insufficient control of his rate. The diltiazem dose was then increased to 60mg TID on [1-6] due to persistent tachycardia with good effect on his rate. EP was consulted to help guide the management of his arrhythmia and they recommended discontinuing his diltiazem and instead attempting to control his rhythm (and rate) with amiodarone. He was started on 400mg PO TID x1 week, with the plan to decrease to [Hospital1 ] dosing x1 week then QD dosing. Once he had received an adequate amiodarone load, the plan was to attempt another DCCV as an outpatient. Mr. [Known lastname ] discussed this plan with Dr. [Last Name (STitle) 73] who also wanted him to wear [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor upon discharge. Mr. [Known lastname ] was instructed in the use of [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor and was told to send in rhythm strips to Dr. [Last Name (STitle) 73] daily, so his rate and his intervals could be monitored daily. Despite the initiation of amiodarone, Mr. [Known lastname ] also needed a beta-blocker to keep his rate under control. His beta-blocker was slowly increased up to 75mg PO QID and was then switched to Toprol XL 300mg PO QD prior to discharge. The Toprol XL and amiodarone allowed Mr. [Known lastname ] to achieve a resting heart rate of 90-100s. Coumadin was started on [1-4] with a goal INR of [1-7]. He was kept on a heparin gtt until his INR was therapeutic. He was discharged on 3mg of coumadin daily, and his INR on discharge was 2.4. . * Pump: Although Mr. [Known lastname ] had no evidence of heart failure by exam (lungs were CTAB and his JVP was flat), his OSH ECHO and TEE here showed a depressed EF. After receiving IVF in the ER, he had some swelling in his hands and feet which resolved on its own. He never required diuresis with lasix. . * Ischemia: Mr. [Known lastname ] has no evidence of ischemia. His CE enzymes were negative x2. EKG has no evidence of ST or T wave changes. . # ARF: Mr. [Known lastname ] was in mild ARF on admission, w/ Cr of 1.5 and K of 5.8. It resolved after receiving several liters of IVF in the ER. It was most likely prerenal +/- ATN from hypotension. His Cr was 1.2 on discharge (lowest value was 1.0 during his stay). . # FEN: He follwed a regular heart-healthy diet. No IVF were needed. His electrolytes were checked daily and were repleted prn to keep K >4 and Mg >2. . # ACCESS: He had a centrail line (R IJ) placed in the ER initially, but it was pulled after TEE/DCCV. He then had peripheral IVs for IV access. . # PPX: He was on heparin gtt as a bridge to coumadin until his INR was therapeutic. He had a bowel regimen. No PPI was indicated. . # CODE: FULL . # DISPO: To home, with [Doctor Last Name ] of Hearts monitor. Will follow up in Dr.[Name (NI) 107907] office for INR checks. . # COMMUNICATION: brother [Name (NI) ] = ph# [Telephone/Fax (1) 107905] Medications on Admission: Atenolol 50mg PO QD Diltiazem CD 240mg PO QD Warfarin 5mg PO QHS Discharge Medications: 1. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime. Disp:90 Tablet(s) Refills:2 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Please take 400mg (2 tablets) three times a day for 4 more days. Starting on [1-14], take 2 tablets (400mg) twice a day for one week. Starting [1-21], please take 2 tablets (400mg) once a day. . Disp:100 Tablet(s) Refills:2 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:90 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Symptomatic bradycardia and hypotension secondary to high dose atenolol and diltiazem therapy Acute renal failure . Secondary diagnoses: Atrial fibrillation Hypertension Hypercholesterolemia Discharge Condition: Good. HR 100s, BP 123/98, RR 20, sats 97% on RA. Discharge Instructions: 1. Please call your PCP or go to the nearest ER if if you develop symptoms of dizziness, lightheadedness, weakness, malaise, chest pain/pressure, shortness of breath, leg heaviness, nausea, vomiting or any other concerning symptoms. 2. Please take all your medications as prescribed. 3. Please send in a transmission from your [Doctor Last Name ] of Hearts monitor every day. 4. Please follow-up with your PCP [Last Name (NamePattern4) ] [12-6] weeks for follow-up from your hospitalization. Followup Instructions: 1. You will require blood work to be completed at Dr.[Name (NI) 107907] office in 2 to 3 days (no later than Wednesday) to ensure your INR is therapeutic with your current coumadin (warfarin) dosing. 2. You should follow-up with Dr. [First Name (STitle) ] in [12-6] weeks. Please call her office on Monday to make an appointment at your convenience. You should have hepatitis serologies drawn to insure that your elevated liver enzymes are not due to hepatitis infection. You should also have PFTs scheduled since you are starting on amiodarone. 3. Please contact Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73], phone ([Telephone/Fax (1) 1920], to schedule a follow up appointment in 4 weeks for further management of your atrial fibrillation. 4. Please send in a tracing to Dr. [Last Name (STitle) 73] every day from your [Doctor Last Name ] of Hearts monitor.	[ "584.9", "272.0", "E942.4", "E942.9", "427.31", "458.29", "401.9", "427.89" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.62", "88.72" ]	icd9pcs	[ [ [] ] ]	10565, 10571	6198, 9845	366, 489	10825, 10876	3828, 3833	11428, 12343	3087, 3143		9960, 10542		10592, 10592		9871, 9937			10900, 11405								3158, 3809			10748, 10804																	4153, 4584			281, 328				4603, 6175					517, 2609						10611, 10727	3847, 4136								2631, 2678	2694, 3071

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