Split (1)

train · 26.9k rows

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67,689	178,294	40251	Discharge summary	report	Admission Date: [2101-10-15] Discharge Date: [2101-11-4] Date of Birth: [2049-10-8] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: worst headache of life Major Surgical or Invasive Procedure: [2101-10-15] EVD placement [2101-10-15] Cerebral angiogram w/coiling [2101-10-25] peg placement [2101-11-2] VPS placement History of Present Illness: Patient is a 52 year old female who was in the bathroom when she developed the worst headache of her life and syncopized. She awoke briefly but then quickly decompensated. 911 was called and she was taken to an OSH where she was intubated for worsening neurologic exam and a CT of the head was obtained. the CT showed diffuse SAH consistent with a ruptured intracranial aneurysm. She was transferred to [Hospital1 18] for further care. She arrives intubated and sedated, BP prior to transport was reported at 220/120 and was lowered to 126/89 by the time [Location (un) ] broguht the patient to our ER. Per the [Location (un) ] crew she was trying to lift her head off the bed and shrug her shoulders when off sedation in the helicopter. She is unable to participate in a ROS secondary to intubation Past Medical History: Unknown Social History: Unknown Family History: Unknown Physical Exam: On Admission: PHYSICAL EXAM: Gen: Obese, intubated woman in distress. She is sedated HEENT: Pupils: fixed at 1mm bilaterally Neuro: Mental status: intubated and sedated Cranial Nerves: I: Not tested II: Pupils 1mm and nonreactive to light III-XII unable to assess Motor: extensor posture with BUE, TFR [Location (un) ] Toes upgoing bilaterally ON DISCHARGE: Lethargic, EO to voice, PERRL, oriented to self, month, and "hospital" (although through hospital stay she has been only oriented to self majority of the time). BUE is antigravity, but patient is very deconditioned and complains of baseline arthritic pain. [Name (NI) ] - pt can lift antigravity although it is difficult for her to do so, wiggles toes. Head Incision is C/D/I with staples, patient is very diaphoretic and requires daily dsg changes. Pertinent Results: CTA Head [2101-10-15]: FINDINGS: CT head demonstrates hemorrhage in the basal cisterns predominantly in the posterior fossa and suprasellar cistern. Blood is also seen in the fourth ventricle as well as in the lateral and the third ventricles. There is moderate hydrocephalus seen. There is exuberant calcification of the distal vertebral arteries. CT angiography of the head is limited due to insufficient and mistiming of the bolus. Faint visualization of the posterior circulation as well as the anterior circulation arteries is seen. This appears to be a focus of contrast in the suprasellar region adjacent to the basilar tip suspicious for an aneurysm but this could not be confirmed. IMPRESSION: 1. Basal cistern and intraventricular hemorrhage. Moderate hydrocephalus. 2. CT angiography limited due to delayed contrast bolus and poor opacification of the intracranial vascular structures. Subtle focus of hyperdensity in the suprasellar region adjacent to the basilar artery suspicious for an aneurysm. CT Head [2101-10-15]: IMPRESSION: 1. Status post basilar aneurysm clipping and new right frontal approach ventriculostomy catheter with tip in the atrium of right lateral ventricle. Decreased caliber of right lateral ventricle, persistent left lateral ventricular enlargement. 2. Mild redistribution of diffuse subarachnoid hemorrhage and intraventricular hemorrhage as detailed. CT HEad [10-21]: 1. Status post basilar aneurysm clipping with repositioning of right frontal approach ventriculostomy catheter. Mild increase of lateral ventricles is without evidence of hydrocephalus. 2. Interval redistribution of subarachnoid and intraventricular hemorrhage since [2101-10-15]. 3. No new hemorrhage or acute vascular territory infarction is noted. CTA Head [10-21]: IMPRESSION: 1. No siginificant change in the foci of SAH and IVH from recent CT. 2. Patent major arteries, where well seen. Limited assessment for the patency of the coiled Basilar tip aneurysm and adjacent P1 segments [Month/Year (2) ] US/Doppler [10-27]: IMPRESSION: No evidence of lower extremity DVT. Right-sided [Hospital Ward Name 4675] cyst MRI [10-28]: 1. No evidence of intracranial infection. 2. Subacute wedge-shaped left cerebellar infarct, as above. 3. Stable subarachnoid and intraventricular blood; stable ventricular size. CT Torso [10-30]: IMPRESSION: 1. No cause for the patient's fever identified. No evidence of pneumonia or abscess. 2. 13-mm splenic arterial aneurysm. 3. Fibroid uterus. 4. Prominent main pulmonary artery, suggestive of underlying pulmonary arterial hypertension CT Head [11-2]: IMPRESSION: 1. Interval placement of a ventriculoperitoneal shunt catheter with tip in the superior third ventricle. 2. Pneumocephalus, as above. CT Head [2101-11-4]: Stable appearance of ventricle size. VPS cath in place. Brief Hospital Course: 52F who was admitted with a SAH after a basilar tip aneurysm rupture. Upon admission an EVD was placed and she went emergently to angio for coiling. She was admitted to the ICU for close monitoring and Nimodipine was started. On [10-16] the angio sheath was removed and an angio seal was placed. She remained in the ICU and on [10-19] her EVD was clamped which patient only tolerated for a few hours before her ICPs climbed > 20 and sustained thus her EVD was re-opened. On [10-20] a clamping trial was again attempted without success given the increase in her ICPs and she has persistent fevers for which CSF fluid was sent for analysis. [10-21] patient was confused and not redirectable, concern for vasospasm lead her to have a CTA which was negative for vasospasm. [10-22] persistant fevers, pan cultred. Another clamping trail was attempted and was unsuccessful. CSF was sent for culture and lopressor was started for tachycardia. PEG was discussed for further nurtritional advancement. On [10-23] patient's SBP was liberalized and her keppra was discontinued. Exam remains the same with alert and oriented to self, moving all extremities. She has had multiple feeding trails with speech therapy and it was recommended that she have a peg placed. She underwent this procedure on [10-27]. On [10-28] we had to replace her EVD drain as it had fallen out and we were no longer able to get an accurate pressure [Location (un) 1131] or drain CSF. Serial imaging from [10-28] remained stable. Clamping trials were attempted time after time and failed. She underwent a VPS placement on [2101-11-2]. Post-op she was stable but had decreased urine output and received IV fluid boluses, she then became hypertensive and had some wheezing and received Lasix x2, UOP increased and patient remained stable. ID continued to follow patient. She remained afebrile. ID recommended antibiotics for 14 days post VPS placement. On [2101-11-4] she was discharged to rehab- [Hospital3 ] in [Hospital1 3597], NH Medications on Admission: Unknown Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Vancomycin 1000 mg IV Q 12H CSF infection 5. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 6. CefTAZidime 2 g IV Q8H 7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for rash. 8. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 11. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: started on [11-4]. 12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP>160. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 19. 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. 20. 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. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Basilar Tip Aneurysm SAH obstructive hydrocephalus dysphagia morbid obesity Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Angiogram with coiling: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in 4 weeks with Head CT w/o contrast. Please call [Telephone/Fax (1) 4296] to make this appointment. Staple removal 10 days post-op. [Month (only) 116] be discontinued at Rehab. Completed by:[2101-11-4*]	[ "331.4", "787.20", "V85.44", "285.9", "727.51", "278.01", "263.9", "780.60", "112.2", "780.62", "430" ]	icd9cm	[ [ [] ] ]	[ "96.6", "43.11", "02.34", "88.41", "02.39", "96.71", "02.2", "38.97", "38.91", "39.72" ]	icd9pcs	[ [ [] ] ]	9205, 9252	5159, 7219	331, 471	9372, 9372	2254, 5136	11484, 11784	1389, 1398		7277, 9182		9273, 9351		7245, 7254			9549, 10542	10568, 11461							1442, 1545																	1779, 2235								268, 293										499, 1317	1599, 1765						1427, 1427	9387, 9525							1339, 1348	1364, 1373
22,604	116,134	839	Discharge summary	report	Admission Date: [2200-12-28] Discharge Date: [2200-12-31] Date of Birth: [2129-6-25] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 5850] is a 71-year-old male with an extensive cardiac history. His last cardiac catheterization was [7-25] during which he had a stent to his D1 and presented with unstable angina. Patient describes stable angina as substernal chest pain with walking "one city block". He states his chest pain was relieved with rest. Today the patient describes sudden onset of substernal chest pain at rest while having a bowel movement around 2 pm. Per patient report and wife, had an ETT at Dr.[Name (NI) 5765] office on Friday that was within normal limits. Today, his chest pain was [8-2] consistent with previous angina associated with nausea, dry heaves, positive shortness of breath, and perfuse diaphoresis. The patient called EMS, his wife was not home. His blood pressure at the time was 168/92 with a pulse of 90. Patient had missed his am medications. The patient was given aspirin, sublingual nitroglycerin, albuterol, and his chest pain decreased to [3-2]. At the outside hospital Emergency Department, the patient was started on Plavix, Integrilin, and Heparin, intravenous nitroglycerin, morphine sulfate, and Lopressor. His electrocardiogram showed anterior ST elevations, and he was taken to the catheterization laboratory. At the catheterization laboratory, he was shown to have a complex bifurcation stenosis at the left anterior descending artery/D1. Balloon angioplasty was performed to the D1 and left anterior descending artery with residual 30% stenosis in each. Patient was chest pain free status post procedure. He was then transferred to [Hospital1 69] for further management. At [Hospital1 69], the patient was asymptomatic with no chest pain, no shortness of breath, and his vital signs were stable. PAST MEDICAL HISTORY: 1. CABG in [2181], LIMA to the left circumflex, saphenous vein graft to the PDA. Cardiac catheterization [2200-4-23] performed for dyspnea on exertion, patent LIMA to the left circumflex, patent saphenous vein graft to the PDA, 80% stenosis of the proximal left anterior descending artery. The patient had balloon angioplasty, but no stenting of this lesion as the stent could not be passed. Cardiac catheterization on [2200-8-10] performed for continued dyspnea on exertion. The patient had PCI of the left main into the diagonal with atherectomy and stenting of a long segment of disease from the distal left main to a major high first diagonal branch and proximal left anterior descending artery. The previously treated mid left anterior descending artery on [4-24] was widely patent. The patient had PTCA of ostial left anterior descending artery, pulmonary capillary wedge pressure was 7. 2. Diabetes x20 years, diet controlled. No hemoglobin A1C on CCC records. 3. Left kidney atrophy since childhood, question infectious versus congenital anomaly. 4. Hypertension. 5. Chronic renal insufficiency. 6. Chronic vascular diabetic nephropathy with a baseline creatinine of 1.2-1.5. 7. High cholesterol. 8. Carotid stenosis. 9. Barrett's esophagus with esophageal strictures. 10. Gout. 11. Mild aortic insufficiency. 12. High homocysteine levels. 13. Osteoarthritis. MEDICATIONS ON ADMISSION: 1. Lipitor 10 q am, 40 q pm. 2. Atenolol 125 q day. 3. Aspirin 325 q day held for recent EGD x2 weeks. 4. Plavix 75 q day. 5. Allopurinol 100 q day. 6. Imdur 60 q day. 7. Folic acid 3 [Hospital1 ]. 8. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mEq q day. 9. Lasix 20 q day. 10. Norvasc 10 q day. 11. Prevacid 30 q day. 12. Lotensin 10 q day. 13. Vitamin E. 14. Vitamin B1, B6, and B12. 15. Vioxx. SOCIAL HISTORY: The patient is a retired construction worker. He drinks two gin and tonics or vodka tonics each night. No history of DT's or withdrawal seizures per patient and per wife. [Name (NI) ] tobacco history. Lives with wife. She is a nurse. REVIEW OF SYSTEMS: Two-pillow orthopnea, negative PND, negative change in baseline lower extremity edema, no fevers, chills, upper respiratory symptoms, no diarrhea, no abdominal pain. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 150-170/60-80, heart rate 80-90, normal systolic, respiratory rate 19-22, sat 99% on 2 liters nasal cannula. Weight is 94.5 kg. In general, alert and oriented times three, anxious in appearance, chest pain free. HEENT: Pupils constricted, equal bilaterally, status post bilateral cataract surgery. Extraocular muscles are intact. Heart regular, rate, and rhythm, S1, S2, [1-29] soft systolic murmur at the left upper sternal border. Lungs are clear anteriorly. Anterior chest wall with rib tenderness to palpation. Abdomen is benign. Extremities: 2+ pitting edema bilaterally, per patient is baseline. Distal pulses not palpable, DP and PT pulses dopplerable bilaterally. Groin hematoma: Right groin status post catheterization, indurated, nontender, 4 x 4 cm hematoma. Neurologic is alert and oriented times three. DATA ON ADMISSION: Hematocrit 39.4, white count 11.3, platelet count 201. Chemistries: 138, 4, 103, 23, 16, and 1.3. Of note, creatinine was 1.6 at outside hospital. Glucose 145. PT 12.9, PTT 44.2, INR 1.1. Calcium 8.2, magnesium 1.0, phosphorus 2.7, albumin 4.3. Cardiac enzymes: CK 189 at outside hospital. At [Hospital1 188], 2,149, MB of 3.1 at outside hospital to 169 at [Hospital1 1444]. Troponin went from 0.03 at the outside hospital to greater than 50 at [Hospital1 346]. Of note, the outside hospital laboratories were at 4 pm and the [Hospital1 190] laboratories were at 8 pm. ELECTROCARDIOGRAMS: When performed by the EMT, the electrocardiogram showed sinus rhythm with a right bundle branch, left axis deviation, [Street Address(2) 1766] elevations in the anterior leads and 2-[Street Address(2) 2051] elevation in the inferior and lateral leads at the outside hospital, normal sinus rate at 72 with a right bundle branch block, ST elevations V1 and V2 with [Street Address(2) 1766] elevations in II, III, and aVF, V4 through V6 and aVL with [Street Address(2) 1766] depressions. At [Hospital1 190], sinus with a normal axis and normal intervals, no bundle branch block, 1-[Street Address(2) 1766] depressions in the lateral leads, [Street Address(2) 4793] depressions in the inferior leads and borderline left ventricular hypertrophy. ASSESSMENT AND PLAN: This is a 71-year-old male with recurrent myocardial infarction secondary to stenosis, plaque of the left anterior descending artery territory. The patient is status post angioplasty to the left anterior descending artery and D1. Electrocardiogram changes resolving. The patient is chest pain free. The patient is transferred to the [Hospital1 69] CCU for closer monitoring, groin hematoma status post catheterization, history of bleeding. 1. From a cardiac standpoint, the patient was continued on Integrilin for 18 hours, aspirin, and Plavix. Heparin was held secondary to the groin hematoma. The patient was given initially metoprolol 5 mg IV x3 for a heart rate normal sinus in the 90s. He was then given 75 mg po Lopressor. He was started on Captopril 12.5 tid and a nitroglycerin drip to keep his blood pressure between 110-120 systolic and to decrease preload and therefore cardiac stress. His CKs were continued to be cycled. Daily electrocardiograms were checked, and he was continued on his statin. From a pump standpoint, the patient had an echocardiogram on the 6th that showed decreased ejection fraction of 35-40%. Of note, the patient's last ejection fraction was 50% on [2200-4-24] with this echocardiogram showing severe hypokinesis of the left ventricle, anterior wall, and septum. From the rhythm standpoint, patient was continued on Telemetry with normal sinus rhythm. He was placed on Lopressor [Hospital1 ]. On Telemetry, he was noted to have NSVT, highest 4. EP was consulted as this patient has a known low ejection fraction and myocardial scarring along with NSVT. The EP consult, they performed a signal average electrocardiogram which was positive by [1-26] criteria with a QRS of greater than 114 and a LAF of greater than 38. It was decided that the patient should follow up after discharge on the 29th at 1:10 pm to have more formal EP studies. 2. Renal: History of chronic renal insufficiency with baseline creatinine of 1.2-1.6. The patient was given postcatheterization hydration at 75 cc of normal saline per hour. He was also treated with Mucomyst 600 po x2 and his magnesium was repleted for a magnesium of 1.0, he received 4 grams of magnesium sulfate x1. His magnesium corrected to 1.5 on [2200-12-30]. 3. Neurologic: The patient was noted to be agitated on evenings and required Ativan prn and a few doses of 1 mg of Haldol for agitation. He however, had no episodes of DT's or withdrawal seizures. He was placed on a CWA scale, but never had a CWA level of greater than 10. The patient was discharged to home on [2200-12-31]. He had no further episodes of chest pain or shortness of breath. He had worked with Physical Therapy and ambulated well without decrease in sats and was able to walk stairs without significant elevation in blood pressure or heart rate. DISCHARGE MEDICATIONS: 1. Imdur 60 q day. 2. Metoprolol 100 qid. 3. Captopril 12.5 tid. 4. Folic acid 3 mg [Hospital1 ]. 5. Plavix 75 q day. 6. Atorvastatin 50 q day. 7. Allopurinol 100 q day. 8. Aspirin 325 q day. 9. Protonix 40 q day. 10. Multivitamin. 11. Thiamine. 12. Vitamin E. [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern1) 1731], M.D. [MD Number(1) 1732] Dictated By:[Last Name (NamePattern1) 5851] MEDQUIST36 D: [2201-1-25] 19:12 T: [2201-1-27] 07:41 JOB#: [Job Number 5852]	[ "427.1", "410.91", "530.81", "401.9", "250.00", "414.00", "V45.81", "424.1", "303.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]									9457, 10004				3380, 3815																															4096, 4284	5436, 9434														163, 1941							5168, 5419								1963, 3354	3832, 4076
23,743	135,945	3654	Discharge summary	report	Admission Date: [2108-12-25] Discharge Date: [2108-12-31] Date of Birth: [2050-2-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8684] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: NG lavage [12-25] History of Present Illness: 58y/o M with CAD, hyperlipidemia, ETOH abuse, DM2, CRI, who started binge drinking since the beginning of [Month (only) 404], going to a bar and having [4-20] drinks per night. Despite drinking, patient was feeling well until last friday [12-21] when he began having midepigastric abdominal pain, which did not radiate. Pain was [3-25] in severity and would come and go. Pain was not related to food or drinking. On Sunday [12-23], 3 days PTA, patient began having BRBPR, 1 episode/day. No melena. No diarrhea, stool was formed and coated with red [Last Name (LF) ], [First Name3 (LF) ] [First Name3 (LF) ] draining into bowel. On Sunday patient also began vomiting after any PO intake. Pt began having decreased appetite and PO intake. No [First Name3 (LF) ] noted in emesis. On day of admission, patient also noticed tremoring in his hands. Otherwise, patient denies any mental status changes. No chest pains, SOB. No fevers/chills, wt changes or other systemic symptoms. . Here he was started on cipro/flagyl, given 3L of NS, given 35mg of valium, lopressor 25mg x 1. NGL showed coffee ground emesis. Past Medical History: 1. CAD s/p 95% RCA lesion with stent. EF >60% all done in [2-17] 2. Psoriasis 3. HTN x 20 years 4. DM2 x 5 years 5. Hyperlipidemia 6. Etoh Abuse: h/o DT and GIB/gastritis 7. CRI (b/l 1.4) 8. GERD with Barretts esophagus 9. hyperplastic polyps in the descending colon, sigmoid colon and rectum, polypectomy in [8-18] Social History: lives with in-laws, works at [Hospital1 ], no tobacco, has had DT's and blackouts in past. Family History: Mother with DM, died from MI age 68, father with PD Physical Exam: vitals: Tm 98.9 Tc 97.5 P 80-104 BP 120-140/60-70 Sat 94-96%RA In: IV 2300 PO 150 Out: 1060 UOP stool 100 . GEN: overweight, NAD, ruddy complexion, breathing comfortably, not anxious SKIN: diffuse psoriatic plaques on BL LE and lower abdomen HEENT: MMM, sclerae injected, no nystagmus, PERRL, EOMI NECK: obese, difficult to appreciate JVP, no LAD Lungs: CTAB CV: RRR, nl S1/S2, no m/r/g AB: protuberant, +BS, NTND, difficult to assess HSM given body habitus but liver not enlarged by percussion EXTREM: good distal pulses, wwp, no c/c/e NEURO: a and ox 3, CNII-XII grossly intact, strength 5/5 x4, mild fine tremor in BL hands, difficulty performing [Doctor First Name ] particularly with R hand, HTS intact, no pronator drift Pertinent Results: [2108-12-25] 10:47PM GLUCOSE-157* UREA N-16 CREAT-1.4* SODIUM-142 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-13* ANION GAP-32* [2108-12-25] 10:47PM CALCIUM-8.0* PHOSPHATE-1.4# MAGNESIUM-1.3 [2108-12-25] 10:47PM WBC-6.6 RBC-3.08* HGB-11.5* HCT-31.2* MCV-101* MCH-37.3* MCHC-36.8* RDW-15.2 [2108-12-25] 10:47PM PLT COUNT-71* [2108-12-25] 08:48PM LACTATE-2.1* [2108-12-25] 08:48PM O2 SAT-97 [2108-12-25] 08:48PM freeCa-1.12 [2108-12-25] 03:03PM HGB-11.9* calcHCT-36 [2108-12-25] 02:50PM GLUCOSE-145* UREA N-17 CREAT-1.4* SODIUM-141 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-12* ANION GAP-32* [2108-12-25] 02:50PM IRON-129 [2108-12-25] 02:50PM OSMOLAL-328* [2108-12-25] 02:50PM URINE HOURS-RANDOM [2108-12-25] 02:50PM URINE HOURS-RANDOM [2108-12-25] 02:50PM URINE UHOLD-HOLD [2108-12-25] 02:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2108-12-25] 02:50PM HGB-11.2* HCT-31.5* [2108-12-25] 12:20PM TYPE-ART TEMP-37.3 PO2-118* PCO2-21* PH-7.23* TOTAL CO2-9* BASE XS--16 [2108-12-25] 12:20PM LACTATE-7.2* [2108-12-25] 12:05PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2108-12-25] 11:00AM ACETONE-LARGE OSMOLAL-359* [2108-12-25] 11:00AM [Year/Month/Day ]-NEG ETHANOL-184* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2108-12-25] 11:00AM CK-MB-NotDone [2108-12-25] 11:00AM LIPASE-47 [2108-12-25] 11:00AM ALT(SGPT)-112* AST(SGOT)-109* CK(CPK)-58 ALK PHOS-74 AMYLASE-61 TOT BILI-1.4 [2108-12-25] 11:00AM ALT(SGPT)-112* AST(SGOT)-109* CK(CPK)-58 ALK PHOS-74 AMYLASE-61 TOT BILI-1.4 . [2108-12-29] Stool Culture: C. Dif negative, fecal culture and campylobacter culture pending upon discharge. Brief Hospital Course: 57y/o M with ETOH abuse, DM2, CAD, hypercholesterolemia, CRI, HTN, psoriais who presented with a 3 d h/o hematochezia, n/v, decreased po intake, withdrawing from ETOH. . In the MICU, pt was found to have ETOH withdrawl, possible GI bleed, elevated lactate, and alcoholic ketoacidosis. Pt was seen by GI and felt to have likely [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears and esophagitis given his cofee grounds on NGL. GI also felt his BRBPR was from hemorrhoids or diverticulosis or polyps (given h/o polyps on [2105] colonoscopy). Pt seen by toxicology and placed on Valium 10 mg q6hr for 4 doses and then 5 mg q6hr for 8 days. . Upon transfer from the MICU: . # BRBPR: No gross [Year (4 digits) ] noted on stools, all guaiac negative since admission, hct stable with no more abdominal pain. While in the MICU the pt had q6-8 hr hct checks. Upon transfer to the floor, the pts hct was checked daily given he had no further evidence of bleeding. The most likely etiology of lower GI bleed was felt to be hemorrhoids (ddx of diverticuli vs avm vs hemorrhoid). Stool Culture was sent on [2108-12-29], C. Dif was negative and fecal and campylobacter culture were pending upon discharge. GI did not feel there was need for emergent scope. They recommended EGD and sig or colonoscopy once pt is discharged. Pts outpt PCP will arrange this. . #Coffee Grounds: Found on NGL. Per GI, likely [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] vs esophagitis vs gastritis. EGDs [9-18] have shown erythema in the antrum consistent with gastritis. The pt was continued on Pantoprazole 40 mg PO BID. . # ETOH withdrawal: The pt was placed on Valium standing 10mg q6 for 4 doses then 5mg q6. He was also given Valium 5 mg PO Q6H:PRN CIWA >10. He was given daily Thiamine, folate, multivitamin. He was hydrated while in the MICU, but once transferred to the floor he was eating well and no longer required fluids. While on the floor, the pt only required 1 dose of Valium for CIWA of 12. On the day of discharge, all valium was discontinued and the pt was monitored for 8 hrs prior to discharge. . # Tachycardia: Pts HR was up to 137 on admission; on transfer to the floor it was 80s-100s. Was likey [1-17] dehydration/etoh/med non compliance/ withdrawing. Pt became less tachycardic after hydration and his metoprolol was restarted (and increased from 25 to 50 mg [Hospital1 ]). Metoprolol was finally titrated up to 75 mg po tid. . # Metabolic acidosis: Gap resolved from 27 on admission to closing by [12-28]. Gap and non gap components: Per GI, gap acidosis was likely secondary to ketones from starvation ketoacidosis,and lactic acidosis, etoh, n/v. Source of lactate unclear. Markedly improved and in normal range after hydration . # HTN: Initially the pts metoprolol was held given concern for hemodynamic stability. This was ultimately restarted and increased to 75 mg po tid. . # DM2: FSQID, RISS, [Last Name (un) ] diet. DM poorly controlled with A1c of 11.8. Will need f/u as outpt regarding need for oral hypoglycemics. . # Acute on chronic renal failure: IVF hydration improved Cr from 1.7 to 1.1. BL Cr 1.4-1.6. Cr increased to 1.7 on day of discharge. Pt was hydrated with 500cc NS and Cr improved to 1.6. . # CAD: s/p 3 stents in [2-17]. EF: >60%, mild symmetric LVH. The pt was continued on lipitor 10 mg [Last Name (LF) ], [First Name3 (LF) ] 81mg QD, plavix 75mg QD. . # TI: wall thickening shown on CT abdomen but no fever, no wbc, no abd pain, no diarrhea, exam belly exam unremarkable. The pt was started on cipro/flagyl while in the MICU given his hematochezia, however the antibiotics were discontinued on [12-28] upon transfer to the floor. . # Thrombocytopenia: likely [1-17] early cirrhosis and dilution, mild portal htn-->splenomegaly & sequestration. Baseline plt 100s. . #Anemia: Hct at 31.5, BL Hct 40, when pt admitted hct was 38, lowest was 27. Pt did not require on transfusions and his hct was stable at 30 at the time of discharge. . # Transaminitis: likely [1-17] etoh. Have decreased from admission ALT 112, and AST 109 to now ALT 49 and AST 38. Markedly improved to normal. Medications on Admission: 1. Protonix 40mg [Hospital1 ] 2. Gabapentin 300mg [Hospital1 ] 3. MVI 4. Thiamine 100mg QD 5. FOlate 1mg QD 6. Metoprolol 50mg tid 7. [Hospital1 ] 81mg QD 8. Plavix 75mg QD 9. Lipitor 10mg [Hospital1 ] 10. Hydrocotisone cream 1% for psoriasis Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:135 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawl hematochezia coffee ground gastric content Discharge Condition: stable, hemodynamically stable, hematocrit stable Discharge Instructions: 1) Please take all medications as prescribed 2) Please call your doctor or return to the ER for bloody emesis, bloody stool, feeling faint, dizziness, chest pain, shortness of breath, or any other concerning symptoms 3) Please follow up with the [Hospital3 8063] outpatient program Followup Instructions: 1) Please call to make an appointment for follow up with Dr. [Last Name (STitle) ] for within 1 week after discharge ([Telephone/Fax (1) 608]) 2) Please call the number given to you by case management for the [Hospital3 8063] outpatient program	[ "276.2", "V45.82", "285.9", "291.81", "276.51", "401.9", "250.00", "584.9", "585.9", "578.9", "414.01", "303.91", "287.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10072, 10078	4654, 8873	323, 346	10183, 10235	2827, 4631	10569, 10829	2005, 2058		9183, 10049		10099, 10162		8899, 9160			10259, 10546								2073, 2808																									278, 285										374, 1528															1550, 1876	1892, 1989
62,950	178,428	36436+58079+58080	Discharge summary	report+addendum+addendum	Admission Date: [2101-6-2] Discharge Date: [2101-6-8] Date of Birth: [2044-11-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion/ Paroxysmal nocturnal dyspnea Major Surgical or Invasive Procedure: coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery)-[2101-6-2] History of Present Illness: 56 year old female with known coronary artery disease, status post stenting, cardiomyopathy, and two recent CHF admissions ([Month (only) ]/[March 2101])reports progressive dyspnea on exertion and Paroxysmal Nocturnal Dyspnea referred for cardiac catheterization for further evaluation.Cath report revealed multivessel coronary disease. Dr.[Last Name (STitle) 914] was consulted for Coronary revascularization. Past Medical History: CAD s/p MI and LAD stenting in [2092] with repeat stenting for ISR PVD LE claudication s/p left leg angioplasty for an ischemic leg per patient report ?[2096] Cardiomyopathy Chronic systolic heart failure s/p admissions [Month (only) ] and [2101-3-20] Diabetes mellitus Hypertension per records from outside MD (patient reports this to be inaccurate) Hyperlipidemia Past Surgical History= [2069] Cholecystectomy s/p abdominal aortic aneurysm repair at the [Hospital 882] hospital approximately 15 years ago (per patient report) Social History: Lives with:HUSBAND & DAUGHTER [Name (NI) ]:CAUCASIAN Tobacco:QUIT 1MONTH AGo: 2PPD X40 YRS ETOH:NONE Family History: Family History: (parents/children/siblings CAD < 55 y/o):FATHER S/P MI AND DIED AGE 55 Physical Exam: Physical Exam Pulse:64 Resp:18 O2 sat: 99%RA B/P Right: 161/63 Left:168/61 Height:5'4" Weight:150 lbs General:Alert & oriented Skin: Dry [] intact [X] HEENT: PERRLA [X] EOMI [X], No dentures Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] No Murmur, gallops or rubs. 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:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:NO Left:NO Pertinent Results: [2101-6-7] 06:15AM BLOOD WBC-10.9 RBC-3.90* Hgb-11.3* Hct-34.6* MCV-89 MCH-28.9 MCHC-32.5 RDW-15.4 Plt Ct-290 [2101-6-2] 12:45PM BLOOD WBC-15.3# RBC-2.40# Hgb-7.1# Hct-20.5# MCV-85 MCH-29.4 MCHC-34.4 RDW-15.6* Plt Ct-310 [2101-6-5] 01:09AM BLOOD PT-13.8* PTT-29.5 INR(PT)-1.2* [2101-6-2] 12:45PM BLOOD PT-14.7* PTT-34.3 INR(PT)-1.3* [2101-6-7] 06:15AM BLOOD Glucose-78 UreaN-43* Creat-1.7* Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 [2101-6-3] 03:29AM BLOOD Glucose-77 UreaN-19 Creat-1.3* Na-140 K-4.2 Cl-112* HCO3-20* AnGap-12 [2101-6-4] 04:56PM BLOOD ALT-18 AST-27 LD(LDH)-374* AlkPhos-58 Amylase-16 TotBili-0.8 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 26] [Hospital1 18] [Numeric Identifier 82554] (Complete) Done [2101-6-2] at 9:39:05 AM 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: [2044-11-16] Age (years): 56 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease. ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [2101-6-2] at 09:39 Interpret MD: [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD Test Type: TEE (Complete) 3D imaging. Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 6507], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 30% to 40% >= 55% Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (?#). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed (LVEF=35-40 %). There is moderate anterior wall and antero-septal hypokinesia. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Slightly improved global and focal LV systolci function with background inotropic support. 2. Trace MR and trace TR. 3. Intact aorta Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, Interpreting physician [Last Name (NamePattern4) ] [2101-6-2] 17:12 [Known lastname ],[Known firstname 26] [Medical Record Number 82555] F 56 [2044-11-16] Radiology Report RENAL U.S. PORT Study Date of [2101-6-4] 10:20 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2101-6-4] 10:20 AM RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED Clip # [Clip Number (Radiology) 82556] Reason: LOW UO SP CABG,EVAL FOR STENOSIS [Hospital 93] MEDICAL CONDITION: 56 year old woman with low uo s/p CABG REASON FOR THIS EXAMINATION: stenosis Provisional Findings Impression: GWp SAT [2101-6-4] 4:52 PM PFI: 1. Limited portable renal ultrasound demonstrating no hydronephrosis, no nephrolithiasis and no solid renal mass. 2. Right renal artery resistive index measured at 0.85, 0.76, 0.78 and infrarenal flow with resistive indices 0.77, 0.79 and 0.80. 3. Left renal artery resistive index measured at 0.87, 0.88 with elevated velocities measured at 160, 200 cm/sec. Velocities and resistive indices in the intrarenal portion appear normal at 0.71, 0.84, and 0.84. Final Report INDICATION: 56-year-old woman with low urine output status post CABG, query stenosis. COMPARISON: None available. PORTABLE RENAL ULTRASOUND: Grayscale and color Doppler son[Name (NI) 493] images were obtained that demonstrate the right kidney to measure 10.8 cm pole to pole and the left 10.3 without evidence for hydronephrosis, nephrolithiasis, or renal mass. On the right main renal artery demonstrates flow velocity between 71 and 87 cm/sec and resistive index measured at 0.85 and 0.76. Infrarenally, the upper, mid, and lower velocities are measured at 76, 62 and 103 cm/sec and the resistive indices 0.79, 0.77 and 0.80. Right renal venous flow is normal. On the left, the main renal artery velocity is measured at 200 and 166 cm/sec, with resistive index at 0.88 and 0.87. The interlobar velocities are measured in the upper, mid and lower pole at 83, 56 and approximately 40 cm/sec. Resistive indices are measured at 0.84, 0.71, and 0.70. A Foley catheter is demonstrated within the decompressed bladder. IMPRESSION: 1. No son[Name (NI) 493] evidence for hydronephrosis, left nephrolithiasis, or renal mass. 2. Normal arterial and venous flow demonstrated at the right kidney. 3. In this limited portable son[Name (NI) 493] study, there are elevated velocities and elevated RIs demonstrated in the left renal artery concerning for stenosis. Consider MRA for further evaluation. A non contrast MRA examination is possible if patient's renal function precludes administration of contrast. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) 5206] [Name (STitle) ] DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21884] Approved: SUN [2101-6-5] 4:17 PM Imaging Lab Brief Hospital Course: On [6-2] Mrs.[Known lastname 29390] underwent coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery) with Dr.[Last Name (STitle) 914]. Cross clamp time= 97 minutes/ Cardiopulmonary bypass time= 132 minutes. Please refer to Dr[Last Name (STitle) 5305] operative report for further details. She was transferred to the CVICU hemodynamically stable requiring Milrinone to optimize cardiac output. She awoke neurologically intact and was extubated on POD#1. She was weaned off inotropes. Beta-blockers optimized per Blood Pressure tolerance. All lines and drains were discontinued in a timely fashion. Psychiatry was consulted for postoperative delirium. She continued to progress and on POD# 4 was transferred to the step down unit for further monitoring. Her rhythm went into rapid atrial fibrillation and was treated with Amiodarone. She converted to sinus rhythm, no anticoagulation required. She was diuresed for right pleural effusion evident on chest xray. The remainder of her postoperative course was essentially uncomplicated and on POD# 6 she was cleared for discharge to rehab for further strength, endurance and increase in daily activities. All follow up appointments were advised. Pt. should have a MRA as an outpt. for follow up of possible left renal artery stenosis. Please restart metformin when creatinine has normalized. Medications on Admission: Glyburide 5mg one tablet twice a day Plavix 75mg daily every morning Atenolol 25mg daily every morning Imdur 30mg daily every morning Lisinopril 5mg daily every morning Furosemide 40mg one tablet every morning Simvastatin 20mg one tablet every morning Metformin 500mg one tablet twice a day Ecotrin 81mg daily every morning Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: 400 mg [Hospital1 ] until [6-12], then 400 mg daily for 7 days, then 200 mg daily ongoing. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing/sob. 11. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: please assess for dose reduction after one week. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): please assess for dose reduction when oral lasix is decreased. 14. Humalog insulin per sliding scale QID. Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 3320] Discharge Diagnosis: status post coronary artery bypass grafting x4 (left internal mammary artery grafted to left anterior descending artery/Saphenous vein grafted to Obtuse Marginal #1/#2/Posterior descending artery)-[2101-6-2] -myocardial infarction /LAd stenting '[2092] -lower extremity claudication, s/p Left leg angioplasty '[96] -Cardiomyopathy -CHF: [Month (only) ].& [March 2101] -Diabetes Mellitus -Hypertension -hyperlipidemia - postop acute renal failure -s/p Choleycystectomy'[69] Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incision dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks, please call for appointment# [Telephone/Fax (1) ] Dr. [Last Name (STitle) 5310] in [2-22] weeks, please call for appointment Dr [Last Name (STitle) ],[Last Name (un) 82557] M. [Telephone/Fax (1) 82558], Please call for appt to be scheduled in [1-21] weeks; NOTE: should have MRA as outpatient to follow up on possible left renal artery stenosis Completed by:[2101-6-8] Name: [Known lastname 13189],[Known firstname ] Unit No: [Numeric Identifier 13190] Admission Date: [2101-6-2] Discharge Date: [2101-6-8] Date of Birth: [2044-11-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1543] Addendum: Please note: Follow up appt is to be made with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 4 weeks [Telephone/Fax (1) 1477] ( not Dr. [Last Name (STitle) ]. Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 1541] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2101-6-8] Name: [Known lastname 13189],[Known firstname ] Unit No: [Numeric Identifier 13190] Admission Date: [2101-6-2] Discharge Date: [2101-6-8] Date of Birth: [2044-11-16] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1543] Addendum: Additional discharge diagnosis: postop atrial fibrillation Discharge Disposition: Extended Care Facility: Life Care Center - [Location (un) 1541] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2101-6-8**]	[ "276.1", "584.5", "272.4", "412", "276.2", "285.9", "296.80", "250.00", "V45.82", "425.4", "428.23", "428.0", "427.31", "401.9", "443.9", "293.9", "414.01", "411.1", "440.1" ]	icd9cm	[ [ [] ] ]	[ "36.13", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	15985, 16213	9981, 11466	360, 562	13911, 13918	2539, 5784	14231, 15263	1749, 1822		11842, 13277	7556, 7595	15934, 15962		11492, 11819			13942, 14208							5833, 6727	1837, 2520																									271, 322	7627, 9958									590, 1014															1036, 1590	1606, 1717				6738, 7516
5,504	194,910	22897	Discharge summary	report	Admission Date: [2125-6-25] Discharge Date: [2125-7-4] Date of Birth: [2064-3-9] Sex: M Service: MEDICINE Allergies: Miacalcin Attending:[First Name3 (LF) 2485] Chief Complaint: ICH, bowel incontinence Major Surgical or Invasive Procedure: TEE, multiple arthocenteses, central line placement History of Present Illness: 61 yo m with MMM including CAD, AVR on coumadin fell on friday, had fevers thgough weekend then bowel incontinence on Sun -> wife brought to [Name (NI) ]. At OSH found to have 2 small ICH on head CT. No hydro or mass effect, also changes consistant with old strokes. Had elevated INR. Neck CT showed old dens fracture and no acute fracture. . Upon admit, had continued fevers to 101. In afib with RVR abd labile blood pressures - in SBP 70's - 90s. Given 7.5 L of NS without change in BP. Pt denied CP, Abd pain, dysuria, cough. In ED given ceftriaxone with 5 mg SC Vit K and 2 [Location 16678] and admitted to MICU. Past Medical History: CAD s/p MIx2 CVA x2 (with residual deficits of R arm) Prosthetic valve AICD placement EtOH abuse (? historic) CAP Chronic back pain Social History: + EtOH; states he used to have a problem, but has curtailed drinking in recent years to 3-4 beers/day + Tobacco Lives with wife in [Location (un) 1773] walk-up apt. At present, wife is in poor health and cannot aid appreciably in his home health needs. Family History: N/A Physical Exam: PE: 101, 112, SBP 108/72 not on pressors,Alert to person only. C-collar in place. dry mucus membranes. lungs clear. tach with II/VI SEM. no stigmata of endocarditis. Left knee and elbow are erythematous, painful and swollen. decreased patellar reflexes. did not coorperate well with motor exam. no rectal tone. Pertinent Results: [2125-7-3] 03:04AM BLOOD WBC-18.0* RBC-3.38* Hgb-9.4* Hct-28.5* MCV-84 MCH-27.7 MCHC-32.9 RDW-16.4* Plt Ct-370 [2125-6-25] 06:30AM BLOOD WBC-8.5 RBC-4.50* Hgb-13.3* Hct-37.7* MCV-84# MCH-29.6 MCHC-35.3* RDW-15.5 Plt Ct-64# [2125-6-25] 06:30AM BLOOD Glucose-170 UreaN-28* Creat-1.0 Na-128* K-4.6 Cl-94* HCO3-19* AnGap-20 [2125-6-25] 06:30AM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.6* Mg-1.8 [2125-6-25] 04:44PM BLOOD Type-ART Temp-37.2 Rates-/32 O2 Flow-4 pO2-58* pCO2-21* pH-7.50* calHCO3-17* Base XS--4 Intubat-NOT INTUBA TEE: MV and AVR endocarditis Brief Hospital Course: The patient was aggressively treated for sepsis [3-7] MV and AVR endocarditis thought to be due to bactreal translocation from poor dentition. He had multiple complications from his sepsis and endicarditis including respiratory failure, septic emboli to his head, and bilateral septic elbows and knees. The patient was intubated, treated with vanc, gent, and oxacillin, and had daily arthocentesis for his septic elbows and knees. His course was complicated by afib with RVR and an ICH which was thought to be due to trauma with a high INR or septic emboli. He eventually becausme pressor dependant and the decision was made to do comfort measures only. The patient expired on [7-4]. Medications on Admission: Meds: Coumadin, Plavix, norvasc, lisinopril, klonapin, fentanyl patch for back pain of herniated discs Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: endocarditis Discharge Condition: expired	[ "427.31", "806.20", "584.9", "428.0", "V53.32", "995.92", "518.84", "431", "576.8", "724.9", "711.09", "287.5", "286.6", "421.0", "E888.9", "038.11", "996.61", "785.52" ]	icd9cm	[ [ [] ] ]	[ "88.72", "96.04", "00.17", "96.6", "38.93", "99.05", "99.06", "99.07", "99.04", "96.72", "81.91" ]	icd9pcs	[ [ [] ] ]	3270, 3279	2396, 3089	292, 345	3335, 3345	1799, 2373		1447, 1452		3242, 3247		3300, 3314		3115, 3219											1467, 1780																									229, 254										373, 1000															1022, 1155	1171, 1431
10,810	195,991	11704	Discharge summary	report	Admission Date: [2111-12-29] Discharge Date: [2112-1-6] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 86yo man with significant cardiac history with hypertension, hypercholesterolemia, CAD s/p CABG, CHF and COPD (requiring 1.5 L at baseline) presented to the emergency department with several complaints, including overall weakness, lethargy, cough and constipation/diffuse abdominal pain. Initial vitals in the ED were 96.0, 133, 122/56, 22, and 94% on NRB -> 86% on 3L NC. While in teh ED, he received treatments directed at his COPD with solumedrol and combivent; his CHF with lasix; and finally potential PNA with levaquin. CXR revealed CHF w/ b/l effusions. Admitted to the MICU and observed o/n, swallowing studies revealed aspiration of thin liquids. Antibiotics were d/c'd in MICU as pt was not felt to have infiltrate on CXR or definitive infection (afebrile and w/ improving WBC). Called out to floor on [12-31] and arrived on 50% VM with SPO2 in 90% range. Diuresed with increasing lasix regimen over the next several days with net urine output ranging from 200-1000cc/ 24hrs. Despite diuresis, pt with persistent 02 requirement (on 50% venti mask) along with bilateral effusions; with 40IV [Hospital1 ] lasix, BP in 90-100 range with decreasing urine output. Transferred to CHF service for likely natrecor +/- dopamine. Past Medical History: 1) CAD s/p CABG in '[99] 2) CHF with EF of 35% 3) atrial fibrillation 4) hypercholesterolemia 5) COPD 6) vertigo 7) spinal stenosis 8) h/o myocardial infarction, last reportedly one month ago in setting of UGI bleed 9) recent UGI bleed ([10-12] [Hospital1 2025])--> 2 vessels cauterized Social History: reports no etoh/drugs/current tobacco (past history of 1 [1-9] ppd for 15 years) Now lives in [Hospital3 ] facility. Has support from two daughters. Physical Exam: 97.6, 109, 90-100/50-52, 50% venti mask w/ SPO2 91-94% gen: AOx2, dysarthric, tachypneic heent: perrl, eomi; ptosis of right eye lid CV: irregular, tachycardic; no m/r/g resp: + b/l decreased BS w/o ronchi and dullness to percussion at bilateral lung bases. abd: soft, NT, ND; normoactive bowel sounds extr: 1+ pitting edema bilaterally with stasis changes and erosion on right heel and 3 X 5cm ulceration with surrounding erythema on right calf Pertinent Results: [2111-12-29] 10:30PM ALT(SGPT)-25 AST(SGOT)-29 CK(CPK)-19* ALK PHOS-95 AMYLASE-15 TOT BILI-0.5 [2111-12-29] 10:30PM LIPASE-15 [2111-12-29] 10:30PM cTropnT-0.04* [2111-12-29] 10:30PM ALBUMIN-3.8 [2111-12-29] 10:06PM TYPE-ART PO2-196* PCO2-34* PH-7.46* TOTAL CO2-25 BASE XS-1 COMMENTS-LARGE AIR [2111-12-29] 06:00PM CK(CPK)-23* [2111-12-29] 06:00PM PT-24.3* PTT-38.1* INR(PT)-3.7 Micro data: [12-29] Bcx pending [12-30] BCx pending UCx pending . admit CXR: Bilateral effusions with nontypical CHF due to underlying emphysema . echo Severe pulmonary artery systolic hypertension. Regional left ventricular systolic dysfunction c/w multivessel CAD. Mild-moderate mitral regurgitation. Mild aortic regurgitation. . KUB: There are gas-filled loops of non-dilated small bowel with gas present in the colon and rectum and no evidence for intestinal obstruction. There are vascular calcifications. No obvious soft tissue masses or radiopaque calculi. . Brief Hospital Course: Pt was admitted with decompensated heart failure and blood pressure could not tolerate his home diuretic regimen. Pt was admitted to the MICU and then to the floor after he had stabilzed. The hypoxia was thought to be [2-9] aspiration pneumonia and CHF. Despite maximizing diuretics and treating the pneumonia, pt's oxygen requirement continued to increase. After discussions with the family and emphasizing the pt's poor prognosis, the decision was made to make the patient comfortable. He was placed on a morphine drip and expired soon thereafter. Medications on Admission: advair discus [Hospital1 ] asa 81 qD colace 100mg qD ferrex 150 qD lasix 40 qD isosorbide 10 TID lexapro 10 qD lipitor 20 qD omeprazole provigil spiriva coumadin Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: Primary: 1. Systolic Heart Failure - interval new wall motion abnormalities. 2. Acute Exacerbation of COPD. 3. Upper GI Bleed NOS. 4. Hypoxia. 5. Bilateral Lower Extremity Heel Ulcer. 6. Ischemic Toe Ulcer. 7. Left Bundle Brunch Block. 8. Acute Renal Failure. 9. Hypernatremia. Secondary: 1. COPD/Emphysema. 2. CABG [2099] - Angioraphy [Hospital1 2025] [10/2111] without intervenable lesions. 3. NSTEMI x 4. 4. Duodenal Bleeding Ulcer - cauterized at [Hospital1 2025]. 5. Atrial Fibrillation. 6. Hypercholesterolemia. 7. Spinal Stenosis. 8. Compression Fracture. 9. Peripheral Vascular Disease. 10. Chronic Renal Insufficiency. 11. Iron Deficiency Anemia. 12. Cerebellar Degeneration. Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "V66.7", "414.8", "311", "496", "593.9", "401.9", "V12.72", "272.0", "280.9", "276.0", "410.92", "428.0", "427.31", "V45.81", "414.00", "578.9" ]	icd9cm	[ [ [] ] ]	[ "00.13", "96.6" ]	icd9pcs	[ [ [] ] ]	4364, 4379	3559, 4119	278, 285	5125, 5134	2534, 3536	5187, 5194			4335, 4341		4400, 5104		4145, 4312			5158, 5164								2066, 2515																									231, 240										313, 1555															1577, 1877	1893, 2051
1,347	109,456	19175+19176	Discharge summary	report+report	Admission Date: [2126-8-1] Discharge Date: [2126-8-10] Date of Birth: [2058-8-5] Sex: F Service: CONTINUATION: HOSPITAL COURSE: The patient was taken to the Surgical Intensive Care Unit after operation for fluid management. In brief, the patient's postoperative course was essentially unremarkable. A Swan catheter was in on postoperative day one to gage her fluid status and measuring cardiac output. She remained intubated until postoperative day number five and she was aggressively hydrated postoperative day one for low urine output and her blood pressure was controlled by Nitroglycerin intravenous drip and she was started on beta blocker, Lopressor 10 mg q6hours. She is empirically started on a five day course of Levofloxacin and Flagyl for prophylactic treatment. From postoperative day three, she is started on some Lasix to help mobilize fluid and she responded to the diuretic effectively. She is essentially negative for two liters every day from postoperative day number three and, by postoperative day number five, she is tolerating well mechanical ventilation. She is successfully extubated on that day. After extubation, the patient remained in the Intensive Care Unit for two more days. During that time, she was agitated and self discontinued her own central line and attempt was made to replace central venous catheter which failed and she was successfully placed with a small bore intravenous for peripheral fluids and peripheral intravenous antibiotics. She is then started on regular diet for which she tolerated well with good ostomy output. She was transferred to the floor on [2126-8-8], postoperative day number seven, and remained afebrile with good blood pressure control. She had a minimal amount of pain and was on two liters of oxygen with nasal cannula. She receives aggressive pulmonary therapy and was ambulating with assistance of physical therapy. She is making a good amount of urine every day and is discharged to rehabilitation facility for further physical rehabilitation. MEDICATIONS ON DISCHARGE: 1. Lisinopril 15 mg p.o. once daily. 2. Metoprolol 100 mg p.o. twice a day. 3. Colace 100 mg p.o. twice a day. 4. Albuterol inhaler as needed. DISCHARGE DIAGNOSIS: Sigmoid diverticulitis. CONDITION ON DISCHARGE: Stable. Dictated By:[Name8 (MD) 6276] MEDQUIST36 D: [2126-8-10] 11:27 T: [2126-8-10] 12:13 JOB#: [Job Number 52305] Admission Date: [2126-8-1] Discharge Date: [2126-8-10] Date of Birth: [2058-8-5] Sex: F Service: GENERAL SURGERY HISTORY OF THE PRESENT ILLNESS: Ms. [Known lastname 52306] is a 67-year-old lady who initially presented to her primary care physician with fevers and left lower abdominal pain and distention in early [2126-6-4]. Subsequent workup including a CT scan showed sigmoid diverticulitis, thickening of the adjacent sigmoid colon wall, and a large presacral abscess with a right adnexal mass. Subsequently, she was admitted to the hospital and treated with IV antibiotics including Levaquin and Flagyl. She has also been started on a beta blocker and an ACE inhibitor for her hypertension. She tolerated that admission and was discharged to home with levofloxacin and Flagyl. She now returns to Dr.[Name (NI) 4999] service for surgical management of her diverticulitis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Ovarian cyst. 3. Diverticulitis. 4. Pelvic mass. SOCIAL HISTORY: Retired. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Metoprolol 5 mg. 2. Atenolol 75 mg b.i.d. 3. Lisinopril 30 mg b.i.d. HOSPITAL COURSE: The patient was taken to the Operating Room on [2126-8-1] for scheduled low-anterior resection of the sigmoid colon and also resection of the pelvic mass. She underwent general anesthesia. Dr. [Last Name (STitle) 1888] performed a sigmoid colectomy and a diverting ileostomy and Dr. [First Name (STitle) 1022] from the Gynecology Service performed a resection of the pelvic mass. She tolerated the procedure well. Intraoperatively, there were transient EKG changes and urine output was low which required 10 liters of fluid during the operation. She was subsequently transferred to the Surgical Intensive Care Unit for postoperative fluid management. [Last Name (NamePattern4) 1889], M.D. [MD Number(1) 1890] Dictated By:[Name8 (MD) 6276] MEDQUIST36 D: [2126-8-10] 10:09 T: [2126-8-10] 10:24 JOB#: [Job Number 52307]	[ "401.9", "562.11", "518.81", "220", "997.5", "E878.6", "424.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "46.01", "89.64", "48.63", "65.49" ]	icd9pcs	[ [ [] ] ]											2263, 2288	2093, 2241		3680, 4577				3586, 3662																																																								3408, 3482	3499, 3563	2313, 3386
8,509	182,361	3381	Discharge summary	report	Admission Date: [2135-2-17] Discharge Date: [2135-2-23] Service: Medical Intensive Care Unit and then transferred to the Medical service HISTORY OF PRESENT ILLNESS: This is an 85-year-old female with history of CAD, hypertension, atrial fibrillation status post pacemaker implantation, who awoke the morning of [2-17] with blood on her hands, reportedly called a taxi cab, but sounded confused on the telephone, and therefore the cab called 911. The patient was taken to Wooden, where she received anterior packing for epistaxis. This afternoon after discharge from Wooden Hospital Emergency Department, the VNA visited the patient and noted increasing blood on the packing and blood on the patient. The patient was taken to the [Hospital1 18] Emergency Department. Vital signs on arrival in the Emergency Department were a pulse of 78, blood pressure 153/75, oxygen saturation 98% on room air. Otolaryngology was consulted and an acute posterior bleeding was noted on exam. ENT placed posterior nasal packing to stop the bleeding. Review of systems via daughter was entirely negative. There was some question about a report of patient having fallen. Patient denied fall multiple times, but had mentioned a fall once to her daughter. There was no evidence of trauma. At baseline, the patient has some confusion with her medications, places, dates, and names. PHYSICAL EXAM: On physical exam, her vital signs were afebrile, pulse at 71, blood pressure 146/72, and oxygen saturation 100%, respiratory rate 18. General: She was in no apparent distress. Her HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Her mucous membranes were dry. There was dried blood in the posterior oropharynx. There was a Foley in her left nares with no visible acute bleeding. She had no lymphadenopathy on neck examination. Cardiovascular is regular rate and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Lung examination is clear to auscultation bilaterally. Abdomen is soft, nontender, and nondistended with active bowel sounds. Extremities are warm with no clubbing, cyanosis, or edema. Neurological examination: She was awoken to voice, oriented x1. PAST MEDICAL HISTORY: 1. Coronary artery disease, PTCA and stent of PDA, posterior LAD, and anterior RCA in 03/98. 2. Hypertension. 3. Atrial fibrillation status post A-V ablation with pacemaker implantation [11/2131]. 4. Dementia. 5. High cholesterol. 6. CVA secondary to hypotension in the watershed area. No history of embolic cerebrovascular accidents [10/2130]. 7. AAA 3.2 x 3.6 [3-3]. 8. Hematuria. 9. Epistaxis. 10. Antral gastritis. 11. Diverticulosis. 12. Pleural effusion. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. q.d. 2. Lipitor 10 mg p.o. q.d. 3. Coumadin 2 mg Monday, Tuesday, Wednesday, and Friday, 3 mg on Saturday and Sunday. 4. Lisinopril 20 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She smoked two packs per day x50 years. No alcohol. She lives alone. She has VNA visit her. FAMILY HISTORY: Diabetes, cancer, and leukemia. LABORATORIES ON ADMISSION: Her white blood cell count was 7.6, hematocrit 40.4, platelets 276. Chem-7: Sodium 142, potassium 5.0, chloride 107, bicarb 26, BUN 54, creatinine 1.2. Glucose 78. INR of 2.7. Differential was 71.7 neutrophils, 20.7 lymphocytes. HOSPITAL COURSE: This 85 year old presented with epistaxis of unclear etiology. There was some question whether it was secondary to her Coumadin, but her INR was excessively high. It was 2.7 on admission. Spontaneous bleed is possible, but there is a possibility of trauma, however, by history this seems unlikely. She also had dry mucous membranes, which may be contributing. 1. Epistaxis: The patient was seen by Otolaryngology upon admission. He had posterior-anterior left nares packing placed as well as a Foley catheter for posterior pressure. The patient's bleeding was stable with the packing. She had two IVs placed, and she was typed and crossed when she had bleeding. On admission, her hematocrit was 40.4. On the following day it had dropped to 25.7. The patient was transfused to bring her hematocrit up. Her hematocrit was followed closely while she was in the ICU and she was stable. She was transferred to the general medical floor for further followup. On the medical floor, her hematocrit remained largely stable, however, it did trend down slightly the day prior to discharge, therefore the patient was transfused two additional units, which brought her hematocrit up appropriately. On [2135-2-22], Otolaryngology removed her nasal packing. The patient had no epistaxis overnight. A plan was made to hold both her aspirin for two additional weeks. She will restart this on [3-7]. In addition, her Coumadin was discontinued. It was felt that given he age and her mental status, difficulty taking the Coumadin, a decision was made to stop the Coumadin from long-term anticoagulation and instead prevent embolic events with aspirin alone. 2. Hypertension: The patient's blood pressure was followed closely to keep the blood pressure less than 150/90 given the increased blood pressure will contribute to further epistaxis. Her blood pressure was well controlled with captopril, which was titrated up while she was in-house. The blood pressure had been several for several days on captopril 100 t.i.d. and was changed to lisinopril 30 q.d. prior to discharge. This medication should be titrated up to 40 mg p.o. q.d. if her blood pressure does not appear adequately controlled on 30 q.d. 3. Coronary artery disease: The patient had a history of ischemic coronary artery disease. She had been on aspirin and Lipitor for secondary prevention for further coronary events. The Lipitor was continued while the patient was in-house. Her aspirin was on hold. She will restart this on [3-7] with 325 mg p.o. q.d. 4. Abdominal aortic aneurysm: The patient has a history of abdominal aortic aneurysm. Her blood pressure was followed closely to make sure that she does not become hypertensive during this hospital stay. 5. Atrial fibrillation: The patient's atrial fibrillation is well rate controlled with a ventricular pacemaker. Her heart rate was regular rate and rhythm throughout her hospital stay. She will need to resume aspirin 325 mg p.o. q.d. for long-term prevention of embolic events. 6. Renal: On admission, the patient's BUN and creatinine were noted to be elevated. Her BUN was 54 and her creatinine was 1.2. Likely the patient was dehydrated on admission and that some of the elevated BUN may have been secondary to the bleeding. The patient was encouraged to take good p.o. and her BUN was noted to decrease from 54 to 33 prior to discharge. Her creatinine remained stable at about 1.1. Her baseline ranges from 0.8 to 1.1 by past hospital data. 7. Nutrition: Initially, the patient was kept NPO secondary to the epistaxis. Her diet was advanced to liquids and then to soft solids. The patient was noted to be tolerating soft solids well prior to discharge. She did need some encouragement to take adequate p.o. The patient will be continued on a soft solid diet, and she should receive Boost Plus supplements t.i.d. after discharge. 8. Mental status changes: During the hospital stay, the patient was noted to be increasingly confused. Given her baseline status is oriented x1, it was likely related to disorientation from being in the hospital. She was given a dose of Zyprexa to decrease her agitation given patient was trying to pull out her packing. The Zyprexa dose made the patient quite somnolent for about 24 hours. The head CT was done to rule out any possible bleed given the prolonged effect of the Zyprexa on the patient. By report, the head CT was negative for bleed. Patient's mental status significantly improved with the discontinuation of the packing and the discontinuation of any antipsychotics or benzodiazepines. The patient was appropriate, cooperative, and oriented x1 prior to discharge. 9. Infectious disease: The patient was started prophylactically on the course of Ancef given that the patient had nasal packing in place and the concern for possibility of toxic shock syndrome with nasal packing. Post packing removal, the patient will be continued on a one-week course of Keflex 500 mg p.o. q.i.d. to prevent any sinusitis from related to the packing. 10. Code status: The patient had a very coherent conversation with Dr. [Last Name (STitle) ] regarding her wishes for end-of-life care. She decided that she would prefer to be DNR/DNI, and this was documented in the medical chart. DISCHARGE CONDITION: Stable. Patient is alert, cooperative, and oriented x1, and taking good p.o. DISCHARGE STATUS: To extended care facility. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Docusate 100 mg p.o. b.i.d. 4. Multivitamin one p.o. q.d. 5. Keflex 500 mg p.o. q.i.d. x7 days. 6. Lisinopril 30 mg p.o. q.d. 7. Aspirin enteric coated 325 mg p.o. q.d. to start [2135-3-7], please hold until [2135-3-7] secondary to recent nosebleed. DISCHARGE FOLLOWUP: The patient's daughter should arrange followup with Dr. [Last Name (STitle) ] within the month following discharge. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Name8 (MD) 3482] MEDQUIST36 D: [2135-2-23] 09:45 T: [2135-2-23] 09:43 JOB#: [Job Number 15654]	[ "414.01", "790.92", "784.7", "427.31", "441.4", "276.5", "401.9", "V45.82", "V45.01" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]				8728, 8854			3093, 3139		8877, 9198				2754, 2963	3407, 8706										1415, 2231																												9219, 9571							186, 1399							3154, 3389								2253, 2728	2980, 3076
68,905	133,206	46892	Discharge summary	report	Admission Date: [2105-7-14] Discharge Date: [2105-7-15] Date of Birth: [2035-12-6] Sex: M Service: CARDIOTHORACIC Allergies: pseudoephedrine / NSAIDS / antihistamines / aspirin / Lovenox Attending:[First Name3 (LF) 5790] Chief Complaint: chronic aspiration, admitted for PEG tube Major Surgical or Invasive Procedure: [2105-7-15]: Percutaneous endoscopic gastrostomy tube placement History of Present Illness: 69 yoM with a 25 year history of a C4/C5 cervical fracture and spinal cord injury with resultant paraplegia. Approximately 3 years ago the patient underwnet tracheostomy for ventilation as he had devloped multiple pneuomnias after aspiration events. He was seen by our service during a [Month (only) 956] admission fo complex pneumonia, during which time he underwent a Right VATS decortication and drainage of a complex parapneumonic effusion. He is now presenting for g-tube placement in the setting of inability to tolerate feeds and chronic dobhoff placement. Of note, he has had gastrostomy tubes before, once after the initial [2105]5 years go, and one more time 4 years ago during a particularly complex pneumonia. Past Medical History: C5/C7 spinal cord injury with quadriplegia x 25 yrs Pressure ulcer on right ischial tuberosity UTI Pneumonia Ventilatory failure Hypothyroid Hyperlipidemia Chronic foley catheter placement Chronic left hip fracture Chronic aspiration History of clostridium Difficile colitis MRSA SIADH PUD Social History: Mr. [Known lastname 3265] is married with children. He comes from [Hospital 100] Rehab. He is bedbound from his C5-C7 spinal cord injury but has movement of his left hand and minimal movement of his right hand, which is fused. He used to work as a carpenter prior to the injury. He denies smoking or etoh use. Family History: non contributory Physical Exam: Discharge vital signs: T96.5, P 62 NSR, BP 129/88, RR 20, 96% 40% humidfied trach collar Discharge Physical Exam: Gen: pleasant in NAD NecK: # 7 trach, with passey muir valve intact. pt vocalizing Lungs: rhonchi bilaterally, R VATS incisions healed CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND, PEG C/D/I GU/GI: foley inplace. flexiseal with brown loose stool. Ext: warm without edema, right #22 g peripheral IV. Right ischial tuberosity stage I pressure ulcer Pertinent Results: Labs: [2105-7-15] 03:43AM [Month/Day/Year 3143] WBC-6.4 RBC-3.13* Hgb-10.0* Hct-28.9* MCV-92 MCH-31.8 MCHC-34.6 RDW-15.2 Plt Ct-367 [2105-7-14] 09:05PM [Month/Day/Year 3143] Neuts-69.6 Lymphs-19.7 Monos-4.8 Eos-5.4* Baso-0.5 [2105-7-14] 09:05PM [Month/Day/Year 3143] PT-13.3 PTT-27.9 INR(PT)-1.1 [2105-7-15] 03:43AM [Month/Day/Year 3143] Glucose-140* UreaN-16 Creat-0.3* Na-131* K-4.1 Cl-97 HCO3-25 AnGap-13 [2105-7-14] 09:05PM [Month/Day/Year 3143] ALT-42* AST-27 LD(LDH)-109 AlkPhos-69 Amylase-23 TotBili-0.2 [2105-7-15] 03:43AM [Month/Day/Year 3143] Calcium-8.4 Phos-4.4 Mg-3.0* [2105-7-14] 09:05PM [Month/Day/Year 3143] Albumin-3.7 Calcium-9.1 Phos-4.6# Mg-1.8 Iron-55 [2105-7-14] 09:05PM [Month/Day/Year 3143] calTIBC-285 Ferritn-515 TRF-219 [2105-7-14] 09:05PM [Month/Day/Year 3143] Triglyc-165* [2105-7-14] 09:05PM [Month/Day/Year 3143] TSH-4.6* [2105-7-14] CT abdomen Preliminary Report !! WET READ !! Since [2105-3-9] there has been marked improvement of a right pleural effusion, with a small amount of residual fluid and mild to moderate adjacent atelectasis. There has been worsening left basilar atelectasis with a concern for a small coexisting consolidation (2:3). An NG tube terminates within the stomach. There is an approximate 2.9 cm window between the xyphoid tip and transverse colon where there is a direct percutaneous pathway to the stomach (301b:37). Four non-obstructing left renal calculi. Left-approach intrathecal device. Cholelithiasis. Marked osteopenia with erector spinae atrophy. CXR [2105-7-14]: IMPRESSION: Comparison of portable chest examinations indicates lesser pulmonary congestion and decreased size of heart silhouette. Observe that portable chest examinations cannot get details with greater certainty. An NG tube is present and reaches well below the diaphragm EKG [2105-7-14]: Sinus rhythm with A-V conduction delay. Anterolateral lead T wave abnormalities are non-specific but cannot exclude myocardial ischemia. Clinical correlation is suggested. Since the previous tracing of [2105-3-12] rate is slower and T wave changes appear slightly more prominent but may be no significant change. Brief Hospital Course: Mr. [Known lastname 3265] was admitted to the Thoracic surgery service on [2105-7-14] for planned PEG tube placement as needed for nutrition r/t chronic aspiration. The patient was kept in the ICU overnight and remained stable resting on the ventilator at night. He was taken to the operating room at 3pm on [2105-7-15] where Dr. [Last Name (STitle) ] placed a percutaneous endoscopic gastrostomy tube. He did well and recovered in the unit to his baseline and was deemed stable for transfer back to rehab. He remained afebrile and hemodynamically stable throughout his hospital course. Speech and swallow evaluated him [2105-7-14] and made the following recommendations: 1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE! 2. Monitor O2 Sats / respiration while valve is in place. 3. Do not allow the patient to sleep with the valve in place. 4. If the patient is taking PO's, please deflate the cuff and place the PMV for eating and drinking. 5. PMV wear schedule is up to the discretion of the nurse and/or respiratory therapist. 6. Follow-up s/p PEG placement to enusre PMV tolerance and assess possibility for green-dye swallow study. The patient and his wife were aware of transfer back to [Hospital1 ]. The patient should resume all care and medications he came in on. He should followup with us in a month or so in clinic when he is more stable off the ventilator. Medications on Admission: N-acetylcystiene 200 mg TID, artifical tears 1 drop TID, chlorhexidine swish and spit [Hospital1 ], cholestyramine 4 grams [Hospital1 ], gabapentin 400 mg TID, garamycin nebulizers 80mg TID, synthroid 75 mcg daily, omeprazole 20 daily, oxybutinin 5 mg [Hospital1 ], simethicone 80 mg [Hospital1 ], NaCl 1 gram [Hospital1 ], vancomycin PO 125 mg [Hospital1 ], acetominophen prn, albuterol prn, ativan prn, collagenase daily, zinc oxide topical [Hospital1 ] Discharge Medications: 1. white petrolatum-mineral oil 56.8-42.5 % Ointment [Hospital1 ]: One (1) Appl Ophthalmic DAILY (Daily) as needed for eye drops. 2. chlorhexidine gluconate 0.12 % Mouthwash [Hospital1 ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 3. cholestyramine-sucrose 4 gram Packet [Hospital1 ]: One (1) Packet PO BID (2 times a day): give other meds 1 hour before or 4-6 hours after. 4. gabapentin 400 mg Capsule [Hospital1 ]: One (1) Capsule PO Q8H (every 8 hours): give via PEG. 5. levothyroxine 75 mcg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. oxybutynin chloride 5 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 8. acetylcysteine 10 % (100 mg/mL) Solution [Hospital1 ]: One (1) neb Miscellaneous three times a day: intratracheal. 9. simethicone 80 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO BID (2 times a day). 10. sodium chloride 1 gram Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day): via PEG tube. 11. vancomycin 125 mg Capsule [Hospital1 ]: One (1) Capsule PO every twelve (12) hours. 12. gentamicin sulfate (PF) 80 mg/8 mL Solution [Hospital1 ]: One (1) dose Intravenous every eight (8) hours: inhaled. 13. acetaminophen 325 mg/10.15 mL Suspension [Hospital1 ]: [11-26] ml PO every 4-6 hours as needed for pain. 14. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler [Month/Year (2) ]: Two (2) puffs Inhalation every six (6) hours: give with mucomyst. 15. lorazepam 0.5 mg Tablet [Month/Year (2) ]: half Tablet PO at bedtime. 16. zinc oxide 40 % Ointment [Month/Year (2) ]: One (1) application Topical twice a day: right ischial tuberosity pressure sore. 17. Santyl 250 unit/g Ointment [Month/Year (2) ]: One (1) application Topical once a day: to right ischeal tuberosity pressure sore. 18. oxycodone 5 mg/5 mL Solution [Month/Year (2) ]: [2-8] teaspoons PO every [5-13] hours as needed for pain: from PEG tube. Discharge Disposition: Extended Care Discharge Diagnosis: C5/C7 Spinal cord injury with quadriplegia x 25 yrs Pressure ulcer on right ischial tuberosity UTI Pneumonia Ventilatory failure Hypothyroid Hyperlipidemia Chronic foley catheter placement Chronic left hip fracture Chronic aspiration History of clostridium Difficile colitis MRSA History of SIADH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 3265] was admitted for PEG tube for nutrition. He came out of the operating room around 330pm and recovered to his preoperative baseline. Resume ventilatory support and trach collar trials as previously doing. No medication changes. PEG Tube: Keep to gravity x 24 hours, then may start tube feedings slowly. Tube feeding and residual checks per protocol. Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if pt has redness or purulent drainage from PEG site. [Month (only) 116] give crushed meds via PEG now. Right peripheral IV for transport then dc per primary team. For L DVT of unknown chronicity- would resume lovenox bridge as your were and coumadin to start on [2105-7-16] pm. Call if any signs of bleeding. Followup Instructions: Followup with Dr. [Last Name (STitle) ] in one month for PEG check. Call for appointment [Telephone/Fax (1) 2348]. Completed by:[2105-7-15]	[ "E989", "244.9", "518.83", "V46.11", "707.04", "V44.0", "344.1", "907.2", "707.20", "272.4" ]	icd9cm	[ [ [] ] ]	[ "43.11", "96.6", "96.71" ]	icd9pcs	[ [ [] ] ]	8752, 8767	4659, 6093	370, 440	9108, 9108	2392, 4636	10039, 10193	1874, 1892		6628, 8729		8788, 9087		6119, 6605			9243, 10016								1907, 1996																									289, 332										468, 1204								9123, 9219							1226, 1518	1534, 1858		2021, 2373
18,673	147,973	26390	Discharge summary	report	Admission Date: [2132-9-3] Discharge Date: [2132-9-8] Date of Birth: [2058-10-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 73 y/o with COPD on 2.5-3.5L O2 at baseline, OSA and obesity hypoventilation syndrome, dCHF, discharged [2132-8-24] now presents with agitation and altered mental status with hypoxia and O2 sats 70s on BipAp with 5L. Pt agitated then somnolent at initial presentation and Farsi-only speaking so history obtained via daughter. Daughter reported increased agitation and altered mental status x 2-3 days with O2 sats 60s-70s at home. Daughter has also noted increased LE edema and weight gain which prompted a phone call to her PCP and increased lasix dose from 80daily to 100mg daily with some mild improvement in edema. She has had decreased appetite, PO intake, energy level at home with difficulty with ADLs. No recent history of fever, cough, chills, sputum production, CP, abd pain, or other complaints other than chronic right thigh pain last 1-2 months. Daughter also reports med compliance and compliance with BiPap at night. . In the ED, initial vs were: T98.8 HR96 BP180/60 RR18 O2 sat93%3L. Patient was given azithrhomycin and also received haldol 2.5mg IM for agitation. She was started on BIPAP although continually pulled at mask. ABG 7.30/82/34. Patient and daughter affirmed that pt was DNI/DNR. VS prior to transfer 99.2 77%on Bipap 18/10 with 5L HR 92 115/71 RR 20. . On arrival to the medicine intensive care unit, she was somnolent with O2 sats 90s on neb then low 80s on BiPap Past Medical History: - CAD; s/p 4 vessel CABG in [2119] - CHF; EF 55%, mild AS - obesity hypoventilation syndrome - obstructive sleep apnea - DM2 - ventricular tachycardia; s/p ICD in [2127] - hypothyroidism - schizophrenia - COPD - Pneumona treated in [4-7] at [Hospital1 ] Social History: - lives in [Hospital3 ] alone w/home health aide - daily visits from daughter - smoked 1.5 ppd X 30 years, quit in [2123] - at baseline can do most ADLs (wash face, comb hair, etc) Family History: - mother died of MI (age unknown) Physical Exam: PE on admission: General: elderly woman, obese, lying comfortably in bed in no acute distress; calm and generally cooperative; occasionally agitated, trying to get out of bed, but more calm when speaking with daughter [Name (NI) 4459]: [Name2 (NI) ], atraumatic Neck: supple, unable to interpret JVP 2/2 body habitus Lungs: Poor inspiratory effort. Speaking in full sentences upon arrival to floor. Rhonchorous BS bilaterally. Occasional expiratory wheezes. Cardiovascular: Distant heart sounds. Normal S1 and S2. No m/r/g appreciated. Abdomen: obese, distended but non-tender; active bowel sounds Ext: non-edematous, warm and well-perfused Neuro: moving all extremities PE on discharge: VS:t:97.3 hr: 58 BP: 108/34 RR: 19 sP02: 93% on mask ventilation General: elderly woman, obese, lying comfortably in bed in no acute distress; calm and generally cooperative; occasionally agitated, trying to get out of bed, but more calm when speaking with daughter [Name (NI) 4459]: [Name2 (NI) ], atraumatic Neck: supple, unable to interpret JVP given redundant neck folds Lungs: Mild bilateral crackles heard through anterior chest. Speaking in full sentences. Cardiovascular: Distant heart sounds. Normal S1 and S2. No m/r/g appreciated. Abdomen: obese, anasarcic and distended but non-tender; active bowel sounds Ext: non-edematous, warm and well-perfused Neuro: moving all extremities, trace bilateral peripheral edema Pertinent Results: Labs on Admission [2132-9-3] 09:52PM TYPE-ART TEMP-36.6 RATES-/28 PEEP-5 O2-60 PO2-127* PCO2-87* PH-7.28* TOTAL CO2-43* BASE XS-10 INTUBATED-NOT INTUBA VENT-SPONTANEOU [2132-9-3] 09:52PM LACTATE-0.6 [2132-9-3] 09:40PM GLUCOSE-218* UREA N-32* CREAT-0.9 SODIUM-134 POTASSIUM-4.6 CHLORIDE-90* TOTAL CO2-36* ANION GAP-13 [2132-9-3] 09:40PM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-1.8 [2132-9-3] 09:40PM WBC-9.1 RBC-3.32* HGB-9.4* HCT-29.8* MCV-90 MCH-28.2 MCHC-31.4 RDW-16.2* [2132-9-3] 02:50PM CK(CPK)-61 [2132-9-3] 02:50PM cTropnT-<0.01 [2132-9-3] 02:50PM CK-MB-NotDone proBNP-1368* [2132-9-3] 02:50PM DIGOXIN-<0.2* Labs on Discharge [2132-9-8] 06:17AM BLOOD WBC-6.8 RBC-3.22* Hgb-9.2* Hct-29.1* MCV-90 MCH-28.4 MCHC-31.4 RDW-15.7* Plt Ct-227 [2132-9-8] 06:17AM BLOOD Neuts-75.9* Lymphs-17.9* Monos-3.9 Eos-2.1 Baso-0.2 [2132-9-8] 06:17AM BLOOD Plt Ct-227 [2132-9-8] 06:17AM BLOOD Glucose-107* UreaN-35* Creat-1.1 Na-141 K-3.4 Cl-91* HCO3-44* AnGap-9 [2132-9-3] 02:50PM BLOOD CK(CPK)-61 [2132-9-7] 06:09AM BLOOD Vanco-10.0 [2132-9-8] 06:33AM BLOOD Type-[Last Name (un) ] Temp-37.3 pO2-33* pCO2-87* pH-7.37 calTCO2-52* Base XS-19 Intubat-NOT INTUBA Comment-VENTIMASK Brief Hospital Course: 73 y/o with COPD, OSA, obesity hypoventilation syndrome, CHF admitted with altered mental status secondary to hypercarbic hypoxic respiratory failure. # Hypercarbic Hypoxic Respiratory failure: Mrs [Known lastname 65259] was found to be profoundly agitated and confused, incomprehensible to her daughter even in Farsi. Her altered mental status was have some contribution from hypoxia due to pulmonary edema. She remained afebrile, without an elevated white count through out her hospital stay, and no evidence of pneumonia was recognized on CXR. She was found to have significant pulmonary edema. The patient was placed on a lasix gtt then transitioned to IV boluses. She developed a contraction alkalosis and hypokalemia with lasix therapy, and required repletion with potassium chloride. Clinically she has improved with respect to her respiratory status, her 02 sats remaining in the high 80s to low 90s on mask ventilation during the day and bipap at night. She is maintaining these sats on Nasal Canula 02. She continues to have a permissive hypercarbia, but she is mentating well and her oxygenation status remains goog. Her CXR shows evidence of decreased fluid overload. She was delirious during her stay, required haldol in addition to her antipsychotics for treatment of her schizophrenia, however her mental status has noew improved back to her baseline. She will continue on lasix 120mg po daily X 2 days. She should then restart her home dose lasix of 80mg daily. . # Coagulase Negative Staphylococcus Bacteremia - The patient was found to have 4/4 bottles with CNS. She was placed on vancomycin with a planned 14 day course. The patient has no systemic signs and symptoms of infection. Follow up surveillance cultures were negative. . # DM2: She was managed with her glyburide and sliding scale insulin. . # Hyperlipidemia: simvastatin . She remains DNR/DNI Medications on Admission: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H prn 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILYI (). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal four times a day. 5. Rozerem 8 mg Tablet Sig: One (1) Tablet PO once a day. 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 10 mg in AM, 5 mg in PM. Disp:90 Tablet(s) Refills:0 7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 13. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 14. Trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO three times a day. 17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 19. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for SOB, wheezing. 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB. 22. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Hypoxemic Hypercarbic Respiratory Failure Discharge Condition: Fair, on Oxygen, nasal canula. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "V45.02", "414.00", "428.33", "491.21", "244.9", "790.7", "327.23", "295.60", "V46.2", "041.10", "293.0", "V45.81", "428.0", "250.00", "518.81", "278.00" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	8949, 9020	5069, 6950	343, 349	9105, 9274	3798, 5046		2297, 2332				9041, 9084		6976, 8926											2347, 2350																	3044, 3779								282, 305										377, 1779							2364, 3030								1801, 2074	2090, 2281
28,447	174,212	32748	Discharge summary	report	Admission Date: [2187-12-7] Discharge Date: [2187-12-25] Date of Birth: [2112-1-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: Traumatic fall resulting in T11-T12 fracture. Major Surgical or Invasive Procedure: 1. Reduction of T11-T12 fracture 2. Posterior instrumented fusion of T10-L3 3. Tracheostomy 4. Percutaneous endoscopic gastrostomy 5. Inferior vena caval filter 6. Tube thoracostomy 7. Continuous bladder irrigation History of Present Illness: HPI: 75 y.o. M presents from [Hospital3 ] intubated, s/p fall from standing on [2187-12-6] 9:00 pm. Fall was not witnessed, and patient refused to go to ED immediately post-fall. on [2187-12-7] at 3:45 am he was transported via ambulance to [Hospital3 ] due to increase in pain, where he was intubated due to declining respiratory status. He was transported to [Hospital1 18] ED, and trauma services consulted us at 14:15 pm. Thoracic CT done here shows severe kyphosis & ankylosing spondylitis with fracture through T11-12 anterior and middle columns. as well as narrowing of space at T11-12 spinal processes. Past Medical History: 1. Chronic obstructive pulmonary disease 2. Ankylosing spondylitis 3. Congestive heart failure 4. Insulin-dependent diabetes mellitus 5. Peripheral vascular disease 6. Hypercholesterolemia 7. Obstructive sleep apnea Social History: Has two drinks of whiskey daily, lives with his wife, non-[Name2 (NI) 1818] x 4 years. Family History: nc Physical Exam: PHYSICAL EXAM: O: T:96.7 BP:161 /92 HR:96 R: 14 O2Sats 100% intubated Gen: Intubated, difficult to arouse, off Propofol x 25 minutes, opens eyes to painful stimuli HEENT: Pupils: 1mm - 0.5 bilaterally, bilateral corneal reflexes present Neck: C-collar Extrem: Severe PVD, with cellulitis, poor perfusion over fingers and toes, cyanotic fingers bilaterally Neuro: Intubated, off propofol x 25 min. does not follow commands, opens eyes to painful stimuli Motor: Withdraws bilateral upper and lower extremities to painful stimuli. Toes downgoing bilaterally Reflexes: Br Pa Ac Right 1 2 1 Left 1 2 1 Pertinent Results: CT T spine 1) Severe kyphosis & ankylosing spondylitis with fracture through T11-12 anterior and middle columns. In inferoposterior corner of T11, T11-12 left facet joint and right T12 pars. There is anterior splaying of the T11-12 disc space, with 2.3cm separation anteriorl; associated closing of space between T11-12 spinal processes. 2) Atelectasis. Interstitial pulmonary edema, bilateral pleural effusion consistent with CHF. Calcific pleural plaques, likely related to old asbestos exposure. WBC RBC Hgb Hct MCV MCH MCHC RDW Plt 9.5 4.61 15.1 45.2 98 32.8* 33.5 14.9 277 Neuts Bands Lymphs Monos Eos 86.4* 7.5* 5.4 0.4 0.3 pH 7.26 pCO2 89 pO2 34 HCO3 42 BaseXS 8 Na:147 K:4.9 Cl:95 TCO2:39 Glu:111 Lactate:1.4 freeCa:1.12 PT: 13.8 PTT: 28.3 INR: 1.2 Trop-T: 0.04 Brief Hospital Course: Pt transferred to [Hospital1 18] from [Hospital3 3583]. Pt arrives intubated. Pt with CT findings compatible with "bamboo spine" likely secondary to ankylosing spondylitis with acute fracture at T11-12. Syndesmophyte disruption along the anterior and posterior longitudinal ligaments with T11 inferior endplate fracture and fracture involving both inferior facet joints. Acute lordotic angulation at T11-12 and marked widening of the disc space also was noted. Follow up MRI revealed ankylosis of the cervical and thoracic spine. Fracture through T11-12 disc with disruption of the anterior and posterior longitudinal ligaments. Mild trauma to the interspinous region without definite evidence of disruption of the ligamentum flavum. No intraspinal hematoma or extrinsic spinal cord compression. No evidence of intrinsic spinal cord signal abnormalities. Pt also noted to have large left-sided pleural effusion on CT of the chest. Initially, fall was thought be related to a coronary event. Pt was seen by cardiology, but given pt's negative CE, EKG, and echo, it was felt that the patient did not fit the profile of an acute ischemic event as the precipitant of his fall. Pt was brought to the OR with neurosurgery on [2187-12-9]. Pt had Laminectomy T10-L2, Pedicle screw insertion, segmental, T10-L3, Local autograft, Posterolateral arthrodesis T10-L3, and fracture reduction, open, T10-L3. In the immediate post op period, the patient was unable to be weaned from his vent. Lasix was administered to decrease pulmonary edema. Pt was noted to have thick secretions requiring frequent suctioning. Repeat chest CT on [12-13] demonstrated a large simple left pleural effusion with partial loculation anteromedially, nodular pleural thickening in right hemithorax, highly suspicious for malignant mesothelioma in the setting of asbestos-related pleural plaques. Further evaluation with PET/CT was requested when patient stabilized. In addition, Pt had left chest tube placed with one liter of effusion removed and sent for cytology. Cytology was negative for malignant cells. Urology was briefly consulted for hematuria in setting of indwelling foley x ~7 days. They recommended urine cytology, CT urogram, and follow up in [3-23] weeks. On [2187-12-21], pt was brought to OR for trach/PEG/filter. He has failed multiple attempts at extubation due to ventilatory failure and CO2 retention. The patient is expected to need long-term ventilatory support. The patient also is not capable of eating and is not expected to be able to eat normally with the tracheostomy in place for prolonged period. He is also at high risk for venous thrombo-embolic disease and has problems with heparinization due to hematuria. He is therefore considered an appropriate candidate for IVC filtration. Patient deemed suitable for vented rehabilatation placement on [2187-12-24]. Medications on Admission: Medications prior to admission: Byetta 10mg [Hospital1 ] Cozaar 50 mg [Hospital1 ] Furosemide 40 mg [Hospital1 ] Cilostazol 100 mg [Hospital1 ] Pravastatin 20 mg QD Lantus 15 units QHS ? Diabetes medicine 4 mg QD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day). Disp:600 cc Refills:2 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). Disp:900 ML(s) Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:10 aerosol Refills:0 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:2 tubes Refills:2 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:10 aerosol Refills:2 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). Disp:[Numeric Identifier 31034] units Refills:2 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:150 ML(s) Refills:2 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain. Disp:150 ML(s) Refills:0 12. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) ml Injection QMOWEFR (Monday -Wednesday-Friday). Disp:100 ml Refills:2 15. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) cc PO TID (3 times a day). Disp:450 cc Refills:2 16. Morphine Sulfate 2 mg IV Q6H:PRN pain 17. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. Disp:100 ml Refills:2 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: 0-28 units Subcutaneous four times a day: FS 121-140, 2 units FS 141-160, 4 units FS 161-180, 6 units FS 181-200, 8 units FS 201-220, 10 units FS 221-240, 12 units FS 241-260, 14 units FS 261-280, 16 units FS 281-300, 18 units FS 301-320, 20 units FS 321-340, 22 units FS 341-360, 24 units FS 361-380, 26 units FS 381-400, 28 units. Disp:1000 units Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. Traumatic fall 2. Ankylosing spondylitis 3. Thoracic spine fracture, T11-T12 4. Chronic obstructive pulmonary disease 5. Congestive heart failure 6. Insulin-dependent diabetes mellitus 7. Obstructive sleep apnea 8. Simple left pleural effusion 9. Hematuria Discharge Condition: Good Discharge Instructions: 1. Call office or go to ER if fever/chills, discharge or redness from surgical wounds, chest pain, shortness of breath, neurological deficits. 2. Follow up with Trauma Surgery and Neurosurgery as indicated. 3. Wean ventilatory support as tolerated. Trach care per protocol. Tube feeds per protocol. 4. Physical therapy per protocol. Followup Instructions: Trauma Surgery, Dr. [Last Name (STitle) ], 1-2 weeks, please call for appointment. Neurosurgery, Dr. [Last Name (STitle) 548], 1-2 weeks, please call for appointment. Urology, Dr. [Last Name (STitle) 770], 1-2 weeks, please call for appointment.	[ "428.0", "E888.9", "805.2", "511.9", "428.22", "518.81", "250.00", "599.7", "496", "263.9", "737.10", "720.0", "272.0", "780.57" ]	icd9cm	[ [ [] ] ]	[ "96.6", "81.05", "96.04", "81.63", "38.7", "31.1", "00.33", "96.72", "43.11", "99.04", "34.04", "99.77", "03.53" ]	icd9pcs	[ [ [] ] ]	8721, 8800	3073, 5981	361, 578	9104, 9111	2257, 3050	9494, 9757	1602, 1606		6261, 8698		8821, 9083		6007, 6007			9135, 9471								1636, 2238												6039, 6238													276, 323										606, 1239															1261, 1478	1494, 1586
16,658	150,900	25609	Discharge summary	report	Admission Date: [2108-7-17] Discharge Date: [2108-7-19] Service: NEUROSURGERY Allergies: Hydrochlorothiazide Attending:[First Name3 (LF) 1835] Chief Complaint: 85 y M s/p fall from bed, R SDH over frontal/parietal convexity. Major Surgical or Invasive Procedure: neuro observation w/ stable SDH History of Present Illness: 85 year old man with cardiac hx, and seizure d/o on dilantin who lives alone, was leaning over to put on slippers at 4AM and tumbled over, hit his head on table. He believes he may have lost consciousness, does not know for how long; got off floor and onto bed, called rescue and was brought to [Hospital3 10310] Hospital, head ct showed sdh and midline shift, was transferred to [Hospital1 18] for further w/u. Of note, pt reports multiple falls in past few months, with hitting head, no loc during those falls. No recent seizure activity. C/o being sleepier than usual today since fall, but able to provide history. Head pain, but no visual/hearing/speech/language/memory/motor/sensory phenomena reported. C/o shoulder, neck pain in addition to head pain. Past Medical History: 1. CAD, s/p 2x CAD/MI 5 yrs ago s/p pacemaker 2. Seizure disorder (no seizures in the past several years) 3. Diabetes 4. BPH 5. HTN 6. Hypothyroid 7. Gout, 8. Cataracts s/p surgery 9. Macular degeneration 10. Multiple falls 11. CHF (EF~20-25%) 12. A Fib 13. h/o CVA w/ central blindness 14. Shoulder Pain Social History: Has 3 daughters who live in [Name (NI) 14663] and a housekeeper that comes q week. He is widowed twice and one of his daughters died several years ago. He is dependent in all his instrumental ADL's (cooking, shopping, transportation, managing finances, and medications) except for grooming. He lives alone in the house he has lived in for the past 20 years. His daughter [Name (NI) 1439] comes to the house TID to prepare meals and administer medications. He prepares his own breakfast. Family History: non-contributory Physical Exam: hr 89 bp 124/68 rr 19 97%RA gen: nad, elderly man, awake and answering questions GCS: 15 Heent: clear op, MMM. scalp lac above right brow; ecchymosis and swelling over high pareital area on right Neck: hard collar in place CV: regular pulm: clear Abd: soft ext: slightly cool but 1+ pulses throughout, no edema Neuro: GCS 15 MS: awake, alert, oriented to self, [2108-6-22], [Hospital1 18] (but says "[Location (un) 8985]" instead of "[Location (un) 86]") CN: perrlb, 3mm->2mm bilat, eomi, no nystagmus, visual fields intact, sensation to lt/pp nl over face, no facial asymmetry, tongue/uvula/palate midline, and scm's strong Motor: Moves all extremities, normal tone; exam limited by pain in bilateral shoulders (says left shoulder chronic), best [1-28] left deltoid with pain, best [2-25] right deltoid with pain; could not assess drift. Biceps and triceps at least 4+/5 and symmetric, with pain, and wrists and finger flexion/extension [4-26]. Lower ext: 5-/5 hip flexion bilat, [4-26] hams/quads and [4-26] foot dorsi/plantarflexion. Coarse postural tremor right worse than left hand. Sensation: intact to LT, PP upper and lower extremities equally Reflexes: 2+ biceps, [Last Name (un) ] bilat; 1+ triceps bilat; 2+ patellars and 1+ achilles bilat, toes downgoing bilat Coordination: slow finger tapping bilat, cannot assess finger to nose because of arm and shoulder pain. Did not assess gait/fall risk with known bleed. Pertinent Results: Labs at arrival to [Hospital1 18]: na 136 cl 104 bun 37 gluc 157 k 3.9 co2 28 creat 1.7 WBC 5.28, Hb 11.1, hct 34.3, plt 147 FSBG 224 INR 1.06 [2108-7-17] 10:15AM BLOOD Glucose-210* UreaN-35* Creat-1.5* Na-141 K-3.9 Cl-103 HCO3-29 AnGap-13 [2108-7-19] 06:30AM BLOOD Glucose-108* UreaN-29* Creat-1.4* Na-140 K-3.6 Cl-102 HCO3-28 AnGap-14 [2108-7-18] 02:13AM BLOOD PT-13.1 PTT-22.1 INR(PT)-1.1 [2108-7-19] 06:30AM BLOOD PT-13.2 PTT-25.3 INR(PT)-1.2 [2108-7-17] 10:10AM BLOOD WBC-10.5 RBC-4.63 Hgb-11.7* Hct-35.9* MCV-78* MCH-25.3* MCHC-32.5 RDW-16.1* Plt Ct-141* [2108-7-19] 06:30AM BLOOD WBC-13.5# RBC-4.10 Hgb-10.3* Hct-31.9* MCV-78* MCH-25.1* MCHC-32.2 RDW-16.0* Plt Ct-129* Dilantin = 13.0 ([7-19]) Digoxin = 1.9 ([7-19]) Brief Hospital Course: Mr. [Known lastname 63916] is an 85 year old who presented to [Hospital1 18] s/p mechanical fall from bed. CT performed in the ED showed right temporo-parietal subdural hematoma <~11mm with mild midline shift and multiple old infarcts in his left occipital lobe, unchanged from his outside hospital scan. On initial presentation he was c/o being sleepier than usual, however he was able to provide a history. He was A&Ox3 He was admitted to the trauma ICU for q 2 hour neuro checks and observation. He was started on Dilantin seizure prophylaxis and his anticoagulation medicaitons were held. On hospital day #2, a repeat CT scan showed an unchanged R subdural hematoma and his neurological status remained unchanged. He was transfered to the floor and tolerated a regular diet. His dilantin level was maintained at a therapeutic level. A geriatrics consult was obtained and recommendations were made to assess the patient's home enviroment for safety. We have recommended that he follow-up with their service or his primary doctor [First Name (Titles) ] [Last Name (Titles) ] of his poly-pharmacy. On hospital day #3, he remained neurologically stable. He was awake, alert, oriented with GCS= 15 and denied headache, visual changes, or n/v. His motor exam was [3-27] GS, 4+ biceps, and 4 triceps bilaterally. His dilantin level and digoxin level were therapeutic on discharge. He will follow-up with Dr. [Last Name (STitle) ] in 4 weeks in clinic with a CT scan prior to his appointment. He is to continue his dilantin therapy for seizure prophylaxis. Medications on Admission: Protonix 40 mg daily Plavix 75mg daily Dilantin 100mg TID Lasix 80 mg daily Synthroid 0.075mg daily Allopurinol 300mg daily Amiodarone 400mg daily Digoxin 0.125 mg daily Lescol 5mg daily Glyburide 10mg daily Proscar 5mg daily Toprol 50mg daily Aldactone 12.5 mg daily Nitropatch 0.4mg qhs Discharge Medications: Allopurinol 300mg PO daily Calcium Carbonate 650mg PO BID Digoxin 0.125 PO daily Lasix 40mg PO daily Glyburide 10mg PO QAM Synthroid 75mcg PO daily Lisinopril 5mg PO daily Metoprolol XM 25mg daily Pantoprazole 40mg PO daily Phenytoin 100mg PO TID Spironolactone 12.5 PO QHS Discharge Disposition: Extended Care Facility: Rehab -[Location (un) 14663] Discharge Diagnosis: Traumatic subdural hematoma -stable. Discharge Condition: stable Discharge Instructions: Please [Name8 (MD) 138] M.D. for fever > 101.5, exacerbation of symptoms, change in mental or neurological status. Please call clinic for follow-up appointment and schedule head CT prior to follow-up with Dr. [Last Name (STitle) ]. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in the [Hospital 4695] clinic in 4wks with repeat head CT scan prior to his appointment. Follow-up with Geriatrics ([Telephone/Fax (1) 719]) for [Telephone/Fax (1) ] of his poly-pharmacy and home safety evaluation. Follow-up with primary doctor [First Name (Titles) ] [Last Name (Titles) ] of medications and fall risk reduction. Completed by:[2108-7-19]	[ "414.00", "852.21", "600.00", "250.00", "244.9", "458.0", "E884.4", "V45.01", "427.31", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6513, 6572	4295, 5874	296, 329	6652, 6660	3505, 4272	6948, 7374	1982, 2000		6214, 6490		6593, 6631		5900, 6191			6684, 6925								2015, 3486																									192, 258										357, 1125															1147, 1454	1470, 1966
59,924	158,989	40025	Discharge summary	report	Admission Date: [2175-3-31] Discharge Date: [2175-4-13] Date of Birth: [2107-8-31] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5569] Chief Complaint: abdominal pain, ischemic colitis Major Surgical or Invasive Procedure: [2175-3-31] open 4.2 cm infrarenal AAA repair w/ 18 mm Dacron tube graft [2175-4-2] exploratory laparotomy with sigmoid colectomy and end colostomy. History of Present Illness: The patient, a lovely, active, 67-year-young hypertensive former heavy cigarette smoking lady with emphysema, moderately-severe obstructive chronic pulmonary disease with recurrent pneumonias, presenting to Vascular Surgery (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43078]) with 3 weeks with atheroembolization, clearly tender purple toes, and to have a 4.2-cm intact infrarenal aneurysm, likely with shaggy thrombus by CTA. After medical optimization, cardiac and pulmonary optimization by Dr. [Last Name (STitle) 88034] and Dr. [Last Name (STitle) 88035], and after a full discussion of the risks, benefits, and alternatives including aortobifemoral bypass and transfemoral stent graft repair, the patient and her family desire definitive repair, accepting nonpulmonary complications, specifically higher in her case. Past Medical History: PMH: left thalamic ICH [10-16], HTN, COPD, thyroid disease, CAD, type 2 diabetes mellitus, previous smoker PSH: Open infrarenal AAA repair w/ dacron [2175-3-31] (Dr. [Last Name (STitle) 43078]; TAH and BSO Social History: Substance use history: per family, h/o EtOH > 20 years ago, now occasionally has one glass of wine during special occasions. Per OMR, h/o 40 pack-years tobacco, quit [2169]. No other substances. Family History: Father died age [Age over 90 ] w/complications of Alzheimer's. Mother is aged 96 w/mild memory issues and is retired RN. Physical Exam: Physical exam on [4-2] by Transplant/Hepatobiliary Consult: VS: 99.9 99.6 87-92 150's/60's 17 99% 2L I/O's: 2230/780 BMx2 CVP 7-9 UOP: 100 cc last hr Gen: AOx1-2, lethargic CVS: RRR Pulm: increased work or breathing Abd: Distended, TTP throughout + rebound +voluntary guarding. Peritonitis LE: No LLE, warm well perfused Pertinent Results: Labs: [2175-4-2] 7.0>26<103 133 104 19 AGap=6 -------------< 151 4.8 28 0.8 Ca: 8.1 Mg: 2.1 P: 2.0 ALT: 26 AP: 71 Tbili: 0.5 AST: 48 LDH: 251 [Doctor First Name ]: 59 Lip: 16 Lactate:0.9 pH 7.35 pCO2 46 pO2 93 HCO3 26 BaseXS 0 Imaging: [4-2]: CT Abd: s/p AAA repair w/ expected postsurgical appearance surrounding aorta and expected small pneumoperitoneum. Intermediate density fluid layer in pelvis, likely postsurgical. No e/o aorto-enteric fistula. Nonspecific mildly dilated loops of small bowel w/ fluid levels, but no transition point, may represent post-op ileus but early ischemia not entirely excluded. Although there is normal bowel wall enhancement throughout and no pneumatosis. Study not timed for eval of vessels but celiac and SMA appear patent w/ atherosclerotic calcification at origin. [Female First Name (un) 899] not well visualized. Moderate b/l simple fluid attenuation pleural effusions. [4-6]: Low lung volumes but no acute intrathoracic process [4-7]: CT abd: There are moderate bilateral pleural effusions, not significantly changed compared with the prior study. There is associated compressive atelectasis at the lung bases. There is a small amount of perihepatic fluid. No biliary duct dilatation. The patient is status post abdominal aortic aneurysm repair and there is a small amount of air seen within the aneurysm sac. This has decreased significantly in extent compared to the prior study. The pancreas is unremarkable in appearance. There has been interval creation of a left lower quadrant colostomy. There is a small amount of free fluid in the right paracolic gutter. No enlarged mesenteric or retroperitoneal lymph nodes. Atherosclerotic calcification of the aorta involves the origin of both the celiac and SMA. This is also unchanged compared to multiple prior studies. There is a tiny amount of free air seen anteriorly within the abdomen at the level of the stomach (2:28); this was present on the prior study also. Brief Hospital Course: Ms. [Known lastname ] [Last Name (Titles) 1834] elective open 4.2 cm infrarenal AAA repair w/ 18 mm Dacron tube graft on [2175-3-31] with Vascular Surgery (Dr. [Last Name (STitle) 43078]. The patient had been doing as expected post-operatively until early [2175-4-2] when she started having increased confusion and lethargy when OOB to chair. Her mental status continued to wax and wane throughout the day. Her abd was increasingly distended and tender to palpation with concern for peritonitis. She started V/C/F. Guaiac originally was negative, and she had a normal brown BM around 4PM. However, 1 hr later the patient had a moderate BM with blood and no clots. On examination, she was markedly distended and diffusely tender with guarding. CT scan was fairly unrevealing demonstrating simply fluid in the pelvis and perihepatic space but no clear changes for ischemia in her colon. Laboratory studies have been relatively unremarkable. However, given the patient's significant exam and clinical course following her AAA repair, concern for ischemic colitis is significant. Risks and benefits of exploratory laparotomy, sigmoid colectomy and end colostomy were discussed with the patient and her family. The patient was somewhat confused so her daughter, her healthcare proxy, provided consent. Patient [Month/Day/Year 1834] exploratory laparotomy with sigmoid colectomy and end colostomy. She was transferred to the SICU for continuing resuscitation and monitoring post-operatively. Patient was extubated on POD#1 ([2175-4-3]) of her colectomy. Patient was found to be confused after extubation. A CT scan of her head showed resolving thalamic hemorrhage, maxillary sinus swollen. A diagnosis of post-operative delirium was made with Psychiatry consult on [4-5]. She was taken off Ativan and given Precedex which improved her mental status mildly. On [4-8], she was started on clear liquid diet given gas in ostomy bag but promptly vomited and the ICU team held off on further POs. Her Plavix was restarted on [4-8]. TPN was continued. Vancomycin was discontinued in the morning. She received nebulizer treatments for wheezing every 4hrs. She was given a one time dose of Lasix 20mg x 2 for a goal diuresis of 1L per day. Her mental status continued to improve. During workup of her post-operative delirium, she had an RPR that was sent that came back positive. Treponemal antibodies were sent. ID deferred treatment until the results from these tests returned back. On [4-9], she was transferred to the floor. She was started on Lasix 20mg IV twice a day for anasarca. She continued to produce gas in her ostomy bag w/ little output after her transfer out of the unit. Her nausea and vomiting resolved. TPN was continued on the floor. On [4-11], she had a KUB to evaluate for an ileus/obstruction and revealed no abnormalities. She was advanced to a regular diet. She tolerated a regular diet and had a slight increase in ostomy output (30ccs). The primary team recommended milk of magnesia, but did not receive a dose prior to her transfer to rehab. On [4-12], she continued to tolerate a regular diet and TPN was discontinued. Her weight continued to trend down, but she had persistent lower extremity edema. She received [Male First Name (un) ] hose. She was switched from IV to PO Lasix. On the day of discharge, her weight was down to 68.9kgs, which was slightly higher than her admission weight 63.5kgs. The results from her treponemal antibodies returned back nonreactive and quantitative RPR titers were 1:2. Medications on Admission: Cozaar 100 mg PO daily , Lopressor 25mg PO BID HCTZ 12.5mg PO daily Xanax 0.25 mg PO prn Home oxygen 2.5 L at night, and sometimes during the day Symbicort [Hospital1 ], ProAir prn Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation q4h () as needed for sob, wheezing. 9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 10. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. 13. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO ONCE (Once) for 1 doses: Dose can be given at rehab. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: Ischemic Colitis . Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you during your hospital. You were admitted after you developed acute abdominal pain. We found that you had ischemic colitis. During your hospitalization, you had a sigmoid colectomy, Hartmann's procedure and an end colostomy was placed. You tolerated the procedure. You tolerated the procedure well and you are now ready for discharge. Prior to discharge, you worked with an ostomy nurse and she provided instructions on how to care for your ostomy after discharge. Please record the output of your ostomy daily and take note of the quantity, color and consistency. If you notice increased ostomy output, please call your primary care physician or surgeon. During your hospitalization, we changed a few of your medications, which include a diuretic called Lasix. Please continue to take this medication after discharge. It will reduce the fluid retention in your lower extremities. You will be transferring to NewEngland [Hospital1 ] in [Location (un) 701] Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 to 2 weeks. Please see below for your appointment details: Provider: [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2175-4-28] 1:40	[ "998.59", "401.9", "276.69", "276.3", "285.9", "V15.82", "441.4", "557.0", "445.02", "496", "567.29", "V46.2", "E878.2", "293.0", "571.5", "568.0", "789.59", "250.00", "458.29", "414.01" ]	icd9cm	[ [ [] ] ]	[ "03.90", "38.14", "38.44", "46.10", "00.40", "99.15", "45.76", "54.59" ]	icd9pcs	[ [ [] ] ]	9689, 9771	4416, 8015	337, 496	9853, 9853	2388, 4393	11067, 11340	1860, 1988		8251, 9666		9792, 9792		8041, 8228			10004, 11044								2003, 2369																									264, 299										524, 1382						9811, 9832		9868, 9980							1404, 1625	1641, 1844
3,974	117,581	8333+8334	Discharge summary	report+report	Admission Date: [2144-7-14] Discharge Date: Date of Birth: [2085-10-3] Sex: F Service: Coronary Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 59 year old woman with a five day history of inspiratory chest pressure, which increased over the last three days to shortness of breath at rest, orthopnea and paroxysmal nocturnal dyspnea. The patient went to see her primary care physician, [Name10 (NameIs) 1023] discovered a new systolic murmur associated with a low grade fever. The patient was noted to have a white blood cell count of 14,000 and was admitted to [Hospital3 3834]. A transthoracic echocardiogram at that point showed severe mitral regurgitation which was previously unknown, inferior hypokinesis but no vegetations. Blood cultures were drawn at that time and the patient was prophylactically begun on vancomycin, ciprofloxacin and gentamicin. Cardiac enzymes were cycled and CK came back at 78 and troponin 0.231. The patient's shortness of breath worsened throughout her hospital course and a CT scan of the chest was performed to rule out dissection, which was negative. Electrocardiogram showed ST elevation in inferior leads and the patient was transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for a cardiac catheterization. Upon admission to the catheterization laboratory, the patient was noted to be in severe respiratory distress. She was intubated and had transient hypotension requiring Dopamine for blood pressure support. Cardiac catheterization showed 40% eccentric left main stenosis, and 95% mid-right coronary artery, which was stented and had 0% residual. The patient was then transferred to the Coronary Care Unit for hemodynamic monitor and stabilization while on an intra-aortic balloon pump. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Severe trigeminal neuralgia. 3. Porphyria cutanea tarda. 4. Raynaud's syndrome. 5. Chronic pain syndrome. 6. Depression. 7. Migraines. PAST SURGICAL HISTORY: Left eye enucleation. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient does not use alcohol but has a smoking history. ALLERGIES: Sulfa, Valium, erythromycin and barbiturates. MEDICATIONS ON TRANSFER: Lovenox 40 mg s.c.b.i.d., fentanyl patch 100 mcg q.3 days, vitamin E, vitamin B12, Lopressor 12.5 mg p.o.q.6h., Protonix 40 mg p.o.b.i.d., ibuprofen 1,600 mg p.o.q.d. PHYSICAL EXAMINATION: On physical examination on admission to the Coronary Care Unit, the patient had a temperature of 97, blood pressure 131/69, heart rate 119, respiratory rate 15; ventilator settings, tidal volume 600, respiratory rate 15, PEEP 5, FiO2 100%. General: Patient intubated and sedated but occasionally responsive to sternal rub. Head, eyes, ears, nose and throat: Non-elevated jugular venous pressure, right pupil reactive, left eye prosthesis, neck supple, no lymphadenopathy. Cardiovascular: Tachycardia, III/VI early peaking systolic murmur, no rubs or gallops. Chest: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: 1+ dorsalis pedis and 2+ posterior tibialis pulses bilaterally, no lower extremity edema, no bruits appreciated over catheterization site. Neurologic: Patient moved all four extremities spontaneously. LABORATORY DATA: Admission white blood cell count was 14.1, hemoglobin 9.7, hematocrit 28, platelet count 295,000, sodium 136, potassium 3.2, chloride 101, bicarbonate 20, BUN 16, creatinine 0.7, glucose 213, calcium 7.3, phosphorous 4.7 and magnesium 1.7. Electrocardiogram status post catheterization showed normalization of ST changes in inferior leads, with mild diffuse ST changes in the septal and lateral leads with a left atrial abnormality, patient was in sinus rhythm. CORONARY CARE UNIT COURSE: 1. Coronary artery disease: The patient was stabilized in the catheterization laboratory and sent up to the floor on an Integrilin drip which was continued for 18 hours, aspirin and Plavix for an inferior myocardial infarction. Please see history of present illness section for the complete cardiac catheterization report. The intra-aortic balloon pump was pulled on hospital day number one with no complications. The patient was started on Captopril which was titrated up to 50 mg three times a day and metoprolol which her blood pressure did not tolerated, so this was not continued. Natrecor and intravenous nitroglycerin were used to maintain a systolic blood pressure around 110. Nipride was transiently used for additional blood pressure control. 2. Valvular dysfunction: The patient was admitted with new onset severe mitral regurgitation, which was noted at the outside hospital. It is assumed that the mitral regurgitation was due to an ischemic event. An echocardiogram performed at [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] showed 3+ mitral regurgitation, no aortic insufficiency, inferior hypokinesis, akinesis and a left ventricular ejection fraction of 45%. The patient was aggressively diuresed with Lasix as needed, with Natrecor and intravenous nitroglycerin for preload control while in the Coronary Care Unit. Despite medical management, her mitral regurgitation persisted and there seemed to be no improvement with revascularization. Therefore, the patient was taken to the Operating Room on [2144-7-28] for a mitral valve replacement and coronary artery bypass grafting. 3. Infectious disease: The patient was admitted to the outside hospital with a low grade fever in the setting of a new onset systolic murmur. She was pancultured and started on empiric antibiotics. Blood cultures were negative for any organisms. Upon transfer to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], the patient was febrile throughout her Coronary Care Unit course, with temperature spikes to 102 to 103. The patient defervesced only briefly on hospital day number two. Her white blood cell count was elevated for a majority of the time, with the high reaching 18,000. The patient was blood cultured times ten, with no growth on any sample. Sputum culture on [2144-7-15] showed E. coli which was pansensitive. The patient was treated with aspiration pneumonia with a course of Levaquin and ceftazidime for seven days. A transesophageal echocardiogram was performed to rule out the possibility of endocarditis as fevers remained elevated for the first two weeks of hospitalization, which showed no vegetations but was consistent with 3+ mitral regurgitation. Upon discontinuation of ceftazidime and Levaquin, the patient's fever defervesced, her white blood cell count fell and her differential count was noted to have 5% eosinophils. Therefore, it was assumed that the patient elevated fever was related to a drug reaction to ceftazidime. Of note, after discontinuation of the medications, a rash appeared on both the trunk and the arms. The rash was much improved on transfer. 4. Hematology: The patient had a falling hematocrit status post her coronary artery bypass grafting. Given her history of coronary disease, the patient was transfused on three occasions of two units, for a total of six units. She has stabilized at a hematocrit of 35. Concerning her porphyria cutanea tarda, her primary hematologist, Dr. [First Name8 (NamePattern2) 1692] [Last Name (NamePattern1) 14714], was contact[Name (NI) ] and indicated no acute intervention for the disease at this point. He also stated that there was no contraindication for the cardiothoracic surgical procedure and there was no reason the patient could not be started on warfarin post procedure. 5. Pulmonary: The patient was extubated on hospital day number two. She continued to have an oxygen requirement of five liters via nasal cannula throughout her Coronary Care Unit course. This was thought to be secondary to pulmonary edema from pulmonary congestion from her mitral regurgitation as well as a left lower lobe aspiration pneumonia, which was treated. 6. Disposition: The patient was transferred to the cardiothoracic surgery service on [2144-7-26] for mitral valve replacement with coronary artery bypass grafting. An additional discharge summary will be dictated upon discharge from the surgery service. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 6240] MEDQUIST36 D: [2144-7-31] 11:44 T: [2144-8-3] 07:40 JOB#: [Job Number ] Admission Date: [2144-7-14] Discharge Date: [2144-8-3] Date of Birth: [2085-10-3] Sex: F Service: Cardiothoracic Surgery CHIEF COMPLAINT: Chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 1511] is a 58-year-old woman with a 5-day history of chest pain and dyspnea on exertion, progressively worsening. She went to see her primary care physician who heard [Name Initial (PRE) ] [3-25] murmur. She had a low-grade fever at this time, and an echocardiogram performed at [Hospital3 15174] revealed severe mitral regurgitation, inferior hypokinesis, and no vegetation. She was subsequently transferred to [Hospital1 190] for cardiac catheterization. Left main coronary artery revealed a 40%, left anterior descending artery with minor irregularities, left circumflex was diminutive. The right coronary artery was a large dominant vessel with diffuse irregularities. The middle right coronary artery was 95% stenosed. A stent was placed, and post stent examination revealed 0% stenosis. Ms. [Known lastname 1511] was placed on aspirin, Plavix, and Integrilin for eight hours, nitroglycerin, and started on an ACE inhibitor. Ms. [Known lastname 19161] subsequent hospital course was remarkable for fever and an elevated white blood cell count. Sputum cultures grew out Escherichia coli which were sensitive to Levaquin and ceftazidime. Ms. [Known lastname 1511] was double-covered with both Levaquin and ceftazidime for this pneumonia. Ms. [Known lastname 1511] continued to be followed, but her condition was not improving following stent revascularization. Therefore, she was subsequently evaluated for surgical intervention. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Porphyria cutanea tarda. 3. Raynaud's phenomenon. 4. Trigeminal neuralgia. 5. Chronic pain syndrome. 6. Migraines. 7. Depression. FAMILY HISTORY: Family history was unremarkable. SOCIAL HISTORY: Ms. [Known lastname 1511] is a smoker. MEDICATIONS ON ADMISSION: Outpatient medications included Fentanyl patch 100 mcg every 72 hours, Dilaudid 2 mg p.o. as needed, Protonix 40 mg p.o. q.d., ibuprofen 800 mg p.o. b.i.d., vitamin E, vitamin B12. ALLERGIES: Intolerant to SULFA, BARBITURATES, ERYTHROMYCIN, VALIUM. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed a temperature of 97, blood pressure was 133/96, heart rate was 103, respiratory rate was 15, oxygen saturation was 98%. The head was normocephalic and atraumatic. The neck was supple with no bruits. Heart was regular in rate and rhythm with a 2/6 systolic ejection murmur. The chest was clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended, with normal active bowel sounds. The extremities were without clubbing, cyanosis or edema. HOSPITAL COURSE: Following medical management, Ms. [Known lastname 1511] was subsequently taken to the operating room on [2144-7-28] for coronary artery bypass graft times two and mitral valve replacement. The coronary artery bypass graft grafts included left internal mammary artery to left anterior descending artery and saphenous vein graft to right coronary artery. The mitral valve was replaced with a #25 CarboMedics mechanical valve. The operation was performed without complications, and Ms. [Known lastname 1511] was subsequently transferred to the Cardiothoracic Intensive Care Unit. She was weaned off drips and extubated. She was hemodynamically stabilized and transfused packed red blood cells due to a decreased hematocrit. On postoperative day two, Ms. [Known lastname 1511] was transferred to the floor. Coumadin therapy was started, and Plavix was discontinued when Coumadin reached a therapeutic level. Ms. [Known lastname 1511] continued to do well. She was tolerating an oral diet, and her pain was controlled with oral medications and a Fentanyl patch. She was ambulating well with Physical Therapy. DISCHARGE DISPOSITION: On [2144-8-3], Ms. [Known lastname 1511] was felt to be stable to be discharged home with home oxygen and visiting nurse assistance. PHYSICAL EXAMINATION ON DISCHARGE: Physical examination on discharge revealed the patient was afebrile, vital signs were stable. The head was normocephalic and atraumatic. The neck was supple. The lungs were clear to auscultation bilaterally. The heart was regular in rate and rhythm. The incision was clean, dry, and intact. The abdomen was soft, nontender, and nondistended, with normal bowel sounds. Extremities were without clubbing, cyanosis or edema. MEDICATIONS ON DISCHARGE: 1. Docusate 100 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. q.d. 3. Captopril 50 mg p.o. t.i.d. 4. Protonix 40 mg p.o. q.d. 5. Metoprolol 75 mg p.o. b.i.d. 6. Fentanyl patch 100 mcg q.72h. 7. Dilaudid 2 mg to 4 mg p.o. q.4-6h. as needed for pain. 8. Lasix 20 mg p.o. q.d. (times seven days). 9. Potassium chloride 20 mEq p.o. q.d. (times seven days). 10. Ibuprofen 600 mg p.o. q.4-6h. as needed. 11. Warfarin 3 mg p.o. q.d. (or as directed). DISCHARGE FOLLOWUP: Ms. [Known lastname 1511] was to follow up with her primary care physician in three to four weeks and with Dr. [Last Name (STitle) 70] in six weeks. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Ms. [Known lastname 1511] was to be discharged home with visiting nurse assistance. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times two. 2. Mechanical mitral valve replacement. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 11235] MEDQUIST36 D: [2144-8-6] 11:09 T: [2144-8-6] 12:52 JOB#: [Job Number 29506]	[ "414.01", "714.0", "443.0", "424.0", "428.0", "507.0", "410.41" ]	icd9cm	[ [ [] ] ]	[ "36.11", "35.24", "96.71", "88.56", "36.15", "39.61", "37.23", "99.20", "96.04" ]	icd9pcs	[ [ [] ] ]	12838, 13001						10749, 10783	14296, 14684				13472, 13927	10871, 11662	11681, 12814								2090, 2113																2503, 8956		14131, 14275	13016, 13445								8974, 9011			13948, 14116							9040, 10543														2311, 2480	10565, 10731	10800, 10844
202	108,295	9855	Discharge summary	report	Admission Date: [2145-10-22] Discharge Date: [2145-10-24] Date of Birth: [2070-1-17] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 783] Chief Complaint: Left Flank Pain Major Surgical or Invasive Procedure: Percutaneous Nephrostomy Tube Placement History of Present Illness: 75 year old female with history of right staghorn calculi, colon cancer, and hyptertension, who presented to her PCP 2 days prior to admission with complaints of left flank pain, chills, and decreased urine output for 3 days. Pt was started on cipro and flagyl for presumed diverticulitis. When WBC returned high, the patient was sent for outpatient CT scan which revealed new left 6mm obstructing stone at the urovesicular junction with mild hydronephrosis, ureteral dilation, and perinephric stranding. Pt was subsequently sent to [Hospital 882] Hospital where she was found to have WBC 27.8, Creat 3.4, and UA with 100 WBC, + heme, +leuk esterases. At the time her BP was 88/43 after 3L of IVF and pt was started on dopamine and transferred to [Hospital1 18] and urology team was consulted. Past Medical History: 1. R Staghorn nephrolithiasis for 20years on ampicillin prophylaxis and now atrophic 2. Colon CA s/p resection '[40] 3. Tonsillectomy 4. HTN 5. Diverticulitis 6. h/o EtOH abuse Social History: Pt lives with husband [Name (NI) ] [Telephone/Fax (1) 33105]. Pt has 2 children and 4 grand children. Has a remote hx of smoking (20pack years but quit 20 years previous) and hx of EtOH abuse. She quit drinking 9 years previous. Family History: NC Physical Exam: Physical Exam: VS: Tc: 98.8 HR: 88 BP: 115/60 RR: 12 SaO2: 98% on 2L NC Gen: pleasant female lying in bed in NAD. Conversing in full sentences and interacting appropriately. HEENT: PERRL, EOMI, mmm CV: RRR, S1, S2, no murmurs, rubs, gallops Chest: CTA bilaterally Abd: soft, NT, ND, BS+ Back: no CVA tenderness Ext: warm, well perfused, no clubbing, cyanosis, edema Neuro: A+O x3. Pertinent Results: CXR [2145-10-22] 12:03 AM: 1) Cardiomegaly and minor left basilar atelectatic changes. 2) Hiatal hernia. . [2145-10-24] 05:49AM BLOOD WBC-9.1 RBC-3.08* Hgb-8.9* Hct-27.3* MCV-89 MCH-28.8 MCHC-32.6 RDW-17.9* Plt Ct-184 [2145-10-23] 10:32PM BLOOD Hct-26.3* [2145-10-23] 04:00AM BLOOD WBC-12.9* RBC-2.93* Hgb-8.4* Hct-26.2* MCV-89 MCH-28.8 MCHC-32.3 RDW-18.1* Plt Ct-177 [2145-10-22] 05:38AM BLOOD WBC-19.7* RBC-3.35* Hgb-9.7* Hct-29.7* MCV-89 MCH-28.9 MCHC-32.6 RDW-17.6* Plt Ct-225 [2145-10-21] 11:40PM BLOOD WBC-25.7* RBC-3.55* Hgb-10.3* Hct-31.0* MCV-87 MCH-29.1 MCHC-33.3 RDW-16.6* Plt Ct-206 [2145-10-24] 05:49AM BLOOD Neuts-67.2 Lymphs-25.0 Monos-4.3 Eos-2.8 Baso-0.7 [2145-10-23] 04:00AM BLOOD Neuts-84.3* Bands-0 Lymphs-11.7* Monos-2.3 Eos-1.5 Baso-0.3 [2145-10-22] 05:38AM BLOOD Neuts-91.1* Bands-0 Lymphs-6.6* Monos-2.0 Eos-0.2 Baso-0.1 [2145-10-21] 11:40PM BLOOD Neuts-84* Bands-6* Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2145-10-22] 05:38AM BLOOD PT-13.9* PTT-28.6 INR(PT)-1.2 [2145-10-21] 11:40PM BLOOD PT-14.4* PTT-23.5 INR(PT)-1.3 [2145-10-24] 05:49AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-139 K-3.4 Cl-109* HCO3-25 AnGap-8 [2145-10-23] 10:32PM BLOOD Glucose-90 UreaN-20 Creat-0.8 Na-139 K-3.5 Cl-109* HCO3-24 AnGap-10 [2145-10-23] 04:00AM BLOOD Glucose-87 UreaN-26* Creat-1.0 Na-142 K-3.1* Cl-113* HCO3-23 AnGap-9 [2145-10-22] 05:38AM BLOOD Glucose-108* UreaN-48* Creat-1.6* Na-142 K-3.5 Cl-111* HCO3-20* AnGap-15 [2145-10-21] 11:40PM BLOOD Glucose-85 UreaN-54* Creat-2.0* Na-141 K-2.7* Cl-109* HCO3-15* AnGap-20 [2145-10-24] 05:49AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.5* [2145-10-23] 10:32PM BLOOD Calcium-8.2* Phos-1.7* Mg-1.6 [2145-10-23] 04:00AM BLOOD Calcium-7.9* Phos-2.0# Mg-1.5 Iron-14* [2145-10-22] 05:38AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.8 [2145-10-21] 11:40PM BLOOD Calcium-7.3* Phos-3.6 Mg-1.6 [2145-10-23] 04:00AM BLOOD calTIBC-183* Ferritn-136 TRF-141* CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2145-10-24]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. URINE CULTURE (Final [2145-10-23]): NO GROWTH. AEROBIC BOTTLE (Final [2145-10-28]): NO GROWTH. ANAEROBIC BOTTLE (Final [2145-10-28]): NO GROWTH. . [Numeric Identifier 33106] INTRO CATH OR STENT INTO URETHER [2145-10-22] 10:20 AM Reason: Please place nephrostomy tube Contrast: [Hospital 13288] [Hospital 93] MEDICAL CONDITION: 75 year old woman with L obstructive UVJ stone, renal failure, and urosepisis REASON FOR THIS EXAMINATION: Please place nephrostomy tube HISTORY: A 75-year-old female with urosepsis, ureteral stone, and need for decompression of the renal collecting system. PROCEDURE/FINDINGS: The procedure was performed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ]. Dr. [Last Name (STitle) ], the staff radiologist, was present and supervising throughout. After the risks and benefits of the procedure were discussed with the patient and informed consent was obtained, the patient was placed prone on the angiography table. Her left flank was prepped and draped in the standard sterile fashion. 400 mg of intravenous Ciprofloxicin was administered. The skin and subcutaneous tissues in the left flank region were anesthetized with 10 cc of 1% Lidocaine. Using ultrasound guidance, attempts were made to advance a 22-gauge Chiba needle into a posterior lower pole calyx. After several attempts, however, this proved unsuccessful. The patient was then given 40 cc of 60% Optiray intravenously. Using fluoroscopy, a new 22-gauge Chiba needle was advanced through an anesthetized region in the left flank into an opacified middle pole calyx. After the stylet was removed, urine was aspirated confirming our position within the renal collecting system. The urine sample was sent for culture. An antegrade nephrostogram was then performed via hand injection of nonionic contrast. This revealed a mildly dilated collecting system with complete obstruction identified at the level of the distal ureter. A .018 guide wire was advanced through the Chiba needle into the proximal ureter under fluoroscopic visualization. The skin entry site was incised with a #11 blade scalpel. The access needle was exchanged for a 6-French Accustick sheath with inner dilator and metallic stiffener. Upon entry into the renal parenchyma, the metallic stiffener was removed. The Accustick sheath and inner dilator were advanced over the wire until the tip was positioned in the proximal ureter. The guide wire and inner dilator were removed. A .035 [Last Name (un) 33107] wire was then advanced through the Accustick sheath into the distal ureter. The [Last Name (un) 33107] wire could not be advanced beyond the area of obstruction into the bladder. At this time, the Accustick sheath was exchanged for a 6-French 23 cm bright-tip angiographic sheath. With the sheath tip positioned in the proximal ureter, a 5-French Kumpe catheter was advanced through the angiographic sheath into the distal ureter. Using the [Last Name (un) 33107] wire, attempts were made to traverse the area of obstruction. Again, this was unsuccessful and the [Last Name (un) 33107] wire was exchanged for a .035 angled glidewire. Using this wire, in combination with the 5-French Kumpe catheter, the area of obstruction was successfully passed. With the glidewire positioned in the bladder, beyond the area of obstruction, the Kumpe catheter was exchanged for a 5-French vertebral catheter. The glidewire was then exchanged for a .035 super-stiff Amplatz wire. At this time, the vertebral catheter and 6-French angiographic sheath were removed. An 8-French 24 cm internal/external nephroureteral stent was then advanced over the Amplatz wire into the bladder. The super-stiff Amplatz wire was removed. The catheter pigtails were formed and locked in the bladder and in the right renal pelvis. A hand injection of nonionic contrast confirmed the appropriate positioning of the nephroureteral stent. The catheter was secured to the skin using a #0 silk suture. A Stat- Lock device was applied, followed by a dry sterile dressing. The catheter was placed to external bag drainage and may be capped in approximately 24 hours. COMPLICATIONS: None. MEDICATIONS: 1% Lidocaine. 400 mg intravenous Ciprofloxicin. 2 mg of Versed and 100 mcg of Fentanyl were administered in intermittent doses with continuous monitoring of vital signs by the nursing staff. CONTRAST: 90 cc of 60% Optiray. IMPRESSION: 1. Antegrade nephrostogram revealed mild left hydronephrosis with a complete obstruction identified at the level of the distal ureter, secondary to stone presence. 2. Successful placement of a 24 cm 8 French internal/external nephroureteral stent via a left posterior middle pole calyx. The catheter has side holes extending throughout its length and was placed to external bag drainage. The catheter may be capped for internal drainage in approximately 24 hours. Brief Hospital Course: 75 year old female with right staghorn calculi for >20 years and new left obstructing calculi with hydronephrosis, ureteral dilation and perinephric stranding associated with increasedd WBC count, tachycardia, hypotension refractory to fluids and increased creatinine. . 1. Sepsis: Although pt has no fever and no tachypnea, pt does have an elevated white count, with tachycardia as well as a positive UA suggesting pylonephritis and urosepsis. . A). Source was most likely urosepsis with positive UA, and obstructing stone by CT scan. She was treated with broad spectrum antibiotics with cefepime and cipro. Urology was already consulted as was IR. A percutaneous nephrostomy tube was placed [10-22] by IR with resultant good urine output. . B). Hemodynamics: Pt had hypotension temporarily requiring pressors and IVF to bring up CVP. Pressors were successfully weaned. She had been mentating appropriately suggesting mental status would be an appropriate measure. . 2. Acute Renal Failure: It was secondary to obstructive stone lesion (pt already with atrophic R kidney, now presenting with obstructive lesion in L kidney). No history of renal insufficiency as per patient. The percutaneous nephrostomy tube was placed and the patient's creatinine improved with fluid hydration. . 3. Anemia of chronic decrease with decreased hematocrit over past 9 months (HCT 36 in [1-6])plus possible blood loss from nephrostomy stent placement and IVF this admission. The patient has a history of colon cancer with a normal colonoscopy last year. Iron studies were normal and the patient was guaiac negative. . 4. Hypertension was controlled on metoprolol. . The patient was discharged in good condition with follow up in urology clinic with Dr. [Last Name (STitle) 9125] [Telephone/Fax (1) ]. She was restarted on prophylactic amoxicillin as an outpatient. Medications on Admission: 1. ASA 81mg once daily 2. Atenolol 25mg once daily 3. Amoxicillin 250mg once daily 4. MVI 5. Recent cipro/flagyl . All: sulfa -> jaundice Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for 6 days. Disp:20 Tablet(s) Refills:0 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Amoxicillin 250 mg Capsule Sig: One (1) Capsule PO once a day: Start amoxicillin after finished taking the final 10 days of the ciprofloxacin. 8. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks: start after completion of ciprofloxacin course. Take 2 hours before or 2 hours after antacid therapy. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: nephrolithiasis with secondary hydronephrosis septic shock pyelonephritis iron deficiency anemia ARF secondary: h/o R Staghorn nephrolithiasis for 20 years on ampicillin prophylaxis and now atrophic Colon CA s/p resection '[40] Tonsillectomy HTN Diverticulitis h/o EtOH abuse Discharge Condition: stable, tolerating oral diet, afebrile, ambulating without difficulty Discharge Instructions: Continue with prior outpatient medications. Continue with Ciprofloxacin to complete a total of 14 days and then resume your regular dose of amoxicillin. Notify your doctor in case of recurrent nausea, abdominal pain, blood in stools, diarrhea, fevers, back pain, or blood in your urine. Call your doctor or return to the ED in case of recurrent fevers, increasing or decreasing urine output, change in color/quality/odor of the nephrostomy urine, or pain with urination. Please call Dr. [Last Name (STitle) ] tomorrow and arrange to go to the laboratory for follow up testing of your chemistry panel, calcium, magnesium, and blood counts and phosphorous in the next two days and see Dr. [Last Name (STitle) ] this week. Start iron supplementation for iron deficiency anemia after completion of ciprofloxacin course. Followup Instructions: Schedule follow up with Dr. [Last Name (STitle) ] in Urology this week. Call tomorrow to schedule an appointment. Follow up with Dr. [Last Name (STitle) ] this week. Call tomorrow to arrange for laboratory testing: chemistry panel, calcium, magnesium, blood counts and phosphorous before your appointment. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "V10.05", "995.92", "584.9", "785.52", "276.8", "591", "285.9", "599.0", "038.9", "276.2", "592.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "00.17", "55.03" ]	icd9pcs	[ [ [] ] ]	12290, 12339	9229, 11110	298, 339	12663, 12734	2093, 4559	13609, 14058	1655, 1659		11303, 12267	4596, 4674	12360, 12642		11136, 11280			12758, 13586								1689, 2074																									243, 260	4703, 9206									367, 1172															1194, 1382	1398, 1639
3,120	146,449	24345	Discharge summary	report	Admission Date: [2150-9-25] Discharge Date: [2150-9-28] Date of Birth: [2079-8-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2932] Chief Complaint: syncope and bradycardia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Name13 (STitle) 61671] is a 71 year old man with a past medical history significant for hypertension and hypercholesterolemia who presented to the [Hospital1 18] on [2150-9-25] with a chief complaint of loss of consciousness. Earlier that day, the patient was getting up from a chair to get a drink when he felt faint. He states that he fell to his knees and lost consciousness. He does not think that he sustained trauma to his head. When he awoke, the patient felt confused. In association with this event, the patient denies any chest pain, shortness of breath, or nausea though he did report significant diaphoresis and a few minutes of shaking chills. He denies having any bowel or bladder incontinence. The patient returned to his chair and EMS was called. EMS found the patient to be diaphoretic with a HR in the 40's, BP 80/palpable. He was given atropine x 2 without effect. . In the [Hospital1 18] ED, the patient's heart rate was 43 and his SBP was 105. He was started on calcium gtt and his symptoms resolved spontaneously before he could receive glucagon for suspected beta blocker toxicity. His SBP returned 120-130 though his heart rate continued to be in the 40's. As such, the patient was transferred to the MICU for further evaluation and treatment. . On review of systems, the patient denied any recent chest pain, nausea, vomiting, diarrhea, abdominal pain, change in appetite, or weight loss. He denies any recent weakness, change in vision, or change in hearing. He does note occasional spells of "dizziness" every week or so. He has not had any recent changes in medication. In particular, his atenolol dose has not been changed for at least one year. . Of note, the patient has been taking 75 mg of atenolol for the last year. He was told by his new PCP [Last Name (NamePattern4) ] [9-7] to stop taking the medication because of "low potassium" but continued to take it. . While in the MICU, the patient ruled out for MI with tropnin T negative x 3. His HR initially ranged 39-46. His atenolol, terazosin, and timolol eye drops were held. His blood pressure was controlled with IV hydralazine. The patient developing wheezing and was started on nebs and then advair. His bradycardia resolved (HR 59 on leaving the MICU) and was felt to be due to beta blocker toxicity. His work-up included an echocardiogram which showed left atrial dilation and normal LV function (LVEF >55%) as well as a TSH that came back as high with a normal total T4. Based on the resolution of his bradycardia, the patient was transferred to the [Hospital1 139] B general medical service. His terazosin and timolol were restarted and the patient was started on a regular dose of lisinopril. Past Medical History: Hypertension Asthma BPH Hypercholesterolemia Right eye cataract s/p surgical repair in [2148] Right eye macular hole s/p surgical repair in [2148] Social History: Works in construction but is semi-retired (only works occasionally). Lives at home with his wife and daughter. Quit smoking 20 years ago and does not drink alcohol. Family History: Father died at a young age from prostate cancer. Brother died of stomach cancer. Physical Exam: VS: T 98.6, BP 100/71, HR 93 (80-93), RR 20, O2Sat 96-99/RA Gen: In bed, comfortable, NAD HEENT: Sclera anicteric, R pupil less reactive than left (s/p cataract surgery on R) with oval shape of right pupil, OP clear without exudate or erythema, neck supple with no LAD, no JVD, carotid pulses 2+ bilaterally with no bruit CV: RRR, II/VI SEM, no r/g, radial, brachial, DP and PT pulses 2+ bilaterally Pul: CTA B Abd: obese abdomen, s/nt/+bs, no HSM Ext: no LE edema Neuro: A&Ox3, CN II-XII intact, strength 5/5 in all muscle groups (extensors and flexors in upper and lower extremities), 2+ patellar, biceps, and brachioradialis reflexes bilaterally, sensation to light touch intact bilaterally in upper and lower extremities. Pertinent Results: [2150-9-27] 05:57AM BLOOD Glucose-122* UreaN-9 Creat-0.8 Na-143 K-3.5 Cl-106 HCO3-26 AnGap-15 [2150-9-26] 05:01AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-9-25] 09:52PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-9-25] 12:40PM BLOOD cTropnT-<0.01 [2150-9-25] 12:40PM BLOOD TSH-5.8* [2150-9-25] 12:40PM BLOOD T4-7.7 (normal) [2150-9-28] 09:32AM BLOOD Free T4-1.2 (normal) [9-16] TTE: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [9-25] CXR: Plate-like opacity in the left lower lung zone most likely represent atelectasis Brief Hospital Course: Mr. [Name13 (STitle) 61671] is a 71 year old man with a past medical history significant for hypertension and hypercholesterolemia who presented to the [Hospital1 18] on [2150-9-25] following a syncopal event. . #Bradycardia: Mr. [Name13 (STitle) 61671] was evaluated in the ED and the MICU and his syncopal event was felt to be due to bradycardia. The patient had negative cardiac enzymes and ruled out for MI while in the MICU. After holding his atenolol, his bradycardia resolved and the patient was transferred to the general medical floor. His work-up also included an echocardiogram which showed only left atrial dilation and normal LV function (LVEF >55%) as well as a TSH that came back as high with a normal total T4 and free T4. Based on the resolution of his bradycardia, the patient was transferred to the [Hospital1 139] B general medical service. His terazosin and timolol were restarted and the patient was started on a regular dose of lisinopril. His bradycardia was attributed to the atenolol that he was taking so he was not discharged on this medication. The patient was recorded on telemetry as having a run of approximately 10 PVC's twice one evening. Given his bradycardia and recorded telemetry events, the patient was discharged with a 24 hr holter monitor. His primary care doctor will follow-up on the results of that study. He should also have follow-up thyroid function tests in 6 weeks as an outpatient, given elevated TSH, although free T4 normal. . #Hypercholesterolemia: The patient was maintained on his home regimen of Atorvastatin 10 mg PO DAILY as well as aspirin while in-patient. . #Asthma: The patient's asthma was managed with advair and PRN nebs. He was discharged on flovent 110 mcg 2 puffs [Hospital1 ] as well as PRN albuterol nebs for wheezing. . #BPH: The pateint's terazosin was held while he remained bradycardic, but was restarted when his heart rate returned to a normal range. He was discharged on his home dose of this medication. . #Hypertension: Patient was started on 5mg of lisinopril and re-started on hctz 25 which he was already on. He was given explicit instructions not to take a beta-blocker (atenolol) until instructed by a doctor to do otherwise. He will need electrolytes and renal function checked in the next week to be followed up by his PCP. [Name10 (NameIs) ] was given prescription for this. He reported prn use of 40mg of lisinopril. We explained that he is not to take prn lisinopril, but rather 5 mg everyday. Medications on Admission: Atenolol 75 mg (patient has been taking "as needed" but PCP told him to stop taking it recently) Terazosin 5 mg per day Lipitor 10 mg per day Hydrochlorothiazide 25 mg per day Timolol eye drops Lisinopril 40 mg ("as needed" for headache, has not taken for > 1 week) Norflex 100 mg ("as needed" for headache, has not taken for > 1 week) . Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every six (6) hours as needed for wheezing: Please take if you experience wheezing symptoms from your asthma. Disp:1 1 Refills:1 8. Flovent 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Disp:1 inhaler Refills:1 Outpatient Lab Work Chem-7 to be drawn [2150-10-2] Please report results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4401] at [Hospital1 3372]. [Hospital1 756] Internal Medicine Associates Clinic. Discharge Disposition: Home Discharge Diagnosis: syncope, bradycardia Discharge Condition: good Discharge Instructions: If you feel faint, have an increase in sweating, chest pain, shortness of breath, or any other change in your health please contact your primary care doctor or go to the emergency department. . You have a scheduled appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4401] at the [Hospital1 756] Internal Medicine Associates Clinic Suite C on [10-12] at 2:10 PM. . You are being sent home wearing a heart monitor. Please return to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] tomorrow ([2150-9-29]) at 1:00 PM to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] Holter [Last Name (un) ] in the [Hospital1 ] Building, [Apartment Address(1) ] ([Location (un) 10043]). . We have added a number of medications to your regimen. Please follow the list we have given you. You should not take a beta-blocker such as atenolol or metoprolol until instructed to do so by a doctor. . Please have your labs checked as instructed. You have been given a prescription for this. Dr. [Last Name (STitle) 4401] will follow this up. . You should also have your thyroid function checked when seen by Dr. [Last Name (STitle) 4401]. Followup Instructions: If you feel faint, have an increase in sweating, chest pain, shortness of breath, or any other change in your health please contact your primary care doctor or go to the emergency department. . You have a scheduled appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4401] at the [Hospital1 756] Internal Medicine Associates Clinic Suite C on [10-12] at 2:10 PM. . You are being sent home wearing a heart monitor. Please return to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] tomorrow ([2150-9-29]) at 1:00 PM to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] Holter [Last Name (un) ] in the [Hospital1 ] Building, [Apartment Address(1) ] ([Location (un) 10043]). [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2150-9-28]	[ "427.89", "493.90", "780.2", "E858.3", "244.9", "972.9", "272.0", "427.69", "585.9", "600.00", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9106, 9112	5176, 7690	338, 345	9176, 9182	4315, 5153	10573, 11613	3472, 3554		8078, 9083		9133, 9155		7716, 8055			9206, 10550								3569, 4296																									275, 300										373, 3096															3118, 3274	3290, 3456
8,199	176,558	49194	Discharge summary	report	Admission Date: [2181-1-31] Discharge Date: [2181-2-22] Date of Birth: [2136-4-2] Sex: M Service: MEDICINE Allergies: Demerol Attending:[First Name3 (LF) 6114] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: s/p intubation History of Present Illness: 44 yo man with hx of depression, h/o IVDA and history of testicular pain with fevers, SOB, productive cough,left sided pleuritic pain, body aches for the last 5days. Also of note sister at home with same symptoms. He denies any other symptoms including N/V, constipation, diarrhea. Thus limiting his ability to eat, drink and get around. Currently he is dyspnic and tachypnic, able to speak a few words at a time, but working to breathe. Anxious about condition. Brought in after encouragement of sister. On arrival, febrile, tachycardic, tachypneic, hypoxic, with LLL infiltrate on CXR. Refused HIV testing. Admitted to MICU for sepsis/pneumonia/resp distress. Past Medical History: peptic ulcer disease depression with hx of SA hx of testicular pain asthma with prn albuterol history of IVDA Social History: smokes 1 pack cigs/week, no current drug use, but prior history of IVDA in distant past. Family History: diabetes- mother recently died [10-12] aftr MICU stay Physical Exam: 102.3 113/79 135 36 87% ra aao, anxious, able to speak a few words with dyspnea perrl, 5 mm bilaterally, injected sclerae, dry MM, clear OP ctab, decreased breath sounds lt. base, no wheezes, tachypnea, pos. use of accessory muscles reg. rhythm, tachy, no murmurs abd soft nt/nd, pos bowel sounds no edema Pertinent Results: [2181-1-31] 09:30PM D-DIMER-3541* [2181-1-31] 09:30PM PT-17.2* PTT-37.5* INR(PT)-1.9 [2181-1-31] 09:30PM PLT SMR-NORMAL PLT COUNT-157 [2181-1-31] 09:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2181-1-31] 09:30PM NEUTS-21* BANDS-29* LYMPHS-44* MONOS-1* EOS-0 BASOS-0 ATYPS-1* METAS-4* MYELOS-0 [2181-1-31] 09:30PM WBC-2.8# RBC-4.78 HGB-13.8 HCT-41.3 MCV-86 MCH-28.9 MCHC-33.5 RDW-13.1 [2181-1-31] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2181-1-31] 09:30PM CRP-GREATER TH [2181-1-31] 09:30PM CORTISOL-55.3* [2181-1-31] 09:30PM CK-MB-7 [2181-1-31] 09:30PM cTropnT-<0.01 [2181-1-31] 09:30PM ALT(SGPT)-28 AST(SGOT)-77* CK(CPK)-1562* [2181-1-31] 09:30PM GLUCOSE-66* UREA N-25* CREAT-1.5* SODIUM-130* POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-21* ANION GAP-20 [2181-1-31] 09:52PM LACTATE-6.6* [2181-1-31] 10:09PM LACTATE-5.4* [2181-1-31] 10:09PM TYPE-ART TEMP-39.1 PO2-108* PCO2-30* PH-7.42 TOTAL CO2-20* BASE XS--3 INTUBATED-NOT INTUBA COMMENTS-NRB 10 L/M [2181-1-31] 11:27PM LACTATE-3.8* [2181-1-31] 11:27PM TYPE-ART PO2-126* PCO2-33* PH-7.36 TOTAL CO2-19* BASE XS--5 [2181-1-31] 11:28PM LACTATE-3.7* [2181-1-31] 11:44PM URINE RBC-[2-10]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2181-1-31] 11:44PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2181-1-31] 11:44PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.011 [2181-1-31] 11:44PM GRAN CT-1010* [2181-1-31] 11:44PM FIBRINOGE-556* [2181-1-31] 11:44PM PT-17.3* PTT-39.2* INR(PT)-1.9 [2181-1-31] 11:44PM PLT COUNT-112* [2181-1-31] 11:44PM WBC-1.8* RBC-3.94* HGB-11.6* HCT-34.4* MCV-87 MCH-29.5 MCHC-33.8 RDW-12.9 [2181-1-31] 11:44PM ALBUMIN-2.6* CALCIUM-6.7* PHOSPHATE-2.7 MAGNESIUM-0.7* [2181-1-31] 11:44PM LIPASE-15 [2181-1-31] 11:44PM GLUCOSE-60* UREA N-21* CREAT-1.1 SODIUM-133 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-20* ANION GAP-13 [2181-1-31] 11:44PM LD(LDH)-301* CK(CPK)-1576* ALK PHOS-37* AMYLASE-60 TOT BILI-0.8 Brief Hospital Course: A/P: 44M, found to be HIV positive with CD4 85, now w/ sepsis secondary to multilobar Strep pneumoniae pneumonia. * Sepsis secondary to pneumonia: Blood culture + for Strep. pneumo. PCP negative, flu negative. -- Pan cultured and vanco/ceftriaxone/azithro/and steroids for community acquired pneumonia and PCP; Blood cultures 2/23 with pan [Last Name (un) 36] strep pneumo. Vanco d/c'd [2-2], bactrim/steroids d/c'd on [2-4]; but maintained on bactrim ppx. -- Continued on CTX and azithromycin for 14 days. -- Legionella negative. -- Transfused 2 units of blood. Intubated on the 24th due to respiratory failure, placed on AC; Extubated [2-16]; suffered some symptoms of opiate w/d for approx 4 days after extubation, with tachycardia, diaphoresis, tremor, agitation. Resolved spontaneously. Completed 14 day course of CTX and 7 days of azithro with resolution of fever, resp failure, infiltrates. * Coagulopathy: resolved w/ vitamin K * ARF: resolved with hydration. * Pancytopenia: likely related to marrrow suppresssion from sepsis, HIV - will follow up as outpatient. * D/C'd home on [2-22] after several days of inpatient PT with stabilization of gait, with PCP and ID [Name9 (PRE) 702]. Medications on Admission: prn albuterol trazadone Discharge Medications: 1. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QOD (). Disp:15 Tablet(s) Refills:2 5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: MSSA pneumonia, HIV/AIDS Discharge Condition: Stable Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2181-2-27] 3:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13632], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2181-3-20] 10:00	[ "584.9", "276.1", "995.92", "284.8", "785.52", "038.2", "070.32", "536.3", "481", "042", "518.81", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.6", "03.31", "33.24", "38.91", "96.04", "99.04" ]	icd9pcs	[ [ [] ] ]	5749, 5755	3894, 5117	275, 291	5824, 5832	1644, 3871	5855, 6237	1239, 1298		5191, 5726		5776, 5803		5143, 5168											1313, 1625																									228, 237										319, 984															1006, 1117	1133, 1223
41,004	167,004	17669	Discharge summary	report	Admission Date: [2151-2-25] Discharge Date: [2151-3-3] Service: MEDICINE Allergies: Darvocet-N 100 / Codeine / Fosamax / Darvon / Doxycycline Attending:[First Name3 (LF) 5608] Chief Complaint: Femoral fracture Major Surgical or Invasive Procedure: ORIF of right History of Present Illness: Ms. [Known lastname ] is a [Age over 90 ] yo woman with multiple medical problems including CAD, HTN, aortic stenosis, and hyperlipidemia, who was transferred from an OSH ED for management of a spontaneous R femur fracture. Per the patient, she was standing and felt a snap of her right leg and fell to the ground. No head trauma or LOC. She presented to [Hospital6 17032] and was found to have a right femur fracture about cemented right hemiarthroplasty. On arrival to the [Hospital1 18] ED, her vitals were all within normal limits. She was evaluated by the orthopedics service and decision was made for ORIF this morning. Her evaluation in the ED was notable for a leukocytosis to 13 with left shift and also an elevated creatinine of 1.4. Her baseline creatinine is not known, however the patient has no known history of renal disease. In the ED, she received 1L NS and morphine 2mg IV. She is being admitted to the orthopedics service. Medical consult is requested for pre-operative risk assessment and management of her renal failure. . The patient at baseline is not very active. She rarely leaves her house and reports that she does get dyspneic with walking and needs to stop and lay down to catch her breath. She cannot quantify the distance she is able to walk. She does not climb stairs. She denies chest pain with exertion or at rest. She does have chronic ankle edema, for which she was started on a water pill (presumably lasix) in the past year. She also notes a remote history of a syncopal event many years ago while at a church event, but reports that her doctor evaluated her without finding a clear cause. She denies orthopnea (sleeps with one pillow) or PND. . ROS: (+) per HPI. Denies recent fevers or chills. No chest pain or shortness of breath. Denies prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. Denies nausea, vomiting, diarrhea, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: -Aortic stenosis-- last TTE in our system from [2144] with mild-mod AS and [Location (un) 109] of 1.3cm, EF 70% -Coronary artery disease-- no history of MI per pt -Hyperlipidemia -Hypertension -GERD -Colon CA s/p ileocecectomy in [2144] -Breast CA s/p bilateral mastectomy -Glaucoma -History of skin cancer -Spinal stenosis s/p back surgery -s/p R oophorectomy -s/p appendectomy Social History: She is a widow. She is the oldest of 10 children, never had any children of her own. She lives in an apartment with 24h care. She prepares her own meals and is able to dress herself, however she does require assistance with bathing. She walks with a walker. Has a neighbor who does her shopping and cleaning. Family History: Non contributory Physical Exam: PHYSICAL EXAMINATION: Vitals: T 97.0, BP 172/76, HR 81, RR 20, O2 sat 96% 2L --> 86% on RA Gen: NAD. Oriented x3. Very hard of hearing. HEENT: NCAT. Sclera anicteric. EOMI. Dry MM, OP clear, no exudates or ulceration. Neck: Supple, JVP elevated to ear lobe at 30 degrees. CV: RRR with occasional skipped beats, [4-3] harsh systolic murmur heard throughout the precordium without radiating to the carotids or axilla. Chest: Crackles bilaterally up to the mid-lung fields, no wheezes appreciated. Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: R leg is externally rotated, 1+ pitting edema in the bilateral LE to mid-calf. Skin: Scattered echymoses over the trunk and extremities. Neuro: Alert and oriented x 3, deferred strength exam due to pt discomfort with exam Pertinent Results: ================== ADMISSION LABS ================== [2151-2-25] 09:00PM BLOOD WBC-13.6* RBC-3.41* Hgb-12.0 Hct-36.9 MCV-108# MCH-35.1# MCHC-32.4 RDW-16.5* Plt Ct-239 [2151-2-25] 09:00PM BLOOD PT-13.6* PTT-24.2 INR(PT)-1.2* [2151-2-25] 09:00PM BLOOD Glucose-188* UreaN-44* Creat-1.4* Na-140 K-5.1 Cl-104 HCO3-27 AnGap-14 [2151-2-26] 06:50AM BLOOD Calcium-9.3 Phos-5.1# Mg-1.8 ECHO ([2151-2-26]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.9 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-30]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Severe calcific aortic stenosis. Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Mild to moderate mitral regurgitation. AP SUPINE CHEST RADIOGRAPH: ([2151-2-26]) The cardiomediastinal silhouette is unremarkable. A right-sided pacer with its leads overlying the right atrium and right ventricle are stable. There is improvement in vascular congestion without evidence of effusion, consolidation, or pneumothorax. Extensive degenerative changes in the shoulders are stable since [65] hours prior. IMPRESSION: Pulmonary edema since [65] hours prior. There is no evidence of acute cardiopulmonary process. ORIF right femur: ([2151-3-1]) There is a right hip arthroplasty. Fracture through the proximal femoral shaft including cement adjacent to the distal tip of the femoral Arthroplasty component is demonstrated. This is now transfixed by lateral fixation plate with multiple transverse fixation screws and cerclage wires. The fracture components are in near anatomical alignment. There is no evidence of hardware complication. For complete details of surgery, please consult the operative report. Brief Hospital Course: [Age over 90 ] year-old woman with severe aortic stenosis, CAD, and HTN, now with an acute spontaneous right femur fracture with post operative hypotension . # HIP FRACTURE: Patient with spontaneous femoral head fracture at home. Initially evaluated at local hospital, then transferred to ortho service for repair. Patient was medically optimized in the medical service given her severe aortic stenosis and volume overload. Patient underwent ORIF on [2151-2-27] which was complicated by post operative hyoptension (see below). Patient had no bleeding at surgical site and pain was adequately controlled with scheduled acetaminophen and PRN Morphine IR. Patient was able to transfer to chair with assistance and at time of discharge she was weight bearing as tolerated with assitance. She needs prophylaxis with heparin SC for 4 weeks post-op. She will need to follow up in 2 weeks ; please call [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 19448] NP[Telephone/Fax (1) 49176] to set up an appointment. . # POST OP HYPOTENSION: Multifactorial in this elderly woman with severe valvular heart disease and fixed cardiac output, acute blood loss, and sedation / intraoperative beta blocker administration. Given estimated loss of ~400cc blood and 10pt Hct drop, hypovolemia was the most likely contributor to hypotension. Lastly, although sinus tachycardia / atrial fibrillation is compensatory in setting of hypovolemia, given her fixed cardiac output she may have benefited from more agressive rate control, however difficult to do in setting of vasopressor requirement. Patient was maintained on Neosynephrine drip and transfused a total of 3 units of PRBC over 48hrs. Course complicated by acute renal failure (see below) however without development of pulmonary edeme. Vasopressors were weaned off successfuly and at time of discharge patient was back on home dose of 25mg [Hospital1 ]. . # Hypoxia: Noted during admission, improved with pre-operatively diuresis. No significant oxygen requirement at this time, at time of discharge she did not require any. # ACUTE RENAL FAILURE: Most likely result of poor forward flow from AS and also from hypovolemia and anemia. Patient improved with transfusion and very gentle rehydration. At time of discharge creatinine was 1.3. . # CAD: No clear documentation, however given age calcific atherosclerosis is highly likely. We continued statin, beta blocker and aspirin . # ATRIAL FIBRILLATION: Unclear how long she has had this arryhtmia, however more prominent in setting of acute pain and peri-op. Patient was not systemically anticoagulated during this admission and was noted to be mostly in sunus rhythm at time of discharge. Rate control achieved with metoprolol 25mg [Hospital1 ]. . # HTN: Continued home regimen with Metoprolol. . #Agitation- Presumed [3-2] sundowning in setting of ICU; received home ambien 5mg qhs. She also was given zyprexa zydis 2.5mg with much improvement. # Hyperlipidemia: We continued simvastatin 40mg PO daily . # FEN/GI: Low sodium diet . # PPX: Heparin [Hospital1 ] given low body weight. # CODE: Confirmed DNR/DNI . Medications on Admission: -ASA 325mg PO daily -Simvastatin 40mg PO daily -prilosec 20mg PO daily -Metoprolol 25mg PO TID -Colace 100mg PO daily prn -Iron SR 325mg PO daily -Tylenol 1000mg PO BID -Ambien 10mg PO qHS -Melatonin 500mcg PO qHS -Lidoderm patch -?? [Name (NI) 49177] pt reports being started on a water pill in the past year for ankle swelling Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<90 or HR<55. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia: agitation. Discharge Disposition: Extended Care Facility: [Hospital6 25759] & Rehab Center - [Location (un) ] Discharge Diagnosis: Right Femoral Fracture Hypotension Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted to the hospital because you fractured your hip. It was repaired and you tolerated the procedure well. You were discharged to rehab for further care. Patient should continue medications as directed Patient should receive physical therapy daily Followup Instructions: Patient will need follow up in 2 weeks with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP [Telephone/Fax (1) 9769] Completed by:[2151-3-3*]	[ "V45.01", "307.9", "403.90", "E878.1", "276.50", "398.91", "996.44", "V10.05", "285.1", "396.2", "585.3", "799.02", "414.01", "V10.3", "V43.64", "458.29", "272.4", "365.9", "584.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "79.35" ]	icd9pcs	[ [ [] ] ]	10642, 10728	6230, 9380	281, 296	10806, 10814	3972, 6207	11179, 11351	3146, 3164		9765, 10619		10749, 10785		9406, 9742			10838, 11156								3179, 3179														3201, 3953											225, 243										324, 2389															2411, 2804	2820, 3130
20,902	181,399	45084	Discharge summary	report	Admission Date: [2192-11-22] Discharge Date: [2192-11-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Medication overdose, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is an 85 year-old male with hx of CHF (EF <20%) s/p ICD and pacemaker, Afib on Coumadin, and CKD who presents to the ED after an accidental medication overdose. Per report, when taking his morning medications, the patient took his entire day's worth of medications at one time. Per his [First Name3 (LF) 802], she was called by the VNA at 9:30 am who thought he just seemed a little "off," normal vitals signs, afebrile at that time. The home health aide came at 11am and found him to be confused, partially undressed and incontinent of urine on his clothing and found that he had emptied (and presumably taken) Thursday's medication contained. He was referred to the emergency department. . In the ED, he was oriented to person though confused re: place and time. His SBP ranged between 80s-90s, toxicology was consulted and the patient received glucagon. He was mentating well and heart rhythm V-paced in the 50s (usual setting). . On arrival to the ICU, the patient reports feeling tired and increased urinary frequency but otherwise feels well. He denies visual changes or headache. . Of note, he had a recent hospitalization [8-7] for a RLE cellulitis and 3rd toe ulcer that was treated with Unasyn. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, chest pain, shortness of breath, lower extremity oedema, cough, lightheadedness, gait unsteadiness, headache, rash or skin changes. Past Medical History: -CHF EF <20%, s/p ICD for hx VT -Severe tricuspid regurgitation, mild to moderate mitral regurgitation -Left Bundle Branch Block ([2187]) -Atrial fibrillation on anticoagulation -BPH ([2182]) -Sigmoid polyps ([2188]) -Diverticulosis -GI bleed ([2188]) -Chronic renal insufficiency 1.5-1.7 -Actinic keratosis -Iron deficiency anemia -Presyncope, Falls -Allergic rhinitis -Hearing Loss -Gout -Appendectomy -Hernia Repair Social History: He lives alone in [Hospital3 4634]. Visiting Angels comes on MF, and [First Name8 (NamePattern2) 24979] [First Name8 (NamePattern2) 3146] [Location (un) 4628] Elder Care Services comes on MWF to help patient shower. Patient has groceries bought for him. His nephew and [Name2 (NI) 802] [First Name8 (NamePattern2) ] [Name (NI) 13039] - next of [Doctor First Name ]) are quite active in his care. He quit smoking over 40 years ago. No EtOH. Family History: non-contributory Physical Exam: Tm 99.6 Tc 99.1 112/56 p60 R20 100%RA Heart rhythm: V Paced GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL RESP: CTA B, CV: RRR. No mrg. Abd: benign. Ext: No cee. Pertinent Results: [2192-11-23] 03:54AM BLOOD WBC-7.0 RBC-2.54* Hgb-8.8* Hct-25.6* MCV-101* MCH-34.5* MCHC-34.3 RDW-14.3 Plt Ct-166 [2192-11-23] 03:54AM BLOOD PT-24.3* PTT-35.7* INR(PT)-2.4* [2192-11-23] 03:54AM BLOOD Glucose-84 UreaN-63* Creat-2.1* Na-134 K-4.8 Cl-99 HCO3-24 AnGap-16 [2192-11-22] 08:32PM BLOOD ALT-14 AST-17 LD(LDH)-204 AlkPhos-62 TotBili-1.1 [2192-11-23] 03:54AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3 [2192-11-22] 08:32PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.9 Mg-2.8* Iron-25* [2192-11-22] 08:32PM BLOOD calTIBC-330 VitB12-1000* Folate-GREATER TH Hapto-191 Ferritn-39 TRF-254 [2192-11-22] 08:32PM BLOOD TSH-0.58 [2192-11-23] 03:54AM BLOOD Digoxin-1.9 [2192-11-22] 01:15PM BLOOD Digoxin-2.4* [2192-11-22] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CXR: [11-22] IMPRESSION: No acute cardiopulmonary process. . [2192-11-27] 09:25AM BLOOD WBC-8.2 RBC-2.84* Hgb-9.5* Hct-28.9* MCV-102* MCH-33.6* MCHC-33.0 RDW-14.2 Plt Ct-229 [2192-11-27] 09:25AM BLOOD PT-26.0* INR(PT)-2.6* [2192-11-27] 09:25AM BLOOD Glucose-188* UreaN-42* Creat-1.6* Na-137 K-3.8 Cl-98 HCO3-26 AnGap-17 [2192-11-27] 09:25AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.2 . EKG: Ventricular paced rhythm at 55 beats per minute. Atrial mechanism is unclear but appears to be atrial fibrillation. One natively conducted QRS complex. Compared to the previous tracing of [2191-3-24] no major change is apparent. Brief Hospital Course: # Medication overdose: Per the patient's [Date Range 802] she states he only took one day's worth of medications all at one time. Toxicology was consulted in the ED. The patient's was given glucagon in the ED for possible BBlockers inotxication. The patient was not started on Digibind because he had a AICD and pacemaker inplace. The patient did not exhibit worsening ventricular ectopy or arrhythmias. The patient's initial digoxin level was 2.4 and returned to 1.9 the following day. He was restarted on Digoxin when he arrived at floor. The patient was back to his baseline mental status when he arrived in the ICU. The rest of the patient's medications were held including his BBlockers and diuretics and the patient was monitored for adverse effects. The potassium level was elevated initially at 5.1, but reduced to 4.8 in the morning. His medications were restarted gradually. Due to ongoing renal failure (improving), diuretics were held at discharge; to be evaluated at PCP follow up. . # Altered mental status: The patient's family states that he is usually very responsible about taking his medications as directed. The patient may have become confused prior to taking medications. Unclear etiology of confusion; pt was given 2 days of levofloxacin for concern of possible respiratory infection, however, the evidence for this was limited and was subsequently discontinued. Pt was found to have a urinary tract infection with >100k enterococcus; unclear if this was initial infection that caused pt to be ill, or if this was a complication of a foley catheter that he had in ICU (appears to have been d/c'd [11-23]). Treated with Augmentin, and switched to Ampicillin per ID on discharge. . # Urinary tract infection; as above. . # Anemia: The patient's Hct was 26.3 on admission. Hct was stable during his admission. However, his baseline Hct is usually around 30-32. Hemolysis labs were checked and negative. Pt does have a h/o GI bleed in the past. The patient has been on Fe supplementation and Fe studies were consistent with Fe deficiency. . # Acute on chronic renal failure: The patient's creatinine on admission was 2.7; Cr 1.7 at time of discharge, which appears worse than baseline. Diuretics held at discharge; will need PCP reevaluation within 1 week to evaluate for restarting diuretics. . # CHF: Most recent EF was <20% in [2187]. Patient's medications were held secondary to potential overdose. SBP in 90-100s. Medications restarted gradually; diuretics continued to be held . # Atrial fibrillation: On Coumadin. V-paced in 50s INR 2.4. he was placed back on coumadin. . # Code: DNR/DNI Medications on Admission: Digoxin 125 mcg PO DAILY Tamsulosin 0.4 mg po qhd Omeprazole 20 mg po daily Warfarin 5 mg 3X/WEEK, 2.5mg 4X/WEEK Ascorbic Acid 500 mg daily Ferrous Sulfate 325 mg daily Multivitamin daily Vitamin E 400 unit daily Acetaminophen prn Docusate Sodium 100 mg po bid Toprol XL 12.5 mg daily Lisinopril 2.5 mg po daily Spironolactone 25 mg po daily Lasix 80 mg po daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 100 mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: medication overdose pneumonia acute renal failure Urinary tract infection Discharge Condition: stable Discharge Instructions: you took all your medications at one time. you were confused, maybe because of pneumonia. we had to stop all your medication because you had acute renal failure. we were able to restart your medications gradully. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Fluid Restriction: [2184] ML daily. continue the antibiotic for 7 days . Followup Instructions: [Last Name (LF) 1576],[First Name3 (LF) 1575] [Telephone/Fax (1) 1579]; you will be contact[Name (NI) ] with an appointment in approx 1 week. (office contact[Name (NI) ] [11-27] for appointment)	[ "458.9", "600.00", "V45.02", "599.0", "707.22", "428.0", "427.31", "293.0", "562.10", "V45.01", "972.1", "280.9", "E858.3", "584.9", "276.1", "041.04", "974.4", "585.9", "274.9", "707.05", "428.22", "V15.88", "403.90", "V58.61", "E858.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8635, 8712	4515, 5530	307, 313	8830, 8839	3024, 4492	9279, 9501	2776, 2794		7566, 8612		8733, 8809		7178, 7543			8863, 9256								2809, 3005																									225, 269										341, 1812								5545, 7152							1834, 2270	2286, 2760
13,350	175,787	44840	Discharge summary	report	Admission Date: [2105-2-6] Discharge Date: [2105-2-14] Date of Birth: [2036-12-8] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old male with a one month history of exertional angina and occasional rest angina who underwent a cardiac catheterization on [2105-2-6] which demonstrated a 70% stenosis of left main, 30% stenosis at the origin of the LAD and a 70% stenosis involving large first diagonal and a slightly more serious 80% stenosis a bit distally on that vessel. Also a 30% stenosis of the left circumflex, 90% stenosis of the left circumflex after the OM1 and 80% before larger branch back to the OM2 and 100% right mid RCA stenosis. PAST HISTORY: Significantly the patient has a past medical history of chronic renal insufficiency, hypertension, hypercholesterolemia, positive family history for father with MI at 66 and a brother with an MI at age 53 and also had a past surgical history of anal fissure surgery, some knee surgery and appendectomy in the remote past. The patient has no known drug allergies. HOSPITAL COURSE: Based on the findings at cardiac catheterization, cardiothoracic surgery was consulted and deemed appropriate for coronary artery bypass surgery. So on [2105-2-9] the patient was taken to the operating room where he underwent a coronary artery bypass grafting times five, his grafts were LIMA to LAD, sequential saphenous vein to OM1 and OM2, saphenous vein to PDA and saphenous vein to diag. The patient tolerated the procedure well without complication. Postoperatively was transferred to the cardiac surgery recovery unit, maintained on Neo-Synephrine and Amiodarone was started for postoperative atrial fibrillation. The patient was weaned off his pressors, started on a diet and transferred out of the ICU. On the floor the patient was weaned off his pacer, had his chest tubes and wires removed and began working with physical therapy and was deemed safe for discharge home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE MEDICATIONS: Colace 100 mg po bid, Lasix 20 mg po bid for 7 days, Zantac 150 mg po bid, ASA 325 mg po q d, Lescol 20 mg po q h.s., KCL 20 mEq po q day for 7 days, Amiodarone 400 mg po q day, Metoprolol 12.5 mg po bid and Percocet 5/325 [11-19] po q 4-6 hours prn for pain. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 22409] MEDQUIST36 D: [2105-2-14] 09:04 T: [2105-2-14] 09:16 JOB#: [Job Number ]	[ "401.9", "272.0", "427.31", "414.01", "413.9", "V17.3", "593.9" ]	icd9cm	[ [ [] ] ]	[ "88.53", "36.15", "37.22", "39.61", "36.14", "88.56", "42.23", "88.72" ]	icd9pcs	[ [ [] ] ]									2105, 2648					1128, 2018																																													183, 1110																	2043, 2081
64,590	160,850	36319	Discharge summary	report	Admission Date: [2123-4-5] Discharge Date: [2123-4-6] Date of Birth: [2102-5-1] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: Gunshot Wound to Lower Abdomen Major Surgical or Invasive Procedure: 1) Exploratory Laparotomy 2) Exploratory Thoracotomy History of Present Illness: 22 yoM sustaining a gunshot wound in the field who was admitted emergently. Arrived to the hospital in pulseless electrical activity (PEA). Underwent resuscitation and was taken emergently to the operating room for exploration. Past Medical History: none Social History: none of note Family History: none of note Physical Exam: On Arrival: Neuro - AAO x 0 CV: PEA - undergoing CPR actively RESP: not breathing - emergently intubated GI: soft. Single gunshot entrance wound to the LLQ Ext: cool, mildly mottled, pulse only with CPR. Pertinent Results: [2123-4-5] 06:15PM HGB-9.3* calcHCT-28 [2123-4-5] 06:15PM TYPE-ART PO2-475* PCO2-76* PH-6.49* TOTAL CO2-8* BASE XS--39 -ASSIST/CON [2123-4-5] 06:39PM GLUCOSE-277* LACTATE-17.5* NA+-137 K+-6.8* CL--115* TCO2-5* Brief Hospital Course: Patient was resuscitated in the ER and intubated. After regaining heartbeat, and blood pressure, he was taken to the ER emergently where he underwent laparotomy and thoracotomy. For specifics ont he procedure please refer to operative note. After an extensive operation he was taken to the Trauma ICU where he required extensive care and resuscitation with fluid anbd blood products over night. he expired in the early morning hours of HD 2. Medications on Admission: none of note Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: gunshot wound causing: 1) Left iliac Vein rupture 2) Sigmoid colon perforation 3) Small Bowel Perforation 4) Splenic laceration 5) Left posterior diaphragmatic injury 6) Left pulmonary laceration Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226]	[ "863.54", "865.12", "860.3", "958.2", "E965.4", "862.1", "998.11", "902.54", "286.9", "E849.7", "780.65", "863.39", "276.2" ]	icd9cm	[ [ [] ] ]	[ "99.07", "34.03", "45.62", "99.04", "34.04", "99.05", "96.71", "99.06", "99.60", "45.76", "54.12", "41.5", "96.04", "34.82", "39.32" ]	icd9pcs	[ [ [] ] ]	1773, 1782	1235, 1681	342, 396	2021, 2030	983, 1212	2083, 2218	729, 743		1744, 1750		1803, 2000		1707, 1721			2054, 2060								758, 964																									272, 304										424, 655															677, 683	699, 713
80,350	113,374	6001	Discharge summary	report	Admission Date: [2106-6-26] Discharge Date: [2106-7-11] Date of Birth: [2039-6-30] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Ventricular peritoneal shunt placement [2106-6-28] History of Present Illness: Pt is a 66 yo male w/ PMHx sig for who was recently admitted to [Hospital1 18] from [5-18] - [6-9] for hospitalization related to a non-aneurysmal SAH with complicated hospital course now readmitted for altered mental status and CT scan from [6-24] that showed marked hydrocephalus. The patient initially presented to [Hospital1 18] on [5-18] for altered mental status and gait difficulties. CTA of the end showed SAH in the basilar cisterns, with no evidence of aneurysm by CT and conventional angiogram. The patient's initial CT scan from [5-18] showed evidence of hydrocephalus that resolved on the following CT from [5-19]. The patients hospital course was complicated respiratory distress requiring intubation, pneumonia, and fluctuating mental status. Neurology saw the patient and felt that b/l SDH could be causing the impaired mental status. The patient then went for b/l frontal burr holes. Eventually he was transferred to step down and eventually to a rehab unit. At rehab, the patient continued to have difficulty with attention and orientation. He had a head CT on [6-24] that showed marked hydrocephalus. As a result, he was transferred back to [Hospital1 18] for planned VP shunt. Past Medical History: DIABETES MELLITUS [2053] COLONIC POLYPS [2099] CORONARY ARTERY DISEASE [2093] HYPERTENSION UMBILICAL HERNIA ELEVATED PSA [12/2103] Social History: He lives alone and has sister who lives in [Name (NI) 108]. Family History: 3 brothers died of MIs, father died of MI, no history of aneurysms. Physical Exam: Vitals: T 98.1; BP 137/76; P 89; RR 18; O2 sat 97% RA General: lying in bed NAD HEENT: NCAT, moist mucous membranes Neck: supple Pulmonary: CTA but shallow breaths Cardiac: regular rate and rhythm, with no m/r/g Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: Lethargic but opens eyes to stimulation. States name. Shows thumb, raises arms. Year - [2103], month - [Month (only) ] hospital - [Hospital1 18]. Fluent speech with no paraphasic or phonemic errors. Drifts off without repeated stimulation. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. V, VII: facial sensation intact, facial strength symm. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: SCM [5-5] XII: Tongue midline without fasciculations. Motor/[Last Name (un) ]: Normal bulk. Normal tone. Does not comply with formal strength testing but moves arms purposefully and withdraws in all four extremities to painful stimuli. Sensation: intact to pinprick, light touch, vibration, and position sense. Does not extinguish to double simultaneous stimulation Reflexes: Bic T Br Pa Ac Right 2 2 2 0 0 Left 2 2 2 0 0 Toes downgoing bilaterally. Pertinent Results: CT HEAD W/O CONTRAST [2106-6-28] 1. Interval right frontal ventriculostomy catheter with persistent unchanged moderately severe hydrocephalus. 2. Minimally larger right frontal subdural collection measuring up to 10 mm compared to prior 9 mm. Unchanged left frontal subdural collection. BILAT LOWER EXT VEINS [2106-6-29] No evidence of deep vein thrombosis in either leg NECK,SOFT TISSUE US [2106-6-26] Small hypoechoic nodules as described above within the right and left lobes of thyroid without aggressive features. No definitive mass seen in the midline region of the neck, underlying region of palpable concern. If clinical concern persists, recommend CT of the neck for further evaluation. Series of CT HEAD w/o contrast: [7-2] IMPRESSION: 1. Increased hypodense bilateral frontal subdural collections, more prominent on the right with new small amount of blood layering along the right frontal convexity. These findings could be related to marked decrease in ventricular size and re-expansion of bilateral subdural spaces. Close followup is recommended. 2. Right frontal ventriculostomy catheter in the right lateral ventricle is unchanged . [7-6] IMPRESSION: 1. Marked interval increase in ventriculomegaly compared to [7-2], with unchanged configuration of the VP shunt catheter in the right lateral ventricle. 2. Stable bilateral subdural collection, without evidence of new bleeding. [7-7] IMPRESSION: 1. Persistent ventriculomegaly with right frontal VP shunt in unchanged configuration, compared to [7-6], but overall worsened compared to [7-2]. Some narrowing of the suprasellar cistern due to enlargement of the third ventricle is also unchanged. 2. Stable bilateral subdural collections. 3. No new intracranial hemorrhage. [7-9] IMPRESSION: 1. No interval change since yesterday's exam, with persistent ventriculomegaly and stable bilateral subdural collections. 2. Unchanged scattered mastoid air cell opacification. CT CHEST [7-6]: Slightly suboptimal bolus timing. Bilateral small segmental PE, non occlusive, predominantly in the left and right lower lobe and in the right upper lobe. Mild right pleural effusion, bilateral atelectasis. No evidence of right heart strain. No other lung parenchymal changes. Brief Hospital Course: 67M s/p nonaneurysmal SAH and external hydrocephalus presented from rehab with altered mental status. Outpatient head CT showed an increase in hydrocephalus and the patient was admitted to the neurosurgical service for VP shunt placement. VP shunt was placed without complication on [6-28]. Patient was transferred to the MICU on HD#4 for respiratory distress due to aspiration pneumonitis. The patient was stable for transfer to the medical floor on HD#6. Additional hospital course was complicated by aspiration pneumonia treated with broad-spectrum antibiotics. Nasogastric tube feeding was initiated. Frequent adjustments to the VP shunt were made by the neurosurgery team. Heparin IV was started to treat pulmonary emboli diagnosed on [7-6] after discussing the risks and benefits of anticoagulation with the neurosurgery team. On [7-9] a meeting was held with the primary medical team, palliative care team (Dr. [First Name (STitle) 9305] [Name (STitle) 4261] and [First Name4 (NamePattern1) 501] [Last Name (NamePattern1) 23636], NP), the patient's sister (and healthcare proxy) and the patient's brother-in-law. We discussed Mr. [Known lastname 23637] strong religious beliefs and advanced directives about end-of-life care. These preferences were reinforced via communication with his primary care physician who had spoken openly with the patient about his beliefs on a prior occasion. Despite an unclear prognosis, the patient's sister stated clearly that Mr. [Known lastname ] would not favor having a gastrostomy tube placed for a more permanent means of delivering nutrition, nor would he favor transfer to a rehabilitation facility. His family stated unequivocally that Mr. [Known lastname 23637] preference would be a comfort-based approach to his care. Comfort measures only were instituted that day and he was transferred to inpatient hospice on [7-10]. He passed away at 12:24 AM on [2106-7-11]. Medications on Admission: Keppra 500 mg [Hospital1 ] Colace 200 mg [Hospital1 ] Amantadine HCL 50 mg q day Glimepiride 2 mg Metoclopramide 5 mg tid Metformin 500 mg q 8 Lisinopril 10 mg daily Lactulose 30 ml [Hospital1 ] Atenolol 25 mg daily MVI Trazadone 25 mg qhs Omeprazole 40 mg qhs Insulin Glargine 44 units qhs Folate Lipitor 80 mg q day Insulin Regular Heparin 5000 sc tid Ipatropium Albuterol Discharge Medications: none. Discharge Disposition: Expired Discharge Diagnosis: External Hydrocephalus Hyperkalemia Resp alkalosis Hyperglycemia Acute Gastritis with hematemesis Tachypnea Submandibular mass Chemical pneumonitis from aspiration Hypocarbia Acute renal failure Dehydration Hypertension Leukocytosis Pulmonary emboli Subdural fluid collections Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2106-7-14]	[ "276.51", "780.97", "V58.67", "324.0", "507.0", "276.7", "250.12", "331.4", "276.3", "784.2", "286.9", "438.89", "564.00", "415.19", "V66.7", "285.9", "584.9", "535.01", "401.9", "348.30", "786.06" ]	icd9cm	[ [ [] ] ]	[ "02.34", "38.93", "96.6" ]	icd9pcs	[ [ [] ] ]	8055, 8064	5624, 7587	336, 393	8384, 8389	3314, 5601	8441, 8569	1938, 2008		8025, 8032		8085, 8363		7613, 8002			8413, 8418								2023, 2321																								2340, 2340	275, 298										421, 1669	2629, 3295							2355, 2613							1691, 1840	1856, 1922
24,978	128,725	52661	Discharge summary	report	Admission Date: [2187-10-5] Discharge Date: [2187-10-10] Date of Birth: [2133-1-26] Sex: M Service: [Company 191] FIRM HISTORY OF PRESENT ILLNESS: This is a 54-year-old gentlemen with a past medical history significant for AIDS, most recent CD4 count 99 and viral load greater than 300,000, congestive heart failure, diabetes [Company ] and history of lymphoma who presents with a one week history of Voluminous diarrhea 10 to positive abdominal pain which is diffuse, not related to foot intake or bowel movements. No nausea or vomiting. Decreased appetite and decreased po intakes times seven days. Patient does have a recent history of C. difficile toxin positive on [2187-9-18]. He was treated with Flagyl for one week at that time with good resolution of his diarrhea, but subsequent recurrence in two to three weeks. Also reports to admission and rigors at home one day prior to admission. He also noted decreased urine output for one to two days with no urine output for 18 hours prior to admission. He reports weakness and fatigue, also, increased sensitivity to light, flash photophobia for three days with accompanied neck stiffness/pain which is new for him. No confusion or mental status changes. In the Emergency Room, the patient was afebrile. Blood pressure was 62/36. Respiratory rate was between 25 and 35 and heart rate was 100. He was noted to have a creatinine of 4.3 with a baseline of 0.8. An anion gap of 16, white blood cell count of 9.8 with 18% bands. Arterial blood gases showed a pH of 7.36, pCO2 of 30, pO2 of 71. Also notable is five days history of Vioxx that he started for lower back pain. Also reports subjective shortness of breath for one to two days. No relationship to exercise. In the Emergency Room, he was orthostatic by heart rate. Urine and blood cultures were sent. Chest x-ray showed mild congestive heart failure. Electrocardiogram was without change. Vancomycin, Ciprofloxacin and Flagyl were initiated. He was given four days of normal saline with minimal blood pressure response. Foley was placed with small amount of concentrated urine output. The patient was admitted to the Medical Intensive Care Unit because of his hypotension and acute renal failure. He was hydrated overnight and was transferred to the General Medicine Floor the following day. PAST MEDICAL HISTORY: 1. HIV/AIDS diagnosed in [2172]. Most recent CD4 count 99, viral load 312, 000 in [2187-8-11]. HIV complicated by history of PCP [Last Name (NamePattern4) ] [2181], history of [Doctor First Name ] of the right groin, history of Nocardia of the right lower extremity. 2. Non-Hodgkin's lymphoma diagnosed [2184], status post chemotherapy with CHOP. No XRT. 3. History of congestive heart failure and Adriamycin induced cardiomyopathy. Ejection fraction of 40% in [2187-7-11]. 4. C. difficile diarrhea, treated. 5. Type 2 diabetes. 6. Hypertension. 7. Peripheral neuropathy. 8. Depression. 9. History of fatty liver and hepatomegaly with probable small hemangioma in the right lobe of his liver. MEDICATIONS: Acyclovir 400 mg b.i.d., Diflucan 200 mg q.d., Klonopin 0.5 mg b.i.d., Epivir 150 mg b.i.d., Mepron 750 mg b.i.d. for PCP prophylaxis, Neurontin 300 mg q.d., nortriptyline 25 mg q.d., Prilosec, Prozac 10 mg q.d., Kaletra 3 tablets b.i.d., Zerit 48 mg b.i.d., Toprol XL 50 mg q.d., Flagyl 500 mg t.i.d. started [10-4]. Vioxx times one week for lower back pain. ALLERGIES: Bactrim causes syndrome and delavirdine causes a rash. FAMILY HISTORY: Mother with diabetes [Month (only) ] and acute leukemia. Father diabetes [Name2 (NI) ] and a cerebral hemorrhage. SOCIAL HISTORY: The patient lives with partner in [Name (NI) 86], very occasional alcohol use. Remote marijuana use, no intravenous drug use. Questionable smoking history. Works as a haircut shop owner. PHYSICAL EXAMINATION: Vital signs: Temperature 97.2. Blood pressure 62/46. Respiratory rate 25-35. Heart rate 100. Blood pressure lying down 72/44 with a heart rate of 96, sitting up blood pressure is 70/44 with a heart rate of 108. In general, alert and oriented times three, pleasant in no apparent distress. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light. Extraocular muscles were intact. Dry mucous membranes. Neck: Supple, no lymphadenopathy. Positive tenderness on posterior palpation. Lungs: Right basilar rales, coarse breath sounds in the bilateral bases, otherwise, clear to auscultation. Heart: Regular rate and rhythm S1, S2, no murmurs. Abdomen: Normal active bowel sounds, soft liver edge decreased, 3 cm below costal border and tender. Diffuse mild tenderness, no rebound and no guarding. Lower extremities: Warm, no cyanosis, clubbing or edema. Neurological: [4-14] motor bilateral lower extremity and upper extremity. Sensory decreased symmetric bilateral lower extremity. Back: Diffuse erythroderma branching back, chest and upper extremities. PERTINENT LABORATORY DATA: White blood cell count 9.8, hematocrit 32.8, platelets 87,000. Differential: 57% neutrophils, 18% bands, 8% lymphocytes, 13% monocytes, INR 1.4, PT 14, PTT 33. Sodium 134, potassium 4.9, chloride 99, bicarbonate 19, BUN 41, creatinine 4.3, glucose 104, ALT 34, AST 55, alkaline phosphatase 60, T bilirubin 0.8. Urinalysis: Trace blood, nitrate positive, protein greater than 300, ketones trace, small bilirubin, [2-12] red blood cells, 21-50 white blood cells, many bacteria, 0-2 white blood cells, casts, no glucose. Chest x-ray: Slight cardiomegaly, mild upper zone redistribution, question of mild congestive heart failure. Electrocardiogram: Normal sinus rhythm at 100, right bundle branch block, left axis deviation, T wave inversion in V1, III, T wave finding in aVF old, ST elevation V3 to V6, V3 to V4 more pronounced, V5 and V6 old. Calcium 6.5, magnesium 1.2, phosphorus 3.2. Urine creatinine 279. Urine sodium 51 with a FeNA of 0.6. Arterial blood gases: pH 7.36/30/71 on room air. Lactate 1.9. Cryptococcal antigen negative. [12-12] aerobic blood culture bottles grew gram positive cocci in pairs and clusters and eventually grew Staph coag negative. C. difficile from [10-5] positive. C. difficile on [10-6] negative. MCV 100. Thecal culture: No enteric rods, no Salmonella, Shigella, no Campylobacter, no vibrio, no E. Coli 0157:H7. Vitamin B12 820, folate 13.1, absolute CD4 count 78, hemoglobin A1C 8. Urine cultures: Microsporidia negative, cryptosporidia negative, Isosporidium negative, cyclosporin negative. CT of the head normal. Renal ultrasound: No hydronephrosis, small cortical defect within the lower pole of the right kidney likely related to medical renal disease or old infection. Urine dip done on [10-6] showing large blood, 2+ protein, negative white blood cells, negative glucose, negative nitrate, negative ketones. Sediment showing numerous muddy blood cast, occasional white blood cells, occasional epithelial tubular cells. IMPRESSION: This is a 54-year-old gentlemen with history of AIDS and congestive heart failure admitted with seven days of perfuse diarrhea, fevers and chills found to be in acute renal failure with a creatinine of 4.3 and hypotensive and admitted to the Medical Intensive Care Unit for one night, transferred to the floor after receiving aggressive intravenous hydration and starting antibiotics. SUMMARY OF HOSPITAL COURSE: 1. Infectious Disease: It was felt that the patient's diarrhea was the most likely source of his fevers and chills and had caused severe dehydration leading to hypotension, acute renal failure with prerenal and intrarenal ATM effect. Given his history of AIDS, a SMV cryptococcus [Doctor First Name ] were checked as were microsporidia, cryptosporidia, Isospora and cyclosporia when these were negative. Given his recent consumption of shellfish, vibrio was also checked and this was negative. Given his increased white blood cells, count with left shift and increased bands, as well as a guaiac positive nature on the floor, bacterial cultures of stools including Campylobacter, Salmonella and Shigella were checked and were all negative. Given his recent antibiotics and his recent C. difficile infection, the C. difficile was rechecked, one was negative and one was positive. Ova and parasites were negative and E. coli 0157H7 was also negative. Patient's first urinalysis was consistent with a urinary tract infection, although the urine culture showed no growth. Second urinalysis and sedimentation was consistent with ATN and not a urinary tract infection. ATN was most likely secondary to decreased perfusion of the kidneys during his hypotensive episode. An lumbar puncture was deferred given resolution of his neck stiffness and pain and a clinical picture not consistent with meningitis. The patient remained afebrile after 24 hours after admission. The patient's diarrhea continued and actually worsened to become more watery in consistency and more frequent as his hospital stay went on until the day of discharge. He remained afebrile and continued to have diffuse abdominal tenderness. The Staph coag negative that grew in his blood was considered a contaminant, however, before this was isolated, he was placed back on vancomycin which had been discontinued when he moved to the floor. His Ciprofloxacin and Flagyl were continued also. His CD4 count was lower than it had been in the past and this made opportunistic infections as the cause of his diarrhea more likely and that is why his microsporidian, cryptosporidia, Isosporidium, cyclosporia was sent. Patient's Ciprofloxacin was increased to 500 mg b.i.d. as his renal function improved and his Flagyl was also continued. An antidiarrheal [Doctor Last Name 360] was avoided especially since he was found to be C. difficile positive. And eventually, two days prior to discharge, his Ciprofloxacin was discontinued. Patient continued with pandemia and this should be followed up as an outpatient. It may be secondary to his C. difficile infection. If his diarrhea had continued without improvement, CT of the abdomen and colonoscopy with biopsies to rule out CMV and [Doctor First Name ] would have been considered more seriously. His acyclovir was held off because of his renal dysfunction. He continued to be hydrated until two days prior to discharge when his intravenous fluids were discontinued since he was taking good po intake. 2. Cardiovascular: Patient's hypotension was most likely secondary to dehydration from his diarrhea. Other possibilities postulated were septic shock with infection and cardiogenic shock, although, he did not have any signs and symptoms of congestive heart failure. His blood pressure did not initially respond to aggressive intravenous hydration, but then did and he was transferred to the floor. His blood pressure on the floor remained stable throughout his four days. 3. Renal: Patient was presenting with acute renal failure most likely secondary to prerenal from decreased perfusion from his hypotension and ATN. His Vioxx was also held as this may have been a contributing factor five days prior to admission. No hydronephrosis was on renal ultrasound. His medications were initially renally dosed and he was hydrated aggressively. His renal function remarkably improved to normal within two days after starting his aggressive hydration. Patient was found to have metabolic acidosis but normal lactate and with compensatory increased respiratory rate. After his kidney function resolved, his medications were increased back to their normal doses. His Foley was discontinued on hospital day number three. 4. Gastrointestinal: Patient with history of hepatomegaly and now with abdominal tenderness. This most likely secondary to his diarrhea versus ischemic bowel from his hypotension. His exam was following and was unchanged so an abdominal CT was not done. 5. Diabetes [Doctor First Name ]: Patient was placed on a regular insulin sliding scale. Hemoglobin A1C was sent and was found to be elevated at 8 which is better than his value in [2187-7-11] which was 8.5, but still showing that his diabetes is not well-controlled. This should be discussed as an outpatient. CONDITION OF DISCHARGE: Stable. DISCHARGE STATUS: To home. PATIENT DISCHARGE INSTRUCTIONS: Patient is to follow-up with Dr. [Last Name (STitle) 2148] within one week. Patient is to call the Infectious Disease fellow on call if he experiences any more fevers or chills or increased in his diarrhea or pain. DISCHARGE MEDICATIONS: As prior to admission with the addition of Flagyl 500 mg t.i.d. for a total course of 21 days. DISCHARGE DIAGNOSES: 1. HIV/AIDS. 2. C. difficile diarrhea. 3. Diabetes [Last Name (STitle) ]. 4. Congestive heart failure. 5. Hypertension. 6. Peripheral neuropathy. 7. Depression. [Doctor First Name 1730] [Name8 (MD) 29365], M.D. [MD Number(1) 29366] Dictated By:[Last Name (NamePattern1) 7069] MEDQUIST36 D: [2187-10-13] 09:34 T: [2187-10-13] 09:34 JOB#: [Job Number 44907]	[ "042", "276.4", "584.5", "E930.7", "112.0", "276.5", "428.0", "425.9", "008.45" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]							3589, 3713	12813, 13252	12696, 12792							12451, 12672																			7507, 12426			3948, 7478																					180, 2366															2388, 3572	3730, 3925
17,936	100,804	6751	Discharge summary	report	Admission Date: [2184-6-10] Discharge Date: [2184-6-24] Date of Birth: [2137-11-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: massive hematemesis Major Surgical or Invasive Procedure: Esophageal gastro-duodenoscopy Transjugular Intrahepatic Portal-Systemic Shunt [First Name9 (NamePattern2) 25667] [Last Name (un) ] Tube Placement Emoblization of gastric arteries History of Present Illness: 46 yo M with sleep apnea, GERD, asthma, no known hx of liver failure who presents hematemesis with bright red blood. He states 2 days prior to admission, he had BRBPR and dark stools and felt pre-syncopal while sitting on a toilet as if things were "graying out". He however did not have any abdominal pain, nausea, vomiting at this time. He then went to work the day after and continued his daily desk job at an investment firm and did okay throughout the day. He after dinner then exactly at 9:10 pm began vomiting up a sink full of blood. He then felt extremely pre-syncopal in teh bathroom and may have had a period of syncope in the bathroom. His wife found him lying on the bathroom floor awake and called 911. He then got up and layed down on his bed. EMS arrived at that time and he walked down the stairs and then was brought to the ED. His vitals on arrival were 98.8, 111, 108/64, 100% on RA. He then had 1.5L of bloody vomitus in the ED. His initial hct was 22 and he was given 2U of PRBC and 2L of NS and his hct increased to only 25. He was transferred up to the ICU urgently and GI plans doing a stat EGD. . He states that he does not drink, no tobacco, does not use any NSAIDS/ASA products. He does not have any hx of liver disease. Stable GERD with diet control and prevacid. Past Medical History: GERD Asthma OSA Social History: works, married, no tob, no ETOH Family History: none Physical Exam: Temp 98.1, BP 133/84, HR 80, RR 21, O2 sat: 100% on 2L NC GEN- lying in bed in NAD, AAOX3, obese HEENT- NG tube with bright red blood CV- tachy, regular, no M CHEST- CTAB ABD- soft, NT/ND, +BS EXT- no edema bilaterally NEURO- AAOX3 Pertinent Results: [2184-6-10] 10:30PM BLOOD WBC-8.5 RBC-2.59* Hgb-7.7* Hct-22.0* MCV-85 MCH-29.7 MCHC-35.0 RDW-16.5* Plt Ct-125* [2184-6-11] 02:40AM BLOOD WBC-7.2 RBC-2.98* Hgb-8.9* Hct-25.3* MCV-85 MCH-29.8 MCHC-35.0 RDW-15.0 Plt Ct-59# [2184-6-11] 04:57AM BLOOD Hct-29.1 [2184-6-11] 07:48AM BLOOD Hct-28.1* [2184-6-11] 10:45PM BLOOD WBC-16.8# RBC-3.95# Hgb-12.0# Hct-32.7 MCV-83 MCH-30.4 MCHC-36.8* RDW-16.3* Plt Ct-118* [2184-6-14] 01:39PM BLOOD Hct-25.9* Plt Ct-61* [2184-6-24] 03:27AM BLOOD WBC-4.0 RBC-3.03* Hgb-9.1* Hct-26.7* MCV-88 MCH-29.9 MCHC-34.0 RDW-17.5* Plt Ct-131* [2184-6-10] 10:30PM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.4* [2184-6-23] 03:54AM BLOOD PT-15.6* PTT-32.1 INR(PT)-1.4* [2184-6-11] 11:30AM BLOOD Fibrino-167 [2184-6-10] 10:30PM BLOOD Glucose-216* UreaN-15 Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-27 AnGap-12 [2184-6-17] 03:01AM BLOOD Glucose-120* UreaN-18 Creat-1.0 Na-143 K-3.6 Cl-108 HCO3-26 AnGap-13 [2184-6-24] 03:27AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-142 K-3.3 Cl-107 HCO3-29 AnGap-9 [2184-6-10] 10:30PM BLOOD ALT-29 AST-35 LD(LDH)-145 AlkPhos-59 TotBili-0.9 [2184-6-12] 02:00AM BLOOD ALT-38 AST-53* AlkPhos-61 TotBili-4.6* [2184-6-12] 10:54AM BLOOD DirBili-0.5* [2184-6-13] 03:30AM BLOOD ALT-122* AST-177* AlkPhos-56 TotBili-3.1* [2184-6-22] 03:30AM BLOOD ALT-29 AST-48* TotBili-1.2 [2184-6-10] 10:30PM BLOOD Lipase-30 [2184-6-21] 06:45PM BLOOD proBNP-150* [2184-6-10] 10:30PM BLOOD Albumin-3.2* Calcium-8.4 [2184-6-23] 03:54AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 [2184-6-11] 08:23AM BLOOD Iron-250* [2184-6-11] 08:23AM BLOOD calTIBC-261 Hapto-<20* Ferritn-51 TRF-201 [2184-6-13] 03:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [2184-6-11] 08:23AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2184-6-11] 09:35AM BLOOD [Doctor First Name ]-NEGATIVE [2184-6-11] 09:35AM BLOOD IgG-1069 IgA-361 IgM-74 [2184-6-21] 12:34AM BLOOD Vanco-5.9* [2184-6-11] 05:09AM BLOOD Type-ART pO2-139* pCO2-54* pH-7.27* calHCO3-26 Base XS--2 [2184-6-16] 06:42AM BLOOD Type-ART Rates-18/ Tidal V-650 PEEP-5 FiO2-40 pO2-104 pCO2-39 pH-7.43 calHCO3-27 Base XS-1 -ASSIST/CON [2184-6-22] 01:58PM BLOOD Type-ART pO2-85 pCO2-42 pH-7.46* calHCO3-31* Base XS-5 [2184-6-11] 10:58PM BLOOD Lactate-2.5* [2184-6-20] 08:48AM BLOOD Lactate-1.6 [2184-6-21] 12:08AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2184-6-21] 12:08AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.018 [2184-6-21] 12:08AM URINE RBC-[12-6]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0 [2184-6-21] 12:08AM URINE CastHy-0-2 . [6-15] TIPS procedure: IMPRESSION: 1. Successful placement of a tip using 10-mm x 94-mm Wallstent. Portosystemic gradient post-procedure was 7 mm H2O. 2. Innumerous gastroesophageal varices are present, which were embolized by using 15 mL absolute alcohol and two 8-mm by 5-cm coils. The blood flow in the gastroesophageal varices has been decreased. . CXRs: starting on [6-11] demonstrated mild vascular prominence, bibasilar opacities consistent with atelectasis, worsened over the week with addiotional fluid resuscitation. . [6-11]: Duplex dopplers: IMPRESSION: 1. Very coarse and echogenic liver consistent with chronic liver disease. 2. The portal vein is patent. However, the flow is slow and reversed. 3. The hepatic veins appear to be patent. . [6-12]: RUQ u/s: RIGHT UPPER QUADRANT ULTRASOUND: Limited study. There is a new TIPS in place. There is wall-to-wall flow demonstrated. The velocities are 18, 21, and 55 cm/sec in the proximal, mid and distal TIPS respectively. The hepatic veins and arteries are patent. The portal vein could not be imaged. IMPRESSION: Wall-to-wall flow within the TIPS, with slow velocities as described above. This could be related to the immediate post-procedure period, however, short interval follow up is recommended to ensure patency. . [6-13] TIPS u/s: TIPS ULTRASOUND: A TIPS is patent. There is wall-to-wall flow inside the TIPS. The main portal vein is patent. There is normal direction of flow in the main portal vein. The blood flow velocity in the main portal vein is 50 cm/sec which is adequate. There is no velocity gradient through the TIPS. The flow velocities in the TIPS are as follow: Proximal TIPS 88 cm/sec. Mid TIPS 115 cm/sec, and distal TIPS 930 cm/sec. The left portal vein was adequately imaged and there is reversed flow. IMPRESSION: TIPS is patent with satisfactory flow velocities. No evidence of TIPS dysfunction. . Echo [6-22]: Conclusions: The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high stroke volume. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. Brief Hospital Course: 46 yo M with hx of GERD, asthma who presents with UGIB, syncope. . # Variceal Bleed with Blood Loss Anemia and hemorrhagic shock: Patient presented with large amounts of hematemesis and pre-syncope. On arrival to the ICU, he began vomiting ~2L of bright blood briskly. He had an emergent EGD secondary to concern for variceal bleed with questionable NASH given obesity. He was resuscitated with 7 units of PRBCs and 2U of FFP. He was given Unasyn IV x 1 and an octreotide bolus and drip were started given variceal bleeding. He had 3 large bore IVs in place. During the EGD, he continued to have brisk hematemesis and bleeding varices were found. However, due to severe bleeding, the EGD was terminated early and a decision was made to take him to the OR for intubation and placement of a [Last Name (un) 10045] tube. After the [Last Name (un) 10045] was placed, the gastric balloon was inflated to 40 and the position in the stomach was confirmed by fluoro in the OR. The patient was subsequently taken for embolization by IR, with EtOH and coil embolization of varices. He continued to have a large amount of bleeding and an emergenct TIPS procedure was performed. U/S with dopplers was initially questionable for proper flows, however repeat U/S showed good flows s/p TIPS. The bleeding stabilized after a total of 12 Units of PRBCs. His HCT remained stable, and the octreotide was discotinued and [Last Name (un) ] tube was removed. A Dophoff tube was placed nasogastrally and tube feeding initiated without any recurrence of bleeding. . # Resp failure: The patient was found to have a LLL infiltrate initially on admission, completed 10 day levo course, also started on flagyl on admission, subsequently found to have c.diff in stool. Plan to continue flagyl for additional 14 days (until [7-6]) for c.diff. - sedated on fentanyl, versed, took several days for sedation to wear off. Pt was extubated on [6-21] without any difficulty - he was about 10L positive after extensive fluid resuscitation, required lasix and diuril to remove the fluid, diuresed approximately 1-2 L daily. Pt orthostatic once getting out of bed, likely [2-19] long period of inactivity, stopped agressive diuresis. Patient may remain fluid overloaded given suggestion of diastolic CHF in presence of hyperdyamic EF on echo, although difficult to assess clinically. . # Fevers: - pt continued to have high fevers on levo, flagyl, known sources included klebsiella pneumonia, c.diff colitis. He completed a 10 day course of levofloxacin, continue flagyl for additional 14 days. Central lines were removed, no evidence of line infection. Pt was also clinically felt to have sinusitis related to nasal intubation given presence of purulent nasal secretions. He defervesced after extubation. . # Cirrhosis: - no significant hx of etoh, thought to be [2-19] NASH. Hep B serology c/w previous vaccination, neg Hep C, Hep A - possible liver bx in the future, f/u with hepatology as outpt - echo revealed hyperdynamic left ventricular systolic function (EF 80%) - INR elevated initially, responded to PO vitamin K. - started on rifaximin and lactulose for prophylaxis s/p TIPS, titrate to [3-20] BMs daily . #PPX - protonix twice daily, sc heparin . #FEN: started on a soft diet after extubated, iniatially on tube feeds via Dophoff gastric tube, repleted lytes prn . # acceess: R Arterial line replaced [2184-6-19]. Picc placed [6-22]. . # Full CODE . #Contact [Name (NI) ] [Name (NI) 25668] - wife, cell: [Telephone/Fax (1) 25669] Medications on Admission: prilosec albuterol [Doctor First Name 130] advair Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 12 days. Tablet(s) 5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inh Inhalation twice a day as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Variceal bleeding Cirrhosis Obstructive Sleep Apnea Discharge Condition: stable Discharge Instructions: Please follow-up with your primary care doctor after your rehabilitation. [Location (un) ] a follow-up appointment with your liver doctor to discuss further treatment plans. You were admitted with large amounts of bleeding requiring multiple invasive procedures to stop this bleeding. Please take your lactulose and rifaximin every day in order to prevent toxins from building up as your liver will not clear them fully. Do not hesitate to seek medical attention if you develop lightheadedness, dark or bloody stools, nausea, vomiting or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician [Name9 (PRE) ] your liver doctor [First Name (Titles) ] [Last Name (Titles) ] an appointment in [3-20] weeks. Completed by:[2184-6-24]	[ "572.3", "461.9", "428.0", "493.90", "327.23", "518.81", "530.81", "456.8", "038.9", "482.0", "008.45", "507.0", "278.01", "785.59", "285.1", "571.5", "995.92", "571.8", "456.20", "286.7" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.34", "44.44", "99.05", "42.33", "39.1", "96.72", "38.91", "99.04", "96.06", "96.04", "38.93", "99.07" ]	icd9pcs	[ [ [] ] ]	11878, 11949	7694, 11267	335, 525	12045, 12054	2227, 7671	12678, 12885	1953, 1959		11372, 11855		11970, 12024		11293, 11349			12078, 12655								1974, 2208																									276, 297										553, 1848															1870, 1888	1904, 1937
71,998	168,058	6927	Discharge summary	report	Admission Date: [2177-3-1] Discharge Date: [2177-3-5] Date of Birth: [2111-11-2] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1481] Chief Complaint: abdominal pain, melena Major Surgical or Invasive Procedure: liver biopsy History of Present Illness: Mr [Known lastname ] is 65M former orthopedic surgeon who initially presented to the ED with dyspnea and melanotic stools. He has been feeling dyspneic for 1-2 weeks prior to presentation accompanied by epigastric pain that radiated to his back. Patient initially thought the pain was coming from his gallbladder - he requested a RUQ U/S from his PCP, [Name10 (NameIs) ] which a mass was discovered in his liver. The mass was 15 cm per report. CT with po and IV contrast was then obtained to better define the mass and confirmed a large mass in his left lobe. He underwent EGD that showed a mass in the cardia. Per patient's report, the biopsy of the mass was nondiagnostic, however he was told it was likely a leiomyosarcoma based on the location. He was due to get an EUS on [3-3]. However, before that could happen, he had an episode of melena and felt lightheaded. He therefore presented to the ED with concern for an UGI bleed. In the ED, SBP was 120 and HR was in the 70s. He was admitted to the MICU for serial HCTs and for EGD. GI performed EGD and it revealed a 6 cm submucosal lesion with 3 areas of ulceration. The mass was quite friable and started to ooze a bit with manipulation, and so a biopsy was unable to be obtained. A surgical consult was initially placed to Dr. [Last Name (STitle) 468]. However, he suggested the consult be directed to Dr. [Last Name (STitle) ]. Past Medical History: BPH, leiomyosarcoma with mets to liver, ruptured biceps tendon, ?IgA deficiency Social History: Former orthopedic surgeon, now practices as an attorney. Lives with his wife who is his HCP. [Name (NI) ] tobacco use. Drinks [1-11] glasses wine/night. No IVDA Family History: Grandfather with [Name2 (NI) 499] CA - lived to age of 95. Physical Exam: Physical Exam on Admission: Vitals: T 98.0, HR 64, BP 100/64, RR 16, O2 98%RA GEN: NAD, A&O x 3 H&N: no palpable LNs, no scleral icterus LUNGS: Clear B/L CV: RRR, nl S1 and S2 ABD: soft, ND, slightly TTP in epigastric region, no hernias, no masses EXT: no c/c/e RECTAL: Guaiac neg, large prostate Physical Exam on Discharge: AF VSS GEN: NAD, A&Ox3 HEENT: PERRL, EOMI, MMM RRR: RRR PULM: CTAB, no respiratory distress, no W/R/R ABD: S/ND, mild epigastric tenderness EXT: warm/dry, no C/C/E Pertinent Results: [2177-3-1] 09:40AM BLOOD WBC-7.5 RBC-3.59* Hgb-8.9* Hct-28.2* MCV-79* MCH-24.7* MCHC-31.5 RDW-15.5 Plt Ct-333 [2177-3-5] 06:55AM BLOOD WBC-7.4 RBC-4.24* Hgb-10.8* Hct-34.3* MCV-81* MCH-25.5* MCHC-31.5 RDW-16.7* Plt Ct-278 [2177-3-1] 09:40AM BLOOD Neuts-62.5 Lymphs-32.0 Monos-3.2 Eos-2.0 Baso-0.3 [2177-3-1] 09:40AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1 [2177-3-5] 06:55AM BLOOD PT-12.7 PTT-26.4 INR(PT)-1.1 [2177-3-1] 09:40AM BLOOD Glucose-119* UreaN-30* Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [2177-3-5] 06:55AM BLOOD Glucose-99 UreaN-9 Creat-1.0 Na-142 K-4.6 Cl-105 HCO3-28 AnGap-14 [2177-3-1] 09:40AM BLOOD ALT-57* AST-37 AlkPhos-132* TotBili-0.3 [2177-3-5] 06:55AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8 [2177-3-2] 03:00AM BLOOD calTIBC-408 VitB12-483 Folate-11.6 Ferritn-64 TRF-314 [2177-3-2] 03:00AM BLOOD TSH-4.1 [2177-3-4] 07:15AM BLOOD HCG-<5 [2177-3-2] 03:00AM BLOOD CEA-1.1 AFP-9.3* [2177-3-2] 03:00AM BLOOD IgA-LESS THAN [2177-3-1] 09:40AM BLOOD IgA-LESS THAN [2177-3-2] 11:01AM BLOOD CA [86]-9 -Test IMAGING: [2177-3-4] spiral CT w/ triple phase contrast: 1. Large heterogeneously enhancing mass predominantly centered about the fundus of the stomach as detailed above with overall features concerning for GIST tumor. 2. Three heterogeneously enhancing masses within the liver as detailed above with a large left hepatic mass resulting in replacement and expansion of the left lobe, and discrete masses within segments V and VI of the liver, concerning for metastasis. . [2177-3-4] XR L hip: No metastatic disease. . [2177-3-4] U/S-guided Liver Biopsy: 1. Technically successful percutaneous targeted biopsy of liver mass under real-time ultrasound guidance. Post-procedure orders were entered into the provider order entry system. . [2177-3-1] EGD: Large subepithelial mass with three deep cratered ulcers were noted in the gastric cardia - these ulcers are not amenable to endoscopic therapy. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: The patient was admitted to the MICU. Serial hcts were checked and he was transfused 2 units of pRBCs. An emergent EGD was performed which revealed a large 6cm submucosal lesion with 3 areas of ulceration. A biopsy was not performed as the tissue looked very friable. Afterwards, the patient's hct stabilized and his melena stopped. As the patient was stable, he was transferred to the floor. The heme/onc team was consulted. They recommended obtaining a biopsy of the liver mass to establish a tissue diagnosis. The patient therefore underwent ultrasound-guided biopsy of the liver mass on [2177-3-4]. On the same day, the patient underwent spiral CT with triple phase contrast to better define the liver metastases. Once these images were obtained, the hepatobiliary team was consulted about possible resectability. The report noted that the mass was consistent with a GIST tumor. The patient was discharged home the next day. Though he still had epigastric pain, he was otherwise doing well. He was afebrile with stable vital signs. His hct had been stable and he had no more episodes of melena. He was out of bed and ambulating independently and voiding without problems. Medications on Admission: Dutasteride 5mg PO QHS, Terazosin 2 mg PO QHS Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. 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 3. Terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: gastric mass with hepatic metastasis Upper gastrointestinal hemorrhage Discharge Condition: good/stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid driving or operating heavy machinery while taking pain medications. You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Please call Dr.[Name (NI) 1482] office to schedule a follow-up appointment.	[ "531.90", "285.1", "578.9", "151.0", "796.3", "197.7", "279.01" ]	icd9cm	[ [ [] ] ]	[ "50.11", "45.13" ]	icd9pcs	[ [ [] ] ]	6351, 6357	4722, 5907	292, 307	6471, 6485	2651, 4699	7593, 7676	2060, 2125		6004, 6328		6378, 6450		5933, 5981			6509, 7570								2140, 2154															2466, 2632										230, 254										335, 1752							2168, 2438								1774, 1855	1871, 2044
32,496	101,215	34664	Discharge summary	report	Admission Date: [2142-8-14] Discharge Date: [2142-8-29] Date of Birth: [2095-1-22] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2142-8-14] Emergent Replacement of Ascending Aorta and Subtotal Arch with Aortic Valve Replacement utilizing a 25mm Pericardial Valve. [2142-8-16] Re-exploration for Bleeding History of Present Illness: Mr. [Known lastname 7842] is a 47 year old male who presented to OSH with left sided chest pain, dizziness and diaphoresis while showering. CTA revealed Type A aortic dissection. He was emergently med flighted to the [Hospital1 18] for surgical intervention. Past Medical History: Hypertension Dyslipidemia s/p Vasectomy Social History: Employed as Financial Advisor. Married, lives with his wife. Denies tobacco but admits to occasional marijuana. Denies history of ETOH abuse. Family History: No premature coronary artery disease. Physical Exam: At the time of discharge, Mr. [Known lastname 7842] was found to be awake, alert, and oriented. His heart was of regular rate and rhythm. His lungs were clear to auscultation bilaterally. His sternal incision was clean, dry, and intact. His sternum was stable. His abdomen was soft, non-tender, and non-distended. +1 edema was noted in his extremities. Pertinent Results: [2142-8-14] Intraop TEE: PREBYPASS - The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%) Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The ascending aorta is markedly dilated. The descending thoracic aorta is mildly dilated. A mobile density originating from the right sinus of Valsalva is seen in the ascending aorta, transverse arch and descending thoracic aorta consistent with an intimal flap/aortic dissection. The aortic valve leaflets (3) are mildly thickened. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. POSTBYPASS - LV systolic function remains normal. There is a well seated, well functioning bioprosthesis in the aortic position. There is mild valvular AI. A graft appears in the ascending aorta and transverse arch. The disection flap is still present in the distal arch and descending thoracic aorta. Flow is visualized in the true lumen. The study is otherwise unchanged from prebypass. [2142-8-15] Renal Ultrasound: No renal arterial abnormality detected. Normal renal arterial waveforms. [2142-8-19] Head MRI: Probable chronic small vessel infarct within the inferolateral aspect of the right cerebellar hemisphere. [2142-8-28] 09:17AM BLOOD WBC-9.5 RBC-2.92* Hgb-8.7* Hct-25.8* MCV-88 MCH-29.7 MCHC-33.6 RDW-15.0 Plt Ct-449* [2142-8-29] 05:55AM BLOOD Glucose-108* UreaN-13 Creat-1.1 Na-137 K-3.9 Cl-104 HCO3-26 AnGap-11 [2142-8-28] 09:17AM BLOOD ALT-76* AST-36 AlkPhos-192* TotBili-1.3 Brief Hospital Course: Mr. [Known lastname 7842] was emergently brought to the operating room where Dr. [First Name (STitle) ] performed replacement of his ascending aorta and subtotal arch along with aortic valve replacement. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU in critical condition. Initially coagulopathic, he required multiple blood products. Postoperative TEE was notable worsening pericardial effusion with questionable signs of early tamponade. He concomitantly had a slight decline in renal function. Renal ultrasound showed no evidence of aortic dissection into the renal arteries. On postoperative day two, he returned to the operating room for re-exploration. Given prolonged period of sedation and intubation, tube feedings were started for nutritional support. As sedation was weaned he became extremely agitated with question of nonpurposeful movements. Head CT scan and MRI were obtained which did not show any large area of territory infarct. Neurology service was consulted and attributed his altered mental status to most likely toxic-metablolic encephalopathy. He remained hypertensive and continued to require Labetolol drip for adequate blood pressure control. He also experienced postop fevers, and pan-cultures were obtained. He was empirically started on antibiotics for possible ventilator associated pneumonia along with positive blood cultures. Over several days, clinical improvements were noted. He was eventually extubated on postoperative day nine. He was transferred to the step down floor. He was seen in consultation by the physical therapy service. He was gently diuresed. A PICC line was placed and he was screened for rehab. By post-operative day 15 he was ready for discharge to rehab. Medications on Admission: Transfer meds: IV Esmolol, IV Nipride Home meds: HCTZ 25 qd, Zocor, Lisinopril 10 [Hospital1 ], Viagra prn Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): completes [2142-9-7]. 2. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): completes [2142-9-7]. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 5. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection twice a day for 7 days. Disp:qs Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. 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 8. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Type A Aortic Dissection, Aortic Insufficiency - s/p Repair Postoperative Bleeding/Pericardial Effusion - s/p Re-exploration Postoperative Toxic-Metabolic Encephalopathy Hypertension Dyslipidemia Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks, call for appt Dr. [Last Name (STitle) ] in [3-11] weeks, call for appt CTA scan in 3 months to evaluate aneurysm Please follow weekly LFTs/BUN/Creatinine while on antibiotics [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2142-8-29]	[ "286.7", "443.21", "443.29", "441.03", "424.1", "999.31", "E934.2", "349.82", "E879.8", "790.7", "486", "401.9", "518.5", "423.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "88.72", "96.72", "39.59", "38.44", "38.45", "35.21", "38.93", "39.61", "37.12" ]	icd9pcs	[ [ [] ] ]	6105, 6202	3091, 4890	288, 474	6442, 6449	1443, 3068	6785, 7132	1008, 1047		5051, 6082		6223, 6421		4916, 5028			6473, 6762								1062, 1424																									238, 250										502, 770															792, 833	849, 992
49,964	177,862	37127	Discharge summary	report	Admission Date: [2142-10-30] Discharge Date: [2142-11-10] Date of Birth: [2096-5-28] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: weakness Major Surgical or Invasive Procedure: right suboccipital craniectomy with decompression placement EVD transesophogeal echocardiogram History of Present Illness: HPI: Patient is a 46 yo man with history of obesity who who presented to [Hospital3 417] Medical Center [2142-10-29] with complaint of several days weakness, fatigue and falls. He had been feeling unwell for about three weeks and had been falling out of bed in the mornings. He was unable to stand [10-29] Am and father called EMS. Progressive weakness and lethargy for 3 weeks according to family. Had a head CT [10-29] at 21:22 showing cerebellar mass. MRI was performed this afternoon and showed large right cerebellar mass with areas of hemorrhage, significant mass effect and associated hydrocephalus. Report describes near effacement of the 4th ventricle and mass effect on the brain stem. There is striated enhancement of the lesion with the mass measuring 6.2 x 5.4 cm. Past Medical History: none Social History: Social Hx: Recently unemployed from computer work. Positive tox for marajuana, no tob. occasionaly ETOH. Family History: Family Hx: mother had stroke late in age. Father alive with HTN, PVD and DM. Physical Exam: PHYSICAL EXAM: O: T: 98.9 BP: 164/95 HR: 76 R 17 O2Sats 99 vented Gen: intubated, sedation with propofol just turned off HEENT: Pupils: [2-12] bilaterally EOMs: absent with Doll's maneuver Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: unresponsive to voice. Moves x 4 to noxious stimulation. Does not follow commands. Eyes closed. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. No blink to threat. III, IV, VI: Extraocular movements absent with Doll's manevuer. Eyes midline. V, VII: Face symmetric. Corneals absent bilaterally. VIII: unresponsive IX, X: weak gag to suction. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Antigravity x 4 to noxious stim and symmetric. Sensation: withdraws x 4. Reflexes: B T Br Pa Ac Right 0 0 0 0 0 Left 0 0 0 0 0 Toes upgoing bilaterally Coordination: could not assess Physical Exam on Discharge: A&Ox3 Pupils: 3-2mm bilaterally face symmetrical tongue midline Slight L pronator drift Motor: [4-17] throughout Incision: c/d/i Pertinent Results: Labs: 138 105 15 AGap=14 ------------< 323 4.3 23 1.0 Ca: 8.5 Mg: 2.2 P: 3.4 12.8 10.0 >< 235 38.8 CT/MRI: MRI from OSH shows: large right cerebellar mas with areas of hemorrhage, significant mass effect and associated hydrocephalus. Report describes near effacement of the 4th ventricle and mass effect on the brain stem. There is striated enhancement of the lesion with the mass measuring 6.2 x 5.4 cm. Brief Hospital Course: Pt was admitted to the hospital on neurosurgery service to ICU for close neurologic monitoring. He had placement of EVD with normal ICPs. He was readied for the OR including MRI wand study and on [10-31] went to OR where under general anesthesia he underwent right suboccipital craniectomy with excision of necrotic brain from infarct. He tolerated this procedure well, remained intubated and transferred back to ICU. Post op CT showed good decompression without new hemorrhage. His EVD continued to function and was clamped on POD#2 and removed the next day. He was extubated on POD#2 and tolerated this well although did have issues with sleep apnea requiring CPAP. His neurologic exam improved and he was following commands, conversant and full motor exam. His incision was clean and dry with staples. He was seen in consultation by the stroke neurolgy team. He underwent TTE which showed no vegetations and he underwent TEE which showed a PFO which will be followed up as an out patient by neurology. CTA of head and neck revealed no evidence of stenosis in the carotid or vertebral arteries. He was transferred to stepdown POD#4 and diet and activity were advanced. He was started on steroids for cerebral edema and these were weaned down post op; pt had elevated glucose and found to have HgA1C of 11.9 and seen in consultation by the [Last Name (un) ] team for insulin management. He had PT/OT evaluations that felt he was approprite for discharge to home. Diabetes teaching was done by nursing. He was refusing VS and lab work. He verbalized refusal to use CPAP at home. He was discharged to home with prescriptions for the next several days as well as prescriptions for his ongoing needs to bring to the free care clinic during the week. Medications on Admission: Home Meds: none Medications at transfer: Fentanyl gtt, Versed, propofol,nitropaste, lopressor IV, RISS, ASA 325 daily, lorazepam 1mg Q2hrs prn, Nexium 40mg daily, heparin 5000 SC q12, RISS, colace,acetaminophen Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO Q6H PRN as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: right cerebellar infarct newly diagnosed diabetic obstructive hydrocephalus obstructive airway disease morbid obesity Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in 7 days and fax results to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[First Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST PLEASE CALL [Telephone/Fax (1) 657] TO SCHEDULE AN APPOINTMENT WITH NEUROLOGY IN ONE MONTH WITH DR. [Last Name (STitle) ] Completed by:[2142-11-15]	[ "780.01", "331.4", "250.00", "431", "278.00", "434.91" ]	icd9cm	[ [ [] ] ]	[ "38.91", "01.59", "88.72", "02.2", "38.93" ]	icd9pcs	[ [ [] ] ]	6034, 6040	3297, 5064	328, 425	6202, 6226	2842, 3274	7657, 8006	1425, 1504		5326, 6011		6061, 6181		5090, 5303			6250, 7634								1534, 1844															2688, 2823										280, 290										453, 1256	1975, 2660							1859, 1959							1278, 1284	1300, 1409
12,110	105,928	1438	Discharge summary	report	Admission Date: [2172-2-21] Discharge Date: [2172-3-28] Date of Birth: [2097-8-29] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / lisinopril / Toprol XL Attending:[First Name3 (LF) 1505] Chief Complaint: incisional chest pain/sternal click Major Surgical or Invasive Procedure: [2172-2-21] Sternal debridement/pect. flaps/plating [2172-2-28] Sternal washout/Removal of Hardware/VAC Dressing [2172-3-6] Mediastinal exploration, evacuation of hematoma and control of pulmonary bleeding. History of Present Illness: This 74 year old male with severe COPD and extensive cardiac history in [2171-10-5]. Since surgery in [2171-10-5], patient has always complained of a sternal click and incisional discomfort. This finding was confirmed at his postoperative visit in [2171-12-5]. At that time, his incisional discomfort was described as mild and did not affect his routine ADL's. However over the last several weeks following another bout of pneumonia with significant coughing episodes, his sternal click and incisional discomfort have significantly worsened. Currently, he rates his pain 10 out of 10 and is no longer able to function. He denies fevers, chills,palpitations, orthopnea, PND, syncope and pedal edema. He has just completed a course of Prednisone and Levofloxacin for presumed pneumonia. The ACE inhibitor was also recently stopped due to persistent dry cough. He presents for surgical repair. Past Medical History: Mitral Regurgitation s/p redo redo sternotomy and redo Mitral valve replacement chronic obstructive pulmonary disease Asthma Hypertension Hyperlipidemia paroxysmal Atrial fibrillation h/o peptic ulcer Descending aortic anuerysm 2.8cm (followed by Dr. [Last Name (STitle) ] s/p removal of bladder cancer [2166] ) s/p coronary artery bypass s/p redo sternotomy, mitral valve replacement,MAZE Social History: -Tobacco history: quit 20 years ago, 65 pack year history -ETOH: occasional wine with dinner -Illicit drugs: no reported illicit drug use Retired UPS trailer driver (20 years), lives at home with wife. 3 children, 1 grandchild. Active lifestyle (rides bikes, motorcycles, golfs) Family History: Family history is significant for a mother who died in her 60s of cardiac causes, a father who died in his 40s of unknown (?cancer) causes, a sister who died in her 40s from an MVC (with known CAD) and a brother who has significant CAD Physical Exam: VS: BP 152/77 HR 92 RR 18 SAT 97% room air gen: patient is somewhat anxious, and has obvious discomfort when moving and taking deep breaths CV: regular rate and rythm, [1-10] murmur appreciated pulm: [Month/Day (4) 7968] breath sounds at bases o/w clear abd: soft, nontender, nondistended with NABS extremities: minimal pedal edema inc: significant sternal non-[Hospital1 ] with flail segments. extremely painful with palpation. incision is clean, dry and intact with no signs of infection. Pertinent Results: IMPRESSION: 1. Bony dehiscence, the length of the postoperative sternum, with little to suggest associated infection. 2. Left upper lobe lung lesions could be inflammatory or early malignancy. Careful followup, noted. 3. Right upper lobe hematoma, pulmonary hemorrhage and pleural effusion last seen on [11-9] have resolved. 4. Severe emphysema. Probable tracheomalacia. [2172-2-24] 05:00AM BLOOD WBC-11.9* RBC-3.79* Hgb-10.8* Hct-32.3* MCV-85 MCH-28.5 MCHC-33.4 RDW-16.9* Plt Ct-209 [2172-2-24] 05:00AM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-103 HCO3-25 AnGap-14 [2172-2-20] 01:00PM BLOOD ALT-18 AST-24 LD(LDH)-397* AlkPhos-90 TotBili-0.4 [2172-2-24] 05:00AM BLOOD Calcium-8.6 Mg-2.0 [2172-2-27] CT SCan 1. Thickened soft tissues with components of both hemorrhagic and complex Preliminary Reportfluid and gas extending anteriorly along the sternum and retrosternally may Preliminary Reportrepresent normal, post-operative change. Infection in any of these collections Preliminary Reportand in the fluid pocket in the left upper is indeterminate. Preliminary Report2. Stable left upper lobe lung lesions could be inflammatory or malignant, Preliminary Reportand warrant followup CT in no more than six months.. Preliminary Report3. Resolving post-inflammatory changes related to prior hematoma in the right Preliminary Reportupper and right lower lobes. Preliminary Report4. Stable severe emphysema. Preliminary Report5. Possible inward displacement of aortic intimal calcifications with Preliminary Reporteccentric thickening of aortic wall may represent intramural hematoma vs Preliminary Reportdissection, though comparative evaluation with recent limited as described Preliminary Reportabove. Please correlate with clinical symptoms. CT Scan [2172-2-20] 1. Bony dehiscence, the length of the postoperative sternum, with little to suggest associated infection. 2. Left upper lobe lung lesions could be inflammatory or early malignancy. Careful followup, noted. 3. Right upper lobe hematoma, pulmonary hemorrhage and pleural effusion last seen on [11-9] have resolved. 4. Severe emphysema. Probable tracheomalacia. Brief Hospital Course: The patient is a 74-year-old male who 1-1/2 months ago underwent a third time re-do mitral valve operation. He did well for about 30 days following which he got an upper respiratory infection resulting in severe coughing and a sterile dehiscence of the sternum. A CT scan was obtained which showed left upper lobe lung lesions which could be inflammatory or early malignancy. Thoracic surgery was consulted who recommended a repeat CT in 3 months. He had sternal plating performed at which time the adhered lung to the undersurface of the sternum had a couple of tears with resulting pneumothorax. The air leak subsequently infected the sterile sternum and the plates and resulted in a secondary infection requiring removal of the plates and packing of the wound for awhile. He after that underwent pectoral flap advancements by Plastic Surgery filling in the gap between the sternum and closure over chest tube and drains. He was susequently extubated on [3-6] and had some coughing episodes and then sudden increased drainage in his chest tube and development of hematoma under his pectoral flap and massive hemoptysis. He returned to the Operating Room emergently for mediastinal exploration, evacuation of the hematoma and control of pulmonary bleeding. He subsequently was extubated again and progressed slowly. Vancomycin was dosed by level and the Infectious Disease service followed him closely. He had some dysphagia and a Dobhoff tube was placed for tube feedings. He slowly progressed and the diet advanced to the present solids and thin liquids as tube feeds were weaned and dicontinued. He had a fair amount of confusion after the last operation, but was clearing. His short term memory remained marginal at times. He twice had a significant leukocytosis, without an obvious source and then this resolved Vancomycin will continue for 8 weeks total (through [4-27]) and ID followup is arranged. The sternal wound is clean and healing and the two JP drains remain in situ, being managed by the Plastic Surgical service. He was ready for rehab on [3-28] and was sent to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] . All follow up appointments were made. . Medications on Admission: - verapamil 240 mg daily - lovastatin 40 mg daily - aspirin 81 mg daily - losartan 25 mg daily - albuterol MDI 2puffs prn - ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler: Two (2) Puff Inhalation QID (4 times a day). - tramadol 50 mg as needed for pain - fluticasone-salmeterol 250-50 mcg/dose Disk: One (1) Disk with Device Inhalation once a day - furosemide 20 mg every other day - iron 325 mg daily Discharge Medications: 1. vancomycin 500 mg Recon Soln Sig: 750 mg Recon Solns Intravenous Q 24H (Every 24 Hours): last dose [2172-4-27]. 2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SQ Injection TID (3 times a day). 5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 6. Enteric Coated Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 9. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [4-10] hours as needed for fever or pain. 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 weeks. 14. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. potassium chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Doctor Last Name 5749] [Doctor Last Name ] Village - [Location (un) ] Discharge Diagnosis: sternal dehiscence s/p plating and pectoral flaps s/p debridement, removal of hardware s/p emergent sternal exploration, repair of pulmonary injury and sternal closure Coronary artery disease Chronic Systolic Congestive Heart Failure chronic obstructive pulmonary disease Asthma Hypertension Hyperlipidemia paroxysmal Atrial fibrillation Peptic Ulcer Disease Descending aortic aneurysm 2.8cm (followed by Dr. [Last Name (STitle) ] s/p removal of bladder cancer [2166] - s/p coronary artery bypass [2152] s/p coronary artery bypass grafts s/p redo sternotomy, mitral valve replacement/MAZE [2164] s/p redo,redo sternotomy, mitral valve replacement [2171] Discharge Condition: Alert and oriented x3, nonfocal. Forgetful at times Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema; 2 J-P drains in place 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 cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: Cardiac Surgery: Dr.[Last Name (STitle) ]([Telephone/Fax (1) 170]) on [2172-4-22] at 1:45pm Cardiologist:Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2172-4-6] at 10:30am Please call to schedule appointments with your: Infectious Disease: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]([Telephone/Fax (1) 457]) on [2172-5-5] at 9:30am weekly CBC, lytes,BUN,creatinine, trough vancomycin level while on Vanco.phne results to [Hospital ] clinic at [Hospital1 18] [Telephone/Fax (1) 457] Primary Care: Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8522] in [4-9] weeks ([Telephone/Fax (1) 8577]) Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours . Please schedule follow up appointment with Plastic and Reconstructive Surgery, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]: [Telephone/Fax (1) 1416] Completed by:[2172-3-28]	[ "285.9", "401.9", "428.22", "458.29", "518.51", "998.31", "998.11", "V45.81", "276.3", "427.31", "272.4", "E879.8", "998.59", "599.0", "V42.2", "428.0", "482.83", "041.12", "790.7", "512.2", "V10.51", "041.04", "998.12", "730.28", "493.20", "414.00" ]	icd9cm	[ [ [] ] ]	[ "34.79", "38.93", "84.94", "83.82", "77.61", "39.98", "78.61", "34.1", "96.72", "96.6", "96.04" ]	icd9pcs	[ [ [] ] ]	9307, 9485	5199, 7412	335, 556	10205, 10402	3005, 5176	11172, 12258	2226, 2463		7875, 9284		9506, 10184		7438, 7852			10426, 11149								2478, 2986																									260, 297										584, 1490															1512, 1912	1928, 2210
4,522	130,976	51516+51517+59355	Discharge summary	report+report+addendum	Admission Date: [2189-9-29] Discharge Date: Date of Birth: [2155-6-30] Sex: F Service:Medicine ADDENDUM: HOSPITAL COURSE: Multiple electrocardiograms were performed during this admission. The electrocardiogram on admission, [2189-9-29] showed sinus rhythm, poor R wave infarction, T wave inversions in leads I and AVL, and nonspecific T wave flattening in leads V3 through V6. Compared with the previous tracing done on [2189-9-10], T wave inversions in leads I and AVL are new. The latest electrocardiogram at the time of dictation was from [2189-10-8] and shows sinus tachycardia with no diagnostic interim change from the prior electrocardiogram. Pathology [2189-10-5], shows no diagnostic abnormality. Echocardiogram performed on [2189-9-29] was read as: Left atrum normal in size, interatrial septum not fully visualized, left ventricular cavity size normal, left ventricular systolic normal with a left ventricular ejection fraction greater than 65%, right ventricular chamber size and free wall motion normal, aortic valve leaflets appear structurally normal, mitral valve normal, trivial mitral regurgitation, moderate pulmonary artery systolic hypertension, small to moderate size circumferential pericardial effusion which is echodense, particularly anteriorly, which is suggestive of possible organization, probably significant respirophasic duration in mitral and tricuspid inflow patterns, no right atrial collapse is identified in suboptimal views; the right ventricular free wall appears somewhat extrinsically compressed with no clear diastolic collapse; compared with prior echocardiogram on record from [2189-5-19], the pericardial and pleural effusions were noted to be new. Repeat echocardiogram on [2189-10-12] was read as follows: Left atrium normal in size, right atrium moderately dilated, left ventricular wall thickness normal, left ventricular cavity size normal, overall left ventricular systolic function normal with a left ventricular ejection fraction greater than ...................; right ventricular systolic function appears depressed, there is abnormal systolic septal motion position consistent with right ventricular pressure overload, aortic valve leaflets appear structurally normal with good leaflet excursion; there is mild pulmonary artery systolic hypertension, significant pulmonic regurgitation is seen, no pericardial effusion is noted, no intracardiac shunt seen, no thrombus seen, no pericardial effusion seen. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3022], M.D. [MD Number(1) 3023] Dictated By:[Name8 (MD) 2058] MEDQUIST36 D: [2189-10-15] 18:40 T: [2189-10-18] 10:15 JOB#: [Job Number 106799] Admission Date: [2189-9-29] Discharge Date: Date of Birth: [2155-6-30] Sex: F Service:Internal Medicine CHIEF COMPLAINT: Chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: [Known firstname ] [First Name4 (NamePattern1) 12967] [Known lastname 174] is a 34-year-old African American female with a past medical history significant for a large saddle pulmonary embolus with paradoxical aortic arch embolus s/p embolectomy with patent foramen ovale closure approximately five weeks prior to the time of admission who presented with chest pain and shortness of breath on [9-29] to the [Hospital1 ] [First Name (Titles) 2142] [Last Name (Titles) ]. The patient, as stated, had been admitted to the [Hospital6 1708] approximately five weeks prior to admission where she was found to have a massive pulmonary arch of the aorta. The patient underwent PFO closure and embolectomy and was intubated for approximately three days, status post surgery. The post surgical period was evidently complicated by patient noncompliance and although the plan was to begin the patient on Coumadin at that time, she had left against medical advice from [Hospital6 15291]. At this admission, the patient complains of two weeks of worsening shortness of breath and chest pain. The patient states that she cannot finish a sentence or stand up without worsening dyspnea. The patient describes her chest pain as a "[9-28] stabbing, burning pain, worsening with motion, nonradiating and alleviated with Roxicet," which she has been taking for the ten days prior to admission. The patient did complain of a cough at the time of admission. The patient reports a temperature of 101.5 measured at home for the two days prior to admission with some nausea at home, however, the patient denied vomiting, diarrhea. She did complain of constipation. The patient had been using oral contraceptive pills prior to the time of admission to the [Hospital6 1708] which she had discontinued by the time of admission to the [Hospital1 ]. The patient did state that she quit tobacco use approximately two weeks prior to admission. She denied cough/sputum/hemoptysis/leg sxs. PAST MEDICAL HISTORY: Peptic ulcer disease, pulmonary embolus with patent foramen ovale and thrombus within the arch of the aorta treated at the [Hospital6 1708] with PFO closure and embolectomy during [Month (only) 216] of this year, depression, hypotension, cesarean section, IVC filter placed on [Hospital6 1708], status post jaw trauma. depression,PTSD, GERD, chronic back pain,obesity ALLERGIES TO MEDICATIONS: Dystonic reaction to Trilafon. MEDICATIONS AT THE TIME OF ADMISSION: Coumadin 2 mg po q.h.s., Atenolol 25 mg po q.d., Lasix 4 mg po q.d., potassium chloride 20 cc po q.d., zanaflex 4 mg po t.i.d., Neurontin 600 mg po q.a.m. and 1200 mg po q.h.s., klonopin 3 mg po q.d., Risperdal 2 mg po q.h.s., Trazodone q.h.s. prn, Zoloft 200 mg po q.a.m., hydrocortisone cream. SOCIAL HISTORY: The patient lives with her daughter. PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Temperature 98.8. Blood pressure 112/91. Weight was 271 pounds. Pulse oxygen 96% on one liter. Respirations were approximately 26. Mucous membranes were moist. There was no trauma. There were no lesions in the oropharynx. There was no lymphadenopathy. There was no noted jugular venous distention, however, in this obese patient with a large neck, this determination was difficult. There were noted to be crackles in the left middle lung field and egophony was later noted in the left middle lung field as well. The rate and rhythm were regular without murmurs. There was a question of an extra heart sound. On abdominal examination, this was a markedly obese patient with a soft, nontender abdomen with positive bowel sounds. There was on examination of the chest wall noted to be a small amount of serous drainage from the wound site. LABORATORY, X-RAY, ELECTROCARDIOGRAM AND OTHER TESTING: Hematocrit at the time of admission was 30.7, white blood cells 6.1, hemoglobin 9.4. The differential was 58.1% neutrophils, 32.8% lymphocytes, 4.2% monocytes, 4.3% eosinophils, 0.6% basophils. Platelets at the time of admission were 471. PT at the time of admission was 14.9, PTT was 24.6, INR was 1.5. Sedimentation rate measured on [10-1] was 41. Reticulocyte count measured on [10-3] was 2.2. Anti-thrombin III measured on [10-3] was 88 with a normal range of 72 to 110, protein C measured on [10-3] was 78 with a reference range of 67-123. Urinalysis on [9-29] had a specific gravity of 1.011 and was otherwise negative. Pleural fluid analysis performed on [10-2] had 5,800 white blood cells, hematocrit of 2.5%, 11% polys, 49% lymphocytes, 4% monocytes, 8% mesothelial cells and 28% macrophages. Chem-7 at the time of admission was as follows: Sodium 140, potassium 4.3, chloride 103, bicarbonate 27, BUN 10, creatinine 0.9, glucose 94, ALT measured on [10-1] was 19, AST on the same date was 18, alkaline phosphatase on the same date was 155, total bilirubin was 0.2. GGT measured on [10-2] was 137, reference range of 8 to 35. A troponin measured on [9-30] was less than 0.3. TIBC measured on [10-2] was 311, ferritin 132, transferrin 239, haptoglobin measured on [10-5] was 338, homocystine measured on [10-3] was 5.3 with a reference range of 4.5 to 12.4. TSH was 1.6 on [9-30] with a free T4 of 4.8. HIV antibody measured on [10-5] was negative. Toxicology screen was negative. Pleural chemistry in addition to the above had a total protein of 3.3, a glucose of 120, and an LDH of 289. Multiple arterial blood gases were done during this admission. Please see the computer record for further details. Lactate measured on [10-5] was 1.8 falling to 1.1 by [10-7]. Hematocrit at the time of this dictation is 31.2 on [10-15], however, hematocrit has been as low as 23.4 on [10-3] during a period when the patient was anticoagulated. PT at the time of the current dictation is 14.7 with an INR of 1.2, PTT of 78.1 and the patient is on heparin. Fibrinogen measured on [10-5] was 654. Gram stain from lingular transbronchial biopsy performed on [10-5] showed no PMNs and no microorganisms. Broth from tissue did however grow out coag negative Staph, no acid fast bacilli were seen on direct smear. No fungus was isolated. Bronchial alveolar lavage performed on [10-5] yielded 1+ PMNs, no microorganisms, sparse oral pharyngeal flora were seen, no acid fast bacilli were seen on direct smear and no fungus was isolated. PCP was not seen on immunofluorescent tests. Bronchial washings taken from [10-4] showed 1+ PMNs and no microorganisms with sparse oropharyngeal flora growth on culture and no fungal growth. Pleural fluid from [10-2] had no PMNs and no microorganisms with no growth on the culture media. Blood culture from [10-1] had no growth and that is the final report as did a set of blood cultures from [9-30]. Testing for factor 5 Leiden was done and was negative for mutation. IMAGING STUDIES: Chest CT performed on [9-29] showed the following: IMPRESSION: 1. Left upper lobe and left lower lobe pneumonia with a moderate left pleural effusion. 2. A filling defect in the pulmonary artery going to the left lower lobe consistent with a thrombus which is age indeterminate. This thrombus is nonocclusive given the history of chronic pulmonary embolus and the consolidation of left lung. The desaturation is probably due to the superimposed infection. CT of the chest was repeated multiple times. The latest at the time of this dictation was from [10-13] which showed the following: 1. Extensive ground glass opacity and reticulation throughout the right lung with only minimal involvement of the left lung. The findings are nonspecific and could reflect a symmetric distribution of hemorrhage, edema or diffuse alveolar damage in the appropriate clinical setting. 2. An enlarged main pulmonary artery and question of small emboli in the branch of the left pulmonary artery, but no large central obstructing embolus evident, although CT angiography techniques were not employed limiting this study. Multiple chest x-rays were performed during this admission and will not be reviewed here except for the following admission test x-ray PA and lateral on [9-29] which showed a left basilar opacity with alveolar bronchograms suggesting an infectious process or atelectasis. There was also a pleural effusion on the right basilar subsegmental atelectasis was noted. Ultrasound performed on [10-4] of the liver and gallbladder had an impression of no gallstones. Additional chest films will be reviewed in brief, although the reader should refer to full reports for additional information. A chest film performed on [9-30] of the right and left lateral decubitus positions were performed which showed "free flowing left-sided pleural effusion. There may be a small right-sided pleural effusion as well." INCOMPLETE DICTATION [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3022], M.D. [MD Number(1) 3023] Dictated By:[Name8 (MD) 2058] MEDQUIST36 D: [2189-10-18] 10:29 T: [2189-10-18] 10:29 JOB#: [Job Number ] Name: [Known lastname 32], [Known firstname ] [Last Name (NamePattern1) ] Unit No: [Numeric Identifier 17429] Admission Date: [2189-9-29] Discharge Date: Date of Birth: [2155-6-30] Sex: F ADDENDUM: HOSPITAL COURSE: The patient was admitted with the complaints as above including chest pain and shortness of breath: she was initially felt to have a left upper lobe and a left lower lobe thrombus of indeterminate age according to CT scan. The patient was begun on antibiotics including 1 gm of Ceftriaxone IV q 12 day beginning on [9-30] as well as 1 gm of Vancomycin given on [9-30]. On [10-1] the patient was begun on 1.25 gm of Vancomycin q 12 hours, all for presumed pneumonia. The patient was also begun on Levofloxacin 500 mg po q day on [9-30]. In addition, the patient was begun on [9-30] injury syndrome. This after consulting cardiothoracic surgery. The Indomethacin was changed in the face of hematocrit drop and gastrointestinal bleeding to Vioxx in the dosage of 50 mg po q day on [10-4], although it was initially suspected that the patient might have pneumonia, she did not present with a fever nor did she present with an elevated white blood cell count. CT surgery consult on [9-30] suggested the differential diagnosis of post pericardiotomy syndrome vs pericarditis vs recurrent PE with lower lobe pneumonia. The patient was noted at the time of admission to have a pericardial effusion. To the date of this admission, this pericardial effusion did not lead to signs of tamponade nor was there radiographic evidence of such. The patient was initially anticoagulated with Heparin, however, in the face of dropping hematocrit and OB+ stool, Heparin was discontinued on [10-3] and the patient was transfused times two units for hematocrit drop from approximately 27.2 to 23.8. Because of concern about the potential underlying coagulopathy, Heparin was restarted on [10-5]. Because of her extensive psychiatric history including leaving the [Hospital6 17430] against medical advice, the patient was seen on [9-30] by psychiatry which suggested minimizing non essential sedating medications until the patient was more alert. Bronchoscopy performed on [10-2] showed dynamic collapse throughout with moderate amount of purulent secretions throughout the left bronchi. Echocardiography on [10-3] continued to show small circumferential pericardial effusion. As noted above, the patient's hematocrit fell between [10-2] and [10-3] from 27.2 to 23.8. A nasogastric lavage was dip positive for blood but there was no gross blood at that time. The patient continued to have OB positive stools and hematocrit stabilized post transfusion. The patient was seen by hematology and it was suggested that laboratories be sent for hypercoagulability work-up which have been negative to date, however, in light of the patient's compromised lung status, decision was made to restart anticoagulation as the patient was clinically not greatly improved. The patient was again sent for bronchiolar alveolar lavage with transbronchial biopsy of the lingula on [10-5] which again showed diffuse dynamic collapse and purulent secretions form the left and now from the right upper and middle lobe as well. The patient was seen on [10-5] by the infectious disease service who felt that it was less likely that the patient had pneumonia. It was suggested that the patient be checked for HIV which ultimately returned negative because of the suggestion was made in light of the patient's continuing pneumonic processes without elevated white count or fever. On [10-5] intern was called to see the patient for shortness of breath, status post bronchoscopy with oxygen saturation approximately 68% on three liters, increasing only to 88% on five liters as well as tachypnea. The patient, at that time was diuresed for presumed pulmonary edema and was also given nebulizers and improved and stayed on the floor. On [10-7] the patient was transferred to the Intensive Care Unit for increasing dyspnea and desaturation on non rebreather on the floor. At that time the patient was felt possibly to be in ARDS. In the MICU the patient was treated with Ceftaz and Clindamycin for a presumed nosocomial pneumonia and/or aspiration pneumonia and aggressively was diuresed for pulmonary edema. Follow-up chest x-ray showed improvement in the infiltrate in the right lung. An echo was performed which was within normal limits. Bronchial alveolar lavage is negative, tissue is negative, washings were negative as were pleural fluid and blood cultures negative at the time. On [10-14] CT of the chest showed diffuse ground glass appearance in the right lung and in the focal region on the left lung which could represent the infectious process. A hemorrhage or diffuse alveolar damage although it was considered odd that it was less than unilateral, oxygen requirements in the MICU decreased with diuresis in the Intensive Care Unit and the patient on [10-14] required only 50% Venti Mask and oxygen saturation of 96 and was transferred back to the floor. The patient was continued on Heparin as well as Coumadin for presumed coagulopathy although again it should be noted that today these, including anti-thrombin III, protein C and factor 5 leiden were negative. It was still unclear whether the patient had actually originally had a pneumonia or other pneumonic process. Interventional pulmonology was reconsulted who suggested holding on empiric steroids but pursuing the possibility of open lung biopsy to confirm or rule out the possibility of post pericardial injuries. Pulmonary re-consult suggested the possibility of "trapped lung" regarding her left lower lobe collapse and felt thoracic surgery should reconsult re: possible surgical decortication. They want to f/u with pt as outpatient in several weeks and she is to have repeat chest ct to re-assess. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3258], M.D. [MD Number(1) 3259] Dictated By:[Name8 (MD) 1690] MEDQUIST36 D: [2189-10-19] 00:04 T: [2189-10-20] 21:45 JOB#: [Job Number ]	[ "511.9", "311", "486", "518.81", "428.0", "285.9", "423.9", "578.9", "415.11" ]	icd9cm	[ [ [] ] ]	[ "38.91", "34.91", "33.27", "38.93" ]	icd9pcs	[ [ [] ] ]														12466, 18469																																			2941, 2978										3007, 5020															5043, 5818	5835, 9952			9970, 12448
32,034	176,981	33551	Discharge summary	report	Admission Date: [2187-1-29] Discharge Date: [2187-2-3] Date of Birth: [2150-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: Difficulty swallowing, sore throat s/p hockey stick trauma to neck Major Surgical or Invasive Procedure: Open reduction internal fixation of two laryngeal fractures and direct laryngoscopy. History of Present Illness: Patient is a 36yM who, two days ago (on [2187-1-27]), was hit in the anterior neck with a hockey stick. He did not immediately seek medical attention but he subsequently developed odynophagia, throat pain and voice change. He was seen at OSH where a CT scan of the neck demonstrated a right-sided comminuted thyroid lamina fracture with associated laryngeal hematoma. He did not have any shortness of breath or respiratory symptoms at the time, however, he was fiberoptically intubated for airway protection and transferred to [Hospital1 18] ED. Past Medical History: R knee arthroscopy Social History: works as an investigator Family History: noncontributory Physical Exam: Initial Exam: T: 98.0 P 78 BP 143/88 RR 18 SpO2 100% RA Gen:nasotracheally intubated, awake, alert, oriented. Responds appropriately to questions. HEENT: No facial swelling. OP no erythema/exudates or masses. Neck soft, mild tenderness to palpation anterior neck. No crepitus. No masses or hematomas palpated. Trachea midline. CV: RRR Resp: Lungs CTAB Abd: Soft, NT, ND Ext: no edema, no trauma Pertinent Results: IMAGING: CXR [2187-1-29]: FINDINGS: AP bedside upright portable chest radiograph is reviewed without comparison and demonstrate thin-caliber endotracheal tube terminating only 2.8 cm above the carina. The mediastinal contours are within normal limits. The heart is normal size. The pulmonary asculature is normal, allowing for low lung volumes. The lungs are grossly clear. CT Neck [2187-1-30]: Status post placement of lateral plate and screws over the anterior and posterior fracture of the right thyroid cartilage, with no complication including no pneumomediastinum or subcutaneous emphysema. [2187-1-29] 09:22PM GLUCOSE-91 LACTATE-0.9 NA+-144 K+-3.8 CL--97* TCO2-29 [2187-1-29] 09:17PM UREA N-21* CREAT-0.9 [2187-1-29] 09:17PM estGFR-Using this [2187-1-29] 09:17PM AMYLASE-75 [2187-1-29] 09:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2187-1-29] 09:17PM WBC-5.8 RBC-4.70 HGB-14.5 HCT-41.0 MCV-87 MCH-30.9 MCHC-35.3* RDW-12.9 [2187-1-29] 09:17PM PLT COUNT-258 Brief Hospital Course: On HD 1 ([2187-1-29]) the pt was admitted with the history and exam as above. He was s/p fiberoptic intubation at the OSH for airway protection after he was found to have multiple thyroid cartilage fractures. The otolaryngology service was consulted, and the pt underwent operative fixation of the fractures on HD2. The pt tolerated the procedure well, and returned intubated to the trauma icu post-operatively. On HD3 the pt remained intubated due to airway edema and R sided laryngeal hematoma s/p his ORIF. The pt also had a post-op fever to 102.2, the fever evaluation was negative, and the temperature trended down over 24 hours to normal. On [2187-2-1] (HD 4), the pt had a good cuff leak and was extubated with no complications. The [Doctor Last Name ] drain in his neck was also pulled by the ENT service on HD 4. On HD 5 the pt remained stable without airway concerns or stridor and was sent to the floor from the ICU. On HD 6, meeting all goals prior to d/c, the patient was discharged in good condition. Medications on Admission: None Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed: take for pain not controlled by over the counter medications. Disp:30 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while taking narcotic pain medication. hold for loose stools. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Two right-sided thyroid cartilage fractures. Discharge Condition: Good Discharge Instructions: Please call your physician or go to the emergency room if you develop chest pain, shortness of breath or any difficulty breathing, lightheadedness, fever greater than 101.5, foul smelling or colorful drainage from your wounds, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, diarrhea, inability to eat or drink, or any other symptoms which are concerning to you. Activity: You may resume activity as tolerated. Diet: You may resume your regular diet. Medications: Resume your home medications. Take any new medications as prescribed. You should take a stool softener with your pain medication. Your pain medication may make you drowsy, so please do not drive while taking pain medicine. It is VERY important that you continue to cough and deep breath at least 10x every hour to optimize lung expansion. This is very important to do in order to prevent pneumonia which is a common complication associated with trauma patients. Follow up with the ENT surgeons regarding your thyroid cartilage fractures in [12-24] weeks. Please call Dr.[Name (NI) 18353] office at ([Telephone/Fax (1) 53978] to arrange an appointment. Followup Instructions: Follow up with the ENT surgeons regarding your thyroid cartilage fractures in [12-24] weeks. Please call Dr.[Name (NI) 18353] office at ([Telephone/Fax (1) 53978] to arrange an appointment.	[ "E917.0", "E878.8", "998.89", "807.5", "780.6" ]	icd9cm	[ [ [] ] ]	[ "31.42", "96.71", "31.64" ]	icd9pcs	[ [ [] ] ]	4140, 4146	2681, 3714	380, 467	4235, 4242	1599, 2658	5461, 5666	1151, 1168		3769, 4117		4167, 4214		3740, 3746			4266, 5438								1183, 1580																									274, 342										495, 1051															1073, 1093	1109, 1135
47,472	152,561	23095	Discharge summary	report	Admission Date: [2159-10-10] Discharge Date: [2159-10-15] Date of Birth: [2077-1-25] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Transfer from outside hospital for repeat catheterization Major Surgical or Invasive Procedure: cardiac catheterization thrombin injection History of Present Illness: This is an 82 year-old caucasian male with a history of mild congestive heart failure, s/p 4 previous myocardial infarctions, s/p CABG x 4 [2141], s/p TIA who presented to an OSH with dizziness, described as spinning sensation. He had been having angina since [2154]. However in the past few weeks, he has had worsening daily chest pain, releived by NTG. He was seen in OSH ED with CP and ECG showed new LBBB. He was taken to the cath lab and found to have chronically occluded native arteries and posterior descending artery with 40-50% diffuse lesion. No interventions were performed. The pt was transferred to the CCU where he was found to have a elev in his cardiac enzymes, peaking at - CK 271, CK-MB 43.2, trop 0.85. Initially the plan was to continue medical therapy with asa, plavix, bb, statin and nitrates however on evening of [10-9] had recurrent L sided CP which resolved with 1 SL nitro. Patient's films reviewed by Dr. [Last Name (STitle) 8467] who felt he had a tight left main that could be stented. he was transferred to the [Hospital1 18] for repeat catheterization. On arrival to the [Hospital1 18] floor the patient was CP free. He had no SOB, dizziness or headache. ROS was negative. He was given prehydration in preparation for cath on [10-11]. Past Medical History: Cardiac History: [2141]: CABG x 4 vessel: SVG to RCA. [2145] Angioplasty OM branch distal to graft [10/2155]: Stress test with evidence of small inf wall MI, ant apical and lateral ischemia. EF 40%, inferior hypokinesis, distal anterior severe hypokinesis, diskinesis of apex. Other History: Dyslipidemia TIA s/p hernia repair Social History: Lives with his wife. [Name (NI) ] ETOH, tobacco or illicit drug use Family History: Non-contributory Physical Exam: VS - T 98 HR 72 BP 92/44 RR 12 Sat 97 Gen: elderly, caucasian male, no acute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP 8 cm CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: midline sternal scar Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [2159-10-10] 06:45PM GLUCOSE-106* UREA N-13 CREAT-1.0 SODIUM-141 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11 [2159-10-10] 06:45PM CALCIUM-8.7 PHOSPHATE-2.7 MAGNESIUM-2.1 CHOLEST-126 [2159-10-10] 06:45PM TRIGLYCER-57 HDL CHOL-42 CHOL/HDL-3.0 LDL(CALC)-73 [2159-10-10] 06:45PM WBC-6.5 RBC-4.12* HGB-12.9* HCT-36.4* MCV-89 MCH-31.4 MCHC-35.5* RDW-13.3 [2159-10-10] 06:45PM PLT COUNT-227 [2159-10-10] 06:45PM PT-14.7* PTT-58.8* INR(PT)-1.3* CARDIAC ENZYMES: [2159-10-11] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.74* [2159-10-12] 12:25AM BLOOD CK-MB-NotDone cTropnT-0.74* [2159-10-12] 08:59AM BLOOD CK-MB-NotDone cTropnT-0.69* [2159-10-12] 04:47PM BLOOD CK-MB-NotDone cTropnT-0.64* [2159-10-11] 06:10AM BLOOD ALT-20 AST-31 CK(CPK)-64 AlkPhos-40 TotBili-0.5 [2159-10-11] 02:10PM BLOOD CK(CPK)-51 [2159-10-11] 04:20PM BLOOD CK(CPK)-47 [2159-10-12] 12:25AM BLOOD CK(CPK)-60 [2159-10-12] 08:59AM BLOOD ALT-22 AST-29 CK(CPK)-68 TotBili-0.8 [2159-10-12] 04:47PM BLOOD CK(CPK)-62 DISCHARGE LABS: [2159-10-15] 05:35AM BLOOD Hct-32.2* [2159-10-15] 05:35AM BLOOD Glucose-95 UreaN-14 Creat-1.1 Na-138 K-4.5 Cl-104 HCO3-27 AnGap-12 [2159-10-15] 05:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 ECG [2159-10-10]: Sinus rhythm. Left atrial abnormality. Left bundle-branch block. No previous tracing available for comparison. CARDIAC CATHETERIZATION REPORT [2159-10-11]: COMMENTS: 1. Selective coronary angiography of the LMCA demonstrated 70% distal LMCA stenosis, 100% proximally occluded LAD, 70% ostial LCX stenosis with 80% stenosis in the AV groove branch. 2. Limited hemodynamics were performed. The systemic arterial pressures were normal measured 110/56mmHg. 3. Successful stenting of the LMCA with a 3.0x15mm Xience stent that was postdilated to 3.25mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 4. Course later complicated by hematoma and pseudoaneurysm treated with thrombin injection. 5. Patient participated in Champion PCI study involving randomization to Plavix or Cangrelor. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal systemic arterial pressures. 3. Successful stenting of the LMCA into the LCX. ECG [2159-10-11]: Sinus rhythm. The tracing is marred by baseline artifact. There is Q-T interval prolongation. Compared to the previous tracing of [2159-10-10] left bundle-branch block is no longer recorded and the rate is slower. A repeat tracing of diagnostic quality is suggested. ECG [2159-10-12]: Sinus rhythm. Left atrial abnormality. Left bundle-branch block is new as compared with prior tracing of [2159-10-11] and similar to that recorded on [2159-10-10]. The presence of left bundle-branch block may be rate-related. Right Femoral Vascular US [2159-10-13]: RIGHT FEMORAL VASCULAR ULTRASOUND: Grayscale and color and pulse wave Doppler examination was performed in the right groin region. Examination reveals a 3.1 x 2.7 x 1.7 cm pseudoaneurysm in the right groin, with visualization of the neck connecting the pseudoaneurysm to the right common femoral artery. The neck demonstrates to and fro flow, and is located slightly superomedially along the pseudoaneurysm. Normal flow is demonstrated in the common femoral artery. Wall-to-wall flow and normal compressibility is demonstrated in the right common femoral vein. Flow is also demonstrated in the greater saphenous vein. IMPRESSION: Pseudoaneurysm arising from right common femoral artery as described above. Brief Hospital Course: This is an 82 year old male with history of multiple myocardial infarctions, coronary artery bypass graft with four vein grafts in [2141], and chronic angina who was found to have NSTEMI at an outside hospital, underwent cardiac cath there demonstrating three vessel coronary artery disease and left main stenosis. No interventions were performed at the outside hospital and he was transferred to [Hospital1 18] for left main coronary artery stenting. 1) Coronary Artery Disease: Cardicac catheterization demonstrated three vessel disease and 70% stenosis of the left main coronary artery which was successfully stented with a drug eluting stent. Patient remained chest pain free throughout this hospitalization. He was started on metoprolol and lisinopril and will continue taking plavix, simvastatin, aspirin, and sublingual nitroglycerin as needed. He will follow up with his outpatient cardiologist, Dr. [Last Name (STitle) ]. 2) Femoral Hematoma: Following catheterization patient developed an expanding hematoma at access site. During this episode of bleeding patient became bradycardic and unresponsive. He regained responsiveness after intravenous fluid and one dose of atropine. Hematoma was stablized and patient was transferred to the CCU. Patient remained hemodynamically stable and was transferred back to the cardiology floor service. On hospital day 4 patient determined to have right femoral pseudoaneurysm diagnosed by a femoral bruit and confirmed by ultrasound. He was seen by the vascular surgery team who performed a thrombin ejection on [2159-10-15]. At time of discharge he was ambulating without any groin discomfort. He will follow up with Dr. [Last Name (STitle) ] from vascular surgery as an outpatient. 3) Pump: Patient remained euvolemic. An ECHO at the outside hospital on [2159-10-8] showed normal left ventricular systolic function with EF 40-45%. 4) Rhythm: Patient remained in sinus rhythm with likely rate related left bundle branch block. 5) Hypercholesterolemia: Patient was continued on his outpatient dose of simvastatin. Patient was a FULL code during this admission. Medications on Admission: Simvastatin Aspirin 325 mg daily Nitroglycerin 0.4 mg SL Plavix 75 mg daily Osteo [Hospital1 ]-Flex 1500 mg daily Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. Vitamin B-12 250 mcg daily. Beta Carotene 25,000 unit daily B Complex daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain. 4. Acetaminophen 500 mg Tablet Sig: 0.5 Tablet PO every [3-11] hours as needed for pain. 5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Osteo [Hospital1 ]-Flex 1500mg daily 9. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Beta Carotene 25,000 unit Tablet Sig: One (1) Tablet PO once a day. 12. B Complex Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Non-ST Elevation Myocardial Infarction, Status Post Percutaneous Intervention and stent to the left main coronary artery, Right groin hematoma, Right common femoral artery pseudoaneurysm status post thrombin injection Secondary:Dyslipidemia, status post coronary artery bypass graft in [2141], status post hernia repair Discharge Condition: good, chest pain free Discharge Instructions: You were transferred to this hospital in order to have a cardiac catheterization. You had the cardiac catheterization performed and had a stent placed in one of your heart vessels. Following the procedure you had groin bleeding and went to an intensive care unit until the bleeding had stabilized. You were then transferred back to the regular cardiology floor. We then determined that you had an outpouching of your right groin blood vessel called a pseudoaneurysm. The vascular surgeons performed a procedure to remedy this defect in your vessel. You will need to follow up as listed below. You were started on the following NEW medications: -Lisinopril 5 mg daily -Metoprolol succinate (Toprol XL): This will replace your metoprolol tartrate. You should take the rest of your medications as directed. If you develop chest pain, shortness of breath, dizziness, or pass out please contact your primary care provider or come to the emergency department for evaluation. Followup Instructions: You should follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on Tuesday [2159-10-30] at 11:00. The office phone number is [Telephone/Fax (1) 62] VASCULAR Ultrasound [Hospital ] Medical Office Bldg (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2159-10-25] 3:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2159-10-25] 4:30 You should make an appointment to follow up with your primary care provider [Last Name (NamePattern4) ]. [Last Name (STitle) ] within 7-10 days of discharge. Completed by:[2159-10-18]	[ "E879.0", "401.9", "442.3", "997.2", "458.29", "V70.7", "414.2", "780.2", "414.02", "998.12", "428.0", "410.71", "412", "414.01" ]	icd9cm	[ [ [] ] ]	[ "00.40", "36.07", "00.45", "99.29", "00.66" ]	icd9pcs	[ [ [] ] ]	9982, 9988	6559, 8700	341, 386	10365, 10389	2909, 2909	11411, 12082	2180, 2198		9005, 9959		10009, 10344		8726, 8982		5103, 6536	10413, 11388			3996, 5086					2213, 2890																					3427, 3979				243, 303										414, 1712					2926, 3409										1734, 2075	2091, 2164
58,854	191,510	44385	Discharge summary	report	Admission Date: [2129-10-3] Discharge Date: [2129-10-19] Date of Birth: [2056-1-14] Sex: F Service: MEDICINE Allergies: Aspirin / Folic Acid / Milk / Cephalexin / adhesive / peanuts / Oxycodone Attending:[First Name3 (LF) 4616] Chief Complaint: difficulty ambulating Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 73-year-old woman with a history of primary biliary cirrhosis, atrial fibrillation s/p PPM, who was admitted [Date range (1) 95162] with LUE swelling and pain and had an ultrasound guided biopsy of her scapular mass [2129-9-21] showing adenocarcinoma. Two days ago she developed walking [2-24] bilateral hip pain. It has taken her longer to get up the few stairs into their home. She denies weakness, numbess. She endorses bilateral extremity edema which may be worsening. Her left shoulder pain continues to be painful. She has been taking tylenol at home for pain. She had planned to see her radiation oncologist, Dr. [Last Name (STitle) 31823] at Shields radiation oncology at 3pm today to start treatment to the left shoulder with treatment planned through [10-21]. She was unable to get radiation as her pacemaker is in the radiation field. She was seen in [Hospital 478] clinic for initiation of care. She was found to have lower extremity weakness L>R with exam limited by pain. She appeared to be in pain and was moaning in the clinic. She was referred for admission for evaluation of her left weakness and pain control. Past Medical History: PAST MEDICAL HISTORY: 1. Colon polyps: [2123]. 2. Hypertension. 3. Osteopenia: BD [2124]. 4. Primary biliary cirhosis. 5. Eczema. 6. Afib s/p pacer placement [6-/2129], on metoprolol and pradaxa. 7. Former smoker: 30 PACK YR hx. PAST SURGICAL HISTORY 1. Appendectomy: [2064]. 2. Arthroscopy bilateral knee: [2114], [2122]. Social History: Pt is married, without children. She is a retired social worker. She endorses a 30 year smoking history of 1 pack per day. She stopped drinking alcohol following her diagnosis of PBC. She denies history of other drug use. Family History: Mother: [Name (NI) 11964] @50. Deceased: at age: 60. MGM: Unknown hx. Deceased: at age: 80s. MGF: Unknown hx. Deceased: at age: 60s. Father: Renal failure after surgery. Deceased: at age: 51. PGM: Stroke. Deceased: at age: 70s. PGF: Unknown hx. Deceased: at age: 60s. Sis: X 1 MS. [Name13 (STitle) ]. [Last Name (un) ]: N/A. Children: N/A. Other: 3 maternal uncles with [Name2 (NI) ]. Physical Exam: INITIAL PHYSICAL EXAM: Vitals - T: BP: HR: 66 RR: 18 02 sat: 94% pm RA GENERAL: well appearing female, mild distress, occasionally moaning HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs LUNG: mild bibasilar crackles, otherwise CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: - RUE: no edema, full ROM, sensation intact - LUE: 3+ pitting edema to shoulder, large subcutaneous mass palpable over left shoulder and scapula, tender to palpation, ROM limited at shoulder but full at elbow and wrist - LLE: 3/5 strength at hip flexor, [5-28] at knee extensor/flexor, [5-28] at ankle flexor, sensation intact, 2+ pitting edema - RLE: 4/5 strength at hip flexor, [5-28] at knee extensor/flexor, [5-28] at ankle flexor, sensation intact, 2+ pitting edema PULSES: 1+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: [2129-10-3] 10:00AM UREA N-14 CREAT-0.8 SODIUM-134 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-12 [2129-10-3] 10:00AM estGFR-Using this [2129-10-3] 10:00AM ALT(SGPT)-19 AST(SGOT)-31 ALK PHOS-174* TOT BILI-0.5 [2129-10-3] 10:00AM ALBUMIN-3.3* CALCIUM-9.7 [2129-10-3] 10:00AM WBC-12.4* RBC-3.55* HGB-10.2* HCT-30.9* MCV-87 MCH-28.8 MCHC-33.0 RDW-14.7 [2129-10-3] 10:00AM NEUTS-81.5* LYMPHS-13.4* MONOS-5.0 EOS-0.1 BASOS-0 [2129-10-3] 10:00AM PLT COUNT-413 Brief Hospital Course: 73F with PMH of atrial fibrillation, primary biliary cirrhosis, with newly diagnosed metastatic adenocarcinoma of left scapula of unknown primary admitted for increased pain and difficulty ambulating with hospital course complicated by acute drop in sodium from 134 on admission to 119 on [10-11] and changes in mental status. # Metastatic adenocarcinoma of unknown primary: Patient recently diagnosed with adenocarcinoma to left shoulder of unknown primary. Pt received further eval for primary site including RUQ US, upper and lower endoscopy, and thin sliced CT abd/pelvis with no primary source of cancer identified. Pt received bone scan which revealed extensive uptake of tracer to left scapula, and also to right iliac [Doctor First Name 362], left acetabulum, and right sixth rib which possibly represents osseous metastases. Mammogram pending to evaluate for possible breast cancer. Pt also with left upper extremity swelling which has been unchanged over weeks and is likely secondary to tumor. Past ultrasound of left arm revealed no DVT. Beacause of severe pain to scapula, pt has been getting [Doctor First Name 16859] daily to site for pallative pain management. Pain control has been managed with dilaudid (? allergy to oxycodone) and [Name (NI) 16859] (pt started with session 1 of 5 on [2129-10-5]). She has severe lymphedema in the left arm [2-24] tumor in the shoulder and this has worsened over hospital course. LUE US showed non-occlusive thrombus, not getting anticoagulation. PT will tried lymphedema wrapping and she received ice/ heat packs prn. She also received aggressive pain regimen as well. She received 5 days of [Month/Day (2) 16859] and started chemo on [2129-10-18] despite that primary has not yet been discovered. Her small bowel is the only area that has not been adequately investigated for cancer. # Difficulty ambulating: Xray of hip showed left iliac bone suspicious lytic lesion with cortical disruption pointing more to mets for cause of pain in hips. Bone scan confirmed this suspicion. Pt also has lower extremity chronic lymphedema that may be contributing to decreased mobility. Pt's right ventricular cavity is dilated with normal free wall contractility. Edema is likely not from CHF given pt's normal EF. LENIS showed no DVT. TTE showed normal EF with dilated right ventricle. Pt had compression stockings (TEDS) and ace bandages placed to help with lower extremity edema # Acute on Chronic Hyponatremia: low sodium has been a chronic issue for patient with baseline of approximately 130. On admission Na was 134. Over the course of three says starting [10-10], pt's Na dropped to 119. At first this was though most likely due to hypovolemia (as pt as NPO with bowel prep over [2-25] days) therefore pt was given aggressive IV fluids over one day and Na improved initially to 123 and then dropped again to 119. There was most likely a component of SIADH and pt was fluid restricted and sent to MICU for treatment with hypertonic saline. Pt spent two days in [Hospital Unit Name 153] for correction with hypertonic saline for level of 120 with MS changes. Her mental status improved. Renal followed pt and recommended salt tabs, fluid restrition, Laisx PRN, and high osmolarity food/diet. The thought is that SIADH is the predominant feature of her hyponatremia but was likely confounded by hypovolemia earlier in hospital course. She appeared intravascularly euvolemic but is total body overloaded. She was discharged with a sodium level of 127 on sodium chloride tabs 1mg PO bid. She will have blood drawn as an outpatient to check her sodium (in addition to post-chemotherapy CBC). MICU Course: The patient was admitted to the MICU for administration of 3% saline at 25cc per hour based on renal recommendations. This was started on the evening of transfer and sodium levels were checked q4hrs. On transfer, sodium was 123. The next morning after 15 hours of hypertonic saline infusion, her sodium rose to 128. Hypertonic saline was discontinued and normal saline was initiated. Sodium remained stable at 126 so saline was then stopped per renal recommendations. Her mental status has improved somewhat from the time of initial transfer. # [Last Name (un) ]: creatinine rise [10-11] to 1.5 up from .6- .8 prior to [10-10]. This increase correlated to when pt received IV contrast for CT scan therefore CIN suspected. However also on the ddx pt was started on high dose Ibuprofen on [10-9] to help with [Last Name (un) 2043] pain. And pt had been on ACE I (both of which have since been discontinued because of nephrotoxicity). FENA from [10-8] was .05% pointing more to prerenal process. # Atrial fibrillation s/p PPM [6-/2129] on pradaxa at home. Pacemaker is located on the left side, the same side of pt's scapula tumor and is in the radiation field. Pt received pacemaker evaluation [10-4] which indicated approx 20% pacemaker dependent. Pt continued home sotalol and pradaxa was held while in house as pt needed procedures for cancer workup. # HTN: normotensive. Continued home lisinopril. # Primary biliary cirrhosis: continued home urodiol TRANSITIONAL ISSUES: ======================= Pt remained full code while hospitalized Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. [Month/Year (2) 95160] NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 2. Dabigatran Etexilate 150 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Sotalol 80 mg PO BID 5. Ursodiol 500 mg PO BID 6. Acetaminophen 500 mg PO Q6H:PRN pain 7. Ascorbic Acid 250 mg PO DAILY 8. Calcium Carbonate 600 mg PO DAILY 9. Vitamin D 400 UNIT PO DAILY 10. Cyanocobalamin Dose is Unknown PO DAILY 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Ferrous Sulfate 325 mg PO DAILY 13. flaxseed NF unknown Oral prn 14. Loratadine NF 10 mg Oral prn rash 15. Systane NF (peg 400-propylene glycol) 0.4-0.3 % OU [Hospital1 ] 16. Selenium Sulfide Dose is Unknown TP Frequency is Unknown Discharge Medications: 1. Sotalol 80 mg PO BID 2. Ursodiol 500 mg PO BID 3. Acetaminophen 500 mg PO Q6H:PRN pain 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Loratadine NF 10 mg Oral prn rash 6. [Hospital1 95160] NF (cycloSPORINE) 0.05 % OU [Hospital1 ] 7. Senna 1 TAB PO BID:PRN constipation 8. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days Stop after dose on [10-27]. Treating UTI. RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #16 Tablet Refills:0 10. Morphine SR (MS Contin) 30 mg PO Q12H hold for rr<12 or if pt sedated RX morphine [Avinza] 30 mg 1 capsule(s) by mouth q12hrs Disp #4 Capsule Refills:0 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath/wheezing 12. Simethicone 40-80 mg PO QID:PRN gas pain 13. Sodium Chloride 1 gm PO BID 14. Ascorbic Acid 250 mg PO DAILY 15. Cyanocobalamin 25 mcg PO DAILY 16. Calcium Carbonate 600 mg PO DAILY 17. Dabigatran Etexilate 150 mg PO DAILY 18. Ferrous Sulfate 325 mg PO DAILY 19. Lisinopril 5 mg PO DAILY 20. Systane NF (peg 400-propylene glycol) 0.4-0.3 % OU [Hospital1 ] 21. Vitamin D 400 UNIT PO DAILY 22. HYDROmorphone (Dilaudid) 2-4 mg PO Q2H:PRN pain do not give if rr<12 or oversedated RX hydromorphone [Dilaudid] 2 mg [1-24] tablet(s) by mouth q2hrs Disp #8 Tablet Refills:0 23. Sarna Lotion 1 Appl TP QID:PRN itching Discharge Disposition: Extended Care Facility: [Hospital1 ] Senior Healthcare of [Location (un) 1439] Discharge Diagnosis: - adenocarcinoma, unknown primary origin - hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [Known lastname 95161], You were admitted to [Hospital1 18] under the Oncology Medicine service on [2129-10-3] for pain in your left hip and difficulty walking following your recent discharge on [2129-9-22]. Your stay was complicated by hyponatremia (low levels of sodium in your blood), which required a brief stay in the ICU. You did well in the ICU, and your sodium levels rose to a level where it was safe to transfer you back to the floor. During your stay, you completed 5 radiation treatments to your left shoulder tumor. You do not need further radiation therapy and do not need to follow-up with the radiation oncologist. Also, you started your first chemotherapy dose on Tuesday, [2129-10-18]. Upon discharge, if you develop any of the following, please come to the Emergency Department or call your doctor immediately at [Telephone/Fax (1) 22]: Fever, chills, nausea, vomiting, diarrhea, blood in your stool or darker than normal bowel movements, worsening fatigue, pallor, numbness/tingling, difficulty moving or confusion, chest pain, trouble breathing, abdominal pain, new rash, new bleeding, new bruising, swelling in part of your body, or other symptoms that concern you. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2129-11-7] at 8:15 AM With: CHECKIN HEM ONC CC9 [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2129-11-7] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [Telephone/Fax (1) 6568] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2129-11-7] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 26] [Last Name (NamePattern1) 8402], 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	[ "571.6", "757.0", "457.1", "198.5", "455.0", "338.3", "041.49", "584.9", "453.83", "427.31", "V45.01", "199.1", "253.6", "518.0", "V15.82", "560.1", "276.50", "E947.8", "401.9", "599.0" ]	icd9cm	[ [ [] ] ]	[ "99.25", "45.16", "45.23", "89.45", "92.29" ]	icd9pcs	[ [ [] ] ]	11792, 11881	4249, 9437	358, 364	11981, 11981	3724, 4226	13406, 14360	2189, 2592		10359, 11769		11902, 11960		9551, 10336			12157, 13383								2630, 3705																		9458, 9525							296, 320										392, 1561								11996, 12133							1605, 1933	1949, 2173
30,610	180,378	7838+55879	Discharge summary	report+addendum	Admission Date: [2165-5-7] Discharge Date: [2165-5-9] Date of Birth: [2121-12-11] Sex: F Service: MICU-GREEN HISTORY OF PRESENT ILLNESS: This is a 43 -year-old female with a history of lupus with nephritis, pericarditis, on prednisone and CellCept, also with diabetes mellitus type 2 and asthma, presented on [5-6] to [Hospital3 3583] and was transferred to [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] with diagnosis of periorbital cellulitis and sepsis. The patient complains of a swollen, painful eye one day prior to arrival. This pain started getting worse two hours prior to admission and the patient was unable to open her eye on the morning of admission. She was able to drive herself to the Emergency Department at [Hospital3 3583] where a CT scan showed no orbital involvement. The patient was given vancomycin. Arterial blood gas was drawn and the patient was noted to be acidotic with a pH of 7.29, pCO2 26, pO2 74. The patient was emergently intubated due to concern for acidosis. Documentation unavailable on status for airway at this time. The patient was also noted to have a temperature of 103 F. After intubation, the patient's systolic blood pressure dropped to 60 and did not respond to fluid boluses. The patient was started on Dopamine and remained very tachycardic, so that this was changed to norepinephrine. Before intubation, the patient had complained of retrosternal chest pain radiating to both arms. An electrocardiogram showed, by discharge summary, "inferolateral ischemia" (electrocardiogram copy is unavailable.) the patient was also given imipenem and stress dose Solu-Medrol at 125 mg IV times one. The patient was transferred to [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for further care. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus on prednisone times three years, complicated by pericarditis, nephritis, positive anticardiolipin antibody, history of skin thrombosis. 2. Diabetes mellitus type 2 times ten years with retinopathy. 3. Acute pancreatitis, complicated by methicillin - resistant Staphylococcus aureus peritonitis, vancomycin resistant enterococcus bacteremia, Serratia bacteremia in [2164-7-10]. 4. Asthma. 5. Hypertriglyceridemia. 6. Chronic anemia with baseline hematocrit of 30. 7. Leukopenia with white blood cell count 1.4 to 8.5. 8. Steroid induced myopathy. 9. History of methicillin - resistant Staphylococcus aureus abscess in lower extremity in [2163-11-9]. 10. Pulmonary embolism, status post withdrawal of Coumadin in [2164-2-8]. ADMITTING MEDICATIONS: Neurontin 200 mg po q day, Zaroxolyn 2.5 mg tid, dicloxacillin 500 mg [Hospital1 ], [Doctor First Name ] 60 mg q day, Zanaflex 4.0 mg q HS, Ativan 4.0 mg q HS prn, prednisone 5.0 mg po q day, recently increased to 10 mg po q day due to presumed lupus nephritis flare, Percocet prn, Lipitor 10 mg po q day, Procardia 90 mg po q day, Lasix 60 mg po tid, Lopressor 50 mg po q day, Coumadin 3.0 mg po q day, Prilosec 20 mg po q day, Paxil 20 mg po q day, CellCept [Pager number ] mg po bid, Atacand 64 mg po q day, iron 325 mg po bid, multivitamin 1.0 mg po q day, Flovent 110 mcg two puffs [Hospital1 ], Serevent two puffs [Hospital1 ], Albuterol two puffs [Hospital1 ], Benadryl 50 mg prn. The patient also reports being started on Nortriptyline for insomnia recently. TRANSFER MEDICATIONS: Imipenem 250 mg IV q twelve hours, Zantac, vancomycin 1.0 gm IV times one, regular insulin sliding scale, hydrocortisone 100 mg IV tid, norepinephrine at 5.0 mcg per minute, morphine sulfate prn, Ativan prn, CellCept. ALLERGIES: The patient reports shortness of breath to IV contrast dye and drug rashes to multiple medicines, including Linezolid, imipenem, ceftazidime, azithromycin, levofloxacin, penicillin. SOCIAL HISTORY: The patient is divorced with two children. She does not drink or smoke. PHYSICAL EXAMINATION: Temperature 97.2 F, heart rate 113, blood pressure 115/68. Ventilator settings: SIMV 800 X 14 with positive end expiratory pressure of 5 and FiO2 of 100%. The patient is intubated and barely responsive. Her right eye is erythematous, more so than her left, with her right eye swollen shut and crusted vesicles under the right eye. She is intubated. Her heart is tachycardic with no murmurs. Her lungs are clear to auscultation bilaterally from anterior approach. Abdomen is soft and tender to deep palpation in all four quadrants. Extremities are without clubbing or cyanosis. She has 1+ pitting edema bipedal. LABORATORY DATA: At [Hospital3 3583], white blood cells 13.8, hematocrit 32.7, platelets 215,000 at 08:00 AM. At 05:00 PM white blood cells was 12.3, hematocrit 21.6, platelets 216,000. Differential 75 polys, 9 bands, 8 lymphocytes. Sodium 157, potassium 5.1, chloride 104, bicarbonate 13, BUN 49, creatinine 2.6. Calcium 7.8, total protein 5.4, total bilirubin 0.2, alkaline phosphatase 90. LDH 417, AST 19, ALT 17, CPK 30, carboxyhemoglobin 3.7, albumin 2.2. Serum acetone negative. Arterial blood gas: pH 7.29, pCO2 26, pO2 74, 91% on room air prior to intubation. CT scan of orbits, read by outside hospital radiologist is superficial subcutaneous swelling around right eye, no abnormality within the orbit. Scattered, mild mucosal thickening of right maxillary sinus with diffuse ethmoid air cell disease, question of minimal sinusitis. At [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] white blood cells 14.8, hematocrit is 30.7, platelets 207,000. PT 34.7, INR 8.0, PTT 66.3. pH 7.34, pCO2 18, pO2 212, on FiO2 65%. Lactate 1.0. Urinalysis: specific gravity 1.008, large blood, negative nitrate, protein greater than 300, trace glucose, trace ketones, bilirubin negative, 5 red blood cells, no white blood cells, no bacteria, no epithelial cells. Sodium 134, potassium 4.6, chloride 106, CO2 9.0, BUN 34, creatinine 3.5, glucose 358. ALT 14, AST 26, CK 53, alkaline phosphatase 72, total bilirubin 0.2, albumin 2.0, calcium 7.1, phosphorus 4.4, magnesium 1.0. Electrocardiogram: sinus tachycardia with no T-wave inversion, no ST-T wave changes, no Q-waves, normal R-wave progression. HOSPITAL COURSE: 1. Cardiovascular: The patient was felt to be hypotensive, likely either to septic shock, anaphylaxis, or reaction to sedating drugs used for intubation. Notably, the patient received seven liters of normal saline at [Hospital3 3583], as well as two units of packed red blood cells. Her continuing tachycardia was felt to be compensatory for fluid depletion. Continuous arterial blood pressure monitoring was obtained through the right radial artery. The patient received a 500 cc normal fluid saline bolus and was started on high volume sodium bicarbonate drip at 200 cc per hour. It was possible to rapidly wean the patient off of pressors and her blood pressure remained stable from that time. All anti-hypertensives were initially held, but as the patient recovered, Lopressor was resumed, followed by other cardiac medicines. Troponin I returned at 2.2. The patient did have continuous mild substernal chest pain radiating to both arms, which increased with chest wall palpation. This was believed to be secondary to lupus pericarditis and as electrocardiogram had no changes. However, to be safe, the patient was started on aspirin and pharmacologic cardiac stress evaluation should be considered when the patient is fully recovered. 2. Pulmonary: The patient was hyperventilated with positive pressure and dilation on the morning of admission. Her responsiveness rapidly improved with therapy and she was given a trial of pressure support ventilation on the afternoon of [5-7]. She tolerated this quite well and was extubated in the evening of [5-7]. Post extubation gas was pH 7.43, pCO2 29, pO2 76, on 40% oxygen. Oxygen was rapidly weaned until the patient had peripheral oxygen saturations of 92% to 96% on nasal cannula. Lungs remained clear and the patient had no further acute pulmonary issues on this admission. 3. Infectious Disease: Due to her immunocompromise status and concern for periorbital cellulitis with sepsis, the patient was started on Meropenem 500 mg q 24 hours as well as continued vancomycin dosing for levels. In retrospect, it is felt that hypotension was likely secondary to drug reaction, rather than sepsis and as broad coverage as Meropenem probably was not required. However, as the patient is improving on vancomycin and Meropenem, it is felt not to be safe to narrow therapy until the patient's symptoms have fully resolved. The patient's fevers rapidly resolved and she became afebrile. Ophthalmology was consulted on the morning of [5-7] and concurred that there was no orbital involvement. Infectious Disease was consulted and recommended continuation of vancomycin and Meropenem with reasoning described above. CT scan sinuses was repeated at their recommendation and showed preseptal soft tissue swelling and inflammatory soft tissue changes in the perinasal sinuses with a question of sinusitis. No air fluid levels were noted. Ear, Nose, and Throat service was consulted and felt that there was no fluid collection that could be drained. Conservative therapy with antibiotics was recommended. The patient was initially started on acyclovir due to concern that the lesions on her face could be herpetic in nature. Direct fluorescent antibody staining was sent and was negative; at this point acyclovir was halted. Bacterial cultures of the vesicles, blood and urine, were unrevealing and we were unable to narrow antibiotic coverage due to lack of a specific bacterial organism to treat. The patient received symptomatic management including Afrin for a question of sinusitis. 4. Gastrointestinal: The patient rapidly resumed a renal diet after extubation. Liver panel was normal. There were no other gastrointestinal issues. 5. Hematologic: The patient received 0.5 mg of IV vitamin K secondary to an INR of 8.0. Her INR decreased to 1.6 with this therapy and no further vitamin K was administered. The patient resumed Coumadin 3.0 mg q HS, although close INR monitoring is indicated, due to concern for overdose at that dose. The patient was also started on heparin for a history of lupus anticoagulant and elevated PTT even with anticoagulation reversed. The patient remains on a heparin drip, currently at 1,050 units per hour and it is recommended that this be continued until INR is therapeutic due to history of pulmonary embolism off Coumadin. DIC panel was negative. The patient received a third and final unit of packed red blood cells at [Hospital3 ] - [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] with appropriate response with hematocrit. 6. Endocrine: The patient received regular insulin sliding scale due to elevated blood sugars, probably secondary to stress dose steroids. The patient's rheumatology and renal outpatient attendings were consulted. It was felt that the patient's lupus nephritis had been stable on prednisone and CellCept had been started in the hopes of getting the patient off prednisone. However, due to acute immunocompromise, CellCept was discontinued and the patient was eventually returned to her outpatient dose of prednisone 10 mg q day. The patient's primary care physician and renal attending have been informed and this will be managed further at [Hospital3 6265]. 7. Neurologic: The patient's outpatient symptomatic neuropsychiatric therapy was resumed, including Zanaflex, Ativan, Percocet, Paxil, Neurontin, Benadryl. 8. Renal: The patient was felt to be in acute on chronic renal failure on admission due to rapid rise in creatinine. Urine electrolytes were sent with a calculated fractional excretion of sodium of 3.33% and this was felt to confirm the diagnosis of acute tubular necrosis. The patient initially received aggressive bicarbonate drip due to profound metabolic acidosis, receiving approximately 400 mEq of bicarbonate over the course of twelve hours. CellCept was discontinued as above. Stress dose steroids were initially continued at hydrocortisone 100 mg q eight hours, but this was rapidly weaned to her outpatient dose of prednisone. Renal service was consulted on the morning of [5-7]. Their recommendation was supportive management, including fluid restriction. Complement was measured and found to be low with a C3 of 65 and a C4 of 9.0. Outpatient rheumatologist was Dr. [Last Name (STitle) ], was contact[Name (NI) ] and felt that this was consistent with outpatient and that there was no increase in the activity of her lupus. The patient received Tums 1.0 gm tid with meals for hyperphosphatemia which stabilized at a level of 6.0 mg/Dl. The patient's creatinine stabilized between 3.5 and 4.0 and she began to diurese on her own on the morning of [5-9]. At the request of Dr. [Last Name (STitle) 18998], outpatient nephrologist, Renal service as asked whether Cytoxan would be more appropriate than CellCept. Their feeling was that full resolution of acute tubular necrosis as well as a renal biopsy would be required before this therapy could be started. 9. Fluids, electrolytes, and nutrition: As above, the patient received approximately 2.5 liters of dextrose 5% in water with 100 mEq of sodium bicarbonate. Her blood pressure rapidly resolved and fluid restriction was initiated. She received gentle potassium and calcium repletion and oral calcium carbonate was given for hyperphosphatemia as above. The patient was started on a renal diet with supplements on [5-8]. 10. Prophylaxis: The patient received Prilosec and IV heparin during her admission. DISPOSITION: The patient was felt to be stable from a cardiopulmonary standpoint on [5-9]. Her infection was responding well to broad spectrum antibiotics. Her only remaining medical issue is resolving acute renal failure. Due to the need for several days of hospitalization, the decision was made by the patient and her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 23220], to transfer the patient to [Hospital3 6265] for further medical management. She is to be transferred in stable condition. DISCHARGE MEDICATIONS: Neurontin 200 mg po q day, [Doctor First Name ] 60 mg po q day, Zanaflex 2.0 mg po q HS, may repeat times one, Lorazepam 4.0 mg po q HS prn, prednisone 10 mg po q day, Percocet one to two tablets po q four to six hours prn, Lipitor 10 mg po q day, Procardia XL 90 mg po q day, Lopressor 50 mg po bid, Coumadin 3.0 mg po q PM, Prilosec 20 mg po q day, Paxil 10 mg po q day, iron sulfate 325 mg po bid, multivitamin 1.0 mg po q day, Flovent 110 mcg two puffs po bid, Serevent two puffs po bid, Albuterol two puffs q four hours prn, Benadryl 25-50 mg q HS prn, heparin IV currently at 1,050 units per hour for PTT 60 to 100, calcium carbonate 1.0 gm tid with meals, erythropoietin 7,000 units subcutaneous Tuesday, Thursday, and Saturday, regular insulin sliding scale qid, enteric coated aspirin 325 mg po q day, clotrimazole cream to groin [Hospital1 ], vancomycin check daily levels and dose for random vancomycin level of less than 15, Meropenem 500 mg q twelve hours, Afrin two puffs [Hospital1 ] times three days, then stop. FOLLOW UP: 1. The patient requires at least fourteen days of vancomycin and Meropenem, after which it is recommended that these be continued until full resolution of signs and symptoms and clearing of CT scan sinuses which should be repeated upon resolution of symptoms. 2. The patient should be continued on IV heparin with daily INR checked until INR is therapeutic. INR should be monitored closely due to suspected Coumadin overdose on admission. 3. The patient may require outpatient cardiac stress evaluation as above. 4. The patient is to continue to have prednisone at this time. It will be left to the patient's nephrologist, Dr. [Last Name (STitle) 18998] and rheumatologist, Dr. [Last Name (STitle) ], as to further management of her lupus nephritis. It is felt that either prednisone or CellCept would be reasonable; however, before starting Cytoxan therapy, it is recommended that the patient have full resolution of acute tubular necrosis and receive repeat renal biopsy. DISCHARGE DIAGNOSES: 1. Periorbital cellulitis. 2. Metabolic acidosis, presumed secondary to infection. 3. Hypotension of unknown origin, suspected sepsis and/or drug reaction. 4. Diabetes mellitus. 5. Asthma. 6. Hypertriglyceridemia. 7. Insomnia. 8. Suspected lupus pericarditis. 9. Lupus anticoagulant. 10. Acute tubular necrosis in the setting of lupus nephritis. 11. Hyperphosphatemia. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3851] Dictated By:[Last Name (NamePattern1) 8352] MEDQUIST36 D: [2165-5-9] 11:43 T: [2165-5-9] 13:16 JOB#: [Job Number 24466] cc:[Telephone/Fax (1) 28277] Name: [Known lastname 4941], [Known firstname 2803] Unit No: [Numeric Identifier 4942] Admission Date: [2165-5-7] Discharge Date: [2165-5-13] Date of Birth: [2121-12-11] Sex: F Service: MED-BLUMGA ADDENDUM: [First Name8 (NamePattern2) 1693] [Known firstname ] [Known lastname ] was transferred from the Medical Intensive Care Unit to the General Medicine Inpatient [Hospital1 ] on [5-10]. On the floor she continued to get vancomycin for a two week course and Meropenem, also for a total of a two week course. Her heparin was continued for two days, then discontinued once her INR was therapeutic for two days. She was discharged with an INR of 3.3. She continued to improve steadily and feels much better at the time of transfer. She is being transferred to [Hospital3 4121] to continue her antibiotics, for further fluid management, and observation of her renal function. DISCHARGE MEDICATIONS: Include Coumadin 5.0 mg po q day, CellCept [Pager number ] mg po bid, Bactrim double strength one tablet po on Monday, Wednesday, and Friday, prednisone 50 mg po q day, Lipitor 10 mg po q day, Flovent 110 mcg two puffs inhaled [Hospital1 ], Serevent two puffs inhaled [Hospital1 ], Epogen 7,000 units subcutaneous on Tuesday, Thursday, Saturday, Paxil 20 mg po q day, multi-vitamin tablet po q day, iron supplementation 325 mg po bid, Prilosec 20 mg po q day, Lopressor 50 mg po q day, calcium carbonate 1.0 gm po tid, regular insulin sliding scale, enteric coated aspirin 325 mg po q day, Procardia XL 90 mg po q day, Neurontin 200 mg po q day, [Doctor First Name 1866] 60 mg po q day, Albuterol two puffs inhaled q four hours prn, Ativan 1.0 mg po q HS prn, Benadryl 25 mg to 50 mg po bid prn, Percocet 5/325 one to two tablets po q four to six hours prn, Zanaflex 2.0 mg po q HS, vancomycin 1.0 gm prn levels less than 15, usually once q day, Meropenem 500 mg IV bid, supposed to be continued until [2165-5-23], and NPH 18 units q AM, 6 units q HS. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Transferred to [Hospital3 4121]. Accepting physician is [Last Name (NamePattern4) ]. [Last Name (STitle) 4943], phone number [Telephone/Fax (1) 4944]. [First Name11 (Name Pattern1) 520] [Last Name (NamePattern4) 521], M.D. [MD Number(1) 522] Dictated By:[Last Name (NamePattern1) 2034] MEDQUIST36 D: [2165-5-13] 15:55 T: [2165-5-14] 09:20 JOB#: [Job Number 4945]	[ "376.01", "584.9", "585", "250.01", "710.0", "038.9", "583.81", "286.9" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]				19262, 19736				16492, 18143	18167, 19240					6326, 14405																		15481, 16471						4038, 6309																			3511, 3925		171, 1872															1894, 3488	3942, 4015
28,607	196,092	31972	Discharge summary	report	Admission Date: [2125-10-8] Discharge Date: [2125-10-11] Date of Birth: [2064-4-18] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: headache Major Surgical or Invasive Procedure: left burr hole drainage of subdural hematoma History of Present Illness: HPI: Mr. [Known lastname 17385] is a 61 y/o male with a history of EtOH abuse who fell at ground level approximately 8 days ago. He went to his PCP 3 days latter with severe left frontal headache and was treated with tylenol. He presented again today with mild confusion and headache to an outside hospital. CT of head was obtained which revealed 1.4 cm left frontal subdural hematoma with 12 mm of midline shift. He was transferred to [Hospital1 18] and neurosurgery was consulted. Past Medical History: PMHx: HTN MI x 7 EtOH abuse Social History: PSHx: cervical and lumbar spine surgeries coronary stent x 4 Family History: Family Hx: heart disease Physical Exam: PHYSICAL EXAM: T: 99.8 BP: 144/89 HR: 98 R 15 O2Sats 98% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3 to 2 bilaterally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [3-17] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact 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 [5-19] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: CT/: Head CT shows 1.4 cm left frontal subdural hematoma with 12 mm of midline shift. Post-OP CT: 1. Status post left subdural hematoma evacuation, with a small amount of left subdural blood remaining. 2. Small left frontal intraparenchymal hemorrhage. 3. Mild (7 mm from 14 mm) left-to-right subfalcine herniation. [2125-10-8] 07:50PM WBC-10.4 RBC-4.53* HGB-14.3 HCT-40.9 MCV-90 MCH-31.6 MCHC-35.0 RDW-17.0* [2125-10-8] 07:50PM NEUTS-72.1* LYMPHS-21.3 MONOS-6.1 EOS-0.4 BASOS-0.2 [2125-10-8] 07:50PM PLT COUNT-424 [2125-10-8] 07:50PM PT-10.7 PTT-23.4 INR(PT)-0.9 [2125-10-8] 07:50PM ALBUMIN-4.0 [2125-10-8] 07:50PM ALT(SGPT)-7 AST(SGOT)-15 ALK PHOS-79 AMYLASE-52 TOT BILI-0.4 [2125-10-8] 07:50PM LIPASE-30 [2125-10-8] 07:50PM GLUCOSE-119* UREA N-13 CREAT-0.9 SODIUM-135 POTASSIUM-2.9* CHLORIDE-89* TOTAL CO2-29 ANION GAP-20 [2125-10-8] 10:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2125-10-8] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.022 [2125-10-8] 10:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-8.0 LEUK-NEG [2125-10-8] 10:20PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 Brief Hospital Course: Pt was admitted to the ICU for close neurologic monitoring. He was taken to the OR [10-9] for burr hole drainage of left subdural hematoma. This was done under general anesthesia, he tolerated this procedure well, was extubated and transferred back to ICU. He was placed on dilantin for seizure prophylaxis. He remained neurologically intact. Incisions were clean and dry. His activity and diet were advanced. His post op CT showed improvement of SDH and of subfalcine herniation. He was transferred out of the ICU to floor. PT and OT evaluated pt and found him safe to go home. Medications on Admission: All: NKDA Medications prior to admission: plavix 75 mg po qd ASA 325 mg po qd crestor 50 mg po qd HCTZ atenolol 25 mg po bid Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Rosuvastatin 20 mg Tablet Sig: 2.5 Tablets PO once a day. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Outpatient Physical Therapy Please provide physical therapy 3x/wk to improve endurance. Discharge Disposition: Home Discharge Diagnosis: Subdural hematoma Discharge Condition: neurologically stable, exam normal. Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair beginning [10-13]. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE RETURN TO THE OFFICE IN [7-24] DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN [4-20] WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[2125-10-11]	[ "E888.9", "V45.82", "414.01", "401.9", "303.91", "852.21" ]	icd9cm	[ [ [] ] ]	[ "01.31" ]	icd9pcs	[ [ [] ] ]	5711, 5717	3760, 4348	329, 375	5778, 5815	2459, 3737	7093, 7394	1047, 1074		4524, 5688		5738, 5757		4374, 4385			5839, 7070								1104, 1359												4417, 4501													281, 291										403, 900	1652, 2440							1374, 1636							922, 952	968, 1031
66,517	172,789	36879	Discharge summary	report	Admission Date: [2142-6-15] Discharge Date: [2142-6-26] Date of Birth: [2083-9-6] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 974] Chief Complaint: motorcycle crash Major Surgical or Invasive Procedure: [2142-6-15] Arthrotomy washout right elbow. Irrigation and debridement of left lower leg. Irrigation and debridement left Morel lesion thigh and flank. [2142-6-18] Circumferential debridement from the gluteal fold to the ankle of the skin, subcutaneous tissue of left leg with the proximal control of the saphenous vein and application of dressing. [2142-6-19] Debridement of the left leg with vac placement [2142-6-25] Debridement of the left leg History of Present Illness: 59 year old male who was riding his motorcycle. He was hit by a drunk driver. He was thrown 50 feet. Helmet was intact but unknown loss of conscience. He sustained multiple injuries: - large degloving injury to left leg - L proximal fibula nondisplaced fracture - R elbow abrasion that enters olecranon bursa - L scapular body fracture - R lateral rib fx 3,4,5,6 - L non-displaced buckling rib fx 4,5,6 - Spinous process fractures T8-11 - L eyebrow laceration Past Medical History: Alcohol use, although no recent abuse known. Cirrhosis, portal hypertension, without known hepatitis C status Social History: divorced x2 but supportive girlfriend, family in area. ETOH abuse in the past. Occupation: car salesman Family History: Unknown Physical Exam: Expired. Pertinent Results: [2141-6-16]: CT Head: No intracranial hemorrhage or fracture. CT C-spine: Mid-cervical spondylosis, without fracture or listhesis CT Abdomen and Pelvis: 1. Multiple osseous injuries including bilateral rib fractures and lower thoracic spinous process fractures. Left scapular inferior body fracture also noted. 2. Cirrhosis with splenomegaly, suggesting portal hypertension. 3. Periportal and retroperitoneal lymphadenopathy, with prominent mediastinal nodes, of unknown etiology. While cirrhosis may explain some of these findings, follow-up CT is recommended to help exclude neoplasm, such as lymphoma. 4. Right basilar consolidation more likely represents atelectasis than aspiration. 5. Chronically occluded left common iliac artery, with reconstitution of the left external iliac artery. [2142-6-25] Abdominal Ultrasound: No ascites in upper abdomen. Lower abdomen obscured by bowel gas. [2142-6-26] CT Abdomen and Pelvis: 1. Pneumatosis coli of the ascending, descending, and sigmoid colon. Intraluminal air also within portions of the distal small bowel. While ischemia is in the differential, given that the patient is intubated and has a significant amount of subcutaneous air secondary to trauma, the etiology maybe non- ischemic. Small amount of intrahepatic air, likely in the biliary system. 2. Increased ascites. 3. Increased, predominantly basilar, lung consolidations bilaterally. 4. Multiple fractures as described above including probable nondisplaced fracture of the right acetabulum. Brief Hospital Course: Mr. [Known lastname 19484] is a 58 year-old man with no confirmed medical history who was admitted to trauma ICU [2142-6-15] after a motorcycle crash on the early morning of the same day. He was thrown 50 feet from his motorcycle after collision with automobile, was wearing a helmet, but sustained multiple injuries: - large degloving injury to left leg - L proximal fibula nondisplaced fracture - R elbow abrasion that enters olecranon bursa - L scapular body fracture - R lateral rib fx 3,4,5,6 - L non-displaced buckling rib fx 4,5,6 - Spinous process fractures T8-11 - L eyebrow laceration On [2142-6-15] patient went to the OR for two procedures. First procedure was for an exposed right elbow joint. This was washed out then closed. The second procedure was irrigation and debridement of a left Morel-[Doctor Last Name 83285] lesion ("A variant of a true open fracture is an extensive lumbosacral fascial degloving injury similar to that described in Morel-[Doctor Last Name 83285] syndrome") of the pelvis, lower torso, thigh. Two wound vacs were placed in the upper and lower leg. He was aggressively resuscitated after the OR in which he lost 1500cc of blood. Through this admission he had a total of 14 units of PRBCS, 2 bags of plateletes, 5 units of FFP and one unit of cryopercipate. Repeat CT scan on the day of admission of his abdomen and pelvis due to his hypotension which was negative for injury or any source of bleeding. On [2142-6-17] he was started on Tubefeeds. On [2142-6-18] he was taken back to the OR for further debridement of necrotic skin and subcutaneous tissue (entirety of skin excised) from gluteal fold to ankle, with wet to dry dressing placed. [2142-6-19] he returned to the OR for further debridement, washout and placement of a wound vac. He continued to have high output (>3 Liters/daily) throughout the hospital stay. On [2142-6-22] wound vac was changed at the bedside. On [2142-6-24] the patient started to spike high fevers. Blood culture one out of 4 bottles grew out Ecoli. He had a new central line placed and cultures were drawn. On [2142-6-25] patient's total bili continued to increase. Patient started to go into renal failure. Patient developed a rigid abdomen and had a bladder pressure of 34. Bladder pressure decreased to 15 after a large bowel movement. Patient was started on pressures. Lactate started to increase. [2142-6-26] Concern that the leg was causing sepsis patient went to the OR for leg debridement and washout of the left lower extremity. The necrotic tissue was debrided but felt that this was not enough to cause him to be deterriotating so quickly. He then got a CT scan of his abdomen and pelvis which showed Pneumatosis coli of the ascending, descending, and sigmoid colon. At this point it was felt that he had non-survivable injuries. A discussion was had with the family in which it was decided to make him comfort measures. Pressors were stopped. Fentanyl drip was increased and ventilatory support was withdrawn. He expired shortly after that. Medications on Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Multi-organ system failure status post motorcycle crash Discharge Condition: Death Discharge Instructions: None Followup Instructions: None Completed by:[2142-6-27]	[ "891.1", "785.4", "V66.7", "E812.2", "285.1", "276.2", "789.47", "823.01", "569.89", "881.11", "805.2", "780.60", "572.2", "811.09", "873.42", "038.9", "890.1", "995.92", "518.5", "785.52", "286.9", "807.04" ]	icd9cm	[ [ [] ] ]	[ "86.22", "38.91", "08.81", "96.59", "83.39", "80.12", "96.72", "93.57", "38.93" ]	icd9pcs	[ [ [] ] ]	6338, 6347	3154, 6254	329, 794	6447, 6455	1610, 1627	6508, 6544	1557, 1566		6309, 6315		6368, 6426		6280, 6286			6479, 6485								1581, 1591																									273, 291										822, 1287		1636, 3131													1309, 1420	1436, 1541
11,931	172,747	20277	Discharge summary	report	Admission Date: [2166-12-11] Discharge Date: [2166-12-17] Date of Birth: [2088-6-7] Sex: F Service: Vascular Surgery HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old female with a history of TIAs, presented with slurred speech, facial droop, and left sided weakness to [Hospital 1474] Hospital on [2166-12-9] and found to have a 95% right internal carotid artery stenosis via MRI. Patient was transferred to [Hospital1 1444] for procedure. PAST MEDICAL HISTORY: 1. Anemia. 2. Myelodysplasia. 3. Hypertension. 4. TIA's. PAST SURGICAL HISTORY: D&C. MEDICATIONS AT HOME: 1. Hydralazine 50 mg p.o. t.i.d. 2. Labetalol 300 mg p.o. b.i.d. 3. Hydrochlorothiazide 50 mg p.o. q.d. 4. Losartan 50 mg p.o. q.d. 5. Bumetanide 1 mg p.o. q.d. 6. Verapamil SR 240 mg p.o. q.d. SOCIAL HISTORY: Patient is a nonsmoker and nondrinker. PHYSICAL EXAMINATION: On admission, patient was afebrile with blood pressure of 212/52, pulse 76, respiratory rate 12, and 98% on room air. Patient's physical exam: Patient was in no apparent distress, alert and oriented times three. Cranial nerves II through XII intact. Mild pronator drift of the left arm, no diplopia. Patient was 5+ muscle strength on the right, the left was 5- biceps, 4+ triceps, 4+/5- grips. Patient had 2+ palpable pedal pulses, 2+ radial pulses bilaterally, no bruits noted on physical exam. Patient was originally admitted to the Trauma SICU. The patient is status post right carotid endarterectomy on [2166-12-15]. Patient tolerated the procedure well. Please see op note. Patient was transferred to the Vascular SICU in stable condition, afebrile, heart rate of 68, and blood pressure of 180/89. Patient had good urine output and laboratory values within normal limits. Patient underwent an unremarkable postoperative course with an arterial line in place and blood pressure monitoring. Postoperatively, patient's blood pressure control was kept systolic 180. The nitroglycerin drip was D/C'd on postoperative day one. Patient was seen by Physical Therapy and educated on home safety and muscle rehabilitation. Patient was D/C'd to home on postoperative day two in stable condition, afebrile, stable vital signs with good urine output. Patient's examination is remarkable for 2+ pulses x4 extremities, 5+ strength, sensation intact. Patient's wound was clean, dry, and intact, and slightly edematous, and ecchymotic. Patient's blood pressure upon discharge is 121/61 with range of 120-180 the day prior. DISCHARGE DIAGNOSIS: Internal carotid artery stenosis status post right carotid endarterectomy on [2166-12-15]. DISCHARGE MEDICATIONS: 1. Tylenol 325 mg p.o. 1-2 tablets q.4-6h. prn pain. 2. Aspirin 325 mg p.o. q.d. 3. Verapamil 240 mg p.o. q.d. 4. Bumetanide 1 mg p.o. q.d. 5. Losartan 50 mg p.o. q.d. 6. Hydrochlorothiazide 50 mg p.o. q.d. 7. Labetalol 300 mg p.o. b.i.d. 8. Hydralazine 50 mg p.o. t.i.d. FOLLOW-UP INSTRUCTIONS: Patient was instructed to followup with Dr. [Last Name (STitle) ] in [8-21] days. Patient was also instructed to contact physician if experiencing recurrence of symptoms, drainage/redness from his incision site. DISCHARGE CONDITION: Good. Patient's was discharged with home PT and home safety evaluation from strength training. Patient was also discharged with VNA for vital signs check, blood pressure monitoring, and medication overview, wound check, and home safety evaluation. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 3365] MEDQUIST36 D: [2166-12-18] 16:12 T: [2166-12-19] 07:20 JOB#: [Job Number 54442]	[ "276.1", "285.9", "238.7", "724.3", "433.10", "276.8", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.12", "88.41" ]	icd9pcs	[ [ [] ] ]				3209, 3743					2667, 2940		2548, 2644									619, 814		592, 598		1039, 2526														894, 1023																					175, 488													2965, 3187		510, 568	831, 871
72,083	148,506	50087+59220	Discharge summary	report+addendum	Admission Date: [2120-11-1] Discharge Date: [2120-11-6] Date of Birth: [2051-4-24] Sex: F Service: NEUROSURGERY Allergies: Aspirin Attending:[First Name3 (LF) 1835] Chief Complaint: brain mass Major Surgical or Invasive Procedure: [2120-11-1]: Right Craniotomy and resection of mass History of Present Illness: This is a 69yo woman with history of metastatic small cell carcinoma of the lung, diagnosed in [5-/2119] and non-operable abdominal mets s/p palliative chemo and radiation. She went to [State 1727] for the weekend on [2120-10-14], but by [2120-10-16], she was feeling hot and vomiting and had unsteady gait; her husband had difficulty waking her up; her temperature was 102. She was admitted to [Hospital ] Hospital in [State 1727] for febrile neutropenia and changes in mental status; she was treated with cefepime. MRI of the head on [2120-10-16], showed a 2.8 x 2.8 x 3.1 cm solitary mass in the right frontal lobe with rim enhancement and with an irregular wall and with apparent cystic or necrotic center; there was mild-to-moderate edema and mild mass effect on the right frontal [Doctor Last Name 534]; there was regional overlying dural enhancement; there were no other lesions in the brain. The patient was referred to Neurosurgery and the risks and benefits of undergoing surgical resection were discussed with the patient. She has decided to proceed with resection and now electively presents. Past Medical History: Oncologic past medical history: - small cell carcinoma of lung primary s/p chemo and radiation - Large R abdominal mass causing T12-L3 neurologic symptoms currently on palliative chemotherapy with taxol and recent initiation of radiation to the abdominal mass. - HTN - Anxiety - COPD - GERD Social History: Married, lives with husband, retired from State Department processing tax forms. Continues to smoke [1-15] pack per day. No etoh or illicits. Family History: No known fhx of lung cancer Physical Exam: upon discharge: alert and oriented x 3, grossly full motor in all 4, incision well healing Pertinent Results: [11-1] MRI Brain: IMPRESSION: Right frontal lobe lesion is stable to slightly increased in size since [2120-10-16]. [11-1] NCHCT: IMPRESSION: Status post resection of a right frontal lobe mass with expected postsurgical changes. No large intracranial hematoma. No evidence of an acute major vascular territorial infarction. [11-2] Brain MRI: Postoperative study with presence of blood products in the operative cavity which limits evaluation for residual neoplasm, although no definite neoplasm is identified at this time. Recommend followup imaging after resolution of acute postoperative changes. [11-2] CXR: Overall, cardiac and mediastinal contours are likely stable given the patient rotation on the current examination. The lungs appear well inflated without evidence of focal airspace consolidation to suggest pneumonia or aspiration. There is a small layering right effusion. The pulmonary vasculature is slightly less well defined and likely reflects interval development of mild interstitial edema. No pneumothorax. [11-3] CXR: FINDINGS: Right PICC terminates in the lower superior vena cava. Small to moderate, apparently partially loculated right pleural effusion has slightly increased in size from the prior radiograph. Otherwise, no relevant changes since the recent study. Brief Hospital Course: Pt electively presented and underwent a craniotomy and resection of mass. Surgery was without complication. She was extubated and transferred to the ICU. Post op Head CT revealed post operative changes without hemorrhage or evidence of stroke. She was confused but followed commands and MAE's. She remained stable overnight and on [11-2]. Routine post op MRI revealed good resection. She was started on SQH for DVT prophylaxsis. On [11-3] she continued to be confused but was stable so she was cleared for transfer to the floor. A slow decadron wean was initiated. She lost peripheral IV access, and due to her need for constant IV access (inpt and outpt) a PICC line was placed. In the evening her telemetry was showing a sustained HR in the 150's. She was given 5mg of Lopressor. Her HR came down to 130's but SBP was in the 90's so she wasn't given another dose. EKG revealed SVT, Labs were stable. She was given an IVF bolus and her HR returned to the 80's with a SBP in the 120's. She remained neurologically stable throughout this episode. On [11-4] speech and swallow were consulted for a safety evaluation. PT and OT were consulted for assistance with discharge planning who found her appropriate for discharge to home with services. Medications on Admission: cipro, compazine, decadron, dilaudid, lisinopril, ativan, neurontin, omeprazole, oxycontin, zofran, spiriva Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 600 mg PO TID 3. Lisinopril 5 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Dexamethasone 2 mg po q12 hrs Duration: 60 Days RX dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Senna 1 TAB PO DAILY 8. LeVETiracetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 9. Lorazepam 0.5 mg PO HS 10. Ondansetron 8 mg PO Q8H:PRN n/v 11. Acetaminophen 325-650 mg PO Q6H:PRN pain, T>38.5 12. HYDROmorphone (Dilaudid) 1-2 mg PO Q3-4H pain RX hydromorphone 2 mg 1 tablet(s) by mouth q3-4hr Disp #60 Tablet Refills:0 13. Oxycodone SR (OxyconTIN) 20 mg PO Q12H RX oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 14. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 15. Ciprofloxacin HCl 500 mg PO Q24H Duration: 5 Days RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth 5d Disp #5 Tablet Refills:0 16. Bisacodyl 10 mg PO/PR DAILY 17. Clotrimazole 1 TROC PO 5X/DAY Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Right frontal mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Craniotomy for Tumor Excision ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with staples so you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ?????? You have an appointment in the Brain [Hospital 341] Clinic on [2120-11-25] at 1pm. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions Completed by:[2120-11-6] Name: [Known lastname 16961],[Known firstname 1163] Unit No: [Numeric Identifier 16962] Admission Date: [2120-11-1] Discharge Date: [2120-11-6] Date of Birth: [2051-4-24] Sex: F Service: NEUROSURGERY Allergies: Aspirin Attending:[First Name3 (LF) 599] Addendum: Added Rx for Decadron taper Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 600 mg PO TID 3. Lisinopril 5 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Dexamethasone 2 mg po q12 hrs Duration: 60 Days RX dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Senna 1 TAB PO DAILY 8. LeVETiracetam 1000 mg PO BID RX levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 9. Lorazepam 0.5 mg PO HS 10. Ondansetron 8 mg PO Q8H:PRN n/v 11. Acetaminophen 325-650 mg PO Q6H:PRN pain, T>38.5 12. HYDROmorphone (Dilaudid) 1-2 mg PO Q3-4H pain RX hydromorphone 2 mg 1 tablet(s) by mouth q3-4hr Disp #60 Tablet Refills:0 13. Oxycodone SR (OxyconTIN) 20 mg PO Q12H RX oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 14. Prochlorperazine 10 mg PO Q6H:PRN nausea, vomiting 15. Ciprofloxacin HCl 500 mg PO Q24H Duration: 5 Days RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth 5d Disp #5 Tablet Refills:0 16. Bisacodyl 10 mg PO/PR DAILY 17. Clotrimazole 1 TROC PO 5X/DAY 18. Dexamethasone 3 mg PO Q8HRS Duration: 4 Doses This is your current dose. After 4 doses please taper to 2mg every 8hrs. Tapered dose - DOWN RX dexamethasone 1 mg 3 tablet(s) by mouth every eight (8) hours Disp #24 Tablet Refills:0 19. Dexamethasone 2 mg PO Q8HRS Duration: 6 Doses Begin after completing the 3mg Q8hrs taper. Tapered dose - DOWN Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) 102] [Name6 (MD) ] [Last Name (NamePattern4) 603] MD [MD Number(2) 604] Completed by:[2120-11-6*]	[ "V87.41", "300.00", "348.5", "V15.3", "530.81", "197.6", "305.1", "599.0", "496", "198.3", "162.9", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.97", "01.59" ]	icd9pcs	[ [ [] ] ]	9980, 10195	3513, 4768	283, 341	6161, 6161	2162, 3490	7693, 8508	2007, 2036		8531, 9957		6120, 6140		4794, 4903			6311, 7670								2051, 2051																									233, 245									2067, 2143	369, 1510								6176, 6287							1564, 1825	1841, 1991
83,398	183,778	54979	Discharge summary	report	Admission Date: [2189-8-12] Discharge Date: [2189-8-15] Date of Birth: [2120-4-24] Sex: F Service: MEDICINE Allergies: Nabumetone Attending:[Name (NI) 9308] Chief Complaint: palpitaions, new onset of A-fib Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Ms. [Known lastname 3647] is a 69F with a h/o of HTN, DMII, hyperlipidemia who is presenting from cardiologist office with new onset afib and moderate-to large pericardial effusion. Patient initially presented to her [Known lastname 3390] with light headedness and dizziness in mid [Month (only) ], denied any chest pain or palpitations at the time. By the time she saw a doctor, she reports that her symptoms had since resolved. About a month later, the patient had EKG with e/o afib at 77 BPM, and with low voltages, as per report. At this point, she was referred to cards for ECHO given new onset afib. ECHO showed e/o moderate to large pericardial effusion, 2.7-3.0cm posterior to LV and 1.8-1.9cm anterior to RV. No RV indentation, however, e/o early tamponade physiology, given respirophasic variation of TV and MV inflow. While at cardiology appt, noted to have elevated JVP (10-12cm) with + Kussmals sign. Given her presentation and size of effusion, was sent to the ED. Initially in the ED, VS: 98.1 89 155/83 16 99%. EKG with afib, low voltage, and CXR with e/o globular heart suggestive of cardiomegaly or large pericardial effusion. The patient was initially admitted to the [Hospital1 1516] service. The patient was feeling well, and nervous about being hospitalized. The patient is now s/p cath lab and pericardiocentesis, drained 750 cc of cloudy seroud fluid with subxiphoid drain sutured in placed. On arrival to the CCU, the patient reports feeling well; though she continues to be nervous about being in the hospital. She does reports having some back pressure that she thinks might be related to needing to urinate. She also endorses some coughing with deep inspiration. Does endorse some discomfort around the site of her pericardial drain. Denies any current chest pain. Denies any abdominal pain. Denies noticing any LE edema. Past Medical History: PAST MEDICAL HISTORY: -HTN -DMII -hyperlipidemia -Anxiety MEDICATIONS: Hydrochlorothiazide 12.5 mg Oral Capsule 1 cap daily Lorazepam 1 mg Oral Tablet 1 tablet at bedtime as needed Lisinopril 40 mg Oral Tablet 1 tablet daily for hypertension Atenolol 50 mg Oral Tablet take 2 tabs twice daily Metformin 500 mg Oral Tablet 2 tablets in AM, 1 tablet in PM (1500mg daily) Pioglitazone (ACTOS) 30 mg Oral Tablet 1 tab daily Simvastatin 20 mg Oral Tablet 1 tablet every evening for cholesterol Social History: SOCIAL HISTORY -Home Situation: lives in senior housing -Occupation: retired, previously was a secretary -Tobacco: none -ETOH: none -Illicit drugs: none Family History: FAMILY HISTORY: HTN, CVA, colon Ca Physical Exam: Physical Exam on Admission: VS- T=97.8 BP=183/95 HR=92 RR=20 O2 sat=97% on RA GENERAL- WDWN in NAD. Oriented x3. Anxious mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK- JVP distended to 10-12cm with +Kussmauls CARDIAC- irregular, distant. No m/g/r 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- 1+ pitting edema bilaterally. No femoral bruits. SKIN- No stasis dermatitis or ulcers PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Physical Exam on Discharge:Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 37.1 ??????C (98.7 ??????F) HR: 78 (76 - 92) bpm BP: 117/73(84) {117/54(73) - 152/104(111)} mmHg RR: 12 (12 - 25) insp/min SpO2: 93% Heart rhythm: AF (Atrial Fibrillation) Wgt (current): 100.9 kg (admission): 101.4 kg GENERAL- well appearing, obese woman, NAD, laying comfortably in bed, noted to have slight anxiety HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK- supple, JVP elevated to the edge of the mandible CARDIAC- irregular, S1, S2, no murmurs/rubs/gallops appreciated LUNGS- clear to auscultation b/l, no wheezes/rhonchi/crackles appreciated ABDOMEN- Soft, obese, nontender, nondistended, +BS EXTREMITIES- trace pitting edema bilaterally, distal extremities warm and well perfused Neuro: CN 2-12 grossly intact, normal muscle strength and sensation Pertinent Results: [2189-8-12] 11:36AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.004 [2189-8-12] 11:36AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2189-8-12] 11:36AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 [2189-8-12] 11:32AM GLUCOSE-123* UREA N-12 CREAT-0.7 SODIUM-144 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-16 [2189-8-12] 11:32AM estGFR-Using this [2189-8-12] 11:32AM cTropnT-<0.01 proBNP-592* [2189-8-12] 11:32AM CALCIUM-10.1 PHOSPHATE-3.5 MAGNESIUM-2.0 [2189-8-12] 11:32AM TSH-1.7 [2189-8-12] 11:32AM [Doctor First Name ]-POSITIVE * TITER-1:40 [Last Name (un) ] [2189-8-12] 11:32AM RHEU FACT-6 [2189-8-12] 11:32AM WBC-7.0 RBC-4.58 HGB-14.1 HCT-42.2 MCV-92 MCH-30.9 MCHC-33.5 RDW-13.9 [2189-8-12] 11:32AM NEUTS-76.5* LYMPHS-15.4* MONOS-6.1 EOS-1.6 BASOS-0.3 [2189-8-12] 11:32AM PLT COUNT-150 [2189-8-12] 11:32AM PT-11.7 PTT-34.8 INR(PT)-1.1 Brief Hospital Course: Ms. [Known lastname 3647] is a 69F with a history of HTN, DMII, hyperlipidemia p/w new onset afib and pericardial effusion, s/p pericardiocentesis with drain placed. ACUTE ISSUES # pericardial effusion: Found to have new pericardial effusion now s/p pericardiocentesis. She had a drain placed which continued to drain fluid and the drain was pulled on [2189-8-14]. She initially drained 750 of cloudy serosanguinous fluid. Her drain output was monitored overnight and she continued to put out 350 cc. By 1 pm the following day the output had significantly decreased and the drain was pulled after a repeat echo showed minimal pericardial effusion with no evidence of tamponade physiology. The differential for new effusion is broad, including malignancy versus infection versus rheumatologic cause. Her TSH was normal, [Doctor First Name ] positive but titer only 1:40. Cytology showed no malignant cells. It is possible this may have been a viral myocarditis causing the effusion however malignancy can not totally be ruled out despite normal cytology. The patient will be followed by both her primary care physician and also with cardiologist Dr. [Last Name (STitle) ] where she will get a repeat echo. # rhythm: Pt presented with new onset of afib, possibly in setting of effusion. Currently rate controlled on atenolol. Her CHADS score is 2 and will need anticoagulation. Will start anticoragulation on Monday [2189-8-17] and her INR will be checked on Tues [2189-8-18] and she will follow up with her primary care doctor in the outpatient setting. I called her [Month/Day/Year 3390]'s office and left a message for her [Month/Day/Year 3390] about starting coumadin and how she will need to be followed up with anticoagulation. # coronaries: No h/o CAD. ECHO with normal ejection fractin. However, due to suboptimal quality, a focal wall motion abnormality cannot be excluded. On aspirin 81 mg and simvastatin 20 mg for prevention. # pump: Echo showed a normal ejection fraction with no definite wall motion abnormalities on ECHO. # HTN: We held her held her hctz continued ACE-i. We found her K was a bit low here so we are going to check her K in the outpatient setting with the lab slip. If K is low [Month/Day/Year 3390] may want to switch to aldactone for HTN # Type 2 Diabetes: We held oral hypoglycemics and put her on insulin sliding scale. She takes home pioglitazone which is known to possibly cause heart failure rarely and can present as pericardial effusion. [Month/Day/Year 3390] may consider changing her oral meds to a different medication # Anxiety: - Continue lorazepam TRANSITIONAL ISSUES: #Pericardial Effusion: Pt will follow up with cardiologist this week and will have a repeat echo in the outpatient settign to monitor the effusion. #Afib: CHADS of 2, will need anticoagulation. Will start anticoragulation on Monday [2189-8-17] and her INR will be checked on Tues [2189-8-18] and she will follow up with her primary care doctor in the outpatient setting. I called her [Month/Day/Year 3390]'s office and left a message for her [Month/Day/Year 3390] about starting coumadin and how she will need to be followed up with anticoagulation. #HTN: We found her K was a bit low here so we are going to check her K in the outpatient setting with the lab slip. If K is low [Month/Day/Year 3390] may want to switch to aldactone for HTN #DM2: She takes home pioglitazone which is known to possibly cause heart failure rarely and can present as pericardial effusion. [Month/Day/Year 3390] may consider changing her oral meds to a different medication Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtriuswebOMR. 1. Hydrochlorothiazide 12.5 mg PO DAILY 2. Lorazepam 1 mg PO QHS:PRN anxiety 3. Lisinopril 40 mg PO DAILY 4. Atenolol 100 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO 2 TABS QAM, 1 TAB QPM (1500MG TOTAL) 6. Pioglitazone 30 mg PO DAILY 7. Simvastatin 20 mg PO QHS 8. Acetaminophen 650 mg PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Atenolol 100 mg PO BID RX atenolol 100 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 3. Lisinopril 40 mg PO DAILY 4. Lorazepam 1 mg PO QHS:PRN anxiety 5. Simvastatin 20 mg PO QHS 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO 2 TABS QAM, 1 TAB QPM (1500MG TOTAL) 8. Pioglitazone 30 mg PO DAILY 9. Aspirin 81 mg PO MON, WED, FRI RX Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 10. Warfarin 2.5 mg PO DAILY16 Please start taking this medication on Monday [2189-8-17] goal INR [2-27] RX Coumadin 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 11. Outpatient Lab Work Please check an INR and K (potassium) on [2189-8-18] Dr. [Last Name (STitle) 3390]: [Name10 (NameIs) ],[Name11 (NameIs) 104572] [Name Initial (NameIs) ]. [Telephone/Fax (1) 6087] will follow up with the results. Please fax results to his office at [Telephone/Fax (1) 6808] ICD 427.31 (atrial fibrillation) Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 3647], It was a pleasure taking care of you here at [Hospital1 18]. You were admitted because of atrial fibrillation and because there was some fluid around your heart. The fluid was drained and sent off for lab studies which showed no malignant cells. You should be aware that fluid around your heart is concerning because it can constrict the heart from beating normally. We would like for you to please follow up with your cardiologist when you go home. Because you have atrial fibrillation we are going to start you on a new medication for anticoagulation called coumain which you will start taking on Monday [2189-8-17] and you need to see your [Month/Day/Year 3390] on [Name Initial (PRE) ] regular basis to adjust the dose of this medication. We also want for you to please get your blood drawn on Tuesday after you start your coumadin. Should you feel dizzy, lightheaded, or severely fatigued you should call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 2258] or come back to the emergency department. You can also call your [Telephone/Fax (1) 3390] [Name Initial (PRE) 3390]: [Name10 (NameIs) ],[Name11 (NameIs) 104572] [Name Initial (NameIs) ]. [Telephone/Fax (1) 6087] We made the following changes to your medications: please START coumadin on Monday [2189-8-17] please GET BLOOD DRAWN on Tuesday [2189-8-18] - the results will be faxed to your [Month/Day/Year 3390] please START Aspirin We CHANGED your dose of atenolol - it was increased. This is to treat your A-fib Followup Instructions: [Month/Day/Year 3390] [Name Initial (PRE) 648]: Monday, [8-17] at 10:30am With: [Name6 (MD) 104572] [Last Name (NamePattern4) 104576],MD Location: [Location (un) 2274]-[Location (un) ] Address: 26 CITY [Doctor Last Name ] MALL, [Location (un) ],[Numeric Identifier 6086] Phone: [Telephone/Fax (1) 6087] Cardiology Appointment: Thursday, [8-20] at 1:50am With:Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 112274] Location:[Hospital1 ] [Location (un) 4363], [Location (un) 86], [Numeric Identifier 91688] Phone: [Telephone/Fax (1) 2258*]	[ "423.8", "423.3", "401.9", "427.31", "272.4", "250.00", "300.00" ]	icd9cm	[ [ [] ] ]	[ "37.0" ]	icd9pcs	[ [ [] ] ]	10825, 10831	5632, 8279	296, 317	10916, 10916	4586, 5609	12703, 13333	2946, 2967		9745, 10802		10852, 10895		9307, 9722			11067, 12387								2982, 2996															3748, 4567			8300, 9281	12416, 12680						225, 258										345, 2230							3010, 3721	10931, 11043							2274, 2744	2760, 2914
40,940	166,373	37272	Discharge summary	report	Admission Date: [2190-1-3] Discharge Date: [2190-1-9] Date of Birth: [2122-8-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Hematemasis Major Surgical or Invasive Procedure: intubation, EGD History of Present Illness: This is a 67 year old male with a history of hypertension and heavy alcohol use who presents from home with hematemasis and melena. Patient was in his usual state of health until the morning of presentation. He woke up at 3 AM and vomited bright red blood into his sink. He went back to sleep and woke back up at 6 AM and had a dark red bowel movement and vomited blood again. He called an ambulance. He was not experiencing any lightheadedness, dizziness, chest pain, difficulty breathing, abdominal pain. He was experiencing nausea and vomiting as above. He was brought to [Hospital3 2783] emergency room. There are no records available from his visit to [Hospital1 2436] but per ER reports he had an NGT placed which was draining frank blood. He received IV protonix and received one unit of PRBCs and was transferred to this hospital for further management. . In the ED, initial vs were: T: 97.8 P: 106 BP: 120/90 R: 16 O2 sat 96% on 2L. He had 1 liter normal saline. He was started on an octreotide drip and admitted to the MICU. . On arrival to the MICU he denies lightheadedness, dizziness, chest pain, difficulty breathing, nausea, vomiting, abdominal pain, dysuria, hematuria, leg pain. He endorses a history of dyspnea on exertion which is chronic for which he was recently started on advair. He denies a personal history of heart disease but has a strong family history of coronary disease. He endorses heavy drinking but has not had a drink for one week. He endorses a recent upper respiratory tract infection one week ago but symptoms have resolved. He endorses mild lower extremity edema and orthopnea without paroxysmal nocturnal dyspnea. He has had minimal hematemasis before but this is his first significant gastrointestinal bleeding. He has no known history of liver disease. He takes aspirin 81 mg daily but denies heavy NSAID use. All other review of systems is negative in detail. Past Medical History: Hypertension Dyspnea on exertion Alcohol Abuse Social History: Lives with his grandaughter. He has a 90 pack year smoking history but quit 20 years ago. [2-13] gallon of hard alcohol per week, last drink 6 days ago. No history of hospitalizations for alcohol abuse or withdrawal. No other illicit drug use. Family History: Two brothers who died of coronary disease in 50s and 60s. Father died of coronary disease in his 70s. No history of gastrointestinal bleeding or malignancies. Physical Exam: On presentation to the MICU: T: 99.7 BP: 163/79 P: 107 R: 22 O2: 96% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, NGT in place draining blood Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, trace pitting edema to shins . . On transfer to the floor: Vitals: T: 99.6 BP: 150/70 P: 93 R: 22 O2: 92% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, NGT in place draining blood Neck: supple, JVP not elevated, no LAD Lungs: Wheezing bilaterally. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, trace pitting edema to shins Pertinent Results: Labs on admission: ......13.9 16.7 ------ 238 ......40.7 . N:82.4 L:13.3 M:3.9 E:0 Bas:0.4 . PT: 14.4 PTT: 25.0 INR: 1.2 . 142 108 33 -------------------Glucose 107 5.0 26 0.7 . Ca 8.1 Mg 2.0 Phos 3.2 . ALT 22 AST 17 AlkP 60 Tbili 0.6 Lipase 13 . UA negative for blood, infxn, trace ketones, glucose neg . Hpylori pending [2190-1-4] 7:58 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [2190-1-4]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. MORAXELLA CATARRHALIS. MODERATE GROWTH. BCx negative to date x2 . . EKG [1-3] Sinus tachycardia. Otherwise, normal tracing. No previous tracing available for comparison. . [1-3] CXR IMPRESSION: Left basilar opacification may be atelectasis although pneumonia cannot be completely excluded. Consider repeat PA and lateral with encouraged inspiration. Repeat lateral may help locate the tip of the OG tube which is only seen to the level of the distal esophagus. . [1-5] CXR FINDINGS: As compared to the previous radiograph, the patient has been extubated. The nasogastric tube has also been removed. The size of the cardiac silhouette is unchanged. There is unchanged atelectasis at the left lung base. No evidence of pneumothorax, no newly appeared focal parenchymal opacity. An older very subtle opacity at the bases of the right upper lobe is slightly better seen than on the previous examination. Brief Hospital Course: Assessment and Plan: 67 hypertension and heavy alcohol use who presents from home with hematemasis and melena. Upper gastrointestinal bleeding: On admission to the MICU patient was tachycardic with stable blood pressure. He was started on IV pantoprazole, an octreotide drip, and 3 large bore IVs were placed. Upper endoscopy showed ulcer in stomach with nearby vessels suspicious for recent bleed, which was injected with epinephrine and electrocautery was performed. Patient was intubated during procedure due to difficulty tolerating procedure (not due to hypoxia or respiratory distress). Hct's were serially checked and stable. No further episodes of bleeding. He was transfered to the floor on [2190-1-6]. On arrival to the floor her was asymptomatic and hemodynamically stable. His diet was advanced and he was switched to oral medications. H. pylori serology was positive and he was treated with pantoprazole, clarithromycin and ammoxicillin. He had an epsiode of melena with some bright red blood on [2190-1-7]. Serial hematocrits were stable between 28 at 31% and he had no repeat episodes of melena or hematochezia. Pneumonia: Patient had L sided infiltrate on CXR, subjective productive cough, and temperature of 100.3 and a sputum gram stain was positve for Moraxella. He was started on a five day course of levofloxacin. Once H. pylori serologies were positive, he was started on triple therapy and levofloxacin was stopped as amoxicillin and clarithromycin provided adequate CAP coverage. Wheezing/Hypoxia: On arrival to the floor, patient had significant bilateral wheezing and was dependent on supplemental oxygen, with an oxygen saturation of 95% on 3L NC. Of note, he describes becoming short of breath at home walking up one flight of stairs, and that this has been a chronic problem for many years. He was treated with his home dose of salmeterol/fluticasone, and given albuterol/ipratropium nebulizer treatments. His breathing improved substantially, and was able to ambulate with assistance and supplemental oxygen on the floor. He will likely require pulmonary function tests and further treatment for possible COPD as an outpatient. He was discharged with supplemental oxygen and home physical therapy. Hypertension: Patient was hypertensive on arrival to the floor with SBP 140-170. He was restarted on his home dose of lisinopril 40mg PO daily, and his blood pressure decreased to a SBP of 110-140. History of alcohol abuse: No history of withdrawal. Last drink per report [2189-12-31]. Started on Valium CIWA scale, and thiamine, folate, multivitamin, but never developed any withdrawal symptoms or required valium. Patient was counseled extensively about the risk of repeated GI bleeding with alcohol use, more generally about the health benefits of alcohol cessation. Medications on Admission: Lisinopril 40 mg daily Advair 250/50 1 puff [Hospital1 ] Aspirin 81 mg daily Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:120 Disk with Device(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxygen Oxygen 2-3L/min, continuous for portability, pulse dose system. Dx: COPD 5. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) for 7 days. Disp:56 Capsule(s) Refills:0 6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days. Disp:28 Tablet(s) Refills:0 7. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [2-13] puff Inhalation twice a day as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 Discharge Disposition: Home With Service Facility: Allcare VNA Discharge Diagnosis: Upper GI Bleed Hypertension History of Alcohol Abuse Discharge Condition: Vitals stable, ambulating without difficulty. Discharge Instructions: You were admitted for bleeding in your stomach to the ICU. There you had an endoscopy that showed an ulcer which was injected with medication to stop the bleeding. This ulcer and bleeding are likely from long-term alcohol use. It is very important to stop drinking. The following medication changes were made: 1. STOPPED: Aspirin. Because of the bleeding in your stomach, you should stop taking your aspirin as it can worsen bleeding. Your primary care doctor will determine when and if you should restart it. 2. STARTED: Pantoprazole 40mg once a day. You were started on this medication which helps to heal ulcers. You should continue taking this at home indefintely. 3. STARTED: Amoxicillin 1000mg by mouth, twice daily for 7 days. AND Clarithromycin 500mg by mouth twice daily for 7 days. You tested positive for the bacteria Helicobacter pylori, which can cuase ulcers. These two antibiotics will treat this. 4. ADDED: Mulitvitamin. Because of your alcohol abuse, you were started on a multivitamin. You should continue taking one tablet once a day indefinitely. 5. ADDED: Albuterol inhaler, please use inhaler twice daily as needed for shortness of breath of wheezing 6. ADDED: Hydrochlorothiazide 25mg take once daily. For blood pressure. 6. Oxygen: Please use supplemental oxygen, set at 2L/min No other medication changes were made, you should continue all your other home medications as directed. Please review all medication changes with your primary physician. Several appointments were made for you as listed below. It is extremely important for you to keep these appointments. Additionally, you will need a repeat endoscopy in 8 weeks. The GI doctor you have an appointment with will schedule that with you when you see him. If you cough up or thrown up any blood, have blood in your stool, chest pain, shortness of breath, abdominal pain, high fever or any other concerning symptoms, please seek medical care immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: You have an appointment with your primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 42896], [Street Address(2) 42812], [Hospital1 ], [Numeric Identifier ] on [1-19] at 1pm. It is very important that you keep this appointment. If you need to change the appointment, please call [Telephone/Fax (1) 26408]. You were also scheduled for an appointment with the Dr. [First Name8 (NamePattern2) 1255] [Name (STitle) 1256] on [2190-2-10] 1pm in Gastroentrology here at [Hospital1 18]. If you need to change this appointment, please call [Telephone/Fax (1) 463].	[ "V15.82", "491.21", "276.8", "429.3", "285.1", "535.50", "303.90", "041.86", "272.0", "482.83", "401.9", "531.40" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "44.43" ]	icd9pcs	[ [ [] ] ]	9762, 9804	5670, 8498	323, 340	9901, 9949	3891, 3896	12020, 12659	2633, 2793		8630, 9739		9825, 9880		8524, 8607			9973, 11997								2808, 3872										4620, 5647															272, 285										368, 2281							3910, 4579								2303, 2352	2368, 2617
47,795	120,186	13927	Discharge summary	report	Admission Date: [2185-12-21] Discharge Date: [2185-12-25] Date of Birth: [2125-8-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catherization with drug eluting stent to left anterior descending artery. History of Present Illness: Mr. [Known firstname 2251] [Known lastname 33754] is a 60 yo male with CAD, HTN, borderline DM who recently underwent a cardiac cath with a stent LAD that did not fully deploy who presents with CP that began at noon today. The patient was shoveling snow at a moderate pace when he developed the chest pain. CP became very severe and was similar to CP (SSCP with radiation to right shoulder) with his previous MI so he presented to the ED. He reports diaphoresis, but he denies associated nausea, vomiting, SOB, palpitations or dizziness. He has been experiencing DOE regularly for the past year or so. Patient presented in [9-21] with complaints of excertional chest pain similar to his chest pain prior to his MI in [2181]. He was seen by Dr. [Last Name (STitle) 5076] in clinic and underwent cardiac cath on [2185-9-29] that showed a totally occluded LAD and 80%. The LAD was a very small vessel, and was crossed and stented. In the proximal portion of the stent, there was substantial rigidity of the LAD and it would not fully dilate. This resulted in a 40-50% residual stenosis but normal flow into the distal vessel. He continued to have excertional SOB and discussed with Dr. [Last Name (STitle) 5076] CABG vs PCI and returned on [2185-10-27] with stent placement to the OM1 lesion. Today, he was found to have acute stent thrombosis in LAD stent with hyper-acute T waves in the anterior leads. In the ED, He was started on heparin and given 4mg IV morphine. Potassium was 6.8, but hemolyzed. He was taken to the cath lab where the clot was extracted with an aspiration catheter. A balloon was used first, but arotational atherectomy was required followed by recurrent ballooning. At the end of the case TIMI 3 flow was restored an the patient did not have any residual stenosis. On arrival to floor, he reports some mild nausea and SOB. He is not in any distress. He denies chest pain or pressure. 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. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+) HTN (+) CHOL (+) Borderline DM 2. CARDIAC HISTORY: MI in [2181] -PERCUTANEOUS CORONARY INTERVENTIONS: s/p stent to LAD on [2185-9-29] s/p stent to OM1 on [2185-10-27] 3. OTHER PAST MEDICAL HISTORY: - Colon Cancer: [2181] s/p resection, radiation and chemotherapy - COPD - Lower back Arthritis - Tonsillectomy - Hernia - h/o train accident right arm disability. Social History: He is not currently working but would like to return to employment. He does not currently smoke cigarettes but did smoke 1.5 packs for 30 years. He quit in [2178]. He does not drink alcohol and is very active physically. -Illicit drugs: denied Family History: + for DM & CAD. Father died at the age of 48 of MI. One sister dies at 10 months from congential heart disease. Another sister died at age is 35 years from MI. Physical Exam: GENERAL: WDWN 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: unable to assess JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTA anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: + scars. Soft, obeses NTND. bilat lower quad tenderness. no rebound/guarding. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. no hematoma dressing C-D-I. SKIN: scar on right shoulder. chronic macular erythematous rash on chest. PULSES: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2185-12-21] 07:25PM GLUCOSE-151* UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-23 ANION GAP-18 [2185-12-21] 01:15PM WBC-9.9# RBC-5.90 HGB-17.9 HCT-50.8 MCV-86 MCH-30.4 MCHC-35.3* RDW-13.1 [2185-12-21] 01:15PM NEUTS-79.9* LYMPHS-12.0* MONOS-4.0 EOS-3.7 BASOS-0.4 [2185-12-21] 01:15PM PT-11.6 PTT-25.2 INR(PT)-1.0 [2185-12-21] 01:15PM CK(CPK)-208* [2185-12-21] 01:15PM cTropnT-0.01 [2185-12-21] 01:15PM CK-MB-4 [2185-12-21] 07:25PM CK(CPK)-5122* [2185-12-22] 06:17AM BLOOD CK(CPK)-3040* [2185-12-22] 06:17AM BLOOD CK-MB-379* MB Indx-12.5* cTropnT-8.59EKG: EKG: [12-21] 13:15 - SR 81 Hyper-acute T waves in V1-V4 no ST changes [12-21] 16:06 - SR 87 less that 1 mm STE in V1 -V4 TELEMETRY: ST 100 2D-ECHOCARDIOGRAM: [2185-10-28] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CARDIAC CATH: [2185-12-21]: LMCA: Normal LAD: acute stent thrombosis in mid LAD LCX: widely patent stend in OMB. Minor lumen irregularities in LCX RCA: not injected. CXR: [2185-12-21]: Mild interstitial pulmonary edema. Linear opacity projecting over the region of the proximal SVC and left brachiocephalic vein which may be artifactual versus retained catheter, not seen in the prior CT study (CT [2183-5-13]). Clinical correlation advised and repeat imaging as warranted. 2D-Echo: [2185-12-22] The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with near akinesis of the distal segments and apex and hypokinesis of the mid septum and mid anterior wall. 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 tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate focal LV systolic dysfunction, consistent with CAD (LAD territory). No significant valvular abnormality seen. Brief Hospital Course: Mr. [Known firstname 2251] is a 60 yo gentleman with pre-diabetes, HTN, and CAD who presents with chest pain and was found to have an acute stent thrombosis. 1. CORONARIES: Patient presented with stent thrombosis in LAD stent that was not full expanded. Treated with arotational atherectomy followed by recurrent ballooning with restoration of TIMI 3 flow. CK and CKMB peaked at 5122 and > 500 respectively. Patient was given 1L NS for renal protection post catheterization and had no evidence of acute kidney injury through duration hospital stay. Tolerated procedure well, with no complications. He was continued on his ACS medications: ASA 325, metoprolol, lisinopril, atorvastatin. Plavix was discontinued and he was bolused 60mg of prasugrel and started on a regimen of 10mg daily given history of instent restenosis. Also started on omeprazole for gastritis prevention given anticoagulation with numerous medications. Post cath ECHO showed EF of 30-35% with moderate focal LV systolic dysfunction. Patient was started on coumadin withheparin bridge for LV thrombus prophylaxis. He was discharged on lovenox to complete bridge to therapeutic INR goal of [2-15]. 2. COPD/sob: stable, continued on home medications of flovent and albuterol inhalers. Maintained adequate O2 saturations on room air. 3. Impaired glucose tolerance: Finger sticks monitored QACHS throughout hospital stay; patient placed on sliding scale insulin as needed to maintain euglycemia. A HA1C was pending at the time of discharge 4. HTN - remained normotensive on metoprolol and lisinopril as above. Of note, metoprolol tartrate was switched to long acting form during hospital stay and uptitrated as tolerated by blood pressure to maintain optimal heart rate. 5. Hyperlipidemia: stable, continued on home dose of atorvostatin 80mg. Lipid panel at goal with LDL < 70 and HDL of 41. Medications on Admission: Albuterol sulfate (proair) 90mcg MDI q 6 hours PRN non compliance Atorvastatin 80mg one tablet at night Fluticasone 50mcg spray two puffs nasal daily -non compliance Fluticasone (flovent) 44 mcg MDI two puffs INH twice a day non compliance Folic acid 1mg Tablet daily Lisinopril 10mg one tablet daily Metoprolol Succinate (Toprol XL) 50mg one tablet daily Aspirin 325mg daily Omega-3 fatty acids 1200mg one capsule daily Plavix 75mg once daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take every day for at least one year, do not stop taking unless Dr. [Last Name (STitle) ] tells you to. . Disp:30 Tablet(s)* Refills:11 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). Disp:1 bottle Refills:2 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take up to three tablets 5 minutes apart. Call Dr. [Last Name (STitle) ] if you have chest pain. . Disp:25 Tablet, Sublingual(s) Refills:0 9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 10. Flovent HFA 44 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 11. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Outpatient Lab Work Please check your INR on [2185-12-27] via your VNA and call results to Dr. [Last Name (STitle) ] [Last Name (STitle) ] office at [Telephone/Fax (1) 3070] 14. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: continue 5mg daily until your are advised to change your dose. You will have your INR checked w/ goal 1.8-2.5. Disp:60 Tablet(s) Refills:2 15. Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 7 days. Disp:7 syringe Refills:0 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: ST Elevation Myocardial Emphysema Hypertension Hyperlipidemia Discharge Condition: stable, aa0x3, sats >95% RA, ambulating Activity Status:Ambulatory - Independent Level of Consciousness:Alert and interactive Mental Status:Clear and coherent Discharge Instructions: You had a major heart attack because the stent clotted off and your heart function is weakened. We have changed the medicine from Plavix to Prasugrel to try to keep the stent open. You will continue on your other medicines. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking fish oil, this can interact with all of the other blood thinners 2. Start taking Prasugrel, this is to keep the stent open. You will need to take this every day for one year and possibly longer. Do not stop taking this medicine unless Dr. [Last Name (STitle) ] tells you to. Missing doses on this medicine can cause the stent to clot off again and lead to another heart attack. 3. Continue to take a aspirin 325 mg. 4. Start taking Coumadin to prevent blood clots in your heart. You will need to have your coumadin level checked frequently and keep the level between 1.8 and 2.5. Please continue on 5mg daily until your level is checked. 5. Stop taking Plavix. 6. Decrease the Lasix dose to 20mg daily. Please check your INR via your VNA and have them call results to Dr. [Last Name (STitle) ] [Last Name (STitle) ] office at [Telephone/Fax (1) 3070] 7. Start taking Omeprazole to prevent stomach upset from the blood thinners. 8. You will take Lovenox 150mg daily that will be given by your VNA until your INR reaches 1.8. 9. Your Toprol XL was increased to 75mg daily Followup Instructions: Primary Care: Provider: [First Name11 (Name Pattern1) 20] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 3070] Date/Time: Thursday [12-29] at 4:00pm. Provider: [First Name11 (Name Pattern1) 20] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 3070] Date/Time:[2186-3-6] 2:00 Cardiology: Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time: [1-17] AT 11:20AM. Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2186-6-13] 11:20	[ "V10.05", "V15.3", "414.01", "272.4", "401.9", "410.81", "996.72", "V87.41", "492.8", "250.00", "E879.0", "414.2", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.40", "00.66", "37.22" ]	icd9pcs	[ [ [] ] ]	12073, 12131	7334, 9220	328, 412	12237, 12363	4598, 7311	13915, 14709	3582, 3746		9714, 12050		12152, 12216		9246, 9691			12422, 12769								3761, 4579			2971, 3099																			12789, 13892			278, 290										440, 2868								12377, 12398		3130, 3298					2890, 2951	3314, 3566
17,182	174,352	2586	Discharge summary	report	Admission Date: [2180-10-23] Discharge Date: [2180-10-27] Date of Birth: [2106-12-15] Sex: M Service: [Location (un) ] HISTORY OF PRESENT ILLNESS: The patient is a 73 year old male with moderate severe aortic stenosis and severe chronic obstructive pulmonary disease admitted three times in the past six months for chronic obstructive pulmonary disease exacerbation, most recently last week. The patient had arranged a visiting nurse. The patient met compliance to assure he is on his proper medications at home. Per the daughter, the patient is unable to keep his medications straight and he sometimes misses doses. The patient is here with similar symptoms to prior admissions and states he feels better off his medications. The patient was administered intravenous steroids and oxygen by face mask in the Emergency Department, and he was transferred to the floor where he became more short of breath. He has had some fevers at home reportedly and intermittent atypical chest pain episode on the day prior to the day of admission, left-sided pleuritic pain and general discomfort with dyspnea. REVIEW OF SYSTEMS: Review of systems was negative for headache, vision changes, change in appetite and positive for chest pain with shortness of breath, negative for orthopnea, paroxysmal nocturnal dyspnea, edema, diaphoresis. Occasional constipation, no bright red blood per rectum. ALLERGIES: The patient has no known drug allergies. HOME MEDICATIONS: Albuterol 2 puffs q.i.d., Afrin 81 q.d., Atrovent 4 puffs b.i.d., calcium carbonate 500 t.i.d., Flovent 2 puffs b.i.d., Lac-Hydrin prn, Levofloxacin finished this course on [9-23], Prednisone taper ended on [10-24], Protonix 40, Serevent discus, Vitamin D. PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease with an FEV1 of 0.98, aortic stenosis, critical valve area of 0.8 cm on an echocardiogram in [2180-3-14]. Osteoarthritis. Dyspepsia status post treatment for Helicobacter pylori in [2174]. Hyperlipidemia. Peripheral vascular disease. Ichthyosis. History of herpes zoster. Degenerative joint disease and cervical spondylitis. SOCIAL HISTORY: The patient is Somalian, a retired engineer, lives with his wife and three children. He quit tobacco six years ago, no alcohol, no other medications or illegal drugs. PHYSICAL EXAMINATION: Temperature 95.2 axillary, heartrate 107, blood pressure 148/76, respiratory rate 29, 100% on facemask. The patient is an elderly Somalian male lying in bed in moderate severe respiratory distress. Head, eyes, ears, nose and throat: Nasal flaring, pupils equally round, and reactive to light, extraocular movements intact, dentures are in place. Neck supple, notable for accessory muscle use. Cardiovascular, tachycardiac, distant S1 and S2. Pulmonary, poor air movement, tachypnea, diffuse wheezes. Abdominal examination: Normal bowel sounds, soft, mild left lower quadrant tenderness. Extremities: No edema. Neurological: alert and oriented. Per family moves all extremities grossly intact. LABORATORY DATA: Laboratory data on admission notable for lactate of 4.4 and blood gases which initially were 7.34, 47, 228 and progressed to 7.21, 60, 159. White count 11.4, hematocrit 34.2, creatinine 1.1. HOSPITAL COURSE: This 73 year old male with chronic obstructive pulmonary disease exacerbation with multiple recent admissions, readmitted for shortness of breath, stabilized in the Emergency [Hospital 13064] transferred to the floor and developed worsening respiratory failure. Respiratory failure - The patient was transferred to the Intensive Care Unit where he was placed on BiPAP in light of his respiratory fatigue and increased secretions with worsening hypoxia. He was started on Azithromycin 500 mg times one and then 250 mg times four days. The patient was weaned off of biPAP and had improving respiratory status. Chest x-ray showed heart and mediastinal contours stable. Aorta, slightly avulsed, lungs clear without effusion, consolidations or pneumothorax. Shortness of breath improved and the patient was transferred back to the floor on [2180-10-25] and was continued on steroids and was changed to p.o. Prednisone 60 to begin a long taper. Continued on nebulizers, chest physical therapy, Azithromycin, incentive spirometry. The patient improved on this course. At the time of discharge it was thought the patient would be a good candidate for outpatient pulmonary rehabilitation. Congestive heart failure/volume overload - In the Emergency Department the patient had good diuresis with Lasix 20 mg intravenously. Continued diuresis while in the Emergency Room noted creatinine up to 1.3. In the Medicine Intensive Care Unit the patient continued his diuresis, BUN and creatinine were heavily followed. The patient had an echocardiogram to assess cardiac function which revealed an ejection fraction of 50% with mild symmetric left ventricular hypertrophy, 1+ aortic regurgitation, aortic valves are severely thickened and deformed. Mitral valve with 1 to 2+ mitral regurgitation, moderate 2+ tricuspid regurgitation when compared with prior studies. In [2180-3-14], the left ventricle was less hyperdynamic and the aortic valve orifice area is now further reduced to 0.7 cm squared. The patient's cardiologist, Dr. [Last Name (STitle) ] was consulted who felt that this could be managed as an outpatient and cardiac function was not the cause of his admission or repeated admissions which are likely due to chronic obstructive pulmonary disease. He recommended further outpatient treatment for his cardiac problems. Chest/epigastric pain - Per primary care notes, this is a chronic non-cardiac pain. The patient had ruled out and did have a small increase in troponins, maximum of 0.02 probably due to demand in the setting of tachycardia and tachypnea. The patient's pain appeared worse postprandially while the patient is on Protonix. He has had a history of gastritis in the past. Gastrointestinal was consulted as he has had Helicobacter pylori in the past, they recommend an outpatient workup of the questionable gastritis. They recommend a ten day period off Protonix prior to a Helicobacter pylori breast test. This will be followed up with his outpatient provider. Acute renal failure - The patient's increase in BUN and creatinine in the setting of diuresis returned to baseline prior to his discharge. Elevated blood glucose levels - Most likely secondary to steroid use. The patient was covered with an insulin drip in the Intensive Care Unit and then transitioned to an insulin sliding scale and q.i.d. fingersticks. Hemoglobin A1c was measured and found to be 6.9. The patient's lowest blood glucose even on the sliding scale were in the 150 range. [Last Name (un) ] Diabetes was consulted and recommended starting Glucotrol XL 5 p.o. q.d. as well as increasing the patient's Humalog sliding scale. They recommend a trial of Metformin 500 mg q.d. as the patient's creatinine returned to a baseline of 1.0 and we were no longer concerned about congestive heart failure as this medication may precipitate congestive heart failure. The patient had a nutrition evaluation and teaching on diabetic diet and follow up was arranged at [Hospital ] Clinic. The patient was assessed by physical therapy and occupational therapy. FINAL DIAGNOSIS: 1. Chronic obstructive pulmonary disease exacerbation 2. Moderate to severe aortic stenosis 3. Congestive heart failure 4. Diastolic dysfunction 5. Osteoarthritis 6. Chest pain, noncardiac 7. Dyspepsia, status post Helicobacter pylori treatment in [2174] 8. Hyperlipidemia 9. Peripheral vascular disease 10. Ichthyosis 11. History of herpes zoster 12. Degenerative joint disease 13. Cervical spondylosis FOLLOW UP: The patient has follow up scheduled for rehabilitation services on [11-2]. Pulmonary function tests on [2180-11-13]. Follow up with Dr. .................. [2180-11-13]. Follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13065], as well as [Hospital ] Clinic, [Doctor Last Name 2866] [2180-11-30]. DISCHARGE CONDITION: The patient is requiring nebulizers, chest physical therapy, does not desaturate with walking although has dyspnea with mild exertion. He is tolerating p.o. DISCHARGE MEDICATIONS: 1. Calcium carbonate 500 t.i.d. 2. Vitamin D 400 q.d. 3. Pantoprazole 40 4. Aspirin 81 5. Acetaminophen prn 6. Lac-Hydrin lotion 7. Prednisone 60 mg for a total of 5 doses, Prednisone 50 mg for another total of 5 doses followed by Prednisone 40 mg for a total of 5 doses followed by Prednisone 30 mg for another total of 5 doses followed by Prednisone 20 mg for another total of 5 doses followed by Prednisone 10 mg for another total of 5 doses followed by Prednisone 5 mg for another total of 5 doses, each as q.d. dose. 8. Azithromycin 250 mg for a total of a four day course. 9. Glipizide 5 mg tablets q.d. 10. Humalog sliding scale prn .................. 11. Senna 12. Docusate 13. Nebulizers prn as well as his home pulmonary medications DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-735 Dictated By:[Last Name (NamePattern1) 5713] MEDQUIST36 D: [2180-10-26] 15:00 T: [2180-10-26] 16:37 JOB#: [Job Number 13066]	[ "424.1", "491.21", "272.4", "443.9", "251.8", "428.32", "428.0", "518.81", "584.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				8279, 8438					8461, 9442					3310, 7396	7413, 7831													1501, 1767				7843, 8257						2376, 3292						1161, 1482															185, 1141															1790, 2167	2184, 2353
43,673	145,356	37795+58171	Discharge summary	report+addendum	Admission Date: [2132-9-17] Discharge Date: [2132-9-22] Date of Birth: [2052-9-17] Sex: M Service: SURGERY Allergies: Ambien / Codeine Attending:[First Name3 (LF) 1390] Chief Complaint: Fell down [3-23] stairs Major Surgical or Invasive Procedure: Splenic angiography with embolization of 2nd and 3rd branches History of Present Illness: Mr. [Known lastname ] is a 79 year old male who fell down [3-23] stairs and fell on the recycle bin. He denied loss of consciousness,visual changes or dizziness. His main complaint was abdominal pain. He was seen in the Emergency Room at [Hospital6 302] and had a hematocrit of 47. His CT scan revealed a splenic laceration which was activelt bleeding and therefore he was transferred to [Hospital1 18] for further management. Past Medical History: 1. COPD 2. CAD s/p coronary stent placement 3. Hypertension 4. Hypercholesterolemia Social History: Widowed, lives alone, children supportive ETOH none Tobacco remote Family History: non contributory Physical Exam: Temp98 HR 76 BP 140/80 RR 22 O2Sat 95% HEENT NCAT, conjunctiva pale, sclera anicteric PERRLA Neck supple, non tender Chest clear, no deformities, tender left lower ribs Abd tenderness over left lower quadrant Ext calves soft, no lacerations, non tender Pertinent Results: [2132-9-16] 11:39PM WBC-12.3* RBC-4.74 HGB-13.2* HCT-40.5 MCV-85 MCH-27.9 MCHC-32.7 RDW-14.6 [2132-9-16] 11:39PM LIPASE-33 [2132-9-16] 11:39PM UREA N-17 CREAT-0.9 [2132-9-16] 11:46PM GLUCOSE-112* LACTATE-1.5 NA+-137 K+-4.6 CL--98* TCO2-26 [2132-9-17] 07:25AM HCT-35.5* [2132-9-17] 10:34AM HCT-33.5* [2132-9-17] 04:50PM HCT-33.7* [2132-10-7] Abd CT : 1. Heterogeneous predominantly enhancing expansile lesion in the posteromedial spleen consistent with either an intrasplenic lesion, such as hemangioma, with extra- splenic hemorrhage or intrasplenic contusion and extra-splenic hemorrhage. 2. Decreased perisplenic hematoma and stable amount of hemorrhagic fluid within the pelvis. 3. Small right pleural effusion. 4. Gallstones without evidence of acute cholecystitis. 5. Sigmoid diverticulosis without evidence of acute diverticulitis. 6. Multiple renal cysts, the largest on the right measuring up to 13.1 cm. 7. Partially thrombosed 4.2 cm infrarenal abdominal aortic aneurysm. [2132-10-8] Interventional Radiology : Coil and Gelfoam embolization of two tertiary splenic branches which supplied AV fistula and apparent intraparenchymal pseudoaneurysms as well as Gelfoam embolization of the third branch supplying irregular contrast collection in the subcapsular region of the spleen. A large inferior splenic branch remains patent supplying approximately 30% of remaining perfused splenic tissue Brief Hospital Course: Mr. [Name13 (STitle) 1358] was admitted to the TSICU for close monitoring, serial hematocrits and blood pressure monitoring. His pain was well controlled with a Morphine PCA. His hematocrit on admission was 37 and after serial checks dropped to 33 and stabilized there. On [2132-9-19] he underwent arteriography and embolization of the 2nd and 3rd branches of the splenic artery. He tolerated the procedure well, continued to have his hematocrits followed and they remained stable. He was subsequently transferred to the Trauma floor for further management where he continued to make good progress. He abdominal pain was minimal and generally relievewith Tylenol. He was up and ambulating with the use of a cane. The Physical Therapy service recommended home physical therapy and supervision at home over the first 24 hours. His grandaughter who is a nurse will be staying with him. His blood pressure during his hospitalization was generally lower in the 90-100/60 range. Therefore his pre admission medications were adjusted and will have to be followed by his PCP as he may require the full dose in time. Pior to discharge he had a Pneumovax vaccine as well as influenza. After an uneventful recovery he was discharged home with VNA services for cardiovascular assessment and home physical therapy. Medications on Admission: Ppropranolol 20 mg PO QID Isosorbide 60 mg PO Daily Amlodipine 10 mg PO DAily Zocor 10 mg Po Daily Spiriva 1 INH Daily ASA 81 mg 3times/week Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for any loose stools. 5. Propranolol 20 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [5-26] hours as needed for pain. Disp:20 Tablet(s) Refills:0 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO three times a week as taken pre admission. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: splenic laceration grade II Acute blood loss anemia Discharge Condition: stable, tolerating a regular diet,ambulating without assistance Discharge Instructions: If your temperature is greater than 101.5 and you feel ill ie. lethargic, no appetite,abd pain or anything alse unusual please return to the Emergency Room. No heavy lifting or straining Increase your activity as tolerated Followup Instructions: Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2359] for a follow up appointment in 2 weeks. Call your primary care physician for [Name Initial (PRE) ] follow up appointment in 2 weeks. Completed by:[2132-9-22] Name: [Known lastname ],[Known firstname 126] A Unit No: [Numeric Identifier 13444] Admission Date: [2132-9-17] Discharge Date: [2132-9-22] Date of Birth: [2052-9-17] Sex: M Service: SURGERY Allergies: Ambien / Codeine Attending:[First Name3 (LF) 4216] Addendum: Of note, Mr. [Known lastname ] DID NOT receive Pneumovax and the influenza vaccine as he had both of them 2 weeks prior to admission. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. [First Name11 (Name Pattern1) 499] [Last Name (NamePattern4) 4218] MD [MD Number(2) 4219] Completed by:[2132-9-22]	[ "807.03", "E880.9", "902.23", "414.01", "V45.82", "285.1", "865.03", "441.4", "496", "401.9", "272.0" ]	icd9cm	[ [ [] ] ]	[ "39.79", "88.47" ]	icd9pcs	[ [ [] ] ]	6376, 6592	2840, 4159	304, 368	5294, 5360	1356, 2817	5632, 6353	1049, 1067		4350, 5119		5219, 5273		4185, 4327			5384, 5609								1082, 1337																									237, 266										396, 842															864, 949	965, 1033
75,597	126,370	39092	Discharge summary	report	Admission Date: [2201-4-2] Discharge Date: [2201-4-5] Date of Birth: [2138-8-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2195] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD with biopsies History of Present Illness: 62 yo M h/o CAD s/p CABG, AS s/p bioprosthetic AVR, DM2, AFib on AC, ?PUD p/w dizziness and worsened DOE x 5-7 days. The patient states that at baseline he has 20-25 step DOE. He also noted "two-toned stool" which he described as normal appearing on one side and dark black on the other side. The patient states that he first presented with similar symptoms two months ago to [Hospital 4199] Hospital, at which time, per his report, an EGD was performed and he was diagnosed with an ulcer. He is not sure what treatment was initiated other than "changing some meds around." After this presentation, his stools returned to [Location 213] and his DOE and dizziness resolved until this acute presentation. He went to his doctor's office, who referred him to an OSH ED. At this time he was found to be tachycardic and have an INR of 2.9 and a Hct of 21 with guaiac positive, black stool. He was transferred to [Hospital1 18] ED for further evaluation. Vitals were 63, 103/47, 21, 98% on RA, afebrile. At this time, it was confirmed with his surgeon at [Hospital1 2025] that a bioprosthetic valve was used for his AVR. He was then reversed with 2u FFP + 10 mg IV Vit K. Repeat Hct in ED was 21. Attempted NG tube placement twice for lavage but failed, causing a nosebleed that was halted with Afrin. Patient was admitted to ICU for further management. . Review of systems: Denies fevers, chills, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, hematuria, or dysuria. Past Medical History: - bicuspid aortic valve leading to stenosis s/p bioprosthetic AVR in [2200-8-2] - CAD with 3VD s/p CABG in [2200-8-2] - AFib, on anticoagulation with warfarin - DM2 - HTN - HLP - degenerative lumbar disc disease - h/o umbilical hernia repair Social History: 2 ppd x 45 yrs, quit [2200-8-2]. 3 quarts of beer/day x 40 yrs, last drink [2200-11-2]. No h/o IVDU. Family History: Sister had unknown heart murmur and died at age 10 Physical Exam: Vitals: T: 97.8 BP: 135/65 P: 69 R: 19 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM slightly dry Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, [3-7] harsh early systolic murmur heard best @ LUSB but radiates across precordium Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2201-4-2] 07:30PM WBC-7.2 RBC-3.15* HGB-6.0* HCT-21.2* MCV-67* MCH-19.0* MCHC-28.3* RDW-17.6* [2201-4-2] 07:30PM NEUTS-64.0 LYMPHS-25.2 MONOS-8.1 EOS-2.5 BASOS-0.3 [2201-4-2] 07:30PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL PENCIL-OCCASIONAL BITE-1+ [2201-4-2] 07:30PM PLT COUNT-137* [2201-4-2] 07:30PM PT-23.2* PTT-27.7 INR(PT)-2.2* [2201-4-2] 07:30PM GLUCOSE-183* UREA N-23* CREAT-1.3* SODIUM-141 POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15 . CXR: No consolidation or edema is evident. There is evidence of prior median sternotomy, vascular clips consistent with CABG, and a prosthetic valve. There is mild aortic tortuosity. The cardiac silhouette is top normal for size. No effusion or pneumothorax is noted. The osseous structures reveal extensive degenerative changes throughout the thoracic spine. Discharge Labs: [2201-4-5] 08:20AM WBC-7.9 RBC-3.97* Hgb-8.9* Hct-28.8* MCV-73* Plt Ct-139* Glucose-263* UreaN-15 Creat-1.0 Na-138 K-4.0 Cl-104 HCO3-23 AnGap-15 Brief Hospital Course: 62 yo M h/o AVR, CAD s/p CABG, AFib on coumadin, recent h/o PUD p/w GI bleed # GI bleed: Likely UGIB given melenic stools and recent h/o PUD as seen on EGD @ OSH (per patient). Patient's anticoagulation status made him more susceptible to recurrent GI bleeding. Pantoprazole IV BID was started, he received 2 RBC units and H pylori serologies were sent. He underwent EGD the following day, which showed erosions in the stomach, but no ulcers. Colonoscopy was recommended in 2 weeks. At discharge he was started on triple therapy for H.pylori. # Elevated Cr: Initially unclear if this represented ARF as patient's baseline Cr was not known. Pre-renal failure could be consistent with the patient's history of GI bleeding. - Cr improved with fluid hydration and transfusions #Leukocytosis: Elevated WBC count noted on [2201-4-4], which resolved on [2201-4-5] with no intervention. # Afib: Currently in NSR. Initially held rate controlling medication as not needed, BP low-normal. Holding Warfarin in setting of GI bleed. Patient's CHADS2 = 3 assuming he has CHF (not clearly documented, but likely given medications of metoprolol succinate, lasix, lisinopril, and ROS positive for DOE at baseline). Warfarin not prescribed at discharge as risks of recurrent GI bleed deemed to be very high; to be discussed further by outpatient PCP and Cardiologist. # CAD/AVR: Anticoagulation not needed as valve is bioprosthesis. CAD appears stable as patient chest-pain free. Patient's statin was continued; beta-blocker and Lisinopril were re-started at half-dose as patient's blood pressure was only mildly elevated. Aspirin held in setting of recent GIB. Would re-start as an outpatient. At the time of discharge, SBP=125. # DM2: Metformin held; would re-start at discharge. # HTN: Antihypertensives held initially in setting of active bleeding and acute renal failure; adjustments as above. PCP: [Last Name (NamePattern4) ].[Last Name (STitle) ] [Telephone/Fax (1) 25050] CHA [Location (un) 3786] Family Health Center Medications on Admission: ASA 81 protonix 40 [Hospital1 ] pravastatin 80 hs metformin 500 [Hospital1 ] thiamine 100 qday folate 1 qday MVI 1 tab qday warfarin 6-12 mg qday metoprolol succinate 100 qday lasix 20 qday amlodipine 10 qday lisinopril 40 qday Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 10 days. Disp:40 Tablet(s) Refills:0 11. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: GI Bleed Acute Renal Failure Hypertension Coronary Artery Disease Aortic Valve Replacement Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with anemia secondary to a GI bleed. You received 3 units of packed red blood cells, and underwent an EGD which showed inflammation in your stomach, but no ulcers. Your Coumadin was held, as was your Aspirin, and should continue to be held until you meet with your primary care doctor. You were also started on treatment for an H.pylori infection, including amoxicillin and clarithromycin, which you should take for 10 days. Your Lisinopril was decreased from 40mg a day to 20mg a day, and your Metoprolol was decreased from 100mg a day to 50mg a day. The rest of your medications were unchanged. Followup Instructions: Please follow-up with Dr.[Last Name (STitle) ] in three to five days for a blood pressure check and to adjust your blood pressure medications. Please bring all of your medications with you so that you can confirm you are taking everything correctly.	[ "427.31", "584.9", "V58.61", "V58.67", "V42.2", "535.41", "250.00", "414.00", "272.4", "401.9", "288.60", "V45.81", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.16" ]	icd9pcs	[ [ [] ] ]	7413, 7419	4051, 6095	322, 341	7553, 7553	2935, 3862	8341, 8597	2301, 2353		6381, 7390		7440, 7532		6121, 6358			7700, 8318			3878, 4028					2368, 2916																				1767, 1884					274, 284										369, 1748								7568, 7676							1906, 2157	2173, 2285
53,084	103,543	40872	Discharge summary	report	Admission Date: [2153-3-25] Discharge Date: [2153-4-4] Date of Birth: [2067-11-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1899] Chief Complaint: Shortness of breath. Transfer for NSTEMI/GIB/PNA Major Surgical or Invasive Procedure: Cardiac Cath History of Present Illness: 85yoM with no primary care for 25+ years presenting from [Hospital 89271] Hospital with NSTEMI, PNA, and GI bleed. . The patient reports acute onset shortness of breath which began last night which has been progressively worsening. He denies chest pain, lightheadedness, dizziness, or pedal edema, orthopnea, PND. He also reports 2-3 weeks of increasing dyspnea on exertion and cough. He presented to [Hospital3 ] and was found to have an NSTEMI. He was given ASA 325 but reported intermittent bloody bowel movements and was found to have gross blood on rectal exam, and was not started on Heparin gtt. When asked, the patient reported he has intermittent BRBPR for the past 2 weeks. D-dimer was elevated. He underwent a CTA at [Location (un) ] which showed a question of b/l PNA and was given Levofloxacin, negative for PE. He was transferred to [Hospital1 18] for further management. . In the ED, initial vitals were: 97.9 105 133/74 18 97% 2L NC ECG was significant for anterolateral ST depressions. Cardiology was made aware. Troponin was 0.31. WBC was 21.9 and portable CXR showed bilateral infiltrates. The patient had another rectal exam which showed frank blood in the rectal vault. NG lavage was negative. GI was made aware, and agreed the source of bleed is likely lower source. Hct was 28.0. He was given Pantoprazole 80mg IV and type and screened. He was admitted for further management. Past Medical History: none per patient Social History: 35 pack years, recently less. 1 drink/week. Retired. Family History: non-contributory Physical Exam: On admission: VS: 98, 111/58, 84, 20, 97%RA GENERAL: alert, interactive, lying supine, NAD HEENT: Sclerae anicteric. PERRL, EOMI. MMM. NECK: Supple. JVP 3 cm above sternal angle at 30deg CARDIAC: RRR, II/VI HSM heard best at apex. No S3 or S4. No thrills, lifts. LUNGS: Clear ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: no C/C/E. Extremities warm and well perfused. SKIN: No ulcers, scars, or xanthomas. Mild hyperpigmentation of anterior shins PULSES: Right: Femoral 2+ Carotid 2+ Dopplerable DP/PT [Name (NI) 2325]: Femoral 2+ Carotid 2+ Dopplerable DP/PT On discharge: unchanged Pertinent Results: On admission: [2153-3-25] 08:10PM BLOOD WBC-21.9* RBC-2.91* Hgb-9.6* Hct-28.0* MCV-96 MCH-33.1* MCHC-34.4 RDW-14.2 Plt Ct-349 [2153-3-25] 08:10PM BLOOD Neuts-88.6* Lymphs-6.0* Monos-5.2 Eos-0.1 Baso-0.1 [2153-3-25] 08:10PM BLOOD PT-14.0* PTT-24.4 INR(PT)-1.2* [2153-3-25] 08:10PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-135 K-4.1 Cl-101 HCO3-21* AnGap-17 [2153-3-25] 08:10PM BLOOD CK(CPK)-330* [2153-3-26] 06:30AM BLOOD ALT-19 AST-39 CK(CPK)-230 AlkPhos-70 TotBili-0.8 [2153-3-26] 06:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.0 Mg-1.9 Cholest-203* [2153-3-26] 06:30AM BLOOD Triglyc-66 HDL-77 CHOL/HD-2.6 LDLcalc-113 [2153-3-26] 07:08AM BLOOD %HbA1c-6.1* eAG-128* [2153-3-26] 03:04AM BLOOD Lactate-2.5* Hematocrit and WBCs [2153-3-25] 08:10PM BLOOD WBC-21.9* Hct-28.0* [2153-3-26] 03:45PM BLOOD WBC-17.8* Hct-28.0* [2153-3-27] 07:00PM BLOOD Hct-23.0* [2153-3-30] 07:00AM BLOOD WBC-13.0* Hct-26.5* [2153-4-4] 07:50AM BLOOD WBC-11.4* Hct-28.8* Creatinine [2153-3-25] 08:10PM BLOOD Creat-1.3* [2153-3-26] 03:45PM BLOOD Creat-1.4* [2153-3-27] 08:36PM BLOOD Creat-1.6* [2153-3-28] 05:53PM BLOOD Creat-1.7* [2153-4-1] 09:30AM BLOOD Creat-1.2 [2153-4-4] 07:50AM BLOOD Creat-1.3* Cardiac enzymes [2153-3-25] 08:10PM BLOOD CK-MB-32* MB Indx-9.7* [2153-3-25] 08:10PM BLOOD cTropnT-0.31* [2153-3-25] 08:10PM BLOOD CK(CPK)-330* [2153-3-26] 02:11AM BLOOD CK-MB-21* MB Indx-8.0* cTropnT-0.36* [2153-3-26] 02:11AM BLOOD CK(CPK)-262 [2153-3-26] 06:30AM BLOOD CK-MB-16* MB Indx-7.0* cTropnT-0.44* [2153-3-26] 06:30AM BLOOD CK(CPK)-230 [2153-3-28] 03:43AM BLOOD CK-MB-4 cTropnT-0.54* [2153-3-28] 03:43AM BLOOD CK(CPK)-107 MICROBIOLOGY Blood, urine, sputum cultures - no growth IMAGING TTE ([3-26]): IMPRESSION: extensive inferior-posterior myocardial infarct with secondary moderate-to-severe mitral regurgitation; "severe" aortic stenosis (most likely with a component of low flow/low gradient physiology); reduced stroke volume and cardiac output CXR: IMPRESSION: Acute pulmonary edema with underlying centrilobular emphysema, an extensive pneumonia is a less likely possibility. CARDIAC CATH: 1. Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a 40-50% eccentric and calcified stenosis. The LAD had an 80% calcified mid LAD stenosis with 100% distal occlusion. The LCx had a 100% ramus branch occlusion, an 80% tubular OMB1 stenosis. There was an occluded small OMB2. The RCA had a 60% diffuse stenosis which was calcified and leading to a PDA. 2. Resting hemodynamics demonstrated mildly elevated left sided filling pressures with mean PCWP 21 mmHg. There is mild pulmonary artery systolic hypertension with PASP of 42 mmHg. The cardiac index is preserved at 2.52 L/min/m2 (using an assumed oxygen consumption). There was moderate aortic stenosis with a calculated aortic valve area of 1.19 cm2 (based on an assumed VO2). FINAL DIAGNOSIS: 1. Severe three vessel coronary artery disease. 2. Moderate to severe mitral regurgitation. 3. Moderate aortic stenosis. 4. Moderate pulmonary artery hypertension. 5. Mildly elevated pulmonary capillary wedge pressure. CAROTID U/S: Right ICA 60-69% stenosis. A more severe [Country ] stenosis cannot be excluded due to the presence of calcifiedplaque. Left ICA 40-59% stenosis. Right verterbral artery appears occluded. L vertebral open. SPIROMETRY: Impression: Severe obstructive ventilatory defect with a moderate gas exchange defect. There are no prior studies available for comparison. TEE: IMPRESSION: Regional left ventricular systolic dysfunction. Mild to moderate mitral regurgitation. Moderate thickened aortic valve with significant aortic stenosis present (though not quantified). Brief Hospital Course: 85yoM with no primary care for 25+ years presenting from [Hospital 89271] Hospital with posterior/inferior NSTEMI, PNA, and GI bleed. . ACTIVE ISSUES . # CORONARIES: The patient presented with acute onset dyspnea and was found to have an NSTEMI with elevated CE's. He was started on ASA 325, Atorvastatin 80mg, and Metoprolol. He was not originally started on heparin or plavix given GIB (see below) and was trasnfused 1U pRBCs to minimize cardiac demand ischemia. After undergoing a flex sig, a cath was performed and showed "LAD disease, with ramus occluded, diseased circ, 60% RCA, and aortic valve area 1.1 without gradient". Given the extent of his disease, the option of a CABG and valvular repair was offered. However, cardiac surgery evaluated him and determined that he would not be a good surgical candidate and should be medically managed at this point. His valvular disease was not significant enough to warrant mitral and aortic valve replacements, but should be monitored. On discharge, he will begin taking the follow medications for optimal medical management: aspirin 325 mg daily, Atorvastatin (Lipitor) 80mg daily, metoprolol 75mg daily, and lisinopril 5mg. . # PUMP: On admission, he appeared euvolemic without evidence of volume overload. An ECHO on [3-26] showed 3+ MR and severe aortic stenosis with depressed EF35%. However after medical treatment and diuresis, a repeat ECHO showed 2+ MR and a TEE confirmed these findings. He will follow-up with Dr. [Last Name (STitle) 1911] as an outpatient for repeat TTE and management of his heart failure with the likely initiation of diuretic therapy. . # GI Bleed: The patient reported intermittent bloody bowel movements in the past, BRBPR with stool. Likely lower source, diverticulosis vs polyp vs AVM. GI was consulted. He was made NPO and underwent a flexible sigmoidoscopy on [3-27] which showed a polyp and bleeding hemorroids. His polyp was not removed given the bleeding risk and recent MI and should be followed as an outpatient with GI for this issue. He required 1 U pRBCs on [3-27] but then stopped bleeding with stable hematocrit. He will need a colonoscopy as an outpatient. His Plavix was held on discharge and he should receive his colonoscopy before restarting this. He will also be continued on omeprazole for gastric protection while taking ASA. . # Community-acquired pneumonia: The patient reported cough and shortness of breath for the past 2-3 weeks, and underwent CTA at OSH which showed evidence of b/l PNA, and was given a dose of Levofloxacin. He denied fevers and b/l lower lobe opacities are more likely CHF exacerbation in the setting of NSTEMI given infiltrates are bilateral and patient is not an aspiration risk. However, given his elevated white count of 21.9, which may be all or partially due to his NSTEMI and GI bleed, his Levofloxacin was continued for 5 days. . TRANSITIONAL ISSUES . # Follow-up care: Mr. [Known lastname 36413] will be seeing Dr. [Last Name (STitle) 1911] for outpatient Cardiology appointments. At this point, he will be assisted in setting up an appointment with a primary care physician, [Name10 (NameIs) 1023] will then be coordinating his care. Since he has not been watched by the medical system for a while, he should be encouraged to follow-up closely, given that he is on many new medications and will new follow-up imaging to monitor his valvular function. . # Health screening: He will likely need routine health maintenance, most notably a colonoscopy, especially given his GI bleeding and anemia. Follow-up with a new PCP will be essential for him to follow his routine health care maintenance. Medications on Admission: No home medications Discharge Medications: 1. atorvastatin 80 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. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule, Delayed Release(E.C.)(s) 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:45 Tablet Extended Release 24 hr(s) Refills:2 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Outpatient Lab Work Please check chem-7 on Friday [4-6] with results to Dr. [Last Name (STitle) 1911] at [Telephone/Fax (1) 11767] Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Non ST Elevation myocardial infarction Aortic Stenosis, valve area 1.2 Moderate Mitral Valve Regurgitation Acute systolic congestive heart failure Acute Kidney Injury Lower GI Bleed Carotid Stenosis Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and had a cardiac catheterization that revealed many blockages in your heart arteries. You have been started on many medicines to help your heart function better and recover from the heart attack. You were also found to have blockages in the arteries in your neck that could lead to a stroke if these blockages worsen. You had some bleeding from your rectum that appeared to be due to internal hemorrhoids but you absolutely need to have a colonoscopy to look at your whole colon to make sure there are no other areas of bleeding or polyps. You also were found to have emphysema or COPD due to your smoking. It is extremely important that you do not start smoking again. Your kidneys were not working well due to your heart problems but now have almost returned to [Location 213] function. Your heart is weak after the heart attack and you had some fluid retention that was treated with diuretics. We are not sending you home on diuretics now but you need to weigh yourself every day in the morning and call Dr. [Last Name (STitle) 1911] if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. . We started you on the following medicines: 1. Start taking aspirin 325 mg daily to prevent another heart attack 2. STart taking Atorvastatin (Lipitor) to prevent further blockages in your arteries from cholesterol buildup 3. Start taking metoprolol to prevent another heart attack and lower your heart rate 4. Start taking Lisinopril to lower your blood pressure and help your heart pump better. 5. Start taking Omeprazole to protect your stomach from the aspirin. . It is extremely important that you take all of your medicines and follow up with your doctors. Followup Instructions: Department: CVI [Location (un) ], [Apartment Address(1) ] When: WEDNESDAY [2153-5-9] at 2:00 PM With: [Last Name (un) 1918] [Doctor Last Name ] [Telephone/Fax (1) 11767] Building: [Location (un) 20588] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please call Dr. [Last Name (STitle) ] office on Monday [4-9] to ask for names of Primary Care Physicians in the area that he would recommend. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1905]	[ "401.9", "285.9", "V15.82", "410.71", "211.3", "599.0", "584.9", "523.9", "486", "414.01", "428.0", "492.8", "428.21", "433.30", "433.10", "396.2", "455.2" ]	icd9cm	[ [ [] ] ]	[ "88.53", "88.56", "37.23", "88.72", "45.24" ]	icd9pcs	[ [ [] ] ]	10971, 11020	6447, 10123	352, 367	11278, 11278	2593, 2593	13162, 13748	1940, 1958		10193, 10948		11041, 11257		10149, 10170		5622, 6424	11429, 13139								1973, 1973																	2563, 2574								264, 314										395, 1812							2608, 5605	11293, 11405							1834, 1852	1868, 1924
81,543	198,462	44752	Discharge summary	report	Admission Date: [2141-10-23] Discharge Date: [2141-10-28] Date of Birth: [2092-4-6] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing / Bactrim Attending:[First Name3 (LF) 1384] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [2141-10-24]: Right iliac angiogram and transplanted renal arteriogram. [2141-10-25]: Transplant kidney biopsy History of Present Illness: 49M renal transplant [10-6] states he felt increasingly short of breath since [3-1] PM this afternoon, and was told to come in by transplant coordinator. Denies f/c, felt nauseous earlier today, and had small amount of diarrhea. Also c/o 'dark urine' otherwise in USOH. Past Medical History: 1. CAD s/p [Month/Day (3) ] to OM1 in [9-2] and [Month/Day (1) ] to RCA in [5-5] 2. End-stage renal disease, on HD since [6-3] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [2137-3-29]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Kidney transplant, right iliac fossa [2141-10-14]. Social History: The patient lives with his wife and 2 sons in [Name (NI) 669]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [Last Name (un) 95749]-[Doctor Last Name 3532] disease. Physical Exam: 79 195/68 25 82% [Hospital ] clinic weight 222 lbs (preop 208) NAD, no JVD, diffuse rales rrr, abdomen s/nt/nd, incision c/d/i, no peripheral edema. Pertinent Results: [Age over 90 ]\|105\|61 AGap=18 [Cr trend 3.5->3.1->3.0, repeat K 5.1] -------------<438 6.0\|22 \|3.0 6.9>10.9/34<210 PT: 12.1 PTT: 28.9 INR: 1.0 UA: + glucose + ketones - leuks - nitrites Imaging: CXR: bilateral fluffly infiltrates c/w pulmonary edema EKG: unchanged from previous, no signs of ischemia Brief Hospital Course: Pt was admitted and found to be in pulmonary edema. He was sent to the SICU. He received 100mg IV lasix with good effect. His blood pressure was controlled with IV medications including nitroglycerin Gtt. His pulmonary status quickly improved and he was transferred to the floor. He was started on nifedipine for his blood pressure control and this was titrated up to 90mg daily for the ext release pill. There was concern about renal artery stenosis, and an ultrasound of the graft confirmed this. He then had an angiogram to further evaluate this and it was negative for renal artery stenosis. We then decided to treat him with optimal medical management. It was decided to obtain a renal biopsy to rule out rejection. This demonstrated evidence of interstitial nephritis which was likely secondary to his bactrim. We therefore stopped the bactrim. His Cr trended down over the next few days from a peak of 4.8 to 4.2 prior to discharge. He was tolerating a diet, ambulating, and making good urine. He will continue on the rest of his immunosuppresives and prophylactics. He was started on pentamadine for PCP prophylaxis, and this will be continued on a monthly basis. His blood pressure will be further managed as an outpatient and repeat labs will be done on monday [2141-10-30]. Medications on Admission: Plavix 75 qd, lantus 20 u [Month/Day/Year ], humalog sliding scale - patient does not know, isosorbide mononitrate ER 60', Loperamide 2-4 mg QD PrN diarrhea, toprol XL 200 [Hospital1 ], Cellcept [Pager number ]'', Nitro 0.4 qd prn, nystatin suspension 5 mL QIDACHS, Prilosec 40'', Lyrica 25', Darvocet-N 100 [12-30] q4-6prn, ranitidine 300hs, Kayexalate prn, Tacro 12'', Trazodone 50-100 hs, bactrim ss', Valcyte 900', [Month/Day (2) ] 325 qd Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QPM (once a day (in the evening)). 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Subcutaneous 15. Tacrolimus 1 mg Capsule Sig: Nine (9) Capsule PO twice a day. 16. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:30 Tablet Sustained Release(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: CHF Hypertension Hyperglycemia (Type 2 DM) s/p kidney transplant [2141-10-14] Discharge Condition: Stable/Good Discharge Instructions: Please call the transplant clinic at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications Your medications have been changed, please follow your new medications regimen and insulin scale Labwork every Monday and Thursday with results to transplant clinic fax # [Telephone/Fax (1) 697] Followup Instructions: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-10-31] 11:20 [Month/Day/Year 2841] LABORATORY Phone:[Telephone/Fax (1) 2846] Date/Time:[2141-11-6] 1:00 [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2141-11-8] 8:00	[ "327.23", "V58.67", "362.01", "585.9", "428.0", "250.53", "250.13", "357.2", "580.9", "272.4", "403.00", "250.63", "V42.0", "799.02", "707.14", "V49.72", "070.32", "271.0", "E931.0", "250.43" ]	icd9cm	[ [ [] ] ]	[ "88.45", "55.23", "88.47" ]	icd9pcs	[ [ [] ] ]	5923, 5980	2504, 3809	316, 437	6106, 6120	2164, 2481	6552, 6942	1606, 1975		4322, 5900		6001, 6085		3835, 4299			6144, 6529								1990, 2145																									257, 278										465, 745															767, 1409	1425, 1590
9,822	130,029	4603	Discharge summary	report	Admission Date: [2150-1-17] Discharge Date: [2150-1-29] Date of Birth: [2074-4-3] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[First Name3 (LF) 905] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: central venous line (subclavian) intubation History of Present Illness: 75 yo female with PmHx of DM, asthma, HTN, hyperlipidemia who presented from her [Hospital3 ] home [1-17] with respiratory distress. On admission, she was found to have an O2 sat of 85% on RA, and was given nebs/IV lasix. Her initial ABG was 7.12/47/152/16 with lactate of 8, and CPAP was initially begun in the ED. She was noted to be bradycardic, with a ?junctional escape rhythm at a rate of 48 bpm in the setting of hyperkalemia (K=7), and was given atropine. However, she subsequently became hypotensive, was started on dopamine, and was electively intubated. Of note, several medications were apparently changed [1-13] by her PCP, [Name10 (NameIs) 19566] initiation of Cardtia XT 300mg daily, with discontinuation of nifedipine. ED course also notable for empiric initiation of levofloxacin, vancomycin, flagyl, and hydrocortisone. Micu course notable for resolution of her hyperkalemia, which was thought to be secondary to a combination acute on chronic renal failure and [Last Name (un) ] toxicity, with resolution of normal sinus rhythm (rate in the 70s), and pressors were waned off on hospital day one. Her renal function improved, with Cr 1.4 the morning of [Hospital 12145] transfer to the floor (baseline 0.8 - 1.2). She was successfully extubated [1-20], though required intermittent noninvasive ventilation for hypercarbia thought to be secondary to combination of sedative medications and poor baseline respiratory status. She also was noted to be febrile, and was treated empirically for possible MRSA pneumonia (sputum cultures positive for MRSA), with defervescence on [1-17]. Furthermore, discussion with outpatient psychiatrist revealed that patient has atypical reaction (extreme agitation/?psychosis) to midazolam, which may have contributed to her altered mental status during weaning period. She was also noted to have hypernatremia, which was thought to be secondary to crystalloid given during initial fluid resuscitation in the setting of acute renal insufficiency. Her hypernatremia improved with free water repletion. PMHx: HTN, DM II with neuropathy/nephropathy, asthma, increased lipids, ?parkinsonism, paranoid schizophrenia, bipolar disorder, obesity, osteoarthritis, GERD, BPD, Diabetic neuropathy, R TKR, Anemia, CRI. Diverticulitosis. ?hepatic cyst, S/p right total knee replacement ([2147]). Past Medical History: 1. Status post right total knee replacement 2. DM II, c/b neuropathy and nephropathy. 3. Osteoarthritis. 4. Hypertension. 5. Asthma. 6. Hypercholesterolemia. 7. Parkinson's. 8. Obesity. 9. GERD. 10. Bipolar/paranoia. 11. History of falls. Social History: Shx: lives in an [Hospital3 ] facility. No known h/o tobacco or alcohol use. Family History: NC Physical Exam: Vital Signs: Temp 98.4, BP 130/60, HR 84, RR 20, SaO2 94% RA, last 4 fs in reverse order: 84, 62, 174, 98. Gen: patient seated in the nursing area in [Female First Name (un) 1634] chair, NAD, awake&alert, nad CV: RRR nl S1 S2, no M/R/G appreciated Pulm: scattered expiratory rhonchi throughout Abd: obese, protruberant, NT, +BS EXT: No edema CV: 2+ PT, DP pulses bilaterally Neuro: Awake, alert, oriented to person and place Brief Hospital Course: MICU course: * BRADYCARDIA/HYPOTENSION: Bradycardia was thought to be secondary to either junctional rhythm vs. hyperkalemic arrhythmia, as potassium was >7 on admission. Hyperkalemia was thought to be secondary to a combination acute on chronic renal failure and [Last Name (un) ] toxicity. Following correction of hyperkalemia, patient returned to [Location 213] sinus rhythm with rate in the 70s. Consequently, blood pressure normalized and patient was easily weaned off pressors on hospital day one. * RESPIRATORY DISTRESS: Patient was initially intubated upon arrival given hemodynamic collapse. However, patient was not extubated until hospital day 3, as patient was noted to be extremely agitated during spontaneous breathing trials despite excellent objective indications of successful extubation (low RSBI, appropriate respiratory rates and tidal volumes). Nonetheless, patient was successfully extubated, but required intermittent noninvasive ventilation for hypercarbia thought to be secondary to combination of sedative medications and baseline COPD. Discussion with outpatient psychiatrist revealed that patient has atypical reaction (extreme agitation/?psychosis) to midazolam, which may have explained patient's mental status during weaning period. * BACTERIAL PNEUMONIA: Given above difficulty with extubation and intermittent fevers, sputum gram stain and cultures were sent, and patient was found to have MRSA pneumonia. Prior to microbiological data, patient was empirically started on levofloxacin and metronidazole, but vancomycin was added following identification of Staphylococcus aureus in sputum culture [1-17]. This colony was later found to be oxacillin resistant, and patient was continued on vancomycin. Patient was afebrile by third day of treatment, with low grade temperature elevations. * BORDERLINE PERSONALITY DISORDER: According to outpatient psychiatrist, patient is easily agitated at baseline and is best managed by a combination of quetiapine, valproic acid, and oxazepam PRN. Following medical stabilization, patient was restarted on quetiapine and valproic acid with PRN lorazepam for acute bouts of agitation. Quetiapine was uptitrated as needed. Nonetheless, patient continued to require 1:1 precautions - which outpatient psychiatrist felt would be expected at patient's baseline mental status. * HYPERNATREMIA: Thought to be due to large sodium load during initial fluid resuscitation in the setting of acute renal insufficiency. Patient was given a combination of free water boluses via NG tube and D5W to correct free water deficit 50%/day. By the end of MICU course, patient's free water deficit had largely corrected. * ACUTE ON CHRONIC RENAL FAILURE: On admission, patient's creatinine was 2.7, thought to be secondary to hypoperfusion during bradycardic episode. With recovery of hemodynamics, patient's urine output and renal function improved accordingly. [Hospital1 ] Course: The patient was called out to the floor from the intensive care unit on Thursday [1-22]. * PSYCH/AGITATION: She experienced some agitation and getting out of bed although she was unsteady on her feet. She was placed on 1:1 sitter for one night on [1-26]. * BACTERIAL PNEUMONIA: She completed a 10 day course of vancomycin, levofloxacin, and metronidazole on [1-27]. She has not experienced any fevers or respiratory difficulty since being called out of the unit and was successfully weaned off of oxygen. * CHRONIC RENAL FAILURE/HYPERKALEMIA: Her renal function has remained at baseline of 0.8-1.2 on the wards without hyperkalemia. She was started on losartan [1-29] and hydralazine was discontinued (due to concerns for compliance). She will need monitoring of potassium to ensure that hyperkalemia does not recurr on this medication. * HYPOTENSION * She experienced no further hypotension and instead experienced hypertension throughout her course on the floor. Medications on Admission: albuterol prn, asa, Avandia, Depakote ER, Diovan, Prozac, Glucophage, lasix, lipitor, neurontin, Serax, seroquel, Cartia XT, oxycodone Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Divalproex Sodium 500 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO QHS (once a day (at bedtime)). 3. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) ml PO BID (2 times a day). 6. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 12. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Four (24) Units Subcutaneous q am. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous at bedtime. 18. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 20. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 21. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 22. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital ] - [Location (un) ] Discharge Diagnosis: bradycardia hypotension bacterial pneumonia sepsis hypernatremia acute renal failure chronic renal failure Discharge Condition: Good Discharge Instructions: Please take all of your medications as prescribed. If you experience shortness of breath, chest pain, worsening cough or fevers, call your doctor or return to the Emergency Department. Followup Instructions: Please follow up with your primary care doctor [First Name (Titles) 3] [Last Name (Titles) 1988] below on [2-10] th. Provider: [Name10 (NameIs) ],[Name11 (NameIs) 9119] [Name12 (NameIs) 9120] MEDICINE (PRIVATE) Where: ADULT MEDICINE UNIT [Hospital3 ] HEALTHCARE - 1000 [Location (un) ] - [Location (un) 2352], [Numeric Identifier 9121] Phone:[Pager number ] Date/Time:[2150-2-10] 11:30 [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2150-1-29]	[ "276.0", "583.81", "584.9", "250.42", "518.82", "428.0", "995.92", "E942.4", "482.41", "295.30", "V09.0", "038.9", "507.0", "276.7", "E939.4", "403.91", "427.89", "785.52" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.93", "96.71", "93.90", "96.6", "99.04", "00.17" ]	icd9pcs	[ [ [] ] ]	9879, 9944	3588, 7542	279, 324	10095, 10101		10334, 10894	3115, 3119		7727, 9856		9965, 10074		7568, 7704			10125, 10311								3134, 3565																									232, 241										352, 2737															2759, 2999	3015, 3099
81,844	127,525	40305	Discharge summary	report	Admission Date: [2176-11-1] Discharge Date: [2176-11-13] Date of Birth: [2124-4-7] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: MVC Major Surgical or Invasive Procedure: Biopsy of L4 for foraminal tumor History of Present Illness: 55M who was in his usual state of health and was driving when he lost control of his vehicle secondary to inclement weather and fish tailed into the highway barrier. He was taken to [Hospital ] Hospital and reported decreased sensation and movement to his lower extremities and was transferred to [Hospital1 18] for further care. Past Medical History: None Social History: Married with children. Wife at bedside. Family History: NC Physical Exam: O: T: 99.2 BP: 114/65 HR: 73 R 15 O2Sats 98% Gen: WD/WN, comfortable, NAD. HEENT: R forehead laceration Neck: in hard collar Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [Last Name (un) 938] G R 3 -4 3 0 0 2 0 0 0 0 0 L 3 -4 3 0 0 2 0 0 0 0 0 Bilateral grasps 0/5, no finger mvmt bilaterally. Sensation: Intact to light touch throughout, proprioception negative. Sensation intact to temperature from nipple line up. Reflexes: B T Br Pa Ac Right 0 0 0 3 0 Left 0 0 0 3 0 Proprioception: negative Toes mute bilaterally Rectal exam: decreased sphincter control On Discharge: A&Ox3 Motor: D B T IP [Initials (NamePattern5) 12643] [Last Name (NamePattern5) ] AT [Last Name (un) 938] R 3 4 3 3 0 0 WIGGLES TOES L 2 3 3 2 0 0 WIGGLES TOES Incision: c/d/i Pertinent Results: MR CERVICAL,THORACIC,LUMBAR SPINE W/O CONTRAST [2176-11-1] 1. Contusion of the cervical spinal cord at C3-C4; no evidence of hemorrhage. 2. Discontinuity of the anterior longitudinal ligament at C5-C6 and C6-C7, possibly due to underlying osteophytes, but injury to the structure is also possible. 3. Mass centered near the right L4-L5 neural foramen, suspicious for a schwannoma. An osseous lesion such as giant cell tumor or osteoblastoma is also possible. Malignancy is also possible, and continued workup is suggested, when patient is able. A contrast-enhanced lumbar spine MRI could be obtained for further evaluation in a non emergent setting. Brief Hospital Course: 52 y/o M transfer from [Hospital ] Hospital s/p MVC. Found to have decreased sensation and movement in LE. CT c-spine showed prevertebral edema at C4. An MRI of c, t, and l spine was done which showed cord contusion at C3-4 and L4 lesion. Patient remained in c-collar. On examination, patient was antigravity with biceps and triceps in RUE and [2-23] in LUE, minimal to no movement in BLE. Patient was placed on pressors to keep MAP>80. On [11-3], patient was taken off pressors and placed on neurontin. On [11-4], patient was transferred to step down with slightly improved. On [11-6], patient was febrile with a temp of 101.2. U/A was negative. On [11-7], he was afebrile and coumadin was started for long term DVT prophylaxis. He was taken to IR for biopsy of his L4 lesion. Exam remained stable post biopsy. No adjunct therapy needed for lesion at L4 and patient was screened for rehab. On [11-9] Pt's neurological exam slightly improved with new ability to wiggle toes. He also stated that his sensation was improving. On [11-10] Pt was again febrile and chest x ray was negative for infiltrative process and U/A and culture were negative. He had no further episodes of fever while in the hospital. His coumadin was increased to 7.5mg daily on this day as he had no increase in INR with 5mg daily. On [11-13] Pt was discharged to rehab facility in stable condition. He must have daily INR checks and coumadin should be titrated accordingly for goal INR of [2-20].5. Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/fever. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. sodium chloride 0.65 % Aerosol, Spray Sig: [1-20] Sprays Nasal QID (4 times a day) as needed for dryness. 8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. 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. 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q1H:PRN Pain 15. Lorazepam 0.5-1 mg IV HS:PRN insomnia/anxiety Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: C3-4 contusion, L5-4 foraminal tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: ?????? Do not smoke. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar for 3 months. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? 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, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in [7-27] days (from date of surgery) for removal of your staples/sutures and/or a wound check. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. [Name10 (NameIs) ] can also be removed at the rehab facility ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739] to be seen in 4 weeks. ??????You will x-rays/CT-scan prior to your appointment. ??????You will also need daily INR checks, goal INR 2-2.5 [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2176-11-13]	[ "952.04", "V58.61", "E816.0", "780.60", "239.2" ]	icd9cm	[ [ [] ] ]	[ "86.11" ]	icd9pcs	[ [ [] ] ]	5457, 5527	2627, 4143	323, 358	5608, 5608	1945, 2604	7036, 7818	828, 832		4198, 5434		5548, 5587		4169, 4175			5743, 7013								847, 1023																	1722, 1926								280, 285										386, 726								5623, 5719							748, 755	771, 812
25,876	131,372	43349	Discharge summary	report	Admission Date: [2191-2-24] Discharge Date: [2191-3-1] Date of Birth: [2149-8-30] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1115] Chief Complaint: hyperglycemia, CP, SI Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 41yo gentleman with h/o type 1 DM, hepatitis C and polysubstance abuse who presented with chest pain and passive SI, and was found to have hyperglycemia to 985. The history is somewhat limited by patient sleepiness, but per him, he was doing well until about three days ago, when home stress caused him to start drinking again and doing cocaine. He said he drank about 3 gallons of hard liquor over the past 3 days and was doing cocaine daily. He reports his last drink was just before going to the ED and his last cocaine was 7pm the night before admission. During this time, he lost track of his insulin and was not taking it. On the morning of admission, he developed substernal chest heaviness radiating to his shoulder and worse with exertion. For this as well as passive SI, he presented to the ED. . In the emergency department initial vitals. He was given aspirin and ativan. EKG did not show evidence of ischemia. Labs were notable for glucose of 985, k of 5.0, anion gap of 19 (ABG not done), positive urine ketones, positive urine cocaine, negative in serum (other tox screen negative). His sodium was 122, which corrected to 136.2. Calculated osmolality was 316 and 344 with corrected sodium). WBC was 6.2 and CEs were normal x 1. CXR was felt to be normal. He was given 10mg IV regular insulin and started on an insulin gtt at 8U/hr. By the time of signout, he was finishing his 2ng liter of NS with a 3rd to be hanged upon leaving the ED. He remained hemodynamically in the ED. . vitals before transfer. 81 113/57 13 97%RA AF . REVIEW OF SYSTEMS: (+)ve: as per HPI (-)ve: fever, chills, night sweats, loss of appetite, fatigue, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: Type 1 DM followed at [Last Name (un) ] Chronic Hepatitis C - has been referred to Liver Center Polysubstance abuse - heroin overdose in 96 and 00, has been on suboxone from Dr. [Last Name (STitle) 93335] Alcohol abuse - reports gets shaky but no known h/o seizures or DTs Bipolar disorder h/o suicide attempts (by cutting himself, by overdose) s/p appendectomy Cardiac cath in [2189] with non-obstructive coronary disease Dyslipidemia Social History: Works as roofer. Longest period of sobriety was 17 months with help of NA/AA. Has had frequent lapses. Mr. [Known lastname ] only smokes tobacco when he is on a drinking binge. He has a 9yo daughter with whom he is close. Lives with his girlfriend, who does not use drugs or drink. Family History: Both parents were alcoholics. Physical Exam: GENERAL: sleepy, but cooperative and in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: 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, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. No stigmata of chronic liver disease. NEURO: A&Ox3. Appropriate but sleepy, frequently falls asleep. Wakes right back up with prompting and is cooperative. CN 2-12 intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: endorses passive SI Discharge exam: 97.0 120/56 57 18 95RA awake, alert, cooporative. Mood improved. physical exam unchanged. Pertinent Results: [2191-2-24] 06:50AM GLUCOSE-985* UREA N-20 CREAT-1.3* SODIUM-122* POTASSIUM-5.0 CHLORIDE-82* TOTAL CO2-21* ANION GAP-24* [2191-2-24] 09:15AM ACETONE-TRACE OSMOLAL-308 Brief Hospital Course: 41 yo with history of DMI, multiple admissions for DKA, HCV, polysubstance abuse, and bipolar disorder who presents with hyperglycemia, elevated gap, and positive ketones in the setting of insulin noncompliance. . Primary Diagnosis: 250.13 DIABETES TYPE I, KETOACIDOSIS Elevated BG, gap, and positive serum ketones in setting of noncompliance of insulin and cocaine binge consistant with DKA vs hyperglycemia with starvation/ketotic state. Noncompliance is likely precipitant, other causes could be infection but no focal signs of infection, UA negative for infection, and CXR clear. Corrected sodium 136.2. GAP closed to 12 upon arrival to ICU with normalization of Bicarb. His insulin gtt was continued until his BG normalized and his gap closed. He was transitioned to lantus per [First Name8 (NamePattern2) ] [Last Name (un) 387] DKA protocol with q 1 hr finger sticks, goal 100-200. On the floor his glucoses were managed with lantus 30, humalog 4 with meals(higher if carb load, patient carb counts). . ACUTE RENAL FAILURE: likely volume depletion in setting of hyperglycemia and etoh binge. Cr returned to baseline with IVF. . Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL Secondary Diagnosis: 304.20 DRUG USE/DEPENDENCE, COCAINE significant EtOH in last three days. cocaine as above. CIWA started, but not required. Psych and social work consulted. Discharged to partial hospital program. . Secondary Diagnosis: 296.80 BIPOLAR DISORDER, UNSPECIFIED Passive SI in ED. Psychiatry saw the patient and recommended inpatient psych admission initially; therefore a section 12 was placed and a 1:1 sitter was employed. However, as the [Hospital 228] medical condition stabilized and home psych medications were restarted his mood improved and SI resolved. He denied further suicidality. After discussion by the psych team with the patient, his girlfriend and his outpatient treaters, he was found stable for discharge home with close psych follow up and enrollment in a partial hospital treatment program. . #. HCV, chronic: stable. f/u as o/p. . CODE STATUS: Full . EMERGENCY CONTACT: [First Name8 (NamePattern2) 1060] [Last Name (NamePattern1) 93337] [Telephone/Fax (1) 93336] Medications on Admission: Meds [First Name8 (NamePattern2) ] [Last Name (un) 387] notes: Lantus 100/ml as directed Simvastatin 5mg take 1 tablet (5MG) by ORAL route every day in the evening Suboxone 8mg-2mg place 1 tablet (8MG) by Sublingual route every day allow to dissolve slowly in mouth without chewing or swallowing Humalog 100/ml as directed Accu-chek Aviva test 4-5X/day Insulin Syringe Ultra-fine Ii 31gx5/16" Abilify 30mg once at bedtime Aspirin 81mg once a day Wellbutrin Sr 150mg once a day Accu-chek Comfort Curve as directed Glucagon Emergency Kit 1mg as needed Viagra 100mg take [2-12] -1 tablet as directed Ketostix Reagent as directed Discharge Medications: 1. Lantus 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous at bedtime. 2. Humalog 100 unit/mL Cartridge Sig: Four (4) units Subcutaneous with meals and snack: with sliding scale. Please also take with carbohydrate counting as instructed. 3. Simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Buprenorphine-Naloxone 8-2 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual TID (3 times a day). 5. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 250.13 DIABETES TYPE I, KETOACIDOSIS Secondary Diagnosis: 311 DEPRESSION, NOS Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL Secondary Diagnosis: 070.54 HEPATITIS, C CHRONIC Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: As we discussed, you were admitted for high glucoses related to not taking your insulin. Please continue to take your insulin as prescribed. We also strongly recommend that you refrain from using any alcohol or other drugs. You are being discharged to a partial hospital program for further management of your depression. Followup Instructions: Therapy appointment today at 4pm with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and a 4:30 Suboxone group appointment today. Intake appointment at [Hospital ] Hospital [Telephone/Fax (1) 35932] in JP tomorrow, Wednesday, [3-2] at 9 am. Provider: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5004] [Last Name (NamePattern1) ], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2191-3-21] 4:00	[ "786.51", "272.4", "276.1", "303.01", "276.52", "V62.84", "584.9", "V15.81", "070.54", "414.01", "305.1", "304.21", "250.13", "V58.67", "296.80", "285.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7930, 7936	4259, 4473	293, 300	8230, 8230	4056, 4236	8720, 9176	3089, 3121		7174, 7907		7957, 7957		6511, 7151			8374, 8697								3136, 3929						3945, 4037														1920, 2298					232, 255										328, 1901			8181, 8209			7976, 8013		8244, 8350							2320, 2770	2786, 3073
44,751	134,218	44863+58762	Discharge summary	report+addendum	Admission Date: [2114-10-23] Discharge Date: [2114-10-24] Date of Birth: [2049-9-12] Sex: M Service: CHIEF COMPLAINT: Left arm weakness. HISTORY OF PRESENT ILLNESS: Patient presented to the emergency room. He is a 65-year-old male with a history of coronary artery disease status post CABG, status post angioplasty, history of chronic obstructive pulmonary disease, history of bladder carcinoma status post resection, with a left internal carotid artery stenosis of 90% and right internal carotid artery stenosis of 70%, and alcoholism who presents with left arm weakness. On the evening prior to admission patient felt that his left hand was weak at about 10 p.m. Because he has a history of carotid stenosis he was concerned and called the emergency department at 1 a.m. He was urged to come, but because he wanted to continue to drink, he did not present to the emergency room until the morning of [2114-10-21]. His last drink was 4 a.m. on [2114-10-21]. He felt less weak. Of interest, the patient presented to [Hospital 770] Hospital 2 weeks prior to admission with abdominal pain. Evaluation was negative and the patient was discharged to home. At the presentation in emergency room patient was noted to be ataxic with left leg weakness. He was very shaky and Ativan was given. He was brought to head CT and afterwards he became somnolent with respiratory depression. Patient now is admitted for continued monitoring for alcohol withdrawal and evaluation for stroke. ALLERGIES: Wellbutrin causes patient to have tremors. MEDICATIONS ON ADMISSION: 1. Albuterol 3 puffs q.2h. p.r.n. 2. Atrovent inhaler p.r.n. 3. Flovent 1 to 2 puffs b.i.d. 4. Neurontin 600 mg in the morning, then 800 mg in the evening and 800 mg at bedtime. 5. Paroxetine 10 mg daily. 6. Avodart 0.5 mg daily. 7. Flomax 0.4 mg daily. 8. Lipitor 20 mg daily. 9. Metoprolol 25 mg daily. 10.Aspirin 81 mg daily. 11.Multivitamin. PAST MEDICAL HISTORY: Coronary artery disease with left main trunk disease of 50% and left anterior descending artery stenosis of 90% status post angioplasty in [2097], followed by coronary artery bypasses in [2106]. History of chronic obstructive disease with severe obstructive pattern with an FVC of 65% predicted and an FEV1 of 32% predicted on inhalers. Alcohol cirrhosis status post TIPS in [2106] with associated history of ascites. Bladder carcinoma status post resection in [2104]. Umbilical hernia repair in [2106]. Tobacco use. History of gallstones. History of depression. HABITS: Patient drinks 12 to 15 drinks per day. He notes that he has been in detoxification about 30 times in the past, the longest length of sobriety was 4 years. He denies any history of seizures or delirium tremors related to his alcohol abuse in the past. He is a current smoker. PHYSICAL EXAMINATION: Vital signs: 98.6, 94, 24, O2 saturation 96% on 6 liters, blood pressure 134/70. General appearance: Somnolent, responsive to sternal rub, thin and weak in appearance. Skin is positive for telangiectasias on the chest. There is a median sternotomy incision which is well healed. His HEENT exam shows extraocular movements intact and pupils equal, round, reactive to light and accommodation. His oropharynx is clear. He has dry mucous membranes with mild glossitis with fissure tongue. He has upper and lower dentures in place. Neck is supple, there are no masses or lymphadenopathy. There is no thyromegaly or carotid bruits. Heart: Regular rate and rhythm with normal S1, S2. Lungs are clear to auscultation bilaterally. Abdominal exam is soft, nondistended, right side ecchymosis extending to the lower left side and extending down to the scrotum. The right upper quadrant is tender to palpation. There is no rebound or guarding. The bowel sounds are hypoactive. There is hepatomegaly 5 cm below the costal margin. Extremities show venous stasis changes with 1+ lower extremity edema bilaterally. Pulse exam shows a palpable DP and PT bilaterally. Neurologic exam is as follows: Mental status is stuporous and arousable with voice and sternal rub. Cranial nerves II-XII are intact. Motor, normal bulk and tone bilaterally. Bilateral tremors. Right upper and lower extremities strength is intact. Left upper extremity with good strength, lower extremity at least antigravity but weaker compared to right extremity. Sensation: Withdraws to pain x4. Coordination: Shaky with finger-to-nose on the left, but might be due to weakness. Ataxia with heel-to-shin on the left. Gait was deferred. HOSPITAL COURSE: Patient was admitted to the medical service. CT of the abdomen was obtained in the emergency room, which showed a right rectus sheath hematoma and no evidence of intraabdominal high density fluid collection. TIPS in place with nodular contour of the liver likely presenting underlying cirrhosis with mild splenomegaly. There is cholelithiasis. There was moderate height loss of L1 vertebral body. The MRI/MRA showed a limited study of the brain demonstrating no evidence of acute infarct. Chest x-ray with no evidence of acute pulmonary process. The head CT was a limited evaluation, particularly with posterior fossa secondary to patient motion. No definite evidence of intracranial hemorrhage. Questionable left posterior density lesion within the mid brain. Characterization was limited secondary to artifact. Patient was continued on current medications at home. He was placed on SEWA scale. Thiamin and folate were added to his medical regimen. His CKs and troponins were negative. His LFTs were normal. White count was 6.5, hematocrit 36.3, platelets 225. Coags were normal. Vascular was consulted on [10-22]. Patient's ultrasound from outside hospital on [10-18] demonstrated right internal carotid artery of 90% and left internal carotid artery of 70%. Patient had previous similar symptoms, but left AMA from the hospital. He has experienced a right amaurosis x6 in the last month with questionable drooling on the right side. No aphasia, no dysarthria. No history of stroke. No residual arm weakness. Recommendations were heparin for goal PTT of 60 to 80. The CTA done on [10-22] showed a high grade focal stenosis at the bifurcation on the right with moderate left internal carotid artery stenosis. Cardiology was consulted for perioperative assessment. Recommendations were to continue his beta blocker, aspirin, and Statin as well as continue the IV heparin. No further cardiac workup at this time since his last stress was negative. Addiction service was consulted, but the patient was not currently interested in any substance abuse treatment. On [2114-10-23] the patient underwent a right carotid endarterectomy under general anesthesia. He was transferred to the PACU in stable condition. Neurologically he was intact. There were no new deficits. He did have systolic hypertension immediately perioperatively and patient was placed on Neo-Synephrine for hemodynamic support. This was continued overnight and was weaned the following day. He did receive 1 unit of packed red blood cells with improvement in his systolic pressure. His systolic pressure improved and he was weaned off nitro and was transferred to the regular nursing floor for continued postoperative care. Remaining hospital course was unremarkable. Patient will be discharged to home stable. Will continue all previous medications. To followup with Dr. [Last Name (STitle) 1391] in 2 weeks' time. He is to call for an appointment at [Telephone/Fax (1) 1393]. He should call the office if the neck wound develops any swelling, bleeding, redness, or drainage. He is to call the office if he develops any new symptoms of stroke. DISCHARGE DIAGNOSES: 1. Carotid disease bilaterally, right greater than left, status post right carotid endarterectomy with Dacron patch, angioplasty. 2. History of alcohol abuse, stable. 3. History of alcoholic cirrhosis status post TIPS. 4. History of coronary artery disease status post angioplasty with coronary artery bypass graft in [2106]. 5. History of chronic obstructive pulmonary disease. 6. History of benign prostatic hypertrophy. 7. History of prostatic carcinoma, resected. 8. History of depression, on medications, stable. 9. History of umbilical hernia repair. 10.History of tobacco use, current. 11.History of gallstones, asymptomatic. 12.Postoperative blood loss anemia, transfused. 13.Postoperative hypertension requiring vasopressor support, treated. [Known firstname ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2114-10-24] 17:22:30 T: [2114-10-25] 08:59:20 Job#: [Job Number 95971] Name: [Known lastname 15232],[Known firstname 77] Unit No: [Numeric Identifier 15233] Admission Date: [2114-10-21] Discharge Date: [2114-10-25] Date of Birth: [2049-9-12] Sex: M Service: SURGERY Allergies: Wellbutrin / Zithromax / Keflex Attending:[Known firstname 231] Addendum: [2114-10-25] d/c to home stable. c/o headache without localizing symptoms rellieved with percoset. Discharge Disposition: Home [Known firstname 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2114-10-25]	[ "305.1", "285.9", "799.02", "433.30", "600.00", "571.2", "291.81", "303.91", "729.89", "433.10", "458.29", "572.2" ]	icd9cm	[ [ [] ] ]	[ "38.12", "94.62", "00.41", "00.44", "99.04" ]	icd9pcs	[ [ [] ] ]	9262, 9413							7737, 9239					1603, 1954	4578, 7716																								2870, 4560											151, 171										200, 1577															1977, 2847
12,518	166,069	50284	Discharge summary	report	Admission Date: [2144-5-11] Discharge Date: [2144-5-18] Date of Birth: [2074-3-25] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 70-year-old woman with known aortic stenosis, who has a three-month history of worsening chest pressure and fatigue with walking more than 20 minutes. She was admitted to [Hospital1 190] on [4-10] for further evaluation. PAST MEDICAL HISTORY: 1. Left lower extremity cellulitis. 2. Hypertension. 3. Hyperlipidemia. 4. Aortic stenosis. 5. Appendectomy. 6. Venous stasis ulcers status post skin graft. PREOPERATIVE MEDICATIONS: 1. Atenolol 100 mg p.o. q.d. 2. Hydrochlorothiazide 25 mg p.o. q.d. 3. Lisinopril 5 mg p.o. q.d. 4. Lipitor 10 mg p.o. q.d. 5. Os-Cal 500 mg p.o. b.i.d. 6. Aspirin 325 mg p.o. q.d. ALLERGIES: No known drug allergies. HOSPITAL COURSE: Patient was taken to the cardiac catheterization laboratory on [4-10], which showed an ejection fraction of 50% ostial 40% RCA lesion, otherwise no significant coronary disease, aortic valve area of 0.45 cm squared with a peak gradient of 65 mmHg. Left ventricular end diastolic pressure of 25. Patient was taken to the operating room by Dr. [Last Name (STitle) 70] on [5-12] and underwent aortic valve replacement with a #21 [Company 1543] Mosaic Porcine valve. Patient was transported to the Intensive Care Unit in stable condition on Neo-Synephrine and propofol infusion. Please see operative note for further details. During the initial postoperative period, the patient was noted to have moderate amount of bleeding from the chest tube as well as labile hemodynamics. Discussion was had with Dr. [Last Name (STitle) 70], and decision was made to take the patient back to the operating room for re-exploration of bleeding. In the operating room, patient continued to have labile hemodynamics. Patient was started on low-dose milrinone with improvement in hemodynamics. In the operating room, it was found the patient had a small bleeding site thought to be due to a sternal wire. This was cauterized. Patient was transported back to the Intensive Care Unit in stable condition. Patient remained intubated on her first postoperative night, continued on milrinone with adequate cardiac index as well as Levophed for blood pressure support. Patient was weaned and extubated early morning postoperative day #1. The milrinone was weaned to off with continued adequate cardiac output and the Levophed was weaned off by postoperative day #2. The patient was noted to have a drop in platelet count and a Heparin antibody was sent, which was subsequently negative. The pulmonary artery catheter was removed. Patient was started on low-dose Lasix and Lopressor. Patient was transferred from the Intensive Care Unit to the regular part of the hospital. Patient began ambulating with Physical Therapy. Patient's chest tubes were removed without incident. On postoperative day #3, patient's pacing wires were removed. By postoperative day #3, the patient completed a level 5 with Physical Therapy, and by postoperative day #6 the patient was cleared for discharge to home. CONDITION ON DISCHARGE: Vital signs stable. Heart: Regular rate and rhythm without rub or murmur. Lungs are clear bilaterally. Incision is clean, dry, and intact. Sternum is stable. Abdomen: Positive bowel sounds, positive bowel movement, grossly benign. LABORATORY DATA: White blood cell count 4.6, hematocrit 27.6, platelet count 171. Sodium 141, potassium 4.2, chloride 102, bicarb 30, BUN 16, creatinine 0.3, glucose 110. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Potassium chloride 20 mEq p.o. b.i.d. x7 days. 3. Lasix 20 mg p.o. b.i.d. x7 days. 4. Colace 100 mg p.o. b.i.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Percocet 1-2 tablets p.o. q.4-6h. prn. 7. Lipitor 10 mg p.o. q.d. DISCHARGE STATUS: The patient is to be discharged to home in stable condition. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Status post aortic valve replacement. 3. Reoperation for bleeding. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [Last Name (STitle) ] in [1-17] weeks. Patient is to followup with Dr. [Last Name (STitle) 70] in [5-21] weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 1541] MEDQUIST36 D: [2144-5-19] 13:19 T: [2144-5-19] 13:26 JOB#: [Job Number 104872]	[ "424.1", "414.01", "998.11", "401.9", "E878.8", "272.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "99.07", "38.91", "38.93", "99.04", "39.61", "99.06", "96.04", "34.03", "89.64", "35.22", "37.23", "88.56", "88.53", "96.71" ]	icd9pcs	[ [ [] ] ]								3974, 4065	3613, 3953					845, 3152																			607, 827																										160, 401													4090, 4560		423, 581		3177, 3590
16,786	194,264	16928	Discharge summary	report	Admission Date: [2122-4-9] Discharge Date: [2122-4-18] Date of Birth: [2082-7-26] Sex: F Service: MEDICINE Allergies: Amoxicillin / Sulfa (Sulfonamides) / Bactrim / Iodine; Iodine Containing / Abciximab Attending:[First Name3 (LF) 443] Chief Complaint: STEMI Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: The patient is a 39F with AML s/p [First Name3 (LF) 3242] complicated by GVHD, h/o CAD s/p DES to LAD and BMS to D1 in [11-16], who awoke from sleep with acute onset of SSCP. She had profuse diaphoresis, mild nausea, some SOB, but no radiation, no V/F/C/cough/syncope. She was treated by EMS with [Month/Day (1) ] and brought to [Hospital1 18]. . In the ED she received 5mg IV Lopressor and 600mg [Hospital1 ]. Inferior ST elevations were noted on EKG. She was taken emergently to the cath lab where severe diffuse narrowing and thrombus was seen in the LCx. Thrombectomy and stenting with BMS were performed, and she was transferred to the CCU for further monitoring. . She has been on coumadin for DVTs but has been very sensitive to her dose. Her last INR was 1.3 last [Last Name (LF) 2974], [First Name3 (LF) ] the patient. . She was also recently treated for presumed C. diff. She initiates antibiotics when she suspects she has C. diff based on the appearance and smell of her diarrhea, and she recently took 2 weeks of Flagyl, last dose [2122-4-1]. Past Medical History: 1. AML: diagnosed [4-14] s/p allo-related SCT [10-14] (sister was donor) Cytoxan/MTX/TBI. 2. CAD s/p STEMI [11-16] with 2VD s/p DES in LAD, POBA D1 with BMS to mid D1. 3. GVHD: skin, gut, left hand digit amps x4, chronic immune suppression cellcept, entocort, prednisone, rituxan. 4. Chronic left upper extremity brachiocephalic DVT, bilateral PEs, and femoral vein DVT. 5. Ankle fracture in left ankle s/p surgical repair [8-17] 6. Asthma 7. Eczema 8. Migraine headaches 9. HTN 10. Type 2 DM - ? steroid induced 11. dyslipidemia Social History: Immigrated from [Country 6257] at young age and lived in MA since. Currently lives with husband and two sons (12yo, 14yo) mother-in-law on [Location (un) 1773]. no alcohol abuse. smoking down to 2-3 cig per day. no illicits Family History: no cad, mother died of cancer, no sudden death Physical Exam: Blood pressure was 160/102 mm Hg while supine. Pulse was 95 beats/min and regular, respiratory rate was 28 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of ~6cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. Anterior and lateral lung exam revealed mild expiratory wheezing at the left lung base. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft, nontender, and mildly distended. The extremities had no pallor, cyanosis, or clubbing. There was [3-15]+ bilateral lower extremity edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue revealed subcutaneous induration from Lovenox injections. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2122-4-9] 08:30AM PT-13.1 PTT-133.9* INR(PT)-1.1 [2122-4-9] 08:30AM cTropnT-0.03* [2122-4-9] 08:30AM CK(CPK)-25* [2122-4-9] 08:30AM GLUCOSE-266* UREA N-14 CREAT-0.4 SODIUM-137 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-28 ANION GAP-15 [2122-4-9] 08:50AM PLT COUNT-573* [2122-4-9] 08:50AM WBC-13.4# RBC-3.24 HGB-10.6* HCT-32.8* MCV-101* MCH-32.7* MCHC-32.3 RDW-17.7* [2122-4-9] 09:45PM HCT-34.9* [2122-4-9] 09:45PM CK-MB-200* MB INDX-11.0* [2122-4-9] 09:45PM CK(CPK)-1811* [2122-4-9] 09:45PM UREA N-13 CREAT-0.4 POTASSIUM-4.3 . IMAGING/STUDIES: [2122-4-9] CARDIAC CATHETERIZATION: 1. Inferior STEMI 2. Large LCx thrombus. 3. Elevated left and right sided filling pressures. 4. Successful stenting of the distal LCX (bare metal). 5. Successful stenting of the proximal LCX (bare metal . [2122-4-9] ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately-to-severely depressed (ejection fraction 30 percent) secondary to dyskinesis of the inferior free wall and posterior wall, and severe hypokinesis of the inferior septum and lateral wall. There is no ventricular septal defect. 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 structurally normal. There is no mitral valve prolapse. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2121-10-20], left ventricular contractile function is significantly worse. . . C. Cath [2122-4-13]: COMMENTS: 1. Coronary angiography of this left dominant system revealed single vessel coronary artery disease. The left main coronary artery demonstrated mild plaquing. The LAD had an ostial 70% before the stent and 40% stenoses in the D1 origin and proximal segments. The LCX had a hazy filling defect with 50% stenosis in the proximal stent and multiple filling defects in the AV groove stent. The RCA was not imaged. 2. Hemodynamic evaluation revealed normal right sided filling pressures (mean RA was 5 mm Hg and RVEDP was 6 mm Hg). Pulmonary artery pressures were normal (PA pressure was 20/10 mm Hg). Left sided filling pressures were low (mean PCW pressure was 3 mm Hg). The patient was subsequently started on pressors and transfused with blood and the left sided filling pressures rose (mean PCW pressure increased to 18 mm Hg). Systemic arterial pressures were normal on pressors (aortic pressure was 130/8 mm Hg). Cardiac output was normal on pressors (CI was 2.9 L/min/m2). 3. Successful thrombectomy and balloon angiplasty of the LCx with a 2.5 balloon and a 3.25 NC balloon in the proximal stent. However hypercoagulable state complicated the procedure with recurrentpatent stent sites in the proximal and distal LCX with a possible cut off of the distal LPL secondary to embolization. (See PTCA comments) 4. Iatrogenic AV fistula at left groin access site secondary to repeated attempts for arterial and venous puncture. 5. Hypotension secondary to possible anaphlactiod reaction to abciximab vs. bleeding at left groin access site. Responded to volume resusciatation with blood and vasopressor agents. 6. Prolonged manual compression at left groin access site (2.5 hrs), followed by Femstop to maintain hemostasis. . . Brief Hospital Course: 39F w/ h/o AML s/p [Month/Day/Year 3242] complicated by GVHD, h/o CAD s/p STEMI and PCI to LAD and D1 in [11-16], presents with STEMI and found to have LCX disease in setting of subtherapeutic INR. Her active issues during this hospitalization include: . ## STEMI/Cardiac Ischemia: Pt's STEMI ([2122-4-9]) felt to be multifactorial in etiology including likely thrombus from subtherapeutic INR, possible contribution of prothrombotic state. She was preloaded with 600 mg [Month/Day/Year ] and s/p two BMS to distal and proximal LCx. She was ultimately started on [Month/Day/Year ], [Month/Day/Year ], Crestor for dyslipidemia, metoprolol, and ACE inhibitor. TTE revealed EF 30% which was significantly depressed from prior Echo reports. There was question whether she would benefit from staged additional stenting; however, ultimately, it was decided at that time that she should have outpatient stress test to aid in decision making. . On day of planned discharge ([2122-4-13]), patient developed sudden substernal chest pain, STEMI in infero-posterior distribution. While waiting for urgent cath, she developed 5 seconds of Vtach and then bradycardia to 20's. She returned to NSR without medication/intervention and was taken down to cath. In cath lab, it was noted that she had in-stent thrombosis in LCx with copious clot which reformed almost immediately after removal. In cath lab, she lost significant blood, transfused 5UPRBCs, transiently on phenylephrine. Abciximab was started in addition to bivalirudin in light of continued clot formation. Post cath, her platelets were noted to be 197 (from 580's before), there was concern for HIT-T (in setting of having been on Lovenox) and she was started on argatroban gtt. This diagnosis was ultimately felt to be unlikely given HIT AB was negative, platelets rebounded rapidly (300's on discharge), and the fact that she has long history of exposure to Lovenox prior to this without incident. . Hematology was consulted to weight in on Pt's predisposition to clot. The concensus amongst hematology consult, Pt's primary oncologist (Dr. [First Name (STitle) 1557], and CCU team was that this was not HITT. Apoliprotein A nl; B2 glycoprotein was pending at time of discharge. It was decided to restart Lovenox, and patient will follow-up with Dr. [First Name (STitle) 1557] in regards to long term anti-coagulation. She was discharged with Lovenox 60 mg SQ [Hospital1 ]. Other cardiac meds on discharge include [Hospital1 ] 75 mg [Hospital1 ] (given tendency to clot), [Hospital1 ] 325, Toprol XL 100 [Hospital1 ], Lisinopril 5 QD, Crestor 40 QD, Lasix 40 QD. . ## Chronic DVTs/PE: Patient has history of poorly controlled INR on coumadin. This was felt to be multifactorial (gut GVHD, poor access and difficult blood draws for INR checks). Patient had been on lovenox as well as coumadin in the past. At this admission, it was felt that she should be anticoagulated with Lovenox and then follow-up with Dr. [First Name (STitle) 1557] as noted above. . ## Hemodynamic instability: In Cath lab developed hypotension, transfused 5UPRBCs, transiently needed phenylephrine. Post-cath, she remained hemodynamically stable, but still required an additional 3U PRBC's over the next 3 days to maintain HCT >28. By discharge, her blood pressures were controlled in SBP 120-140's with Toprol XL 100 [Hospital1 ], Lisinopril 5 QD, and her Hct was 36.8. . ## AV Fistula: After cath on [2122-4-12], U/S with evidence of small left AV fistula. CT scan negative for RP bleed. Repeat U/S 48 hrs later revealed no fistula. . ## h/o AML, GVHD: Stable. She continued cellcept, entocort, prednisone, Lasix. Patient and her husband will follow-up with Dr. [First Name (STitle) 1557] upon discharge for further treatment and will also discuss anticoagulation with Lovenox. . ## leukocytosis: Felt to be [2-13] resolving C. diff versus stress reaction from STEMI. She remained afebrile and hemodynamically stable. Stool negative for C. diff. UCx grew GNR and speciation was E. coli sensitive to ciprofloxacin. She completed a 7 day course. . ## FEN: repleted lytes prn, cardiac/diabetic diet . ## Access: -- R fem line d/c'd -- IR U/S guided placement of double lumen midline -> d/c'd at discharge -- Note: Discussed with Dr. [First Name (STitle) 1557], who would prefer more permanent access; however, radiology feels that in order for port to be placed, she would first need further thrombectomy/procedure to clear brachiocephalics. This issue was deffered for outpatient. . ## PPx: lovenox, PPI . ## Code: full, discussed with patient . ## Communication: husband . For outpatient follow-up: 1) Cards: Pt instructed to call to schedule an appointment to see Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ]. 2) Heme: Pt instructed to f/u with Dr. [First Name (STitle) 1557] regarding heme work-up, further immunosuppressant therapy, and long-term anticoagulation with Lovenox . - B2-glycoprotein Pending at discharge. - Pt should have repeat U/A as outpatient to ensure clearance of UTI Medications on Admission: -- Aspirin 81 mg DAILY -- Metoprolol Tartrate 25mg [Hospital1 ] -- coumadin 0.5mg [Doctor First Name ]/Tu/Th (last dose 3/27) -- Lasix 20mg qam -- Acyclovir 400 mg tid -- Budesonide 3 mg PO tid -- Fluconazole 200 mg Tablet [Hospital1 ] -- Mycophenolate Mofetil 500 mg qid -- Prednisone 5 mg qd -- Lantus 35 Units Subcutaneous qam -- Humulin SS -- Nexium 40 mg Tablet qd -- magnesium oxide 400mg [Hospital1 ] -- folic acid 1mg qd -- calcium carbonate 500mg tid -- Cholecalciferol (Vitamin D3) 400 unit Tablet DAILY -- oxycodone 5mg [Hospital1 ] -- Oxycodone-Acetaminophen 5-325 mg Q4-6H prn -- Ativan 1mg prn Discharge Medications: 1. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO tid (). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:14 syringe Refills:8 5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Insulin Please resume your outpatient insulin regimen. 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:60 Tablet(s) Refills:1 11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:2 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): PLease check with Dr. [First Name (STitle) 1557] regarding long term dose. Disp:90 Tablet(s) Refills:2 18. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). Disp:60 Tablet Sustained Release 24 hr(s) Refills:2 19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 20. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day for 3 weeks. Disp:42 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Primary: 1. ST segment elevation myocardial infarction 2. urinary tract infection 3. cardiac ischemia s/p stent placement 4. Thrombocytopenia 5. Graft versus Host disease 6. Dyslipidemia 7. Hypertension . Secondary: 1. AML 2. GVHD 3. Chronic left upper extremity brachiocephalic DVT, on coumadin with labile INRs 4. h/o recurrent C. diff 5. asthma 6. eczema 7. migraine headaches 8. diabetes - steroid induced Discharge Condition: Stable. Afebrile. Chest pain free. Tolerating PO. Discharge Instructions: You were admitted to the hospital because you had a heart attack. You underwent cardiac catheterization with thrombectomy and stenting. Then, you had another heart attack in the same area of the heart. You may have an underlying predisposition to clot, which is not clearly elucidated at this time. You should follow-up with your hematologist/oncologist, Dr. [First Name (STitle) 1557]. . You should call your doctor or return to the ER if you have any of the following symptoms: fever > 101.4, chest pain, shortness of breath, numbness or tingling, weakness, dizziness, intractable nausea/vomiting or any other concerning symptoms. . Please take all of your medications as prescribed. We have made changes to the dosages to your medications, so please adhere to the new regimen provided at this discharge. . Importantly, you will need to take [First Name (STitle) ] 75 mg twice a day and Lovenox injected blood thinner. . Please follow up with all appointments as instructed. Followup Instructions: Please call to make an appointment with your cardiologist, Dr. [First Name (STitle) ] ([Telephone/Fax (1) 7236], to schedule follow-up regarding your recent heart attacks. . Also, please call Dr. [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 3237] to reschedule to appointments that you missed while you were in the hospital.	[ "995.0", "V49.62", "996.85", "410.71", "996.72", "414.01", "E932.0", "287.5", "V58.61", "401.9", "305.1", "E934.8", "289.81", "V12.51", "599.0", "453.8", "041.4", "205.00", "285.1", "447.0", "272.4", "251.8", "458.29", "E878.0" ]	icd9cm	[ [ [] ] ]	[ "00.40", "36.06", "38.93", "00.66", "88.55", "00.46", "00.17", "37.21", "88.56", "99.20", "99.04", "37.23" ]	icd9pcs	[ [ [] ] ]	15368, 15443	7460, 12588	349, 374	15897, 15949	3942, 7437	16982, 17382	2328, 2376		13266, 15345		15464, 15876		12614, 13243			15973, 16959								2391, 3923																									304, 311										402, 1492															1514, 2062	2078, 2312
77,469	102,373	29629	Discharge summary	report	Admission Date: [2153-10-9] Discharge Date: [2153-10-13] Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 5119] Chief Complaint: [First Name3 (LF) ], hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Initial history and physical is as per the ICU team . Ms. [Known lastname ] is an 84 yo female with DMII, CHF (last EF 30%), presenting to the ED with [Known lastname ]. She was referred to the ED by visiting nurse [First Name (Titles) ] [Last Name (Titles) ] on VS check. Per hx from [Last Name (Titles) 802] who last saw her 2 weeks, states that patient had a cough and has chronic SOB. She is wheelchair bound secondary to generalized muscle weakness. . In the ED her initial vitals were T 103.5 (rectal), BP 113/73, HR 80, RR 16, with transient increase in RR to 30. Her BP then briefly dropped to SBP 70s which returned to >110 with IVFs (1.5L NS). She was satting 93-97% on RA. On CXR, she was found to have a likely RUL infiltrate. Placement of a right IJ line was attempted with the complication of entering the right carotid artery, no hematoma was observed after pressure held. A right EJ was placed as well as a left femoral line. . On interviewing the patient, she has no acute complaints except for L lower leg pain which she states is not new. She denies chest pain, shortness of breath, cough, pain with inspiration, abdominal pain, nausea or vomiting. She states that she otherwise is comfortable. . ROS: Denies HA, Cough, Chest Pain, Vomiting, Abdominal Pain, Chills, Dysuria. No recent trauma. Past Medical History: PVD s/p bypass [2151] DM2 with complications neuropathy HTN cardiomyopathy - systolic CHF with EF 35-40% chronic LE edema hyperlipidemia osteoporosis GERD s/p appy B12 deficiency vertebral disc surgery - hardware in lumbar spine Pacemaker - [Hospital3 9642] in [2149] for intermittent AV block and bradycardia Social History: She lives with her son, who has mental illness. Denies any tobacco, alcohol or IVDU. Her [Last Name (LF) 802], [Name (NI) 1154] [Name (NI) 23531] is a nurse on [Wardname 836] here at [Hospital1 18] and is her HCP. She has a visiting nurse once weekly, but likely needs a home health aid per her [Hospital1 802]. Family History: There is no family history of premature coronary artery disease or sudden death Physical Exam: T=36.9, BP=105/70, RR=15, HR=71 paced, SpO2=100% Gen: Well nourished, NAD HEENT: EOMI. Sclera Anicteric. No scleral edema. Irregular pupil borders, evidence of prior cataract surgery. Minimal exudate on oropharynx. Moist mucus membranes. Upper/Lower dentures in place. Neck: No lymphadenopathy. Palpable carotid upstrokes. Right EJ in place. No hematoma appreciated Cards: Distant heart sounds. RRR. Systolic murmur heard at LLSB. Lungs: Bronchial breath sounds heard at Right apex. Otherwise CTAB. Abd: Soft, nontender, nondistended. Positive bowel sounds. No organomegaly. Ext: 10cm area of superficial ulceration consistent with a tear on medial left shin. Bilateraly 1+ pitting edema up to mid-shins; tender to palpation. Neuro: Hard of hearing with better hearing on Left. Barely able to raise legs off bed. Wiggles toes. Psych: Alert. Knows own name and that of PCP. [Name10 (NameIs) ] to state location, but knows she is in a hospital. Able to describe weather, but was unable to state current month. Pertinent Results: [2153-10-9] 01:00PM WBC-12.4# RBC-3.84 HGB-12.3 HCT-36.0 MCV-94 MCH-32.1* MCHC-34.2 RDW-14.3 [2153-10-9] 01:00PM NEUTS-90.8* LYMPHS-6.6* MONOS-2.1 EOS-0.2 BASOS-0.2 [2153-10-9] 01:00PM PLT COUNT-219 [2153-10-9] 01:00PM GLUCOSE-282* UREA N-27* CREAT-1.3* SODIUM-134 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-16 [2153-10-9] 01:10PM LACTATE-1.6 [2153-10-9] 01:00PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.1 [2153-10-9] 01:00PM CK-MB-3 cTropnT-0.04* proBNP-[Numeric Identifier ]* [2153-10-9] 01:00PM CK(CPK)-297* [2153-10-9] 08:44PM PT-13.2 PTT-25.3 INR(PT)-1.1 [2153-10-9] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2153-10-9] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [2153-10-9] 12:45PM URINE RBC-[2-28]* WBC-[2-28] BACTERIA-MANY YEAST-NONE EPI-0 AP PORTABLE CHEST, [2153-10-9] IMPRESSION: Suggestion of right suprahilar or mediastinal airspace process, likely pneumonia. Repeat radiography recommended after appropriate therapy. EKG: Rate 85bpm. Baseline artifact. Probable sinus rhythm with atrial sensed and ventricular paced rhythm but baseline artifact makes assessment difficult. Since the previous tracing of [2152-9-25] sinus rate is faster and there appears to be atrial sensed and ventricular paced rhythm. Legionella Urinary Antigen (Final [2153-10-10]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 71024] AT 14:25PM ON [2153-10-10] - 4I. PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. URINE CULTURE (Final [2153-10-11]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S Brief Hospital Course: 84 year old female with PMH of DM2, CHF, s/p PPM in [2148], chronic LE edema who presented to the ED after a visiting nurse found her to be febrile. # Legionella Pneumonia/sepsis: Patient had RUL infiltrate on CXR with [Year (4 digits) ] on admission and elevated white count. Due to low blood pressure with SBP in the 80s at times, patient received an arterial line yesterday and levophed, which was subsequently weaned. Urine culture data is positive for Legionella, and patient was given levofloxacin which was started in the ED. Blood cultures were negatvie to date. Pt instructed to complete 14 day course of Levofloxacin as coverage for legionella. . # Enterococcus UTI: Patient's UA in the ED showed many bacteria with few WBC and negative Leuk esterase. Urine culture grew >100k enterococcus. Patient was intitailly on vancomycin in the ICU this was changed to ampacillin and the patient was instructed to complete a 7 day course. An attempt was made to discontinue the patient's foley but she was unable to urinate and had a significant amount of urinary retention. An attempt should be made to remove the patient's foley in a few days after antibiotic course completed. . #Delirium: Patient's mental status seemed to wax and wane at times. Was likely related to acute infection. Electrolytes were stable. Patient did not require any pharmocologic restraint. TSH, free t4, RPR, b12, folate, pending. The patient reportedly has some baseline cognition issues at home and is extremely heard of hearing. Patient seen by geriatrics consult team who agrred with our management and recommended frequent reorientation . #Chronic Systolic CHF: Patient has history of systolic CHF with EF=30% on [2152-9-22]. BNP=[Numeric Identifier ] in ED with unknown baseline. Multiple CXR are inconsistent with a CHF exacerbation. Patient did not complain of shortness of breath. Stirct I/os were monitored. Before discharge the patient was restarted on her beta blocker, ace inhibitor, and lasix. . # Left Leg Ulcer: Chronic issue. Appears superficial without substantial erythema. Wound care with antibiotic ointment, moist barrier w/ sterile gauze. . # DM2: Patient was covered with a regular insulin sliding scale. Glipizide was restarted at discharge. . #Hyperlipidemia: The patient was continued on ezetimibe . # Hypothyroidism: Patient recently prescribed synthroid by Dr. [Last Name (STitle) 713]. Will continue levothyroxinedose of 25 mcg daily. . # PPx: SC heparin, PPI . # Code: Full Code (confirmed with HCP) . # Dispo: PT recommended STR but patient refuses to go. Patient will be discharged hoe with home VNA services. . # Contact: [Name (NI) 1154] [Name (NI) 4587] ([Name (NI) ]) [Telephone/Fax (1) 71025] Medications on Admission: Ezetimibe 10 mg qd Furosemide 120 mg qd Glipizide 2.5 mg qd Vicodin 1 tab qid prn pain Levobunolol 0.25 % Drops - 1 drop in each eye twice a day Lisinopril 2.5 mg Tablet - 1 Tablet(s) by mouth daily Toprol XL 25 mg qd Tylenol 500 mg qd ASA 325 mg qd Vitamin B12 1000 mcg qd Colace 100 mg qd Senna Vitamin D 400u qd Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 4. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Levaquin 750 mg Tablet Sig: One (1) Tablet PO q48h: Continue through [2153-10-22]. 13. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): Continue through [2153-10-17]. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Legionella Pneumonia Enterococcus UTI Discharge Condition: Good Discharge Instructions: -Complete course of levaquin for Legionella pneumonia (take through [10-22]) -Complete course of ampacillin for enterococcus UTI (take through [10-17]) -Take all other medications as prescribed -VNA nursing should attempt to remove you foley on Monday (after receiving antibiotics for UTI) and ensure that you are able to void. -Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. -Adhere to 2 gm sodium diet. -Follow up with your PCP next week [Name9 (PRE) 21421] follow up with podiatry and the heart failure NP as already scheduled. -Return to ED if have worsening shortness of breath, chest pain, [Name9 (PRE) ]/chills or other worrisome signs/symptoms. Followup Instructions: 1. Please call [Telephone/Fax (1) 719] on Monday and arrange follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 713] for next week. 2.Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2153-11-21] 10:30 3. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2153-12-19] 11:00 4. Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 1240]:[Telephone/Fax (1) 62] Date/Time:[2153-12-19] 11:30 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122] Completed by:[2153-10-13]	[ "707.10", "272.4", "482.84", "733.00", "788.20", "357.2", "250.60", "599.0", "244.9", "428.22", "V45.01", "038.8", "530.81", "585.9", "V43.3", "425.4", "293.0", "995.91", "440.20", "440.4", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.91" ]	icd9pcs	[ [ [] ] ]	9817, 9874	5585, 8348	253, 260	9956, 9963	3466, 5562	10706, 11516	2337, 2418		8714, 9794		9895, 9935		8374, 8691			9987, 10683								2433, 3447																									177, 215										288, 1622															1644, 1968	1984, 2321
18,916	115,893	28956+57619	Discharge summary	report+addendum	Admission Date: [2200-6-16] Discharge Date: [2200-7-1] Date of Birth: [2160-7-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1781] Chief Complaint: multi trauma Major Surgical or Invasive Procedure: 1. Lower extremity angiography via the right common femoral arterial approach. 2 The left superficial femoral artery to posterior tibialis bypass with reversed right greater saphenous vein, 4 compartment fasciotomy of left lower extremity. 3. PROCEDURES: a. Closed reduction knee dislocation. b. Closed reduction proximal tibial plateau fracture. c. Application of multiplanar external fixator. d. ORIF left tibial plateau and External fixator History of Present Illness: 39 yo Male +ETOH fell down stairs with left tibial plateau fracture, posterior knee dislocation with cold left foot Past Medical History: PAST PSYCHIATRIC HISTORY: Denies PAST MEDICAL HISTORY: Denies Social History: SUBSTANCE ABUSE HISTORY: - Uses [12-27] bags per day of heroin - Consumes 12-18 beers daily - Occasional Benzos (1-2 times per week) - Multiple detox admits in past - History of withdrawal from heroin and EtOH (denies history of seizures) - Longest period of sobriety 8 months - Smokes 1ppd tobacco Family History: non contributary Pertinent Results: [2200-6-29] BLOOD WBC-7.2 RBC-2.79* Hgb-8.5* Hct-24.5* MCV-88 MCH-30.6 MCHC-34.8 RDW-14.7 Plt Ct-570* [2200-6-29] BLOOD Plt Ct-570* [2200-6-29] BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-140 K-4.2 Cl-103 HCO3-29 AnGap-12 [2200-6-29] BLOOD Calcium-8.6 Phos-4.4 Mg-2.2 Brief Hospital Course: Pt admitted on [6-16] PROCEDURES: Left lower extremity angiography via the right common femoral arterial approach. PROCEDURES: 1. Closed reduction knee dislocation. 2. Closed reduction proximal tibial plateau fracture. 3. Application of multiplanar external fixator PROCEDURE: The left superficial femoral artery to posterior tibialis bypass with reversed right greater saphenous vein, 4 compartment fasciotomy of left lower extremity. Pt tolerated all the procedures well Psyche consulted for Agitation and question of opiate withdrawal, there recommendations were. RECOMMENDATIONS: Monitor for alcohol and benzodiazepine withdrawal with CIWA Ativan 2mg IV q2hrs PRN CIWA > 10 Bentyl, Robaxin and NSAIDs PRN GI discomfort, cramping and pain associated with opiate withdrawal For acute agitation, offer Haldol 5mg IV QID:PRN in lieu of Ativan (as this will cloud withdrawal vs. intoxication picture) Monitor EKG while using neuroleptics (can cause QTc prolongation) MVI/Thiamine/Folate IV Pt had post operative normal course / VAC dressing on fasciotomy site changed every third day [6-23] Pt transferred to orthopedics for closure of fasciotomy site / and closed reduction of fracture. [Date range (1) 12535] On Ortho service. patient stable. VSS. On Methadone 10mg [Hospital1 ] without symptoms od withdrawal. Receiving physical therapy ([Hospital1 19489] on Left), pin care and wound VAC to medial fasciotomy left thigh. Left bypass graft palpable. [2200-6-26]: Ortho performed ORIF left tibial plateau and External fixator [Date range (1) 24392] Continues on Ortho service. Stable from Vascular standpoint. Medial Fasciotomy VAC changed every 3 days. Graft is palpable. VSS. Tmax 100.9. Pain controlled with Dilaudid. Patient working with physical therapy and is extremely motivated for rehab. Patient transferred back to Vascular Service [2200-6-30]: Patient stable. Left graft pulse palpable and PT. Plan for transfer to rehab. Continue pin care and DSD to Ortho surgical sites. Medial fasciotomy site: Wound VAC. Methadone decreased to 5mg [Hospital1 ]. [2200-7-1]: To rehab. Will continue Metadone taper.Will continue 5mg [Hospital1 ] [7-1] and stop on [7-2]. Continue PT, [Name (NI) 19489] [Name (NI) ]. Medial wound VAC to get reapplied on arrival to rehab. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): pt on tapered dose...will continue 5mg [Hospital1 ] [7-1] and stop on [7-2] . 8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Posterior knee dislocation of the left side with decreased ABI. Schatzker 5 tibial plateau fx. Compartment syndrome Ischemic left foot. Left popliteal dissection. POSTOPERATIVE DIAGNOSIS: Left knee dislocation. Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ??????You should get up out of bed every day and gradually increase your activity each day ??????Increase your activities as you can tolerate- do not do too much right away! Continue [Hospital1 19489] status [Hospital1 ] 2. It is normal to have swelling of the leg you were operated on: ??????Elevate your leg above the level of your heart (use [12-27] 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: ??????You should gradually increase your activity ??????Increase your activities as you can tolerate- do not do too much right away! ??????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 100.5F for 24 hours ??????Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Physical Therapy: Activity: Out of bed to chair Left lower extremity: Non weight bearing Followup Instructions: Call dr [Last Name (STitle) ] office and schedule an appointment for 2 weeks after DC. She can be reached at [Telephone/Fax (1) 2395] Call Ortho: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1005] ([Telephone/Fax (1) 2007] or Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. ([Telephone/Fax (1) 2007] in 2 weeks Completed by:[2200-7-1] Name: [Known lastname 11877],[Known firstname ] Unit No: [Numeric Identifier 11878] Admission Date: [2200-6-16] Discharge Date: [2200-7-1] Date of Birth: [2160-7-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3717] Addendum: Patient to rehab not home with services Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 2314] [First Name11 (Name Pattern1) 798] [Last Name (NamePattern4) 3683] MD [MD Number(1) 3724] Completed by:[2200-7-1]	[ "836.52", "904.41", "443.9", "303.01", "E880.9", "305.1", "823.00", "305.50" ]	icd9cm	[ [ [] ] ]	[ "79.36", "99.04", "39.29", "79.06", "88.48", "79.76", "78.16", "93.59", "83.14" ]	icd9pcs	[ [ [] ] ]	8419, 8658	1686, 4034	326, 776	5571, 5580	1381, 1663	7561, 8396	1344, 1362		4089, 5213		5337, 5550		4060, 4066			5604, 7041	7067, 7445								7463, 7538																								274, 288										804, 921															999, 1007	1023, 1328
26,149	103,320	22132	Discharge summary	report	Admission Date: [2157-6-21] Discharge Date: [2157-6-27] Date of Birth: [2120-1-29] Sex: M Service: [Doctor First Name 147] Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 1556] Chief Complaint: MVC, abdominal pain Major Surgical or Invasive Procedure: 1)Splenectomy 2)Small Bowel resection History of Present Illness: 37 y/[Initials (NamePattern4) ] [Last Name (NamePattern4) 4746] with MVC rollover, presented next day with severe abdominal pain to OSH. CT scan showed splenic laceration with free fluid/blood in the peritoneum. Pt was transfered to [Hospital1 18] for difinitive care. Past Medical History: None Social History: +tobacco/occasional EtoH/ denies IVDA Family History: noncontributory Physical Exam: upon arrival: Vitals: 100.8 117/67 106 20 100%sat General: GCS 15, obviously in pain HEENT: PERRL 3-2mm BL, c-collar in place, no hemotypanum, no oropharyngeal trauma, trachea midline Chest: RRR no m/r, CTABL with equal BS Back: left flank echymosis/abrasion, right hip/flank abrasion/echymosis Ab: distended, firm, diffusely tender, pos guarding Pelvis: no instability Ext: left shoulder abrasion, right anterior leg abrasion, 2+DPP BL Rectal : good tone, heme neg Pertinent Results: [2157-6-21] 10:24PM TYPE-ART PO2-170* PCO2-49* PH-7.28* TOTAL CO2-24 BASE XS--3 [2157-6-21] 10:24PM LACTATE-1.0 [2157-6-21] 10:24PM O2 SAT-98 [2157-6-21] 10:13PM GLUCOSE-140* UREA N-15 CREAT-1.0 SODIUM-139 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-21* ANION GAP-12 [2157-6-21] 10:13PM CALCIUM-7.6* PHOSPHATE-3.9 MAGNESIUM-1.5* [2157-6-21] 10:13PM WBC-19.3# RBC-4.77# HGB-14.1# HCT-41.2# MCV-86 MCH-29.5 MCHC-34.1 RDW-14.0 [2157-6-21] 10:13PM FIBRINOGE-226 Brief Hospital Course: Pt taken to OR where a distal illeum mesenteric injury was appreciated in addition to the splenic laceration. Pt's spleen and small bowel was resected and he was transfered to the SICU intubated and in stable condition. After an uncomplicated SICU stay pt was extubated and transfered to the floors in good condition. On the floors pt did well aside from some episodes of hypoxia secondary to a small infiltrate/area of atelectasis in the RLL which resolved with Lasix and aggressive pulmonary toilet. Pt was slowly advanced to a regular diet, his pain was well controlled throughout. On the day of discharge pt was educated about the risks of being asplenic and the neccesary precautions he would need to take. He also recieved H. flu, meningicoccal, and pneumovax vaccines. He also recieved a prescription for a MedAlert bracelet. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain for 3 days. Disp:36 Tablet(s)* Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 3 days. Disp:6 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1)Splenic Laceration 2)Asplenia 3)Motorvehicle Crash 4)small bowel ischemia Discharge Condition: Good Discharge Instructions: 1)You had your spleen removed and as a result you are at risk for serious infections especially in these initial days after your operation. It is therefore imperative that you call a physician immediately if you have a fever or chills. 2)We have given you 3 vaccines which correspond to 3 types of bacteria that you are at particular risk for serious infection with now that you no longer have a spleen. These vaccines do not last forever. You must follow up with your PCP as soon as possible to discuss a plan for further vaccination in the future. 3)You should also wear a MedAlert bracelet for which you have been given a prescription so that other physicians are aware that you do not have a spleen in the case that you cannot tell them that yourself. 4)You have had abdominal surgery and your small bowel removed. As such you should call a physician immediately if you have any persistent abdominal pain, diarrhea, constipation, nausea, vomiting, chest pain, or shortness of breath, or any other concerning symptoms. 5)You will need to follow up in the Trauma clinic next week as instructed below. Followup Instructions: 1)Call your PCP as soon as possible to discuss your hospital course, health status, need for future follow up, vaccinations. 2)Follow up at the Trauma clinic one week from tomorrow. Call [Telephone/Fax (1) 56358] as soon as possible to make an appointment. You will have your staples removed at that time.	[ "997.3", "865.02", "868.03", "518.0", "863.29", "E812.9", "E878.6" ]	icd9cm	[ [ [] ] ]	[ "45.62", "41.5", "96.04", "99.04", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	2992, 2998	1813, 2654	321, 361	3118, 3124	1294, 1790	4279, 4593	772, 789		2709, 2969		3019, 3097		2680, 2686			3148, 4256								804, 1275																									262, 283										389, 673															695, 701	717, 756
64,122	159,540	39467+58296	Discharge summary	report+addendum	Admission Date: [2130-3-14] Discharge Date: [2130-3-30] Date of Birth: [2071-12-20] Sex: M Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 2777] Chief Complaint: AAA Major Surgical or Invasive Procedure: PROCEDURES: 1. Endovascular stent graft repair of abdominal aortic aneurysm. 2. Stent graft treatment of bilateral common iliac stenosis. 3. Right common femoral and superficial femoral artery endarterectomy and vein patch angioplasty. History of Present Illness: This is a 58-year-old gentleman with severe, disabling, bilateral claudication who had arteriography demonstrating severe right common iliac stenosis and moderate left common iliac stenosis. He had also had an abdominal aortic aneurysm measuring 4.5 cm. Because of the aneurysm and the severe calcific stenosis of the right common iliac, it was not felt to be safe to treat with percutaneous angioplasty and stenting without dealing with the aneurysm. He also had a focal occlusion of the SFA at its origin on the right. He also has severe disease of left popliteal with evidence of distal embolization. Plan for initial treatment was endovascular stent graft repair of the abdominal aortic aneurysm which would allow substantial dilation of the common iliac stenoses after covering them with stent grafts, and simultaneously performing the endarterectomy and patch angioplasty of the proximal SFA occlusion. Because of the complexity of the procedure, two attendings were scrubbed. Past Medical History: hyperlipidemia, hypertension, abdominal aortic aneurysm, hepatitis C. Social History: He drinks occasional alcohol. He works as a machinist. He is on his feet all day. His stated height and weight are 5'[29]" and 170 lbs. Family History: n/c Physical Exam: On exam, he is in no distress. Pulse is 86. Respirations are 17. Blood pressure is 165/108. HEENT exam is unremarkable. Neck is supple with no cervical bruit. Chest is clear. Heart is regular. Abdomen is soft and nontender. Aorta is mildly prominent. It does not feel like he has a large aneurysm. Extremities are notable for the absence of cyanosis, ulceration, or edema. He has palpable femoral pulses, which feel normal. I cannot palpate popliteal or pedal pulses bilaterally. Pertinent Results: [2130-3-15] 04:16AM BLOOD WBC-7.2 RBC-3.47* Hgb-12.4* Hct-34.4* MCV-99* MCH-35.7* MCHC-35.9* RDW-13.0 Plt Ct-102* [2130-3-15] 04:16AM BLOOD Glucose-221* UreaN-14 Creat-0.9 Na-136 K-3.7 Cl-102 HCO3-29 AnGap-9 [2130-3-14] 12:30PM BLOOD Glucose-167* Lactate-2.3* Na-138 K-4.1 Cl-104 Brief Hospital Course: [Known lastname ],[Known firstname ] was admitted on [3-14] with AAA. Agreed to have an elective surgery. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that she would undergo: PROCEDURES: 1. Endovascular stent graft repair of abdominal aortic aneurysm. 2. Stent graft treatment of bilateral common iliac stenosis. 3. Right common femoral and superficial femoral artery endarterectomy and vein patch angioplasty. Prepped, and brought down to the endo suite room for surgery. Intra-operatively, was closely monitored and remained hemodynamically stable. Tolerated the procedure well without any difficulty or complications. Post-operatively, transferred to the PACU for further stabilization and monitoring. Was then transferred to the VICU for further recovery. While in the VICU, received monitored care. When stable was delined. Diet was advanced. When stabilized from the acute setting of post operative care, was then transferred to floor status. On the floor, remained hemodynamically stable with pain controlled. Continues to make steady progress without any incidents. Discharged home in stable condition. Received preoperative hydration. On DC the creatinine is stable. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn for pain. Disp:30 Tablet(s) Refills:0 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: AAA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? If instructed, take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [3-2] 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 It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [5-3] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2130-4-20] 1:15. Please call for location Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2130-4-20] 1:45 Completed by:[2130-3-15] Name: [Known lastname 13810],[Known firstname 77] Unit No: [Numeric Identifier 13811] Admission Date: [2130-3-14] Discharge Date: [2130-3-30] Date of Birth: [2071-12-20] Sex: M Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 726] Addendum: The patient was admitted on [3-14] to indergo endovascular stent graft repair of his abdominal aortic aneurysm. Intra-operatively, was closely monitored and remained hemodynamically stable. He tolerated the procedure well and was taken to the post-anesthesia care unit in stable conditions. Was then transferred to the VICU for further recovery. While in the VICU, received monitored care. When stable was delined. Diet was advanced and tolerated. On the floor, remained hemodynamically stable with pain controlled. Mr [Known lastname ] was deemed ready for discharge on [2130-3-14] when he developed crampy abdominal pain which progressed and culminated with bloody bowel movement. The General Surgery service was consulted and the patient was taken to the operating room for an exploratory laparosopy converted to opern procedure for mesenteric ischemia. The reader is referred to the operative note for details. The patient was transferred to the SICU postoperatively for further monitoring. When stable, he was transferred to the VICU. Chief Complaint: AAA Major Surgical or Invasive Procedure: PROCEDURES: 1. Endovascular stent graft repair of abdominal aortic aneurysm. 2. Stent graft treatment of bilateral common iliac stenosis. 3. Right common femoral and superficial femoral artery endarterectomy and vein patch angioplasty. [2130-3-15] Diagnostic laparoscopy converted to open. ERCP with 5 cm biliary stent placed, no sphincterotomy History of Present Illness: The patient is young male with an abdominal aortic aneurysm and severe claudication both from iliac stenoses bilaterally as well as profound right femoral artery occlusive disease. The plan was to treat his aneurysm with a stent graft and allow aggressive treatment of his iliac artery stenoses within the stent graft portion and then a separate right femoral endarterectomy be performed. Co-surgeon in the same specialty required due to the complexity of the anatomy, the significant amount of thrombus in the infrarenal neck, as well as the severe iliac disease as well as the small iliac arteries making risk of perforation a problem. Past Medical History: hyperlipidemia, hypertension, abdominal aortic aneurysm, hepatitis C. Family History: n/c Physical Exam: On exam, he is in no distress. Pulse is 86. Respirations are 17. Blood pressure is 140/80. HEENT exam is unremarkable. Neck is supple with no cervical bruit. Chest is clear. Heart is regular. Abdomen is soft and nontender, pos bs Extremities are notable for the absence of cyanosis, ulceration, or edema. He has palpable femoral pulse His Ex Lap Incision is c/d/i, Staples removed Pertinent Results: [2130-3-30] 07:25AM BLOOD WBC-6.0 RBC-3.67* Hgb-12.7* Hct-37.5* MCV-102* MCH-34.6* MCHC-33.8 RDW-13.2 Plt Ct-332 [2130-3-27] 06:26AM BLOOD PT-13.8* PTT-29.0 INR(PT)-1.2* [2130-3-30] 07:25AM BLOOD Glucose-152* UreaN-20 Creat-1.0 Na-133 K-5.4* Cl-96 HCO3-28 AnGap-14 [2130-3-24] 05:44PM BLOOD ALT-62* AST-89* CK(CPK)-59 AlkPhos-195* Amylase-384* TotBili-2.3* DirBili-2.1* IndBili-0.2 [2130-3-25] 05:16AM BLOOD ALT-79* AST-111* AlkPhos-239* Amylase-430* TotBili-4.2* [2130-3-26] 06:11AM BLOOD ALT-93* AST-129* AlkPhos-240* Amylase-306* TotBili-2.6* DirBili-2.0* IndBili-0.6 [2130-3-27] 06:26AM BLOOD ALT-108* AST-125* AlkPhos-227* TotBili-1.4 DirBili-1.0* IndBili-0.4 [2130-3-28] 05:11AM BLOOD ALT-106* AST-117* AlkPhos-201* Amylase-2952* TotBili-1.2 DirBili-0.7* IndBili-0.5 [2130-3-29] 04:44AM BLOOD ALT-159* AST-203* AlkPhos-179* Amylase-582* TotBili-1.0 [2130-3-30] 07:25AM BLOOD ALT-227* AST-277* AlkPhos-186* Amylase-316* TotBili-1.2 [2130-3-26] 06:11AM BLOOD Lipase-280* [2130-3-28] 05:11AM BLOOD Lipase-2937* [2130-3-29] 04:44AM BLOOD Lipase-733* [2130-3-30] 07:25AM BLOOD Lipase-255* [2130-3-28] 05:11AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.8 Mg-2.2 [2130-3-22] 05:25AM BLOOD calTIBC-186* Ferritn-1718* TRF-143* [2130-3-15] 5:44 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [2130-3-18]): No MRSA isolated. US: Partial thrombosis of the right basilic vein, picc removed CTA POST EVAR: IMPRESSION: 1. Mild bowel wall thickening of the sigmoid colon without surrounding stranding or other signs of inflammation. Air in the contiguous bladder is likely secondary to catheterization (please correlate). 2. Aneurysmal dilatation of the right common femoral artery with surrounding soft tissue swelling is likely related to recent instrumentation. 3. Mild cholelithiasis with a small amount of peri-cholecystic fluid is non-specific. If clinically indicated, an ultrasound can be obtained for further evaluation. LIVER / GALL BLADDER US: IMPRESSION: 1. Diffusely echogenic liver consistent with fatty infiltration. More advanced liver disease including hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study. No focal liver lesions identified. 2. Gallbladder adenomyomatosis and non-obstructing intraluminal gallstones. 3. Splenomegaly. 4. 4 mm non-obstructing right renal calculus. The clinical team additionally reports a history of elevated amylase and lipase. While no gallstones are identified in the common bile duct on this examination, the distal duct is poorly visualized and if choledocholithiasis becomes of clinical concern, for example if there is rising bilirubin, then MRCP could be obtained for further assessment. ABDOMINAL FILM: Large and small bowel are both distended with air and fluid, with fluid levels indicating stasis. The degree of small bowel distention is greater than large, for example left upper quadrant loops measures 38 mm across, but there is still sufficient gas in the colon to make a paralytic ileus the more likely diagnosis than small-bowel obstruction. I see minimal subdiaphragmatic free air, presumably residual of recent surgery, and no intramural emphysema in the gut. There is moderate bowel wall edema in the small bowel, best seen on the supine views in the centrally collected small bowel loops. There may also be ascites. If symptoms persist, I would strongly recommend CT scanning of the abdomen for detection of subtle findings of ischemia. Dr [Last Name (STitle) 13812] was paged at the time of approval. CXR/PA: FINDINGS: In comparison with study of [3-21], the nasogastric tube has been removed and the right subclavian PICC line remains. The heart is normal in size and there is no evidence of vascular congestion, pleural effusion, or acute pneumonia. Brief Hospital Course: [3-14] The patient was admitted on [3-14] to undergo endovascular stent graft repair of his abdominal aortic aneurysm. Intra-operatively, was closely monitored and remained hemodynamically stable. He tolerated the procedure well and was taken to the post-anesthesia care unit in stable conditions. Was then transferred to the VICU for further recovery. While in the VICU, received monitored care. When stable was delined. Diet was advanced and tolerated. [2130-3-15] On the floor, remained hemodynamically stable with pain controlled. Mr [Known lastname ] was deemed ready for discharge on [2130-3-15] when he developed crampy abdominal pain which progressed and culminated with bloody bowel movement. The General Surgery service was consulted and the patient was taken to the operating room for an exploratory laparoscopy converted to open procedure for mesenteric ischemia. The reader is referred to the operative note for details. The patient was transferred to the SICU postoperatively for further monitoring. Pt was put on Cipro, Flagyl and Vanco. Pt kept NPO. NG tube placed for post op ileus. [3-16] - [3-19] general Surgery Following NPO, IV fluids, Vancomycin DC'ed. Awaiting return of bowel Function. on [3-18] pt with BS's. NGT removed on [3-18], replaced [3-19] for N/V increase distention and bilious emesis, pt continued with flatulence. [3-20] - [3-21] As above, pt started to have increase in WBC, Had swelling in LLE - got LENI, negative for DVT. PPI started for bowel protection TPN started for nutrition purposes. KUB revealed air in colon, Bowel regime started. Pt allowed to ambulate and get OOB [3-22] NGT clamp trial initiated, pt with flatulence with pos BS, kept NPO. WBC normalizes. Has increase in LFT. Pt has history of Hep C. NGT removed. [3-23] Continued with TPN, Nutrition now following. LFT increased more, now amylase / Lipase elevated. RUQ US ordered. NPO, IV fluids. [3-24] Clears initiated. LFT still increased, Amylase / Lipase elevated. RUQ US: 1. Diffusely echogenic liver consistent with fatty infiltration. More advanced liver disease including hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study. No focal liver lesions identified. 2. Gallbladder adenomyomatosis and non-obstructing intraluminal gallstones. 3. Splenomegaly. 4. 4 mm non-obstructing right renal calculus. [3-25] TPN, Pt with mild epigastric RUQ pain. Pt had CTA of ABD and pelvis, GI consulted for possible ERCP. Made NPO for possible ERCP. CT scan. See results below. IMPRESSION: 1. Mild bowel wall thickening of the sigmoid colon without surrounding stranding or other signs of inflammation. Air in the contiguous bladder is likely secondary to catheterization (please correlate). 2. Aneurysmal dilatation of the right common femoral artery with surrounding soft tissue swelling is likely related to recent instrumentation. 3. Mild cholelithiasis with a small amount of peri-cholecystic fluid is non-specific. If clinically indicated, an ultrasound can be obtained for further evaluation. Pt hypertensive, HTCZ and Lisinopril added for BP control. Epigastric pain resolved. GI agrees to ERCP the following Monday LFT, Amylase and Lipase trend [3-26] - [3-27] Diet ADAT. Pt remains pain free, TPN continued. Awaiting ERCP. LFT, Amylase and Lipase trend [3-28] - [3-29] Pt gets ERCP: no filling defect has mild diffuse dilatation. 5 cm biliary stent placed, no sphincterotomy, no stones Tolerating diet. Pt remains pain free, TPN discontinued. LFT, Amylase and Lipase trend. [3-30] Ready for DC. LFT, amylase and lipase remain elevated. Pt abdominal exam remains pain free. Tolerating Diet Follow - up Has lab slip will follow LFT and lipase and amylase with PCP. [Name10 (NameIs) ] appointment with PCP in one week. Foxed DC summary to PCP [Name Initial (PRE) 4682]. Pt will call Dr[Name (NI) 4425] office, has number. Will arrange interval lap CC CY. Has follow up with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] in 2 weeks, will repeat CTA at that time. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn for pain. Disp:30 Tablet(s) Refills:0 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pletal 100 mg Tablet Sig: One (1) Tablet PO twice a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. pantoprazole 40 mg Tablet, [Last Name (NamePattern4) 13813] Release (E.C.) Sig: One (1) Tablet, [Last Name (NamePattern4) 13813] Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, [Last Name (NamePattern4) 13813] Release (E.C.)(s) Refills:2 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 11. Outpatient Lab Work Chem 10, LFT, Amylase and Lipase Name: [Last Name (LF) ],[First Name3 (LF) ] C Fax: [Telephone/Fax (1) 13814] Discharge Disposition: Home with Service Discharge Diagnosis: AAA Pancreatitis Elevated LFT's - Advance liver desease Post operative illeus Adenomyomatosis and non-obstructing intraluminal gallstones Hyperkalemia HTN post operative period Mesenteric Ischemia increase cholesterol hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? If instructed, take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [3-2] 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 It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [5-3] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Discharge Instructions for Acute Pancreatitis You have been diagnosed with acute pancreatitis. Your pancreas is inflamed or swollen. The pancreas is an organ that produces chemicals and hormones that help you digest food and use sugar for energy. Gallstones are one of the most common causes of this condition. These hard stones form in the gallbladder, which shares a passage with the pancreas into the small intestine. If gallstones block this passage, fluid can??????t escape the pancreas. The fluid backs up and causes inflammation. Immediate Home Care Find someone to drive you to appointments. Acute pancreatitis is a serious condition, and you should never drive if you are experiencing symptoms. Stop drinking if your illness was caused by [Date Range 13815]. Ask your doctor [First Name (Titles) 13816] [Last Name (Titles) 13815] abuse programs and support groups such as Alcoholics Anonymous. Ask your doctor [First Name (Titles) 13816] [Last Name (Titles) 13817] medications that can help you stop drinking. Take your medications exactly as directed. [Male First Name (un) ]??????t skip doses. Eat a low-fat diet. Ask your doctor [First Name (Titles) ] [Last Name (Titles) 13818] and other diet information. Learn to take your own pulse. Keep a record of your results. Ask your doctor [First Name (Titles) 13819] [Last Name (Titles) 13820] mean that you need medical attention. Ongoing Care Tell your doctor about any medications you are taking. Some can cause acute pancreatitis. Tell your doctor if you lose weight without dieting. Watch for symptoms that indicate your pancreatitis has returned. These symptoms include abdominal pain, nausea and vomiting, and fever. Keep all follow-up appointments with your doctor. [First Name (Titles) 13813] [Last Name (Titles) 13821]s are common with this illness You also have a lab slip, you should get you labs drawn in two to three days and have then faxed to your PCP. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 491] Date/Time:[2130-4-20] 1:15. Please call for location Provider: [First Name11 (Name Pattern1) 168] [Last Name (NamePattern4) 730], MD Phone:[Telephone/Fax (1) 11071] Date/Time:[2130-4-20] 1:45 Please call Dr.[Name (NI) 4425] office for a follow up appointment in [3-31] weeks to discuss your liver function and possible need for removal of your gall bladder. His office can be reached at ([Telephone/Fax (1) 4464]. Appointment [1039-4-11] Name: [Last Name (LF) ],[First Name3 (LF) ] C Location: [Location (un) 5229]-[Location (un) ] Address: 111 [Doctor Last Name 13822] DR, [Location (un) ],[Numeric Identifier 13823] Phone: [Telephone/Fax (1) 11122] Fax: [Telephone/Fax (1) 13814] [First Name11 (Name Pattern1) 168] [Last Name (NamePattern4) 730] MD [MD Number(2) 731] Completed by:[2130-3-30]	[ "796.2", "560.1", "440.8", "272.0", "276.7", "441.4", "E878.8", "997.4", "577.1", "571.8", "070.70", "557.9", "440.21", "574.20", "E849.7" ]	icd9cm	[ [ [] ] ]	[ "39.50", "39.90", "54.12", "99.15", "00.44", "39.71", "00.41", "00.40", "51.87", "88.47", "00.46", "38.18", "54.21" ]	icd9pcs	[ [ [] ] ]	19978, 19997	14610, 18761	9144, 9511	20271, 20271	10715, 14587	25009, 25998	10291, 10296		18784, 19955		20018, 20250					20422, 22439	22465, 24986							10311, 10696																									9101, 9106										9539, 10181								20286, 20398							10203, 10275	1650, 1795
13,354	164,241	17886	Discharge summary	report	Admission Date: [2111-9-4] Discharge Date: [2111-9-12] Date of Birth: [2066-8-25] Sex: F Service: HEPATOBILIARY SURGERY SERVICE BRIEF CLINICAL HISTORY: The patient is a 45-year-old woman who is status post segment 8 resection in [3-14] for symptomatic focal nodular hyperplasia and persistent pain. The mass was not completely resected because it would have required a complete right hepatic lobectomy which was not believed to be indicated because of the benign nature of her disease. 80% of the mass was excised with a small amount of residual tumor being left posteriorly. She subsequently underwent embolization of a pseudoaneurysm following an episode of hemorrhage at the resection site. Following this, she continued to have significant right upper quadrant pain and; after much discussion, it was felt that this was appropriate for repeat resection of segment 8. Preoperative workup included colonoscopy initially on [2111-5-4], which was incomplete and a full colonoscopy on [2111-6-2], which was normal to the cecum. EGD was normal. The residual focus of FNH in the liver was unchanged but felt to be the cause of her persistent pain. This has been incapacitating to her and she strongly desires definitive right hepatic lobectomy. PRIOR MEDICAL HISTORY: Nephrolithiasis. TMG. Premenstrual syndrome. Status post laparoscopic cholecystectomy. Depression. Tubal ligation. Aforementioned segment 8 resection. Aforementioned focal nodular hyperplasia. SURGERY: Laparoscopic cholecystectomy. Dilation and curettage. Tubal ligation. MEDICATIONS: 1. [Doctor First Name ] 180 mg p.o. q.d. 2. Paxil 37.5 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Lithium 450 p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: At the time of her surgery, the patient's vital signs were height of 5 feet 4 inches, weight of 164 pounds, temperature 99.1 degrees, pulse 64, blood pressure 108/42, respirations 18, saturating 99 percent on room air. In general, the patient is described as a well-developed Caucasian female, in no acute distress. HEENT examination shows that there is no scleral icterus. Pupils are equal and reactive bilaterally. Cranial nerves II through XII are grossly intact. There is no evidence of any anterior or posterior lymph node adenopathy. There is no thyromegaly. Lungs are clear to auscultation bilaterally. Cardiac examination demonstrates normal S1 and S2. No S3, murmurs, rubs, or gallops. Abdomen exam is benign. There is a well-healed midline xiphoid subcostal skin incision with no evidence of any incisional hernias. On superficial and deep palpation, there is no evidence of any hepatomegaly, splenomegaly, masses, or any focal tenderness. Peripheral examination shows good circulation. No evidence of any edema. BRIEF CLINICAL COURSE: On [2111-9-4], the patient was taken to the operating room, and underwent a right hepatic lobectomy at segments 5 through 8. Procedure was performed without complication. Anesthesia was general endotracheal. She received approximately 10 liters of IV fluid, 4 units of FFP, 1 unit of platelets, and 1 of cryo and had about 2 liters of fluid return to her via the Cell [Doctor Last Name 10105], 3 liters of crystalloid. Decision was made to keep the patient intubated and transferred electively into the intensive care unit. She was maintained on a propofol drip. Demerol was continued. There was a right IJ in place with Cordis and two JPs were kept in place. LABORATORY DATA: Postoperative laboratory studies included a hematocrit of 36.3, an INR of 1.2, and a lactate of 6.1. The patient was started on Unasyn for empiric coverage. HOSPITAL COURSE: The first postoperative night, the patient had episodes of transiently low blood pressure into the 80s, although hematocrit was stable at 28.9. One unit of packed red blood cells was given. Epidural likewise was adjusted to try and improve blood pressure. On the morning of postoperative day one, the patient was extubated without complication. Later the following day, the patient was moved out of the intensive care unit to the normal surgical floor. Throughout her urine output was excellent and JP drains continued to drain between 50 and 400 cc of fluid. By postoperative day four, the patient was continuing to do well. Epidural was discontinued. Lasix was started to accelerate diuresis. On postoperative day five, diet was advanced to regular. Analgesia was switched to oral medications. By [2111-9-11] or postoperative day seven, the patient was continuing to do excellent and able to get out of bed and ambulate. Her lateral JP drain was removed. The following day, on postoperative day eight or [2111-9-12], after a final evaluation by Dr. [Last Name (STitle) ] and the rest of the surgical team, she was deemed to be an appropriate candidate for discharge and arrangements were made for her to be discharged to home. FOLLOWUP: The patient has good access to nursing help through her affiliation of a nursing [Hospital1 ] and declined VNA for her JP care. She was, however, trained on how to empty her JPs and will do so at home. She will follow up with Dr. [Last Name (STitle) ] in one-to-two weeks following discharge. DISCHARGE MEDICATIONS: 1. Vicodin 1 to 2 tablets p.o. q.[3-17] h. 2. Colace 100 mg p.o. b.i.d. 3. Cephalexin 500 mg p.o. q.6 h. x4 days. DIAGNOSES: The patient is status post right hepatic lobectomy. Nephrolithiasis. TMG. Premenstrual syndrome. Status post laparoscopic cholecystectomy. Depression. Tubal ligation. Aforementioned a segment 8 resection. Aforementioned focal nodular hyperplasia. DISPOSITION: The patient is discharged to home in the care of her family. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD, Ph.D. [Numeric Identifier 8353] Dictated By:[Last Name (NamePattern1) 49587] MEDQUIST36 D: [2111-9-21] 14:36:37 T: [2111-9-22] 00:15:21 Job#: [Job Number 49588]	[ "568.0", "530.81", "458.29", "285.1", "751.69", "571.8" ]	icd9cm	[ [ [] ] ]	[ "54.59", "99.07", "99.05", "88.74", "50.3", "99.04", "99.00" ]	icd9pcs	[ [ [] ] ]									5303, 6051					3710, 5280
11,691	138,190	30346	Discharge summary	report	Admission Date: [2187-3-10] Discharge Date: [2187-3-22] Date of Birth: [2165-11-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5755] Chief Complaint: Transferred to ICU for necrotic pancreatitis Major Surgical or Invasive Procedure: IR placement of NJ tube, IR guided PICC line placement History of Present Illness: 21 year old health female presented to [Hospital1 1562] Hosptial two days prior to presentation with four days of epigastric and back pain. The pain was approximately [2-10] when it first began and she thought it was gas. She took alka seltzer but the pain did not improve. She subsequently developed bilious non-bloody emesis. The pain progressed to [9-12] in severity such that it hurt to sit up straight. She described it as someone stabbing her in the back radiating to her stomach. Upon admission her amylase >6000 and lipase >3000 with Tbili of 4.2. Her WBC was 13K with 11% bands. On HD 2 her amylase decreased to 1700 and her lipase decreased to 1877. Her Tbili decreased to 1.4. HIDA scan did not show obsturction of the cystic duct or CBD. US of the abdomen demonstrated cholelithiasis but no obstructing stones and no finding c/w cholelicytitis. On hospital day 3 she became tachy to the 120s and her WBC increased to 22.1K The patient's CT scan demonstrated central pancreatic necrosis without any pseudocysts and ? narrowing of portal ciruclation. She also became tachycardic to the 120s. Of note she has been on imipenum on since admission for her low grade fevers since admission with a Tmax of 100.5 in the last 24 hours prior to transfer. She was initially transferred to the floor, however after surgery reviewed her OSH CT scan they felt that should just remain in the ICU for aggresive fluids. . ROS On review of systems, the pt. denied recent chills. No night sweats or recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: S/p C-section on [2186-11-29] Social History: The patient lives at home with her husband and baby. [Name (NI) 4906] in the [Company 16410] transferred to [Hospital3 ] just 2 weeks ago. The baby was [Name2 (NI) ] in [Name (NI) 72191] [Name (NI) 72192]. No history of tobacco of IVDA. Drinks socially. No spider bites Family History: Mother is alive with htn. Father is alive with htn. No family history of GI disease Physical Exam: T 98.6 HR 120 BP 124/86 RR 16 O2Sat 100% RA Gen: NAD Heent: PERRL, EOMI, MM dry, OP clear Lungs: CTA B/L Cardiac: Tachy, S1/S2 no murmurs Abd: obese, soft, + tenderness at RUQ, no rebound or gaurding Ext: no edema Neuro: AAOx3 Pertinent Results: hcg < 5 . ECG: Sinus tach at 117 bpm. No acute changes. . urine and blood cx: negative . Studies/Imaging: . RUQ US [2187-3-10] (OSH) Targted US of portal vein, splenic vein and smv normal flow within the portal vein, splenic vein and smv. Normal waveforms. No evidence of thrombosis involving the distal splenic vein distal smv or portal vein. . CT: [2187-3-10] (OSH) The pancreas appears abnormally swollen with pronounced surrounding inflammatory soft tissue stranding with fluid density around the region compatable with acute pancreatitis. There is heterogenous lack of enhancement/hypodensity involving the body of the pancreas suspicious for pancreatic necrosis. Splenic vein, superior MV and SMA appear patent. The distal splenic vein at the portal confluence appear quite narrowed. Some thickening of the duodenum along this region is noted. There is a prominent fluid density in the LUQ beneath the pancreas. Prominent fluid density is seen in the RUQ along the liver. Impression: 1. Acute pancreastitis with associated pleural effusions, ascites, abnormal bowel wall thickening involving the duodenum is identified. Heterogenous hypodensity involving a significant segment of the body of the pancreas significant for pancreatic necrosis. Narrowing of the distal smv and distal splenic vein near the portal confluence conceivably related to the pronounced inflammation throughout this region. Partial thrombosis would look similar. 2. Layering gall bladder sludge within the gallbladder. . HIDA Scan: [2187-3-9] (OSH) Prompt uptake of radiotracer throughout the liver on the initial images of the exam. Radiotracer demonstrated within the small bowel within 30 minutes. GB faintly visualized after 60 mins with the addition of morphine. Patinent brought back for imaging 60 mins later revealing an elongated gallbladder definitely filled with radiotracer. Impression: Radiotracer extending into the small bowel as well as into the gallbladder as descrbied. No evidence of acute cholecystitis or biliary obstruction. . [2187-3-8] (OSH) Flat and upright KUB demonstrates no free air. Unremarkable [Last Name (un) ] pattern. . [2187-3-8] (OSH): Chest PA/L: no acute process. . ABDOMINAL ULTRASOUND, LIMITED [2187-3-11]: Examination was limited by patient body habitus. The imaged portion of the liver is normal in echotexture. There is no intrahepatic biliary ductal dilatation. The right hepatic duct is seen and measures 3 mm, which is normal. The portal vein is patent and demonstrates normal hepatopetal flow. Multiple echogenic foci are seen in the region of the gallbladder which demonstrate posterior shadowing and are most consistent with gallstones. The pancreas demonstrates diffuse hypoechogenicity consistent with pancreatitis. IMPRESSION: Limited examination secondary to patient body habitus. No evidence for intrahepatic biliary ductal dilatation. The common bile duct is not seen secondary to shadowing artifact most likely from gallstones. Diffuse edema throughout the pancrease consistent with the patient's history of pancreatitis. . CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST [2187-3-12]: Limited examination of the lung bases displays small bilateral pleural effusions (left greater than right) with areas of compression atelectasis within the lung bases. No large pericardial effusion is identified. The liver, gallbladder, spleen, stomach, adrenal glands, and kidneys appear grossly unremarkable. There is a large amount of stranding and fluid surrounding the entire pancreas with areas of nonenhancement involving the pancreatic body and neck, affecting around one- third of the pancreatic parenchyma. Fluid is noted to track along the left anterior pararenal space and into the left flank as well as into the pelvic cavity. Examination of the vasculature is grossly limited due to poor scan quality due to patient body habitus, however, the arterial and venous systems appear grossly patent. A small area of narrowing is noted within the distal splenic vein near its anastomotic site into the portal confluence, which likely relates to surrounding pancreatic edema (521B:28). No dominant pseudocyst is identified. Intra-abdominal bowel appears grossly unremarkable. There is a single slightly prominent loop of small bowel within the left upper quadrant, which may represent an early sentinel ileus. No free air is noted within the abdominal cavity. No pathologically enlarged pelvic or retroperitoneal lymph nodes are identified. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: As noted above, there is a small amount of simple fluid within the pelvic cavity adjacent to the uterus with the remaining portion of the intrapelvic bowel, foley containing urinary bladder, and adnexa appearing unremarkable. No pathologically enlarged inguinal or pelvic lymphadenopathy is identified. BONE WINDOWS: No suspicious blastic or lytic lesions are identified. IMPRESSION: 1. Diffuse pancreatitis with necrosis within pancreatic neck/body involving approximately one- third of the pancreatic parenchyma. Evaluation for vascular complications is limited due to poor resolution caused by patient body habitus. 2. Small, left greater then right, pleural effusions. . CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST [2187-3-18]: There has been interval resolution of the pleural effusions bilaterally with no residual at the lung bases. There is no evidence of pericardial effusion. The liver, gallbladder, spleen, adrenal glands, and kidneys are unremarkable. There appears to be more well-defined borders surrounding the pancreas with better demarcation of fat and soft tissue. Within the neck and body of the pancreas, at the site of previously seen non-enhancement, there are more well-circumscribed areas of low attenuation again consistent with necrotic pancreas. There is no evidence of vascular abnormalities within the splenic artery. The portal vein is not well demonstrated given the phase of the current study. There is no free fluid or free air. The small and large bowel are within normal limits. There is a nasojejunal tube in place. CT PELVIS WITH IV CONTRAST: The urinary bladder, rectum, sigmoid colon are within normal limits. There is no pelvic lymphadenopathy. BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. Interval improved evolution of necrotizing pancreatitis with demonstration of more defined borders between the pancreas and adjacent surrounding fatty tissue suggesting a decrease in the inflammatory change. Again noted and more well demarcated on today's study are foci of hypodensities within the neck and body of the pancreas suggestive of necrosis. 2. Interval resolution of pleural effusions. Brief Hospital Course: A/P: 21 y/o female with who presents from OSH with pancreatitis found to be necrotizing pancreatitis per CT scan, transferred to ICU for aggresive fluids . ## Necrotizing Pancreatitis: CT showed 30% necrosis. Patient was kept NPO initially but was started on jejunal feeds once her ileus resolved. She completed a 10 day course of imipenem given the presence of necrosis. An IR NJ tube was placed for feeding. After several days of bowel rest, her pain resolved and her diet was advanced. She was tolerating a low fat diet without pain at the time of discharge and enteral feeds were discontinued. Follow-up CT due to complaints of some new back pain (which resolved with relief of her constipation) showed interval improvement of the pancreatitis, still without evidence of a pseudocyst. Surgery and GI followed throughout her admission. Plan for outpatient follow-up for cholecystectomy given cholelithiasis. Patient had a slight bump in her LFTs with refeeding prior to discharge, but was without pain. GI will follow-up LFTs outpatient and see her in clinical follow-up to monitor. . ## Leukocytosis: Most likely from pancreatitis and pain. Cultures negative. S/p C-section but CT without pelvic abscess and no evidence of pseudocyst. Patient had no signs/symptoms of infection. She completed a course of imipenem and subsequently remained afebrile off all antibiotics. She will call her PCP if she develops any symptoms, including fever. . ## PPx: PPI, sc heparin . ## Dispo: patient discharged to home without services Medications on Admission: Medications on Transfer from floor: Diluadid prn Imipenem Protonix . Medications at home: OCPs- [Female First Name (un) ] . Medications on transfer from OSH: Dilaudid PCA - discontinued for transfer Phenergan 12.5 mg IV q 6 hours prn Zofran 4 mg IV q 4 hours prn Protonix 40 mg IV qd Imipenem 500 mg IV q 6 hours IVF at 250 cc/hr with 20 meq/L Discharge Medications: 1. Outpatient Lab Work Please draw CBC, sodium, potassium, chloride, bicarbonate, BUN, creatinine, ALT, AST, alk phos, t bili, and lipase on [2187-3-26] and fax results to [Telephone/Fax (1) 63792] Discharge Disposition: Home Discharge Diagnosis: necrotizing pancreatitis Discharge Condition: good: no pain, afebrile, tolerating low fat diet Discharge Instructions: Please call your primary care doctor or go to the emergency room if you experience worsening abdominal pain, diarrhea, vomiting, temperature > 101, or other concerning symptoms. Please follow the low fat diet. Please have labs drawn on Monday to check your liver enzymes. Please attend all follow-up, as instructed below. You can take tylenol for your pain. For pain not relieved with tylenol, please call your primary care doctor or go to the emergency room. Followup Instructions: Please follow-up with the surgeon, Dr. [Last Name (STitle) ], on Tuesday, [4-17], [2186] at 10:00 AM to prepare for your elective cholecystectomy. Location: [Hospital1 18], [Hospital Ward Name ], [Hospital Unit Name 72193]. Phone: ([Telephone/Fax (1) 22750] Please follow-up with the gastroenterologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3708], on Tuesday, [2187-4-17] at 2:30. Location: [Hospital1 18], [Hospital Ward Name ], [Hospital Unit Name ], [Location (un) 453]. Phone: [Telephone/Fax (1) 463] Please call to schedule follow-up with your primary care doctor ([First Name4 (NamePattern1) 11556] [Last Name (NamePattern1) ]) within 1-2 weeks to follow-up this hospital admission. Phone: ([Telephone/Fax (1) 72194]	[ "560.1", "574.20", "401.9", "263.9", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	11923, 11929	9753, 11294	361, 419	11998, 12049	2963, 9730	12562, 13390	2616, 2701		11692, 11900		11950, 11977		11320, 11389			12073, 12539				11410, 11669				2716, 2944																									277, 323										447, 2232															2254, 2289	2305, 2600
10,799	169,904	49997	Discharge summary	report	Admission Date: [2156-6-6] Discharge Date: [2156-6-12] Date of Birth: [2088-11-7] Sex: M Service: CME SERVICE: Coronary Care Unit HISTORY OF PRESENT ILLNESS: This is a 67 year old male patient with a history of coronary artery disease, hypertension, congestive heart failure with an ejection fraction over 55 percent, status post coronary artery bypass graft in [2148], aortic valve replacement in [2148] status post redo in [2151], status post DDD pacemaker placement in [2151], who presents with chest pain. The patient reports developing substernal chest pain with minimal movement since [Month (only) 116] when he received a blood transfusion for hemoptysis. Over the four days prior to admission, the patient reports progressive substernal chest pressure occurring at rest on the day of admission. The pain is described as nine out of ten and radiating to his left arm, associated with shortness of breath and nausea. The patient denies lightheadedness or palpitations. He reports stable lower extremity edema. The patient's wife brought the patient to the Emergency Department where the patient was noted to be hypertensive and ruling in for an myocardial infarction. In addition, the patient's hematocrit was noted to be 24.0 with guaiac positive stool. Per the patient's wife, the patient had been taken off aspirin and Plavix since [2156-5-31] secondary to "black stool". In addition, the patient's Coumadin dose had been decreased by his primary care physician [Name Initial (PRE) 767] 3 mg to 2 mg q h.s. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2148], left internal mammary artery to left anterior descending, saphenous vein graft to PDA. 1. Status post aortic valve replacement in [2148]; status post redo in [2151] for shortness of breath and increasing aortic insufficiency. 1. Status post DDD pacemaker placement in [2151]. 1. Hypertension. 1. Congestive heart failure with an echocardiogram significant for an ejection fraction of over 55 percent, trace aortic insufficiency, dilated left atrium and moderate pulmonary hypertension. 1. History of atrial flutter. 1. Chronic obstructive pulmonary disease. 1. Hypercalcemia status post parathyroidectomy in [2132]. 1. Lupus. 1. Chronic thrombocytopenia. 1. Hypothyroidism. MEDICATIONS: 1. Levoxyl 0.125 mg p.o. q day. 2. Lasix 40 mg p.o. q day. 3. Coreg 12.5 mg twice a day. 4. Imdur 30 mg q day. 5. Coumadin 2 mg q h.s. 6. Vitamin B6, 15 mg q day. 7. Folic acid. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient previously worked as a truck driver but is now on disability. He is married with three children. He reports over 30 pack year smoking history but quit smoking. The patient reports minimal alcohol use. PHYSICAL EXAMINATION: Temperature 98.2 F.; blood pressure 158/70; heart rate 84; 100 percent on a 100 percent non rebreather. In general, laying in bed in mild distress. HEENT: Normocephalic, atraumatic. Extraocular movements intact. Oropharynx is clear with moist mucous membranes. Heart is regular rate and rhythm, normal S1 and a mechanical S2. Neck with no evidence of jugular venous distention. Lungs are clear to auscultation with mild crackles in the right lung base. Abdomen with normoactive bowel sounds, obese, nontender, nondistended. Rectal: Guaiac positive stool per the Emergency Department. Extremities with no clubbing or cyanosis. There is trace edema in the bilateral lower extremities and skin findings consistent with chronic venous stasis. The patient has two plus dorsalis pedis pulses, two plus femorals and no evidence of carotid bruits. LABORATORY DATA: White blood cell count 6.9. hematocrit 24.4, platelets 200, INR 1.6. Sodium 139, potassium 4.4, chloride 103, bicarbonate 21, BUN 38, creatinine 1.6, glucose 128. CK 351, MB 8, troponin 0.16. EKG paced at a rate of 96 beats per minute. HOSPITAL COURSE: 1. NON-ST ELEVATION MYOCARDIAL INFARCTION: As noted previously, the patient was admitted with a several day history of progressive substernal chest pressure in a setting of anemia and gastrointestinal bleed. The patient was noted to have elevation in his cardiac enzymes to a peak CK of 351, a troponin of 0.35. The etiology of the elevation in the patient's cardiac enzymes is considered likely secondary to demand ischemia versus a non-ST elevation myocardial infarction in the setting of a low hematocrit. Given the patient's gastrointestinal bleed, he was evaluated by the Gastroenterology Consult Service. The patient was continued on aspirin, Plavix, Lipitor and a beta blocker for his coronary artery disease. The patient's outpatient cardiologist, Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ], was contact[Name (NI) ] regarding workup for the patient's coronary artery disease. The decision was made to discharge the patient and have him followup with an outpatient stress test three to four weeks after discharge. 1. CONGESTIVE HEART FAILURE: The patient was evaluated with an echocardiogram which revealed an ejection fraction of 30 percent, marked dilation of the left atrium, moderate dilation of the right atrium, and a moderately dilated left ventricular cavity with moderate to severe global left ventricular hypokinesis. The patient exhibited no signs or symptoms consistent with congestive heart failure and was continued on his beta blocker and ACE inhibitor which were titrated as tolerated by the patient's heart rate and blood pressure. 1. RHYTHM: The patient was monitored on telemetry throughout his hospitalization and on the day of discharge, had a 13 beat run of nonsustained ventricular tachycardia. The patient was asymptomatic with stable vital signs during this episode. This nonsustained ventricular tachycardia is concerning for ischemia related changes. It is anticipated that the patient will have a stress test as an outpatient with a possible revascularization procedure. The patient will also be followed by the Electrophysiology Cardiologist as an outpatient. 1. GASTROINTESTINAL BLEED: As noted previously, the patient was admitted with a history of melena and noted to have a hematocrit of 24.0 on admission. The patient was transfused five units of packed red blood cells throughout his admission. The Gastroenterology consultation service was contact[Name (NI) ] and performed an EGD on [2156-6-7], which was significant for likely nonsteroidal, anti-inflammatory associated gastropathy and duodenopathy with the most likely source of bleeding being the patient's gastritis. The patient was continued on a proton pump inhibitor twice a day throughout his hospitalization. His melenotic stool resolved throughout the remainder of his hospitalization and he remained hemodynamically stable with a stable hematocrit. 1. STATUS POST AORTIC VALVE REPLACEMENT: Once the patient was hemodynamically stable, Coumadin was restarted with a heparin drip. The patient's INR was subtherapeutic until the day of discharge when it was 3.3. It is anticipated that the patient will have his INR checked two days after discharge, the results of which will be sent to Dr. [Last Name (STitle) ] in Cardiology who will titrate his Coumadin dose as necessary until the patient establishes care with a new primary care physician as an outpatient. 1. HYPOTHYROIDISM: The patient was continued on his outpatient dose of Levoxyl. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to home with close followup. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed secondary to gastritis. 2. Non-ST elevation myocardial infarction. 3. Status post aortic valve replacement / DDD pacemaker. 4. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q day. 2. Aspirin 325 mg p.o. q day. 3. Lisinopril 40 mg p.o. q day. 4. Metoprolol XL 100 mg p.o. q day. 5. Coumadin 3 mg p.o. q day. 6. Gemfibrozil 600 mg p.o. twice a day. 7. Atorvastatin 40 mg p.o. q day. 8. Pantoprazole 40 mg p.o. q 12 hours. 9. Pyridoxine 50 mg p.o. q day. 10. Levothyroxine 125 micrograms p.o. q day. 11. Senna 8.6 mg p.o. twice a day. 12. Colace 100 mg p.o. twice a day. 13. Folic acid 1 mg p.o. q day. FOLLOW UP: 1. The patient will be followed by Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] in Cardiology. Dr.[Name (NI) 9388] office will contact the patient for a followup appointment within four weeks after discharge. It is anticipated that the patient will also have a stress test and be followed by the Electrophysiology cardiologist. 2. The patient is encouraged to contact his new primary care physician to schedule [Name Initial (PRE) ] followup appointment within one week after discharge. The patient will have an INR drawn on [Last Name (LF) 766], [2156-6-14], the results of which will be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], who will adjust his Coumadin dose as necessary. The patient's volume status should be addressed at his next appointment and his Lasix restarted as necessary, although it is notable that the patient had no signs or symptoms of congestive heart failure throughout this admission. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 4958] Dictated By:[Last Name (NamePattern1) 12325] MEDQUIST36 D: [2156-6-12] 14:55:46 T: [2156-6-12] 19:44:13 Job#: [Job Number 104393]	[ "416.8", "535.41", "496", "V45.01", "428.0", "427.32", "410.71", "710.0", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.13" ]	icd9pcs	[ [ [] ] ]								7812, 7983	8006, 8476					4033, 7684																		8487, 9797						2906, 4016																					194, 1590															1612, 2649	2666, 2883	7709, 7791
63,598	140,012	32373	Discharge summary	report	Admission Date: [2155-4-1] Discharge Date: [2155-4-4] Date of Birth: [2084-7-15] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 2736] Chief Complaint: chest pain Major Surgical or Invasive Procedure: PCI w/thrombectomy and BMS placement in RCA History of Present Illness: The patient is a 70 yo woman with h/o metastatic pancreatic cancer s/p chemotherapy (cycle 13 of gemcitabine) yesterday who presented to the ED with chest pain. She reportedly woke up at midnight with sharp sub-sternal 10/10 chest pain. She took Maalox without improvement. She had associated SOB and diaphoresis, but no nausea or abdominal pain. She called EMS at 5 am. EMS noted STE in II, III and AVF with reciprocal changes in I and aVL. . In the ED, her initial VS were T 98.3, P 96, BP:125/68, R 19, and O2 100% on RA. She was given ASA 325 mg and Morphine. Her EKG showed STE in II, III, and avF, with deep depressions in I and aVL and v2, so she was started on Plavix and a heparin gtt and was sent to the cardiac cath lab. In the cath lab, patient was found to have a proximally occluded RCA and underwent thrombectomy and BMS placement. LAD and LCX were normal. During the case, patient was hypotensive, suggestive of a RV infarct, and receieved atropine and dopamine for SBP 60/40. She was noted to have a fair sized hematoma around her sheath. She was stabilized and transferred to the CCU with SBPs in the 90s. Right heart catheterization showed RA 19, PCWP 16, CDI 2.15. . On the floor, patient feels well and denies any complaints. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for some DOE, which she attributes to chemotherapy, and the absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Locally advanced pancreatic cancer with radiologic evidence of metastases to lungs, on gemcitabine chemotherapy GERD s/p appendectomy s/p hysterectomy . Social History: Lives alone [Location (un) 6409], finds support in her son [Name (NI) 75611] who lives in [Name (NI) 27663]. He is HCP. - Tobacco: 30 pack years, quit approx 1 month ago - ETOH: denies . Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Physical Exam: On admission to CCU: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Dry mucus membranes. NECK: Supple with JVP of 14 cm, hepatojugular reflex to ear CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Well healed subcostal scar. No HSM or tenderness. Active BS EXTREMITIES: Bleeding around R femoral cath site; non tender; No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ Radial pulses; dopplerable DPs . Pertinent Results: - LABORATORY DATA: WBC: 6.8 Hgb/Hct: 10.3/30.8 (Hct 31.7 on outpatient labs, yesterday)Plt 366 . 142 \| 113 \| 21 / 175 4.8 \| 18 \|1.2 \ . PT/PTT/INR: 15.3/150/1.3 . CK: 250 CKMB: ** TnT: 0.24 . ABG: pH7.33 pCO239 pO2119 HCO321 BaseXS-4 - ECG: [2155-4-1] 5:44 AM: Sinus at 94 bpm. STE in II, III, avF with depressions in I, aVL and V2. . - ECHO ([2153-8-30]): The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-24]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Normal global and regional biventricular systolic function. Mild to moderate mitral regurgitation and mild aortic regurgitation. . . Brief Hospital Course: 70 year old woman with h/o metatstatic pancreatic cancer who presented from home with chest pain consistent with inferior STEMI, now status post thrombectomy and BMS to proximal RCA. . # STEMI: Pt now s/p inferior/RV STEMI with some hemodynamic instability in cath lab, s/p thrombectomy and BMS to RCA. She had some hemodynamic instability in the cath lab requiring dopamine and atropine, these were attributed to a vagal reperfusion response in the setting of stenting her RCA occlusion. She remained asymptomatic and hemodynamically stable throughout the remainder of her hospitalization. After PCI, she was continued on integrellin for 18 hours. She was started on plavix and aspirin which she was instructed to continue taking daily until otherwise told by Dr. [Last Name (STitle) ]. She was started on atorvastatin 80 mg which was switched to crestor 40 mg daily on discharge- lipid panel was checked (see below). Patient had a post-MI echocardiogram which showed an EF of 40-45% and regional biventricular systolic dysfunction, c/w inferior and RV myocardial infarction. She will follow up with Dr. [Last Name (STitle) ]. . # PUMP: S/P inferior/RV STEMI with hemodynamic instability in cath lab requiring atropine and dopamine. This transient response was attributed to reperfusion of her RCA after stenting. She remained hemodynamically stable for the remainder of her hospitalization. She was gradually started on metoprolol and lisinopril and had an echocardiogram (see above). . # RHYTHM: Was monitored on telemetry and remained in sinus rhythm. . # HTN - Remained normotensive after her RV MI without any periods of hypotension. Her home HCTZ was discontinued and she was started on lisinopril 5 mg daily. Her metoprolol was downtitrated to 37.5 mg daily in the extended release formulation. . # HLD - Lipid panel showed HDL of 19 and LDL of 85. Was discharged on crestor 40 mg daily. . # Pancreatic cancer- Metastatic with presumed involvement of lungs on CT chest. Is now s/p cycle 13 of gemcitabine on [3-31] with discussion of different regimens in the future pending response. Patient's oncologist Dr. [Last Name (STitle) ] was notified of her admission and follow up was scheduled for [4-14]. She did not become neutropenic during this admission. . # [Last Name (un) ]: Creatinine of 1.2 on admission, up from baseline of 0.8-1.0. Likely secondary to pre-renal etiology in setting recent MI as it improved to baseline with fluid rehydration. . # Anemia: Patient presented with chronic anemia at baseline around 31, likely secondary to cancer and chemotherapy. Her hematocrit trended down to 22.3 during this admission- CT abdomen/pelvis was done and negative for a RP bleed. There no significant groin hematoma. She received 2 units pRBCS and hematocrit remained stable thereafter. . CODE: Patient's DNR/DNI was suspended for this admission given her recent MI. She was discharged w/ DNR/DNI reactivated. Medications on Admission: HOME MEDICATIONS (per [3-31] oncology clinic note, confirmed w/ pt): HCTZ 25 mg daily Creon 6000-[Numeric Identifier 24587]-[Numeric Identifier ] unit capsules, 2 caps TID Metoprolol tartrate 37.5 mg PO BID Prochlorperazine 10 Q6H PRN nausea Acetaminophen PRN Ibuprofen PRN Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop tkaing unless Dr. [Last Name (STitle) *] tells you to. Disp:30 Tablet(s)* Refills:2 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 6. Creon 6,000-19,000 -30,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO three times a day. 7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:45 Tablet Extended Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: ST elevation myocardial infarction Hypertension Hyperlipidemia Pancreatic Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking part in your care. You had a heart attack and needed a cardiac catheterization which showed a blockage in your right coronary artery. This blockage was opened and a stent was placed to keep it open and prevent another heart attack. You will need to take a full dose aspirin every day and Plavix to prevent the stent from clotting off and causing another heart attack. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking aspirin and plavix unless Dr. [Last Name (STitle) ] tells you to. Your blood count was low after the procedure and we did a CT scan to check for bleeding, it did not show any bleeding. You recieved 2 units of blood for your anemia. Please follow the activity restrictions that the physical therapist discussed with you. . We made the following changes to your medicines: 1. Start taking Aspirin 325 mg and Plavix 75 mg daily for at least one month 2. Change the Metoprolol to 37.5 mg daily and change to a once a day formulation 3. Start taking Crestor again to lower your cholesterol 4. STOP taking Ibuprofen, take tylenol instead for any pain 5. STOP taking hydrochlorothiazide for now 6. Start taking Lisinopril 5mg to help your heart recover from the heart attack. Followup Instructions: . Cardiology: [2155-4-29] 09:30a Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] [Hospital Ward Name ] clinical CENTER, [Location (un) ] CC7 CARDIOLOGY (SB) . Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2155-4-14] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], 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: MONDAY [2155-4-14] at 11:00 AM With: [First Name8 (NamePattern2) 25] [Last Name (NamePattern1) ], 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: MONDAY [2155-4-14] at 12:00 PM With: [First Name4 (NamePattern1) 4617] [Last Name (NamePattern1) 4618], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Hospital ] MEDICAL ASSOCIATES, PC Address: [2155], [Location ],[Numeric Identifier 16354] Phone: [Telephone/Fax (1) 30837] Appointment: Wednesday [4-9] at 12:30PM Completed by:[2155-4-5]	[ "V15.82", "410.41", "285.9", "414.01", "157.8", "401.9", "584.9", "530.81", "197.0", "272.4" ]	icd9cm	[ [ [] ] ]	[ "00.45", "00.66", "00.40", "36.06", "37.23", "88.56", "99.20" ]	icd9pcs	[ [ [] ] ]	9565, 9622	5116, 8063	281, 326	9747, 9747	3738, 5093	11175, 12635	2747, 2866		8399, 9542		9643, 9726		8089, 8376			9898, 11152								2881, 3719			2246, 2324																						231, 243										354, 2135								9762, 9874		2355, 2512					2158, 2226	2529, 2730
83,079	180,509	5977	Discharge summary	report	Admission Date: [2121-10-4] Discharge Date: [2121-10-13] Date of Birth: [2052-4-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8263] Chief Complaint: left abdominal pain Major Surgical or Invasive Procedure: L hepatic artery embolization at bifurcation History of Present Illness: Mr. [Known lastname 1968] is a 69 yo male with HIV, HEP C, and multifocal HCC, who presented to the ED today after experiencing sudden onset of central abd pain upon rising from a leaning position. His pain was sharp and radiating across his central abdomen. He denies previous similar episodes. He denies diarrhea, constipation, chest pain, fevers chills, BRBPR, melena. . In the ED, HR was in the 80s, he was AF, BP was 100-130 systolic. His abd was distended and tender though not peritoneal per report. He had no resp issues per report. 2 large bore IVs were placed. His initial HCT was 38 (BL 42), which fell to 33.9 upon repeat. He had a CT abd/pelvis which showed hemoperitoneum concerning for hemorrhage from a metastasis. Surgery saw him and felt he was a poor candidate. IR was consulted and agreed to do an IR guided chemoembolization. He received .5 to 1L liter of IVF during his ED stay and received dilaudid for pain. . ROS: as per HPI. He also endorsed worsening dyspnea upon awaking in the morning over the last few months. He denies orthopnea. Past Medical History: -HIV, last CD4 197 [6-27], last viral load < 48 [6-27] -Hep C, last viral load 693,000. diagnosed serologically on [2110-12-16]. HCV genotype 1. -HCC Social History: The patient has been smoking one to two packs for the last 50 years and denies EtOH. He denies any recent intravenous drug abuse. He worked in the entertainment industry as a singer/musician. Family History: diabetes Physical Exam: vitals: 96.0 117/67 HR 86 RR17 94%RA gen: comfortable, pleasant, NAD heent: ncat, mmm, eomi, sclera nonicteric neck: no elevated JVP pulm: bibasilar rales, o/w ctab cv: hrrr, no m/r/g abd: distended, TTP periumbilically, + bs, no guarding extr: no c/c/e, 2+ distal pulses neuro: aox4, cn 2-12 intact grossly Pertinent Results: CBC [2121-10-4] WBC-9.2 RBC-3.89* Hgb-12.9* Hct-38.9* MCV-100* MCH-33.2* MCHC-33.2 RDW-14.4 Plt Ct-299 [2121-10-6] WBC-17.8* RBC-2.66* Hgb-9.0* Hct-26.5* MCV-100* MCH-34.0* MCHC-34.1 RDW-14.2 Plt Ct-256 [2121-10-6] 1 Hct-27.3* [2121-10-6] Hct-25.9* [2121-10-8] WBC-11.6* RBC-2.54* Hgb-8.5* Hct-25.2* MCV-99* MCH-33.4* MCHC-33.6 RDW-14.1 Plt Ct-239 [2121-10-9] WBC-8.4 RBC-2.81* Hgb-9.4* Hct-27.9* MCV-99* MCH-33.6* MCHC-33.9 RDW-14.5 Plt Ct-297 [2121-10-13] WBC-7.7 RBC-2.96* Hgb-10.1* Hct-28.9* MCV-98 MCH-34.0* MCHC-34.8 RDW-15.3 Plt Ct-334 Chemistry [2121-10-4] Glucose-113* UreaN-17 Creat-1.0 Na-138 K-4.9 Cl-103 HCO3-24 AnGap-16 [2121-10-10] Glucose-77 UreaN-10 Creat-0.5 Na-140 K-3.5 Cl-108 HCO3-22 AnGap-14 [2121-10-13] Glucose-93 UreaN-6 Creat-0.6 Na-133 K-3.2* Cl-100 HCO3-26 AnGap-10 LFTs [2121-10-4] ALT-108* AST-80* AlkPhos-124* TotBili-0.3 [2121-10-7] ALT-388* AST-148* LD(LDH)-543* AlkPhos-120* TotBili-1.3 [2121-10-9] ALT-185* AST-77* LD(LDH)-377* AlkPhos-99 TotBili-2.5* [2121-10-11] ALT-106* AST-49* LD(LDH)-434* AlkPhos-85 TotBili-3.0* [2121-10-13] ALT-72* AST-45* LD(LDH)-496* AlkPhos-82 TotBili-1.4 [2121-10-12] Albumin-2.8* [2121-10-4] PT-12.7 PTT-25.3 INR(PT)-1.1 [2121-10-13] PT-13.4 PTT-31.3 INR(PT)-1.1 [2121-10-8] Lactate-1.5 MIcrobiology Blood cx [2121-10-5]: No growth Urine [2121-10-5]: negative [2121-10-8] 2:20 am BLOOD CULTURE Blood Culture, Routine (Final [2121-10-14]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [2121-10-9]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] AT 2:50PM, [2121-10-9]. [2121-10-8] 5:20 am BLOOD CULTURE FINAL REPORT [2121-10-12] Blood Culture, Routine (Final [2121-10-12]): ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). ISOLATED FROM ONE SET ONLY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S PENICILLIN G---------- 2 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final [2121-10-8]): REPORTED BY PHONE TO [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) ] @ 945PM [2121-10-8]. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [2121-10-10]): REPORTED BY PHONE TO [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 22458] [2121-10-10] 1:25PM. GRAM POSITIVE ROD(S). Blood cultures 11/20, [10-10], [10-12] No growth IMAGING CT Abdomen/Pelvis [2121-10-4]: 1. New hemoperitoneum likely secondary to HCC capsular rupture in the left lobe of the liver. 2. Stable appearance of renal cysts, hiatal hernia and diverticulosis. CXR [2121-10-4]: no acute pulmonary process CT Abdomen/Pelvis [10-8] 1. No evidence of active arterial extravasation at this time. Hemoperitoneum is slightly decreased from [10-4]. 2. There is new focal circumferential wall thickening of the colon in the region of the hepatic flexure, over about a 4 cm in segment. A focal ischemic colitis is considered, given the acuity of onset. There is a single diverticulum in the region of abnormal colon, but diverticulitis is thought to be much less likely given the circumferential nature of the findings and the entirely new development since [10-4]. There is stranding of the adjacent pericolonic fat. 3. Hepatocellular carcinoma and shotty mesenteric adenopathy. There is also an enlarged node adjacent to the lower esophagus/hiatal hernia. CT Abdomen/Pelvis [10-9] 1. Circumferential wall thickening involving a short segment of colon in the region of the hepatic flexure, similar in appearance from prior study. No discrete vascular filling defect is identified. However, given this location, focal area of ischemia, from a small mesenteric branch remains in the differential. 2. Hepatocellular carcinoma involving the left lobe of the liver, with residual hemoperitoneum seen, slightly decreased in extent from the prior study. No evidence of active extravasation at this time. Brief Hospital Course: MICU Course Mr. [Known lastname 1968] was admitted to the MICU with a hemoperitoneum seen on CT scan on [2121-10-4]. He underwent embolization of the L hepatic artery at the bifurcation on [2121-10-5]. He tolerated the procedure well. After the procedure, his hematocrit initially dropped from 30.4 to 26.4. IR was made aware and recommended checking coags and a retic count. His retic count was 1.5 and coags were stable. His hematocrit was checked every 4-6 hours for the next 48 hours and was stable. His pain was managed with Dilaudid. He continued to have abdominal pain after the procedure but his abdomen was soft. He had elevated LFTs which were likley from the chemoembolization procedure and were followed and trended down. He was taking sips after his procedure and this diet was advanced as tolerated. For his HIV, he was continued on his HAART therapy. Floor Course by Problem 69 yo with HIV, HCV, multifocal HCC admitted with acute onset abd pain and hemoperitoneum, likely intiiating from HCC in left hepatic lobe now s/p left hepatic arterial embolization. # Abdominal pain: Patient continued to have abdominal pain after his procedure but it was improved from admission. He did not have any signs or symptoms of infection to suggest SBP. A repeat CT scan was obtained on [10-8] to evaluate concern for rebleeding with a slight drop in HCT associated with abdominal pain and low SBPs 80s overnight. He was also made NPO. CT did not show any further bleeding but did show a focal area of transmural inflammation on the hepatic flexure concerning for ischemia or infection. We discussed the findings on CT with radiology who recommended repeating the scan the following day. We also discussed the findings with IR who did not believe the area of inflammation was a result of the embolization procedure. Repeat CT scan with mesenteric angiography was relatively unchanged from prior. He was started on vancomycin as below for enterococcus blood cultures but did not have any other signs or symptoms of infection during the remainder of his hospital course with no fever and no elevated WBC. Since his pain was mildly improved and the CT was not any worse compared with prior, we advanced his diet which he tolerated well and discontinued his antibiotics at discharge. His lactate was normal which was reassuring. Pain was controlled with PO MS Contin with Oxycodone for breakthrough at time of discharge. # Hemoperitoneum / hematocrit drop: Patient had HCT drop after admission from 38 to high 20s, low 30s. This was felt to be secondary to hemoperitoneum and hemodiution. HCT was stable at time of discharge and repeat CTs did not show further bleeding. He did not require any transfusions. # Enterococcus, MSSA, Corynebacterium blood cultures: Pt had positive blood cultures on [10-8] with multiple bugs. He was empirically started on Vanc for GPC in blood cultures but this was discontinued at time of discharge since repeat blood cultures were all no growth and he did not have fever, elevated WBC, or localizing signs to suggest infection. It was felt that positive blood cultures were most likely from contamination but he was instructed to return if he developed fever or worsening abdmonial pain. # Transaminitis: Patient had transaminitis likely secondary to embolization procedure which trended down after. # HCC/Hep C/Cirrhosis: Pt has Hep C and multifocal HCC. He is not candidate for surgical resection or transplant due to multifocality. He was seen by Palliative Care, [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 1764] during stay here and will follow up with Dr. [Last Name (STitle) 23546] as outpatient. # HIV: Continued HAART. Most family members unaware of HIV status # Code: DNR/DNI. Confirmed with pt Medications on Admission: Combivir 150/300mg [Hospital1 ] kaletra 200/50 two tablets [Hospital1 ] omeprazole 20 qday tylenol 650 tid prn ibuprofen 400 tid prn Discharge Medications: 1. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:168 Tablet(s) Refills:0 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:1 bottle Refills:2 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:0 10. Outpatient Lab Work Please do CBC and CHEM 7 on Wednesday [2121-10-15] and fax to Dr. [Name (NI) 23547] office at [Telephone/Fax (1) 1419]. 11. Lac-Hydrin 12 % Cream Sig: One (1) application Topical twice a day: Please apply to dry skin on feet . Disp:1 tube Refills:2 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 days. Disp:2 Tab Sust.Rel. Particle/Crystal(s) Refills:0 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 14. Ibuprofen 200 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for fever or pain. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Primary Diagnosis 1. Hemoperitoneum s/p hepatic artery embolization Secondary Diagnosis 1. Hepatocellular Carcinoma 2. Hepatitis C 3. HIV Discharge Condition: Hemodynamically stable, afebrile, ambulating without difficulty, pain controlled on PO medications Discharge Instructions: You were admitted to the hospital with abdominal pain and you were found to have bleeding in your abdomen. This was most likely a bleed from the cancer in your liver. An embolization was performed to stop the bleeding which was successful. Since you had continued abdominal pain, we obtained a repeat CT scan of your abdomen which showed some inflammation around an area of your colon. We could not determine if this was from decreased blood flow or infection. This remained stable on repeat studies and your abdominal pain improved with MS Contin and Oxycodone as needed for breakthrough pain. You should continue to take MS Contin twice a day and Oxycodone as needed for pain. If your abdominal pain improves, you may stop taking these medications. These medications can affect your judgment so you should avoid driving while taking these medications. We made the following changes to your medications 1. We added MS Contin and Oxycodone for pain control 2. We added Colace, Senna, and lactulose as needed for a bowel regimen which you should take to prevent constipation while you are on pain medications. 3. We added Lac-Hydrin cream for the dry skin on your feet 4. We added Potassium supplements which you should take the next 2 days 5. We added Albuterol inhaler since you were getting albuterol breathing treatments in the hospital and felt like these improved your breathing. Please return to the ER or call your primary care doctor if you develop worsening abdominal pain, nausea, vomiting, chest pain, shortness of breath, fever, chills or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 977]. You will be called with the date and time of your appointment. The number to the office is [Telephone/Fax (1) 3395] if you have any questions. Please follow up with Dr. [Last Name (STitle) ]. You have an appointment on: Friday [10-24] at 9am. Call [Telephone/Fax (1) 13006] if you have any questions.	[ "285.1", "790.4", "070.70", "568.81", "276.8", "155.0", "571.5", "793.4", "305.1", "458.9", "V08", "608.86", "706.8" ]	icd9cm	[ [ [] ] ]	[ "88.48", "39.79", "88.47" ]	icd9pcs	[ [ [] ] ]	13263, 13338	7511, 11318	336, 382	13520, 13621	2254, 7488	15252, 15630	1897, 1907		11509, 13240		13359, 13499		11344, 11486			13645, 15229								1922, 2235																									277, 298										410, 1484															1506, 1670	1686, 1881
63,481	163,357	1404	Discharge summary	report	Admission Date: [2163-12-17] Discharge Date: [2164-2-4] Service: MEDICINE Allergies: Gluten / Augmentin Attending:[First Name3 (LF) 1646] Chief Complaint: Fever and diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy PICC line placement and removal Tunneled Line Placement ERCP [2164-1-9] History of Present Illness: 85 year old man with history of refractory celiac disease, hypertension, history of pulmonary embolism, cystic pancreatic lesions, and osteoporosis who presents with abdominal pain, diarrhea, and lethargy. He was last discharged on [2163-11-30] after an admission for gallstone pancreatitis, pan sensitive E. coli bacteremia, pneumonia, bilateral pleural effusions, and new onset afib. An ERCP during this admission showed a small stone and sludge was extracted and a stent was placed. The plan was for follow up with Dr. [Last Name (STitle) ] for an elective outpatint cholecystectomy in [2-4] months and for repeat ERCP in [5-8] wks for stent removal, balloon sweep, and pancreatic duct evaluation. The pt was discharged to [Hospital ] rehab. 4 days ago later, he developed brown watery diarrhea, non bloody emesis, and inability to take POs. Of note he finished a course of ceftriaxone and azithromycin on [2163-12-8]. He denies fever and is positive for abdominal pain in his left lower quadrant. Per the pt's report he was started on flagyl at rehab which was discontinued due to increased liver enzymes. In the ED vitals were 98.6 112/48 101 22 98% on RA. In the ED he had tenderness in the left abdomen and was guaiac positive. CT abd showed gallstones, air in lumen of gallbladder likely related to ERCP/stent placement, and no evidence of obstruction. There was no evidence of cholangitis. The pt was given IV Flagyl, Vanco, and Zosyn as well as PO Vanco. Surgery did not see a need for surgical intervention. CXR revealed no infiltrates. Temp was 101 rectally. The patient was admitted to [Hospital Unit Name 153] for concern for sepsis. Review of systems: (+) Per HPI. +Recent weight loss (cannot quantify). +Sore throat x 1 day(attributes to dryness). +Mild dysuria. +Visual "disorientation" recently. (-) No fever, chills. No headache. No shortness of breath or pain with inspiration. No chest pain or discomfort. No dizziness, lightheadedness, presyncope, syncope, or palpitations. No dysuria or hematuria. No joint or muscle pain. Past Medical History: - Refractory Celiac Disease; currently getting TPN four nights a week, followed by Dr. [Last Name (STitle) ] [Name (STitle) ] fib-diagnosed in [11-10] -occipital embolic CVA in [12-11] while off AC -?lymphoma per prox ileal bx in [2158] -Gallstone pancreatitis s/p recent ERCP and stent placement -small bowel resection for SBO ([2148]) -ulcerative ileojejunitis ([2150]) & LOA in [2158] for SBO - Severe hypertension - Iron deficiency anemia - RLL pulmonary embolism - incidental finding after a CT scan was performed for evaluation of possible pancreatic mass. On coumadin x six to seven months, stopped recently. - Cystic Pancreatic Lesions - followed with serial CT scans - Kidney Stone - work up of this showed possible pancreatic mass - Subclinical hypothyroidism - Peripheral neuropathy - Osteoporosis - not on a bisphosphonate - Hypogonadism - Anxiety disorder Social History: Most recently at [Hospital ] Rehab but normally lives in [Location 1110]. Wife died in [2163-8-3]. Retired comptroller of [University/College 8436]. No tobacco or EtOH. Family History: No known FH of celiac disease. Physical Exam: Exam upon arrival to medicine floor [2163-12-19]: VS: T 99.4F, BP 120/58 HR 94 RR 18 96% RA GENERAL: NAD HEENT: EOMI, no scleral icterus. MMM, oropharynx clear. Neck supple CARDIAC: RRR with ectopic beats. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: CTAB ABDOMEN: Soft, nondistended, no tenderness (previously diffusely tender), bowel sounds present EXTREMITIES: No edema. Warm. NEURO: Alert and fully oriented, fluent speech. CN 2-12 intact. UE and LE strength 5/5. Normal tone/decreased bulk. PSYCH: Listens and responds to questions appropriately. Appropriate, slightly depressed affect. . on [2163-2-4] Vitals: 98.6 132/64 74 18 96%RA 4BMs/24hours Pain: L upper chest over new tunneled area Access: L tunneled line c/d/i Gen: sitting up in chair HEENT: mm dry CV: irreg irreg, no m Resp: CTAB, no crackles or wheezing Abd; soft, mild-mod distended, nontender, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal, has difficultly remembering things at times. Skin: no changes psych: flat, depressed Pertinent Results: wbc 16->20->20->27->19->25->21 HCT 25.8-30 stable plt 417 BUN/Creat 43/1.2-->49/1.4->28/0.6 on [2-4] [1-24] LFTs wnl, alk phos 126 . INR 2.4 on [2-4] . [1-26] TSH 1.4 HIV neg RPR NR . UA [1-27] neg FeNa 0.6% . [1-24] c-diff neg [1-25] c-diff neg stool O&P neg X2 stool cx neg, including crypto/micro/cyclo [1-23] cath tip cx neg All blood cx neg to date . EGD [1-25] biopsy A. "Gastric ulcer:" 1. Antral and fundic type mucosa with focal erosion, mild associated chronic active inflammation and epithelial regeneration. 2. [Doctor Last Name 6311] stain is negative for H. pylori, with a satisfactory control. B. Duodenum: Duodenal mucosa with marked villous atrophy and increased intraepithelial lymphocytes; see note. Note: The duodenal findings are consistent with involvement by the patient's known celiac disease. At the request of the clinician, slides will be sent for T-cell receptor gene rearrangement studies, and the results will be issued separately in an addendum . . . Imaging/results: CT a/p with contrast [1-26]: 1. New wedge-shaped hypoattenuation in the interpolar region of left kidney may represent infarct, although focal infection and neoplasm are less likely possibilities. Followup contrast enhanced CT or MR when the patient's symptoms resolve recommended to exclude neoplasm. 2. Unchanged mildly dilated small bowel loops around anastomotic site. 3. Unchanged renal and hepatic hypodensities, and likely left lobe hemangioma. 4. Pancreatic cystic lesions, one of which represents IPMN based on prior ERCP stable from [Month (only) ], but both slightly increased since [2159]. 5. Cholelithiasis without evidence of cholecystitis. 6. Atherosclerotic disease of the abdominal aorta and its branches. . . EGD [1-25]: A few small ulcers were found in the antrum and body of the stomach. Cold forceps biopsies were performed for histology at the stomach antrum. Duodenum: : Diffuse blunting of the villi was noted throughout the duodenum. Cold forceps biopsies were performed for histology at the duodenal bulb. Impression: Gastric ulcer (biopsy) Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum . TTE [12-19] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CT Abd [12-19] 1. There is a question of intramural edema involving the descending and sigmoid colons; however, this appearance may simply be due to nondistention and intraluminal fluid as the adjacent fat shows no definite inflammatory change. Please correlate clinically. 2. No change in pancreatic lesions as described, expected pneumobilia, cholelithiasis, probable liver hemangiomas. 3. Small wedge-shaped area of absent contrast enhancement within the inferior pole of the right kidney, likely representing a small infarct, relatively acute or subacute given lack of renal capsular retraction. This area could not be appreciated on the most recent prior study due to lack of intravenous contrast. . Colonic mucosal biopsies: A. Proximal descending: Colonic mucosa with focal acute inflammation and crypt regeneration, suggestive of adjacent injury. B. Distal sigmoid: 1. Colonic mucosa with focal, mildly active colitis and erosion; see note. 2. Immunostain for CMV is negative for viral inclusions, with satisfactory controls. . [2164-1-9] ERCP: Impression: A plastic stent placed in the biliary duct was found in the major papilla. The plastic stent was removed via snare. Evidence of a previous biliary sphincterotomy was noted in the major papilla. Cannulation of the biliary and pancreatic ducts was successful and deep with a sphincterotome using a free-hand wire guided technique. A single 5 mm stone that was causing partial obstruction was seen at the lower third of the common bile duct. A biliary sphincterotomy was successfully extended in the 12 o'clock position using a sphincterotome over an existing guidewire. One stone and sludge/debris was extracted successfully using a balloon catheter. Repeat balloon sweeps were negative and occlusion cholangiogram revealed no residual filling defects. A segmental dilation of the side branches of the pancreatic duct was seen at the head of the pancreas. This was consistent with side-branch IPMN. The main duct was without filling defects. . Brief Hospital Course: Mr. [Known lastname 8435] is an 85 year old man with history of celiac disease, hypertension, history of pulmonary embolism, a fib, osteoporosis, and gallstone pancreatitis who presented with elevated WBC/fever/elevated lactate/diarrhea/ARF. Each of the problems addressed during this hospitalization are described in detail below: . # colitis/GI bleeding: Pt admitted to ICU with sepsis (Febrile, tachycardic, leukocytosis, bandemia (bands 37 on admission), elevated lactate). Based on the clinical presentation, recent Abx course, there was a high suspicion of C. diff colitis, although other etiologies such as other infectious etilogies, ischemic colitis given atrial fibrillation, cholangitis, refractory celiac disease were considered. No evidence of colitis was present on abd CT scan, although this was a noncontrast study. The patient was pan-cultured and started on antibiotic regimen including PO Vanco, Flagyl, and Zosyn. A number of other studies were sent including fecal culture, ova and parasites, C. diff, Yersenia, Shigella, Campylobacter, Microsporidia, Giardia, Cryptosporidium were sent and were negative. The patient was kept NPO, put on TPN. Aggressive fluid resuscitation was given. C. diff toxins were negative x 4 and PO Vancomycin was discontinued on [12-18]. The patient was seen by GI service, who recommended continuing Abx treatment with IV Vanc, Zosyn, Flagyl and contacting ERCP to discuss follow-up of the biliary stent placed on [11-22]. On transfer to the floor, the pt continued to have persistent leukocytosis and diarrhea. The ID team was consulted to discontinue Zosyn given that his picture was consistent with colitis. On [12-21], the pt underwent a flexible sigmoidoscopy which revealed a friable, ulcerative colonic mucosa which was concerning for viral pathologies such as CMV. He was empirically changed to PO vancomycin for concern of severe C diff and started on ganciclovir for empiric CMV coverage. A serum CMV viral load was sent and was negative. Pathology of colon biopsies was consistent with colitis, inflammation. CMV stains on path were negative as well. . Though all C diff and CMV studies have returned negative, a decision was made with GI and ID teams' input to continue both oral vanco and ganciclovir treatment, though Vancomycin PO was d/c'd on [1-2] as cdiff was negative X6. Though his clinical picture seemed to fit C diff (colitis, diarrhea, leukocytosis) his diarrhea seemed to improve when ganciclovir was initiated. With the completely negative infectious results, there was also some strong concern that this event may have been ischemic colitis as the patint also has evidence of embolic infarcts in his brain and has atrial fibrillation, so the decision was made to restart the patient on coumadin with a heparin bridge. . [2163-12-31]. Patient then had approximately 5 bowel movements from 0300 to 0600 passing marroon stools with clots. His HCT was 21.1 on morning labs on [2164-1-1] and was transferred to the ICU. . While in the ICU he receieved 3U of blood and had a negative bleeding scan. He was started on IV PPI and changed back to home medication on [1-2]. His Hct remained stable and he had a brown stool the morning of transfer back to the floor. A repeat Flex sig [2164-1-19] showed good healing of the colonic lesions so anticoagulation was restarted. . On [1-22] his diarrhea began to worsen again. ID and GI were called back to re-examine and another infectious w/u was initiated, but was again unrevealing. An EGD was performed and 2 gastric ulcers were found and biopsies of the small intestine were done in multiple places to r/o MALT. These results showed celiac sprue, with MALT stain pending at the time of discharge. He was started on loperamide for symptomatic improvement which worked well and should be titrated to [3-8] BM's per day. . At the time of discharge the patient had been receiving loperamide and was down to 1-2 BM per day, but was having some increasing abd distention. Plan is to hold all loperamide and restart if BM frequencies increase. Need pathology f/u as well. Need f/u HCT checks and monitoring for s/s of significant bleeding. [Month (only) 116] require intermittant transfusion if HCT drifts down as it has been slowly decreasing over last 2 weeks with blood draws and possibly slow loss from GI source. Would consider transfusion for HCT<24. . # MRSA bacteremia - On [12-18]/2 blood culture bottles grew MRSA. IV Vanco started and PICC line discontinued [2163-12-19] for suspicion that it was the source of the infection. ID was consulted and recommended ordering a TTE which was negative for valvular vegetations. He had a new PICC line placed on the right UE on [12-22]. After further review of his case (hx endocarditis [2162], as well as possible renal infarcts on CT scan). . PICC removed on [12-18] and surveillance blood cultures since admission have been without growth. PICC tip was sent for culture on [2163-12-19] and has final result of no growth. TTE on [2163-12-20] was negative for valvular vegetations; however, could not rule out small vegetations. Patient has a past history of endocarditis in [2162], which increases his risk for recurrent endocarditis and ID consult recommending TEE, which was negative for vegetations on [2164-1-3]. He received a total of 4 weeks of Vancomycin per the ID team, and completed this on [1-17]. At the time of discharge he has a left tunnelled catheter. His discharge was held for a day b/c of a clogged line which cleared with TPA held in the line for 2 hours then drawn out. There has never been any problems flushing the line, just drawing labs back. Patient is a difficult peripheral stick, but can be done if needed. . # UTI - Urinalysis and culture was drawn on [2163-12-29] due to concern for low grade temperatures and a rising leukocytosis at that time. As U/A was unimpressive, treatment decision hinged on a urine culture that was positive for enterobacter on [2163-12-31]. Ciprofloxacin IV was started at that time on [12-30]. Repeat urine cultures 11/30 and [1-3] were negative for enterobacter, but positive for enterococcus. Per ID a repeat UA was performed and was negative for nitrites and leuk esterase. The ID recommended discontinuing ciprofloxacin [1-3] since the enterbacter had cleared and did NOT want to treat the enterococcus (VRE), since this is likely now a colonizer (UA was negative). . # RUE swelling - pt noted to have some RUE edema approximately [12-28]. A RUE US revealed no flow in a portion of cephalic vein, likely representing a superficial vein clot. Due to the ongoing need for PICC line for TPN as well as other indications for anticoagulation (Afib with hx embolic strokes), heparin gtt was entertained, but was not started given his falling Hct and guaiac positive stools. On [1-3], the pt went for an IR guided tunnelled line and had his PICC removed. His RUE swelling is slowly resolving. However, the tunneled line had to be removed (see below). . * Biliary stent - The inpatient GI service recommended that ERCP be contact[Name (NI) ] in order to determine how to manage his biliary stent in the setting of a rising lipase. The team felt that the stent had not migrated, but did agree that the stent would need to be removed. The ERCP team removed the stent on [2164-1-9] without complication. . * Acute on chronic kidney disease (Stage II): On admission, creatinine was noted to be 3.8 up from baseline of 0.6. It was believed to be prerenal and secondary to severe dehydration. With aggressive hydration, his Cr declined back to normal. . * Anion gap acidosis [3-6] lactic acidosis and uremia - This was thought secondary to his severe colitis and MRSA bacteremia. His anion gap was resolved at the time of transfer to the floor. . * Supratherapeutic INR on admission - Secondary to both coumadin and poor PO intake. Vitamin K given in ICU and coumadin/ASA was held given diarrhea and guaiac positive stools. The patient received additional IV Vitamin K as INR on the day of callout was 4.5. His INR improved and was 1.5 on the [12-21]. Given his atrial fibrillation and subacute strokes and renal infarct, ASA was restarted on [12-22] and then stopped in the setting of GIB. There is strong indication for re-anticoagulation to be initiated at lower dose and carefully monitored. Discussion undertaken with patient, daughter and PCP after careful review of [2163-12-9] outside neurology consult report. Pros and cons presented to patient. Anticoag held until repeat Flex Sig was done [2164-1-19], and tunnel line placed [2164-1-20] then restarted. His goal INR should be [3-7] with ideal range 2-2.5 given his high bleeding risk. * Atrial fibrillation with hx embolic strokes: On admission, his ASA and coumadin were held. At [Hospital1 ], he had complained of visual changes and he had a neurology consultation and was found to have subacute strokes - bilateral posterior infarcts (right side affecting posterior temporal and occipital lobes; left side involving medial right occipital lobe). He was restarted on coumadin at [Hospital1 ] at 5mg QHS but had supratherapeutic INRT. On admission, ASA and coumadin were both held. His CT Abd revealed a new renal infarct, may be related to embolic phenomenon from Afib vs. endocarditis. His ASA was restarted on [12-22] then held in the setting of GIB, which was felt to be due to ischemic colitis (other evidence for embolization). He was started on Diltiazem on [1-1] then changed to his home metoprolol on [1-2]. Neurology consult was cancelled in light of pt refusal, and fact that there is strong indication to anticaogulate with careful monitoring. Full discussion with pt and his daughter and he agreed. As above, coumadin restarted [2164-1-20] and INR should be check frequently. would no restart aspirin at this time. . * Transaminitis - Likely related to hypoperfusion from severe diarrhea. Had resolved at time of transfer to the floor. Of note, pt had biliary stent placed [2163-11-23] and after further discussion with ERCP was removed. . * Celiac disease: Has refractory disease and had been on TPN for the past 4 years per his outpatient GI attending. Held intermittant with above complication, but has been restarted without event. The patient will require that all medications be confirmed with the manufacturing company that they are gluten free before he will agree to take them. He has some of his own meds to take that he know is gluten free. . * Benign hypertension: Some of his BP medications were held in the setting of septicemia picture in the ICU. He slowly was restarted on his home metoprolol. The calcium channel blocker and ACEI was no longer needed. . * Hypothyroidism: Continued Levothyroxine. thyroid labs checked. . * History of PE: S/p course of coumadin in past, but now back on anyway for AFib reasons and h/o embolic phenomenon. . * Osteoporosis: Home D2 50,000 units on Mon and Thursday, citracal + D 315-200 units [Hospital1 ] were continued. . * Anxiety disorder: stable Medications on Admission: metoprolol 100 mg po bid captopril 50 mg po tid felodipin 5 mg daily levothyroxine 125 mg po daily coumadin ?dose ondansetron 4 mg IV q6h prn omeprazole 20 mg po daily vitamin E 800 units daily vitamin A B12 1000 mcg daily vit D2 50,000 units Mon/Thurs citracal +D 315-200 units [Hospital1 ] aspirin 81 mg daily albuterol 1-2 puffs q6h prn folic acid 1 mg daily Discharge Medications: 1. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO daily (). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO daily (). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO twice weekly (Monday, Thursday) (). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO daily (). 5. Vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO daily (). 6. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO every twelve (12) hours: continue high dose for 4 weeks, then 40 mg qdaily. 9. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO QID (4 times a day) as needed for gas. 10. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea: titrate to [3-8] BM's per day. Hold if any abdominal distention. 13. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous Q6H (every 6 hours) as needed for congestion. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. 18. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for to buttocks . 19. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for sore throat. 20. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) MG Injection Q8H (every 8 hours) as needed for nausea. 21. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: last INR 2.4 on [2155-2-4]. dose was 4 mg a day, now down to 2mg with ideal dose in that range. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: GIB due to colonic ulcerations MRSA bacteremia of unclear source Celiac Sprue, refractory PUD Atrial fibrillation c/b embolic CVAs Hypertension, benign Recent occipital stroke ([12-11]) Renal infarct Discharge Condition: Stable Discharge Instructions: The patient is being discharge to a facility with the following active problems: 1. diarrhea: has improved some with entercort and loperamide, both at the recommendation of Dr. [Last Name (STitle) ]. Still may need some medication titration, but he's down to 2-4 BM's a day, which is a significant improvement. He still has path pending on the duodenal biopsies to see whether he has MALT lymphoma causing his worsening symptoms. Of note, the patient has significant abdominal distention that is normal for him. It comes and goes depending on his current symptoms. Would hold loperamide anytime there is significant distention. 2. titration of coumadin: INR is 2.4 today, but we'd like to keep it between 2-2.5 if possible. Please monitor frequently as he is a very high bleeding risk, but unfortunately for emoblic events as well. See DC summary for h/o bleeding issues. Suspect coumadin dose to be between 2-4 mg daily 3. WBC's: He still has a high white count despite all our interventions. ID is very confident that this is not an infection, but we believe it should be monitored closely for bandemia or significant increase. Last WBC count was 21 without any bands. 4. Advancing his diet: As of yesterday he was still only drinking occasional water. We have started advancing his diet a bit, which will hopefully improve. He is ok to advance to a gluten free diet as tolerated. 5. Anemia:The patient is at high risk of bleeding his last HCT is 25.8. His HCT level has been varying between 25-30 during his stay. He does have colon ulcers and has guiac + stools, but without any s/s of gross bleeding and stable HCT. [Month (only) 116] require intermittant transfusion if HCT drifts down as it has been slowly decreasing over last 2 weeks with blood draws and possibly slow loss from GI source. Would consider transfusion for HCT<24 and transfer back to [Hospital1 ] for any s/s of significant bleeding. For changes in his condition, would discuss with Dr. [First Name (STitle) ] [Name (STitle) ](GI) and Dr. [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) ](PCP) who are actively involved in his case. He has f/u with Dr. [Last Name (STitle) ] in [Month (only) ], but earlier f/u can arranged if needed. They can be reached at [University/College 8438] and [University/College 8439] with any questions. The patient's Daughter, [Name (NI) ], is exceptional at coordinating the day to day care of her father. She knows him well. Followup Instructions: [2164-4-11] 02:10p [Last Name (LF) ],[First Name3 (LF) ] B. LM [Hospital Unit Name ], [Location (un) ] LIVER CENTER (SB) [2164-3-26] 10:30a [Last Name (LF) ],[Known firstname ] N. SC [Hospital Ward Name ] CLINICAL CTR, [Location (un) ] BONE & MINERAL-CC7 (SB)	[ "009.0", "569.82", "574.20", "E849.7", "427.31", "556.8", "276.51", "V58.61", "041.04", "599.0", "579.0", "V12.51", "996.74", "574.51", "531.70", "999.31", "V02.54", "584.9", "280.0", "403.90", "458.8", "585.2", "790.7", "733.00", "276.2", "440.0", "041.12", "576.1", "E879.8", "041.85" ]	icd9cm	[ [ [] ] ]	[ "99.15", "51.88", "97.55", "99.10", "45.25", "38.93", "45.16" ]	icd9pcs	[ [ [] ] ]	23718, 23784	9853, 21081	245, 346	24032, 24041	4701, 9830	26591, 26908	3598, 3630		21499, 23695		23805, 24011		21107, 21476			24065, 26568								3645, 4682																				2074, 2454					187, 207										374, 2055															2476, 3380	3396, 3582
14,873	175,251	2309	Discharge summary	report	Admission Date: [2175-6-26] Discharge Date: [2175-7-8] Date of Birth: [2108-5-17] Sex: F Service: MEDICINE Allergies: Dyazide / Prozac / Nsaids / Inderal / Cefazolin Attending:[Last Name (NamePattern4) 290] Chief Complaint: rigors, fever Major Surgical or Invasive Procedure: Temporary [Last Name (NamePattern4) 2286] line Intubated Gallbladder percutaneous drain Triple lumen History of Present Illness: This is a 67 year-old female with ESRD s/p failed cadaveric renal tx on HD, recent admission for line sepsis, CAD, dCHF, hx PE, who presented to the ED with fevers and rigors and is transferred to the MICU for hypotension/concern for sepsis in the setting of HD. . Her recent history is notably for being hospitalized at [Hospital1 18] from [Date range (1) 12089] with fevers and culture negative sepsis presumed to be due to a line infection for which her HD catheter was removed and replaced. She had a TTE which did not show any evidence of endocarditis, and as nothing ever grew from her cultures, she was discharged after completing 2 week course of Vancomycin, stopping on 6/31. . On arrival to ED initial VS: 99 102 240/92 20 94% with 2 L, she was actively rigoring with rectal temp of 104, she reported some dyspnea then in setting of fever. Initially very hypertensive but CXR witout fluid overload. Blood cultures were drawn and she was given a dose of vanc/zosyn. She had no possible peripheral access. Given SVC syndrome, attempts at RIJ placement were unsuccessful, as pt has L tunned HD catheter, a femoral line was placed. She was also given tylenol, zofran and 1L NS with improvement in her symtoms. She had 1 episode of bilious vomiting, but no abd tenderness on exam. No localizing symptoms for infection. CXR suggested retrocardiac opacity, pt pt without SOB, cough, hypoxia. A viral NOS/flu syndrome was suspected, pt was admitted on droplet precautions for flu r/o. She does make a small amount of urine, but not enough to send for culture in ED. Here CBC was unremarkable with a WBC of 8.2. She had a trop of 0.11, during last hospitalization wsa 0.8. Elevated K 5.8. LFTs normal. INR 1.9 on coumadin. . On the floor, she was awake and alert and noted to be rigoring, temp 101.9, and complaining of low back pain, chronic for her but more severe than usual. She had a recent sick contact, and for the past several days had been having cold symptoms with productive cough and shortness of breath. Her daughter also stated she had been complaining of a right sided headache, although she denied this at the time of interview. She was given 2mg of morphine and became more somnolent and nauseous but stated that her pain was better controlled. Per her daughter she had started rigoring at 9pm; the family initially assumed she was hypoglycemic and gave her [Location (un) 2452] juice before coming to the ED. . She was undergoing HD on the morning of transfer had became hypotensive with BP in the 80s. No fluid was removed and she was given 300cc. Purulent material was noted to be weeping from her HD line and she was also tachypneic. She was then transferred to the MICU for further management. . On presentation, she was alert and oriented and c/o of lower abdominal pain which was relieved by a BM. She proceeded to have two other BMs of liquidy brown stool. She denied SOB/CP but appeared uncomfortably, grunting with breaths. Past Medical History: -Line infections: Hospitalized in [4-1] for staph epi bacteremia, treated through, re-hospitalized end of [Month (only) 596] for culture negative sepsis, HD line removed. -ESRD - HD MWF -s/p cadaveric renal transplant in [2168] -DM II with retinopathy, neuropathy -h/o PE (dx [1-30]) -SVC syndrome ([1-30]) -Hyperlipidemia -HTN -s/p mult CVA's (recently [2173-8-23]) -CHF [12-26] diastolic function -CAD -Pulmonary artery hypertension -hyperparathyroidism -L2 compression fracture -depression -anemia Past Surgical History: 1. L AV graft [2171] Dr. [Last Name (STitle) 816] Multiple thrombectomies done by Dr. [Doctor Last Name 816] Dr. [First Name (STitle) ] and Dr.[Last Name (STitle) ] and Dr. [First Name (STitle) 2491] (IR). 2. cadaveric renal transplant 3. s/p cataract extraction Social History: Lives with daughter. Retired nurses aid. No tobacco or EtOH use. Walks with cane for balance. Born in [Country ]. HD at [Location (un) ] [Location (un) ] M/W/F. Family History: Father w/ DM and kidney disease and mother w/ HTN. Physical Exam: PHYSICAL EXAM: Admit Vitals - T:97.9 BP:111/50 HR:98 RR:18 02 sat:99% 10L face mask GENERAL: Uncomfortable, moaning HEENT: NCAT. MMM, sclera anicteric. Prominent L cervical node vs SVC/IJ clot. No meningismus. CARDIAC: Tachycardic and regular with harsh 2/6 systolic murmur. HD tunneled catheter on left chest. LUNG: poor air movement. rales at left base. ABDOMEN: Soft, non-tender. + BS, no tenderness over transplant. EXT: No edema. right femoral catheter in place. no rash. NEURO: Awake and answering questions appropriately, appears uncomfortably and grunting during breaths. No focal weakness. Oriented. Pertinent Results: [2175-6-26] 12:05AM BLOOD WBC-8.2 RBC-3.97* Hgb-11.4* Hct-36.8 MCV-93 MCH-28.8 MCHC-31.0 RDW-16.4* Plt Ct-255 [2175-6-26] 12:05AM BLOOD Neuts-84.2* Lymphs-8.6* Monos-5.1 Eos-1.8 Baso-0.2 [2175-6-26] 12:05AM BLOOD PT-20.7* PTT-33.7 INR(PT)-1.9* [2175-6-26] 12:05AM BLOOD Glucose-100 UreaN-48* Creat-7.8# Na-139 K-5.8 Cl-100 HCO3-24 AnGap-21* [2175-6-26] 12:05AM BLOOD ALT-13 AST-21 CK(CPK)-131 TotBili-0.4 [2175-6-26] 01:39PM BLOOD CK-MB-12* MB Indx-2.9 cTropnT-1.10* [2175-6-26] 11:13AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.7 [2175-7-1] 05:37PM BLOOD TSH-1.6 [2175-6-26] 09:25AM BLOOD Type-ART O2 Flow-5 pO2-90 pCO2-34* pH-7.52* calTCO2-29 Base XS-4 Intubat-NOT INTUBA Comment-SIMPLE FAC [2175-6-26] 09:33AM BLOOD Lactate-2.7* [2175-7-7] 06:13AM BLOOD WBC-23.2* RBC-3.46* Hgb-9.9* Hct-32.7* MCV-95 MCH-28.5 MCHC-30.2* RDW-17.4* Plt Ct-407 [2175-7-7] 06:13AM BLOOD Neuts-86* Bands-1 Lymphs-9* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-25* [2175-7-7] 06:13AM BLOOD PT-22.6* PTT-41.2* INR(PT)-2.1* [2175-7-7] 12:28AM BLOOD Fibrino-657# [2175-7-7] 06:13AM BLOOD Glucose-394 UreaN-46* Creat-8.4* Na-141 K-5.2* Cl-105 HCO3-14* AnGap-27* [2175-7-7] 06:13AM BLOOD ALT-2139* AST-7871* LD(LDH)-6740* AlkPhos-113 TotBili-0.4 [2175-7-5] 04:24AM BLOOD Lipase-118* [2175-7-4] 04:17AM BLOOD CK-MB-4 cTropnT-1.79* [2175-7-7] 06:13AM BLOOD Calcium-11.0* Phos-5.3* Mg-2.2 [2175-7-6] 06:10PM BLOOD Type-ART Temp-39.1 Rates-[11-4] Tidal V-450 PEEP-5 FiO2-30 pO2-104 pCO2-29* pH-7.32* calTCO2-16* Base XS--9 Intubat-INTUBATED Vent-CONTROLLED [2175-7-7] 11:57AM BLOOD Lactate-3.1* EKG [6-26] Sinus tachycardia. Baseline artifact. Incomplete right bundle-branch block and non-specific lateral ST-T wave changes. Compared to the previous tracing of [2175-5-16] anterolateral ST-T wave changes are not seen on the current tracing and the rate has increased substantially. Clinical correlation is suggested. Echo [2175-6-28] There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild to moderate ([11-25]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular vegetations seen. Mild to moderate aortic regurgitation. EKG [7-2] Probable ectopic atrial rhythm. Deep T wave inversions in the anterolateral leads suggesting an extensive myocardial infarction. Very minimal ST segment elevation in leads V1-V2. Compared to tracing #1 no significant change. CT [7-2] IMPRESSION: 1. Filling defects consistent with thrombi versus fibrin sheath (from prior catheter) in the superior vena cava and left internal jugular vein. 2. Distention of the gallbladder with surrounding stranding. Acute cholecystitis cannot be ruled out. Suggest HIDA scan or [Month/Day (4) 4338] with Eovist for further followup. CT torso [7-6] CONCLUSION: 1. Multiple new hypodense geographic regions in the liver, spleen, native kidneys and renal transplant that are concerning for hypoperfusion / infarcts. 2. Cholecystostomy tube in situ, with post-procedural low-density lesions in either side of cholecystostomy tube within the right lobe of the liver that could represent biloma, hematoma, but cannot exclude abscess. 2. New low-density lesions identified in the dome of the right lobe of the liver felt most likely to represent infarcts; abscess at the hepatic dome felt less likely. 3. Gas within the lower pole of the renal transplant is new since the previous CT, and is felt likely to relate to prior instrumentation, although gas-forming organism cannot be entirely excluded if infection is present. 4. No intra-abdominal or pelvic drainable collections. Echo [7-7] IMPRESSION: Diffuse thickening of the mitral leaflets with moderate to severe mitral regurgitation. Moderate thickening of the aortic valve leaflets with moderate to severe aortic regurgitation. No discrete vegetation seen, though endocarditis cannot be fully excluded. There is no intracardiac thrombus. Compared with the prior TEE (images reviewed) of [2175-6-28], the mitral leaflets are now diffusely thickened and the severity of mitral regurgitation is markedly increased c/w endocarditis. Aortic valve morphology and severity of aortic regurgitation are grossly similar. Brief Hospital Course: ASSESSMENT & PLAN: 67 year-old female with ESRD s/p failed cadaveric renal tx on HD, recent admission for line sepsis, CAD, dCHF, hx PE, who presented to the ED with fevers and rigors and is transferred to the MICU for hypotension/concern for sepsis in the setting of HD, subsequently developed respiratory failure and was intubated. . # Sepsis: The patient presented with SIRS presumed to be secondary to line infection. Pus was expressed from around the patient's line and MSSA grew from blood cultures from that line. The line was removed. The patient was started initially on meropenem and vancomycin which was narrowed to nafcillin once MSSA was cultured. Other possible etiologies were examined including pneumonia, c.diff., cholycystitis, influenza, endocarditis, UTI, etc. No clear etiology was found through numerous imaging studies and blood cultures. The patient was given IVF to increase MAP and became fluid overloaded and subsequently developed respiratory failure requiring intubation. The patient was given phenylephrine to keep her pressures above a MAP of 65. . The patient remained febrile and a CT torso was conducted. It showed a distended gallbladder and an irregular HIDA scan prompted a gallbladder percutaneous drain. The culture showed normal bile. . For some time she was off pressors though not able to be weaned from the vent. However, she had labile blood pressures and did periodically have need for brief periods of pressors during short periods of hypotension. Starting on [7-6], the patient had consistent hypotension and new degrees of fever, and had a repeat echo and CT torso as well as broadening of antibiotic coverage to include vancomycin and meropenem. The CT torso showed multiple infarcts in the liver, spleen, native kidneys and renal transplant concerning for hypoperfusion/infarcts. Micafungin was added. . An echocardiogram on [7-6] showed thickening of the mitral valve leaflets compared to an earlier echocardiogram of [6-28], and was unable to exclude vegetation, suggesting though not proving endocarditis, which was consistent with the clinical picture. The patient continued not to improve on antibiotics and had dramatically increasing pressor requirements, requiring consistent use of two pressors. A family meeting was held at this time with the decision not to withdraw care, but not to advance care to further pressors or additional interventions. Thus, her pressor use and vent requirements remained the same based on this plan; but with this, she subsequently developed hypotension and acidemia which was followed by arrhythmia and death. The family was present throughout including her two daughters being present at time of death, and agreed with plan of care. Her two daughters consented to a limited autopsy. . Microbiology results which returned after her death showed VRE-positive blood cultures from [7-8] and urine culture from [7-5] (resulted on [7-9]), with blood cultures returning as positive in the setting of having been on vancomycin, meropenem, and micafungin at the time, suggesting that the VRE (as is common) was not sensitive to meropenem, though specific sensitivity testing to meropenem was not performed. . # Cardiac Enzymes/ECG changes: On admission to the unit the patient developed dynamic chages with STEs, RBBB and upright t-waves. This rhythm changed to a more rapid rhythm with deep lateral t-wave inversion and without RBBB. The patient had an elevated troponin-T with a CK-MB index of 2.9, which remained stable. The patient was started on heparin sliding scale, aspirin, statin, metoprolol for rate control (once pressures tolerated). Cardiology was consulted and said the likely cause was demand ischemia in the setting of hypotension. An echo on [6-28] was unremarkable. There was no plan for cath due to bacteremia. The patient subsequently developed sustained V-tach with perfusion. The patient's sedation was increased and lidocaine drip was started with resolution of arrhythmia. Lidocaine was discontinued with stable rhythms. Her CK increased, her statin was stopped with a down trend in CK. Ultimately as above, a later echocardiogram raised suspicion for endocarditis. . # Hypoxemic hypercarbic respiratory failure: The patient presented to the unit after receiving IVF for rescucitation. Her work of breath increased and she was intubated for hypoxemic hypercarbic respiratory failure. She had fluid removed with CVVH and HD and had CXR which showed improvement in her volume status. The patient was unable to be weaned from the ventilator secondary to agitation with lifting of sedation and poor NIF scores. Neuromuscular was consulted and conducted EMG studies which suggested that the patient had diffuse axonal neuropathy and muscular disease. This was not followed up further given her death from other causes as described above. . # ESRD, s/p failed kidney transplant: The patient presented after [Month/Day (1) 2286]. She was on a M,W,F schedule. Renal was consulted. Her HD line was removed due to suspected infection and was replaced 48 hours later. She required CVVH and HD to remove excess fluid and normalize her electrolytes. Her low dose prednisone was continued as were nephrocaps and cinacalcet. . [Month/Day (1) ] on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Month/Day (1) ]:30 Tablet(s) Refills:2 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Epogen Injection 9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [Month/Day (1) ]:30 Tablet(s) Refills:2 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 15U in AM, 2U in PM Subcutaneous twice a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Warfarin 6mg daily Discharge [Month/Day (1) ]: n/a Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "585.6", "250.50", "459.2", "514", "250.60", "038.11", "362.01", "428.30", "996.62", "357.2", "518.81", "416.0", "V12.51", "428.0", "V58.61", "575.0", "403.91", "995.92" ]	icd9cm	[ [ [] ] ]	[ "03.31", "96.6", "96.72", "88.72", "39.95", "96.04", "51.01" ]	icd9pcs	[ [ [] ] ]	16318, 16327	9865, 15140	328, 434	16374, 16383	5199, 9842	16435, 16577	4500, 4552				16348, 16353					16407, 16412						4003, 4293		4583, 5180																									275, 290										462, 3428							15154, 16295								3450, 3980	4309, 4484
69,758	119,269	41462	Discharge summary	report	Admission Date: [2179-2-8] Discharge Date: [2179-3-18] Date of Birth: [2124-12-9] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3963] Chief Complaint: Transfer from OSH for leukocytosis Major Surgical or Invasive Procedure: 1. Placement of R-IJ pheresis line [2179-2-8] 2. Placement of L-IJ central line [2179-2-8] 3. Pheresis [2179-2-8] 4. Bone marrow biopsy [2179-2-8], [2179-2-23], [2179-3-18] 5. IVC filter placement [2179-2-13] History of Present Illness: 54 year-old Spanish speaking female with a history of HTN who was transferred from [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with a leukocytosis of 194K concerning for acute leukemia. . The patient reports 1 week of fevers, sore throat, nausea, vomiting, and abdominal pain. She also endorsed body aches, headache, dizziness, nightsweats and SOB. She presented to [Hospital3 ] ED and was diagnosed with pharyngitis and given antibiotics & pain meds and d/c'd home. She continued to feel ill and presented to [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. There she was noted to have a WBC count of 194K. Her potassium was 1.6 and she reportly had runs of monomorphic narrow complex tachycardia at rates ~250 that lasted less then 10s. She was given 150mg IV amiodarone bolus. She had a fever to 103 so was started on zosyn empirically. She had a positive d-dimer and was started on a heparin gtt. A right IJ CVL was placed. She was transferred to [Hospital1 18] for further management. . In the [Hospital1 18] ED initial VS: Tm:102, HR:120, BP:120/75, RR:20, 95% 5L NC. Labs were remarkable for WBC 185 with 83% blasts, Hct 32.6, Plt 103, K 2.8, Ca 8.3, Phos 2.3, uric acid 5.9, LDH 1052, and fibrinogen 319. The heparin gtt was stopped. Bedside U/S showed a grossly enlarged spleen. Peripheral smear showed large amount of blasts. She underwent a bone marrow biopsy in the ED and was started on hydroxyurea. She was given 1g vancomycin and 1 set of BCx were sent. Additionally, her trop came back 0.28 with flat CK. She was transferred to the [Hospital Ward Name 332] ICU. Past Medical History: - HTN - Borderline Diabetes (diet controlled) - h/o Anemia - s/p C-section - s/p breast surgery for benign lump Social History: The patient was born in [Male First Name (un) 1056] and currently lives by herself. She is married and has a son and daughter-in-law that live in MA. She does not work. Denies EtOH, tobacco, or IV drug use. Family History: Father: arthritis Brother: RA Uncle: colon ca Physical Exam: ADMISSION EXAM: VS: T 102, HR 120, BP 120/75, RR 20, 95% 5L NC GEN: Ill appearing, tachypneic, uncomfortable, and in mild distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, beefy tongue, erythema in the posterior pharynx and exudate on right tonsil NECK: No JVD, carotid pulses brisk, no bruits, + cervical lymphadenopathy, trachea midline, RIJ CVL in place COR: Tachycardic, normal S1 S2, no M/R/G PULM: Bibasilar crackles, no W/R ABD: Soft, distended and tender to palpation, + splenomegaly, no R/G. EXT: No C/C/E, no palpable cords NEURO: Alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . DISCHARGE EXAM: VS: T 98, HR 80, BP 110/70, RR 18, 97-100% on RA GEN: Well-appearing woman in NAD. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM. +Mucositis on left buccal mucosa. NECK: Supple, no LAD, JVP not elevated. COR: Regular, normal S1 S2, no M/R/G. PULM: CTAB. No W/R. ABD: Soft, NT/ND, NABS. EXT: WWP, no edema. NEURO: A&Ox3, CN II-XII intact, strength and sensation intact. Gait normal. SKIN: No rash. Pertinent Results: ADMISSION LABS: [2179-2-7] 11:40PM BLOOD WBC-185.4* RBC-4.40 Hgb-10.9* Hct-32.6* MCV-74* MCH-24.9* MCHC-33.6 RDW-20.2* Plt Ct-103* [2179-2-7] 11:40PM BLOOD Neuts-3* Bands-0 Lymphs-3* Monos-9 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* Other-83* [2179-2-7] 11:40PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL [2179-2-7] 11:40PM BLOOD PT-17.4* PTT-47.3* INR(PT)-1.6* [2179-2-7] 11:40PM BLOOD Fibrino-319 [2179-2-8] 02:25PM BLOOD ESR-29* [2179-2-7] 11:40PM BLOOD Glucose-256* UreaN-7 Creat-0.7 Na-138 K-2.8* Cl-102 HCO3-28 AnGap-11 [2179-2-7] 11:40PM BLOOD ALT-28 AST-43* LD(LDH)-1052* CK(CPK)-45 AlkPhos-74 TotBili-0.6 [2179-2-7] 11:40PM BLOOD Lipase-19 [2179-2-7] 11:40PM BLOOD Albumin-3.4* Calcium-8.3* Phos-2.3* Mg-2.3 UricAcd-5.9* ................................................................ PERTINENT LABS: [2179-2-7] 11:40PM BLOOD CK-MB-2 [2179-2-7] 11:40PM BLOOD cTropnT-0.28* [2179-2-8] 04:34AM BLOOD CK-MB-3 cTropnT-0.25* [2179-2-8] 12:22PM BLOOD CK-MB-3 cTropnT-0.20* [2179-2-10] 03:00PM BLOOD proBNP-4844* [2179-2-8] 03:45PM BLOOD [Doctor First Name ]-NEGATIVE [2179-2-8] 04:34AM BLOOD %HbA1c-9.5* eAG-226* [2179-2-20] 04:30PM BLOOD calTIBC-146 VitB12-657 Folate-7.2 Hapto-419* Ferritn-6433* TRF-112* [2179-2-21] 12:00AM BLOOD TSH-1.4 [2179-2-21] 12:00AM BLOOD Cortsol-18.6 ................................................................ DISCHARGE LABS: [2179-3-18] 12:00AM BLOOD WBC-2.3* RBC-3.11* Hgb-9.3* Hct-27.4* MCV-88 MCH-29.9 MCHC-33.9 RDW-16.4* Plt Ct-354 [2179-3-18] 12:00AM BLOOD Neuts-39* Bands-0 Lymphs-32 Monos-27* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-2* [2179-3-18] 12:00AM BLOOD PT-15.3* PTT-36.4* INR(PT)-1.3* [2179-3-18] 12:00AM BLOOD Gran Ct-923* [2179-3-18] 12:00AM BLOOD Glucose-107* UreaN-13 Creat-1.0 Na-141 K-3.9 Cl-102 HCO3-29 AnGap-14 [2179-3-18] 12:00AM BLOOD ALT-26 AST-30 LD(LDH)-167 AlkPhos-146* TotBili-0.4 [2179-3-18] 12:00AM BLOOD Albumin-4.1 Calcium-9.7 Phos-4.9* Mg-1.8 ................................................................ MICROBIOLOGY: B-Glucan and galactomannan - negative Blood cultures (multiple) - no growth MRSA screen (x2) - negative Rapid Respiratory Viral Screen & Culture (x2) - negative and no growth Catheter tip cx (CVL)- no growth Throat culture - negative for b-strep Viral culture - no HSV growth Stool studies + C. diff - negative CMV VL - undetectable ................................................................ PATHOLOGY: [2179-2-8] Bone Marrow Biopsy: Aspirate Smear: The aspirate material is adequate for evaluation. It consists of several hypercellular spicules. The vast majority of the marrow cellularity is comprised of blasts and promonocytes morphologically similar to those described above. Maturing erythroid and myeloid precursors are rare. Megakaryocytes are present in markedly decreased numbers. Based on a 500 cell Differential: 91% Blasts and Promonocytes, <1% Promyelocytes, <1% Myelocytes, <1% Metamyelocytes, 1% Bands/Neutrophils, 1% Lymphocytes, 2% Erythroid, 5% Monocytes. . Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation, and consists of fragmented trabecular bone, which appears osteopenic. The marrow cellularity is 80-90% and comprised mainly of sheets of large cells with abundant cytoplasm, vesicular and folded nuclei, and prominent nucleoli. Maturing erythroid and myeloid precursors are markedly decreased. Megakaryocytes are rare. Marrow clot section is similar to the biopsy. . Cytogenetics: No clonal cytogenetic aberrations were identified in metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. Note: FISH was performed on a concurrent sample of neoplastic blood assessing for rearrangements of 15;17, 8;21, and 16q22. All results were normal. . [2179-2-8] Peripheral Blood Flow Cytometry: Three color gating is performed (light scatter vs. CD45) to optimize blast and lymphocyte yield. B cells comprise approximately 27% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. T cells comprise approximately 55% of lymphoid gated events, express mature lineage antigens and have a normal helper-cytotoxic ratio of 1.4 (usual range in blood 0.7-3.0). The majority of the cells from this peripheral blood are located in the monocyte/promonocyte gate and express immature antigens, HLA-DR, myeloid associated antigens CD33, CD13 (dim), dim CD15, CD117 (subset), monocyte associated antigens CD14 (variable subset), CD11C, and CD64, as well as CD56 (subset), CD71 and the lymphoid associated antigens CD4, CD7. Cells lack lineage specific B and T cell associated antigens, are CD10 (cALLa) negative, and are negative for CD34 and CD41. Blast cells comprise approximately 90% of total events. . [2179-2-15] Right Thigh Skin Biopsy: Sparse perivascular inflammation and edema involving dermis and subcutis. The findings are non-specific and mild. There is focal perivascular inflammation with a few slightly enlarged mononuclear cells in a fat lobule, however, there is limited adipose tissue in the specimen. The possibility of an underlying panniculitis cannot be fully assessed. The changes are not those of a neutrophilic dermatosis. Special stains ([Last Name (un) 18566], PAS, and gram) are negative for organisms. . [2179-2-17] Right Leg Skin Biopsy: Mild perivascular inflammation and edema involving dermis and subcutis. There is slightly more inflammation observed than in the prior biopsy. While mild, the finding of perivascular mononuclear cells and edema within the dermis and subcutis is unusual. There is some erythrocyte extravasation, however, no definitive vasculitis is observed. Focal basal vacuolization is observed. There is focal lipomembranous fat necrosis which may be observed as a non-specific finding. The findings are not sufficient for erythema nodosum. The changes are not those of a neutrophilic dermatosis. The changes are not suggestive of infection. Rare large atypical cells are seen in dermal perivascular distribution in a background of edema. The morphological findings are suspicious for treated leukemia cutis. Upon additional sections for immunostains, these cells are no longer present and cannot be definitively characterized. CD3 highlights scattered T-cells, a subset of which are reactive for CD4. CD20 reactive B-cells are rare. CD33 is non-contributory. . [2179-2-23] Bone Marrow Biopsy: Aspirate Smear: The aspirate material is adequate for evaluation. It consists of scant hypocellular spicules composed of stromal cells, histiocytes, lymphocytes, and clusters of plasma cells. Rare hemophagocytic histiocytes are present. Erythroid precursors are rare in number with normoblastic maturation. Myeloid precursors appear rare. Megakaryocytes are present in decreased numbers. Based on a limited 100 cell differential shows: 0% Blasts, 1% Promyelocytes, 2% Myelocytes, 2% Metamyelocytes, 0% Bands/Neutrophils, 17% Plasma cells, 59% Lymphocytes, 19% Erythroid. . Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation and consists of fragments of trabecular bone that appears osteopenic, with an overall cellularity of <10%. A small poorly formed lymphohistiocytic granuloma is seen. Eosinophilic debris is present consistent myeloablative chemotherapy. Erythroid precursors are rare in number and exhibit maturation. Myeloid precursors are rare in number and exhibit normal maturation. Megakaryocytes are absent. . Cytogenetics: Tissue cultures were established to obtain cells for cytogenetic and FISH analyses. However, the lack of cells in the specimen provided precluded the ability to perform either analysis. . [2179-3-18] Bone Marrow Biopsy: pending ................................................................ IMAGING: [2179-2-8] TTE: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen. No significant valvular abnormality. Unable to assess pulmonary artery systolic pressures. . [2179-2-8] CXR: Mild cardiomegaly, mediastinal and hilar prominence are most consistent with vascular engorgement, but could be mimicked by adenopathy. There is no pleural effusion and no pneumothorax. IMPRESSION: Probable mild cardiac decompensation. No evidence of pneumonia. Followup chest radiographs recommended. . [2179-2-9] CXR: As compared to the previous radiograph, the patient has received a new right-sided double-lumen dialysis catheter and a new left internal jugular vein catheter. The tip of the first catheter projects over the right atrium, the tip of the left catheter projects over the mid SVC. The lung volumes are small and unchanged. Mild areas of atelectasis at the left lung base. Borderline size of the cardiac silhouette without evidence of pulmonary edema. No evidence of complications, notably no pneumothorax. . [2179-2-9] U/S Bilateral LE Veins: 1. No evidence of DVT bilaterally. 2. Lymphadenopathy. . [2179-2-11] CTA CHEST: 1. Several segmental pulmonary emboli associated with multiple sites of apparent pulmonary infarcts. Clot burden and site of most proximal emboli may be underestimated due to poor vascular enhancement. 2. Infiltrative lymphadenopathy especially of the bilateral hila and infra-hilar regions. . [2179-2-12] CT ABD & PELVIS WITH CONTRAST: 1. Hypodensities within the spleen as described, differential includes either infarctions or involvement with this patient's AML, unfortunately no prior studies to allow assessment for interval change. 2. Other than the above, no other abnormalities which may be acute are appreciated. 3. Note of a fatty liver, probable cyst within the right kidney, fibroid uterus, prominent right inguinal lymph node. 4. Lung bases appear unchanged compared to the chest CT from one day earlier, including findings raising the suspicion of pulmonary infarctions. . [2179-2-12] CT NECK W/CONTRAST: Multiple enlarged lymph nodes compatible with history of AML. Soft tissue density between the right common carotid and jugular veins with differential as discussed above. This could represent a nodal lesion versus phlegmonous tissue. No evidence for abscess is seen. There is no evidence for vascular thrombosis. . [2179-2-15] RENAL U/S: No hydronephrosis, hydroureter, or evidence of renal calculi. . [2179-2-24] TRANSVAGINAL U/S: 1. Markedly thickened and heterogeneous endometrial stripe with apparent increased vascular flow. Findings are consistent with hemorrhage within the cavity possibly from degeneration of a submucosal fibroid, but possibly from other mass, polyp, or vascular malformation. MRI would be best for further characterization. 2. Large fibroid uterus. Brief Hospital Course: 54 year old woman with a history of HTN and borderline DM who initially presented to an OSH with fevers, sore throat, nausea, vomiting, and abdominal pain. She was found to have a leukocytosis of 194K concerning for acute leukemia, so she was transferred to [Hospital1 18] for further evaluation and was found to have AML. Brief hospital course by problem: . # AML: Admission labs at [Hospital1 18] revealed WBC 185K with differential notable for 83% blasts. Bone marrow biopsy from [2179-2-8] was consistent with AML M5 with NPM-1+ and Flt-3- cytogenetics. A pheresis catheter was placed and she underwent leukopheresis. She was started on allopurinol and hydroxyurea. TTE was normal. She started 7+3 chemotherapy (daunorubicin + cytarabine) on [2-9]. Repeat bone marrow biopsy at day 14 ([2179-2-23]) demonstrated an empty bone marrow, consistent with myeloablative therapy, and her ANCs rebounded nicely thereafter. ANC upon discharge was 923. She developed severe oral mucositis, requiring TPN for a short period of time, but this resolved with routine oral care and she is now able to tolerate POs, though her appetite is still depressed. She currently has a small well-healing area of mucositis in the left buccal mucosa. She had a 3rd bone marrow biopsy on [2179-3-18] but results are pending at this time. She will continue her oncology care with Dr. [First Name8 (NamePattern2) 7422] [Last Name (NamePattern1) ], with whom she has an appointment on [2179-3-22]. . # Neutropenic Fever: On admission she was started on vanco/cefepime/azithro for questionable CAP. A CT chest was performed given her hypoxia, which showed PE with basilar infarcts. Her coverage was broadened to vanco/zosyn/levo/amphotericin. Fungal markers (galactomannan and B-glucan) were ultimately negative and she was switched from amphotericin to voriconazole. She developed rigors and a non-painful and non-pruritic diffuse body rash and antibiotics were switched to vanco/meropenem. Oral lesions were consistent with mucositis but suspicious for viral infection (HSV) and she was started on IV acyclovir. Viral culture was ultimately negative. She was transferred from the ICU to the BMT floor on vanc/[Last Name (un) 2830]/voriconazole/acyclovir. She remained afebrile and all cultures were negative so the antibiotics were eventually stopped. She was discharged home on prophylactic fluconazole and acyclovir. . # Hypoxia/PE: She was initially diuresed with gentle IV furosemide boluses as her high respiratory rate and CXR findings were felt secondary to fluid overload given aggressive hydration as part of chemo. Due to concern for PE, CTA was performed and demonstrated bilateral PEs and pulmonary infarction in addition to considerable lymphadenopathy. She had negative bilateral LE dopplers and a CT of the neck and CT abdomen and pelvis showed no evidence of venous thrombosis peripherally or in the more central veins. An IVC filter was placed on [2179-2-13] given the inability to start anticoagulation due to thrombocytopenia. . # Anemia/Thrombocytopenia/Menorrhagia: Initial platelet count was 103 but she became profoundly thrombocytopenic after initiation of chemotherapy. In the ICU she required several platelet infusions though she did not appear to be bumping appropriately. Blood bank was consulted who recommended infusion of only O+ platelets. This trend continued while on the floor, exacerbated by vaginal bleeding. GYN was consulted and a transvaginal U/S showed multiple fibroids and a hypervascular endometrium. They deferred endometrial biopsy due to her neutropenia, and deferred hormonal therapies given the prothrombotic risks in someone with a PE. She was treated conservatively with continued transfusions and [Hospital1 ] hematocrit/plt checks. Her bleeding slowed markedly and her bone marrow began to recover with decreased need for transfusions. She currently has only scant menorrhagia. . # Rash: Patient developed several quarter sized areas of hyperpigmented, raised lesions on her legs shortly after chemotherapy was completed. Dermatology was consulted and two separate biopsies were obtained, but findings were non-specific. The quantity of the infiltrate was not consistent with leukemia cutis but due to the few enlarged perivascular cells and the fact that this did not fit with any typical dermatitis, hemepath was asked to review. Immunostains were unremarkable. The rash resolved without intervention. . # Diarrhea: Patient noted frequent stools without abdominal pain. C. diff toxins, C. diff PCR, and stool studies were negative throughout hospitalization. Etiology likely secondary to chemotherapy and had resolved by discharge. . # [Last Name (un) ]: Creatinine peaked at 2.7 and the nephrology service was consulted. Urine sediment showed muddy brown casts, consistent with ATN, but urine electrolytes were more consistent with contrast-induced nephropathy vs. pre-renal etiology. Numerous nephrotoxic medications including amphotericin-B, acyclovir, and voriconazole were also implicated. Renal U/S negative. Her creatinine began to improve markedly and trended toward baseline as her condition improved. Discharge creatinine was 1.0. . # Type 2 Diabetes: Previously diet-controlled. Admission glucose was 256 and subsequent blood glucoses were significantly elevated. HbA1c 9.5%. She intermittently required an insulin gtt while in the ICU. She was transitioned to NPH [Hospital1 ] and ISS prior to transfer to the floor, which was transitioned to Lantus QHS once D5W was discontinued for treatment of hypernatremia. She was briefly started on glyburide [Hospital1 ], but due to poor appetite and PO intake, her blood sugars were low and the glyburide and insulin was stopped. She will require close follow up and blood sugar monitoring once her appetite improves and she is eating regularly. She may require oral DM meds in the future. . # HTN: The patient was not on any anti-hypertensive medications upon admission but did require treatment during this hospitalization. She was discharged on metoprolol tartrate 50mg [Hospital1 ]. . # Pending Results: bone marrow biopsy from [3-18] . # Code Status: Full Code . A copy of this summary was faxed to Dr. [Last Name (STitle) ] Medications on Admission: None Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:0 2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:0 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Acute myelogenous leukemia . Secondary diagnoses: - Pulmonary emboli - Acute kidney injury - Diabetes mellitus - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 6402], It was a pleasure taking part in your care at the [Hospital1 771]. You were initially admitted to the intensive care unit with fevers, nausea, and vomiting. Lab testing and a bone marrow biopsy showed that you have leukemia which was treated with chemotherapy. You were also found to have a small clot in your lungs which we treated by placing a filter in one of your veins. You had some vaginal bleeding which required some blood transfusions, but this is resolving. After your chemotherapy your white blood cells are trending upward toward normal levels. You will be following up with Dr. [Last Name (STitle) ] for further management of your leukemia and for further chemotherapy. Please see below for details on your future appoitments. Your blood sugars have been high suggesting that you likely have diabetes. You should speak with your primary care doctor about this. . We started the following medications: - Acyclovir for your leukemia - Fluconazole for your leukemia - Metoprolol for your blood pressure - Prochlorperazine for your nausea Followup Instructions: Department: BMT/ONCOLOGY UNIT When: SATURDAY [2179-3-20] at 8:30 AM [Telephone/Fax (1) 447] Building: Fd [Hospital Ward Name 1826] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3971] Campus: EAST Best Parking: Main Garage . Department: Dr. [Last Name (STitle) ] (ONCOLOGY) When: MONDAY [2179-3-22] at 2:45 PM [Telephone/Fax (1) 80105] Location: [Hospital6 3105] [Location (un) ] Completed by:[2179-3-21]	[ "276.8", "584.5", "276.2", "695.2", "278.00", "486", "401.9", "205.00", "250.00", "284.1", "276.3", "276.0", "995.91", "787.91", "288.00", "799.02", "410.71", "780.61", "038.9", "218.0", "528.00", "626.2", "415.19" ]	icd9cm	[ [ [] ] ]	[ "38.97", "38.7", "99.71", "86.11", "99.15", "99.25", "41.31" ]	icd9pcs	[ [ [] ] ]	22345, 22351	15515, 15848	338, 576	22542, 22542	4003, 4003	23809, 24302	2653, 2700		21861, 22322		22372, 22372		21832, 21838			22693, 23786			5501, 15492					2715, 3546		22443, 22521				3562, 3984																			264, 300						15876, 21806				604, 2273					4019, 4887	22391, 22422		22557, 22669	4903, 5485						2295, 2408	2424, 2637
59,141	145,645	7032	Discharge summary	report	Admission Date: [2182-2-13] Discharge Date: [2182-2-20] Date of Birth: [2118-5-23] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Ace Inhibitors / Acebutolol / Atenolol / Betaxolol / Bisoprolol / Carvedilol / Labetalol / Metoprolol / Nadolol / Penbutolol / Pindolol / Propranolol / Timolol Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of breath/Fatigue Major Surgical or Invasive Procedure: [2182-2-13] 1. Left thoracotomy and placement of epicardial left ventricular pacing lead. 2. Repositioning automatic implantable cardioverter defibrillator/biventricular pacer generator. History of Present Illness: Mr. [Known lastname ] is a very ill appearing 63 year old gentleman with a relevant past medical history notable for cardiomyopathy and ventricular tachycardia. He underwent placement of an AICD/PPM in [2175] and subsequent LV lead placement in [2178] for biventricular pacing for heart failure. He developed a pocket infection and the superficial portion of the LV leads were extracted along with the ICD/PPM in [2180]. He later underwent reimplantation of his AICD/PPM in [8-29] but now requires an LV lead for biventricular pacing to help reduce his heart failure symptoms. Over the past 1.5 months he has become profoundly dyspneic with minimal activity and has severe peripheral edema. Given the worsening of his heart failure symptoms, he has been referred to Dr. [Last Name (STitle) 914] for LV lead placement for biventricular pacing. Past Medical History: 1. Nonischemic cardiomyopathy, chronic systolic heart failure. 2. Mitral regurgitation with pulmonary hypertension. 3. Ventricular tachycardia s/p ICD implantation [2175] 4. COPD. 5. Morbid obesity. 6. Spinal stenosis. 7. Right malignant renal tumor, s/p right nephrectomy 8. Stage 4 chronic renal failure. 9. Hypertension. 10. Leg ulcers. 11. Gout Laparoscopic cholecystectomy in [2174], Mini thoracotomy LV Lead placement [8-27] Hernia repair ICD Removal [1-/2181] due to pocket infection Remimplantation of AICD on [2-/2181] - [Company 1543] Serial # [Serial Number 26269] # C154DWK Right nephrectomy [3-/2180] Right ankle skin graft for non-healing ulcer [2-/2180] Social History: retired truck driver - lives with spouse Remote tobacco use (quit when he was 35) No EtOH No illicits. Family History: No family history of premature cardiac disease. Physical Exam: Pulse:90 SR Resp: 24 O2 sat: 100% RA B/P Left: 118/74 Height: 72" Weight: 440.5 General: Morbidly obese gentleman sitting in wheel chair. Short of breath from moving from chair to wheel chair. NAD while sitting. Skin: Warm, dry and intact. Strae noted on abdomen. Well healed left thoracotomy. Hypertrophic Left upper chest pacer pocket scar. Well healed right upper chest pacer pocket. Severe venous stasis changes of bilateral LE's. Palor appears mildly cyanotic. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. Right buccal mucosa with likely canker. Neck: Supple [X] Full ROM [X] JVD 9cm Chest: Expiratory wheeze, left > right, diminshed BS at bases bilaterally. Poor air movement and insp/exp effort. Heart: RRR, Distant heart sounds, Nl S1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Obese, strae noted. Well healed lap cholecsytectomy ports. Extremities: Warm, severe 3+ edema with blisters, chronic venous stasis changes. Varicosities: Likely severe but unable to stand. Neuro: Grossly intact, barely able to stand, walk a few feet or sit which appears mostly related to obesity. + Tremors of Bilaterall UE's Pulses: Femoral Right:1+ Left:1+ DP Right: Non palp Left: Non palp PT [Name (NI) 167]: Non palp Left: Non Palp Radial Right:1+ Left:1+ Carotid Bruit None appreciated bilaterally Pertinent Results: Admission Labs: [2182-2-13] 09:56AM HGB-11.6* calcHCT-35 [2182-2-13] 09:56AM GLUCOSE-117* LACTATE-1.0 NA+-142 K+-4.2 CL--100 [2182-2-13] 03:08PM PT-14.6* PTT-33.9 INR(PT)-1.3* [2182-2-13] 03:08PM PLT COUNT-163 [2182-2-13] 03:08PM WBC-7.9 RBC-3.87* HGB-10.0* HCT-32.5* MCV-84 MCH-25.8* MCHC-30.8* RDW-19.2* [2182-2-13] 03:08PM UREA N-71* CREAT-2.7# CHLORIDE-105 TOTAL CO2-30 Discharge Labs: [2182-2-19] 05:30AM BLOOD WBC-5.9 RBC-3.60 Hgb-9.5* Hct-30.3* MCV-84 MCH-26.6* MCHC-31.6 RDW-19.2* Plt Ct-119* [2182-2-19] 05:30AM BLOOD Plt Ct-119* [2182-2-16] 02:33AM BLOOD PT-14.3* PTT-37.5* INR(PT)-1.2* [2182-2-19] 05:30AM BLOOD Glucose-83 UreaN-72* Creat-3.2* Na-141 K-4.6 Cl-104 HCO3-27 AnGap-15 [Hospital1 18] ECHOCARDIOGRAPHY REPORT Age (years): 63 M Hgt (in): 63 BP (mm Hg): 107/71 Wgt (lb): 450 HR (bpm): 70 BSA (m2): 2.73 m2 Indication: Dilated cardiomyopathy. Left ventricular function. Mitral valve disease. Ventricular ectopy. Date/Time: [2182-2-13] at 11:01 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 20% to 25% >= 55% TR Gradient (+ RA = PASP): 30 to 32 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Severely dilated LV cavity. Severely depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild to moderate ([12-22]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-22]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [Name Initial (NameIs) ] 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) ] [2182-2-15] 12:22 Radiology Report CHEST (PORTABLE AP) Study Date of [2182-2-17] 7:22 AM Final Report HISTORY: Status post CABG. IMPRESSION: AP chest compared to [2-15]: Two frontal views of the chest fail to image lateral aspect of the left lung base. There is no pulmonary edema. Severe cardiomegaly is stable postoperatively and comparable to the preoperative appearance. There is no pulmonary edema. Mild right peribronchial opacification could be atelectasis. Left pleural thickening which developed postoperatively is unchanged. It would be very useful to get conventional chest radiographs of this patient to assess the significance of left pleural abnormality and the right infrahilar opacification. There is no pneumothorax or mediastinal widening. The course of the right subclavian transvenous pacer and pacer defibrillator leads are not clear, but the tip of the defibrillator projects over the floor of the right ventricle, as before. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Brief Hospital Course: [2182-2-13] Mr. [Known lastname ] went to the operating room and underwent Left thoracotomy and placement of epicardial left ventricular pacing lead,and repositioning automatic implantable cardioverter defibrillator/biventricular pacer generator. Please see Dr[Last Name (STitle) 5305] operative note for further details. He tolerated the procedure well and was transferred to the CVICU intubated, sedated, in critical but stable condition. He awoke neurologically intact and was extubated without difficulty. Acute pain services was following postoperatively due to Mr.[Known lastname 26270] epidural. He was weaned off the epidural and placed on oral pain medications. Home cardiac medications were resumed and due to hypotension his antihypertensives were stopped. All lines and drains were discontinued in a timely fashion. He remained in the CVICU for close observation of his renal function as his Creatinine rose transiently from his already elevated baseline. Renal was consulted for acute tubular necrosis. He continued to progress and was transferred to the step down unit for further monitoring. Physical and occupational therapy was consulted for strength and mobility evaluation. The remainder of his postoperative course was essentially uneventful. On POD# seven he was cleared by Dr.[Last Name (STitle) 914] for discharge to rehab on telemetry and will follow up for device check with Dr [Last Name (STitle) 5051]. Medications on Admission: FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - 250 mcg-50 mcg/Dose Disk with Device - 1 puff twice a day FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 1.5 Tablet(s) by mouth twice a day HYDRALAZINE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth three times a day ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Sustained Release 24 hr - 2 Tablet(s) by mouth qam LOSARTAN [COZAAR] - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day MEXILETINE - (Prescribed by Other Provider) - 200 mg Capsule - 2 Capsule(s) by mouth every morning, one tablet every afternoon, one tablet every evening MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day QUINIDINE GLUCONATE - (Prescribed by Other Provider) - 324 mg Tablet Sustained Release - 2 Tablet(s) by mouth qam, one tablet every afternoon, one tablet every evening ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. medications Lasix currently being held - creatinine conitnues to improve - please resume half normal dose of lasix (120mg twice a day - home dose) when fluid balance even - currently autodiuresing with > 1000 ml negative in 24 hours 8. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)): 2 tabs in am 1 tab in afternoon 1 tab in evening . 9. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: please give in afternoon and bedtime - takes 2 tabs in am - see other order . 10. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)): 400mg in am 200mg in afternoon and at bedtime . 11. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO twice a day: 400mg in am 200mg in afternoon and at bedtime . 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as needed for dyspnea. 13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. heart failure and blood pressure medications When able please resume betablocker and home antihypertensives - were held due to blood pressure and renal disease - please add back slowly with goal B/P 110-120 due to heart failure and renal disease 15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q3h as needed for pain. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: malfunctioning biventricular pacing system s/p lead placement chronic systolic heart failure Stage 3 chronic renal failure hypertension chronic venous stasis disease morbid obesity chronic obstructive pulmonary disease Discharge Condition: Alert and oriented x3, nonfocal Thoracotomy incisional pain managed with dilaudid prn Activity Status: Ambulating short distances using walker ~80 ft with assistance Left thoracotomy wound 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 until follow up with surgeon No lifting more than 10 pounds for 4 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Heart center of [Hospital1 ] - for follow up visit Dr [Last Name (STitle) ] for Dr [Last Name (STitle) 914] [3-7] at 915 am [Telephone/Fax (1) 6256] PCP: [Last Name (NamePattern4) ].[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 26237] in 1 week # [Telephone/Fax (1) 26268] Cardiologist: Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5051] in 1 week [Telephone/Fax (1) 6256] - for device check - device clinic aware - please call to verify date and time Nephrology Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 26271] - tuesday [3-19] at 945 am Completed by:[2182-2-20*]	[ "403.90", "278.01", "585.4", "424.0", "E878.1", "496", "996.04", "416.0", "428.0", "414.00", "V45.73", "V10.52", "425.4", "454.0", "428.23", "274.9", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "37.74", "37.79", "88.72" ]	icd9pcs	[ [ [] ] ]	13676, 13706	9130, 10586	468, 669	13969, 14197	3930, 3930	14736, 15432	2441, 2490		11714, 13653		13727, 13948		10612, 11691			14221, 14713			4357, 9107					2505, 3911																									400, 430										697, 1565					3946, 4341										1587, 2304	2320, 2425
31,679	197,697	46794	Discharge summary	report	Admission Date: [2176-7-18] Discharge Date: [2176-7-22] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: Ms. [Known lastname 41236] is an 86yo female with PMH significant for CAD and DM who presented with abdominal pain. Developed RLQ abdominal pain Tuesday with supper accompanied by vomiting. Per notes pain was in RUQ, but today she states that it was in RLQ. Pain was sharp and crampy. Called PCP who recommended the ED, but patient declined. The following she day she improved but symptoms returned around 5pm. No fevers, chills, hemetemesis, SOB, chest pain. Her son brought her to the [Name (NI) ] due to persistent symptoms. . In the ED initial vitals were T 96.6 BP 123/70 AR 111 RR 22 O2 sat 97% RA. She received Levaquin 500mg IV, Flagyl 500mg IV, Morphine, Ativan, and Zofran. NGT was placed. . She was originally sent to MICU for GI evaluation. CT abd/pelvis showed mild cholecystitis with ductal dilatation and labs were in support of an obstructive picture. She also had evidence of gallstone pancreatitis on labs. She had an NGT placed and underwent ERCP which showed large CBD, sludge, small stones, with evidence of ampullary laceration likely from a passed stone. No sphincterotomy was performed because the patient had been on plavix, and instead a stent was placed. Past Medical History: # CAD s/p inferior MI in [2169] w/stent placement # Type 2 DM # Hypertension # h/o bursitis of R hip # Low back pain/lumbar radiculopathy # Glaucoma. # Osteoarthritis Social History: Lives at home with 2 sons. Denies tobacco, alcohol, or IVDA. Family History: non-contributory Physical Exam: Vitals T 98.2, 156/68, 104, 18, 97% RA Gen: Pleasant, NAD, talkative HEENT: NCAT, PERRL, EOMI, MMM, OP clear Neck: supple, no LAD Heart: RRR, nl s1/s2, no MRG Lungs: faint bilateral crackles Abdomen: soft, not distended, discomfort with palpation of lower abd ("always there") and more pinpoint discomfort in RUQ and epigastrum to deep palpation, no rebound or guarding, + BS, no [Doctor Last Name ] Extremities: No edema, 2+ DP/PT pulses bilaterally Skin: Mild jaundice, no rashes Pertinent Results: [2176-7-21] 07:45AM BLOOD Hct-36.4 [2176-7-20] 10:20AM BLOOD WBC-10.8 RBC-4.26 Hgb-12.6 Hct-36.6 MCV-86 MCH-29.6 MCHC-34.5 RDW-15.3 Plt Ct-246 [2176-7-19] 04:45PM BLOOD Hct-31.4* [2176-7-19] 08:00AM BLOOD WBC-13.0* RBC-3.78* Hgb-11.4* Hct-32.3* MCV-85 MCH-30.2 MCHC-35.4* RDW-15.5 Plt Ct-194 [2176-7-18] 03:50AM BLOOD WBC-19.0# RBC-4.49 Hgb-13.7 Hct-38.5 MCV-86 MCH-30.5 MCHC-35.6 RDW-15.8* Plt Ct-252 [2176-7-18] 03:50AM BLOOD Neuts-93.2* Lymphs-4.4* Monos-2.3 Eos-0.1 Baso-0.1 [2176-7-18] 03:50AM BLOOD PT-11.5 PTT-24.2 INR(PT)-1.0 [2176-7-22] 07:45AM BLOOD K-3.9 [2176-7-21] 07:45AM BLOOD UreaN-11 Creat-0.9 Na-141 K-4.2 Cl-110* HCO3-21* AnGap-14 [2176-7-20] 10:20AM BLOOD UreaN-9 Creat-1.0 Na-139 K-2.8* Cl-106 HCO3-18* AnGap-18 [2176-7-18] 03:50AM BLOOD Glucose-226* UreaN-26* Creat-1.3* Na-138 K-2.6* Cl-102 HCO3-18* AnGap-21* [2176-7-22] 07:45AM BLOOD ALT-182* AST-46* AlkPhos-247* Amylase-133* TotBili-1.0 [2176-7-19] 08:00AM BLOOD ALT-427* AST-127* LD(LDH)-189 AlkPhos-308* Amylase-368* TotBili-1.9* [2176-7-18] 03:50AM BLOOD ALT-700* AST-310* AlkPhos-380* Amylase-3524* TotBili-4.5* [2176-7-22] 07:45AM BLOOD Lipase-123* [2176-7-18] 03:50AM BLOOD Lipase-8590* [2176-7-19] 08:00AM BLOOD Albumin-3.4 Calcium-8.3* Phos-2.0* Mg-1.7 [2176-7-22] 07:45AM BLOOD Mg-2.3 [2176-7-18] 04:01AM BLOOD Lactate-1.9 [2176-7-18] 06:03AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2176-7-18] 06:03AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [2176-7-18] 06:03AM URINE RBC-0-2 WBC-[1-29] Bacteri-MOD Yeast-NONE Epi-0-2 [2176-7-18] 3:55 am BLOOD CULTURE #2. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Final [2176-7-20]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] AT 1610 ON [7-18].. ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2176-7-20] 7:54 pm STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2176-7-21] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2176-7-21]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2176-7-19] 1:00 pm BLOOD CULTURE BLOOD CULTURE 1 OF 2.. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [2176-7-19] 4:45 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): CT abd-pelvis - IMPRESSION: 1. Mild gallbladder wall thickening with mild pericholecystic edema/fluid. There is moderate intrahepatic biliary ductal dilatation and mild CBD prominence. These findings could represent an obstruction at the ampulla, although a discreet obstructing lesion is not identified on this study. HIDA nuclear scan could be performed to evaluate for acute cholecystitis. MRCP and/or ERCP would be recommended to exclude ampullary pathology. 2. No evidence for small bowel obstruction. 3. Focal emphysema in the left side and dome of urinary bladder. This could be iatrogenic, however emphysematous cystitis is not excluded. 4. Marked lumbar spine degenerative disease with multilevel significant central canal stenosis and neural foraminal narrowing GALLBLADDER ULTRASOUND: The gallbladder is slightly distended. The wall slightly thickened without evidence of definite edema. No pericholecystic fluid, stones or sludge are seen. The CBD measures 5 mm. The portal vein is patent with appropriate flow directionality. IMPRESSION: Mild gallbladder wall thickening. No stones, sludge or pericholecystic fluid identified. Positive [Doctor Last Name 515] sign per US technologist. In the right clinical setting, these findings could represent cholecystitis. If further clarification is needed, a HIDA scan could be performed. KUB - IMPRESSION: Air-distended small bowel loops at the above limits of normal in terms of caliber. No air-fluid levels. These findings could be consistent with early small-bowel obstruction, although they are not diagnostic. CXR - IMPRESSION: No evidence of free intra-abdominal air. Cardiology Report ECG Study Date of [2176-7-18] 3:46:00 AM Sinus tachycardia Right bundle branch block Primary ST-T wave abnormalities - are nonspecific clinical correlation is suggested Since previous tracing of [2170-2-23], further ST-T wave changes present ERCP - Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Small laceration of the major papilla was noted. Cannulation: Cannulation of the biliary duct was successful and deep using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was mildly difficult. Biliary Tree: There was a filling defect that appeared like sludge in the lower third of the common bile duct. Otherwise common bile duct, common hepatic duct, right and left hepatic ducts, were filled with contrast and visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects Procedures: A 7 cm by 10 fr Cotton-[Doctor Last Name ] biliary stent was placed successfully in the lower third of the common bile duct and middle third of the common bile duct using a Oasis system stent introducer kit. Impression: Laceration of the major papilla Sludge was found in the bile duct. Otherwise the biliary tree was normal. A biliary stent was inserted Recommendations: Return patient to ICU for further treatment and evaluation. Repeat ERCP in 2 months - patient needs to stop Plavix 5 days prior to ERCP for sphincterotomy. Brief Hospital Course: Septicemia, E coli - blood cultures at admission grew E.coli which was pansensitive the likely source was biliary tree (refer below). After initial IV unasyn, cipro was started. Repeat blood cultures were negative at time of discharge. Plan is to complete a course of 14 days total from the negative blood cultures [2176-7-19]. Cholangitis, cholecystitis and acute pancreatits - likely gallstone induced with superimposed infection. ERCP done - read as above. Sphinctrotomy not done given risk of bleed as patient on plavix. surgery was consulted but patient refused to have a cholecystectomy. Hence, advised to follow up with GI as scheduled for an ERCP for a sphincterotomy. The patient should be off plavix for 7-10 days prior to then. Cipro + flagyl -- for total 14 days. Acute renal failure- was prerenal. Resolved with fluids in ICU. Coronary artery disease Diabetes mellitus, controlled with complications Hypertension, benign - these medical problems remained stable. Concern for elder abuse - Daughter [Name (NI) 4134] had mention to SW in ICU that she was worried about patent living with her sons. However, daughter denies that pt is in an "unsafe" situation. The patient lives with 2 sons, one of which [Name (NI) 1193] takes care of her. On many occasions, the physicians talked with the patient who absolutely denied that she was in an unsafe situation. She was eager to return home to her dog and son. she mentions that her son [Doctor Last Name ] takes care of her since her usband died 4 years back. He cooks, cleans for her, does laundry, shops and takes her out for a car ride etc. Patient refused the claim for elder abuse. Said 'If any thing is not safe, I know to go to a home'. SW assistance was obtained as well who also did not feel patient was at risk at home. Home services were arranged for including PT. Medications on Admission: Ibuprofen 800mg PO TID Glyburide 5mg PO daily Plavix 75mg PO daily Nifedical 60mg PO daily Lisinopril 40mg PO daily Travatan eye gtt Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:22 Tablet(s) Refills:0 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. Disp:30 Tablet(s) Refills:0 4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Nifedical XL 60 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 8. Travatan Ophthalmic Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Septicemia, E coli Acute cholangitis, cholecystitis Acute gallstone pancreatitis Acute renal failure Coronary artery disease Diabetes mellitus, controlled with compications Hypertension, benign Discharge Condition: Stable Discharge Instructions: Return to the hospital if you notice abdominal pain, nausea, vomiting, fever, chills, diarrhea, chest pain or any new symptoms of concern to you. Keep your appointments as scheduled. You were diagnosed with infection of the gall bladder and inflammation around the pancreas. For this the surgeons have recommended that you get the gall bladder removed by surgery. However, you have chosen to refuse this. You are advised that if you decide you want to have the surgery - talk with your primary doctor and ask him to set up a follow up appointment with the surgeons for you. Complete the course of antibiotics as prescribed. While you are on the antibiotic (ciprofloxacin), check your blood sugars more closely and they may run lower than usual. If you experience blood sugars < 60 or have symptoms of low blood sugars like tremors, sweating, dizziness, weakness etc - call your primary doctor immediately. Followup Instructions: Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Date/Time:[2176-9-19] 10:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2176-9-19] 10:00 [Last Name (LF) ],[First Name3 (LF) ] L. [0-0-] ([Telephone/Fax (1) 8474] fax)- [2176-8-23] at 1PM. I have also made another appointment with Dr [Last Name (STitle) 1147] for [2176-8-2] - at 11AM.	[ "414.01", "250.00", "584.9", "995.91", "038.42", "574.31", "715.90", "576.1", "577.0", "401.9", "365.9" ]	icd9cm	[ [ [] ] ]	[ "51.87" ]	icd9pcs	[ [ [] ] ]	11585, 11643	8784, 10640	277, 283	11880, 11888	2332, 4068	12847, 13305	1792, 1810		10824, 11562		11664, 11859		10666, 10801			11912, 12824								1825, 2313																									223, 239				5468, 5468			5497, 8761			311, 1503															1525, 1698	1714, 1776
16,943	111,576	28344	Discharge summary	report	Admission Date: [2144-2-18] Discharge Date: [2144-2-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2840] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD- [2144-2-20] Sigmoidoscopy - [2144-2-20] History of Present Illness: [Age over 90 ]yoM with h/o MDS, CAD, CHF (preserved EF), cryptogenic cirrhosis, unconfirmed h/o HBV, GAVE, esophageal, gastric, and rectal varices, endocarditis, CKD, admitted [2144-2-18] with chief complaint of "weakness,". Pt initially presented to [Hospital1 18] ED with complaint of one day of weakness/dizziness and feeling "wobbly" on his feet. Due to his MDS, pt usually requires a PRBC transfusion when he feels weak. His last transfusion was three weeks prior to admission, and he is usually transfused every 2-4 weeks. On admission he denied having chest pain, abdominal pain, fevers, dysuria, bloody or black stools. Past Medical History: 1)CAD s/p PTCA [2123], negative stress test [2141] 2)Sick sinus syndrome, s/p pacemaker [2139] (now on 3rd pacemaker) 3)CHF (ECHO [8-24]: EF 30-35%, apical akinesis, severe hypokinesis of anterior and anteroseptal wall, ECHO [2144-2-19] EF >55%, no wall motion abnormalities, 1+MR) 4)Hx of gastric antral vascular ectasia (GAVE) 5)TIA [2135] 6)CRF, baseline Cr~2.0 7)Myelodysplastic syndrome, thrombocytopenia X 5-6 years 8)Hepatitis B history with "cryptogenic" cirrhosis listed in [Medical Record Number 68809])hx of gastric, esopaphageal, and rectal varices 10)hx of enterococcal endocarditis [2140] 11)BPH 12)Gait disturbance Social History: Social hx: - lives alone in apartment on [Location (un) 448] of daughter's home - recently moved from [Location (un) 9095] - Retired teacher who has traveled extensively to Europe as [Last Name (un) 68810] Scholar - non-smoker - occasional EtOH - no illicit drugs Family History: NC Physical Exam: PE: T 97.8 HR 67 BP 142/67 RR 18 99 2L NC . GEN: AAOx3, NAD, comfortable w/ head of bed elevated HEENT: PERRL/EOMI, anicteric, conjunctiva clr, MMM Neck: supple, no LAD, JVP nondistended CV: RR, irreg rhythm, II/VI SEM at LLSB Resp: coarse BS bil bases, otherwise clear Abd: +BS, soft, NT, ND, no masses Ext: trace BLE edema, R toe wound dressing C/D/I. Neuro: A&Ox3, CN II-XII intact Pertinent Results: [2144-2-18] 07:40AM BLOOD WBC-7.6 RBC-3.36* Hgb-9.6* Hct-30.7* MCV-91 MCH-28.5 MCHC-31.2 RDW-15.4 Plt Ct-48* [2144-2-20] 06:50AM BLOOD WBC-7.1 RBC-2.62* Hgb-7.4* Hct-23.8* MCV-91 MCH-28.2 MCHC-31.1 RDW-15.0 Plt Ct-32* [2144-2-24] 05:00AM BLOOD WBC-5.1 RBC-3.46* Hgb-9.9* Hct-30.4* MCV-88 MCH-28.7 MCHC-32.7 RDW-14.7 Plt Ct-33* [2144-2-19] 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-31* LPlt-3+ [2144-2-24] 12:35PM BLOOD Plt Ct-54# [2144-2-18] 07:40AM BLOOD Glucose-192 UreaN-40* Creat-2.1* Na-135 K-4.0 Cl-97 HCO3-30 AnGap-12 [2144-2-20] 06:50AM BLOOD Glucose-137* UreaN-56* Creat-2.4* Na-132* K-4.2 Cl-98 HCO3-24 AnGap-14 [2144-2-24] 05:00AM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-137 K-3.4 Cl-102 HCO3-24 AnGap-14 [2144-2-25] 05:30AM BLOOD WBC-4.8 RBC-3.60* Hgb-10.2* Hct-32.1* MCV-89 MCH-28.4 MCHC-31.9 RDW-14.7 Plt Ct-58* [2144-2-25] 05:30AM BLOOD Plt Ct-58* LPlt-1+ [2144-2-25] 05:30AM BLOOD PT-13.2* PTT-27.7 INR(PT)-1.1 Brief Hospital Course: ED Course: On arrival to [Hospital1 18] ED, T 98.2 HR 92 BP 142/64 RR 20 99%RA. Pt was admitted for anemia and weakness. . [Location (un) ]: Pt received transfusion to bolster his anemia. Unfortunately, pt experienced a temperature increase during blood transfusion to 100.9, and then fever up to 101.8. Pt recieved full fever w/u, with one of four blood cultures with GPC; he was treated with vancomycin x 1, but when CT max-facial revealed acute sinusitis, vanc was replaced with Augmentin. Also with CKD (creatinine 2.0 at baseline), rose to 2.4. On [2144-2-20], pt spiked a fever to 101.8 and passed BRBPR, melanotic stool, and clots; HR increased to 115 and BP dropped to 70s/40s. Pt was transferred to the ICU for futher care. . MICU: Pt received 950cc NS and had another liter hanging on initial ICU evaluation. He was being transfused two units PRBC, was alert, mentating, denied chest pain, SOB, abdominal pain, nausea. On MICU eval T 97.0 HR 80 BP 90/63 RR 18 100%2L. Pt received protonix, octreotide, PRBCs, FFP, DDAVP, and GI consultation. GI performed EGD and sigmoidoscopy on [2144-2-20], which revealed that the likely source of the GIB was a gastric polyp (which was resected). Hepatology was consulted given h/o cirrhosis, and blood tests failed to reveal HBV infection; hepatology continues to follow. Pt remained hemodynamically stable and was called out to the floor on [2144-2-22]; he experienced one episode of hemoptysis on [2144-2-23] w/o other issues. Pt. underwent speech and swallow eval that showed no evidence of aspiration. . [Hospital1 1516]: Upon arrival to the floor, pt was asymptomatic and without complaint. He was tolerating a regular diet. On [2144-2-24] he was transfused one unit of platelets. He c/o of loose stools and had a Cdiff that was negative. Pt. continued to have guaic + stool after his GI bleed, but his Hct remained upward trending. He was evaluated by PT and felt to be a candidate for rehab. He will require a 14 day total course of Unasyn IV for his Strep G Bacteremia. On day of d/c, pt. had a midline placed for his IV abx. He was d/c to rehab with PCP and GI [Name9 (PRE) 702]. He will also follow-up with his hematologist as scheduled. Medications on Admission: Metolazone 1.25mg qday Omeprazole 20mg [Hospital1 ] Nadolol 80mg qday KCl 20mg [Hospital1 ] Fulbic Iron 325mg qday Flomax 0.4mg qhs ASA 81mg qday lasix 20mg qMWF Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for neck pain. 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD (). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Unasyn 3 g Recon Soln Sig: Three (3) g Intravenous twice a day for eight days. 7. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2 times a day). 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: GI Bleeding Bacteremia Discharge Condition: Good Discharge Instructions: See your own doctor right away or go to the ER if any problems develop, including the following: * Severe Bleeding from your rectum * Markedly bloody stools * Fever > 101 * Difficulty Breathing * Your chest pain or chest discomfort lasts longer than 5 minutes. * Your chest pain or chest discomfort gets worse in any way. * You have angina and your chest pain or chest discomfort is worse, lasts longer than usual or comes on with less activity than usual. * You have angina and your chest pain or chest discomfort is not relieved by your usual medicines. * You develop any shortness of breath, sweats, dizziness, throwing up or nausea with your chest pain or chest discomfort. * Your chest pain or chest discomfort moves into your arm, neck, back, jaw or stomach. * Dizziness * Loss of Consciousness * Anything else that worries you. Even if you feel better and have no further chest pain or chest discomfort, follow-up with your own doctor tomorrow. The Emergency Department is open 24 hours a day for any problems. Followup Instructions: You should follow-up with your primary care doctor as already scheduled: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2144-3-2] 12:00 You should call should you need to reschedule this appointment. You should follow-up with Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] in [7-28] days. You should call ([Telephone/Fax (1) 16940] and schedule an appointment. You should follow-up with the below appointments as previously scheduled. Provider: [Name10 (NameIs) 3242] CHAIR 2 Date/Time:[2144-2-27] 10:00 Provider: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], RN Phone:[Telephone/Fax (1) 3241] Date/Time:[2144-2-27] 10:00 Completed by:[2144-2-25]	[ "041.19", "790.7", "537.9", "571.5", "238.75", "428.0", "456.8", "414.01", "585.9", "584.9", "211.1", "461.9", "562.10", "456.21", "403.91", "578.9", "285.21" ]	icd9cm	[ [ [] ] ]	[ "44.43", "38.93", "43.41", "45.23" ]	icd9pcs	[ [ [] ] ]	6731, 6797	3420, 5669	270, 325	6864, 6871	2424, 3397	8039, 8920	1995, 1999		5889, 6708		6818, 6843		5695, 5866			6895, 8016								2014, 2405																									223, 232										353, 998															1020, 1685	1701, 1979
49,947	175,903	34695	Discharge summary	report	Admission Date: [2117-2-23] Discharge Date: [2117-3-9] Date of Birth: [2044-10-24] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 348] Chief Complaint: Transfer from [Hospital1 ] [Location (un) 620] for transfusion reaction, diarrhea x 2 months Major Surgical or Invasive Procedure: EGD/Colonoscopy [2-24] PICC line placement History of Present Illness: Patient is a 72 year-old female with a past medical history of gout, hypothyroidism, recent diagnosis of iron deficiency anemia who presented to the MICU yesterday from [Hospital1 ] [Location (un) 620] after becomeing hypoxic and hyptensive during a blood transfusion. Patient reports that in [Month (only) 1096] during a routine physical, Hct was found to be 25 from roughly 34-40, WBC count in the 20s, platelets of 650. This prompted a hematology workup for malignancy. Bone marrow biopsy was done and per [Hospital1 ] [Location (un) 620] d/c summary did not show any primary hematologic malignancy and was "most suggestive of iron deficiency anemia" with reactive leukocytosis and thrombocytosis. She was then started on Fe pills. Simultaneously, around the beginning of [Month (only) ], she began to notice diarrhea, described as one loose bowel movement per day along with intermittent vomiting, associated with 15 pound weight loss, decreased appetite and PO intake. She had a CT Scan of her abdomen/pelvis ordered by her PCP last week, which showed "thickening of the wall of the terminal ileum consistent with acute inflammation and associated mildly enlarged mesenteric lymph nodes." . She was scheduled to undergo an outpatient EGD/colonoscopy on [2-24]. She saw her PCP on this date, who was concerned about her presenting complaint of SOB, and thus sent her to the day clinic for transfusion of 2 units prior to the procedures for persistent anemia. After receiving Lasix with the first unit of blood, and became hypotensive with a systolic blood pressure in the 60's. IV fluids were started and her blood pressure came up; with systolics in the 100's and hypoxic. She had another CT Scan abd/pelvis done, which showed new terminal ileitis but also thickening of the colon wall, Mildly dilated small bowel likely representing paralytic ileus, reactive enlargement mesenteric lymph nodes, and pericholecystic fluid. RUQ U/S was done and showed distended gallbladder as well as wall thickening representing edema, however, there were no stones or son[Name (NI) 493] [Name2 (NI) 515] sign. Cipro/Flagyl was started, then started to ceftriaxone/flagyl and patient was transferred to the ICU (secondary to concern for QTc). She was febrile to 102, and recieved roughly 5 L IVFs, sating 97-99% on 2-3L. In light of Hct continuing to drop to 21, and the fact that she was a difficult crossmatch at [Hospital1 ] [Location (un) 620], she was transferred to [Hospital1 18] for transfusion of blood products and crossmatch tests that could more rapidly be obtained. . Upon arrival to [Hospital1 18] ICU, Hct dropped 26.2 -> 22.6 -> transfused 1u PRBC -> 24.2 -> transfused 1u PRBC -> 28.5 without event. GI was consulted. GI was consulted and an EGD/colonoscopy was performed today, which showed: Diverticulosis of the sigmoid colon, descending colon, transverse colon and ascending colon, and Stricture at the ascending colon through which the scope could not pass, and abnormal mucosa in the esophagus, erythema and congestion in the whole stomach. As patient's clinical status had stabilized, antibiotics were stopped. She will get MR enterography tomorrow for visualization of remainder of colon. On transfer, patient is afebrile, HR 72 128/55, 95% RA. Past Medical History: Low back pain Compression fx Gout s/p right knee replacement s/p right rotator cuff repair s/p hysterectomy s/p fall 1 yr ago Social History: lives alone, is a retired teacher. smokes [1-17] cigarettes per day. denies EtOH, drugs. Family History: father is alcoholic Physical Exam: ADMISSION PE: . VS: Temp: Afebrile BP:128 / 55 HR: 72 RR: 18 O2sat 95% RA GEN: pleasant, comfortable, NAD, lying flat in bed as position best for back pain HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII grossly intact. RECTAL: Guiac negative x 2 . DISCHARGE PE: . O: 98.4 127/60 95 20 99% RA GEN: pleasant, comfortable, NAD, lying flat in bed HEENT: PERRL, EOMI, anicteric, MMM, RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, dull pain in upper quadrants b/l, no [Doctor Last Name ] sign, no guarding or rebound, +b/s, soft, nt EXT: no c/c/e; surgical scars on L leg well healed with no swelling or bruising SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII grossly intact. Pertinent Results: ADMISSION LABS: . [2117-2-23] 06:08AM BLOOD WBC-32.9* RBC-3.27* Hgb-7.9* Hct-26.2* MCV-80* MCH-24.2* MCHC-30.2* RDW-21.5* Plt Ct-584* [2117-2-23] 06:08AM BLOOD Neuts-98* Bands-0 Lymphs-1* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2117-2-23] 07:30AM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2* [2117-3-2] 03:52PM BLOOD ESR-92* [2117-3-2] 05:50PM BLOOD ESR-83* [2117-2-23] 06:08AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140 K-4.0 Cl-108 HCO3-23 AnGap-13 [2117-2-23] 06:08AM BLOOD ALT-14 AST-62* LD(LDH)-828* AlkPhos-84 TotBili-0.7 [2117-2-23] 06:08AM BLOOD TotProt-4.6* Albumin-2.1* Globuln-2.5 Calcium-7.2* Phos-2.0* Mg-2.3 [2117-2-23] 06:08AM BLOOD PEP-NO SPECIFI IgG-1108 IgA-377 IgM-155 IFE-NO MONOCLO [2117-3-2] 11:00AM BLOOD HIV Ab-NEGATIVE [2117-3-5] 05:25AM BLOOD Vanco-16.3 [2117-2-23] 06:08AM BLOOD tTG-IgA-8 . ENDOSCOPY [2117-2-24] Abnormal mucosa in the esophagus (biopsy) Erythema and congestion in the whole stomach (biopsy, biopsy) (biopsy) Otherwise normal EGD to third part of the duodenum . COLONOSCOPY [2117-2-24]: Diverticulosis of the sigmoid colon, descending colon, transverse colon and ascending colon Stricture at the ascending colon (biopsy) Erythema and ulceration in the ascending colon (biopsy) (biopsy) Grade 1 internal hemorrhoids The colonoscope was withdrawn and the upper endoscope was used to reach the stricutred area. This, too, could not be advanced. As a result the procedure was lengthy and aborted in the ascending colon at the site of the stricture. Otherwise normal colonoscopy to ascending colon . BIOPSIES: A. Gastroesophageal junction/z-line: Squamous epithelium, within normal limits; no glandular tissue present. B. Body: Corpus mucosa with mild chronic focally active inflammation; [Doctor Last Name 6311] stain negative for organisms with satisfactory control. C. Antrum: Chronic inactive gastritis; [Doctor Last Name 6311] stain negative for organisms with satisfactory control. D. Duodenum: Duodenal mucosa, within normal limits. E. Ascending colon ulcer: Mild lamina propria fibrosis and architectural disarray; multiple levels examined; see note. F. Stricture: Mild lamina propria fibrosis and architectural disarray; multiple levels examined; see note. G. Colon, random: Within normal limits. Note: The changes are nonspecific, but raise the possibility of healed previous injury. . MR ENTEROGRAPHY: 1. Wall thickening, mural edema and hyperemia involving the cecum, ascending colon and approximately 15-cm segment of the terminal ileum, almost certainly from Crohn's disease. More proximal terminal ileum and distal ileum involvement appears more chronic. Cicatrization in the mid ascending colon with fixed narrowing as seen on clonoscopy. No phlegmon, abscess or fistula formation. 2. Ectasia of the infrarenal abdominal aorta and the left common iliac artery. 3. Inferior mesenteric-lumbar venous shunting and possible small venous malformation in the left upper pelvis. . ECHO [3-3]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) 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. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 72 year-old female with a history of chornic low back/knee pain, hypothyroid, 2 months of diarrhea, weight loss, iron-deficiency anemia, radiographic evidence of ileitis/colitis, initially presented s/p transfusion reaction, colonsocopy showing ascending colonic strciture, eneterography consistent with Crohn's, course complicated by C diff and Coag negative staph bacteremia. . #. Diarrhea, Crohn's, and C. Diff: Patient's history of chronic, non-bloody diarrhea for 2 months, in conjunction with weight loss, malabsorption, and lower abdominal cramping likely indicate Crohn's disease. Patient had multiple CT scans from [Hospital1 ] [Location (un) 620] which indicated colitis and ilietis. Initial colonoscopy at [Hospital1 18] showed a stricture in the ascending colon through which the endoscope could not be passed. Biopsies from the stricutre and imaged parts of the colon showed pathology consistent with chronic fibrosis. To obtain more detailed imaging of all sections of the GI tract, MR Enterography was performed, which showed hyperdensity of contrast and bowel wall thickening in areas of the colon and terminal ileum, which is indicative of Crohn's Disease. At around this time, patient's diarrhea worsened, white blood cell count began to increase, she began to spike fevers, and C. diff toxin assay returned positive. She was initiated on a course of PO Vancomycin, began on [3-3], for a total of 2 weeks. Diarrhea was improving back to her baseline prior to discharge. The GI service felt that once her course for treatment of C. Diff colitis is complete, she would begin treatment for presumed inflammatory bowel disease with Entocort 9 mg daily, to begin on Monday [3-15]. The plan is to perform a repeat colonsocpy after treatment with steroids for eventual dilation of the stricture. On discharge, she was still having [1-17] loose bowel movements per day, with intermittent abdominal pain and cramping relieved with defecation. She was tolerating a low residue diet at the time. She will also be discharged on a [Hospital1 ] PPI. . #. Coag negative Staph aureus bacteremia: On [3-3], blood cultures drawn on [3-2] returned as growing coag negative staph aureus in [1-19] bottles. Patient was started on 7-day course of IV Vancomycin, completed on [3-9]. Survellience cultures had no growth by the time of discharge. Patient had a PICC line placed on [3-2] and after the blood cultures returned positive, the PICC line was pulled. TTE showed no evidence of vegetations and she had no other signs or symptoms of endocarditis. She was afebrile at the time of discharge. . #. Transfusion reaction: Patient experienced an acute hemolytic reaction while getting transfused at [Hospital1 ] [Location (un) 620] secondary to inappropriately cross-matched blood. Upon arrival, she was seen by the blood bank team, who determined that she had an Anti-Fya antibody in her blood. After appropriate cross-matching, she received 2 units of PRBCs without a transfusion reaction, and her hematocrit increased appropriately to a baseline of 28-30. Per the blood bank team, in the future, Ms. [Known lastname 23239] should receive Fya-antigen negative products for all red cell transfusions. Approximately 34% of ABO compatible blood will be Fya-antigen negative. A wallet card and a letter stating the above will be sent to the patient by the blood bank team. . #. Fe deficiency anemia: Patient's iron studies indicated that she has a likely iron-deficiency anemia in combination with an anemia of chronic disease. Likely source of the anemia is Crohn's and subsequent malabsorption in the terminal ileum. She was maintained on oral iron, and will be discharged on Iron 325 once daily. Her baseline Hematocrits have been 28-30, 29.8 on the day of discharge. . #. Atelectasis/Oxygen Saturation: Patient had several days of bordeline-low O2 saturations ranging 88-92% on room air on the several days prior to discharge. These saturations would increase to 99% on room air when patient was asked to take a deep breath in. Multiple CXRs indicated that the patient had bilateral atelectasis, likely secondary to immobility. She had no other signs or symptoms of pneumonia or pulmonary embolism. She was repeatedly encouraged to use the incentive spirometer, even though she seems to be non-compliant with it. Upon discharge to acute care facility, she will need to be encouraged both to get out of bed and ambulate and to use the incentive spirometer. . #. Nutritional status: Patient's albumin on admission was 2.1, likely secondary to malabsorption and protein-losing enteropathy from chronic inflammatory bowel disease as above. She was not tolerating POs well upon admission and was maintained on TPN for several days until the PICC line had to be pulled secondary to bacteremia (see above). Albumin several days prior to discharge had improved to 2.4. She was tolerating a low residue diet and was counseled on foods to avoid that would help to reduce her symptoms. . #. Chronic knee/low back pain: Patient has history of chronic low back and knee pain, for which she previously took roxicet while at home. While she was unable to take POs, her pain was maintained with IV morphine. When she was able to tolerate POs, she was transitioned to PO morphine 15 q6 as needed. She repeatedly would ask for IV pain meds and exhibited some evidence of narcotics dependence. It was explained to her that she no longer needed IV morphine and thus it would not be given to her. Patient needs encouragement for physical therapy and ambulation, even given chronic pain. . #. Depression: Patient has had depression for several years, and has been an ongoign issue. She was continue on Fluoxetine 20 mg once a day. . # Gout: Patient's indomethacin was stopped as she was not in an acute flare and NSAIDs can contribute to her chronic diarrhea and anemia. She was continued on Allopurinol. . # Hypothyroidism: TSH checked during admission and was WNL. She was continued on Levothyroxine 50 mcg. Medications on Admission: Allopurinol 300mg daily Indomethacin 75 mg daily Levothyroxine 50 mcg daily Prozac 20mg daily Roxicet PRN Tylenol PRN Citracal/VitD daily MVT daily Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcium citrate-vitamin D3 500 mg(calcium) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: End Date: [3-15]. 7. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux/abd discomfort. 9. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours). 12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO once a day: START: [3-15]. Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: Inflammatory Bowel Disease Acute Hemolytic transfusion reaction Clostridium Difficile Colitis Coagulase Negative Staph Aureus Bacteremia 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 seen in the hospital for both diarrhea and an abnormal reaction to a transfusion of red blood cells. Your diarrhea was likely secondary to a chronic process called inflammatory bowel disease. You will start an anti-inflammatory called entocort next week. You will also be seeing the Gastrointestinal doctors within the next few weeks as listed below. . While you were in the hospital, you also acquired an infection called C diff colitis. You will be trated for one more week with an antibiotic called vancomycin. Once you complete this antibiotic, you will start the entocort next week. . We also found that you had a bacteria in your blood called coagulase negative staph aureus. We treated you with 7 days of IV Vancomycin for this infection. . Our blood bank doctors discovered that your reaction to the transfusion was caused by inappropriately cross matched blood. It was found that you have an antibody in your blood called Anti-Fya antibody. In the future, you should receive Fya-antigen negative products for all red cell transfusions. A wallet card and a letter stating the above will be sent to the patient by the blood bank team. . We made the following changes to your medications: STOPPED Indomethacin STOPPED Roxicet ADDED Ferrous Sulfate twice daily ADDED Oral Vancomycin every 6 hours for another 7 days ADDED Entocort once a day to start on Monday [3-15] ADDED Morphine 15 mg every 6 hours as needed for pain ADDED Pantoprazole 40 mg twice a day ADDED Simethicone as needed for abdominal bloating and discomfort . It was a pleasure taking care of you during your hospital stay. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2117-3-31] at 2:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 22561], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage	[ "999.84", "790.7", "263.0", "338.29", "041.11", "008.45", "244.9", "280.9", "724.2", "274.9", "311" ]	icd9cm	[ [ [] ] ]	[ "45.16", "99.15", "45.25", "38.93" ]	icd9pcs	[ [ [] ] ]	16580, 16657	9123, 15209	404, 452	16838, 16838	5211, 5211	18662, 19031	4084, 4105		15408, 16557		16678, 16817		15235, 15385			17021, 18203								4120, 4703																			18232, 18639				4717, 5192		264, 366										480, 3808					5227, 9100			16853, 16997							3830, 3958	3974, 4068
77,855	190,212	52807+59468	Discharge summary	report+addendum	Admission Date: [2152-8-22] Discharge Date: [2152-9-9] Date of Birth: [2081-12-8] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 613] Chief Complaint: dyspnea, acute renal failure Major Surgical or Invasive Procedure: bilateral percutaneous nephrostomy tubes with repositioning History of Present Illness: 70yoF with h/o DM2, HTN, L iliac artery stenosis s/p stent who presented with DOE and exertional chest tightness x1 wk. . She saw her PCP today where she c/o new onset exertional chest tightness [7-19] associated with neck pain. Also complaining of DOE which was also new and has been progressively worsening as well. She denied diaphoresis, nausea/vomiting, arm / jaw pain. Her vitals were significant for BP 179/88, p105, 100% RA NC. There was concern for new TWI's laterally, and sent to ED. . In the ED: 99.2 98 170/88 18 100% on RA. She denied chest pain, nausea, vomiting, diarrhea, black or bloody stools. She was initially well appearing and exam was reportedly non-focal initially, with clear lungs, RRR, no edema. Labs showed Trop 0.03, ARF with BUN/Cr 64/7.2 (up from Cr 1.4-1.7 baseline), HCO3 20, and K 5.7. EKG concerning for lateral strain pattern STD's with concomitant R precordial J point elevation. Renal consulted; CCU fellow and Atrius Cards notified. . In the ED, she became acutely dyspneic, tachypneic to 30-40's, and satting mid 80% on RA. Exam showed diffuse crackles and increased WOB; she was placed on NRB and given a trial of albuterol inhaler without much effect. Her BP was noted to be 200/100 and there was concern for flash pulmonary edema vs PE vs COPD/asthma. An EJ PIV was placed. CXR showed pulmonary edema. She was given SL NTG then started on Nitro gtt, and given 40 mg IV Lasix x1. BP's improved, then hypoTN to 70/40's and gtt stopped, then restarted when BP's went up to 180/100's; goal SBP 120's. Unable to place arterial line. She was also given 325 ASA. . Vitals before transfer: 97.4 p100 150/87 100% on 4L NC. Currently on Nitro 0.5 mcg/kg/min, and looking much better. . Review of Atrius records shows that she is followed by Atrius Oncologist [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 349]. Per his most recent notes, she was seen in [6-/2152] and per his note: "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated Beta 2 Microglobulin, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." However, there was question whether these were due to the venous obstruction in her iliacs or an evolving lymphoproliferative disorder. Her kidney function was deteriorating as early as [4-/2152]; per Atrius records: Cr [11/2151]: 0.83 [12/2151]: 0.95 [4-/2152]: 1.67 [4-/2152]: 1.44 [6-/2152]: 1.72 . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: # Diabetes Mellitus type II on insulin with renal complications (last A1c 7.5 [6-/2152]) # HTN # [Month (only) 116]-[Last Name (un) 87639] Syndrome: an inherited thrombophilic syndrome; compression of the L common iliac vein between overlying right common iliac artery and overlying vertebral body; associated with unprovoked L iliofemoral DVT and chronic venous insufficiency # L common and external iliac veins angioplasty and stenting on [2152-3-29], discharged on Coumadin # Asthma "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early MM, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." # Lymphadenopathy: multiple enlarged L inguinal LN's noted on pelvic MRV in [7-/2151] -> s/p LN biopsy showing reactive LN # SPONDYLOLISTHESIS, ACQUIRED # SCIATICA # RHINITIS, ALLERGIC Social History: SOCIAL HISTORY From [Country 3594] - Tobacco history: quit 30yrs ago, claims to only smoke [12-12] cig/day - ETOH: denies - Illicit drugs: denies Family History: FAMILY HISTORY: Brother Deceased at 69 Diabetes - Type II Father Deceased train accident Mother Deceased at 72 of MI Son Type 2 diabetes Physical Exam: VS: BP= 178/94 HR= 98 RR=16 O2 sat= 99% 3 L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of the oral mucosa. No NECK: Supple no tracheal deviation CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crakles at bases ABDOMEN: Soft, NTND. No tenderness. BS+ EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: ADMISSION LABS -------------- LABS CHEM [2152-8-22] 07:00PM BLOOD Glucose-146* UreaN-64* Creat-7.2# Na-139 K-5.7 Cl-105 HCO3-20* AnGap-20 [2152-8-24] 06:00AM BLOOD Glucose-98 UreaN-68* Creat-7.8* Na-140 K-4.4 Cl-104 HCO3-24 AnGap-16 [2152-8-30] 07:02AM BLOOD Glucose-160* UreaN-73* Creat-7.0* Na-135 K-4.6 Cl-100 HCO3-24 AnGap-16 [2152-9-3] 06:51AM BLOOD Glucose-91 UreaN-59* Creat-4.1* Na-136 K-4.9 Cl-99 HCO3-25 AnGap-17 [2152-8-23] 01:39AM BLOOD Calcium-10.2 Phos-4.4 Mg-2.2 . CBC [2152-8-22] 07:00PM BLOOD Neuts-55.1 Lymphs-37.2 Monos-4.6 Eos-2.4 Baso-0.6 [2152-8-22] 07:00PM BLOOD WBC-7.3 RBC-2.93* Hgb-9.2* Hct-26.0* MCV-89 MCH-31.3 MCHC-35.3* RDW-15.3 Plt Ct-293 [2152-9-3] 06:51AM BLOOD WBC-8.1 RBC-3.39* Hgb-10.5* Hct-31.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-14.8 Plt Ct-356 [2152-8-23] 04:53AM BLOOD Hapto-192 [2152-8-23] 04:53AM BLOOD Ret Aut-1.1* . COAG [2152-8-22] 08:25PM BLOOD PT-12.1 PTT-23.6 INR(PT)-1.0 . LFTS [2152-8-23] 01:39AM BLOOD ALT-15 AST-15 LD(LDH)-257* CK(CPK)-294* AlkPhos-98 TotBili-0.4 . Urine [2152-8-22] 07:30PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2152-8-22] 07:30PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2152-8-22] 07:30PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 [2152-8-23] 12:24AM URINE Eos-NEGATIVE [2152-8-25] 03:36PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [2152-8-23] 11:27AM URINE U-PEP-NEGATIVE F [2152-8-23] 12:24AM URINE Osmolal-312 [2152-8-23] 11:27AM URINE Hours-RANDOM Creat-62 TotProt-34 Prot/Cr-0.5* Albumin-8.4 Alb/Cre-135.5* [2152-8-23] 12:24AM URINE Hours-RANDOM UreaN-196 Creat-36 Na-95 K-28 Cl-99 . Cardiac [2152-8-22] 07:00PM BLOOD CK-MB-5 cTropnT-0.03* [2152-8-23] 01:39AM BLOOD CK-MB-5 cTropnT-0.05* [2152-8-22] 07:00PM BLOOD CK(CPK)-378* . MISC [2152-8-23] 04:01PM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [2152-8-30] 07:02AM BLOOD CRP-19.8* [2152-8-24] 06:00AM BLOOD Cortsol-12.6 [2152-8-23] 04:53AM BLOOD TSH-1.6 [2152-8-30] 07:02AM BLOOD ESR-83* . DISCHARGE LABS -------------- [2152-9-9] 05:47AM BLOOD WBC-7.8 RBC-3.12* Hgb-9.5* Hct-28.2* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.0 Plt Ct-314 [2152-8-22] 07:00PM BLOOD Neuts-55.1 Lymphs-37.2 Monos-4.6 Eos-2.4 Baso-0.6 [2152-9-8] 06:15AM BLOOD PT-12.9 PTT-26.1 INR(PT)-1.1 [2152-9-9] 05:47AM BLOOD Glucose-114* UreaN-31* Creat-2.8* Na-138 K-4.5 Cl-102 HCO3-25 AnGap-16 [2152-8-23] 04:53AM BLOOD TSH-1.6 [2152-8-24] 06:00AM BLOOD Cortsol-12.6 [2152-8-30] 07:02AM BLOOD CRP-19.8* [2152-8-23] 04:01PM BLOOD [Doctor First Name ]-POSITIVE * Titer-1:40 [2152-8-31] 08:35AM BLOOD PEP-TRACE ABNO b2micro-10.0* IgG-1266 IgA-249 IgM-145 IFE-TRACE MONO . [2152-8-31] 08:35 IGG SUBCLASSES 1,2,3,4 Test Result Reference Range/Units IMMUNOGLOBULIN G SUBCLASS 1 577 382-929 mg/dL IMMUNOGLOBULIN G SUBCLASS 2 429 241-700 mg/dL IMMUNOGLOBULIN G SUBCLASS 3 125 22-178 mg/dL IMMUNOGLOBULIN G SUBCLASS 4 18.9 4.0-86.0 mg/dL IMMUNOGLOBULIN G, SERUM 1[Telephone/Fax (1) 108890] mg/dL THIS TEST WAS PERFORMED AT: [Company ]/CHANTILLY [Numeric Identifier 14272] CHANTILLY, [Numeric Identifier 14273] [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 14274], MD . ALDOSTERONE Test Result Reference Range/Units ALDOSTERONE, LC/MS/MS 2 ng/dL Adult Reference Ranges for Aldosterone, LC/MS/MS: Upright 8:00-10:00 am < or = 28 ng/dL Upright 4:00-6:00 pm < or = 21 ng/dL Supine 8:00-10:00 am [2-23] ng/dL THIS TEST WAS PERFORMED AT: [Company ]/[Numeric Identifier 42067] [Doctor Last Name 42068] HWY [Location (un) ] CAPISTRANO, [Numeric Identifier 42069] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42070], MD [First Name (Titles) ] [Last Name (Titles) ]: Source: Line-L angio . FREE KAPPA AND LAMBDA, WITH K/L RATIO Test Result Reference Range/Units FREE KAPPA, SERUM 62.2 H 3.3-19.4 mg/L FREE LAMBDA, SERUM 107.0 H 5.7-26.3 mg/L FREE KAPPA/LAMBDA RATIO 0.58 0.26-1.65 Free kappa/lambda ratio in serum of normal individuals is 0.26-1.65. Excess production of free kappa or lambda light chains alters the ratio. Ratios outside the normal range are attributed to the presence of monoclonal free light chains. Monoclonal free light chains are found in the serum of patients with multiple myeloma, Waldenstrom's macroglobulinemia, mu-heavy chain disease, primary amyloidosis, light chain deposition disease, monoclonal gammopathy of undetermined significance, and lymphoproliferative disorders. Measurement of free light chain concentration in serum is useful for diagnosis, prognosis,monitoring disease activity and following response to therapy of these disorders. THIS TEST WAS PERFORMED AT: [Company ] [Last Name (un) 63583]-CL 0091 [Location (un) 63584] [Last Name (un) 63583], [Numeric Identifier 63585] [Name6 (MD) 63586] [Name8 (MD) 9529], MD Comment: Source: Line-L angio . RENIN Test Result Reference Range/Units PLASMA RENIN ACTIVITY, 0.68 0.25-5.82 ng/mL/h LC/MS/MS THIS TEST WAS PERFORMED AT: [Company ]/[Numeric Identifier 42067] [Doctor Last Name 42068] HWY [Location (un) ] CAPISTRANO, [Numeric Identifier 42069] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42070], MD [First Name (Titles) ] [Last Name (Titles) ]: HEM# 0200A [8-23] . MICROBIOLOGY ------------ [2152-8-30] 7:02 am SEROLOGY/BLOOD FINAL REPORT [2152-8-31] RAPID PLASMA REAGIN TEST (Final [2152-8-31]): NONREACTIVE. Reference Range: Non-Reactive. . IMAGING ------- [2152-8-22] CXR IMPRESSION: Mild-to-moderate interstitial pulmonary edema. . [2152-8-23] TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with low normal left ventricular systolic function. Mild mitral regurgitation. Mild aortic stenosis. Borderline pulmonary hypertension. . [2152-8-23] Renal artery Doppler IMPRESSION: Severe left and moderate right hydronephrosis with limited Dopplers demonstrating normal main renal arterial waveforms bilaterally. . [2152-8-23] CT Abd/Pelvis without contrast IMPRESSION: 1. Bilateral hydronephrosis and hydroureter extending to the mid at ureters,at the level of L5-S1. There are no stones identified. Questionable increased periaortic soft tissue at L5-S1 which may represent retroperitoneal fibrosis. Consider MRI without contrast for further evaluation. 2. Left iliac venous stent. 3. Lumbar spine DJD with anterolisthesis of L4 on L5. . [2152-8-25] Skeletal Survey IMPRESSION: 1. Degenerative changes as described above. 2. No focal lytic lesions to indicate myelomatous deposits. . [2152-8-25] Bilateral nephrostomy tubes CONCLUSION: 1. Uncomplicated insertion of bilateral percutaneous 8 French nephrostomy catheters. 2. Bilateral mid-to-distal high-grade ureteral obstruction with no passage of contrast material into the urinary bladder. . [2152-8-31] MRI Abd w/out contrast IMPRESSION: 1. Soft tissue draped over the aortic bifurcation, likely involving both ureters. Given the absence of intravenous contrast, findings are nonspecific; however, overall features favor a benign process, such as retroperitoneal fibrosis, rather than malignant or lymphoid tissue. Interval imaging in six months is advised to ensure stability. 2. Left upper pole renal cyst as described. Brief Hospital Course: 70 yo F with a h/o of [First Name8 (NamePattern2) 116] [Last Name (un) 87639] Syndrome who presents with new TWI, hypertension and pulmonary edema. After medical stabilization in the CCU, she was transferred to Medicine for work up and management of acute renal failure and MGUS. . #Pulmonary Edema: Patient was acutely hypertensive in the ED with systolic blood pressure in 200s, with infiltrates on chest X-ray consistent with flash pulmonary edema. Patient was given IV lasix and had a decreasing oxygen requirement. There was no evidence of right heart strain on EKG and concern for pulmonary embolus was low. By transfer to the general medical service, problem had resolved; patient was satting well on room air for the remainder of her hospitalization. . # Acute on chronic kidney injury: Patient had baseline renal insufficency which acutely worsened to a creatinine >7. A renal ultrasound was obtained which showed marked bilateral hydronephrosis. CT abdomen/pelvis was also preformed which did not show clear etiology of the obstruction as it was a non-contrast study, but raised the possibility of retroperitoneal fibrosis. Patient likely has both extrinsic renal failure from obstruction and intrinsic renal failure of an unknown etiology. Both Nephrology and Urology were consulted. Percutaneous nephrostomy tubes were placed on [8-25] and replaced on [8-29]. Drainage from the tubes and Foley gradually became non-bloody, with small amounts of bloody drainage at the time of discharge. During the procedure, Interventional Radiology noted a near complete obstruction of the ureters. Creatinine gradually decreased following the procedure. Nephrology did not believe patient needed dialysis at any point. Creatinine downtrended to [1-13] at time of discharge. A follow-up with Nephrology was recommended for the patient upon discharge, to be arranged by the patient's primary care provider. [Name10 (NameIs) ] will also be contact[Name (NI) ] by Interventional Radiology following discharge to manage her nephrostomy tubes, which are still in place at the time of discharge. Patient will receive VNA services for further management of nephrostomy tubes. Patient was instructed to stop using losartan and chlorthalidone due to her renal function. She was also instructed to cease use of ibuprofen. . who described her MGUS as "anemia, small IgG lambda monoclonal protein, elevated light chains, elevated B2M, transient mild hypercalcemia suggest either an MGUS, an early multiple myeloma, or a low-grade lymphoma. Bone marrow biopsy was non-diagnostic." Pt had negative SPEP, UPEP, and mildly elevated light chains. IgG subclasses were examined and all normal. A CT-guided biopsy of the retroperitoneal fibrosis was performed on [9-8], with cytologic and pathologic testing pending at the time of dishcharge. Patient will follow up with [Location (un) 2274] Hematology/Oncology after discharge to follow up results of biopsy. . # Acute on chronic anemia: Patient was admitted with a hematocrit of 26 which was noted to fall to 20 over the course of her CCU stay. Hemolysis labs were negative and there was no evidence of acute bleed. The acute drop in hematocrit may have been related to resolved hemoconcentration on admission. Patient subsequently had gradual decline in hematocrit on the floor following placement of percutaneous nephrostomy tubes. Patient required a total of 4 units PRBC transfused. Most likely, anemia stems from anemia of chronic disease and kidney failure, combined with acute blood loss from procedure. Uremic platlet dysfunction may have contributed to the prolonged bleeding. We gave ddAVP x 1 over course of admission. By [8-31], patient's hematocrit stabilized at ~28-30, where it remained for the rest of her hospitalization. She will follow up this problem with her primary care provider. . # Hypertension: Patient was hypertensive to the 200s systolic while in the ED and likely had flash pulmonary edema. Patients blood pressure was initially controlled with nitroglycerin drip and transitioned to PO 200 mg metolporol [Hospital1 ]. On the medical floor, her blood pressures were controlled with labetalol and hydralazine and home Losartan and chlorthalidone were held. Patient's blood pressures remained well controlled until time of discharge. Patient was instructed to stop using losartan and chlorthalidone due to her renal function. . # Likely herpetic infection: patient was noted to have a vesicular rash on her lower back during admission. DFA was attempted but uninterpretable. Patient completed an empiric seven day course of valacyclovir for HSV/VZV. . INACTIVE ISSUES --------------- # Diabetes mellitus: patient was maintained on insulin sliding scale. Her metformin was held during admission and it was found that she is not on this medication at home. She is on insulin and will continue this as an outpatient. . TRANSITIONS IN CARE ------------------- . # Follow-up: patient has follow-up appointment with her PCP. [Name10 (NameIs) ] will be contact[Name (NI) ] by Interventional Radiology for a follow-up appointment for her nephrostomy tubes. Her PCP should help her arrange a Nephrology follow-up as well as Heme/Onc follow-up. Her cytologic and pathologic results are pending for her retroperitoneal biopsy, which will be followed up by her PCP and Heme/Onc. Her hematocrit should also be followed, as well as her creatinine going forward. Patient should also have age-appropriate cancer screening, including a colonoscopy. . # Code status: patient is confirmed full code. . # Contact: daughter [Name (NI) 33933] [Telephone/Fax (1) 108891] Medications on Admission: - Chlorthalidone 25 daily - Colace [Hospital1 ] prn - Lantus 20 SQ hs - Metformin 1000 daily - Oxycodone 5mg q4 prn - Percocet 5/325 [12-12] q4-6 prn - B12 - Benadryl 25 mg prn allergies - Ibuprofen 200 2-4 tabs prn Atrius records: - Losartan 100 mg Oral Tablet Take 1 tablet daily - Chlorthalidone 25 mg daily - Warfarin 1 mg Oral Tablet take 8 tablets daily or as directed - Lovenox 80 mg q12 hrs - Lantus 15u hs - Ibuprofen 400 mg prn pain - ASA 81 daily Discharge Medications: 1. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [5-17] hours as needed for allergy symptoms. 2. labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for sbp <100 or pulse <55 . Disp:120 Tablet(s) Refills:0 3. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for sbp<100 . Disp:90 Tablet(s) Refills:0 4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 8. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain: Do not drink alcohol or drive while on this medication. 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not drive or drink alcohol while on this medication. 10. Vitamin B-12 Oral 11. Outpatient Lab Work Please have CBC, Chem7 drawn on [9-12] and fax to attn: [First Name8 (NamePattern2) 22997] [Last Name (NamePattern1) 31] at [Telephone/Fax (1) 6808] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY DIAGNOSIS Retroperitoneal fibrosis Acute on chronic renal failure SECONDARY DIAGNOSIS Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you during your admission to the [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1675] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. You came to the hospital with difficulty breathing and were found to have fluid in your lungs and your heart was having difficulty pumping because of a kidney obstruction. You were admitted to the medical intensive care unit, where we gave you lasix and nitroglycerin to help you safely get rid of the fluid from your lungs. After that, you had no concerns from a heart or lung perspective and were transferred to the general medicine service. A CT scan showed that you had a process obstructing the ureter, the tube running between the kidneys and the bladder. We consulted with nephrologists, urologists, and rheumatologists to help us care for you. We placed nephrostomy tubes into your kidneys to help you urinate given that you had an obstruction. Over time, your kidney function continued to improve while you were in the hospital. We then ran several tests to determine why you were having this process causing kidney obstruction, including blood tests and an MRI. We got a small sample of tissue from the area, and there are tests pending on this sample, which will be followed up by your primary care provider and hematologist/oncologist. PLEASE CONTINUE -all of your home medications EXCEPT as below PLEASE STOP losartan chlorthalidone ibuprofen PLEASE START Labetalol 300 mg by mouth twice a day HydrALAzine 25 mg by mouth every 8 hours You should not take non-steroidal anti-inflammatory medications (NSAIDs) in the future, such as ibuprofen, Aleve, or Advil. Please keep the follow up appointments as recommended below. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] A. Location: [Hospital1 641] Address: [University/College 2899], [Location (un) ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 2115] When: Thursday, [9-14], 3:40 Please discuss seeing a Nephrologist with Dr. [Last Name (STitle) 31]. Dr. [Last Name (STitle) 31] will also help you set up an appointment with your Hematologist/Oncologist Interventional Radiology will get in touch with you within one week to determine what happens next with your nephrostomy tubes. If you do not hear from them in one week, please call them at [Telephone/Fax (1) ]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Name: [Known lastname ],[Known firstname 3650] Unit No: [Numeric Identifier 17835] Admission Date: [2152-8-22] Discharge Date: [2152-9-9] Date of Birth: [2081-12-8] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 1472] Addendum: Discharge paperwork stated that patient was on metformin at home prior to admission. She was instructed to continue this medication after discharge, but it was later confirmed that she does not take this. A prescription was not provided. In addition, her current renal function precludes her from taking this medication. Patient was called and this information was communicated and it was assured that she is not taking metformin and will not in the future. She is taking insulin. Discharge Disposition: Home With Service Facility: [Location (un) 42] VNA [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1473] Completed by:[2152-9-10*]	[ "280.0", "584.9", "591", "514", "599.70", "428.0", "276.7", "403.90", "585.9", "593.4", "250.92", "272.0", "428.31", "273.1" ]	icd9cm	[ [ [] ] ]	[ "55.03", "55.93", "54.24" ]	icd9pcs	[ [ [] ] ]	25427, 25635	14193, 19894	298, 360	21827, 21827	5359, 14170	23804, 25404	4555, 4678		20411, 21592		21693, 21806		19920, 20388			21978, 23781								4693, 5340																									230, 260										388, 3421								21842, 21954							3443, 4351	4367, 4523
31,247	173,039	33993	Discharge summary	report	Admission Date: [2198-7-25] Discharge Date: [2198-8-16] Date of Birth: [2154-7-13] Sex: M Service: CARDIOTHORACIC Allergies: Ancef / Septra Attending:[First Name3 (LF) 5790] Chief Complaint: The patient presents for symptomatic tracheobronchomalacia Major Surgical or Invasive Procedure: [7-25] rigid bronchoscopy and stent removal [7-26] flexible bronchoscopy History of Present Illness: Patient is a 44 year old male with IDDM and TBM. Approximately one year ago patient was hospitalized and treated for apparent asthma. Patient was then transferred to UCSD and was diagnosed with TBM. Patient had polyflex stents placed (y stent). Patient was emergently intubated and trached ([9-6], 11 rouche) when granulation tissue occluded the proximal end of his stent. At that time, the patient was hospitalized for 5 months. Patient reports that his last stent change was [6-7]. has had multiple bronchoscopies over past 2 months for thick secretions. Has been treated twice with IV vancomycin for MRSA (last dose [7-22]). Patient reports thick yellow secretions with small flecks of blood. Patient able to expectorate his sputum with assistance of saline, does not need to suction trach. Denies frequent cough, DOE. Although reports that traveling yesterday has left him tired. Past Medical History: IDDM, TBM, dyslipidemia, restless leg syndrome, CRI, hypothyroidism, diabetic retinopathy, DVT right arm Social History: lives in [Location (un) 11177] with his wife and four year old son. has not worked since last year but is a minister and hospital chaplain. denies ETOH, IVDU. quit smoking in [2190] and had smoked 1-2ppd x 7 years. Family History: noncontributory Physical Exam: vitals: 152/76, HR 78, RR 18-20, T 97.9, O2 Sat 100% on 2L general: very pleasant, well-appearing male neck: trach lungs: ctab, no wheeze. occasional cough cv: rrr, s1s2 abd: s/nt/nd Brief Hospital Course: On [7-24], the pt underwent flexible bronchoscopy. The pt's stent was seen to terminate in the proximal bronchus intermedius with complete occlusion of the right upper lobe. The patient underwent rigid bronchoscopy and stent removal [7-25]. He tolerated the procedure well and was transferred to [Hospital Ward Name 121] 7 following the procedure for continued monitoring. The patient's sputum on [7-27] and later bronchial washings ([8-1]) were positive for MRSA, and the pt was placed on vancomycin. On [7-30], the patient underwent a repeat flexible bronchoscopy, again showing severe TBM, but decreasing granulation tissue. Tracheoplasty was scheduled for the next week. The patient chose to stay in hospital to await his surgery due to concerns for his tracheostomy care and for pain management. Pain management was a concern throughout his hospitalization as he required high doses of narcotics both preoperatively and postoperatively to control his pain. Both the acute pain service and the chronic pain service were consulted. On [7-31], the pt underwent another bronchoscopy for mucus plugging. The preoperative evaluation for tracheoplasty included airway evaluation along with the typical workup. CT airway demonstrated marked TBM with fixed narrowing of the mid and distal left bronchus and ground glass opacities. The Chest CT demonstrated marked tracheobronchomalacia. Small airways were not involved. PFTs were ordered, but were unable to be completed due to the pt's tracheostomy. [Last Name (un) ] endocrinologists were consulted for poor glucose control. [Last Name (un) ] continued to manage the pt's diabetes throughout his preoperative and postoperative course. On the evening of [8-5], the pt's potassium was 6.4. The pt was asymptomatic, and no EKG changes occurred. The pt was treated with kayaxelate, calcium gluconate, and insulin. Potassium dropped to normal range before surgery. On [8-6], intrathoracic tracheoplasty was performed. Mesh was used to reconstruct the airways. A R apical [Doctor Last Name ] drain placed. The tracheostomy tube was changed out. The pt tolerated this procedure well. The pt was sent to the SICU to recover. The following day, flexible bronchoscopy with therapeutic aspiration was performed to remove thick secretions. The bronchoscopy demonstrated tracheal edema with thick secretions in L lung. Posteratively, the pt's CK levels rose above 10,000. The pt was started on a bicarbonate drip. The patient developed lower extremity and scrotal edema following the fluid administrations. The patient was treated with lasix, and the edema decreased. The pt's CK levels were followed throughout his postoperative course until they fell below 600. On [7-21], the pt underwent a swallow evaluation including a barium swallow. The pt passed his evaluation with no signs of aspiration, leak, or fistula. The patient's diet was advanced. On [8-10], a bronchoscopy showed an edematous, erythematous trachea that was patent without necrosis. Granulation tissue was visualized. Following the bronchoscopy, the patient was transferred to the floor. On both [8-10] and [8-13], the pt's hemoglobin dropped to 22.1 and 23.2 respectively, and the pt received blood transfusions. He received the blood with no complications. ID order a CT thorax on [8-15]. On [8-16], as the pt was stable, the pt was discharged home with followup scheduled in 1 week. Medications on Admission: PULMICORT SINEMET 25 mg-100 mg by mouth at bedtime PULMOZYME FENTANYL 25 mcg/hour Patch apply patch q 72 hours HYDROMORPHONE - 4 mg Tablet - by mouth as needed for q 4 hours LANTUS - 15 units q pm HUMALOG LEVOTHYROXINE - 125 mcg Tablet by mouth daily PAXIL MVI FLOMAX - 0.4 mg by mouth daily TEMAZEPAM - 15 mg Capsule by mouth at bedtime VITAMIN C 500 mg Tablet by mouth daily COLACE - 200 mg by mouth daily IRON ZINC - 200 mg by mouth daily Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 4. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Refills:0 5. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. Disp:30 Capsule(s) Refills:0 6. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q8H (every 8 hours) as needed for pain control. Disp:120 Tablet Sustained Release(s) Refills:0 7. Vancomycin 500 mg Recon Soln Sig: Seven [Age over 90 1230]y (750) mg Intravenous Q 12H (Every 12 Hours) for 11 doses. Disp:11 doses Refills:0 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. picc line care Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours. Disp:120 Tablet(s) Refills:0 11. lantus lantus 15 units Sq at bedtime disp one vial no refills 12. humalog humalog insulin dose per sliding scale based om finger sticks before meals and at bedtime disp one vial no refills 13. Paxil CR 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 14. Pulmicort 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) Inhalation twice a day. Disp:60 doses Refills:0 15. Pulmozyme 1 mg/mL Solution Sig: 2.5 mg Inhalation twice a day. Disp:30 doses Refills:0 16. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety for 5 days. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Tracheobroncomalacia Discharge Condition: Good Discharge Instructions: Please call the office of Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 11763] if you experience a fever greater than 101.5, chills, shortness of breath, or chest pain. Incision develops drainage or increased redness You may shower. No tub bathing or swimming for 6 weeks No driving while taking narcotics Take stool softners with narcotics Nothing to eat or drink after midnight [2198-8-20] for bronchoscopy tues with Dr. [Last Name (STitle) ] Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] on Date/Time:[2198-8-21] 11:00am in the [Hospital Ward Name 121] Building, [Hospital1 ] I Chest Disease Center, [Location (un) ] Report to the [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[2198-8-21]	[ "272.4", "250.51", "338.12", "338.4", "519.19", "V58.67", "244.9", "V55.0", "276.7", "V02.59", "493.90", "934.1", "511.9", "362.01", "E915", "585.9", "482.9", "608.86", "728.88", "518.0" ]	icd9cm	[ [ [] ] ]	[ "31.79", "96.05", "33.78", "33.48", "96.6", "96.56", "33.21", "96.71", "33.24" ]	icd9pcs	[ [ [] ] ]	7903, 7955	1992, 5494	340, 423	8020, 8027		8542, 8918	1747, 1764		5989, 7880		7976, 7999		5520, 5966			8051, 8519								1779, 1969																									242, 302										452, 1360															1382, 1489	1505, 1731
2,018	175,507	15803	Discharge summary	report	Admission Date: [2114-4-6] Discharge Date: [2114-5-4] Date of Birth: [2039-7-15] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 17683] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: s/p ex-lap parastomal hernia repair fascial dehiscence History of Present Illness: 74yo female p/w abdominal pain and decreased stoma output. This began [2114-4-5]. Pt noticed increasing pain and became concerned Past Medical History: Breast cancer HTN NIDDM colostomy [3-15] GIB appendectomy fibroid resection Social History: n/a Family History: n/a Physical Exam: nad ctab rrr soft/tender, diminshed bowel sounds cva tenderness Pertinent Results: [2114-4-6] 07:20PM BLOOD WBC-10.9 RBC-4.30# Hgb-12.7# Hct-38.1 MCV-89 MCH-29.5 MCHC-33.4 RDW-13.5 Plt Ct-274# [2114-4-9] 08:19AM BLOOD WBC-8.5 RBC-3.91* Hgb-11.5* Hct-34.2* MCV-87 MCH-29.4 MCHC-33.6 RDW-13.4 Plt Ct-227 [2114-4-13] 01:00PM BLOOD WBC-5.9 RBC-3.78* Hgb-11.2* Hct-34.3* MCV-91 MCH-29.6 MCHC-32.6 RDW-13.2 Plt Ct-287 [2114-4-18] 10:29PM BLOOD WBC-21.7* RBC-3.18* Hgb-9.4* Hct-28.9* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 Plt Ct-290 [2114-4-30] 06:10AM BLOOD WBC-10.4 RBC-2.72* Hgb-8.0* Hct-24.9* MCV-92 MCH-29.4 MCHC-32.1 RDW-14.0 Plt Ct-448* [2114-5-3] 04:30AM BLOOD WBC-6.4 RBC-2.81* Hgb-8.3* Hct-25.5* MCV-91 MCH-29.7 MCHC-32.7 RDW-14.0 Plt Ct-458* [2114-4-6] 07:20PM BLOOD PT-12.3 PTT-22.6 INR(PT)-1.1 [2114-5-1] 07:28PM BLOOD PT-11.9 PTT-21.7* INR(PT)-1.0 [2114-4-6] 07:20PM BLOOD Glucose-173* UreaN-19 Creat-1.6* Na-141 K-4.3 Cl-104 HCO3-24 AnGap-17 [2114-4-11] 12:20PM BLOOD Glucose-104 UreaN-12 Creat-1.2* Na-143 K-3.8 Cl-103 HCO3-29 AnGap-15 [2114-4-13] 06:55AM BLOOD Glucose-115* UreaN-21* Creat-1.8* Na-142 K-5.2* Cl-100 HCO3-31 AnGap-16 [2114-4-17] 06:55AM BLOOD Glucose-98 UreaN-20 Creat-1.5* Na-146* K-4.1 Cl-109* HCO3-28 AnGap-13 [2114-4-19] 02:47AM BLOOD Glucose-134* UreaN-29* Creat-1.8* Na-142 K-3.8 Cl-112* HCO3-21* AnGap-13 [2114-4-24] 02:12AM BLOOD Glucose-175* UreaN-25* Creat-1.2* Na-142 K-4.1 Cl-109* HCO3-24 AnGap-13 [2114-5-3] 04:30AM BLOOD Glucose-116* UreaN-4* Creat-0.9 Na-143 K-3.9 Cl-104 HCO3-32 AnGap-11 [2114-4-6] 07:20PM BLOOD AST-16 Amylase-135* TotBili-0.5 [2114-5-1] 11:11PM BLOOD ALT-7 AST-16 CK(CPK)-50 AlkPhos-77 Amylase-310* [2114-5-3] 04:30AM BLOOD Amylase-200* [2114-4-19] 02:47AM BLOOD Lipase-9 [2114-4-8] 08:05AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9 [2114-5-3] 04:30AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.8 [2114-4-17] 01:56PM BLOOD Type-ART Tidal V-600 FiO2-23 pO2-68* pCO2-42 pH-7.40 calHCO3-27 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2114-4-19] 12:16PM BLOOD Type-ART pO2-111* pCO2-49* pH-7.26* calHCO3-23 Base XS--5 [2114-4-23] 10:11PM BLOOD Type-ART pO2-129* pCO2-44 pH-7.37 calHCO3-26 Base XS-0 [2114-4-27] 04:01AM BLOOD Type-ART Temp-37.2 Rates-/20 pO2-102 pCO2-47* pH-7.41 calHCO3-31* Base XS-3 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2114-5-2] 06:51AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.35 calHCO3-32* Base XS-2 Brief Hospital Course: On [2114-4-6] Ms. [Known lastname ] was admitted to the surgery service under the care of Dr. [Last Name (STitle) ] with a diagnosis of a partial small bowel obstruction secondary to a parastomal hernia. An NG tube was placed and she was resuscitated with IF fluids. On HD 5 her NG tube was d/c'd and over the next several days her diet was slowly advanced. She was tolerating clears until her ostomy output started to decrease. She developed increasing abdominal pain and nausea. An NG tube was replaced and approximately 1600 cc of fecal material was suctioned. On hospital day 12 she was taken to the OR for a parastomal hernia repair and anastomosis of her ileum to her sigmoid colon. For details of the operation, please see Dr.[Name (NI) 22019] operative report. Postoperatively she remained intubated for several days in the ICU. TPN was initiated. On POD 5 she had to return to the OR for a wound dehiscence. Postoperatively from this second operation, Ms. [Known lastname ] did well. Her TPN was weaned down as tube feeds were increased to goal via an NGT. On POD 10 from her initial operation she was transferred to the floor and started on clears. On POD 12 her NG tube was d/c'd and she was tolerating fulls. By POD 13 she was tolerating a regular diet and walking with physical therapy.On HD 26, patient found unresponsive in bed. She was unable to move her extremities or mouth. Appeared to have left facial droop and significant weakness on left side. Vital signs were noted to be stable. Neurology was consulted. A CXR, head CTA were performed and found to be negative. A EEG showed some evidence of slow waves consistent with a post-ictal state. On HD 27, pt noted to have significant imporvement. By HD 28, pt had returned to her baseline state. A VAC dressing was placed at the bedside on the day of discharge for wound healing. The pt was doing well. Medications on Admission: HCTZ Glipizide Metoprolol Discharge Medications: 1. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): titrate to [3-16] BM's/day. . 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: s/p partial small bowel obstruction ex-lap parastomal hernai repair Discharge Condition: good Discharge Instructions: Please call your doctor or the ER if you experience any of the following: increased pain, fever >101.1, nausea, vomitting, increasign diarrhea, chest pain, pus from your wound site or any other concerns. Followup Instructions: Please follow up with Dr [Last Name (STitle) ] in 1 week from discharge. An appointment can be scheduled at ([Telephone/Fax (1) 33502] Please remove VAC prior to follow up for wound evaluation [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845] Completed by:[0-0-0]	[ "569.69", "998.32", "584.9", "250.00", "585.9", "560.89", "038.9", "995.91", "998.59" ]	icd9cm	[ [ [] ] ]	[ "46.73", "54.72", "48.23", "99.15", "45.93", "46.51", "54.61", "46.42", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	6340, 6395	3214, 5106	328, 385	6507, 6514	793, 3191	6766, 7091	689, 694		5183, 6317		6416, 6486		5132, 5160			6538, 6743								709, 774																									274, 290										413, 548															570, 652	668, 673
26,648	103,430	24196	Discharge summary	report	Admission Date: [2114-8-1] Discharge Date: [2114-8-7] Date of Birth: [2068-6-21] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1491] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EGD with banding History of Present Illness: 46 yo F s/p liver transplant '[05] for acute Hep A who is undergoing liver/kidney transplant eval at [Hospital1 18] had colonoscopy and EGD on [7-31] which was notable for grade 3 varices which were banded and an unremarkable colonoscopy. However, she developed abd pain after the colonoscopy. She went home, noted severe abd pain and presented to [Hospital3 ] hospital. Presented with mildly increased distension of abdomen - KUB and CT showed no free air, but did show increased air in colon which could have resulted from [Last Name (un) ]. [Hospital3 ] spoke with Dr. [Last Name (STitle) 497] who recommended paracentesis, but they did not feel comfortable doing this. Therefore, Dr. [Last Name (STitle) 497] requested she receive a dose of ceftriaxone and be transferred to [Hospital1 18]. . In the ED at [Hospital1 18], the patient had a diagnostic and therapeutic paracentesis which drained 2.7L of amber liquid. Peritoneal fluid was negative for SBP with 31 WBC, culture pending. She also received phenergan, morphine, and 1000cc NS. . The patient was admitted to medicine for further evaluation of abdominal pain. Upon arrival to the floor, the patient had 3 episodes of coffee ground emesis (approx 350cc total) with a 6 point drop in Hct. Liver fellow was contact[Name (NI) ] who recommended IV protonix, octreotide, and transfer to MICU for emergent EGD and monitoring. In the MICU an EGD was performed which showed grade III varices which were banded. Following this procedure and multiple blood transfusion, her Hct has stabilized at 34. Given persistent complaints of tense abdomen and pain, have made multiple attempts to repeat paracentesis - hindered by dilated loops of bowel. As her HCT remains stable she was transfered back to medicine for further care. Past Medical History: -liver transplant '[05] for acute hep A (obtained after eating chinese food) now complicated by cirrhosis documented by bx [10-26]. -h/o variceal bleeding s/p banding -osteopenia -h/o scarlet fever Social History: no etoh, drugs, or tobacco. Lives with parents. From [Location (un) 86]. Family History: noncontributory Physical Exam: PE: 98.7 151/80 116 18 94% RA Gen: appears uncomfortable, lying still HEENT: anicteric, MM slightly dry. Neck: supple, no JVD CV: tachy, possible +S4/split S1 Back: no CVA tenderness Abd: +BS, tense, diffuse tenderness to palpation; previous transplant scars; +caput; no obvious rebound, + ventral hernia easily reducable. Ext: no LE edema Skin: +spider [Last Name (LF) 61458], [First Name3 (LF) ] erythema Neuro: somnolent but interactive. A&Ox3. MAEW. strenght [4-26] throughout. sensation in tact to LT. Pertinent Results: [2114-8-1] 09:20PM HCT-33.1* [2114-8-1] 08:43PM URINE HOURS-RANDOM UREA N-470 CREAT-89 SODIUM-<10 [2114-8-1] 08:43PM URINE OSMOLAL-349 [2114-8-1] 08:43PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2114-8-1] 08:43PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2114-8-1] 08:43PM URINE RBC-[2-24]* WBC-[2-24] BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2114-8-1] 08:43PM URINE HYALINE-<1 [2114-8-1] 04:00PM GLUCOSE-153* UREA N-47* CREAT-2.3* SODIUM-135 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-20* ANION GAP-19 [2114-8-1] 04:00PM CALCIUM-8.2* PHOSPHATE-6.1* MAGNESIUM-1.7 [2114-8-1] 04:00PM WBC-18.6* RBC-3.74* HGB-9.5* HCT-30.0* MCV-80* MCH-25.5* MCHC-31.8 RDW-20.3* [2114-8-1] 04:00PM PLT COUNT-113* [2114-8-1] 04:00PM PT-13.8* PTT-27.5 INR(PT)-1.3 [2114-8-1] 01:04PM HCT-30.6* [2114-8-1] 01:04PM PT-13.5* PTT-27.8 INR(PT)-1.2 [2114-8-1] 05:45AM ASCITES WBC-31* RBC-9800* POLYS-45* LYMPHS-5* MONOS-0 MESOTHELI-10* MACROPHAG-40* [2114-8-1] 03:40AM GLUCOSE-123* UREA N-37* CREAT-2.2* SODIUM-138 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17 [2114-8-1] 03:40AM ALT(SGPT)-34 AST(SGOT)-27 ALK PHOS-200* TOT BILI-0.8 [2114-8-1] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7* MAGNESIUM-1.8 [2114-8-1] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7* MAGNESIUM-1.8 [2114-8-1] 03:40AM WBC-12.6# RBC-4.48# HGB-11.0# HCT-36.1# MCV-81* MCH-24.6* MCHC-30.5* RDW-20.9* [2114-8-1] 03:40AM NEUTS-88.2* LYMPHS-6.3* MONOS-4.0 EOS-1.3 BASOS-0.2 [2114-8-1] 03:40AM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-3+ [2114-8-1] 03:40AM PLT COUNT-150 [2114-7-31] 08:20AM CYCLSPRN-80* Brief Hospital Course: 46 y/o female w/ h/o liver transplant for Hep A c/b cirrhosis, and grade 3 esophageal varices, originally admitted with diffuse abdominal pain after colonscopy, now with coffee ground emesis x 3 s/p EGD with banding of varices and persisting ascites. . 1) UPPER GI BLEED: pt w/ coffee ground emesis on [8-1] had grade 3 varices on EGD [8-1], banded. She received a total of 3 U PRBC during MICU course. She is now hemodynamically stable and her HCT has remained stable since transfusions. Patient recieved Octreotide for total of 5 days Patient continued on Protonix 40 mg po BID. Patient given sucralfate. Nadolol was held. . 2) ABDOMINAL PAIN - There was concern for perforation given recent colonoscopy; however, X-ray and Abd CT @ OSH did not show evidence of free air, and repeat upright CXR @ [Hospital1 18] shows no free air. Also considered was SBP from bacterial translocation from colonoscopy. Pt received ceftriaxone at OSH, but pt only had 31 WBC by paracentesis. Abdominal pain improved since initial paracentesis in ED; now ascites redeveloped and pain has returned. Ceftriaxone/Rifaximin was given immunosuppression and elevated WBC. She recieved morphine prn for pain. . A second paracentesis was attempted; however only 10 cc of fluid was removed. She was then taken to have U/S-guided paracentesis, but found to have significantly dilated loops of bowel which hindered further attempts. On repeat US guided paracentesis for [8-6] for symptomatic relieve was successful. Her abdominal pain resolved prior to discharge. . 3) RENAL FAILURE - likely [1-24] to nephrotoxity from cyclosporin; appears to have resolved as pt's creatinine at baseline of 2.2. She was given 25 grams of Albumin after her paracentesis. Her medications were renally dosed . 4) CIRRHOSIS - Cirrhosis of transplanted liver is thought to be [1-24] to prior noncompliance with immunosuppressive meds. Patient being evaluated for a re-transplant by Dr. [Last Name (STitle) 28609] at [Hospital1 18]. pt intially w/ varices and now w/ asterixis. possibly enephalopathic due to increased urea load w/ GIB. Her encephalopathy resolved. Decreased cyclosporin to 50 qd and started sirolimus 4 mg qd on [8-3]. She continued Lactulose and rifamixin for encephalopathy ppx. Diuretics were held given GIB and renal dysfunction. She continued prednisone. Her cyclosporin and sirolimus levels were checked. . 5) DIARRHEA - likely related to Lactulose, resolved prior to discharge . Medications on Admission: 1. levaquin 250 po qd 2. Lactulose prn 3.Lasix 40mg po qd 4. Aldactone 50mg po qd 5. Rifaximib 6. Iron sulfate 7. Protonix 40mg po qd 8. Neoral 100mg po qd 9. Morphine SR 60mg po prn 10. Prednisone 10 mg po qd 11. Calcium supplements Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO tid-qid: Tritrate to 3 bowel movement a day. Disp:q/s ml Refills:2 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sirolimus 2 mg Tablet Sig: One (1) Tablet PO once a day: Do not take on [8-8] and [8-9]. Restart on [8-10] (Friday). Disp:30 Tablet(s) Refills:2 4. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:20 Tablet(s) Refills:0 9. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: SBP, Upper GI bleed Discharge Condition: stable Discharge Instructions: Please call primary care provider or come to emergency room if have increased abdominal pain, vomiting of blood, lightheadedness or any other concerning symptoms. Do not take Rapamune for next 2 days ([8-8] and [8-9], then restart om [8-10] Friday at 2mg daily. Followup Instructions: 1.Dr. [Last Name (STitle) 497] on Monday, transplant coordinator will call 2.Transplant coordinatro will call with appointment Completed by:[2114-8-13**]	[ "996.82", "V15.81", "572.3", "733.90", "578.0", "571.5", "E943.3", "584.9", "456.20", "789.5", "787.91" ]	icd9cm	[ [ [] ] ]	[ "99.04", "42.33", "54.91" ]	icd9pcs	[ [ [] ] ]	9002, 9008	4922, 7417	328, 347	9072, 9081	3112, 4899	9408, 9570	2540, 2557		7701, 8979		9029, 9051		7443, 7678			9105, 9385								2572, 3093																									274, 290										376, 2199															2221, 2429	2445, 2524
57,055	137,252	46060	Discharge summary	report	Admission Date: [2198-7-24] Discharge Date: [2198-8-1] Date of Birth: [2119-2-26] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 4327] Chief Complaint: Nephrolithiasis Major Surgical or Invasive Procedure: Right ureteroscopy and laser lithotripsy History of Present Illness: 79yo PMHx HTN, DM, OSA on CPAP admitted on [2198-7-24] for right ureteroscopy with laser lithotripsy ([7-24] procedure), course complicated by fever to 101 and leukocytosis to 16.2 (w bandemia of 12%) on POD#1,worsening hypoxia on POD#2; Patient was started on empiric coverage with levofloxacin and has remained afebrile >24 hours, but remains with 1-2LNC oxygen requirement, desatting to high 80s on room air. Patient also had one documented fever on [7-24] at 2300 of 101.6 and labs were also notable for [Last Name (un) ] on CKD with creatinine of 1.9. She was transferred to the medicine service this evening for further management On [7-26] patient complained of palpitations. In the setting of continued hypoxia decision made to obtain CTA with prelim read of subsegemental PE in right upper lobe. Patient was started on hep ggt. However as day progressed patient continued to complain of chest fluttering as well as worsening GERD; cardiac enzymes demonstrated trop 1.0; MBI 7.2: 7 CK: 1076. EKG with dynamic ST changes and bedside TTE with ?lateral wall motion abnl. Code STEMI called and cath lab activated. Prior to transfer patient was Plavix loaded; received 325mg of ASA and 10 (of 80) of Lipitor (already on BB, statin). VS prior to transfer HR 80s, 140-150s/70-80s, saturating well on facemask. On arrival to the cath lab, VS: HR 92 166/94 20s 87%. Cath demonstrated left dominant system, LAD 70%proximal occlusion, LCx: large dominant vessel, 50% after OM1, large OM1 90% (hazy, irregular, diffuse); RCA: subtotal occlusion -small vessel. OM1 balloned and drug-eluting stent placed, with resulting TIMI 3flow. Patient receieved a total of 180ml of contrast Vitals on transfer were 99.1, HR 81, BP 140/91 97% on NRB. On arrival to the floor, patient appears quite comfortable on NRB and without complaints. Denies any shortness of breath, cough, chest pain. . REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Hypercholesterolemia. 2. Hypertension. 3. Type 2 diabetes for the last ten years (denies peripheral neuropathy). 4. History of urosepsis with mental status changes. 5. Known CNS microvascular disease. 6. Status post spinal stenosis surgery 5 years ago. 7. Status post cholecystectomy. 8. History of TIAs. 9. Rotator cuff injury from past falls 10. Prior right knee surgery s/p fall (Dr. [Last Name (STitle) 1005] 11. Urinary incontinence (Dr. [Last Name (STitle) ] s/p implantation of neuromodulation device Social History: - Tobacco: 50 to 70-pack-year history of tobacco use, but quit over 30 years ago - Alcohol: Denies - Illicits: Denies Lives in elder housing, family very involved. Daughter [Name (NI) ] is HCP. Family History: No family history of kidney disease or diabetes. There is no family history of stones. The patient's mother had hypertension and stomach CA. The patient's father died of esophageal CA. Physical Exam: PHYSICAL EXAMINATION: VS: As above GENERAL: In NAD, HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of * cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . PE at discharge: HEENT: no JVD CV: RRR, no M/R/G CHEST: CTAB post, no crackles or wheezes ABD: Obese, soft, pt is constipated EXT: no sig edema. Right wrist with diffuse ecchymosis Pertinent Results: On admission: [2198-7-24*] 05:40PM GLUCOSE-206 UREA N-39* CREAT-1.4* SODIUM-136 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 [2198-7-24] 05:40PM estGFR-Using this [2198-7-24] 05:40PM WBC-6.8 RBC-3.62* HGB-11.4* HCT-34.5* MCV-95 MCH-31.4 MCHC-33.0 RDW-15.1 [2198-7-24] 05:40PM NEUTS-76* BANDS-12* LYMPHS-7* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [2198-7-24] 05:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2198-7-24] 05:40PM PLT SMR-NORMAL PLT COUNT-172 [2198-7-25] 03:40PM BLOOD WBC-16.2# RBC-3.48 Hgb-10.9* Hct-33.7* MCV-97 MCH-31.2 MCHC-32.3 RDW-15.2 Plt Ct-149* [2198-7-26] 11:30AM BLOOD WBC-17.3* RBC-3.51* Hgb-10.9* Hct-33.5* MCV-96 MCH-31.2 MCHC-32.6 RDW-14.7 Plt Ct-174 [2198-7-26] 11:30AM BLOOD Glucose-412* UreaN-38* Creat-1.3* Na-136 K-4.2 Cl-100 HCO3-21* AnGap-19 [2198-7-25] 03:40PM BLOOD Glucose-201* UreaN-47* Creat-1.6* Na-136 K-3.9 Cl-101 HCO3-21* AnGap-18 [2198-7-24] 05:40PM BLOOD Glucose-206* UreaN-39* Creat-1.4* Na-136 K-4.5 Cl-104 HCO3-21* AnGap-16 . On discharge: [2198-8-1] 05:45AM BLOOD WBC-13.1* RBC-2.95* Hgb-9.1* Hct-27.9* MCV-94 MCH-30.9 MCHC-32.7 RDW-14.7 Plt Ct-345 [2198-8-1] 05:45AM BLOOD Glucose-207* UreaN-38* Creat-1.2* Na-136 K-4.1 Cl-100 HCO3-25 AnGap-15 [2198-8-1] 05:45AM BLOOD Mg-2.1 [2198-7-28] 05:40AM BLOOD %HbA1c-9.2* eAG-217* [2198-7-28] 05:40AM BLOOD Triglyc-131 HDL-43 CHOL/HD-2.8 LDLcalc-53 Brief Hospital Course: Ms. [Name14 (STitle) 98018] is a 79 y/o female with a history of MMP including diabetes, HTN, depression, who had undergone a right ureteroscopy and laser lithotripsy on [2198-7-24] with post-operative course complicated by STEMI and PE. Active Issues This Admission: # Right ureteroscopy and laser lithotripsy on [2198-7-24]: Pt originally admitted for elective urologic laser lithotripsy and stent due to recurrent renal stones. The procedure had no complications and stones were removed. Urology followed patient while she was here. Stents were left in for now and she will f/u with urology in about a week. # Fever. [Name (NI) 1917] pt spiked to 101. Pt had a postive UA but culture with NGTD. Blood cultures NGTD. Uncertain if fever [2-1] to instrumentation. Patient is incontinent at baseline which puts her at higher risk for infection. Patient completed course of cipro for potential UTI. She remained afebrile throughout remaineder of adission. # Pulmomary Emboli. On POD #3, overnight the patient felt like her heart was "racing", but was without pain or SOB, with increased systolic blood pressures to 150s and tachycardia to 110s. A stat EKG was obtained which revealed sinus tachycardia. She is on her home dose of metoprolol 50 mg [Hospital1 ], and losartan was discontinued. Her WBC increased to 17.3. A repeat CXR again revealed no pneumonia. Patient became progressively hypoxic and CTA showed PE. She was started on a heparin and transitioned to coumadin. Hypoxia subsequently improved. Her INR was 2.4 on day of discharge and INR should be checked again on [8-3]. Transfer to Medcine: It was determined that the patient has multiple comorbidities in the setting of acute hypoxia and will be transfered to the medicine service on [2198-7-26]. # STEMI: Following transfer patient continued to complain of chest fluttering as well as worsening GERD,and cardiac enzymes were notable for trop 1.0; MBI 7.2: 7 CK: 1076. Patient found to have ST changes in the inferior and lateral leads taken to the cath lab found to have 90% occlusion in OM1 with angioplasty and DES successfully implanted. Patient is Left dominant. Also found a proximal LAD occlusion of 70% with no intervention as not thought to be the culprit. On the floor she had episodes of throat "burning" she had repeat EKGs which showed T wave inversions in inferior and lateral leads c/w area reperfused with DES (OM). A repeat catheterization did not show any new blockages and good flow through remaining arteries, no intervention. She was started on Imdur, metoprolol succinate, high dose atorvastatin, plavix and cont home aspirin. She will see Dr. [Last Name (STitle) ] at [Hospital1 18] for f/u and will need to take aspirin and plavix every day for at least one year. She will also continue to take Imdur 30mg daily, metoprolol succinate 100mg daily, and atorvastatin 80mg daily. # Acute on Chronic Diastolic CHF: Pt developed shortness of breath while on cardiology service which improved with diuresis. Echocardiogram showed evidence of anterolateral-inferolateral wall motion abnormalities with LVEF of 40-50%. No previous echo available for comparison and no previous history of heart failure or ACS. She continued to appear volume overloaded on exam and put on standing lasix. It is also likely that her subsegmental PE also contributed to her shortness of breath. Her weight at discharge is 94.8 kg. She will continue to take 60mg of lasix daily as an outpt. # [Last Name (un) ] on CKD- Baseline creatinine around 1-1.3. Peaked at 1.6 [7-25]. On day of dischrge Cr was 1.2. [Last Name (un) ] most likely pre-renal secondary to CHF and decreased CO. CHRONIC ISSUES: # HTN: Patient was treated with Felodopine 10 mg (home med) and [Last Name (un) ] changed to ACEi Lisinopril. # OSA: on CPAP, she should bring in her machine from home. # Hyperlipidemia Continued Atorvastatin 80 mg daily . # DM: Poor blood sugar control at home with A1C 9.2 on metformin only. She was started on sliding scale and glargine was started and uptitrated to 20 units. Glipizide was started at discharge. Pt will be a poor candidate for insulin because of her dementia and will need to be stable on an oral regimen that will likely require [2-2] medicines. #Dementia: stable and at baseline per daughter Continued donepezil #Depression: stable Continued citalopram, trazadone TRASNITIONAL ISSUES: #CAD: patient will follow up with cardiologist Dr [Last Name (STitle) ] #s/p right ureteroscopy and laser lithotripsy on [2198-7-24]: patient will f.u with urology #Hyperglycemia: pt frequently in the high 300s for blood glucose. She is on home oral meds and here is requring insulin. Patient should follow up with pcp about possibly needing to start insulin if oral meds are not working. Medications on Admission: - albuterol sulfate 2 puffs prn - aspirin 81mg daily - atorvastatin 10mg daily - citalopram 40mg daily - donepezil 10mg daily - felodipine 10mg tablet extended release daily - fluticasone 50 mcg Spray 2 puffs daily - gabapentin 300mg qhs - guanfacine 2mg qhs - losartan 50mg [Hospital1 ] - metformin 1,000mg [Hospital1 ] - metoprolol tartrate 50mg [Hospital1 ] - solifenacin 10mg daily - trazodone 50mg qhs Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Donepezil 10 mg PO HS 5. Felodipine 10 mg PO DAILY 6. Gabapentin 300 mg PO HS 7. traZODONE 50 mg PO HS 8. Clopidogrel 75 mg PO DAILY Do not stop this medicine or miss [First Name (Titles) 691] [Last Name (Titles) 4319] for one year 9. Docusate Sodium 100 mg PO BID 10. Senna 2 TAB PO HS 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Furosemide 60 mg PO DAILY 13. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Hold SBP < 100 15. Lisinopril 10 mg PO DAILY Hold for SBP <100 16. Metoprolol Succinate XL 100 mg PO DAILY Hold for SBP <100, HR <55 17. Nitroglycerin SL 0.3 mg SL PRN chest pain may repeat up to 2 times at 10 minute intervals, call 911 if chest pain does not resolve after 2 tabs 18. Warfarin 5 mg PO DAILY16 Duration: 3 Months please check INR on [2198-8-3] 19. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 20. GlipiZIDE 5 mg PO BID Please uptitrate if blood sugars cont to be high 21. guanFACINE NF 2 mg Oral hs 22. solifenacin NF 10 mg Oral daily Discharge Disposition: Extended Care Facility: [Last Name (un) 1687] - [Location (un) 745] Discharge Diagnosis: ST Elevation myocardial infarction Hypertension Diabetes mellitus type 2, poorly controlled S/P right uteroscopy with laser lithotripsy Pulmonary embolus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for a urological procedure which was complicated by kidney failure that has resolved, a small pulmonary embolus and a heart attack. A cardiac catheterization showed blockages in your heart arteries and a drug eluting stent was placed in one of them. You had some chest pain after the heart attack and another cardiac catheterization was performed that did not show any new blockages and there was no further intervention. Your heart is weaker after the heart attack and you will need to take some new medicines to make your heart stronger. Do not stop taking aspirin and plavix or miss [First Name (Titles) 691] [Last Name (Titles) 11014] unless Dr. [Last Name (STitle) ] tells you it is OK. You risk having the stent clot off and causing another heart attack if you don't take these medications every day. Followup Instructions: . Department: COGNITIVE NEUROLOGY UNIT When: WEDNESDAY [2198-8-8] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8384], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: SURGICAL SPECIALTIES When: Daughter [Name (NI) ] has made another appt, please check with her for date and time With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 921] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: THURSDAY [2198-8-30] at 9:30 AM With: [Name6 (MD) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "250.00", "530.81", "327.23", "401.9", "428.33", "788.39", "V45.82", "592.0", "294.20", "410.91", "272.4", "414.01", "599.71", "584.9", "V12.54", "415.19", "428.0", "349.89" ]	icd9cm	[ [ [] ] ]	[ "00.45", "56.31", "59.8", "00.66", "36.07", "88.56", "56.0", "00.59", "00.40" ]	icd9pcs	[ [ [] ] ]	12804, 12882	6313, 10019	297, 339	13080, 13080	4792, 4792	14126, 15143	3591, 3777		11623, 12781		12903, 13059		11180, 11600			13265, 14103								3792, 3792														3814, 4594		4608, 4773	5916, 6290								242, 259										367, 2816							4806, 5901	13095, 13241				10035, 11154			2838, 3358	3374, 3575
19,059	154,958	48192	Discharge summary	report	Admission Date: [2127-6-2] Discharge Date: [2127-6-4] Date of Birth: [2065-11-22] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / apple / bees Attending:[Last Name (NamePattern4) 290] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 61F with history of obesity hypoventilation, trached chronically, CHF EF >60% 4/12, presents with hypoxia at home today when checked by her [Last Name (NamePattern4) 269]. She denies any acute symptoms, no chest pain, no SOB, but when asked, says she feels fluid overloaded, and similar to prior CHF exacerbations. No fevers, no chills. . She was initially admitted to [Hospital1 18] in [11/2126] for hypercarbic respiratory failure requiring intubation and tracheostomy. She was discharged to [Hospital1 ] and she was weaned of the vent. She was managed at rehab with red capping during the day and passe muir valve at night with humidified air. She was then readmitted to [Hospital1 18] [3-/2127] after routine visit to PCP where she was found to be volume overloaded. She was initially admitted to the MICU due to transient hypotension and then was transferred back to the MICU after triggering for hypoxia on the floor. During this admission she was also restarted on sildenafil for her pulmonary hypertension. She was diuresed with IV lasix and discharged on lasix 40 mg po daily. She was admitted [Date range (1) ] with nausea, abdominal pain, dyspnea and SOB. After nebulizer treatments, she was persistently hypoxic to the 70s-80s on FiO2 of 100%. Patient was then started on BiPAP 12/5 FiO2 60% with improved sats to 93%. Patient then became somnolent and desatted to 70s-80s. She was evaluated by respiratory and placed on CMV with TV 350 PEEP 10 FiO2 60% and sat 100%. Blood pressures also dropped to 70s-80s and considered starting peripheral levo but did not. Patient refused central access and ABGs that admission. . In the ED, VS 98.2, 92, 127/87, 22, 85/6L. She was placed on bipap. Labs notable for 144/4.2/96/36/38/2.2<170. BNP was [Numeric Identifier ]. WBC was 11.2 with 91 N, Hct 37.4, Platelets 298. Troponin was 0.04. VBG: 7.34/73/55/bicarb 41 with a lactate of 1.3. Declined ABG. EKG was nonspecific. . She given Furosemide 40mg IV X 1. She was given Nitroglycerin and qickly dropped her SBPs 102-> 80s so it was stopped. She was noted to never look to be in respiratory distress. VS on transfer were 105/70, HR 100, 97% possibly on [5-3], RR 20s. Never febrile. . On arrival to the MICU, she states that she currently feels like her normal self. Her daughter is present for discussion and states that she did not think that her mom looked well yesterday and may have been having difficulty with her breathing but overall did not look good. Both state that she did not increase her lasix to [Hospital1 ] dosing as suggested by Dr. [Last Name (STitle) 3029] (daughter states change not made due to cost). She has been on 2-3L NC at home wihtout fevers or chills. There were no other recent medication changes. Ms. [Known lastname ] states that she had increased her oral fluid intake the past few days, without reason and has been drinking a larger amount of cranberry juice, water and tea. . She was seen by IP on [5-27] and discussion was had to defer to Dr. [Last Name (STitle) 101574] [Name (STitle) 101575] to change to [Initials (NamePattern4) ] [Last Name (NamePattern4) ] T or because of needed nocturnal ventilation stay with a tracheostomy. . Her weight on admission to the floor is 114 kg ( 250.8 lbs). Her most recent discharge weight was 119 kg. Her outpatient weights have been 249 lbs and 251.4 lbs in OMR. Past Medical History: 1. Morbid obesity (s/p gastric bypass [2113]) 2. Obstructive sleep apnea (noctural BiPAP 18/15, home O2 3-4L via nasal cannula) 3. Obesity hypoventilation syndrome 4. Severe pulmonary artery hypertension (attributed to OSA) 5. Cor pulmonale attributed to severe pulmonary hypertension 6. Asthma 7. Osteoarthritis (bilateral knees) 8. Diastolic heart failure (2D-Echo [1-/2124] showing LVEF 70-80%, PAP 64 mmHg) 9. Chronic kidney disease (stage III-IV, baseline creatinine 1.8-2.2) 10. Rosacea 11. Hypertension 12. Iron deficiency anemia 11. s/p ventral hernia repair with mesh and component separation ([5-/2119]) 12. s/p debridement of anterior abdominal wall and complex repair ([6-/2119]) Social History: She has 2 adult children and adopted 3. She notes no tobacco use, rare alcohol use currently. Notes a former heavy alcohol history in the distant past. She denies recreational substance use. Family History: Notable for diabetes mellitus in her mother and sister. Hypertension in siblings, mother and throughout the maternal family as well as kidney disease. Physical Exam: ADMISSION EXAM: Vitals: 98.7, 109/65, 85, 20, 92% on pressure support [12-3], 40% FiO2 General: Somnolent but arousable, oriented x3, no acute distress, frequently falling asleep mid conversation HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, single transient end expiratory wheeze right upper lung field Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: 2+ edema, poor peripheral pulses Neuro: CNII-XII intact, 5/5 strength upper/lower extremities . DISCHARGE EXAM: Vitals: 99.3, 101/53, 87, 26, 95% on facemask General: Alert and oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: 2+ edema, poor peripheral pulses Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Pertinent Results: ADMISSION LABS: [2127-6-2] 01:45PM BLOOD WBC-11.2* RBC-3.75* Hgb-10.1* Hct-37.4 MCV-100* MCH-27.0 MCHC-27.0* RDW-16.7* Plt Ct-298 [2127-6-2] 01:45PM BLOOD Neuts-90.8* Lymphs-5.6* Monos-2.0 Eos-1.4 Baso-0.3 [2127-6-2] 08:10PM BLOOD PT-44.5* PTT-52.4* INR(PT)-4.4* [2127-6-2] 01:45PM BLOOD Glucose-170* UreaN-38* Creat-2.2* Na-144 K-4.2 Cl-96 HCO3-36* AnGap-16 [2127-6-2] 01:45PM BLOOD ALT-12 AST-14 AlkPhos-95 TotBili-0.1 [2127-6-2] 01:45PM BLOOD cTropnT-0.04* proBNP-[Numeric Identifier ]* [2127-6-2] 08:10PM BLOOD cTropnT-0.03* [2127-6-3] 03:10AM BLOOD cTropnT-0.03* [2127-6-2] 01:45PM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2 [2127-6-2] 02:05PM BLOOD Type-[Last Name (un) ] pO2-55* pCO2-73* pH-7.34* calTCO2-41* Base XS-9 Intubat-NOT INTUBA Comment-GREEN TOP [2127-6-2] 02:05PM BLOOD Lactate-1.3 [2127-6-2] 06:12PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.008 [2127-6-2] 06:12PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2127-6-2] 06:12PM URINE RBC-35* WBC-18* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 . DISCHARGE LABS: [2127-6-4] 03:53AM BLOOD WBC-6.6 RBC-2.98* Hgb-8.2* Hct-28.4* MCV-96 MCH-27.7 MCHC-29.0* RDW-17.2* Plt Ct-248 [2127-6-4] 03:53AM BLOOD PT-33.9* PTT-43.9* INR(PT)-3.3* [2127-6-4] 03:53AM BLOOD Glucose-106* UreaN-33* Creat-1.7* Na-146* K-3.3 Cl-99 HCO3-40* AnGap-10 [2127-6-4] 03:53AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.9 [2127-6-3] 03:27AM BLOOD Type-[Last Name (un) ] pO2-168* pCO2-48* pH-7.56* calTCO2-44* Base XS-18 Comment-GREEN TOP . MICROBIOLOGY: [2127-6-2] Urine culture: no growth [2127-6-2] Blood culture: no growth to date . IMAGING: [2127-6-2] CXR: Portable AP upright chest radiograph obtained. A tracheostomy tube is seen. As on prior study, cardiomegaly and pulmonary edema is re-demonstrated. There is no large pleural effusion or pneumothorax. Evaluation for subtle superimposed pneumonia is limited. Mediastinal contour is stably widened. Bony structures appear intact. IMPRESSION: Overall stable exam with pulmonary edema, cardiomegaly. . [2127-6-3] CXR: As compared to the previous radiograph, there is no relevant change. Tracheostomy tube is unchanged. Moderate cardiomegaly with moderate pulmonary edema and likely left pleural effusion. Extensive retrocardiac atelectasis. No evidence of pneumonia. Brief Hospital Course: 61 year old woman with history of obesity hypoventilation with chronic trach, obstructive sleep apnea, pulmonary hypertention, diastolic CHF, who presented with hypoxic respiratory failure. . # Hypoxic respiratory failure: Likely due to CHF exacerbation. Though weights seem to be at baseline, BNP is significantly at upper limit of the patient's normal range and CXR showed pulmonary edema. Patient also reports not taking recommended dosing of lasix and overdoing oral fluids at home. She was diuresed with lasix 80mg IV x2 with good UOP and was then started on lasix 40mg PO BID. No evidence of pneumonia or other acute process on chest x-ray. No history of COPD. Cardiac enzymes negative and ekg negative for ischemic changes. We continued sildenafil for her pulmonary hypertension. Interventional pulmonary adjusted her trach and recommended inflating the cuff with 8cc at night. She will also need to start using the ventilator at night. Her setting should be BiPAP [12-3] with FiO2 50%. She was discharged on her home furosemide regimen. This should be adjusted as necessary. She should have her electrolytes checked [6-5]. . # Waxing/[Doctor Last Name 688] mental status: Likely due to chronic obesity hypoventilation syndrome. Patient with recently elevated INR but not elevated to the point at which you would expect a spontaneous bleed. Mental status improved as her oxygenation improved and was back to baseline at discharge. . # Acute on CKD: Baseline creatinine is 1.6-2.0. Creatinine on admission was 2.2 which improved to her baseline 1.7 upon discharge. . # Hypertension: Patient is not on any antihypertensives at home and has been normotensive during her hospital stay. . # DVT: Held coumadin given supratherapeutic INR on admission (4.4). INR decreased to 3.6 on the day of discharge ([6-4]). Will need to recheck INR tomorrow ([6-5]) and restart coumadin at home dose 2mg daily once INR is less than 3. . # Iron deficiency anemia: HCT has remained within her baseline of high 20s-low 30s. No evidence of GI or other bleeding. Continued iron sulfate supplementation. . # Gout: Continued home prednisone and renally dosed allopurinol (100mg daily). . # Transitional Issues: Patient is having a hard time coping with the fact that she will now need to use the vent at night. She also has a lot of questions regarding traveling with the vent and other logistics. She would benefit from having a social worker speak with her about this. She will need to restart her warfarin once INR <3. Medications on Admission: 1. Cheratussin AC 10 mg-100 mg/5 mL Oral Liquid; [12-30] teaspoon(s) by mouth twice a day as needed for cough 2. Saline Spray 0.9%; [2-1] sprays at least 4 times a day use more frequently for nasal congestion 3. aspirin 81 mg Tab once daily 4. allopurinol [12-30] of a pill, unsure of pill dose 5. furosemide, 1 pill, unsure of dose. [Month (only) 116] be 40mg or 20mg 6. prednisone 2.5 mg Tab daily 7. Desenex 1% Topical Cream dose uncertain 8. Colace 100 mg Cap daily 9. bisacodyl 5 mg Tab, Delayed Release, 2 daily 10. Ferrous Sulfate 325 mg (65 mg Iron); 1 Tablet(s) by mouth every morning 11. warfarin 2 mg Tab daily 12. Flovent HFA 110 mcg/Actuation Inhaler; 2 puffs inhaled twice a day 13. polyethylene glycol 3350 17 gram Oral Powder Packet prn 14. sildenafil 20 mg TID Discharge Medications: 1. Cheratussin AC 10-100 mg/5 mL Liquid [Month (only) ]: [12-30] teaspoons PO twice a day as needed for cough. 2. Saline Nasal 0.65 % Aerosol, Spray [Month/Day (2) ]: [2-1] sprays Nasal four times a day. 3. aspirin 81 mg Tablet, Chewable [Month/Day (3) ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. allopurinol 100 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 5. furosemide 40 mg Tablet [Month/Day (3) ]: One (1) Tablet PO BID (2 times a day). 6. prednisone 2.5 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 7. Desenex Topical 8. Colace 100 mg Capsule [Month/Day (3) ]: One (1) Capsule PO once a day. 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (3) ]: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 10. ferrous sulfate 300 mg (60 mg iron) Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 11. fluticasone 110 mcg/actuation Aerosol [Month/Day (3) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 12. polyethylene glycol 3350 17 gram Powder in Packet [Hospital1 ]: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 13. sildenafil 20 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: CHF exacerbation Obesity hypoventilation Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory with assistance Discharge Instructions: It was a pleasure caring for you at [Hospital1 18]. You were admitted because your oxygenation was low. This was in part due to an exacerbation of your heart failure. We gave you extra lasix to remove some of the fluid. We also think that you will need to start using the ventilator at night to prevent you from having low oxygenation. . weight goes up more than 3 lbs. Followup Instructions: Department: GASTROENTEROLOGY When: MONDAY [2127-6-16] at 12:30 PM With: [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage . Department: MEDICAL SPECIALTIES When: TUESDAY [2127-7-1] at 10:30 AM With: DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3172] [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: [Hospital3 249] When: FRIDAY [2127-7-11] at 11:50 AM With: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "428.0", "274.9", "V58.65", "493.90", "280.9", "403.90", "327.23", "584.9", "518.81", "V12.51", "V44.0", "428.33", "V46.2", "V58.61", "V45.86", "278.01", "585.3", "799.02", "278.03", "715.36", "V65.3", "416.8" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	13149, 13221	8501, 9678	324, 330	13330, 13330	6060, 6060	13879, 14998	4730, 4882		11871, 13126		13242, 13309		11053, 11848			13481, 13856			7217, 8478					4897, 5545						5561, 6041																			277, 286										358, 3773					6076, 7201			13345, 13457			10714, 11027				3795, 4505	4521, 4714
19,620	140,789	49813+49814	Discharge summary	report+report	Admission Date: [2164-7-29] Discharge Date: [2164-8-12] Date of Birth: [2120-9-25] Sex: F Service: [Hospital1 ] MEDICINE This dictation is up until [2164-8-12]. HISTORY OF PRESENT ILLNESS: Patient is a 43-year-old female with past medical history of type 1 diabetes, end-stage renal failure on hemodialysis, and chronic bilateral heel ulcers, neuropathy, personality disorder, who presents with a one day history of chills, fever, and diarrhea without any vomiting or abdominal pain. She reports she has had greater than 20 stools with some incontinence without blood or mucus. Reports drenching sweats. On the last dialysis, on [7-27], her graft was working well at that time. She did not complain of any headache, chest pain, shortness of breath, or urinary symptoms. In the Emergency Department, the patient received 1 liter of normal saline, 1 gram of Vancomycin, 1 gram of ceftazidime, 500 mg of Levaquin, 1 gram of Tylenol, and 600 mg of ibuprofen. PHYSICAL EXAMINATION: Temperature is 101. Heart rate 83. Blood pressure 92/51. Respirations 20. HEENT: Pupils are equal, round, and reactive to light. Dry mucous membranes. Oropharynx is clear. Heart: Normal S1, S2, regular, rate, and rhythm, no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, with normoactive bowel sounds. Extremities are without clubbing, claudication, or edema. She has bilateral heel ulcers. Left ulcer with a sinus tract to the bone. LABORATORIES: White count 24.0, hematocrit 42.3, platelets 463, 93% segs, 5% lymphocytes, 2% monocytes. Sodium is 129, potassium is 5.6, and a hemolyzed specimen. Chloride is 80, bicarb is 24, BUN is 47, creatinine is 8.6, glucose is 230. Lactate is 5.6, anion gap is 25. CHEST X-RAY: No infiltrates. HOSPITAL COURSE: 1. Infectious disease: Patient admitted with a question of sepsis. Patient also with bilateral calcaneus osteomyelitis. Patient initially thought to be septic on admission with a low blood pressure in the 80s/40s, fever, diarrhea on admission, but her only positive blood culture was drawn on [7-29] and it was 1/2 bottles positive for Peptostreptococcus. All of her surveillance cultures have remained negative. She was initially covered empirically with Vancomycin, ceftazidime, and levofloxacin. Her hypotension was then felt to also be secondary to diabetic ketoacidosis as patient had an elevated serum anion gap of 27. Her normal baseline between 14-19. She also had a blood sugar of 230. She was started on an insulin drip and her gap fell by the 11. She was then changed to sliding scale insulin. Patient also has bilateral chronic lower extremity ulcers, and she was followed by Podiatry and Vascular Surgery while on the Medical floor. She had a bone scan, which revealed bilateral osteomyelitis of both calcaneus bones. The patient was then treated with Vancomycin and Zosyn for two days, and then switched to Vancomycin, ceftazidime, and po Flagyl as her IV access became problem[Name (NI) 115] and needed to have her antibiotics dosed at dialysis only. The patient then became febrile to 104 with altered mental status on [8-11] after not having dialysis or antibiotics for three days due to access issues. An emergent femoral catheter was placed for hemodialysis by Interventional Radiology and she received hemodialysis that day, and was treated with Vancomycin, ceftazidime, gentamicin, and po Flagyl. Her mental status improved that day and blood culture was drawn, and she had nothing growing from this blood culture to date. She will continue on Vancomycin, ceftazidime, and Flagyl for a total course of six weeks for treatment of osteomyelitis. 2. Renal: Patient with end-stage renal disease on hemodialysis, awaiting living donor transplant. Patient initially thrombosed her arteriovenous graft on [7-30] during hemodialysis. She was also having borderline hypotension at that time. She was treated with a thrombectomy on [7-31], which then re-thrombosed. She was then scheduled for a Permacath on the floor, but she was unable to have this for multiple days secondary to fevers, scheduling delays. When they attempted to place this Permacath, they were unable because of her bilateral internal jugular occlusions, which were checked by MRV and found to be nonbypassable. The next best access was felt to be a repeat thrombectomy for clotted A-V graft. As her blood pressure had improved at this time, but her repeat thrombectomy was unsuccessful secondary to proximal stenosis. She was then scheduled for a tunneled right femoral catheter, which she was unable to get due to spiking fevers to 104. She had a temporary femoral catheter placed for hemodialysis, and she is now awaiting clearance for her tunneled right femoral catheter. She had cannot have a tunneled femoral catheter due to the left femoral vein being staged for transplant on that side. She has been continued on PhosLo and Epogen during this admission. 3. Gastrointestinal: Admitted with diarrhea and fevers. Diarrhea continued especially after dialysis despite negative stool cultures, ova and parasites and Clostridium difficile toxin negative x3. Yesterday her nurse remarked that her stool is actually well formed, but the patient reports this is still diarrhea. Patient may still be incontinent secondary to autonomic neuropathy. 4. Endocrine/type 1 diabetes complicated by neuropathy, retinopathy, nephropathy, gastropathy, chronic bilateral ulcers, and autonomic dysfunction. Patient initially thought to be in diabetic ketoacidosis with increased gap and hypotension. Her gap responded to an insulin drip and her hypotension was found to be secondary to autonomic neuropathy and improved with treatment of midodrine and fludrocortisone which she has continued during this admission. She was followed by [Last Name (un) ] with very difficult to control blood sugars, was maintained on sliding scale Humalog and pm Lantus. The patient had multiple episodes of low blood sugars as well as excessively high blood sugars in the morning. She was continued on Neurontin. Her heel ulcers have also been followed by Podiatry and debrided surgically on [8-1] with a right medial malleolar abscess, which was sent for culture, which grew multiple organisms. The patient was continued with bedside debridement as performed by Podiatry and is scheduled to go for a subtotal left calcanectomy tomorrow on [8-13]. 5. Cardiovascular: Patient presenting with hypotension initially thought secondary to autonomic neuropathy and diabetic ketoacidosis. Her hypotension is improved with treatment with midodrine and fludrocortisone, and she has had no further episodes of remarkable hypotension. Patient with many vascular access problems including bilateral internal jugular occlusion. Her left femoral vein is currently being reserved for possible future renal transplant. Vascular Surgery has followed the patient and performed an angiogram of her left femoral artery, which was found to be normal, and patient not felt to need any Vascular Surgery at this time. 6. Psychiatry: Patient with a history of personality disorder. Patient also with very labile mood on the floor and very abusive to staff at times. She threatened to leave against medical advice on multiple occasions. 7. Pulmonary: Patient's oxygen saturations have been stable since this admission. 8. Fluids, electrolytes, and nutrition: Initially presenting with hyponatremia, but her sodium of 129 improved to 131 after her insulin drip corrected her serum anion gap in the Medical Intensive Care Unit. She has had no other gross electrolyte abnormalities during this admission, and she was continued on PhosLo tid with meals. 9. Prophylaxis: The patient has been on proton-pump inhibitor, and had podas boots. 10. Code status: Patient is full code. Patient will have her discharge summary addendum upon discharge. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-AAN Dictated By:[Last Name (NamePattern1) 5819] MEDQUIST36 D: [2164-8-12] 19:32 T: [2164-8-15] 13:58 JOB#: [Job Number 104100] Admission Date: [2164-7-29] Discharge Date: [2164-8-29] Date of Birth: [2120-9-25] Sex: F Service: CONTINUATION OF HOSPITAL COURSE: 1. Infectious disease: On [8-12] the patient was taken to the Operating Room for subtotal calcanectomy of her left foot. Tissue cultures were taken at that time and found to be growing [Female First Name (un) ] and MRSA sensitive to Vancomycin. On [2164-8-23] the patient underwent debridement of her right foot with partial calcanectomy with wound debridement and culture. There is no growth from this wound culture. Her antibiotic regimen is currently Vancomycin 1 gram intravenous dosed by levels in dialysis and levels less then 15, Levaquin 250 mg po every 48 hours, Fluconazole 200 mg every 48 hours and Flagyl 500 mg po b.i.d. The patient is to complete a six week course of antibiotics, course beginning on [2164-8-20] to be completed on [2164-9-21]. The patient's blood cultures have been negative to date. Stool cultures have been negative for C-diff. Right heel tissue culture from [8-23] shows no growth and left heel tissue culture showing [Female First Name (un) ] and MRSA sensitive to Vancomycin. The patient has remained afebrile on this antibiotic regimen and per Podiatry she is nonweight bearing on either foot until further follow up with podiatry and surgery. 2. Renal: End stage renal disease on hemodialysis, access issues were reviewed and discussed with the renal team. A tunneled Perm-A-Cath dialysis catheter was placed in the right groin on [8-16]. No further complications were noted. Catheter was used successfully in hemodialysis. Vancomycin was dosed by levels for levels less then 15 and given through the dialysis catheter. The plan is to continue ongoing evaluation of the left groin for kidney transplant. Electrolytes and CBC were monitored every other day in dialysis and currently stable. The patient is to continue her calcium acetate with meals and Nephrocaps. 3. Gastrointestinal: During the remainder of her hospital course the patient has been tolerating her po intake. She has been given a diabetic, renal and low sodium diet, however, known to have episodes of dietary indiscretion. There is no further episodes of loose stools. Stool culture is negative for C-diff. 4. Endocrine: Type 1 diabetes complicated by neuropathy, retinopathy and nephropathy. Blood sugars have been extremely difficult to control secondary to infection, surgery and dietary indiscretions. The patient was followed by [Last Name (un) ]. Blood sugars range from low 50s to high 400s. The patient has been maintained on a sliding scale of Humalog and p.m. Lantus with q.i.d. finger sticks. 5. Cardiovascular: Hypertension, which was noted on admission is now improved with the administration of Midodrine and Fludrocortisone. Volume status has been adjusted in dialysis. The patient maintains stable blood pressures. 6. Psychiatric: The patient has a history of personality disorder, patient with a very labile mood and has been extremely abusive to staff at times. She demonstrates poor coping skills. 7. Pulmonary: The patient does not have any respiratory complaints. O2 sats have been stable on room air. 8. Fluids, electrolytes and nutrition: Volume status and electrolytes have been monitored during hemodialysis. The patient has not had any electrolyte abnormalities during the remainder of her hospital course. 9. Prophylaxis: The patient is currently taking proton pump inhibitors out of bed. 10. Code status: The patient is full code. DISCHARGE CONDITION: Stable. The patient is being discharged to an outside rehab facility. MEDICATIONS ON DISCHARGE: 1. Vancomycin 1 mg dosed in dialysis for levels less then 15. 2. Levofloxacin 250 mg po q 48 hours to be given after hemodialysis. 3. Fluconazole 200 mg po q 48 hours to be given after hemodialysis. 4. Metronidazole 500 mg po b.i.d. 5. Humalog insulin sliding scale plus 14 units of Glargine at bedtime. 6. Calcium acetate ________ po t.i.d. with meals. 7. Midodrine 10 mg po b.i.d. to be held for systolic blood pressures greater then 130. 8. Gabapentin 600 mg po b.i.d. 9. Fludrocortisone acetate .1 mg po q.d. 10. Nephrocaps one capsule po q.d. 11. Synthroid 75 micrograms po q.d. 12. Simvastatin 20 mg po q.d. 13. Ambien 10 mg po q.h.s. 14. Hydromorphone .5 mg intravenous q 6 h prn. 15. Morphine sulfate 2 to 4 mg subq q 4 h prn. FOLLOW UP APPOINTMENTS: The patient has a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1022] in Gyn/Onc offices at [Hospital1 1444] on [2164-8-30] at 1:30 p.m. for colposcopy. The patient also has an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the transplant center on [2164-9-11] at 10:00 a.m. The patient is to also follow up with podiatry in one to two weeks. The patient should see her primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] in one to two weeks. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 7898] MEDQUIST36 D: [2164-8-29] 01:11 T: [2164-8-29] 14:29 JOB#: [Job Number 104101]	[ "785.59", "250.41", "730.07", "250.81", "585", "707.14", "250.61", "682.6", "038.0" ]	icd9cm	[ [ [] ] ]	[ "86.22", "88.48", "39.49", "86.28", "77.88", "86.04", "86.3", "38.95", "39.95", "88.47" ]	icd9pcs	[ [ [] ] ]				11898, 11970								11996, 12747		8420, 11876																								1026, 1847																12772, 13639					228, 1003
45,788	164,259	21762	Discharge summary	report	Admission Date: [2122-1-8] Discharge Date: [2122-1-12] Date of Birth: [2064-1-30] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: s/p seizures Major Surgical or Invasive Procedure: Mechanical Intubation History of Present Illness: 82 year old with h/o of DMII, HTN, Asthma, OSA, dCHF, peripheral neuropathy who is admitted for AMS and hypercapnea. . Patient was recently admitted at [Hospital1 18] [2122-12-29], at the time she had presented with AMS, was found to be hypercarbic and requiring intubation, she was noted to have fluid overload and was diuresed with lasix, she did not have evidence of pneumonia, LENIs were negative, and echocardiogram showed a preserved biventricular systolic function without pulmonary hypertension. Therefore, it was felt that her hypercarbia was due to not wearing night time BIPAP for successive days leading to slow increase in her PCO2 +/- central apnea. She did well after extubation and was discharged to rehab with nighttime BiPAP and oral lasix. . Per her daughter at baseline prior to previous hospitalization was wheelchair bound most of the day but could make a few independent steps to the bathroom. Needed help in ADL. Demented with occasional visual + auditory halucination. At rehad continued to complain of weakness but did PT, walk around some with a walker. Per daughter patient was using BiPAP [Hospital ] rehab but continued to have issues with ill fitting mask. Per rehab patient was fine last night, on check this AM around 10:15 patient was found to be lethargic. No recent fevers or illness recorded. In the ED patient was conversant and reported wearing her BIPAP yesterday evening. Denied HA, blurry vision, CP, SOB, abdominal pain, dysuria, or increased LE edema. Pt stated she's been compliant with meds at rehab. She stated she feel fine except for "tiredness". States she did not sleep well last night, cannot say why. Past Medical History: -type 2 diabetes mellitus -hypertension -atypical peripheral neuropathy with cutaneous sensations ("dust on her skin", seen by [Hospital 878], on gabapentin + olanzapine) - tactile hallucinosis per PCP [Name Initial (NameIs) 15372]: appears to be adult onset asthma. [2106] spirometry is restrictive physiology with bronchodilator response. -macular edema s/p surgery -neovascular glaucoma secondary to her proliferative diabetic retinopathy - blind left eye > right eye -OSA (prescribed BiPAP, not currently using) -osteoarthritis -dementia . Social History: Patient is wheelchair bound due to old osteoarthritis and vision loss. In setting of a few recent falls in her apartment, her daughter stays with her at her apartment. Born and grew up in the Carribean. Worked in a chocolate factory in [Location (un) ] in the [2059]. Arrived in the US in [2070]. Denies tobacco, EtOH, IVDA. Lived with her daughter [Name (NI) ] in [Name (NI) 669] for the past 2 years. Needs help in ADL. In rehab since previous discharge [2121-1-2]. Family History: Father with diabetes mellitus, died at age 69. Mother with heart failure, died at age [Age over 90 ]. Oldest daughter with diabetes mellitus and polymyositis. Youngest daughter with anoxic brain injury [1-22] trauma, in rehab. Physical Exam: On Admission: General: intubated and ventilated, sedated on versed 3mg/h, squeezes hands and wiggles toes to command, no acute distress HEENT: , conjuctiva are hyperemic bilaterally, surgical pupil on the left, non reactive pupils bilaterally, no tenderness with mild pressure on eyes, MMM Neck: supple, hard to assess JVP due to habitus,no LAD CV: distant reguilar heart, no clear murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally on anterior auscultation, no wheezes, rales, ronchi Abdomen: distended, hypertympanic, non-tender, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, tibial edema + bil. Neuro: intubated, ventilated and sedated, squeezes hands and wiggles toes to command, moving 4 limbs, normal DTR's throughout, . On Discharge: Vitals: T: 99.1 BP: 143/90 P: 92 R: 18 O2: 100% RA General: NAD, well appearing. HEENT: Sclera anicteric, MMM, oropharynx clear, adentulous w/o dentures Neck: supple, JVP not elevated, no LAD Lungs: Diffusely rhoncorus. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: Admission: [2122-1-8] 08:45PM WBC-10.2# RBC-4.47* HGB-13.2* HCT-40.2 MCV-90 MCH-29.5 MCHC-32.8 RDW-12.0 [2122-1-8] 08:45PM NEUTS-57.1 LYMPHS-34.9 MONOS-5.4 EOS-2.1 BASOS-0.6 [2122-1-8] 08:45PM PLT COUNT-220 [2122-1-8] 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2122-1-8] 08:45PM PHENYTOIN-LESS THAN [2122-1-8] 08:45PM ALBUMIN-4.5 CALCIUM-10.0 PHOSPHATE-4.3 MAGNESIUM-1.8 [2122-1-8] 08:45PM ALT(SGPT)-31 AST(SGOT)-25 CK(CPK)-297 ALK PHOS-73 TOT BILI-0.4 [2122-1-8] 08:45PM GLUCOSE-586* UREA N-18 CREAT-1.7* SODIUM-139 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-17* ANION GAP-22 [2122-1-8] 10:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2122-1-8] 10:12PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 [2122-1-8] 10:15PM LACTATE-4.1* . Relevant: [2122-1-10] 02:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2122-1-11] 03:45PM BLOOD Phenyto-10.5 [2122-1-10] 02:55AM BLOOD HCV Ab-NEGATIVE [2122-1-9] 02:47AM BLOOD Lactate-2.3* [2122-1-9] 06:10AM BLOOD Lactate-1.2 . Discharge: [2122-1-12] 06:30AM BLOOD Glucose-104* UreaN-9 Creat-1.2 Na-141 K-3.7 Cl-108 HCO3-24 AnGap-13 [2122-1-12] 06:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.5* . Microbio: RPR negative Blood culture x2 negative Urine culture negative GC and CT urine and swab negative . Imaging: [1-8] CT head w/o con: IMPRESSION: No acute intracranial pathology. [1-8] CXRay: IMPRESSION: Right perihilar and left infrahilar opacities, worrisome for aspiration in the setting of suspected seizure, although not entirely specific. [1-9] EEG: Prelim: No signs of seizure [1-10] CXRay: Cardiac size is at the upper limits of normal. The lung fields are clear. The costophrenic angles are sharp. Mild pulmonary plethora may be present. [1-12] Echo: Normal left ventricular cavity size with normal regional and low normal global systolic function. Increased PCWP. No valvular pathology or pathologic flow identified. [1-12] MRI: 1. Unchanged prominent perivascular space versus lacunar infarct on the left basal ganglia. 2. Minimal asymmetry of the temporal ventricular horns, this finding is nonspecific and no frank evidence of mesial temporal sclerosis is identified. 3. There is no evidence of abnormal enhancement or diffusion abnormalities. 4. Polypoid formation noted on the left maxillary sinus, likely consistent with a mucus-retention cyst. Brief Hospital Course: 57 year old male w/ DM, no known sz d/o, p/w seizures in the context of non ketotic hyperosmolar state, intubated for airway protection, loaded with Dilantin, stabilized, extubated, and without recurrence on floor. . # Seizures: Pt presented with 3-4 complex partial seizures on day of admission. [Month/Year (2) 878] was consulted. The seizures were thought to be secondary to CNS effects of non ketotic hypersomolar state (glucose on admission 690) in the setting of medication non-compliance. The pt was treated with insulin and fluids and loaded with dilantin for the seizures. No acute process on CT head or MRI. Tox screen was negative and pt denied heavy drinking or substance abuse. Prelim EEG read did not show any active seizure activity. The patient was discharged on dilantin with [Month/Year (2) ] follow-up. . # Non ketotic hyperosmolar state: Resolved with Insulin and fluids . # DM II: HgbA1c was 13.6%. Family reported pt not compliant over past 2 weeks, but it has likely been longer. Pt had low insulin requirement while on sliding scale and minimal need for insulin when orals were re-initiated. [Last Name (un) ] came to see the patient and agreed that it was safe to discharge pt on metformin and glipizide. The patients glucometer recently broke so the patient was given a script for a new one with instructions to measure [Hospital1 ] pre-meal glucoses. Pt will follow up at [Hospital1 32231] [Hospital ] Clinic. . # Acute on chronic kidney disease: pre renal in the setting of NKHOS and now improved back to baseline after fluid resuscitation. . # Aspiration: CXR demonstrated opacities consistent with aspiration which likely happened during seizures. Pt had minimal cough without fevers or elevated white count. Repeat CXRay showed resolution of opacities. . # Urethral discharge: Seen by nurses in ED. No recurrence while on floor. Urine cultures, CT and GC, RPR were negative. . # Depression: Very depressed after mother passed away and divorce from wife. [Name (NI) ] good social support and does not seem at risk for actively hurting himself at this time. PCP has been following this and it looks like pt has been referred to see psychiatrist. Pt will see PCP later this week. . # Hyperlipidemia: Simvastatin . # Hypertension: Not well controlled in hospital. Increased dose to 40mg. PCP should follow with labs next week. . # Vitamin B 12 Deficient: B12 supplementation. . # Communication: pt's nieces and nephews, first contact [Name (NI) ]: [Telephone/Fax (1) 57182] # Code: full code . TRANSITIONAL: 1) Follow up blood glucoses and that pt is compliant with medications 2) Follow up PCP, [Name10 (NameIs) 878], [Name11 (NameIs) ] [Name12 (NameIs) 32231] Clinic 3) Treat depression 4) Check BMP after increase in lisinopril dose Medications on Admission: GLIPIZIDE - 10 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by mouth twice a day GLOVES - - As directed vinyl (nonlatex) nonsterile medical examination glove size medium LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet - 2 am Tablet(s) by mouth once a day SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - [12-22] Tablet(s) by mouth once a day hs TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to area once a day Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day BLOOD PRESSURE MONITOR [BLOOD PRESSURE KIT] - Kit - Use as directed twice a day Dx:401.9 Hypertension BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test once a day & prn CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Glucometer Please provide patient with One Touch Ultra Test Glucometer and 100 pack of One Touch Ultra Test strips. Directions: BG [Hospital1 ] prior to breakfast and dinner; please review BG should be 80-120 prior to meals. Please keep a record of this to show your PCP and the [Name9 (PRE) ] doctors 2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:0 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Seizures, Hyperosmolar hyperglycemic state from DM II Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [Known lastname 57183], It was a pleasure taking care of you at [Hospital1 18]. You were admitted for seizures most likely from poor control of your diabetes. [Hospital1 878] and diabetes specialists saw you here. You had a head MRI which was negative. It will be very important for you to continue taking your diabetes medications. Please also measure your blood glucoses prior to breakfast and dinner. They should be between 80-120 prior to meals. Please keep a record of this to show your PCP and the [Name9 (PRE) ] doctors. The following changes were made to your medications: Increase Metformin to 1000mg twice a day for diabetes Increase lisinopril to 40mg daily for high blood pressure START Phenytoin for seizures Followup Instructions: Please call [Telephone/Fax (1) 57184] to set up an appointment with the [Last Name (un) ] [Last Name (un) 32231] [Hospital 982] Clinic if you do not hear from them by Wednesday. The following appointments were made for you. Department: BIDHC [Location (un) ] When: FRIDAY [2122-1-16] at 9:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 607], MD [Telephone/Fax (1) 608] Building: 545A Centre St. ([Location (un) 538], MA) None Campus: OFF CAMPUS Best Parking: Department: [Location (un) ] When: THURSDAY [2122-1-22] at 9:30 AM With: DRS. [Name5 (PTitle) ] & PUNTAMBEKAR [Telephone/Fax (1) 3294] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2122-1-12]	[ "266.2", "428.0", "250.60", "357.2", "276.2", "V15.81", "518.81", "403.90", "311", "428.32", "345.10", "282.5", "585.9", "507.0", "V46.3", "584.9" ]	icd9cm	[ [ [] ] ]	[ "89.19", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	12020, 12026	7358, 10185	317, 340	12156, 12156	4789, 7335	13084, 14008	3147, 3386		11111, 11997		12047, 12135		10211, 11088			12306, 13061								3401, 3401																	4228, 4770								264, 279										368, 2038							3415, 4214	12171, 12282							2060, 2621	2637, 3131
41,279	119,314	2622	Discharge summary	report	Admission Date: [2129-7-28] Discharge Date: [2129-8-2] Date of Birth: [2068-1-2] Sex: F Service: MEDICINE Allergies: Glipizide / A.C.E Inhibitors Attending:[First Name3 (LF) 358] Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: [2129-7-29]: Removal of distal phalanx tuft third digit and debridement of ulcerations sub-second and third digits History of Present Illness: 62 yo F w/ poorly controlled DM II on insulin (last Hga1c~ 9.4 in [2127], baseline BG ~300s), HTN, obesity who p/w bilateral foot wounds, R>L, which have been getting worse X 2-3 weeks. Pt reports that the problem began without any particular incident as has failed to improve with conservative treatment (resting, soaks) at home. She presented to the ED today because the situation simply wasn't improving. She reports she's never had foot problems before and believes that the sensation in her feet is fully intact. The pt endoresis mild chills, but has noted noo fever. She denies nausea, malaise, CP or SOB. . In the ED, her VS were Tc: 99.3 HR: 98 BP: 146/80 RR:18 P02: 93% on RA. Her labs were notable for a glucose of >770 and no anion gap. A foot ap/lat XRay was performed that showed right third distal phalynx bone changes c/w early osteomyelitis. She was administered empiric Unasyn and Vancomycin for broad and MRSA coverage, and was started on an insulin gtt. Bedside I&D was performed. The pt was admitted to the MICU for glycemic control with a plan for surgical intervention by podiatry in the AM. . At home, the pt reports she checks her sugar regularly and takes her insulin as directed. She routinely measures sugars ranging from the 50s to the >500. When her sugar is very high she does not some mild visual field "spots" though she is not having this symptom now. . ROS: The pt reports a 15lb unintentional weight loss over the last several months. She has also noted urinary frequency but no urgency or dysuria. Otherwise no nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, DOE, lower extremity oedema, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Allergies: Glipizide / A.C.E Inhibitors Past Medical History: Diabetes(uncontrolled)- dx [2118] HTN chronic LBP asthma L FOOT PAIN HYPERCHOLESTEROLEMIA VERTIGO ULNAR NEUROPATHY ([2121-8-1]) - bilateral by emg as well as mild carpal tunnel and difffuse polyneuropathy. ANEMIA - known Fe def, also question of possible alpha thal DYSPEPSIA CHRONIC RENAL FAILURE, baseline Cr 1.5-1.6 as of [2127] Social History: Lives in the [First Name4 (NamePattern1) 6930] [Last Name (NamePattern1) ] area with her daughter, who has 2 children. Lives in a 3-bedroom apartment. Retired homemaker. Former smoker (2 ppd x 2 years, quick a few years ago). Family History: Father with HTN, mother with HTN, heart trouble and DM. Both lived to their 70s. Other relatives with DM. Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. Loss of fine touch and joint position sense in the feet biaterally. SKIN: +acanthosis nigricans. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: ADMISSION LABS: [2129-7-28] 06:20PM BLOOD WBC-14.7* RBC-4.58 Hgb-9.7* Hct-33.0* MCV-72* MCH-21.2* MCHC-29.5* RDW-16.6* Plt Ct-360 [2129-7-28] 06:20PM BLOOD Neuts-81.0* Lymphs-15.3* Monos-3.0 Eos-0.4 Baso-0.3 [2129-7-28] 06:20PM BLOOD Plt Ct-360 [2129-7-28] 06:20PM BLOOD Glucose-771* UreaN-37* Creat-2.0* Na-125* K-4.8 Cl-83* HCO3-32 AnGap-15 [2129-7-29] 05:16AM BLOOD CK(CPK)-207* [2129-7-29] 01:15AM BLOOD Calcium-9.5 Phos-2.3* Mg-2.4 [2129-7-28] 06:56PM BLOOD Glucose-GREATER TH Lactate-3.5* Na-126* K-4.3 Cl-82* calHCO3-31* . . PERTINENT LABS/STUDIES: Hct: 33.0 ([7-28]) -> 28.7 -> 31.9 -> 27.6 -> 26.7 -> 25.6 ([8-2]) Fe: 24 TIBC 328 B12: 529 Ferritin 26 TRF 252 HgA1c: 13.9% WBC: 14.7 ([7-28]) -> 15.4 -> 22.0 -> 18.6 -> 16.1 -> 13.6 ([8-2]) Cr: 1.9 - 2.1 on this admission CK: 207 ([7-28]), 229 ([7-28]) Troponin: <0.01 U/A: Large blood, 300+ protein, large leukocytes. Urine cultures negative x2 Wound swab ([7-28]): GRAM STAIN (Final [2129-7-28]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final [2129-8-1]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2129-8-1]): NO ANAEROBES ISOLATED. . Tissue culture ([7-28]): GRAM STAIN (Final [2129-7-29]): REPORTED BY PHONE TO [Female First Name (un) 13194] [Doctor Last Name ] @ 4PM [2129-7-29]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). TISSUE (Final [2129-8-2]): ENTEROCOCCUS SP.. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [2129-8-2]): NO ANAEROBES ISOLATED. . Admission ECG: SR 82. Leftward axis deviation. New STD/TWI in I and aVL as compared to [1-31]. . FOOT XRay: right foot - bone changes potentially c/w OM; left foot - linear soft tissue defect on plantar aspect projecting over first digit with no evidence of extent to bone. . . DISCHARGE LABS: [2129-8-2] 04:50AM BLOOD WBC-13.6* RBC-3.58* Hgb-7.6* Hct-25.6* MCV-71* MCH-21.3* MCHC-29.8* RDW-15.4 Plt Ct-315 [2129-7-30] 05:20AM BLOOD Neuts-82.4* Lymphs-12.1* Monos-4.7 Eos-0.6 Baso-0.2 [2129-8-2] 04:50AM BLOOD Plt Ct-315 [2129-8-2] 04:50AM BLOOD Glucose-69* UreaN-41* Creat-2.0* Na-131* K-3.5 Cl-96 HCO3-28 AnGap-11 Brief Hospital Course: 61 yo female with severe hyperglycemia and diabetic foot infection. . # Foot infection: Patient presented with an infection in her right foot. Patient was placed on Vancomycin and Zosyn for the infection, given oxycodone for her pain, and podiatry was consulted. On [7-29], Podiatry debrided the wound and removed the distal portion of her third toe. Her wound was closed two days later. The patient had a leukocytosis to 22 following the procedure, this resolved to 13.6 on the day of her discharge. A culture of the wound and tissue were sent and revealed Enterococcus, Staph. Aureus, and no anaerobes. Patient was placed on Bactrim and Augmentin PO at this time and was instructed by podiatry to continue the course of antibiotics for two weeks. On the day of discharge, patient worked with PT and was able to ambulate on her foot with a [Month (only) ]. She was given a protective shoe and a [Month (only) ] on discharge and a follow-up appointment was made with Podiatry in one week. . # Hyperglycemia: Patient's glucose has been extremely difficult to control. She was admitted with glucose of 771 and had persistent FSBGs in the 300s while on the floor. [Last Name (un) ] was consulted. She was continued on 100 Units of NPH in the morning and 100 U NPH at night as well as an insulin sliding scale. Patient had an episode of hypoglycemia on [8-1] to 62. It was advised, at this time, that the NPH be changed to 100 Units in the morning and 90 Units at dinnertime (instead of bedtime). Patient was discharged on this regimen, and VNA was set up for further glucose monitoring and diabetic patient education. . #Pseudo-hyponatremia: Patient was admitted with a Na of 125 corrected to 135. It was suspected that this was likely related to osmotic effect in setting of marked hyperglycemia as well as hypovolemic hyponatremia in the setting of osmotic diuresis from glucose load. Patient's sugars were controlled with insulin gtt and she was agressively hydrated. Her hyponatremia resolved. However the patient's sodium was 131 on discharge thus the Patient's HCTZ was held in the setting of hyponatremia. . #Acute Renal Failure: Pt had a Cr of 2 on admission, which was increased from her prior baseline of 1.5-1.6 one year ago. It is uncertain whether or not this is her new baseline. Patient's Lasix was held, and the patient was continued on her [Last Name (un) ]. Her [Last Name (un) ] was decreased, however, in the setting of her acute renal failure. . #Possible UTI: Pt with borderline UA in setting of urinary frequency. Treated with Unasyn for foot infection. F/u urine culture. . #HTN: Initially held the patients home [Last Name (un) ] in setting of possible renal failure. Continue the patients b-blocker and restarted the [Last Name (un) ] on discharge. . #Asthma: Was stable throughout hospitalization. Continue home albuterol and Flovent. . #Lipids: Patient was continued home statin. . #Anemia: The patients HCT decline over the course of her hospitalization from 33 to 25 in the setting of IVF. These values should be followed up as an out-patient, likely anemia of chronic disease/inflammation in the setting of her infection. This is in addition to the patients iron deficiency anemia for which she was continued on her home dose of iron. . Medications on Admission: ALBUTEROL SULFATE - 90MCG- 2 PUFFS qid CARMOL 40 - 40% Cream CLONAZEPAM - 500 MCG qhs DILTIAZEM HCL - 180 mg qd FLOVENT - 44MCG Aerosol - 2 PUFFS [Hospital1 ] FUROSEMIDE [LASIX] - 20 mg [Hospital1 ] HYDROCHLOROTHIAZIDE - 25MG qd METFORMIN - 500 mg [Hospital1 ] SIMVASTATIN - 40 mg qd TRIAMCINOLONE ACETONIDE - 0.1 % Ointment [Hospital1 ] prn itching VALSARTAN [DIOVAN] - 320 mg qd ACETAMINOPHEN - 325 mg Tablet X2 prn pain FERROUS SULFATE - 325 mg (65 mg) qd INSULIN NPH HUMAN RECOMB [HUMULIN N] 100 in am, 100 in pm once a day . Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB, cough, wheeze. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 5. Insulin Syringe 0.3 mL 29 X 1 Syringe Sig: One (1) syringe Miscellaneous twice a day. 6. Humulin N 100 unit/mL Suspension Sig: One Hundred (100) Units Subcutaneous every morning. 7. Humulin N 100 unit/mL Suspension Sig: Ninety (90) Units Subcutaneous at bedtime. 8. Triamcinolone Acetonide 0.1 % Ointment Sig: use as directed Topical twice a day as needed for itching. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. CARMOL 40 40 % Cream Sig: use as directed Topical once a day: Please apply every day to affected area. 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). Disp:60 Tablet(s) Refills:2 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:16 Tablet(s) Refills:0 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:56 Tablet(s) Refills:0 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:28 Tablet(s) Refills:0 17. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 18. [First Name5 (NamePattern1) 4886] [Last Name (NamePattern1) 12106] Sig: One (1) Miscellaneous as directed. Disp:1 [Last Name (NamePattern1) ] Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Foot Infection Type 2 Diabetes Secondary: Hypertension Acute on Chronic Renal Failure Discharge Condition: Good. Patient is able to ambulate (partial weight bearing) with PT, and her vital signs are stable. Discharge Instructions: You were admitted to the hospital because you had two foot wounds which were not healing well. On admission, your glucose was very elevated. While you were here, we brought your glucose back under control and we cleaned the wound in your foot. We put you on a two week course of antibiotics to treat the infection if your foot. While you were here, we made the following changes to your medications: 1. We placed you on two antibiotics, Augmentin and Bactrim. You should take these medications, as prescribed, for two weeks. 2. We discontinued your Diltiazem and Cartia XT 3. We increased your simvastatin to 80 mg daily 4. We discontinued your Metformin given your decreased kidney function 5. We are holding your Lasix currently. You should reassess this with your PCP on [Name9 (PRE) 2974]. 6. We decreased your dose of Diovan to 160 mg in light of your decreased kidney function. Please take all medications as prescribed. Please keep all previously scheduled appointments. Please return to the ED or your healthcare provider if you experience increasing pain in your foot, shortness of breath, chest pain, fatigue, confusion, fevers, chills, or any other concerning symptoms. Followup Instructions: PCP: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2129-8-5] 3:45 Podiatry: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2129-8-9] 11:20	[ "041.11", "730.07", "278.00", "585.3", "707.15", "599.0", "584.9", "272.0", "493.90", "403.90", "276.1", "285.9", "731.8", "V58.67", "250.82", "250.42" ]	icd9cm	[ [ [] ] ]	[ "86.22", "38.93", "77.89" ]	icd9pcs	[ [ [] ] ]	13311, 13369	7536, 10855	297, 418	13509, 13612	3857, 3857	14859, 15194	2934, 3041		11452, 13288		13390, 13488		10881, 11429			13636, 14836			7173, 7512					3056, 3838																									247, 259										446, 2297					3874, 7156										2319, 2665	2681, 2918
18,092	101,352	22028	Discharge summary	report	Admission Date: [2198-10-7] Discharge Date: [2198-12-6] Date of Birth: [2140-3-12] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7591] Chief Complaint: Fever and Malaise. Major Surgical or Invasive Procedure: Hickman Line Placement and Removal. History of Present Illness: Mr [Known lastname 5655] is a 58 year old male without significant past medical history who presented to an outside hospital with one month of fevers (up to 103), sweats, and malaise. He also noted increasing generalized weakness and fatigue. He had a decrease in his appetite and 13 pounds weight loss over the previous month. He also noted easy bruising. ROS: The patient did not have an head aches, shortness of breath, dizziness, chest pain, nausea, vomiting, abdominal pain, epistaxis or other bleeding. At the outside hospital he had a WBC of 45.3 (90% Blasts) and a HCT of 25 with 19% nucleated RBC's. He was transfered to [Hospital1 18] for management of a presumptive hematologic malignancy. Past Medical History: DJD S/P Discectomy ([2174]). Had not seen a doctor in 10 years. Social History: The patient was divorced, but lived with his girlfriend, [Name (NI) ]. [Name2 (NI) ] had never used cigarettes or illegal drugs. He quit drinking ETOH in [2174]. He is a private business owner and works as a [Last Name (un) 33982]. Family History: No known cancers, leukemia, or lymphoma. Physical Exam: T98.6 BP123/60 HR88 OS99%RA GEN - NAD. COMFORTABLE. SKIN - LE BRUISING. NO RASHES. HEENT - ANICTERIC. PALE CONJ. MMM. NO LAD. NECK - SUPPLE. NO LAD. RESP - DISTANT BS. GOOD FLOW. CTAB. CV - RRR. S1/S2 NML. NO MGR. NO JVD. ABD - S/NT/ND. POS BS. NO HSM. EXT - POS B/L CLUBBING. NO CYANOSIS OR EDEMA. NEURO - A&OX3. CNII-XII INTACT GROSSLY. STRENGTH AND [Last Name (un) ] TO LT NORMAL THROUGHOUT. Pertinent Results: BONE MARROW BIOPSY AND FLOW CYTOMETRY ([2198-10-7]): AML: Immunophenotypic findings consistent with acute myelogenous leukemia, with an immature phenotype. RVG ([2198-10-8]): Following the intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, first pass and equilibrium images were obtained. The first pass study shows prompt tracer flow through the central circulation. IMPRESSION: 1) Normal LV wall motion. 2) Normal right and left ventricular sizes. 3) LVEF of 55%. CXR ([2198-10-8]): FINDINGS: There is a left subclavian central venous catheter with the tip in satisfactory location in the distal SVC. There is no pneumothorax. The cardiac and mediastinal contours are unremarkable. The pulmonary vascularity is normal, and the lungs are clear. No pleural effusions are seen on this film, although the left costophrenic sulcus is not visualized. The osseous structures and soft tissues are unremarkable to the extent visualized. CT TORSO ([2198-10-17]): IMPRESSION: 1. No infectious source detected. 2. Single 6-mm left upper lobe nodule. 3. Fat-containing right inguinal hernia. RUQ U/S ([2198-10-22]): IMPRESSION: Normal right upper quadrant ultrasound examination. BONE MARROW BIOPSY AND FLOW CYTOMETRY ([2198-10-23]): DIAGNOSIS: Persistent involvement by acute myelogenous leukemia. CT ABD ([2198-10-26]): IMPRESSION - 1. Limited study of the abdomen secondary to significant patient debility as described above. There is no intrahepatic ductal dilatation. 2. Extensive patchy airspace opacities throughout both lungs, which given the patient's neutropenic state could represent a diffuse widespread pneumonia, as well as alveolar hemorrhage. ECHO ([2198-10-26]): 1.The LA is mildly dilated. 2.There is mild symmetric LV hypertrophy. The LV cavity size is normal. There is severe global LV hypokinesis. Overall LV systolic function is severely depressed with more marked anterior and inferior HK. 3.The aortic root is mildly dilated. The ascending aorta is mildly dilated. 4.The AV leaflets (3) appear structurally normal with good leaflet excursion. Trace AI is seen. 5.The MV leaflets are mildly thickened. Mild (1+) MR is seen. 6.There is mild pHTN. 7. There is no pericardial effusion. 8. Normal RV size and function. RUQ U/S ([2198-10-28]): IMPRESSION: No evidence of cholecystitis or dilation of intrahepatic bile ducts. CT CHEST ([2198-10-31]): IMPRESSION: 1. Interval development of diffuse pulmonary opacities throughout both lungs in a central distribution. This may represent pulmonary edema or a diffuse infection. Infectious etiologies include PCP or CMV. Some areas are nodular, which may represent a superimposed fungal infection such as aspergillus. 2. Small bilateral pleural effusions. ECHO ([2198-11-6]): The LA is mildly dilated. LV wall thicknesses are normal. The LV cavity is moderately dilated with severe global HK. No masses or thrombi are seen in the LV. The RV cavity is mildly dilated with moderate free wall HK. The aortic root is mildly dilated. The AV leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) AI is seen. The MV appears structurally normal with trivial MR. There is no MV prolapse. Mild (1+) MR is seen. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. Compared with the report of the prior study (tape reviewed) of [2198-10-26], the LV cavity is now dilated (previous [Last Name (un) ] 6.0cm). The RV cavity and systolic function are similar. CXR ([2198-11-24]): PORTABLE AP CHEST, ONE VIEW: Comparison [2198-10-31]. Since the prior study, the left subclavian line has been removed. There are diffuse multifocal alveolar opacities. Differential includes multifocal pneumonia as well as asymmetric edema. There are no large pleural effusions (left lateral CP angle not included). The heart is upper normal in size. Overall appearances are slightly improved from [2198-10-31]. ECHO ([2198-11-26]): The LA is mildly dilated. The RA is moderately dilated. LV wall thicknesses are normal. The LV cavity is moderately dilated. Overall LV systolic function is severely depressed. The RV cavity is mildly dilated. There is severe global RV free wall hypokinesis. The aortic root is mildly dilated. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The AV leaflets are mildly thickened. Mild (1+) AR is seen. The MV leaflets are mildly thickened. Mild (1+) MR is seen. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [2198-11-6], biventricular systolic function now appears slightly worse. BONE MARROW BIOPSY ([2198-11-27]): DIAGNOSIS - Markedly hypocellular bone marrow for age, with left-shifted granulocytic maturation and markedly decreased erythropoiesis. Acute leukemia is not seen. RUQ U/S ([2198-11-28]): FINDINGS: Sludge is no longer seen in the gallbladder. The gallbladder appears normal without evidence of stones. There is no intrahepatic or extrahepatic biliary ductal dilatation. The liver parenchyma appears unremarkable. Brief Hospital Course: Mr. [Known lastname 5655] was admitted to the [Hospital1 18] BMT service with acute myelogenous leukemia (AML). He subsequently developed severe congestive heart failure after anthracycline chemotherapy. 1) AML: The patient had a white blood cell count of 40,000 to 60,000 on admission. He was started on hydroxyurea for temporary stabilizing measures. A bone marrow biopsy with flow cytometry revealed acute myelogenous leukemia, with an immature phenotype. The patient was started on [7+3] chemotherapy with cytarabine and idarubacin. As anticipated, his cell lines dropped and the patient soon became neutropenic. He thus had neutropenic fevers early in his course (without any obvious source of infection). Empiric antimicrobials and then antifungals were commenced (see below). Approximately two weeks after his [7+3] regimen, a bone marrow biopsy revealed persistent involvement by AML. Re-induction chemotherapy was planned, but the patient developed an acute decline in his repiratory status: pulmonary nodules and then congestive heart failure and atrial fibrillation were noted. The patient's respiratory status declined to a level that he required ICU support (see below). Upon recovery from acute congestive heart failure, the patient returned to the BMT service for re-induction chemotherapy with HIDAC (high-dose cytarabine). He again became profoundly pancytopenic and neutropenic, developing fevers and a presumptive line infection with staph epidermidis. After two to three weeks of pancytopenia, a repeat bone marrow biopsy was obtained because of a concern for persistence of AML. However, the bone marrow was relatively acellular without evidence of leukemia. The patient was started on G-CSF and his neutrophils and other cell lines (to a lesser degree) promptly recovered and his fevers abatted. He required several platelet and packed red blood cell transufusions over his course, but did not require tranfusions over the last several days prior to discharge. On discharge, his platelets were 74, hematocrit was 32.5, white blood cell count of 3.4, and an absolute neutrophil count greater than 3000. He was discharged with oncologic follow-up with Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410] at [Hospital1 18]. 2) Neutropenic Fevers: As mentioned, the patient developed febrile neutropenia after his initial induction chemotherapy. Initial broad-specturm choices were Cefipime, Vancomycin, Caspofungin, and then Ambisome. After persistence of his fevers a chest CT revealed pulmonary edema as well as bilateral nodular opacities, concerning for aspergillosis or pneumocystis gondii infections. Bronchoscopy was not pursued. He was continued on anti-fungals. He was later changed from Cefipime to Meropenem. Late in his course, he grew staph epidermidis from four of four blood culture bottles (anaerobic and aerobic) and his Hickman line was removed. Concominantly with Vancomycin therapy and a rising neutrophil count, his fevers abatted and all follow-up blood cultures were negative. The patient was discharged on two additional weeks of Voriconazole to complete and empiric course of antifungal therapy for his presumptive recovering lung infection. A repeat chest CT was attempted, but the patient could not tolerate the study because of orthopnea. Of note, Caspofungin was changed to Voriconazole because of rising alkaline phosphatase and bilirubin and a concern for causation; these values decreased after the change was made. 3) CHF: As mentioned the patient had a declining respiratory status two weeks after anthracycline therapy. Because of concern for a pulmonary infection, a chest CT was sought, but the patient developed acute worsening of his dyspnea, oxygen desaturation and hemoptysis while on the CT scanner. He was noted to have severe congestive heart failure by imaging. His pre-chemotherapy ventriculogram revealed an LVEF of greater than 55%. Upon developing respiratory failure, his LVEF was 20% with global wall motion depression. He was transferred to the ICU with severe pulmonary edema. He was aggressively diuresed but did not require intubation. The patient stabilized, and was then transferred back to the BMT service. He was followed by Cardiology and the CHF service. He was initially maintained on daily IV Lasix, Beta-Blocker and Digoxin. On account of teniously low blood pressures (systolic blood pressures to the 70s) with Lasix boluses, he was changed to a Lasix drip ([2-16] mg/hr). Thereafter, he made great progress with diuresis and held his systolic blood pressures at a level greater than 90. He was discharged on Lasix 30 mg PO BID along with follow-up with the CHF service. The plan was to add-on an ace-inhibitor and aldactone when the patient's blood pressures could tolerate these agents. 4) AF/RVR: As noted, along with his new onset CHF, the patient developed atrial fibrillation with a rapid ventricular response. His atrial fibrillation persisted throughout his course and he reached heart rates to the 170s early on. He was mainted on beta-blocker and Digoxin as above and his heart rates ranged from the 60's to the 100's late in his course, when his CHF was better controlled. Anticoagulation was not initiated because of thrombocytopenia, associated with his chemotherapy and AML. 5) NSVT: The patient had several episodes of asymptomatic NSVT over his course. Additionally, he had one episdoe of symptomatic NSVT of 12 beats with 3/10 chest discomfort and the sensation of a 'racing heart.' An ECG showed no signs of ischemia. He was continued on beta-blockade. Despite his severe heart failure, he was not deemed a candidate for a BiV/ICD given his low platlets. 6) Hyperbilirubinemia/Elevated Alk Phos: The patient had a large rise in these values early in his course, in conjunction with his severe heart failure. Hepatic and biliary imaging were not remarkable. He then again had an elevation in these values late in his course. The etiology early in the course may have been hepatic congestion via CHF (as there was an associated transaminitis). Later in his course, there was no transaminits. A repeat right upper quadrant ultra-sound was unremarkable. He was changed from Caspofungin to Voriconazole and these values trended downwards. On discharge, his alkaline phosphatase was 500 with a bilirubin of 1.4. The former value peaked in the thousands while the later peaked at 6. Medications on Admission: Alieve PRN Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 6. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day. Disp:qs 1 mo packets Refills:0 8. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 9. Outpatient Lab Work 1) On Monday, [2198-12-9], please go to the lab at [Hospital3 ] to have your blood checked. A CBC, SMA10 (sodium, potassium, chloride, bicarbonate, BUN, urea, and glucose) and digoxin level should be checked. These results should be faxed to your new primary doctor, Dr. [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 57652] at [Telephone/Fax (1) 57653], your new heart failure nurse [First Name (Titles) 3639] [First Name8 (NamePattern2) 6794] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 13133], and to the [Hospital1 18] BMT Floor (7 [Hospital Ward Name 1826]) at [Telephone/Fax (1) 45103]. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Acute Myeloid Leukemia. Secondary Diagnosis: Chemotherapy-Induced Congestive Heart Failure, Staph Epidermidis Bacteremia. Discharge Condition: Fair/Stable Discharge Instructions: 1) Please call Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410] ([Telephone/Fax (1) 3760]), your primary doctor ([First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 57652] at [Telephone/Fax (1) 4018]), the oncall [Hospital1 18] oncologist ([Telephone/Fax (1) 2756]) or go to an emergency department if you have any fevers, chills, back pain, nausea, vomiting, chest pain, palpitations, shortness of breath, cough, or any other concerning symptoms. 2) Please take your medications as instructed. 3) If you have any dizziness, or light-headedness while standing, please do not take your Lasix, Carvedilol (Coreg), or Digoxin and call your doctor immediately. 4) Please follow the dietary instructions of the nutrionist in regards to your heart failure: some of these recommendations include limiting your fluid intake to 1.5 liters per day and limiting your salt intake to 2 grams per day. 5) Weigh yourself daily (with the same scale) and record this so it may be reported to your heart failure and primary doctors. If you gain more than 2 pounds in one day, please call your heart failure doctor. Followup Instructions: 1) On Monday, [2198-12-9], please go to the lab at [Hospital3 ] to have your blood checked. A CBC, SMA10, and digoxin level should be checked to evaluate your blood count, electrolytes, and digoxin level. These results should be faxed to your new primary doctor, Dr. [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 57652] at [Telephone/Fax (1) 57653], your new heart failure nurse [First Name8 (NamePattern2) 3639] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57654] at [Telephone/Fax (1) 13133], and to the [Hospital1 18] BMT Floor (7 [Hospital Ward Name 1826]) at [Telephone/Fax (1) 45103]. 2) Please see Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 410] ([Hospital1 18] Oncology and Bone Marrow Transplant) on [2198-12-13] for the following appointment: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5026], MD Where: [Hospital6 29] HEMATOLOGY/BMT Phone:[Telephone/Fax (1) 3760] Date/Time:[2198-12-13] 10:00 3) Please see your new heart failure doctor, Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 2031] at the Heart Failure Clinic on [2198-12-20]. You may call [Telephone/Fax (1) 3512] to confirm or change this appointment: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2198-12-20] 4:00 4) Please also see your new primary doctor, Dr. [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 57652] for the following appointment: [2199-1-4] at 2:45 PM. You may contact her at [Telephone/Fax (1) 4018] to confirm or change this appointment.	[ "427.31", "518.89", "205.00", "425.4", "117.9", "041.10", "790.7", "996.62", "428.0", "284.8", "790.5", "518.82" ]	icd9cm	[ [ [] ] ]	[ "38.93", "41.31", "99.25", "99.05", "99.04" ]	icd9pcs	[ [ [] ] ]	15115, 15164	7132, 13558	330, 368	15349, 15362	1956, 7109	16569, 18343	1480, 1522		13619, 15092		15185, 15185		13584, 13596			15386, 16546								1537, 1937																									272, 292										396, 1108			15249, 15328			15204, 15228									1130, 1199	1215, 1464
73,612	136,332	54631	Discharge summary	report	Admission Date: [2195-7-4] Discharge Date: [2195-7-14] Date of Birth: [2122-10-10] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2901] Chief Complaint: PEA Arrest at [Hospital ] transferred to [Hospital1 18] Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Pt is a 72 y/o male with PMHx of CAD, CHF, PVD with stent leg (? L or R), HTN, DM2, carotid artery disease, who was transferred to [Hospital1 18] from OSH after a PEA arrest. Per family, patient was at home at kitchen table when he experienced sudden onset chest pain and family called EMS. Pt went into PEA arrest and was given 1 round of epi and atropine and then had ROSC. OSH was worried about STEMI (for unclear reasons at this point) and their lab was unavailable so patient was transferred over to [Hospital1 18] where he went to cath lab. The RCA was totally occluded but collaterals from Left were noted. RHC showed elevated wedge (30s), RA pressures 15, PAP 60. Echo in lab showed moderate MR, mild AI, preserved LV, RV function. Calcified AV. Received lasix IV in lab 80 mg. LV gram showed mild MR, inferiobasal HK with EF about 45%. AS study showed moderate-severe AS with valve area 1.0. Chronic occlusion of RCA and 80% prox LAD with good flow through LAD and LCx. No intervention performed. PA pressure at 80 and wedge pressures a 30-35 Patient was transferred up to CCU and additional history was performed. Per daughter and wife, patient was experiencing on and off chest pains since [Month (only) 404] with associated L arm numbness. Daughter would see him lefting his left arm up with the right as he couldn't move it voluntarily during these episodes. Also having severe SOB, especially while sleeping- severe orthopnea per daughter, also significant bilateral pitting edema. PCP had recently increased his lasix dose from 20mg to 40mg daily. He also recently went to an urgent care clinic 4 days prior to presentation and was given Azithromycin for presumed CAP. Art line placed upon transfer to CCU. Hypotensive to Systolic 80s-90s when sleeping and after fentanyl injections but increases upon awakening. Patient -1 L since cath lab. Started on lasix gtt at 5/hr . REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: CHF per family- on lasix home dose 40 mg daily PVD- Stent in leg (unclear R or L) Bilateral carotid artery disease ? COPD- was told by PCP 3. OTHER PAST MEDICAL HISTORY: . Benign neck tumors Social History: SOCIAL HISTORY -Tobacco history: 1 ppd for many years, current smoker -ETOH: unknown -Illicit drugs: none Family History: FAMILY HISTORY: Father and 2 brothers with CAD Physical Exam: Admnission GENERAL: Intubated, sedated in NAD. Following commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no significant JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic murmer heard over aortic and tricuspid areas. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly ABDOMEN: Soft, non-tender, mildly distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Discharge Summary Pertinent Results: [2195-7-4] 08:42PM WBC-16.8* RBC-4.01* HGB-11.3* HCT-36.2* MCV-90 MCH-28.1 MCHC-31.1 RDW-15.8* [2195-7-4] 08:42PM NEUTS-90.0* LYMPHS-4.5* MONOS-4.3 EOS-0.8 BASOS-0.4 [2195-7-4] 08:40PM HGB-11.4* calcHCT-34 O2 SAT-97 [2195-7-4] 08:42PM PT-11.7 PTT-60.4* INR(PT)-1.1 [2195-7-4] 08:42PM CK(CPK)-70 [2195-7-4] 08:42PM CK(CPK)-70 [2195-7-4] 08:42PM estGFR-Using this [2195-7-4] 08:42PM GLUCOSE-285* UREA N-25* CREAT-1.3* SODIUM-139 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-30 ANION GAP-15 FINDINGS: On the right side the known occlusion of the internal carotid artery is confirmed. On left side a mild amount of calcified plaque is seen in the common and internal carotid arteries. On the right side peak systolic velocities were 24 cm/sec for the common carotid artery and 203 cm/sec for the external carotid artery. No ICA/CCA ratio could be determined on the right side due to complete occlusion of the internal carotid artery. On the left side peak systolic velocities were 75 cm/sec for the proximal internal carotid artery, 106 cm/sec for the mid internal carotid artery, 100 cm/sec for the distal internal carotid artery and 55 cm/sec for the common carotid artery. The left ICA/CCA ratio was 2.0. Vertebral arteries presented antegrade flow. COMPARISON: None available. IMPRESSION: 1. Occlusion of the right internal carotid artery. 2. Less than 40% stenosis of the left internal carotid artery. DR. [First Name (STitle) ] [Name (STitle) ] Approved: MON [2195-7-13] 10:58 PM CTA LOWER EXTREMITIES: IMPRESSION: 1. Filling defect in a moderate segment of the right superficial femoral artery may represent thrombus versus dissection. This was discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] by phone at 10:20 a.m. on [2195-7-5] after attending review. 2. Occluded dorsalis pedis and plantar arteries in the right foot. 3. Significant atherosclerotic disease in the lower extremity vasculature as described above. 4. Diverticulosis without diverticulitis. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) 8711] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: SUN [2195-7-5] 8:53 PM Brief Hospital Course: 72 y/o male with PMHx of Ischemic cardiomyopathy, severe AS, Severe PVD and other medical comorbidities admitted after PEA arrest with CHF exacerbation s/p diuresis and hemodynamic optimization # PUMP: ECHO shows LVEF of 45% with mild MR and AS. The patient was aggressively diuresed and put on nitro gtt titrated to appropriate BPs while in the ICU. He was optimized hemodynamically with captopril and metoprolol tartrate. These medications were then switched to Lisinopril 10 mg daily and PO Lasix as well as Sprironolactone. Patient was over net 6.5 L out, on nasal cannula and discharge. # CORONARIES: The patient was originally billed as a STEMI when transferred to [Hospital1 18] and sent directly to cath lab where 80% occlusion of LAD, 40% LCx, and 100% RCA although with adequate collaterals were found. Given the collaterals supported adequate flow, the CAD was thought to be chronic in nature and no intervention was performed in cath lab. ST depressions noted on EKGs from OSH. The patient was placed on heparin. The patient refused CABG but will discuss the issue further with his outpatient cardiologist. Carotid ultrasound was obtained for pre-op evaluation should the patient decide to pursue coronary artery bypass. The right carotid was found to be occluded and the left 40% stenosed. Aspirin and atorvastatin were continued. The patient's heparin was discontinued on [7-11] as the patient's clinical status improved. The patient did not have any remarkable arrhythmias secondary to condition during this hospital stay. # PERIPHERAL VASCULAR DISEASE: A CTA of the lower extremities was done, showing the following: 1. Filling defect in a moderate segment of the right superficial femoral artery may represent thrombus versus dissection. This was discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] by phone at 10:20 a.m. on [2195-7-5] after attending review. 2. Occluded dorsalis pedis and plantar arteries in the right foot. 3. Significant atherosclerotic disease in the lower extremity vasculature as described above. 4. Diverticulosis without diverticulitis. On the night of admission his right foot was noted to be cool to touch without an appreciation for a dorsalis pedis pulse. Vascular surgery was consulted which led to the CTA of the LE as above. A heparin drip was started. The vascular surgery team did not recommend intervention as he is a poor surgical candidate and the operation would be major. His right lower extremity became warmer over the next few days and a pulse returned without clinical consequence to his R foot. Inactive issues: DM2: The patient has known non-insulin dependent diabetes mellitus, type 2. His metformin was discontinued on admission to the hospital and his glucose was kept under good control with insulin. HTN: The patient's ACE inhibitor was continued. His metoprolol was increased to 125 mg [Hospital1 ]. Transitional Issues: Severe three vessel disease: The patient deferred CABG while in hospital but should discuss the issue further with his outpatient cardiologist. Diabetes: The patient will be discharged on his pre-admission dose of metformin without any insulin. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Family/Caregiver. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Lisinopril 40 mg PO DAILY Hold if SBP <90 3. Metoprolol Tartrate Dose is Unknown PO BID 4. Furosemide 40 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Azithromycin 250 mg PO Q24H 8. DiphenhydrAMINE 50 mg PO HS:PRN Insomnia Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Lisinopril 10 mg PO DAILY Please hold for SBP <95 4. Metoprolol Tartrate 125 mg PO BID Hold if SBP <90, HR<55 5. DiphenhydrAMINE 50 mg PO HS:PRN Insomnia 6. Furosemide 40 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Extended Care Facility: [Hospital 582] Healthcare Discharge Diagnosis: #Acute on Chronic Diastolic Heart Failure with a preserved EF of 45% #Severe 3-vessel Coronary Artery Disease with a 100% occlusion of the RCA (with collaterals) and an 80% occlusion of his LAD that is not amenable to percutaneous intervention #Severe Aortic Stenosis with a gradient of 40mmHg and a valve area of 1.0sq-cm #Peripheral Vascular Disease #Hypertension Discharge Condition: Patient is alert and oriented x 3 and in good mental state. His discharge condition is requiring 2L of O2 by NC which was his home regimen prior to coming in. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Ambulatory Status: _____________---______ Discharge Instructions: Dear Mr [Known lastname 111747], You came to the hospital after a cardiac arrest at an outside hospital with congestive heart failure and intubated (tube in your airway). We gave you lasix (a water pill) and helped you diurese off the extra fluid. You improved with the diuresis and also with control of your blood pressure using Metoprolol Tartrate 125mg twice a day and decreased your previous dose of Lisinopril to 10mg daily. The Metoprolol was higher than your home dose because we wanted to tightly control your heart rate given your severe aortic stenosis. As you were being treated for your heart failure, we were able to wean you off the ventilator that you came to [Hospital3 ] requiring and eventually extubate it. You will be discharged on Metoprolol Tartrate 125 mg [Hospital1 ], Lasix 20 mg PO daily, Spironolactone 12.5 mg daily (new medication), and Lisinopril 10 mg. These are for your congestive heart failure and blood pressure. For your coronary artery disease, we put you on medical management including Aspirin 325mg, Atorvastatin 20mg, and the above doses of your Metoprolol and Lisinopril. After your cardiac catherization, you developed significant ischemia in your right foot. You had lost pulses and it was becoming cold. CT scan showed a possible dissection of your R femoral artery. We consulted vascular surgery who suggested we put you on a Heparin drip (a blood thinner) and your pulses returned and your foot became warm and pink. We removed the Heparin on [7-11] with a plan of continuing to examine the foot to ensure adequate blood flow. After your catherization, you also developed a hematoma in your right thigh. The source was unsure at first with an unidentified reason for your hemoglobin dropping. Later, with a CT scan, your thigh was found to have a 10x10cm hematoma. You were transfused with a total of 4 units of Red Blood Cells and your hemoglobin was checked to make sure that you no longer were bleeding. Your Heparin was also adjusted at that time. Your blood counts have recovered from that episode. You have significant coronary artery disease and valve disease that we believe cannot be treated appropriately with medicines alone. We have recommended to receive open heart surgery to help treat these problems. [Name (NI) ] refused these procedures on multiple occasions. A carotid artery ultrasound (a non-invasive test looking at the blood vessels in your neck) was done showing complete blockage of your right carotid artery and a 40% narrowing of your left. It was a pleasure taking care of you during your admission to the hospital. Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) 819] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Location: [Hospital 46644] MEDICAL ASSOCIATES Address: ONE PARKWAY, [Location (un) ],[Numeric Identifier 75553] Phone: [Telephone/Fax (1) 86181] Appt: [7-20] at 11:45am [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "428.33", "562.10", "401.9", "433.10", "496", "250.00", "305.1", "414.01", "272.4", "428.0", "414.8", "V64.2", "416.8", "458.8", "440.21", "V17.3", "V46.2", "V12.53", "396.2" ]	icd9cm	[ [ [] ] ]	[ "88.53", "88.56", "37.23" ]	icd9pcs	[ [ [] ] ]	10751, 10807	6757, 9378	336, 361	11217, 11376	4346, 6734	14170, 14620	3359, 3392		10441, 10728		10828, 11196		9990, 10418			11526, 14147								3407, 4327			2950, 3147															9717, 9964							233, 298										389, 2842				9395, 9696				11391, 11502		3178, 3201					2864, 2930	3218, 3327
28,933	118,513	21653	Discharge summary	report	Admission Date: [2170-5-19] Discharge Date: [2170-8-7] Date of Birth: [2136-7-24] Sex: M Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2565] Chief Complaint: Fevers and dyspnea Major Surgical or Invasive Procedure: [2170-5-22] - Intubation [2170-5-22] - Bronchoscopy [2170-5-26] - Extubation [2170-6-13] - Gastric Tube Placement [2170-7-16] - PICC line placement [2170-7-25] -tracheal intubation [2170-8-6] -extubation History of Present Illness: Mr. [Known lastname ] is a 33 year old male with h/o large B-cell lymphoma status post allogenic stem cell transplant in [2166], complicated by severe graft versus host disease of the skin and oral mucousa, and recent admission 5/11-23/08 for pneumosepsis and subsequently went to [Hospital1 ] for rehabilitation. While at [Hospital1 ] he developed fever to 102.5 with associated nausea and vomiting and abdominal pain. He was noted to be hypoxic and placed on NRB satting 94%, HR 160s increased from baseline 120s. He continued to have fever and was noted to be "looking worse" prior to transfer to [Hospital1 18]. . In the ED, the patient's vital signs were T 103 (pr), BP 106/63, HR 160, RR 42, O2 sat 80% on RA. He reported fevers, chills, cough and shortness of breath. He also noted abdominal pain. Patient was given IVF and transferred to [Hospital Unit Name 153]. On arrival to the [Hospital Unit Name 153] the patient was on nonrebreather. He was somnolent, but responded to some commands. He was not conversant. Past Medical History: # Large B cell lymphoma, s/p sibling-matched allogenic SCT in [6-/2167] - c/b severe GVHD of skin, GI/mouth - had been receiving photopheresis - TPN dependent (via PICC) # Migraines # h/o vaso-vagal syncope with blood draws # h/o bacteremia # Steroid myopathy # Moraxella sinusitis # Cardiomyopathy - TTE [4-5] EF 45-50% - Likely multifactorial: chemotherapy, radiation, GVHD, tachycardia # Fungemia with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361] ONCOLOGIC HISTORY: The patient was diagnosed with diffuse large B-cell lymphoma in [9-/2165] and treated with eight cycles of R-CHOP and 25 doses of XRT, finished in 6/[2165]. In [6-/2166], relapsed with disease found in periaortic lymph nodes and in the spleen. He received one cycle of ICE chemotherapy on [2166-8-11], underwent autologous stem cell transplant and was discharged [2166-11-11]. Follow up PET scan on [2167-1-30] demonstrated recurrent persistent uptake in the spleen, mesentery, and with new liver and pulmonary lesions. Liver biopsy demonstrated diffuse large B-cell lymphoma and he was treated with three weekly doses of Rituxan but continued to progress. He was treated with salvage therapy with one cycle of MINE chemotherapy as an inpatient starting [2167-4-23] and CT scan demonstrated response in the lung and liver with stable disease in the spleen. The patient was admitted for a second cycle of MINE chemotherapy on [2167-6-4]. He received a nonmyeloablative sibling-matched allogeneic SCT in 8/[2166]. He has had severe chronic GVHD of the skin and oropharyngeal mucosa; he completed Rituxan weekly x4 for GVHD at end of [2170-1-27]. Social History: Prior to this admission, was a [Hospital1 ] resident. Pt has a wife and 6 year old son. [Name (NI) ] worked as a sales manager for [Company 56970]. He has been out of work for several years due to his hospitalizations. He does not smoke and has not had any alcohol intake since prior to transplant. Has a pet dog at home. Family History: His paternal grandmother had breast cancer and a paternal uncle had cancer of an unknown etiology. His father had diabetes and died of a myocardial infarction. Physical Exam: On admission: Vitals: T 98.3, BP 112/66, HR 148, RR 18, O2 sat 97% on NRB. General: Chronically ill appearing male, appearing older than stated age. Dry, flaking skin over scalp. Somnolent. Arouses to voice, follows commands HEENT: NC/AT. Dry flaking skin, alopecia. Dry mucous membranes Neck: Leathery skin, no apparent LAD. RIJ in place. Lungs: Decreased BS at bilateral bases, diffusely rhonchorous. Not coopertive with exam. Cardiac: Tachycardic, regular, S1, S2, no m/g/r. Abdomen: Firm to palpation, non-tender, non-distended, +BS, difficult to assess for HSM due to thickened skin. Skin: Scleroderma-like changes, thickened skin. Areas of hypo and hyperpigmentation over face, back, arms, abdomen. On left side, PICC in place. PICC site c/d/i without erythema/tenderness/induration. Neuro: Somnolent. CNs sym and intact. Pertinent Results: [2170-5-19] 10:35PM LACTATE-1.2 [2170-5-19] 10:30PM CORTISOL-25.3* [2170-5-19] 07:15PM GLUCOSE-107* UREA N-16 CREAT-0.5 SODIUM-136 POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2170-5-19] 07:15PM ALT(SGPT)-29 AST(SGOT)-27 ALK PHOS-78 TOT BILI-0.4 [2170-5-19] 07:15PM LIPASE-12 [2170-5-19] 07:15PM CALCIUM-9.0 PHOSPHATE-1.9* MAGNESIUM-1.4* [2170-5-19] 07:15PM WBC-3.6* RBC-3.27* HGB-11.0* HCT-35.0* MCV-107* MCH-33.6* MCHC-31.3 RDW-18.4* [2170-7-17] 03:39AM BLOOD WBC-7.6 RBC-3.39* Hgb-10.6* Hct-34.0* MCV-100* MCH-31.1 MCHC-31.1 RDW-16.6* Plt Ct-627* [2170-7-16] 02:12AM BLOOD WBC-9.0 RBC-3.13* Hgb-9.7* Hct-31.0* MCV-99* MCH-31.1 MCHC-31.4 RDW-16.6* Plt Ct-586* [2170-7-15] 03:10AM BLOOD WBC-8.6 RBC-3.46* Hgb-10.5* Hct-35.0* MCV-101* MCH-30.4 MCHC-30.1* RDW-16.7* Plt Ct-637* [2170-7-17] 03:39AM BLOOD Neuts-76* Bands-0 Lymphs-12* Monos-11 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2170-7-16] 02:12AM BLOOD Neuts-76* Bands-1 Lymphs-13* Monos-9 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2170-7-15] 03:10AM BLOOD Neuts-80* Bands-0 Lymphs-10* Monos-9 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2170-7-17] 03:39AM BLOOD Plt Ct-627* [2170-7-16] 02:12AM BLOOD Plt Smr-HIGH Plt Ct-586* [2170-7-15] 06:50PM BLOOD PTT-114.7* [2170-7-15] 09:44AM BLOOD PT-14.2* PTT-110* INR(PT)-1.2* [2170-7-12] 04:25AM BLOOD Fibrino-473* [2170-7-17] 03:39AM BLOOD Glucose-109* UreaN-18 Creat-0.3* Na-137 K-5.0 Cl-99 HCO3-29 AnGap-14 [2170-7-16] 02:12AM BLOOD Glucose-101 UreaN-18 Creat-0.4* Na-138 K-4.6 Cl-101 HCO3-31 AnGap-11 [2170-7-15] 03:10AM BLOOD Glucose-90 UreaN-15 Creat-0.3* Na-135 K-4.5 Cl-98 HCO3-27 AnGap-15 [2170-7-17] 03:39AM BLOOD ALT-34 AST-31 LD(LDH)-674* AlkPhos-82 TotBili-0.1 [2170-7-16] 02:12AM BLOOD ALT-37 AST-35 LD(LDH)-671* AlkPhos-80 TotBili-0.2 [2170-7-15] 03:10AM BLOOD ALT-43* AST-43* LD(LDH)-801* AlkPhos-89 TotBili-0.2 [2170-7-11] 03:36AM BLOOD Lipase-125* [2170-7-6] 12:10AM BLOOD Lipase-115* [2170-6-29] 12:58PM BLOOD Lipase-131* [2170-7-17] 03:39AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.6 [2170-7-16] 02:12AM BLOOD Albumin-3.4 Calcium-8.9 Phos-3.2 Mg-1.5* [2170-7-15] 03:10AM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.8 Mg-1.5* [2170-6-11] 04:22PM BLOOD calTIBC-424 Ferritn-230 TRF-326 [2170-5-31] 12:00AM BLOOD VitB12-[2140]* Folate-10.5 [2170-5-24] 04:45AM BLOOD Triglyc-76 [2170-5-19] 10:30PM BLOOD Cortsol-25.3* [2170-6-11] 11:29PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2170-5-24] 04:45AM BLOOD IgG-385* IgA-33* IgM-8* [2170-6-11] 11:29PM BLOOD HCV Ab-NEGATIVE [2170-5-27] 04:22PM BLOOD Type-[Last Name (un) ] Temp-36.2 Rates-/22 O2 Flow-5 pO2-33* pCO2-57* pH-7.43 calTCO2-39* Base XS-10 Intubat-NOT INTUBA [2170-5-20] 02:33AM BLOOD freeCa-1.16 Studies: [5-19] CT of pelvis/abdomen/chest: 1. New right lower lobe consolidation, concerning for pneumonia. 2. Markedly increased left-sided pleural effusion with consolidation. Fluid- filled airways within LLL may represent aspiration or mucous impaction. 3. Stable multifocal bilateral opacities and ground-glass opacities. 4. No acute intra-abdominal pathology. 5. Multiple bilateral healing rib fractures. 6. Stable partially calcified splenic lesion. [6-1] Gallblader US: 1. Gallbladder appears normal without evidence of gallstones. 2. Diffuse mild increased hepatic echotexture consistent with diffuse fatty infiltration, although other advanced forms of liver disease such as cirrhosis or fibrosis cannot be excluded based on this study. 3. Pancreas obscured by overlying bowel gas. [7-23] 1. No acute intra-abdominal process. 2. Persisting left pleural effusion, with associated left lower lobe atelectasis. 3. Improvement of airspace opacity in the right lower lobe, with only residual patchy consolidation. 4. Stable splenic lesion. [6-26] Video Swallow Studie: Mild-to-moderate dysphagia with one episode of trace penetration and aspiration. [7-25] Portable Adomen: 1. GJ tube in expected location. 2. P.O. contrast in colon invokes patency. In the absence of air in small bowel an obstruction of fluid filled loops cannot be excluded, but could be evaluated with CT if warranted. [7-25] CT of head: No evidence of acute intracranial hemorrhage. Right maxillary retention cyst and bilateral mastoid opacification, not adequately assessed. If there is continued concern for intracranial abnormalities, MR [Name13 (STitle) 430] can be considered given the hisotry of NHL. Also CT is less sensitive in the detection of early cerebral edema, for which clinical correlation reg. mental status and a follow up can be helpful as clinically indicated. Brief Hospital Course: 33yo M with large B-cell lymphoma s/p allogeneic stem cell transplant '[66], complicated by severe chronic Graft vs. Host Disease of the skin (scleroderma-like) and oral mucosa (now resolved). . Prior to this admission pt was recently admitted ([4-8] - [4-20]) due to pneumosepsis and tx with ceftriaxone. Pt was d/c and went to [Hospital ] rehab, but he became hypoxic to low 90s, with lower BP, febrile to 102.5, HR 160s incr from baseline 120s, along with n/v and abdominal pain. Pt was found to have new RLL consolidation and increased moderate left sided pleural effusion with compressive LLL atelectasis. . Thus pt was re-admitted (current admission) on [5-19] with pneumonia to the [Hospital Unit Name 153]. He was admitted with a non-rebreather to keep 02 sats in 90s, but eventually went into respiratory failure, and intubated likely due to worsening hypoxia [12-30] pulm edema. Pt was agressively diuresed. Before knowing the final BAL results pt was treated empirically with Vanc/Cefepime/Cipro, then reduced to Cefepime 2 g IV. It was thought that this multifocal lung infection was likely due to Strep pneumoniae +/- Rhinovirus pneumonia. Other issued in the ICU included tachycardia, for which he was continued on IV Metoprolol and Hypogammaglobulinema for which he received IVIG on [5-25]. Pt also had pain with swollowing, and switched to IV meds, and could not tolerate his Gleevac. Pt was weaned was off the vent and extubated [5-26]. Pt required frequent suctioning but stabalized and came to the floor on [5-28]. . Once on the floor pt developed pancreatitis and transaminitis, although the lipase remained elevated pt eventually stopped complaining of mid-epigastric pain - but it was unclear to the team why these enzymes remained elevated. Our team thought it may have been due to fluconazole and was changed to Caspo. The Hepatology team it may be [12-30] TPN use. Currently his ALT/AST are normal, recent lipases are still in 100s (last lipase 115 on [7-6]) but ? thought not to have current pancratitis. Pt also has an elevated LDH - differential: wbc/rbc hemolysis vs PCP (but pt gets daily atorvoquone as prophylaxsis), and all appear unlikely - unknown why pt has elevated LDH, but may be related to above issue. Another thought is that his LFT changes were related to his GVH. . The pt's pneumonia is resolving well. Pt finished his 14d course of Cefepime, and was only on Acyclovir/Caspo for prophylaxsis. The latest CT chest on [6-27] showed "Marked improvement in bibasilar consolidation, with mild residual RLL abnormality with impacted bronchi and peribronchial infiltration. No new consolidations. Decreased but persistent moderate non-hemorrhagic left pleural effusion resulting in extensive left lower lobe atelectasis." . The main issue, prior to the pneumonia and currently, is his severe chronic GVH. His GVH is causing (1) scleroderma-like, leathery, thickening of skin on his entire body leading to immobility and pain with movement from his tense skin, and (2) GI effects - pt originally had severe oral ulcerations now resolved, but currently continues to have aphagia and dysmotility. It is very important to note that on his last admission the pt dramatically improved with Gleevac (unknown mechanism) to the point where his skin began normalizing and he was able to walk again. So our main goal of this admission is to give him Gleevac, which has been very problem[Name (NI) 115]. . Pt has not been able to take food by mouth for 1 year, and has been TPN dependent for 1yr. He had always been able swallow pills by mouth, but this changed during over the course of this admission, and is currently unable even take pills by mouth - therefore completely NPO. Pt always preferred to be fed by GI tract, and we needed a route to give meds that do not have IV formulations (especially Gleevac). So pt had a PEG placed by IR on [6-13]. This PEG became very problem[Name (NI) 115]. . [Name (NI) 1917] pt had abdominal pain at the skin around the PEG site. This pain was separate from the pain he had from the pancreatitis, and was initially attributed to his associated skin tightening from GVH since it was worse with movement. Pt had mild improvement with lidocaine patch, but the pain was severe and started on Morphine PCA, and as this was becoming an unresolving pain Pain Service recommended transitioning to methadone. On [6-22] pt had CT Abd showing no acute intra-abdominal process. On [6-23] pt began having a purulent discharge from the skin around the PEG site. On [6-23] the site was cultured showing only skin flora (4+ G+C in pairs, chains, and clusters). IR and GI were consulted who initially did not believe the site was infected (they said purulent discharge can be a normal finding associated with a PEG). Thus, we asked IR to perform a flow study to evaluate for impingement and patency (due to concurrent high-residuals from tube feeds - see below/next paragraph), and the study on [6-26] showed normal flow. There was no change and on [6-28] swab was repeated again showing skin flora, but continued to have purulent discharge and mild erythema around site. GI was reconsulted and the attending agreed with us that the PEG is infected, and recommended that we treat with antibiotics before removing the PEG. Pt was started on Zosyn/Vanco for this PEG infection, and in [11-29] days pt's purulent discharge and erythema resolved along with near resolution of pt's abdominal pain at the site. While this issue was resolved, pt continues to have diffuse abdominal pain, at baseline [2-5]. The current thought is that the abdominal pain may be due to direct effect of GVH on his bowel. We are now trying to taper down pt's morphine PCA, and transitioning to methadone elixir and tylenol 1000mg QID per PEG, and once off PCA, at that point will add oxycodone elixir for breakthrouh pain. . At the same time, the [Last Name ] problem we had with the PEG was that the pt was not tolerating tube feeds. Pt's TF were started at 5-10cc/hr and could not be advanced (goal 40cc/hr) due to very high residuals (>100cc whenever checked). On [6-23] GI recommended Reglan, which was eventually increased to QID without any benefit. Pt's gastroparesis was so severe that tube feeds were stopped. GI thought gastroparesis was due to the high level of narcotics (pt was getting for abdominal pain). Once pt's PEG infxn was treated, the issue still remained that pt was not getting Gleevac due to the gastroparesis. The thought was then to bipass the stomach and have feeds directly into the jejunum. On [7-4] IR replaced the g-tube with a longer j-tube (current). Pt was restarted on TF and is currently tolerating 5-10cc/hr. The first two days Gleevac (liquid mixture) was pushed the pt vomitted (but it was thought that since the pt was always lying down it was the gastric residuals were regirgitated and not jejunal tube feeds (and hopefully most of the Gleevac was retained). To solve the [Last Name 56971] problem we came to the conclusion that this was due to the high volume of Gleevac (~40cc). Thus, Gleevac is given by holding TF for 1 hr prior, and given very slowly (over 30min -1hr), and then TF are restarted 1 hr after giving Gleevac. This was first tolerated without emesis on [7-6]. Pt is already showing very mild improvements in skin turgor and range of movement of extremities (from 4d of Gleevac). Goal is to decrease narcotic requirement as much as possible to help with GI motility. . Also side note, Pt developed increased SOB on [6-29], with decreasing O2 sat to 90% (pt became very anxious since he knew this is what sent him to the ICU in the first place). Pt was tapered up to 3L/NC to improve SOB. Pt did not have chest pain, we did not want to [Hospital1 1376] a silent MI. Pt's EKG had ST changes from previous, but cardiology consult said these were early repolarizations, and not worrisome of ACS and CE negative. Pt's CXR/Chest CT did not show worsening of pneumonia, and actually showed mild improvement. Pt was already anti-coagulated with Fondaparinox for a PE in [2-3] (attributed cause of his persistent tachycardia). And pt already had a known history of cardiomyopathy with TTE on [2170-4-17] showing EF 45-50%, likely multifactorial- chemotherapy, radiation, GVHD, longstanding hypertension/tachycardia. In the end no cause was found and was attributed to the pt's chest-wall abnormality, meaning the skin rigidity [12-30] GVH, that kept pt from taking deep breaths along with anxiety. Pt's SOB is at baseline currently (averaging 94-96%RA, RR 20). . On [7-25] he received ~10mg IV Dilaudid during the day for pain control and at 1143 PM he got 1mg of IV ativan. Patient became tachypneic and with agonal breaths. He got placed on CPAP and was transfered to the ICU. His CO2 became increasingly high and required intubation. Patient required high-dose fentanyl and midazolam as sedation. Patient was found to have a small consolidate on CXR and was started on Vancomycin for s. aureus pneumonia. Extubation was tried in multiple times putting patient on pressure support. He repeatedly retained CO2 to levels similar to intubation, despite [Last Name (un) 10737] in very low dose of fentanyl for pain control. Patient was fully awake. Discussion took place about the option of tracheostomy, which patient refused. Patient was explained risk and benefits of his election. Then, a couple of days later patient got succesfully extubated on [8-6]. He did well for 24 hours, but kept complaining of anxiety. Morphine was tried without any relief. Patient was explained the risk and benefits of receiving lorazepan (half a dose than before) and wanted his anxiety treated though risks included potential respiratory failure and death. Given his underlying condition, he wished primary goal to be comfort and did not want to be re-intubated or receive agressive care. Ultimately, his respiratory status did again worsen and despite bipap patient condition worsened. In keeping with his wishes, he was not intubated and died. Medications on Admission: 1. Acyclovir 200 mg/5 mL 10 mL PO q8h 2. Fragmin 6000U [Hospital1 ] 3. Magic mouthwash 4. Diltiazem 60mg QID 5. Flovent 110mcg [Hospital1 ] 6. Gleevec 400mg daily 7. Prevacid 30mg daily 8. Lopressor 25mg TID 9. Cellcept 750mg [Hospital1 ] 10. Milk of Magnesia 30ml PO daily 11. Zofran PRN 12. Noxafil 200mg TID 13. Prednisone 15mg PO BID 14. Bactrim 160-800mg 10cc daily 15. Prograf 1mg daily 16. Posaconazole 200mg TID 17. Ativan PRN 18. Reglan 7.5mg TID 19. Bisacodyl 10mg daily 20. Lactulose 20gm daily 21. Dilaudid PRN 22. Morphine sulfate PRN 23. Eucerin creme Discharge Medications: None Discharge Disposition: Expired Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: severe GVHD Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "481", "202.80", "425.4", "995.92", "511.9", "707.01", "536.3", "577.0", "996.85", "038.2", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.6", "34.91", "43.11", "38.93", "88.72", "96.72", "33.24", "99.15" ]	icd9pcs	[ [ [] ] ]	20354, 20428	9538, 19697	334, 567	20484, 20493	4762, 9515	20549, 20559	3732, 3894		20325, 20331		20449, 20463		19723, 20302			20517, 20526								3909, 3909																									276, 296										595, 1650							3923, 4743								1672, 3362	3378, 3716
41,981	118,510	54292	Discharge summary	report	Admission Date: [2183-1-9] Discharge Date: [2183-1-15] Date of Birth: [2129-8-15] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Codeine / Doxycycline / Dilaudid Attending:[Doctor First Name 5911] Chief Complaint: Ms. [Known lastname 111230] presented for scheduled laparoscopic bilateral salpingo-oophorectomies due to bilateral ovarian cysts with solid components. Major Surgical or Invasive Procedure: 1. Laparoscopic bilateral salpingo-oophorectomies, pelvic peritoneal washings with emergent conversion to laparotomy for repair of trocar injury to left common iliac artery and vein. 2. Primary repair of left common iliac artery. 3. Primary repair of left common iliac vein. 4. Blood transfusion. History of Present Illness: Ms. [Known lastname 111230] is a 53-year-old G4, P4-0-0-4 perimenopausal Caucasian female with bigeminy arrhythmia, depression, GERD, and is S/P C/S x4 plus LTL. Ms. [First Name (Titles) 111231] [Last Name (Titles) 1834] a pelvic ultrasound [12/2179] for complaints of abnormal bleeding. It revealed a 7.7 cm right posterior cul-de-sac cyst separate from the right ovary and a 3.5 cm simple left ovarian cyst. The uterus measured 10.9 cm but was otherwise unremarkable with endometrial stripe of 8 mm. She had a followup pelvic ultrasound ([2180-2-2]) that revealed resolution of the 7.7 cm posterior cul-de-sac cyst with a normal right adnexa. She had two left ovarian cysts sizing 2-2.5 cm. Endometrial stripe measured 1.1 cm with a questionable 6-mm endometrial polyp. . In regards to her endometrial lesion and abnormal bleeding, she [Year (4 digits) 1834] an office endometrial biopsy ([2180-1-18]). It revealed scant inactive endometrium with no evidence of endometrial hyperplasia or malignancy. A diagnostic office hysteroscopy ([2180-4-19]) revealed a normal endometrial cavity with no evidence of any endometrial polyps or submucosal fibroids. There were no active issues regarding the endometrial findings and the patient maintained expectant management. In regards to her abnormal bleeding, given the benign endometrial biopsy and normal hematocrit, the patient opted to maintain expectant management. . In regards to her pelvic and left ovarian cysts, it appeared that the patient had remained asymptomatic and this was an incidental finding. The large 7.7 cm right posterior cul-de-sac cyst had resolved spontaneously and the left adnexal cyst appeared to be oscillating in size and simple in nature. Therefore, the patient opted to maintain expectant management with intermittent surveillance given her asymptomatic state. . She recently had a pelvic ultrasound at [Location (un) 620] under Dr.[Name (NI) 14510] (PCP) instructions. PUS ([2182-11-12]) at [Hospital1 ] [Location (un) 620] reveals a uterus measuring 11 x 4.2 x 6 cm. Endometrial stripe measured 7 mm. No endometrial polyp was appreciated. The right ovary measured 3 cm in its greatest dimension with a large 8.9 x 4 cm cyst containing some debris. There was additionally a smaller 1.3 cm nodule within it. A third cystic area with flow was also noted along the edge of this large cystic lesion. On the left, the left ovary measured 5 cm in its greatest dimension and contained a 2.2 cm simple cyst. There was an additional 1.1-cm solid nodule & a small amount of free fluid in the cul-de-sac. . She denied any symptoms related to these PUS findings such as pelvic pain. On review of her menstrual pattern, she does report a pattern of oligomenorrhea consistent with perimenopause. She did skip her menses in [4-/2182], [5-/2182], and [6-/2182] and has then resumed monthly menses in [Month (only) 205] with each episode lasting roughly five to eight days. The amount of bleeding is lighter than her prior moderate to heavy flow noted two years ago. The patient continues to remain asymptomatic. Given the size of the lesions and the solid components, I advised surgical management even though she remains asymptomatic. After careful consideration, the patient would like to proceed with surgical evaluation. A plan for a laparoscopic bilateral salpingo-oophorectomies with possible conversion to laparotomy was discussed. Pelvic peritoneal washings will be obtained. We also discussed the need for a staging procedure should surgical findings reveal a malignant condition. The patient was consented for a laparoscopic bilateral salpingo-oophorectomies, pelvic peritoneal washings, possible laparotomy, and possible staging procedure. She understands that a staging procedure will be performed by one of our gynecologic-oncologist here at [Hospital1 18] if indicated (greatly appreciated). The nature of the surgery, potential surgical risks, likely hospital and postoperative course were discussed with the patient in detail today. Informed consent was obtained. Past Medical History: OB history: G4, P4-0-0-4 - C-sections (x4), [2154], [2156], [2157], and [2160]. GYN History: Menarche age 12. see above for menstrual hx - denies pelvic pain, dyspareunia, pain w/ full bladder or BM. - denies h/o abnormal Pap smears, last Pap ([2182-11-4]) neg SIL. - last mammogram ([2181-12-18]) reportedly neg per pt. next mammogram is scheduled for 1/[2183]. - she is sexually active, prefers opposite sex and reports one sexual partner throughout life. s/p LTL in [2163]. - STD History: Negative. Medical Problems: 1. Bigeminy arrhythmia. 2. Depression. 3. GERD. 4. Abnormal bleeding. 5. Mitral valve prolapse. Past Surgical History: 1. C-section x4 ([2154], [2156], [2157], and [2160]) 2. [2163], Laparoscopic tubal ligation, D&C, for permanent sterilization and abnormal bleeding evaluation. Social History: Denies history of smoking or recreational IV drug use. ~2 Etohic drinks per week. not currently employed and married, living with her husband. denies history of abuse. Family History: - father with hypertension and heart disease - denies fam h/o breast, ovarian, uterine, cervical, vaginal, colon, or any other cancers. denies fam h/o diabetes, hypercholesterolemia, or any other family medical conditions. Physical Exam: GENERAL: Pleasant Caucasian female in no acute distress. VITAL SIGNS: BP 100/60, wt 122 pds, ht 5 ft 0 in. HEENT: normocephalic/atraumatic, anicteric sclera Neck: supple, full range of motion, no thyromegaly or nodules Lymphatic: no palpable neck lymphadenopathy Back: no CVA tenderness Lungs: clear to auscultation bilaterally, good inspiratory effort CV: regular rate and rhythm, no murmurs/rubs/gallops Abdomen is soft, nontender, nondistended, positive bowel sounds. No rebound or guarding. Well-healed low transverse C-section scar. Well-healed laparoscopic punctures. Unremarkable exam. Extremities: no clubbing/cyanosis/edema On bimanual exam, the patient has a small, anteverted, nontender uterus. It is difficult to palpate the right adnexal cyst ? fullness, but no firm parameters appreciated. No left adnexal masses. No CMT, benign exam. Pertinent Results: [2183-1-9] 04:54PM BLOOD WBC-11.8# RBC-2.33# Hgb-7.0# Hct-20.5# MCV-88 MCH-29.9 MCHC-34.0 RDW-13.5 Plt Ct-215 [2183-1-9] 05:40PM BLOOD WBC-10.5 RBC-2.68* Hgb-7.9* Hct-23.4* MCV-87 MCH-29.7 MCHC-34.0 RDW-13.5 Plt Ct-123* [2183-1-9] 07:33PM BLOOD WBC-8.2 RBC-2.64* Hgb-7.9* Hct-22.4* MCV-85 MCH-30.0 MCHC-35.3* RDW-13.6 Plt Ct-104* [2183-1-10] 12:43AM BLOOD WBC-9.7 RBC-3.18* Hgb-9.5* Hct-27.0* MCV-85 MCH-29.8 MCHC-35.0 RDW-13.9 Plt Ct-88* [2183-1-10] 06:27AM BLOOD WBC-10.1 RBC-3.45* Hgb-10.4* Hct-29.1* MCV-84 MCH-30.1 MCHC-35.7* RDW-13.9 Plt Ct-101* [2183-1-11] 07:45AM BLOOD WBC-8.8 RBC-3.18* Hgb-9.6* Hct-27.3* MCV-86 MCH-30.2 MCHC-35.2* RDW-14.1 Plt Ct-125* [2183-1-12] 07:55AM BLOOD WBC-5.8 RBC-3.01* Hgb-9.1* Hct-25.7* MCV-86 MCH-30.1 MCHC-35.2* RDW-13.6 Plt Ct-119* [2183-1-12] 12:50PM BLOOD WBC-5.4 RBC-3.00* Hgb-9.2* Hct-25.7* MCV-86 MCH-30.5 MCHC-35.7* RDW-13.8 Plt Ct-131* [2183-1-13] 08:10AM BLOOD WBC-4.8 RBC-3.02* Hgb-8.9* Hct-25.8* MCV-86 MCH-29.6 MCHC-34.7 RDW-13.8 Plt Ct-173 [2183-1-14] 08:14AM BLOOD WBC-4.9 RBC-3.28* Hgb-9.7* Hct-28.2* MCV-86 MCH-29.7 MCHC-34.5 RDW-14.2 Plt Ct-208 [2183-1-9] 04:49PM BLOOD Fibrino-113* [2183-1-9] 07:33PM BLOOD Fibrino-157 [2183-1-10] 12:43AM BLOOD Fibrino-179 [2183-1-10] 06:27AM BLOOD Fibrino-285# [2183-1-12] 07:55AM BLOOD Fibrino-822# [2183-1-9] 07:33PM BLOOD Glucose-181 UreaN-12 Creat-0.8 Na-142 K-3.8 Cl-111* HCO3-23 AnGap-12 [2183-1-10] 12:43AM BLOOD Glucose-134* UreaN-11 Creat-0.6 Na-140 K-3.9 Cl-110* HCO3-25 AnGap-9 [2183-1-10] 06:27AM BLOOD Glucose-136* UreaN-11 Creat-0.6 Na-139 K-3.7 Cl-109* HCO3-26 AnGap-8 [2183-1-11] 07:45AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-143 K-3.3 Cl-109* HCO3-28 AnGap-9 [2183-1-12] 07:55AM BLOOD Glucose-115* UreaN-9 Creat-0.5 Na-138 K-3.3 Cl-107 HCO3-25 AnGap-9 [2183-1-13] 08:10AM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-139 K-3.4 Cl-108 HCO3-27 AnGap-7* [2183-1-14] 08:14AM BLOOD Glucose-110* UreaN-10 Creat-0.6 Na-138 K-3.3 Cl-106 HCO3-27 AnGap-8 [2183-1-9] 07:33PM BLOOD ALT-30 AST-41* AlkPhos-47 TotBili-0.4 [2183-1-9] 04:47PM BLOOD Type-MIX pO2-58* pCO2-55* pH-7.12* calTCO2-19* Base XS--12 Intubat-INTUBATED [2183-1-9] 05:56PM BLOOD Type-ART Rates-12/0 Tidal V-586 PEEP-5 O2 Flow-4 pO2-460* pCO2-37 pH-7.31* calTCO2-20* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [2183-1-9] 08:11PM BLOOD Type-ART Temp-35.5 Rates-/12 Tidal V-500 PEEP-5 FiO2-60 pO2-307* pCO2-38 pH-7.41 calTCO2-25 Base XS-0 -ASSIST/CON Intubat-INTUBATED [2183-1-10] 01:18AM BLOOD Type-[Last Name (un) ] pH-7.30* Comment-GREEN TOP Brief Hospital Course: Ms [Known lastname 111230] [Last Name (Titles) 1834] laparoscopic bilateral salpingoophorectomies and pelvic washings that was complicated by a trocar injury to the left common iliac artery and vein injury. She had an emergent conversion to a laparotomy with a primary vessel repair (with assistance from Gynecologic Oncology, General Surgery, and [Last Name (Titles) ] Surgery-- please see operative reports for details). Ms. [Known lastname 111230] was transferred after the procedure to the ICU intubated, in stable conditon. Patient was extubated in AM POD#1 and called out of the ICU. Her course is described below by system: . RESPIRATOY: Ms. [Known lastname 111230] was extubated on post-operative day #1 and had no respiratory complications during her admission. . HEME: Ms. [Known lastname 111230] [Last Name (Titles) 1801] was noted to have a consumptive coagulopathy. She recieved a total of 10u PRBC, 7u FFP, 1000cc Cellsaver, 1u plts in terms of blood products. Her post-operative HCT was stable. The INR and fibrinogen were followed and noted to normalize by discharge. She remained hemodynamically stable and never required pressors in her post-operative course. . [Last Name (Titles) ]: [Last Name (Titles) ] surgery followed her as a consultative service and advised q4 hour pulse checks, bedside ABIs, DVT prophylaxis (SC hep ppx transitioned to 81mg aspirin daily), compression stockings as outpatient, activity restrictions as an outpatient and follow-up with Dr. [Last Name (STitle) ]. . ID: Ms. [Known lastname 111230] was treated with a broad spectrum antibiotic regimen including vancomycin, Cipro, and Flagyl from [1-9] until [1-12]. She remained afebrile on and off antibiotics. . FEN/GI: Patient complained of nausea. She was treated with Zofran, Protonix, Reglan, Tums, and Bicitra for nausea likely secondary to medications and GERD. She had bowel movements, flatus and no abdominal distension, making the diagnosis of ileus unlikely. Her diet was advanced as tolerated. Nutrition was consulted to ensure appropriate calorie intake. Ms. [Known lastname 111232] weight was noted to be elevated and her exam revealed edema from fluid retention. She responded well to diuresis with IV lasix. . NEURO: Ms. [Known lastname 111232] pain was well-controlled with a morphine PCA which was transtioned to po vicodin on [2183-1-13] POD#4. She demonstrated full neurologic function and was alert and oriented throughout her recovery. . OTHER: Social work consult was offered to aid in family coping and deconditioning, but patient declined. Patient with strong family support. Physical therapy was consulted. . She recovered smoothly and was transferred from the ICU to the VICU on POD#1, then to a regular floor on post-operative day #5 and discharged home on postoperative day #6 in good condition: ambulating and urinating without difficulty, tolerating a regular diet, and with adequate pain control using PO medication. She had follow-up with the [Year (4 digits) 1106] and gynecology services. Medications on Admission: ERYTHROMYCIN - (Prescribed by Other Provider) - 500 mg Tablet - one Tablet(s) by mouth once a day LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - Dosage uncertain SERTRALINE - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth once a day Discharge Medications: 1. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: maximum daily Tylenol (acetaminophen) is 4000mg, each Vicodin contains 500mg Tylenol (acetaminophen). Disp:50 Tablet(s) Refills:0 2. 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 3. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:40 Tablet, Rapid Dissolve(s) Refills:0 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for anxiety. Disp:60 Tablet(s) Refills:0 6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:60 Tablet(s) Refills:0 7. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: complex ovarian cysts laceration to common iliac vein and artery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. Followup Instructions: Please call Dr.[Name (NI) 93885] office for a follow-up appointment for staple removal this Friday. Please call Dr.[Name (NI) 111233] office for a follow-up in 2 weeks. Provider: [Name6 (MD) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 8246] Date/Time:[2183-2-14] 8:00 Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3628] (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2183-2-14] 9:15 Provider: [Name10 (NameIs) 14633],EQUIPMENT [Name10 (NameIs) ] [Name10 (NameIs) 3628] (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2183-2-14] 10:15 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 5913]	[ "787.02", "276.69", "627.9", "E878.8", "620.8", "300.4", "424.0", "998.11", "E870.0", "998.2", "E935.2", "530.81", "620.2", "220", "998.12", "V26.51", "V64.41", "427.5", "997.1" ]	icd9cm	[ [ [] ] ]	[ "39.31", "39.32", "65.63", "54.11" ]	icd9pcs	[ [ [] ] ]	14399, 14405	9792, 12884	463, 762	14514, 14514	7142, 9769	15422, 16121	6025, 6251		13202, 14376		14426, 14493		12910, 13179			14665, 15199					15214, 15399	5640, 5822		6266, 7123																									267, 425										790, 4934								14529, 14641							4956, 5617	5838, 6009
76,698	172,378	28613	Discharge summary	report	Admission Date: [2165-3-13] Discharge Date: [2165-3-26] Date of Birth: [2096-8-6] Sex: F Service: NEUROLOGY Allergies: morphine / Strawberry Attending:[First Name3 (LF) 17813] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD for MAC Tracheal intubation for lumbar puncture [3-18] Lumbar puncture by interventional [Month/Year (2) ] [3-19] History of Present Illness: 68 y/o female with dementia, PAF, severe OA of hip, and neurogenic bladder c/b recurrent urinary tract infections presenting from rehab with hematemesis. Per sister, pt has been feeling unwell with URI-like symptoms for the last five days. She has had five days of subjective fevers, headache, congestion, rhinorrhea, cough, SOB, and nausea. She then had episode of coffee ground emesis today. BP was 80/33 during transport per EMS. In the ED, initial VS were: 97 88 88/37 16 100%. NG lavage cleared from dark brown to tan with 750cc fluids. She had melanotic stool that was guaiac positive in the ED. CBC showed Hct of 23 (had been 33 on discharge on [2165-2-18]); INR 1.4; WBC 13; lactate 2.8. She was given pantoprazole bolus and placed on drip. She received IVF bolus with BPs stable in systolic 100s. . On arrival to the MICU, pt is complaining of pain in back and legs. Past Medical History: - Neurogenic bladder with recurrent urinary tract infections - Hypertension - Anemia - Hyperlipidemia - Paroxysmal atrial fibrillation - Gastroesophageal reflux disease - Severe osteoarthritis of her left hip - Small bowel obstruction s/p lapatomy in [4-/2164] - Lumbar discectomy in [2123]. T6-9 laminectomy done in [Month (only) 956] [2158] done due to residual fluid left in spinal canal. Non ambulatory since Social History: Previously lived at [Hospital1 1501]-Roscommon on the Parkway; now lives at High Gate. Widowed. Has one child. No longer working. Previously smoked two packs per day for 40 years, but quit eight years ago. No alcohol use. Family History: Father deceased at age 57 from a heart virus. Her brother is alive but had leukemia as well as complications of a brain bleed and he also had coronary artery disease status post MI. Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented x 3 (though requires , agitated, complaining of pain HEENT: Sclera anicteric, dry MM, 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: Severe contractures and atrophy of the LE b/l, 2+ pitting edema b/l Neuro: CNII-XII intact, moving all extremities, following commands . MICU ADMISSION EXAM Vitals: 98.7F, 154/78, HR 97, RR 40, O2Sat 95% RA General: moaning, does not answer to orientation questions, withdraws from pain. HEENT: Sclera anicteric, conjugate gaze, pupils dilated ~ 4-5 mm and reactive, MMM Neck: supple, JVP difficult to assess, no LAD CV: regular, slight tachycardic, normal S1 and S2, no m/r/g Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-distended, diminished bowel sound, no tenderness, no guarding. BM revealed malordorous dark brown with mixed red upon wiping. GU: Foley in place Ext: spastic movements, contracture and atrophy of the LE, 2+ edema Neuro: not alert or oriented, does not follow commands, dilated pupils but reactive, conjugate gaze, difficult to assess other CNs, moving all four extremities but with spastisity, difficult to assess for DTR Discharge Neuro Exam: aaox2 (person, place, not year or date). Language fluent with intact comprehension although she often is nonsensical. Moves RUE with full strength. LUE has chronic ROM limitations at the shoulder and elbow. Wiggles toes/legs bilaterally. Pertinent Results: ADMISSION LABS [2165-3-13] 08:44PM BLOOD WBC-13.8# RBC-2.47# Hgb-7.8# Hct-23.6# MCV-96 MCH-31.5 MCHC-33.0 RDW-14.1 Plt Ct-278# [2165-3-13] 08:44PM BLOOD Neuts-81.9* Lymphs-13.7* Monos-3.3 Eos-0.8 Baso-0.3 [2165-3-13] 08:44PM BLOOD PT-15.2* PTT-33.6 INR(PT)-1.4* [2165-3-13] 08:44PM BLOOD Glucose-152* UreaN-40* Creat-0.9 Na-141 K-4.8 Cl-106 HCO3-24 AnGap-16 [2165-3-14] 05:15AM BLOOD ALT-16 AST-32 [2165-3-14] 05:15AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0 [2165-3-13] 10:09PM BLOOD Lactate-2.8* [2165-3-14] 05:43AM BLOOD Lactate-1.3 . [3-14] URINALYSIS [2165-3-15] 07:40AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.013 [2165-3-15] 07:40AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [2165-3-15] 07:40AM URINE RBC-20* WBC-59* Bacteri-FEW Yeast-NONE Epi-<1 TransE-1 . DISCHARGE LABS [2165-3-26] 04:00AM BLOOD WBC-7.2 RBC-2.60* Hgb-8.0* Hct-25.2* MCV-97 MCH-30.9 MCHC-31.8 RDW-18.3* Plt Ct-200 [2165-3-26] 04:00AM BLOOD Plt Ct-200 [2165-3-26] 04:00AM BLOOD Glucose-79 UreaN-13 Creat-0.7 Na-144 K-3.9 Cl-113* HCO3-24 AnGap-11 [2165-3-24] 05:52AM BLOOD ALT-11 AST-26 LD(LDH)-199 AlkPhos-104 TotBili-0.2 [2165-3-26] 04:00AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.3* [2165-3-25] 06:46AM BLOOD Albumin-2.5* Calcium-8.2* Phos-2.7 Mg-1.5* [2165-3-22] 06:45AM BLOOD Triglyc-77 HDL-22 CHOL/HD-3.3 LDLcalc-36 [2165-3-25] 06:46AM BLOOD Phenyto-18.3 [2165-3-19] 03:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-114* Polys-8 Lymphs-79 Monos-0 Macroph-13 [2165-3-19] 03:30PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-265* Polys-6 Lymphs-82 Monos-0 Macroph-12 [2165-3-19] 03:30PM CEREBROSPINAL FLUID (CSF) TotProt-36 Glucose-67 [2165-3-19] 15:30 HERPES SIMPLEX VIRUS PCR Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Herpes Simplex Virus PCR Specimen Source CSF Result Negative Not Applicable [2165-3-19] 2:16 pm CSF;SPINAL FLUID Source: LP TUBE #3. GRAM STAIN (Final [2165-3-19]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2165-3-22]): NO GROWTH. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. . MICRO [2165-3-16] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2165-3-15] URINE Legionella Urinary Antigen - Negative [2165-3-15] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-FINAL INPATIENT FINAL REPORT [2165-3-18] HELICOBACTER PYLORI ANTIBODY TEST (Final [2165-3-18]): POSITIVE BY EIA. (Reference Range-Negative). [2165-3-15] URINE URINE CULTURE-FINAL {PROVIDENCIA STUARTII, PSEUDOMONAS AERUGINOSA} INPATIENT FINAL REPORT [2165-3-19] URINE CULTURE (Final [2165-3-19]): THIS IS A CORRECTED REPORT [2165-3-18]. Reported to and read back by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] AT 11:45AM ON [2165-3-18]. PROVIDENCIA STUARTII. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. GENTAMICIN AND TOBRAMYCIN sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. PREVIOUSLY REPORTED AS GENTAMICIN AND TOBRAMYCIN RESISTANT ON [2165-3-17]. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROVIDENCIA STUARTII \| PSEUDOMONAS AERUGINOSA \| \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ S 4 S MEROPENEM-------------<=0.25 S 4 I NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2165-3-14] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2165-3-14] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2165-3-14] BLOOD CULTURE Blood Culture, Routine-PENDING . IMAGING [3-14] CXR There is a hazy opacity at the right base, slighly worsened since the prior radiograph most consistent with infectious process. A small right pleural effusion is unchanged from prior radiographs. There is mild prominence of the pulmonary vasculature, consistent with congestion. Cardiomediastinal silhouette is mildly enlarged and unchanged. No pneumothorax. Again seen is chronic dislocation of the left glenohumeral joint. IMPRESSION: 1. Slightly increased hazy opacity at the right lower lung most consistent with pneumonia. 2. Mild pulmonary [Month/Year (2) 1106] congestion. . [3-15] CT HEAD [Month/Year (2) ]: There is no evidence of intra-axial or extra-axial hemorrhage, edema, mass effect or shift of normally midline structures. The [Doctor Last Name 352]-white matter interface is preserved without evidence of acute major [Doctor Last Name 1106] territorial infarct. The ventricles and sulci are slightly prominent but proportional, consistent with age-related involutional changes. [Doctor Last Name ] calcifications of the bilateral carotid siphons are noted. Scattered punctate hyperdensities in the CSF spaces of the middle cranial fossa may be related to prior myelogram. Mucus retention cysts are noted in the left maxillary sinus and bilateral sphenoid sinuses. There is near-complete opacification of the right maxillary sinus and bilateral ethmoid air cells. The mastoid air cells are well pneumatized bilaterally. The bony calvarium appears intact. IMPRESSION: 1. No acute intracranial process. 2. Sinus disease as detailed above. . [3-16] MR [First Name (Titles) ] [Last Name (Titles) ]: There is no acute intracranial infarction or hemorrhage. The axial T2 and FLAIR sequences are markedly degraded by motion artifact. There is no hydrocephalus or midline shift. Major intracranial flow-voids are preserved. There is opacification of the right maxillary sinus, and bilateral ethmoid and sphenoid air cells. There is slow diffusion within the right maxillary and the ethmoid sinuses which may represent retained secretions or underlying infection. IMPRESSION: Suboptimal MRI study, secondary to image degradation by motion artifact. 1. No acute intracranial abnormality seen. 2. Interval development of right maxillary and bilateral ethmoid and sphenoid sinus inflammatory disease. As above, there is slow diffusion in the right maxillary sinus and bilateral ethmoid air cells which may represent underlying pyogenic infection or retained secretions; [Last Name (Titles) 4493] should be closely correlated, clinically. EEG: [3-15]: IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of generalized periodic epileptic discharges (GPEDs) indicative of areas of cortical irritability with potential epileptogenicity. In addition, there were periods of electrodecrement associated with tonic arm flexion at times accompanied by a few myoclonic jerks. These [Month/Year (2) 4493] are likely indicative of brief electrographic seizures with clinical correlation. Background activity alternated between epochs of diffuse mixed theta and delta slowing, GPEDs, and brief episodes of electrodecrement. [3-16]: IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of generalized periodic epileptic discharges (GPEDs) indicative of multiple areas of cortical irritability with potential epileptogenicity. In addition, there were periods of electrodecrement associated with tonic arm flexion, more on the left, with some myoclonic jerks. These [Month/Year (2) 4493] are likely indicative of electrographic and clinical seizures. Background alternated between three following patterns: diffuse theta and delta slowing, GPEDs, and brief periods of electrodecrement. [3-17]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a severe diffuse encephalopathy with frequent paroxysmal features. The latter actually takes the form of generalized paroxysmal interictal epileptic activity, as described. These are also referred to as GPEDs. Compared to the prior day's recording, there were no significant changes. [3-18]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a severe diffuse encephalopathy with at least two different and distinct patterns. The first is a burst and burst suppressive pattern with sharp and slow sharp transients as the bursting phenomenon but long duration suppression to follow those. This alternates with what appears to be a diffuse encephalopathy with a theta and delta frequency rhythm present over the anterior head regions with relative loss of activity posteriorly. There were short duration runs of rhythmic theta activity in the central regions at appeared without any clinical accompaniment. [3-19]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a severe encephalopathy. This encephalopathy was manifest by a suppression of voltage over all head regions with the presence of a diffuse theta rhythm with no clear anterior-posterior gradation. There were no focal features on the routine record although subtle asymmetries were noted on the quantitative analysis. There were no seizures or interictal discharges of note. Compared to the prior day's recording, there were no significant changes. [3-20]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of the presence of a moderate to moderately severe diffuse encephalopathy. There were no clear focal abnormalities identified. There were no sustained seizures seen. There were some potential interictal sharp discharges noted in a multifocal distribution. [3-21]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of disorganized and slow background activity and bursts of generalized slowing indicative of mild to moderate encephalopathy which is etiologically non-specific. There were no focal asymmetries or epileptiform features. Compared to the prior day's recording, there was slight improvement in background activity. [3-22]: IMPRESSION: This is an abnormal continuous video EEG due to the presence of a slow background in the 6 Hz range which later improved to 7 Hz range with bursts of generalized slowing indicative of a mild encephalopathy that is etiologically non-specific. There were very rare generalized blunted sharp waves indicative of generalized cortical irritability but no electrographic seizures were seen. Compared to the previous day's recording, there is an improvement in the background frequency, particularly during the second half of the recording. [3-23]: IMPRESSION: This is an abnormal continuous video EEG due to the presence of a slow background initially in the [4-25] Hz range which later improved to a better organized 7 Hz range background in the second portion of the recording. These [Month/Day (3) 4493] are indicative of a mild encephalopathy that is etiologically non-specific. No clear epileptiform discharges were seen. Compared to the previous day's recording, there is an improvement in the background frequency and organization, particularly during the second half of the recording. [3-24]: pending Brief Hospital Course: This is a 68 yo F with reported reported dementia, ? h/o seizure, PAF, known neurogenic bladder with frequent UTIs initially presented with hemetemesis to the MICU, later was transferred to the floor, but re-transferred back to the MICU for AMS. # UGIB [12-20] duodenal ulcer. Per report, had coffee ground emesis at rehab and guaiac-positive melanotic stool in ED. Upper GI source suspected as had reported melena in the ED as well. Received vitamin K for elevated INR to 1.4, and aspirin and fondaparinaux was held. She was transfused 2 U PRBC's with appropriate hematocrit response from 23 to 29. She was evaluated by GI who performed an EGD with MAC anesthesia which showed a large, healing duodenal ulcer at the bulb which was the likely source of prior bleeding. In addition, EGD also revealed a duodenal submucosal mass, which will require outpatient EUS for further work up. She received another pRBC after being transferred to the floor. She was switched to pantoprazole 40 mg [Hospital1 ]. H. pylori antibody was found to be positive. However, given the complexity of her other medical issues, treatment was deferred in the MICU, but will need to be followed up in the outpatient setting. GI outpatient follow up scheduled. Her HCT has remained stable around 25-26. # Altered mental status. Multifactorial, likely [12-20] seizure and underlying infection. Patient was A&O x3 on admission. She was noted to become unresponsive requiring sternal rub the morning after transfer to the floor from MICU. Rhythmic movement was noted in her UE, which subsided with 1 mg Ativan. However, mental status did not improve. There was initial thought about opioid overdose given patient's history of opioid use for chronic pain, although she did not receive more than her normal home dose. Narcan was administered and patient had signs of withdrawal by vital sigs, but mental status remained poor. Neurology was consulted for work-up of possible seizure (see below) given reported history and being on low dose keppra. She was started on vancomycin and cefepime empirically for possible UTA given + UA (see below) and ? RLL pneumonia on CXR. Blood culture was negative. Repeat urine culture showed Providencia stuartii and Pseudomonas aeruginosa. Mental status slowly improved throughout her course. At discharge she was aaox2. # Seizure. After neurology was consulted for ? seizure given reported history although there was no definitive diagnosis from the past, EEG showed status epilepticus. CT head and MRI head did not show acute intracranial process. AEDs were started and titrated upward. She was loaded on keppra, fosphenytoin, and valproate. She continued to have intermittent seizures through these AEDs, so lorazepam was also started. Bed-side LP was unsuccessful, and patient was intubated electively for IR guided LP given chronic contracture. She was started on ampicillin, acyclovir and continued vancomycin for presumed meningitis. However, CSF was negative, and antimicrobials were taken off. She was continued on EEG monitoring and her AED regimen was changed to her current discharge meds with good seizure control: keppra 1500mg [Hospital1 ] and phenytoin 100mg tid. # UTI. Her repeat urine culture taken at the time of AMS grew providencia stuartii and psueomonas aeruginosa, both of which were sensitive to cefepime. She completed treatment prior to discharge. # Leukocytosis. WBC elevated to 13.8 on admission. No obvious source of infection indentified initially, although CXR with effussion in right hemithorax and urinalysis suggestive of infection (although has neurogenic bladder and chronically self caths with history of recurrent UTI's). Leukocytosis resolved after IVF hydration and transfusion, suggesting reactive leukocytosis. # Paroxysmal afib: HR 80s; EKG shows sinus rhythm. Has CHADS of 1. Is likely on fondaparinaux for DVT prophylaxis, not afib. Given recent GIB will defer further consideration of anticoagulation at this time, but may be considered in the future. # Chronic LE contractures. Unable to ambulate since lumbar distectomy in [2123]. Has chronic pain for which she is on narcotics. Patient was kept on home baclofen. Oxycontin and oxycodone were discontinued and then restarted at 1/2 the previous dose in hopes of improving her mental status. She was discharged on the half dose of MS Contin with good pain control. These may need to be adjusted in the future. # Fondaparinux. It is unclear the reasons for fondaparinux. PCP and rehab were contact[Name (NI) ] to clarify but no one seemed to know the reasons. It seemed to have been carried over from past admissions. Based on the initial dosage from rehab, patient was assumed to be on it for DVT prophylaxis. No heparin was given while in the MICU given recent GIB. # HLD. Patient was continued on atorvastatin. # CAD. ASA was held given GIB. # HTN. Lasix was held given hypotension on initial presentation. It was restarted on [3-24]. # GYN. Pt was noticed to have a labia mass by nursing staff. GYN was consulted, who biopsied the mass. The patient will follow up in [Hospital ] clinic for the results. PENDING LABS: labia biopsy results pending. To be followed up in [Hospital ] clinic TRANSITIONAL CARE ISSUES: [] treatment for H. pylori [] EUS for duodenal submucosal mass (GI f/u appt set up already) [] GYN followup Medications on Admission: Medications: (per last d/c summary [2165-2-18]; patient unable to verify) 1. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for Muscle spasm. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipaion. 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 16. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for Pain. 18. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 20. simethicone 80 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. ipratropium bromide 0.02 % Solution Sig: [11-19] puff Inhalation Q6H (every 6 hours) as needed for wheeze. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [11-19] puff Inhalation Q6H (every 6 hours) as needed for wheeze. 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). 9. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [11-19] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. levetiracetam 1,000 mg Tablet Sig: 1.5 Tablets PO twice a day. 11. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO three times a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed) as needed for groin. 18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for breakthrough pain. Disp:30 Tablet(s) Refills:0 19. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:30 Tablet Extended Release 12 hr(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: Upper GI bleed anemia duodenal ulcer duodenal mass UTI labia mass nonconvulsive status epilepticus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: aaox2 (person, place, not year or date). Language fluent with intact comprehension although she often is nonsensical. Moves RUE with full strength. LUE has chronic ROM limitations at the shoulder and elbow. Wiggles toes/legs bilaterally. Discharge Instructions: Dear Mrs. [Known lastname ], You were admitted to [Hospital1 18] for vomiting up blood. You were initially seen in the ICU and underwent a endoscopy that showed a healing duodenal ulcer as well as a submucosal duodenal mass that you should follow up with the GI doctors as [Name5 (PTitle) ] outpatient. Please also ask them to follow up regarding your diagnosis of H. Pylori that has not yet been treated. You received transfusions of red blood cells and your blood counts have trended down slowly but stabilized. Afterwards you were noted to be very somnolent and found to have non-convulsive seizures. We monitored you on EEG and adjusted your anti-seizure medications, increasing the Keppra which you took at home and starting a new medication called Dilantin. Your EEG improved and you had no further evidence of seizures during the last several days of your hospitalization. During your stay you also had a UTI that was treated. GYN also saw you regarding your labia and took a biopsy. Please follow up with Dr. [Last Name (STitle) ] in their clinic regarding these results as they are still pending at time of discharge. Of note, we decreased your long-acting MS Contin by half to see if you continued to have pain control without mental suppression. You appeared stable on this regimen for the past 2 days. This may need to titrated up in the future if pain is not controlled. Followup Instructions: Please follow up in [Hospital 875] clinic with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [4-17], [2164] at 3:30 PM. Her office can be reached at [Telephone/Fax (1) 3294] if you need to re-schedule this appointment. Please follow up with GYN regarding labia biopsy. There is no need for suture removal as they will dissolve on their own: Please see Dr. [Last Name (STitle) ] in [Hospital ] clinic on [4-12] 10am for follow up. The clinic is located in [Hospital Ward Name 23] Bldg, [Hospital Ward Name 516], [Hospital1 18] Please follow up with GI regarding duidenal ulcer and mass: Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 590] Date/Time:[2165-4-19] 9:20 GI Provider: [Name10 (NameIs) 2606] [Name11 (NameIs) 2607], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2165-4-24] 3:30 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2165-8-1] 9:00	[ "599.0", "276.0", "427.31", "294.20", "285.1", "728.85", "041.7", "272.4", "401.9", "V58.61", "625.8", "345.3", "041.89", "V49.86", "537.9", "530.81", "532.40", "715.35", "414.01", "596.54" ]	icd9cm	[ [ [] ] ]	[ "89.19", "03.31", "38.93", "99.15", "96.04", "45.13", "96.71" ]	icd9pcs	[ [ [] ] ]	25230, 25320	16030, 21318	296, 427	25463, 25463	3982, 16007	27314, 28313	2061, 2246		23255, 25207		25341, 25442		21479, 23232			25886, 27291								2261, 3963																									244, 258		21344, 21453								455, 1347								25478, 25862							1369, 1799	1815, 2045
70,097	137,788	37112	Discharge summary	report	Admission Date: [2138-12-22] Discharge Date: [2139-1-9] Date of Birth: [2063-7-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2138-12-25] left heart cateterization, coronary angiography, left ventriculogram Perm-A-Cath placement [2139-1-5] [2138-12-29] Coronary Artery Bypass Graft x 4 (Left internal mammary artery to left anterior descending, Saphenous vein graft to diagonal, Saphenous vein graft to obtuse marginal, Saphenous vein graft to left posterior descending artery) History of Present Illness: This 75 year old white male presented to [Hospital3 417] Hospital ED on [12-19] with chest pain and shortness of breath for 1 week. Upon presentation he had a new LBBB and his Troponin was 7.9. A TTE showed a depressed LVEF and global hypokinesis. He was pain free and then developed severe CP on [12-21] and was transferred to [Hospital1 18]. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 recent Myocardial Infarction Insulin dependent Diabetes Mellitus Dyslipidemia Hypertension Chronid Kidney Disease stage 3-4 chronic lymphocytic leukemia Congestive heart failure Peripheral vascular disease Chronic obstructive pulmonary disease Peripheral neuropathy Cataracts Anxiety on Bupropion Basal Cell skin ca s/p resection s/p Appendectomy Social History: -Tobacco history: 50 pack years, stopped 10 yrs ago. -ETOH: no -Illicit drugs: no lives with wife. independent with ADLs. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: Admission: Pulse:64 Resp: 18 O2 sat: 99% 2 liters O2 B/P Right: 107/62 Left: Height: 68" Weight: 79.5 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 + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [2138-12-29] Echo: PRE BYPASS The left atrium is moderately dilated. The left atrium is elongated. 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. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with mild apical dyskinesis, lateral wall akinesis, severe hypokinesis of all mid and distal sements, and mild basal hypokinesis of all segments. 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 aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly to moderately thickened but aortic stenosis is not present. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a small pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There are bilaqteral pleural effusions. 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 and norepinephrine by infusion. There is normal right ventricular systolic function. The left ventricle displays apical akinesis with slight improvement in all the rest of the segments. The mid and distal segments are still severely hypokinetic with the basal segments showing moderate hypokinesis. Overall EF is about 20%. Valvular function appears unchanged from pre-bypass. The thoracic aorta appears intact. [2139-1-9] 06:02AM BLOOD WBC-12.0* RBC-3.64* Hgb-10.6* Hct-31.5* MCV-87 MCH-29.0 MCHC-33.6 RDW-17.0* Plt Ct-191 [2139-1-8] 05:52AM BLOOD WBC-10.9 RBC-3.66* Hgb-10.5* Hct-31.6* MCV-86 MCH-28.6 MCHC-33.2 RDW-17.1* Plt Ct-171 [2138-12-29] 11:45AM BLOOD Neuts-69.6 Lymphs-25.7 Monos-2.9 Eos-1.4 Baso-0.3 [2139-1-9] 06:02AM BLOOD Glucose-139* UreaN-74* Creat-5.0# Na-136 K-5.4 Cl-97 HCO3-30 AnGap-14 [2139-1-7] 04:57AM BLOOD Glucose-123* UreaN-79* Creat-4.7# Na-137 K-4.5 Cl-99 HCO3-27 AnGap-16 [2139-1-6] 04:26AM BLOOD Glucose-124 UreaN-69* Creat-3.3# Na-138 K-4.0 Cl-100 HCO3-29 AnGap-13 [2139-1-9] 06:02AM BLOOD ALT-193 AST-307* LD(LDH)-409* AlkPhos-172* Amylase-255* TotBili-12.9* [2139-1-8] 05:52AM BLOOD TotBili-12.1* DirBili-10.0* IndBili-2.1 [2139-1-7] 04:57AM BLOOD ALT-135* AST-272* LD(LDH)-390* AlkPhos-159* TotBili-13.6* DirBili-11.4* IndBili-2.2 [2139-1-6] 04:26AM BLOOD ALT-105* AST-232* LD(LDH)-380* AlkPhos-141* Amylase-175* TotBili-13.6* DirBili-10.8* IndBili-2.8 [2138-12-22] 03:10PM BLOOD ALT-17 AST-29 LD(LDH)-325* CK(CPK)-49 [2138-12-25] 04:35AM BLOOD ALT-63* AST-191* LD(LDH)-420* CK(CPK)-361* AlkPhos-65 TotBili-0.7 Brief Hospital Course: This 75 year old male presented with recent-onset chest pain, shortness of breath and an acute infarction. He had recurrent pain and was transferred here for further care. He remained pain-free and was worked up cardiac surgery. He was cleared by hematology and subsequently was seen by the renal team and dialysis was started preoperatively for his worsening renal function. He was taken to the Operating Room on [12-29] for coronary artery bypass grafting. The initial plan was to proceed with off-pump coronary artery bypass grafting, but in the Operating Room he was found to have adhesive pericarditis and he was also becoming hemodynamically unstable and it was decided to proceed with the operation on full cardiopulmonary bypass. He underwent coronary artery bypass grafting x4. See operative note for full details. He was transferred to the CVICU in stable condition on Milrinone, Epinenphrine, Levophed and Vasopressin. He was started on a Lasix drip on POD#1 due to a low urine output. He was extubated on POD#2. He was started on an Amiodarone drip due to ventricular arrythmias and EP was consulted due to his low EF. Renal continued to monitor renal function and on POD#7 he was dialyzed when his BUN reached 110. H estabilized and vasoactive medications were weaned off and he was started on Norvasc and low dose beta blockers. He did have a bradycardic episode and was atrial paced at 56 for a brief period. Echocardiography on [1-2] showed an EF 15-25%, 1+ mitral regurgitation and no pericardial effusion. The patient also had an increased total bilirubin to a peak of 16. Right upper quadrant ultrasound showed sludge but no evidence of biliary obstruction or distention of the gall bladder or an acute process. Hepatology was finally consulted on [1-8] due to persisitently elevated LFTs and hyperbilirubinemia. Multiple serology studies were sent to evaluate for hepatitis and are pending at discharge. He was transferred to the step down unit on POD#6 in stable condition. He has had no further ventricular ectopy on Amiodarone 200 mg daily. He was dialyzed for the first time post operatively on [1-5]. A tunnelled hemodialysis catheter was placed for long term hemodialysis needs uneventfully. Medications were adjusted for his renal failure and as he had rhythm issues postoperatively and the LFTs rose before Amiodarone was begun it was not discontinued completely. He continued M-W-F dialysis without problems. His urine output is minimal and the Foley catheter was removed. He may require periodic straight catheterization after discharge. He has been covered with sliding scale insulin postoperatively and not been restarted on his long acting insulin (Lantus 26 units [Hospital1 ]) at discharge as his oral intake and appetite have been subpar. He is very deconditioned and was transferred for further recovery and continued dialysis before eventual discharge home. Followup for his various medical providers will be as outlined elsewhere. Medications on Admission: Cartia XT 300mg daily furosemide 40mg daily bupropin SR 150mg [Hospital1 ] Tricor 145mg daily asa 81 daily Diovan 80mg daily Leukeran 2mg daily procrit every 2 wks lantus 26u sc qAM and qPM Humalog SSI clotrimazole cream prn basis alevel prn klonopin 0.1mg daily On transfer: Leukeran 2mg daily ASA 325 dialy Lipitor 80mg daily Plavix 75mg daily Aspart SSI Levamir 26 U [Hospital1 ] Levaquin 500mg PO Q2days Pepcid 20mg PO q2days Procrit 10000u t/th/sat sc prn meds: tylenol sl nt morphine 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml Injection ASDIR (AS DIRECTED). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 15. Insulin Regular Human 100 unit/mL Cartridge Sig: as below Injection ac and HS: 100-140:2 units SQ 141-180:4 units SQ 181-220:6 units SQ 221-260:8 units SQ 261-300:10units SQ. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 insulin dependent Diabetes Mellitus Dyslipidemia Hypertension Chronid Kidney Disease stage 3-4 chronic lymphocytic leukemia Congestive heart failure Peripheral vascular disease Chronic obstructive pulmonary disease Peripheral neuropathy Cataracts Anxiety s/p resection basal cell carcinoma s/p Appendectomy Discharge Condition: Good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170])- [2139-2-9] at 1pm Dr. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] in 2 weeks ([Telephone/Fax (1) 6699]_ Dr. [Last Name (STitle) 83624] [Name (STitle) 83625] in 2 weeks ([Telephone/Fax (1) 27174]) Dr. [Last Name (STitle) 21628] in 4 weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2139-1-9]	[ "416.8", "275.3", "414.01", "403.91", "414.2", "584.9", "V10.83", "428.41", "250.60", "426.3", "496", "272.4", "410.71", "428.0", "423.1", "585.6", "300.00", "440.20", "204.10", "V58.67", "357.2", "285.21" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.93", "38.95", "96.71", "37.23", "39.61", "88.56", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]	10733, 10805	5701, 8716	331, 698	11217, 11223	2453, 5678	11627, 12128	1675, 1789		9264, 10710		10826, 11196		8742, 9241			11247, 11604								1804, 2434																									281, 293										726, 1089															1111, 1520	1536, 1659
44,817	133,724	21795	Discharge summary	report	Admission Date: [2195-11-17] Discharge Date: [2195-12-3] Date of Birth: [2149-2-14] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5911] Chief Complaint: Patient presented for laparoscopic hysterectomy secondary to symptomatic fibroid uterus (menorrhagia, anemia, back pain) Major Surgical or Invasive Procedure: - Total laparoscopic hysterectomy - Diagnostic laparoscopy, open small bowel resection and reanastamosis secondary to bowel injury/ perforation - IR-guided drainage of peri-splenic fluid collection History of Present Illness: Ms. [Known lastname ] is a 46 yo G5P1 who reports irregular menses every 20-30 days with five days of very heavy flow consistent with menorrhagia. She also complains of increasing dysmenorrhea with her menstrual flow with right-sided pain, worse than left. In addition, she notes increasing urinary frequency, pelvic pressure, and bilateral back pain. She denies any constipation. Pelvic ultrasound ([2194-10-17]) revealed the uterus measuring 14.5 x 7.5 x 9.8 cm with multiple fibroids, the largest 8.1 cm intramural with degenerative changes. Normal EMS 3 mm, but it was posteriorly displaced by the large anterior fibroid. Normal ovaries bilaterally. Followup surveillance ultrasound, ([2195-8-19]) revealed uterus 11.6 x 9.9 x 9 cm with a dominant fundal fibroid of 9.1 cm. Normal EMS 8 mm, distorted posteriorly from anterior fibroid. Normal ovaries bilaterally. Office endometrial biopsy for the menorrhagia evaluation [2195-9-10] revealed proliferative endometrium. Prior EMB ([2195-3-16]) also revealed secretary endometrium, day 17. Both benign findings. Past Medical History: OB History: G5, P1-0-4-1. SVD x 1 @ term in [2183], 4 x TAB GYN History: Menarche at age 13. LMP [2195-9-25], irregular menses, every 20-30 days, five days of heavy flow menorrhagia, significant dysmenorrhea since [91]/[2191]. Denies abnormal Pap smear. Last Pap smear on [2195-6-29], negative SIL, last mammogram [8-/2195] reportedly within normal limits. The patient is sexually active, prefers opposite sex. Reports three sexual partners throughout life. Not currently using any birth control. Reports a history of chlamydia in the past. No other STDs. Medical Problems: 1. Symptomatic fibroids. 2. Hypercholesterolemia. 3. "Head tightness" being managed with nortriptyline. Surgical History: [2172]-[2192], D&C x4 (termination of preg's x4) Social History: Denies any cigarette smoking, alcohol intake, or recreational IV drug use. She is currently employed as an assistant in a daycare. She is divorced and currently dating, lives with her son. Denies history of domestic violence or abuse. Family History: Reports a family history notable for hypercholesterolemia, but denies any other GYN cancers or family cancers or other family medical conditions. Physical Exam: On discharge: Tmax: 98.9, Tcurrent 96.3 BP 120/78 HR 76 RR 16 O2Sat 99%RA NAD, sleeping RRR CTAB Abd soft/NT/ND, +BS Incision clean/dry/intact, no erythema or drainage, steri-strips in place Ext NT, no edema Pertinent Results: Imaging: CTA [2195-11-19]: No evidence of pulmonary embolism. Pneumaperitoneum/ ascites greater than expected following lsc surgery. Moderate pneumomediastinum. Trace L pneumothorax. Small b/l pleural effusions with atelectasis. Thyroid nodule 15mm x 12mm. CTabd/pelvis [2195-11-19]: Large amount of free air, hemoperitoneum and findings concerning for ischemic small bowel loop in the pelvis are concerning for mesenteric/bowel injury. Dilated loops of small and large bowel most compatible with component of ileus. CXR [2195-11-20]: Bibasilar atelectasis and small pleural effusions are present, left >right. CXR [2195-11-21]: Nasogastric tube courses below the diaphragm, but the tip is not seen. There are bilateral moderate pleural effusions with bibasilar atelectasis. Right PICC terminates in the cavoatrial junction. No appreciable change since prior study. Portable Abdomen [2195-11-21]: Seated portable upright abdominal radiograph demonstrates multiple air-fluid levels in the small bowel and probably colon. Air is seen throughout colon and small bowel. No pathologically dilated colon or small bowel identified. CT abd/pelvis [2195-11-23]: 1. Status post new resection of small bowel with primary anastomosis in the low pelvis. No evidence of anastomotic leak. Interval resolution of free air and decrease in amount of fluid within the abdomen, although diffuse stranding and some fluid persists. There remains areas of enhancement of the peritoneum. Additionally there is increased organization of a fluid collection along the inferior tip of the spleen. This collection is amenable to drainage under ultrasound guidance. 2. Increase now small-to-moderate bilateral pleural effusions, with collapse of visualized basal segments of the lower lobes. 3. Findings sugestive of non-occlusive thrombosis in pelvic portion of left gonadal vein. CT abd/pelvis and IR drainage infrasplenic fluid collection, [2195-11-26]: 1. Interval increase in the left subdiaphragmatic collection and unchanged left infrasplenic collection. 2. 2-mm right lower lobe nodule. In the absence of risk factors no further followup is necessary. 3. Ultrasound-guided drainage of 5 cc of bloody purulent fluid from the left infrasplenic collection. The sample was sent for Gram stain and culture. MRCP [2195-12-1]: 1. No evidence of acute pancreatitis. 2. Near complete resolution of left upper abdominal fluid collections. 3. A 2.3 cm region of non-enhancement of the inferior pole of the spleen with proteinaceous content likely explained by prior infarction. 4. Minimal pericholecystic fluid, probably explained by third spacing. 5. Two small simple hepatic cysts. 6. Bilateral small pleural effusions and basilar atelectasis. Laboratory: HCT 25.3 ([11-18]) -> 28.4 ->31.9 -> 27.5 ([11-20]) -> 20.8 -> 20.8 -> 1 unit PRBC's on [11-21] -> 24.9 ([11-21]) -> 22.3 -> 23.0 -> 21.6 -> 22.0 ([11-24]) -> 2 units PRBCs -> 29.9 ([11-25]) -> 28.4 -> 29.5 -> 29.4 -> 29.8 ([11-29]) -> 30.9 -> 28.1 -> 29.3 ([12-2]) WBCs: 15.4 ([11-18] post-op) -> 12.1 ([11-19]) -> 13.6 ([11-20]) -> 11.9 ([11-21]) -> 9.2 ([11-22]) -> 8.4 ([11-23]) -> 11.1 ([11-24]) -> 11.9 ([11-25]) -> 16.5 ([11-26]) -> 15.5 ([11-27]) -> 16.6 ([11-28]) -> 16.0 ([11-29]) -> 9.8 ([11-30]) -> 7.6 ([12-1]) -> 6.0 ([12-2]) Chem 10 [11-19]: Glucose 127* mg/dL Urea Nitrogen 14 mg/dL Creatinine 0.7 mg/dL Sodium 135 mEq/L Potassium 3.6 mEq/L Chloride 103 mEq/L Bicarbonate 26 mEq/L Anion Gap 10 mEq/L Calcium, Total 7.8* mg/dL Phosphate 2.2* mg/dL Magnesium 1.8 mg/dL Chem 10 [2195-11-30]: Glucose 90 mg/dL Urea Nitrogen 9 mg/dL Creatinine 0.7 mg/dL Sodium 139 mEq/L Potassium 3.8 mEq/L Chloride 106 mEq/L Bicarbonate 23 mEq/L Anion Gap 14 mEq/L Calcium, Total 7.8* mg/dL Phosphate 3.5 mg/dL Magnesium 1.9 mg/dL LFTs post-op [11-19]: ALT 10 IU/L AST 14 IU/L Alk Phos 46 IU/L Amylase 251* IU/L Tbili 0.6 mg/dL Lipase 22 IU/L LFTs [11-25]: ALT 61* IU/L 0 - 40 AST 64* IU/L 0 - 40 LD 334* IU/L 94 - 250 Alk Phos 155* IU/L 39 - 117 Amylase 169* IU/L 0 - 100 Tbili 0.5 mg/dL 0 - 1.5 Lipase 138* IU/L 0 - 60 LFTs [11-28]: ALT 87* IU/L 0 - 40 AST 89* IU/L 0 - 40 Alk Phos 105 IU/L 39 - 117 Amylase 165* IU/L 0 - 100 Tbili 0.3 mg/dL 0 - 1.5 Lipase 200* IU/L 0 - 60 LFTs [11-30]: ALT 55* IU/L 0 - 40 AST 32 IU/L 0 - 40 Alk Phos 81 IU/L 39 - 117 Amylase 168* IU/L 0 - 100 Tbili 0.3 mg/dL 0 - 1.5 Lipase 277* IU/L 0 - 60 LFTs [12-3]: ALT 28 IU/L 0 - 40 AST 16 IU/L 0 - 40 Amylase 137* IU/L 0 - 100 Cardiac enzymes normal [11-21], [11-22], [11-25] CRP [11-19]: 240.5 UA [11-23], [11-25]: normal x 2 Cultures: UCx [11-23], [11-25]: negative x 2 Blood Cx [11-19], [11-20], [11-23] x 2: negative x 4 Stool negative for Cdiff on [11-24] and [11-26] Intra-op peritoneal fluid culture [11-19]: 1+ PMNs, rare growth coag negative staph, no anaerobes [11-26] perisplenic fluid culture: no PMNs, no microorganisms, no growth aerobic or anaerobic cultures. Pathology Specimens: [11-17]: Uterus and cervix, hysterectomy: A. Leiomyoma. B. Adenomyosis. C. Inactive endometrium. D. Cervix with squamous metaplasia. [11-19]: I. Small intestine, segmental resection (A-G): 1. Small intestinal segment with focal disruption and necrosis of the muscularis propria, marked serositis and extensive submucosal edema. 2. Defect in muscularis propria focally extends to one (unoriented) resection margin; viable mucosa at both resection margins. 3. No intrinsic mucosal abnormalities otherwise recognized. II. Omentum, biopsy (H-I): 1. Consistent with appendix epiploica with focal calcification. 2. No endometriotic tissue identified. Brief Hospital Course: Ms. [Known lastname ] was admitted from the PACU to the gynecology service after her total laparoscopic hysterectomy/ cystoscopy ([2195-11-17]) given extended length of procedure as well as post-op dizziness and tachycardia. Patient did well the night of POD #0 however had persistent low grade tachycardia with heart rate in the ~100's. POD #1, patient was started on clears, transitioned to PO pain meds, and her IV was saline locked. Throughout the day her vitals remained stable with persistent low grade tachycardia. Hct was checked and found to be 25.3, this was repeated and was stable. She had an EKG which showed sinus tachycardia without ST changes. In the evening she began to feel slightly distended and was taking less orally due to feeling of fullness. The following morning on POD 2, her heart rate was up to the 110's and UOP less than adequate at 20cc/hour. She responded modestly to 500ml IVF bolus. Given unexplained persistent tachycardia she had a CTA to rule out pulmonary embolism. This study was negative for pulmonary embolism but revealed pneumoperitoneum. A CT abdomen/pelvis was ordered to assess her bowel injury given the aptient's increasing abdominal distention and new symptoms of nausea and vomiting suspicious for a post-operative bowel injury likely related to her recent laparosocpic hysterectomy. While obtaining the preliminary CT results, the decision was made to proceed to the operating room for surgical exploration ([2195-11-19])for a likely bowel perforation. She was given Levaquin and Flagyl prior to surgery. A general surgery consult was requested. The patient was taken to the operating room by the GYN team and had a diagnostic laparoscopic exploration that confirmed the findings of a bowel injury. The general surgery team performed a exploratory laparotomy and found a 1.5 cm bowel perforation and stool in the abdominal cavity. A small bowel resection and reanastomosis procedure was performed by Dr. [First Name (STitle) ] and the general surgery team (greatly appreciated). Her abdominal incision was closed primarily with staples on the skin and with wicks spaced between the skin staples. She was transferred to the [Hospital Unit Name 153] post-operatively for closer monitoring. . In the ICU # Bowel perforation: Patient remained hemodynamically stable with the exception of tachycardia. She received levo/Flagyl pre-operatively and was broadened to vanco/Zosyn in the ICU. Blood cultures, urine cultures were drawn. Patient was bolused fluids to keep urine output at a goal of 30-50 cc/hour. Her pain was controlled with Dilaudid PCA and Toradol. The patient remained NPO with NG tube to suction and TPN was initiated via PICC. On ICU day two the patient's WBC count was trending down, she was afebrile and blood cultures remained negative. Her HCT trended down to 20.8 and she was given 1unit PRBCs with appropriate bump in HCT to 24.9. The patient had one episode of chest tightness that lasted for several minutes. There were no EKG changes and cardiac enzymes were negative. Morphine relieved this pain. The patient then complained of abdominal discomfort and Abdom XRay showed findings consistent with an ileus. CXR also done at this time showed increased pleural fluid so the patient was given 10 IV Lasix with good urine output. She remained hemodynamically stable and was called out to the floor on [2195-11-22]. . The patient did well initially on her transfer to the floor. She continued on TPN and was transitioned to sips on [11-23]. Vanc and Zosyn were continued. She did have an isolated T max of 101.0 on [11-22], and spontaneously defervesced to 97.6. She was continued on 2L NC to maintain O2sats in high 90s. The NGT was kept in place until [11-23], when a clamp trial revealed low residual, so it was removed. However, she did spike a fever to 101.0 again on the evening of [11-23], and had new complaint of abdominal pain; blood and urine cultures were done, as was a CT of the abdomen and pelvis. The final read on this revealed no anastomotic leak, but did find an infrasplenic fluid collection, which was read as amenable to drainage. Of note, this was now POD #6 (TAH) and #4 (SBR). The patient did continue to complain of bilateral flank and upper-abdominal pain, but denied nausea or vomiting and continued to tolerate sips. She did have dizziness with walking. She was noted to have passed flatus and loose bowel movements on [11-24]. Her Hct was found to be 21.6, and the decision was made to transfuse 2 units of blood. Her diet was also advanced to clears and she was continued on TPN. Flagyl PO was started given clinical concern for C. diff, and stool samples were sent. She received the two units without incident. On POD #8/#6, she was noted to have a Tmax of 100.2. She did complain of feeling urgency to have a bowel movement and continued to have "upset stomach" but had been tolerating her clear diet well. She also c/o some mild chest discomfort, which was thought to be likely due to subcutaneous air. Notably, she had been weaned to room air at this point. An EKG was done, as were cardiac enzymes and all were normal. Her post-transfusion Hct was 29.9. This pain appeared to resolve. Her diet was advanced to full liquids and her Foley was d/c'd. A set of LFTs were done which revealed a mild transaminitis as well as elevated amylase and lipase. On POD #[10-19], Ms. [Known lastname ] complained of retching and nausea. She remained afebrile but had a white count of 16.5. She had been kept NPO overnight for drainage of the perisplenic fluid collection to assess for an abscess. Flagyl was changed back to IV as it was thought she may be having intolerance to the PO form. The collection was drained uneventfully in IR (no obvious pus, no growth on culture), and the patient was started back on her full liquid diet. On POD#[11-19], she was tolerating the liquids well, and she was advanced to a regular diet. She remained afebrile. Her LFTs continued to be mildly elevated, and it was felt she had TPN-related transaminitis. TPN was stopped on [11-28], and calorie counting was initiated. She was transitioned to PO pain meds on [11-28]. Her abdominal exam remained benign and she had no further episodes of nausea or retching. Notably, her WBCs were still elevated, but she had no other signs of infection. This value finally did begin to normalize by [11-30], 2 days after discontinuing TPN. Nothing grew out of the perisplenic fluid collection. However, LFTs, amylase, and lipase continued to be elevated. It was decided to perform an MRCP to evaluate for any pathology related to the hepatobiliary system. This was done on [12-1] (POD#14/12), and revealed no acute findings. Ms. [Known lastname ] continued to do well. She ambulated around the floor frequently, produced appropriate amounts of urine, had resolution of diarrhea, continued to be afebrile, and tolerated a regular diet. Her lipase and amylase appeared to reach a peak on [12-1] and decreased after this. She completed a full two-week course of antibiotics on [12-3], and at this point she was discharged home in good condition. Medications on Admission: simvastatin 20mg, nortriptyline 10mg Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not exceed 4000mg Tylenol (acetaminophen) in 24hours. Disp:50 Tablet(s) Refills:0 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:0 4. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:120 Tablet, Chewable(s) Refills:2 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Symptomatic Fibroid uterus, Menorrhagia, Anemia Extensive Endometriosis Bowel Injury Complication related to Hysterectomy TPN-related transaminitis Unexplained elevated lipase/amylase Discharge Condition: Stable Discharge Instructions: NOTHING in the vagina for 3 MONTHS . No intercourse, no tampons. No heavy lifting for 3 MONTHS. You may take a shower and pat dry your incisions. No soaking in hot tubs/ baths x 2 weeks. Do not drive while taking narcotics. Please call your doctor for severe pain, nausea/vomiting, fever, chest pain, shortness of breath, redness/drainage from your incision, or any other concerns. Followup Instructions: Provider: [Name6 (MD) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 8246] Date/Time:[2195-12-18] 11:00 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 5913] Completed by:[2195-12-8]	[ "E874.0", "997.39", "568.81", "569.83", "997.5", "564.3", "518.0", "998.81", "V64.41", "787.3", "280.0", "272.0", "998.2", "997.1", "567.22", "568.89", "625.3", "E870.0", "627.0", "788.5", "276.1", "617.0", "794.8", "567.9", "285.1", "617.5", "998.11", "218.1", "427.89" ]	icd9cm	[ [ [] ] ]	[ "45.62", "38.93", "54.91", "99.15", "54.92", "54.21", "99.21", "57.32", "88.76", "68.41", "54.23", "68.29", "99.04" ]	icd9pcs	[ [ [] ] ]	17315, 17321	9086, 16308	451, 651	17549, 17558	3260, 9063	17999, 18245	2864, 3012		16395, 17292		17342, 17528		16334, 16372			17582, 17976								3027, 3027																	3041, 3241								291, 413										679, 1776															1798, 2592	2608, 2848
32,330	172,616	52309	Discharge summary	report	Admission Date: [2112-4-28] Discharge Date: [2112-6-7] Date of Birth: [2048-8-10] Sex: F Service: SURGERY Allergies: Aspirin / Nsaids Attending:[First Name3 (LF) 6088] Chief Complaint: Abdominal/back pain,chest pain Major Surgical or Invasive Procedure: [2112-4-28] 1. Open transabdominal repair of ruptured infrarenal abdominal aortic aneurysm with 12-mm Dacron graft. 2. Left groin exploration and left leg angiogram. [2112-4-29] Evacuation of hematoma with VAC closure. [2112-4-30] 1. Exploratory laparotomy. 2. Removal of intra-abdominal packing. 3. Silastic abdominal wall closure ([State 19827] patch). [2112-5-11] Removal of [State 19827] patch and delayed abdominal closure. History of Present Illness: 63 year old woman with known history of hypercholesterolemia and peptic ulcer disease s/p gastric bypass some years ago was involved in a low-speed MVC. Crash was preceded by patient developing chest pain, abdominal pain. She was brought to the [Hospital1 18] where she was found to be hypotensive. She was intubated and CT abdomen showed a ruptured AAA aneurysm. She was taken emergently for repair. Past Medical History: Peptic ulcer disease s/p bypass, hypercholesterolemia, AAA Social History: Patient is a registered nurse and works in a nursing home. Her only next of [Doctor First Name ] is her sister [Name (NI) 108142] [Name (NI) ]. Family History: Not assessed. Physical Exam: VS: AFVSS Gen: NAD, A+OX3, supine on bed Lungs: CTAB, no wheezes/crackles/rhonchi Heart: RRR, normal S1/S2 Abd: Soft, NT/ND +BS, Montomgery straps intact Ext: No edema Pulses: Fem DP PT L: Palp --- Dop R: Palp Dop Dop Pertinent Results: Admit CBC: [2112-4-28] WBC-5.0 RBC-3.33* Hgb-8.7* Hct-28.8* MCV-86 MCH-26.1* MCHC-30.2* RDW-16.7* Plt Ct-517* Discharge CBC: [2112-6-7] WBC-6.8 RBC-3.50* Hgb-9.9* Hct-32.1* MCV-92 MCH-28.4 MCHC-31.0 RDW-15.6* Plt Ct-504* Admit Chem 10: [2112-4-28] Glucose-218* UreaN-17 Creat-1.0 Na-135 K-4.5 Cl-102 HCO3-16* AnGap-22* Calcium-8.1* Phos-6.5* Mg-2.1 Discharge Chem 10: [2112-6-7] Glucose-126* UreaN-11 Creat-0.4 Na-139 K-4.5 Cl-103 HCO3-30 AnGap-11 Calcium-8.8 Phos-4.0 Mg-2.0 [2112-5-12] 03:30AM BLOOD TSH-3.5 C-Diff + X 1, however [6-4] C-Diff is negative Sputum on admission was positive for PSEUDOMONAS AERUGINOSA, but 9 days prior to discharge there was no growth seen All other cultures such as blood and urine were negative for microorganisms. (Urine had small amounts of yeast). CT of chest and abdomen ([4-28]): 1. Acute abdominal aortic anuerysm rupture with large retroperitoneal hematoma and marked amount of active contrast extravasation. There are associated signs of hypovolemic shock including hyperenhancement and perfusion abnormalities of the intraabdominal organs and bowel and a flattened IVC. 2. Saccular aneurysm of the ascending thoracic aorta at the level of the brachiocephalic artery, without evidence of rupture. ECHO ([4-28]): The left atrium is normal in size. Overall left ventricular systolic function is moderately depressed (LVEF= 40%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Renal US ([5-3]): 1. Slightly increased echogenicity of the kidneys consistent with chronic renal parenchymal disease. Bilateral small simple cysts. No hydronephrosis. 2. Normal RIs bilaterally with normal acceleration times in the main renal artery at the hilum of the kidney. No evidence of renal artery stenosis. Upper and Lower extremity US ([5-9]): LEFT LOWER EXTREMITY DVT ULTRASOUND: [Doctor Last Name ] scale and Doppler examination of the left common femoral, superficial femoral and popliteal veins was performed. Normal compressibility, augmentation, waveforms and Doppler flow is demonstrated. There is no evidence of intraluminal clot. IMPRESSION: No evidence of DVT. LEFT UPPER EXTREMITY DVT ULTRASOUND: Grayscale and Doppler examination of the left internal jugular, subclavian, axillary, basilic, brachial and cephalic veins was performed. Except for a segment in the distal portion of one of the two brachial veins, normal compressibility, augmentation, waveforms and Doppler flow is demonstrated. The segment of one of the two brachial veins demonstrates absence of Doppler flow and absence of compressibility, consistent with DVT. IMPRESSION: Thrombosis of a distal segment of one of the two brachial veins. Patency of all other remaining veins of the left upper extremity. ECHO ([5-13]): IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [2112-5-11], the current study is technically superior, and aortic regurgitation is now seen. The overall findings appear similar. CT chest and abdomen ([5-13]): IMPRESSION: 1. No evidence of pulmonary embolus. 2. No evidence of active extravasation from the aortic aneurysm repair. Slight interval decrease in the size of the retroperitoneal hematoma which still has high density material they may be iodine from initial extravasation reabsorbing, but some hemorrhage since surgery can not be excluded. 3. Occluded [Female First Name (un) 899] as expected. High grade stenosis celiac artery origin and moderate stenosis proximal SMA places the patient at increased risk for mesenteric ischemia. No abnormal bowel evident. 4. No intra-abdominal abscess. 5. Atelectasis with superimposed aspiration or focal pneumonia. Effusion at the right lung base. 6. Right renal infarcts, mostly lower pole. Moderate right renal artery stenosis. 7. Ulcerative plaque in the left common iliac and dangling plaque in the aorta. Bilateral moderate common iliac artery narrowing. Unchanged aneurysm in the right brachiocephalic. MRI Cervical ([5-20]): IMPRESSION: Straightening and reversal of the cervical lordosis. Multilevel degenerative changes of the cervical spine as described in detail above. Brief Hospital Course: The patient is a 63-year-old female who presented to the emergency department after being involving a low-speed motor vehicle collision. However, she was complaining of intense back pain and was found to be hypotensive in the 80s. The patient underwent abdominal CT scan which revealed active extravasation from an infrarenal abdominal aortic aneurysm with a contained rupture into the right retroperitoneum. The patient was then immediately brought to the operating room ([2112-4-28]) for urgent open repair. The patient was not a candidate for endovascular repair given the size of her native arteries. Following the AAA repair, the patient's abdomen was unable to be closed due to massive fluid resusitation and left open and VAC dressing was placed. The patient was extremely coagulopathic, cold and acidotic. The patient was brought back to the intensive care unit where she was resuscitated and rewarmed. POD1 ([4-29]): Over night, the patient improved. Pt still remained critically ill but acidosis resolved, renal function was good and left foot was remarkably improved with PT signal. However, there is still a fair amount of bloody drainage coming through her abdominal wound VAC dressing. Therefore, it was decided to take the patient back to the operating room for exploration, evacuation of the hematoma. Evacuation of hematoma with VAC closure ([2112-4-29]). There was no evidence of bleeding. The liver was also explored and a previously noticed liver laceration was found to be not actively bleeding. A very small branch off of the IVC was seen to have a small tear and this was also suture ligated place. An abdominal VAC was reapplied and the patient was transferred in stable condition to the ICU intubated. There were no complications. POD5 ([5-3]): The Trauma service was consulted for assistance with abdominal wall closure. Patient was taken to the OR ([2112-5-3]) and there was seen to be no possibility of primary abdominal wall closure and a component release was deemed not feasible at this time. A [State 19827] patch abdominal wall closure was done and the patient then returned to the cardiovascular intensive care unit. POD7 ([5-5]): Bronchoscopy with BAL was performed due to pt experiencing hypoxia. Diffuse copious thick greenish secretions were produced. Sputum cx sent. CXR was negative for PNA and PTX. Zosyn/vanc/cipro started POD11 ([5-9]): Sputum cx grew pan sensitive pseduomonas. POD13/8 ([5-11]): Patient was extubated, the patient was asked to say one word to start speaking (such as'hi") and she instead stated "let me die". Psych was consulted given the h/o past suicide attempts. Psychiatry believed this was delirium and rec 1:1. Patient started having right side epistaxis, There is no clear precipitating event, although the team believes it may have started after use of a suction catheter. POD13/8 ([5-11]): Patient was taken back to OR to take down the [State 19827] patch and delayed abdominal closure. The patch was removed and the fascia was closed and skin retention sutures were placed. The patient tolerated the procedure well, and was transported back to the CDICU. POD14/9/1 ([5-12]): ENT evaluated the epistaxis that had persisted despite numerous attempts at packing as well as silver nitrate cautery of the anterior septum by the primary team. Hemostasis was achieved with one merocel in place. ENT recommended: removal of packing in 5 days, epistaxis precautions (No nose-blowing, no straining, no heavy lifting), aggressive BP control, bactroban / Vaseline ointment to both nostrils [Hospital1 ], if bleeding develops, try several sprays of afrin and squeeze tip of nose to hold pressure for 15 minutes. Patient experienced delirum and was pulling out lines. Psych rec haldol 1mg IV bid and 1mg [Hospital1 ]/prn severe agitation. Pt also had a h/o opiate abuse and was withdrawal was monitored and rec to tx withdrawal sx. POD15/10/2 ([5-13]): CTA torso showed no PE, LLL collapse. TTE: normal study, no elevated RA pressures, no tamponade. Left chest tube was inserted for pneumothorax. Pt reintubated. POD16/11/3: Right chest tube was inserted for pneumothorax POD19/14/6 ([5-17]): Pt extubated. POD20/15/7 ([5-18]): Speech and swallow was consulted to evaluate pt's oral and pharyngeal swallow function to determine the safest PO diet. Pt presents with signs of aspiration of ice chips and thin liquid. Based on these results, pt should remain primarily NPO including medication and no ice chips at this time. Physical therapy saw the patient and cleared her for rehab. F/u visit from Pscyh showed improved delirium, no evidence of depression or suicidal ideation. Psych saw patient and recommended restart neurontin. POD21/16/8 ([5-19]): Thoracic surgery was c/s regarding recent history of bilateral pneumothorax and consultation regarding chest tube removal. Thoracic rec clamp R tube, check CXR in 4 hours, if no PTX, pull tube. Repeat the process for the contralateral tube. Left chest tube was clamped then pulled. Patient was found to be encephalopathic and her left side to be mildly weak on previous day. However, this morning, her left-sided weakness was noted to be more pronounced, and Neurology was consulted for further evaluation. The pt indeed had a flaccid quadriparesis, worse in an upper motor neuron distribution. She had posterior column dysfunction as noted by problems with vibratory and proprioceptive sense; reflexes are not increased at this point, however. Neurology rec image the C-spine with an MRI. POD22/17/9 ([5-20]): Right chest tube was clamped then pulled. CXR showed no PTX. MRI of spine showed no cord injury. Patient was transferred to the vascular step down unit. POD24/19/11 ([5-22]): Right upper ext u/s showed upper arm organizing hematoma, basilic non-occlusive DVT. POD25/20/12 ([5-23]): Speech and swallow re-eval'ed patient. Pt continued to have s/sx of aspiration. Pt was recommended to continue primary NPO status with continued use of the dobhoff as her primary means of nutrition and hydration. She may continue to take small tsps of nectar thick liquids and may attempt [11-18] tsp bites of puree, alternating between the two with her chin tuck. POD26/21/13 ([5-24]): CXR showed left sided PNA. Pt was febrile, abd pain, WBC 22 -> panCx'd, abx restarted. POD27/22/14 ([5-25]): Patient triggered for sat 76%, C. diff +, UCx: E. coli. Patient transferred back to VICU (step down unit). Speech and swallow recommended cont NPO. Stool cultures came back positive for C. diff. Patient started on Cipro for UTI and PO flagyl for C.diff. POD28/23/15: UCx positive for E.coli. POD29/24/16 ([5-27]): Speech and swallow rec continue tube feeds, trials of moist, pureed solids only, 1:1 supervision during meals, aspiration precautions and meds via the feeding tube. On [6-1], tube feeds were advances to Probalance Full strength at 80 ml/hr cycled between 6 PM and 6AM. POD35/30/22 ([6-2]) Due to a weak voice and recommendation from speech and swallow, ENT was consulted. Small granulomas were noted on the posterior vocal folds and a PPI was started. Outpatient follow-up was recommended. Patient getting TF through Dobhoff awaited placement to Rehab that would accept her. General surgery will remove retention sutures on a outpatient follow-up. Patient will continue 14 course of PO flagyl for C diff that will end on [6-17]. All other antibiotics finished their course during hospital stay. POd37/32/24 ([6-4]) Pt had episode of BRBPR ~10cc while defecating. Patient c/o burning sensation while defecating. Hct was up from 28->33. Patient had vital signs WNL and UOP was good. Abd was soft nt/nd. Patient continued to have streaks of blood in stool. POD 40/35/27 ([6-6]) Pt continues to have BRBPR but much less. Rectal examination suggestive of internal hemmorhoids. Hct stable at 32. Patient is AFVSS. Her TF are now at 85 cc/hr which meets her caloric goal of 1300-1600 cal/day and protein goal of 60-80 gm/day. We also started her on Remeron 7.5 mg qHS in hopes that this medication would stimulate appetite. She will continue on her Flagyl until [2112-6-17]. In rehab, she will need the following services: PT/OT, Nutrition, Speech/Swallow, and Psychiatry. Medications on Admission: Unknown, possibly Neurontin, Inderal, Lipitor, Lexapro, Protonix, Reglan, Abilify? Doses are unknown, there was no med sheet when she was admitted. Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] (2 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 13. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 2 Weeks 14. Insulin Regular Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Glucose Insulin Dose 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: End of regimen: [2112-6-17]. Disp:33 Tablet(s) Refills:0 16. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 ] - [Location (un) ] Discharge Diagnosis: Ruptured AAA Discharge Condition: Stable 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 [4-24] 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 [12-20] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2112-6-8] 9:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 1837] [Telephone/Fax (1) 7732]: Call for an appointment in [12-20] weeks. Completed by:[2112-6-7]	[ "482.1", "E879.8", "568.81", "455.2", "286.9", "444.22", "599.0", "348.30", "453.8", "784.7", "998.2", "721.1", "E819.0", "518.5", "276.2", "441.3", "512.1", "V45.86", "285.1", "553.9", "008.45" ]	icd9cm	[ [ [] ] ]	[ "34.04", "53.9", "93.59", "21.03", "38.44", "33.24", "39.32", "88.48", "54.72", "96.6", "99.15", "96.72" ]	icd9pcs	[ [ [] ] ]	16881, 16947	6375, 14755	306, 762	17004, 17013	1739, 6352	19754, 20075	1470, 1485		14953, 16858		16968, 16983		14781, 14930			17037, 19301	19327, 19731							1500, 1720																									236, 268										790, 1197															1219, 1280	1296, 1454
12,752	107,086	17819+56891	Discharge summary	report+addendum	Admission Date: [2167-2-23] Discharge Date: [2167-2-28] Service: Medicine ADMISSION DIAGNOSES: 1. Fall. 2. Stroke. DISCHARGE DIAGNOSES: 1. Endocarditis. 2. Hemorrhagic stroke. 3. Sepsis. 4. Congestive heart failure. 5. Renal failure. HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old male with no significant past medical history who presented to the Emergency Room after experiencing right sided weakness after a fall on the day of admission. The patient provides a vague history, however, describes the event as follows, the patient experienced left sided shoulder pain for approximately one week in the subsequent developing swelling and a mass over his left sternoclavicular joint. The patient went to his primary care physician where [Name Initial (PRE) ] reported x-ray of his shoulder was negative. On the day of admission the patient reported continued right sided lower extremity pain/numbness, which caused a fall. In the Emergency Room he was noted to have a right facial droop. The patient's last dental work was [10-20]. In the Emergency Room the patient was pan cultured and started empirically on Vancomycin, Gentamycin for endocarditis and sent for a CT to evaluate the patient's chest mass and a CT to evaluate the patient's neurological deficits. PAST MEDICAL HISTORY: 1. Depression. 2. Left sided shoulder bursitis. 3. No history of valve replacement. 4. Diabetes. 5. Cholesterol. 6. Stroke. 7. Cancer. 8. Rheumatic fever. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Zoloft. 2. Oxycodone. SOCIAL HISTORY: No alcohol, tobacco or intravenous drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs 96.5, blood pressure 126/53, heart rate 82, respiratory rate 16, 95% on 2 liters. In general he is an elderly man lying in bed slightly agitated. HEENT anicteric. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucosa dry. Neck soft, supple. No JVD. No carotid bruits. Cardiovascular regular rate and rhythm. S1 and S2. 2 out of 3 systolic murmur at the right upper sternal base. Chest is clear to auscultation bilaterally. A 4 cm by 5 cm firm lesion over the left sternoclavicular joint. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities no cyanosis or edema. Neurologically slightly agitated, alert and oriented times three with right sided facial droop, right sided weakness. Extremities notice of splinter hemorrhages in extremities. LABORATORY: White blood cell count 22.9, hematocrit 38.3, platelets 285 and 87, L 3, monocytes 1, 9 bands. Electrolytes sodium 143, K 4.8, chloride 106, bicarb 24, BUN 48, creatinine 1.4, glucose 103, INR 1.3. Urinalysis hazy, small leukocyte esterase, large blood, protein 30, greater then 50 white blood cells, 6 to 10 red blood cells, many bacteria. Electrocardiogram normal sinus rhythm at 80 beats per minute, left axis, normal intervals, Qs in 1 and AVL. No ST changes. No T wave inversions. Intraventricular conduction delay. Chest x-ray showed no congestive heart failure, infiltrate or obvious emboli. CT of the head showed two intraparenchymal fossae of hemorrhage seen at the [Doctor Last Name 352] and white matter junction one most posteriorly along the phallic at the widex and the other within the left mid parietal lobe. These findings likely consistent with the patient's known history of septic emboli. CT of the chest revealed joint effusion with enhancing margins and suggestion of tiny focus of air within at the left sternoclavicular joint. This likely represents an abscess, incidental node in the lymph nodes in the prevascular space some of which are borderline enlarged. On [2-22] ALT 96, AST 74, LD 400, CK 133, alkaline phosphatase 308, amylase 308. Urine culture came back staph aurous coag positive, resistant to Penicillin. Blood cultures came back positive, staph aurous coag positive resistant to Penicillin. Echocardiogram from [2-23] showed limited study, because the patient was uncooperative. The images are poor, left ventricular wall thickness are normal. The left ventricular cavity size is normal. Overall left ventricular systolic functio is normal. LVEF of greater then 55%, no mass or vegetations are seen in the aortic valve, at least trace aortic regurgitation is seen. The mitral valve appears mildly thickened, mild 1+ mitral regurgitation is seen. No pericardial effusion. Echocardiogram from [2-24] shows the left atrium is normal. The left ventricular cavity size is normal, over left ventricular systolic function appears mildly depressed with probable distal septal hypokinesis, right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened, moderate 2+ aortic regurgitation was seen. No abscess seen. The mitral valve leaflets are mildly thickened, moderate 2+ mitral regurgitation is seen, moderate pulmonary arterial systolic hypertension with trivial pericardial effusions. There is a mobile echo dense mass seen on the ventricular side of the anterior mitral leaflet, which may represent a vegetation versus ruptured corti. Compared to the prior study from [2-23] an echo dense may have been present in the prior study, but images were suboptimal. Chest x-ray from [2-22] mild upper zone redistribution with no pulmonary edema. Chest x-ray from [2-23] consistent with slight left heart failure. This is worsened in the interval. Chest x-ray from [2-24] showed worsening left heart failure with early pulmonary edema. Chest x-ray from [2-26] shows OG tip below the left hemidiaphragm and increasing congestive heart failure. Chest x-ray from [2-27] shows persistent left basilar opacity and worsened right lower lung lobe zone patchy opacity indicating worsening infiltrates with developing pneumonia to be considered. Head CT on [2-24] possible slight progression of left posterior frontal hemorrhage is noted. A question of a new high right cerebral vertex subarachnoid hemorrhage. Head CT from [2-27] showed a stable hemorrhagic region compared with the prior study. There were new areas of hypodensity within the left occipital lobe corresponding to a left PCA distribution. These findings were discussed with the house staff. HOSPITAL COURSE: Neurological: The patient initially evaluated by head CT, which showed areas of hemorrhagic stroke initially thought likely due to septic emboli. The patient continued on Vancomycin. Once sensitivities came back from the urine and blood the patient's antibiotic regimen was changed to Oxacillin once the sensitivity came back. Changed to Oxacillin once the sensitivities came back sensitive to Oxacillin. Ceftriaxone was later added in his hospitalization on [2-27] when a chest x-ray showed possible development of a pneumonia. The patient's symptoms were thought likely due to septic emboli. Cardiovascular: The patient presented with likely sequela from septic emboli. An echocardiogram was performed on his presentation. Dictation cut off. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Last Name (NamePattern1) 201] MEDQUIST36 D: [2167-3-16] 08:36 T: [2167-3-20] 10:37 JOB#: [Job Number 49455] Name: [Known lastname 9160], [Known firstname 9161] Unit No: [Numeric Identifier 9162] Admission Date: [2167-2-23] Discharge Date: [2167-2-28] Date of Birth: [2085-8-24] Sex: M Service: Medicine HOSPITAL COURSE (continued): 2. Cardiac. Patient with no prior medical history. Patient ruled in for an MI, however, patient could not be anticoagulated secondary to hemorrhagic stroke. On the second day of admission patient developed congestive heart failure and had to be diuresed. This congestive heart failure led to his transfer to the MICU for respiratory support. Echocardiogram was performed twice on the day of admission to evaluate for endocarditis. The results noted above. Cardiothoracic surgery was involved in consult during the hospital course to evaluate for valve debridement and/or replacement, given continued septic emboli. 3. Surgery. The patient presented with a sternoclavicular mass. Surgery was consulted on presentation. Patient had surgical debridement of sternoclavicular abscess. 4. Renal. The patient developed elevated BUN and creatinine throughout his hospitalization course. 5. Neuro. The patient presented with hemorrhagic stroke. Patient continued to have small strokes through his hospitalization considered likely to be embolic in origin. Patient was followed in-house by neurology. 6. Code. The patient was DNR/DNI. The patient's code status was changed to comfort measures only upon transfer to the medical intensive care unit. Patient deceased on [2167-2-28]. Family was at the bedside, and denied request for autopsy. [Name6 (MD) 1034] [Name8 (MD) 1035], M.D. [MD Number(1) 1036] Dictated By:[Last Name (NamePattern1) 3021] MEDQUIST36 D: [2167-3-19] 21:02 T: [2167-3-25] 12:10 JOB#: [Job Number 9163]	[ "711.01", "431", "584.9", "428.0", "342.90", "041.11", "038.11", "410.71", "421.0" ]	icd9cm	[ [ [] ] ]	[ "83.09", "96.6" ]	icd9pcs	[ [ [] ] ]							1659, 1677	156, 260						6359, 9254																							112, 135	1700, 6341																					289, 1314															1336, 1579	1596, 1642
20,747	123,229	4078	Discharge summary	report	Admission Date: [2138-11-12] Discharge Date: [2138-11-18] Date of Birth: [2086-3-6] Sex: M Service: MEDICINE Allergies: Erythromycin Base / Protamine / Minoxidil Attending:[First Name3 (LF) 826] Chief Complaint: Called ambulance for weakness, diarrhea; brought to [Hospital1 18] for bradycardia Major Surgical or Invasive Procedure: Right internal jugular venous catheter placement History of Present Illness: This is a 52 year old man with multiple medical problems, including type I diabetes, s/p renal transplant, CAD, and PVD, who called [Company 191] today. He tells me that he was feeling very weak and had two bowel movements today, loose, and the typical dark color which he associates with his iron supplementation. Per the [Company 191] note he was having diarrhea and fecal incontinence. He denies this to me. He was urged to come in for evaluation and called for an ambulance. When the ambulance arrived, EMS found him to be bradycardic in the 30s, and unresponsive, and EMS transcutaneously paced him in the field to the 60s. When he arrived in the emergency department they got a heart rate in the 60s, RR of 12, and were evidently unable to obtain a blood pressure. He had O2 sats of 93-95% in the first 15 minutes of being in the ED. . In the ED his EKG revealed diffuse ST depression, especially in v4-6; cardiology was consulted and ultimately did not feel that the EKG was significantly different than prior EKGs and was unlikely to represent an ischemic event. He was found to be hyperkalemic and received insulin, glucose, and calcium. With concern for infection he received vancomycin; piperacillin-tazobactam (Zosyn) was also ordered in the ED but it is not clear whether this was actually given by the notes in the ED flow sheet. A central line was placed in the RIJ. An abdominal CT scan (based on elevated LFTs but normal Alk phos by labs as well as complaint of abdominal pain and diarrhea), and a head CT scan were performed; the abdominal CT showed no clear acute abdominal process, though could not use contrast for renal reasons; it did show some stranding around the distal colon and some gallbladder wall edema. The head CT was also negative by initial read although a formal read was not available. A chest x-ray showed atelectasis vs consolidation, while the bottom portion of the abdominal CT also showed effusion and atelectasis as well as an area of possible infectious consolidation. . He had a brief period of hypotension in the ED for which he was put on dopamine; this was turned off before transit to the MICU. In terms of review of systems he denies chest pain, palpitations, dyspnea, syncope or pre-syncope; he affirms back pain which he says has worsened since his power wheelchair broke and he can no longer sit properly in it. He denies fevers or sweats; he says he felt cold today; he denies shaking chills. Past Medical History: DM I with diabetic retinopathy, nephropathy, neuropathy CAD: --CABG: [2125] LIMA-LAD, SVG-PDA, SVG-RI, SVG-OM (occluded) --PCI: [2135-1-21] LMCA with no flow limiting stenoses; LAD contained a 90% proximal lesion before becoming totally occluded just after a large septal; LCX contained diffuse disease, up to a 95% mid vessel; OM1 was totally occluded; ramus branch had a 70% proximal lesion; RCA was totally occluded proximally. Congestive heart failure: LVEF 25-30% ([7-3]) CVA [2135] R BKA L AKA Right fem-tibial bypass surgery in [2125]. RLE bursitis Cellulitis in [2131]. Chronic renal failure due to acute tubular nephropathy in [2131] s/p renal transplant (second living related renal transplant in [2122]) Listeria infection in [2132]. Shingles in [2132]. Squamous cell carcinoma was diagnosed and removed in [2133]. Anemia of chronic disease Glaucoma Gastroparesis Gastritis Diveriticulosis Social History: Lives at home with wife. Fifteen pack year history of tobacco use per OMR. No history of alcohol, IVDU. Family History: Noncontributory Physical Exam: General Appearance: Overweight / Obese Eyes / Conjunctiva: speech slurred (apparent baseline) Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Bronchial: slight bronchial breath sounds bilaterally, No(t) Wheezes : ) Abdominal: Soft, Bowel sounds present, Tender: Skin: Cool, keratoses on back; bandage in place from ?skin biopsy Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): [Hospital1 ], [Location (un) ], [12-11], recent news events, Movement: Not assessed, Tone: Not assessed Guaiac negative Pertinent Results: [2138-11-11] 10:05PM BLOOD WBC-13.6* RBC-3.63* Hgb-11.3* Hct-34.0* MCV-94 MCH-31.1 MCHC-33.2 RDW-18.3* Plt Ct-282 [2138-11-13] 03:59AM BLOOD WBC-11.2* RBC-3.30* Hgb-10.3* Hct-30.6* MCV-93 MCH-31.1 MCHC-33.5 RDW-18.7* Plt Ct-243 [2138-11-18] 05:25AM BLOOD WBC-9.7 RBC-3.00* Hgb-9.3* Hct-28.3* MCV-94 MCH-31.0 MCHC-32.9 RDW-18.8* Plt Ct-187 [2138-11-11] 10:05PM BLOOD Neuts-82.0* Lymphs-11.5* Monos-4.8 Eos-1.3 Baso-0.4 [2138-11-14] 05:24AM BLOOD Neuts-81.9* Lymphs-11.1* Monos-4.7 Eos-2.1 Baso-0.1 [2138-11-11] 10:05PM BLOOD Glucose-100 UreaN-101* Creat-4.2* Na-128* K-GREATER TH Cl-96 HCO3-18* [2138-11-12] 03:22AM BLOOD Glucose-104 UreaN-99* Creat-3.9* Na-135 K-6.5* Cl-101 HCO3-24 AnGap-17 [2138-11-12] 11:26AM BLOOD Glucose-60* UreaN-101* Creat-4.0* Na-133 K-5.8* Cl-97 HCO3-24 AnGap-18 [2138-11-14] 05:24AM BLOOD Glucose-113* UreaN-90* Creat-4.4* Na-133 K-3.8 Cl-99 HCO3-22 AnGap-16 [2138-11-18] 05:25AM BLOOD Glucose-170* UreaN-77* Creat-4.3* Na-141 K-3.2* Cl-101 HCO3-28 AnGap-15 [2138-11-11] 10:05PM BLOOD PT-47.4* PTT-37.1* INR(PT)-5.3* [2138-11-12] 09:13PM BLOOD PT-54.9* INR(PT)-6.4* [2138-11-14] 05:24AM BLOOD PT-32.4* INR(PT)-3.4* [2138-11-18] 05:25AM BLOOD PT-24.3* PTT-34.2 INR(PT)-2.4* [2138-11-11] 10:05PM BLOOD ALT-188* AST-305* CK(CPK)-1487* AlkPhos-90 TotBili-0.6 [2138-11-14] 05:24AM BLOOD ALT-332* AST-161* LD(LDH)-546* CK(CPK)-884* AlkPhos-96 TotBili-0.4 [2138-11-17] 06:03AM BLOOD ALT-224* AST-99* AlkPhos-90 TotBili-0.3 [2138-11-18] 05:25AM BLOOD ALT-166* AST-62* [2138-11-11] 10:05PM BLOOD Lipase-49 [2138-11-11] 10:05PM BLOOD CK-MB-6 cTropnT-0.26* [2138-11-13] 03:59AM BLOOD CK-MB-6 cTropnT-0.38* [2138-11-14] 05:24AM BLOOD CK-MB-5 cTropnT-0.34* [2138-11-11] 10:05PM BLOOD Albumin-3.5 Calcium-8.6 Phos-6.4# Mg-3.0 [2138-11-18] 05:25AM BLOOD Calcium-6.9* Phos-4.2 Mg-2.2 [2138-11-15] 05:54AM BLOOD calTIBC-203* Ferritn-174 TRF-156* [2138-11-15] 05:54AM BLOOD TSH-2.8 [2138-11-15] 05:54AM BLOOD PTH-821* [2138-11-13] 03:59AM BLOOD rapmycn-17.6* [2138-11-14] 05:24AM BLOOD rapmycn-19.2* [2138-11-15] 05:54AM BLOOD rapmycn-10.0 [2138-11-17] 06:03AM BLOOD rapmycn-8.2 [2138-11-11] 09:54PM BLOOD Glucose-95 Lactate-4.3* Na-131* K-8.7* Cl-98* calHCO3-17* [2138-11-11] 09:54PM BLOOD freeCa-1.01* [2138-11-12] 11:26AM URINE RBC-0-2 WBC-3 Bacteri-FEW Yeast-MOD Epi-0-2 [2138-11-12] 11:26AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2138-11-12] 11:26AM URINE Hours-RANDOM UreaN-438 Creat-40 K-82 TotProt-234 Prot/Cr-5.9* . Micro: Blood ([2138-11-12]): No growth to date. Urine ([2138-11-12]): >100,000 Yeast forms Urine legionella antigen ([2138-11-14]): Negative Sputum ([2138-11-14]): <10 PMN's, no culture done. Influenza DFA ([2138-11-12]): Negative. MRSA screen ([2138-11-12]): Positive for MRSA. EBV PCR 80 genomes/lymphocyte BK <500 copies CMV VL undetectable . Imaging: EKG ([2138-11-11]): Low amplitude P waves. Supraventricular bradycardia. Left atrial abnormality. Mild P-R interval prolongation. Intraventricular conduction delay. Left bundle-branch block with marked left axis deviation. ST-T wave abnormalities. Since the previous tracing of [2138-10-27] the rate is slower and more irregular. The possibility of blocked atrial premature beats must be considered but P waves are not obvious. The QRS complex is wider. ST-T wave abnormalities, especially anterior ST segment elevation, is not seen. Clinical correlation is suggested. . CXR ([2138-11-11]): 1. Worsening left lower lobe opacity, worrisome for pneumonia. 2. Patchy opacity within the right lower lobe which could represent atelectasis or second focus of infection. 3. Small left pleural effusion, which may be slightly increased from prior. . CT head ([2138-11-11]): 1. Hypoattenuating region in the posterior left frontal lobe with focal sulcal and fissural prominence, new since the [5-2] study, favoring encephalomalacia from an interval infarction, with peripheral mineralization. In this setting, consider MR [First Name (Titles) 151] [Last Name (Titles) ], if there is persistent concern regarding superimposed more acute ischemia. 2. No acute intracranial hemorrhage. 3. Extensive, chronic-appearing sinonasal inflammatory disease, not present on the [5-2] study, s/p sinus surgery, as before. . CT abd/pelvis ([2138-11-11]): 1. No evidence of free intraperitoneal air or abscess. 2. Bilateral pleural effusions. 3. Edematous gallbladder wall, the finding is nonspecific, and can be seen in a variety of causes, including third spacing. Acute cholecystitis not entirely exclude, US and HIDA scan However, given symptomatology, further evaluation with HIDA scan could help differentiate. 4. Mild stranding adjacent to the descending colon, which contains scattered diverticula. Mild colitis or diverticulitis might be present. 5. Non-specific perirectal mild stranding, can be seen in the setting of proctitis or be related to third spacing. 6. Dense atherosclerotic calcifications of the abdominal aorta and vessels. . Renal transplant U/S ([2138-11-12]): Diminished systolic upstroke and diastolic flow within the transplant kidney,findings that are concerning for rejection, ATN or more proximal renal arterial stenosis. Clinical correlation is recommended. . TTE ([2138-11-13]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with anterolateral wall contracting the best. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with depressed free wall contractility. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2137-7-25], the left ventricular systolic function is worse. Mitral regurgitation and tricuspid regurgitation are worse. . CXR ([2138-11-14]): Improvement of the left lower lobe opacification that could be atelectasis or area of pneumonia. Decreasing amount of left pleural effusion, now small. Cardiomediastinal silhouette is stable. There is a suggestion of impression of the right tracheal wall that could represent a thyroid mass. . Thyroid U/S ([2138-11-14]): Normal thyroid. Brief Hospital Course: ASSESSMENT AND PLAN: 52 year old man with multiple medical problems including type I diabetes, ESRD on a second transplant, and significant coronary artery and peripheral vascular disease, who presented with weakness and found to have bradycardia and hyperkalemia. . The patient presented with unstable bradycardia in the setting of acute renal failure and hyperkalemia. He received successful treatment for hyperkalemia in the ED and was admitted to the ICU in NSR. He remained in normal sinus rhythm with improved heart rate with holding of his beta-[Month/Day/Year 7005]. He was evaluated by the cardiology consult service who felt this most likely represented a bradyarrhythmia associated with electrolyte disturbances. At the time of discharge, the patient had some relative hypokalemia with significant [Name (NI) 17941] repletion demands. The patient was re-started on beta-[Name (NI) 7005] therapy after improvement in cardiac status for several days. Of note, the patient did develop elevated cardiac enzymes (to peak Trop T 0.38, negative CK-MB) with non-diagnostic EKG changes. This was felt unlikely to represent true ischemia and instead to represent possible demand in the setting of an infection and poor clearance with acute on chronic renal failure. TTE did reveal worsening systolic function with EF 20% and severe diastolic dysfunction. He continues on a cardiac regimen of aspirin, statin, beta-[Last Name (LF) 7005], [First Name3 (LF) ]-acting nitrate, hydralazine and diuretics. He will follow-up with his outpatient cardiologist for ongoing management of severe chronic systolic and diastolic CHF. There was high concern for an infectious precipitant to the patient's decompensation. He did present with a leukocytosis. He was also noted to have mild transaminitis and Alk Phos elevation of unclear significance and trending towards normal on serial measurements. CT abdomen/pelvis revealed some mild gallbladder edema and possible colitis as well as a possible aspiration pneumonia, confirmed on CXR. He was started on vancomycin, levofloxacin and flagyl. Blood cultures as well as urine legionella antigen were negative. EBV, CMV and BK viral loads were sent for work-up of immunosuppressive-associated atypical infections though all of these were low or undetectable. Urine cultures grew >100,000 yeast forms. The patient was discharged on a course of levofloxacin, metronidazole for presumed aspiration pneumonia +/- colitis or other GI infection and fluconazole for yeast UTI. The patient presented with acute on chronic renal failure with Cr >4 up from baseline [12-29]. Renal transplant ultrasound revealed changes concerning for rejection. There may also be a component of pre-renal etiology in the setting of acute infection and poor cardiac function. Infectious work-up as above revealed a yeast UTI. Rapamycin levels were supratherapeutic and this was transiently held. He is discharged on rapamycin every other day dosing for the duration of fluconazole therapy to increase to daily dosing upon completion of this medication. Repeat rapamycin levels will be obtained by home nurse [First Name (Titles) ] [Last Name (Titles) 13835] 1 week and sent to the patient's nephrologist for review and dosage adjustment. The patient's home diuretics were held. HCTZ was discontinued and torsemide was continued at a reduced dose at the time of discharge. He was also started on calcitriol. His home allopurinol was reduced to every other day dosing for renal impairment. He was followed by the renal consult service while in the ICU and was on the renal service upon MICU call-out. His Cr stabilized but did not return to baseline at the time of discharge. The patient will follow-up in his outpatient nephrologist's office for ongoing care of this issue. The patient was also found on admission to have supratherapeutic INR. This was likely due to impaired clearance in the setting of multi-organ injury and significant infection. He did receive vitamin K PO for reversal and was discharged on coumadin with therapeutic INR. He was discharge with a clear plan to have home nurse INR checks and to continue close monitoring through the [Hospital3 ]. Head CT obtained in the ED in the setting of lethargy revealed no acute bleeding but did show some interval change in appearance including hypoattenuation in the posterior left frontal lobe possibly consistent with enceophalomalacia and less likely interval stroke. In the setting of improved mental status MRI was not pursued. The patient continued on fixed dose and sliding scale insulin. As evaluation for a non-specific irregularity in the area of the thyroid gland seen on CT, the patient underwent a thyroid ultrasound revealing a normal thyroid gland. Medications on Admission: asa 81 daily insulin humalog+lantus rapamune 1 mg on odd-numbered days, 2 mg on even-numbered days prednisone 5 mg daily reglan 5 mg [Hospital1 ] ferrous sulfate 650 mg daily omeprazole 40 mg daily zocor 80 mg daily [calcitriol 0.5 mg [Hospital1 ]--ran out?] allopurinol 300 mg daily hydralazine 25 mg TID imdur 30 mg daily coreg 25 mg [Hospital1 ] stool softener aranesp 200 mcg 1x/10 days warfarin 2.5 mg daily hctz 25 mg MWF klor-con 200 meq QID torsemide 60 mg 2x . nitro sl prn Discharge Medications: 1. Outpatient Lab Work VNA: A home nurse will check your INR on [2138-11-19] and [2138-11-21] and additional days as determined by the coumadin clinic. On Wednesday [2138-11-19], have the VNA page the coumadin clinic nurse at [Telephone/Fax (1) ] #[Numeric Identifier 17942] to discuss the results and obtain dosage recommendations. On all other days, have the VNA fax the results to the [Hospital3 ] at [Telephone/Fax (1) ] and then obtain recommendation from the coumadin clinic regarding dosage changes. . Please also check Rapamune level this MONDAY, [2138-11-24]. Have results faxed to the [Hospital 2793] clinic at [Last Name (un) ] Diabetes Center [Location (un) 86]. Fax ([Telephone/Fax (1) 17943]. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. [Telephone/Fax (1) ]:4 Tablet(s) Refills:0 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. [Telephone/Fax (1) ]:12 Tablet(s) Refills:0 13. Gatifloxacin 0.3 % Drops Sig: One (1) drop OS Ophthalmic QID (4 times a day). 14. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop(s) OS Ophthalmic QID (4 times a day). 15. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) drop OS Ophthalmic QID (4 times a day). 16. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl(s) OS Ophthalmic DAILY (Daily) as needed for at 11PM. 17. Insulin Lispro 100 unit/mL Cartridge Sig: See instructions. Subcutaneous See instructions: Use as directed by [Hospital ] Clinic. 18. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. [Hospital ]:6 Tablet(s) Refills:0 19. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 20. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 23. Insulin Glargine 100 unit/mL Cartridge Sig: Fifteen (15) units Subcutaneous every dinnertime. 24. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 25. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 26. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO every other day while on Fluconazole for 6 days: Please take 1mg EVERY OTHER DAY while on Fluconazole. Once Fluconazole finished, then increase to 1mg DAILY. [Hospital ]:30 Tablet(s) Refills:1 27. Aranesp SureClick -Polysorbate 200 mcg/0.4 mL Pen Injector Sig: One (1) Subcutaneous Every 10 days. 28. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Have your blood checked every other day and obtain recommendations on dosing from the coumadin clinic. 29. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 30. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO LUNCH (Lunch). 31. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: [Month (only) 116] take 1 pills every 5 minutes for chest pain. Call your doctor or go the ER if you must take this medication. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Pneumonia UTI Chronic systolic heart failure Discharge Condition: Good, hemodynamically stable, afebrile throughout admission, satting mid-upper 90s on room air Discharge Instructions: You were admitted after being found to have a slow heart rate and lethargic by EMS. You were found to also have low blood pressure and high potassium blood levels. You were treated for these conditions in the MICU, then transferred to the floor when you were stable. You are being treated for a pneumonia with oral antibiotics. You will finish a 10-day total course of these after discharge. . You were also found to have a yeast urinary tract infection. You will be treated with a 10-day total course of anti-fungal medication for this as well. . Your Rapamune medication levels were found to be high, and you were found to have acute renal failure. You will be following up further with Dr. [First Name (STitle) 805] as an outpatient. Please continue your Rapamune at 1mg EVERY OTHER DAY while you are on the Fluconazole. When you finish the Fluconazole, increase to 1mg DAILY. VNA will check your Rapamune level on MONDAY, [2138-11-24], with results faxed to the [Hospital 2793] clinic. . Your Coumadin level was found to be high on admission. Your dosage is now resumed at 2.5mg daily. A home nurse will check your INR on [2138-11-19] and [2138-11-21]. On Wednesday [2138-11-19], have the VNA page the coumadin clinic nurse at [Telephone/Fax (1) ] #[Numeric Identifier 17942] to discuss the results and obtain dosage recommendations. On all other days, have the VNA fax the results to the [Hospital 3052] at [Telephone/Fax (1) ] and then obtain recommendations from the coumadin clinic regarding dosage changes. Please follow-up with the [Hospital 191] [Hospital ] Clinic on [2138-12-1]. . The following changes were made to your medications: - TAKE Levofloxacin 250mg by mouth daily x 4 more days - TAKE Flagyl 500mg by mouth three times daily x 4 more days - TAKE Fluconazole 200mg by mouth daily x 6 more days - DECREASE Torsemide to 60mg by mouth DAILY - DECREASE Allopurinol to 300mg EVERY OTHER DAY - STOP HCTZ - STOP Alendronate (while renal function recovers) - TAKE Rapamune 1mg by mouth EVERY OTHER DAY while you are on Fluconazole. Once you finish the Fluconazole, increase to 1mg by mouth DAILY. - INCREASE Ferrous sulfate to 325mg by mouth THREE TIMES daily - TAKE Calcitriol 0.25mcg by mouth daily . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . If you experience any fever, chills, worsening swelling, chest pain, shortness of breath, lethargy, burning with urination or ED. Followup Instructions: CARDIOLOGY: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] ([Telephone/Fax (1) ]) [2138-12-1] 11:00 . Primary care: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP ([Telephone/Fax (1) ]) [2138-12-1] 1:00PM - Will follow-up your pending blood cultures . [Hospital ] Clinic ([Telephone/Fax (1) ]) [2138-12-1]. A home nurse will check your INR on [2138-11-19] and [2138-11-21]. On Wednesday [2138-11-19], have the VNA page the coumadin clinic nurse at [Telephone/Fax (1) ] #[Numeric Identifier 17942] to discuss the results and obtain dosage recommendations. On all other days, have the VNA fax the results to the [Hospital3 ] at [Telephone/Fax (1) ] and then obtain recommendation from the coumadin clinic regarding dosage changes. Please follow-up with the [Hospital 191] [Hospital ] Clinic on [2138-12-1]. . RENAL: Dr. [First Name (STitle) 805] ([Telephone/Fax (1) ]) [2138-12-11] 4:00PM . VNA will check your Rapamune level on MONDAY, [2138-11-24], with results faxed to the [Hospital 2793] clinic.	[ "724.5", "250.61", "362.01", "276.1", "410.71", "428.20", "440.20", "427.89", "403.91", "250.51", "585.6", "E849.0", "790.92", "274.9", "536.3", "250.71", "V45.81", "996.81", "276.8", "428.0", "414.00", "E878.0", "338.29" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	21542, 21599	12114, 16892	389, 440	21688, 21785	4895, 12091	24335, 25463	4043, 4061		17438, 21519		21620, 21667		16918, 17415			21809, 24312								4076, 4876																									263, 351										468, 2936															2958, 3905	3921, 4027
59,385	138,446	40662	Discharge summary	report	Admission Date: [2125-7-16] Discharge Date: [2125-7-23] Date of Birth: [2045-3-29] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: [2125-7-16] AVR (27 mm CE Magna pericardial)/CABG x4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA) History of Present Illness: 71 year old male has a history of chronic renal insufficiency, aortic valve disease and s/p RCA stenting in [2119] and stenting x 2 of the proximal and mid LAD with Xience drug eluting stents in [2123]. His [Location (un) 109] by catheterization last year was noted at 1.5cm2. He reports about one year of dyspnea on exertion that is sometimes associated with lightheadedness. Currently he becomes short of breath after walking 20 feet at a fast pace or with raking for 10 minutes. He also reports a recent evaluation at a hospital in [Location (un) 24402] for chest pain that resolved with nitroglycerin. He apparently ruled out for an MI and was discharged to home. His most recently cardiac testing was done in [Month (only) 958] and [2125-3-30] while down in [State 108]. Nuclear stress testing revealed mild anterior ischemia and an LVEF of 34%. An echo showed a severely enlarged LV at 6.3cm with an LVEF of 55% and an aortic valve area of 0.7cm2. He was referred for cardiac catheterization to assess his coronary arteries and the severity of his aortic valve stenosis. He is now being referred to cardiac surgery for revascularization and aortic valve replacement. Past Medical History: coronary artery disease s/p [2119] RCA stenting [2123] LAD [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 Aortic insufficiency/stenosis Chronic renal insufficiency Macular degeneration Tonsillectomy as a child Right Wrist fracture s/p surgery BPH s/p partial prostatectomy Remote hematuria B cataract surgeries Social History: Lives with:Wife Contact: [Name (NI) 2155] [Name (NI) 88943] (wife) Phone #[Telephone/Fax (1) 88944] Occupation:retired Cigarettes: Smoked no [] yes [x] quit in [2083] 50-60 PY HX Other Tobacco use:none ETOH: [12-31] drink/week [x] Illicit drug use: none Family History: Premature coronary artery disease- none Physical Exam: Pulse:66 Resp:15 O2 sat:97/RA B/P Right:150/55 Left:139/56 Height:5'6" Weight:165 lbs General:EXAM on BEDREST Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []; no JVD Chest: Lungs clear bilaterally anterolaterally Heart: RRR [x] Irregular [] Murmur [x] grade _SEM 3-4/6 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x], no HSM/CVA tenderness Extremities: Warm [x], well-perfused x[] Edema [] none Varicosities: None [x] Neuro: Grossly intact [x]MAE [5-3] strengths,nonfocal exam Pulses: Femoral Right: dressing Left:2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit murmur radiates to B carotids Pertinent Results: Echocardiogram: [7-16] Conclusions PRE BYPASS 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 left atrial appendage emptying velocity is depressed (<0.2m/s). 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. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). The inferior wall demonstrates the most severe hypokinesis but all of the other segments are moderately to severely depressed. The right ventricular free wall demonstrates borderline normal free wall function. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.7 cm2). Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is a very small pericardial effusion. There is a globular mass about 1 cm in diamter seen in the pericardial space between the left atrial appendage and ascending aorta. It may represent epicardial fat but clinical correlation is suggested. Dr. [Last Name (STitle) 914] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being AV paced. Epinephrine is being administered by IV infusion. There is normal right ventricular systolic function. The left ventricle displays improved systolic function of all segments. The inferior wall displays moderate hypokinesis. The septum displays a "bounce" likely secondary to ventricular pacing. The other segments display borderline normal systolic function. Left ventricular ejection fraction is about 40%. There is a bioprosthesis located in the aortic position. It appears well seated and there is normal leaflet function. The maximum gradient across the valve was 15 mmHg with a mean of 8 mmHg at a cardiac output of about 6 liters/minute. No aortuic regurgitation is seen. The mitral regurgitation is improved - now mild. The thoracic aorta is intact after decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD, on [2125-7-16] 14:21 Admsiion Labs: [2125-7-23] 07:20AM BLOOD WBC-5.4 RBC-3.47* Hgb-10.1* Hct-29.1* MCV-84 MCH-29.2 MCHC-34.8 RDW-13.7 Plt Ct-212 [2125-7-22] 05:45AM BLOOD WBC-4.6 RBC-3.49* Hgb-10.3* Hct-29.5* MCV-85 MCH-29.5 MCHC-34.8 RDW-13.7 Plt Ct-154 [2125-7-23] 07:20AM BLOOD Glucose-114* UreaN-20 Creat-1.5* Na-139 K-4.6 Cl-106 HCO3-25 AnGap-13 [2125-7-22] 05:45AM BLOOD Glucose-115* UreaN-25* Creat-1.6* Na-140 K-4.7 Cl-106 HCO3-27 AnGap-12 [2125-7-21] 05:00AM BLOOD Glucose-114* UreaN-28* Creat-1.5* Na-138 K-4.4 Cl-104 HCO3-24 AnGap-14 [2125-7-23] 07:20AM BLOOD Mg-2.2 [2125-7-21] 05:00AM BLOOD Mg-2.3 Brief Hospital Course: The patient was a same day admission for AVR/CABG with Dr. [Last Name (STitle) 914]. Please see operative report for details, in summmary he had: 1. Aortic valve replacement with a 27-mm [Doctor Last Name ] Magna Ease aortic valve bioprosthesis (serial # [Serial Number 88945], Model # 3300TFX 2. Coronary bypass grafting x4: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the first diagonal coronary artery; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary; as well as reverse saphenous vein single graft from aorta to posterior descending coronary artery. 3. Endoscopic left greater saphenous vein harvesting. 4. Epiaortic duplex scanning. His bypass time was 152 minutes with a crossclamp of 124 minutes. He tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition on Propofol and Epinephrine infusions, for recovery and invasive monitoring. He remained hemodynamically stable in the immediate post-op period, woke neurologically intact and was extubated. POD 1 found the patient alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, he weaned from inotropic and vasopressor support. Beta blockade was initiated and the patient was gently diuresed toward the preoperative weight. Norvasc was resumed for hemodynamic control. The patient was transferred to the telemetry floor for further recovery. All tubes lines and drains were removed per cardiac surgery protocol. He developed atrial fibrillation. Amiodarone was started and beta blocker titrated. He converted to Sinus Rhythm within hours. He develped a let upper extremity phlebitis for which he was started on Vancomycin. This improved and he was transitioned to PO Levaquin on discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The patient was discharged to [Hospital3 ] in [Location (un) 24402],ME on POD 7. At that time he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He is to follow up with Dr [Last Name (STitle) 914] on [2125-8-14] 1:30pm. Medications on Admission: Plavix 75 mg daily ( last dose 6/29) ACETYLCYSTEINE - (Prescribed by Other Provider) - Powder - to be taken the night prior to procedure/Morning of procedure DILTIAZEM HCL [DILTZAC ER] - (Prescribed by Other Provider) - 180 mg Capsule, Extended Release - 1 Capsule(s) by mouth every morning DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth every evening ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth every evening PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth every evening Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth every morning VIT C-VIT E-LUTEIN-MIN-OM-3 [OCUVITE] - (Prescribed by Other Provider) - 150 mg-30 unit-[Unit Number *] mg-150 mg Capsule - 1 Capsule(s) by mouth twice a day Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 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. 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 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 8. doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 weeks. 16. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed for abrasions. 17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 1 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 24402], ME Discharge Diagnosis: aortic stenosis/insufficiency coronary artery disease s/p AVR(tissue)CABG x4 [2119] RCA stenting [2123] LAD [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 Chronic renal insufficiency Macular degeneration Tonsillectomy as a child Right Wrist fracture s/p surgery BPH s/p partial prostatectomy Remote hematuria B cataract surgeries Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ bilaterally 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) 914] Tuesday, [Telephone/Fax (1) 170] Date/Time:[2125-8-14] at 1:30 Cardiologist: Dr. [Last Name (STitle) 2257] [8-8] at 11:10am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 19219] [Telephone/Fax (1) 88946] in [4-3] 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:[2125-7-23]	[ "E879.8", "V02.54", "999.2", "585.9", "V45.82", "414.01", "428.0", "427.31", "424.1", "451.84", "285.9" ]	icd9cm	[ [ [] ] ]	[ "36.13", "35.21", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	11692, 11770	6453, 8716	299, 407	12165, 12394	3176, 6430	13233, 13803	2304, 2346		9966, 11669		11791, 12144		8742, 9943			12418, 13210								2361, 3157																									238, 260										435, 1638															1660, 1994	2010, 2288
56,091	124,155	40057	Discharge summary	report	Admission Date: [2103-1-15] Discharge Date: [2103-1-18] Service: MEDICINE Allergies: Protonix Attending:[First Name3 (LF) 1711] Chief Complaint: chest pressure, s/p LAD stent placement Major Surgical or Invasive Procedure: cardiac catheterization with BMS x 2 placed in LAD History of Present Illness: 86 yo F with h/o HTN, CAD s/p Lcx stent [2093] after MI, CKD baseline Cr 1.8-2 presented initially to [Hospital3 19345] on [1-6] with chest pain. She had chest pressure intermittently with exertion for several weeks prior, worsening in the 4 days prior to admission with shortness of breath as well. Day of admission, had chest pain at rest with shortness of breath so presented to LGH ER. In the ER, she experienced cardiopulmonary arrest with asystole, improved with atropine and CPR. Was intubated and in ICU from [Date range (1) 9396], and ruled in for NQWMI, with trop 2.15, CPK 63, EKG suggestive of anterior MI. BNP was 2718, was diuresed with IV lasix. Initially INR was elevated, which delayed cath. Cath was done prior to arrival today, [1-15], which showed total occlusion of LAD, patent LCx stent and RCA with 70-80% stenosis. She was transferred here for LAD intervention. . At cath lab, got BMS in LAD with proximal dissection, stented again with overlapping BMS. On arrival to floor, sheath remains in place in R femoral. She has no chest pain, shortness of breath, nausea or other complaints. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: LCx stent [2093], s/p MI -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -CAD s/p MI in [2093] PTCA/stent to LCX in [2093]. Repeat cath in [2095] showed patent stent, rca small, 95% small diagonal. -diabetes with peripheral neuropathy and nephropathy -atrial arrythmia on coumadin -pneumonia in the past -temporal arteritis -s/p CCY -dCHF with EF 60% in [2100] Social History: -Tobacco history: denies -ETOH: denies -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission: VS: 86 100/61 99% 2L GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds at bases, no wheezes 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: + stasis dermatitis LLE, no ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP dopplerable PT 1+ Left: Carotid 2+ Femoral 2+ DP dopplerable PT 1+ Pertinent Results: [2103-1-15] 11:50PM SODIUM-136 POTASSIUM-3.4 CHLORIDE-89* [2103-1-15] 11:50PM CK(CPK)-120 [2103-1-15] 11:50PM CK-MB-6 cTropnT-1.19* [2103-1-15] 11:50PM PLT COUNT-249 [2103-1-15] 07:45PM GLUCOSE-157* UREA N-73* CREAT-2.4* SODIUM-138 POTASSIUM-3.8 CHLORIDE-90* TOTAL CO2-29 ANION GAP-23* [2103-1-15] 07:45PM CALCIUM-9.2 PHOSPHATE-6.1* MAGNESIUM-1.5* [2103-1-15] 07:45PM WBC-9.8 RBC-4.06* HGB-11.5* HCT-35.1* MCV-87 MCH-28.4 MCHC-32.9 RDW-16.7* Cardiac Cath [1-15]: COMMENTS: 1. Limited coronary angiography of this right dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had a 99% proximal stenosis. The Lcx had minor luminal irregularities with a patent stent. The RCA was not engaged and known to have a 70% stenosis from prior angiography. 2. Limited hemodynamics revealed normal central pressure of 121/74 mmHg. 3. Successful PTCA and stenting of proximal LAD with overlapping 2.5x18mm Integrity bare metal stent (more distal) and 2.5x12mm Integrity bare metal stent (more proximally). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Normal blood pressure. 3. Successful PCI of proximal LAD with two overlapping BMS. 4. ASA indefinitely, Plavix 2-4 weeks. Brief Hospital Course: 86 yo F with h/o HTN, CAD s/p Lcx stent [2093] after MI, CKD baseline Cr 2.4 presented initially to [Hospital6 3105] on [1-6] with chest pain, s/p cardiac arrest and asystole resucitated after CPR and atropine. Now s/p cath with BMS x2 for 99% LAD occlusion. # CARDIAC ARREST: During cardioversion, Ms. [Known lastname ] went into asystole, she was resuscitated and transferred to the CCU. She was intubated and she had a temporary pacer placed, and was started on pressor support for blood pressure maintenance. On the morning of [2103-1-18], her blood pressure dropped to the 50s/30s, and required triple pressors to increase blood pressure. She had been following commands that morning, and moving all extremities (6am). Shortly after (8-9am) she was noted to have hemiparesis and an upgoing toe, likely secondary to a new stroke. She was being anticoagulated throughout the event, so thrombotic stroke was less likely, and it was thought to possibly be due to watershed infarct in the setting of the severe hypotension. Her family was called, and her status was discussed with her HCP. She was made DNR/DNI (she had been DNR/DNI, and reversed for the cardioversion), and the decision was made to terminally extubate. She expired in the early afternoon on [2103-1-18]. THE REST OF THE ADMISSION WAS AS BELOW. # CORONARIES: At OSH, LAD occlusion of 99% was noted and she was transferred here for intervention. BMX x 2 were placed in LAD. Cardiac enzymes were trending down on arrival and patient had no complaints of chest pain, shortness of breaht, or anginal type sx. Home aspirin metoprolol, and simvastatin were continued, along with plavix which was started at [Hospital3 12748]. She will cont these meds as outpatient and f/u with her outpatient cardiologist, Dr. [Last Name (STitle) 29070]. # PUMP: Pt has h/o diastolic CHF with EF 60% per OSH records, and was on lasix at home. On [1-8], f/u TTE was done at [Hospital3 ] that showed decreased EF to 30% and anteroapical hypokinesis. On initial exam, she had lower ext edema and decreased breath sounds at bases. Was diuresed with IV lasix initially, then was transitioned to <<<<<<<<>>>>>>>. ACE or [Last Name (un) ] was considered to optimize CHF regimen, but pt with [Last Name (un) ] and discussion with PCP revealed that [Name9 (PRE) ] had been tried in the past but was stopped because of hyperkalemia. Instead, isosorbide dinitrate and hydralazine were started. As they were well tolerated, isosorbide mononitrate instead of dinitrate was started because of once a day dosing. # RHYTHM: Has a h/o afib on coumadin at home, with rate control with metoprolol 100 mg [Hospital1 ]. EKG showed RBBB and LAFB, alternating with IVCD without RBBB so EP was consulted. Recommended TEE cardioversion and starting amiodarone, baseilne TSH nl and AST/ALT slightly elevated but trending downwards. Coumadin had been held at OSH and was restarted along wtih a heparin gtt, for her high risk of clot in the setting of afib with apical wall motion anormality. During TEE cardioversion, on [1-17], pt went into asystole, was resuscitated and transferred to CCU # DM: continued home glargine and SSI # HTN: Home doxazosin was discontinued and instead isosorbide mononitrate and hydralazine were started, as described above. # HLD: continued statin # Anemia: procrit as outpatient # Acute on chronic renal disease: baseline Cr 1.8-2, now with Cr of 2.4 on transfer from OSH. Likely [2-28] diuresis at OSH, and also had two caths in one day. Medications on Admission: Aspirin 325 mg daily Plavix 75 mg daily (started at OSH) Metoprolol 100 mg [Hospital1 ] Warfarin 1 mg daily Doxazosin 1 mg [Hospital1 ] Zetia 10 mg daily Procrit as directed Lasix 20 mg daily Lantus 35-40 units QHS Novolog SSI TID Simvastatin 20 mg daily Calcium 500 mg [Hospital1 ] Ferrous sulfate 150 mg daily 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). 3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35) Subcutaneous at bedtime. 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[2103-1-22]	[ "V70.7", "428.0", "785.51", "427.31", "410.71", "272.4", "427.32", "412", "583.81", "V58.61", "427.5", "585.9", "276.2", "428.43", "285.21", "403.90", "250.40", "250.60", "414.01", "V45.82", "V12.53", "357.2" ]	icd9cm	[ [ [] ] ]	[ "99.62", "96.71", "00.46", "00.40", "36.06", "96.04", "88.72", "00.66" ]	icd9pcs	[ [ [] ] ]	10151, 10160	4967, 8545	256, 308	10211, 10220	3654, 4761	10276, 10314	2658, 2773		8919, 10128		10181, 10190		8571, 8896		4778, 4944	10244, 10253								2788, 2788			2125, 2225																						177, 218										336, 2012							2802, 3635			2256, 2561					2034, 2105	2577, 2642
109	174,489	14861	Discharge summary	report	Admission Date: [2142-7-3] Discharge Date: [2142-7-4] Date of Birth: [2117-8-7] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[First Name3 (LF) 2817] Chief Complaint: dyspnea, hypertension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently discharged on [7-1] after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ED, but was otherwised managed with oral antihypertensives and CPAP. . She was doing well until the evening of [7-2] when she notes the gradual onset of dyspnea. She denied f/c/cp/ha/abd pain/diarrhea, or constipation. She was having regular, soft, daily BMs. . On [7-3] she awoke, and describes n/v x 2, with increasing dyspnea, and headache. She did not want to wait until dialysis at 4PM and therefore presented to [Hospital1 18]. . In ED VS= 97.7 [Telephone/Fax (2) 43606] 100%RA. Labs were notable for HCT 23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute process, ECG unchanged from prior. No UA sent, though she does make some urine. She was started on nitro gtt with modest improvement of SBPs to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with BP 221/130 at the time of transfer. She refused abdominal CT. Renal was consulted, but felt HD not indicated today. . . ROS: Negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +HA. denies visual changes, slurrring speech, numbness, weeakness. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [2135]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [2135] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - 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] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [Month (only) 956]-[Month (only) 958], [2142]. 15. Pericardial effusion 16. CIN I noted in [2139], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - 97.7 88 220/150 19 100%2L BC. General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTA B, with few crackles at bases. CV: RR, nl S1, S2 +S3, no rubs appreciated. Abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative [Doctor Last Name ], no rebound, gaurding. Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: Lab Results on Admission: [2142-7-3] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4# SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ALT(SGPT)-14 AST(SGOT)-44 LD(LDH)-264* ALK PHOS-115 TOT BILI-0.4 ALBUMIN-3.2* WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4 RDW-18.3* [2142-7-3] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5 BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2* [2142-7-3] 06:00PM CK-MB-5 cTropnT-0.17CK(CPK)-58 [2142-7-3] CXR: IMPRESSION: Unchanged moderate cardiomegaly with pulmonary edema. Again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive urgency. . # hypertensive urgency - On presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [2-12] hypertension. states she did take her PO meds. Hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below SBP 120. She evenutally became hypotensive to SBP of 90 which resolved on its own. She was continued on CPAP overnight and discontinued in the am. She was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. She remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - On presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. She did have hypoactive bowel sounds on admission. She was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with HD with plan to follow BMs closley. Her pain improved the am of discharge and she had no further vomiting. . # ESRD on HD - She is currently getting HD SaTuTh, though did not get HD on the day of presenation. As there was no acute indication for HD on presentation, she received HD on the following am, day of discharge. She was continued on sevelamer. . # anemia - chronic anemia, likely [2-12] CKD and SLE, currently above baseline, though has h/o GIB. She received 2 unit PRBCs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of PPI [Hospital1 ]. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - pt with goal INR [2-13], but this was stopped after recent admission [2-12] supratherapeutic INR. INR currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continued on celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hypertension. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Tablet(s) 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hypertensive emergency anemia, erythropoetin deficiency Secondary: chronic renal failure on hemodialysis lupus nephritis Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted for hypertensive urgency and treated in the intensvie care unit with IV medications to decrease your blood pressure. You also received 2 units of blood and hemodialysis before you were discharged home. It is essential that you take all of your prescribed blood pressure medications and present regularly for your Tuesday, Thursday, Saturday dialysis. Please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. Followup Instructions: You have the following appointment scheduled. Please contact your provider if you are unable to make these appointments. Your dialysis is scheduled for Tuesday, Thursday, Saturday. Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2142-7-30] 2:00 Provider: [Name10 (NameIs) 14201] CLINIC Phone:[Telephone/Fax (1) 2664] Date/Time:[2142-8-8*] 3:15	[ "338.29", "403.01", "789.00", "V58.61", "285.21", "787.01", "425.4", "V12.54", "287.5", "710.0", "582.81", "285.29", "443.89", "327.23", "585.6", "V12.51", "345.90", "531.90", "364.3" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.04" ]	icd9pcs	[ [ [] ] ]	9357, 9391	4882, 7028	313, 328	9566, 9592	4109, 4121	10183, 10613	3510, 3540		7875, 9334		9412, 9545		7054, 7852			9616, 10160								3555, 4090																									252, 275										356, 1791							4136, 4859								1813, 3362	3378, 3494
31,200	178,270	34632	Discharge summary	report	Admission Date: [2177-7-30] Discharge Date: [2177-8-5] Date of Birth: [2095-2-6] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2087-7-29] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 82 y/o male c/o chest pain over past six months with increase in episodes with activity. First underwent ETT which was positive. Then had a cardiac cath which revealed left main/three vessel disease. Past Medical History: Hypertension, CVA, Benign Prostatic Hypertrophy, Gout, s/p Appendectomy, s/p Tonsillectomy Social History: Denies tobaccco and ETOH use. Family History: Both parents died from heart failure in 70's. Physical Exam: VS: 51 16 [11/2148] GEN: NAD Skin: Unremarkable HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -carotid bruit Chest: CTAB Heart: RRR -murmur Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -JVD Neuro: A&O x 3, MAE, non-focal Pertinent Results: [7-29] Chest CT: 1. Atherosclerosis involving the aorta and coronary arteries as described with ascending aorta free of bulky calcifications up to 6 cm above the aortic valve. 2. Ground-glass nodular opacity and solid pulmonary nodules as described, followup in six months is recommended with a chest CT. 3. Degenerative changes of the thoracic spine as described with some diffuse osteopenia. [7-30] Echo: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. The left ventricle contracts normally. The RV is normal in size and systolic fxn. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. An epi-aortic scan showed posterior atheroma, and helped place the cannula and cross-clamp. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are myxomatous. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Patient is in NSR, on low dose phenylephrine infusion. Good biventricular systolic fxn. No AI. Aorta intact. Trace MR. [2177-7-29] 01:45PM BLOOD WBC-3.9* RBC-3.98* Hgb-12.6* Hct-37.5* MCV-94 MCH-31.6 MCHC-33.5 RDW-13.2 Plt Ct-147# [2177-8-1] 07:55AM BLOOD WBC-7.3 RBC-2.95# Hgb-9.3* Hct-26.3* MCV-89 MCH-31.5 MCHC-35.3* RDW-15.2 Plt Ct-106* [2177-7-30] 12:44PM BLOOD PT-16.3* PTT-42.8* INR(PT)-1.5* [2177-7-31] 02:29AM BLOOD PT-14.4* PTT-33.1 INR(PT)-1.3* [2177-7-30] 02:23PM BLOOD UreaN-17 Creat-0.9 Cl-109* HCO3-28 [2177-8-1] 07:55AM BLOOD Glucose-113* UreaN-22* Creat-1.1 Na-135 K-4.4 Cl-101 HCO3-30 AnGap-8 [2177-8-4] 06:15AM BLOOD WBC-4.9 RBC-3.09* Hgb-9.5* Hct-28.0* MCV-91 MCH-30.6 MCHC-33.8 RDW-14.9 Plt Ct-152 [2177-8-4] 06:15AM BLOOD Plt Ct-152 [2177-8-5] 12:20PM BLOOD Glucose-136* UreaN-20 Creat-1.2 Na-138 K-4.6 Cl-97 HCO3-34* AnGap-12 [Known lastname 79442], [Known firstname ] [Hospital1 18] [Numeric Identifier 79443]Portable TTE (Complete) Done [2177-8-4] at 3:51:07 PM 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: [2095-2-6] Age (years): 82 M Hgt (in): 65 BP (mm Hg): 109/62 Wgt (lb): 155 HR (bpm): 70 BSA (m2): 1.78 m2 Indication: Pericardial effusion. ICD-9 Codes: 424.0, 424.2 Test Information Date/Time: [2177-8-4] at 15:51 Interpret MD: [Name6 (MD) ] [Name8 (MD) 4082], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [Name2 (NI) 11320] E. [Location (un) ], RDCS Doppler: Full Doppler and color Doppler Test Location: [Location 13333]/[Hospital Ward Name 121] 6 Contrast: None Tech Quality: Adequate Tape #: 2008W057-0:20 Machine: Vivid [7-20] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.5 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Right Atrium - Four Chamber Length: 5.6 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.3 cm Left Ventricle - Fractional Shortening: 0.52 >= 0.29 Left Ventricle - Ejection Fraction: >= 65% >= 55% Left Ventricle - Stroke Volume: 103 ml/beat Left Ventricle - Cardiac Output: 7.18 L/min Left Ventricle - Cardiac Index: 4.04 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 7 < 15 Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 27 Aortic Valve - LVOT diam: 2.2 cm Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms TR Gradient (+ RA = PASP): 26 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). False LV tendon (normal variant). Estimated cardiac index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal image quality - poor suprasternal views. Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No pericardial effusion. CLINICAL IMPLICATIONS: Based on [2176] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2177-8-4] 17:20 Brief Hospital Course: Mr. [Known lastname ] was a same day admit on [2177-7-30] after undergoing pre-operative work-up as an outpatient. He was taken directly 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. Initially post-op he had some increased bleeding and required blood transfusions with resolution of his bleeding. Within 24 hours, he was weaned from sedation, awoke neurologically intact and was extubated. By post-op day two, his pressors were weaned off and he was started on beta-blockade, aspirin and a statin. He was then transferred to the step down unit for further recovery. Mr. [Known lastname ] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postopertive strength and mobility. The remainder of his postoperative course was uneventful and he was ready for discharge home on postoperative day six. Medications on Admission: Atenolol 25mg qd, Flomax 0.4mg qd, Allopurinol 100mg qd, Zestril 10mg qd, Aspirin 81mg qd, Niacin 1500mg qAM, 1000mg qPM, Plavix 75 mg qd (last dose 7/11), Omeprazole 20mg qd, Finasteride 5mg qd, NTG Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Allopurinol 100 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:50 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 7. Niacin 500 mg Tablet Sig: see below Tablet PO twice a day: please take 1500mg in the am and 1000mg in the pm. Disp:150 Tablet(s) Refills:0 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day for 7 days. Disp:14 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Hypertension, CVA, Benign Prostatic Hypertrophy, Gout, s/p Appendectomy, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 5686] in [2-16] weeks [Telephone/Fax (1) 11554] Dr. [Last Name (STitle) ] in [1-15] weeks [Telephone/Fax (1) 10508] CT scan in 6 months for evaluation of nodular opacity and solid pulmonary nodules Completed by:[2177-8-5]	[ "440.0", "274.9", "413.9", "414.01", "458.29", "V12.54", "401.9", "600.00", "998.11", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "36.12", "99.04" ]	icd9pcs	[ [ [] ] ]	10662, 10711	7758, 8825	283, 370	10911, 10917	1090, 7295	11687, 12032	776, 823		9075, 10639		10732, 10890		8851, 9052			10941, 11664								838, 1071							7318, 7735																		233, 245										398, 599															621, 713	729, 760
63,755	113,270	31660	Discharge summary	report	Admission Date: [2151-12-23] Discharge Date: [2151-12-27] Date of Birth: [2085-9-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5790] Chief Complaint: recurrent left effusion Major Surgical or Invasive Procedure: [2151-12-23] Left VATS pleural biopsy and talc pleurodiesis, and flexible bronchoscopy by Dr. [Last Name (STitle) ]. History of Present Illness: Mr. [Known firstname ] [Known lastname ] is a pleasant 66 year old male s/p endostenting of his aortic aneurysm as well as left subclavian to left common carotid artery bypass and a left common carotid to right common carotid artery bypass on [2151-11-15]. During his hospitalization the patient had a left thoracentesis by Dr. [Last Name (STitle) ] on [2151-11-17] for large left exudative pleural effusion. Cytology was negative for maligant cells. The patient was discharged from the hospital [2151-11-19] and returns to see Dr [Last Name (STitle) ] today for followup of his left effusion. The patient states his breathing has improved, but he does not exert himself much. He doesn't walk outside. He denies fevers, chills, but has "some" nightsweats. He has yellow sputum productive cough. He denies dizziness, or any other issues and has multiple appointments to see various physicians. Past Medical History: Past Medical History: - Coronary Artery Disease - COPD - Hyperlipidemia - Hypertension - Calcified aorta - New finding of Left lingula lung mass - Bilateral Pleural Effusions; s/p left thoracentesis [2151-11-8] - Hypothyroidism - Trauma to lower extremities - Emphysema Past Surgical History: - coronary artery bypass grafting surgery x5 in [2137] - [Hospital3 ] Dr.[Name (NI) 43096] - Polypectomy [2151] - Right elbow seroma, s/p debridement and drainage - Appendectomy Social History: Occupation: retired Last Dental Exam:has only 2 native teeth; no recent dental care Lives with wife in [Name (NI) 1411] Race:Caucasian Tobacco:[1-15] cigarettes daily ETOH:[4-18] glasses of wine daily Family History: Brothers with CAD. One brother died of MI at age 57, another brother with CABG in early 50's. Physical Exam: VS: T98.6, BP 120/70, HR 94 SR, RR 18, O2 sats on RA 92% Physical Exam: Gen: pleasant in NAD Lungs: rales BLL, clear B upper CV: RRR, S1, S2, no MRG Abd: distended, nontender Ext: l>r edema 1+ in left leg, trace in right, warm extremities. Uro: intact foley catheter. Neuro: A and O x 4, ambulating halls. Pertinent Results: [2151-12-27] 06:35AM BLOOD WBC-9.0# RBC-3.09* Hgb-9.2* Hct-28.7* MCV-93 MCH-29.6 MCHC-31.9 RDW-16.8* Plt Ct-202 [2151-12-27] 06:35AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-133 K-4.7 Cl-96 HCO3-31 AnGap-11 [2151-12-27] 06:35AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1 Brief Hospital Course: Mr. [Known lastname ] was admitted on [2151-12-23] where he underwent left VATs pleurodiesis for recurrent pleural effusion. Initially he was kept overnight in the PACU related to retained CO2, and required CPAP, which was weaned off, and CO2 on ABG was per patients baseline. The patient also required fluid bolus and albumin for low urine output which eventually resolved itself. The patient was transferred to the floor [2151-12-24]. Chest tubes were removed on [2151-12-25] without issue. Unfortunately the patient had a foley catheter placed with prostatic trauma, therefore urology was consulted and recommended foley placement x 7 days with follow up in one week. The patient's urine output has cleared. Of note the pleural biopsy revealed a small amount of enterococcus sensitive to only linezolid. ID approval was obtained to discharge patient on such. The patient has adequate pain control, is on room air, ambulating the halls, has had a bowel movement, and has been cleared by Dr. [Last Name (STitle) ] for discharge home. The patient will have a CBC and urology visit in one week, and see Dr. [Last Name (STitle) ] with CXR in 2 weeks. He has been given written and verbal discharge instructions. He has had physical therapy home referral as recommended by Physical therapy. Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours). Disp:30 Tablet(s) Refills:0 6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-15] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:28 Tablet(s) Refills:0 10. Cyanocobalamin 50 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: follow up with primary care doctor [First Name (Titles) ] [Last Name (Titles) ] panel in next 2 weeks regarding dose. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Recurrent left pleural effusion s/p Left VATS pleurodiesis. 2. COPD 3. CAD 4. Hyperlipidemia 5. HTN 6. Endostenting of his aortic aneurysm as well as left subclavian to left common carotid artery bypass and a left common carotid to right common carotid artery bypass on [2151-11-15] Discharge Condition: Stable. Discharge Instructions: -You may shower, but cover chest tube sites with a bandaid. -Do not drive while taking narcotics. -Walk with family three times a day. -Keep urinary catheter in, and secure with leg bag. Make sure you do not tug at this. Followup Instructions: 1. Follow up with Dr. [First Name (STitle) ] [Name (STitle) ] office (urology - for your urinary catheter) in one week. Please call for follow up appointment ([Telephone/Fax (1) 4376]. Tell them when making your appointment that you have catheter and you have just left the hospital. 2. Follow up with Dr. [Last Name (STitle) ] on [2152-1-11] at 10am in [Hospital1 ] 116 on [Hospital Ward Name 517]. Please get chest xray 45 minutes prior in clinical center [Hospital Ward Name ] 3th floor radiology. 3. Follow up with your primary care physician in the next two weeks. 4. You will need a CBC, and chemistry blood draw in one week. Completed by:[2151-12-27]	[ "867.0", "244.9", "E879.6", "401.9", "V45.81", "511.9", "414.00", "996.76", "E928.9", "272.4", "440.0", "496" ]	icd9cm	[ [ [] ] ]	[ "34.92", "33.24", "34.20" ]	icd9pcs	[ [ [] ] ]	5461, 5519	2924, 4237	347, 474	5853, 5863	2626, 2901	6133, 6829	2189, 2285		4260, 5438		5540, 5832					5887, 6110						1745, 1941		2372, 2607																									284, 309										502, 1426															1470, 1722	1957, 2173
1,687	171,217	52964	Discharge summary	report	Admission Date: [2127-7-2] Discharge Date: [2127-7-8] Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 3984] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 83 yr old female with multiple medical problems including CAD, recurrent endometrial cancer s/p debulking surgery in [4-/2127] who was complaining of pain all over so an ambulance was called. En route to the hospital, pt developed severe substernal chest pain and became hypotensive to the 60s. On arrival to the [Name (NI) ], pt's BP 70/palp and she was given IL NS and she improved to 100/50. She was complaining of abd pain and and noncontrast abd CT was done to rule out AAA. There was no AAA on CT but there was diffuse stranding surrounding the colon consistent with pancolitis. The pt's son stated that pt has been having diarrhea for the past several days, no n/v. Also he stated that she was not taking good po because she was "trying to kill herself." . In the [Name (NI) ], pt's BP dropped again into the 80s and she given another liter of IVF. At this point, the lactate returned normal but due to the pt's tenuous BP, a central line was placed for monitoring of CVP. She received a total of 3L of IVF along with levaquin/flagyl for suspected abd source. Surgery was consulted given the concern for mesenteric ischemia and recommended IVF and abx. . Of note, pt was recently diagnosed with recurrent emdometrial carcinoma in [4-10] when she presented to the ED for abdominal pain and had a CT abdomen which showed extensive omental involvement. During her hospital course she had several episodes of chest pain but cardiac cath was deferred. She underwent extensive debulking and is now undergoing chemotherapy with carboplatin. She was recently readmitted for chest pain and near-syncope and again, w/u was negative. Past Medical History: 1. Coronary artery disease s/p cath [4-8] showing 100% occlusion RCA, 80% occlusion LAD, PCI to LAD then s/p ETT MIBI [11-9] showing reversible anteroir defect, medically managed. . 2. Recurrent endometrial cancer. Originally diagnosed [2122] s/p TAH/BSP om [2122] showing grade III papillary serous carcimona in a polyp then re-presenting [4-10] with increasing abdominal pain. CT showed new (from [3-10]) omental soft tissue infiltation c/w metastatic carcinomatosis, with ascites. She underwent exploratory laparotomy, drainage of ascites,total omentectomy and radical dissection for tumor debulking [2127-4-28] with Dr. [First Name (STitle) 1022]. The omentum and ascending colon mass showed extensive involvement by papillary serous adenocarcinoma. She is now on carboplatin chemotherapy by Dr. [Last Name (STitle) 150] (most recent treatment [6-6]). . 3. Type II diabetes mellitus; diet controlled 4. Reflux/Gastritis 5. Hypercholesterolemia 6. Rheumatoid arthritis 7. Osteoarthritis 8. Hypertension 9. Chronic back pain: Severe multilevel disc and degenerative changes 10. Depression. History of suicidal ideation. Followed by outpatient psychiatry: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ]. 11. Headaches 12. h/o BPV 13. Anxiety Social History: widow, lives alone, son and daughter live nearby, daily homemaker Family History: no h/o CAD, father: prostate cancer at age [Age over 90 ] years Physical Exam: Exam: temp 96.2, BP 90/34 (MAP 56), HR 62, R 12, O2 100% 2L, CVP 7-8; I/O: 3.5L/ Gen: NAD, resting comfortably HEENT: PERRL, EOMI, MMM Neck: jugular veins flat; no bruits; R IJ in place CV: RRR, 3/6 systolic murmur at RUSB Chest: clear Abd: +BS, soft but diffusely tender to palpation esp in midline distal to umbilicus where a mass is palpated; no rebound, no peritoneal signs; guaic neg loose green stool Ext: warm, no edema, 2+ DP, radial pulses Neuro: CN 2-12 intact, moves all ext Pertinent Results: [2127-7-2] 01:00PM CK(CPK)-25* [2127-7-2] 01:00PM CK-MB-NotDone cTropnT-<0.01 [2127-7-2] 07:30AM CK(CPK)-21* [2127-7-2] 07:30AM CK-MB-NotDone cTropnT-<0.01 [2127-7-1] 10:10PM CK(CPK)-40 [2127-7-1] 10:10PM cTropnT-<0.01 [2127-7-1] 10:10PM CK-MB-NotDone [2127-7-2] 04:15PM URINE HOURS-RANDOM CREAT-66 SODIUM-77 [2127-7-2] 04:15PM URINE EOS-NEGATIVE [2127-7-2] 03:30PM HCT-28.7* [2127-7-2] 08:16AM LACTATE-1.4 [2127-7-2] 07:30AM GLUCOSE-97 UREA N-54* CREAT-1.6* SODIUM-139 POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-18* ANION GAP-14 [2127-7-2] 07:30AM CK(CPK)-21* [2127-7-2] 07:30AM CALCIUM-7.6* PHOSPHATE-4.3 MAGNESIUM-1.9 [2127-7-2] 07:30AM WBC-5.7 RBC-3.09* HGB-9.2* HCT-26.5* MCV-86 MCH-29.7 MCHC-34.6 RDW-15.3 [2127-7-2] 07:30AM PLT COUNT-197 [2127-7-2] 12:49AM LACTATE-1.8 [2127-7-2] 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2127-7-2] 12:30AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-MANY EPI-0-2 [2127-7-1] 10:10PM GLUCOSE-133* UREA N-66* CREAT-2.3# SODIUM-136 POTASSIUM-5.3 CHLORIDE-103 TOTAL CO2-18* ANION GAP-20 [2127-7-1] 10:10PM ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-42 AMYLASE-47 TOT BILI-0.4 [2127-7-1] 10:10PM CK(CPK)-40 [2127-7-1] 10:10PM LIPASE-27 [2127-7-1] 10:10PM WBC-9.6 RBC-4.00* HGB-11.7* HCT-34.6* MCV-87 MCH-29.2 MCHC-33.8 RDW-15.2 [2127-7-1] 10:10PM CALCIUM-8.3* PHOSPHATE-5.0# MAGNESIUM-2.2 [2127-7-1] 10:10PM NEUTS-80.5 BANDS-0 LYMPHS-15.0* MONOS-4.2 EOS-0.2 BASOS-0.1 ATYPS-0 METAS-0 MYELOS-0 [2127-7-1] 10:10PM PLT COUNT-244# [2127-7-1] 10:10PM PT-12.0 PTT-18.7* INR(PT)-1.0 EKG: NSR at 74bpm, nl axis; nl intervals; TWI in V1-V2 with flat T waves in V3 (old) . CXR: There has been interval placement of a right IJ central venous catheter with its tip in the right atrium. There is no pneumothorax. The lungs remain clear. . Abd CT: 1. Interval development of diffuse stranding surrounding the colon from the cecum down to the rectum. This is consistent with a pancolitis. Most likely this is infectious in etiology given its distribution. 2. Left adrenal adenoma. 3. No evidence of abdominal aortic aneurysm. 4. Soft tissues again demonstrate a seroma within the anterior abdominal wall, which is unchanged from the prior study. Repeat Abdominal CT: 1. Worsening severe pancolitis. Increasing fluid throughout the abdomen and small bilateral pleural effusions. Imaging findings are most consistent with C. difficile colitis. No evidence of megacolon. 2. Palpable abnormality could correspond to fluid filled ventral hernia, which measures 4.2 x 3 cm. 3. Unchanged left adrenal mass. Brief Hospital Course: A/P: 83 yr old female with hx of CAD, recurrent endometrial cancer s/p recent debulking surgery who presents with chest pain and abd pain, hypotension and found to have colitis on abd CT . 1. Abd Pain: Mostly likely secondary to C.diff colitis given recent antibiotic use, ddx includes mesenteric ischemia, obstruction, colitis vs worsening chronic abd pain from her cancer. Mesenteric ischemia initally concerning given the severity of her pain but less likely now that lactate has returned nl and guiac neg. Obstruction also less likely given that pt is passing stool and having freq bowel movements. Pt recently on cipro and has been hosp frequently so is at risk for c diff colitis and other infectious etiologies of acute diarrhea such as salmonella, shigella, campylobacter, e.coli . Serial abd exams were performed; surgery was consulted and felt that given clinical picture of diarrhea with toxic granulations, and pancolitis, most c/w C diff colitis, therefore recs po flagyl, no levo and nonoperative case. We sent stool for c diff and cx, Shigella, Campylobacter, E coli, Salmonella, with results negative. The pt was started on levaquin and flagyl on [2127-7-2]. D/c'd levaquin on [2127-7-4]. Continued flagyl, initially PO then converted to IV given her continued nausea and concern for absorption. She was continued on IVF NS at 150cc/hour given her poor PO intake. We followed her lactate levels given concern for mesenteric ischemia, however lactate is WNL x 2, with guiaic negative, so less likely. We did not feel an MRA was indicated. No anti diarrhea meds were administered as this could worsen infectious diarrhea, could precipitate toxic megacolon in c diff. - On [7-6] she was looking worse and a repeat CT was performed, this showed worsening of her pancolitis. The following day she again looked worse with increased pain. At that time she also had one guiaic positive stool. There was some difficulty obtaining labs but when obtained she was noted to have a metabolic acidosis, felt to be due to diarrhea, and a stable HCT. Attempts at a blood gas were unsuccessful. She continued to have abdominal pain and was maintained with increasing pain medications and IV Flagyl. At that time a family meeting was held. The family expressed wishes that she not be placed on a breathing machine. In addition they did not want any further surgery under any circumstances. The following day she was hypotensive, with SBP in the 90s. She was started on IV fluids with no improvement of her pressure. An ABG was performed at that time which showed Po2 74* Pco2 23* pH 7.19 with a lactate of 7.0. At that point there was concern that she was septic or had perforated her bowel. She was started on pressors for hypotension and transferred to the MICU for further management. - Micu course: Sepsis: The patient was transferred to the MICU [2127-7-7] in septic shock. She was hypotensive with elevated lactate. Etiology of sepsis was thought to be bowel related with DDx including C. difficile toxic megacolon vs bowel ischemia. She was started on levophed, neosynephrine, and vasopressin, but despite all efforts her blood pressure continued to decline. She was also treated with levofloxacin, metronidazole, and Zosyn for broad coverage. Prn morphine was given for pain control. The patient's son and other family members confirmed her desire not to be intubated or have any further surgery. Despite all efforts, we were unable to support her blood pressure. Code status was changed to DNR/DNI, and she expired [2127-7-8]. 2. Hypotension: On admission she was hypotensive with concern that it could be cardiogenic vs septic vs volume depletion. On admission she described chest pain, however there were no EKG changes and CE flat x 1 making cardiogenic less likely. Sepsis was initially high on differential given severe abd pain, however she was afebrile and had no leukocytosis. Volume depletion was felt to be contributing as pt had been taking poor po. A central line was begun in ER to monitor CVP. CVP followed in ED and remains [6-13] after 3L of fluid. Her BP remained stable on the floor, and her central line was discontinued. Levo/flagyl was given initially for suspected abd source. Levaquin was d/c'd [2127-7-4], and flagyl continued as C diff colitis was felt to be the most likely source. Anti-hypertensive medications were held. She again became hypotensive on [2127-7-7] at which time she was tranferred to the MICU for pressors and further management as above. . 3. Chest Pain: She has been frequently admitted with chest pain and medically managed rather than taking for catheterization. We ruled out MI with 3 sets cardiac enzymes negative. EKG was without ischemic changes, telemetry monitoring was without arrhythmia. She was continued on aspirin and lipitor. We held her beta-blocker, nitrates and ACEI as low bp. . 4. ARF: On d/c 2 weeks ago, creatinine of 1.0 and now elevated to 2.3. ARF likely due to pre-renal given reports of poor po intake. UA negative for infection and no new drugs to implicate AIN. Hypotension could also be contributing, causing ATN, if she has been hypotensive at home. Creatinine trended down from 2.3, responding well to hydration. Urine lytes consistent with prerenal azotemia. Her medications were renally dosed. . 5. Metabolic Acidosis: Pt with gap of 15 so pt with both gap and non-gap metabolic acidosis (based on delta-delta gap). Etiology of gap acidosis likely acute renal failure and of non-gap acidosis likely diarrhea. Lactate nl, no ketones to indicate starvation ketoacidosis. We followed lactate given concern for mesenteric ischemia. On the day of transfer to the MICU she had a worsening metabolic acidosis with elevated lactate. . 6. Anemia: Hct close to baseline of 33-35. Type and screen was sent with the plan to tranfuse for hct<30. . 7. DM: diet controlled, RISS diabetic/heart-healthy diet . 8. Endometrial Cancer: Pt of Dr.[Name (NI) 109169], now on carboplatin for recurrence. Her last carboplatin was [6-26]. Dr. [Last Name (STitle) 15521] was notified on [7-2] that the patient was here. . 9. Psych: per son, pt not eating is passive attempts to commit suicide. Continued on celexa. Social work consulted. Psychiatry was notified pt was here and evaluated her. . 10. FEN: DM/cardiac diet, IVF 150cc/hour NS . 11. Ppx: SQ heparin, PPI . 12. Code: full . . . Medications on Admission: 1. Atorvastatin Calcium 10 mg qd 2. Citalopram Hydrobromide 20 mg qd 3. Isosorbide Dinitrate 20 mg tid 4. Meclizine 12.5 mg tid 5. Trazodone 50 mg qhs 6. Nitroglycerin 0.3 mg Tablet prn 7. Metoprolol Tartrate 100mg [Hospital1 ] 8. Clotrimazole 1 % Cream 9. Aspirin 325 mg qd 10. Pantoprazole Sodium 40 mg qd 11. Oxycodone 5 mg q6hr prn 12. Cyanocobalamin 50mcg qd 13. Folic Acid 1 mg qd 14. Levothyroxine Sodium 125 mcg qd 15. Heparin Sodium 5000 tid 16. Lisinopril 5 mg qd Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Colitis 2. Endometrial cancer Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "995.92", "414.01", "V10.42", "785.52", "250.00", "197.5", "276.5", "008.45", "V45.82", "584.9", "276.2", "714.0", "272.0", "197.6", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	13702, 13711	6691, 13145	228, 234	13787, 13796	3920, 6668	13849, 13982	3329, 3398		13674, 13679		13732, 13766		13171, 13651			13820, 13826								3413, 3901																									174, 190										262, 1910															1932, 3229	3245, 3313
4,964	141,950	45345	Discharge summary	report	Admission Date: [2154-2-12] Discharge Date: [2154-3-8] Service: CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: On [2154-2-11], the patient was admitted to [Hospital1 69]. He is an 89 year old man with upper quadrant abdominal pain, starting at noon on the day of admission. The pain was sharp and stabbing without radiation, without any aggravating or alleviating factors. No nausea and vomiting, no fevers, no chills. The patient had a normal appetite without food aversion. Normal bowel movements times two on the day of admission. Positive flatus. No urinary symptoms. No reflux or metallic taste in the mouth. PAST MEDICAL HISTORY: 1. The patient suffers from coronary artery disease. 2. Status post myocardial infarction. 3. Hypertension. 4. Hypercholesterolemia. 5. Syncope. 6. Prostate cancer. 7. Asthma. 8. Spinal stenosis. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: Negative for tobacco. Occasional alcohol. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Lipitor 20 mg. 3. Toprol XL 25 mg q. day. 4. .................... 50 12.5. 5. Norvasc 5 q. day. 6. Vioxx 50 mg q. day. 7. Fosamax. 8. Ambien prn. PHYSICAL EXAMINATION: On admission, physical examination showed a temperature of 96.8; heart rate of 72; blood pressure 145/66; respiratory rate of 18; saturation rate of 92% on room air. The patient is an elderly male, in mild distress. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm. No murmurs, rubs or gallops. Abdomen was soft. Tender in the upper quadrant, right greater than left. Mildly distended. Normoactive bowel sounds. Normal tone. Guaiac negative. Rectal: No pain and no edema. LABORATORY DATA: White count on admission was 12.9; hematocrit of 35; platelets of 407 with 86% neutrophils and 0 bands. Chemistries were 137; 5.4; 96; 33; BUN 48; creatinine 1.5; glucose of 167; AST of 13; ALT of 21; alkaline phosphatase of 57; T bilirubin of .3; amylase 40; lipase of 20; lactate of 1.7. PT was 13.1; PTT was 26.5 and INR was 1.1. Urinalysis was negative. CTA showed no abdominal aortic aneurysm, no free air around the gastric antrum. Subhepatic fluid. Gallbladder was normal without fluid. HOSPITAL COURSE: The patient is an 89 year old man with coronary artery disease, hypertension, spinal stenosis. He was doing well until the onset of upper abdominal pain at noon on the date of admission, without previous episodes. Positive coronary artery disease with catheterization in [11-20] revealing occluded left anterior descending. He appeared tired and uncomfortable. Abdomen was distended, tympanitic with upper abdominal tenderness and guarding. White blood count, as I said before was 12.9. CT scan was as mentioned before; thickened antrum, free air along the gastrohepatic ligament and extravasation of contrast. ASSESSMENT AND PLAN: Gastric perforation. The patient was to proceed urgently to the operating room for exploration or biopsy with ongoing resuscitation. Ongoing antibiotics were administered. There was perioperative beta blockade and postoperative Intensive Care Unit care was planned. Postoperatively, the patient's vital signs were stable but the patient was in atrial fibrillation without apparent atrial fibrillation complications. The patient received Amiodarone load times two and intravenous Metoprolol q. six hours and was transferred to the unit. On postoperative day number one, Surgical Intensive Care Unit day one, the patient had decreased Propofol and was allowed to waken. He was weaned to PSE and was planned to extubate. He was continued on Levofloxacin and Fluconazole. On postoperative day number two, the patient's cardiac output was adequate. He had a fixed heart rate and was on low dose Neo. He was actually extubated that day. Incidentally J tube and G tube for feeding were placed intraoperatively. Cardiology continued to follow the patient throughout his hospital course and followed along with enzymes. Beta blockade was continued throughout postoperative day number three and four. The patient was given 10 mg of Lasix on postoperative day number three, to be net even. J tube feeds with Peptamen was started on postoperative day number three. The patient was continued on Levo and Flagyl. The patient was transferred to the floor on [2154-2-15] on postoperative day number three and tube feeds were increased to 20, changed to Impact. The patient didn't actually make it to the floor until postoperative day number four. The patient began running low grade fevers on postoperative day number five and six. However, he still looked good and passed a bedside swallowing evaluation on postoperative day number six. He was started on slowly advanced diets. His belly started becoming distended on postoperative day number seven. CT scan with contrast was done on that day, showing fluid with air anterior to the gastric fundus and adjacent to the body of the stomach and thickening at the gastric remnant. This fluid with rim enhancement adjacent to the caudate lobe; small liver laceration, without evidence of obstruction at that time. The patient's white count of postoperative day number 7 was 17.1 and continued to rise to 21.6 by postoperative day number 11 and 26.1 by postoperative day number 12. The patient was advanced to full liquid diet on postoperative day number eight and was given Lasix 20 mg intravenous times one for increased weight. The patient began having some confusion without fevers and stable vital signs; however, he had increased work of breathing on [2-20], postoperative day number eight. An arterial blood gases was sent at that time showing blood gas of 7.45; 49; 151; 135 and 9. Physical therapy continued with the patient throughout the hospital course as per cardiology. They recommended Amiodarone 400 mg q. day until discharge. On [2154-2-23], the patient was noted to have left arm weakness, on postoperative day number 11. Neurology was consulted to evaluate this weakness and neurology noted that after the patient's emergent exploratory laparotomy for perforated duodenal ulcer, the patient's postoperative course had been relatively stable, although he had been in paroxysmal atrial fibrillation and had been in sinus rhythm over the past three days prior to neurology's visit. Around 10 or 11 o'clock, the morning of [2-23], the patient was noted to be significantly weaker in his left upper extremity, as he could not lift it. His arm was found to be flaccid by our surgical house staff. He did not notice any dysarthria, facial numbness, weakness or hemi-anesthesia. He had waxing and [Doctor Last Name 688] mental status over the past 72 hours prior to his neurology visit on [2-23] but was attributed to pain medication. However, he became less alert and confused in the evening and it was thought to be sun downing. He was never weak in his extremities at this time, however. ASSESSMENT: At that time, assessment showed a [Age over 90 ] year old man with various risk factors, including age, hypertension, coronary artery disease, paroxysmal atrial fibrillation, now presenting with four to five hour history of sudden onset of left sided weakness, arm greater than leg. Neurologic examination confirmed a left facial droop, almost flaccid left arm and upper motor neuron weakness in the left lower extremity. There was also decreased sensation of temperature and light touch on the left arm and face. The presentation was suspicious for stroke but many possible etiologies involving the face, arm and leg may indicate either occlusion of the right internal carotid artery, although there would be expected more signs, including field cut, neglect, etc.; however, the most likely scenario is embolic etiology for pad or carotid effecting vasculature territories or M1 occlusion effecting subcortical descending like fibers. Due to surgery, he was not a candidate for TPA but neurology noted that he would likely benefit from anticoagulation. The patient had a Stat magnetic resonance scan done and on [2154-2-24], after normal head CT, magnetic resonance scan showed no evidence of stroke. Repeat magnetic resonance scan two days later also showed no evidence of stroke. Both were diffusion weighted magnetic resonance scan with flare. Carotid ultrasound and TTE were both performed. Carotid ultrasound showed narrowing of less than 40%, bilateral internal carotid artery and TTE showing normal left atrium; normal left ventricle; apical left ventricular aneurysm; mild regional left ventricular systolic dysfunction and focal akinesis of distal anterior and inferior walls; 1+ mitral regurgitation; mild thickening of atrioventricular valve and moderate PA; hypertension with an ejection fraction of 40%. At the time of CT scan of the abdomen in prior hospital course, the patient had aspirated a minimal amount of gastrografin. The patient's respiratory status was watched carefully for any evidence of pneumonia or pneumonitis and did not show any. Infectious disease was consulted for increasing leukocytosis. From [2-24], postoperative day number 12, recommendations were to consider to start on Unasyn and Fluconazole for yeast coverage, from abscess swab from operating room culture which showed 3+ PMN's, sparse yeast and gamma strep. Stool was also sent for Clostridium difficile and was negative. The patient had significant respiratory distress on [2154-2-25] and was transferred to the unit after having blood gas of 7.22, 86, 145, 37 and 4. The patient was in the unit on postoperative day number 14 and three units of blood were given for a hematocrit of 23.5 at that time. The patient was intubated in the unit and neurology continued to follow and to continue heparin with PTT goal of 40 to 60 for anticoagulation for clinical stroke, regardless of negative imaging and the goal SPP was 110 to 120 to increase perfusion. EEG was not necessary. Stroke team began to follow on [2154-2-26]. Infectious disease recommended continuing Fluconazole and Unasyn, also on [2144-2-27] until discharge, for six weeks. On postoperative day number 15, the patient was neurologically intact. Cardiac-wise, he was continued on aspirin and beta blockade. He was weaned and extubated with pressure support of 5 and PEEP of 5. He was extubated. He was continued on tube feeds. He was kept even on genitourinary. He was continued on antibiotics. Propofol was discontinued at that time. On postoperative day number 16, the patient had a white count of 13.6 and was continued on anticoagulation, beta blockage, nebulizers and chest physical therapy and tube feeds were restarted. Pulmonary was consulted on [2154-3-1] and recommended aggressive diuresis. Two doses of Lasix were given on postoperative night of day 16 and the patient also had previous pulmonary consult which, as said before, recommended aggressive diuresis and possibly right upper extremity duplex and questionable use of Bi-pap to decrease work of breathing and aide in decreased PC02. The patient's left sided weakness persisted. On postoperative day number 18 and 19, the patient continued to have mild respiratory distress but was improving. On postoperative day number 21, the patient was made DNR/DNI for decompensating respiratory and neurologic status. The patient had bedside swallowing evaluation on [2154-3-7], after the patient was transferred to the floor on [2154-3-5], postoperative day number 21 and failed bedside swallowing evaluation. On [2154-3-8], the patient and family had family meeting with attending, Dr. [Last Name (STitle) 468], and it was thought that the patient would be best managed under the aegis of Hospice at nursing home and was discharged on [2154-3-9] to Hospice. FINAL DIAGNOSES: 1. Duodenal ulcer perforation. 2. Clinical stroke. 3. Respiratory distress. 4. [Location (un) ] patch for duodenal ulceration perforation. 5. Status post anticoagulation for stroke. MEDICATIONS: 1. Aspirin 81 mg tablet p.o. q. day. 2. Amiodarone 200 mg tablet one p.o. q. day. 3. Tums 500 mg tablet one p.o. four times a day. 4. Captopril 12.5 mg tablet p.o. three times a day. 5. Pepcid 20 mg tablet one p.o. twice a day. 6. Multi-vitamin. 7. Lopressor 37.5 mg tablet p.o. twice a day. 8. Also was given prescriptions for Morphine and Ativan, as required by Hospice. The patient was discharged in fair condition, as DNR/DNI to extended care facility under Hospice care and was instructed to call for any concerns. Family was spoken to and understood the diagnoses. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 8275] Dictated By:[Name8 (MD) 6297] MEDQUIST36 D: [2154-3-8] 07:16 T: [2154-3-8] 19:51 JOB#: [Job Number 96832]	[ "486", "414.01", "997.02", "532.50", "112.0", "427.31", "518.81", "E878.8", "707.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.6", "44.42", "43.19", "99.04", "96.71", "46.39", "88.72" ]	icd9pcs	[ [ [] ] ]													1050, 1221	2294, 11894								918, 925							11911, 12957									1244, 2276											101, 118										147, 667															689, 894	942, 1024
14,423	140,018	51433	Discharge summary	report	Admission Date: [2109-8-6] Discharge Date: [2109-8-15] Service: MEDICINE Allergies: Opioid Analgesics Attending:[First Name3 (LF) 348] Chief Complaint: Malaise Major Surgical or Invasive Procedure: Debridement of R toe ulcer . PICC line placement History of Present Illness: 82 y/o M with h/o DMII, CAD, non healing foot ulcer, s/p right hallux amputation ([7-5]) and wound closure ([7-9]), MSSA infection, who presents to ED with chief complaint of lethargy and fatigue, feels "week as a kitten", found to have fever to 102, tachycardia to 120's, hypotension (SBP in 80's-90's). . In ER, given 4 L IVF with rise in SBP to 110's. Also given clinda/Vanco IV abx. Subsequently remained HD stable. PIV in place. WBC 13.8. . Recent admit [Date range (1) 106644] with MSSA bacteremia. Source was foot ulcer which also grew MSSA. Initially treated with nafcillin, CTX, flagyl. Upon discharge ([Hospital3 6560] and Rehab), he completed a 2 week course of dicloxacillin, with last dose 10 days ago. . Also on that admit, noted to have acute blood loss from bleeding peptic ulcer. EGD revealed gastic ulcerations (fundus and antrum). He was transfused 2U pRBC prior to discharge (Hct 28.5) and started on ferrous sulfate 325mg po qd. He was also instructed to hold coumadin . Past Medical History: 1. CAD s/p CABG in [2090] for 80% distal LMCA, 90% mid LAD, 90% prox d2, 80% prox OM1 and 80% mid RCA disease 2. CHF [2109-7-4] EF of 25% 3. PVD (Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1391]) s/p right fem-af op bpg 4. AF on anti-coagulation 5. s/p L foot debridement in [9-5] (Dr [First Name (STitle) 3209] 6. Hyperlipidemia 7. DM2 8. Diabetic neuropathy (multiple foot ulcers followed with Dr [First Name (STitle) 3209] in Podiatry) 9. MSSA bacteremia- source R foot ulcer Social History: Lives with wife. Stopped smoking 40 years ago. no ETOH or drugs. Family History: no hx of DM or HTN Physical Exam: vitals- T 96.1, HR 77 irreg, BP 101/60, RR 16, 100% on 2L 02 gen- non-toxic, mentating, a&o x 3 heent- EOMI. OP clear neck-non-distended jvp pulm- CTA b/l cv- irreg, no murmurs, rubs, gallops abd- soft, NT/ND. NABS ext- cool dist ext on left. RLE warm w/ erythema around R distal hallux. R hallux s/p amputation, dressed w/ gauze w/o purulent drainage. non-palpable dist pulses b/l (dopplerable); neuro- CNII- XII intact, language fluent. Pertinent Results: R Ankle/Foot X-ray 1. Prominent soft tissue swelling at the first toe amputation site with a probable small ulceration of the distal soft tissues. The appearance of the remaining aspect of the first metatarsal is unchanged, although radiographs have limited sensitivity for detection of osteomyelitis. 2. Additional postoperative changes of the right foot are unchanged. . MICRO DATA: ========= FINAL REPORT [2109-8-8] AEROBIC BOTTLE (Final [2109-8-8]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [2109-8-8]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE . [2109-8-6] 6:00 am SWAB RT. HALLUX. GRAM STAIN (Final [2109-8-6]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Brief Hospital Course: 82 y/o M w/ h/o CAD, DMII, R foot ulcer, s/p recent amputation, MSSA bacteremia, who presents with fever/hypotension . # MSSA Bacteremia: Initially presented with hypotension and SIRS criteria including fever, tachycardia, leukocytosis, was admitted to the Medical ICU. Hypotension was fluid responsive after 2.5L NS and he had no evidence of end organ damage. He did not require pressor support. Given his recent MSSA bacteremia (S to oxacillin, clinda) and preliminary R hallux wound culture with GP Cocci, he was treated empirically with vanco/clinda IV. Blood culture data returned 4/4 bottles positive for methicillin sensitive staph aureus, and antibiotics were tapered to IV nafcillin. Suspected source was his R hallux ulcer which also grew MSSA. This ulcer was debrided by the podiatry service. Surveilence blood cultures remained negative to date and he has remained hemodynamically stable; his last positive blood culture was on [2109-8-6]. Oral dicloxacillin was discussed as an alternative antibiotic, but he will be discharged on a two week course of nafcillin IV because of his high grade bacteremia and diabetes (To be continued through [8-20]). He got a transesophageal echo as an inpatient to rule out endocarditis given his risk factors, which was negative. . # DM type 2: Controlled with sliding scale insulin while inpatient. Resumed metformin and glyburide. With rising creatine, will monitor for hypoglycemia in the setting of being on glyburide as well as problems with metformin. Please consider changing to glipizide if this becomes a problem. . # CAD/CHF: s/p CABG in [2090]; no signs of active ischemia or volume overload. Continued on simvastatin, ASA. Metoprolol, lasix held until HD stable and subsequently re-started. Will start lisinopril today prior to discharge for improved mortality benefit. Will need a creatinine check 10 days after starting ACE-I (on [8-23]) to ensure that Cr not elevated. Consider starting spironolactone if his creatinine remains stable over next few days. . # Acute on chronic renal failure: Initial creat 1.5, baseline creat 1.2-1.4. Likely pre-renal component. Volume repleted with IVF's and pRBC and creatinine returned to baseline levels. On discharge, he was 1.5. He should have this checked in one week. . # Insomnia/anxiety: The patient had an episode where he crawled out of bed after receiving Ativan and Ambien. We stopped both of these medications and gave him haldol for sleep (2mg) with good effect. As a result of this, he has an abrasion of his right elbow which is superficial in nature, not requiring stitches. He also required olanzapine for anxiety. He should follow up with his PCP for his chronic anxiety/insomnia problems. . # Atrial fib: Rate controlled, holding coumadin anti-coagulation in setting of recent GI bleed. Follow-up with cardiology as outpatient to assess whether or not to restart coumadin given that patient is a fall risk. . # Anemia: Initial hematocrit 26. guaiac negative. Transfused 1 unit pRBC given h/o CAD and PVD with appropriate increase to 29. His hematocrit has been stable since. . # R foot ulcer: As above, treated with antibiotics and debridement. Podiatry and Vascular surgery consulted. Vanco given for MSSA and levo/flagyl empirically at first, switched to nafcillin prior to discharge. He needs to follow up with vascular surgery as an outpatient given his non-healing ulcer and repeated infections as well as with Dr. [First Name (STitle) 3209] of podiatry for repacking/resuturing of foot. . # Dispo: Patient seen by PT/OT and it was felt that the best thing for him in terms of rehabilitation is to go to a rehab center. Medications on Admission: 1. Folic Acid 1 mg PO DAILY 2. Terazosin 2 mg PO HS 3. Cyanocobalamin 1000 mcg PO DAILY 4. Multivitamin PO DAILY 5. Aspirin 81 mg PO DAILY 6. Metoprolol Tartrate 50 mg PO BID 7. Omeprazole 20 mg PO once a day 8. Ferrous Sulfate 325 PO daily 9. Glyburide-Metformin 5-500 mg PO twice a day. 10. Simvastatin 20 mg PO qhs 11. Lasix 20mg QOD Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Hydrocortisone Valerate 0.2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 12. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1) 2g Intravenous Q6H (every 6 hours): Started on [8-6], to continue through [8-20]. 14. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:qs Tablet(s) Refills:0 15. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for anxiety. 16. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Terazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Staph aureus bacteremia (methicillin sensitive) secondary to foot ulcer Discharge Condition: Good Discharge Instructions: Please call if you have any fever/chills, worsening or uncontrolled foot pain, worsening malaise, fatigue. . You will need 2 weeks of treatment with IV Naficllin (First day on [8-6] to continue through [8-20]) . Please check creatinine in 10 days to ensure stable (ACE-I started on day of discharge). Followup Instructions: -Provider: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2109-8-16] 3:10 . -Dr. [Last Name (STitle) 1391] of Vascular Surgery ([Telephone/Fax (1) 14585] Date/Time:[2109-8-28] at 9:45 . -Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern4) 21383], MD Phone:[Telephone/Fax (1) 1954] Date/Time:[2109-8-28] 3:30 . -Provider: [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 126], M.D. Phone:[Telephone/Fax (1) 127] Date/Time:[2109-11-22] 10:00	[ "707.15", "785.52", "272.4", "427.31", "584.9", "428.0", "038.11", "250.60", "357.2", "585.9", "995.92", "V45.81", "276.52", "443.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "77.68", "99.04" ]	icd9pcs	[ [ [] ] ]	9376, 9446	3639, 7319	231, 281	9562, 9569	2461, 3616	9926, 10552	1966, 1986		7706, 9353		9467, 9541		7345, 7683			9593, 9903								2001, 2442																									184, 193										309, 1319															1341, 1866	1882, 1950
61,180	149,459	42571+58542	Discharge summary	report+addendum	Admission Date: [2198-12-17] Discharge Date: [2198-12-18] Date of Birth: [2135-6-14] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8263] Chief Complaint: chest pain, fatigue Major Surgical or Invasive Procedure: Placement of right internal jugular line History of Present Illness: This is a 63 year old gentleman with PMHx significant for ETOH abuse (hx of DTs), and htn not currently receiving medical care who presents with symptoms of fatigue, mild cough and acute onset substernal chest pain. . Per ED report, he reports the onset of substernal chest pain was acute and associated with dyspnea and was pleuritic in nature. He reprots it occurred several times this morning while he was coughing and self resolved. In this setting he reports a progressive history of fatigue, maliase. He denies nausea, diaphoresis, emesis, diarrhea of constipation. He has not looked at his stool and cannot report BRB or melanotic stool. He does have chronic diarrhea. This history was confirmed on the ICU however history taking was limited secondary to somnolence. . The patient reports 2 gallons a day history of vodka per day. Last drink was at 7PM last night. He reports a positive history of DTs in the past and frequent admissions to ICU for detox. . In the ED inital vitals were, 97.3 107 149/107 24 100% RA. Physical exam was significant for clear lung exam, mild tenderness to the epigastrium. Labs demonstrated serum etoh 56, hct 34, creatinine 0.9, potassium 3.2, lactate 2.3 and troponin 0.01. A d-dimer was 1410. A serum toxic was otherwise negative. He was given 1mg Ativan po x2, 2mg ativan IV, potassium choloride repletion and folic acid. A CT abdomen and pelvis was obtained which demonstrated no acute intra-abdominal process and 2.8 cm hepatic lesion with recommendation for follow-up MRI. Of note he had many attempts at peripheral access which failed. A right IJ was placed under sterile conditions. Pulmonary embolism was considered on the differential however unable to perform CTA [2-7] access issues. . On arrival to the ICU, initial vitals were: T 99, HR 96, BP 184/111 18 97% RA with systolic BPs in the low 200s on arrival. he was chest pain free. He was given 10mg IV hydralazine with initial improvement in his SBPs in the 170s. He was started on a nitroglycerin gtt in the setting of reported chest pain, and blood pressure control. He was somnolent on exam, easily aroused but difficult to maintain mentation. A phone call to his wifes listed number revealed she had no phone. Past Medical History: Hepatitis C Hypertension ETOH abuse: History of DTs and ICU admissions for detox Social History: - Tobacco: unclear - Alcohol: 1 gallon vodka per day - Illicits: quit IV heroin 18 years ago - Housing: lives with wife. They are both homeless. Family History: Could not be obtained as when the author met the patient they were insisting upon leaving against medical advice. Physical Exam: Admission Physical Exam: Vitals: 97.3 107 149/107 24 100% RA General: Somnolent, mildly tremulous, arousable to loud voice but difficult to maintain attention HEENT: mildly injected conjunctivae, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Physical Exam: Pt with bloodshot eyes, able to walk independently and speak coherently. I was not able to examine him as upon arrival to the floor he insisted upon leaving immediately. Pertinent Results: Admission Labs: [2198-12-17] 05:40AM WBC-5.2 RBC-3.63* HGB-11.5* HCT-34.0* MCV-94 MCH-31.7 MCHC-33.8 RDW-13.4 [2198-12-17] 05:40AM NEUTS-61.9 LYMPHS-29.4 MONOS-5.1 EOS-2.8 BASOS-0.8 [2198-12-17] 05:40AM PLT COUNT-180 [2198-12-17] 05:40AM ASA-NEG ETHANOL-56* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2198-12-17] 05:40AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-1.4* [2198-12-17] 05:40AM cTropnT-<0.01 [2198-12-17] 05:40AM ALT(SGPT)-50* AST(SGOT)-105* LD(LDH)-232 ALK PHOS-87 TOT BILI-0.9 [2198-12-17] 05:40AM LIPASE-58 [2198-12-17] 05:40AM GLUCOSE-76 UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 [2198-12-17] 05:46AM LACTATE-2.3* [2198-12-17] 05:57AM PT-10.8 PTT-33.2 INR(PT)-1.0 [2198-12-17] 05:59AM D-DIMER-1410* [2198-12-17] 12:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.5 LEUK-NEG [2198-12-17] 12:41PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2198-12-17] 03:30PM CK-MB-3 cTropnT-<0.01 [2198-12-17] 03:30PM ALT(SGPT)-47* AST(SGOT)-89* CK(CPK)-186 ALK PHOS-82 TOT BILI-1.3 [2198-12-17] 03:30PM GLUCOSE-91 UREA N-9 CREAT-0.8 SODIUM-139 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13 Microbiology: Blood culture x 2 ([2198-12-17])- NGTD, pending Urine culture ([2198-12-17])- NGTD, pending Imaging: Chest PA/Lat X-ray ([2198-12-17])- No acute chest pathology. CT abdomen/pelvis ([2198-12-17])- CT OF THE ABDOMEN: There is a focal area of atelectasis in the left lung base. The lungs are otherwise clear without pleural effusion. The visualized portions of the heart and pericardium are unremarkable. The liver is diffusely hypodense, consistent with fatty liver. In segment III of the liver is a 2.8 x 1.7 cm hyperdense lesion (2:24). The liver otherwise enhances homogeneously. The hepatic and portal veins are patent. The gallbladder, pancreas, and spleen are unremarkable. The adrenal glands are diffusely enlarged, without a focal mass, suggestive of adrenal hyperplasia. The kidneys enhance and excrete contrast without evidence of hydronephrosis or stones. There are multiple subcentimeter hypodensities in both kidneys too small to characterize. The stomach and small bowel are unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. There is no free air or free fluid. CT OF THE PELVIS: The appendix is normal. There is sigmoid diverticulosis without evidence of diverticulitis. The other portions of the colon are otherwise unremarkable. The rectum, seminal vesicles, urinary bladder, and prostate are unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no pelvic free fluid. VASCULATURE: There are mild atherosclerotic changes throughout the descending aorta and iliac arteries without significant stenosis. OSSEOUS STRUCTURES: There are no suspicious osseous lytic or blastic lesions. IMPRESSION: 1. No acute intra-abdominal process. 2. Hepatic steatosis. 3. 2.8 cm hyperdense hepatic lesion in segment III of the liver which is not fully characterized on this study. Given the patient's history of liver disease, MRI of the liver is recommended for further evaluation. 4. Bilateral adrenal hyperplasia. 4. Diverticulosis without evidence of diverticulitis. Brief Hospital Course: 63 year old gentleman with PMHx significant for ETOH abuse (hx of DTs), and htn not currently receiving medical care who presents with symptoms of fatigue, mild cough and acute onset substernal chest pain. ETOH ABUSE: History of significant ETOH abuse with history of DTs. Unable to wean ativan requirement past q2hrs in emergency room and therefore not suitable for general medical floor given nursing requirements for management. Positive ethanol on tox screen. Last drink at 7pm the night prior to admission. Patient was placed on CIWA scale with valium. He was [Doctor Last Name ] [9-21] on the night of admission mostly for agitation and tremor. He was given thiamine and folate supplementation. Valium requirement was spaced out to q4h and he required a total of 15mg on HD1. - SW consult obtained and patient appeared pre-contemplative. He was given information about [Hospital 86] Healthcare for the Homeless Program to locate a caseworker to assist with findingpermanent housing, be referred to a primary care physician, [Name10 (NameIs) ] then be referred to a therapist and psychiatrist. ACUTE DYSPNEA/PLEURITIC CHEST PAIN: Patient complained of shortness of breath and pleuritic chest pain on arrival. Concern was for pulmonary embolism vs ACS/unstable angina. Cardiac enzymes were negative x 2 and EKG showed no ST depressions or elevations. Chest xray not concerning for mediastinal widening or infiltrate. D-dimer elevated concerning for PE/DVT, however, a CTA was not performed as very low suspicion for PE. Pain resolved on day of admission, and patient had no further complaints. HYPERTENSION: Hypertensive on admission to the [Hospital Unit Name 153], unresponsive to hydralazine 10mg IV. He was started on a nitroglycerin drip which was discontinued shortly after arrival. He was started on clonidine 0.3mg po BID as home anti-hypertensive regiment was unclear. [Name2 (NI) ] received an additional 10mg of IV hydralazine with good blood pressure response. In addition, his pressures improved following valium for high CIWA scores. Per home pharmacy, patient is on nifedipine XR 60mg po daily which was restarted on hospital day 1. TRANSAMINITIS: Mild transaminitis noted on admission. Etiology is likely acute alcoholic hepatitis vs chronic viral hepatitis (history of hepatitis C) vs cirrhosis. Synthetic function was intact with INR 1.0. CT abdomen and pelvis notable for hepatic steatosis and hyperdense hepatic lesion. LIVER NODULE: Nearly 3cm discrete liver nodule seen on CT scan. In setting of significant etoh hx, poor medical care and recent fatigue concerning for underlying liver disease/malignancy. Pt informed of this at time of discharge but declined further evaluation. FATIGUE: History of progressive fatigue. Unclear etiology. Weight loss? Liver nodule concerning for malignancy. Normocytic mild anemia on admission. Upon arrival to the floor patient and wife insisted upon leaving. Despite this author repeatedly asking them to stay citing his current [Location (un) ] problems along with the new liver mass seen on his CT of the abdomen. They both insisted on leaving at 10 pm at night from the hospital. (See OMR note for further details.) Pt appeared competent. He was able to walk independently. He was thus discharged against medical advice. Medications on Admission: Nifedipine XR 60mg po daily Discharge Disposition: Home Discharge Diagnosis: Primary: Alcohol abuse New Liver mass Secondary: Hepatitis C Hypertension H/o delerium tremens ? Schizophrenia Discharge Condition: He was speaking coherently and was able to ambulate independently. Discharge Instructions: Pt was discharged against medical advice. He and his wife refused to wait for their discharge paperwork. Followup Instructions: [Name (NI) ] pt left AMA. He will need to urgent follow up to address his medical and psychological problems. Name: [Known lastname 14495],[Known firstname 14496] Unit No: [Numeric Identifier 14497] Admission Date: [2198-12-17] Discharge Date: [2198-12-18] Date of Birth: [2135-6-14] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 14498] Addendum: Time spent on discharge activity was >30 minutes. Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 14499] MD [MD Number(2) 14500] Completed by:[2198-12-18]	[ "786.09", "291.81", "786.52", "303.01", "401.9", "780.79", "573.9", "533.90", "070.70", "295.90", "305.1", "790.4" ]	icd9cm	[ [ [] ] ]	[ "38.97", "94.62" ]	icd9pcs	[ [ [] ] ]	11622, 11788	7254, 10586	326, 368	10825, 10894	3852, 3852	11047, 11599	2913, 3028				10691, 10804		10612, 10641			10918, 11024								3068, 3636																									267, 288										396, 2626					3868, 7231										2648, 2731	2747, 2897		3661, 3833
15,784	131,899	1819	Discharge summary	report	Admission Date: [2113-9-10] Discharge Date: [2113-9-15] Date of Birth: [2036-1-24] Sex: M Service: Next issue, infectious disease. The patient had hypothermia and low white blood cell count. The patient had blood cultures and urine cultures, none of which were positive. It seemed unlikely that infectious disease was cause of this patient's symptoms. The patient was discharged in good condition on [2113-9-15] to home with VNA care. DISCHARGE MEDICATIONS: Plavix, 75 mg PO q day; Lasix, 40 mg PO q day; Lisinopril, 5 mg PO q day; metoprolol, 50 mg PO b.i.d.; Coumadin, 3 mg PO q h.s.; Glyburide, 2.5 mg PO b.i.d.; iron, 325 mg PO q day; B12 intramuscularly once a month. FOLLOW-UP: The patient had follow-up appointments with Dr. [Last Name (STitle) 8906] in one week, Dr. [Last Name (STitle) 1683] [9-25] at 4 p.m., [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6160] of Hem/Onc [2113-09-25] at 10:30 a.m., and with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10029], Neurology, in one to two months. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 4786] Dictated By:[Name8 (MD) 8330] MEDQUIST36 D: [2114-1-6] 14:12 T: [2114-1-9] 07:33 JOB#: [Job Number 10171]	[ "412", "276.5", "429.79", "427.31", "458.9", "584.9", "287.5", "428.0", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]									496, 1390
83,184	182,447	40781	Discharge summary	report	Admission Date: [2198-5-28] Discharge Date: [2198-6-1] Date of Birth: [2145-6-3] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic Mitral valve prolapse/Mitral valve regurg Major Surgical or Invasive Procedure: S/P MV repair (#30 physio ring)[2198-5-28] History of Present Illness: 52-year-old gentleman with a 10 year history of a heart murmur who was noted to have a more pronounced murmur on exam this past [Month (only) 956]. He was subsequently sent for an echocardiogram which revealed significant mitral regurgitation. He underwent an transesophageal echocardiogram and a cardiac catheterization for further diagnostic evaluation. His transesophageal echocardiogram was reported to have severe mitral regurgitation. He underwent a cardiac MRI for further assessment which revealed a moderately dilated left ventricle with a slightly depressed ejection fraction. He denies any exertional fatigue, shortness of breath, chest pain, or palpitations. Given thsese findings, he has been referred for surgical evaluation. Past Medical History: Mitral valve prolapse Social History: Race: Caucasian Last Dental Exam: Every 6 months Lives with: He is married, lives with his spouse and two children. Occupation: Engineer Tobacco: Denies ETOH: Rarely Family History: Family History: No family history of premature coronary artery disease or sudden death. Physical Exam: Physical Exam: Pulse: 65 Resp: 16 O2 sat: 100% BP 118/69 Height: 72" Weight: 165 General: WDWN in NAD Skin: Warm, Dry and intact. No C/C/E HEENT: NCAT, PERRLA, EOMI, sclera anicteric. OP Benign. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, III/VI mid systolic 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:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right: None Left: None Pertinent Results: ECHO [2198-5-28] PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. The mitral valve leaflets are elongated. There is moderate/severe posterior leaflet mitral valve prolapse. There is partial posterior mitral leaflet flail. An eccentric, anteriorly directed jet of Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Unchanged LV and RV systolic function, with EF = 40-45%. 2. A complete annuloplasty ring is identified in mitralposition. Well seated and stable with good anterior and posterior leaflet excursion. 3. Redundant anterior leaflet with chordal [Male First Name (un) ] is seen. There is only trace valvular mitral regurgitation, no appreciable LVOT gradient or any evidence of turbulenty flow in the LVOT. 3. No other change [2198-5-31] 05:05AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.2* Hct-32.0* MCV-90 MCH-31.6 MCHC-35.0 RDW-13.3 Plt Ct-122* [2198-5-30] 04:50AM BLOOD WBC-9.0 RBC-3.38* Hgb-10.6* Hct-29.3* MCV-87 MCH-31.4 MCHC-36.2* RDW-13.1 Plt Ct-84* [2198-5-31] 05:05AM BLOOD UreaN-12 Creat-0.9 Na-140 K-4.6 Cl-102 [2198-5-30] 04:50AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-134 K-4.0 Cl-98 HCO3-28 AnGap-12 Brief Hospital Course: Mr [Known lastname ] was admitted and taken directly to the operating room where he underwent a mitral valve repair (#30 physio ring II). Arrived to the ICU immediately post-operatively intubated and sedated. Awoke from sedation and was weaned from sedation and extubated. Required NGT drip briefly for hypertension. Betablockers and diuretics were started on POD#1 and he was transferred to the stepdown unit for ongoing post-operative care. Chest tubes and pacing wires were removed per protocol. He was noted to have a small left pneumo on CXR but has remained sable. He was evaluated by physical therapy for strength and conditioning. He was cleared for discharge to home on POD# 4. All follow up appointments have been arranged. Medications on Admission: none Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 5 days. Disp:5 Tablet, ER Particles/Crystals(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 7665] Home Care Services Discharge Diagnosis: Mitral valve prolapse S/P MV repair (#30 physio ring) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema, drainage or Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Wound check Cardiac surgery office [6-6] at 11:15 am Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] [6-21] at 1:00 pm Cardiologist: Dr [Last Name (STitle) ] [Telephone/Fax (1) 127] [7-10] at 2:30pm [Hospital1 18] [Hospital Ward Name ] - [Hospital Ward Name ] building [Location (un) 436] Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 81364] [Telephone/Fax (1) 63696] in [2-20] weeks Completed by:[2198-6-1]	[ "276.52", "424.0", "429.5" ]	icd9cm	[ [ [] ] ]	[ "35.12", "39.61" ]	icd9pcs	[ [ [] ] ]	6044, 6114	4190, 4929	363, 412	6212, 6388	2220, 3333	7230, 7840	1447, 1521		4984, 6021		6135, 6191		4955, 4961			6412, 7207								1552, 2201																									269, 325										440, 1186															1208, 1231	1247, 1415				3343, 4167
10,567	107,500	601	Discharge summary	report	Admission Date: [2198-6-17] Discharge Date: [2198-7-6] Date of Birth: [2149-8-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: HD cath placement PICC line placement History of Present Illness: 48M in USOH until two nights ago, developed "grabbing" lower abdominal pain lasting minutes which resolved spontaneously. Next morning with shaking chills and presented to [Hospital 4683]. Initially with (?)tick-borne dz, treated with doxycycline. Subsequent blood cultures - 2 sets, multiple bottles growing gram-positive rods, gram-negative rods, and gram positive cocci in pairs. Febrile to 104, rigors on [2198-6-16], but hemodynamically stable and benign abdomen. SBP in 130s, HR 70s. Labs at OSH notable for WBC 14K (5 bands), HCT 39.6, PLT 175, Creatinine 1.0, total bili 7.4 (3.4 direct, 4.0 indirect), transaminases in 200s, alk phos 83. Abdominal U/S with dilated CBD (7mm)and GB sludge. Abdominal CT with air in biliary tree and dilated CBD. Concern was for ascending cholangitis and plan for ERCP. Given polymicrobial bacteremia and air in biliary tree, pt transfered directly from OSH to [Hospital Unit Name 153] for monitoring given risk of septic shock. . On arrival pt complained only of low back pain which he has had for the past day since lying in bed. Feels drained, but no abd pain. No recent wgt loss/gain, change in bowel habits, no N/V/D. Miild HA. Past Medical History: GERD, lower back surgery, diverticulitis. Social History: married with 2 young children. No smoking, + occ Etoh. Family History: No known hx of CA, heart disease. Physical Exam: T: (104.3) 99.2 BP: 114/79 HR: 95 RR:12 O2saturation 100% on RA Gen: Pleasant, well appearing. Jaundiced. Laying in bed. HEENT: No conjunctival pallor. + icterus. Slightly dry mucous membranes. Oropharynx clear. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No JVD. No thyromegaly. CV: RRR. Normal S1 and S2. No murmurs, rubs or [Last Name (un) 549] appreciated. LUNGS: Clear to auscultation bilaterally. Decreased breath sounds in lower lung fields, bilaterally. No wheezes, crackles, or rhonci appreciated. ABD: No surgical scars. Normal active bowel sounds. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. EXT: Warm and well perfused. No clubbing or cyanosis. No lower extremity edema, bilaterally. SKIN: Jaundiced, No rashes. NEURO: Alert and oriented to person, place, date. Pertinent Results: [2198-7-6] 09:49AM BLOOD WBC-6.7 RBC-3.18* Hgb-9.9* Hct-28.2* MCV-89 MCH-31.2 MCHC-35.1* RDW-14.1 Plt Ct-549* [2198-7-4] 05:23AM BLOOD WBC-7.9 RBC-2.50* Hgb-7.7* Hct-23.0* MCV-92 MCH-30.9 MCHC-33.6 RDW-14.0 Plt Ct-649* [2198-6-17] 08:15PM BLOOD WBC-28.4* RBC-3.70* Hgb-12.9* Hct-32.9* MCV-89 MCH-34.8* MCHC-39.0* RDW-14.9 Plt Ct-146* [2198-6-28] 05:19AM BLOOD Neuts-80.9* Lymphs-6.6* Monos-10.3 Eos-1.9 Baso-0.2 [2198-6-19] 12:43AM BLOOD Fibrino-592* [2198-6-18] 12:28PM BLOOD Parst S-NEGATIVE [2198-6-18] 06:34PM BLOOD QG6PD-9.1 [2198-6-18] 06:34PM BLOOD Ret Aut-1.6 [2198-7-6] 09:49AM BLOOD Glucose-176* UreaN-43* Creat-10.2# Na-138 K-3.8 Cl-98 HCO3-26 AnGap-18 [2198-6-28] 05:19AM BLOOD Glucose-97 UreaN-90 Creat-15.0# Na-125 K-4.5 Cl-87* HCO3-18* AnGap-25* [2198-6-17] 08:15PM BLOOD Glucose-109* UreaN-38* Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-21* AnGap-20 [2198-7-6] 09:49AM BLOOD ALT-8 AST-11 AlkPhos-148* TotBili-1.4 [2198-6-27] 05:32AM BLOOD ALT-26 AST-28 LD(LDH)-499* AlkPhos-112 TotBili-2.5* [2198-6-19] 12:43AM BLOOD ALT-181* AST-285* LD(LDH)-1662* CK(CPK)-292* AlkPhos-86 Amylase-800* TotBili-21.8* DirBili-19.2* IndBili-2.6 [2198-6-21] 05:52AM BLOOD Lipase-184* [2198-7-6] 09:49AM BLOOD Calcium-8.4 Phos-6.4# Mg-2.0 [2198-7-4] 05:23AM BLOOD Calcium-7.9 Phos-9.4* Mg-2.0 [2198-6-21] 06:13PM BLOOD calTIBC-204* Ferritn-GREATER TH TRF-157* [2198-6-18] 06:34PM BLOOD Triglyc-387* [2198-6-17] 08:15PM BLOOD TSH-1.9 [2198-6-17] 08:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2198-6-28] 05:19AM BLOOD PEP-NO SPECIFI [2198-6-27] 05:32AM BLOOD C3-105 C4-16 [2198-6-29] 05:23AM BLOOD HIV Ab-NEGATIVE [2198-6-17] 08:15PM BLOOD HCV Ab-NEGATIVE [2198-6-17] 08:15PM BLOOD LEPTOSPIRA ANTIBODY-Test [2198-7-4] 04:10PM URINE Color-STRAW Appear-Clear Sp [Last Name (un) ]-1.005 [2198-7-4] 04:10PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2198-6-18] 12:27PM URINE Hours-RANDOM UreaN-202 Creat-71 Na-44 K-41 Cl-36 Phos-0.6 HCO3-LESS THAN [2198-7-3] 06:06AM URINE Hours-RANDOM Creat-47 Na-68 [2198-6-27] 09:02AM STOOL CLOSTRIDIUM DIFFICILE TOXIN B ASSAY-Test [2198-7-4] URINE URINE CULTURE-FINAL INPATIENT [2198-7-3] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2198-7-1] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [2198-7-1] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [2198-6-27] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2198-6-26] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [2198-6-25] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2198-6-25] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2198-6-24] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2198-6-24] URINE URINE CULTURE-FINAL INPATIENT [2198-6-24] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2198-6-23] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2198-6-21] STOOL OVA + PARASITES-FINAL INPATIENT [2198-6-20] STOOL OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2198-6-20] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [2198-6-19] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2198-6-19] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2198-6-18] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2198-6-18] URINE URINE CULTURE-FINAL INPATIENT [2198-6-17] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [2198-6-17] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT [2198-6-17] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT CT OF THE ABDOMEN: The lung bases are clear. Hypoattenuation of the liver (45 Hounsfield units versus 65 Hounsfield units for the spleen) is consistent with fatty infiltration. There is heterogeneous perfusion of the liver with focal areas of nonenhancement in the posterior aspect of the right lobe - 1.5 x 1.3 cm in the posterior medial aspect (3b:133) and 2.9 x 2.7 cm more latarally (3b:140) as well as other small hypoattenating foci. There is no intra- or extra- hepatic biliary dilatation and no evidence of intrabiliary air. One tiny focus of air (3a:70) The gallbladder is mildly distended measuring 4.1 cm, however there is no wall edema or pericholecystic fluid. No radiopaque gallstones are seen. There is no pancreatic ductal dilatation and the pancreas is unremarkable. The adrenal glands are normal. Two tiny hypoattenuating lesions within the left kidney are likely cysts. The kidneys enhance and excrete contrast normally. There is no free air or free fluid in the abdomen. The small bowel appears normal. Extensive diverticulosis of the sigmoid colon and milder diverticulosis of the descending colon are noted with no evidence of diverticulitis. The appendix is normal. CT OF THE PELVIS: Contrast fills the bladder. The prostate gland is not enlarged, and has dystrophic calcifications within it. The sigmoid colon again is notable for diverticulosis. The rectum is normal. No pelvic free fluid or lymphadenopathy. No bone findings of malignancy. IMPRESSION: 1. Focal areas of hypoperfusion within the liver, in a background of heterogeneous perfusion. Given patient's clinical situation (leukocytosis, Total bilirubin level of 30), these findings are concerning for hepatic necrosis. No evidence of biliary dilatation or intrabiliary gas to suggest cholangitis, though this can be a subtle radiographic diagnosis. Recommend ERCP or MRCP for further evaluation. ADDENDUM: Review of outside hospital CD performed at [Hospital ] Hospital at 12:35 PM on [2198-6-17] reveals small foci of intrahepatic biliary air. The patient has no apparent history of recent ERCP or remote sphincterotomy. This finding is concerning for emphysematous cholangitis, though the lack of air on the current study, and the lack of intrahepatic biliary dilatation or inflammatory changes in the porta hepatis makes this less likely. 2. Fatty infiltration of the liver. 3. Left renal cyst. 4. Sigmoid diverticulosis without diverticulitis. 5. Normal appendix. ERCP - IMPRESSION: Opacification of the biliary tree without abnormality detected. Per endoscopist's report there was direct visualization of a periampullary diverticulum. US liver - IMPRESSION: 1. Rounded hypoechoic 2.2 cm lesion within the left lobe of the liver. This can be further evaluated with MRI. 2. Echogenic liver which can be seen in fatty infiltration. Other forms of advanced liver disease including hepatic fibrosis/cirrhosis cannot be excluded. 3. No stones or hydronephrosis. 4. Pneumobilia which is expected status post biliary stent placement. 5. Sludge-filled gallbladder. MRI L spine - IMPRESSION: 1. Low T1 signal within the bone marrow could be consistent with a reactive or infiltrative marrow lesion. No evidence of bone marrow edema. 2. Large right-sided paracentral and foraminal disc herniation at L5-S1 likely compressing the right S1 nerve root. Conclusions: The left atrium is elongated. Left ventricular wall thickness, cavity size, and 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 root is moderately dilated at the sinus level. The ascending aorta and arch are moderately dilated. No dissection flap is seen/suggested (does not exclude). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Dilated ascending aorta and arch. No valvular pathology or pathologic flow identified. Renal ultrasound [2198-6-19]. FINDINGS: The right kidney measures 12.5 cm. The left kidney measures 13.7 cm. No hydronephrosis, stone, or mass is identified. The bladder is decompressed and poorly evaluated. Doppler evaluation is limited by patient respiratory motion throughout the exam. High resistive indices in the right mid and lower pole measure 0.79 and 0.75 respectively. Resistive indices in the right upper pole is within normal limits at 0.64. Arterial and venous waveforms of the main right and left renal artery and vein are unremarkable, though limited due to respiratory motion. The left kidney demonstrates an elevated resistive index at the lower pole measuring 0.78. The mid and upper pole demonstrates resistive indices of 0.62 and 0.64 respectively. IMPRESSION: 1. No hydronephrosis. 2. Although evaluation is limited by patient respiration, slightly elevated resistive indices in the right mid and lower pole and left lower pole are nonspecific findings. These may represent an underlying medical renal disease and Doppler follow up is recommended. CT PELVIS W/O CONTRAST [2198-6-23] 5:02 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: ABD DISTENSION/PAIN Field of view: 42 [Hospital 93] MEDICAL CONDITION: 48 year old man with recent hepatic necrosis, bacteremia and new onset acute renal failure, now with abdominal pain and distension REASON FOR THIS EXAMINATION: r/o appendicitis, diverticulitis, obsturction CONTRAINDICATIONS for IV CONTRAST: recent renal failure INDICATION: Hepatic necrosis, bacteremia and renal failure, now with abdominal pain and distention. Rule out obstruction, diverticulitis or appendicitis. COMPARISON: Abdominopelvic CT, [2198-6-17]. TECHNIQUE: Multidetector helical scanning of the abdomen and pelvis was performed without contrast due to renal failure. Oral contrast was administered. CT OF THE ABDOMEN: The lung bases demonstrate a new right-sided pleural effusion that is small, with associated atelectasis. No consolidations or nodules are identified. There is a tiny pericardial effusion, likely physiologic and the heart size is normal. The liver is again heterogeneous in attenuation with focal stable hypoattenuating areas in the posterior right lobe, concerning for hepatic necrosis. Intrahepatic biliary air is seen, likely related to CBD stent which is seen entering the duodenum. The gallbladder is nondilated with no pericholecystic inflammatory changes or fluid. The spleen and adrenal glands are unremarkable. The kidneys have enlarged since the prior scan and there is mild residual contrast enhancement (last contrast injection was 5 days ago) consistent with known acute renal failure. There is no free air or free fluid. Contrast passes through nondilated loops of small bowel with no evidence of obstruction. There is no bowel wall thickening. The colon has scattered diverticuli with no evidence of diverticulitis. The appendix is normal. CT OF THE PELVIS: The bladder is unremarkable. A small amount of free fluid is seen in the pelvis, measuring simple fluid density, presumably related to resuscitation. Sigmoid colon and rectum are unremarkable with diverticulosis but no diverticulitis. BONE WINDOWS: Joint space narrowing at L5-S1 is noted with no suspicious lytic or sclerotic lesions. IMPRESSION: 1. No new intra-abdominal findings to explain the patient's sudden abdominal pain. No bowel obstruction or free air. Diverticulosis without diverticulitis. The appendix is normal. 2. Heterogeneous attenuation of the liver with focal areas of hypoattenuation in the posterior right lobe, unchanged since the prior exam and again suggesting hepatic necrosis. Further evaluation is limited due to lack of IV contrast. 3. CBD stent seen entering the duodenum with associated intrahepatic biliary air. 4. Small amount of free fluid in the pelvis liked related to resuscitation MRI - IMPRESSION: High signal intensity lesions seen within the liver and spleen, most likely abscesses given the patient's history of polymicrobial bacteremia. Evaluation is limited without intravenous contrast. Focal infarctions in the liver sre less likely. Segment VII amorphous wedge- shaped lesion peripheral to suspected abscess may be reactive edema or infectious spread. Limited interrogation of the portal vein is unremarkable on these non- contrast sequences. [Numeric Identifier 4684] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [2198-7-5] 8:56 AM Reason: For dialysis [Hospital 93] MEDICAL CONDITION: 48 year old man with ARF, needs a permanat HD access REASON FOR THIS EXAMINATION: For dialysis INDICATION: This is a 48-year-old man with acute renal failure, presents for placement of a tunneled hemodialysis catheter for dialysis. Details of the procedure and possible complications were explained to the patient and informed consent was obtained. Timeout was performed. RADIOLOGISTS: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], nurse practitioner, performed the procedure supervised by Dr. [First Name (STitle) 4685] [Name (STitle) 4686], attending radiologist. Using sterile technique, local anesthesia, and conscious sedation, the right internal jugular vein was punctured via just ultrasound guidance using a micropuncture set. Hard copy of ultrasound images were obtained before and immediately after venous access documenting vessel patency. The tract was dilated with serial dilators and a peel-away sheath was then placed. A subcutaneous tunnel was made on the right anterior chest wall and the catheter was introduced through the tunnel and placed through the peel-away sheath with its tip positioned in the right atrium under fluoroscopic guidance. The peel- away sheath was then removed. Position of the catheter was confirmed by chest x-ray in one view. The incision on the neck was closed with Dermabond. The catheter was secured to the skin and a sterile dressing was applied. The patient tolerated the procedure well. There were no immediate complications. Moderate sedation was provided administering divided doses of Versed and fentanyl throughout the total intraservice time of 55 minutes, during which the patient's hemodynamic parameters were continuously monitored. The total dose administered of fentanyl was 100 mcg and of Versed 3 mg. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided tunneled hemodialysis catheter placement via the right internal jugular venous approach with the tip in the right atrium. Ready for use Brief Hospital Course: Sepsis from aeromionas, enterococcus fecium, clostridium - the exact source of infection was not clear, could be from a diverticular infection that tracked up to the portal system. The liver abscesses were confirmed on MRI abdomen. Prolonged course of antibiotics was recommended by the ID consult team - levofloxacin atleast toll [2198-7-23] when ID follow up is arranged. A repeat MRI was recommended by the liver team for follow up of the abscesses. Prior to discharge, the patient was afebrile for several days and cultures were negative at the time of writing this discharge sumary. Acute renal failure - Acuite tubular necrosis on dialysis - the patient developed ATN as a result of sepsis. Was initially anuric, last started urinating and was non-oliguric. Despite this his creatinine continued to rise and after a break of 6 days of HD when his creat was upto 15 and started getting acidotic, he was restarted on HD via a tunnelled cath. HD arranged for 3/wk (T,T,S) at [Location (un) ] as below. Given this is ARF, it is a possibility that the patinet's kidneys may recover. Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1366] will follow patient there. Anemia - likely multifactorial - sepsis, renal failure, malnutrition. Started on Fe and epo with HD and alsot transfused 2 units prior to discharge with dialysis. The patient will get a repeat MRI and then an ID follow up. he is advised to continue to take the levofloxacin and flagyl till the ID follow up and thereafter at their discretion. HD to continue per Dr [Last Name (STitle) 1366]. Advised to follow up with PCP. The abnormal MRI L spine (refer above) will need follow up. Deferred to PCP for follow up. Medications on Admission: prilosec Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 20 days. Disp:60 Tablet(s) Refills:0 2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 20 days. Disp:10 Tablet(s) Refills:0 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:60 Tablet(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): with dialysis. Discharge Disposition: Home Discharge Diagnosis: Sepsis from aeromionas, enterococcus fecium, clostridium Liver lesions/abscess Acute renal failure - Acuite tubular necrosis on dialysis Anemia Discharge Condition: stable Discharge Instructions: Dialysis has been arranged for next week on tuesday. The dialysis nurse has explained the details to you. Call your doctor if you have any symptoms of concern to you. keep your appointments. make a follow up appointment with Dt [Last Name (STitle) 4687] in the next 1 week. Followup Instructions: Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2198-7-17] 4:20 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 457] Date/Time:[2198-7-23] 11:45 Provider: [Name Initial (NameIs) ] SUITE GI ROOMS Date/Time:[2198-8-23] 8:00 Please call Dr [Last Name (STitle) ],[First Name3 (LF) ] H. [Telephone/Fax (1) 4688] -	[ "289.59", "577.0", "997.4", "403.91", "562.10", "263.9", "285.21", "038.0", "572.0", "995.92", "283.9", "576.1", "038.3", "584.5", "573.3" ]	icd9cm	[ [ [] ] ]	[ "38.95", "99.04", "45.23", "51.87", "39.95" ]	icd9pcs	[ [ [] ] ]	20284, 20290	17401, 19117	321, 361	20478, 20487	2667, 12070	20816, 21283	1731, 1766		19176, 20261	15378, 15431	20311, 20457		19143, 19153			20511, 20793								1781, 2648																									275, 283	15460, 17378									389, 1576															1598, 1642	1658, 1715
24,114	126,126	23140	Discharge summary	report	Admission Date: [2199-9-12] Discharge Date: [2199-9-17] Date of Birth: [2134-3-12] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3127] Chief Complaint: Absence of Portal Vein flow on surveillance Duplex Major Surgical or Invasive Procedure: TPA History of Present Illness: In the course of routine workup for conversion from Prograf to Rapamune, a liver duplex to evaluate for Hepatic Artery thrombosis was done on [9-12] per protocol. No right portal vein flow was demonstrated on the ultrasound, patient admitted for evaluation and treatment. Otherwise patient feels well, occasional chills without fever. Occasionally has dyspnea, denies chest pain, palpitatations, HA, dizziness, nausea, vomiting or dysuria. Does have constipation Past Medical History: S/P OLT [2199-7-17] Lyme Disease [2190] Liver Cirrhosis [2196] RFA [2198] Hepatic Cyst - aspirated [2198] Social History: lives with two daughters in [Name (NI) 7188] RI Still smoking approx 10 cigarettes/day Family History: n/a Physical Exam: On Admission: VS: 99.2, 90, 20, 117/65, 98% RA Gen: A+O, NAD, bronze skin tone HEENT: Anicteric sclera, no thrush, PERRLA Lungs: Rales/rhonchi in bilateral lower lobes Card: RRR, no murmur Abd: Distended, soft, umbilical hernia (Reducible, + BS, tender R lateral lower abdomen and R lateral upper quadrant at ribs Extr: L>R edema (2+ L, 1+ R) 2+ DP's Pertinent Results: On Admission: [2199-9-12] 12:15PM SODIUM-135 POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-26 UREA N-23* CREAT-1.8* ANION GAP-16 GLUCOSE-111* ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-97 TOT [Month/Day/Year ]-0.5 ALBUMIN-3.7 CALCIUM-9.2 MAGNESIUM-2.1 FK506-12.1 WBC-3.1* RBC-3.31* HGB-9.9* HCT-30.0* MCV-91 MCH-29.9 MCHC-32.9 RDW-15.6* PLT COUNT-123* PT-14.2* PTT-32.2 INR(PT)-1.3* Chem 7 on [9-16] Na: 136, K: 4.4 Cl: 102, CO2: 28 BUN: 13, Cr: 1.4, Glu 87 Brief Hospital Course: 65 y/o Male s/p OLT on [2199-7-17] with uncomplicated post op course now admitted with question of Right PV thrombosis due to very low flow on surveillance U/S for Rapamycin conversion. Initial CTA performed showed a large thrombus at the Portal Vein confluence with absence of flow to the Right Portal Vein. Liver enzymes were normal. Patient received Bicarb and mucomyst, immunosuppresives continued at home dose. Patient transferred to the SICU for thrombolysis of the thrombus with TPA in conjunction with heparin therapy. Post-TPA venogram on [9-14] showed marked improvement in the main portal vein, with the appearance of the pre-existing filling defect. Some filling defects remain present in a small ileal branch connected to the superior mesenteric vein. Balloon angioplasty and stent placement in the main portal vein were also performed with good immediate angiographic result. Patient continued on heparin drip and was started on Coumadin on [9-15]. Abdominal duplex and liver doppler on [9-16] showed patent main and left portal vein. Patent anterior right portal vein with no flow identified in posterior right portal vein. On [9-17] patient had one episode of nausea and vomiting x 1. He felt better post, hernia remained reducible, and was able to tolerate lunch without further incident. Patient continued on heparin drip through [9-17]. Will d/c home on Coumadin 2 mg daily and have labs drawn on Thursday [9-19]. For now patient will remain on Prograf. Rapamune conversion may occur on outpatient basis, and will be reevaluated. Medications on Admission: FK [12-30], Pred 10, MMF [12-30], Valcyte 450 qod, fluc 400', bactrim ss', colace 100", protonix 40' Discharge Medications: 1. Outpatient [Name (NI) ] Work PT/INR, Chem 10, CBC, AST, ALT, T [Name (NI) ], Alk Phos, Albumin, Trough Prograf Level every Monday and Thursday. Please Fax results to [Hospital 1326] Clinic at [Telephone/Fax (1) 697] 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 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. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day for 10 days. 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD. 7. Mycophenolate Mofetil 500 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Dosage may change based on [Telephone/Fax (1) ] results. Disp:60 Tablet(s) Refills:2 9. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 doses. Discharge Disposition: Home Discharge Diagnosis: Portal Vein Thrombosis s/p OLT [7-4] TPA thrombolysis Coumadin therapy Discharge Condition: Stable Discharge Instructions: Please call [Telephone/Fax (1) 673] if you experience any of the following symptoms: Easy bleeding or bruising Nausea/vomiting/diarrhea/inability to eat Jaundice or weight gain of more than 3 pounds in a week Pain in the abdomen Any other symptoms concerning to you Get labs drawn every Monday and Thursday and have them faxed to transplant center at [Telephone/Fax (1) 697]: CBC, Chem 12, AST, ALT, Alk Phos, T [Name (NI) ], Albumin, PT with INR Trough Prograf level Followup Instructions: Please call [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 673] to schedule follow up appointment. Make sure you get labs drawn this Thursday [9-19] Completed by:[2199-9-18]	[ "452", "V42.7", "V10.07" ]	icd9cm	[ [ [] ] ]	[ "99.10", "39.50", "00.40", "39.90", "00.45" ]	icd9pcs	[ [ [] ] ]	4750, 4756	2014, 3593	365, 371	4874, 4883	1533, 1533	5411, 5644	1140, 1145		3753, 4727		4777, 4853		3619, 3730			4907, 5388								1160, 1160																									275, 327										399, 867							1547, 1991								889, 1016	1032, 1124
50,502	138,410	38174	Discharge summary	report	Admission Date: [2124-7-20] Discharge Date: [2124-7-25] Date of Birth: [2044-9-14] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Prednisone / Amoxicillin Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: -status post Mitral Valve Repair (#30mm CE Physio II ring) and resect P1 flail leaflet-[2124-7-21] History of Present Illness: 79 year old gentleman with a history of mitral and tricuspid regurgitation followed by serial echocardiogram. He recently became quite symptomatic with dyspnea on exertion. An echo was obtained which showed severe mitral regurgitation with mild left ventricular dilatation. Given the progression of his symptoms and severity of his disease, he has been referred for surgical management. Past Medical History: MR/TR - Chronic Atrial fibrillation - Mild Dementia, Memory Loss - History of Gout - Hypertension - Prostatism - Hemorrhoids Past Surgical History: - s/p TURP - Nasal Polyps Social History: Race: caucasian Last Dental Exam: full dentures Lives with: wife Occupation: retired teacher/football coach Tobacco: Denies-occ.pipe smoking in past ETOH: Denies Family History: Family History: Denies premature coronary disease Physical Exam: Admission Physical Exam Pulse: 92 Resp: 18 O2 sat: 94% RA B/P Right: 163/86 Ht=5'[24].5" wt=97.1 Kg General: Elderly male, no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - holosystolic murmur best heard at left lower sternal border Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [Name (NI) 167]: Left: Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: [2124-7-25] 04:45AM BLOOD WBC-11.3* RBC-3.87* Hgb-10.9* Hct-34.3* MCV-88 MCH-28.2 MCHC-31.9 RDW-15.2 Plt Ct-162 [2124-7-20] 03:55PM BLOOD WBC-9.8 RBC-5.04 Hgb-14.2 Hct-42.5 MCV-84 MCH-28.2 MCHC-33.4 RDW-15.5 Plt Ct-228 [2124-7-25] 04:45AM BLOOD PT-13.1 INR(PT)-1.1 [2124-7-20] 03:55PM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2* [2124-7-25] 04:45AM BLOOD Glucose-106* UreaN-35* Creat-1.4* Na-144 K-3.9 Cl-106 HCO3-31 AnGap-11 [2124-7-20] 03:55PM BLOOD Glucose-96 UreaN-20 Creat-1.1 Na-143 K-3.6 Cl-103 HCO3-32 AnGap-12 [2124-7-20] 03:55PM BLOOD ALT-16 AST-20 LD(LDH)-188 AlkPhos-92 TotBili-0.6 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 85152], [Known firstname ] [Hospital1 18] [Numeric Identifier 85153] (Complete) Done [2124-7-21] at 9:16:04 AM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2044-9-14] Age (years): 79 M Hgt (in): 71 BP (mm Hg): 142/78 Wgt (lb): 213 HR (bpm): 71 BSA (m2): 2.17 m2 Indication: Atrial fibrillation. Mitral valve disease. Shortness of breath. ICD-9 Codes: 786.05, 424.0, 424.2 Test Information Date/Time: [2124-7-21] at 09:16 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 168], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: ie33 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 6.8 cm <= 4.0 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Findings LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mildly dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Torn mitral chordae. Moderate to severe (3+) MR. [Name13 (STitle) 15110] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions PREBYPASS The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. POSTBYPASS The patient is not receiving inotropic support post-CPB. There in no mitral regurgitation. An annuloplasty ring is well-seated in the mitral position. The peak transmitral gradient is 4 mm Hg at a cardiac output of 5.1 L/min. Biventricular systolic function is preserved and all other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings were discussed with the surgeon intraoperatively. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [Name Initial (NameIs) ] certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician ?????? [2117] CareGroup IS. All rights reserved. Brief Hospital Course: Mr.[Known lastname ] was admitted to the hospital the day prior for surgery for Heparin bridge and groin ultrasound to evaluate for AV fistula at cath site. Vascular was consulted for assessment of his right groin hematoma and no intervention was required. He was brought to the operating room on [2124-7-21] where he underwent Mitral Valve repair (#30mm CE Physio II ring/resection of P1 flail)with Dr.[Last Name (STitle) ]. Please see Dr[Last Name (STitle) ] operative report for further details. 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, at his baseline mildly demented, and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Nursing Care Rehabilitation in good condition with appropriate follow up instructions. Medications on Admission: *Coumadin 2.5mg MWF and 5mg on Tu/TH/S/S.Last dose=[2124-7-16] Benicar 40mg daily Digoxin 0.25mg daily Colchicine 0.6mg daily Aricept 10mg daily Namenda 10mg twice daily Lasix 40mg daily Norvasc 5mg daily Fexofenadine prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 10. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 12. Warfarin 1 mg Tablet Sig: MD to dose Tablet PO Once Daily at 4 PM: INR goal =2-2.5 for Atrial Fibrillation. Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Nursing Care - [Location (un) 6981] Discharge Diagnosis: -mitral and tricuspid regurgitation -status post Mitral Valve Repair (#30mm CE Physio II ring)-[2124-7-21] Chronic Atrial fibrillation - Mild Dementia, Memory Loss - History of Gout - Hypertension - Prostatism - Hemorrhoids Past Surgical History: - s/p TURP - Nasal Polyps Discharge Condition: Alert and oriented x2-3,(baseline)dementia nonfocal. Ambulating with steady gait. Incisional pain managed with Ultram/Tylenol as needed Incisions: Clean, dry, intact Sternal - healing well, no erythema or drainage Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([Telephone/Fax (1) 170]). Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. Please call cardiac surgery office with any questions or concerns ([Telephone/Fax (1) 170]). Answering service will contact on call person during off hours.* Followup Instructions: You are scheduled for the following appointments Surgeon:Dr.[Last Name (STitle) ] #[Telephone/Fax (1) 170], appointment for Thursday, [8-24], at 1:15pm Please call to schedule appointments with your Primary Care: Dr.[Last Name (STitle) 3390]: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 78085] in [2-12] weeks Cardiologist:[Last Name (LF) ],[First Name3 (LF) 198] [Telephone/Fax (1) 14525] in [2-12] 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= chronic Atrial Fibrillation Goal INR: 2.0-2.5 First draw:[2124-7-26] Completed by:[2124-7-25]	[ "288.60", "424.0", "600.90", "427.31", "397.0", "294.8", "429.5", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.12" ]	icd9pcs	[ [ [] ] ]	10385, 10517	7403, 8962	322, 428	10838, 11058	2063, 7380	11916, 12703	1253, 1289		9244, 10362		10538, 10766		8988, 9221			11082, 11893						10789, 10817		1304, 2044																									262, 284										456, 845															867, 992	1058, 1221

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